Venous lymphatics - Presentation, investigation and therapy

Question 1

Define what a varicose vein is

Answer 1

A varicose vein is a dilated and tortuous, often superficial, vein

most commonly found in lower limbs

Question 2

Risk factors of varicose veins

Answer 2

Age
Female (20-25% females, 10-15% men)
Pregnancies
DVT
Standing for long periods (occupation)
Family history

Question 3

associated symptoms of varicose veins (11)

Answer 3

Burning
Itching
Heaviness
Tightness
Swelling
Discolouration
Phlebitis - blood clot blocks a vein close to the surface of your skin - not as risky as DVT
Bleeding
Disfiguration
Eczema
Ulceration

Question 4

treatment options for lymphoedema

Answer 4

elevation

drainage

Question 5

what vein does the saphenous vein enter?

Answer 5

the deep vein

Question 6

where is the saphenofemoral junction found?

Answer 6

2.5cm below and lateral to the pubic tubercle

here the left saphenous vein perforates the cribiform fascia and empties into the femoral vein

Question 7

Does the short saphenous vein run up the anterior or posterior side of the leg? what vein does it drain into

Answer 7

posterior

drains into the popliteal vein (deep system)

Question 8

what is the function of perforating veins?

Answer 8

they connect the superficial and deep venous circulation

Question 9

where are deep veins found?

Answer 9

within muscular compartments

they can withstand higher pressure

Question 10

what 3 things assist low flow against gravity? (back to the heart)

Answer 10

Valves
Calf muscle pump
Perforating veins

Question 11

Causes of valvular failure? (4)

Answer 11

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.

Question 12

what happens to venous pressure when a valve fails?

Answer 12

venous pressure increases, there is dilatation of the distal vein and further valvular incompetence

Question 13

3 special tests to test competency of venous valves

Answer 13

tap test
Trendelenburg/tourniquet test
Doppler test

Question 14

How does the tap test work and how does it test competency of venous valves?

Answer 14

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.

Question 15

Doppler test

Answer 15

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.

Question 16

investigations for venous system

Answer 16

Ultrasound can demonstrate the valves, the anatomy of the varicose vein (e.g. tortuosity), and can be used to show dynamic blood flow e.g. reflux

Question 17

Classification of venous disease C0 and C6?

Answer 17

C0 - no visible or palpable signs of venous disease

C6 - active venous ulcer

Question 18

First line treatment for venous disease

Answer 18

endovenous treatement

Question 19

Second line treatment for venous disease

Answer 19

Ultrasound guided foam sclerotherapy

Question 20

third line treatment for venous disease

Answer 20

open surgery

Question 21

when should intervention not be offered for varicose veins?

Answer 21

if the deep venous system is obstructed eg DVT or in pregnancy

Question 22

what should be offered instead of intervention if no suitable?

Answer 22

compression hoisery

Question 23

Endovenous treatment for varicose veins

Answer 23

The LSV or SSV is cannulated under ultrasound guidance.

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 whole vein wall – either by heat or laser. This causes fibrosis and occlusion of the vein, and subsequently

This causes the veins to close and eventually turn into scar tissue

Question 24

which is the main superficial vein associated with varicose veins?

Answer 24

saphenous vein

Question 25

foam sclerotherapy for varicose veins

Answer 25

under ultrasound guidance, a chemical foam is injected into the affected vein. The foam damages the venous walls, causing fibrosis and occlusion.

Question 26

open surgery for varicose veins

Answer 26

groin incision is made and the saphenofemoral junction is exposed

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 torn away using small, ‘stab’ incisions and a small hook instrument.

Question 27

chronic venous insufficiency can be caused by what?

Answer 27

Failure of calf muscle pump, Superficial venous reflux
or Deep venous reflux (surgery, DVT, congenital)

Venous obstruction (heart failure, portal hypertension, obesity)

Question 28

Pathophysiology of chronic venous insufficiency?

Answer 28

venous hypertension - endothelial leak - oedema (impaired tissue perfusion) - increased perfusion distance - impaired healing - inflammation - fibrinogen, tissue damage - impaired tissue perfusion

Question 29

Chronic venous insufficiency

Answer 29

Oedema
Telangiectasia - widened venules cause threadlike red lines or patterns on the skin
Eczema
Haemosiderin pigmentation
Hypopigmentation
Lipodermatosclerosis - changes in the skin of the lower legs
Ulceration

Question 30

define venous ulcers and describe common associations

Answer 30

Breach in the skin between the knee and ankle joint, present for >4 weeks

Gaiter area - side of leg between knee and ankle
Granulomatous (red) base
Shallow
Irregular margins
Exudative, oedematous
Painless, pulses present

Question 31

where are arterial ulcers found

Answer 31

over toe joints
anterior shin
under heel
over ankle bone

Question 32

what test is used to exclude arterial disease?

Answer 32

Ankle-brachial Pressure Index

Question 33

pathophysiology of primary lymphoedema?

Answer 33

Congenital
Praecox (early): around puberty
Tarda (late): age >35

Question 34

pathophysiology/causes of secondary lymphoedema?

Answer 34

Malignancy
Surgery
Radiotherapy
Infection

Question 35

Filariasis (parasitic disease), TB and pyogenic infection can cause what?

Answer 35

lymphoedema