Assessment

The sites of venous reflux can be estimated from the anatomical distribution and hand-held Doppler assessment. The Trendelenberg tourniquet test is less often employed now but may be a useful examination of venous reflux. The patient lies supine and the examiner raises the leg and massages the dilated veins towards the trunk until they are empty. A tourniquet is then applied around the upper third of the thigh and the patient is asked to stand. Filling below the tourniquet

Long saphenous vein

Figure 15.19. Ligating branches of the long saphenous vein. (a) Only the common stem of the superficial iliac vein (sciv) and the anterolateral vein (alv) are ligated resulting in continued reflux down the thig and 'recurrent' varicose veins. (b) Correct procedure where all three veins are ligated.

Long saphenous vein

Long saphenous vein

Figure 15.19. Ligating branches of the long saphenous vein. (a) Only the common stem of the superficial iliac vein (sciv) and the anterolateral vein (alv) are ligated resulting in continued reflux down the thig and 'recurrent' varicose veins. (b) Correct procedure where all three veins are ligated.

indicates incompetence between the deep and superficial systems (i.e. short saphenous or perforator(s)). Release of the tourniquet will show whether there is reflux from above (i.e. sapheno-femoral or a perforator depending on the position of the tourniquet). Repeating this test by applying the tourniquet at different levels will give added information.

Hand-held Doppler assessment with the patient standing can diagnose reflux in the popliteal fossa or at the sapheno-femoral junction. Flow is augmented by manually squeezing the calf. Reflux is present if reverse flow of more than 1s is detected on releasing the calf. Popliteal fossa reflux may be in the deep veins or the sapheno-popliteal junction and requires confirmation with venous duplex imaging. This is also required for the pre-operative assessment of recurrent varicose veins, where there is any suggestion of deep venous thrombosis (DVT) now or in the past or if the distribution of veins is unusual.

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