Troyanov-Trendelenburg test. With the patient in a horizontal position, the limb being examined is elevated to empty the superficial veins. A tourniquet is applied to the upper third of the thigh to compress the superficial veins (control of the correct application of the venous tourniquet is the pulsation of the peripheral arteries distal to the application site). The patient assumes a vertical position. Remove the tourniquet and visually determine the rate of filling of the superficial veins of the thigh. If the veins are filled with a retrograde wave of blood within 1-3 s, we can conclude that there is valvular insufficiency of the superficial veins.
Hackenbruch test. With the patient in an upright position, the fingers of the researcher’s hand are placed on the area of the saphenofemoral anastomosis of the limb under study (just below and medial to the middle of the Poupart’s ligament). The patient makes 2-3 cough shocks. If the valves of the superficial veins are incompetent, the doctor palpates the jerk-like movements of blood along the superficial veins.
Schwartz's test. With the patient in an upright position, the patient's left arm is placed on the superficial veins in the lower third of the thigh. With the right hand, the researcher causes jerky movements of blood in the retrograde direction when tapping the saphenous vein in the upper third of the thigh. With palpation of a retrograde blood wave, a conclusion is made about valvular insufficiency of the superficial veins.
Tests to detect insufficiency of communicating veins
Prett's test 2. With the patient in a horizontal position, the limb being examined is raised at an angle of 60° to empty the superficial veins. An elastic bandage is used to bandage the leg from the toes to the upper third of the thigh. After moving to a vertical position, the second bandage is used to bandage the leg from the groin fold in the distal direction. An interval of 10 cm wide is maintained between the bandages, for which the first bandage is gradually removed. If a varicose node appears between the bandages, this indicates the presence of an incompetent communicating vein in this place.
Modified Burrow-Shaneys test. With the patient in a horizontal position, the superficial veins are emptied by raising the limb being examined. Four venous tourniquets are applied: above the ankles, above and below the knee joint, in the upper third of the thigh. In an upright position, the patient lifts on his toes to contract the muscles of the limb being tested. The appearance of varicose nodes between the tourniquets indicates the presence of incompetent communicating veins in these places.
Tests to determine the functional state of deep veins and their patency
Delbe-Perthes marching test. With the patient in an upright position, a tourniquet is applied below the knee joint to compress the superficial veins. The patient walks quickly for 3-5 minutes. Emptying of the superficial veins indicates the usefulness of the valve apparatus of the deep veins and their good patency.
Prett's test. With the patient in a horizontal position, elastic banding of the limb being examined is performed. The patient is offered an hour of slow walking with a bandaged leg. The absence of bursting pain and swelling of the limb being examined indicates the passage of deep veins.
Surgical tactics. Patients with the initial stages of chronic venous insufficiency without pronounced varicose veins, trophic disorders and swelling of the extremities can undergo sclerotherapy on an outpatient basis.
Patients with varicose veins with a decompensated course of the disease are subject to complex surgical treatment, including venectomy on the thigh and leg, supra- or subfascial ligation of insufficient communicating veins.
Patients with recanalized forms of postthrombotic disease must undergo endoscopic dissection of the perforating veins of the leg and resection of the posterior tibial veins. In occlusive forms of the disease, bypass autovenous bypass operations are performed.
It should be emphasized that the treatment of chronic venous insufficiency is based on conservative therapy, which is carried out before, during and after surgical treatment.
Determining the patency and functional state of the deep veins is strictly mandatory not only when deciding on surgical treatment, but also in all cases of medical and labor examination and the appointment of treatment and preventive recommendations. The condition of the deep veins of the lower extremities can be assessed based on the following tests:
- The Delbe-Perthes test (marching test) is performed with the patient in an upright position. A rubber tourniquet or cuff from a device for measuring blood pressure is applied to the limb being examined in the middle third of the thigh, with figures not exceeding 60-80 mm Hg. The patient is asked to walk quickly or march in place for 5-10 minutes. If the tension of the saphenous veins decreases or they collapse completely, the deep veins are passable, the test is considered positive. If pain appears in the calf muscles and the saphenous veins do not empty, one should think about a violation of the anatomical usefulness of the deep veins. In these cases, it is advisable to use radiopaque venography. The Delbe-Perthes test is the most common, as it provides the most reliable information about the condition of the deep veins. The march test may not always be indicative in case of functional valvular insufficiency of the deep and communicating veins, occlusion of perforating veins, which is quite rare, as well as in obese people with pronounced subcutaneous fat and in inductive changes in soft tissues. In these cases, they resort to modifications of the Delbe-Perthes test: Mahorner and Ochsner test, Chervyakov test.
- The Mahorner-Ochsner test involves walking with tourniquets applied at different levels: in the upper, middle and lower third of the thigh. If the deep veins are passable and the communicating veins are healthy, then there is a decrease in tension, and sometimes a complete disappearance of varicose veins.
