Venous Disease

Question 1

What are varicose veins?

Answer 1

Long, tortuous, dilated veins of the superficial venous system

Question 2

What is the underlying pathology of varicose veins?

Answer 2

Blood from superficial veins passes into deep veins via perforator veins (sapheno-fem/pop juncn)
Incompetent valves –> venous hypertension – DILATATION

Question 3

What is the anatomical distribution of varicose veins?

Answer 3

Long saphenous (med mall, up inner thigh to groin)
Short saphenous (popliteal, down back of leg)

Question 4

What are the primary causes of varicose veins?

Answer 4

Unknown

Congenital valve absence (v. rare)

Question 5

What are the secondary causes of varicose veins?

Answer 5

Superficial varicosities 2o to deep vein incompetence

• Prev DVT
• Raised systemic venous pressure (pelvic tumour, pregnancy, AVF)

Question 6

What are the potential complications of varicose veins?

Answer 6

Ulcers (long term fluid buildup)
Blood clots
Bleeding

Question 7

How are doppler ultrasound probes used to diagnose varicose veins?

Answer 7

Listen for flow in incompetent valves

• veins occluded
• on release flow >0.5-1 second indicates incompetence

Question 8

What are the two main venous systems in the lower limb?

Answer 8

Superficial

Deep

Question 9

Where does the deep venous system drain?

Answer 9

Muscular compartment

Question 10

Where do the deep veins run?

Answer 10

Alongside the major arteries

Question 11

What veins comprise the superficial venous system?

Answer 11

Long saphenous (medial) --> Saphenofemoral
Short saphenous (lateral) --> Popliteal

Question 12

Where does the superficial venous system drain?

Answer 12

Skin

Superficial Tissues

Question 13

Where are the deep and superficial venous systems joined?

Answer 13

Saphenofemoral

Saphenopopliteal

Question 14

What are perforating veins?

Answer 14

Communications between the two systems

Question 15

What drives venous return to the heart?

Answer 15

Muscular pump action by the calf

Inspiration decreasing intrathoracic pressure

Question 16

What are the main sx of varicose veins?

Answer 16

Unsightly apperance
Tirdeness, aching
Oedema of ankles
Itching/nocturnal cramps

Question 17

What are the signs of deep venous insufficiency?

Answer 17

Haemosiderosis
Eczema
Lipodermatosclerosis

Question 18

What is deep venous insufficiency?

Answer 18

POSTPHLEBITIC LIMB
Incompetent valves of deep venous system
Calf pump no longer efficiently returns blood to thoracic cavity

Question 19

What are the causes of deep venous insufficiency?

Answer 19

Primary - Congenital absence of valves

2o - DVT, AVF

Question 20

What are the sx/signs of deep venous insufficiency?

Answer 20

Lower limb pain/discomfort
Oedema
Varicose veins
Haeomsiderin deposition (gaiter area)
Eczema
Atrophie blanche
Lipodermatosclerosis
Ulceration

Question 21

What investigations are appropriate in suspected deep venous insufficiency?

Answer 21

Duplex Sonography/Venography

Question 22

How can deep venous insufficiency be managed?

Answer 22

Only symptomatic management available

Question 23

What investigations are commonly used in venous disease?

Answer 23

Hand-held Doppler –> Identifies reflux at sapheno-fem/pop junctions
Duplex scanning - Valvular/perforating vv incompetence, large vv occlusion
Venography - Fluoroscopy used to find deep vv occlusion/perf vv reflux

Question 24

What is the Trendelenberg test?

Answer 24

No longer recognised method of diagnosis
Involves elevating the leg and applying tourniquets at different levels to identify the lowest point of deep-sup incompetence

Question 25

What are the indications for treatment for varicose veins?

Answer 25

Grossly dilated/symptomatic varicosities
Haemorrhage
Concomitant deep venous insufficiency
Incompetent perforator veins

Question 26

What are the non-surgical management options for varicose veins?

Answer 26

Lifestyle advice - avoid standing, exercise, wt loss
Graded compression stockings
Endothermal ablation - USS guided ablation of vv
Sclerotherapy - sclerosant injected into vv, compression bandaging for 2/52 allows fibrosis

Question 27

What are the surgical management options for varicose veins?

Answer 27

GOLD STANDARD
Disconnect great saphenous from femoral vv
Incompetent perforators ligated

Question 28

What are the potential complications of untreated varicosities?

Answer 28

Haemorrhage

Phlebitis - vv become hard, tender, erythematous