Questions and Answers
What does a Doppler/Duplex scan NOT assess?
Which test assesses for incompetent perforators with gradual filling from below?
What is a key disadvantage of using compression garments?
What does the Modified Perthe's Test aim to rule out?
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In Fegan's method, the marking of blowouts is used to identify what?
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Which symptom indicates a positive result in the Modified Perthe's Test?
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What is the primary function of perforators in the venous system?
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Where does the short saphenous vein (SSV) drain?
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Which named perforator is located below the knee?
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What is the significance of the Giacomini vein in surgery?
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What should be done before operating on the Sapheno-popliteal junction?
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Which of the following statements about the short saphenous vein (SSV) is incorrect?
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What is the primary characteristic of varicose veins?
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Which of the following is NOT a type of varicose vein?
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What factor is NOT associated with an increased risk of developing varicose veins?
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What condition is indicated by increased pressure in superficial veins during exercise?
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Which of the following accurately describes a reticular vein?
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What symptom is commonly associated with varicose veins?
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Which clinical classification indicates the presence of varicose veins?
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What does the 'P' in the pathophysiological classification denote?
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In anatomical classification, which option refers to superficial veins?
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Which clinical test is specifically used for detecting DVT?
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What classification designation is used for telangiectasias or reticular veins?
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For perforator incompetence, which test can be used?
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What is the primary disadvantage of the Endovenous Laser Therapy (EVLT)?
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Which technique does NOT require continuous pull-back during the procedure?
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What is the role of the sclerosant in foam sclerotherapy?
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What is a notable characteristic of Dodd and Cockett procedure?
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Which of the following newer modalities is indicated to collapse dilated veins using a glue?
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What kind of light is used in the Trivex procedure?
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Which type of vein is characterized as having a fan-shaped pattern of telangiectasia?
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What condition is indicated by a depigmented area surrounded by dilated veins?
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Which of the following is a sign of advanced venous disease characterized by a contracture of the tendo achilles?
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Which clinical finding is commonly associated with Gaiter's area?
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Which type of vein is generally considered the earliest sign of advanced venous disease?
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What is the most common nerve injury associated with greater saphenous vein surgery?
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Which complication of varicose veins is characterized by a hard nodule?
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What feature is characteristic of a varicose or venous ulcer?
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Which complication of varicose vein surgery occurs most frequently?
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Where is the most common site for varicose venous ulcers?
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What is the primary objective of the Trendelenburg procedure?
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Which of the following vessels is NOT included in the tributaries ligated during the Trendelenburg procedure?
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Which procedure is considered the latest advancement for treating GSV + SFJ incompetence?
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What is the primary concern regarding venous stripping during surgical procedures?
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What is the treatment of choice for SSV + SPJ incompetence as stated in the surgical management?
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What is the procedure aimed at treating perforator incompetence?
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What percentage of the venous system is comprised of the deep system?
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What is the location of the sapheno-femoral junction (SFJ)?
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Which vein is closely associated with the saphenous nerve below the knee?
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What could be a potential complication when raising the Great Saphenous Vein (GSV)?
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What is a significant use of the Great Saphenous Vein (GSV) in surgery?
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Which type of lower limb ulcer typically presents with normal arterial pulsations and sloping margins?
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What is the primary management strategy for venous ulcers?
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What type of ulcer is most commonly associated with malignant transformation from long-standing conditions?
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Which condition is characterized by absent deep veins and a cutaneous naevus?
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In the context of arterial ulcers, what sensation typically accompanies the condition?
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What is the management approach for Parkes-Weber Syndrome?
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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.
