Varicose Veins

Varicose veins

Q. 1

Physical examination on a 65-year-old man with mild congestive heart failure reveals varicose veins, ankle edema, and inflammation of much of the skin near the ankles of both legs. The affected skin exhibits edema, erythema, mild scaling, and brown discoloration. The edges of skin involvement are poorly defined. On one ankle, a one centimeter diameter ulcerated area is seen within the erythematous area. The patient says that his leg lesions look much worse than they feel. Which of the following is the most likely diagnosis?

 A

Atopic dermatitis

 B

Lichen simplex chronicus

 C

Stasis dermatitis

 D

Seborrheic dermatitis

Q. 1

Physical examination on a 65-year-old man with mild congestive heart failure reveals varicose veins, ankle edema, and inflammation of much of the skin near the ankles of both legs. The affected skin exhibits edema, erythema, mild scaling, and brown discoloration. The edges of skin involvement are poorly defined. On one ankle, a one centimeter diameter ulcerated area is seen within the erythematous area. The patient says that his leg lesions look much worse than they feel. Which of the following is the most likely diagnosis?

 A

Atopic dermatitis

 B

Lichen simplex chronicus

 C

Stasis dermatitis

 D

Seborrheic dermatitis

Ans. C

Explanation:

This is stasis dermatitis, which is a common complication of chronic lower leg edema, typically due to either congestive heart failure, venous incompetence, or both.

The condition may be neglected by both the patient and the physician because of its relative lack of symptoms.

However, it should be taken seriously because once skin breakdown occurs, the resulting ulcer may be very difficult to treat successfully.

Helpful measures in the treatment of stasis dermatitis include elevating the ankles above the heart, properly fitted support hose, and tap water compresses.

Ulcers are treated with compresses and bland dressings.

Oral antibiotics are used when an ulcer becomes infected.

Atopic dermatitis is an itchy inflammation of the skin that appears to have an allergic basis.
Lichen simplex chronicus can also involve the ankles, but the lesion is very itchy, tends to be relatively localized, and is not typically accompanied by ankle edema.
Seborrheic dermatitis causes diffuse scaling (dandruff) of the scalp.
 
Ref: Suurmond D. (2009). Section 16. Skin Signs of Vascular Insufficiency. In D. Suurmond (Ed), Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 6e.

Q. 2

Which of the following is the first treatment of choice in a case of rupture of varicose veins at the ankle ?

 A

Rest in prone position of patient

 B

Application of a tourniquet proximally

 C

Application of a tourniquet distally

 D

Direct Pressure and Elevation

Q. 2

Which of the following is the first treatment of choice in a case of rupture of varicose veins at the ankle ?

 A

Rest in prone position of patient

 B

Application of a tourniquet proximally

 C

Application of a tourniquet distally

 D

Direct Pressure and Elevation

Ans. D

Explanation:

Rupture of varicose vein is not a life threatening condition.

If it ruptures bleeding is controlled by direct pressure and elevation of the area.

Ref: Current Medical Diagnosis and Treatment 2012, Chapter 12;
2. ECG: Practical Applications Pocket Reference Guide By Kathryn Lewis, Page 70


Q. 3

Which of following are features of Klippel- Trenaunay syndrome:

1. Varicose veins
2. Cutaneous birthmark
3. Limb hypertrophy
4. Deep veins are often anomalous
5. Saphenous vein striping can be hazardous

 A

1,2,3,4 true & 5 false

 B

1,2,3,5 true & 4 false

 C

1,3,5 true & 2,4 false

 D

All are true

Q. 3

Which of following are features of Klippel- Trenaunay syndrome:

1. Varicose veins
2. Cutaneous birthmark
3. Limb hypertrophy
4. Deep veins are often anomalous
5. Saphenous vein striping can be hazardous

 A

1,2,3,4 true & 5 false

 B

1,2,3,5 true & 4 false

 C

1,3,5 true & 2,4 false

 D

All are true

Ans. D

Explanation:

Klippel- Trenaunay syndrome:

If extensive varicose veins are encountered in young patient, especially if unilateral and an atypical distribution (lateral leg), Klippel- trenaunay syndrome must be considered.

