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Varicose Vein OSCE Examination Quiz

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A 24-year-old woman has prominent varicose veins in an unusual pattern over the outer calf. Listening over the largest varicose vein, you hear a continuous whooshing bruit. What best explains this finding?

A Vein valves that fail to close properly, letting blood flow backwards when she stands up
B A fresh clot blocking a deep vein and raising resistance to the outflow of blood
C Inflammation of a superficial vein causing local irritation and tenderness
D An abnormal artery-to-vein connection, letting high-pressure blood flow into the superficial veins ✓
E Long-standing lymphatic blockage causing protein-rich fluid to build up in the tissues

The answer is D: An abnormal artery-to-vein connection, letting high-pressure blood flow into the superficial veins

Explanation

Why D is correct

See Trendelenburg and Tourniquet Tests. Option D is correct. A bruit is a sound made by turbulent blood flow. Ordinary varicose veins are caused by weak valves and slow, low-pressure backward flow, which is silent. A continuous whoosh over a varicose vein therefore suggests that arterial blood is entering the vein through an arteriovenous fistula or malformation, an abnormal direct connection between an artery and a vein. This is more likely in a young person with varicose veins in an unusual pattern, such as the outer calf. A rare condition, Klippel-Trenaunay-Weber syndrome, includes congenital arteriovenous fistulas along with varicose veins and skin birthmarks. In an OSCE, listening over varicose veins for a bruit is a way to find this rare cause. Memory aid: a whoosh in a vein means artery blood has got in.

Bruit: a sound made by turbulent blood flow.
Ordinary varicose veins: silent, because the backward flow is slow and low pressure.
Cause of a bruit: arterial blood entering the vein through an arteriovenous fistula or malformation.
Rare syndrome: Klippel-Trenaunay-Weber syndrome includes congenital arteriovenous fistulas with varicose veins.

Why the other options are incorrect

A. Vein valves that fail to close properly, letting blood flow backwards when she stands up: This is the usual cause of primary varicose veins, but backward flow through failed valves is slow, low-pressure blood. It does not normally produce a bruit.
B. A fresh clot blocking a deep vein and raising resistance to the outflow of blood: A clot in a deep vein causes pain and swelling of the limb by blocking venous outflow. It does not make a whooshing sound over a superficial varicose vein.
C. Inflammation of a superficial vein causing local irritation and tenderness: Inflammation of a superficial vein (superficial thrombophlebitis) makes a vein hard, red and tender. It does not produce a continuous whooshing sound.
E. Long-standing lymphatic blockage causing protein-rich fluid to build up in the tissues: Lymphatic blockage causes lymphoedema, a firm swelling of the limb. It involves fluid in the tissues and has nothing to do with turbulent blood flow in a vein.

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More questions from this set. Start the quiz to answer them and see each explanation.

1
A 42-year-old woman is seen in a vascular clinic for troublesome varicose veins. You have noted varicose veins along the inner calf, mild skin discolouration at the ankle, and bedside tests suggesting leaky superficial veins. What is the best next investigation to confirm the underlying problem and guide treatment?
2
A 42-year-old woman has a soft, compressible swelling over the right saphenofemoral junction (where the great saphenous vein joins the deep vein in the groin) and varicose veins along the inner thigh. The swelling empties when she lies down and elevates the leg. When she stands again, you feel an impulse there as she coughs. What best explains this finding?

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