Venous Disease and Chronic Ulcers Flashcards
What is chronic venous disease?
Disease where VR is impaired leading to sustained venous HTN
What are the 3 main pathological mechanisms contributing to the development of chronic venous disease?
ROC:
Reflux
Obstruction
Calf muscle pump failure
Describe the superficial venous system of the lower limb
Greater saphenous vein
Small saphenous vein
Anterior accessory saphenous vein
Vein of Giacomini
Describe the deep venous system of the lower limb
Tibial veins
Popliteal vein
Superficial femoral vein
Common femoral vein
External iliac vein
Common iliac vein
What structures join the superficial and deep venous systems?
Perforating veins (with unidirectional valves to prevent reflux)
Saphenofemoral junction (SFJ)
Saphenopopliteal junction (SPJ)
What is the prevalence of chronic venous insufficiency in the adult population?
10-35%
What % of recognised ulcers have been present for >12 months?
50%
Describe the pathophysiology of venous disease
Blood flows from superficial to deep veins through unidirectional valves During exercise, a combination of the calf muscle pump, vein patency and valvular competence reduces venous pressure from 90 mmHg to 30 mmHg Failure of any or all of these systems results in chronic venous insufficiency Pathway from venous HTN to ulceration not fully understood and still debated (“white cell trapping” and “fibrin cuff” theories are most popular)
Describe the “white cell trapping” hypothesis of venous disease
WBCs are larger and less deformable than RBCs When perfusion pressure is reduced by venous HTN, WBCs plug capillaries and RBCs build up behind WBC activation occurs Endothelial adhesion by WBC releases proteolytic enzymes and oxygen free radicals causing endothelial and tissue damage
Describe the “fibrin cuff” hypothesis of venous disease
Increased venous pressure is directly transmitted to capillaries resulting in capillary elongation and increased endothelial permeability Larger molecules such as fibrinogen become deposited into tissues Fibrinogen is converted to fibrin Accumulation of fibrin acts as barrier to oxygen and causes tissue hypoxia leading to ulceration
CEAP classification for chronic venous disease
Clinical classification Etiologic classification Anatomic classification Pathophysiologic classification
Categories of clinical classification in CEAP
C0: no visible or palpable signs of venous disease C1: telangiectasies or reticular veins C2: varicose veins C3: oedema C4a: pigmentation or eczema C4b: lipodermatosclerosis or atrophie blanche C5: healed venous ulcer C6: active venous ulcer Then can be S: symptomatic or A: asymptomatic
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Telangiectasies or reticular veins (C1)
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Lipodermatosclerosis (C4b)
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Atrophie blanche (C4b)
Symptoms of chronic venous disease
Pain (aching, tightness) Skin irritation Calf heaviness Muscle cramps
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Venous eczema
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Varicose veins
Categories of etiologic classification in CEAP
Ec: congenital Ep: primary Es: secondary (post-thrombotic) En: no venous cause identified
Categories of anatomic classification in CEAP
As: superficial veins Ap: perforator veins Ad: deep veins An: no venous location identified
Categories of pathophysiologic classification in CEAP
Pr: reflux Po: obstruction Pr,o: reflux and obstruction Pn: no venous pathophysiology identifiable
What is a varicose vein?
Elongated, tortuous, dilated vein (thin-walled,, valve deformed, resulting in abnormal blood flow and bulging of the skin)
Distinguish between primary and secondary varicose veins
Primary: affecting superficial veins or perforators in the absence of deep incompetence Secondary: associated with deep venous incompetence from recanalisation of previous DVT (i.e. venous obstruction)
What are the only solid predisposing factors for varicose veins?
Genetics Previous DVT
How much risk does genetics confer for varicose veins?
If both parents affected, risk is 90% If one parent affected, risk is 25% for males and 62% for females
Describe the clinical presentation of varicose veins
Cosmetic issues (e.g. telangiectasia, reticular veins, varices) Pain (general leg ache or heaviness) Swelling (early on causes ankle pitting oedema, later may become indurated) Thrombophlebitis Bleeding Skin changes (varicose eczema, pigmentation, lipodermatosclerosis, atrophie blanche) Ulceration
Thrombophlebitis
How can venous claudication be distinguished from arterial claudication?
Arterial: resolves with rest Venous: does not resolve with rest but requires elevation for 10-20 mins
“Inverted champagne bottle” is the common descriptor for this skin change seen in venous disease
Lipodermatosclerosis
What Ix should be performed in the setting of varicose veins?
Venous duplex Descending venography
Descending venography method
Dye injected and XRs taken
Describe the principles of conservative management for varicose veins
Elevation Avoid standing still (activate calf muscle pump) Dressings for ulceration Graduated compression stockings
Classes of graduated compression stockings
1: 45 mmHg
Options for varicose vein therapy
Conservative Sclerotherapy Open surgery Endovenous laser therapy (EVLT) Radiofrequency ablation (RFA)
What different kinds of sclerotherapy are there? What is the difference between the two?
