Varicose Veins

Question 1

General inspection

Answer 1

• With the patientstanding(if able) look for signs ofvenous diseasefrom thefront,sideandbackof thelegs.
• Surgical scarsmay be relevant to the patient’s presentation. It is worth clarifying what operation the patient had by asking the patient and confirming with their medical records if able.
• It is important to note that modern venous treatments are nowminimally invasiveand therefore they’ll beno scars(NICE now recommends minimally invasive surgery for varicose veins as first-line treatment).Traditional treatmentin the past did result in alow groin scaron the affected side.

Question 2

Venous Eczema

Answer 2

Venous eczemaoccurs as a result of venous hypertension causing fluid to collect in the tissues. The stasis of this fluid in the soft tissues results in activation of the innate immune response and subsequent inflammation.

Venous eczemahas the followingclinical characteristics:

• Itchy red, blistered and crustedplaques; or dry fissured andscalyplaques on one or both lower legs (commonly mistaken for cellulitis).
• Atrophie blanche: star-shaped ivory-white depressed atrophic plaques with red dots within the scar (dilated capillaries) and surrounding hyperpigmentation (due to haemosiderin deposition).
• Orange-brown patches of pigmentation caused by haemosiderin deposition.
• Lipodermatosclerosis (described below).

Question 3

Lipodermatosclerosis

Answer 3

Lipodermatosclerosisis a form of panniculitis (inflammation of the subcutaneous fat) caused by ongoing activation of the innate immune response in soft tissues (secondary to venous hypertension).
Lipodermatosclerosishas the followingclinicalcharacteristics:

• Skin hardening (often referred to as induration)
• Hyperpigmentation
• Erythema
• Swelling
• Inverted champagne bottle appearance

Question 4

Venous Ulcers

Answer 4

Venous ulcersare thought to be caused by the improper functioning of venous valves and typically develop along the medial aspect of the distal leg. A venous ulcer can be defined as a full-thickness defect of the skin that fails to heal spontaneously and is sustained by chronic venous disease.

Venous ulcerspresent with the followingclinical characteristics:

• Large, irregular border with sloping edges
• Shallow depth
• Often located over the medial aspect of the ankle (referred to as the gaiter region).
• Associated with mild pain

Question 5

Saphena Varix

Answer 5

Asaphena varixis a dilation of thesaphenousvein at its junction with the femoral vein in the groin. It typically presents as alumparound2-4cm inferior-lateral to the pubic tubercle. It often has abluish tinge, issoft to palpateand will vanish when the patient lies down which can help differentiate it from an inguinal hernia.

Question 6

Varicosites

Answer 6

• Temperature
• Overlying erythema in the distribution of the vessel and tenderness on palpation is indicative of phlebitis.
• A tender and hard (“cord-like”) varicosity is indicative of thrombophlebitis (thrombosis with associated inflammation).

Question 7

Lower limb

Answer 7

• Assess for oedema
• Assess pulses - femoral, popliteal, tibial, dorales pedis

Question 8

Tap Test

Answer 8

Thetap testprovides a crude assessment oflower limb venous valve competency. It is rarely performed in modern clinical practice, but it is worth understanding what the test involves.

To perform thetap test:

1.Place one finger, with a small amount of pressure, onto the saphenofemoral junction (SFJ) which is located 4cm inferior-lateral to the pubic tubercle.

2.Tap the varicose vein you are assessing, which should be located lower down the leg.

3.If your finger over the SFJ detects a thrill, this suggests that there is continuity of the vein due to incompetent venous valves (normally the venous valves should prevent the thrill transmitting along the entirety of the vessel).

Question 9

Doppler test

Answer 9

• Confirm the origin of the incompetence (e.g. SFJ, SPJ).
• Assess whether the veins are suitable for endovenous treatment (radiofrequency or laser ablation) as veins need to relatively straight to permit the passage of the catheters.
• Establish the function of the deep venous system – if the deep veins are incompetent the patient may be relying on the superficial venous system for the return of venous blood thus treating the superficial veins may cause chronic limb swelling.

Question 10

Trendelenburg test

Answer 10

One legshould be assessed at a time.

1.Position the patient lying flat on the examination couch.

2.Lift the patient’s leg up (as far as the patient is comfortable with) and empty the superficial veins by milking the leg towards the groin (SFJ).

3.Place a tourniquet over the saphenofemoral junction (SFJ) – this is found approximately 2-3cm below and lateral to the pubic tubercle.

4.Ask the patient to stand and observe for filling of the veins:

• At this point, if the veins have not filled and remain collapsed, it indicates the incompetent venous valve(s) was/were at the level of the SFJ.
• If the veins have filled up again, it indicates the incompetent valve(s) is/are inferior to the SFJ (i.e. perforator veins – veins that drain venous blood from superficial to deep veins within the muscle).

5.Repeat the test with the patient lying down, placing the tourniquet 3cm lower than the previous position. Ask the patient to stand and observe venous filling once again.

6.Repeat this sequence until filling stops and the location of the incompetent venous valves is localised.

Question 11

Cough impulse test

Answer 11

Place your hand over the saphenofemoral junction (2-3cm below and lateral to the pubic tubercle) and ask the patient to cough.

2.If you feel an impulse over the SFJ this indicates a saphena varix (dilatation of the saphenous vein at the SFJ).

Question 12

Perthes Test

Answer 12

Perthe’s testis used to distinguish between venous valvular insufficiency in the deep, perforator and superficial venous systems.

1.Apply a tourniquet at the proximal mid-thigh level whilst the patient is standing.

2.Ask the patient to walk around the room (or continually alternate between standing on tip-toes and flat feet) for 5 minutes.

If the varicose veins becomelessdistended, it suggests that there isnodeepvenousvalvular insufficiency, because the calf muscle is able toemptythevaricoseveinsby pumping blood from the superficial venous system to the deep venous system. This result would suggest there is a primary problem with the superficial veins.

If the varicose veinsremaindistended(or become more distended) it suggests thereisalsoa problemwith thedeepvenoussystem, preventing the drainage of blood from the superficial varicose veins. In this circumstance, the patient may also experiencepainin the leg due tovenous hypertension. A potential cause of deep venous obstruction is adeepveinthrombosis.

Question 13

Further assessments

Answer 13

• Doppler ultrasound:to enable further bedside assessment of incompetent venous valves and the identification of thrombosis.
• Venous duplex scanning:for a comprehensive assessment of lower limb venous drainage.
  ABPI
  Peripheral artertial examination
  Abdominal examination