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Core Conditions - Vascular > Varicose Veins > Flashcards

Varicose Veins Flashcards

1
Q

What are varicose veins?

In brief, what causes them?

A

varicose veins are torturous dilated superficial veins

they are caused by weak vein walls causing dilatation and valve incompetence

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2
Q

What is the epidemiology of varicose veins?

Why do a higher proportion of women present with them?

A
  • very common affecting 40% of men and 32% of women
  • higher proportion of women present possibly due to the cosmetic effect veins have, or because they appear earlier than in males
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3
Q

What are the risk factors for varicose veins?

A
  • increasing age
  • pregnancy
  • increasing numbers of pregnancies
  • family history
  • long periods of standing - e.g. occupation as a teacher, shop assistant, surgeon, etc.
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4
Q

What are the 2 venous systems of the lower limbs and how are they connected?

A

there is a deep and a superficial venous system

deep veins are found underneath the deep fascia of the LL

superficial veins are found in subcutaneous tissue and will eventually drain into deep veins

there are numerous perforating branches that connect the two systems

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5
Q

What are the 2 mechanisms in place to maintain adequate venous return against gravity?

Which is usually compromised in varicose veins?

A

Presence of valves:

  • prevents backflow of blood distally
  • the mechanism implicated in varicose veins

Pressures generated by muscles:

  • the deep venous system is assisted by pressures generated by muscles, mainly the calf muscles
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6
Q

What is the pathophysiology involved in varicose veins?

What causes them?

A
  • weakness in the vein wall causes dilatation of the vein
  • if this occurs around a valve, then the cusps of the valve can no longer meet in the middle
  • the valve becomes incompetent, resulting in backflow of blood and inadequate drainage
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7
Q

What are the most common valves involved in varicose veins?

A

those around the saphenofemoral junction in the groin

they can occur in other places, such as the junction between the short saphenous vein and the popliteal vein

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8
Q

What is the difference between primary and secondary varicose veins?

A

Primary varicose veins:

  • develop from vein wall weakness, dilatation and incompetent valves

Secondary varicose veins:

  • result from pelvic or abdominal masses obstructing blood from returning from the lower limbs
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9
Q

What other conditions are varicose veins sometimes confused with?

A

typical varicose veins are often referred to as truncal veins

reticular veins:

  • tortuous dilated veins that are not part of the long / short saphenous vein system

telangiectasia:

  • thread veins / spider veins which are dilated venules
  • can be associated with varicose veins
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10
Q

What are the “truncal veins”?

A
  • great saphenous vein
  • small saphenous vein (sometimes known as lesser saphenous vein)
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11
Q

Why do varicose veins only really occur in superficial veins and not deep veins?

A
  • deep veins are supported by the surrounding muscles
  • superficial veins have much less muscle support
  • congestion in superficial veins is more likely to result in bulging, dilatation and twisting of the veins
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12
Q

What is the major symptom of varicose veins?

A

most varicose veins are asymptomatic

the main reason they are noticed is due to their appearance on the legs

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13
Q

If varicose veins are symptomatic, what does the patient usually describe?

A

patients tend to describe their symptoms as a sensation / discomfort:

  • heavy legs
  • aching
  • swelling of the legs
  • itching
  • night cramps
  • hot or burning sensations
  • restless leg syndrome
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14
Q

How are the complications of varicose veins divided?

A
  • complications as a direct result of the varicose veins
  • complications that result from venous hypertension
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15
Q

How is the size of the varicose veins related to venous hypertension?

A

venous hypertension is associated with varicose veins

the size of the varicose veins appears to have NO correlation to the degree of venous hypertension

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16
Q

What are the complications resulting directly from the varicose veins themselves?

A
  • bleeding
  • superficial thrombophlebitis
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17
Q

What happens in superficial thrombophlebitits?

A

commonly involves the saphenous veins and is associated with varicosities

there is local superficial inflammation of the vein wall, with secondary thrombosis

a blood clot has formed and is blocking one or more of the superficial veins of the leg

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18
Q

How does superficial thrombophlebitis present?

A

presents with a painful, tender cord-like structure

with associated redness and swelling

19
Q

What are the complications of varicose veins that occur as a result of venous hypertension?

A
  • oedema
  • venous ulceration
  • pigmentation changes
  • varicose eczema
  • lipodermatosclerosis
20
Q

When taking a history and the patient is listing symptoms of varicose veins, what is important to consider?

A

because of the appearance of the veins, patients often attribute all their symptoms to this

it is important to check whether all the symptoms can be attributed to the veins

if not, this may need to be treated separately

21
Q

Why is it important to check for history of DVTs and risk factors for DVTs even though varicose veins do not increase the risk of DVTs?

A
  • ensure to ask about contraceptive pill / hormone replacement therapy
  • if patients have surgery on their legs, they are at increased risk of DVTs post-op
  • they may require prophylactic heparin
22
Q

What are the stages involved in the clinical examination for varicose veins?

What 2 specific tests are performed?

A
  • Introduction
  • Explain procedure & gain consent
  • Wash hands
  • Expose the site of the veins
  • Inspect the area
  • Palpate the area
  • Cough impulse
  • Trendelenburg test
  • Abdominal examination
  • Summarise findings and conclude
23
Q

For the examination of varicose veins, how should the patient be exposed and positioned?