- The Chervyakov test is performed in those patients who do not have visible varicose veins. The calf circumference is measured at a certain level when it is raised (1st measurement), in a lowered position (2nd measurement) and after a 3-minute walk with a tourniquet (3rd measurement). The coincidence of 1 and 3 measurements indicates the patency of the deep veins.
- Ivanov's test. The patient is in a horizontal position. The limb being examined is slowly raised upward until the superficial veins are completely emptied. The angle formed by the raised limb and the plane of the couch is determined (the “compensation angle”), then the patient stands up and, after tightly filling the varicose dilated superficial veins, a rubber tourniquet is applied to the middle third of the thigh. The patient lies down on the couch again, the limb is quickly raised to the previously determined “compensation angle”, and the emptying of the veins is observed. If the veins quickly collapse, this indicates good patency of the deep veins. If the latter are obstructed, emptying of the superficial veins does not occur.
- Strelnikov's test ("cuff" method). A sphygmomanometer cuff is placed on the patient in an upright position on the thigh or lower leg (depending on the purpose of the study), the pressure in which is adjusted to 35-40 mm Hg. At the same time, the superficial veins swell. Then the patient is transferred to a horizontal position and if emptying of the superficial veins occurs, this indicates that the deep veins are passable. The last two tests differ from the Delbe-Perthes test in that they do not reflect the state of the perforating vein valves and the function of the deep vein valves.
- Mayo-Pratt test. The patient, who is in a horizontal position, is tightly bandaged with an elastic bandage from the fingers to the upper third of the thigh (or put on a rubber stocking). Then they suggest walking for 20-30 minutes. The absence of unpleasant subjective sensations indicates good patency of the deep veins. If, after a long walk, severe bursting pain appears in the lower leg area, then the patency of the deep venous system is impaired. The Mayo-Pratt test is based on the subjective sensations of the patient, so its result cannot be considered reliable.
- Lobelin test of Firth and Heichal. A limb with varicose veins is bandaged with an elastic bandage, eliminating the possibility of superficial blood circulation. Lobelia is injected into one of the veins of the foot (1 mg per 10 kg of weight). If within 45 sec. If a cough does not appear, the patient must take a few steps in place and again wait 45 seconds. If a cough does not appear, we can assume that the deep veins are obstructed. This is confirmed by the appearance of a cough after removing the elastic bandage in a horizontal position.
The principle of other medicinal methods is no different from lobeline. These methods are simple, but they are all very subjective, not accurate enough and very often cause side effects.
If the data from the performed functional tests turn out to be questionable or insufficiently reliable, and also indicate obstruction of the deep veins, it is necessary to resort to more objective, instrumental methods of examination. These include ultrasound Dopplerography, oscillography, plethysmography, capillaroscopy, rheovasography, skin thermometry, radioindication, electromyography, phlebotonometry, etc. X-ray contrast methods are carried out at the final stage of a comprehensive examination, when all other functional and instrumental methods fail to establish the patency of the deep veins and the condition valve apparatus.
M.Averyanov, S.Izmailov, G.Izmailov, M.Kydykin, Yu.Averyanov
Chronic diseases of the veins of the lower extremities,
Indicates valvular insufficiency in the veins. Lying on his back, the patient raises his leg up. Stroking from the foot to the groin helps empty the saphenous veins. Then they squeeze the large saphenous vein at the place where it flows into the femoral vein, without removing the finger, ask the patient to stand up. In healthy individuals, the saphenous veins are filled from the distal side. If it takes more than 2 seconds to fill the veins, then the test proceeds normally. If the vein fills quickly from below, or there is valvular insufficiency of the collateral veins, a Perthes test should be performed immediately. If, after removing the fingers, the veins fill from top to bottom, the test is considered positive.
Alekseev's test
Allows you to establish 3 degrees of venous valve insufficiency. First, the Brodie-Troyanov-Trepdelenburg test is checked. If it turns out to be positive, the patient is placed on his back, the limb being examined is raised up and asked to move the foot at the ankle joint (the venous system of the limb is emptied). Then a tourniquet is applied at the groin until the veins and arteries are compressed. After this, the patient stands up and lowers the limb into a special boot-shaped vessel filled with warm water, at the upper edge of which there is a water outlet tube. The displaced water is measured in milliliters. This volume of the limb is marked (U). Then quickly remove the tourniquet and wait 15 seconds. Blood flows down through the arteries and veins (with valvular insufficiency), the volume of the limb increases and displaces water, which is again measured in milliliters. This will be the total volume of arteriovenous inflow in 15 seconds (U 1). Next, only the arterial inflow (volume of capillary-venous filling) is determined in 15 seconds. For this, the patient is put back to bed. After the veins are emptied, a tourniquet is applied until the veins and arteries are compressed, a tonometer cuff is placed below it, and the pressure is set to 70 mm Hg. Art. (for compression of veins only). Then the patient stands up, lowers his leg into the vessel, and quickly removes the tourniquet. After 15 seconds, measure the volume of displaced water (U 2). Perform the calculation:
a) volume of retrograde venous filling:
U = U 1 - U 2 ml of blood in 15 seconds;
b) volume of retrograde venous filling rate:
S = (U 1 - U 2) / 15 ml/sec;
c) the volumes of people's limbs are always different. For accuracy, it is necessary to calculate 1000 cm of the limb being examined.
