Vein Disease - Chronic Venous Disorder (CVD) - Venous Reflux

Vein Disease - Sometimes the Source of Serious and Life-threatening Complications.

Vein Disease and Venous Reflux

Vein disease or chronic venous disorder (CVD) is a medical condition whose spectrum ranges from visually apparent abnormalities, such as varicose veins and spider veins, with or without associated symptoms, to severe and life-threatening conditions. Venous disease is quite common - about 15 percent of the adult population is affected. It occurs more frequently in people over age 50, and is somewhat more common in women than in men. Risk factors for venous disease include: family history, obesity, pregnancy, prolonged standing, trauma, surgery, medications, and lifestyle.

Varicose and spider veins visible on the surface of the skin are usually the tip of the iceberg. Diseased veins that feed into the visible varicose veins often lie hidden deeper in the skin. Ultrasound imaging allows a physician to see the entire network of diseased veins. Finding the root source of visible varicose veins is imperative for the effective treatment of venous disease.

Venous insufficiency or venous reflux is by far the most common cause of venous disease. It refers to the condition where blood escapes from its normal flow path towards the heart and flows in a retrograde direction in the veins, down into an already congested leg and other regions of the body. Venous insufficiency or venous reflux occurs when incompetent or defective vein valves fail to promote the normal return of blood to the heart against the pull of gravity, leading to congestion in the veins of the lower legs (venous hypertension). Physical inactivity often contributes to the problem; when we walk around, the muscle activity in our calves and thighs squeeze the deep veins and facilitate the return of deoxygenated blood to the heart. During long periods of sitting, this mechanism is inactive and the venous pressure in the lower leg increases. Over time, the vein walls may begin to 'give in' and stretch out due to the sustained pressure, and the one-way valves in these veins begin to fail, causing the blood to flow backwards and pool in the lower leg, further increasing venous pressure.

Venous insufficiency often starts at the major drainage points where the main superficial veins empty the venous blood into the deep veins. At these points, genetically weak valves are susceptible to giving in to the high pressure and high flow conditions that exist in the deep veins and allow the blood to flow in the reverse direction. Once a section of these main (truncal) veins fail and dilate, valves further down the vein will often sequentially fail from the accumulating pressure to eventually form unsightly veins and sometimes lead to more serious conditions. Fortunately these complications can now be prevented by means of safe and minimally invasive procedures that are performed in a doctor's office. They include spider vein removal with sclerotherapy, bulging vein removal with foam sclerotherapy, varicose vein treatment with either VNUS Closure or EVLT, or laser vein treatment.

It should be pointed out that having varicose veins does not necessarily mean that you have venous reflux, and the presence of reflux does not mean that you will inevitably get the complications associated with it. However, If not treated, venous insufficiency can sometimes cause restless legs at night, leg cramps, hardening of the tissues above the ankle, heaviness and pain in the legs, and may progress to a number of more serious and less common complications that are described below.

Bleeding from Superficial Veins

Some patients with long-standing high pressure in the veins may develop an area that bleeds through small sites, no larger than pinholes. Most of these occur around the ankle, but spontaneous bleeding can also occur anywhere there is high venous pressure. Bleeding from a superficial vein can be quite dramatic at times. If this occurs, the patient should immediately elevate the leg. This will relieve the pressure and stop the bleeding. Pressure should then be applied and medical attention sought, so that the bleeding veins are closed with sclerotherapy. Further diagnostic tests with ultrasound can often determine the cause of the bleeding.

Edema or Leg Swelling

Edema refers to increase in volume of fluid in subcutaneous tissue characterized by leg swelling, which indents with pressure. Edema usually occurs in the ankle region, but may extend to the foot and leg. If the source of the swelling is from fluid retention from diet, heart or kidney problems, the swelling tends to be equal in both legs. Unequal swelling of the legs; on the other hand, can be caused by vein disease (venous edema) or lymphatic disease. A comprehensive physical examination and testing will be required to make the diagnosis. Depending on the cause, leg swelling can be managed with medications, compression, massage, or varicose vein treatment.

