Surgery Marrow Pg 477-486 (Vascular Surgery)
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Questions and Answers

Which type of varicose veins is most commonly caused by deep vein thrombosis (DVT)?

  • Dermal flares
  • Primary varicose veins
  • Secondary varicose veins (correct)
  • Reticular veins

    • Females have a lower risk of developing varicose veins compared to males.

    False

    What is the typical diameter of a varicose vein?

    3mm

    The condition where superficial veins experience increased pressure with exercise is referred to as _____ hypertension.

    <p>ambulatory venous</p> Signup and view all the answers

    Match the types of veins with their diameters:

    <p>Varicose vein = &gt;3mm Reticular vein = 1-3mm Dermal flares/Thread veins = ≤1mm</p> Signup and view all the answers

    Which of the following is the most common nerve injury associated with varicose vein surgery?

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

    Wound infection is now a common complication of varicose vein surgery.

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

    What is the most common site for varicose/venous ulcers?

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

    Varicose veins can lead to superficial thrombophlebitis and _____ due to poor venous circulation.

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

    Match the following complications of varicose veins with their descriptions:

    <p>Bleeding = Decreased by limb elevation Calcification of veins = Hard nodule Pigmentation = Skin discoloration Lipodermatosclerosis = Thickening of the skin</p> Signup and view all the answers

    Where does the Great Saphenous Vein (GSV) terminate?

    <p>Saphenofemoral junction</p> Signup and view all the answers

    The Short Saphenous Vein (SSV) originates from the medial side of the dorsal venous arch.

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

    Name one important surgical consideration when operating on the Great Saphenous Vein.

    <p>Care should be taken to avoid damaging the sural nerve.</p> Signup and view all the answers

    The __________ vein connects the Great Saphenous Vein and can lead to recurrence after surgery.

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

    What veins are primarily involved in the condition known as varicose veins?

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

    Match the following perforators with their locations:

    <p>Hunterian perforators = Thigh Dodd's perforator = Above the knee Boyd's perforator = Below the knee Cockett's perforators = Above the medial malleolus</p> Signup and view all the answers

    There are approximately 50-100 perforators in the venous system.

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

    What anatomical structure should be carefully marked during surgery on the Short Saphenous Vein?

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

    Which procedure is considered the treatment of choice for incompetent great saphenous vein (GSV) and small saphenous vein (SFJ)?

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

    Superficial circumflex iliac vein is commonly ligated to prevent recurrence.

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

    What is the main purpose of performing flush ligation?

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

    The Dodd & Cockett procedure is performed as a multiple ________ procedure.

    <p>sub-fascial</p> Signup and view all the answers

    Match the procedures to their descriptions:

    <p>Traditional Procedure = Flush ligation of SFJ before surgery Endovenous Laser Ablation Therapy = Treatment of choice for incompetent veins Dodd &amp; Cockett Procedure = Multiple sub-fascial procedure SEPS = Sub-fascial endoscopic perforator surgery</p> Signup and view all the answers

    Which of the following statements about venous stripping is true?

    <p>It is performed only up to the knee.</p> Signup and view all the answers

    What is the most common cause of acute arterial occlusion?

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

    The latest procedure for treating incompetent GSV and SFJ includes stripping.

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

    Name one of the procedures for perforator incompetence.

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

    Paresthesia is one of the clinical features of acute arterial occlusion.

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

    Ligation is performed to reduce ________.

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

    What is the primary investigation method for diagnosing acute arterial occlusion?

    <p>Duplex scan</p> Signup and view all the answers

    What is typically done in the Traditional Procedure for incompetent GSV + SFJ?

    <p>Flush ligation of SFJ</p> Signup and view all the answers

    The management option for a patient with acute arterial occlusion presenting late with gangrene is _____

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

    Match the following clinical features of acute arterial occlusion with their descriptions:

    <p>Pain = Discomfort or hurt in the affected area Pallor = Pale coloration of the skin Pulselessness = Absence of blood flow detectable at pulse points Poikilothermia = Cold limbs due to lack of blood supply</p> Signup and view all the answers

    Which of the following is part of the Clinical Classification for venous disease?

