Varicose Veins

Question 0

Risk factors for varicose veins

Answer 0

Family hx!!
Pregnancies
Obesity
Occupation

Question 1

Definition of varicose veins and natural hx

Answer 1

Dilated subcutaneous vein with reversed blood flow
5% will develop venous ulcer
NICE guidelines: everybody with symptomatic varicose veins should be referred for assessment
Txt is highly cost effective

Question 2

Pathophysiology of varicose veins

Answer 2

Primary valve problem in perforating veins ->
Incompetent valves inn perforating veins ->
High pressure from calf muscle pump transmitted outwards ->
Superficial venous hypertension ->
Varicose veins ->
Progressive descending incompetance

Question 3

Pathophysiology of post-thrombotic limb

Answer 3

Previous DVT -> Damages deep vein valves* -> see rest of varicose vein pathophysiology

*More likely to develop: lipodermatosclerosis, venous ulceration, “post thrombotic limb”
Lipodermatosclerosis: rock hard palpation over ankle

Question 4

Chronic venous hypertension

Answer 4

Damages subcutaneous fat which becomes fibrotic, called lipodermatosclerosis
Skin around the ankle feels hard and is tethered to subcutaneous tissues
Known as the “inverted champagne bottle” leg
Commonly associated with deep vein reflux

Question 5

Clinical staging from CEAP classification

Answer 5

C1 thread veins
C2 varicose veins
C3 oedema
C4a pigmentation and / or eczema
C4b lipodermatosclerosis 
C5 healed ulcer ('atrophie blanche')
C6 active ulcer

Question 6

Tap test

Answer 6

Normal tap: tap distally and feel impulse proximally with your other hand
Abnormal tap: tap proximally and feel impulse transmitted distally
Implies superficial vein valvular incompetence with retrograde flow
Often performed with hand-held doppler

Question 7

Tourniquet test / Trendeleberg test

Answer 7

Empty superficial veins by raising the leg with the patient lying flat
Apply tourniquet high in the thigh, compressing the superficial veins
Ask the patient to stand
If the veins below the tourniquet fill up, this implies that the incompetent perforators are below that level
If veins remain empty, the incompetent perforator is above that level

Question 8

Interventional treatments for varicose veins

Answer 8

Foam sclerotherapy
Endothermal ablation (laser or radiotherapy)
Surgery: high tie and strip (Trendelenburg procedure) and/or avulsions via stab incisions
Rate of clinical recurrence of varicose veins at 3 years is approximately 20%

Question 9

Wells Criteria for diagnosis of DVT

Answer 9

WELLS PENIS or 5 patient factors and 5 leg signs

W whole leg swelling
E edema - pitting more on one side
L leg tender over deep veins (calf or thigh)
L leg big (>3 cm at calf diameter)
S Superificial veins dilated
P previous DVT
E explanation - alternative possibility likely
N neoplasia
I immobilisation 
S surgery in previous month