Varicose vein examination

Question 1

Inspection

Answer 1

Ensure pt adequately exposed
Inspect from all sides while standing up
Easiest by kneeling down and asking pt to turn around

Question 2

What to look for on inspection (standing up)

Answer 2

-Varicosities - i.e. dilated, tortuous veins along long and short saphenous systems
-Skin changes + ulceration from chronic varicosities especially medial gaiter area
-Scars from prev surgery (avulsion)
-Sapheno varix in groin
-port wine stains/soft tissue limb hypertrophy

Question 3

What skin changes can occur with varicose veins?

Answer 3

-Lipodermatosclerosis
-Venous eczema
-Haemosiderin staining
-“atrophie blanche” - white patches found in areas healed ulceration
-Oedema

Question 4

What is lipodermatosclerosis?

Answer 4

Lower extremity panniculitis (fat inflammation)

Question 5

What is haemosiderin staining?

Answer 5

Residue of haemoglobin from blood leaking out of capillaries

Question 6

What is significance of port wine stains and soft tissue limb hypertrophy with varicosities?

Answer 6

-Klippel-trenaunay syndrome

Question 7

Palpation

Answer 7

Pt standing

-Feel at sapheno-femoral junction for sapheno varix
-If swelling present, check for palpable thrill and cough impulse which indicates incompetent valve between superficial and deep systems
-Feel down leg over course of long saphenous + short saphenous veins for tenderness along veins which may indicate perforator incompetence

Pt lying
-Look for varicosities collapsing as pt lies down

Question 8

Which long saphenous vein perforators are clinically important?

Answer 8

-5,10, 15 cm above medial malleolus
-a few centimetre below knee joint
-A few centimetres above knee joint
-In adductor canal
-In upper thigh

Question 9

What is the purpose of trendelenburg/tourniquet test?

Answer 9

-Elucidate if varicosity is due to sapheno-femoral junction incompetence or perforator incompetence
-Has largely been superseded in clinical practice by doppler

Question 10

Performing trendelenburg test

Answer 10

-With pt supine, lift their leg to 45 degrees + empty veins (may be aided by ‘milking’ veins)
-Occlude sapheno-femoral junction, ask pt to stand up ensuring finger or thumb is firmly over junction
-If superficial veins do not fill and varicosities are controlled at level of sapheno-femoral junction by occluding it, this strongly suggests sapheno-femoral incompetence.
-Can be confirmed by releasing pressure from sapheno-femoral junction that will cause blood to return from femoral vein into saphenous (through incompetent sapheno-femoral junction), resulting in varicosities becoming prominent
-As the pt stands, if veins fill from below with sapheno-femoral junction occluded, incompetent perforators are most likely cause for varicosities.

Question 11

Performing tourniquet test

Answer 11

-Follows same principles as trendelenberg but easier to perform as uses tourniquet to control sapheno-popliteal junction rather than examiners fingers
-If varicosities are due to perforator incompetence, can be performed further down leg to identify level of incompetence
-Once superficial venous system has been controlled with tourniquet you can perform perthe’s test to assess patency of deep venous system, important if considering varicose vein surgery

Question 12

Perthe’s test

Answer 12

-With pt standing and with tourniquet still around thigh, ask pt to go up and down on tiptoes or ask them to walk, excercising calf muscles
-If deep system is intact, calf pumps encourage venous return
-If deep system is occluded or valves are incompetent, when pt performs this action venous return is restricted and blood forced into superficial system from deep system
-This causes engorgement of superficial veins associated with bursting pain

Question 13

Doppler ultrasound

Answer 13

To assess sapheno-femoral incompetence using hand held doppler:
-Hold doppler probe at 45 degree angle to skin at level of sapheno-femoral junction and squeeze pt’s calf.
-It pt with competent sapheno-femoral junction you will hear short ‘swoosh’ as you squeeze, but this ceases when you let go of calf
-If sapheno-femoral junction is incompetent, there is more prolonged ‘swooooosh’ of blood as it regurgitates back down through incompetent valve
-Can be repeated at any level along course of superficial venous system to assess for perforator incompetence

Question 14

Where is sapheno-femoral junction?

Answer 14

~4cm below + lateral to pubic tubercle

Question 15

Where is pubic tubercle?

Answer 15

a rounded bony projection located on the lateral end of the pubic crest.

