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70 Cards in this Set
- Front
- Back
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Are varicose veins more common in males or females? %? What is the CEAP classification of venous disease?
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40% of females
20% of males Clinical, Etiology, Anatomical site, Pathophysiology |
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Describe the 'C' Clinical classification of venous disease
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Based on signs:
none = 0 telengiectasia/reticular veins (spider veins) = 1 varicosities = 2 swelling = 3 lipodermatosclerosis (skin changes - most marked in LL) = 4 healed ulceration = 5 active chronic venous ulcer (MC LL medial aspect; sloped edges, base of ulcer may be granulation tissue, chronic skin changes typical) = 6 |
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Are venous ulcers painful? If severe pain assoc, what does it suggest?
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No, unless infected in cellulitis
If severe pain -> arterial involvement. Test by palpating DP and PT |
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If a chronic leg ulcer is present for a long time, what is it at risk of developing? What is its typical appearance?
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SCC - Marjolin's ulcer, raised everted edge
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What is the 'E' Etiology of venous disease - primary vs secondary? Common sites?
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Primary 2/2 incompetent valves
- Most common site saphenofemoral junction reflux into great saphenous system - saphenopopliteal junction -> small saphenous Secondary 2/2 previous DVT causing incompetent valves or venous obstruction |
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The 'A' anatomical site of venous disease classified as superficial and deep. Where are these located?
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Superficial - saphenofemoral -> great saphenous, saphenopopliteal junction -> small saphenous, perforating veing in thigh (connect with GSV), calf medially (connect with posterior arch vein)
Deep venous - iliac, femoral, popliteal calf vessels |
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Describe the 'C' Clinical classification of venous disease
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Based on signs:
none = 0 telengiectasia/reticular veins (spider veins) = 1 varicosities = 2 swelling = 3 lipodermatosclerosis (skin changes - most marked in LL) = 4 healed ulceration = 5 active chronic venous ulcer (MC LL medial aspect; sloped edges, base of ulcer may be granulation tissue, chronic skin changes typical) = 6 |
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What is the 'E' Etiology of venous disease - primary vs secondary? Common sites?
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Primary 2/2 incompetent valves
- Most common site saphenofemoral junction reflux into great saphenous system - saphenopopliteal junction -> small saphenous Secondary 2/2 previous DVT causing incompetent valves or venous obstruction |
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The 'A' anatomical site of venous disease classified as superficial and deep. Where are these located?
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Superficial - saphenofemoral -> great saphenous, saphenopopliteal junction -> small saphenous, perforating veing in thigh (connect with GSV), calf medially (connect with posterior arch vein)
Deep venous - iliac, femoral, popliteal calf vessels |
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Which veins of the lower limb enter the popliteal vein?
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(in order distal to prox) ant tibial, peroneal/posterior tibial, soleal, gastrocnemial, small saphenous
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What primary investigation would you do for LL venous disease? Which structures would you look out for?
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Duplex USS - shows sites of incompetence and obstruction (great saph, small saph, perforators, deep veins)
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What are some conservative treatments for venous disease/varicose veins?
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regular walking
weight reduction avoid prolonged sitting/standing frequent leg elevation compression stockings - class I-III for 20-40mmHg at ankle; provide greater compression than graduated compression stockings for DVT Px (not suitable for mobile outpatient) |
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What class of venous disease is sclerotherapy suitable for?
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C1/C2 - telengiectasia, reticular veins; localised varicosities with no saphenofemoral or saphenopop incompetence and no deep venous incompetence or obstruction; hypertonic saline or athoxysclerol used
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What class of venous disease is varicose vein surgery suitable for? What does it involve?
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C2-C6 to correct superficial venous incompetence, rarely performed for DEEP venous disease e.g. femorofemoral bypass for iliac obstruction or valve recon
Involves high ligation or stripping of the great/small saph v (as close as poss to saph-fem/saph-pop jn; also excision of tributaries and incompetent perforators Also RFA, laser therapy, 'foam' sclerotherapy for obliteration |
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What are the clinical manifestations of post-thrombotic syndrome/chronic venous insufficiency (e.g. after post-op DVT)?
