Varicose Veins Investigation and Management
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Questions and Answers

What does a Doppler/Duplex scan NOT assess?

  • Flow status
  • Reflux
  • Presence of a DVT (correct)
  • Flow direction

    • Which test assesses for incompetent perforators with gradual filling from below?

  • Morrisey's Cough Impulse
  • Trendelenburg Test (correct)
  • Modified Perthe's Test
  • Multiple Tourniquet Test

    • What is a key disadvantage of using compression garments?

  • They are not suitable for any arterial disease
  • They increase exercise tolerance
  • They have low compliance (correct)
  • They are always effective

    • What does the Modified Perthe's Test aim to rule out?

    <p>Deep vein thrombosis (DVT)</p> Signup and view all the answers

    In Fegan's method, the marking of blowouts is used to identify what?

    <p>Incompetent perforators</p> Signup and view all the answers

    Which symptom indicates a positive result in the Modified Perthe's Test?

    <p>Increased pain and swelling</p> Signup and view all the answers

    What is the primary function of perforators in the venous system?

    <p>Connect superficial veins to the deep venous system</p> Signup and view all the answers

    Where does the short saphenous vein (SSV) drain?

    <p>Sapheno-popliteal junction</p> Signup and view all the answers

    Which named perforator is located below the knee?

    <p>Boyd's perforator</p> Signup and view all the answers

    What is the significance of the Giacomini vein in surgery?

    <p>It connects with the great saphenous vein and can cause recurrence after surgery</p> Signup and view all the answers

    What should be done before operating on the Sapheno-popliteal junction?

    <p>Mark the location radiologically</p> Signup and view all the answers

    Which of the following statements about the short saphenous vein (SSV) is incorrect?

    <p>It drains into the great saphenous vein</p> Signup and view all the answers

    What is the primary characteristic of varicose veins?

    <p>Dilated and tortuous veins</p> Signup and view all the answers

    Which of the following is NOT a type of varicose vein?

    <p>Tertiary</p> Signup and view all the answers

    What factor is NOT associated with an increased risk of developing varicose veins?

    <p>Age above 50</p> Signup and view all the answers

    What condition is indicated by increased pressure in superficial veins during exercise?

    <p>Ambulatory venous hypertension</p> Signup and view all the answers

    Which of the following accurately describes a reticular vein?

    <p>Diameter between 1-3mm</p> Signup and view all the answers

    What symptom is commonly associated with varicose veins?

    <p>Dull, aching pain</p> Signup and view all the answers

    Which clinical classification indicates the presence of varicose veins?

    <p>C2</p> Signup and view all the answers

    What does the 'P' in the pathophysiological classification denote?

    <p>No venous pathology identified</p> Signup and view all the answers

    In anatomical classification, which option refers to superficial veins?

    <p>A1</p> Signup and view all the answers

    Which clinical test is specifically used for detecting DVT?

    <p>Modified Perthes test</p> Signup and view all the answers

    What classification designation is used for telangiectasias or reticular veins?

    <p>C1</p> Signup and view all the answers

    For perforator incompetence, which test can be used?

    <p>Fegan's method</p> Signup and view all the answers

    What is the primary disadvantage of the Endovenous Laser Therapy (EVLT)?

    <p>Continuous pull-back required</p> Signup and view all the answers

    Which technique does NOT require continuous pull-back during the procedure?

    <p>Radiofrequency Ablation (RFA)</p> Signup and view all the answers

    What is the role of the sclerosant in foam sclerotherapy?

    <p>To collapse the dilated vein</p> Signup and view all the answers

    What is a notable characteristic of Dodd and Cockett procedure?

    <p>Involves superficial and deep vein treatment</p> Signup and view all the answers

    Which of the following newer modalities is indicated to collapse dilated veins using a glue?

    <p>Endovenous Glue Therapy</p> Signup and view all the answers

    What kind of light is used in the Trivex procedure?

    <p>Sub-cutaneous illumination</p> Signup and view all the answers

    Which type of vein is characterized as having a fan-shaped pattern of telangiectasia?

    <p>Corona phlebectasia</p> Signup and view all the answers

    What condition is indicated by a depigmented area surrounded by dilated veins?