UGS (usually for larger veins) Microsclerotherapy (for smaller veins)
What different options are their for surgical management of varicose veins?
SFL (saphenofemoral ligation) SPL (saphenopopliteal ligation) GSV strip Stab phlebectomy (removing varicose veins on surface of legs; tiny punctures are made and veins are removed through these)
How is EVLT performed?
Endovenous laser treatment treats varicose veins using an optical fiber that is inserted into the vein to be treated, and laser light, normally in the infrared portion of the spectrum, shines into the interior of the vein; this causes the vein to contract, and the optical fiber is slowly withdrawn
How is RFA performed?
Under ultrasound guidance, a radiofrequency catheter is inserted into the abnormal vein and the vessel treated with radio-energy, resulting in closure of the involved vein Usually used to treat the greater saphenous, small saphenous and perforator veins
What are the 3 most common kinds of ulcer?
Ischaemic Neuropathic Stasis/venous NB Ulcers may be of mixed aetiology (arterial/venous, neuroischaemic)
List 4 other types of ulcer
Infective Neoplastic Systemic disease Traumatic
List 3 types of infective ulcers
Syphilis Mycobacterium Osteomyelitis
List 5 types of neoplastic ulcers
SCC BCC Melanoma Metastatic Kaposi’s sarcoma
List 4 features on Hx of ischaemic ulcers
Painful ulcer Hx of claudication or rest pain CV RFs Previous peripheral vascular surgery
What is the typical location of an ischaemic ulcer?
Distal periphery, over dorsum of foot or pretibia
What is the typical appearance of an ischaemic ulcer?
Punched out edges Ulcer base: poorly developed grey granulation tissue Surrounding skin is pale or mottled with no signs of inflammation Little bleeding when debrided
List 5 signs of chronic arterial insufficiency
Atrophic nails/skin Venous guttering Slow capillary return Absent pulses Beurger’s +ive
List 2 features on Hx of a neuropathic ulcer
Painless Hx of DM or other causes of neuropathy
What is the typical location of neuropathic ulcer?
Deep, on pressure points or calluses
Give 6 examples of pressure points on the feet
Plantar surface of MTP joints “Bunion” or “bunionette” areas Dorsum of IP joints Base of 5th metatarsal MM or LM Callused posterior rim of heel pad
List 4 signs of neuropathy
Hypoaesthesia Proprioception 2-point discrimination Vibratory perception
Describe 3 features of distorted foot architecture
Hyperextension of MTP joints Hyperflexion of IP joints Charcot’s deformity (“rocker-bottom” appearance)
List 4 features on Hx of a venous ulcer
Hx of venous insufficiency (varicose veins, superficial thrombophlebitis or DVT, variceal bleeding) Previous venous surgery
Describe the typical location of a venous ulcer
Over gaiter area (commonly medial malleolus)
Describe the typical appearance of a venous ulcer
Larger and irregular edge Shallow Moist granulating base Surrounded by zone of inflammation and stasis dermatitis
List 6 signs associated with venous insufficiency
Varicose veins Pitting oedema Varicose eczema Pigmentation Lipodermatosclerosis Atrophie blanche
Compare the 3 main types of ulcer by their most common site
Arterial: distal at toe tips, pressure areas
Venous: gaiter area
Neuropathic: dorsum of PIP/DIP, plantar surface MTP, MM or LM, heel, other calloused areas
Compare the 3 main types of ulcer by size/shape/depth
Arterial: small deep Venous: large, irregular, shallow Neuropathic: variable
Compare the 3 main types of ulcer by their base
Arterial: pale and sloughy Venous: granulating Neuropathic: granulating
Compare the 3 main types of ulcer by their edges
Arterial: punched out Venous: sloping and shallow Neuropathic: punched out
What initial investigations should be performed in the case of an ulcer?
Basic bloods: FBE, UEC, CRP, glucose, HbA1c, vasculitic screen, ESR, thrombophilic screen Swab M/C/S XR +/- bone scan +/- MRI Duplex (arterial or venous) CTA DSA Biopsy
List 6 principles of treatment for ulcers
Bed rest Elevation or dependency IV Abx Dressings Debridement/split skin graft Treat underlying aetiology (revascularisation, compression stockings/varicose vein surgery, pressure offloading footwear/total contact cast)
What kind of ulcer? Why?
Arterial
What kind of ulcer? Why?
Neuropathic
What kind of ulcer? Why?
Venous
Spot diagnosis
Venous eczema
Spot diagnosis
Atrophie blanche
Scarring after skin injury with poor perfusion
Spot diagnosis
Lipodermatosclerosis
