VV Flashcards
What is the most common site for venous disorders?
Lower limb
What is the location of the superficial venous system?
in subcutaneous fat superficial to the deep fascia
What is the direction of blood flow in veins?
from superficial to deep
from below upwards
if the superficial system is compromised will it lead to venous insufficiency?
- no because the deep system carries about 85 - 90% of venous circulation
What are the superficial veins?
- long saphenous vein –> femoral
- short saphenous vein –> popliteal
What are the deep veins?
- Venae Comitants of Anterior & Posterior Tibial veins, & peroneal arteries
- popliteal vein
- femoral vein
- valveless blood lakes in calf muscles
What are the veins included in the communicating-perforating systems?
- mid-thigh perforator
- above knee perforator
- below knee perforator
- 3 medial ankle perforators
- 1 lateral ankle perforator
What is the cause of blow-out?
incompetent perforators
What is the pressure in capillaries?
arterial end = 32mmHg
venous end = 12mmHg
What is the venous pressure in a foot vein on standing?
100mmHg
What is the venous pressure in a foot vein on standing?
100mmHg
What enables the return off blood against gravity to the heart from the lower limb?
calf muscle pump
- pressure rises to 200-300mmHg during muscle contraction
How does the blood move from the superficial to the deep venous system?
during muscle relaxation when the pressure falls in the superficial system, blood moves through saphenous junctions & perforating veins into the deep system
What are the factors that help venous return to the heart?
- muscle pump
- uni-directional valve
- negative intra-thoracic pressure
- transmitted arterial pulsations
What are varicose veins?
dilated, elongated, tortuous veins with demonstrable reflux
What are the pathological changes that occur in a varicose vein?
- vein wall becomes fibrotic with atrophy of the elastic & muscle fibers (if a wound occurs there will be gapping & hemorrhage)
- valve cusps become incompetent (increases spread of varicosity)
- venous stasis –> congestion, edema & anoxia with decreased nutrition in skin & sc tissues
What are the common locations of varicosities?
- anal canal: hemorrhoids
- esophagus: gastro-esophageal varices
- spermatic cord: varicocele
- abdominal wall: Caput Medusae in portal hypertension & inferior vena cava obstruction
- Neck & chest wall: superior vena cava obstruction
Why do varicose veins most commonly occur in the lower limb?
- length of veins
- vertical position (against gravity)
- large volume of blood
- liability of compression of iliac veins by pregnant uterus or any pelvic-abdominal mass
What is the most common venous disorder of the leg?
primary varicose veins
What are the factors affecting the prevalence of primary varicose veins?
- AGE: incidence increases with age
can occur in young patients with congenital weak mesenchyme - GENDER: 75% of patients are women (incidence increases with pregnancy)
- BODY MASS & HEIGHT: high bmi increases incidence
- PREGNANCY
- FAMILY HISTORY: familial susceptibility
- HABITS: smoking, constipation, prolonged standing
What is the pathogenesis of primary varicose veins?
- incompetence of valves
- weakness of vein wall
- leukocyte infiltration: liberation of toxic products by monocytes like collagenase
What are the clinical types of dilated veins?
- spider
- tubular
- serpentine
- saccular
- blow-out (incompetent perforator)
- saphena varix (blow out at sapheno-femoral junction)
What are the venous complications of primary VV?
BLEEDING: - spontaneous or after mid trauma - stops by elevation & pressure INFLAMMATION - superficial thrombophlebitis
What are the cutaneous complications of primary VV?
- dermatitis & eczema
- pigmentation (hemosiderin deposition)
- lipodermatosclerosis (pigmented woody indurated skin)
- Ulcer in Gaiter’s area
- Marjolin’s ulcer (malignancy)
What are the limb complications that could occur due to primary VV?
- EDEMA (mild)
- inverted champaign bottle appearance
What are the symptoms of a patient may present with in PRIMARY VARICOSE VEINS?
