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Examination in Arterial Diseases
https://t.me/med1917
Fig. 5.54: Gangrene on left index finger. Note patient has
already undergone left cervical sympathectomy.
141
mation) or acquired (usually traumatic) or iatrogenic
(Cimino fistula done for haemodialysis).
Sites: Limbs, either part or whole of the limb may
be involved. Part may be in toes or fingers; lungs;
brain in circle of W illis; other organs like bowel, liver.
Clinical features: Structural changes in the limb: Limb
is lengthened due to increase blood flow since
developmental period; limb girth is increased
(Robertson’s giant limb); limb is warm; continuous
thrill and continuous machinery murmur is heard all
over the lesion; dilated arterialised varicose veins are
seen due to increased blood flow and due to valvular
incompetence; often there will be bone erosion or
extension of A VF into the bone as such. Physiological
Changes: Because of the hyperdynamic circulation,
there will be increased cardiac output and so often
congestive cardiac failure.
Complications: Haemorrhage; thrombosis; cardiac
failure.
Acquired Arteriovenous Fistula (AVF): Causes:
1. T rauma in femoral; popliteal; brachial; wrist; aorta
venacaval; abdomen - It may be following road traffic
accidents, penetrating wounds, cock-fights injury
(Common in South India). 2. After vascular surgical
intervention for major vessels. 3. Therapeutic: AVF
is created (cimino fistula) for renal dialysis to achieve
arterialisation of veins and also to have hyperdynamic
circulation so that adequate venous assess can be
achieved for long time haemodialysis. Common sites
are wrist, brachial and femoral region.
Pathophysiology: Physiological changes: Cardiac
failure due to hyperdynamic circulation. Structural
changes: Changes at the level of fistula—Blood flows
from high pressure artery to low pressure vein
causing diversion of most of the blood. Between
the artery and vein, at the site of fistula, dilatation
develops with fibrous sac formation called as
aneurysmal sac. This presents as warm, pulsatile,
smooth, soft, compressible swelling at the site with
continuous thrill and continuous machinery murmur.
It is warm at the site. Changes below the level of the
fistula—Because of diversion of arterial blood distal
part becomes ischaemic. Because of arterialisation
of high pressure veins, and valvular incompetence,
it results in varicose veins. Changes proximal to the
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A
B
SRB’s Clinical Surgery
D
C
Figs 5.55A to E: Congenital arteriovenous malformation involving right upper limb, axillary region and part of right half of
neck and face. Note the limb lengthening and widened girth. Limb is warmer. Limb should be measured at each level.
Auscultation reveals continuous bruit over the limb. Note the dilated tortuous veins due to hyperdynamic circulation.
E
Examination in Arterial Diseases
https://t.me/med1917
Fig. 5.56: Arteriovenous fistula diagrammatic
representation.
143
Fig. 5.57: Acquired arteriovenous fistula in the wrist over
radial vessels. It should be palpated for compressibility and
thrill. It should be auscultated for bruit.
fistula—Hyperdynamic circulation causes cardiac
failure. If pressure is applied to the artery proximal
to the fistula, swelling will reduce in size, thrill and
bruit will disappear, pulse rate and pulse pressure
Fig. 5.58: AV fistula done for haemodialysis
(Cimino fistula).
becomes normal. This is called as Nicoladoni’s sign
or Branham’ s sign. Cardiac failure may be very severe
in traumatic A VF (Often resistant to drug therapy) (Figs
5.55A to E to 5.58).
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SRB’s Clinical Surgery
Examination in
6
Writing a Case Sheet for Varicose
Veins (Long Case)
Name:
Address:
Age:
Sex:
Occupation: Varicose veins are more common in
people who stand for long hours like bus conductors,
nurses, doctors, surgeons, manual labourers, watchmen, athletes, traffic policemen, etc. Occupation also
may exacerbate the condition.
Varicose vein is more common in females (10:1).
It is not commonly seen in Africa.
Chief Complaints
Pain in the leg/thigh/foot of significant duration present
on one or both side.
Swelling/dilated veins in the leg of significant
duration.
Pigmentation/ulceration in the leg with duration
(Fig. 6.1).
History
History of Present Illness
Pain
History of pain in the leg/foot/or thigh with duration
should be noted. Origin of pain and its severity , nature
of onset whether acute or insidious should be asked.
Character of pain— dull aching or cramping should
be asked. Whether pain gets aggravated by walking/
standing should be noted. Dull aching pain along the
line of the vein is typical and usually gets aggravated
Venous Diseases
Fig. 6.1: Varicose vein leg of great/long saphenous
vein. It is tortuous, elongated dilated vein.
in the evening and relieved by lying down. Pain in
calf of short duration, may be due to co-existing deep
vein thrombosis (DVT). Pain also can be due to ulcer/
periostitis/infection. Often severity of the symptoms
is not related to the severity of varicose veins. Small
varicose veins may be more symptomatic than large
one. In bilateral varicose veins, only one limb may
be symptomatic and other limb may not. Bursting
severe pain while walking may be due to deep vein
thrombosis. Crampy pain during night (night cramps)
is very common in these patients. Feeling of heaviness
is common (Figs 6.2A to 6.3B).
