Venous and Lymphatic Disease Flashcards
Fill in the blanks.
The great saphenous vein is a large venous blood vessel running near the inside surface of the leg from the ankle to the groin. It arises from the _________________ and drains into the ___________.
dorsal venous arch
femoral vein
The small saphenous vein is a _________ vein of the leg. It drains the ________ surface of the leg, and runs up the _________ surface of the leg to drain into the ___________.
superficial
lateral
posterior
popliteal vein
The dorsal venous arch of the foot connects the _______________ to the _____________.
great saphenous vein
small saphenous vein
The deep plantar arches drains into the _____________ and the _______________.
small saphenous vein
posterior tibial vein
Dorsal venous arch drains into the _______________, which passes anterior to the _________ __________, up the ________ aspect of the leg.
great saphenous vein
medial malleolus
medial
The deep plantar arch drains into the ______________ which travels ________ to the lateral malleolus, up the __________ aspect of the leg and drains into the ____________.
lesser saphenous vein
posterior
posterior
popliteal vein (deep system)
What are the function of the valves within veins in the lower limbs?
To assist low flow against gravity back to the heart, prevent back flow.
What are the causes of venous valvular failure?
(4)
surgery
DVT
hormonal changes (e.g. in pregnancy)
pelvic tumour
Why does blood get drained into the deep veins from the superficial veins via the perforator veins?
deep veins are within muscular compartments and can withstand higher pressure
Outline briefly the pathophysiology behind venous valvular failure/varicose veins.
- if one valve fails
- hydrostatic pressure builds up (flow reduced)
- dilation in distal vein
- further valvular incompetence
What are the risk factors for venous valvular failure?
(6)
Age
Female (20-25% females, 10-15% men)
Pregnancies
DVT
Standing for long periods (occupation)
Family history
What are the symtoms of varicose veins/venous valvular failure?
(7)
Burning/Itching
Tightness
Discolouration (erythema)
Pitting oedema
Phlebitis (inflammation of the vein)
Bleeding
Ulceration
How are varicose veins diagnosed?
What investiagtions/tests are used in diagnosis?
Explain how they work/what the results indicate.
(4)
Examination: inspection/palpation
Tap test (tests for tap travelling between valves, if felt then there is an abnormality as valve should insulate tap)
Trendenelburg/tourniquet test
Doppler (saphofemoral junction: wooshing sound (normal), two soudns (abnormal))
Which imaging technique can be used to assess for varicose veins?
ultrasound
In the CEAP classification of chronic venous disease:
What is the clinical classification of C2?
varicose veins
In the CEAP classification of chronic venous disease:
What is the clinical classification of C3?
oedema
In the CEAP classification of chronic venous disease:
What is the clinical classification of C4a?
pigmentation or eczema
In the CEAP classification of chronic venous disease:
What is the clinical classification of C4b?
lipodermatosclerosis
In the CEAP classification of chronic venous disease:
What is the clinical classification of C5?
healed venous ulcer
In the CEAP classification of chronic venous disease:
What is the clinical classification of C6?
active venous ulcer
In the CEAP classification of chronic venous disease:
Which clinical classifications qualify for treatment?
C3+
What are the treatment options available for varicose veins?
What is a another option available in cases where intervention is unsuitable?
- Endovenous treatment
- Ultrasound guided foam scleropathy
- Open surgery
Compression hosiery e.g. anti-embolism stocking
Outline the process of endovenous intervention.
(3)
- catheter is inserted via a cannula inserted into the great or lesser saphenous vein just distal to saphenofemoral or saphenopopliteal junction.
- area surrounding vein is anaesthetised.
- catheter is used to cause injury (heat or laser) to the vein leading to fibrosis and occlusion of the vein.
What are the complications of endovenous intervention?
(3)
skin burns
paraesthesiae
phlebitis (inflammation of the vein)
Outline the process of foam scleropathy.
- Under ultrasound guidance, a chemical foam is inserted into the vein via cannula.