    <p>No visible/palpable veins</p> Signup and view all the answers

    The CEAP classification includes anatomical, clinical, etiological, and pharmacological categories.

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

    What clinical test is used to assess SFJ (superficial femoral junction) incompetence?

    <p>Trendelenburg test</p> Signup and view all the answers

    The classification of venous disease that involves the presence of edema is classified as C______.

    <p>3</p> Signup and view all the answers

    Match the following classifications with their correct descriptions:

    <p>C4a = Secondary to venous disease E = Etiological Classification P = Pathophysiological Classification A = Anatomical Classification</p> Signup and view all the answers

    What does the Trendelenburg test assess?

    <p>Incompetence of perforators</p> Signup and view all the answers

    Morrissey's Cough Impulse test indicates incompetence of the deep veins.

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

    What is the primary purpose of a Doppler/Duplex scan in evaluating varicose veins?

    <p>To assess blood flow and direction.</p> Signup and view all the answers

    Compression garments are typically classified as Class _____ compression garments for varicose veins.

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

    Match the tests with their related functions:

    <p>Trendelenburg Test = Assesses venous reflux Morrissey's Cough Impulse = Tests competence of SFJ Multiple Tourniquet Test = Localizes incompetent perforators Modified Perthe's Test = Rules out DVT</p> Signup and view all the answers

    Which of the following treatment methods does NOT require continuous pull-back during the procedure?

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

    Foam Sclerotherapy is primarily used for veins larger than 3mm in diameter.

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

    What is the primary mechanism of action for Endovenous Glue Therapy?

    <p>Cyanoacrylate glue collapses dilated veins.</p> Signup and view all the answers

    The ______ procedure involves multiple perforator ligation with a single incision.

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

    Match the following varicose vein treatment methods with their mechanisms:

    <p>Endovenous Laser Therapy = 1470 nm laser generates heat Radiofrequency Ablation = 120°C heat over 20 seconds Trivex = Transilluminated powered phlebectomy Foam Sclerotherapy = Injection of sclerosant to create foam</p> Signup and view all the answers

    What is corona phlebectasia commonly characterized by?

    <p>A fan-shaped pattern of telangiectasia</p> Signup and view all the answers

    Malleolar flare is a symptom often associated with varicose veins.

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

    What is the primary clinical finding associated with corona phlebectasia?

    <p>Fan-shaped pattern of telangiectasia</p> Signup and view all the answers

    The appearance of _____ is commonly linked to venous insufficiency.

    <p>malleolar flare</p> Signup and view all the answers

    Match the following terms related to varicose veins with their descriptions:

    <p>Corona phlebectasia = Fan-shaped pattern of telangiectasia Malleolar flare = Superficial venous congestion around the ankle Telangiectasia = Small dilated superficial blood vessels Venous insufficiency = Inability of veins to properly return blood</p> Signup and view all the answers

    Which type of ulcer is characterized by a site at the dorsum/lateral side of the foot?

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

    Trophic ulcers have normal arterial pulsation.

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

    What is the mainstay treatment for venous ulcers?

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

    _____ Ulcers may lead to squamous cell carcinoma.

    <p>Long-standing venous</p> Signup and view all the answers

    Which of the following is NOT a feature of Klippel-Trenaunay Syndrome?

    <p>High output cardiac failure</p> Signup and view all the answers

    Match the type of ulcer with its characteristic sensation:

    <p>Venous Ulcer = Normal Arterial Ulcer = Painful Trophic Ulcer = Decreased Sensations Diabetic Ulcer = Decreased Sensations</p> Signup and view all the answers

    What is the approved drug for increasing microvascular perfusion in the management of venous ulcers?

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

    Surgery is recommended for Parkes-Weber Syndrome.

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

    Study Notes

    Varicose Veins

    • Varicose veins are dilated and tortuous veins with defective valves.
    • Primary varicose veins are caused by congenital defects in the vein walls or valves.
    • Secondary varicose veins are more common, often caused by deep vein thrombosis (DVT) or tumors.
    • Other risk factors include prolonged standing, female gender, family history, and pregnancy.

