Varicose veins, venous leg ulcers & superficial vein thrombosis Flashcards
Risk factors for varicose veins
Increasing age, FH, female, pregnancy, obesity, prolonged standing or sitting, DVT
Define varicose veins, reticular veins and telangiectasis (spider/thread veins)
Varicose veins: > 3mm diameter in upright position
Reticular veins: 1-3mm diameter, usually asymptomatic.
Telagiectasias: < 1mm diameter
What skin changes might you see with varicose veins?
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
Self-care advice for varicose veins
1) Lose weight if overweight
2) Light-moderate physical activity
3) Avoid sitting/standing for prolonged periods
4) Elevate legs
When to refer to vascular for consideration of interventional treatments
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.
Management of varicose veins if referral not indicated
Compression stockings - grade 2 if tolerated
Advice for pregnant women with varicose veins
1) They are common and often improve after pregnancy
2) Compression stockings can improve symptoms but do not precent varicose veins emerging
ABPI and compression stockings
< 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
Interventions for varicose veins
Vascular will first assess with duplex USS to confirm diagnosis.
1) Endothermal ablation
2) Foam sclerotherapy
3) Ligation and stripping
Acute vs chronic lipodermatosclerosis
Acute (sclerosing panniculitis) - painful inflammation above the ankles.
Chronic - painful, hardened, tight, red or brown skin. If circumferential can lead to inverted bottle appearance.
Treating venous eczema and lipdermatosclerosis
1) Emollient >= 2x/day
2) Topical steroid - in flares of LDS use very potent cream
Define leg ulcer
A break in the skin below the knee that has not healed within 2 weeks
What is the most common leg ulcer and where is it normally found?
60-80% are venous ulcers, typically occurring in the gaiter area of the leg
Symptoms of venous insufficiency
Pain, heaviness & itching of leg, worse at the end of the day and relieved by elevation
Drugs that can cause leg ulcers
Delay wound healing: hydroxycarbamide, immunosuppressants, antipsychotics, BB, nicrorandil, steroids, NSAIDs, anticoagulants, radiotherapy
Cause ulceration: nicrorandil, hydroxycarbamide, radiotherapy
Increase oedema: CCB, NSAIDs
Venous ulcer examination
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
Venous ulcer investigations
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
Examination of arterial ulcer
1) Well demarcated, punched out appearance
2) PAD: pallor, loss of hair, nail dystrophy, coldness and CRT > 4s
RhA leg ulcer
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
DM leg ulcer
Can be venous, arterial or neuropathic
Neuropathic: under calluses/pressure points. Clean edge and base, deep, can expose bone/tendon
Difference between ulcer associated with BCC and SCC
BCC: rolled edge
SCC: everted edge
If ulcer is unusual or does not respond to treatment refer
Management of venous leg ulcer
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
When to refer a venous leg ulcer after initial assessment
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
When to refer venous leg ulcer after compression therapy initiated
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
Managing infected venous leg ulcer
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
Managing oedema in patient with venous leg ulcer
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
Managing eczema in patient with venous leg ulcer
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
Pentoxifylline: indication, CI, caution, SE
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
Most commonly affected vein in superficial vein thrombosis / thrombophlebitis
60-80% affects saphenous vein and its tributaries of the lower limbs
Trousseau syndrome & Mondor’s disease
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
Virhow’s triad
Increased risk of thrombus formation:
1) Vessel wall damage
2) Venous stasis
3) Hypercoaguability of the blood
Most common risk factor for superficial vein thrombosis of lower legs
Varicose veins: stasis, 80% with SVT have varicose veins
What features of superficial vein thrombosis or patient factors increase risk of DVT?
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
Complications from superficial venous thrombosis
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
Features of superficial venous thrombosis
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
How to tell the difference between superficial vein thrombosis and DVT
DVT: generalised pain and swelling of leg not localised to thrombosed vein
Lymphangitis
Management of superficial vein thrombosis
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
