venous peripheral vascular examination Flashcards
overview of the examination
1 - WIPER intro 2 - inspection 3 - standing palpation 4 - special tests 5 - ascultation 6 - closing
introduciton steps
WIPER
standing
underwear
pain
inspection
this should be all standing
shape of legs (beer bottle), eczema, venous stars, haemosiderin deposition, scars, ankle swelling, lipodermatosclerosis.
compression stockings, haemosiderosis - looks black deposition lipdermatosclerosis - looks a bit shiny and tight venous ulcer - wet raggedy and red arterial ulcer = punched out
palpation
- temperature change and pitting oedema
- inspect in the path of the long and short saphenous veins and establish the distribution of the varicose veins.
- specific palpation and inspection of both the long and short saphenous veins for tenderness or thrombosis.
- examine for saphena-varix at the siphon-femoral junction and feel for cough impulse here and at the siphon-popliteal junction.
special tests
1 - while PT is standing perform the tap test by placing finger at the bottom of a long varicosity and taping above it. comment on the presence of an impulse.
2 - offer to perform the trendelenberg’s or tourniquet test (likely just say to do one).if the veins below the tourniquet fill then the incompetent perforators originate below this level. suggest to repeat the test and continue occluding vessels distally until there is no superficial filling.
3 - offer to perform Perches’ test
ascultation
1 - ascultate over any obvious varicosities for bruits suggestive of an artery-venous malformation.
what happens after ascultation
finish. thank pt and help get dressed.
to complete - Ex peripheral arterial system, abdo rectum and pelvis for IVC obstruction, ABPI, neuro assessment of the lower limbs.
what happens in trendelenberg’s test
not to be confused with trendelenberg’s sign.
The Trendelenburg Test or Brodie-Trendelenburg test is a test which can be carried out as part of a physical examination to determine the competency of the valves in the superficial and deep veins of the legs in patients with varicose veins.
With the patient in the supine position, the leg is flexed at the hip and raised above heart level. The veins will empty due to gravity or with the assistance of the examiner’s hand squeezing blood towards the heart.
A tourniquet is then applied around the upper thigh to compress the superficial veins but not too tight as to occlude the deeper veins. The leg is then lowered by asking the patient to stand.
NB - conflicting sources. another source says that trendelenberg’s is to use 2 fingers to compress the saphonfemoral junction, and that the tourniquet test uses a tourniquet around the upper thigh. fine point but imp to know…
Normally the superficial saphenous vein will fill from below within 30-35 seconds as blood from the capillary beds reaches the veins; if the superficial veins fill more rapidly with the tourniquet in place there is valvular incompetence below the level of the tourniquet in the “deep” or “communicating” veins. After 20 seconds, if there has been no rapid filling, the tourniquet is released. If there is sudden filling at this point, it indicates that the deep and communicating veins are competent but the superficial veins are incompetent.[2]
The test is reported in two parts, the initial standing up of the patient (positive or negative based on rapid filling) and the second phase once the tourniquet is removed (positive or negative based upon rapid filling).
For example, a possible outcome of the test would be negative-positive meaning that the initial phase of the test was negative indicating competence in the deep and communicating veins and the second phase of the test was positive meaning that there is superficial vein incompetence.
The test can be repeated with the tourniquet at different levels to further pinpoint the level of valvular incompetence:
above the knee - to assess the mid-thigh perforators
below the knee - to assess incompetence between the short saphenous vein and the popliteal vein.[3]
Superficial veins of the leg normally empty into deep veins, however retrograde filling occurs when valves are incompetent, leading to varicose veins.
another source = . Perform the Trendelenberg test. Encourage the varicose veins to empty by stroking them in the direction of flow and raise the leg to remove blood further. Use fingers or a tourniquet to occlude the
saphenofemoral junction. Ask the patient to stand. Remove the pressure – if the veins fill, there is incompetence (if the incompetency is low down the leg, the veins may still fill even if you are still occluding the saphenofemoral junction). The principle of the test is that varicose veins occur due to
retrograde flow of blood through incompetent valves from deep to superficial veins. If you stop the
backflow, the VVs remain collapsed, but fill when you release the pressure because backflow can
occur again
what is Perthes’ test
Similar to Trendelenberg test.
Release a bit of tourniquet, but pt raises up and down on toes after releasing.
If perforating calf veins have competent valves, calf pump will function, making varicosities less tense.
The Perthes test is a clinical test for assessing the patency of the deep femoral vein prior to varicose vein surgery. It is named after German surgeon Georg Perthes.
The limb is elevated and an elastic bandage is applied firmly from the toes to the upper 1/3 of the thigh to obliterate the superficial veins only. With the bandage applied the patient is asked to walk for 5 minutes. If deep system is competent, the blood will go through and back to the heart. If the deep system is incompetent, the patient will feel pain in the leg.
• Assesses(competency(of(deep(venous(system((
• Pt(standing(and(veins(filled((
• Apply(tourniquet(at(level(of(SFJ((to(occlude(
superficial(venous(system)(
• Ask(pt(to(walk(for(5mins((
• Veins(become(engorged(and(painful(N(deep(
venous(system(occluded((blood(pools(as(
unable(to(go(through(either(the(deep(system(
[occluded](or(superficial(system([torniquet])(
what is the tourniquet test
This is for when you think the incompetency is low down the leg (eg.
veins still fill even when pressure applied to saphenofemoral junction in Trendelenberg test). The
veins are emptied of blood and the tourniquet applied below the level of a suspected perforator. If
there is incompetence the veins will remain collapsed and will fill in a retrograde manner when the
tourniquet is released.
What other investigations might you want to do in a patient with varicose veins?
Duplex ultrasound
Colour Doppler can identify retrograde flow of blood at incompetent valves and perforators.
What is a varicose vein?
Varicose veins occur due to retrograde flow of blood through incompetent valves from deep to
superficial veins.
What is the basic anatomy of the long and short saphenous veins?
Long saphenous vein passes anterior to medial malleolus up the medial aspect of the calf to behind
the knee, then up the middle aspect of the thigh to join the common femoral vein in the groin at the
saphenofemoral junction. (ie. up medial aspect of leg)
Short saphenous vein passes behind lateral malleolus and up posterior aspect of calf. Commonly
joins popliteal vein at the saphenopopliteal junction – 2cm above posterior knee crease. (ie. up back
of calf)
How can lower limb venous disease present?
How can lower limb venous disease present?
4 types of venous leg disease:
DVT
Varicose veins
Superficial thrombophlebitis
Chronic venous insufficiency and ulceration
The four cardinal symptoms they present with are: Pain, Swelling, Discolouration, Ulceration
