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Yr3 Surgery: Vascular > Venous Disorders > Flashcards

Venous Disorders Flashcards

1
Q

Remind yourself of a brief outline of venous system in lower limb

A

Go revise MSK/see Complete Anatomy App for more!

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2
Q

What are varicose veins?

A

Varicose veins are tortuous dilated segments of vein associated with valvular incompetence.

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3
Q

Describe the pathophysiology of varicose veinss

A

Valves in perforating veins, which connect deep and superficial veins in leg, become incompetent resulting in blood from deep veins flowing back into superficial veins. Results in engorgement & dilation of superifical veins.

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4
Q

State some risk factors for developing varicose veins

A
  • Prolonged standing
  • Obesity
  • Pregnancy
  • Family history
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5
Q

What % of variose veins are idiopathic?

State some potential secondary causes of varicose veins

A
  • 98% of varicose veins are primary idiopathic varicose veins.
  • Secondary causes may include:
    • deep venous thrombosis
    • pelvic masses (e.g. pregnancy, uterine fibroids, and ovarian masses)
    • arteriovenous malformations (such as Klippel-Trenaunay Syndrome).
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6
Q

State & describe the 3 types of varicose veins

A
  • trunk varicose veins – near to the surface of the skin and are thick and knobbly; they’re often long
  • reticular varicose veins – these are red and sometimes grouped close together in a network
  • telangiectasia varicose veins – also known as thread veins or spider veins, these are small clusters of blue or red veins that sometimes appear on your face or legs; they’re harmless and, unlike trunk varicose veins, do not bulge underneath the surface of the skin
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7
Q

State symptoms of varicose veins

A
  • Heaviness
  • Muscle cramps
  • Aching
  • Itching
  • “cosmetically unappealing leg”
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8
Q

State what you might find on examination of someone with varicose veins

A
  • Varicose eczema (skin hyperpigmentation & dry skin)
  • Lipodermatoscerlosis
  • Oedema
  • Ulcers
  • Atrophie blanche
  • Positive Trendelenburg’s test
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9
Q

Describe how to perform the Brodie Trendelenburg test and explain what the results mean

A
  • Pt lie supine
  • Elevate leg to drain superficial veins
  • Then tie torniquet just above leg- tight enough to occlude superifical veins
  • Ask pt to stand
  • Normally, take around 30seconds for superfical veins to fill
  • If rapid filling occurs, this indicates valvular incompetence below the level of the tourniquet (as superficial veins have filled quicker becasue their drainage into deep veins is impaired)
  • If no rapid filling, remove tourniquet and if rapid filling above level of tourniquet occurs this signifies saphenofemoral junction incompetence
  • Therefore you can keep moving tourniquet further down leg to determine the level of the incompetence
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10
Q

What is atrophie blanche?

A

star-shaped ivory-white depressed atrophic plaques with red dots within the scar (dilated capillaries) and surrounding hyperpigmentation (due to haemosiderin deposition).

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11
Q

What is a saphena varix?

A

A saphena varix is a dilatation of the saphenous vein at the saphenofemoral junction in the groin. As it displays a cough impulse, it is commonly mistaken for a femoral hernia; suspicion should be raised in any suspected femoral hernia if the patient has concurrent varicosities present in the rest of the limb. These can be best identified via duplex ultrasound and management is via high saphenous ligation.

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12
Q

What is the gold standard investigation for variose veins?

A

Duplex ultrasound assessing:

  • Valve incompetence at the great/short saphenous veins and any perforators
  • Deep venous incompetence, occlusion (deep venous thrombosis) and stenosis must also be actively looked for.
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13
Q

What classification has been developed to allow standardised reporting method for the clinical manifestations of varicose veins?

A

CEAP classification. Reports:

  • Clinical features
  • aEtiology
  • Anatomical
  • Pathophysiology
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14
Q

Discuss the management of varicose veins, split your answer into:

  • Non-surgical
  • Surgical
A

Non-Surgical

  • Education: advise on avoiding prolonged standing, weight loss
  • Mobilisation/exercise (increase calf muscle action)
  • Elevate legs when possible to aid drainage
  • Compression stockings

Surgical

  • Endothermal ablation (catheter inserted into vein and radiowaves used to heat the vein and make it permanently collapse. Done under USS. Local or general anaesthetic)
  • Foam sclerotherapy (inject sclerosing agent into vein which causes inflammatory reaction causing vein to collapse. Done under USS. Local anaesthetic)
  • Stripping (make incision in groin or popliteal fossa, find refluxing vein, tie it off and strip it away)
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15
Q

