Venous disorders Flashcards
Veins vs arteries
Veins:
* Valves
* Larger lumen
* Thin muscle and elastic layers
* Use pulsation of arteries in upper limb for venous return
Arteries:
* Thick muscle and outer wall
* No valves
Vein drainage simple structure
- Superficial vein
- Communicating/perforator vein
- Deep vein
Blood moves superficical to deep
Examples of superficial veins and deep veins
- Long and short saphenous vein = superficial
- Popliteal = deep
Anatomy short vs long saphenous
- Short saphenous - lateral, drains into popliteal vein at the saphenopopliteal junction
- Long saphenous - medial, drain at saphenofemoral junction
Where are these junctions?
Great saphenous –> femoral
Short saphenous –> popliteal
Contents of femoral triangle
- NAVEL
- Femoral nerve, artery, vein, empty space, lymphatics
Drainage system of leg - veins
Great saphenous = medial
Image shows superficial and deep venous system
Two pumps in body
- Heart
- Calf muscles - containing venous sinusoids filled with blood ready to be returned to heart with contraction of muscle
What is ambulatory venous HTN?
- When relax calf muscle, blood drains from superficial to deep system through perforators
- Each time this occurs, superficial vein pressure reduces
- Valve failure/obstruction = AVH due to pressures not being reduced
- = dilation of superficial venous system
What is a varicose vein?
- Abnormally dilated
- Tortuous
- SC veins
- 3mm or more in diameter
More common in women than men
RF for varicose vein
- Immbolity
- Pregnancy
- Standing still occupation
- Obesity
- FH
Classifying varicose veins
- CEAP
- Clinical
- Etiological
- Anatomical
- Pathophysiology
5 questions to ask for varicose?
- Is it definetely varicose?
- Site - great saphenous, short saphenous or unamed?
- Uncomplication or complicated - pigmentation, ulceration, thrombosed, bleeding etc
- Level of incompetent valve
- Deep venous system competency? - if rubbish = relying on superficial only, cannot remove superficial ones as will be no venous drainage
CEAP classification of varicose veins
Symptoms of varicose veins
- Aching/heaviness
- Worse with prolonged standing
- Relieved by elevation/compression
- Swelling
- Itching
- Bleeding
Referral criteria for varicose vein surgery
- Symptomatic primary or symptomatic recurrent
- Lower limb skin changes eg pigmentation/eczema caused by chronic venous insifficiency
- Superficial vein thrombosis - hard painful veins
- Venous leg ulcer - not healed within 2 weeks
Management VV other than surgery if do not meet criteria
- Reassurance
- Lifestyle advice - DATES, avoid prolonged standing
- Compression hosiery - acts as calf muscle pump (can be below knee or above thigh)
Investigations for VV
- USS venous duplex - gold standard - flow and vessel wall findings not just flow like in doppler, asses for valve competence
Surgery options for VV
- EVLA - high temp waves to ablate veins (endovenous laser ablation)
- ERFA - high freq to ablate (endovenous radiofrequency ablation)
2nd line
* Foam sclerotherapy US guided (can cause transient vision loss)
* Venous stripping - high tie (find saphenofemoral junction and tie, strip vein out)
Problem with vein stripping
- Nerve damage
- Long saphenous - saphenous nerve
- Short saphenous - sural nerve damage
How to tell difference with USS of vein vs artery?
- Artery pulsates
- Veins do not
What are phlebectomies?
- Local small incisions to remove isolated superficial varicose veins
- See scar in image
Post op complications of varicose vein surgery
- Haemorrhage
- Recurrence
- Wound infection
- Injury to adjacent structure - saphenous or sural nerve
- Parasthesia
- Scar
Intra-op complications during varicose vein surgery
- Damage to surrounding structures - veins, arteries, nerves
- Bleeding
- DVT
- MI
- Stroke/TIA
Management of venous ulcers
- Compression bandaging - URGO KTwo
What is Saphena Varix?
- Dilatation of the saphenous vein at the saphenofemoral junction in the groin.
- Displays a cough impulse, it is commonly mistaken for a femoral hernia
- suspicion should be raised if the patient has concurrent varicosities present in the rest of the limb.
- These can be best identified via duplex ultrasound and management is via high saphenous ligation.
Signs on exam of varicose veins (other than vein itself)
- Signs of venous insufficiency eg ulceration, varicose eczema, or haemosiderin deposition.
When to not use compression stockings?
- If mixed arterial and venous problem
- Need to measure ankle brachial pressure index
Pressures in RA to leg veins
- Column of blood 100mmHg - each time walk increases by 2-3x to ensure venous return
Arterial vs venous ulcer
Management of venous ulceration
- Compression therapy - 40mmHg pressure
- Four layer bandaging, stockings, short stretch bandaging or compression wraps
- UNLESS arterial insuffienciency
Can you treat varicose veins if you have a DVT surgically?
- NO - removing part of superficial venous when deep venous system is compromised can worsen the venous hypertension as drainage from leg is even worse now
- If varicose veins and DVT, need to have non-surgical management and offer intervention potentially in future
How does thermal ablation work?
- Heating vein from inside
- Using radiofrequency or laser catheters
- = irreversible damage to vein
- = fibrosis and closure of vein lumen
- Under US guidance
- Local or general anaesthetic
How does foam sclerotherapy work?
- Injecting sclerosing (irritating) agent into varicosed vein
- = inflammatory response
- = closure of vein
- Under US guidance to ensure foam does not enter deep venous system
- Local anaesthetic
