venous & Lymphatic Disease - Presentation, Investigation & Therapy Flashcards
how many people does varicose veins affect?
at least one third of the population
what is a varicose vein?
varicose vein is a dilated and tortuous, often superficial vein
where are varicose veins most commonly found?
lower limbs
where is the long saphenous vein?
dorsal venous arch drains into the LSV, which passes anterior to the medial malleolus, up the medial aspect of the leg
where is saphenofemoral junction
Found 2.5cm below and lateral to the pubic tubercle
Here the LSV perforates the cribiform fascia and empties into the femoral vein (deep system)
where is the short saphenous?
The plantar venous arch drains into the SSV which travels posterior to the lateral malleolus, up the posterior aspect of the leg and drains into the popliteal vein (deep system)
what mechanisms are there to assist low flow against gravity back to the heart?
valves
calf muscle pump
perforating veins to drain blood into the deep system
what are the causes of valvular failure?
surgical or traumatic disruption of the valve.
DVT: can initially cause obstruction to venous flow, and even as the vein re-canalises through the thrombus, this canal will be a high-pressure avalvular channel.
Hormonal changes in pregnancy can cause weakness of the veins and valves, leading to venous incompetence. The enlarged uterus can cause mechanical obstruction to venous flow within the deep system,
Similarly a large pelvic tumour also could, leading to increased pressure within the distal venous systems.
what happens to the venous pressure when one valve has failed?
there is a dilation of the distal vein and further valvular incompetence
what are the risk factors for varicose
age female pregnancy DVT standing for long periods family history
what is history of varicose veins?
Burning Itching Heaviness Tightness Swelling Discolouration Phlebitis Bleeding Disfiguration Eczema Ulceration
what are the different type of tests?
tap test
trendelenburg/tourniquet test
doppler
what is 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.
what is the Trendelenburg/tourniquet 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.
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.
what is the doppler
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 should patients be complaining of to get treatment?
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 mnagement options for varicose veins?
First line: Endovenous treatment
Second line: Ultrasound guided foam sclerotherapy
Third line: Open surgery
how is endovenous treatment inserted?
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 complications of endovenous treatment?
Complications: Skin burns, paraesthesiae (0-10%), phlebitis (5%), deep vein thrombosis (1%).
what does foam sclerotherapy do?
under ultrasound guidance, a chemical foam is injected into the affected vein. The foam damages the venous walls, causing fibrosis and occlusion.
what are the omplications of foam sclerotherapy?
The vein should be occluded (with pressure) proximally to prevent foam migrating and causing the potential complications of stroke ,TIA or MI. Thrombophlebitis (7%) and skin pigmentation (6%) can also occur.
what is open surgery?
Under GA, a groin incision is made and the saphenofemoral junction is exposed.
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.
Small superficial varicose veins are avulsed using small, ‘stab’ incisions and a small hook instrument.
what are the complications of open surgery?
Anaesthetic risk, wound infection, damage to nearby nerves (saphenous and sural nerves), bleeding.
how does venous insufficiency?
failure of calf muscle pump
superficial venous reflux
deep venous reflex
venous obstruction
chronic venous insufficiency symptoms?
oedema telangiectasia eczema haemosiderin pigmentation hypopigmentation lipodermatosclerosis ulceration
what are venous ulcers?
breach in the skin between the knee and ankle joint, present for >4weeks
investigations for venous ulcers
history
examination
ABPI
what is treatment for venous ulcers?
exclude arterial disease wound care elevation compression bandaging shockwave therapy
what is treatment of Lymphoedema
elevation
drainage
