11/13/24, 7\:11 PM Guide | Varicose vein examination

Varicose vein examination

Table of contents

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
l e g s . T h i s w i l l i n v o l v e m e
y o u r t r o u s e r s o
"
Explain the need for a chaperone\:
c h a p e r o n e , w o u l d t h a t b e o k ?”
“ O n e o f t h e w a r d s t a
Gain consent to proceed with the examination.
Adequately expose the patient's lower limbs.
Position the patient standing.
Ask the patient if they have any pain before proceeding with the clinical examination.

General inspection

Clinical signs

Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology\:
Scars\: may indicate previous surgical procedures or healed ulcers.
Ulcers\: indicative of venous and/or arterial disease.

Objects and equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
clinical status\:
Medical equipment\: note any compression stockings and wound dressings.
Mobility aids\: items such as wheelchairs and walking aids give an indication of the patient's current mobility status.
Vital signs\: charts on which vital signs are recorded will give an indication of the patient's current clinical status and how
their physiological parameters have changed over time.
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient's recent
medications.

Leg inspection

With the patient standing (if able) look for signs of venous disease from the front, side and back of the legs.

Surgical scars

Surgical scars may be relevant to the patient's presentation. It is worth clarifying what operation the patient had by asking the
patient and con
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It is important to note that modern venous treatments are now minimally invasive and therefore they'll be no scars (NICE now
recommends minimally invasive surgery for varicose veins as
a low groin scar on the a

Venous eczema

Venous eczema occurs as a result of venous hypertension causing
soft tissues results in activation of the innate immune response and subsequent in
Venous eczema has the following clinical characteristics\:
Itchy red, blistered and crusted plaques; or dry
cellulitis).
Atrophie blanche\: star-shaped ivory-white depressed atrophic plaques with red dots within the scar (dilated capillaries) and
surrounding hyperpigmentation (due to haemosiderin deposition).
Orange-brown patches of pigmentation caused by haemosiderin deposition.
Lipodermatosclerosis (described below).
If you're not sure if the patient has venous eczema, ask “Is it itchy?”
. Varicose eczema is often intensely pruritic and a this is a
common indication for intervention.

Lipodermatosclerosis

Lipodermatosclerosis is a form of panniculitis (in
innate immune response in soft tissues (secondary to venous hypertension).
It is an advanced manifestation of chronic venous insu
causes including deep venous incompetence and calf muscle pump failure.
Lipodermatosclerosis has the following clinical characteristics\:
Skin hardening (often referred to as induration)
Hyperpigmentation
Erythema
Swelling
Inverted champagne bottle appearance

Venous ulcers

Venous ulcers are thought to be caused by the improper functioning of venous valves and typically develop along the medial
aspect of the distal leg. A venous ulcer can be de
is sustained by chronic venous disease.
Venous ulcers present with the following clinical characteristics\:
Large, irregular border with sloping edges
Shallow depth
Often located over the medial aspect of the ankle (referred to as the gaiter region).
Associated with mild pain
Venous ulcers di
clearly de

Saphena varix

A saphena varix is a dilation of the saphenous vein at its junction with the femoral vein in the groin. It typically presents as a
lump around 2-4cm inferior-lateral to the pubic tubercle. It often has a bluish tinge, is soft to palpate and will vanish when
the patient lies down which can help di

Arterial disease

Arterial disease is important to be aware of when assessing and treating problems of the venous system. One of the common
treatment options for varicose veins is compression therapy (with compression stockings or bandages). If a patient has a
signi
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Likewise, if the patient has venous ulcers, the
trying to treat super
Clinical signs of peripheral arterial disease include\:
Peripheral pallor
Peripheral cyanosis\: bluish discolouration of the skin associated with low SpO 2
in the a
Reduced temperature
Gangrene\: tissue necrosis secondary to inadequate perfusion. Typical appearances include a change in skin colour (e.g. red,
black) and breakdown of the associated tissue.
Hair loss\: associated with PVD due to chronic impairment of tissue perfusion.
Arterial ulcers\: typically small, well-de
most peripheral regions of a limb (e.g. the ends of digits).
Haemosiderin deposition (1)

