varicose veins

Question 1

causes of varicose veins ?

Answer 1

1. primary (before pregnancy, after 2nd or 3rd pregnancy, prolonged standing at work)
2. secondary to DVT
3. congenital (klippel-trenaunay syndrome : varicose veins, limb hypertrophy, skin pigmentation)

Question 2

pathophysiology? most common vein affected?

Answer 2

brief pathophysiology: damage of SFJ valve -> increase pressure in LSV -> damage to LSV valves and varicose veins

90% affects the LSV

Question 3

symptoms and focus on hx?

Answer 3

symptoms like CVI (leg heaviness and achiness after prolonged standing relieved by walking, LL non pitting painful edema and cramps)

in hx focus on DVT risks (post trauma/ ortho surgery, OCP use, pregnancy)

Question 4

brief outline for physical exam?

Answer 4

inspect: skin pigmentations/ulcers, edema

palpation:
1. feel along the coarse of LSV and SSV (is it hard or soft?) -> cough impulse at SFJ while supporting the pt with other hand
positive cough impulse if thrill is detected

2. high torniquet test
   lift leg, milk the vein upward, apply torniquet, pt stands and watch the veins (empty), then open the torniquet (vein is filled again positive test)
3. multiple torniquet test for perforators
   apply above knee, below knee, mid leg, above ankle and repeat
4. perthe test for deep system
   apply high torniquet and ask pt to exercise (heel, toe) -> pain means positive

check pedal pulses

Question 5

investigations?

Answer 5

doppler: detect reflux

duplex: real time visualization of veins and valves, detect reflux, check location of perforators and function of valves

Question 6

management?

Answer 6

1. conservative with compression stocking and sclerotherapy (sclero is mainly for below knee)
2. high ligation of (SFJ/SPJ) + stripping of (LSV/SSV) with or without sclerotherapy (for below knee only). the stripping of LSV continues to 10cm below knee
   complication: saphenous nerve injury
3. minimally invasive: endovascular venous ablation procedures, subfacial perforator surgery.
   Both are equally effective, day-case, offer less pain and bruising compared to surgery. They have the same recurrence rate as that of surgery

Question 7

complications of varicose veins?

Answer 7

superficial thrombophlebitis, superficial vein thrombosis, venous ulcers