Varicose veins and ulcers

Question 1

What are varicose veins

Answer 1

Tortuous dilated segments of veins due to valvular incompetence
Incompetent vales allow blood to flow back in to the superficial system from the deep venous system - at the sapheno-femoral and sapheno-popliteal junctions.
Results in dilation of the superficial veins and venous hypertension

Question 2

What are the risk factors for varicose veins

Answer 2

Prolonged standing
Obesity
Pregnancy
Family history

Question 3

What are some secondary causes of varicose veins

Answer 3

DVT
Pregnancy
Pelvic masses - uterine fibroids and ovarian masses
Arteriovenous malformations

Question 4

What are the clinical features of varicose veins

Answer 4

Cosmetic issue - visible veins and discolouration of the skin
May cause
- pain
- Aching
- Swelling - often worse on standing and at the end of the day
- itching

They are present in the course of the great and short saphenous veins

Question 5

What is the course of the great saphenous vein

Answer 5

It is formed by the dorsal venous arch of the foot and ascends up the medial side of the leg, passing anteriorly to the medial malleolus and posteriorly to the medial condyle of the femur
It drains into the femoral vain just inferior of the inguinal ligament

Question 6

What is the course of the short saphenous vein

Answer 6

It is formed by the dorsal venous arch of the foot then ascends posteriorly to the lateral malleolus. It ascends on the posterior side of the leg between the two heads of the gastrocnemius muscle and empties into the popliteal vein in the popliteal fossa.

Question 7

What are the complications of varicose veins

Answer 7

Bleeding
Ulceration
Thrombophlebitis
Skin changes

Question 8

Where are venous ulcers commonly found on the leg

Answer 8

Over the medial malleolus in the gaitor area

Question 9

What are the clinical features of venous insufficiency

Answer 9

Oedema - due to blood pooling in the legs and fluid moves out into the interstitium
Ulcers - over medial malleolus
Lipodermatosclerosis - tapering of the legs above the ankles, fat necrosis causing inverted champagne bottle appearance
Atrophie blanche - abnormality of scar formation. White tissue formed with small red dots of dilated capillaries
haemosiderin skin staining - due to deposition of haemosiderin from RBC which have become damaged

Question 10

What is a saphena varix

Answer 10

dilatation of the saphenous vein at the saphenofemoral junction
It has a cough impulse so can be mistaken for a femoral hernia

Question 11

How can you differentiate between a femoral hernia and a saphena varix

Answer 11

Duplex ultrasound

Question 12

How are saphena varix’s managed

Answer 12

High saphenous ligation

Question 13

How are varicose veins classifed

Answer 13

CEAP classification

Question 14

What are the main differentials for varicose veins

Answer 14

DVT
Ischaemic ulcers
cellulitis

Question 15

How are varicose veins investigated

Answer 15

Gold standard: Duplex ultrasound - to assess valve competence of both the great and short saphenous veins and any perforators
Deep vein incompetence, DVT and stenosis must also be looked for.

Question 16

How are varicose veins managed?

Answer 16

Non-invasive

1. Patient education - weight loss, decrease standing, increase exercise
2. compression stockings - augments muscle pump, if interventional treatment not appropriate
3. 4 layer bandaging for venous ulcers - graduated compression aimed at augmenting muscle pump

Surgical treatment
NICE Criteria for referral
1. Symptomatic
2. Lower limb skin changes - haemosiderin staining/eczema
3. Superficial vein thrombosis - hard painful veins
4. Venous leg ulcer - break in the skin below the knee that has no healed in 2 weeks

• vein ligation, stripping and avulsion - make an incision identify responsible veins, tie them off and strip it away
• foam scleropathy - inject sclerosing agent into varicose vein and inflammatory reaction causes vein to close - done under ultrasound
• Thermal ablation - done by heating the vein from the inside causing irreversible damage to the vein to close it off

Question 17

How can you examine varicose veins

Answer 17

Intro, consent, ask about pain
expose patients legs
Position: Standing
General inspection:
- front and behind
- ask patient to turn out their legs so you can see medial aspect (where venous ulcers are and the route of great saphenous)
- look for signs of varicose veins - oedema, lipodermatosclerosis, eczema, pigmentation and ulceration
Palpation (check with patient first where pain is)
- feel the veins (may not be visible)
- feel for cough impulse at the sapheno-femoral junction
Percussion
- genetly feel over the saphenous opening whilst tapping the varicosities distally
- if you can feel the impulse transmitted it implies incompetent valves = Chevriers tap sign

Trendelenbergs test

Question 18

What is trendelbergs test (varicose veins)

Answer 18

patient lies supine, lift leg and milk it proximally to empty it of venous blood
Occlude the SFJ
Keeping pressure on the SFJ ask the patient to stand up
If there is no venous filling saphenofemoral junction incompetence is demonstrated
If there is filling of the veins then the incompetence must be lower down the leg
test can be repeated at lower levels with a tourniquet to demonstrate level of incompetence

