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Examination in Venous Diseases
https://t.me/med1917
151
A
Figs 6.11A to C: Small/short saphenous vein varicosity can be present along with other types like of GSV or perforators.
Occasionally it can be isolated small saphenous vein varicosity. Saphenopopliteal junction is variable; but since usual
site is in the lower part of the popliteal fossa, tourniquet is applied at the lower line of popliteal fossa after emptying the
vein by elevation. On standing and releasing the tourniquet, rapid filling of small saphenous vein observed from above
downwards signifying saphenopopliteal incompetence.
Modified Perthe’s Test
Tourniquet is tied just below the saphenofemoral
junction without emptying the vein. Patient is asked
to do a brisk walk which precipitates bursting pain
in the calf and also makes superficial veins more
prominent. It signifies DVT.
DVT is contraindicated for any surgical intervention
of superficial varicose veins. It is also contraindicated
for sclerosant therapy.
Homan’s Test
Homan’s test is dorsiflexion of the foot to elicit pain/
tenderness in the calf and Mose’s sign is squeezing
the relaxed calf muscles sideward to elicit pain/
tenderness. Both tests signify deep vein thrombosis
(DVT) (Fig. 6.15). Point to be remembered is that
in case of acute DVT, Homan’s/Mose’s tests should
be done cautiously as it will precipitate the dislodgement of the clot and embolism. On deep palpation
of the calf, thickening and tenderness is felt in the
calf—Neuhof’s sign. After applying tourniquet at
saphenofemoral junction, patient is asked to walk and
without removing the tourniquet, limb is elevated—
persisting prominent superficial veins will be observed
in DVT—Linton’s test.
B
C
Bone thickening in the shin (tibia and ankle) is
important which signifies periostitis (Fig. 6.16).
Measurement of limb length and girth is taken
especially in arteriovenous malformation with varicose
veins and also to find out deformities.
Always varicose veins and perforators should be
marked with a marking ink especially prior to surgery
after taking consent.
Auscultation of the vein for bruit/venous hum (Fig.
6.17).
Examination of peripheral pulses are important
(dorsalis pedis/anterior tibial/posterior tibial/popliteal/
femoral).
Regional lymph nodes: V ertical group of inguinal
nodes and external iliac nodes (above and medial aspect
of the inguinal ligament) are palpated (Fig. 6.18).
Ankle joint movements (plantar and dorsiflexion)
are checked for any restriction. Inversion and eversion
are elicited in subtalar joint.
Examination of the opposite limb both in standing
and lying down position should not be forgotten.
Abdomen should be examined for any mass which
might be compressing the inferior vena cava (IVC) or
iliac veins causing varicose veins (Figs 6.19 and 6.20).
Examination of other systems should also be done
(Fig. 6.21).
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SRB’s Clinical Surgery
A
D
B
C
E
F G
Figs 6.12A to G: Note the different phases of multiple tourniquet tests.
Ideally rubber tourniquet should be used.
Examination in Venous Diseases
https://t.me/med1917
153
Fig. 6.13: Schwartz test
is done to confirm the
presence of continuous
column of blood.
A
A
Figs 6.14A toC: Fegan’s test to find out the site of perforator. It is done both in standing and
lying down position. It is done prior to surgery to have a clear idea about the site of the perforator.
B C
B
Fig. 6.15A and B: Homan’s test and Mose’s sign to find
out acute DVT. In Homan’s test foot is dorsiflexed to elicit
pain/tenderness in the calf. Squeezing the relaxed calf
muscles sideward to elicit pain/tenderness is Mose’s sign.
Fig. 6.16: Bone thickening is checked over tibia and ankle
joint using thumb. It suggests periostitis. Note also the skin
changes.
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SRB’s Clinical Surgery
Fig. 6.17: Auscultation over the groin for venous hum/
bruit (of AVF) is done when needed.
Fig. 6.18: Lymph nodes in the region/groin (vertical inguinal
nodes) should be examined in presence of complications
like ulcer. External iliac nodes (above and medial aspect of
the inguinal ligament) should also be palpated whenever
required.
Fig. 6.19: Abdomen should be palpated for mass and
ascites. Mass may compress the major veins causing lower
limb varicose veins.
