CHRONIC VENOUS DISEASE OVERVIEW
Chronic venous disease is a common disorder that affects the veins of the legs. These veins carry blood from the legs to the heart. Normal veins have a series of valves that open and close to direct blood flow from the surface of the legs to the deep leg veins, from which calf muscles pump blood back to the heart. The valves also control the pressure in smaller veins on the legs' surface.
If the valves within the veins fail to work properly, there is a blockage to normal flow, or the calf muscles cannot pump properly, blood can flow backwards in the veins and pool in the legs. The pooled blood can increase pressure in the veins. This can cause problems that range in severity from mild (such as a feeling of leg heaviness, aching, or dilated or unsightly veins) to severe (such as swelling of the leg, ankles or feet, skin color changes, skin rash on the leg, recurrent skin infections, and chronic ulcers). People who develop these more severe symptoms are said to have "chronic venous insufficiency."
Chronic venous disease can sometimes affect the arms, for example, after a blood clot. This article focuses on chronic venous disease in the legs ("lower extremities").
CHRONIC VENOUS DISEASE CAUSES
Any problem that increases pressure in the veins in the legs can dilate the veins. This can damage the valves, which leads to even higher pressures and worsened vein function and can eventually lead to chronic venous disease.
The pressure inside the veins can increase for a number of reasons, including:
- A clot inside a vein – A clot will block blood flow through the vein and cause pressure to build up. Often this causes permanent damage to the vein or valves, even after the clot has dissolved.
- Leg injury or surgery – Injury or surgery that blocks the flow of blood through a vein can increase pressure.
- Excess weight or weight gain – The added weight of pregnancy or obesity can increase pressure in the veins of the legs and damage the veins and valves.
- Standing or sitting for too long – Standing or sitting for prolonged periods without walking can decrease the movement of blood from the legs toward the heart and lead to increased pressure in the veins and pooling of blood. This is because the muscles in the legs play an important role in the circulation of blood, acting as a pump to move blood from the legs back to the heart.
CHRONIC VENOUS DISEASE SYMPTOMS
Chronic venous disease can cause enlarged veins, skin irritation, skin rash, skin discoloration, itching, swelling, and skin ulcers. The legs may feel heavy, tired, or achy, usually at the end of the day or after prolonged standing.
Dilated veins — The most frequent feature of venous disease is widening (dilation) of the veins. Dilated veins may appear as thin blue flares, often called spider veins or much wider, twisted veins, called varicose veins, that bulge on the surface.
Swelling — Long-standing chronic venous disease can cause swelling (edema) in the ankles and lower legs. Sometimes this swelling is evident only at the end of the day; other times it is present all the time. Swelling almost always decreases with leg elevation, so it may be less prominent in the morning.
The area just above the ankle bones is often the first place that swelling is seen. However, swelling can be caused by conditions other than chronic venous disease, so this problem should be evaluated to determine the cause.
Skin changes — Pooling of blood and increased pressure in the veins over months to years can cause the skin to become tan or a reddish-brown color. Often, the skin changes are initially noticeable around the ankle, starting first on the inside of the ankle, but frequently occur over the shins and on the foot.
Pooling of blood in the legs often causes the skin to become irritated and inflamed. This can cause redness, itching, dryness, oozing of fluid, scaling, open sores from scratching, and crusting or scabbing. Some people develop brown or red shiny areas that are hard and scar-like and can be painful. This usually happens after many years of venous disease but can occur suddenly.
Venous ulcers — Open, nonhealing sores caused by chronic venous disease are called venous ulcers or venous stasis ulcers. The most common location for stasis ulcers is low on the inner ankle, but they can also occur on the outer ankle and on the shin area. Venous ulcers never occur above the knee and do not usually occur on the foot itself or the toes. Venous ulcers that occur above the ankle are often the result of an injury, or trauma such as from repeated scratching. More than one ulcer can occur at a time.
Venous ulcers often begin as small sores but can expand to become quite large. Venous ulcers are usually moderately uncomfortable, tender to touch, shallow, have a red appearance at the base, and may ooze or drain small to large amounts of fluid.
