examination of venous system of lower extremities · • the venous pumping system consists of the...

Examination of venous

system of lower

extremities

Martina Part, MD. PhD.

Dept.of Dermatovenerology

Faculty of Medicine Comenius University

ANATOMY OF THE VEIN SYSTEM IN THE LOWER

EXTREMITIES

• the vein system in the lower limb is anatomically classified by its relationship to the fascia

• we devide the vein system into superficial, deep system and the connecting perforating veins

ANATOMY OF THE VEIN SYSTEM IN THE LOWER

EXTREMITIES

• more than 40 perforating veins connecting deep and superficial veins

HEAMODYNAMICS OF THE VENOUS SYSTEM

• important for the heamodynamics is the vein pump function of the lower extremities

• in the upright position a significant amount of blood is translocated to lower extremities veins

• during resting muscular action and valves in the veins form a powerful pumping system aiding venous blood return to the heart

HEAMODYNAMICS OF THE VENOUS SYSTEM

• the venous pumping system consists of the muscle, the distal calf and

the foot pumps

• muscular contraction is the main activator of the pump system

• muscle contraction increases the intraluminal blood pressure to more

than 100 mmHg

• the pressure in the muscle veins is 3 times higher than in the superficial

veins

• competent valves prevent retrograde flow

HEAMODYNAMICS OF THE VEIN SYSTEM

• in the normal lower leg in the supine position blood flows slowly through the veins and the pressure in the ankle is 70-100 mmHg , falling to 10-20 mmHg during walking and about 55 mmHg while sitting

• if the valves are incompetent the blood oscillates up and down in the segments

HEAMODYNAMICS OF THE VEIN SYSTEM

• the resulting retrograde flow in the veins (venous reflux) leads to ambulatory venous hypertension, increase blood volume and oedema

• the more extensive and distal the venous reflux the greater the risk of ulcer formation

• this venous hypertension leads to distension of the perforators and valve dysfunction

• the venous hypertension is transmitted to the nutritional capillaries in the papillary dermis

DIAGNOSIS – PATIENT ASSESSMENT

a correct diagnosis at the start of the treatment will allow choice of the

most appropriate treatment

ulcer history:

• we have to estimate, to ask for duration of the ulcer, pain and other subjective symptoms, family history of veins disorders, information regarding varicose veins, deep thrombosis, what treatments have been given for the ulcer – topical treatment, compression, surgery etc.


medical history:

• for chronic ulcers there are some diseases that are important like: cardiovascular diseases, diabetes, intake of some drugs –especially warfarin, furosemid


clinical examination:

• inspection of the limb – the location of the ulcer, number, size

• inspection of the skin - varicose veins, oedema, trophic skin changes

• inspection of the ulcer – the edges and the base of the ulcer

• edges: are the edges shallow or punched out, are there signs of epithelization

• base: is it healthy granulating red, yellow or greenish covered, or are even black necrosis present – requires a swab taken for bacteriological culture

• is the wound wet or dry

SPECIAL TESTS IN VENOUS INSUFFICIENCY

Cough impulse test(in standing patient)

• By palpating the tight at fossa ovalis over the saphenofemoraljunction

• The patient is asked to cough

• Palpable thrill at the saphenofemoral junction (it is a result ofturbulent retrgrade flow)

• indicates reflux in the saphenofemoral junction


Tap test or percussion test(in standing patient)

• By palpating the saphenofemoral (SF) junction

• The greater saphenous vein is tepped at the level of the knee.

• A palpable tramsmitted imuplse at the SF junction means that the greatersaphenous vein is dilatated with blood.

• The SF junction is than tapped when the greater saphenous vein is palpatedat the knee.

• A palpable transmitted pulse at the area of knee indicates incompetence ofgreat vein valves (between SF junction and the knee)


Trendelenburg test• Determination of the competency of the

valves in the superficial and deep veins of the legs in patients with varicose vein

• The leg is flexed at the hip and raised above heart level (45 degrees).

• The veins will empty due to gravity or with the assistance of the examiner's hand squeezing blood towards the heart.

A tourniquet is applied around the upper thigh to

compress the superficial veins but not too tight as to

occlude the deeper veins. The leg is then lowered by

asking the patient to stand.


Trendelenburg test• Normally the superficial saphenous vein will fill from below within 30–35

seconds as blood from the capillary beds reaches the veins

• If the superficial veins fill more rapidly with the tourniquet in place there is valvular incompetence below the level of the tourniquet in the "deep" or "communicating" veins.

• After 20 seconds, if there has been no rapid filling, the tourniquet is released. If there is sudden filling at this point, it indicates that the deep and communicating veins are competent but the superficial veins are incompetent


Perthes test(in standing patient)

• It is perfomrmed with a tourniquet positioned below the knee.

• The patient is asked to walk for 5 minutes or to performe 10 heel rises (activationof the calf muscle pump)

• If deep system is competent, the blood will go through and back to the heart.

• If the deep system is incompetent, the patient will feel pain in the leg.


hand held Doppler assesment:

• is an extremely useful tool that should be used on regular basis

• is based on the reflection of ultrasound signals from the cells moving in blood stream

• this reflection causes the change of frequency, which are reproduced as A sound (speed of blood flow)

• venous signal - a low-frequency ( recalls"wind")

• arterial signal - high frequency and pulse synchronous

Examination of venous system

• examination of venous system of the lower limbs (v. femoralis, v. poplitea and tibialis posterior)

• it can give valuable information regarding the presence of venous insufficiency

Examination of venous system

Color Doppler ultrasound

- is especially important for patients who may be considered for venous surgery

- venous surgery may prevent recurrence of the venous ulcer

Color Doppler ultrasound


additional investigations

Plethysmography

- this method is non-invasive, globaly measure venous function in

the leg

- the most commonly reported parameter is the venous

recovery time which is a measure of the time to refill distal veins after

exercise

- the shorter the RT the more severe the venous insufficiency

- RT of less than 18 seconds in standing position is considered

pathological


Phlebography

- is an invasive investigation

- requires use of iodine contrast material

- ascending and descending

- can give only anatomical information and

only very limited heamodynamic information

Phlebography

Clinical symptoms of thrombosis of deep venous system

Prattʼs sign

•It is an indication of femoraldeep vein thrombosis.

•It is seen as the presence of dilated pretibial veins in the affected leg, which remain dilated on raising the leg.


Homansʼs sign

•Pain in the calf on dorsiflection of the patientʼs foot at the ankle while the knee is extended


Lowenberg ʼs sign

•the sign is positive when pain is elicited rapidly when a blood pressure cuff is placed around the calf and inflated to 80 mmHg

Preventive measures

• Walking

• Exercise

• Appropriate body weight

• Appropriate shoes

• Elevation of legs

• Avoidance of long periods of sitting/standing/sitting position with crossed legs

Compressive therapy:

Creation of the pressure on veins and tissues:

- valve function

- better circulation,

- retrograde filtration

Disappearance of oedema and improvement of circulation.

Compressive therapy

Creation of the pressure on veins and tissues:

- better valve function

- better circulation

- better retrograde filtration

Disappearance of oedema and improvement of circulation.

examination of venous system of lower extremities · • the venous pumping system consists of the...

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