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Common lower limb venous vascular system exam questions for medical finals, OSCEs and MRCP PACES

Click on the the example questions below to reveal the answers

 

Question 1:

What is the definition of varicose veins?

  • Varicose veins are abnormally dilated, localised and lengthened veins

 

What distribution do most varicose veins follow?

  • 90% patients have varicose veins in the distribution of the long saphenous vein, 15% in the short saphenous vein. 5% of patients have both.

 

Question 2:

What is the course of the long saphenous vein?

  • The long saphenous vein originates just anterior to medial malleolus, runs along medial aspect of calf giving off 3 calf perforator branches at 3, 5 and 10cm above the medial malleolus and along the medial thigh to join the femoral vein at the saphenofemoral junction (SFJ) in the groin.

 

What is the course of the short saphenous vein?

  • The short saphenous vein originates posterior to the lateral malleolus, runs up the posterior calf like a stocking seam and joins the popliteal vein at a variable level within the popliteal fossa

 

Question 3:

What are the risk factors for primary varicose veins?

  • Female gender (F:M = 9:1)
  • Family history
  • Increased number of pregnancies

 

Question 4:

What are possible causes of secondary varicose veins?

  • Previous DVT
  • Pelvic pressure (ovarian tumour, pregnancy, radiotherapy)
  • Congenital malformation (Klippel-Trenaunay syndrome)
  • AV fistulae (congenital or acquired)
  • Severe tricuspid regurgitation

 

Question 5:

What are the symptoms of varicose veins?

  • Aching pain (usually after a period of standing)
  • Ankle swelling
  • Itching
  • Bleeding
  • Most varicose veins are asymptomatic and the major issue is cosmetic

 

Question 6:

What conservative measures are there to treat varicose veins?

  • Leg elevation
  • Compressions stockings
  • Weight loss
  • Regular exercise to aid venous return
  • Treatment of underlying cause in secondary varicose veins

 

Question 7:

What endoscopic measures are there to treat varicose veins?

  • Foam sclerotherapy (US-guided) plus post-op compression for 6 days
  • Radiofrequency ablation (VNUS)
    • A catheter technique under local anaesthetic
  • Endovenous laser ablation (EVLA)

 

Question 8:

What surgical options are there for patients with varicose veins?

  • Sapheno-femoral flush ligation plus LSV stripping (below knee to avoid paraesthesia) plus avulsion
  • Sapheno-popliteal ligation plus/minus SSV stripping plus avulsion

 

Question 9:

What are possible signs of venous insufficiency?

  • Haemosiderin deposit
  • Venous eczema
  • Lipodermatosclerosis and inverted champagne bottle shaped legs
  • Atrophie blanche
  • Venous ulcers
  • Scars from healed venous ulcers
  • Venulectasias (thread veins), venous stars
  • Ankle flare

 

Question 10:

How do you do the Trendelenberg test and what does it show?

  • Ask patient to lie down
  • Lift leg to 45 degrees and milk veins (rub along them from distal to proximal)
  • Apply pressure over the saphenofemoral junction (SFJ) with two fingers
  • Ask patient to stand
  • If veins immediately refill this suggests incompetence below level of SFJ
    • If veins refill only after releasing pressure from SFJ this suggests incompetence at level of the SFJ

 

Question 11:

How do you do the tourniquet test and what does it show?

  • Ask patient to lie down
  • Lift leg to 45 degrees and milk leg veins (rub along them from distal to proximal)
  • Apply tourniquet between saphenofemoral junction (SFJ and mid-thigh
  • Ask patient to stand
  • If varicose veins immediately refill, incompetence must be below the level of the tourniquet
  • Repeat, moving the tourniquet more and more distally until veins do not immediately refill – this is the level of valve incompetence

 

Question 12:

How do you do the Perthes’ test and what does it show?

  • Ask patient to stand
  • Apply tourniquet just below knee
  • Ask patient to flex their knee ten times
  • If the varicose veins empty, the valvular incompetence is above the level of the tourniquet
  • Rapid refilling implies incompetence of the calf perforator veins
  • Pain suggests DVT