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Edema
Skin and subcutaneous tissue changes Chronic venous ulcer (MC medial aspect of lower leg) |
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What is the DVT incidence in Stroke, Orthopedic Sx and Gen Surg patients in the absence of prophylaxis?
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Stroke - 55%
Orthopedic Sx (THA, TKA, multitrauma) - 50% Gen Surg - 25% |
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What are the modalities available for VTE prophylaxis?
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Mechanical - Graduated compression stockings (GCS), Intermittent pneumatic compression (IPC), Venous Foot Pump (VPF)
Pharm - Low-dose unfrac heparin (LDUH), LMWH (enoxaparin and dalteparin - pentasaccharide and FXa targets), pentasaccharide (fondaparinux - only FXa target) |
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What are the indications for IVC as VTE prophylaxis?
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Proven proximal DVT (to prevent PE, if anticoagulation C/I)
Patients with major trauma or pelvic fracture who cannot receive mech or pharm px MUST be removed - Cx LT filter migration, perforation of IVC, chronic venous obst) |
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Who are high-risk gen surg patients for VTE Px? Which modes are best?
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>60yo with additional VTE RF (previous VTE, thrombophilia, cancer, estrogen tx, pregnancy, active inflammation, strong fhx dvt, obesity) or MAJOR surgery >40yo non-ortho, non-cancer (major = intraabdominal sx or >45min)
LDUH=LMWH (A evidence) > LDUH/LMWH+GCS+IPC (B); Fondaparinux (B) |
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What is the effectiveness of DVT pharm prophylaxis in ortho surg - THA/TKA? What would you use in hip fracture surgery?
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Use Fondaparinux 2.5mg/day or LMWH enox 40mg/day or dalt 5000U/day
LMWH before or after op Fondaparinux started 8 hours AFTER surgery Cont for 4-6 weeks +/- GCS/IPC Evidence: Fondaparinux>LMWH>Vit K antag (Warfain)>LDUH>aspirin>GCS LDUH/LMWH/fonda can be used with hip fx surgery +/- IPC + GCS Commence immediately on admission if emergency hip fx surg req'd |
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What are the characteristics of varicose veins?
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visible
dilated elongated tortuous |
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What is the anatomy of the long saphenous system?
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begins in dorsum of foot, runs anterior to the medial malleolus along the medial aspect of the calf and thigh and ends at the saphenofemoral junction where joins the common femoral vein
Major tributary: posterior arch vein- joins the long saphenous just below the knee (drains blood from medial calf and has peforators that communicate with the deep system) Lots of tributaries join just before saphenofem jn- if don't deal with these in surgery varicose veins will recur |
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Where is the saphenofemoral junction?
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2-3cm below and lateral to the pubic tubercle
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Where is the junction between she short femoral and popliteal vein?
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variable location- few cm above and below the knee crease
becomes the femoral vein then the external iliac vein as it passes beneath the inguinal ligament |
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Where are the perofrating veins found?
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Medial side of the lower 1/3 of the calf between the posterior arch vein and the posterior tibial veins
junction of middle and lower 1/3 of thigh Inconsistent location |
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Pressure generated by the calf muscles?
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250mmHg
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Prognosis of varicose veins that occur during pregnancy?
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partial regression occurs following delivery but there is a progression of the varicosities with succeeding pregnancies
Tributaries of the internal iliac vein and even the ovarian vein may be involved- producing posterior thigh and vulval varices |
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What is thrombophlebitis?
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Thrombosis in a segment of varicose vein: signs of inflammation spreading from a hard lump (thrombosed vein)
Usually resolves in a period of days as long as the thrombosis does not spread to the deep venous system (extension to common femoral is very dangerous) |
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Where does superficial vein thrombosis extend to?