A
B
Figs 6.20A and B: Bilateral lower limb varicosity with features
of IVC obstruction. Lateral and front abdominal and chest
veins become prominent with flow from below upwards.
(Normal flow is away from umbilicus. Below the umbilicus
flow is downwards; above, it is upwards). Direction of venous
flow should be confirmed using two fingers kept apart.
Examination in Venous Diseases
https://t.me/med1917
Fig. 6.21: Chest (cardiac and respiratory systems) should
be examined. It is relevant in AV fistula/IVC obstruction.
Investigations for Varicose Veins
Laboratory Studies
No currently available lab tests are useful in the
diagnosis or treatment of varicose veins. It is mainly
to assess presence/absence of DVT which is absolute
essential prior to intervention.
155
Venous Doppler in varicose veins
To find out DVT—very important
To find out saphenofemoral, saphenopopliteal incompetence
To find out perforator incompetence
Uniphasic signals signify flow in one direction—normal;
Biphasic flow signifies reversal flow with incompetence
Duplex Scan
Duplex scan is a highly reliable U/S Doppler imaging
technique (Here high resolution B mode ultrasound
imaging and Doppler ultrasound is used) which along
with direct visualisation of veins, gives the functional
and anatomical information, and also colour map.
Examination is done in standing and lying down
position and also with V alsalva manoeuvre. Hand held
Doppler probe is placed over the site and visualised
for any block and reversal of flow . DVT is very well
identified by this method. All patients with varicose
vein should be assessed preoperatively by ultrasound
for proper venous mapping (V enous Haemodynamical
Mapping; VHM; Cartography), marking on the
patient’s limb manual and ultrasound guidance (using
permanent marker). All sur geries should be done under
the guidance of on table ultrasound. Postoperatively,
all patients should be assessed using ultrasound for
result and residual venous diseases (Figs 6.22 to 6.24).
Specific Tests
Venous Doppler
With the patient standing; the Doppler probe is placed
at saphenofemoral junction and later wherever
required. Basically by hearing the changes in sound,
venous flow, venous patency, and venous reflux can
be very well identified. A uniphasic signal means flow
is in one direction. A biphasic signal means flow in
both forward and reverse direction suggesting
incompetence. Reversal can often be better appreciated
by releasing a tourniquet applied earlier at saphenofemoral junction.
Fig. 6.22: Duplex can (with Doppler machine) used for
varicose veins and DVT.
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Fig. 6.23: Ultrasound showing IVC thrombosis.
SRB’s Clinical Surgery
Descending venogram is done when ascending
venogram is not possible and also to visualise
incompetent veins. Here contrast material is injected
into the femoral vein through a cannula in standing
position. X-ray pictures are taken to visualize deep
veins and incompetent veins.
Phlebography
Ascending phlebography defines obstruction
Descending phlebography identifies valvular incompetence
Regularly not required to be done
Plethysmography
It is a noninvasive method which measures volume
changes in the leg.
Photo plethysmography: Using probe transmission
of light through the skin, venous filling of the surface
venules which reflects the superficial venous pressure
is measured. Initially patient performs dorsiflexion
at ankle for 10 times to empty the venules and pressure
tracing falls on photo plethysmography . Patient takes
rest and refilling occurs. In normal people, it occurs
through arterial inflow in 20-30 seconds. In venous
incompetence filling also occurs by venous reflux and
so refilling time is faster than normal. Disadvantage:
Site of reflux cannot be localised by this method.
Fig. 6.24: Venous haemodynamic mapping (VHM) of the
Venography/Phlebography
Ascending venography was a very common investigation done earlier to Doppler period.
A tourniquet is tied above the malleoli and the vein
of dorsal venous arch of foot is cannulated. Water
soluble dye injected, flows into the deep veins (because
the applied tourniquet prevents its flow into superficial
veins). X-rays are taken below and above knee level.
Any block in deep veins, its extent, perforator status
can be made out by this.
Note: In the presence of Duplex scan ascending
venography is not a necessary investigation. If DVT
is present, surgery or sclerotherapy are contraindicated.
lower limb.