Determination of blood discharge from arteries into varicose veins
Determination of the discharge of blood from arteries into veins with varicose veins is carried out using the following functional tests:
1) determination of venous blood oxygen saturation. Blood is taken simultaneously from the cubital, varicose veins and femoral artery. If there is a discharge, the oxygen content in the cubital vein is 50-60%, in the varicose vein - 70-90% (almost reaches the level of arterial blood),
2) determination of venous pressure with the patient lying down. Normally, in this position, the pressure in the cubital veins is often equal to that in the varicose veins. When blood is discharged from the arteries, it is much greater, sometimes 2-5 times higher than the pressure in the cubital vein;
3) Pratt test with a syringe: when a varicose vein is punctured, scarlet blood enters the syringe under pressure, sometimes in a pulsating stream (wide anastomosis);
4) contrast venography in a standing position. In the presence of a discharge, a rapid release of the veins from the contrast mass is observed;
5) arteriography: in the case of wide anastomoses, it shows almost simultaneous filling of the artery and veins;
6) determination of the speed of blood flow through the veins; tests with radioactive isotopes, calcium chloride, lobeline - they make it possible to distinguish varicose veins arising from insufficiency of the vein valves (slowing blood flow) from varicose veins due to the discharge of blood from the arteries into the veins (accelerating blood flow). These substances are injected into a vein at the ankle while standing.
Firta-Khizhal lobeline test
In the supine position, an elastic bandage is applied to the superficial veins of the lower limb. In a standing position, a 1% solution of lobeline is injected into the dorsal vein of the foot at the rate of 1 mg per 1 kg of the patient’s weight and the time of cough onset is noted. The patient stands quietly for 45 seconds. If a cough does not appear, the patient is asked to take a few steps in place and again wait 45 seconds. If there is no cough, the patient is placed on his back and his leg is raised high.
Normally, with good patency of the deep veins, a response to the administration of lobeline appears in the first 45 seconds or immediately after the patient takes 2-3 steps. The appearance of a cough in a lying position with a raised leg indicates difficulty in outflow through the deep veins.
Delbe-Perthes marching test
In a standing position, a tourniquet is applied to the thigh, compressing only the superficial veins. Then the patient is asked to pass. If the valves of the collatars connecting the superficial veins with the deep ones are functioning and the deep veins are passable, then the stagnant veins are emptied.
Pratt sample
After measuring the circumference of the leg, the patient is placed on his back, and by stroking the veins along the course, they are emptied of blood. An elastic bandage is applied to the leg from the toes to reliably compress the saphenous veins. Then the patient is offered a 10-minute walk. The appearance of pain during this time indicates obstruction of the deep veins. An increase in calf circumference after walking with repeated measurements also indicates obstruction of the deep veins.
Kuyanova passive finger test
In a standing position, the trunk of the dilated great saphenous vein is compressed. Without removing the fingers, the patient is placed on the couch with his leg raised at an angle of 60-80°. When the deep veins are patted, the blood immediately completely leaves the dilated vein, along which a retraction groove is formed.
Kuyanova active finger test
In a standing position, the trunk of the great saphenous vein is compressed with the patient's finger. Then, standing on a healthy leg and leaning on some object, at the pace of a step, the patient performs 15-20 flexions and extensions in the knee joint of the affected leg. After the cessation of movements in cases of complete patency of the deep veins, the dilated saphenous vein becomes empty.
Ivan's test
The patient is standing on the couch. Wait until the varicose veins fill with blood. Then the patient is seated so that the legs do not change their vertical position. Despite the preserved vertical position of the lower leg, varicose veins will subside.
Orthostatic test
The patient rests in bed for 0.5-1 hour. His legs are bandaged from bottom to top with an elastic bandage. The pulse is counted repeatedly and blood pressure is measured, then the patient stands up, his pulse is counted again and the pressure is measured. After 5 minutes, the bandages are removed, as a result of which blood pressure decreases abruptly and the patient complains of dizziness. The test result allows you to decide whether it is necessary to wear elastic stockings.
Burrow-Shaneys three-strand test
The patient lies on his back and raises his leg. After the saphenous veins are emptied, 3 tourniquets are applied: near the inguinal fold, in the middle of the thigh and below the knee. The patient is asked to stand on his feet. Rapid swelling of the veins before the tourniquets are removed in any part of the limb indicates the presence of perforating veins with valve insufficiency in this part. Rapid filling of varicose veins on the lower leg indicates the presence of altered perforating veins below the tourniquet.