A
  • patient should remove trousers, keep underwear on
  • patient should be STANDING
  • this is because gravity allows the full extent of the veins to be seen
24
Q

What should be noted upon inspection of varicose veins?

Why should both the front and back of the legs be inspected?

A
  • note the full distribution of the veins (including which leg!)
  • presence of any skin changes
    • eczema
    • redness
    • hair loss
    • presence of ulcers
  • check the front & back as the short saphenous vein runs along the posterior aspect of the leg
25
Q

What needs to be checked before palpation of varicose veins?

A

Before starting palpation, ask if the patient is in any pain

26
Q

What should be noted and checked for on palpation of varicose veins?

A
  • if veins are tender, this may indiciate thrombophlebitis
  • if veins are hard, this may indicate thrombosis
  • palpate skin surrounding veins to check for signs of lipodermatosclerosis or atrophie blanche
  • check that the skin is warm to touch
27
Q

What does the cough impulse test for?

How should it be performed?

A

it is a sign for incompetence of the saphenofemoral junction

  • fingers placed over the SF junction (5cm inferomedial to the femoral pulse)
  • patient is asked to cough
  • if the junction is incompetent, a fluid thrill will be felt
28
Q

What does the Trendelenburg test look for?

A

this test is used for assessing the site of incompetence but does not do it very accurately

29
Q

How is the Trendelenburg Test performed and what are you looking for?

A
  • patient lies down with their leg elevated
  • torniquet is tied around the site of the saphenofemoral junction
  • patient stands up
  • you should see a slow reflow of blood into the veins from below the torniquet
  • look at the veins as you release the torniquet

if the SF junction is incompetent, there will be a sudden flow of blood into the veins from ABOVE the torniquet site

  • if this is not the case, then repeat, gradually working the torniquet site further distally until the site of incompetence is found
30
Q

Why is an abdominal examination performed when assessing varicose veins?

A

to locate any abdominal or pelvic masses that could cause secondary varicose veins

31
Q

What is the investigation of choice for varicose veins?

What does this show?

A

Colour Doppler venous scan

this will show the site and the degree of valve incompetence and can assess the deep venous system

32
Q

When may an arteriogram be needed in investigation of varicose veins?

A

if there are concurrent arterial problems and surgery is being considered

the arteriogram may be required to prevent the formation of ulcers after surgery

33
Q

How are the majority of varicose veins treated?

A

treatment is often not needed so the patient is reassured and other causes of their symptoms are treated

surgical treatment for cosmetic purposes is not available on the NHS unless there is a severe impact on the quality of life or psyche of the patient

34
Q

When might compression stockings be used to treat varicose veins?

A
  • if patient’s main symptoms are oedema or aching to relieve these symptoms
  • can be used as an assessment to the effectiveness that surgery may have
35
Q

What are the different types of surgery available for varicose veins?

A
  • traditional surgery
  • endovenous laser therapy (EVLT) and radiofrequency ablation (RFA)
  • injection sclerotherapy / foam sclerotherapy
36
Q

What happens during traditional surgery to treat varicose veins?

A
  • under general anaesthetic, incisions are performed at two sites (knee and groin)
  • the saphenofemoral junction is ligated and the vein is stripped (pulled out), with smaller veins on the calf pulled out using multiple small stab avulsions

this removes a large part of the superficial venous drainage of the leg, but the deep veins can compensate

37
Q

What are the possible complications and recurrence rate of traditional surgery for varicose veins?

A
  • often bruising after surgery
  • 17% of patients suffer from minor complications, such as neuralgia due to damage to surrounding structures
  • major complications are rare
  • recurrence rate is 20-30% after 10 years
38
Q

What are the benefits of newer techniques (EVLT & RFA) to treat varicose veins?

A
  • can be performed under local anaesthetic
  • minimally invasive
  • quicker recovery times

(however, long-term effectiveness remains to be seen)

39
Q

What is involved in endovenous laser therapy (EVLT) / radiofrequency ablation (RFA) to treat varicose veins?

A
  • small incision to the vein is made distally, and a catheter is inserted
  • a laser or high frequency alternating current is passed into the vein as the catheter is slowly withdrawn
  • this will heat up the blood and ablate the targeted vein
  • avulsions of smaller veins in the calf can accompany this procedure
40
Q

What is involved in sclerotherapy in general?

A
  • a sclerosant is an irritating solution that is injected directly into a vein
  • the sclerosant irritates the vein and causes it to swell
  • swelling cuts off the flow of blood and causes the vein to shrink
41
Q

Why is injection sclerotherapy hardly used anymore?

What was involved in the procedure?

A
  • a sclerosant is injected into the targeted vein, which causes it to shrink
  • this is accompanied by at least 2 weeks of compression stockings
  • it is no longer used due to high relapse rates
42
Q

What is involved in foam sclerotherapy?

A
  • the sclerosant is mixed with other substances, including air
  • the foam is injected into the vein, which spreads fast and causes the vein to spasm
43
Q

What are the problems / complications associated with both injection and foam sclerotherapy?

A
  • if the sclerosant is injected outside of the vein, it can cause necrosis and scarring
  • there is a small risk of DVTs if the sclerosant/foam enters a deep vein via perforating branches
44
Q

What may cause a relapse of varicose veins following any type of surgery?

A

after all types of surgery there is a relapse rate which could be due to:

  • neovascularisation (formation of new vessels) and their dilatation
  • or other veins that were previously unaffected becoming dilated

Core Conditions - Vascular (7 decks)

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