Venous disease

Question 1

What veins are in the superficial system of the lower limb?

Answer 1

• GSV
• SSV
• some others

Question 2

Where are the superficial veins located in relation to the deep muscle fascia?

Answer 2

superficial

Question 3

What is the pathway of the greater saphenous vein?

Answer 3

dorsal venous arch of foot ->passes anterior to the medial malleolus ->runs up the medial calf and thigh -> joins the femoral vein at the saphenofemoral junction (4cm below and 4cm lateral to the pubic tubercle)

Question 4

What is the pathway of the small saphenous vein?

Answer 4

lateral dorsal venous arch of foot -> travels up the posterior calf -> drains into the popliteal vein

Question 5

What are the 2 positions where the superficial drain into the deep veins?

Answer 5

• saphenopopliteal junction

- saphenofemoral junction

Question 6

What are the veins of the deep system?

Answer 6

• tibial vein, popliteal vein, femoral vein and deep femoral vein -> common femoral vein

Question 7

Where are the deep veins located?

Answer 7

• deep to the muscle fascia either within or between muscles

Question 8

Where are the perforating veins located?

Answer 8

• 3 in medial calf

- 3 in the thigh

Question 9

What are the 3 mechanisms of venous hypertension?

Answer 9

• venous obstruction
• valvular reflux
• failure of calf-muscle pump

Question 10

What are the 2 theories for the pathway from venous htn to ulceration?

Answer 10

1. white cell trapping hypothesis - WBCs plug capillaries -> RBCs build up behind -> WBC activation -> endothelial activation -> release of enzymes and ROS -> tissue and endothelial damage
2. fibrin cuff hypothesis - high venous pressure leads to fibrin deposition and trapping in venous walls -> hypoxia -> ulceration

Question 11

What are the criteria used to classify the severity of venous disease?

Answer 11

C = clinical classification (e.g. presence of ulcers, oedema)
E = etiological classification (e.g. congenital, primary or secondary to DVT)
A = anatomical classification (superficial, deep or perforating veins)
P = pathophysiological classification (reflux, obstruction or calf muscle pump failure)

Question 12

What is a varicose vein?

Answer 12

• dilated, tortuous and elongated veins

- usually superficial or perforators

Question 13

What are the predisposing factors for DVT?

Answer 13

• genetics

- previous DVT

Question 14

What is the clinical presentation of chronic venous disease?

Answer 14

• cosmetic
• pain
• swelling
• thrombophlebitis
• bleeding
• skin changes
• ulceration

Question 15

What kind of pain is felt in chronic venous disease?

Answer 15

• general leg ache or heaviness that is worse at the end of the day

Question 16

What is venous claudication?

Answer 16

• pain that does not resolve with rest

- requires 10-20 mins elevation for relief

Question 17

Where does varicose eczema occur and why?

Answer 17

• medial calf above the medial malleolus

- this is where the perforator veins are located

Question 18

What is varicose eczema?

Answer 18

• RBCs escape through the vein wall into the skin
• break down
• haemosiderin is deposited in the skin where it is a pigment and an irritator

Question 19

What is lipodermatosclerosis and where does it occur?

Answer 19

• fibrosis of skin and underlying subcutaneous tissue
• occurs most distally in the lower limb where the pathological effects of venous hypertension are most profound
• gives an inverted champagne bottle appearance of the lower limb

Question 20

What is the best investigation for venous disease?

Answer 20

venous duplex ultrasound

Question 21

What is atrophie blanche?

Answer 21

a confluence of white, depressed scars from previous venous ulcers

Question 22

What are the characteristics of a venous ulcer? (site, appearance, pain?)

Answer 22

• located over gaiter area
• large, irregular edge, shallow
• moist granulating base
• surrounded by a zone of inflammation
• may have a dull ache

Question 23

What are the characteristics of an arterial (ischaemic) ulcer?
(site, appearance, pain?)

Answer 23

• located in the periphery over dorsum of foot or pretibial area
• small, punched out edges
• sloughy base of grey poorly formed granulation tissue
• surrounding skin is pale or mottled
• little bleeding when debrided
• painful

Question 24

What are the characteristics of a neuropathic ulcer?

Answer 24

• located over pressure points or calluses
• punched out with a granulating base
• painless

Question 25

What are the principles of management of venous ulceration?

Answer 25

• bed rest
• elevation
• IV antibiotics
• dressings
• debridement/skin graft
• treatment of underlying pathology (revascularisation, compression stockings)