Venous and lymphatic disease

Question 1

Define varicose veins and list common sites?

Answer 1

Dilated tortuous veins due to venous valve insufficiency.

Superficial veins of the leg.
Short Saphenous: below the knee posterolaterally
Long Saphenous: the whole length of the leg on the medial surface.

Question 2

What are the complications of varicose veins?

Answer 2

Bleeding, Itching, Aching, Oedema

Deep venous insufficiency:

• Superficial Thrombophlebitis
• Varicose Eczema
• Venous Ulceration
• Haemosiderine deposits
• Lipodermatosclerosis
• Atrophie blanche

Question 3

Underline the normal venous physiology of the leg?

Answer 3

Superficial capillaries> Superficial Veins > Perforator veins > Deep veins into the vena cava.

Blood collected from superficial venous capillaries is directed upward and inward via one-way valves into superficial veins.
These in turn drain via perforator veins, which pass through muscle fascia into deeper veins buried under the fascia.

When these valves become faulty it increases the pressure on the superficial veins and they become tortuous and dilated.

Question 4

Describe the non invasive investigations used for diagnosis?

Answer 4

Doppler:

The probe is placed on the vein and you compress the limb below the probe.

A sound when the limb is compressed shows anterograde flow towards the valve.

If a sound is heard on release of compression that indicates retrograde flow.

Duplex scan:

Ultrasound + colour doppler therefore can see retrograde flow. It is the gold standard for diagnosis.

Question 5

What are the indications for varicose vein interventions?

Answer 5

Symptoms of Deep venous insufficiency, affecting quality of life

Question 6

What interventions are used for varicose veins?

Answer 6

Endothermal ablation or US guided sclerotherapy

Surgical:
Vascular stripping

Question 7

Describe the general management of venous disease?

Answer 7

Raising legs when possible.
Compression stockings.
Avoid standing for long periods of time.
Exercise regularly and weight loss

Question 8

Describe features of venous ulcers?

Answer 8

Shallow
May be painful but not as severe as arterial.
Often large.
Borders are often not clearly defined.

Occur over areas of thinned skin, typically over the medial malleolus and medial section of the shin.

Question 9

Describe the management of venous ulcers?

Answer 9

Must rule out arterial disease with ABPI first.

Debridement and cleaning.
Abx if infected
4 layer compression bandaging with leg elevation
Once heeled, long term compression stockings.

Pentoxifylline if the ulcers are chronic (increases microvascular circulation.)

Question 10

What is lymphoedema?

Answer 10

Lymphoedma is a condition in which there is deficient lymphatic drainage causing:

• hard swelling
• usually bilateral
• a heavy feeling and ache in the affected body regions.

Question 11

Differentiate between primary and secondary lymphoedema?

Answer 11

Primary Lymphoedema: Due to inherited genetic abnormalities in the lymphatic drainage. (Milroys disease)

Secondary Lymphoedema: secondary to another cause in someone with previously normal lymphatic drainage;

Question 12

Describe the causes of secondary lymphoedema?

Answer 12

• Surgical removal of lymphatics following cancer (e.g. breast)
• Radiotherapy damage.
• Can also be caused by parasites in tropical countries (filaria)
• Repeated cellulitis
• Malignancy

Question 13

Describe the management of lymphoedema?

Answer 13

Cannot be cured management is supportive:

• Raise legs whenever possible
• Compression stockings
• External pneumatic compression (essentially an air pump on a cuff)
• Physical massages
• ABx for recurrent cellulitis