Venous disorders - Varicose veins, chronic venous insufficiency

Question 1

What is chronic venous insufficiency?

Answer 1

An inability to pump blood back to the heart.

Sequence of events:

• failure of calf muscle pump
• Venous hypertension
• Venous enlargement and stasis

CVI causes blood to “pool” or collect in these veins, and this pooling is called stasis. This term is often assigned to when both the superficial and deep veins of the legs begin to fail.

Question 2

Presentation of chronic venous insufficiency

Answer 2

• Ankle oedema - pitting oedema
• Venous ulceration
  
  • ​Leg ulcer (usually in gaiters area - above medial malleolus), classically painless

Question 3

What are varicose veins?

Answer 3

Long torturous and dilated veins of the superficial venous system (long and short saphenous veins)

Question 4

What is the sequence of events in the formation of varicose veins?

Answer 4

• Valves prevent backflow of blood deep to superficial veins
• If they become incompetent = venous hypertension and dilation of superficial veins occurs (valves become leaky)

Question 5

What are primary causes of varicose veins?

Answer 5

• Unknown
• Congenital valve absence

Question 6

What are secondary causes of varicose veins?

Answer 6

• Obstruction - DVT, ovarian tumour, foetus
• Valve destruction
• Arteriovenous malformation
• Contipation
• Overactive muscle pumps

Question 7

What are symptoms of varicose veins?

Answer 7

• Nocturnal cramps
• Leg swelling
• Localised discomfort
• Pruritis

Question 8

What are signs of varicose veins?

Answer 8

• Oedema
• Exczema
• Ulceration
• Haemorrhage
• Superficial thrombophlebitis
  
  • ​Phlebitis
  • Vein is painful, tender and hard with overlying redness
• Telangeictasia - dilation of capillaries
• Lipodermatosclerosis - skin hardness from subcutaneous fibrosis caused by chronic inflammation and fat necrosis
• Atrophe blanche

Question 9

What is the following?

Answer 9

Lipodermatosclerosis - skin hardening from subcutaneous fibrosis caused by chronic inflammation and fat necrosis

Question 10

What is the following?

Answer 10

Atrophe blanche - white scarring ay the site of a previous, healed ulcer

Question 11

What is the following?

Answer 11

Superficial thrombophlebitis

Question 12

How would you examine varicose veins?

Answer 12

• Inspect - ulceration, long and short saphenous distribution
• Palpate - tenderness, hardness, pulses (if ulceration so arterial cause can be ruled out)
• Cough reflex at SFJ, Percussion test
• Auscultate - bruits for AV malformation
• Abdominal examination for masses

Question 13

Special tests used in varicose vein examination

Answer 13

• Tap test
  
  • ​One hand over saphenofemoral junction and other over long saphenous vein above the knee
  • Tap saphenofemoral - transmitted pulse indicates incompetant valves
• Hand held doppler
  
  • ​squish calf while doing doppler - “whoosh” x2 as it goes up and down
• Trendelenburg
  
  • ​Lie paitent flat
  • Drain superficial veins by increasing leg
  • Apply pressure over saphenofemoral junction
  • If varicose veins dont dilate you are acting as a competent valve

Question 14

What is the purpose fo the cough reflex at the SFJ?

Answer 14

To test for saphena varix - a dilation of the saphenous vein at its junction with the femoral vein in the groin. Can be mistaken for femoral hernia

Question 15

What is the Trendelenburg test?

Answer 15

• Ask the patient to sit on the edge of the examination couch.
• Elevate the limb as far as is comfortable for the patient and empty the superficial veins by ‘milking’ the leg towards the groin.
• With the patient’s leg still elevated, press with your thumb over the sapheno-femoral junction (2–3 cm below and 2–3 cm lateral to the pubic tubercle). A high thigh tourniquet can be used instead.
• Ask the patient to stand while you maintain pressure over the saphenofemoral junction.
• If SFJ reflux is present, the patient’s varicose veins will not fill until your digital pressure, or the tourniquet, is removed. This is becuase all collaterals have functional valves, whereas the SFJ does not

Question 16

What other invesigations other than examination would you perform is someone had varicose veins?

Answer 16

Doppler ultrasound - listen for flow in incompitent valves e.g. the SFJ. or short saphenous behind the knee

Question 17

How would you manage someone with varicose veins?

Answer 17

• Education
  
  • ​avoid long standing and elevate legs,
  • support stockings,
  • lose weight,
  • regular walks
• Endovascular treatment (secondary prevention)
  
  • ​Radiofrequency ablation
  • Endovenous laser ablation
  • Injection sclerotherapy - damages lining of veins so that your body destroys the vein and it will disspear
• Surgery (if severely crippled by symptoms)

Question 18

What is radiofrequency abliation therapy?

Answer 18

https://www.youtube.com/watch?v=vSE9YQLWVDY

A catheter is inserted into the vein and heated to 120^oC destroying the endothelium and closing the vein

Question 19

What is Endovenous laser ablation?

Answer 19

https://www.youtube.com/watch?v=lwtKctuByIQ

Similar to radiofrequency ablation, but uses laser instead

Question 20

What is injection sclerotherapy?

Answer 20

https://www.youtube.com/watch?v=wmZVZ6jlHxo

Aither liquid or foam can be used. Sclerosant is injected into the varicosities at multiple sites and the vein compressed for a few weeks to avoid thrombosis

Question 21

What surgical procedures are used for treating varicose veins?

Answer 21

• Vein stripping
• Ligation of SFJ and SPJ (surgical tying of veins)

Question 22

On ABPI when is compression banding acceptable?

Answer 22

If >0.8