Venous & lymphatic disease Flashcards
What are varicose veins?
A varicose vein is a dilated and tortuous, often superficial, vein
They are most commonly found in the lower limbs and are expected to affect about 1/3rd of the population
What features assist the flow of blood back up the legs?
Valves in the veins
Calf muscle pump
Perforating veins:
- Drain blood into deep veins which can withstand higher pressures
What causes valvular failure?
Surgery/trauma
DVT
Pregnancy
Pelvic tumour
How does a failed valve lead to varicose vein formation?
Venous pressure increases
Dilation of distal vein
Leading to further valvular incompetence
What are the risk factors for Varicose veins?
Old Female Pregnancies DVT Occupation involving lots of standing Family history
What symptoms can varicose veins cause?
Burning Itching Heaviness Tightness Swelling Discolouration Phlebitis Bleeding Disfiguration Eczema Ulceration
What are the 3 special palpative tests for varicose veins?
Tap test
Trendelenburg/Tourniquet test (similar)
Doppler test
Describe the Tap test
Place one hand over the saphenofemoral junction and one over the long saphenous vein above the knee.
Tap the saphenofemoral junction – a transmitted impulse at the knee indicates an incompetence of the valves between the two hands.
Describe the Trendelenburg test
Lie the patient flat. Drain the superficial veins by raising the leg and stroking the veins towards the trunk.
Apply pressure over the saphenofemoral junction. Keep this pressure on as you ask the patient to stand.
If the varicose veins don’t dilate on standing, you are preventing this by ‘acting’ as a competent valve preventing backflow of blood. If you release your hand you will see the veins refill as the patient’s saphenofemoral junction valve is incompetent.
Describe how the Tourniquet test is different from the Trendelenburg test
The Tourniquet test is a similar test, using a tourniquet instead of your hand, and repeating the test at 10cm intervals down the leg (the approximate distance between perforating veins) to find the level of incompetence.
Describe the Doppler test
Hold a doppler probe over the saphenofemoral junction. Squeeze the calf muscles. In a patient with competent superficial veins you will hear a ‘whoosh’ as the blood flows upwards into the deep system.
In a patient with an incompetent saphenofemoral junction you will hear two waves as the blood flows upwards and then refluxes downwards again.
What are the investigations for varicose veins?
Palpating tests
Ultrasound
How is chronic venous disease (varicose veins) classified?
CEAP classification
Aetiologically
Anatomically
Pathologically
When should treatment be offered to patients with chronic venous disease?
Bleeding varicose veins
Symptomatic varicose veins (including aching, discomfort, swelling, heaviness and itching)
Recurrent symptomatic varicose veins
Lower limb skin changes of chronic venous insufficiency
Superficial venous thrombosis
Venous leg ulcer – active or healed
What is first line management for chronic venous disease?
Endovenous treatment
What is the second line treatment for chronic venous disease?
Ultrasound guided foam sclerotherapy
What is the third line treatment for chronic venous disease?
Open surgery
What is the treatment option for chronic venous disease if intervention is unsuitable?
Why might intervention be unsuitable?
Hosiery
Intervention would be unsuitable for DVT or pregnancy related CVD
Describe the process of Endovenous treatment
The LSV or SSV is cannulated under ultrasound guidance.
A catheter is passed up the length of the the vein to just distal to the saphenofemoral or saphenopopliteal junction.
Local anaesthetic is used for the small skin puncture, and then is infiltrated in the superficial tissues around the length of the vein.
The catheter causes injury to the vein wall – either by heat or laser. This causes fibrosis and occlusion of the vein, and subsequent ablation/disappearance of the vein.
What are the risks of endovenous treatment
Complications:
Skin burns
Paraesthesiae (0-10%) (pins n needles)
Phlebitis (5%)
Deep vein thrombosis (1%).
What is Foam slcerotherapy?
Chemical foam injected into affected vein, under US guidance
Foam causes fibrosis & occlusion
