Chronic Venous Insufficiency - Venous Reflux Los Angeles
Chronic venous insufficiency (CVI)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, disfiguring and life altering conditions. Venous insufficiency is quite common – about 15 percent of the adult population will be affected sometime in life. It occurs more frequently in people over age 50, and is somewhat more common in women than in men. Risk factors for venous insufficiency include: family history, obesity, pregnancy, prolonged standing, trauma, surgery, medications, and lifestyle.
Varicose and spider veins visible on the surface of the skin are often similar to the tip of an iceberg—there is quite a bit underneath the skin that the naked eye cannot see. Diseased veins that feed into the visible varicose veins are often hidden deeper in the fat layer under the skin. Ultrasound imaging allows a vein doctor 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 and varicose veins.
Superficial venous reflux is by far the most common cause of venous disease or CVI. It refers to the condition where blood reverses flow from its normal flow path towards the heart and flows in a retrograde direction in the superficial veins, down into an already congested leg and other regions of the body. Venous reflux occurs when incompetent or defective one-way 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 sequentially fail, causing the blood to flow backwards and pool in the lower leg, further increasing venous pressure.
Blood flow in healthy veins vs flow in dilated veins with incompetent valves.
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 varicose vein treatment with either Venefit (VNUS Closure) or Endovenous Laser Therapy (EVLT).
It should be pointed out that having varicose veins does not always 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, untreated venous insufficiency is a progressive condition and invariably will cause more symptoms over time, like restless legs at night, leg cramps, heaviness, numbness, itching and pain in the legs, and may progress into 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 bulging veins large enough and close enough to the surface of the skin that an accidental minor trauma may lead to bleeding points, often no larger than a pinhole. 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. Although sclerotherapy may be helpful in some of these cases, a diagnostic venous ultrasound exam will often be needed first to determine the underlying cause of the bleeding.
Venous pigmentation, also known as Hemosiderin staining of the skin is a relatively common late complication of untreated superficial venous insufficiency or venous reflux resulting in chronic venous hypertension. The buildup of venous pressure in the superficial, dilated veins leads to leakage of red blood cells from the capillaries into the surrounding tissues under the skin. Over time, the breakdown of the hemoglobin content of the red blood cells in these tissues leads to the accumulation of Hemosiderin, resulting in long term and potentially permanent brown pigmentation of the overlying skin. This condition is unfortunately difficult to treat and typically does not resolve even when the underlying venous congestion is adequately treated. Possible treatment modalities that have been reported to be helpful include intense pulsed light (IPL) and tattoo removal lasers.
VENOUS PIGMENTATION OR HEMOSIDERIN STAINING
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 therapy, 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 – RIGHT ANKLE SWELLING AND REDNESS
In advanced cases, the skin may ooze, crust, crack, and become scaly and hard. It may sometimes progress into 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 achieved by treating the underlying venous reflux as well as the resultant skin irritation. 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 adequately treated.
Venous Stasis Ulcers
The formation of open large ulcers, known as venous stasis ulcers, is the most serious complication of untreated superficial venous insufficiency and chronic venous congestion. These chronic non-healing ulcers typically occur 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, foam sclerotherapy, or the SEPS procedure 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 dramatically reduce the risk of ulcer recurrence, which can be as high as 30% without treating the underlying venous congestion.
Superficial Venous Thrombosis and Thrombophlebitis
Superficial venous thrombosis refers to the formation of a blood clot, or thrombus, in the superficial venous system just under 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, tender or swollen due to inflammation (phlebitis). The most commonly encountered causes for superficial venous thrombosis include the infusion of irritating intravenous fluids into the vein, local trauma or injury to a vein, blood stagnation in dilated varicosities, complication from a medical procedure, an inherited tendency for blood clotting, pregnancy, and use of certain types of contraceptives.
Typically, thrombophlebitis occurs in the legs but may also occur in the arms. Thrombophlebitis may cause severe pain within the vein. 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. Measures that halt the progression of this condition and relieve its symptoms may include application of warm and moist heat to the area, elevation of the extremity, compression stockings, and the use of non-steroidal anti-inflammatory drugs (NSAID), such as Ibuprofen. However, if you are diagnosed to have superficial phlebitis and you notice that your symptoms are getting worse, or the inflamed section of the vein is moving up the leg, the clot may be progressing towards the deep venous system and you should seek immediate medical care. Ultrasound should be performed to rule out involvement of the upper saphenous vein in the thigh, 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 or partial occlusion of one or more of the major deep leg veins results in significant leg swelling and tenderness of the leg muscles. 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. One of the most important factors that predispose people to DVT include conditions that result in sluggishness of blood flow, such as prolonged bed rest and immobility, pregnancy, and obesity. Another important factor is the hyperactivity of the clotting mechanism in conditions such as the trauma of surgery, direct injury to veins, contraceptive use, family history of DVT, previous DVT history, and occult cancer. 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 sequential compression devices for the legs 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.
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.