Varicose veins and venous ulcers Flashcards
Differentiate the great and lesser saphenous veins
- Great saphenous vein: Dorsum of foot (medial) ➔ anterior to medial malleolus ➔ medial leg and thigh ➔ saphenous opening of deep fascia of thigh ➔ saphenofemoral junction ➔ femoral vein
- Lesser saphenous vein: Dorsum of foot (lateral) ➔ posterior to lateral malleolus ➔ deep fascia of leg ➔ saphenopopliteal junction ➔ popliteal vein
Define varicose veins
Tortuous, dilated, superficial leg veins, associated with valvular incompetence
Describe the classification of varicose veins
- Thread: intradermal dilated veins (pink/purple)
- Reticular: subdermal 1-2mm diameter (blue)
- Truncal: long or short saphenous
Why is it important to classify varicose veins?
Reticular and thread varicose veins are not associated with lower limb symptoms ➔ no pathological significance.
Truncal varicose veins are associated with lower limb symptoms
How must varicose veins be assessed and why?
Patient must be standing, otherwise trunkal varicose veins will not be visible.
This is due to gravity’s effect on venous blood.
How can the aetiology of varicose veins be grouped?
- Congenital
- Primary idiopathic (98%)
- Acquired
Name a congenital cause of varicose veins
Klippel-Trenaunay syndrome: failure to form blood and/or lymph vessels
Characterised be port-wine stain, venous/lymphatic malformation, soft tissue hypertrophy
Name two acquired causes of varicose veins
- Pelvic mass:
- Pregnancy
- Tumour
- Uterine fibroids
- Ovarian mass
- Pelvic venous abnormality:
- AV fistula
- DVT
- Post-pelvic surgery
- Irradiation
Name three risk factors for varicose veins
- Increasing age
- FHx
- Female
- Pregnancy
- Obesity
- Prolonged standing or sitting
- PMH of DVT
Name four symptoms in varicose veins
Majority are asymptomatic
Symptoms are associated with trunk varices:
- Pain
- Aching
- Itching
- Swelling
- Heaviness
When are symptomatic varicose veins worse?
- End of day
- Hot weather
- Premenstruation
Name three complications of varicose veins
- Bleeding
- Thrombophlebitis
- Venous HTN:
- Oedema
- Atrophy blanche; haemosiderin
- Venous eczema
- Lipodermatosclerosis
- Ulceration (commonly at gaiter region)
Conduct one examination for varicose veins
Request two investigations
- Examinations:
- Trendelenburg (tourniquet) test
- Tap test
- Investigations:
- Handheld doppler
- Most accurate outpatient tool for Dx of primary varicose veins
- Colour duplex
- Gold standard for defining anatomy and incompetence
- Handheld doppler
Describe Trendelenburg (tourniquet) test for varicose veins
- Whilst supine, raise leg to empty veins
- Apply tourniquet high in the thigh (SFJ)
- Ask patient to stand
- Look for varicose filling
- No filling: release tourniquet, reassess
- filling after release suggests SFJ incompetence
- Filling: suggests incompetent perforators below level of SFJ
- No filling: release tourniquet, reassess
- Repeat above (mid-thigh) and below knee (SPJ)
Outline primary care treatment options of varicose veins
- Reassurance: majority unlikely to cause complications
- Common in pregnancy; tend to improve afterwards
- Lifestyle advice:
- Weight loss and exercise
- Avoid prolonged sitting/standing
- Elevate legs when possible.
- Compression stockings
- Referral to Vascular services - requires criteria to be met
How does superficial thrombophlebitis present?
- Tender, inflamed varicose vein
- Overlying redness and heat
- Feels firm due to venous thrombosis
Tx:
- Elevation; warm compress; encourage activity
- Consider compression stocking; NSAIDS
Outline the NICE criteria for varicose vein referral to secondary care vascular services
- Symptomatic primary/recurrent varicose veins
- Lower limb skin changes
- Potential chronic venous insufficiency
- Superficial vein thrombosis
- Suspected venous incompetence
- Venous leg ulcer ➔ 2 week referral
- Healed venous leg ulcer
Outline secondary care treatment options of varicose veins
- Surgical removal or ligation
- Foam sclerotherapy
- Endothermal ablation
Define leg ulcer
- Break in the skin below the knee
- Has not healed within 2 weeks
Name four vascular causes of leg ulcers
- Venous (85%):
- Venous HTN
- Varicose veins
- Arterial:
- Atherosclerosis
- AV malformation
- Vasculitis: SLE, RA, scleroderma, PAN, GPA
- Lymphatic
Name a neuropathic cause of leg ulcers
- Diabetic neuropathy
- Peripheral neuropathy
Name a haematological cause of leg ulcers
- Polycythaemia rubra vera
- Sickle cell anaemia
Name two traumatic causes of leg ulcers
- Burns
- Cold injury
- Pressure sore
- Radiation
Describe the distribution of venous leg ulcers
- Calf
-
Gaiter
- Calf muscle pump failure ➔ venous ulcer
- Foot
Outline the management of venous ulcers
- Exclude arterial insufficiency and other causes
- Venous duplex colour scan
-
Compression bandages
- ABPI >0.8 ➔ 4-layer bandaging
- ABPI >0.5 ➔ 3-layer bandaging
Describe preventative measures of venous ulcer recurrence
- Keep mobile
- Varicose vein surgery
- remove, ligate, or fuse
- Below-knee class 2 (anti-emboli) compression stocking