The classic triad is varicose vein, limb hypertrophy, and a cutaneous birthmark (portwine stain or venous malformation).

Because the deep veins are often anomalous or absent, saphenous vein striping can be hazardous.

Standard treatment for patients with Klippel- Trenaunay syndrome is gradual support stockings, limited stab avulsion of symptomatic varices after thorough duplex ultrasound vein mapping, and occasional surgery for correction of limb length discrepancy”.

Ref: CSDT 11/e, page 884

Quiz In Between


Q. 4

Varicose veins are seen in –

 A

DVT

 B

Superficial venous thrombosis

 C

AV fistula

 D

a and c

Q. 4

Varicose veins are seen in –

 A

DVT

 B

Superficial venous thrombosis

 C

AV fistula

 D

a and c

Ans. D

Explanation:

Answer is ‘a’ i.e. DVT; ‘c’ i.e. A-V fistula

  • Varicose veins are dilated tortuous superficial veins in the lower extremity, usually bilateral.
  • Imp. risk factors for varicose veins are female sex                                                 

 – prolonged standing

– pregnancy (esp. multiparity)                

– obesity family history

  • Varicose veins are aetiology-wise of 2 types

A)     Primary (more common)

Primary varicose veins are thought to be due to genetic or developmental defects in the vein wall that causes diminished elasticity and valvular incompetence.

B)       Secondary

Secondary varicose veins arise from destruction or dysfunction of valves caused by trauma deep venous thrombosis

A-V fistula nontraumatic proximal venous obstruction (pregnancy, pelvic tumor)


Q. 5

Most commonly varicose veins are seen with ‑

 A

Long saphenous vein

 B

Short saphenous vein

 C

Both

 D

popliteal and femoral vein

Q. 5

Most commonly varicose veins are seen with ‑

 A

Long saphenous vein

 B

Short saphenous vein

 C

Both

 D

popliteal and femoral vein

Ans. A

Explanation:

Ans is ‘a’ ie. long saphenous vein 

” The usual distribution of varicose veins is below the knee in branches of the greater saphenous system.”


Q. 6

Regarding varicose veins, which one of the following statements is true –

 A

Over 20% are recurrent varicosities

 B

The sural nerve is in danger during stripping of the long saphenous vein

 C

The saphenous nerve is closely associated with the short saphenous vein

 D

5% oily phenol is an appropriate sclerosant for venous sclerotherapy.

Q. 6

Regarding varicose veins, which one of the following statements is true –

 A

Over 20% are recurrent varicosities

 B

The sural nerve is in danger during stripping of the long saphenous vein

 C

The saphenous nerve is closely associated with the short saphenous vein

 D

5% oily phenol is an appropriate sclerosant for venous sclerotherapy.

Ans. D

Explanation:

Ans. is (d) i.e. 5% oily phenol is an appropriate sclerosant for venous sclerotherapy 

  • There are no confusions regarding option ‘b’ and ‘c’. both of these have been asked so many times before. – Sural nerve accompanies short saphenous vein and is in danger during its stripping – Saphenous nerve is in danger during stripping of long saphenous vein
  • About option ‘a’

“Recurrent varicosities are seen in 10-15% cases” [Ref. Recent Advance in surgery No. -26]

  • Abount option ‘d’

– KDT, writes that 5% phenol in almond oil or peanut oil is used as a sclerosant.

–  We do not know whether it’s the appropriate sclerosant or not but at least it’s the appropriate answer.

  • Sclerosing agents

These are irritants causing inflammation, coagulation and ultimately fibrosis, when injected into hemorrhoids, piles or varicose vein mass. They are used only for local injection.