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Often 15cm or more proximal to the clinical signs of inflamm
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Management of thrombophlebitis extending above the level of the knee?
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urgent operative ligation of saphenofemoral junction or full anticoagulation
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Management of varicose vein haemorrhage
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Bleed will continue as long as limb is dependent and can lead to exanguination
Pressure above the bleeding point Do NOT torniquet- rise in venous pressure produced by tourniquet may worsten bleeding |
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Can varicose veins cause ulceration?
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yes, common cause
usually skin changes occur first |
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Varicose veins in children?
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Rare, associated with major abnormalifies of the venous system e.g. AVM
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What does the distribution of varicose veins tell you?
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if medial/involve thigh: long saphenous likely involved
if lateral/involve calf: short saphenous |
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What can confirm the diagnosis of saphenofemoral incompetence?
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cough impulse over promenant veins
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Which findings suggest that a patient doesn't have "straightforward" venous disease?
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Varices of the medial aspect of the upper thigh may indicate pelvic venous insufficiency
The presence of significant leg oedema is unlikely to be due to varicose veins alone Prominent superficial veins extending above the level of the inguinal ligament in the suprapubic area suggests that these veins are dilated collaterals which have formed in response to deep venous obstruction Ulcers sited proximal to the mid-calf level are unlikely to have a venous aetiology |
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Why is a narrow tourniquet used when testing for venous incompetance?
above patella: thigh perforators below knee- short saphenous if this does not work- problem is in falf communicating veings |
occludes the superficial veins but does not affect the deep veins
veins fill slowly (30-60s) because of arterial inflow or rapidly if due to venous reflux |
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Major indications for duplex ultrasound prior to varicose vein surgery?
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(most ppl do for all)
Clinical doubt To identify level at which short saphenous enters the popliteal vein Locating incompetent perforating veins Recurrent varicose veins- find sites of recurrence |
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Where are the sites of recurrence post varicose vein surgery?
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system not previously treated
in the groin following saphenofemoral ligation (major tributary not treated/neovascularisation between deep and superficial system through scar tissue/incompetence of perforating veins |
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Is treatment of varicose veins essential?
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No, few serious sequillae of untreated varicose veins
except in patients with complication/pre-ulcerative changed in calves |
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Compression stockings in pts with varicose veins
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help alleviate symptoms
Below knee compression stocking providing 20-30mmHg of pressure |
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When is injection therapy appropriate for varicose veins?
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Only when major sites of deep and superficial incompetance have been controlled- controls the small vessels that remain. Major component is compression which fascilitates fibrous reorganisation and inhibits recanilization
small veins: hypertonic saline injection. |
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Describe saphenofemoral ligation?
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3cm skin incision 1cm above the groin crease below and lat to the pubic tubercle.
Expose the saphenofemoral J. Dissect long saphenous and tributaries- livide tributaries and ligate saphenous at junction. Explore femoral vein proximal and distal to ensure that there are no more tributries. |
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What do you have to be careful of in saph-pop ligation?
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sural nerve injury
fat in the popliteal fossa makes dissection difficult ultrasound helps |
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Which part of the saphenous vein should be stripped?
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groin to knee
below knee not useful and can cause neuritis of the saphenous nerve |
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Distance between incisions in multople venous extractions?
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2-4cm apart
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Which patients get ligation of perforating veins?
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recurrent, venous changes in lower limb
NOT a cosmetic procedure |
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Post-op care of venous ligation?
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firm bangaging to promote haemostasis from extraction sites- comes off 24-48hrs--> then put on elastic stockings as leg tends to swell
early and continued mobilization if bilat- stay O/N |
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Recurrence rate after varicose vein stripping?
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15-20%
Injection therapy used to obliterate telangectatic vessels that cant be removed surgically |
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What makes lymphoedema different from other kinds of oedema?
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High protein content- brauny oedema unlike the filtration oedema of heart and renal failure
exact content varies with site e.g. chylomicrons in GIT, but everywhere contains albumin |
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What are the tissues in the body that do NOT have lymphatic vessels?
