Venous and Lymphatic Disease Flashcards
Varicose veins
Definition: A varicose vein is a dilated and tortuous, often superficial, vein
Most commonly found in the lower limbs
Landmark anatomy for varicose veins
Course of the long saphenous vein:
Dorsal venous arch drains into the LSV, which passes anterior to the medial malleolus, up the medial aspect of the leg
Saphenofemoral junction:
Found 2.5cm below and lateral to the pubic tubercle
Here the LSV perforates the cribiform fascia and empties into the femoral vein (deep system)
Short saphenous vein:
The plantar venous arch drains into the SSV which travels posterior to the lateral malleolus, up the posterior aspect of the leg and drains into the popliteal vein (deep system)
Function of veins in lower limbs
To assist low flow against gravity (back to the heart):
Valves
Calf muscle pump
Perforating veins to drain blood into the deep system – deep veins are within muscular compartments and can withstand higher pressure
Causes of valvular failure in veins
surgical or traumatic disruption of the valve.
DVT: can initially cause obstruction to venous flow, and even as the vein re-canalises through the thrombus, this canal will be a high-pressure avalvular channel.
Hormonal changes in pregnancy can cause weakness of the veins and valves, leading to venous incompetence. The enlarged uterus can cause mechanical obstruction to venous flow within the deep system,
Similarly a large pelvic tumour also could, leading to increased pressure within the distal venous systems.
Once one valve has failed venous pressure increases, there is dilatation of the distal vein and further valvular incompetence.
Risk factors for varicose veins
Age Female (20-25% females, 10-15% men) Pregnancies DVT Standing for long periods (occupation) Family history
Diagnosis: History for varicose veins
Burning Itching Heaviness Tightness Swelling Discolouration Phlebitis Bleeding Disfiguration Eczema Ulceration
Tap test
Place one hand over the saphenofemoral junction and one over the long saphenous vein above the knee.
Tap the saphenofemoral junction – a transmitted impulse at the knee indicates an incompetence of the valves between the two hands
Trendelenburg/tourniquet test
Lie the patient flat. Drain the superficial veins by raising the leg and stroking the veins towards the trunk.
Apply pressure over the saphenofemoral junction. Keep this pressure on as you ask the patient to stand.
If the varicose veins don’t dilate on standing, you are preventing this by ‘acting’ as a competent valve preventing backflow of blood. If you release your hand you will see the veins refill as the patient’s saphenofemoral junction valve is incompetent.
The Tourniquet test is a similar test, using a tourniquet instead of your hand, and repeating the test at 10cm intervals down the leg (the approximate distance between perforating veins) to find the level of incompetence.
How to use a Doppler for varicose veins
Hold a doppler probe over the saphenofemoral junction. Squeeze the calf muscles. In a patient with competent superficial veins you will hear a ‘whoosh’ as the blood flows upwards into the deep system.
In a patient with an incompetent saphenofemoral junction you will hear two waves as the blood flows upwards and then refluxes downwards again.
main investigation for varicose veins
Ultrasound can demonstrate the valves, the anatomy of the varicose vein (e.g. tortuosity), and can be used to show dynamic blood flow e.g. reflux
Clinical classification for venous insufficiency
C0- no visible or palpable signs of venous disease
C1- teleangiectasies (visible spider veins)
C2- varicose veins
C3- oedema
C4a- pigmentatino or eczema
C4b- lipodermatosclerosis (inflammation of fat) or athtophie blanche
C5- healed venous ulcer
C6- active venous ulcer
Etiological classification for varicose veins
Ec- congenital
Ep- primary
Es- secondary
En- no venous cause identified
Anatomical classification of varicose veins
As- superficial veins
Ap- perforating veins
Ad- deep veins
An- no venous location identified
Pathophysiology classification of varicose veins
Pr- reflux
Po- obstruction
Pr,o- obstruction and reflux
Pn- no venous pathophysiology identifiable
When should treatment be offered for varicose veins
On the NHS, NICE guidelines state that treatment should be offered to patients complaining of:
Bleeding varicose veins
Symptomatic varicose veins (including aching, discomfort, swelling, heaviness and itching)
Recurrent symptomatic varicose veins
Lower limb skin changes of chronic venous insufficiency
Superficial venous thrombosis
Venous leg ulcer – active or healed
Management options for varicose veins
First line: Endovenous treatment
Second line: Ultrasound guided foam sclerotherapy
Third line: Open surgery
If intervention is unsuitable, offer compression hosiery.
Intervention shouldn’t be offered if the deep venous system is obstructed e.g. DVT, or in pregnancy (hosiery instead).
Endovenous treatment
The LSV or SSV is cannulated under ultrasound guidance.
A catheter is passed up the length of the the vein to just distal to the saphenofemoral or saphenopopliteal junction.
Local anaesthetic is used for the small skin puncture, and then is infiltrated in the superficial tissues around the length of the vein.
The catheter causes injury to the vein wall – either by heat or laser. This causes fibrosis and occlusion of the vein, and subsequent ablation/disappearance of the vein.
Complications: Skin burns, paraesthesiae (0-10%), phlebitis (5%), deep vein thrombosis (1%).
Foam sclerotherapy
Again under ultrasound guidance, a chemical foam is injected into the affected vein. The foam damages the venous walls, causing fibrosis and occlusion.
Complications: The vein should be occluded (with pressure) proximally to prevent foam migrating and causing the potential complications of stroke ,TIA or MI. Thrombophlebitis (7%) and skin pigmentation (6%) can also occur.
Open surgery for varicose veins
Under GA, a groin incision is made and the saphenofemoral junction is exposed.
The saphenous vein is ligated from the femoral vein. An instrument is passed along the length of the saphenous vein and then used to strip the vein out.
Small superficial varicose veins are avulsed using small, ‘stab’ incisions and a small hook instrument.
Complications: Anaesthetic risk, wound infection, damage to nearby nerves (saphenous and sural nerves), bleeding.
Venous insufficiency causes
Failure of calf muscle pump
Superficial venous reflux
Deep venous reflux (surgery, DVT, congenital)
Venous obstruction (heart failure, portal hypertension, obesity)
Pathophysiology of venous insufficiency
venous insufficiency venius hypertension endothelial leak oedema increased perfusion distance impaired healing inflammation fibrinogen, tissue damage impaired tissue perfusion
Chronic venous insufficiency
Oedema Telangiectasia Eczema Haemosiderin pigmentation Hypopigmentation Lipodermatosclerosis Ulceration
Venous ulcers
Breach in the skin between the knee and ankle joint, present for >4 weeks Gaiter area Granulomatous (red) base Shallow Irregular margins Exudative, oedematous Painless, pulses present
Investigations for ulcers
history
examination
ABPI (arterial brachial pressure index)
Treatment for venous ulcers
Exclude arterial disease (ABPI)
Wound care – little role for systemic antibiotics
Elevation
Compression bandaging
Shockwave therapy
Primary lymphoedema
Congenital
Praecox: around puberty
Tarda: age >35
Secondary lymphoedema
Malignancy
Surgery
Radiotherapy
Infection
Treatment of lymphoedema
Elevation
Drainage
