Venous & Lymphatic Disease - Presentation, Investigation & Therapy Flashcards
What are varicose veins?
Swollen and enlarged veins that usually occur in the legs and feet
What are swollen and enlarged veins that usually occur in the legs and feet called?
Varicose veins
What percentage of the population is estimated to be affected by varicose veins?
33%
What is A?
Saphenofemoral junction
What is B?
Superficial iliac circumflex vein
What is C?
Anterior lateral tributary
What is D?
Femoral vein
What is E?
Deep femoral vein
What is F?
Anterior tributary vein
What is G?
Dorsal venous arch
What is H?
Posterior arch vein
What is I?
Greater saphenous vein
What is J?
Posterior medial tributary
What is K?
Pudendal vein
What is L?
Deep and superficial inferior epigastric vein
What is A?
Posteromedial superficial thigh vein
What is B?
Vein of Giacomini
What is C?
Saphenopopliteal junction
What is D?
Lesser saphenous vein
What is E?
Dorsal venous arch
What is F?
Posterolateral tributary vein
What is G?
Anterolateral superficial thigh vein
What is the course of the long saphenous vein?
Dorsal venous arch drains into the long saphenous vein which passes anterior to the medial malleolus, up the medial aspect of the leg
What does LSV stand for?
Long saphenous vein
Where is the saphenofemoral junction?
2.5cm below and lateral to the pubic tubercle
What happens at the saphenofemoral junction?
Long saphenous vein perforates the cribiform fascia and empties into the femoral vein (deep system)
What does the dorsal venous arch drain into?
Long saphenous vein
What does the long saphenous vein drain into?
Femoral vein
Where does the long saphenous vein drain into the femoral vein?
Saphenofemoral junction
Where is the short saphenous vein?
Planter venous arch drains into the short saphenous vein which travels posterior to the lateral malleolus, up the posterior aspect of the leg and drains into the poplital vein (deep system)
What does SSV stand for?
Short saphenous vein
What does the planter venous arch drain into?
Short saphenous vein
What does the short saphenous vein drain into?
Poplital vein
What things assist blood flow back to the heart against gravity?
Valves
Calf muscle pump
Perforating veins to drain blood into deep system (deep veins are within muscular compartments and can withstand higher pressures)
Why can deep veins withstand higher pressures than superficial veins?
They are within muscular compartments
What are some causes of valvular failure?
Surgical or traumatic disruption of the valve
Deep vein thrombosis (DVT)
Hormonal changes in pregnancy
Large pelvic tumour
What does DVT stand for?
Deep vein thrombosis
How can hormonal changes in pregnancy cause valvular failure?
Weakness of the veins and valves, leading to venous incompetence
Enlarged uterus can cause mechanical obstruction to venous flow deep within the system
How can a large pelvic tumour cause valve failure?
Increase pressure within the distal venous system and disrupt it
What happens to venous pressures once one valve fail?
It increases
What is venous incompetence?
Veins do not work correctly
What is it called when veins do not work correctly?
Venous incompetence
What are risk factors for venous incompetence?
Age
Females more than males
Pregnancies
Deep vein thrombosis
Standing for long periods of time (occupation)
Family history
What is seen in the history for venous incompetence?
Burning
Itching
Heaviness
Tightness
Swelling
Decolourisation
Phlebitis
Bleeding
Disfigurement
Eczema
Ulceration
What is phlebitis?
Inflammation of a vein
What is inflammation of a vein called?
Phlebitis
What does the examination for venous incompetence involve?
Looking
Feeling
What are some special tests for venous incompetence?
Tap test
Trendelenburg test
Doppler
What is the tap test?
1) Place one hand over the saphenofemoral junction and one over the long saphenous vein above the knee
2) Tap the saphenofemoral junction
3) A transmitted impulse at the knee indicates an incompetence of the valves between the two hands
What is the trendelenburg test?
1) Lie the patient flat and drain the superficial vein by raising the leg and stroking the vein towards the trunk
2) Apply pressure over the saphenofemoral junction, keep this pressure on as the patient stands
3) If the varicose veins don’t dilate on standing (you are preventing this by your hands acting like a valve) release your hands and you will see the veins refill as the patients saphenofemoral junction valve is incompetent
What is the process of using a doppler for venous incompetence?
1) Hold the doppler probe over the saphenofemoral junction
2) Squeeze the calf muscle, in competent superficial veins you will hear a ‘whoosh’ as the blood flows upwards into the deep vein system
3) In a patient with an incompetent saphenofemoral hunction you will hear two waves as the blood flows upwards and then refluxes downwards again
What investigation is done for venous incompetence?
Ultrasound
How can ultrasound help diagnose venous incompetence?
Can demonstrate the valves, anatomy of the varicose veins and can be used to show dynamic blood flow such as reflux
What are the different classifications of chronic venous disease?
C0
C1
C2
C3
C4a
C4b
C5
C6
What is C0?
No visible or palpible signs of venous disease
What is C1?
Teleangiectasies or reticular veins
What is C2?
Varicose veins
What is C3?
Oedema
What is C4a?
Pigmentation or eczema
What is C4b?
Lipodermatosclerosis or athrophie blanche
What is C5?
Healed venous ulcer
What is C6?
Active venous ulcer
When should treatment for varicose veins?
When the patient is compaining of:
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 are the management options for varicose veins?
1) Endovenous treatment (laser treatment used to treat varicose veins)
2) Ultrasound guided foam sclerotherapy (injecting a chemical into the affected vein that inflames the lining and causes them to block)
3) Open surgery
What is endovenous treatment for varicose veins?
Laser treatment
What is laser treatment for varicose veins known as?