Question 16

What would be implication if veins remain engorged when pt lies down?

Answer 16

-Consider arterio-venous fistula or venous obstruction

Question 17

What are the surface markings of long saphenous vein?

Answer 17

-Commences from medial venous arch
-Runs 2cm in front of medial malleolus
-Ascends along medial border of tibia
-Runs hands breadth medial to medial border of patella
-Empties into femoral femoral vein at sapheno-femoral junction: 4cm below and lateral to pubic tubercle

Question 18

What are the surface markings of short saphenous vein?

Answer 18

-Commences from lateral venous arch
-Runs behind lateral malleolus
-Ascends along leg lying in midline
-Empties into sapheno-popliteal junction (lies 4-5cm above posterior joint line of knee)

Question 19

What nerves accompany short and long saphenous veins?

Answer 19

-Saphenous nerve accompanies long vein from knee down to medial foot (supplies sensation to medial foot)
-Sural nerve accompanies short saphenous vein from posterior aspect of knee to lateral aspect foot (supplies sensation to lateral foot)

Question 20

To complete the examination:

Answer 20

-Full neurovascular examination lower limbs (venous ulcers can be confused with arterial/neuropathic ulcers
-Auscultate vein for bruits suggestive of AV fistula
-Abdominal exam and PR if history is suggestive abdominal/pelvic pathology contributing to varicosities
-Doppler ultrasound: to enable further bedside assessment of incompetent venous valves and the identification of thrombosis.
Venous duplex scanning: for a comprehensive assessment of lower limb venous drainage.
Ankle-brachial pressure index (ABPI) measurement: to assess arterial perfusion.

Question 21

Examination full summary

Answer 21

1. Inspection with pt standing up
2. Palpation with pt standing up
3. Inspection on lying down

Special tests:
-Trendelenberg
-Tourniquet
-Perthe’s
-Doppler

To complete examination:

Question 22

What is a saphena varix?

Answer 22

A saphena varix is a dilation of the saphenous vein at its junction with the femoral vein in the groin. It typically presents as a lump around 2-4cm inferior-lateral to the pubic tubercle. It often has a bluish tinge, is soft to palpate and will vanish when the patient lies down which can help differentiate it from an inguinal hernia.

Question 23

Varicose vein pathophysiology

Answer 23

-Develop due to incompetent one way valves
-Leads to leakage, retrograde flow and pooling of blood in superficial venous system
-Thinner weaker walls of superficial system make them more prone to dilatation and tortuosity

Varicose veins develop due to the incompetence of the one-way valves, leading to the leakage, retrograde flow and consequently, pooling of blood in the superficial venous system.

Additionally, the weaker, thinner walls of the superficial veins (as opposed to the stronger and thicker walls of the deep veins) make them more prone to the effects of the high-pressure build-up of blood leading to distension of the venous walls and tortuosity of the affected venous segment.3,4

This manifests as bulging of the skin over the affected vein (figure 1).

Question 24

Varicose veins investigations

Answer 24

Varicose veins are usually a clinical diagnosis and investigations are not required.

However, a duplex ultrasound scan can confirm the diagnosis of varicose veins by assessing for the reflux of blood in less obvious cases. Ultrasound also helps rule out a DVT and can be useful when planning management.2,3

Importantly, an ankle-brachial pressure index (ABPI) can exclude peripheral arterial disease before compression therapy is considered

Question 25

What treatment options are available for varicose veins?

Answer 25

Management of varicose veins consists of both surgical and conservative options.

In addition, lifestyle changes are encouraged including exercise and weight loss.

Varicose veins are likely to recur after treatment, but for most patients, treatment offers relief from symptoms for a significant period (with the length varying from patient to patient).

Question 26

What conservative options are available for varicose veins?

Answer 26

Compression therapy
-Only if surgical management declined/considered not suitable (e.g. pregnancy)

The main non-surgical option for managing varicose veins is compression therapy using bandages or stockings.

However, compression therapy is not recommended by NICE unless surgical intervention is declined or considered inappropriate. One such case where it can be deemed not suitable is pregnancy. In this situation, only non-surgical options should be considered unless exceptional circumstances warrant surgical intervention.

Before using compression therapy, it is important to exclude arterial insufficiency by performing an ankle-brachial pressure index (ABPI).

Question 27

What Surgical options are available for varicose veins?