    Pathophysiology

    • Normal blood return against gravity is maintained by:
      • Increased intra-thoracic pressure during inspiration.
      • Compression of surrounding muscles.
      • Decreased pressure in superficial veins during exercise.
    • Increased pressure in superficial veins during exercise, especially in the presence of valve dysfunction, can lead to ambulatory venous hypertension.

    Clinical Features

    • Common presentations include:
      • Dilated veins: Varicose veins (>3mm), reticular veins (1-3mm), and thread veins (≤1mm).
      • Dull, aching pain.
      • Pigmentation due to hemosiderin deposition.

    Surgical Management

    • The document focuses on surgical management of incompetent great saphenous vein (GSV) and small saphenous vein (SFJ).
    • Endovenous Laser Ablation Therapy (EVLT) or Radiofrequency Ablation (RFA) are the preferred treatments for incompetent GSV + SFJ.
    • Incompetent perforators can be addressed through Dodd & Cockett procedure or SEPS (Sub-fascial endoscopic) perforator surgery.

    Complications

    • Complications of Varicose Vein Surgery:
      • Wound infection (less common due to antibiotics).
      • Bruising.
      • Recurrence (more common in SSV).
      • Bleeding.
      • Injury to vessels.
      • Injury to nerves (most common in GSV and SSV surgery).
    • Complications of Varicose Veins:
      • Bleeding.
      • Calcification of veins.
      • Superficial thrombophlebitis.
      • Pigmentation.
      • Lipodermatosclerosis.
      • Ulceration.
      • Marjolin's ulcer.

    Varicose/Venous Ulcers

    • Most commonly occur in the gaiter area (above the medial malleolus).
    • Shallow ulcers with sloping edges, pale granulation tissue, pigmented margins, and non-healing.

    Saphenous Veins

    • GSV (Great Saphenous Vein): Begins in the dorsal venous arch of the foot, ascends along the medial side of the leg, and terminates at the saphenofemoral junction.
    • SSV (Short Saphenous Vein): Originates from the lateral side of the dorsal venous arch, ascends along the posterior aspect of the leg, and terminates at the sapheno-popliteal junction.

    Perforators

    • Connect the superficial and deep venous systems.
    • Different perforators are named based on location, including Hunterian perforators, Dodd's perforator, Boyd's perforator, Cockett's perforators, and May/Kuster's perforator.

    Giacomini Vein

    • Connects the GSV and is a cause of recurrence after surgery.

    Important Considerations for Surgery

    • Careful anatomical marking of the sapheno-popliteal junction is crucial.
    • Surgeons should be mindful of the sural nerve's proximity to the GSV.

    Types of Lower Limb Ulcers

    Feature Venous Ulcer Arterial Ulcer Trophic Ulcer Diabetic Ulcer
    Site Gaiter Area Dorsum/lateral side Sole/base of great toe Sole/base of great toe
    Arterial Pulsation Normal Absent Normal May be absent
    Dilated Veins Present N/A N/A N/A
    Sensations Normal Painful ↓ Sensations ↓ Sensations
    Margins Sloping Punched out Punched out Punched out

    Management of Venous Ulcers

    • Bisgaard Regime: Education, limb elevation, elastic compression stockings (Grade III), multi-layer compression bandage, surgery, and pentoxifylline.

    Marjolin's Ulcer

    • Malignant transformation of long-standing venous ulcers or burns.
    • Commonly squamous cell carcinoma (SCC).
    • Characterized by raised and everted edges (cauliflower-like).
    • Wide local excision is the treatment of choice.

    Associated Syndromes

    • Klippel-Trenaunay Syndrome: Mesodermal abnormality, non-familial, characterized by absent deep veins and cutaneous naevus.
    • Parkes-Weber Syndrome: Multiple arteriovenous (A-V) fistulas, high output cardiac failure, and limb hypertrophy.

