Venous and Lymphatic Disease

Question 1

What are varicose veins?

Answer 1

Dilated and tortuous, often a superficial vein and commonly found in lower libs

Question 2

Describe the course of the long saphenous vein

Answer 2

Dorsal venous arch drains into the LSV, which passes anterior to the medial mallows and up the medial aspect of the leg

Question 3

What is the saphenofemoral junction?

Answer 3

Where the LSV perforate the cribriform fascia and empties into the femoral vein (deep system)

Question 4

Describe the course for the small saphenous vein

Answer 4

The plantar venous arch drains into the SSV which travel posterior to the lateral mallows, up the posterior aspect of the leg and drain into the popliteal vein (deep system)

Question 5

What assists the flow of blood back to the heart?

Answer 5

Valves
Calf mucle pump
Perforating veins drain blood into the deep system

Question 6

What are causes of valvular failure?

Answer 6

Surgical or traumatic disruption of the valve
DVT
Hormonal changes in pregnancy
Large pelvic tumour

Question 7

Why can a DVT cause valvular failure?

Answer 7

Initially causes obstruction to flow, but although the vein reanalyses through the thrombus, this canal will be a high-pressure valvular flow

Question 8

Why do hormonal changes in pregnancy cause valvular failure?

Answer 8

Can weaken veins and valves, leading to venous incompetence

The enlarged uterus can cause mechanical obstruction to venous flow within the deep system

Question 9

Why do large pelvic tumours cause valvular failure?

Answer 9

Cause mechanical obstruction to venous flow within the deep system, leading to increased pressure

Question 10

How does the failire of one venous valve affect other valves?

Answer 10

Once one valve has failed, venous pressure increases causing dilatation of the diastole vein and further valvular incompetence

Question 11

What are risk factors for valvular disease?

Answer 11

Age 
Female
Pregnancies
DVT
Standing for long periods of time (occupation)
FH

Question 12

What are symptoms of valvular disease?

Answer 12

Burning 
Itching 
Heaviness
Tightness 
Swelling 
Discolouration 
Phlebitis 
Bleeding 
Disfiguration 
Eczema 
Ulceration

Question 13

What is phlebitis?

Answer 13

Inflammation of a vein

Question 14

What are the examination techniques for assessing varicose veins?

Answer 14

Observation
Palpatation
Special tests:
tap test
touniquet test
doppler

Question 15

What is the tap test for testing for varicose veins?

Answer 15

Place one hand over the saphenofemoral junction
Other hand on LSV above knee

Tap the junction - if feel impulse at LSV then indicate incompetence

Question 16

What the the Tourniquet Test for varicose veins?

Answer 16

1. Lie patient flat and drain superficial veins by raising leg and stroking veins towards trunk
2. Apply touniquet over saphenofemoral junction
3. Ask patient to stand
4. If veins do not fill, and observe for any signs of varicose veins reappearing
5. If the varicose veins do not fill back up, this indicates the problem is above the tourniquet level, but if it fills back up, this indicates the problem is below the tourniquet level

Question 17

Describe the doppler test for varicose veins

Answer 17

1. Hold doppler probe ver sphenofemoral junction
2. Squeeze calf muscles
3. In patient with competent veins there is a whoosh sound
4. In patient with incompetent saphenofemoral junction there will be 2 waves as blood flows upwards and then refluxes downwards again

Question 18

What investigation should be carried out for varicose veins and why?

Answer 18

Ultrasound - demonstrates the valves, the anatomy (tortuous) and can be used to show dynamic blood flow i.e. reflux

Question 19

Describe CEAP classification of chronic venous disease C0

Answer 19

No visible or palpable signs of venous disease

Question 20

Describe CEAP classification of chronic venous disease C1

Answer 20

Teleangiectasies or reticular veins

Question 21

Describe CEAP classification of chronic venous disease C2

Answer 21

Varicose veins

Question 22

Describe CEAP classification of chronic venous disease C3

Answer 22

Oedema

Question 23

Describe CEAP classification of chronic venous disease C4a

Answer 23

Pigmentation or eczema

Question 24

Describe CEAP classification of chronic venous disease C4b

Answer 24

Lipodermatosclerosis or atrophie blanch

Question 25

Describe CEAP classification of chronic venous disease C5

Answer 25

Healed venous ulcer

Question 26

Describe CEAP classification of chronic venous disease C6

Answer 26

Active venous ulcer

Question 27

What are the 3 etiological classifications?

