Varicose veins and venous ulcers Flashcards

1
Q

Differentiate the great and lesser saphenous veins

A
  • 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
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2
Q

Define varicose veins

A

Tortuous, dilated, superficial leg veins, associated with valvular incompetence

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3
Q

Describe the classification of varicose veins

A
  • Thread: intradermal dilated veins (pink/purple)
  • Reticular: subdermal 1-2mm diameter (blue)
  • Truncal: long or short saphenous
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4
Q

Why is it important to classify varicose veins?

A

Reticular and thread varicose veins are not associated with lower limb symptoms ➔ no pathological significance.

Truncal varicose veins are associated with lower limb symptoms

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5
Q

How must varicose veins be assessed and why?

A

Patient must be standing, otherwise trunkal varicose veins will not be visible.

This is due to gravity’s effect on venous blood.

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6
Q

How can the aetiology of varicose veins be grouped?

A
  • Congenital
  • Primary idiopathic (98%)
  • Acquired
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7
Q

Name a congenital cause of varicose veins

A

Klippel-Trenaunay syndrome: failure to form blood and/or lymph vessels

Characterised be port-wine stain, venous/lymphatic malformation, soft tissue hypertrophy

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8
Q

Name two acquired causes of varicose veins

A
  • Pelvic mass:
    • Pregnancy
    • Tumour
    • Uterine fibroids
    • Ovarian mass
  • Pelvic venous abnormality:
    • AV fistula
    • DVT
    • Post-pelvic surgery
    • Irradiation
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9
Q

Name three risk factors for varicose veins

A
  • Increasing age
  • FHx
  • Female
  • Pregnancy
  • Obesity
  • Prolonged standing or sitting
  • PMH of DVT
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10
Q

Name four symptoms in varicose veins

A

Majority are asymptomatic

Symptoms are associated with trunk varices:

  • Pain
  • Aching
  • Itching
  • Swelling
  • Heaviness
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11
Q

When are symptomatic varicose veins worse?

A
  • End of day
  • Hot weather
  • Premenstruation
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12
Q

Name three complications of varicose veins

A
  • Bleeding
  • Thrombophlebitis
  • Venous HTN:
    • Oedema
    • Atrophy blanche; haemosiderin
    • Venous eczema
    • Lipodermatosclerosis
    • Ulceration (commonly at gaiter region)
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13
Q

Conduct one examination for varicose veins

Request two investigations

A
  • 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
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14
Q

Describe Trendelenburg (tourniquet) test for varicose veins

A
  • 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
  • Repeat above (mid-thigh) and below knee (SPJ)
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15
Q

Outline primary care treatment options of varicose veins

A
  • 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
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16
Q

How does superficial thrombophlebitis present?

A
  • Tender, inflamed varicose vein
  • Overlying redness and heat
  • Feels firm due to venous thrombosis

Tx:

  • Elevation; warm compress; encourage activity
  • Consider compression stocking; NSAIDS
17
Q

Outline the NICE criteria for varicose vein referral to secondary care vascular services

A
  • 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
18
Q

Outline secondary care treatment options of varicose veins

A
  • Surgical removal or ligation
  • Foam sclerotherapy
  • Endothermal ablation
19
Q

Define leg ulcer

A
  • Break in the skin below the knee
  • Has not healed within 2 weeks
20
Q

Name four vascular causes of leg ulcers

A
  • Venous (85%):
    • Venous HTN
    • Varicose veins
  • Arterial:
    • Atherosclerosis
    • AV malformation
    • Vasculitis: SLE, RA, scleroderma, PAN, GPA
  • Lymphatic
21
Q

Name a neuropathic cause of leg ulcers

A
  • Diabetic neuropathy
  • Peripheral neuropathy
22
Q

Name a haematological cause of leg ulcers

A
  • Polycythaemia rubra vera
  • Sickle cell anaemia
23
Q

Name two traumatic causes of leg ulcers

A
  • Burns
  • Cold injury
  • Pressure sore
  • Radiation
24
Q

Describe the distribution of venous leg ulcers

A
  • Calf
  • Gaiter
    • Calf muscle pump failure ➔ venous ulcer
  • Foot
25
Q

Outline the management of venous ulcers

A
  • Exclude arterial insufficiency and other causes
  • Venous duplex colour scan
  • Compression bandages
    • ABPI >0.8 ➔ 4-layer bandaging
    • ABPI >0.5 ➔ 3-layer bandaging
26
Q

Describe preventative measures of venous ulcer recurrence

A
  • Keep mobile
  • Varicose vein surgery
    • remove, ligate, or fuse
  • Below-knee class 2 (anti-emboli) compression stocking