VASC - Venous disease

Question 1

How do you standardize the severity of venous disease?

Answer 1

CEAP classification

Clinical Classification
Etiologic classification
Anatomic classification
Pathophysiologic classification

Question 2

Define varicose veins

• primary

- secondary

Answer 2

Elongated, tortuous, dilated veins

Primary: Affecting superficial veins or perforators in the absence of deep incompetence

Secondary: Associated with deep venous incompetence from recanalization of previous DVT. Venous obstruction

Question 3

Clinical Px/complaints of varicose veins

Answer 3

•Cosmetic issue
–telangiectasia, reticular veins, varices

•Pain
–General leg ache or heaviness
–Venous claudication (pain does not resolve with rest but requires elevation for 10-20 min)

•Swelling
–Early ankle pitting oedema
–Later become indurated

•Skin changes
–Varicose eczema
–Pigmentation
–Lipodermatosclerosis: “Inverted champagne bottle”
–Atrophie blanche (confluence of white, depressed scars)

Others: Thrombophlebitis, Bleeding, Ulceration

Question 4

Ix of varicose veins

Answer 4

Venous duplex

Descending venography

Question 5

(5) classes of Rx of varicose veins

Answer 5

1. conservative
–elevate legs
–avoid standing still
–Dressings for ulceration
–graduated compression stockings

2. Sclerotherapy
   –UGS
   –Microsclerotherapy

3. Open Surgery
–SFL
–SPL
–GSV strip
–Stab phlebectomy

4. Endovenous Laser Therapy (EVLT)
5. Radiofrequency Ablation (RFA)

Question 6

Types of leg ulcerations (3 main + 4 others)

Answer 6

1. Ischaemic
2. Neuropathic (DM, ETOH, spinal cord lesions, tabes dorsalis, syringomyelia)
3. Stasis / venous
4. Infective (syphilis, mycobacterium, osteomyelitis)
5. Neoplastic (SCC, BCC, melanoma, metastatic, Kaposi’s sarcoma)
6. Systemic disease (pyoderma gangrenosum)
7. Traumatic (thermal burns, radiation, bites)

Question 7

Describe ischaemic ulcers

Answer 7

•Painful ulcer
•History of claudication or rest pain
•Cardiovascular risk factors
•Previous peripheral vascular surgery
–Location: distal periphery, over dorsum of foot or pretibia
–Punch-out edges
–Ulcer base => poorly developed gray granulation tissue
–Surrounding skin is pale or mottled with no signs of inflammation
–Little bleeding when debrided

Question 8

Signs of chronic arterial insufficiency

Answer 8

• atrophic nails / skin
• venous guttering
• Slow capillary return
• Absent pulses
• Beurger’s +ve

Question 9

Describe neuropathic ulcers

Answer 9

•Painless
•History of diabetes or other causes of neuropathy
–Deep
–Location: pressure points or calluses
•plantar surface of MTP joints
•“Bunion” or “bunionette” areas
•Dorsum of IP joints
•Base of 5th MT
•MM or LM
•Callused posterior rim of heel pad

–Signs of neuropathy
•Hypoaesthesia
•proprioception
•2-point discrimination
•Vibratory perception

Question 10

(4) Signs of neuropathy

Answer 10

• Hypoaesthesia
• proprioception
• 2-point discrimination
• Vibratory perception

Question 11

Features of distorted foot architecture

Answer 11

• Hyperextension of MTP joints
• Hyperflexion of IP joints
• Charcot’s deformity

Question 12

Describe venous ulcers

Answer 12

•History of venous insufficiency
–varicose veins
–superficial thrombophlebitis or DVT
–variceal bleeding
•Previous venous surgery

–Larger and irregular edge
–Shallow
–Location: over gaiter area (commonly medial malleolus)
–Moist granulating base
–Surrounded by zone of inflammation and stasis dermatitis

Question 13

Associated signs of venous insufficiency

Answer 13

• varicose veins
• pitting oedema
• varicose eczema
• Pigmentation
• Lipodermatosclerosis
• Atrophie blanche

Question 14

Comparison of ulcers by site

Answer 14

1.Arterial
–distal at toe tips
–Pressure areas

2.Venous
–gaiter area

3.Neuropathic
–dorsum of PIP / DIP
–Plantar surface MTP
–MM or LM
–Heel
–Other calloused areas

Question 15

Ix of leg ulcers

Answer 15

• FBE / U&E / CRP / glu / HbA1C / vasculitic screen / ESR / thrombophilic screen
• Swab m/c/s
• Xray ± bone scan ± MRI
• Duplex (arterial or venous)
• CTA
• DSA
• Biopsy

Question 16

Rx of leg ulcers

Answer 16

–Bed rest
–Elevation or dependency
–IV antibiotics
–Dressings
–Debridement / split skin graft

–Treat underlying aetiology
•Revascularisation
•Compression stockings / Varicose vein surgery
•Pressure offloading footwear / Total contact cast