Examination in Venous Diseases
https://t.me/med1917
145
A
B
Figs 6.2A and B: Long saphenous vein varicosity. Note
the prominent of veins and blow outs. Note the diagrammatic
representation of varicose veins.
A B
Figs 6.3A and B: Photo of short saphenous vein
varicosity and its diagrammatic location.
Ulcer
History of mode of onset, duration, site of onset should
be noted. Ulcer on the medial aspect of the ankle is
due to long saphenous vein varicosity; on the lateral
aspect is due to short saphenous vein varicosity.
Discharge from ulcer—its type, smell, quantity signifies the severity of the infection. Itching and bleeding
in the ulcer bed are also important to be noted.
History of trauma—Often minor trauma precipitates
ulcer formation in patients with varicose vein.
History of bleeding from the vein/ulcer is an important
presentation.
History of swelling around the ankle: Its duration;
whether regressed any time with or without any
medication; or progressive; relation to work/standing/
lying down should be noted. History suggestive of
difficulty/altered gait due to pain/swelling/deformity
should be noted.
Pigmentation
It is due to stasis and release of chemicals and usually
occurs around ankle region. It is associated with itching
and often ulceration.
History of Pain/Lump in the Abdomen
Abdominal mass/pregnancy may compress IVC/iliac
veins and cause bilateral varicose veins. If compression
is one side iliac veins, then varicose vein is unilateral.
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History of Similar Complaints on the Other Leg
SRB’s Clinical Surgery
Varicose veins are often bilateral.
Past History
History suggestive of earlier deep vein thrombosis
like pain, calf swelling and fever should be noted.
History of immobilisation, hospitalisation; history of
any previous surgery should be noted.
Treatment History
History of previous surgery for varicose vein, drug
intake like warfarin for DVT, injection therapy—
sclerotherapy, wearing stockings/crepe bandages
should be noted.
Personal History
In females, history of varicose veins in pregnancy,
and post-delivery period, use of oral contraceptive
(may cause deep vein thrombosis) should be noted.
History of smoking/alcohol/ working pattern should
be noted
A
B
Family History
Varicose veins may be familial, which are bilateral
and severe, observed in young individuals. V alves are
absent/defective in these patients.
General Examination
Pulse—Rate/rhythm/character/condition of vessel wall
should be noted; blood pressure is measured. Other
detailed general examination is done for anaemia/
oedema/jaundice/clubbing/lymphadenopathy. Raise
in temperature/attitude of the patient/nutritional
assessment by skin texture, subcutaneous fat, weight,
body mass index/any other relevant findings should
be mentioned.
Local Examination
Examination of lower limbs—symptomatic limb
should be examined first.
Inspection
Examination of limbs in standing position is the first
method in varicose veins (Figs 6.4A to D).
C
Figs 6.4A to D: Inspection of varicose veins should be done
in standing position. Great saphenous veins on both sides
should be inspected along medial aspect in standing
position. Short/small saphenous vein should be inspected
from behind.
Limb
D
Limb is looked for dilated long saphenous vein on
the medial side and for short saphenous vein on
posterior and lateral side. Other communicating veins
are also looked for. Beginning of the varicosity in the
foot, later its extent above also should be examined.
Great saphenous vein tortuosity often extends into the
thigh whereas short saphenous vein varicosity ends
at popliteal region. Always limb is looked for skin
changes, pigmentation, oedema, ankle flare, and
ulcer. Extent, size, shape, floor , margin, edge, discharge
in an ulcer and surrounding area, deformity should
Examination in Venous Diseases
https://t.me/med1917
A
Figs 6.5A and B: Bilateral varicose veins involving both
great and small saphenous veins.
be noted. Cough impulse at saphenous opening
(Morrisey’s) may be significant (Figs 6.5A to 6.6B).
Swelling
In superficial varicose veins it may be a localised
swelling/segmental tortuous vein. Diffuse swelling may
be due to oedema/DVT.
Skin Changes
Colour changes: It may be linear redness/reddish blue
colour in superficial thrombophlebitis; massive
oedema with pallor and tenderness—Phlegmasia alba
dollens (DVT of femoral vein with lymphangitis and
palpable pulse); Phlegmasia cerulea dolens [It is
cyanotic mottled skin with massive tight oedema due
B
to occlusion of major veins (iliofemoral vein) and collaterals with absence ankle pulses] may cause venous
gangrene. Texture of the skin: Skin may be stretched
shiny, oedematous (in DVT); may also present with
eczema; ulcers and scar around the ankle. Loss of hair
and nail brittleness may be feature of impending venous
gangrene.