Talman sample
A tourniquet 2-3 m long made of a soft rubber tube is applied from the bottom up to the raised leg in a supine position. The distance between the turns of the tourniquet is 5-6 cm. The patient stands up. Appearing varicose nodes indicate the presence of perforating veins in this area. Then remove the tourniquet from bottom to top, marking new areas of perforating veins.
Myers test
At the knee level, the leg is covered by the examiner's hand, the fingertips are placed on the great saphenous vein and the latter is pressed against the inner surface of the femoral condyle. The fingertips of the other hand are located on the vein in the groin area or below the shin. After hitting the vein with the second hand, the first one feels the force of the blood flow. According to the author, using this test one can judge the caliber of the vessel and the condition of the vein valves.
Mayo test
In the supine position, a tourniquet is applied to the upper thigh, compressing only the saphenous veins, and then the leg is bandaged with a rubber bandage from the toes to the groin. If during long walking (0.5 hours or more) severe pain and thickening of the lower leg appear, then the deep veins are impassable.
Morner-Ochsner test
Essentially it is a modification of the Perthes test and consists of 3 tests: a tourniquet should be applied for the first time in the upper third of the thigh while walking; the second time - in the middle third of the thigh and the third time - in the lower third of the thigh. The tourniquet is also moved. It becomes possible to identify and localize communication veins with valve insufficiency, as well as determine the patency of deep veins.
Schwartz sample
The patient stands so that the varicose nodes are stretched as much as possible. The doctor places one “listening” hand on the upper end of the large saphenous vein, and with the finger of the other hand applies light pushes to the nodes below. The transmission of the push indicates valve insufficiency. determined by fingers placed on dilated veins.
Sicara symptom
The patient is asked to cough while standing. If the valves are insufficient, a wave is visible to the eye in the great saphenous vein.
Astrov's symptom
Serves as a differential diagnostic symptom between a femoral hernia and a varicose vein. After repositioning the node below it, the great saphenous vein is pressed. If it is a reducible femoral hernia, the node remains; if it is an aneurysmal node of the great saphenous vein, the node disappears and reappears after the pressure on the vein stops.
SYNDROMES
Cruvelier-Baumgarten syndrome
Sharp dilatation of the veins of the anterior abdominal wall, splenomegaly, moderate cirrhosis of the liver. A noise is heard in the navel area. The pain is localized not only in the feet and legs, but also often, which is very typical, in the hips, buttocks and lumbar region. A severe form of intermittent claudication often develops. Characteristics of the syndrome: ivory-colored skin of the limbs, lack of hair growth on the lower third of the thigh.
DISEASES
Pratt-Piulax-Vidal-Barraki disease
It is characterized by the discharge of arterial blood into the veins through arterial-venous anastomoses of a reticular nature. This is the main cause of varicose veins.
Parkes-Weber-Rubashov disease
The discharge of arterial blood into the veins through arterial-venous anastomoses of a larger caliber than in Pratt-Piulax-Vidal Barraki disease.
The advent of ultrasound duplex scanning has virtually completely replaced the performance of functional tests when varicose veins are suspected. The step test, three-strand test, cough test and Valsava test do not require complex equipment and are performed by a surgeon as part of a physical examination.
The essence of functional tests is to assess normal hemodynamics, which allows us to draw a conclusion about the location and source of the problem. Incompetent perforating veins lead to increased hydrodynamic pressure. Typically, emptying of the deep veins occurs under the action of the muscle pump of the lower leg. If the perforator valves are incompetent, the pressure created in the deep venous system is transferred to the superficial veins. All functional tests study the reaction of the venous system to load:
- the initial state is assessed visually;
- is compared with the result obtained after the test.
The data obtained allows you to quickly make a diagnosis and check the effectiveness of treatment.
Veins of the leg
Tests used for varicose veins divided into three categories, depending on the component of the venous system being tested:
- Heckenbruch-Sicard, Trendelenburg, Schwartz tests - determine the condition of surface pipeline valves.
- The Hackenbruch, Thalmann tests, the second from Pratt and the tourniquet test from Sheinis - evaluate the consistency of the perforating veins.
- Mayo-Pratt, Delbe-Perthes test - aimed at deep veins.
Each test, e.g. marching test, evaluates the reaction of superficial veins to various situations - compression, compression, physical activity.
Valsalva maneuver
The Valsalva maneuver is a special breathing technique that is used to diagnose disorders in the autonomic nervous system and restore normal heart rhythm. The technique is named by the 17th century Italian physician Antonia Maria Valsalva. You are supposed to exhale when your airway is blocked. A simplified version of the maneuver is used to balance pressure in the ears to relieve congestion.
Hemodynamics of the Valsalva maneuver
During forced exhalation with the glottis closed, intrathoracic pressure changes, affecting venous return, cardiac output, blood pressure and heart rate.
