Chronic Venous Insufficiency and Ulcers Flashcards
What are Varicose Veins?
Tortuous, dilated, superficial!! veins a/w venous HTN and incompetent valves
Which veins have valves? Superficial or Deep veins
Both have valves but deep veins have more valves and theyre more functionally significant for venous return.
Honours: The Perforators have good valves as well. So the main places for valves are the deep and perforators. That is why superficial veins are harvested for grafts
How many perforators are there in the LL
It varies from person to person but there are (variations are common)
1 or 2 in the thigh
3 in the leg
Is chronic venous insufficienct more common in men or women?
Males tend to have deep vein reflux whereas females tend to have superficial vein reflux => why varicose veins are more likely in women
Males tend to have deep vein reflux whereas females tend to have superficial vein reflux => why varicose veins are more likely in women
What are the main deep veins of the lower limb. State the in the order of flow
What are the main superficial veins of the LL?
Indicate where the superficial veins drain into the deep ones
Deep veins are Tibial -> Popliteal -> Femoral -> Iliac
Superficial are the Lesser and Greater Saphenous veins
1) The LSV drains into the popliteal vein and SPJ (Saphenopopliteal junction)
2) The GSV drains into the femoral vein at the SFJ (Saphenofemoral junctions)
3) The 3 Leg perforators are between the LSV and Tibial vein (sometimes popliteal)
4) The 1/2 Thigh perforators are between the GSV and Femoral vein
Which veins run between the muscle compartments of the leg (e.g. gastronemus)
Deep veins
What role does intra–abdominal pressure play in chronic venous insufficiency?
Give a few examples that would serve as RFs
Increased intra-abdominal pressure means that there is increased resistance to venous return to the heart
=> Pregnancy, Obesity, smoking, Ace inhibitors lead to chronic venous insufficiency
List the RF for chronic venous insufficiency
You are in a long case with a patient with clear varicose veins. The consultant asks you what are the main sites of reflux in this patient. What will you say?
SFJ
SPJ
Perforators
AKA wherever the superficial and deep system meet
Using pathophysiology, give the signs and symptoms of Chronic venous insufficiency
You are asked to perform an examination in a long case for a patient with a history of chronic venous insufficiency
What position should the patient be in during the exam?
What findings are you looking for?
Patient must be in a standing position
What are the complications of Chronic venous insufficiency and varicose veins?
You are asked to take a history from a patient with obvious varicose veins. What should you elicit
Sx, complications, and Rf
Use the image to confirm
How would you diagnose chronic venous insufficiency?
What if youre unsure?
Clinically alone
Hx + exam including abdomen, pelvis, and trendelenberg test…
If unsure, Doppler/Duplex US may be used
Investigations are not performed in the diagnosis of chronic venous insufficiency other than supportive tests for etiology etc…
What is the Gold standard investigation? When is it used?
Duplex US (not doppler) used as gold standard when
1) Insufficient clinical exam for diagnosis
!!2) If patient is a candidate for surgery in order to plan and map out anatomy!!
What does TED stand for?
Thromboembolic Deterrent stocking
You are trying to decide which stockings are best to put on a patient with chronic venous insufficiency. What options are there in general and which one is best for this case.
Answer includes a lot of information about each. There is another time this comes in surgical miscellaneous asking about them all
Grade 1 = White/yellow = TEDs = VTE prophylaxis (15-20mmHg)
Grade 2 = Brown/Blue = Venous insufficiency (20-25) NOTE: brown is used here according to the lecture.
=> we use this
Grade 3 = Brown/Green = Lymphoedema (or severe venous insufficiency) (25-35)
Extra cuz rarely actually used:
Grade 4 = Purple = Very severe lymphoedema/venous insufficiency (40+)
Nice extra note: these are 3 sizes for each (S,M,L) instead of what it used to be which was specific measurements
You have chosen grade 2 stockings for venous insufficiency. Will you prescribe it below the knee or above the knee and why?
What information will you provide to the patient when prescribing them?
Below the knee due to better compliance and more comfortable
Wear all day except when going to bed.
Apply moisturiser or lubricant overnight after taking it off
Do not wash with hot water as it is nylon based
What is the conservative management for all patients with chronic venous insufficiency?
Compression stockings are considered medical but wont be completely wrong to state it here
What is the medical management for all patients with chronic venous insufficiency?
What about if they have a hx of DVT?
What are the indications for surgical management of chronic venous insufficiency?
