Venous and Lymphatic Disease

Question 1

Explain the structure of arteries

Answer 1

Thick walls with small lumen
Have strong elastic and smooth muscle layer
Makes greater control of blood and good for high pressure

Question 2

Explain the structure of veins

Answer 2

Wider diameter than arteries and have limited amounts of elastic fibre as smooth muscle
Have valves so better at low pressure delivery

Question 3

How does the deep venous system work?

Answer 3

Uses calf pump - acts with popliteal vein to push against blood and compress vein to help venous return
Also returns by long and short saphenous vein - gravity and valves

Question 4

What is included in superficial venous system?

Answer 4

Long and short saphenous veins

Question 5

Explain the long saphenous vein

Answer 5

Runs up medial aspect of calf and then thigh joining to deep venous system at saphenous-femoral junction in femoral junction
Has several perforating veins which transport blood from superficial to deep venous system

Question 6

Explain the short saphenous vein

Answer 6

Sole of foot drains to this vein, then goes up posterior aspect of calf and drains to popliteal vein through perforations

Question 7

What is the deep venous system made up of?

Answer 7

Tibial, popliteal and femoral vein

Question 8

Explain the deep venous system

Answer 8

Carries deep within tissues under gastrocnemius and soleus and deep within muscular compartments of the thigh
Under inguinal ligament. Femoral becomes external iliac then internal iliac to become common iliac. Drains to IVC

Question 9

What are the 2 main forms of venous disease?

Answer 9

Chronic venous insufficiency and varicose veins

Question 10

What are varicose veins due to?

Answer 10

Superficial venous insufficiency - normally damage to the valves within the venous system

Question 11

What are the risk factors for varicose veins?

Answer 11

Recent DVT, pregnancy, tumours as compression causes increased pressure, and any trauma - surgical or direct

Question 12

How is pregnancy a risk factors for venous disease?

Answer 12

Hormonal changes and uterus sitting on deep iliac veins

Question 13

What happens if the whole part of the superficial venous system is affected?

Answer 13

Blood flows back down leg and causes stasis and oedema

Question 14

What are the risk factors for venous insufficiency?

Answer 14

Increasing age, female sex (pregnancy), previous DVT or trauma and prolonged standing which can increases venous pressure over long time

Question 15

What is chronic venous insufficiency?

Answer 15

When there is damage to venous system over long period of time
Combination of deep and superficial diseases
Is followed by venous hypertension

Question 16

Describe the cycle of chronic insufficiency?

Answer 16

Venous hypertension - endothelial leak as damage to veins - oedema
Oedema created distance for perfusion so causes impaired healing, inflammation and tissue damage
End up with ulceration

Question 17

What are some minor symptoms for varicose veins?

Answer 17

Unsightly and distended veins
Mild so go away when lying down

Question 18

What are the symptoms for venous disease?

Answer 18

Itching, burning, previous infection, ulceration, swelling, tightness in legs and discolouration if left unnoticed

Question 19

What can be seen on examination of venous disease?

Answer 19

Most distended veins when standing
Look for the long and short saphenous vein
Oedema, discolouration and eczema

Question 20

Explain the Trendelenburg test

Answer 20

Patient laying flat. Raise leg above level of heart. Press at level of saphenous-femoral junction. Ask patient to stand and look to see if vein fills
If vein does not distend then junction is occluded so where problem lies

Question 21

Explain the tap test

Answer 21

Lay patient flat. Place hand of saphenous-femoral junction and tap over long saphenous vein just above the knee
If tapping is transmitted then likely backflow of blood

Question 22

What does the Doppler test show?

Answer 22

Assesses flow

Question 23

What investigations should be carried out in venous disease?

Answer 23

Complete peripheral vascular examination, ankle brachial pressure index and venous duplex ultrasound scanning which is used for diagnosing

Question 24

What does the venous duplex ultrasound scan show?

Answer 24

Size of vessel, flow within and if it has backflow
Usually done in secondary care

Question 25

Explain the CEAP classification

Answer 25

C- clinical manifestations
E - eitology
A - anatomic distribution
P - pathophysiology

Question 26

What is C4 in CEAP classification?

Answer 26

Changes in skin and subcutaneous tissue secondary to chronic venous disease
Above C4 is treated by SIGN guidelines

Question 27

Explain C5 and C6 on CEAP

Answer 27

C5 is healed to have to be C6 first which is active venous ulcer

Question 28

What are the signs of venous insufficiency?

Answer 28

Oedema, telangiectasia, venous eczema, lipodermatosclerosis, ulceration and hemosiderin pigmentation

Question 29

How is chronic venous insufficiency managed?

Answer 29

Conservative management as not easy target for superficial vein to fix.

Question 30

What is involved in conservative management?

Answer 30

Compression bandaging and elevation if they do not have arterial supply problem
Allows reduction in oedema and reverses vicious cycle

Question 31

What happens if patient does not keep on top of compression bandaging?

Answer 31

Intermittent flares of cellulitis and venous ulceration

Question 32

What is the treatment for varicose veins?

Answer 32

Endovenous treatment
Foam sclerotherapy and surgical intervention

Question 33

Explain laser or radiofrequency ablation

Answer 33

Endovenous treatment
Under duplex US which diagnoses superficial insufficiency.
Insert cannula into long saphenous vein above knee insert wire to saphenous-femoral junction
Insert Laser fibre or RFA fibre

Question 34

How does laser or RFA treatment work?

Answer 34

Cause damage to tissues by intensely heating up the inside of the vein.
Laser and RFA removed and vein sticks to itself and closes off
Local anaesthesia used - 200ml in groin and knee area

Question 35

What should patients do after endovenous treatment?

Answer 35

Compression bandaging immediately after
Helps vein wall keep stuck together

Question 36

Explain foam sclerotherapy

Answer 36

If cant undergo laser or RFA
Common in smaller areas of varicosity
Scalarising agent is mixed with air to create foam which is ejected into veins. Causes irritant effect and causes vein to collapse down on itself. Then causes thrombosis of vein

Question 37

Describe surgical intervention for varicose veins

Answer 37

Aimed at removing the diseased vein bur now rarely used
The long saphenous vein is pulled out then compression bandaging post-operatively will stop bleeding as venous and low pressure
Can cause bleeding and is painful