1.          Phenol (5%) in almond oil or peanut oil.

2.         Ethanolamine oleate (5%) in 25% glycerine and 2% benzyl alcohol.

3.         Sod. Tetradecyl sulfate (3% with benzyl alcohol 2%) Polidocanol (3% inj)

Quiz In Between


Q. 7

Surgery in varicose veins is NOT attempted in presence of –

 A

Deep vein thrombosis

 B

Multiple incompetent perforators

 C

Varicose veins with leg ulcer

 D

All of the above

Q. 7

Surgery in varicose veins is NOT attempted in presence of –

 A

Deep vein thrombosis

 B

Multiple incompetent perforators

 C

Varicose veins with leg ulcer

 D

All of the above

Ans. A

Explanation:

Ans. is ‘a’ i.e., Deep vein thrombosis 

Deep vein thrombosis is a contraindication for tA of varicose veins.

Varicose vein surgery should never be attempted in a case where deep vein thrombosis exists along with varicose veins, because in these cases superficial veins are the only valved venous pathway and excising them will only aggravate the condition.


Q. 8

A patient presents with varicose veins. Color Doppler evaluation shows sapheno femoral junction incompetence and dilatation of GSV. Deep veins appear normal. Management options include all of the following except:

 A

Endovascular stripping

 B

Sapheno femoral flush ligation with stripping

 C

Sclerotherapy

 D

Stab avulsion

Q. 8

A patient presents with varicose veins. Color Doppler evaluation shows sapheno femoral junction incompetence and dilatation of GSV. Deep veins appear normal. Management options include all of the following except:

 A

Endovascular stripping

 B

Sapheno femoral flush ligation with stripping

 C

Sclerotherapy

 D

Stab avulsion

Ans. C

Explanation:

Ans is ‘c’ i.e. Sclerotherapy 

Sclerotherapy is used for telangiectatic vessels and varicose veins less than 3 mm in diameter. – Schwartz.

So here in this case where great saphenous vein is insufficient along with SFJ incompetence sclerotherapy would be of no use.

For incompetent SFJ and GSV, Flush ligation and stripping of the saphenous system is performed. This is traditionally performed by ligating the saphenofemoral junction and the major proximal saphenous vein branches through a small incision in the groin. Then the saphenous vein is removed to the point of clusters of varicosities. The saphenous vein can also be ablated by either radiofrequency ablation or endovenous laser treatment.

Varicose veins

Varicose veins are veins that have become enlarged and tortuous. The term commonly refers to the veins on the leg, although varicose veins can also occur elsewhere.

Varicose veins are classified as either primary or secondary.

Primary varicose veins are thought to be due to genetic or developmental defects in the vein wall that cause diminished elasticity and valvular incompetence. Most cases of isolated superficial venous insufficiency are primary varicose veins.

Secondary varicose veins arise from destruction or dysfunction of valves caused by trauma, deep venous thrombosis, arteriovenous fistula, or nontraumatic proximal venous obstruction (pregnancy, pelvic tumor).

Management:

Elastic compression stockings: Majority of patients may be managed with elastic compression stockings alone not needing any interventional treatment.

Interventional treatment:

Saphenous vein flush ligation and stripping:

Flush ligation and stripping of the saphenous system is performed for patients with an incompetent valve at the saphenofemoral junction and varicosities throughout the length of the greater saphenous vein. It is the preferred treatment for patients with GSVs of very large diameter (>2 cm). GSV stripping is associated with a lower rate of recurrence of varicose veins and a better quality of life than saphenofemoral junction ligation alone.

Endovenous laser treatment and radiofrequency ablation:

Closure of the GSV and small saphenous vein can be accomplished with radiofrequency ablation or laser.

In these techniques, the distal thigh or proximal calf GSV is punctured with a 21-gauge needle under ultrasound guidance. A sheath is placed over a guidewire, and the laser fiber or RFA catheter is advanced until it is near to, but not at, the saphenofemoral junction. The vein is treated as the catheter is withdrawn. Endovenous laser treatment and RFA result in durable ablation of the GSV, with rates of varicose vein recurrence and clinical severity scores comparable to those seen with open surgery.

