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Stem A (symptomatic GSV reflux)
A 48-year-old multiparous woman presents with aching, heaviness, and visible tortuous veins on the left leg worse after prolonged standing. Examination: dilated long saphenous territory varicosities; ankle haemosiderin staining; no active ulcer. ABPI 1.1. Duplex: SFJ incompetence with GSV reflux to the calf; deep veins patent.
Stem B (venous ulcer — for part d)
Separately, a 62-year-old has a shallow, granulating ulcer above the medial malleolus with surrounding lipodermatosclerosis and venous eczema. ABPI 1.0.
Questions
a) Define varicose veins and give the CEAP clinical class for Stem A. (2 marks)
Varicose veins: subcutaneously dilated, tortuous veins ≥3 mm in diameter in the upright position (chronic venous disease).
Stem A with skin pigmentation without ulcer = C4a (pigmentation) under CEAP clinical class (C0–C6). Full CEAP also records etiology, anatomy, pathophysiology (e.g. Ep, As, Pr).
b) Pathophysiology of primary varicose veins and why duplex is mandatory before intervention. (3 marks)
Valve incompetence (often SFJ/SPJ or perforators) → reflux → ambulatory venous hypertension → vein wall dilatation → further valve failure. Pregnancy, standing occupation, obesity, family history contribute.
Duplex maps reflux segments, junction incompetence, perforators, and excludes deep venous obstruction — never strip/ablate if deep veins are the only outflow (can worsen ischaemia of drainage).
c) Management options with first-line interventional choice and conservative measures including compression class. (5 marks)
Conservative: leg elevation, weight loss, exercise/walking, avoid prolonged standing; Class II compression (≈18–24 mmHg ankle) if arterial supply adequate (ABPI check).
Intervention (symptomatic C2–C6 with proven reflux): endovenous thermal ablation first-line in most guidelines — EVLA or RFA of GSV under tumescent anaesthesia; foam sclerotherapy for tributaries/recurrent segments; surgery (high ligation + stripping) if endovenous unsuitable.
CLASS trial: endovenous and surgery both effective vs foam alone for GSV disease. Consent: recurrence, DVT, nerve injury, skin burns/pigmentation (sclerotherapy).
d) Stem B — diagnosis, compression therapy detail, and when to biopsy. (5 marks)
Venous leg ulcer (C6) in gaiter region — differentiate arterial (punched out, lateral/toes, low ABPI), neuropathic, malignant.
ABPI ≥0.8 (ideally ≥0.9): high compression multilayer bandaging (e.g. four-layer, sub-bandage pressures targeting therapeutic venous hypertension reduction) until healed, then stockings.
If ABPI 0.5–0.8: modified compression specialist only; <0.5: do not compress — vascular referral.
Treat superficial reflux after healing started/MDT (ESCHAR: surgery reduces recurrence). Adjunct: pentoxifylline 400 mg TDS where used.
Biopsy if atypical, non-healing 6–12 weeks despite therapy, everted edges, or suspected Marjolin’s SCC.
Additional teaching points
Trendelenburg/tourniquet tests historical — duplex replaced them.
Bleeding varix: elevate, compress, suture; then definitive reflux treatment.
Superficial thrombophlebitis: NSAIDs, compression; anticoagulate if near junctions/extensive per local protocol.