Venous Insufficiency

What is Venous Insufficiency?

Venous insufficiency is a condition which affects the veins of the legs. In healthy veins, blood is pumped from the legs up to the heart. Blood is pumped upwards due to a series of valves within the veins directing blood flow from the superficial veins to the deep veins leading back to the heart.  Contraction of the calf muscles also aid in pumping the blood flow back up to the heart.

When the valves within the veins are damaged or not working properly, blood flows backwards resulting in a pooling of blood in the legs. Pooling of blood in the legs increases the pressure in the veins leading to venous hypertension. This increase in pressure can cause mild symptoms of leg heaviness and aching or in chronic cases may progress to severe symptoms.

What are the symptoms?

Symptoms of venous insufficiency include:
 
  • Dull aching, heaviness, or cramping in the legs
  • Pain relieved with leg elevation and aggravated while standing
  • Edema (swelling of the legs)
  • Skin discoloration
  • Prominent veins (varicose veins)
  • Skin ulcers
  • Itching, tingling, burning, or throbbing sensation in the legs or feet
  • Leg weakness

What are the causes?

Several causes may lead to venous insufficiency including:
 
  • Congenital- born with weak vein walls or abnormal valves
  • Deep vein thrombosis (DVT) – blocks the blood flow through a vein. This increases pressure in the vein and may lead to permanent vein or valvular damage.
  • Superficial Phlebitis- infection of the superficial vein in the legs can cause damage to the veins and valves.
  • Direct leg injury to the veins or valves
  • Increase in body weight (i.e. pregnancy, obesity) – increases pressure in the veins
  • Weakness in the leg muscles- standing or sitting for long periods of time without walking can decrease the draining of blood from the legs, resulting in increase pressure and pooling of blood.
  • Structural compression from other structures in the pelvis.
  • Chronic fibrotic changes within the veins

What are the risk factors?

Those at risk of developing venous insufficiency include:
 
  • Family history of venous insufficiency
  • Sex: women are more prone than men
  • Increasing age
  • Varicose veins
  • History of deep vein thrombosis
  • Obesity
  • Pregnancy
  • Prolonged sitting or standing
  • Muscle weakness
  • Trauma to the legs
  • Cancer

What are the complications?

If venous insufficiency is left untreated, complications may arise due to the high pressure within the vein and reduced clearance of metabolites from the legs.
 
Complications include:
 
  • Pain
  • Infection
  • Swelling of the legs
  • Non-healing venous skin ulcers
  • Recurrent cellulitis
  • Stasis dermatitis
  • Thrombophlebitis

How is it diagnosed?

Venous insufficiency is diagnosed based around 3 parameters.
 
These parameters include: Patient History, Physical Examination, and Testing.
 
 
 
A. Patient History:
 
Symptoms give a strong clue in diagnosing venous insufficiency.
 
Typical symptoms include:
 
  • Swelling, throbbing, cramping, heaviness, and burning in the legs
  • Development of leg pain after standing or sitting for long periods of time
  • Pain that is relieved by elevating the legs
  • Warmth aggravates symptoms while cold relieves them
 
 
B. Physical Examination:
 
The appearance of the leg gives an idea of whether venous insufficiency is present.
 
Skin discoloration, swelling, stasis dermatitis, cellulitis, and dilated veins may be noticed in the legs.
 
Venous skin ulcers if present are typically located over the inner aspect of the ankle, but can also be present over the leg.
 
A manual maneuver known as The Trendenlenburg test may help in distinguishing insufficiency due to valvular damage. This is done by elevating the leg to empty the veins and applying pressure to block the junction where reflux is occurring from the deep to superficial veins. While maintaining this blocking, the patient is asked to stand. If the lower portion of the vein remains empty or slowly fills, the occlusion is removed. If this is followed by rapid filling, the junction has been correctly identified. If filling occurs with the occlusion, this may indicate a valvular problem in the deep veins.
 
 
 
C. Tests
 
Laboratory investigations:
 
Blood analysis: Elevated platelets levels increase the susceptibility to clot formation.
 
Diagnostic Studies:
 
  • Venous Reflux Study: this is a non-invasive test carried out in our clinic used to detect the presence of venous insufficiency
  • Venous Doppler: is a non-invasive test done in our clinic showing the direction of blood flow and detects thrombus (clot) formation
  • Magnetic Resonance Venography (MRV): is an imaging study used to provide a detailed picture of the deep and superficial veins of the legs using radio waves within a strong magnetic field
  • Direct Contrast Venography: is an invasive test used to detect venous and nonvascular causes of leg pain and edema
  • Intravenous Ultrasound (IVUS): A catheter is placed into the veins in the pelvis and an ultrasound image is taken from inside the vein. This gives an accurate assessment of whether there are any obstructions to blood flow.

How is it treated?

The goal in treatment is to reduce symptoms and correct the underlying problem.
 
Conservative treatment:
 
  • Weight loss: Losing weight can boost the blood flow in your legs.
  • Leg Elevation: Legs are elevated just above the level of your heart for about 30 minutes and should be done three to four times a day. Elevation improves the drainage of blood and metabolites from the lower extremities. This helps relieve symptoms in patients with mild venous insufficiencies.
  • Exercise: Foot and leg exercises help to improve symptoms. Movement helps prevent stasis of blood and also helps the calf muscles pump blood up towards the heart.
 
 
  • Graduated Compression: this is the cornerstone of treatment.
 
Compression stockings can be used in all patients with venous insufficiency and is available in our clinic.  Compression stockings apply a greater amount of pressure toward the ankle while pressure tapers as it goes up the leg. Compression stockings prevent pooling of blood and help to improve blood flow from the lower extremities.
 
 
Compression bandages are used for patients with severe symptoms including severe leg swelling or ulcers. Ulcers must have a dressing on before the application of a compression bandage. Application should be done by trained personnel. The bandage must stay dry and covered while bathing. If the bandage becomes wet, the bandage should be removed due to development of potential infection. The bandage may be changed once to twice a week.
 
Procedures:
 
The goal of these procedures is to improve the venous circulation by correcting insufficiencies by removing the reflux pathways.
 
  • Sclerotherapy: is a chemical ablation done by injecting a sclerosing agent into the vein, causing the vein to collapse.
  • Thermal Ablation: is a minimally invasive technique using intense thermal energy to irreversibly destroy an incompetent or diseased vein.  This procedure is carried out in our clinic.
  • Vein ligation or Stripping: is a surgical procedure done to remove veins requiring the use of incisions. Ligation and stripping are becoming outdated due to ablation techniques.
  • Venous Stenting: is a procedure similar to stents in other blood vessels, where a wire is guided through a narrowed portion of a blood vessel, after which a balloon is used to open the vein up to its original size. finally, a metal stent is placed, to act as scaffolding, keeping the vessels open.

Video Showing how a stent is placed.

How can I prevent this?

  • Lose weight
  • Avoid prolonged standing or sitting
  • Be more physically active by walking or running to promote the calf pumping function
  • Elevate your legs to improve circulation
  • Correct the underlying problem to prevent progression
  • Change your sitting or standing position regularly
  • Protect your legs from injury