During the first phase of the Valsalva maneuver, intrathoracic (intrapleural) pressure becomes positive due to the compression of the thoracic organs when the chest is compressed. External compression of the heart, blood vessels and cardiac chambers increases, reducing transmural pressure on the walls. Venous compression is accompanied by an increase in right atrial pressure, which impedes venous return to the chest.
A decrease in venous return when the chambers of the heart are compressed reduces the preload against the background of significant pressure inside the chamber. According to the Frank-Starling law, cardiac output decreases. The aorta contracts and the pressure in the vessel increases. But in the second phase of the test, the aortic is reset due to a drop in cardiac output. Under the influence of baroreceptors, the heart rate changes: in the first phase it decreases due to an increase in pressure in the aorta, and in the second it increases.
When breathing is restored, aortic pressure decreases briefly as the force of external pressure disappears. The heart reflexively begins to beat faster - this is phase three. The pressure in the aorta increases, cardiac output increases and the pulse rate slows down again - phase four. Aortic pressure increases due to effects on baroreceptors due to increased vascular resistance.
Such changes always occur when a person tries to exhale with contracted abdominal muscles or reflexively holds his breath, strains when going to the toilet and lifts weights.
Using the test for varicose veins
The Valsava test is used in clinical medicine to assess venous return in varicoceles, abdominal hernias, and deep vein thrombosis. The test is used in addition to CT and MRI examinations.
With varicose veins, it is necessary to increase intrathoracic pressure in order to block the outflow of venous blood from the lower part of the body from the inferior vena cava. Straining reveals valve incompetence - blood reflux, which is recorded by an ultrasound sensor. Inhalation leads to a decrease in the outflow of venous blood, tension leads to a cessation, and exhalation leads to an increase in the rise of blood to the heart.
The diameter of the vessels during the Valsava maneuver increases by 50%, which, in case of valve insufficiency, increases the pressure and reveals the reverse flow of blood. If the valves are healthy, then the test is negative. The saphenous vein can be palpated in a similar manner. When a wave appears, a conclusion is made about the incompetence of the perforating or deep veins.
Using an ultrasound sensor, pathological reflux lasting more than 0.5 seconds is determined. The maneuver is used to evaluate the saphenofemoral junction, the proximal portion of the great saphenous and common femoral vein.
Varicocele. a — B-mode: dilatation of the veins of the pampiniform plexus. b — EC mode: pronounced dilation of the veins during the Valsalva maneuver.
Straining is not always possible. The test does not work if the tone of the abdominal muscles is weak, if you are overweight, or if there is no diaphragmatic breathing (cervical spine problem). The test is modified: with the sensor installed in place of the valve, forced exhalation is performed while the doctor presses on the abdominal wall.
Schwartz test
Schwartz test was described by a French surgeon in the second half of the 19th century. Helps assess the condition of the valves of the long and short saphenous veins. The patient is placed in a standing position so that the nodes are stretched. To perform the test, the fingers of the right hand are placed along the long saphenous vein in the proximal thigh, where it connects to the deep femoral vein. Then lightly tap the knots down the leg with the left hand. If the tremors are felt with the right hand, then valve insufficiency is detected.
The test can be done in another way: with the fingers of your right hand, press on the dilated veins in the proximal part of the thigh, and with your left hand, palpate the veins of the lower leg. If the impulse is transmitted and heard by the left hand with each press, this confirms the incompetence of the valves. If the valve were functioning normally, the shock would only be felt in the next valve, since the venous lumen is limited between them. Sometimes it is difficult to detect an enlarged vein in the upper thigh, so the test is not always suitable for patients who are overweight or have deep veins.
You can use the test version proposed by McKelling and Heyerdahl. Carry out jerk-like movements in the area of the oval fossa, and with the other hand listen to them above the shin.
The Schwartz test is not related to the formula of the same name associated with determining the volume of final urine - approximately 1.5 liters or 1 ml/minute. The rate of reabsorption in the tubules is assessed, at which up to 99% of the primary substance is absorbed back into the blood. The glomeruli filter up to 180 liters per day. GFR (glomerular filtration rate) or creatinine clearance is calculated using the Schwartz formula. Renal perfusion is impaired due to hyperaldosteronism and increased production of renin during hypoxia in newborns.
Delbe Perthes marching test
The Perthes test is a physical examination technique that involves applying a tourniquet over the proximal leg. The patient is placed on the couch so that the vessels are filled, and only the superficial veins are tightened. Therefore, the pressure should not be too strong. Then he is asked to walk for 5 minutes or do calf raises. The marching test involves activating the muscle pump to empty the superficial highways. When an obstruction (thrombosis or reflux) exists in the deep venous system, activation of the gastrocnemius pump causes paradoxical filling of the superficial venous system. To check the result, the patient is placed on his back and then his leg is elevated. If varicomas distal to the tourniquet do not disappear after a few seconds, deep vein exploration should be performed.
Delbe Perthes marching test
The Delbe-Perthes marching test is questioned by many experts, since it can give a false negative result when a tourniquet is applied both below and above the blockage site. A false positive result occurs when the perforating veins are obstructed.
