Venous and Lymphatic Disease Flashcards
What are varicose veins?
Common disease.
Tortuous dilated superficial veins.
Multifactorial.
Primary VVs - valvular dysfunction, leaflet of valves not meeting properly allowing the back flow of blood.
Where are the common sites of varicose veins?
Long saphenous - 80-87%
Short saphenous - 21-30%
(alone 13%, combined 21%)
In which sex are varicose veins more prevalent?
20-25% females
10-15% males
How many procedures take place for varicose veins in the UK per year?
> 100,000
20% operations - recurrent veins.
What are the important things to find out in the history of someone with varicose veins?
Age when veins appeared
Occupation (normally find its when people are on their feet a lot)
Pregnancy, esp twins, big babies
Previous DVT/major trauma, good reason for DVT - white leg of pregnancy
Family history
Signs and symptoms
Any complications
What are the symptoms and signs of varicose veins?
Cosmesis Localised or generalised discomfort in the leg Nocturnal cramps Swelling Acute haemorrhage Superficial thrombophlebitis Pruritus - itching Skin changes
What is superficial thrombophlebitis?
Thrombosis and inflammation of superficial veins which results in pain and erythema. Usually benign but can be complicated by DVT.
How can you assess varicose veins?
Can use duplex to see flow of blood in the veins, to prove it is actually back flowing.
What are the indications for intervention with varicose veins?
Symptoms Superficial thrombophlebitis Signs of chronic venous insufficiency Bleeding Cosmetic - anxiety of disease progression
What are different methods that can be used to treat varicose veins?
Surgery - high tie, stripping, multiple stab avulsions Injection (sclerotherapy) Minimally invasive procedures Compression Conservative (may include compression)
What are the contra-indications for surgery in the treatment of varicose veins?
Previous DVT (collaterals)
Arterial insufficiency
Patient co-morbs
Morbid obesity
Describe the surgery done to treat varicose veins.
Conventional surgery under GA.
Ligation of the sapheno-femoral or sapheno-popliteal junctions
Vein stripping and multiple stab avulsions
PIN (perforate invaginate) stripping
What are common complications with VV surgery?
Minor haemorrhage
thrombophlebitis, haemotoma
Wound problems, severe pain
What are less common complications with VV surgery?
Sural/saphenous nerve damage.
What are rare complications with VV surgery?
Damage to deep veins, arteries, nerves, DVT.
What are the minimally invasive treatments of main trunk varicosities?
Foam sclerotherapy (chemical reaction with endothelium) Endovenous laser ablation (EVLA) - thermal ablation Radio frequency ablation (VNUS) - thermal ablation
What are the benefits of minimally invasive treatment options?
Can use local anaesthetic
Potential advantages -
Reduce surgical trauma (bruising, scarring - no incisions) less pain
Reduced time off work
Don’t req an operating theatre
Potential to increase patient throughput
Clinical and cost-effectiveness compared to conventional surgery?
What are results like with minimally invasive procedures?
Short to medium term just as effective clinically as surgery.
Long term results awaited.
Cost effectiveness unknown.
Describe the EVLA technique.
Micropuncture needle inserted into the incompetent long or short saphenous veins using US.
Guide wire introduced, and manoeuvred to saphenous junction with deep vein using US.
Catheter and laser fibre introduced over guide wire to 1cm below junction.
Describe the VNUS technique.
Closure device used.
Heats vein to 85 degrees Celcius.
Describe the foam sclerotherapy technique.
Needle inserted into the incompetent veins under US control.
Foam injected, prevented from entering deep venous system.
Describe how compression hosiery works.
100% compression at the ankle region, 70% at shins and 50% just below knees - theoretically prevents back flow?
What conditions are associated with chronic venous insufficiency?
Ankle oedema Telangectasia Venous eczema Haemosiderin pigmentation Hypopigmentation 'atrophie blanche' Lipodermatosclerosis Venous ulceration
What is telangectasia?
‘Spider veins’
Small dilated BVs near the surface of the skin.
What is lipodermatosclerosis?
Inflammation of the subcutaneous fat.
Involves a colour change of the skin of the lower legs.
What is the pathophysiology of CVI?
Venous hypertension
Venous engorgement and stasis
Imbalance of Starling Forces and fluid exudate
Standing motionless - pressure at foot about 90mmHg, active movements - pressure falls to 30mmHg. Known as ambulatory venous pressure (AVP).
High AVP - failure of muscle pump, valves or outflow obstruction - venous hypertension.
What is the aetiology of CVI?
Failure of calf muscle pump Superficial venous reflux Deep venous reflux Venous obstruction Neuromuscular Obesity Inactivity
What is the definition of a leg ulcer?
Breach in the skin between knee and ankle joint, present for over 4 weeks.
What are the differentials of leg ulceration?
Almost 80% purely venous in origin.
Up to 20% have significant arterial disease
Diabetes, rheumatoid arthritis, vasculitis, CT disease
What are you looking for in examination if you see a leg ulcer?
Signs of CVI, oedema, locomotor system, vascular.
What investigations would you do if you saw a leg ulcer?
ABPI, Duplex
ABPI if low worried about arterial system.
If its to do with venous insufficiency where would you expect the location of the leg ulcer to be?
Above medial or lateral malleoli.
If its to do with arterial problems where would you expect the location of the leg ulcer to be?
Over toe joints, anterior shin, over malleoli, under heel.
If its to do with neuropathic problems where would you expect the location of the leg ulcer to be?
Over toe joints, under heel, over malleoli, under metatarsal head, inner side of first metatarsal head.
How do you treat leg ulceration?
Multi-layer graduation, elastic, high grade compression therapy (EXCLUDE ARTERIAL DISEASE).
Dressings - non-adherent dressings if painful - hydrocolloid/foam dressing
Systemic and topical therapy - not proven - most ulcers colonised rather than infected
Exercise - calf muscle pump.
What is lymphedema?
Localised fluid retention and swelling caused by impaired lymphatic system function.
What are the causes of lymphedema?
Primary - congenital, praecox before age of 30, trade after age of 30.
Secondary - malignancy, surgery (radical mastectomy, groin/axillary dissection), radiotherapy, infection (filariasis/TB/pyogenic) - deposits in lymph nodes (stops them functioning properly).
How is lymphoedema treated?
Elevation and manual drainage, banding or pneumatic compression.
What is Klippel-Trenaunay Syndrome?
Rare congential condition in which the BVs/lymph vessels fail to form properly.
