Venous Disease

is a very common problem and  can range from a minor annoyance to life threatening severity. There are two primary types of vein problems, venous insufficiency and venous thrombosis.

Risk Factors - Venous disease affects people of all ages. There are significant risk factors for development of venous thrombosis and /or venous insufficiency.

• Surgery or trauma 
• Prolonged immobilization 
• Malignancy (cancer) 
• Changes in blood clotting factors 
• Smoking 
• Pregnancy 
• Obeisity
• Lack of exercise
• Past history of venous thrombosis
• Prolonged standing or sitting
• Family history of varicose veins

 Many of these can not be controlled, however by changing your lifestyle you can reduce the tendency to develop venous disease.

• Avoid porlonged immobilzation or standing 
• Exerciese (water exercise / aerobics is especially good) 
• Stop smoking 
• Lose weight if necessary 
• Wear properly fitted compressive stockings 

How the Veins Work - 

The veins of the body carry blood from the organs and tissues back to the heart in contrast to the arteries which carry blood to the organs. There are three types of veins - superficial, deep, and perforating veins. The superficial veins, lie just under the skin and are generally small and numerous. Their function is to drain blood from the skin and subcutaneous tissues. There are two main superficial veins called the saphenous veins. The deep veins are large veins deep in the muscle and they function as the primary conduit to carry blood out of the limb. They drain the muscles and organs as well as the superficial veins. Perforator veins connect the deep and superficial veins.

Veins are elastic and collapsible; blood flows with very low pressure and against gravity. There are two mechanisms that work together in order to accomplish this function, the calf muscle pump and valves. As the calf muscle contracts, it squeezes the veins and pumps the blood out, this is referred to as the calf muscle pump. Valves are thin bicuspid leaflet like structures that open one way to allow blood to flow towards the heart and quickly close preventing blood from flowing backward. If a valve is not functioning, the blood is permitted to flow backward allowing the pooling of blood and resulting in vein distension.

  Normal closed valve Normal open valve Damaged incompetent valve

This is an ultrasound image of a femoral vein. The open valve is clearly visualized on the left and with inspiration, the valve closes on the right image.

Venous insufficiency and valve function

Veins are elastic and collapsible; blood flows with very low pressure and against gravity.  There are two mechanisms that work together in order to accomplish this function, the calf muscle pump and valves . As the calf muscle contracts, it squeezes the veins and pumps the blood out, this is referred to as the calf muscle pump. Valves  are thin bicuspid leaflet like structures that open one way to allow blood to flow towards the heart and quickly close preventing blood from flowing  backward. If a valve is not functioning, the blood is permitted to flow backward allowing the pooling of blood and resulting in vein distension. Leaky one way valves cause what is called venous insufficiency. This can be thoroughly evaluated with duplex ultrasound - however this takes significant experience and skill.  Most providers of vascular ultrasound services typically look for blood clots and unfortunately, many do a very marginal job evaluating venous insufficiency. QVI has extensive experience in evaluating this condition and provides training for technologists from around the country. 

Superficial Veins -

The superficial veins are poorly supported beneath the skin. When the valves begin to leak (venous insufficiency), an increased pressure is transmitted into the veins. Over time, the veins tend to enlarge and stretch. If the dysfunction occurs in the tiny superficial veins, spider veins form. There are several treatment options for spider veins including compression stockings, injection, and/or laser. What’s right for you depends upon many factors and should be discussed with your doctor.

The larger superficial veins can be seen bulging and twisted beneath the skin (varicose veins). In addition to being unsightly, they can result in symptoms ranging from aching, a feeling of heaviness, tenderness, swelling in the in the limb to skin erosion and ulceration. As with spider veins, treatment options are varied and may include compression stockings, injection, laser, and a variety of surgical procedures depending upon many factors and the severity of the varicosities.  See venous treatments In the case of ulceration, treatment is generally more aggressive. If insufficiency occurs in both the superficial and deep system compressive stockings are usually recommended.

Figure 1 Figure 2 Figure 3 Figure 4

 

Fig 1 - large varicose vein on the left leg

Fig 2 - Smaller spider and reticular veins resulting in skin discoloration

Fig 3 - varicose veins that began bleeding spontaneously

Fig 4 - End stage of untreated venous disease - ulceration

Venous thrombosis, or a blood clot in the vein, is an acute problem and as such, it is important treatment is sought quickly. If a blood clot is in the superficial veins, serious complications are rare, and treatment is conservative, often with anti-inflammatory medications. There may be localized pain or tenderness, swelling, and redness along the vein and a hard lump or cord may be felt under the skin.

Deep veins

Venous thrombosis in a deep vein is a very serious problem. Left untreated, there is a tendency for the clot to grow or propagate. The major potential danger is a blood clot breaking loose which lodges in the lungs preventing oxygen from entering the blood. This is called a pulmonary embolus and while it occurs in a relatively small percentage of patients with deep vein thrombosis (DVT), it can be fatal.

Symptoms of DVT are variable depending upon the location and extent of the clot and whether the vein is partially or completely obstructed. This obstruction backs up blood behind the blockage as blood has to weave its way around the obstruction through other small veins. Swelling is a major symptom to suspect DVT. Pain and tenderness may also be present as a result of inflammation.

Treatment of DVT usually consists of intravenous administration of a potent blood thinner to stop the clotting quickly. Many times this involves a hospital stay although some patients may be candidates for outpatient blood thinners. Once the blood is thinned to a “therapeutic level” an oral blood thinner is prescribed for an additional 3-6 months. The blood thinner prevents more clot from forming but does not generally dissolve the clot. The body can dissolve or lyse the clot over time. The formation of a blood clot results in a scarring of the walls of the vein and damage to valves. If extensive, this can result in what is called post phlebitic syndrome leading to discoloration of the skin and ultimately venous ulceration. Therefore, it is important to minimize the extent of the clot by timely treatment.