Answer 27

Ec: congenital Ep: primary En: no venous cause

Question 28

What are the 3 anatomical classifications?

Answer 28

As: superficial Ap: perforating Ad: deep veins An: no venous location

Question 29

What are the 3 pathophysiology classifications?

Answer 29

Pr: reflux Po: obstruction Pr, o: reflux and obstruction Pn: no venous patholophysiology

Question 30

When should treatment be offered?

Answer 30

``` Bleeding varicose veins Symptomatic varicose veins Recurrent symptomatic VV Lower limb skin changes of chronic venous insufficiency Superficial venous thrombosis Venous leg ulcer - active or healed ```

Question 31

What are the 3 steps to surgery?

Answer 31

1. Endovenous treatment 2. Ultrasound guided foam sclerotherapy 3. Open surgery If intervention unsuitable (obstructed DVT or pregnancy): compression hosiery

Question 32

How is endovenous treatment carried out?

Answer 32

1. LSV or SSV cannulated 2. Catheter inserted distal to sapheno-femoral/popliteal junction 3. Local anaes. infiltrated in superficial tissues around vein 4. Cather injures vein wall with heat or laser -> fibrosis and occlusion of the vein

Question 33

What are complications with endovensou treatment?

Answer 33

Skin burns Paraesthesiae Phlebitis DVT

Question 34

What is foam sclerotherapy?

Answer 34

A chemical is injected into affected vein and the foam damages the venous walls -> fibrosis and occlusion

Question 35

What are the complication with foam sclerotherapy?

Answer 35

The vein should be occluded (with pressure) to prevent foam migrating: can cause stroke, TIA or MI Thrombophlebitis Skin pigmentation

Question 36

How is the open surgery carried out?

Answer 36

1. Under GA, groin incision made and then saphenogemoral junction exposed 2. instrument passed through saphenous vv, then strip vv out 3. Small superficial varicose veins are removed

Question 37

What are possible complications of open surgery?

Answer 37

Anaethetic risk Wound infection Damage to nearby nerves Bleeding

Question 38

What can causes venous insufficiency?

Answer 38

Failure of calf muscle pump Superficial venous reflux Deep venous reflux (surgery, DVT, congenital) Venous obstruction (HF, portal hypertension obesity)

Question 39

Describe the pathophysiology of venous insufficiency

Answer 39

1. Venous insufficiency 2. Venous HPT 3. Endothelial leak 4. Oedema (5. Increased perfusion distance 6. Impaired healing 7. Inflammation 8. Fibrinogen, tissue damage) 9. Impaired tissue perfusion Can go from 4 -> 9

Question 40

What are symptoms of chronic venous insufficiency?

Answer 40

``` Oedema Telangiectasia Eczema Haemosiderin pigmentation Hypopigmentation Lipodermatosclerosis Ulceration ```

Question 41

What are venous ulcers?

Answer 41

Breach in the skin between knee and ankle joint, present for > 4weeks

Question 42

What are characteristic of venous ulcers?

Answer 42

``` Gaiter area Granulomatous (red) base Shallow Irregular margins Exudative, oedematous Painless, pulses present ```

Question 43

What are investigations for venous insufficiency?

Answer 43

History Examination ABPI (ankle-brachial pressure index) - excludes arterial disease

Question 44

What is the treatment for venous insufficiency?

Answer 44

Wound care Elevation Compression bandaging Shockwave therapy

Question 45

What are primary causes for lymphoedema?

Answer 45

Congenital Praecox: around puberty Tarda: age > 35

Question 46

What are secondary causes for lymphoedema?

Answer 46

Malignancy Surgery Radiotherapy Infection

Question 47

What is the treatment for lymphoedema?

Answer 47

Elevation | Drainage