Air plethysmography: Patient is initially in supine
position with veins emptied by elevation of leg. Air
filled plastic pressure bladder is placed on calf to detect
volume changes. Minimum volume is recorded. Patient
turned to upright position and venous volume is
assessed. Maximum venous volume divided by time
required to achieve maximum venous volume gives
the venous filling index (VFI). VFI is a measure of
reflux. Ejection fraction is volume change measured
prior and after single tip toe manoeuvre which is a
measure of calf pump action. Residual venous fraction
is an index of overall venous function which is venous
volume in the leg after 10 toetip manoeuvres divided
by venous volume prior to manoeuvre. A patient with
increased VFT and diminished ejection fraction will
benefit from surgery.
Ambulatory Venous Pressure (AVP)
It is an invasive method. Needle inserted into dorsal
vein of foot is connected to transducer to get its pressure
Examination in Venous Diseases
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which is equivalent to pressure in the deep veins of
the calf. T en tiptoe manoeuvres are done by the patient.
With initial rise in pressure, pressure decreases and
eventually stabilizes with a balance. Pressure now is
called as ambulatory venous pressure (AVP). After
stopping exercise, veins are allowed to refill with return
of pressure to baseline. Time required for pressure
to return to 90% of baseline is called as venous refilling
time (VRT). Raise in AVP signifies venous hypertension. Patients with AVP more than 80 mm Hg has
80% chances of venous ulcer formation.
Varicography
Here non-ionic, iso-osmolar, non-thrombogenic
contrast is injected directly into the variceal vein to
get a detailed anatomical mapping of the varicose veins.
It is used in recurrent varicose veins or with anatomical
variations.
Arm-Foot Venous Pressure
Foot pressure is not more than 4 mm Hg above the
arm pressure. Foot venous pressure will be as high
as 10-15 mm Hg above of hand venous pressure—
Raju test.
Patients with varicose veins may have spuriously
positive D-dimer test result because of chronic low
level thrombosis within varices.
Muscle pump ejection fraction assessment may
be useful to demonstrate reflux.
U/S abdomen, peripheral smear, platelet count,
and other relevant investigations are done depending
on the cause of the varicose veins.
If venous ulcer is present, then the discharge is
collected for culture and sensitivity , biopsy from ulcer
edge is taken to rule out Marjolin’s ulcer, plain
X-ray of the part is taken to find out periostitis
(Figs 6.25A and B).
Radioactive Fibrinogen Test
Sodium iodide 100 mg orally is given to the patient
24 hours before the test to block the thyroid activity.
125
I
labelled fibrinogen 100 µ curies is injected intravenously. First radioactivity of heart is measured by
placing the scintillation counter over the precordium.
Reading obtained by this is adjusted as 100%. After
157
A
B
Figs 6.25A and B: Venous ulcer showing periostitis
that legs are elevated using adjustable stands and to
prevent venous pooling, scintillation counter is placed
over the calf. Counting in the leg is done from below
upwards at 5 cm intervals. Procedure is done in
preoperative period; on 1st, 3rd and 6th postoperative
days. A 20% or more rise in percentage value suggests
deep vein thrombosis in leg. I
is used (earlier I
because it has got softer radioaction and its detectability
is possible with much lighter and mobile apparatus.
Routine Investigations
Haematocrit, blood urea, serum creatinine, blood
sugar; Chest X-ray, ECG. It is mainly done to prepare
the patient for surgery-for anaesthesia purpose.
features in the X-ray taken.
125
131
labelled fibrinogen was used)
labelled fibrinogen
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SRB’s Clinical Surgery
Surgical Anatomy of Lower Limb Veins
Superficial venous system: It is located in the saphenous compartment which is between subcutaneous
plane and deeper aponeurotic plane. GSV and SSV
are in this plane.
Great (Long) saphenous vein (GSV)—It runs from the
medial end of the dorsal venous arch up along the
anteromedial aspect of the leg and thigh until it empties
into the femoral vein. There is one valve at this
junction—is called as ostial/terminal valve and reflux
through it is called as ostial reflux. There is one more
valve proximal to the main junctional tributary veins
and is called as pretermial valve. More than 50% reflux
occurs at preterminal valve (preterminal r eflux ).
