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Flashcards in VASC - Venous disease Deck (16)

How do you standardize the severity of venous disease?

CEAP classification

Clinical Classification
Etiologic classification
Anatomic classification
Pathophysiologic classification


Define varicose veins
- primary
- secondary

Elongated, tortuous, dilated veins

Primary: Affecting superficial veins or perforators in the absence of deep incompetence

Secondary: Associated with deep venous incompetence from recanalization of previous DVT. Venous obstruction


Clinical Px/complaints of varicose veins

•Cosmetic issue
–telangiectasia, reticular veins, varices

–General leg ache or heaviness
–Venous claudication (pain does not resolve with rest but requires elevation for 10-20 min)

–Early ankle pitting oedema
–Later become indurated

•Skin changes
–Varicose eczema
–Lipodermatosclerosis: “Inverted champagne bottle”
–Atrophie blanche (confluence of white, depressed scars)

Others: Thrombophlebitis, Bleeding, Ulceration


Ix of varicose veins

Venous duplex
Descending venography


(5) classes of Rx of varicose veins

1. conservative
–elevate legs
–avoid standing still
–Dressings for ulceration
–graduated compression stockings

2. Sclerotherapy

3. Open Surgery
–GSV strip
–Stab phlebectomy

4. Endovenous Laser Therapy (EVLT)

5. Radiofrequency Ablation (RFA)


Types of leg ulcerations (3 main + 4 others)

2.Neuropathic (DM, ETOH, spinal cord lesions, tabes dorsalis, syringomyelia)
3.Stasis / venous

4.Infective (syphilis, mycobacterium, osteomyelitis)
5.Neoplastic (SCC, BCC, melanoma, metastatic, Kaposi’s sarcoma)
6.Systemic disease (pyoderma gangrenosum)
7.Traumatic (thermal burns, radiation, bites)


Describe ischaemic ulcers

•Painful ulcer
•History of claudication or rest pain
•Cardiovascular risk factors
•Previous peripheral vascular surgery
–Location: distal periphery, over dorsum of foot or pretibia
–Punch-out edges
–Ulcer base => poorly developed gray granulation tissue
–Surrounding skin is pale or mottled with no signs of inflammation
–Little bleeding when debrided


Signs of chronic arterial insufficiency

•atrophic nails / skin
•venous guttering
•Slow capillary return
•Absent pulses
•Beurger’s +ve


Describe neuropathic ulcers

•History of diabetes or other causes of neuropathy
–Location: pressure points or calluses
•plantar surface of MTP joints
•“Bunion” or “bunionette” areas
•Dorsum of IP joints
•Base of 5th MT
•MM or LM
•Callused posterior rim of heel pad

–Signs of neuropathy
•2-point discrimination
•Vibratory perception


(4) Signs of neuropathy

•2-point discrimination
•Vibratory perception


Features of distorted foot architecture

•Hyperextension of MTP joints
•Hyperflexion of IP joints
•Charcot’s deformity


Describe venous ulcers

•History of venous insufficiency
–varicose veins
–superficial thrombophlebitis or DVT
–variceal bleeding
•Previous venous surgery

–Larger and irregular edge
–Location: over gaiter area (commonly medial malleolus)
–Moist granulating base
–Surrounded by zone of inflammation and stasis dermatitis


Associated signs of venous insufficiency

•varicose veins
•pitting oedema
•varicose eczema
•Atrophie blanche


Comparison of ulcers by site

–distal at toe tips
–Pressure areas

–gaiter area

–dorsum of PIP / DIP
–Plantar surface MTP
–MM or LM
–Other calloused areas


Ix of leg ulcers

•FBE / U&E / CRP / glu / HbA1C / vasculitic screen / ESR / thrombophilic screen
•Swab m/c/s
•Xray ± bone scan ± MRI
•Duplex (arterial or venous)


Rx of leg ulcers

–Bed rest
–Elevation or dependency
–IV antibiotics
–Debridement / split skin graft

–Treat underlying aetiology
•Compression stockings / Varicose vein surgery
•Pressure offloading footwear / Total contact cast

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