    CEAP Classification

    • A clinical, etiological, anatomical, and pathophysiological classification system for venous disease.
      • Clinical (C): Co, Cl, Ca, Car, C3, CA, C4a, C4b, C4c, C5, C6, Clor, etc.
      • Etiological (E): Congenital, Primary, Secondary, No venous etiology identified.
      • Anatomical (A): Superficial veins, Perforator vein, Deep vein, No venous location identified.
      • Pathophysiological (P): Reflux, Obstruction, Reflux & Obstruction, No venous pathology identified.

    Clinical Tests and Investigations

    • For SFJ incompetence: Trendelenburg test, Morrissey's cough impulse, Schwartz test.
    • For perforator incompetence: Trendelenburg test, Multiple tourniquet test, Fegan's method.
    • For DVT: Modified Perthes test.

    Doppler/Duplex Scan

    • Used to assess flow direction and presence of reflux (retrograde flow lasting ≥0.5 sec).

    Management

    • Adjunctive Management:
      • Compression Garments: Class III compression garments (25-35 mmHg).
      • Horse Chestnut Seed Extract: Safe and efficacious in treating chronic venous hypertension, improves symptoms and reduces leg volume.

    Varicose Vein Treatment Methods

    • Endovenous Laser Therapy (EVLT): Utilizes 1470 nm laser to generate heat (60 J/cm).
    • Radiofrequency Ablation (RFA): Generates heat at 120°C over 20-second cycles.
    • Dodd and Cockett Procedure: Multiple sub-fascial procedure.
    • SEPS (Sub-fascial Endoscopic Perforator Surgery): Multiple perforator ligation with a single incision.

    Newer Modalities

    • Endovenous Glue Therapy: Cyanoacrylate glue collapses dilated veins.
    • Trivex: Transilluminated powered phlebectomy to visualize and identify varicose veins subcutaneously.
    • Foam Sclerotherapy: Injecting a sclerosant (e.g., air, sodium tetradecyl sulphate) that collapses the dilated vein.

    Other Clinical Findings

    • Corona phlebectasia/malleolar flare: Fan-shaped pattern of telangiectasia at the ankle.
    • Atrophic blanche: White, porcelain-like plaques, typically occur in the lower leg, result of poor tissue oxygenation.

    Acute Arterial Occlusion

    • Most commonly caused by an embolus, often originating from the heart.
    • Risk factors: History of coronary artery disease (CAD) and atrial fibrillation.
    • Clinical features: 6 P's - Pain, Pallor, Paresis, Pulselessness, Paresthesia, Poikilothermia (cold limbs).
    • Investigations: Duplex scan (Color Doppler + 8 mode USG).
    • Management:
      • Early presentation (within 6-8 hours): Thrombolysis using Fogarty's balloon.
      • Late presentation with gangrene: Amputation.
    • Reperfusion injury:
      • Anaerobic metabolism initially due to arterial block.
      • Free radical injury after restoration of blood flow.

    Tests for Varicose Veins

    • Trendelenburg Test: Assesses rapid filling from above versus gradual filling from below.
    • Fegan's Method: Identify incompetent perforator sites by feeling along the vein and marking blowouts.
    • Morrissey's Cough Impulse: Check for incompetence at SFJ by observing a cough impulse.
    • Multiple Tourniquet Test: Localize incompetent perforators by applying tourniquets at various levels.
    • Modified Perthes Test: Rule out DVT by observing pain and swelling changes after walking with a tourniquet below the SFJ.

    Investigation

    • Doppler/Duplex Scan: Assesses flow direction and presence of reflux.
      • Red = flow away from heart.
      • Blue = flow towards heart.

    Management

    • Adjunctive Management:
      • Compression garments: Class III compression garments (25-35 mmHg), but can be challenging with co-existing arterial disease.
      • Horse Chestnut Seed Extract: Safe and effective for chronic venous hypertension.

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    Description

    This quiz explores varicose veins, including their definition, types, and pathophysiology. It covers risk factors, clinical features, and the body's mechanics in maintaining blood flow. Test your knowledge on this common vascular condition.

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