Vascular: Peripheral venous disease

Question 1

What are varicose veins?

Answer 1

Dilated and tortuous superficial veins, most often affecting the lower limb

Question 2

What causes varicose veins?

Answer 2

They occur due to incompetence of the valves between the deep and superficial venous systems, resulting in retrograde flow and pooling of blood in the superficial venous system

Question 3

Which veins are affected in varicose veins?

Answer 3

Superficial veins (lower limb)

Question 4

What do the varicose veins look like?

Answer 4

Dilated + tortuous

Question 5

How do varicose veins present?

Answer 5

1) Visible superficial veins
2) Pain
3) Cramping or heaviness
4) Oedema
5) Discolouration - due to increase haemosiderin deposits
6) Haemorrhage
7) ± venous ulcers

Question 6

What causes discolouration in varicose veins?

Answer 6

Increase haemosiderin deposits

Question 7

What are indications for treatment in varicose veins (otherwise not required)?

Answer 7

1) Bleeding
2) Pain
3) Ulceration
4) Thrombophlebitis
5) Significant psychological morbidity

Question 8

What lifestyle modifications are recommended for varicose veins?

Answer 8

1) Reduce long periods of standing
2) Elevate lower limbs when possible
3) Support stockings
4) Weight loss
5) Walking

Question 9

What are treatment options for varicose veins?

Answer 9

1) Radiofrequency ablation - destruction of the endothelium of the vein via high temperature catheter
2) Endovenous laser ablation - destruction of the vein using laser
3) Injection sclerotherapy - injection of sclerosant substance at several points in the vein, leading to occlusion
4) Surgery - avulsion therapy or stripping of the vein

Question 10

What is first line intervention for varicose veins?

Answer 10

Radiofrequency ablation

Question 11

Which patients are typically affected by venous ulcers?

Answer 11

Middle aged women

Question 12

Where do venous ulcers occur?

Answer 12

Gaiter area (below the knee + above the ankle) - typically medial side incl. medial malleolus

Question 13

How do venous ulcers/venous ulcer disease present?

Answer 13

1) Large
2) Shallow
3) Sloping edges
4) Bleed/ooze - sloughy
5) Oedema
6) Eczema
7) Skin thickening
8) Haemosiderin deposition of the lower leg

Question 14

What do venous ulcers typically occur alongside?

Answer 14

Other features of chronic venous insufficiency - e.g. haemosiderin deposition, lipodermatosclerosis, atrophie blanche ± venous eczema, swelling

Question 15

What are features of chronic venous insufficiency?

Answer 15

1) Haemosiderin deposition
2) Lipodermatosclerosis
3) Atrophie blanche

Question 16

What are the most common form of skin ulcers?

Answer 16

Venous ulcers

Question 17

What causes venous ulcer formation?

Answer 17

Long standing venous hypertension which leads to incompetence of venous valves

Question 18

What type of condition is venous ulcer disease?

Answer 18

Common, chronic, recurring condition

Question 19

What are risk factors for venous ulcer disease?

Answer 19

1) Obesity
2) Immobility
3) Varicose veins
4) Previous DVTs
5) Age
6) Previous trauma to the leg

Question 20

What lifestyle advice is given for managing venous ulcer disease?

Answer 20

1) Keep ulcer clean
2) Encourage mobility
3) Weight reduction
4) Leg elevation at rest

Question 21

What are topical treatments for venous ulcer disease?

Answer 21

1) Emollient treatment of the leg
2) Compression bandaging - aimed at improving venous return from the leg

Question 22

What must patients with venous ulcer disease have before using compression bandaging?

Answer 22

ABPI - to exclude concomitant arterial disease as bandaging will worsen arterial supply to the leg

Question 23

Which medication can be given for venous disease if patients don’t respond to initial treatment (lifestyle advice and bandaging)?

Answer 23

Pentoxifylline (a vasoactive agent that improves the flow of blood by reducing its viscosity)

Question 24

What are surgical options for venous ulcer disease (not usually necessary)?

Answer 24

1) Debridement
2) Skin grafting

Question 25

What are potential complications of venous ulcer disease?

Answer 25

1) Immobility – due to pain
2) Infection and sepsis
3) Osteomyelitis
4) Decreased quality of life

Question 26

What is superficial thrombophlebitis?

Answer 26

Thrombus formation in superficial venous vasculature

Question 27

Where does superficial thrombophlebitis most commonly occur?

Answer 27

Lower limbs

Question 28

What are the symptoms of superficial thrombophlebitis?

Answer 28

1) Pain
2) Itching
3) Discolouration of skin

Question 29

How is superficial thrombophlebitis managed?

Answer 29

1) Typically resolves spontaneously without treatment
2) Compression stockings - may be useful in management and prevention