147
Figs 6.6A and B: Long saphenous vein varicosity. Note
the prominent of veins and blow outs.
Cough Impulse
Morrissey’s cough impulse—Here patient is asked to
cough and impulse on coughing is observed at the
saphenous opening—saphena varix. It is done in lying
down position after emptying the vein (Fig. 6.7).
Palpation
Ulcer, if present should be described with tenderness,
induration, warmness, mobility , fixity to the underlying
bone, etc.
Brodie-Trendelenburg Test (Brodie 1846;
Friedrich Trendelenburg 1924)
Vein is emptied by elevating the limb and milking
the vein in lying down position; a tourniquet is tied
just below the saphenofemoral junction (or saphenofemoral junction can be occluded using a thumb).
Saphenous opening is located 3.5 cm below and lateral
to the pubic tubercle. Pubic tubercle is palpated along
the adductor longus tendon which is identified by
adducting the thigh against resistance. Patient is asked
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Fig. 6.7: Morrissey’s cough impulse.
SRB’s Clinical Surgery
to stand quickly. When tourniquet or thumb is released,
rapid filling from above signifies saphenofemoral
incompetence. This is Trendelenburg test I.
A
In Tr endelenburg test II, vein is emptied again in lying
down position and tourniquet is applied at saphenofemoral junction. After standing without releasing the
tourniquet, the limb is observed. Filling of vein rapidly
from below upwards can be observed within 30-60
seconds. It signifies perforator incompetence (Figs
6.8A to 6.10D).
Tourniquet Test for Short Saphenous Vein
T ourniquet is applied at saphenopopliteal junction after
emptying the short saphenous vein by elevation.
Saphenopopliteal junction is not in constant position
and so it is better applied at the level of lower boundary
of popliteal fossa. The tourniquet is released in standing
position to look for the rapid filling from above which
suggests saphenopopliteal incompetence (Fig. 6.11).
Three/Multiple Tourniquet Test
(Oschner’s Mahoner’s Test) (Figs 6.12A to G)
To find out the site of incompetent perforators, three
tourniquets are tied after emptying the vein-I 1. Just
B
C
Figs 6.8A to C: Emptying of the superficial varicose vein is
important in all tourniquet tests for varicose veins. It is done
in lying down position with elevating and milking the vein.
Emptying is not done in modified Perthe’s test. Note the
marking of the saphenofemoral junction before applying the
tourniquet is important.
below saphenofemoral junction; 2. Above knee level;
3. Another below knee level; 4. Additional tourniquets
may be applied at below-knee and above ankle level.
Patient is asked to stand; filling of veins and site of
filling is looked for. Then tourniquets are released
Examination in Venous Diseases
https://t.me/med1917
A
149
B
Figs 6.9A to C: Note the site of applying the tourniquet at saphenofemoral junction. It is 3.5 cm below
from below upwards to look again for incompetent
perforators. Individual perforators may be tested by
and lateral to pubic tubercle. Ideally rubber tourniquet should be used.
junction. The bandage is released later to see the ‘blow
outs’ as perforators.
C
repeating the procedure. On standing if veins become
prominent between upper most and second tourniquets,
it means adductor canal perforator incompetence.
Prominent veins between middle and lower signifies
below knee perforator incompetence; and prominent
veins below lower tourniquet, signifies incompetence
of lower leg perforators.
Fegan’s Test (George Fegan, Dublin)
Line of varicose vein is marked. On standing, the site
where the perforators enter the deep fascia bulges and
these points are also marked. On lying down, button
like circular depressions (crescentric gaps) in the deep
fascia are felt at the marked out points which confirms
the perforator site (Figs 6.14A to C).
Schwartz Test
In standing position, when lower part of the vein in
leg is tapped, impulse is felt at the saphenous junction
or at the upper end of the visible part of the vein.
It signifies continuous column of blood and all
valves between two fingers are incompetent. Positive
Ian-Aird Test
On standing, proximal segment of long saphenous vein
is emptied with two fingers. Pressure from proximal
finger is released to see the rapid filling from above
which confirms saphenofemoral incompetence.
test is usually found in gross venous varicosity (Fig.
6.13).
Perthes Test
The affected lower limb is wrapped with elastic
Pratt’s Test
Esmarch bandage is applied to the leg from below
upwards with a tourniquet tied at saphenofemoral
bandage and the patient is asked to walk around and
exercise. Development of severe crampy pain in the
calf signifies DVT. Test is often subjective.
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SRB’s Clinical Surgery
A
C
Figs 6.10A to D: Tourniquet test. Tourniquet is applied after emptying the vein
by elevating the leg and milking. Patient is asked to stand, tourniquet is released
immediately and saphenous vein is observed. Rapid filling of vein from above
signifies LSV varicosity with saphenofemoral incompetence. In test II-tourniquet
applied after emptying is retained and limb is observed in standing for rapid filling
of the vein from below upwards in 1 minute. It means perforators are incompetent.
B
D
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