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Symptoms of Chronic Venous Disease of the Lower Extremities

Symptoms of Chronic Venous Reflux are usually progressive and can be tolerated by the patient for many years due to its gradual onset until chronic skin changes such as cellulitis or ulceration sets in.

• Aching and throbbing leg pain
• Heavy and tired legs
• Skin surface Telangiectasias and Spider veins
• Dark pigmentation above the ankle and lower legs
• Leg and ankle swelling
• Inflammation of skin,
• Cellulitis, sometimes requiring hospitalization and antibiotic
• Eczema
• Brawny skin discoloration
• Ulceration in the lower legs
• Unable to wear proper shoes
• Leg cramping during the day or at night
• Restless leg syndrome.

Risk Factors in the Development and Worsening of Venous Disease

Multiple risk factors have been identified that can lead to, or worsen the chronic condition. Among the most important are:

• Heredity (family history)
• Standing occupation
• Prolonged sitting
• Tall stature
• Obesity
• Heavy lifting
• Limb trauma
• Deep/Superficial Vein Thrombosis (clots)
• Multiple pregnancies
• Loss of Calf Muscle function
• Ankle, knee, hip, abdominal or pelvic surgery
• Female gender
• Hormone Replacement Therapy and/or Birth Control Pills
• Surgical procedures (Abdomen, Pelvis, Hip, Knee, Ankle, Foot)

VARICOSE VEINS

Varicose veins are those that bulge above the skin, are very tortuous, ropelike, sometimes they rupture spontaneously due to the increase internal pressure. See photo. The patient and everyone can identify these veins when the legs are exposed. Patients usually refrain from wearing shorts and/or swim wear. The can be quite painful, they can be easily traumatized and develop thrombus (clot). When the clot is close to a deep vein, the clot can break away and travel to the lung. This is known as Deep Vein Thrombosis with Pulmonary Embolism.

Heredity is a primary factor in over 90% of varicose veins cases. Other contributing factors include: Pregnancy, obesity, hormone therapy, prolonged standing or sitting. These can be treated with excellent cosmetic results with:

1. Surgical removal through a series of minute, 2-3mm incisions in the office by a procedure known as Microphlebectomy followed by a compression bandage which is left in place for 5 days or more. This is covered by insurance, but can only be repeated -if necessary- every 3 months.
   
   
2. They can also be treated by Ultrasound Guided Sclerotherapy. An FDA approved Sclerosant medication is mixed with Air, C02, or O2 and agitated in between two syringes, resulting in a thick foam which is then injected into the vein under ultrasound imaging. This modality of treatment can be repeated every two weeks. Provided that the veins are 4mm or larger, this treatment is covered by insurance.

GREATER SAPHENOUS, SMALL SAPHENOUS AND INCOMPETENT PERFORATOR VEINS

These veins are the most important superficial veins and they all communicate with the deep venous system. When the valves become incompetent, blood flow reverses direction from the deep towards the surface. This phenomenon is not normal (the normal flow direction is from the superficial veins towards the deep veins); it leads to the development of varicosities, swelling, skin discoloration, inflammation and ulceration.

The Greater Saphenous Vein is the longest vein in the body, and it runs inside the leg in its own compartment, from the sole of the foot to the groin where it dives and connects to the deep system. When valves at the end of the GSV become incompetent, blood reverses direction (from the deep towards the superficial) anytime a person cough's, strains, is upright and when they bear down. This BIDIRECTIONAL flow results in further filling of the vein. This overburdens the blood volume carried by the superficial veins leading to stretching, dilatation and sometimes tortuosity . The end result is Venous reflux disease, (varicosities, swelling, skin changes, etc).

The classical treatment of Greater and Small Saphenous insufficiency has been Ligation and Stripping. This surgical procedure is usually performed in the hospital under general or spinal anesthesia. This operation is slowly been replaced by a simpler, less invasive, catheter based (Radiofrequency and Laser) procedure that can be done in the outpatient office setting under local anesthesia in under 30 minutes without any need to take pain medication or time off work.


SPIDER VEINS

Spider and Telangiectasias are the blue or red blood vessels at the skin level that are often seen in the inside of the knee, lateral thigh and around the ankles. Eighty five % of the time, these veins are associated with venous reflux disease and venous hypertension in the deeper communicating veins. This results in enlarged and swollen veins. They are often darker and more noticeable than varicose veins. They are more common in women and are worsened by hormone replacement therapy and/or birth control pills and sometimes are observed following pregnancy. Although these surface veins are mainly a cosmetic problem, they can also be an indication of more serious venous disease below the surface. Non-symptomatic spider veins can often be found around the face and chest as well as the legs.

Treatment offered at the Pittsburgh Vein Center: Spider veins respond well to sclerotherapy which should be the first line of treatment. Those that measure less than 0.3 mm are not amenable to sclerotherapy but can be treated with special Skin Lasers.


FACIAL VEINS

Unsightly veins can be observed around the eyes, temple and forehead. Although they do not pose a health risk, they can be treated successfully with sclerotherapy and a variety of Lasers that use Light as the treatment source.


SCLEROSANTS

Sclerosing agents approved by the FDA

• Sodium Tetradecyl Sulfate (SOTRADECOL) .The Pittsburgh Vein Center uses this product.
• Sodium Morrhuate (Fatty acids in cod liver oil)
• Hypertonic Saline (18% to 30%)

Sclerosing agents awaiting FDA approval

• Polidocanol (Aethoxysklerol)
• Polyiodide iodine (Varigloban)

CELLULITIS

This is an inflammatory condition of the skin and the subcutaneous (fatty layer) tissues that is commonly associated with chronic swelling of the legs, usually below the knees. Swelling can lead to blistering and weeping, thus opening the door to bacterial. The skin becomes red, warm to the touch, very painful and often requires hospitalization, I.V. fluids and antibiotics to control it. This can be a very serious infection in a diabetic individual. Recurrent episodes of cellulitis can result in thickening of the skin giving the appearance of elephant skin. Swelling can be the result of venous reflux disease and this is a treatable condition at the Pittsburgh Vein Center.


VENOUS ULCERS

Venous ulceration is the most common and serious consequence of severe chronic venous insufficiency. It is not uncommon to see in our clinic patients with continuous or intermittent leg ulceration for prolonged periods of time ranging from a few months to several years. All of these patients have been treated with conventional methods prior to coming to the Vein Center.

The availability of Duplex ultrasound in recent times has enhanced our understanding of venous ulcerations mainly due to the closed relationship they bear with venous reflux disease. We now know that correcting venous reflux in the affected limb, these chronic ulcers can heal in a few weeks, thus removing the associated pain, suffering and disability that goes with this condition.

The fundamental treatment of venous ulcers is compression therapy. Such compression is most often combined with topical agents in wound healing and/or negative pressure and vacuum systems. To prevent the development of recurrent ulceration, it is necessary to prevent the development of recurrent deep venous thrombosis and treat all the incompetent veins.

Also, any communicating perforator vein in the vicinity of the ulceration may need to be interrupted, ligated, divided or closed with special catheters that deliver heat. Another option is ultrasound guided sclerotherapy. All of these modalities are accompanied by compression therapy and frequent office visits until the ulcer is healed. This can take up to several weeks.


LIPODERMATOSCLEROSIS

This condition results from the abundant presence of fibroblasts in the dermis of patients with lipodermatosclerosis. Dermal fibroblasts are active skin replacement cells and are characterized by an ability to produce collagen and induce fibrosis. These cells in patients with venous ulcers have been found to behave abnormally.


LYMPHEDEMA

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