Varicose veins

Question 1

What are the different types of varicose veins?

Answer 1

• Primary
  
  • Uncomplicated saphenofemoral valvular incompetence
  • Greater saphenous distribution, positive tourniquet test
  • No stasis sequelae or morning ankle oedema
• Secondary
  
  • Perforator venous incompetence
  • Secondary to postphlebitic syndrome

Question 2

Clinical features of varicose veins?

Answer 2

• Cosmetic issues
• Worsening => pain, swelling, itch
• Varicosities in the course of the saphenous veins
• Features of venous insufficiency

Question 3

What are the features of venous insufficiency?

Answer 3

• Oedema
• Varicose eczema
• Lipodermatosclerosis
• Haemosiderin skin staining

Question 4

Complications of varicose veins?

Answer 4

• Bleeding
• Ulceration
• Thrombophlebitis

Question 5

What is a saphena varix?

Answer 5

• Dilatation of saphenous vein at saphenofemoral junction in the groin
• Displays a cough impulse
• Can be mistaken for a femoral hernia
• Tx: High saphenous ligation

Question 6

What is pictured here??

Answer 6

Varicose eczema

Question 7

What is pictured here??

Answer 7

• Superficial thrombophlebitis
  
  • Inflammatory process that causes a blood clot to form

Question 8

What is pictured here??

Answer 8

• Lipodermatosclerosis
  
  • inverted champagne bottle

Question 9

Describe the classification of varicose veins?

Answer 9

• CEAP classification
  
  • C => clinical features
  • E => etiology
  • A => anatomical
  • P => pathophysiology

Question 10

Describe the investigations into suspected varicose veins?

Answer 10

• Duplex ultrasound (gold standard)
  
  • Assesses valve competence

Question 11

What is pictured here??

Answer 11

• Haemosiderin skin discolouration
  
  • Venous insufficiency

Question 12

Femoral hernia + varicosities in the rest of the limb = __________ ?

Answer 12

Saphena varix

Question 13

When should varicose veins be treated?

Answer 13

• Refferred to a vascular service if:
  
  • Symptomatic
  • LL skin changes
  • Superficial vein thrombosis
  • Venous leg ulcer

Question 14

Treatment for varicose veins?

Answer 14

• Patient education
  
  • Prolonged standing, weight loss, increase exercise
• Compression stockings
  
  • If interventional treatment is inappropriate
• Invasive treatments
  
  • Foam scleropathy
  • Radiofrequency ablation
  • Ligation
    
    • High saphenous vein ligation
    • Ligation of incompetent perforators

Question 15

What investigation should be performed prior to compression bandaging?

Answer 15

Ankle-brachial pressure index

Question 16

What is Virchows triad?

Answer 16

• Hypercoaguability
• Stasis of venous blood flow
• Disruption of venous intimal lining

Question 17

Describe Vein ligation?

Answer 17

• Incision made in groin or popliteal fossa
• Vein is identified, tyed off then stripped away
• Surgeon should be aware of saphenous and sural nerves

Question 18

Describe Foam scleropathy?

Answer 18

• Sclerosing agent injected directed into varicosed veins under US guidance
• Inflammatory response closes off the vein
• Only requires local anaesthetic

Question 19

Describe radiofrquency ablation?

Answer 19

• Heating of the vein from the inside under US guidance
• Irreversible damage to the vein which closes it off
• Performed under local or general anaesthetic

Question 20

What is CEAP classification used for?

Answer 20

Assess manifestations of chronic venous disease

Question 21

Describe the C component of CEAP classification?

Answer 21

• C - clinical features
  
  • C0: No signs
  • C1: Telangiectasias, reticular veins
  • C2: Varicose veins
  • C3: Oedema
  • C4: Secondary skin alterations
    
    • C4a: Pigmentation, eczema or both
    • C4b: Lipodermatosclerosis
  • C5: Healed venous ulcer
  • C6: Open venous ulcer
• A: asymptomatic
• B: symptomatic

Question 22

Describe the E component of CEAP classification?

Answer 22

• E - etiological
• Ep: Primary (develops independent of othe diseases)
• Es: Secondary to another disorder
• Ec: congeital (present at birth)
• En: Absence of identifed aetiology

Question 23

Describe the A component of CEAP classification?

Answer 23

• A(s1-s5)
  
  • Superficial venous system
• A(d6-16)
  
  • Deep venous system
• A(p17-p18)
  
  • Perforating veins
• An
  
  • Unidentified anatomical location

Question 24

Describe the P component of CEAP classification?

Answer 24

• P - pathophysiology
  
  • Pr : Reflux
  • Po: Obstruction
  • Pro: Reflux/obstruction
  • Pn: Unidentified venous pathophysiology

Question 25

Describe the difference between a doppler and duplex ultrasound?

Answer 25

• Duplex ultrasound
  
  • Valve competence
  • Meausre blood flow through the veins
• Doppler ultrasound
  
  • Pulses?

Question 26

What is thrombophlebitis?

Answer 26

• Inflammation of the vein
• Usually caused by a blood clot
• Increased risk in someone with varicose veins

Question 27

Describe Postphlebitic syndrome?

Answer 27

• Also known as post-thrombotic syndrome
• Symptomatic chronic venous insuffieicny after DVT

Question 28

Describe the Tourniquet test?

Answer 28

• (if using fingers = Trendelenburg test)
• Position patient flat
• Elevated leg as far as posiible to empty superficial veins
• Place a tourniquet over saphenofemoral junction
• Ask patient to stand and observe for filling of the veins
  
  • If they do not fill -> venous valve incompetence at level of SFJ
  • If they do fill -> repeat 3cm down to find level of incompetence

Question 29

Describe stasis sequelae?

Answer 29

• (stasis dermatitis)
• Inflammation of the skin due to chronic venous insufficiency
• Itching, scaling, hyperpigmentation

Question 30

Describe the process of haemosiderin deposition

Answer 30

• Blood pools in the venous due to poor valvular function
• Haem is broken down and the iron is stored in the tissues
  
  • Haemosiderin is an iron-storage complex