Answer 27

Endovenous:
1) endothermal ablation (laser treatment or radiofrequency ablation)
2) US guided foam sclerotherapy

Open
-Ligation and stripping
-Phlebectomy: avulsion via stab incisions

Endovenous techniques
Endovenous techniques aim to block the faulty veins, which has the same benefit as removing them. It is preferred to open surgery as these techniques are minimally invasive.

Options include:

Endothermal ablation (first line) involves either radiofrequency ablation or endovenous laser treatment
Ultrasound-guided foam sclerotherapy (second line)
Rarer techniques, such as the use of glue, steam, and mechanochemical devices
Open surgery
Open surgery is only considered if endovenous techniques are deemed inappropriate.

Options include:

Ligation and stripping: incompetent veins are tied off (ligated) and removed (stripped)
Phlebectomy (stab avulsions): varicose veins are pulled out through small incisions

Question 28

Venous vs arterial ulcers

Answer 28

Venous ulcers: typically large and shallow ulcers with irregular borders that are only mildly painful. These ulcers most commonly develop over the medial aspect of the ankle.

Arterial ulcers: typically small, well-defined, deep ulcers that are very painful. These ulcers most commonly develop in the most peripheral regions of a limb (e.g. the ends of digits).

Question 29

Venous ulcer investigation

Answer 29

-Clinical diagnosis
-Venous duplex can confirm incompetence
-ABPI to determine if arterial component/whether compression therapy would be appropriate
-Swab if infection suspected

The diagnosis of venous ulcers is clinical, with the
underlying venous insufficiency confirmed by Duplex Ultrasound. Most commonly venous incompetence occurs at the sapheno-femoral or sapheno-popliteal junctions, although it may occur in any perforator.

An Ankle Brachial Pressure Index (ABPI) is required to assess for any arterial component to the ulcers and to determine whether compression therapy will be suitable. If infection is suspected (i.e. erythematous or with purulent exudate) then consider microbiology swabs and antibiotics.

Take swab cultures if suspecting an associated infection. Consider a thrombophilia and vasculitic screening in young patients, especially if there is a suspicion or family history of prothrombotic and autoimmune diseases.

Question 30

Venous ulcer management

Answer 30

-Lifestyle changes: weight reduction, improved nutrition
-Antibiotics if evidence of infection
-Compression bandaging (If ABPI >0.6)
-Surgical treatment of varicose veins

Conservative management for venous ulcers warrants leg elevation and increased exercise (promoting the calf muscle pump action which aids venous return). Encourage lifestyle changes, including weight reduction and improved nutrition, as appropriate.

Antibiotics should only be prescribed with clinical evidence of a wound infection (most wounds are colonized, therefore swab results should only be acted upon if evidence of infection).

The mainstay of management is via multicomponent compression bandaging, changed once or twice every week; 30-75% of venous leg ulcers will heal after six months of compression therapy. Eight randomised clinical trials demonstrated improved time to healing with compression versus no compression treatment.

Importantly, the ABPI must be measured as at least greater than 0.6 before any bandaging is applied. Appropriate dressings and emollients are crucial in maintaining surrounding skin health.

If there is concurrent varicose veins, these should be treated with endovenous techniques or open surgery*, as improving venous return will allow for the healing of the venous ulcers.

*Recent trial data on the use of surgical treatment of varicose veins in patients with venous ulceration demonstrated that surgery decreases the chance of ulcer recurrence (ESCHAR study), and that early treatment of varicose veins decreases the time for ulcer healing (EVRA trial)

Question 31

Post op complications varicose vein surgery

Answer 31

-DVT
-Thrombophlebitis
-Bleeding
-Nerve damage
-Disease recurrence

Whilst the complications will be specific for each procedure, typical complications seen post-operatively include haemorrhage, thrombophlebitis (important for foam or ablation treatments), DVT (important for any endovenous treatments), disease recurrence, and nerve damage (specifically saphenous or sural nerves).

Question 32

Varicose vein criteria for referral to vascular team

Answer 32

-Symptomatic varicose veins
-Skin changes
-Ulcer
-Superficial vein thrombosis

Symptomatic primary or recurrent varicose veins
Lower‑limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency
Superficial vein thrombosis (characterised by the appearance of hard, painful veins) with suspected venous incompetence
A venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks)