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Surgery M4 part 1 > VV > Flashcards

VV Flashcards

1
Q

What is the most common site for venous disorders?

A

Lower limb

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2
Q

What is the location of the superficial venous system?

A

in subcutaneous fat superficial to the deep fascia

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3
Q

What is the direction of blood flow in veins?

A

from superficial to deep

from below upwards

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4
Q

if the superficial system is compromised will it lead to venous insufficiency?

A
  • no because the deep system carries about 85 - 90% of venous circulation
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5
Q

What are the superficial veins?

A
  • long saphenous vein –> femoral

- short saphenous vein –> popliteal

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6
Q

What are the deep veins?

A
  • Venae Comitants of Anterior & Posterior Tibial veins, & peroneal arteries
  • popliteal vein
  • femoral vein
  • valveless blood lakes in calf muscles
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7
Q

What are the veins included in the communicating-perforating systems?

A
  • mid-thigh perforator
  • above knee perforator
  • below knee perforator
  • 3 medial ankle perforators
  • 1 lateral ankle perforator
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8
Q

What is the cause of blow-out?

A

incompetent perforators

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9
Q

What is the pressure in capillaries?

A

arterial end = 32mmHg

venous end = 12mmHg

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10
Q

What is the venous pressure in a foot vein on standing?

A

100mmHg

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10
Q

What is the venous pressure in a foot vein on standing?

A

100mmHg

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11
Q

What enables the return off blood against gravity to the heart from the lower limb?

A

calf muscle pump

- pressure rises to 200-300mmHg during muscle contraction

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12
Q

How does the blood move from the superficial to the deep venous system?

A

during muscle relaxation when the pressure falls in the superficial system, blood moves through saphenous junctions & perforating veins into the deep system

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13
Q

What are the factors that help venous return to the heart?

A
  • muscle pump
  • uni-directional valve
  • negative intra-thoracic pressure
  • transmitted arterial pulsations
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14
Q

What are varicose veins?

A

dilated, elongated, tortuous veins with demonstrable reflux

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15
Q

What are the pathological changes that occur in a varicose vein?

A
  • 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
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16
Q

What are the common locations of varicosities?

A
  • 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
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17
Q

Why do varicose veins most commonly occur in the lower limb?

A
  • 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
18
Q

What is the most common venous disorder of the leg?

A

primary varicose veins

19
Q

What are the factors affecting the prevalence of primary varicose veins?

A
  • 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
20
Q

What is the pathogenesis of primary varicose veins?

A
  • incompetence of valves
  • weakness of vein wall
  • leukocyte infiltration: liberation of toxic products by monocytes like collagenase
21
Q

What are the clinical types of dilated veins?

A
  • spider
  • tubular
  • serpentine
  • saccular
    - blow-out (incompetent perforator)
    - saphena varix (blow out at sapheno-femoral junction)
22
Q

What are the venous complications of primary VV?

A 
BLEEDING: 
- spontaneous or after mid trauma
- stops by elevation & pressure 
INFLAMMATION
- superficial thrombophlebitis
23
Q

What are the cutaneous complications of primary VV?

A
  • dermatitis & eczema
  • pigmentation (hemosiderin deposition)
  • lipodermatosclerosis (pigmented woody indurated skin)
  • Ulcer in Gaiter’s area
  • Marjolin’s ulcer (malignancy)
24
Q

What are the limb complications that could occur due to primary VV?

A
  • EDEMA (mild)

- inverted champaign bottle appearance

25
Q

What are the symptoms of a patient may present with in PRIMARY VARICOSE VEINS?

A
  • 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..)
26
Q

What should first be examined generally if the patient has primary VV?

A

search for secondary causes

  • general appearance
  • abdomen (abdominal mass)
  • scrotum (femoral vein thrombosis)
  • rectum (pelvic masses)
27
Q

What will be seen upon inspection of a patient presenting with primary varicose veins?

A
  • 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)
28
Q

What will be felt upon palpation in primary vv?

A
  • 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
29
Q

What test should be performed upon percussion?

A

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
30
Q

What special test should be preformed to differentiate between primary & secondary VV?

A
  • MODIFIED PERTHE’S TEST
31
Q

What special tests should be preformed to detect the sites of incompetent perforators?

A
  • Trendelenburg test

- Multiple tourniquet test

32
Q

What is the best investigation for diagnosis of primary VV?

A

doppler & duplex

  • presence of varicosities
  • affected veins
  • reversal of blood flow
  • sites of incompetent perforators
  • state of deep venous system
33
Q

What method of investigation should be used to exclude presence of secondary cause?

A

Ultrasound of abdomen

34
Q

What are the indications of conservative management in primary VV?

A
  • mild varicosities
  • pregnancy
  • old patients
  • contraindications to operations
35
Q

What are the methods followed in conservative treatment?

A
  • 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
36
Q

What are the indications of compression sclerotherapy?

A
  • minor varicosities unsuitable for surgical removal (reticular & spider)
  • postoperative residual or recurrent varicosities
37
Q

What are the contraindications of compression sclerotherapy?

A
  • fat legs (difficult bandaging & fat necrosis)
  • acute cellulitis
  • veins in sites impossible to compress
  • history of allergic reactions
  • pot-phlebitic syndrome
38
Q

What are the complications of compression sclerotherapy?

A
  • ecchymosis & pigmentation
  • thrombophlebitis
  • DVT
  • skin necrosis (injection ulcer)
  • allergic reactions
39
Q

What are the indications of surgical treatment?

A
  • large varicose veins
  • leg pain & edema interfering with daily activities
  • cosmetic reasons
  • complications
40
Q

What are the types of operative procedures that could be used in primary VV?

A
  • 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
41
Q

What is the cause of SECONDARY VV?

A

high venous pressure in superficial venous system as a result of

  • DVT
  • extrinsic pressure on pelvic veins (pregnancy or tumors)
  • A-V fistula
42
Q

How is secondary VV treated?

A

ligation of perforators (subfascial ligation)

43
Q

What’s the difference between primary & secondary VV?

A

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

Surgery M4 part 1 (47 decks)

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