Varicose veins

Question 1

what are the symptoms of varicose veins?

Answer 1

• visible dilated veins
• pain
• cramps
• tingling
• heaviness
• restlessness

Question 2

What are the signs of varicose veins?

Answer 2

• oedema
• eczema
• ulcers
• skin colour changes
• lipodermatsclerosis (skin harness)

Question 3

What is the pathophysiology of varicose veins?

Answer 3

• normally blood from superficial veins in the leg drain into the deep veins.
• at the junction where the veins meet valves prevent backflow of blood.
• IF VALVES BECOME INCOMPETENT —-> venous dilation and hypertension of superficial veins ocurs!

Question 4

What are the risk factors for varicose veins?

Answer 4

• prolonged standing
• obesity
• OCP
• pregnancy

Question 5

What Invx are done for varicose veins?

Answer 5

1) Trendelenburg’s test
2) cough impulse
3) tourniquet test
4) Perthes test
5) Doppler USS

Question 6

What is Trendelenburg’s test

Answer 6

The Trendelenburg test is used to determine the site of valvular incompetence in a patient with varicose veins.

-Assesses if the SFJ valve is competent
-Lie the patient down
Raise their legs and firmly ‘milk’ the blood up their legs (by placing two hands firmly around their leg and moving slowly proximal), draining venous blood from their varicose veins
-Place two fingers on the SFJ
Ask patient to stand, keeping your fingers firmly in place
-If varicosities are controlled they will not rapidly fill
-Release your fingers, and they then fill up
-This shows there is incompetence at the SFJ

Question 7

what is the cough impulse (for varicose veins)

Answer 7

Cough impulse test
Palpate at the SFJ (2-4cm inferio-lateral to the pubic tubercle) and ask the patient to cough
If positive (i.e.: you feel a cough impulse), this suggests there is a Saphena Varix

Question 8

What is the tourniquet test for varicose veins?

Answer 8

Tourniquet test:
- Ask patient to lie down and left their leg up
- Drain the venous blood from the leg as above
-Apply a tourniquet on the SJF
-Ask patient to stand up
Look for refill of the varicose vein - normal is a few seconds
-If no refill this suggests that it is the SFJ valve (or a more proximal valve) that is incompetent
-You can confirm by taking off tourniquet - if a incompetent valve there, will have a sudden gush filling from above when remove tourniquet
-If the varicose vein does refill with the torniquet still in place around the SFJ, then this suggests that the incompentence is more distal
In this case, repeat the test at more distal points down the leg - e.g. once above the knee and once below the knee
-More distal sites of incompentence causing varicose veins include the short saphenous veins, and the deep perforators that join with the deep venous system of the leg

Question 9

What is perthe’s test?

Answer 9

Perthe’s test:
Determines if the deep femoral veins are competent or not
Apply a tourniquet at the mid thigh level with the patient standing
Ask the patient to either a) walk around the room for 5 minutes, or b) repeatedly alternate between standing on tip-toes to standing on flat feet for 5 minutes
Results:
If deep system is competent, the blood will go through and back to the heart, and the patient will have no symptoms. If the deep system is incompetent, the patient will feel pain in the leg and the varicosities will increase in size

Question 10

What is the treatment for varicose veins?

Answer 10

Lifestyle:

• avoid prolonged standing
• support stockings
• lose weight

Injection therapy

Surgery

Question 11

What are the differentials for varicose veins?

Answer 11

• Obstruction : DVT, ovarian tumour.
• Valve destruction (DVT)
• atriovenous fistulae / malformations