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brain and spinal cord
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Where does the thoracic duct terminate?
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junction between the subclavian and the IJV
1-4L/d go through thoracic duct |
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When can temporary lymphoedema occur?
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in a limb on account of muscle inactivity e.g. prolonged sitting
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What is primary lymphoedema?
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intrinsic abn in lymphatic vessels
15% aplastic 65% hypoplastic 20% varicose, dilated, incompetent due to fibrosis of the draining lymph nodes leaks into skin, through skin, into peritoneum/thorax/urine often vilat/symmetrical |
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Cause of filiariasis?
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nematode: Wucheriua bancrofti
Mosquito-bourne parisite of tropical regions Others: LGV/TB/recurrent non-specific infection |
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Tumours causing lower limb lymphoedema?
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cervic, ovary, uterus, prostate
metastatic |
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What are the pathological consequences of lymohoedema?
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recurrent infection e.g. cellulitis
thickening of skin with hyperkeratosis lymohangiosarcoma- very long term |
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How to distinguish lymphoedema from venous oedema?
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duplex doppler
make sure you also assess the iliac system specific investigations: not usually used but include lymphoscintography (radiolabelled colloids injected into interdigital spaces and should appear within 30min in regional nodes if lymphatic vessels are normal) reduced uptake = hypoplastic/obliterated vessels, in acquired this may be normal but slower in more proximal nodes May accentuate primary lymphoedema/give rise to infection/inflammation |
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What does CT scanning tell you about nodes?
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enlargement if obstructive
may be diminished in congenital |
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Management of lymphoedema
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essentially conservative
preserve quality of skin (moisturise), prevent lymphangitis and reduce limb size |
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Management of skin infections in lymphoedema?
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early rx with systemically administered penicillin
most common port of entry is interdigital tinea (Rx antifungal powder, oral griseofulvin) if recurrent: long-term daily prophylaxis with 250mg penicillin BD |
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Management of oedema in lymphoedema
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sleep with foot of bed elevated
30-50mmHd compression stockings pantyhose/thick stockings if whole limb oedema. Intermittent pneumatic compression will help |
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Indications for surgery in lymphoedema?
What does this involve? |
rare: oedema refract to conserv mx, repeated sepsis, skin changes/swelling suggest neoplasm
excision of subcut tissue (Charles operation) Attempt lymphatic bypass: still experimental |
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Signs and symptoms of saphena varyx?
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substantial varicose veins elsewhere
soft and diffuse swelling empties with minimal pressure and re-fills venous hum on auscultation cough impulse |
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Management of saphena varyx?
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high saphenous ligation
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What are haemorrhoids?
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abnormal dilataion of the normal venous cusioning of the anal canal: They are located in the submucosal layer in the lower rectum and may be external or internal based upon whether they are below or above the dentate line.
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Risk factors for developing symptomatic haemorrhoids?
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advancing age, diarrhea, pregnancy, pelvic tumors, prolonged sitting, straining, and chronic constipation. The association with chronic constipation, however, was not supported in a large epidemiologic study: all factors cause deterioration of the connective tissue that connects the haemarrhoid to the underlying sphincter--> bulge into canal and cause symptoms
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Clinical features of haemarrhoids?
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bleeding, anal pruritus, prolapse, and pain due to thrombosis
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Are haemorrhoids usually palpable?
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not unless large- blood inside them usually empties when insert finger
Demonstrate on proctoscopy: bulge into the lumen as withdraw the proctoscope |
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Management of haemorrhoids
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fluid and fibre first line
if significant prolapse: office based procedures e.g. banding/sclerotherapy thrombosed: oral/topical analgesia, stool softeners, sitz baths and excision if pain too severe: excise within 48-72hrs for rapid relief of sx Surgical haemorrhoidectomy if v. large/prolapse and can't tolerate office procedures- v. painful and lots of complications |
