Vascular: Venous Disease Flashcards
how should you examine a person with venous disease?
both standing up and sitting down, former to look for varicosities
where can you palpate the dorsalis pedis?
lateral to the extensor hallucis longus tendon; if not obvious, tell them to pull the hallux upwards
where can you palpate the posterior tibial pulse?
posterior and inferior to the medial malleolus
which type of waveform signifies more severe disease?
continuous monophasic
why should you exclude arterial disease before treating the venous disease?
- compression on arterial disease will worsen the arterial disease
- you have to examine pulses and ABPI before treating the patient
what should you ask the patient in the history?
- occupation (people who work long hours standing are more prone to venous disease)
- family history
- pregnancy
- race
- previous episodes
- smoking (mainly arterial disease)
- obesity
- history of DVT
- history of trauma and major surgery and malignancy
clinical examination of venous disease
- inspection: engorged veins, haemosiderin pigmentation, venous eczema
- peripheral pulses
- look at the gaitre area
- to look for varicosities of the GSV, tell them to externally rotate the leg to visualise that part of the leg more
- peripheral pulses
investigation of venous disease
- doppler
- ABPI
- duplex scan
management of venous disease
- 4-layer bandaging
- Daflon
- ECMS (stimulates the calf muscles, increases venous return and reduced swelling)
general advice for the patient
- maintain compression
- weight loss, change in diet and exercise
- smoking cessation
- monitor and control pulse, BP, glucose to maintain health
what do you do in a duplex scan?
- check compressibility of the vein
- look for coloured flow
- check the pulse wave
how do you assessment the superficial veins?
- check the junctions and their competencies
what is the Valsalva manoeuver?
moderately forceful attempted exhalation against a closed airway, usually done by closing one’s mouth, pinching one’s nose shut while expelling air out as if blowing up a balloon
treatment of venous disease
- endovascular treatment
- sclerotherapy
- open surgery
- radiofrequency ablation
- 4-layer bandaging
what are the 4 layers in the 4 layer bandage?
- non-adherent dressing
- wadding
- crepe
- cohesive bandaging
what is the aim of compression therapy?
- prevent venous insufficiency and reflux
- stop fluid build up at the ankle
what is sclerotherapy?
- an irritant chemiacl is mixed with air to make the foam
- this is fed into the vein through a butterfly needle, guided by ultrasound
- the leg is wrapped up, depending on the length of the vein being destroyed
- this bandage is removed a week after
how is traditional surgery done?
- incision is made through the groin, find the vein and ligate it here
- remove the vein by stripping
- 2 types: pin and plastic disposable
- the stripper is passed through the vein, vein is stitched through it and the vein is stripped
- this risks pulling out the sural/saphenou nerve
what is high energy ablation?
- can either be done through laser or radiofrequency
- the energy is passed through the vein which burns the vein to stop the venous reflux
- in RFA, cold saline is injected into the surroundings of the vein to prevent burning the surroundings
what is vein glue?
- the glue is injected into the vein
- the area is pressed so that the vein closes
- no need for bandging or risk of burns here
- only require local anaesthetic
basic classification of veins
- superficial (above the fascia)
- deep (below the fascia)
list the deep veins of the leg
- anterior tibial
- posterior tibial
- peroneal
- popliteal
- profunda femoris vein
- common femoral vein
- external iliac
- common iliac
list the superficial veins of the leg
- great saphenous
- short saphenous
describe the path of the great saphenous vein
- starts at the dorsum of the foot
- goes up to the groin following a posteromedial route
- penetrates the fascia to meet the femoral vein at the saphenofemoral junction
describe the path of the small saphenous vein
- lateral aspect of the foot
- goes until the popliteal fossa to join the popliteal vein at the saphenopopliteal vein
what other types of veins can cause varicosities?
perforator veins
explain the physiology of veins and valves
- there are multiple mechanisms that help blood move upwards:
- valves
- contraction of calf muscle
- change in intrathoracic pressure
- if you do not supply the heart with that blood, there is a drop in CO, a drop in blood going to the brain, causing syncope
pathophysiology of venous disease
- in venous HTN, the pressure in the veins is high, highest in the ankle region due to incompetent valves
why are varicose veins important?
since a lot of blood is accumulated in the veins and they are under a high pressure, they can bleed torrentially if nicked
what are venous telengiectasias?
- spidery veins
- these are not treated, unless symptomatic
how do you do the Tredelenburg test?
- lie the patient flat to empty the veins
- tighten the tourniquet above the defect
- stand the patient up
- if you have tightened above the defect, the varicosities should not refill
what type of skin changes can you see in venous disease?
- oedema
- discolouration
- dermatitis
- venous eczema (mainly in the gaiter area - flaky and whitish)
- ulceration
- haemosiderin pigmentation
symptoms of thrombophlebitis
- pain
- swelling
- heat
- difficult to move the limb
management of thrombophlebitis
- NSAIDs
- compression stockings
