Venous and Lymphatic Disease

Question 1

What causes varicose veins?

Answer 1

Valvar dysfunction

Question 2

Where are the common sites for varicose veins?

Answer 2

Long saphenous - 80-87%,

Short saphenous - 21-30%

(alone 13%, combined- 21%)

Question 3

Which gender is most likely to get varicose veins?

Answer 3

Question 4

What are the symptoms and signs of varicose veins?

Answer 4

Cosmesis

Localised or generalised discomfort in the leg

Nocturnal cramps

Swelling

Acute haemorrhage

Superficial thrombophlebitis (inflammation of the wall of a vein with associated thrombosis, often occurring in the legs during pregnancy.)

Pruritus - itching

Skin changes

Question 5

What are the indications for surgery on varicose veins?

Answer 5

? Symptoms

Superficial thrombophlebitis

Signs of chronic venous insufficiency

Bleeding

Others: cosmetic

anxiety that disease may progress

Question 6

What are the possible treatments for varicose veins?

Answer 6

Surgery

–High tie, stripping, multiple stab avulsions

Injection (sclerotherapy)

Minimally invasive procedures

Compression

Conservative (may include compression)

Question 7

What are contraindications for surgical intervention of DVT?

Answer 7

Previous DVT (collaterals)

Arterial insufficiency

Patient co morbidity

Morbid obesity

Question 8

What are the surgical treatments for varicose veins which are under GA?

Answer 8

Ligation of the sapheno-femoral or sapheno-popliteal junctions

Vein stripping and multiple stab avulsions

Question 9

What is the surgical treatment of varicose veins?

Answer 9

Ligation and Stripping

Ligation is when you cut and seal the vein in two places.

The first cut is made near your groin at the top of the varicose vein. The second cut is made further down your leg, usually around your knee or ankle.

The section of the vein is then pulled out

Question 10

Where is ligation usually taken place?

Answer 10

The sapheno - femoral or sapheno - popliteal junctions

Question 11

What are the varicose vein surgery complications?

Answer 11

Common:

minor haemorrhage,

thrombophlebitis (inflammation of the wall of a vein with associated thrombosis, often occurring in the legs during pregnancy., haematoma (a solid swelling of clotted blood within the tissues.)

wound problems, severe pain

Less Common:

sural/saphenous nerves

Rare:

damage to deep veins, arteries, nerves, DVT

Question 12

What are the minimally invasive treatments of main trunk varicosities?

Answer 12

Foam sclerotherapy

–chemical reaction with endothelium

Endovenous laser ablation (EVLA)

–thermal ablation

Radiofrequency ablation (VNUS)

–thermal ablation

All methods are used to seal the vein

Question 13

What are the advantages of local anaesthetic?

Answer 13

Potential advantages

–reduce surgical trauma (bruising, scarring: no incisions) less pain

–reduce time off work

–do not require an operating theatre

–potential to increase patient throughput

Question 14

When might scleropathy not be available?

Answer 14

When there is history of DVT

Question 15

When is surgery recommended?

Answer 15

If endothermal ablation treatments and sclerotherapy are unsuitable for you

Question 16

What are the stages of the Laser (EVLA) - technique?

Answer 16

Micro puncture needle is inserted into the incompetent long or short saphenous using ultrasound

Guidewire is moanouvered to saphenous junction with deep vein using ultrasound.

Catheter and laser fibre introduced over guidewire to 1cm below the junction

(Micro punture needle - guidewire - catheter and laser fibre)

Question 17

What is VNUS?

Answer 17

Uses heat to close vein (85 degrees C)

Question 18

How is foam scleropathy administered?

Answer 18

Question 19

What are signs of chronic venous insufficiency?

Answer 19

Ankle oedema

Telangectasia - Dilation of capillaries causing them to appear as small red or purple clusters, spidery appearance

Venous eczema - lower legs

Haemosiderin pigmentation – yellowish brown pigment formed by the breakdown of haemoglobin

Hypopigmentation “atrophie blanche”

Lipodermatosclerosis

Venous ulceration

Question 20

What is thepathophysiology of chronic venous insufficiency?

Answer 20

Venous hypertension – with right heart failure

Venous engorgement and stasis (distension of vein woth blood)

Imbalance of Starling forces and fluid exudate

Question 21

What is AVP

Answer 21

Known as ambulatory venous pressure( AVP)

Active movements: pressure falls to 30mmHg

Question 22

What does high AVP mean?

Answer 22

High AVP -failure of muscle pump, valves, or

outflow obstruction

Venous Hypertension

Question 23

How can the calf muscle pump fail?

Answer 23

–Superficial venous reflux

–Deep venous reflux

–Venous obstruction

–Neuromuscular

–Obesity

–Inactivity

Question 24

What is a leg ulceration?

Answer 24

–breach in the skin between knee and ankle joint, present for over 4 weeks

Question 25

What is the differential dagnosis of leg ulceration?

Answer 25

–Almost 80% purely venous in origin

–Up to 20% have significant arterial disease

–diabetes, rheumatoid arthritis, vasculitis, CT disease

Question 26

What is treatment for leg ulceration?

Answer 26

Compression therapy

Dressings (non-adherent)

Excersize

(Not systemic and topical therapy - not proven - most ulcers colonised rather than infected)

Question 27

What are the primary causes of lymphoedema?

Answer 27

–Congenital

–Praecox (means it happens at an earlier stage of life)

–Tarda (happens after the age of 35)

Question 28

What are the secondary causes of lymphoedema?

Answer 28

–Malignancy

–Surgery (Radical mastectomy; groin/axillary dissection)

–Radiotherapy

–Infection (Filariasis/tuberculosis/pyogenic)

Question 29

What is treatment of lymphoedema?

Answer 29

Elevation and drainage

Compression