- The foam causes damage to the vessel wall resulting in fibrosis, scarring and occlusion.
What are the complications of foam scleropathy.
(3)
- MI, stroke, TIA
- thrombophlebitis (like DVT in superficial veins)
- skin pigmentation
In treatment of varicose veins with open surgery, where is the initial incision made on the lower limb?
What is the next step?
How are small, superficial varicose veins removed?
saphenofemoral junction
the saphenous vein is ligated from the femoral artery and then a tool is inserted down the length of it and used to extract the vein.
small veins - removed using a ‘stab’ incision, and a hook removal.
What are the complications associated with open repair surgery for varicose veins?
(3)
- general anaesthesia
- nerve damage
- wound infection
Give examples of chronic venous insufficiency?
(4)
- deep venous reflux (e.g. DVT)
- superficial venous reflux
- venous obstruction (e.g. congestion, HF, portal hypertension)
- failure of calf muscle pump
Outline the pathophysiology of chronic venous insufficiency.
(8)
- venous reflux/valve failure
- Starling’s forces are compromised
- venous hypertension
- infiltration, oedema
- increases perfusion distance (= impaired tissue perfusion)
- impaired healing
- inflammation
- fibrosis (= impaired tissue perfusion)
What are the signs and symptoms of chronic venous insufficiency?
oedema
lipodermatosclerosis
haeamsiderm pigmentation
hypopigmentation
ulceration
eczema
telangiectasia
What is telangiectasia?
- widening of venules cause threadlike, red lines or pattern on skin.
- referred to as spider veins.
What is lipodermatosclerosis?
How does it present?
- changes in the skin of the lower legs.
- form of lower extremity panniculitis (inflammation of the subcutaneous fat).
- presents with pain, hardening of skin, change in skin colour and tapering of the legs above the ankle (inverted champagne bottle).
Signs and symptoms include pain, hardening of skin, change in skin color (redness), swelling, and a tapering of the legs above the ankles.
What is haemosiderin pigmentation?
(2)
- pigmentation due to deposits of hemosiderin protein
- stores iron in tissues which gives an orangey colour.
What are the characteristics of a venous ulcer?
(6)
- shallow and flat, irregular margins
- granulation/redness
- inflammation/exudative
- oedema
- black/brown
- gaiter area (above ankle to below knee; medial and lateral sides)
What are the characteristics of an arerial ulcer?
- deep wound, punched out margins
- ischaemic surrounding; shiny, tight, hairless skin
- no exudate, unless infected
- necrotic tissue may be present
Where are venous ulcers most likely to form?
above medial and lateral malleoli (sides of ankles)
Where are arterial ulcers most likely to form?
(4)
pressure points:
- under heel
- over malleoli
- over toe joints
- anterior shin
Where are neuropathic ulcers most likely to form?
(5)
How can you tell when it is not neuropathic?
- under heel
- over malleoli
- over toe joints
- under metatarsal head
- inner side of metatarsal head
when it is painful
What investigations are carried out to diagnose the ulcer type?
History
Examination
ABPI (ankle brachial pressure index - rules out arterial disease)
What is the main contraindication for compression bandaging?
arterial disease (leads to acute limb ischaemia)
How are venous ulcers treated?
(4)
Wound care – little role for systemic antibiotics
Elevation
Compression bandaging
Shockwave therapy
What can lead to lymphoedema?
(secondary causes)
(4)
- Malignancy
- Surgery (after breast surgery, patients wear protective sleeves to avoid upper limb oedema)
- Radiotherapy
- Infection
What can lead to lymphoedema?
(primary causes)
Milroy’s disease (congenital lymphedema). This disorder begins in infancy and causes lymph nodes to form abnormally.
Meige’s disease (lymphedema praecox). This disorder often causes lymphedema around puberty or during pregnancy, though it can occur later, until age 35.
Late-onset lymphedema (lymphedema tarda). This occurs rarely and usually begins after age 35.
What is the treatment for lymphoedema?
elevation
compression bandaging
drainage
