Recently, I had some “vein work” done on my legs. For about two years, I had had some swelling in my ankles at the end of the day, something that had never happened to me before. I also had a varicose vein in my right leg and some spider veins. This experience caused me to learn more about varicose veins and the associated problems of venous insufficiency.
Venous insufficiency means the veins and the valves connected with them do not function properly. Veins are different from arteries. Arteries are muscular and pump oxygenated blood throughout the body. Veins, which are not muscular, return unoxygenated blood back to the heart from the extremities. The valves in veins become weakened over time, and the veins have trouble returning blood up from the legs. The veins then become dilated, and are called varicose veins. Over time, chronic venous insufficiency develops, and disfiguring changes occur in the lower legs, as well as other possible complications.
My maternal grandmother, who had eight pregnancies, had severe venous insufficiency in her lower legs. She had been a beautiful young woman, and I never realized what a psychological impact the disfigured legs must have had on her. They were discolored, a reddish color, with really thin skin that developed sores that took a long time to heal. One of my earliest memories of her (I was about 5 years old) was when she was recovering from a hospitalization for her leg ulcers. She must have had problems with her legs for a good part of her adult life.
Until I experienced my vein procedures, I was not aware of how widespread the problem of lower extremity venous insufficiency was or about the additional complications that could happen to people with the disorder. About 6-7 million people in the USA (population 333 million) are affected, upwards of about 7% of the male population and 40% of the female population. That is a lot of people!
There are two interconnected venous systems in the legs, deep and superficial veins connected by veins called perforating veins. The valves in the superficial and perforating veins keep the blood from flowing backwards. Over time, these weakened valves become floppy and do not close completely, so the blood flows backward and causes the superficial veins to dilate becoming varicose veins.
The deep veins are well-supported by the muscles of the legs, but the superficial ones do not have that support. As the pressure in the superficial leg vessels increases, it causes venous hypertension.
What are the risk factors? Being female, having had pregnancies, being overweight, leading a sedentary lifestyle, smoking, prolonged standing (think operating room personnel, teachers, salesclerks), and prior deep vein thrombosis (blood clot) are all risk factors. Some risk factors are hereditary and cannot be changed. Aging, high blood pressure, and leg injuries are also risk factors.
Because of the increased pressure of the blood in the leg veins, changes in the skin can occur. The lower legs take on a brownish color, extending to about one or two inches below the knee, called the “gaiter area.” This happens because the increased pressure in the veins of the lower legs causes red blood cells to leak out into the skin. When the red blood cells break down, they release something called hemosiderin, which causes discoloration. Over time, this can worsen. Stasis dermatitis occurs when red, crusted, weepy skin develops. This is sometimes called venous eczema. Hardening and tightening of the skin occurs. This becomes the set-up for leg ulcers to develop.
Symptoms that someone might experience include leg pain, swelling ankles, cramping or throbbing sensations, spider veins, varicose veins, and skin discoloration. Advanced symptoms can consist of blanching skin lesions, atrophy (thinning) of the top level of the skin, increasing coppery pigmentation of the skin, and skin changes in the “gaiter” pattern. Many symptoms are relieved by resting with the legs elevated and the use of compression stockings.
The medical diagnosis is generally made by examination of the legs and ultrasound. The treatment goals are to reduce the swelling and discomfort, stabilize the skin appearance, remove painful engorged veins, and heal ulcers.
Compression, by use of support stocking, is the first mode of treatment. Compression stockings can be used long-term but will only help those who use them. Elevation of the legs when possible and avoidance of standing for long periods of time are important. Losing weight and increasing exercise, especially to increase leg strength, also helps.
This disorder is not “benign,” that is, without complications. It carries a large disease burden in the population and progressively worsens as someone ages. Skin changes are disfiguring. Skin ulcers are common and difficult to heal. Severe varicose veins can rupture through the skin and cause hemorrhaging. If untreated, a person can develop clots in the veins (phlebitis), and these can also occur deeper (called deep vein thrombosis), and lead to life-threatening pulmonary embolism (blood clot[s] in the lungs).
In the past, the main mode of treatment was vein stripping. This procedure has declined in frequency due to post-operative complications. At this time, the two major major ways of treating dilated varicose veins are sclerotherapy and endovenous thermal ablation.
In sclerotherapy, a substance is injected into the vein, causing it to collapse and seal itself. The circulation in the vein is then forced to go deeper into the leg, where the deeper vessels are supported by more muscle and have intact valves.
In endovenous thermal sclerotherapy, a very thin tube is threaded into the diseased blood vessel, and using radio frequency or laser, the vein is heated, causing it to seal off.
I had both legs treated over several visits to the vein clinic. Radio ablation and sclerotherapy with foam were used. I have continued to wear heavy-duty support hose daily. I am pleased with the results. My big varicose vein is gone. In general, I no longer have swelling of my ankles and lower legs.
My message to anyone with varicose veins or any signs of venous insufficiency is to consult with a vascular physician and consider treatment to prevent possible future complications. The information in this blog is not meant to replace care by a physician but to give you information to help you ask informed questions about your health care.
