Lower limb venous disease

Question 1

What are the seven classes in the CEAP classification of venous disease?

Answer 1

0: No visible or palpable signs of venous disease
1: Telangiectasia, reticular veins, malleolar flare
2: Varicose veins
3: oedema without skin changes
4: skin changes: pigmentation, venous eczema, lipodermatosclerosis
5: skin changes with healed ulceration
6: skin changes with active ulceration

Question 2

What is the difference between chronic venous disease and chronic venous insufficiency?

Answer 2

Chronic venous disease refers to the full spectrum C0-C6 while the term chronic venous insufficiency refers to the more severe manifestations (C4-6)

Question 3

What are risk factors for venous disease

Answer 3

-Increasing age
-Pregnancy
Needs more evidence:
-Family history
-Obesity
-Prolonged standing
-Caucasian race
-Diet poor in fibre

Question 4

Which veins do not have valves

Answer 4

Valves are only absent in the common iliac veins, vena cava, the portal system and cranial sinuses

Question 5

Venous hypertension causes the clinical manifestations of venous disease. How does venous insufficiency (causing hypertension) occur?

Answer 5

1. Venous pump overwhelmed by massive downflow in incompetent superficial veins (varicose veins)
2. Deep vein thrombosis
3. Deep veins obstructed by external pressure
4. inborn deficiency of valves or inherent weakness in vein walls
5. Prolonged inactivity of the muscles in a dependant position
6. Muscle dysfunction/ paralysis
7. Skeletal problems, arthritis, injury

Question 6

What is the difference between primary and secondary venous insufficiency

Answer 6

• Primary: no underlying aetiologic mechanism can be identified
• Secondary insufficiency occurs when an obvious cause leads to destruction or dysfunction of the venous valves

Question 7

Symptoms of venous disease

Answer 7

• Most are asymptomatic
• Aching
• Throbbing
• Itching
• leg fatigue
• Heaviness
• Swelling
• Symptoms are worse at the end of the day and are alleviated by elevation

Question 8

Complications of the varicosities

Answer 8

• Thrombophlebitis –> potential for pulmonary embolism (rare)
• Varicosity may rupture and bleed either from trauma or spontaneously

Question 9

Complications of the incompetence and venous hypertension

Answer 9

oedema, skin hyperpigmentation, itching, eczema, lipodermatosclerosis, breakdown of the skin with ulceration

Question 10

What is a submalleolar flare

Answer 10

Fan-shaped pattern of small, intra dermal veins located around the ankle or the dorsum of the foot

Question 11

What is telangiectasia

Answer 11

dilated intradermal venules <1mm in size

Question 12

What are reticular veins

Answer 12

dilated, non palpable subdermal veins < 3 mm

Question 13

What are varicose veins

Answer 13

dilated, palpable subcutaneous veins > 3 mm

Question 14

What is the distribution of the great and short saphenous vein?

Answer 14

• Great saphenous vein: medial calf and thigh

- Short saphenous vein: posterolateral calf

Question 15

With handheld doppler ultrasound, what period of reflux is significant

Answer 15

any reflux lasting >0.5 seconds is significant

Question 16

Duplex doppler is the investigation of choice. What are indications for duplex doppler

Answer 16

• Patients with varicose veins prior to any intervention
• Patients with C4- C6 disease
• Suspected deep venous pathology (DVT or reflux)
• Suspected perforator incompetence
• Recurrent varicose veins

Question 17

what are the recommendations for each class of compression stocking?

Answer 17

I: varicose veins, mild oedema
II: moderate/ severe varicose veins, ulcer prevention, gross varices
III: Post phlebitic limb, recurrent ulceration, lymphoedema

Question 18

How can reticular veins and telangiectasias be treated?

Answer 18

• In the absence of incompetence, reticular veins may be treated with sclerotherapy or avulsions through small stab incisions
• Telangiectasias are treated by microinjections of sclerosant or laser sclerotherapy

Question 19

What are commonly used sclerosants?

Answer 19

-Polidocanol and sodium tetradecyl sulphate

Question 20

Patients with trunk varicosities and confirmed sapheno-femoral or -popliteal incompetence are best treated surgically, what should be done to deal with the incompetence?

Answer 20

• Sapheno-femoral or -popliteal disconnection and ligation of all the branches in the region of the junction
• Saphenous vein should be stripped to knee joint
• Varicosities avulsed through multiple small stab incisions

Question 21

What are the complications of surgical management of venous disease?

Answer 21

• DVT
• Pulmonary embolism
• damage to saphenous nerve
• Sural nerve damage

Question 22

Treatment of thrombophlebitis

Answer 22

• Compression stockings
• Anti-inflammatory drugs
• Rest
• Definitve venous surgery