Venous + Lymphatic Disease: Presentation, Investigation + Therapy Flashcards
What are varicose veins?
Torturous dilated superficial veins
What are the most common sites for varicose veins?
Long saphenous vein
Short saphenous vein
What are primary varicose veins caused by?
Valvular dysfunction
Which sex has the higher prevalence of varicose veins?
Females
What is important when taking a history of varicose veins?
- Age of onset
- Occupation
- Pregnancies (esp, multiples + large babies)
- Previous DVY/major trauma
- Family history
- Signs and symptoms
- Complications
What are the signs and symptoms of varicose veins?
- Cosmesis
- Localised or generalised discomfort in the legs
- Nocturnal cramps
- Swelling
- Acute haemorrhage
- Superficial thrombophlebitis
- Pruritus
- Skin changes
How are varicose veins assessed?
Duplex ultrasound
What are the indications for intervention with varicose veins?
- Superficial thrombophlebitis
- Signs of chronic venous insufficiency
- Bleeding
- Cosmetic
- Anxiety that disease may progress
What are the treatment options available for varicose veins?
- Surgery
- Injection
- Minimally invasive procedures
- Compression
- Conservative
What surgical options are available for varicose veins?
- High tie (ligation of the sapheno-femoral or sapheno-popiteal junctions)
- Vein Stripping
- Multiple stab avulsions
What are the relative contra-indications against superficial venous surgery?
- Previous DVTs
- Arterial insufficiency
- Patient co morbidity
- Morbid obesity
What are the common complications with VV surgery?
- Minor haemorrhage
- Thrombophlebitis haematoma
- Wound problems
- Severe pain
What are the less common VV surgery complications?
Sural/saphenous nerves
What are the rare VV surgery complications?
Damage to deep veins, arteries, nerves, DVT
What are the minimally invasive treatments of main trunk varicosities?
- Foam sclerotherapy (chemical reaction with endothelium)
- Endovenous laser ablation (thermal ablation)
- Radiofrequency ablation (thermal ablation)
What are the potential advantages of local anaesthetic minimally invasive treatment options for VV?
- Reduce surgical trauma= less pain
- Reduce time off work
- Do not require an operating theatre
- Potential to increases patient throughput
What are the results of minimally invasive treatment options for VV?
- Short to medium term just as effective clinically as surgery
- Long term results awaited
- Cost effectiveness is not known
Describe EVLA, laser technique in the treatment of VV.
- Micro puncture needle inserted into the incompetent long or short saphenous veins using ultrasound
- Guide wire introduced and manoeuvred to saphenous junction with deep vein using ultrasound
- Catheter and laser fibre introduced over guide wire to 1 cm below junction
- Closure by VNUS which heats vein to 85C
Describe the foam sclerotherapy technique in the treatment of VV.
- Needle inserted into incompetent veins under ultrasound control
- Foam injected, prevented from entering deep venous system
When are compression stockings usually used in the treatment of VV?
Normally following another treatment such as surgery
What clinical presentations are associated with chronic venous insufficiency?
- Ankle oedema
- Telangectasia
- Venous eczema
- Haemosiderin pigmentation
- Hypopigmentation ‘atrophie blanche’
- Lipodermatosclerosis
- Venous ulceration
What is the pathophysiology of CVI?
- Venous hypertension
- Venous engorgement and stasis
- Imbalance of Starling forces and fluid exudate
What is the pressure at the foot when standing motionless?
~90mmHg
What does the pressure drop to at the foot when there is active movement?
~30mmHg
What is the ambulatory venous pressure?
Change in pressure from standing motionless to active movement
What dose a raised AVP suggest?
- Failure of muscle pump, valves or outflow obstruction
- Venous hypertension
What can failure of calf muscle pump be due to?
- Superficial venous reflux
- Deep venous reflux
- Venous obstruction
- Neuromuscular
- Obesity
- Inactivity
Leg ulcer
Breach in the skin between knee and ankle joint present for over 4 weeks
What is the differential diagnosis of leg ulceration?
- Diabetes
- Rheumatoid arthritis
- Vasculitis
- CT disease
What vessels are usually associated with leg ulceration?
- Almost 80% purely venous in origin
- Up to 20% have significant arterial disease
What would be found on clinical examination of leg ulceration?
- Signs of CVI
- Oedema
- Locomotor system
- Vascular
What investigations should be carried out for leg ulceration?
- ABPI (ankle brachial pressure index)
- Duplex
What is a complication of CVI?
Leg ulceration
What is the treatment for leg ulceration excluding arterial disease?
- Multi-layer graduated, elastic, high grade compression therapy
- Non-adherent dressings or hydrocolloid/foam dressing if painful
- Systemic and topical therapy
- Exercise the calf muscle pump
What are the causes of primary lymphoedema?
- Congenital
- Praecox
- Tarda
What are the secondary causes of lymphoedema?
- Malignancy
- Surgery (radical mastectomy: groin/axillary dissection)
- Radiotherapy
- Infection (filariasis/tuberculosis/pyogenic)
What are the treatment options for lympoedema?
- Very limited treatment options
- Elevation and manual drainage
