Varicose veins, venous leg ulcers & superficial vein thrombosis

Question 1

Risk factors for varicose veins

Answer 1

Increasing age, FH, female, pregnancy, obesity, prolonged standing or sitting, DVT

Question 2

Define varicose veins, reticular veins and telangiectasis (spider/thread veins)

Answer 2

Varicose veins: > 3mm diameter in upright position

Reticular veins: 1-3mm diameter, usually asymptomatic.

Telagiectasias: < 1mm diameter

Question 3

What skin changes might you see with varicose veins?

Answer 3

1) Hyperpigmentation (brown-red) due to haemosiderin deposition

2) Venous eczema: itchy, red, scaly skin

3) Lipodematosclerosis: painful, hardened, tight skin

4) Atophie blanche: star-shaped white, depressed atrophic scars, surrounded by red spots

5) venous leg ulcers: gaiter area (ankle - mid-calf)

6) Superficial vein thrombosis: hard, painful veins

Question 4

Self-care advice for varicose veins

Answer 4

1) Lose weight if overweight

2) Light-moderate physical activity

3) Avoid sitting/standing for prolonged periods

4) Elevate legs

Question 5

When to refer to vascular for consideration of interventional treatments

Answer 5

1) Primary or recurrent varicose veins associated with lower limb symptoms - pain, swelling, heaviness, itching

2) Lower-lib skin changes - pigmentation, eczema etc.

3) Superficial vein thrombosis

4) Active venous leg ulcer that has not healed within 2 weeks

5) A healed venous leg. ulcer.

Question 6

Management of varicose veins if referral not indicated

Answer 6

Compression stockings - grade 2 if tolerated

Question 7

Advice for pregnant women with varicose veins

Answer 7

1) They are common and often improve after pregnancy

2) Compression stockings can improve symptoms but do not precent varicose veins emerging

Question 8

ABPI and compression stockings

Answer 8

< 0.5 - contraindicated
0.5-0.8 - should avoid, but reduced compression can be used under specialise advice.
0.8-1.3 - safe to use.
> 1.3 - vessels are incompressible therefore cannot rely on result - needs specialist vascular assessment

Question 9

Interventions for varicose veins

Answer 9

Vascular will first assess with duplex USS to confirm diagnosis.

1) Endothermal ablation

2) Foam sclerotherapy

3) Ligation and stripping

Question 10

Acute vs chronic lipodermatosclerosis

Answer 10

Acute (sclerosing panniculitis) - painful inflammation above the ankles.

Chronic - painful, hardened, tight, red or brown skin. If circumferential can lead to inverted bottle appearance.

Question 11

Treating venous eczema and lipdermatosclerosis

Answer 11

1) Emollient >= 2x/day
2) Topical steroid - in flares of LDS use very potent cream

Question 12

Define leg ulcer

Answer 12

A break in the skin below the knee that has not healed within 2 weeks

Question 13

What is the most common leg ulcer and where is it normally found?

Answer 13

60-80% are venous ulcers, typically occurring in the gaiter area of the leg

Question 14

Symptoms of venous insufficiency

Answer 14

Pain, heaviness & itching of leg, worse at the end of the day and relieved by elevation

Question 15

Drugs that can cause leg ulcers

Answer 15

Delay wound healing: hydroxycarbamide, immunosuppressants, antipsychotics, BB, nicrorandil, steroids, NSAIDs, anticoagulants, radiotherapy

Cause ulceration: nicrorandil, hydroxycarbamide, radiotherapy

Increase oedema: CCB, NSAIDs

Question 16

Venous ulcer examination

Answer 16

1) Gaiter area: ankle –> mid calf
2) Gently sloping irregular edge
3) If healing, will have granulation tissue
4) Slough - dead tissue, cream or yellow
5) Signs of venous insufficiency: hyperpigmentation, venous eczema, lipodermatosclerosis, atrophie blanche
6) Look for varicose veins - lying & standing
7) Ankle mobility - affects calf muscle pump function
8) Signs of co-exisiting PAD: hair loss, coldness on palpation, dusky appearance on lowering leg, CRT > 4s, peripheral pulses, abdominal aneurysm

Question 17

Venous ulcer investigations

Answer 17

1) ABPI of both legs to exclude PAD
2) FBC, U&E, LFT, HbA1c - anaemia, dehydration (raised urea) & low albumin (malnutrition), DM can delay healing
3) Swabs if infected

Question 18

Examination of arterial ulcer

Answer 18

1) Well demarcated, punched out appearance
2) PAD: pallor, loss of hair, nail dystrophy, coldness and CRT > 4s

Question 19

RhA leg ulcer

Answer 19

Can be venous, arterial or vasculitic

Vasculitic: calf or dorsum of foot, deep, well demarcated with punched out appearance

Syemtic vasculitis: nail fold infarcts, splinter haemorrhages , multiple deep, necrotic ulcers

Question 20

DM leg ulcer

Answer 20

Can be venous, arterial or neuropathic

Neuropathic: under calluses/pressure points. Clean edge and base, deep, can expose bone/tendon

Question 21

Difference between ulcer associated with BCC and SCC

Answer 21

BCC: rolled edge

SCC: everted edge

If ulcer is unusual or does not respond to treatment refer

Question 22

Management of venous leg ulcer

Answer 22

1) Clean and dress ulcer - TVN/DN:
- wash leg in tap water & dry
- debride slough or necrotic tissue
- use non-adherent dressings
- do not use antibacterial dressings (silver, iodine, honey) routinely or topical antimicrobials or antiseptics

2) Immediate compression therapy
- SIGN - high compression multilayer compression bandaging
- strongest compression they can tolerate (grade 1-3)
- assess within 24-48h for skin complications from compression
- replace every 3-6 months
- seek urgent advice if symptoms of PAD -numbness/tingling/pain/dusky toes