Venous Stasis Dermatitis

Venous stasis dermatitis, also known as venous eczema, is a common inflammatory skin disease that occurs on the lower extremities in patients with severe chronic venous congestion. It can arise as discrete patches or affect the leg all the way around the ankle. Symptoms of this condition include swelling (typically concentrated around the legs or ankles), changes in skin color and texture, and pain. The affected skin is itchy, and assumes red, purple, or brown colors.

STASIS DERMATITIS - ANKLE SWELLING AND PURPLE SKIN

STASIS DERMATITIS - BROWN DISCOLORATION OF THE SKIN

In advanced cases, the skin may ooze, crust, crack, and become scaly and hard. It may sometimes progress into venous ulcers or a condition known as Lipodermatosclerosis, whereby fat under the skin is destroyed, and the lower legs shrink to take the shape of inverted Coke bottles.

ADVANCED VENOUS STASIS DERMATITIS - LIPODERMATOSCLEROSIS

Venous stasis dermatitis is thought to develop due to poor transfer of nutrients and oxygen to the tissues secondary to impaired circulation and chronic blood stagnation. Leakage of blood constituents into the surrounding tissues and activation of inflammatory cells and fibroblasts is broadly responsible for the swelling and other observed changes.

Venous stasis dermatitis treatment is usually performed in two phases: treating the irritation, and treating the varicose veins that originally caused the condition. Medications, compression stocking, and diuretics may also be prescribed. These promote better blood circulation and assist in removing excess liquid.

It should be emphasized that stasis dermatitis will usually recur, unless the underlying veins and venous reflux are treated. Stasis pigmentation; on the other hand, is notoriously difficult to treat and typically does not resolve even when the underlying stasis dermatitis is well controlled with topical and vein therapy. Possible treatment modalities that have been reported to be helpful include intense pulsed light (IPL) and tattoo removal lasers.

Venous Stasis Ulcers

Open large ulcers, known as venous stasis ulcers, are a form of chronic non-healing ulcers in lower legs and ankle region. Although most leg ulcers are caused by severe venous congestion, some may be caused by poor flow in the arteries leading to the foot. Venous ulcers typically occur within areas of dark, reddish-brown skin, sometimes with partial skin loss, and may release yellow or greenish drainage. The skin surrounding the ulcer is commonly inflamed, darker, occasionally with white scar tissue, and may be firm to the touch, or itches. Diagnostic testing will help determine the particular origin of the ulcer.

VENOUS STASIS ULCER

Venous ulcers do not heal without treatment, and tend to be chronic, with frequent relapses. Although these ulcers could be managed or even heal with local wound care (by keeping the wound clean and dry), compression therapy, elevating the legs, and antibiotics; treatment of the underlying venous disease, is essential to prevent a recurrence. In severe cases, the damaged skin is replaced with a skin graft. Effective vein treatments for venous ulcers include Endovenous Ablation, or foam sclerotherapy, depending on the venous abnormalities that are causing the ulcer. Often the ulcer will heal within weeks of treatment. Treatment of the underlying venous disease has proven to reduce the risk of ulcer recurrence, which can be as high as 30% without vein treatment.

Superficial Venous Thrombosis and Thrombophlebitis

Superficial venous thrombosis is a blood clot, or thrombus, which develops in a vein close to the surface of the skin. The blood clot commonly appears as a red streak along the course of an affected vein, which may feel warm and tender or swollen due to inflammation (thrombophlebitis). The most commonly encountered causes for blood clots include cancer, prolonged immobility, complication from a medical procedure, local trauma, Injury to a vein, an inherited tendency for blood clotting, pregnancy, contraceptive use, or the infusion of irritating intravenous fluids into the vein.

