What is Chronic Venous Insufficiency (Backup of Blood in the Leg Veins)?
Chronic venous disease (CVD) is a condition that primarily affects the veins in the legs, leading to symptoms like leg heaviness, swelling, tiny blood vessels appearing on the surface of the skin (telangiectasia), and enlarged, twisted veins (varicose veins). This condition is mainly caused by ongoing high pressure in the leg veins when standing or walking, and the inflammation that results from it. It’s believed that over 2.5 million people in the U.S. have CVD, and about one in five of these individuals end up developing venous ulcers, which are open sores on the skin.
CVD and venous ulcers can seriously impact a person’s life, making it hard for them to work or participate in social activities and significantly reducing their quality of life and financial security. In fact, about 2 million work days are lost to venous ulcers every year, and more than one in ten workers with venous ulcers are forced to retire earlier than planned.
Financially speaking, the cost of dealing with venous ulcers is quite high, hitting the health system hard. An estimated $1 billion is spent each year in the U.S. just on treating chronic wounds, which equates to $3 billion when you factor in the cost of caring for venous ulcers specifically.
What Causes Chronic Venous Insufficiency (Backup of Blood in the Leg Veins)?
The exact cause of chronic venous disease (CVD) is still unclear. However, it seems to have a link with certain genetic disorders, such as Klippel-Trenaunay and Parkes-Weber, which are known to result in CVD.
There are various risk factors linked with CVD, including:
* Age: The risk of getting CVD increases as you get older.
* Sex: It affects both men and women.
* Overweight: Being overweight puts extra pressure on your veins and can lead to CVD.
* Use of oral contraceptives: Certain birth control pills can increase the risk.
* Tobacco use: Smoking is a known risk factor for many vascular diseases.
* Pregnancy: Hormonal changes during pregnancy can lead to CVD.
* Family history of varicose veins: If varicose veins run in your family, you have a higher risk of developing CVD.
* History of deep vein thrombosis: Previous instances of deep vein blood clots increase your risk of CVD.
* History of thrombophlebitis: A prior history of vein inflammation due to a blood clot is also a risk factor.
* History of leg injuries: Past injuries to the leg can sometimes lead to CVD.
* Prolonged standing or sitting: Being in the same position for long periods puts pressure on the veins in your legs and increases the risk of CVD.
Risk Factors and Frequency for Chronic Venous Insufficiency (Backup of Blood in the Leg Veins)
- Chronic venous disease becomes more likely as people get older.
- Women are three times more likely than men to develop this condition.
- Research shows that every year, about 2.6% of women and 1.9% of men are diagnosed with this disease.
- Varicose veins, a type of chronic venous disease, are more common in developed and industrialized countries than in less developed ones.
Signs and Symptoms of Chronic Venous Insufficiency (Backup of Blood in the Leg Veins)
Chronic venous insufficiency (CVI) is a condition with several main symptoms including bulging veins (like small spider veins called telangiectasias, reticular veins, and larger twisted ones known as varicose veins), swelling in the leg, discomfort in the leg, and changes to the skin.
Varicose veins are large, twisted veins that often bulge above the skin’s surface and tend to increase in size as time goes on.
Cases of swelling are usually noted starting around the ankle and gradually move up the leg. It’s characterized by a soft, denting quality and typically does not affect the front part of the foot. Blockage in the veins located deeper within the leg can cause leg pain that feels better when resting.
There are also changes that can occur on the skin which include darkening of the skin due to iron depositing in the skin and a type of skin rash. There is also a thickening of the skin and the underlying fat called lipodermatosclerosis.
Venous ulcers, which are open sores, most often form above the inner ankle. Other risks include skin infections and inflammation of veins close to the skin’s surface.
The Clinical, Etiology, Anatomic, and Pathophysiology (or CEAP) system has been adopted worldwide to diagnose and treat CVI consistently. The revised venous clinical severity score is also used alongside the CEAP classification to accurately gauge the severity of CVI and it is particularly useful in monitoring how effective treatment is.