Stab avulsion phlebectomy: is the technique to treat secondary branch varicosities. The patient’s varicosities are marked after standing to allow for optimal dilation and visualization of affected veins. Small 1-mm incisions are made along Langer skin lines and the vein is retrieved with a hook. Continuous retraction of the vein segment affords maximal removal of the vein and direct pressure is applied over the site. Incisions are made at approximately 2-cm intervals.

Sclerotherapy: Injection sclerotherapy can be successful in varicose veins vessels. Sclerotherapy acts by destroying the venous endothelium. Sclerosing agents include hypertonic saline, sodium tetradecyl sulfate, and polidocanol.


Q. 9

A pt presented with pulsating varicose veins of the lower limb. Most probable diagnosis is

 A

Klippel Trenaunay syndrome

 B

Tricuspid regurgitation

 C

DVT

 D

Right ventricular failure

Q. 9

A pt presented with pulsating varicose veins of the lower limb. Most probable diagnosis is

 A

Klippel Trenaunay syndrome

 B

Tricuspid regurgitation

 C

DVT

 D

Right ventricular failure

Ans. A

Explanation:

Ans. is ‘a’ ie Klippel-Trenaunay Syndrome 

Klippel- Trenaunay Syndrome :is characterized by

Congenital AV fistulas

Cutaneous hemangiomas

Varicose veins

Hypertrophy of involved extremity

Absence of deep venous system (so pathological superficial veins should not be removed without evidence of an intact deep system)*

Another syndrome closely associated with A-V malformations is:

Kasabach-Merritt syndrome characterised by:

thrombocytopenia* and

– hemorrhagic manifestation *

– d/t trapping & destruction of platelets* within the AV malformations*.

Quiz In Between


Q. 10

Injection sclerotherapy for varicose veins is by using

 A

Phenol

 B

Absolute alcohol

 C

70% alcohol

 D

All

Q. 10

Injection sclerotherapy for varicose veins is by using

 A

Phenol

 B

Absolute alcohol

 C

70% alcohol

 D

All

Ans. A

Explanation:

Ans. is a  i.e. Phenol 

Sclerosing agents mentioned in the latest editions of Schwartz, CSDT and Bailey are:

–     hypertonic saline,

–     sodium tetradecyl sulfate, and

–     polidocanol

2 other sclerosants are mentioned in KDT 6/e p597

– Ethanolamine oleate

– Phenol in almond oil or Peanut oil


Q. 11

An operated case of varicose veins has a recurrence rate of –

 A

About 10%

 B

About 25%

 C

About 50%

 D

Over 60%

Q. 11

An operated case of varicose veins has a recurrence rate of –

 A

About 10%

 B

About 25%

 C

About 50%

 D

Over 60%

Ans. A

Explanation:

Ans. is ‘a’ i.e., About 10 % 


Q. 12

Operations for varicose veins are best accomplished by-

 A

Stripping

 B

Multiple subcutaneos ligatures

 C

Subfascial ligatures

 D

Division and ligation at the superficial venous system

Q. 12

Operations for varicose veins are best accomplished by-

 A

Stripping

 B

Multiple subcutaneos ligatures

 C

Subfascial ligatures

 D

Division and ligation at the superficial venous system

Ans. A

Explanation:

Ans. is ‘a’ i.e., Stripping 

Quiz In Between


Q. 13

Investigation of choice for varicose veins:

March 2012, March 2013

 A

Duplex ultrasound imaging

 B

Standard Doppler examination

 C

Varicography

 D

Venography

Q. 13

Investigation of choice for varicose veins:

March 2012, March 2013

 A

Duplex ultrasound imaging

 B

Standard Doppler examination

 C

Varicography

 D

Venography

Ans. A

Explanation:

Ans: A i.e. Duplex ultrasound imaging

Investigation of varicose veins

  • Many now believe that all patients with varicose veins should undergo an assessment by duplex scan
  • Standard Doppler examination is not an accurate method of establishing incompetence of the lesser saphenous incompetence. In all cases of short saphenous incompetence a further investigation is desirable; this is usually carried out by duplex scanning
  • Varicography is an extremely useful investigation in patients with recurrent varicose veins or those with complex anatomy
  • Venography is not used as a standard investigation in patients with varicose veins but is useful if the duplex scan indicates, but cannot confirm, the presence of post-thrombotic change.

