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Varicose vein, Venous ulcer.pptx
- 1. Clinical Meet Varicose veins ,Varicose ulcer Dr Kiran G N
- 2. • Mr AB • 56 Years/M • Presenting complaint - Dilated veins on the left leg 6 years - Discoloration of left leg 3 year - Ulcer over the left ankle 1 year
- 3. History
- 4. Occupation Symptomatology • Dilated veins • Discoloration • Ulceration-Spontaneous/Trauma • Pain -Dull aching, towards the end of the day, night cramps -Aggravating/Relieving factors. • Edema • Itching • Bleeding
- 5. • Previous history of leg swelling and pain/ DVT • Negative history Arterial insufficiency- Claudication/Rest pain Other system involvement- Rash,joint pain • Past history-Medical / Surgical (Prolonged bed rest, major surgeries) • Family history • In female- Obstetric history (DVT/Varicose vein) • Drug History- Anticoagulation
- 7. Clinical examination • In what position you would like to examine the patient?
- 8. Inspection • Attitude, ROM Ankle joint • Ulcer – Arterial vs Venous • Edema • Eczema/pigmentation • Scar • Varicosities, which territory
- 9. Commonest site for venous ulcer ?
- 11. Gaiter Area GSV Posterior arch vein Corona Phelbectatica (Tributaries of perforating veins of calf)
- 12. What Why ? *
- 14. Tests for SFJ incompetence Perforator incompetence Deep vein thrombosis Perthes test Modified Perthe’s test Homan’s sign Mose’s sign Brodie- Trendelenburg test 2 Multiple tourniquet test Pratt’s test Fegan’s test Brodie- Trendelenburg test 1 Morrissey’s Cough Impulse Test
- 16. Brodie- Trendelenburg test • First placed in the recumbent position • Legs are raised to empty the veins, hastened by milking the veins proximally. • SFJ compressed with the thumb of the clinician / tourniquet below SFJ • Patient is asked to stand up quickly.
- 18. SFJ SPJ
- 20. • Multiple tourniquet (3/4) is tied after emptying the superficial veins . • The patient is now asked to stand up. • Veins above the tourniquet fill up - presence of incompetent perforator above the tourniquet. • Veins below the tourniquet fill rapidly - presence of incompetent perforator below the tourniquet. Multiple tourniquet test Perforator incompetence
- 22. Morrissey’s Cough Impulse Test • The limb is elevated to empty the varicose veins. • The limb is then put to bed and the patient is asked to cough forcibly. • An expansile impulse is felt in the long saphenous vein particularly at the saphenous opening if the sapheno-femoral valve is incompetent. • Similarly a bruit may be heard on auscultation. SFJ incompetence
- 23. Pratt’s test • Firstly an elastic bandage is applied from toes to the groin. • A tourniquet is then applied at the groin. This causes emptying of the varicose veins. • The tourniquet is kept in position and the elastic bandage is taken off. • The same elastic bandage is now applied from the groin downwards. • At this point the perforators 'blow outs' or visible varices can be seen. Perforator incompetence
- 24. Fegan’s test • In standing posture the places of excessive bulges within the varicosities are marked. • The patient now lies down. • The affected limb is elevated to empty the varicosed veins. • The examiner palpates along the line of the marked varicosities carefully and finds out gaps or pits in the deep fascia which transmit the incompetent perforators. Perforator incompetence
- 26. • A tourniquet is tied round the upper part of the thigh tight enough to prevent any reflux down the vein. • The patient is asked to walk quickly with the tourniquet in place • If the communicating and the deep veins are normal the varicose veins will shrink • If the communicating and the deep veins are blocked the varicose veins will be more distended.
- 27. Percussion
- 28. Schwartz test • Percuss the long saphenous varicose vein in the lower part of the leg an impulse can be felt at the saphenous opening with the other hand.
- 29. Peripheral pulses to be checked in all patients Pitting edema Thickening, warmth of the skin Ulcer ??? Lymphnodes Is it Pulsatile – AVM Shallow, over medial malleolus Superficial to deep fascia Slopping edge Signs of ischemia will be absent Peripheral pulses palpable
- 30. • Contralateral limb — should be examined for presence of varicose veins and different tests to plan treatment.
- 31. Abdominal examination is a must Engorged veins on the abdomen Any mass / swelling DRE +/-
- 33. • Chronic venous insufficiency of left lower limb with varicosities along the course of GSV with/without SFJ incompetence and perforator incompetence at ____________ • with CEAP classification of _____________ CEAP similar to TNM Staging
- 35. Clinical
- 36. C2 C3 C4 C5 C6 C1 Clinical
- 37. Etiological
- 38. Anatomical
- 40. Modified CEAP • For research purposes , sub group analysis. • Same as Basic CEAP, with addition that any of 18 named venous segments can be used as locators for venous pathology. • In Basic CEAP, single highest descriptor can be used for clinical classification.
- 41. Modified CEAP
- 42. Revised CEAP
- 43. C2 C3 C4 C6 Ep AsAp Pr CEAP classification
- 44. Discussion
- 45. Definitions • Varicose veins: • Abnormally dilated, tortuous, subcutaneous veins ≥ 3mm in diameter measured in upright position with demontrable reflux. • Reticular veins : • Tortuous subdermal veins,1-3mm • Telangiectasia: • Dilated intradermal venules < 1mm
- 46. Pathophysiology AMBULATORY VENOUS HYPERTENSION • Ambulatory venous pressure. Abnormal value, > 30 mmHg • Duplex scan. Valve closure time, abnormal value, > 0.5 s
- 47. Incompetence Reflux (DVR) Obstruction Pathophysiology AMBULATORY VENOUS HYPERTENSION Deep system Superficial system Perforator system SFJ incompetence SPJ incompetence
- 48. Primary Vs Secondary Varicose veins Primary • Congenital paucity of valves • Stretching of valve rings • Weakness /muscle wasting • Stretching of deep fascia Secondary • DVT/ PTS • Pelvic tumours • Pregnancy • AV Fistula • Varicosity(KTS) • May Thurner Syndrome
- 49. Pathophysiology
- 50. Flags in varicose veins
- 51. Flags in varicose veins KTS ------ Young patient Lateral Marginal veins Telengectasia Limb Hypertrophy
- 53. Thank you