Image Based Question – 72024

Correct Answer » B Explanation

Ans:B. Duplex imaging.

Varicose veins is shown in the image.

VARICOSE VEINS

Primary:

• Congenital absence or incompetence of valves

• Inheritance with FOXC2 gene

• Klippel-Trenuanay syndrome

• Congenital AV fistula

• Cutaneous hemangiomas

• Hypertrophy of involved limb

• Absence of deep venous system

Secondary:

• Recurrent thrombophlebitis

• Occupational – prolonged standing

• Obstruction to venous return – abdominal tumors, retroperitoneal fibrosis

• Pregnancy
• Iliac vein thrombosis

Clinical features

• Lipodermatosclerosis(brawny induration) pigmentation, thickening, chronic inflammation and induration of skin in calf muscle and around ankle.

Brodie-Trendelenburg test

• 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

• 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.

Cough impulse (Morrisey’s test)

• Locate the saphenofemoral junction(2-4cm inferolateral to pubic tubercle) and ask the pt to cough

• Impulse or fluid thrill felt indicates saphenofemoral incompetence.

Modified Perthes Test:

• Ask the pt to stand and tourniquet is applied at SF junction and ask to walk

• Superficial veins become prominent – indicate deep vein thrombosis.

Three tourniquet test

• To find the site of incompeter“: perforator

• Tourniquets at SFJ, above knee level, below knee level

Fegan’s test:

• Detect the perforators

Investigations:

• Duplex Ultrasound imaging – gold standard

• Doppler examination – only when duplex is not available

• Phlebography – not needed in primary venous insufficiency. Only performed as preoperative adjuncts when deep venous reconstruction is being planned

• Ascending phlebography – differentiates primary from secondary insufficiency

• Descending phlebography – identifies specific valvular incompetence suspected on B mode scanning.

Medical treatment

• Calcium dobesilate

• Diosmin

• Hesperidin

• Toxerutin

Surgical management:

• Trendelenburg’s operation (juxta femoral flush ligation + stripping the varicose vein) for SFJ incompetency

• Subfacial ligation of Cockett and Dodd :perforator incompetence with SF competency

• VNUS closure(ablation catheter introduced into the SF junction and slowly with drawn)

• TRIVEX – veins identified by subcutaneous illumination; injection of fluid & superficial veins are sucked

• Endo venous laser ablation(EVLA)

• Sclerotherapy