Question 19

How can you identify where the Sapheno-femoral junction is

Answer 19

Feel for the femoral pulse then go medially and 2 finger breadths below the inguinal ligament

Question 20

What are the post op complications

Answer 20

General - bleeding, infection, anaesthetic complications
Specific
DVT - with endovenous procedures (ablation)
damage to sural and saphenous nerves - causes neuritis
Thrombophlebitis - important in ablation or scleropathy
Disease recurrence

Question 21

Where are venous ulcers most likely to be found

Answer 21

Over the medial malleolus and the medial side of the calf

Question 22

Where are neuropathic ulcers most likely to be found

Answer 22

Over the heel
heads of the first and fifth metatarsal
Found in pressure areas of the foot

Question 23

What most be tested before 4 layer bandaging is used for ulcer management

Answer 23

ABPI

can only bandage if ABPI is >0.7

Question 24

Where are arterial ulcers commonly found

Answer 24

Lateral malleolus
Lateral foot
Between toes
Tips of toes

Question 25

What are the clinical features of venous ulcers

Answer 25

Shallow
Granulation tissue at base
Features of venous insufficiency

Question 26

What are the clinical features of arterial ulcers

Answer 26

Painful 
small deep lesions 
Well defined margins
Necrotic base 
Associated with signs of ischaemia of the limb
Secondary to arterial insufficiency 
often develops over a long time
little to no healing - no granulation tissue 
Associated signs 
- cold limb 
- absent pulses
- necrotic toes 
- hair loss

Question 27

What are the clinical features of neuropathic ulcers

Answer 27

typical hx of peripheral neuropathy
painless ulcers on pressure points on the foot
punched out lesions
May have burning/tingling in legs due to painful neuropathy
may have neuropathy in the glove and stocking distribution with warm feet and good pulses

Question 28

What is the pathophysiology of venous ulcers

Answer 28

Retrograde flow in the venous system in the superficial venous system causes venous dilation
Leading to pooling of the blood distally
Fibroblasts migrate to the area
Impedes oxygen flow to the skin
Less oxygen gets to the skin so poor healing
typically over the path of the short an great saphenous veins

Question 29

What are the risk factors for venous ulcers

Answer 29

DVT 
Pre-existing venous incompetence 
Trauma 
pregnancy 
Obesity

Question 30

What are the risk factors for arterial ulcers

Answer 30

Peripheral arterial disease 
Hypertension 
Hyperlipidaemia 
increase age
Family history 
Obesity 
Physical inactivity

Question 31

How should arterial ulcers be investigated

Answer 31

Ankle brachial pressure index
to measure further extent of peripheral vascular disease
Location of arterial disease can be located using imaging - ultrasound, CT angiography

Question 32

How are arterial ulcers managed

Answer 32

Conservative management

• Lifestyle change = alcohol cut down, smoking cessation, improved diet, more exercise
• Best medical therapy = reduce cardiovascular risk - statins, antiplatelet therapy, optimisation of BP and glucose control

Surgical Management
- Angioplasty with or without stenting
- Bypass graft
Any non healing ulcers with good blood supply may be offered skin reconstruction with grafts

Question 33

How are venous ulcers managed?

Answer 33

Conservative management

• exercise - increase calf movement –> muscle pump
• elevate leg
• emollients for dry skin present
• 4 layer compression bandage - ABPI must be higher than 0.7 (changed twice a week)

if concurrent varicose veins then treat with radiofrequency ablation - improving venous system return will improve healing of ulcers

Question 34

In which conditions do neuropathic ulcers commonly occur in

Answer 34

B12 deficiency - peripheral neuropathy
Diabetes mellitus - diabetic neuropathy

Further compounded by

• foot deformity
• peripheral vascular disease

Question 35

Which investigations should be done in patients with neuropathic ulcers

Answer 35

Blood glucose
Serum b12 levels
ABPI and duplex to assess for concurrent Peripheral arterial disease
Microbiology swab
Any evidence of deep infection (visible bone, ulcers extending to the joints)
X-ray - check for osteomyelitis

Question 36

How are neuropathic ulcers managed

Answer 36

Refer to diabetic foot clinic for MDT approach
Diabetic control optimised - targeting HbA1c <7%
Improved diet and exercise
Cardiovascular disease managed
Regular chiropody to maintain good foot hygiene and appropriate footwear provided e.g. non weight bearing shoes
Signs of infection - antibiotic treatment - flucloxacllin
Ischaemic and necroitc tissue need surgical debridement
In severe cases - amputation

Question 37

What is Charcots foot

Answer 37

Neuroarthropathy whereby loss of the joint sensation results in repeated trauma and deformity occurs.
The deformity then predisposes to neuropathic ulcer formation