Venous and Lymphatic Disease Flashcards
What is the main function of the venous system?
To carry oxygen depleted blood which is rich in metabolism waste products back to the heart
Where do superficial veins drain from?
Drain from superficial tissues into deeper veins which then drain back to the heart
What do veins contain that prevent the back flow of blood?
Valves
When do varicose veins occur?
When blood which should drain superficial to deep backflows and takes the route of least resistance, due to leaky valves within the veins
Why do primary varicose veins occur?
Due to valvular dysfunction
What vessels become varicose veins?
Greater saphenous veins 80-87%
Lesser saphenous veins 21-30%
13% alone
21% combines
What is the prevalence of varicose veins?
20-25% in females
10-15% in males
How many procedures are done in the UK per year for varicose veins?
Over 100,000
What percentage of people who have operations for their varicose veins will have recurrent varicose veins?
20%
What features of the history are important in a patient with varicose veins?
Age when veins appeared
Occupation
Pregnancies - especially twins and big babies
Previous DVT, major trauma or suspected DVT
Family history
Signs and symptoms
Complications
What are the signs and symptoms of varicose veins?
Largely a cosmetic problem - unhappy with the appearance
Localised or general discomfort in the leg
Nocturnal cramps
Swelling
Acute haemorrhage - itching, sports, trauma
Superficial thrombophlebitis
Pruritis
Skin changes e.g. venous eczema, lipodermatosclerosis
What is the standard investigation for varicose veins?
Doppler ultrasound scan of the leg/vein
What are the indications for intervention in varicose veins?
Symptoms Superficial thrombophlebitis Signs of chronic venous insufficiency Bleeding Cosmetic issues (more likely to be treated privately) Anxiety that disease might progress
What are the treatment options for varicose veins?
Surgery - high tie, stripping, multiple stab avulsions Injection (sclerotherapy) Minimally invasive procedures Compression Conservative
What are minimally invasive procedures for the treatment of varicose veins dependent on?
Shape of the vein - requires a long straight vein
What are the relative contraindications for superficial venous surgery?
Previous DVT
Arterial insufficiency
Patient comorbidity
Morbid obesity
What are the conventional venous surgical methods, done under general anaesthetic?
Ligation of the sapheno-femoral or sapheno-popliteal junctions
Vein stripping and multiple stab avulsions
Perforate invaginate stripping
What are the possible complications of superficial venous surgery?
Minor haemorrhage Thrombophlebitis Haematoma Wound problems, severe pain Sural/saphenous nerve damage Damage to deep veins/arteries/nerves DVT
What are the minimally invasive treatment options for main trunk varicosities?
Foam sclerotherapy - chemical reaction with endothelium Endovenous laser ablation (EVLA) - thermal ablation Radiofrequency ablation (VNUS) - thermal ablation
What are the benefits of local anaesthetic minimally invasive treatment options?
Reduce superficial trauma - no incisions, less pain, bruising and scarring reduced
Reduce time off work
Don’t require operating theatre
Potential to increase patient throughput
Short to medium-term results just as effective clinically as surgery
Cost effectiveness and long-term results not yet known
What is involved in the laser EVLA technique?
Micro-puncture needle inserted into the incompetent long or short saphenous vein using ultrasound
Guidewire introduced and manoeuvred to the saphenous junction within the deep vein using ultrasound
Catheter and laser fibre introduced over the guidewire to 1cm below the junction
How does closure VNUS work?
Heats vein to 85 degrees celsius
What is involved in the foam sclerotherapy technique?
Needle inserted into the incompetent veins under ultrasound control
Foam injected, prevented from entering deep venous system
Give examples of chronic venous insufficiency
Ankle oedema Telangiectasia Venous eczema Haemosiderin pigmentation Hypopigmentation - atrophie blanche Lipodermatosclerosis Venous ulceration
What is the pathophysiology of chronic venous insufficiency?
Venous hypertension
Venous engorgement and stasis
Imbalance of Starling forces and fluid exudate
What is the ambulatory venous pressure (AVP)?
Pressure in the foot is 90mmHg when standing motionless, this falls to 30mmHg with active movements - this is known as AVP
How does high AVP result in venous hypertension?
High ambulatory venous pressure results in failure of muscle pump or valves, or outflow obstruction leading to venous hypertension
What are the possible aetiologies of chronic venous insufficiency?
Failure of calf muscle pump Superficial venous reflux Deep venous reflux Neuromuscular Obesity Inactivity
What is a leg ulcer?
Breach in the skin between the knee and ankle joint which is present for over 4 weeks
What percentage of leg ulcers are purely venous in origin?
80%
What percentage of people with leg ulcers will have significant arterial disease?
Up to 20%
What are leg ulcers associated with?
Diabetes
Rheumatoid arthritis
Vasculitis
Cardiothoracic disease
What might be seen on clinical examination of a patient with a leg ulcer?
Signs of chronic venous insufficiency
Oedema
Locomotor and vascular system signs
What investigations are relevant in leg ulcers?
ABPI
Duplex
How are leg ulcers treated before compression therapy?
Antibiotics and dressings applied to remove as much of the infection as possible
What is the treatment of leg ulcers?
Multi-layered graduated, elastic, high-grade compression therapy
Exclude arterial disease
Non-adherant dressings, hydrocolloid or foam dressing if painful
Exercise calf muscle pump
Why are systemic and topical therapies not necessarily useful in leg ulcer treatment?
As most leg ulcers are colonised rather than infected
What are the causes of primary lymphoedema?
Congenital (from birth)
Praecox (present before teenage years)
Tarda
What are the causes of secondary lymphoedema?
Malignancy
Surgery e.g. radical mastectomy, groin/axillary dissection
Radiotherapy
Infection e.g. filariasis, tuberculosis
How is lymphoedema treated?
Elevation and manual drainage
Graduation compression
