VARICOSE VEINS

Short History
• Duration? • Aetiology? Positioning Of The Patient
• Symptoms and complications o Prolonged standing • Standing
o Pain in the lower limbs when standing for a o Past DVT • Supine + Standing (Special Tests)
long time that relieved with elevation of o Family history of VV • Supine
legs o In females ask whether started in pregnancy
o Swelling • Cosmetic concern Exposure
o Pruritus/ eczematous changes/ rash o Pigmentation/ thickening • Up to groin but maintain the dignity of the patient
o History of healed ulcers
o History of bleeding from ulcers
Examination
Standing Supine + Standing (Special Tests)
Inspection (Use a torch) Palpation Tourniquet Test
• Site • Temperature • Elevate the limb à empty veins à apply tourniquet
o Bilateral Vs. Unilateral dilated, tortuous veins • Tenderness just below SFJ and ask the patient to stand up
o Territory of varicosities • Palpable cough impulse at SFJ • If vein fills above the tourniquet: SFJ incompetence
§ LSV: Below knee and above knee, mediallly • Tap test • If vein fills below the tourniquet: Perforator
§ SSV: Below knee, laterally o Place one hand on SFJ and tap incompetence
§ Blow outs from below (normal) • If vein fills both above and below the tourniquet: Both
§ Saphena varix: Groin o Place one hand on varicosities SFJ and perforator incompetance
• Skin and tap from above (abnormal)
• Sites of fascial defects Trendelenberg’s Test
o Lipodermatosclerosis • To demonstrate sapheo-femoral incompetence
§ Replacement of skin and subcutaneous fat by fibrous • Empty the veins
tissure and fibrin deposition
• Locate SFJ below and lateral to pubic tubercle
§ Hyperpigmentation due to haemosiderin deposition
• Apply finger pressure on SFJ à ask the patient to
§ Inverted Champaign bottle appearance
stand up
o Eczema • If the veins do not fill à SFJ incompetence
o Gaps in the skin: Ulcers • Comfirm by removing the finger: Veins will fill up
§ Chronic ulcers • If the veins fill à SFJ may or may not be competent
§ Healed ulcers: White patch (atrophie blanche) but there is distal perforators incompetence
o Scars (never forget the groin)
• Swellings
o Swelling of the ankle
o Visible cough impulse of saphena varix

Supine Other Systems (Offer to examine)

• Distal arterial pulses • Abdomen for pelvic masses
o Because after treatment you are going apply compression • Vagina in females (PV)
• LNs if associated ulcer is present • Rectum in males (PR)

Clinical Surgery

DISCUSSION
1. What do you know about the anatomy of the venous system of the
lower limbs?

2. What investigation would you like to do on this patient?

3. How would you like to treat this patient?

4. What advice would you give the patient regarding surgery

Clinical Surgery