Venous and lymphatic disease - presentation, investigation and therapy Flashcards
Define varicose viens
Dilated superficial veins in the lower limbs
affects largely middle aged woman
What is the cause of varicose veins
Failure of venous valves as they become leaky and lead to back flow of blood
What sites are affected by varicose veins
Long saphenous - 80-87%,
Short saphenous - 21-30%
What is the potential history of a varicose veins pattern
Standing occupation Pregnancy - twins previous DVT Previous major trauma Family history - can be hereditary Complications
What is the signs and symptoms of varicose veins
Cosmesis - disfiguring
Localised or generalised discomfort in the leg
Nocturnal cramps
Swelling
Acute haemorrhage
Superficial thrombophlebitis (inflammation of the wall of a vein associated with thrombosis)
Pruritus - itching
Skin changes
Why does acute haemorrhage occur in varicose veins
Skin becomes fragile over dilated veins so is therefore more prone to bleeding
What skin changes can be seen with varicose veins
discolouration
spider veins
How is varicose veins assessed
With duplex ultrasound:
Non-invasive evaluation of blood flow through arteries and veins
When is intervention for varicose veins required
When symptoms are present
superficial thrombophlebitis
signs of chronic venous insufficiency
bleeding
What is the treatment options for varicose veins
Surgery
Minimally invasive procedures involving thermal ablation:
Endovenous Laser removal
Radio frequency ablation
Injection - sclerotherapy
Compression
What occurs in superficial venous surgery
Happens under general anaesthetic
Tiring of the saphenous vein’s junction and then several tiny cuts are made in the skin through which the varicosed vein is removed
What occurs in the injection of foam sclerotherapy for the treatment of varicose veins
Needle inserted into the incompetent veins under ultrasound control
Foam injected
Foam creates a chemical reaction with endothelium
Thermal ablation occurs destroying incompetent vein tissue with heat
What is the purpose of the ultrasound control when injecting foam
prevented from entering deep venous system
What is the steps in the endogenous later removal technique
Uses ultrasound
Micro puncture needle inserted into the incompetent long or short saphenous veins
Guidewire introduced, and manoeuvred to saphenous junction with deep vein
Catheter and laser fibre introduced over
guide wire to 1cm below junction
and thermal ablation occurs
What occurs in radio frequency ablation (VNUS)
Catheter inserted (thermal ablation) Vein warmed to 85ºC and collapses catheter slowing withdrawn and loses vein
What is the purpose of compression therapy
wear stockings to create a pressure that may drain the vein
What contradictions do you need to consider when performing superficial venous surgery
Previous DVT (collaterals)
Arterial insufficiency
Patient co morbidity
Morbid obesity
What is the possible complications of superficial venous surgery
Minor haemorrhage thrombophlebitis heamatoma wound problems severe pain sural/saphenous nerves are affected
Rare:
Damage to deep veins, arteries and nerves
DVT
What is the advantages of minimally invasive option over surgery for the treatment of varicose veins
reduce surgical trauma (bruising, scarring: no incisions)
less pain
reduce time off work
do not require an operating theatre
potential to increase patient throughput
potentially cost effective
Define chronic venous insufficiency
a condition where veins cannot pump enough blood back to the heart
What is the characteristics signs of chronic venous insufficiency
Ankle oedema
Telangectasia - spider veins
Venous eczema
Haemosiderin pigmentation - orangey colour in the lower limbs
Hypopigmentation “atrophie blanche” - white patches
Lipodermatosclerosis - inflammation of subcutaneous fat in the legs
Venous ulceration
What causes the Haemosiderin pigmentation (orange limbs) in CVI
ruptured blood vessels
What causes hypo pigmentation (white patches) in CVI
loss of nutrients
What is the pathophysiology of CVI
Venous hypertension
Venous engorgement and stasis
Imbalance of Starling forces and fluid exudate
What is ambulatory venous pressure
and what does a high AVP indicate
The fall in pressure from standing motionless to active movements
High =
failure of muscle pump
valves or outflow obstruction
Venous hypertension
What is the potential aetiology of the failure of call muscle pump resulting in CVI
Superficial venous reflux
Deep venous reflux
Venous obstruction
Neuromuscular
Obesity
Inactivity
What is the definition of leg ulceration
Breach in the skin between the knee and the ankle
What is the cause of leg ulcerations
Chronic venous insufficiency arterial disease diabetes, rheumatoid arthritis, vasculitis, Connective tissue disease
What can also be found on examination of leg ulceration
oedema
signs of chronic venous insufficiency
What investigations is needed for leg ulcerations
ABPI (Ankle Brachial Pressure Index) - ratio between the systolic arterial pressure at the ankle and the brachial systolic pressure
Duplex ultrasound
What is the treatment for leg ulceration
Compression therapy - excludes arterial disease
Dressing
Systemic and topical therapy
Exercise - calf muscle pump
What is the primary cause of lymphedema, and when can it occur
Idiopathic:
Congenital - born with
Praecox - before 30
Tarda - after 30
What is the secondary causes of lymphedema
Malignancy
Surgery
(Radical mastectomy; groin/axillary dissection)
Radiotherapy
Infection (Filariasis/tuberculosis/pyogenic)
What is the treatment of lymphedema
Manual drainage - elevation to try and drain the fluid out
compression - to try and rain the fluid out
Define lymphedema
condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system
What is the signs and symptoms of lymphedema
Swelling of part or all of your arm or leg, including fingers or toes.
A feeling of heaviness or tightness.
Restricted range of motion.
Aching or discomfort.
Recurring infections.
Hardening and thickening of the skin (fibrosis)