The CEAP classification is as follows:
- C0 – No signs of vein disease can be seen or felt
- C1 – Small, fine veins such as telangiectasias or reticular veins are present
- C2 – Varicose veins are present
- C3 – There is swelling in the leg
- C4a – Skin discoloration and/or eczema are present
- C4b – Thickening of the skin and/or thinning of tissue beneath the skin (lipodermatosclerosis and atrophy) present
- C5 – A healed venous ulcer is present
- C6 – There is an active venous ulcer
Etiologic Classification:
- Ec – Present from birth
- Ep – Developed on its own
- Es – Developed as a result of another disease
- En – Cause of vein disease not known
Anatomic Classification:
- As – Affects the superficial veins (closer to the skin)
- Ap – Affects the perforator veins (which connect the deep and superficial veins)
- Ad – Affects the deep veins (further beneath the skin)
- An – Location of vein disease not known
Pathophysiological Classification:
- Pr – Vein disease due to reflux (backward flow of blood)
- P0 – Vein disease due to blockage
- Pr/o – Vein disease due to both reflux and obstruction
- Pn – Cause of vein disease not known
Testing for Chronic Venous Insufficiency (Backup of Blood in the Leg Veins)
To correctly diagnose chronic venous disease (or issues with your veins), your doctor will usually start by asking you about your medical history. The doctor will then conduct a thorough examination, where they’ll look for visible signs such as enlarged veins that are easily spotted, like varicose veins or smaller ones like telangiectasia and reticular veins. The doctor will also check for other skin changes such as ulcers (open sores), changes in skin color, and signs of skin inflammation. A tourniquet test, which can be done at the bedside, can help determine if the vein problems are in the deep or superficial (near the skin surface) veins. A handheld device called a Doppler can also be used during this examination to further assess the situation.
Currently, the most commonly recommended way to diagnose chronic venous diseases is through venous duplex imaging. This method combines the use of ultrasound images of both the deep and superficial veins with assessing the blood flow direction in those veins.
An additional test called Air plethysmography (APG) can study different aspects of vein diseases like reflux (backflow of blood), obstruction (blockage), and muscle pump failure (loss of normal leg muscle action). It can give details about the overall function of your veins and help in deciding the right treatment for you.
In situations when the venous duplex does not provide clear results, APG can be helpful. If required, imaging tests like CT (Computed Tomography) scan and MR (Magnetic Resonance) venography can be used to assess for any abnormalities in the larger, deeper veins and nearby structures. These imaging tests are usually considered when surgical intervention might be needed.
Other non-invasive tests include Photoplethysmography, Strain gauge plethysmography, and Foot volumetry. However, in certain scenarios, invasive procedures may still be necessary. These may include contrast venography, which can help identify issues at the junction of the major veins in the thigh, intravascular ultrasound (an ultrasound done from inside the blood vessels), and ambulatory venous pressure measurements (measuring the pressure in the veins while walking). Even though this last test is the gold standard for understanding the disease’s impact, it’s seldom used due to its invasive nature and the availability of other less invasive alternatives.
Treatment Options for Chronic Venous Insufficiency (Backup of Blood in the Leg Veins)
Treatment options for Chronic Venous Insufficiency (CVI) often begin with conservative methods such as compression stockings. These special kinds of garments apply pressure to the lower legs, helping counteract the effects of high blood pressure in the veins. They are available in various forms, including elastic stockings, bandages, and adjustable wraps. When worn correctly, they can significantly reduce pain, swelling, and skin discoloration in most patients. They’re also helpful in healing and preventing the recurrence of ulcers.
Being overweight is a known risk factor for CVI, and maintaining a healthier weight can improve symptoms. Studies have shown that weight loss following weight loss surgery can lead to a reduction in symptoms like swelling and ulcers.
Advanced CVI can affect skin health, making it crucial to prevent infections. This often involves using moisturizers, often those containing lanolin, to minimize skin cracking and flaking. Topical steroids can be used for a particular skin condition called stasis dermatitis. If venous ulcers occur, thorough wound care is needed, which can include various dressings and biological skin replacements. However, the use of silver-impregnated dressings is up for debate.