Endovenous treatment
What is ultrasound guided foam sclerotherapy?
Injecting a chemical into the affected vein that inflames the lining and causes them to block
What is a process involving injecting a chemical into the affected vein that inflames the lining and causes the vessel to block?
Ultrasound guided foam sclerotherapy
What should be offered if interventional treatment is unsuitable?
Compression hosiery
What is a compression hosiery?
Stocking that helps to preven the occurence of venous disorders such as oedema or thrombosis
When should intervention for varicose veins not be offered?
Deep vein system is occluded, hosiery should be used instead
What is the process of endovenous treatment for varicose veins?
1) The LSV or SSV is cannulated under ultrasound guidance
2) Catheter is passed up the length of the vein to just distal of the saphenofemoral or saphenopoplital junction
3) Local anaesthetic is used for the small skin puncture, and is then infiltrated in the superficial tissues around the length of the vein
4) Catheter causes injury to the vein wall (either by heat or laser) which causes fibrosis and occlusion of the vein, the subsequent ablation/disappearance of the vein
What are some complications of endovenous treatment?
Skin burns
Paraethesiae
Phlebitis
Deep vein thrombosis
What is paraethesiae?
Abnormal sensation, typically tingling or prickling (pins and needles)
What is an abnormal sensation, typically tingling and prickling (pins and needles) called?
Paraethesiae
What is the process of foam sclerotherapy?
1) Under ultrasound guidance a chemical foam is injected into the affected vessel
2) Foam damaged the venous wall, causing fibrosis and occlusion
What are some complications of foam sclerotherapy?
Vein should be occluded with pressure proximally to prevent foam migrating and causing stroke, TI or MI
Thrombophlebitis
Skin pigmentation
What is thrombophlebitis?
Inflammatory process that causes a blood clot to form and block a vein, usually in your leg
What is an inflammatory process that causes a blood clot to form and block a vein, typically in your leg?
Thrombophlebitis
What is the process of open surgery?
1) Under general anaesthetic a groin incision is made and the saphenofemoral junction is exposed
2) The saphenous vein is ligated from the femoral vein, an instrument is passed along the length of the saphenous vein and then used to strip the vein out
3) Small superficial varicose veins are avulsed as using small, stab incisions and a small hook instrument
What are some complications of open surgery?
Anaesthetic risk
Wound infection
Damage to nearby nerves (saphenous and sural nerves)
Bleeding
What nerves are near the saphenofemoral junction that can become damaged in open surgery?
Saphenous and sural nerves
What is venous insufficiency?
Condition that occurs when the venous walls and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart
What is a condition that occurs when the venous walls and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart?
Venous insufficiency
What can venous insufficiency be caused by?
Failure of calf muscle pump
Superficial venous reflux
Deep venous reflux (due to surgery, DVT or congenital)
Venous obstruction (due to heart failure, portal hypertension or obesity)
What is the pathophysiology of venous insufficiency?
1) Venous insufficiency
2) Venous hypertension
3) Endothelial leak
4) Oedema
5) Increase perfusion distance
6) Impaired healing
7) Inflammation
8) Fibrinogen tissue damage
9) Impaired tissue perfusion
What are some symptoms of chronic venous insufficiency?
Oedema
Telangiectasia
Eczema
Hemosiderin pigmentation
Hypopigmentation
Lipodermatosclerosis
Ulceration
What is telangiectasia?
Widened venules cause threadlike red lines on the skin
What is it called when widened vessels cause threadlike red lines on the skin?
Telangiectasia
What is eczema?
Condition that causes the skin to become itchy, red, dry and cracked
What is a conditiont that causes the skin to become itchy, red, dry and cracked?
Eczema
What is hemosiderin pigmentation?
Hemosiderin accumulates under your skin and causes yellow, brown or black staining or bruise like appearance
What is it called when hemosiderin accumulates under your skin and causes yellow, brown or black staining or bruise like appearance?
Hemosiderin pigmentation
What is hypopigmentation?
Skin lacks colour
What is it called when the skin lacks colour?
Hypopigmentation
What is lipodermatosclerosis?
Form of inflammation of the layer of fat under the skin
What is a form of inflammation of the layer of fat under the skin?
Lipodermatosclerosis
What is ulceration?
Break in a bodily membrane that impedes the organ of which the membrane is a part from, continuing normal function
What is a break in a bodily membrane that impedes the organ of which the membrane is a part of, continuing normal function called?
Ulceration
What is hemosiderin?
Protein compound that stores iron in your tissues
What are venous ulcers?
Breach in the skin between the knee and ankle joint present for more than 4 weeks
What is the presentation of venous ulcers?
Granulomatous (red) base
Shallow
Irregular margins
Exudative
Painless
Pulses present
What investigations are done for venous ulcers?
ABPI (ankle-brachial pressure index)
What does ABPI stand for?
Ankle-brachial pressure index
What is the treatment of venous ulcers?
Exclude arterial disease
Wound care
Elevation
Compression bandaging
Shockwave therapy
When looking at venous ulcers, what excludes arterial disease?
Ankle-brachial pressure index (ABPI)
What is lymphoedema?
Long term chronic condition that causes swelling in the body’s tissues
What is a long term chronic condition that causes swelling in the body’s tissues?
Lymphoedema
What are the different categories of lymphoedema?
Primary
Secondary
What are different kinds of primary lymphoedema?
Congenital
Praecox (around puberty)
Tarda (age > 35)
What can lymphoedema be secondary to?
Malignancy
Surgery
Radiotherapy
Infection
How is lymphoedema treated?
Elevation
Drainage
What is praecox?
Around puberty
