Varicose veins, Lymphoedema Flashcards
Pathophysiology of varicose veins
One-way flow from supficial → deep normally maintained by valves
Valve failure → ↑ pressure in sup veins → varicosity
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
Hunter’s varicose vein
medial thigh perforator
Cockett’s varicose vein
3 medial calf perforators
primary causes of varicose veins
- Congenitally weak or absent valves
- Prolonged standing
- Pregnancy
- Obesity
Secondary causes of varicose veins
DVT
Constipation
Overactive pumps (e.g. cyclists)
Klippel-Trenaunay
Klippel Trenaunay syndrome
Port wine stain
Varicose veins
Limb hypertrophy (bone/soft tissue)
Symptoms of varicose veins
Pain
Tingling
Bleeding
Swelling
Skin changes of varicose veins
Venous stars
Haemosiderin deposition
Lipodermatosclerosis (panniculitis)
Atrophie blanche
Venous stars
From raised intravenous pressure
Cannot be obliterated by pressure
Panniculitis
inflammation of fat
Lipodermatosclerosis
A type panniculitis
Induration (hardening) of the skin of lower legs in venous insufficiency
Atrophie blanche
White scar on lower leg
sign of vascular inflammation
Thrombophlebitis
clot in vein, could be supreficial or deep
Varicose eczema aka
gravitational eczema
Investigations for varicose veins
- Duplex ultrasonography
- Bloods: FBC, U+E, clotting, G+S
- CXR, ECG
When to refer a patient with varicose veins
Bleeding
Pain
Ulceration
Superficial thrombophlebitis
Severe impact on QoL
classification of chronic venous disease
CEAP classification
- Clinical signs (1-6 + sympto or asympto)
- Etiology
- Anatomy
- Pathophysiology
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)
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)