Sclerotherapy is a treatment where a solution is injected into small to medium-sized varicose veins causing them to close up. It can be used alone or in combination with other treatments. Darkening of the skin around the treatment area is a common side effect, which can be reduced by a procedure called microthrombectomy or removing the blood clot.
Endovenous ablative therapy is a procedure where heat is used to damage the wall of the vein, causing it to close. This is often done using radiofrequency or laser energy, and is generally used as an alternative to vein stripping. It’s a safe and effective treatment for most patients. However, rare complications like deep vein thrombosis and pulmonary embolism can occur.
In cases where veins in the pelvis area are narrowed or blocked, a procedure called endovascular stenting may be used. This involves inserting a small mesh tube into the vein to keep it open. Although restenosis, or re-narrowing of the vein, can occur, it is relatively rare.
For those patients not responsive to any of these therapies, surgical treatment may be considered. The surgical options depend on the specific issues the patient is facing, but can include procedures such as ligation, stripping, and venous valve reconstruction. These surgeries aim to improve blood flow, reduce pain, and promote ulcer healing.
What else can Chronic Venous Insufficiency (Backup of Blood in the Leg Veins) be?
- Severe deep vein blood clot
- Heart failure
- Liver disease called cirrhosis
- Failure of kidneys to function properly
- Hormone-related conditions like underactive thyroid gland
- Side effects from certain medicines, like blood pressure medication (calcium channel blockers), anti-inflammatory drugs (NSAIDs), or diabetes medication (oral hypoglycemic agents)
- Lymphedema, a condition of swelling caused by blockage in the lymphatic system
- Lipedema, a fat disorder mostly occurring in women, leading to the enlargement of the legs and occasionally the arms
- Rupture of a popliteal cyst, a fluid-filled lump behind the knee
- Formation of a soft tissue hematoma or a mass, which is usually a result of blood accumulation outside of the blood vessels
- Exertional compartment syndrome, a painful and potentially severe condition caused by swelling in a muscle compartment
- Teardrop or ripped muscle in the calf (gastrocnemius tear)
Possible Complications When Diagnosed with Chronic Venous Insufficiency (Backup of Blood in the Leg Veins)
If chronic venous disease isn’t treated, it can lead to various complications:
- Chronic venous ulceration
- Deep vein thrombosis (clots in the deep veins)
- Recurrent cellulitis (skin infection)
- Lipodermatosclerosis (hardening of the skin and fat layers)
- Secondary lymphedema (swelling due to a blockage in the lymphatic system)
- Stasis dermatitis (skin inflammation due to poor blood circulation)
- Constant pain/discomfort
- Superficial thrombophlebitis (blood clots and inflammation in superficial veins)
- Secondary hemorrhage (unexpected bleeding)
- Atrophie blanche (white patches on skin due to loss of blood supply)
- Ankle joint stiffness from long-term scarring
Preventing Chronic Venous Insufficiency (Backup of Blood in the Leg Veins)
Patients should be taught how to use compression stockings properly and effectively. These stockings can help ease discomfort, reduce swelling, and prevent any further issues. They should also understand that it’s important they stick to using these stockings at the proper tightness level.
Compression stockings can also help with leg ulcers by helping them to heal and preventing them from coming back.
Patients also need to regularly inspect their skin for any signs of damage or infection. Applying a moisturizer regularly will help prevent the skin from cracking. It’s also advisable for patients to elevate their legs to reduce swelling. They should avoid standing or sitting for too long without breaks.
Maintaining a healthy weight is vital for patients. If there are barriers that make losing weight hard, such as mental health issues like depression or anxiety, eating disorders, medications that cause weight gain, or physical limitations like knee arthritis, these should be identified. Once identified, patients can be directed to the appropriate specialist or given further education on how to manage these issues.
Finally, it’s important that patients understand that chronic venous disease is a long-term health condition. Regular check-ups with healthcare professionals and following the recommended treatment plan are essential to prevent further complications.