3) Pentoxifylline (off-label) 400mg TDS for 3 months
- as adjunct to compression or in absence of compression
- increases microcirculatory blood flow - improve healing

4) After healing offer below-knee graduated compression stockings to prevent recurrence

Question 23

When to refer a venous leg ulcer after initial assessment

Answer 23

1) Diagnostic uncertainty
2) Ulcer is rapidly deteriorating or atypical location (outside gaiter area) or appearance
3) Mixed venous/arterial disease - ABPI < 0.8 (if < 0.5 - urgent referral) or > 1.3.
4) DM - refer to DM ulcer clinic
5) RhA/systemic vasculitis - refer to rheumatology
6) Poor ankle mobility/history of falls

Question 24

When to refer venous leg ulcer after compression therapy initiated

Answer 24

1) Suspected contact dermatitis - to term for patch testing
2) Osteomyelitis - pain ++, fever, malodour, non-healing sinus, oedema around wound - admission for IV Abx
3) Necrotising fasciitis - pain ++, tenderness, dusky-violaceous areas with erythema, crepitus, blisters, necrosis - admission for IV Abx
4) Delayed or no healing after 2 weeks compression - to vascular or dermatologist
5) Recurrent ulcer - to vascular for consideration of superficial venous surgery

Question 25

Managing infected venous leg ulcer

Answer 25

1) Swab

2) Antibiotics: flucloxacillin 500mg QDS for 7 days
- pen allergy: clarithromycin, doxycyline, erythromycin
- seek advice if not improving in 2-3 days/worsening
- if no improvement/worsening check swab result and consider co-amoxiclav or co-trimoxazole if pen allergic.
- if sensitive to first Abx but slow improvement extend course for further 7 days

3) Long term topical antiseptics/antimicrobials is not recommended

Question 26

Managing oedema in patient with venous leg ulcer

Answer 26

1) Elevate leg above hip level for 30 minutes 3-4x/day

2) Pillows under feet whilst asleep

3) iatrogenic: CCB, steroids

4) Comorbidities: HF, CKD

5) Do NOT prescribe diuretic for persistent or worsening oedema

Question 27

Managing eczema in patient with venous leg ulcer

Answer 27

If no signs of infection - emollient, topical steroid , replace bandaging more frequently so topical treatments can be applied

If no improvement - refer to dermatology ?allergic contact dermatitis & patch testing

Question 28

Pentoxifylline: indication, CI, caution, SE

Answer 28

Indication: off-label to promote healing of venous leg ulcer +/- compression bandaging

CI: recent cerebral haemorrhage/retinal haemorrhage, acute MI, severe cardiac arrhythmia, acute porphyria

Caution: DM (hypo), CAD, low BP

SE: arrhythmia, tachycardia, angina, low PLT, aseptic meningitis, haemorrhage

Question 29

Most commonly affected vein in superficial vein thrombosis / thrombophlebitis

Answer 29

60-80% affects saphenous vein and its tributaries of the lower limbs

Question 30

Trousseau syndrome & Mondor’s disease

Answer 30

Recurrent and migratory thrombophlebitis, frequently at unusual sites eg. arm or chest

Mondor’s disease: thrombophlebitis of chest wall veins

Associated with gliomas and adenocarcinomas of GI tract (stomach, pancreas, colon), lungs, breasts, ovaries and prostate

Also associated with Behcet’s (53% within 5y) and Buerger’s disease

Question 31

Virhow’s triad

Answer 31

Increased risk of thrombus formation:

1) Vessel wall damage

2) Venous stasis

3) Hypercoaguability of the blood

Question 32

Most common risk factor for superficial vein thrombosis of lower legs

Answer 32

Varicose veins: stasis, 80% with SVT have varicose veins

Question 33

What features of superficial vein thrombosis or patient factors increase risk of DVT?

Answer 33

1) Superficial thrombus extends near where the affected superficial vein joins the deep veins eg. where long saphenous vein joins femoral vein at groin - SVT of LSV within 3cm of saphenofemoral junction is considered equivalent to a DVT

2) Superficial thrombus is > 5cm in length

3) Reduced mobility

4) Not associated with varicose veins

5) History of PE/DVT.

6) Active cancer

Question 34

Complications from superficial venous thrombosis

Answer 34

1) DVT

2) Infection, especially if result of cannulation

3) Hyoerpigmentation +/- firm subcutaneous nodule

4) Varicose veins if valves are damaged during recanalisation of thrombosed vein

Question 35

Features of superficial venous thrombosis

Answer 35

Pain, tenderness, itching and reddening of skin +/or hardening of skin of surrounding tissue

Symptoms develop over hours to days and resolve in days to weeks, though hardness may persist for several weeks to months

Examination: tender, warm palpable worm-like mass (varicose)/cord (non-varicose) + erythema

Question 36

How to tell the difference between superficial vein thrombosis and DVT

Answer 36

DVT: generalised pain and swelling of leg not localised to thrombosed vein

Question 37

Lymphangitis

Question 38

Management of superficial vein thrombosis

Answer 38

1) Analgesia: NSAID or paracetamol, topical NSIAD for mild and limited SVT. Continue until pain settles, 1-2 weeks.

2) Self-care:
- apply warm, moist towel to limb
- keep leg elevated when sitting
- remain mobile to reduce risk of DVT

3) Consider referral to vascular service for venous duplex scanning
- LMWH/fondaparinux reduce risk of SVT extension and recurrence
- Fondaparinux reduce risk of symptomatic VTE and may be used if increased risk of DVT/PE

4) Offer compression stockings after excluding arterial insufficiency
- Class 1/travel socks (grade 2 likely too painful)

5) If recurrent and no obvious cause/RF investigate for coagulation disorder