Venous and Lymphatic - presentation, investigation and therapy

Question 1

Define what varicose veins are?

Answer 1

Dilated and twisted (tortuous), often superficial, vein

Mostly common in lower limbs

Question 2

Which three factors help with assistance of flow against gravity?

Answer 2

• Valves
• Calf muscle pump
• Perforating veins to drain blood into deep system (deep veins are within muscular compartments and can withstand higher pressure)

Question 3

What are causes of valvular failure?

Answer 3

Surgical or Trauma of valve

DVT: Vein may recanalise through thrombus but canal will be high pressure avalvular channel

Hormonal changes: in pregnancy can cause vein and valve weakness leading to incompetence. Enlarged uterus can cause mechanical obstruction to venous flow within deep system.

Tumours = mechanical obstruction -> increased pressure within distal venous systems.

Question 4

What is, simply, the pathophysiology once a valve has failed?

Answer 4

Venous pressure will increase and there is dilation of distal vein and furthur valvular incompetence

Question 5

What are the risk factors for varicose veins?

Answer 5

Age
Female 
Pregnancies
DVT
Standing for long periods
Family history

Question 6

Which gender is varicose veins more prevalent in?

Answer 6

Females! ( 20-25%)

*For males its only 10-15%

Question 7

What are the clinical symptoms of varicose veins?

Answer 7

Burning 
Itching 
Heaviness
Tightness 
Swelling 
Discoloration
Eczema 
Ulceration

Question 8

What are the clinical signs/examination of varicose veins?

Answer 8

LOOK:
Phlebitis (inflammation of a vein)
Bleeding 
Eczema 
Ulceration

FEEL:
Raised

Question 9

What is the tap test?

Answer 9

Place one hand over the saphenofemoral junction and one over long saphenous vein above knee

Tap the saphenofemoral junction - a transmitted impulse at knee indicates incompetence between two hands

Question 10

What is the trendelenburg/tourniquet test?

Answer 10

Lie patient flat and drain superficial vein by raising leg and stroking vein towards trunk.

Apply pressure over the saphenofemoral junction and ask patient to stand.

If varicose vein dont dilate on standing, your acting as a valve so = incompetence in saphenofermoral junction

The tourniquet test is similar but uses tourniquet instead of hand and repeating the test at 10cm intervals down leg to find level of incompetence.

Question 11

What is the doppler test?

Answer 11

Hold doppler probe over saphenofemoral junction then squeeze calf muscle.

If competent = whoosh sound
If incompetent = two whoosh upward and downward

Question 12

What are investigations for varicose veins?

Answer 12

Ultrasound

- shows valves, anatomy of varicose veins (dilation and tortuousity) and can show dynamic blood flow eg: reflux

Question 13

What is the classification of chronic venous disease?

Answer 13

C0 - No visible or palpable signs of venous disease
C1 - Teleangiectasies or reticular veins
C2 - Vericose veins
C3 - Oedema
C4a - Pigmentation or eczema
C4b - Lipodermatosclerosis or athrophie blanche
C5 - Healed venous ulcer
C6 - Active venous ulcer

Question 14

Whom should treatment be offered to?

Answer 14

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

Question 15

What are the management options for chronic venous disease?

Answer 15

1. First line: endovenous treatment
2. Second line: Ultrasound guided foam sclerotherapy
3. Third line: Open surgery

If intervention is unsuitable offer compression hosiery

Intervention shouldnt be offered if the deep venous system is obstructed eg DVT or in pregnancy

Question 16

What is endovenous treatment?

Answer 16

1. LSV or SSV is cannulated under ultrasound guidance
2. A catheter is passed up the length of the vein is just distal to the saphenofemoral or saphenopopliteal junction
3. Local anaesthetic used for small skin puncture and then infiltrated in superficial tissues around the length of the vein
4. 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.

Question 17

What are complications of endovenous treatment?

Answer 17

Skin burns
Paraesthesiae (0-10%)
Phlebitis (5%)
Deep vein thrombosis (1%)

Question 18

What is foam sclerotherapy?

Answer 18

Under ultrasound guidance, a chemical foam is injected into the affected vein. The foam damages the venous walls, causing fibrosis and occlusion.

Question 19

What are the complications of foam sclerotherapy?

Answer 19

The vein should be occluded (with pressure) proximally to prevent foam migrating and causing the potential complications of a stroke, TIA or TI.

Thrombophlebitis (7%) and skin pigmentation (6%) can also occur

Question 20

What is open surgery?

Answer 20

1. Under GA, a groin incision is made and the saphenofemoral junction is exposed
2. 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.
3. Small superficial varicose veins are avulsed using small stab incisions and a small hook instrument.

Question 21

What are the complications of open surgery?

Answer 21

Anaethetic risk, wound infection, damage to nearby nerves (saphenous and sural nerves), bleeding

Question 22

What can cause venous insufficiency?

Answer 22

Failure of calf muscle pump
Superficial venous reflex
Deep venous reflux (surgery, DVT, congenital)
Venous obstruction (heart failure, portal hypertension, obesity)

Question 23

What is the pathophysiology after venous insufficiency?

Answer 23

Venous insufficiency -> Venous hypertension -> Endothelial leak -> Oedema -> Increased perfusion distance -> Impaired healing -> Inflammation -> Fibrinogen tissue damage -> Impaired tissue perfusion

*note that oedema can also cause impaired tissue perfusion

Question 24

What are the signs of chronic venous insufficiency?

Answer 24

Oedema 
Telangiectasia 
Eczema 
Haemosiderin pigmentation
Hypopigmentation
Lipodermatosclerosis 
Ulceration

Question 25

What are venous ulcers?

Answer 25

Breach the skin between knee and ankle joints, present for >4 weeks

• Gaiter area
• Granulomatous (red) base
• Shallow
• Irregular margins
• Exudative, oedematous
• Painless, pulses present

Question 26

What are the differences in terms of location between venous and arterial ulcers?

Answer 26

Venous = above medial malleoli

Arterial = Over toe joints, anterior shin, under heel or over malleoli

Question 27

What is the treatment for venous ulcers?

Answer 27

Wound care - little role for systemic antibiotics
Elevation
Compression bandaging
Shockwave therapy

Question 28

What is the primary and secondary aetiology behind lymphoedema?

Answer 28

Primary:

• Congenital
• Early onset: around puberty
• Tarda: age >35

Secondary:

• Malignancy
• Surgery
• Radiotherapy
• Infections

Question 29

What is the difference between obliteration and hyperplasia lymphoedema?

Answer 29

Obliteration 92%:

• Distal obliteration (illiac nodules still present)
• Distal and proximal obliteration
• Pelvic obstruction

Hyperplasia 8%:

• Bilateral hyperplasia (abnormal thoracic duct)
• Megalymphatics

Question 30

What is the treatment for lymphoedema?

Answer 30

Elevation and drainage