Varicose Veins Examination

1
Varicose Veins Examination

• SurgSoc OSCE Revision Session
• Mudassar Aslam Nisha Devi
• November 2008

2
Varicose Veins

• Why learn about them?
• Aetiology
• History taking
• Anatomy
• Examination
• Management

3
What are varicose veins?

• Dilated, tortuous veins
• Due to venous incompetence
• Often due to valve dysfunction
• Commonly affecting lower limb

4
Why do we have to know about varicose veins?

• A bread and butter surgical case!
• Have to be able to identify varicose veins, the
  particular venous system affected and the level
  of incompetence
• Chronic venous insufficiency is characterised by
  certain venous changes which you must be able to
  identify

5
Aetiology

• Primary (majority)
• Idiopathic or caused by underlying defect
• Often familial
• Secondary underlying cause
• Pelvic mass/obstruction to outflow
• Previous DVT
• AV fistulae
• Klippel-Trénaunay Syndrome

6
Taking the history

• Presenting Complaint Varicosities,
  abdominal/groin lump saphena varix
• Symptoms heaviness, tension, aching, itching
  commonly after standing
• Pain if thrombophlebitis present
• Risk factors
• Female (x5-10), age, ethnicity, occupation,
  pregnancy, obesity, smoking
• ASK about history of abdominal complaints/cancer,
  DVT, previous other venous complaints

7
Anatomy

• Yes, you must know this!!!
• Part of the examination involves identifying
  which vein is involved and level of incompetence
• Key points
• Deep and superficial venous systems
• Long and short saphenous veins

8
Lower Limb Venous Supply
9
Key points to remember

• 2 venous drainage systems deep and superficial
• Superficial long and short saphenous veins
• Superficial connects to deep system via
  perforators
• Saphenofemoral junction 2-4cm inferolateral to
  pubic tubercle

10
Examination

• General OSCE tips ICEPP
• Introduce be polite and friendly
• Consent to examination
• Expose (adequately!)
• Position (standing initially)
• Pain ask before examining the patient
• Wash hands before examining the patient
• Cover and thank patient, present findings

11
Inspection

• Look at the legs whilst patient is standing
• Examine around the medial malleolus gaiter area
• VVV LAPS
• Varicose veins distribution (LSV, SSV)
• Venous ulcers/eczema
• Venous stars
• Lipodermatosclerosis
• Atrophy blanche
• Pitting oedema
• Scars

12
Inspection

• Atrophy blanche
• Ulceration active and healed
• Leaves a white patch
• Pitting oedema

• Venous ulcers/eczema
• Venous stars (spider veins)

13
Venous Ulcers

• Site
• Most commonly found in the medial gaiter area
• Lower third of the medial aspect of the leg,
  immediately above the medial malleolus
• Shape and size
• Irregular shape, variable size
• Base
• May be covered with yellow slough, when healing
  there is pink granulation tissue
• Surrounding skin
• Poor with signs of chronic venous insufficiency

14
Inspection

• Lipodermatosclerosis
• Literally "scarring of the skin and fat
• A slow process that occurs over a number of years
  and has 2 phases
• Acute
• Venous pooling ?chronic venous hypertension
• RBC forced into surrounding tissue
• Haemoglobin broken down into brown haemosiderin
• Chronic
• Chronic haemosiderin formation leads to fibrin
  deposition
• Skin becomes thickened and shiny
• Skin around ankle constricts and the inverted
  champagne-bottle shape is seen

15
Palpation

• Ask the patient to face you
• Temperature
• Feel with back of hand, should be warm
• If cold, arterial disease may co-exist
• Palpate the vein
• Feel the course of the vein
• Cough impulse

16
Palpation

• Cough impulse
• Locate the saphenofemoral junction (SFJ)
• Feel for the smooth swelling and palpable thrill
  of a saphena varix (cause of groin lump)
• If present, cough test ve

17
Special Tests

• 1. The Trendelenburg test
• Used to assess the competence of SFJ
• Patient lies flat
• Elevate the leg and gently empty the veins
• Palpate the SFJ and ask the patient to stand
  whilst maintaining pressure
• Findings
• If the veins do not refill? SFJ is incompetent
• If the veins do refill ?SFJ may or may not be
  incompetent, presence of distal incompetent
  perforators

18
Special Tests

• 2. Tourniquet test
• Uses a tourniquet to control the junction rather
  than fingers
• Advantage of moving the tourniquet lower
  (mid-thigh region)
• Test is unreliable below the knee
• 3. Perthes Test
• Empty the vein as above, place a tourniquet
  around the thigh, stand the patient up.
• Ask them to rapidly stand up and down on their
  toes filling of the veins indicated deep venous
  incompetence. This is a painful and rarely used
  test.

19
Percussion

• Percussion
• Tap Test
• Place finger at any point along the varicose vein
• Tap the vein proximally (above the finger)
• Incompetent valves allow the transmission of a
  fluid thrill to the finger below
• (unreliable test)
• Direction Test
• Empty a short section of the vein (place one
  finger on the vein and slide another finger
  firmly upwards).
• If the valves are incompetent, the vein will
  refill when you release the top finger.

Competent valve stops the transmission
20
Auscultation

• Auscultation
• Over a large group of veins may indicate a bruit
• Rare indicates an underlying arteriovenous
  malformation

21
To complete my examination would like to

• Use a Doppler ultrasound
• Examine the abdomen for masses ( DRE) to
  ascertain whether the varicose veins are primary
  or secondary
• Complete a peripheral vascular exam for arterial
  supply of the lower limb, including ABPI

22
Presenting Findings..

• Be systematic
• Provide a summary of the history starting with
  present complaint
• Explain the positive findings from your
  examination
• Finish by explaining what you think is the
  problem
• And if youre really going places . . .

23
Management

• Conservative
• Graded compression bandaging
• Compression hosiery
• Medical
• Injection sclerotherapy
• Surgical
• Saphenofemoral ligation
• Below knee saphenous vein stripping high, tie
  and strip
• Multiple avulsions

24
Thank you!

• Any Questions?