Flashcards in Venous and lymphatic disease : Presentation, investigations and therapy Deck (36):
What is a varicose vein?
A varicose vein is a dilated and tortuous, often superficial vein.
- Most commonly found in the lower limbs
Anatomical landmarks in venous and lymphatic disease
- Course of the long
- Saphenofemoral junction
- Short saphenous vein
Describe the coarse of the long saphenous vein
Dorsal venous arch drains into the long saphenous vein, which passes anterior to the medial malleolus, up the medial aspect of the leg
Describe the Saphenofemoral junction
- Found 2.5cm below and lateral to the pubic tubercle
- Here the long saphenous vein perforates the cribiform fascia and empties into the femoral vein (deep system)
Describe the role of the short saphenous vein
The plantar venous arch drains into the short saphenous vein which travels posterior to the lateral malleolus, up the posterior aspect of the leg and drains into the popliteal vein (deep system)
What helps to assist low flow against gravity (back to the heart)?
- Calf muscle pump
- Perforating veins to drain blood into the deep system: deep veins are within muscular compartments and can withstand higher pressure
What are causes of valvular failure?
- Surgical or traumatic disruption of the valve.
- DVT: can initially cause obstruction to venous flow, and even as the vein re-canalises through the thrombus, this canal will be a high-pressure valvular channel.
- Hormonal changes in pregnancy can cause weakness of the veins and valves, leading to venous incompetence.
- A large pelvic tumour also could, lead to increased pressure within the distal venous systems.
Pathophysiology: What occurs once one valve has failed?
Venous pressure increases, there is dilatation of the distal vein and further valvular incompetence.
Risk factors for venous and lymphatic disease
- Age, veins become more elastic and weaken
- Female (20-25% females, 10-15% men)
- Standing for long periods (occupation)
- Family history
Symptoms and signs for VV
Examination for varicose veins
Look and Feel
Special tests for diagnosis of Varicose veins
- Tap test
- Tendeleburg/ tourniquet test
What do you do in a tap test?
- Place one hand over the saphenofemoral junction and one over the long saphenous vein above the knee.
- Tap the saphenofemoral junction: a transmitted impulse at the knee indicates an incompetence of the valves between the two hands.
What do you do in a tourniquet test?
- Lie the patient flat. Drain the superficial veins by raising the leg and stroking the veins towards the trunk.
- Apply pressure over the saphenofemoral junction. Keep this pressure on as you ask the patient to stand.
- If the varicose veins don’t dilate on standing, you are preventing this by ‘acting’ as a competent valve preventing backflow of blood. If you release your hand you will see the veins refill as the patient’s saphenofemoral junction valve is incompetent.
What do you do in a doppler test?
- Hold a doppler probe over the saphenofemoral junction.
Squeeze the calf muscles.
- In a patient with competent superficial veins you will hear a ‘whoosh’ as the blood flows upwards into the deep system.
- In a patient with an incompetent saphenofemoral junction you will hear two waves as the blood flows upwards and then refluxes downwards again.
What is the main investigation technique used for varicose veins?
- Can demonstrate the valves, the anatomy of the varicose vein (e.g. tortuosity), and can be used to show dynamic blood flow e.g. reflux.
CEAP classification of chronic venous disease
C0 - no visible or palpable signs of venous disease
C1 - teleangiectasies or reticular veins
C2 - varicose veins
C3 - oedema
C4a - pigmentation or eczema
C4b - lipodermatosclerosis or athrophie blanche
C5 - healed ulcer
C6 - active venous ulcer
When should treatment be offered to patients with varicose veins?
If they have:
- Bleeding varicose veins
- Symptomatic varicose veins (including aching, discomfort, swelling, heaviness and itching)
- Recurrent symptomatic varicose veins
- Lower limb skin changes of chronic venous insufficiency
- Superficial venous thrombosis
- Venous leg ulcer: active or healed
What are management options for varicose veins?
- First line: endovenous treatment
- Second line: ultrasound guided from sclerotherapy
- Third line: open surgery
If intervention is unsuitable, offer compression hosiery.
When shouldn't intervention be offered for VV?
If the deep venous system is obstructed e.g. DVT, or in pregnancy (hosiery instead)
Features of endovenous treatment for varicose veins
1. The LSV or SSV is cannulated under ultrasound guidance.
2. A catheter is passed up the length of the vein to just distal to the saphenofemoral or saphenopopliteal junction.
3. Local anaesthetic is used for the small skin puncture, and then is infiltrated in the superficial tissues around the length of the vein.
4. The catheter causes injury to the vein wall - either by heat or laser. This causes fibrosis and occlusion of the vein, and subsequent ablation/disappearance of the vein.
What are complications of endovenous treatment?
- Skin burns
- Paraesthesiae (0-10%)
- Phlebitis (5%)
- Deep vein thrombosis (1%)
What is foam sclerotherapy?
Under ultrasound guidance, a chemical foam is injected into the affected vein.
- The foam damages the venous walls, causing fibrosis and occlusion.
Features of foam sclerotherapy
- The vein should be occluded (with pressure) proximally to prevent foam migrating and causing the potential complications of stroke, TIA or MI.
- Thrombophlebitis (7%)
- Skin pigmentation (6%)
What happens in open surgery for varicose veins?
1. Under GA, a groin incision is made and the saphenofemoral junction is exposed.
2. The saphenous vein is ligated from the femoral vein. An instrument is passed along the length of the saphenous vein and then used to strip the vein out.
3. Small superficial varicose veins are avulsed using small, 'stab' incisions and a small hook instrument.
What are complications of open surgery?
- Anaethetic risk
- Wound infection
- Damage to nearby nerves (saphenous and sural nerves)
Features of venous insufficiency
- Failure of calf muscle pump
- Superficial venous reflex
- Deep venous reflux (surgery, DVT, congenital)
- Venous obstruction (heart failure, portal hypertension, obesity)
Features of chronic venous insufficiency
- Haemosiderin pigmentation
What are venous ulcers?
Breach in the skin between the knee and ankle joint, present for >4 weeks
Features of venous ulcers
- Gaiter area
- Granulomatous (red) base
- Irregular margins
- Exudative, oedematous
- Painless, pulses present
Investigations for venous insufficiency
- ABPI: arterial brachial pressure index
Treatment for venous insufficiency
Exclude arterial disease (ABPI)
- Wound care: little role for systemic antibiotics
- Compression bandaging
- Shockwave therapy
What is lymphoedema?
It is a condition of localised fluid retention and tissue swelling caused by a compromised lymphatic system.
Primary pathophysiology of lymphoedema
- Praecox: around puberty
- Tarda: age >35
Secondary pathophysiology of lymphoedema