- asymptomatic
- disfigurement (dilated bluish patches)
- dull aching pain & tiredness in the leg (esp after prolonged standing)
- nocturnal muscle cramps (sustained muscle contraction)
- edema of the leg
- complications (ulcers, itching, bleeding, hyperpigmentation..)
What should first be examined generally if the patient has primary VV?
search for secondary causes
- general appearance
- abdomen (abdominal mass)
- scrotum (femoral vein thrombosis)
- rectum (pelvic masses)
What will be seen upon inspection of a patient presenting with primary varicose veins?
- varicosities at anatomical sites
- veins on abdominal wall or running across the pubis is a sign of an old iliofemoral thrombus
- skin: pigmentation, eczema, ulceration, lipodermatosclerosis
- ankle flare: dilated subdermal veins at ankle (early sign of CVI)
What will be felt upon palpation in primary vv?
- thrill on cough over saphino-femoral junction
- thrombophlebitis: tender cord-like incompressible veins
- FEGAN’S SIGN: fascial defects where perforators pass could be felt as circular openings with sharp edges (BLOW-OUT)
- edema: pitting
What test should be performed upon percussion?
TAPPING TEST
- percuss from below & feel from above: dilated veins belong to short or great saphenous vein?
- percuss from above & feel from below: detect incompetent valves
What special test should be preformed to differentiate between primary & secondary VV?
- MODIFIED PERTHE’S TEST
What special tests should be preformed to detect the sites of incompetent perforators?
- Trendelenburg test
- Multiple tourniquet test
What is the best investigation for diagnosis of primary VV?
doppler & duplex
- presence of varicosities
- affected veins
- reversal of blood flow
- sites of incompetent perforators
- state of deep venous system
What method of investigation should be used to exclude presence of secondary cause?
Ultrasound of abdomen
What are the indications of conservative management in primary VV?
- mild varicosities
- pregnancy
- old patients
- contraindications to operations
What are the methods followed in conservative treatment?
- encourage walking & avoid prolonged standing & sitting
- elevation of foot while resting
- fitting elastic stockings (compression therapy)
- regular exercises & massage (restore muscle tone, relieve congestion & edema)
- symptomatic treatment
- hygiene of limb
What are the indications of compression sclerotherapy?
- minor varicosities unsuitable for surgical removal (reticular & spider)
- postoperative residual or recurrent varicosities
What are the contraindications of compression sclerotherapy?
- fat legs (difficult bandaging & fat necrosis)
- acute cellulitis
- veins in sites impossible to compress
- history of allergic reactions
- pot-phlebitic syndrome
What are the complications of compression sclerotherapy?
- ecchymosis & pigmentation
- thrombophlebitis
- DVT
- skin necrosis (injection ulcer)
- allergic reactions
What are the indications of surgical treatment?
- large varicose veins
- leg pain & edema interfering with daily activities
- cosmetic reasons
- complications
What are the types of operative procedures that could be used in primary VV?
- TRENDELENBURG OPERATION: sapheno-femoral junction disconnection
- stripping of saphenous veins (NOT PREFORMED IN 2RY)
- groin to knee stripping (most common)
- phlebectomy (punchectomy): stab avulsion of varices
new
- ultrasound-guided foam sclerotherapy
- radiofrequency or laser light energy
What is the cause of SECONDARY VV?
high venous pressure in superficial venous system as a result of
- DVT
- extrinsic pressure on pelvic veins (pregnancy or tumors)
- A-V fistula
How is secondary VV treated?
ligation of perforators (subfascial ligation)
What’s the difference between primary & secondary VV?
PRIMARY SECONDARY
- unknown cause - definitive cause
- no DVT - DVT
- in LSV or SSV - in all veins
- easy emptying - takes time
- vein could be large - always small vein
- soft pitting edema - massive edema
- no ulceration - common
- no dermatitis - common
- no ankle flare - common
- -ve Perthe’s test - +ve
- normal AVP - increased AVP
- conservative - conservative
- sclerotherapy - ligations of perforators
- surgical