Noso-finger test
Among the tests, the nasal-finger test is used in neurology and is a coordination test. It determines the pathology of the cerebellum and is not used for varicose veins. The test suggests touching the tip of your nose with your outstretched hand with your eyes closed.
Troyanov-Trendelenburg test
During examination, the surgeon notes dilated veins on the limb, then the Troyanov-Trendelenburg test is performed. The patient lies on his back and his leg is elevated 60 degrees. The doctor drains the varicose veins by stroking the leg from the distal to the proximal end. There is a tourniquet around the thigh. The patient is then asked to stand up.
Troyanov-Trendelenburg test
The results are compared after 30 seconds:
- Zero test - absence of rapid filling of the veins for 30 seconds with the tourniquet, and after its removal, the valves of the deep, perforating and superficial veins are competent.
- A positive test - the veins collapse only after the tourniquet is removed, which means that the valves in the superficial veins are incompetent.
- Double positive - the veins remain swollen both with the tourniquet and after its removal, which means that there is dysfunction of the valves of the deep and perforating vessels with reflux through the superficial vessels.
- A negative test - deep and perforating valve insufficiency is recorded if within 30 seconds the vein quickly fills with blood, and after removing the tourniquet there is no increase in filling. However, filling after 30 seconds of tourniquet placement does not indicate competence of the perforating vessels.
The more deficient the superficial veins, the faster they fill with blood during the tourniquet test. The rate of decline and enlargement of subcutaneous vessels is assessed.
Pratt test
There are several sample options. The simplest of them is that the patient, lying on his back, bends his leg at the knee, grasping the lower leg with both hands and pressing the popliteal vein in the proximal part. The appearance of pain indicates deep vein thrombosis.
The second version of the Mayo-Pratt test is performed when the arteries are well patency, if the pulse in the foot is palpable. The patient lies on his back, lifts his leg, draining the veins. A bandage is applied near the inguinal fold, squeezing the superficial vessels. The patient walks with fixation for 30–40 minutes. If pain appears in the calf area, an obstruction is diagnosed.
The third version of the test - Pratt-2 - is also carried out in a lying position. The veins are emptied by raising the leg. An elastic bandage is applied from the foot to the inguinal fold of the leg, then the tourniquet is tightened.
The patient gets up. The doctor wraps another bandage immediately under the tourniquet, and unties the second one. The bandages replace each other up to the distal part of the lower leg. The gap between them reaches 5–6 cm to see changes in varicose nodes. When they are filled, the incompetence of the valves of the perforating veins is recorded.
Pratt test
Hackenbruch test
The Hackenbruch-Sicart test, or cough test, involves the activity of the diaphragm, the relaxation of which is intended to enhance venous outflow. The doctor places his hand on the saphenofemoral junction, where the great saphenous vein ends. The patient is asked to cough several times so that the doctor listens for the appearance of a pulsation. Increased intra-abdominal pressure affects the inferior vena cava. If a push occurs under the fingers, this indicates insufficiency of the valve connecting the great saphenous and deep femoral veins - the ostial.
Hackenbruch test
Sheinis test
The three-strand test, called the Sheinis test, is performed in the supine position. The condition of perforating veins, which provide outflow from superficial vessels to deep ones, is studied. Three tourniquets are used, which are applied at the inguinal fold, at the level of the mid-thigh and under the knee. The patient is asked to rise to his feet. If the veins swell below the applied tourniquet or above the one that is removed one by one starting from the bottom, then this indicates insufficiency of the valves in a particular area.
Sheinis test
Alekseev's test
The first version of the Alekseev-Bogdasaryan test using a vessel in the shape of a boot was proposed back in 1966. The container, equipped with a tap at the top, is filled with water at a temperature of no higher than 34 degrees. First, the patient is laid down and asked to elevate his legs to clear the veins of blood. Then a tourniquet or bandage is applied at the level of the inguinal fold. The patient places his foot into the vessel, which causes the weight to displace water. The volume of liquid flowing through the tap is measured using a nearby vessel with divisions. The doctor removes the tourniquet, allowing blood to fill the veins, which increases the volume of the lower leg. A little more liquid flows out of the vessel over 15 seconds. The method allows you to evaluate arterial-venous inflow. After 20 minutes, repeat a similar procedure, applying a tonometer cuff with a pressure of 70 mm Hg under the tourniquet. In the same 15 seconds, arterial inflow is determined. The difference between the two measurements is called retrograde venous filling volume. The filling rate is calculated by dividing the volume by 15 seconds. Next, determine the degree of valve insufficiency using the table:
- the first - with a volume of 11–30 ml and a speed of 0.7–2 ml/sec;
- the second - 30–90 ml and 2–5 ml/sec;
- third - more than 90 ml and above 6 ml/sec.
Important! Alekseev's test is performed only after a positive Troyanov-Trepdelenburg test.