Typically, thrombophlebitis occurs in the legs but may also occur in an arm. Thrombophlebitis may sometimes cause severe pain within the vein. This responds readily to therapy with warm, moist heat applied to the area, elevation of the extremity, and to non-steroidal anti-inflammatory drugs (NSAID), such as Ibuprofen. In some cases, more serious conditions can arise, needing treatment with a blood-thinning medication.

Superficial thrombophlebitis is rarely life-threatening; these clots do not break loose and travel to the lungs, unless they move from the superficial system into the deep venous system first. However, if you are diagnosed to have superficial phlebitis and you notice that your symptoms are getting worse, or the clot is progressing up the leg, you should seek immediate medical care. Ultrasound should be performed to rule out involvement of the Saphenous veins, or the deep venous system.

Deep Vein Thrombosis

Deep vein thrombosis (DVT) occurs when a blood clot forms in the deep veins of the body - usually in the leg. Total occlusion of one or more of the major leg veins and the impaired blood return to the heart results in massive leg swelling. Occasionally the clot, or a portion of the clot, can break loose and travel to the heart and lungs, resulting in a potentially life-threatening fatal condition, known as pulmonary embolism.

DVT occurs in over 2.5 million people annually, resulting in 200,000 deaths from pulmonary embolism. Conditions that cause the blood flow in the veins to become sluggish increase the risk of clot formation. These risk factors include prolonged bed rest, surgical procedures, pregnancy, obesity, injury to the veins, prior episodes of DVT, or a family history of DVT. Because DVT can exist without causing symptoms, patients undergoing high-risk surgery, or those who have prolonged illness, bed rest, or trauma, will be prescribed anticoagulant or blood thinning medications to prevent clot formation.

The diagnosis of DVT is most commonly made with ultrasound. Ultrasound is very reliable for discovering blood clots at or above the knee, the location most likely to send off an embolism. Signs and symptoms suggestive of DVT include: sudden one sided painful swelling of an extremity; presence of tenderness to touch in the muscles of the leg; low-grade fever; and possibly chest pain and shortness of breath. Patients experiencing these symptoms must seek immediate medical care. Deep vein thrombosis can often be treated in a hospital with a minimally invasive, catheter-directed procedure that infuses "clot dissolving" medication into the veins. Treatment may also involve the use of anticoagulants and prescription grade compression stockings. Frequent leg elevation and lifelong therapy with elastic stockings may be indicated in order to prevent or treat a major DVT complication.

Pelvic Congestion Syndrome

Pelvic congestion syndrome (PCS), a condition characterized by the presence of varicose veins in the ovarian and pelvic region, has been shown to be the underlying reason in a significant proportion of women with chronic pelvic pain. These women usually are between the ages of 20 - 45 and have a history of multiple pregnancies. The varicose veins usually develop during pregnancy and become larger as time progresses. These women may or may not have leg varicose veins. The pain felt by patients with PCS is usually dull and aching, intensifies with prolonged standing, and worsens throughout the day.

The diagnosis of Pelvic Congestion Syndrome is often difficult as many other conditions can mimic the same symptoms. Symptoms of Pelvic Congestion Syndrome include: varicose veins (vulva, buttocks and legs), swollen vulva / vagina, abnormal and painful menstrual bleeding, pain during intercourse, backache, and vaginal discharge. Specific diagnosis of Pelvic Congestion Syndrome is made using several imaging tests, such as Ultrasound, CT Scan, MRI, or vonography (an imaging technique using X-ray and contact dye). Currently, a minimally invasive technique with no downtime, known as embolization, may be helpful in some cases of PCS. If you have pelvic pain that worsens throughout the day or when standing, you should see an interventional radiologist, who can work with your gynecologist to plan an appropriate treatment modality.

Conclusion

Venous disease can be sudden and serious or chronic and long-term. A phlebologist or vascular surgeon can advise you on the appropriate medical treatment and surgical options that are best for you.