Task N 4 — Answers

1. Valvular Venous Structure and Its Role in the Pathogenesis of Post-Thrombotic Disease

• Reversal of the normal pressure gradient (venous hypertension)
• Blood refluxes from deep to superficial veins via incompetent perforators
• Sustained elevated venous pressure in the distal limb → the hallmark of chronic venous insufficiency / post-thrombotic syndrome (PTS)

2. Clinical Appearance of Thrombosis of the Inferior Vena Cava

• Bilateral lower limb edema — massive, symmetric, extending from feet to groin
• Bilateral leg pain and heaviness
• Cyanosis of both lower limbs (in severe cases)
• Dilated superficial collateral veins over the abdomen and flanks (serving as bypass channels)
• If the renal veins are involved at the level of the thrombus: bilateral flank pain, hematuria, and signs of renal impairment
• If hepatic veins or suprarenal IVC involved: features of Budd-Chiari syndrome (hepatomegaly, ascites, jaundice)

3. Diagnosis of Post-Thrombotic Disease — Its Risk Factors

• History of prior DVT (confirmed by Duplex Doppler or venography)
• Chronic limb symptoms: aching, heaviness, swelling (worse with standing/walking, relieved by elevation)
• Skin changes: brownish hyperpigmentation (hemosiderin deposition), lipodermatosclerosis, venous eczema
• Venous ulceration (typically at the medial malleolus/inner ankle)
• Duplex ultrasonography: demonstrates valvular incompetence, reflux, and residual thrombus/recanalization
• Venous pressure measurements: elevated ambulatory venous pressure confirms hemodynamic incompetence

• Extensive (proximal) DVT — iliofemoral segment most important
• Recurrent ipsilateral DVT
• Inadequate anticoagulation during acute DVT
• Obesity
• Older age
• Varicose veins or pre-existing venous insufficiency
• Female sex
• Persistent thrombus at 1 month (failure of early recanalization)

4. Complications of Deep Veins of Thrombosis

• Pulmonary embolism (PE) — the most feared complication; thrombus from femoral/popliteal veins breaks off, passes through the right heart, and occludes pulmonary arteries; massive PE causes cardiopulmonary arrest and death — Gray's Anatomy for Students
• Phlegmasia cerulea dolens — massive iliofemoral DVT with limb-threatening venous gangrene
• Phlegmasia alba dolens — extensive DVT causing arterial spasm; pale, cool leg

• Post-thrombotic syndrome (PTS) — valvular destruction → chronic venous hypertension → edema, skin changes, ulceration
• Venous ulcers — particularly at the medial malleolus ("gaiter area")
• Chronic venous insufficiency
• Recurrent DVT — damaged venous wall and stasis predispose to re-thrombosis

5. Patient with Trophic Ulcer at Inner Ankle of the Shin — Varicose Veins Secondary to Post-Thrombotic Disease: Examination and Treatment

• Previous DVT episode (confirm with records)
• Duration of ulcer, prior ulcers, previous treatments
• Symptoms of venous insufficiency (swelling, heaviness, aching)

• Location: inner (medial) ankle — classic for venous ulceration
• Ulcer characteristics: size, depth, edges, floor, exudate, signs of infection
• Surrounding skin: pigmentation, lipodermatosclerosis, eczema
• Limb: varicose veins, edema, calf tenderness
• Perforating vein incompetence (Trendelenburg test, cough impulse)

• Duplex Doppler ultrasound — gold standard; maps venous incompetence, identifies patent vs. occluded segments, perforator incompetence
• ABPI (Ankle-Brachial Pressure Index) — mandatory before compression therapy; must exclude arterial disease (ABPI < 0.8 contraindicates high-compression)
• Ascending venography or CT venography — if surgical reconstruction is planned
• Wound swab — if infection suspected
• Biopsy — if ulcer fails to heal or malignant transformation suspected

• Graduated compression therapy — multilayer bandaging or high-compression stockings (30–40 mmHg); cornerstone of venous ulcer management; reduces venous hypertension
• Leg elevation — reduces edema and promotes healing
• Wound care — debridement, appropriate dressings (non-adherent, moisture-retentive)
• Exercise — calf muscle pump activation (walking, ankle exercises)
• Treat infection — systemic antibiotics if cellulitis present

• Subfascial endoscopic perforator surgery (SEPS) — division of incompetent perforating veins
• Varicose vein surgery — stripping or endovenous ablation (laser/radiofrequency) of refluxing superficial veins
• Valvular reconstruction or venous bypass — in selected patients with deep venous reflux
• Skin grafting — for large, refractory ulcers once wound bed is clean

• PTS-related ulcers are chronic and recurrent; long-term compression is essential to prevent recurrence even after healing.