1) Cosmetic
2) Symptomatic to prevent complications
3) Hx of Complications
4) Recurrent varicose veins
List the surgical options available for patients with chronic venous insufficiency
What is the target of all these surgical procedures
Endovascular:
1) Thermal: Radiofrequency or Laser ablation
2) Sclerotherapy
3) Clarivein (mechanical)
Endoscopic: SEPS - Subfascial Endoscopic Perforator surgery
Open :
1) Open Ligation
2) Stab avulsion
3) Vein Stripping
In all of these procedures, the target is the junction itself => SFJ, SPJ, AND PERFORATORS
What are the two types of thermal techniques used as part of endovascular repair for chronic venous insufficiency?
What is the main complication? Explain
Radiofrequency and laser ablation
Main complication:
HIT - Heat-induced Thrombophebiltis (or thrombus)
It is inflammation and thrombus formation at the site of thermal ablation. It is graded as HIT 1,2,3 based on proximity to the junction. The closer it is to the deep venous system (junction), the more likely it is for DVT (deep venous thrombosis) to occur
What is sclerotherapy exactly?
What indication would make you choose this over others?
What must you tell the patient about this surgery?
It is a foam injection that causes fibrosis of the area
Sclerotherapy is mainly used for cosmetic procedures
It is very painful
Is it more dangerous to operate on the short or long saphenous vein? Why?
The Short saphenous vein is more dangerous with everything whether it is stripping, grafting, or ablation.
2 Nerves run near it which are the Saphenous and Sural nerves.
Injury to the saphenous and sural nerves will cause…
Pain, paraesthesia, weakness
Nothing special about them other than they run in close proximity to the short saphenous vein (LSV)
What surgery has the poorest outcomes for chronic venous insufficiency?
Mechanical or Clarivein
What is clarivein?
It is a mechnicochemical ablation which uses:
Mechanical tip to disrupt endothelium
Chemical sclerosant (like sclerotherapy) to ablate the vein
=> very painful and poor outcomes, dont choose this
What is the only endoscopic procedure for chronic venous insufficiency?
Explain it very briefly
SEPS - Subfascial Endoscopic Perforator surgery.
Obviously it is done when the insufficiency is primarily due to perforator incompetence.
Endoscopic approach under GA. Incision made and blunt dissection into the fascia. The perforators are then clipped and thats the end of it
What is the target of open ligation?
SFJ, SPJ
Surgeon tells you they will do a phlebectomy to treat chronic venous insufficiency. What surgery are they referring to?
Stab Avulsions
Which vein(s) is/are targeted for Open repair of chronic venous insufficiency?
Only Great saphenous as short saphenous runs in close proximity to the saphenous and sural nerves leading to paraesthesia, pain, and weakness
Give the full management plans and options for a patient presenting with chronic venous insufficiency like a long case
What are the specific complications of any surgical procedure for chronic venous insufficiency
You are in a long case and you see this. Name the finding
Stab Avulsion scar (typically of tributaries of the GSV and LSV or reticular veins)
You will not see this in an exam cuz of how well healed it is Thats why this one is with plasters
You are in a long case and you see this. Name the finding
open SPJ ligation scar
AND Stab avulsion scars
You are in a long case and you see this. Name the finding
GSV harvesting scar typically for coronary artery bypass surgery
Honours: May also be from vein stripping (much less likely)
You are in a long case and you see this. Name the finding
Telangiectasia
You are in a long case and you see this. Name the finding
Varicose veins with markings for planned surgery based on Duplex US
You are in a long case and you see this. Name the finding
Haemosiderin deposits from the breakdown of RBC into Hb and iron
You are in a long case and you see this. Name the finding
Lipodermatosclerosis
You are in a long case and you see this. Name the finding
Venous ulceration in the medial gator region
You are in a long case and you see this. Name the finding
Duplex US assessing for sites of reflux, anatomy for preparing for surgery, and pattern of deep venous system
You are in a long case and you see this. Name the finding
Laser ablation probe - risk of HIT
You are in a long case and you see this. Name the finding
Radiofrequency probe and main device - Risk of HLT
You are in a long case and you see this. Name the finding
Eczematous rash secondary to stasis dermatitis
Venous ulcer on the left and right image in the medial gator area
You are in a long case and you see this. Name the finding
Venous ulcers bilaterally
Oedema bilaterally + eczematous rash secondary to stasis dermatitis
You are in a long case and you see this. Name the finding
Arterial ulcer on the dorsum of the foot
You are in a long case and you see this. Name the finding
More venous ulcers
You are in a long case and you see this. Name the finding
Mixed arterial and venous ulcer (point is know that it exists so if it has characteristics of both, say that on the exam)
You are in a long case and you see this. Give the management plan
Define an ulcer
It is an area of !!!!full-thickness skin loss of the lower limbs
Give as many causes of ulcers as you can
There are 3 types of ulcers. Describe all 3