Varicose veins

Varicose veins appear as tortuous dilated super
part of the venous system is likely to be a
Great saphenous vein
The great saphenous vein originates at the merging of the dorsal vein of the big toe with the dorsal venous arch of the foot.
After passing in front of the medial malleolus (where it often can be visualized and palpated), it runs up the medial side of the
leg (classically known as the trouser seam). At the knee, it runs over the posterior border of the medial epicondyle of
the femur bone. In the proximal anterior thigh 3-4 centimetres inferolateral to the pubic tubercle, the great saphenous vein
dives down deep through the cribriform fascia of the saphenous opening to join the femoral vein.
¹
Small saphenous vein
The small saphenous vein originates at the merging of the dorsal vein of the
From its origin, it courses around the lateral aspect of the foot (inferior and posterior to the lateral malleolus) and runs along the
posterior aspect of the leg, where it passes between the heads of the gastrocnemius muscle. The small saphenous vein drains
into the popliteal vein, at or above the level of the knee joint.
² The saphenopopliteal junction (SPJ) is anatomically more variable
in position compared to the saphenofemoral junction (SFJ).
Summary
In summary, the great saphenous vein runs all the way up the medial side of the leg and the small saphenous vein drains the
lateral side of the lower leg. Varicose veins on the buttocks and around the genitals are suggestive of pathology a
venous system within the pelvis.
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Varicose veins (5,6)

Assess varicosities

Temperature

Assess the temperature of any varicosities\:
Place the back of your hand along the varicosities to assess their temperature.
Increased temperature is indicative of in

Palpation

Palpate any visible varicosities\:
Palpate the entire length of each varicosity and ask the patient to let you know if they experience any pain.
Overlying erythema in the distribution of the vessel and tenderness on palpation is indicative of phlebitis.
A tender and hard ("cord-like") varicosity is indicative of thrombophlebitis (thrombosis with associated in
Phlebitis
Phlebitis is the term used to describe in
typically caused by trauma and/or infection (e.g. secondary to insertion of an intravenous cannula). In a small number of
cases, it is caused by systemic in

Further assessment of the lower limb

Pitting oedema

Assess for pitting oedema in the limb\:
Apply some pressure with a
has been left behind (e.g. known as pitting oedema).
Continue to move upwards along the leg, repeating this process until you establish at what level oedema extends to.
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Pitting oedema is most commonly caused by heart failure and its presence can impact the integrity of the skin, complicating
the management of venous disease.

Lower limb pulses

Palpate the pulses in the lower limbs to assess the arterial blood supply of each leg.
When assessing the pulses of the lower limbs work proximal to distal - this allows you to assess and compare arterial in
into each leg. If pulses are not palpable, a Doppler can be used to assess blood
Femoral pulse
Palpate the femoral pulse\:
The femoral pulse can be palpated at the mid-inguinal point, which is located halfway between the anterior superior iliac
spine and the pubic symphysis.
Check that the pulse is present and assess the pulse volume.
Popliteal pulse
Palpate the popliteal pulse\:
The popliteal pulse can be palpated in the inferior region of the popliteal fossa.
With the patient lying on the bed, ask them to relax their legs and place your thumbs on the tibial tuberosity.
Passively
pulse, as you compress the popliteal artery against the tibia.
This pulse is often di
structures within the fossa, so the examiner will understand if you are unable to locate the artery.
Posterior tibial pulse
Palpate the posterior tibial pulse\:
The posterior tibial pulse can be located posterior to the medial malleolus of the tibia.
Palpate the pulse to con
Dorsalis pedis pulse
Palpate the dorsalis pedis pulse\:
The dorsalis pedis pulse can be located over the dorsum of the foot, lateral to the extensor hallucis longus tendon, over
the second and third cuneiform bones.
Palpate the pulse to con

Percussion (tap test)

The tap test provides a crude assessment of lower limb venous valve competency. It is rarely performed in modern clinical
practice, but it is worth understanding what the test involves.
To perform the tap test\:
1. Place one
lateral to the pubic tubercle.
2. Tap the varicose vein you are assessing, which should be located lower down the leg.
3. If your
(normally the venous valves should prevent the thrill transmitting along the entirety of the vessel).

Auscultation

Again, auscultation is rarely performed in modern clinical practice and has largely been replaced by modern venous duplex
scanning.
Auscultation involves placing the bell of the stethoscope over the identi
indicates turbulent blood
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Other special tests

Handheld Doppler and venous duplex scanning

Please note that in modern practice all patients under consideration of varicose vein treatment will undergo a venous duplex
scan of the entire super
Con
Assess whether the veins are suitable for endovenous treatment (radiofrequency or laser ablation) as veins need to relatively
straight to permit the passage of the catheters.
Establish the function of the deep venous system – if the deep veins are incompetent the patient may be relying on the
super
You should be aware of traditional tests that were performed routinely before the advent of venous duplex scanning, but note
they are rarely performed in modern practice.
The most common special test would be the use of a handheld Doppler. As a vascular surgeon, I would be far more interested
in whether a candidate could assess the competence of the SFJ with a handheld doppler than perform any of the other
outdated old fashioned special tests.