    <p>Atrophic blanche</p> Signup and view all the answers

    Which of the following is a sign of advanced venous disease characterized by a contracture of the tendo achilles?

    <p>Lipedermatosclerosis</p> Signup and view all the answers

    Which clinical finding is commonly associated with Gaiter's area?

    <p>Ulceration</p> Signup and view all the answers

    Which type of vein is generally considered the earliest sign of advanced venous disease?

    <p>Reticular veins</p> Signup and view all the answers

    What is the most common nerve injury associated with greater saphenous vein surgery?

    <p>Saphenous nerve</p> Signup and view all the answers

    Which complication of varicose veins is characterized by a hard nodule?

    <p>Calcification of veins</p> Signup and view all the answers

    What feature is characteristic of a varicose or venous ulcer?

    <p>Shallow with sloping edges</p> Signup and view all the answers

    Which complication of varicose vein surgery occurs most frequently?

    <p>Injury to nerves</p> Signup and view all the answers

    Where is the most common site for varicose venous ulcers?

    <p>Gaiter area above the medial malleolus</p> Signup and view all the answers

    What is the primary objective of the Trendelenburg procedure?

    <p>To prevent stump dilatation</p> Signup and view all the answers

    Which of the following vessels is NOT included in the tributaries ligated during the Trendelenburg procedure?

    <p>Posterior tibial vein</p> Signup and view all the answers

    Which procedure is considered the latest advancement for treating GSV + SFJ incompetence?

    <p>Endovenous Laser Ablation Therapy (EVLT)</p> Signup and view all the answers

    What is the primary concern regarding venous stripping during surgical procedures?

    <p>Saphenous nerve injury</p> Signup and view all the answers

    What is the treatment of choice for SSV + SPJ incompetence as stated in the surgical management?

    <p>Sub fascial endoscopic perforator surgery (SEPS)</p> Signup and view all the answers

    What is the procedure aimed at treating perforator incompetence?

    <p>Dodd &amp; Cockett procedure</p> Signup and view all the answers

    What percentage of the venous system is comprised of the deep system?

    <p>80%</p> Signup and view all the answers

    What is the location of the sapheno-femoral junction (SFJ)?

    <p>4 cm below and lateral to the pubic tubercle</p> Signup and view all the answers

    Which vein is closely associated with the saphenous nerve below the knee?

    <p>Great Saphenous Vein (GSV)</p> Signup and view all the answers

    What could be a potential complication when raising the Great Saphenous Vein (GSV)?

    <p>Injury to the Saphenous nerve</p> Signup and view all the answers

    What is a significant use of the Great Saphenous Vein (GSV) in surgery?

    <p>It can be harvested for grafting in coronary artery bypass surgery</p> Signup and view all the answers

    Which type of lower limb ulcer typically presents with normal arterial pulsations and sloping margins?

    <p>Venous Ulcer</p> Signup and view all the answers

    What is the primary management strategy for venous ulcers?

    <p>Education and compression therapy</p> Signup and view all the answers

    What type of ulcer is most commonly associated with malignant transformation from long-standing conditions?

    <p>Venous Ulcer</p> Signup and view all the answers

    Which condition is characterized by absent deep veins and a cutaneous naevus?

    <p>Klippel-Trenaunay Syndrome</p> Signup and view all the answers

    In the context of arterial ulcers, what sensation typically accompanies the condition?

    <p>Painful</p> Signup and view all the answers

    What is the management approach for Parkes-Weber Syndrome?

    <p>Supportive care without surgery</p> Signup and view all the answers

    Study Notes

    Investigation

    Doppler/Duplex Scan

    • Evaluates blood flow and directional cues (red = away from heart, blue = toward heart).
    • Detects reflux: superficial vein reflux is considered if retrograde flow lasts more than 0.5 seconds.

    Management

    Adjunctive Management

    • Compression Garments:

      • Class III (25-35 mmHg) recommended.
      • Challenges include low compliance and limited pressure due to concurrent arterial disease (reduced Ankle-Brachial Pressure Index).

    • Horse Chestnut Seed Extract:

      • Safe for chronic venous hypertension; alleviates symptoms and reduces leg swelling.

