Varicose Veins Year 3 Junior Clerkship (Surgery) Stephen WK Cheng

The Problems Notes

A patient with varicose veins. Diagnosis and examination
Differential diagnosis of leg ulcers

Anatomy
Superficial and Deep veins
Long and short saphenous systems
Blood flow is superficial to deep
Perforator sites. The “one hand” rule
The Sapheno-femoral junction

Diseases of veins
Incompetence vs Thrombosis
Superficial vs Deep veins

Pathophysiology
Chronic Venous Insufficiency (CVI)
Venous hypertension
Primary vs Secondary concept
Ambulatory Venous Hypertension
CEAP: Clinical, Etiology, Anatomic, Pathophysiology

Symptoms
Disfigurement
Truncal, Tributary, Reticular, Perforator varicosities
Swelling, ache,
Severe CVI: eczema, pigmentation, ulceration
Complications: bleeding, thrombophlebitis

Examination
Standing. Palpate. Cough. Comment on venous system
Supine. Palpate perforators. Note signs of CVI
The Trendelenberg (Tourniquet) test concept

‘ You must learn how to examine a patient with varicose veins

Investigations
Handheld Continuous Wave Doppler
(Axial reflux, perforator location)
Duplex scan
Unnecessary: venogram, plethysmograms

Treatment of Varicose Veins

Principle: Reduce venous Pressure

Conservative: Elevation, postural adjustments

Graduated compression stockings
Surgery for Varicose Veins Notes
Principles: Ligate incompetent perforators
Remove diseased veins

Sapheno-femoral flush ligation

Avulsion / excision of varicosities
Stripping
Ligation of perforators (open / endoscopic)

Injection Sclerotherapy
Not recommended as primary treatment
Aseptic thrombosis
Compression essential

Severe CVI
The post-thrombotic / post-phlebitic syndrome
Chronic venous hypertension
Chronic venous stasis

Symptoms: Pigmentation, oedema, eczema, ulcers

Etiology of Venous ulcers: Fibrin cuff vs Leucocyte

adhesion theory

Differential Diagnosis of Leg Ulcers

Arterial Signs, painful, pressure areas

Venous Signs of CVI, good pulse, less painful
typical site
Neurogenic Painless, neuropathy (diabetes etc)
Malignant Squamous carcinoma, Irregular, raised
edges, biopsy, Marjolin’s ulcer, LNs.
Infection Chronic osteomyelitis, syphilis etc
Trauma

‘ Leg ulcer is a very common finding in exams

Treatment of Severe CVI

Reduce venous pressure: posture

Treat ulcers - compression bandage, reduce infection
Topical ulcer treatment - skin grafts
Venous surgery - treat superficial venous reflux
Venous reconstruction - treat deep reflux (rarely done)
Deep Vein Thrombosis
The Problems
Differential diagnosis of unilateral leg swellings
Understand the causes of post-operative DVT
How to give prophylaxis against DVT and who?

Virchow’s Triad
Stasis
Trauma
Coagulability

‘ Causes of DVT can be derived from Virchow’s triad

Clinical Features
Predisposing causes?
Silent phlebothrombosis
Thrombophlebitis: swelling, tender, Redness, warmth
Homan’s sign
Massive: Venous gangrene

Diagnostic tests
50% DVT are silent
Gold standards: Duplex ultrasound
Venogram

Significance of Iliofemoral DVT vs Calf vein DVT

Complications of DVT
1. Pulmonary embolism (early)
2. Chronic Venous Insufficiency (late)
3. Chronic venous obstruction (late)

2,3 results in venous hypertension

Pulmonary Embolism
From asymptomatic to potentially fatal
Diagnosis: clinical, V/Q scans, angiogram

Prophylaxis of DVT
Virchow’s Triad:
Stasis: Physical Posturing
Stocking
Intermittent compression
Trauma Avoid

Coagulability Drugs Heparin

Low dose
Subcutaneous

‘ Prophylaxis of DVT can be derived from Virchow’s triad

Treatment of DVT Notes
Posture: Rest, elevation, bandage
Anticoagulation: Heparin
Low molecular weight heparin
Warfarin for 3-6 months
Thrombolysis?
Surgical thrombectomy Rare, for venous gangrene

Inferior Vena Cava Interruption

IVC Filters (Greenfield)
Indications: Recurrent pulmonary embolism
Anticoagulation contraindicated

You may wish to:

C Examine more patients with varicose veins and practice the Toruniquet test (usually in TWH) ‘
C Observe a varicose vein operation (TWH, Tuesday pm) ‘
C Handle a pair of elastic stockings ‘
C See a variety of leg ulcers and make the differential diagnosis (TWH) ‘
C Learn the indications, use, dosage, monitoring, and side effects of anticoagulant drugs in the wards ‘
C Visit the Vascular Laboratory in K14S and observe a venous duplex examination (QMH) ‘