Trendelenburg test (tourniquet test)

This test is used to locate the site of the incompetent venous valves. If using
using a tourniquet instead it's called the tourniquet test.
One leg should be assessed at a time.
1. Position the patient lying
2. Lift the patient's leg up (as far as the patient is comfortable with) and empty the super
the groin (SFJ).
3. Place a tourniquet over the saphenofemoral junction (SFJ) - this is found approximately 2-3cm below and lateral to the pubic
tubercle.
4. Ask the patient to stand and observe for
At this point, if the veins have not
level of the SFJ.
If the veins have
drain venous blood from super
5. Repeat the test with the patient lying down, placing the tourniquet 3cm lower than the previous position. Ask the patient to
stand and observe venous
6. Repeat this sequence until

Cough impulse test

1. Place your hand over the saphenofemoral junction (2-3cm below and lateral to the pubic tubercle) and ask the patient to
cough.
2. If you feel an impulse over the SFJ this indicates a saphena varix (dilatation of the saphenous vein at the SFJ).

Perthe's test

systems.
Perthe's test is used to distinguish between venous valvular insu
1. Apply a tourniquet at the proximal mid-thigh level whilst the patient is standing.
2. Ask the patient to walk around the room (or continually alternate between standing on tip-toes and
Interpretation
If the varicose veins become less distended, it suggests that there is no deep venous valvular insu
muscle is able to empty the varicose veins by pumping blood from the super
This result would suggest there is a primary problem with the super
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If the varicose veins remain distended (or become more distended) it suggests there is also a problem with the deep venous
system, preventing the drainage of blood from the super
experience pain in the leg due to venous hypertension. A potential cause of deep venous obstruction is a deep vein
thrombosis.

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
Example summary
" T o d a y I e x a m i n e d M r S m i t h , a 6 4- y e a r-o l d m a l e. O n g e n e r a l i n s p e c t i o n , t h e p a t i e n t a p p e a r e d c o m f o r t a b l e a t r e s t a n d
t h e r e w e r e n o o b j e c t s o r m e d i c a l e q u i p m e n t a r o u n d t h e b e d o f r e l e v a n c e .
"
" V e n o u s e c z e m a w a s n o t e d o v e r t h e d i s t a l p o r t i o n o f b o t h l o w e r l i m b s a n d a 3 x 3 c m s h a l l o w u l c e r w a s n o t e d o v e r t h e
m e d i a l a s p e c t o f t h e l e f t a n k l e. T h e r e w e r e a l s o s e v e r a l v i s i b l e v a r i c o s e v e i n s n o t e d i n b o t h l e g s w i t h n o e v i d e n c e o f
p h l e b i t i s . P u l s e s w e r e n o r m a l t h r o u gh o u t i n b o t h l o w e r l i m b s .
"
" I n s u m m a r y, t h e s e
"
" F o r c o m p l e t e n e s s , I w o u l d l i k e t o p e r f o r m t h e f o l l o w i n g f u r t h e r a s s e s s m e n t s a n d i n v e s t i g a t i o n s.
"

Further assessments and investigations

Suggest further assessments and investigations to the examiner\:
Doppler ultrasound\: to enable further bedside assessment of incompetent venous valves and the identi
thrombosis.
Venous duplex scanning\: for a comprehensive assessment of lower limb venous drainage.
Ankle-brachial pressure index (ABPI) measurement\: to assess arterial perfusion.
Peripheral arterial examination\: to assess for evidence of arterial disease.
Abdominal examination\: occasionally increased pressure in the abdomen or pelvis (e.g. a large tumour) can occlude venous
return from the legs leading to venous hypertension and varicose veins.

Reviewer

Mr Craig Nesbitt Edits (MD, FRCS, MBChB Hons)
Vascular and Endovascular Consultant

References

1. James Heilman, MD. Adapted by Geeky Medics. Haemosiderin staining. Licence\: [CC BY-SA]. Available from [LINK].
2. Prof. Gerd HoCC BY-SA 3.0 de]. Available from\: [LINK].
3. Milorad Dimić M.D. Adapted by Geeky Medics. Venous ulcer. Licence\: [CC BY 3.0]. Available from\: [LINK].
4. Jonathan Moore. Adapted by Geeky Medics. Arterial ulcer. Licence\: CC BY 3.0. Available from\: [LINK].
5. Thomas Kriese. Adapted by Geeky Medics. Varicose veins. Licence\: [CC BY 2.0]. Available from\: [LINK].
6. Nini00. Adapted by Geeky Medics. Licence\: [CC BY-SA 3.0]. Available from\: [LINK].
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Source\: geekymedics.com
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