Another version of Alekseev's test begins with measuring body temperature between the big and index toes. The patient then walks. If pain does not occur, then walking continues until a distance of 2000 meters is covered. Typically, in patients with thrombosis, the calves begin to hurt after 300–500 meters. Re-measurement is performed:
- an increase in temperature of 1.8–1.9 degrees indicates health;
- a decrease in temperature by 1–2 degrees indicates a circulatory disorder.
This version of the test determines the consistency of collateral blood supply during thrombosis.
Firta-Khizhal lobeline test
The lobeline test involves injecting an alkaloid (lobeline hydrochloride) into a vein in the foot. The substance affects the N-choline receptors of the carotid glomeruli, causing stimulation of the respiratory center. The leg is first wrapped in an elastic bandage, blocking the flow of blood through the superficial veins. The substance is administered at the rate of 1 mg per 10 kg of patient weight. If the drug does not produce a cough after 45 seconds, the patient is asked to walk and wait again for 45 seconds. Veins are considered obstructed if loberine does not rise to the vessels of the heart. If a cough appears in a lying position after removing the bandages, the diagnosis is confirmed.
The patient stands, the doctor compresses the dilated great saphenous vein. Without unclenching his fingers, he asks the patient to lie on the couch with his leg raised 60–80 degrees. If the deep veins are impassable, then blood quickly releases the saphenous vein. A furrow appears, as if from indentation of the skin.
The patient lies on his back, with the leg raised to free the superficial veins. The doctor determines the angle of compensation that is formed between the surface of the couch and the raised leg. The patient is asked to stand up and wait until the veins are filled with blood. Then the middle third of the thigh is bandaged with a tourniquet. The patient lies down on the couch again and raises his leg to the compensation angle. The veins begin to open up. If they subside quickly, then the patency of deep vessels is good. If the patency is impaired, the veins remain swollen.
Other tests for diagnosing varicose veins
There are other modifications of samples. The Myers test involves grasping and pressing the great saphenous vein against the medial femoral condyle with one hand. At the same time, the second hand is either at the level of the inguinal fold or on the lower leg. A blow is made to the veins located above and below. The strength of the blood flow determines the condition of the valves and the mouth of blood vessels. The dynamic Mayo test involves applying a tourniquet at the groin level and bandaging the leg to the foot. When walking for 30 minutes, pain that appears indicates vascular obstruction. The Morner-Ochsner test also involves applying three tourniquets while walking, but in different locations: at the top of the thigh, in the middle and at the bottom. This way you can clarify the area with incompetent perforating and deep veins.
However, the main diagnostic method includes duplex ultrasound scanning, the use of contrast agents and color mapping to determine venous reflux, thrombosis and varicose veins.
Expert opinion
Especially for the readers of our portal, we asked Dr. phlebologist Kirill Mikhailovich Samokhin from the Center for Innovative Phlebology to comment and talk about functional tests and ultrasound examinations for varicose veins:
Varicose veins are an insidious disease, the first symptoms of which the patient may not notice or attribute to current circumstances. It is extremely important not to miss its initial stage. Diagnosis of the condition of the veins, carried out at the right time, reduces the risk of blood clots, prevents the occurrence of venous ulcers, and prevents.
The severity of the disease is not always proportionally related to visual manifestations, therefore the stage of varicose veins and treatment tactics will be determined after diagnostic procedures.
Attention! Under the compulsory medical insurance policy, in the clinic you can undergo a free ultrasound diagnosis of the veins of the lower extremities and get a consultation with a phlebologist.
Survey plan
Each human body is individual, and this is where the difficulties in diagnosing varicose veins lie. The same manifestations may be normal in one person, but a symptom of a disease in another. Diagnosis of the condition of the veins is a set of measures involving several stages:
- consultation with a phlebologist;
- delivery of analyzes and functional tests;
- computer diagnostics of blood vessels.
To make an accurate diagnosis, you need to go through all the stages to the end.
Examination by a phlebologist
Symptoms that indicate the need to visit a doctor:
- Leg pain when walking or playing sports.
- Blood pressure is elevated for any reason.
- A history of varicose veins, thrombosis, diabetes mellitus.
- , swelling and heaviness in the legs.
- If your feet are cold even at normal ambient temperatures.
An appointment with a phlebologist begins with an oral conversation. The doctor will ask you to talk about your complaints, specify the date of onset of the first symptoms of the disease, and collect anamnesis.
Next, a visual inspection is carried out in both horizontal and vertical positions. The doctor will examine and palpate the legs, groin area, pelvis, and abdomen. Attention is drawn to swelling, protrusion of the saphenous veins, and the color of the skin. Afterwards, the doctor issues directions for ultrasound examinations and tests.
Functional tests
To determine the patency of the veins and the conditions of the venous valves, special tests are used.