    Tests

    • Trendelenburg Test: Assesses venous incompetence; gradual filling indicates incompetent perforators, while rapid filling points to superficial femoral junction (SFJ) incompetence.
    • Fegan's Method: Involves palpating the vein and marking areas of reflux to identify incompetent perforators.
    • Morrisey's Cough Impulse: Cough impulse at SFJ indicates incompetency.
    • Multiple Tourniquet Test: Used to localize incompetent perforators by observing dilatation between tourniquets.
    • Modified Perthes Test: Rules out Deep Vein Thrombosis (DVT) based on pain and swelling response when walking post-tourniquet application.

    Types of Varicose Veins

    • Primary Varicose Veins: Caused by defective valves.
    • Secondary Varicose Veins: Often due to deep vein thrombosis (DVT) or tumors.
    • Risk Factors: Prolonged standing, gender (more common in females), family history, pregnancy.

    Pathophysiology

    • Normal Physiology: Venous return is aided by gravity, thoracic pressure changes during inspiration, muscle compression, and exercise.
    • Pathology: Increased pressure in superficial veins with exercise leads to ambulatory venous hypertension.

    Clinical Features

    • Dilated Veins:
      • Varicose veins >3mm diameter; reticular veins 1-3mm; thread veins ≤1mm.
    • Symptoms: Dull, aching pain, and pigmentation due to hemosiderin deposits.

    Anatomy of Superficial Veins

    • Great Saphenous Vein (GSV): Originates from the medial end of the dorsal venous arch; closely associated with the saphenous nerve; drains into the sapheno-femoral junction.
    • Short Saphenous Vein (SSV): Emerges from the dorsal venous arch and drains into the sapheno-popliteal junction.

    Perforator Veins

    • Connect superficial and deep venous systems; approximately 100-150 perforators exist.
    • Notable perforators include:
      • Hunterian (Thigh)
      • Dodd's (Above knee)
      • Boyd's (Below knee)
      • Cockett's (Above medial malleolus)

    CEAP Classification

    • Clinical: Ranges from no visible veins (Co) to active venous ulcers (C6).
    • Etiological: Categories include congenital, primary, secondary (post-thrombotic).
    • Anatomical: Classifies based on vein location - superficial, perforator, deep.
    • Pathophysiological: Involves reflux, obstruction, or a combination.

    Clinical Tests

    • SFJ incompetence: Trendelenburg test, Morrisey's cough impulse.
    • Perforator incompetence: Trendelenburg, multiple tourniquet test, Fegan's method.
    • DVT assessment: Modified Perthes test.

    Treatment Modalities

    • Endovenous Laser Therapy (EVLT): Utilizes a 1470 nm laser; generates heat to close veins; demands catheter withdrawal for vein collapse.
    • Radiofrequency Ablation (RFA): Operates at 120°C for 20 seconds; easier learning curve as continuous pull-back isn't needed.
    • Dodd and Cockett Procedure: Involves multiple ligation of incompetent perforators.
    • Sub-fascial Endoscopic Perforator Surgery (SEPS): Enables ligation of multiple perforators via a single incision.
    • Foam Sclerotherapy: Sclerosants create an inflammatory response to collapse veins; can involve sodium tetradecyl sulfate, polidocanol, etc.

    Complications of Varicose Vein Surgery

    • Common complications include infection, bruising, recurrence, bleeding, and nerve injuries (most frequent being to the saphenous and sural nerves).
    • Risk of marjolin's ulcer from long-standing venous ulcers.

    Venous Ulcers

    • Typical Sites: Primarily found in the gaiter area (above medial malleolus), also above lateral malleolus.
    • Characteristics: Shallow, sloping edges, pale granulation tissue; not healing, with pigmented margins.

    Management of Venous Ulcers

    • Limb elevation, education on care, and the use of compression stockings (grade III).
    • Surgical interventions and the administration of pentoxyphylline to enhance microvascular perfusion.

    Associated Syndromes

    • Klippel-Trenaunay Syndrome: Absent deep veins with varicose vein development; typically non-surgical management.
    • Parkes-Weber Syndrome: Multiple arteriovenous fistulas leading to limb hypertrophy and potential cardiac failure.

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    Description

    This quiz covers the assessment techniques for varicose veins, including Doppler and Duplex scans, along with management strategies like compression garments. Test your knowledge on the flow direction, reflux characteristics, and adjunctive management options for dealing with varicose veins.

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