Varicose Veins
Varicose veins are
dilated, tortuous veins
in the leg. Primary varicose veins are due to superficial venous valve incompetence: blood in the valves refluxes backwards and builds up causing dilatation of the veins. The superficial veins are the long and short saphenous veins. Secondary varicose veins are due incompetence in the deep veins of the leg usually as a result of past deep vein thrombosis. Primary varicosities can be treated by a variety of techniques but the standard is surgical removal of the veins however there are few proven techniques to treat secondary varicosities.
The Routine
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Position the patient standing up.
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Say "Ideally I would like to expose from groin downwards, but to preserve the patients modesty I will keep them in their underwear and expose as necessary"
Inspect
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Varicosities:
Comment on the distribution of the varicosities. They are typically in the distribution of the long saphenous (beginning around the medial malleolus and continuing up the inner thigh to the groin) and the short saphenous (beginning at the popliteal region and continuing down the back of the leg).
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Ulcers:
venous ulcers are the most common type of leg ulcers, typically in the "gaiter" region (abover the lower border of medial malleoli).
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Haemosiderin:
brown pigmentation indicating venous hypertension
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Lipodermatosclerosis
champagne bottle shaped legs
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Venous guttering
(indentations
where veins should be): usually lower medial calf where the calf
perforators are (the "gaiter" area)
Palpation
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Feel the varicosities to follow the distribution and identify any that are thrombosed
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Pulses
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Prominent
saphena varix
a variceal lump at groin saphenofemoral junction
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'Tap' test: tap the veins on the calf whilst palpating the saphenous in thigh, revealing transmitted thrill if veins in continuity (i.e. incompetent valves)
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Doppler at saphenofemoral junction, squeeze calf to identify reflux
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Tourniquet test:
This is to identify the level of venous valve incompetence. Position the patient lying down with one leg raised in the air. Milk out the varicosities of blood by running your hand firmly distal to proximal over them. Apply a tourniquet on the mid thigh. Get the patient to stand up: the varicosities should remain empty if the incompetence is more proximal to the level of the tourniquet. Now undo the tourniquet and the veins should fill with blood. If the test failed (the veins filled with blood when the patient standed immediately) the incompetence is distal to the tourniquet and the test can be repeated with the tourniquet lower down the leg.
"I would Like To"
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Full neurovascular exam of the lower limbs
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Full abdominal exam (as abdominal/pelvic masses can cause varicose veins)
Anatomy
Anatomical landmarks of the long (great) saphenous vein