State some potential complications of varicose veins

A
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16
Q

State some potential complications of surgery for varicose veins

A

Whilst the complications will be specific for each procedure, typical complications seen post-operatively include:

  • haemorrhage
  • thrombophlebitis (important for foam or ablation treatments)
  • DVT (important for any endovenous treatments)
  • disease recurrence
  • nerve damage (specifically saphenous or sural nerves)
17
Q

Explain how varicose veins can lead to varicose eczema and lipodermatosclerosis

A
  • Veins become leaky due to increased pressure
  • Small amounts of blood leak into nearby tissues
  • Haemoglobin in blood breaks down into haemosiderin which is deposited around the shins
  • This gives brown discolouration to skin and causes skin to become dry and inflamed- “varicose eczema”
  • Skin and soft tissue become fibrotic causing tight, narrowed lower legs- “dermatosclerosis”
18
Q

Define lipodermatosclerosis

A

Lipodermatosclerosis is 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).

Lipodermatosclerosis has the following clinical characteristics:

  • Skin hardening (often referred to as induration)
  • Hyperpigmentation
  • Erythema
  • Swelling
  • Inverted champagne bottle appearance
  • Venous ulcers
19
Q

NICE reccommend pts should be referred to vascular services if they meet what criteria? (4)

A
  • Symptomatic primary or recurrent varicose veins
  • Lower‑limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency
  • Superficial vein thrombosis (characterised by the appearance of hard, painful veins) with suspected venous incompetence
  • A venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks)
20
Q

Remind yourself for thrombophlebitis:

  • What it is
  • Symptoms
  • Management
A
  • Thrombus formation in a superficial vein (most commonly the saphenous vein and its tributaries of the lower limbs), with associated inflammation in the tissue surrounding the vein.
  • Pain, tenderness, itching, reddening of the skin, and/or hardening of the surrounding tissue
  • Risk factors: varicose veins, pregnancy, malignancy, thrombophilia, IV cannulation
  • Uncomplicated superficial vein thrombosis usually resolves in 1–2 weeks, although hardness of the vein may persist for longer. If the condition is associated with varicose veins, it has a high likelihood of recurrence unless excision of the varicose vein is performed.
21
Q

Chronic venous insufficiency encompasses what two conditions

A

Chronic venous insufficiency (CVI) refers to functional changes that may occur in the lower extremity due to persistent elevation of venous pressures includes:

  • Varicose veins (superifical veins)
  • Deep venous insufficiency (deep veins)

*The pathophysiology is similar for both the just affect different veins

22
Q

Causes of deep venous insufficiency can be divided into primary and secondary; state some causes of each

A

Primary: underlying defect in wall or valve of vein

Secondary: occurs secondary to damage e.g. following DVT, trauma

23
Q

State some risk factors for developing deep venous insufficiency

A
  • Increasing age
  • Female
  • Pregnancy
  • Previous DVT or phlebitis
  • Stand for long periods of time
  • Smoking
24
Q

Discuss the typical presentation of deep venous insufficiency

A

Symptoms

  • Chronic swollen lower limbs
  • Ache in lower limbs
  • Pruritic
  • Pain in lower limbs
  • Venous claudication (bursting pain or tightness on walking which resolves with leg elevation)

Signs

  • Varicose veins
  • Varicose eczema
  • Lipodermatosclerosis
  • Atrophie blanche
  • Venosu ulcers
25
Q

What is the primary investigation for deep venous insufficiency?

A

Doppler ultrasound

26
Q

Discuss the management of deep venous insufficiency

A

Management is mainly conservative!!

Non-surgical/conservative

  • Compression stockings
  • Analgesia
  • Foot elevation

Surgical

  • Valvuloplasty
  • Stent
27
Q

State some potential complications of deep venous insufficiency

A
  • Cellulitis
  • Chronic pain
  • DVT
  • Ulceration
  • Varicose veins
  • Secondary lymphoedema
28
Q

What is post-thrombotic sydnrome?

A

Damage to veins following thrombosis which causes venous insufficiency and all the associated symtoms & signs

29
Q

What must you do before prescribing compression stockings and why?

A

Rule out peripheral arterial disease using ABPI

Yr3 Surgery: Vascular (6 decks)

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