Venous ulcers can take months to heal. Healing is a gradual process, and the resulting scar is usually shiny pink or red, or white and shiny with red dots. Venous ulcers can come back even after they heal.
CHRONIC VENOUS DISEASE MANAGEMENT
Treatment of chronic venous disease is focused on reducing symptoms, such as swelling, treating skin problems, preventing and treating ulcers, and improving blood flow from the legs.
Leg elevation — Simply elevating the legs above heart level for 30 minutes three or four times per day can reduce swelling and improve blood flow in the veins. Improving blood flow can speed healing of venous ulcers. However, it may not be practical for some people to elevate their legs several times per day. To be effective, it is important to elevate the legs above the level of the heart; simply putting your legs up on a footstool does little to improve drainage of blood from the legs.
Leg elevation alone may be the only treatment needed for people with mild chronic venous disease, but additional treatments are usually needed in more severe cases.
Exercises — Foot and ankle exercises are often recommended to reduce symptoms. Pointing the feet down and up (movement from the ankle) several times throughout the day can help move blood from the legs back to the heart, as can repeatedly lifting the heels off the floor to stand on the toes, repeating several sets of this exercise daily. This may be especially helpful for people who sit or stand for long periods of time. Walking is a good exercise to activate the calf muscle pump.
Compression therapy — Most experts consider compression therapy to be an essential treatment for chronic venous disease. Compression stockings are recommended for most people with chronic venous disease. People with more severe symptoms, such as venous ulcers, often need treatment with compression bandages.
Compression stockings — Compression stockings gently compress the legs and may improve blood flow in the veins by preventing backward flow of blood.
Effective compression stockings apply the greatest amount of pressure at the ankle and gradually decrease the pressure up the leg. These stockings are available with varying degrees of compression.
- Stockings with small amounts of compression can be purchased at pharmacies and surgical supply stores without a prescription.
- People with moderate-to-severe disease, those who stand for long periods of time, and those with venous ulcers usually require prescription stockings. A healthcare provider may take measurements for stockings, or may write a prescription for stockings that can be filled at a surgical supply or specialty store where trained staff take the necessary measurements.
Stockings are available in several styles, including knee-high, thigh-high, and pantyhose with open or closed toes. Knee-high stockings are sufficient for most people. Some people experience skin irritation or pain, especially with initial use of compression stockings, which can be related to improper fit or highly inflamed skin. The following figures show tips for using compression stockings..
Intermittent pneumatic compression pumps — Standard compression stockings may be less effective or difficult to use if you are very overweight or have a lot of swelling. An alternative approach is the use of intermittent pneumatic compression (IPC) pumps.
These devices consist of flexible plastic sleeves that encircle the lower leg. Air chambers lining these plastic sleeves periodically inflate, compress the leg, and then deflate. These are generally used for several hours per day.
Similar to compression stockings, IPC pumps may be painful for some people, particularly with initial use, but this improves as swelling is reduced with treatment.
Compression bandages — People with severe symptoms, like ulcers, may need to be treated with compression bandages. Compression bandages may consist of one or more layers of an elastic wrap and may look similar to a soft cast. These are applied by a nurse or doctor.
Topical medicines may be applied to the skin, and if ulcers are present, they may be covered with special dressings before compression bandages are put on.
The bandages are usually changed once or twice a week and must stay dry. A cast bag or other plastic bag can be placed over the compression bandage to keep it dry while showering. If you have compression bandages and they get wet, or fluid from the wound leaks through the bandages, you should contact your doctor to have them changed.
Dressings — Ulcers may be covered with special dressings before putting on compression stockings or compression bandages. Dressings are important to help ulcers heal. They are used to absorb fluid oozing out of the wound, reduce pain, control odor, remove dead or infected cells, and help new skin cells to grow.
There are several types of dressing material used for venous ulcers. The type and frequency of dressings is determined by the size of the ulcer, amount of drainage, and other factors.
Micronized purified flavonoid fraction is also available as a dietary supplement; when added to compression therapy, it may improve healing of ulcers and many symptoms of chronic venous insufficiency, including lower extremity edema. It is usually taken as two 500 mg tablets daily. Talk to your health care provider if you want to try this.