The condition of the valves of the superficial veins is determined by:
- Troyanov-Trendelenburg test. The patient is asked to take a horizontal position and raise his legs up. A rubber tourniquet is applied to the upper thigh, after which the patient stands up. If blood quickly fills the veins, this indicates a problem with the valves.
- Hackenbruch test(cough test). The doctor places his fingers at the junction of the femoral vein with the great saphenous vein and asks the patient to cough. If the valves fail, your fingers will feel a jolt.
The condition of the valves of the communicating veins is determined by:
- Three-strand test (Sheinis). The patient lies down on the couch and raises the lower part of the body 45 degrees, the doctor applies 3 tourniquets to his legs. One under the knee joint, the rest on the upper and middle part of the thigh. Next, the patient is asked to stand up and walk around. Rapid filling of the veins indicates a problem with the valves.
- Pratt-2 sample. The patient takes a horizontal position, the doctor wraps the leg with a rubber bandage in the direction from the foot to the thigh, and a tourniquet is applied under the groin. The patient stands up, and another rubber bandage begins to be applied under the tourniquet. The lower bandage is gradually removed, and the upper one is wound so that there is a gap of 5-6 centimeters between the turns. The doctor controls the filling of the veins in areas free from bandages: rapid filling of the vessels indicates pathology.
- Talman test– modified three-strand test. The difference is that 1 tourniquet is used instead of 3, which is applied from the foot to the thigh with a distance between turns of 5-6 centimeters.
The patency of the deep veins is determined by:
- Delbe-Perthes marching test. The patient stands, a tourniquet is applied to his legs, compressing only the superficial vessels. The patient walks for 5-10 minutes. The condition of the deep veins is judged by the distribution of blood: if it goes from the saphenous veins to the deep ones, it is considered that the patency of the latter is normal.
- Pratt-1 test. Marks are placed on the calf muscle with a marker, which is used to measure the circumference of the lower leg. Then, in a lying position, an elastic bandage is wrapped around the raised leg, after which the patient walks for 10-15 minutes. Problems with deep veins are indicated by an increase in the diameter of the lower leg and the occurrence of pain in the leg.
The functionality of the valves of the venous system determines Valsalva maneuver. The patient lies down and exhales air into a special tube connected to a pressure gauge for 15 seconds. The test helps determine an increase in the diameter of the veins and the presence of reflux.
Modern medicine has made a step forward in computer diagnostics of vascular diseases. Using ultrasound, you can monitor the condition of the veins in real time and see the picture of blood circulation on the monitor. Without ultrasound, it is impossible to establish an accurate primary diagnosis and select successful treatment tactics.
Examinations with ultrasound machines follow one principle: for better contact of the sensor with the patient’s skin, a conductive gel is applied to the legs. Information about the state of the vascular system is transmitted to the computer and displayed on the monitor. Ultrasound diagnostics can be performed in a clinic without hospitalization.
Doppler (USDG, vascular ultrasound)
One of the most common methods for diagnosing vein disease today. Using an ultrasound wave and a special device (Doppler ultrasound), a two-dimensional picture of blood movement through the veins is observed.
Allows you to quickly assess the patency of veins (superficial and deep), the functioning of venous valves, and the speed of blood circulation. Doppler ultrasound is a simple, harmless, relatively inexpensive procedure with high diagnostic accuracy.
Duplex (UZDS, CDS)
(USD) is considered the “gold” standard for diagnosing varicose veins of the lower extremities. Ultrasound scanning combines two technologies – Dopplerography and real-time scanning of veins.
Duplex scanning makes it possible to analyze the performance of blood vessels, see areas of narrowing (dilation) of veins, and determine the presence of atherosclerotic plaques and blood clots.
Triplex (CDK)
For triplex scanning, the device operates in 3 modes. Traditional and duplex modes are complemented by color Doppler.
With the help of color flow, you can simulate a three-dimensional picture of the condition of the veins in color mode (patency, the presence of narrowings and dilations, the presence of blood clots), the structure of the walls of blood vessels, the speed of blood flow, and anomalies in the development of veins. Even with mild symptoms, this method detects pathologies in the early stages.
Phlebography (angiography)
In some cases, ultrasound diagnostics are not able to provide a comprehensive answer, so an x-ray method is used - angiography. This is an invasive technique in which a contrast agent is injected into the vessel through a catheter, and then observed on an X-ray machine.
Angiography is divided into 3 types: arteriography for the study of arteries, phlebography for veins and lymphography for vessels of the lymphatic bed. The research process and preparation for it are the same in all cases. The difference lies in the puncture site and the contrast injected.
Phlebography makes it possible to diagnose and determine abnormalities in the development of blood vessels. It is not used as a screening test for a number of reasons:
The patient should prepare for the x-ray examination.
- 4 hours before the procedure, stop eating and drink only water.
- Before the study, take tests to determine the degree of blood clotting and allergies to iodine.
After the administration of contrast and during the procedure, the patient may experience discomfort. There is a possibility of side effects from the injection of a contrast agent: nausea, itching, difficulty breathing.