Venous Disease Flashcards
Venous Anatomy
Venous blood drains from the head and neck assisted by gravity when the person is upright.
The lower limbs cannot drain passively – the veins here are divided into superficial and deep veins separated by one-way valves and connected by perforating veins which also contain valves.
Muscle contraction during normal activity ‘massages’ the blood into the deep veins and helps drive it towards the heart. Retrograde flow is prevented by the valves.
Long and Short Saphenous Veins
- Long (great) saphenous vein – passes anterior to the medial malleolus at ankle, up the medial aspect of the calf and thigh to join the common femoral vein at saphenofemoral junction.
- Short (lesser) saphenous vein – passes posterior to the lateral malleolus at the ankle and up the posterior aspect of the calf. It commonly joins the popliteal vein at the saphenopopliteal junction which usually lies 2cm above the posterior knee crease.
Presentation of Venous Disease
It can present in one of four ways – varicose veins, superficial or deep vein thrombosis or chronic venous insufficiency and ulceration.
Venous Symptoms - Pain
Patients with uncomplicated varicose veins may have aching discomfort in the leg, itching and a feeling of swelling. Symptoms are aggravated by prolonged standing and towards the end of the day.
The pain of established deep vein thrombosis is deep seated and associated with swelling below the level of the obstruction.
Superficial venous thrombophlebitis produces a red, painful area overlying the vein involved.
Varicose ulceration can be painless.
Venous Symptoms - Swelling
Associated with varicose veins, deep venous reflux and deep vein thrombosis.
Venous Symptoms - Discolouration
Chronic venous insufficiency causes pigmentation due to deposition of haemosiderin (from breakdown of extravasated blood) in skin leading to lipodermatosclerosis.
This varies in colour from deep blue/black to purple or bright red. It usually affects the medial, lower third but may be lateral if superficial reflux predominates in the short saphenous vein.
Venous Symptoms - Ulceration
Venous ulceration is usually seen above the medial malleolus. It only occurs with severe venous disease and is always associated with lipodermatosclerosis.
Varicose Veins - Definition
Long tortuous and dilated veins of the superficial venous system.
Varicose Veins - Pathology
The deep venous circulation is at a higher pressure than the superficial venous circulation. Where the 2 systems join there are valves which have the purpose of preventing the pressure within the deep system coming out into the superficial system. If these valves go wrong (i.e. become incompetent) then the superficial veins dilate and appear as varicose veins.
The most common sites where this may occur in the lower limb are first at the long saphenous femoral vein junction in the groin, second at the short saphenous popliteal vein junction in the popliteal fossa and third at perforating veins – 3 on the medial calf and in some patients an additional one on the medial thigh (although position of these does vary).
Varicose Veins - Causes
Can be broadly divided into primary and secondary causes:
- Primary – commonest type of varicosities – defect is congenital or even an absence of valves.
- Secondary – thrombosis of deep or superficial veins, overactive muscle pump e.g. in cyclists, AV malformations, pregnancy, abdominal or pelvis mass, ascites, obesity or constipation.
Varicose Veins - Risk Factors
Prolonged standing, obesity, pregnancy, positive family history, oral contraceptives (these need to be stopped 6-8 weeks before surgery due to the risk of DVT) or history of DVT or PE.
Varicose Veins - Clinical Features
- Symptoms – ‘my legs are ugly’ – pain, cramps, tingling, heaviness and restless legs.
- Signs – oedema, venous eczema, ulcers, haemosiderin skin discolouration, haemorrhage, phlebitis, atrophie blanche – white scarring around a healing ulcer and lipodermatosclerosis (skin hardness from subcutaneous fibrosis caused by chronic inflammation and fat necrosis – may produce inverted champagne bottle).
Varicose Veins - Investigations
Colour duplex scanning and marking of perforators, venography to show obstructed veins, collaterals and incompetent perforators and ultrasound to show reflux into superficial veins.
Varicose Veins - Conservative Management
- Treat the underlying cause where possible e.g. obesity or constipation.
- Education – avoid prolonged standing, wear support stockings, weight loss and regular walks.
- Criteria for referral – bleeding, pain, ulceration, superficial thrombophlebitis or impact on QOL.
- Injection sclerotherapy – used for varicosities below the knee if there is no gross sapheno-femoral incompetence. Sclerosant e.g. ethanolamine is injected at multiple sites and the vein compressed for a few weeks to avoid thrombosis. A development of this technique is to mix the sclerosant with air to form foam that is injected at a single site and spreads throughout veins.
- Laser coagulation – used only for small varicosities and thread veins.
Varicose Veins - Surgical Management
More definitive and indicated for patient with sapheno-femoral incompetence and major perforators. There are several choices all of which are day cases:
- Trendelenburg procedure (high tie) – ligation of the long saphenous at entry into the femoral.
- Short saphenous vein ligation – ligation of the short saphenous vein deep in popliteal fossa.
- Multiple avulsions – individual varicosities are stripped through stab incisions on the leg.
- Vein stripping – not usually performed due to potential of damage to the saphenous nerve.
