๐ ็ธฝ็ฎ้ ๏ฝ ๐ ่ฑๆๅๆ๏ผๆฌ็ฏ๏ผ ๏ฝ ๐ ๅฎๆด็ฟป่ญฏ ๏ฝ โญ ็ฒพ่ฏ็ญ่จ
WORKUP
WORKUP
Inspection and palpation are important elements necessary to identify venous disease. Photography can be critical, as patients undergoing treatment for varicose veins often forget the original appearance of their legs, and frequently report that pre-existing lesions were caused by treatment. Inspection is performed in an organized manner, usually progressing from proximal to distal and from anterior to posterior. The perineum, groin, and abdominal wall must also be inspected. Normal veins typically are visibly distended at the foot and ankle and occasionally in the popliteal fossa, but dilated veins above the ankle usually are evidence of venous pathology. Inspection may reveal such findings such as stasis dermatitis, lipodermatosclerosis, ulceration, atrophie blanche, interdigital mycosis, acrocyanosis, eczematous lesions, flat angiomata, clusters of telangiectatic veins, corona phlebectatica, hemosiderin deposition, prominent varicose veins, scars from a prior surgical operation, or evidence of previous sclerotherapy. Skin discoloration or ulceration along the medial aspect of the lower leg often is a sign of chronic venous stasis. Skin changes or ulcerations that are localized only to the lateral aspect of the ankle are more likely to be related to prior trauma or to arterial insufficiency, though small saphenous venous insufficiency may present in this manner as well. Palpation should begin along the anteromedial surface of the lower limb proceeding to the lateral and then finally to the posterior surface of both lower limbs. The location and course of all varicosities should be carefully noted. The GSV may be palpated in thin patients without varicose veins, but it is particularly well appreciated in patients with truncal reflux at the saphenofemoral junction. If reflux is present, a forced cough or Valsalva maneuver may produce expansion at this level. The small saphenous vein may be palpable below the gastrocnemius muscle in some slender or muscular patients. Other superficial veins above the feet are usually not palpable even after prolonged standing.
Currently utilized technologies such as duplex imaging have revealed that the GSV is often not the refluxing vessel causing varicosities. Accessory veins, circumflex veins, or even small groin veins, such as the superficial epigastric vein, may be the source. It should be emphasized that ultrasound technicians are often unfamiliar with superficial venous anatomy and its many variations. The treating physician must therefore be self-
sufficient with regard to handling an ultrasound probe and recognizing the nuances of venous anatomy. The diagnosis of varicose veins is confirmed by the presence of venous reflux, which is diagnosed by duplex ultrasound as retrograde or reversed flow of greater than 0.5 second duration.41,42