Q. 14

NOT a cause of varicose veins:   

March 2013 (f)

 A

Superficial venous thrombosis

 B

Arteriovenous fistula

 C

Deep venous thrombosis

 D

Pregnancy

Q. 14

NOT a cause of varicose veins:   

March 2013 (f)

 A

Superficial venous thrombosis

 B

Arteriovenous fistula

 C

Deep venous thrombosis

 D

Pregnancy

Ans. A

Explanation:

Ans. A i.e. Superficial venous thrombosis

Varicose veins

  • Gold standard method of diagnosing VV: Duplex imaging
  • Sclerosant used in VV: Ethanolamine oleate
  • Test to demonstrate sapheno-femoral incompetence: Brodie-Trendelenburg test
  • MC complication of stripping: Ecchymosis
  • Cocket & Dodds’s operation: Subfascial ligation

Q. 15

Drug used for sclerotherapy of varicose veins are all of the following except:        

September 2007

 A

Ethanolamine Oleate

 B

Polidocanol

 C

Ethanol

 D

Sodium tetradecyl sulfate

Q. 15

Drug used for sclerotherapy of varicose veins are all of the following except:        

September 2007

 A

Ethanolamine Oleate

 B

Polidocanol

 C

Ethanol

 D

Sodium tetradecyl sulfate

Ans. C

Explanation:

Ans. C: Ethanol

Sclerotherapy remains the primary treatment for small-vessel varicose disease of the lower extremities. These small vessels include telangiectasias, venulectasias, and reticular ectasias.

Telangiectasias are flat red vessels smaller than 1 mm in diameter. Venulectasias are blue, sometimes distended above the skin surface, and smaller than 2 mm in diameter.

Reticular veins have a cyanotic hue and are 2-4 mm in diameter.

Large varicosities do not respond as well as small varicosities to sclerotherapy.

Sclerosants include the following:

  • Detergents – Disrupt vein cellular membrane (protein theft denaturation)

–         Sodium tetradecyl sulfate

–         Polidocanol

Sodium morrhuate

–         Ethanolamine Oleate

  • Osmotic agents – Damage the cell by shifting the water balance through cellular gradient (osmotic) dehydration and cell membrane denaturation

–      Hypertonic sodium chloride solution

–     Sodium chloride solution with dextrose

  • Chemical irritants – Damage the cell wall by direct caustic destruction of endothelium

–         Chromated glycerin

–         Polyiodinated iodine

The most commonly used agents are hypertonic saline, sodium tetradecyl sulfate, polidocanol, and chromated glycerin.


Q. 16

Test which is not done for varicose veins:

March 2011

 A

Perthe’s test

 B

Tourniquet test

 C

Trendelenberg test

 D

Adson’s test

Q. 16

Test which is not done for varicose veins:

March 2011

 A

Perthe’s test

 B

Tourniquet test

 C

Trendelenberg test

 D

Adson’s test

Ans. D

Explanation:

Ans. D: Adson test

Varicose veins:

  • Dilated, tortuous superficial veins that result from defective structure and function of the valves of the Saphenous
  • veins, from intrinsic weakness of the vein wall or from high intra-luminal pressure
  • Duplex imaging is gold standard
  • Brodie trendlenburg test demonstrates sapheno-femoral incompetence
  • Stripping if done leads to ecchymosis
  • Scelrosant used: Ethanolamine oleate
  • Cocket and Dodds operation is done (subfascial ligation)

Quiz In Between



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