Varicose Vein Exam


INSPECT
Expose whole lower limb from groin to toes.
Examine lying down and standing up

Note the distribution of veins:
Patterns of Disease
1. long saphenous incompetence
2. short saphenous incompetence
3. incompetence of thigh or calf communicating veins
4. combinations of the above.
Remember that communications exist, such that long saphenous system may fill varices on posterior and lateral calf.

Note features of chronic venous hypertension - oedema, eczema, hemosiderin deposition, lipodermatosclerosis,

Inspect suprapubic and lower abdominal areas for venous collaterals signifying past DVT.
Inspect for vulval varicosities from the vulva down the medial side of the upper thigh.

Caution if (not straightforward disease):
1. varices of medial aspect of upper thigh
- may have pelvic venous insufficience
2. substantial leg oedema
- unlikely varices alone
3. prominent superficial veins above inguinal ligament / suprapubic area
- deep venous obstruction with collateralization
4. ulcers proximal to the mid-calf level
- unlikely to be venous in origin



PALPATE
Feel for venous dilation in the groin (saphena varix).
And elicit for a cough impulse (20% absent anyway).
Turn them around and palpate the upper end of the short saphenous.
Must stand on contralateral limb, and relax muscles bounding the popliteal fossa by allowing knee on examined side to flex slightly.
If short saphenous is normal or impalpable, it is not incompetent.
If it is dilated, mark on the surface with a pen.


TORNIQUET TEST

A legacy procedure entirely replaced by Duplex USS
- but probably should know how to explain it.

1. Lie pt on couch, with examined leg raised (e.g. rested on your shoulder)
- compression stroke the blood out of the veins.

2. Narrow rubber tourniquet placed as high around the thigh as possible, secured with artery forceps.
Important the the tourniquet is tight enough
- stand pt up - do the veins fill?
--> if rapidly fill, then venous reflux
--> if not, then there are no incompetent valves allowing reflux into the superficial veins below the level of the torniquet
--> ie, the problem is incompetence at the saphenofemoral jx.
- note that veins will fill slowly over 30-60s regardless due to the arterial inflow

3. If were not controlled by (2) then replace tourniquet above the patella
- now testing for middle lower third of thigh perforator
--> if controlled, confirms this perforator is the pathological one.

4. If still not controlled, the torniquet is replaced to below the knee to test the short saphenous system

5. If still not controlled, then site of incompetence is below the tourniquet and involves the calf communcating veins.

Doppler US Probe

- can identify incompetence of short and long saphenous system
- relax leg muscles, place over upper end of vein
- compress distally by squeezing calf (for SSV)
- produces a sharp augmentation of the venous flow
- then relax pressure; if valves competent, blood flow stops
-->if incompetent, flow signal continues, indicating blood refluxing into vein.