Varicose veins, Lymphoedema Flashcards by K D

Pathophysiology of varicose veins

One-way flow from supficial → deep normally maintained by valves

Valve failure → ↑ pressure in sup veins → varicosity

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3 main sites for varicose veins

Saphenofemoral Junction: 3cm below and 3cm lateral to pubic tubercle
Saphenopopliteal Junction: popliteal fossa
Perforators: draining Great saphenous vein

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Hunter’s varicose vein

medial thigh perforator

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Cockett’s varicose vein

3 medial calf perforators

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primary causes of varicose veins

Congenitally weak or absent valves
Prolonged standing
Pregnancy
Obesity

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Secondary causes of varicose veins

DVT

Constipation

Overactive pumps (e.g. cyclists)

Klippel-Trenaunay

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Klippel Trenaunay syndrome

Port wine stain

Varicose veins

Limb hypertrophy (bone/soft tissue)

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Symptoms of varicose veins

Pain

Tingling

Bleeding

Swelling

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Skin changes of varicose veins

Venous stars

Haemosiderin deposition

Lipodermatosclerosis (panniculitis)

Atrophie blanche

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Venous stars

From raised intravenous pressure

Cannot be obliterated by pressure

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Panniculitis

inflammation of fat

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Lipodermatosclerosis

A type panniculitis

Induration (hardening) of the skin of lower legs in venous insufficiency

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Atrophie blanche

White scar on lower leg

sign of vascular inflammation

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Thrombophlebitis

clot in vein, could be supreficial or deep

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Varicose eczema aka

gravitational eczema

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Investigations for varicose veins

Duplex ultrasonography
Bloods: FBC, U+E, clotting, G+S
CXR, ECG

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When to refer a patient with varicose veins

Bleeding

Pain

Ulceration

Superficial thrombophlebitis

Severe impact on QoL

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classification of chronic venous disease

CEAP classification

Clinical signs (1-6 + sympto or asympto)
Etiology
Anatomy
Pathophysiology

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Conservative management of varicose veins

Lose weight

Relieve constipation

Education (Avoid prolonged standing, Regular walks)

Class II Graduated Compression (Stockings 18-24mmHg, symptomatic relief and slows progression)

Skin Care (Maintain hydration with emollients, Treat ulcers rapidly)

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indications for minimally invasive therapies for varicose veins

small below knee varicosities not involving great saphenous vein or short saphenous vein

Endovascular techniques for varicose veins

Injection sclerotherapy: 1% Na tetradecyl sulphate
Endovenous laser or radiofrequency ablation

VNUS

Radiofrequency ablation

Catheter inserted and heated to 120 C

Closes the vein

EVLA

Endovenous laser ablation

Injection sclerotherapy

Sclerosant foam or liquid

Liquid for small veins below knee

Post-operative care following endovascular therapy for varicose veins

- Compression bandage for 24hrs - Compression stockings for 1mo

Indications for surgical management of varicose veins

- Saphenofemoral Junction incompetence - Major perforator incompetence - Symptomatic: ulceration, skin changes, pain

Surgical procedures for varicose veins

Ligation (eg Trendelenberg) Microphlebectomy Subfascial endoscopic perforator surgery (SEPS)

Trendelenberg surgery

Saphenofemoral ligation

Microphlebectomy

Multiple avulsions (cuts) to skin to remove the vein, sutures may not be required

Post-op care following surgery for varicose veins

Bandage tightly Elevate for 24h Discharged with compression stockings and to walk daily.

Complications of varicose vein surgery

Damage to cutaneous nerve (e.g. long saphenous) Recurrence: may approach 50%

Bilateral causes of leg swellings

↑ Venous Pressure ↓ Oncotic Pressure Lymphoedema Myxoedema (Hyper- / hypo-thyroidism)

Causes of reduced oncotic pressure

Nephrotic syndrome Hepatic failure

Drug causing raised venous pressure

nifedipine

unilateral causes of leg swellings

Raised venous pressure (Venous insufficiency, DVT) Infection or inflammation Lymphoedema

What is lymphoedema?

Collection of interstitial fluid due to blockage or absence of lymphatics

Primary causes of lymphoedema

Congenital absence Praecox Tarda

Lymphoedema praecox

After birth but \<35yrs F\>M 80% of primary lymphoedema

Lymphoedema tarda

\>35yrs 10 % of cases

Milroy's syndrome genetics

Autosomal dominant F\>M

Milroy's syndrome sx

Bilateral swelling/lymphoedema of lower extremities +/- hydrocele

Secondary causes of lymphoedema

FIIT - Fibrosis: e.g. post-radiotherapy - Infiltration - Infection: TB, Filariasis - Trauma: block dissection of lymphatics

Infiltration causes of lymphoedema

Cancer of prostate, lymphoma

Filariasis

Parasitic disease caused by round worms Main worm: Wuchereria bancrofti

Investigations for lymphoedema

Doppler US Lymphoscintigraphy CT / MRI

Lymphoscintigraphy

Radioactive radiotracer injected into skin Travels up the lymphatics Device on the outside identifies the sentinele node

Conservative management of lymphoedema

Skin care Compression stocking Physio Treat or prevent comorbid infections

Surgical mx of lymphoedema

Debulking operation: - liposuction to reduce the volume of the limb (fat hypertrophy secondary to lymphoedema) - radical debulking (removing all the skin and fat and do skin graft)