Small (Short) saphenous vein (SSV)—It runs from the
lateral end of the dorsal venous arch up along the
posterolateral aspect of the calf until it passes through
the popliteal fossa behind the knee and empties into
the popliteal vein just above the knee. Tributaries are
located in the subcutaneous plane which joins the
saphenous system. Superficial circumflex vein (often
joins AAGSV), superficial external pudendal vein,
superficial inferior epigastric vein, anterior vein of
the leg, posterior arch vein of the leg (joins GSV),
posterolateral venous chains of leg—are different
tributaries. Long intersaphenous communicating vein
often exists between cranial extension of SSV to join
GSV and can be varicose and pathological and is called
as communicating vein of Giacomini-Cruveilhier.
Anterior accessory great saphenous vein (AAGSV,
Anterolateral vein of thigh) is communicating vein
into the GSV anteriorly and laterally. AAGSV communicates into GSV usually just proximal to
preterminal valve (60%); often at confluence (39%);
rarely onto femoral vein (1%). In many patients with
varicose veins it is this vein which is diseased than
GSV. It often receives superficial circumflex vein
before joining the GSV.
Perforator system of veins (communicating veins)—
They pass through the deep fascia carrying blood from
superficial to the deep system. All blood flow is one
way maintained through valves. Incompetence of these
valves leads to appearance of superficial varicosity
during exercise.
Deep venous system: It comprises femoral and
popliteal veins; pairs of venae comitantes of the tibial,
posterior tibial and peroneal arteries (total 6 venae
comitantes, soleal and gastrocnemius veins join to form
popliteal vein); valveless blood lakes within the calf
muscles communicates with superficial system via
saphenofemoral junction, mid-thigh perforators, shortsaphenopopliteal junction and calf perforators.
The calf muscle pump: It is often referred to as
“peripheral heart”. Its inflow into a segment of deep
vein is through intake valves of the perforating veins
and segment of deep vein below . Its outflow is through
outflow valve to the deep vein segment above. It has
got soleal veins (flush up the blood) and gastrocnemial
veins (Gilot) (push up the blood) to have effective
motor venous return (Figs 6.26A to D).
Different Types of Perforators
Para Achillean (Bassi); Ankle perforators: (May
or Kuster); Lower leg perforators between deep veins
and posterior arch vein (Cockett): I (posteroinferior
to medial malleolus), II (10 cm above the medial
malleolus), III (15 cm above medial malleolus);
Gastrocnemius perforators between GSV and deep
veins—upper proximal paratibial (Boyd)—below
knee; Lower and medial paratibial (Sherman); ‘24’
cm perforator between deep veins and GSV; Mid-
thigh perforator between deep vein and GSV (Dodd);
Hach perforator in the posterior thigh; Hunter’s
adductor canal perforator in the thigh (Fig. 6.27).
Physiology of Venous Blood Flow
in Lower Limb
Veins are thin walled vessels with collapsible walls
that assume an elliptical configuration in collapsed
state and circular configuration in the filled state.
V enous valves are abundant in the distal lower extremity and the number of valves decreases proximally,
with no valves in superior and inferior vena cava.
Factors affecting venous return are:
a. Arterial pressure across the capillary increases the
pumping action of vein;
b. Calf musculovenous pump: During contraction
phase of walking, pressure in the calf muscles
increases to 200-300 mm Hg; This pumps the
blood towards the heart; During relaxation phase
of walking, pressure in the calf falls and so it
Examination in Venous Diseases
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Fig. 6.26A
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Fig. 6.26B
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SRB’s Clinical Surgery
Fig. 6.26C
Figs 6.26A to D: Diagrams showing venous anatomy of the lower limb. Also note the
allows blood to flow from superficial to deep veins
through perforators; Normally while walking,
pressure in the superficial system is 20-30 mm Hg
at the level of ankle; During walking, foot pump
mechanism propels blood from plantar veins into
the leg;
Fig. 6.26D
functioning of the valve in the vein.
c. Gravity: Pressure in the vena cava where it enters
the right atrium is very low (-5 mm Hg) which
allows rapid filling of vena cava from high
pressure peripheral veins.
Factors responsible for venous return: Negative
pressure in thorax; Peripheral pump—calf muscle;
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