ABOUT VEIN DISEASE
What do veins do?
Simply stated, veins return the used blood back to the heart. When the venous blood gets to the heart, it gets pumped through the lungs so carbon dioxide can be released and oxygen can be picked up.
Why do veins go bad?
Whenever our feet are lower than our heart, gravity is pulling our blood away from the heart and down toward the center of the earth. We don’t want the blood in our veins to go backward.
So what prevents the blood from going backward?
When blood tries to flow backward, one-way check-valves located in our leg veins prevent the backward flow of blood. This check valve action also prevents the build-up of venous pressure.
When these valves fail, blood can flow back down the leg and venous pressure will increase. This causes the superficial veins to become distended and form varicose veins. This condition goes by several terms: venous reflux, venous insufficiency, venous hypertension, and CVI (chronic venous insufficiency).
We have three sets of veins: superficial veins, deep veins, and perforator veins.
Superficial veins are those veins just below the skin and outside of the muscle compartment. Any vein you can see is a superficial vein. Normally, superficial veins only carry 10% or less of the total venous blood in our legs and are not essential to maintain effective circulation.
Deep veins are located within the muscle compartment. They are close to the bone and accompany the major arteries and motor nerves of the legs. This makes sense carry since we would want the important parts deep in the leg where they are most protected from harm. The deep veins carry 90% or more of the blood out of the leg. In addition to being protected by being deep in the leg, the deep veins also benefit in another way: the muscles squeeze down on the deep veins and help push the blood up the leg as we walk or run. This is why many of us find relief on long flights by pumping our feet up and down. We’re activating what is called the “calf muscle pump.”
Additionally, because the deep veins are surrounded and supported by muscles, they are much less likely to suffer valve failure. The most common cause of deep venous reflux is a deep vein thrombosis (DVT). The blood clot sets off an inflammatory response that often destroys the valves in the area of the clot.
Finally, there are perforator veins. Instead of running up and down the leg, these veins run basically crosswise in the leg. Their job is to carry blood from the superficial veins into the deep veins, where the blood can be returned back to the heart more efficiently.
Fortunately, most venous disease is caused by venous reflux of the superficial veins or perforator veins. The venous reflux problems in the superficial and perforator veins can be treated with minimally invasive techniques with little post-procedure discomfort or downtime.
There are three named superficial veins in the leg:
- the great saphenous vein. This runs from the ankle to the groin on the inside (medial) part of the leg. This is the longest vein in the body.
- the small saphenous vein. This runs up the back of the lower leg.
- the anterior accessory saphenous vein. This vein runs up the outside-front (anterolateral) area of the thigh.
Frequently overlooked sources of venous insufficiency are the perforator veins. These veins have check valves to prevent blood from refluxing from the deep system to the superficial system. When these valves fail, a patient can signs and symptoms of venous insufficiency even when the other three saphenous veins are normal. And, of course, a patient can suffer from any various combination of refluxing veins.
The Alaska Vein Clinic will assess each patient for all sources of venous reflux disease: the superficial veins, the perforator veins, and the deep veins; and prescribe an individual treatment plan based on their pattern of reflux.
In a normal vein, the valves will open to allow the blood to flow up and close to prevent blood from going backward toward the foot.
Defective Valve & Venous Insufficiency
In a vein with a damaged valve, the valves cannot close completely or properly. Because of this problem, blood moves backwards through the valve and down the vein. This is called venous reflux, or venous insufficiency, CVI (chronic venous insufficiency). This leads to venous hypertension and this abnormal pressure can cause the veins to dilated and become varicosed.
Deep veins run deep in the leg, within the muscle compartments, while superficial veins run just beneath the skin.
Perforator veins carry blood from the superficial veins to the deep veins. The perforator veins can also be a source of varicose veins and leg problems. These should always be evaluated during the initial venous reflux exam.
Venous Disease FAQ:
What are varicose veins?
Varicose veins are abnormally large superficial veins, usually caused by venous reflux disease.
Venous reflux disease occurs when the valves in the veins cannot close properly and prevent the backwards flow of blood down the leg. (See further details on the left side of this page.)
Varicose veins can cause aching, heaviness, swelling, itching, burning and muscle cramps. Sometimes they can cause restless legs. In more severe cases they can rupture and bleed. Venous insufficiency can be linked with pigmentation of the legs and skin ulcers.
What are spider veins?
Spider veins, also called telangiectasis, are small or blue visible veins in the skin. They are often seen without venous reflux disease.
Like varicose veins, genetics plays a big role. Pregnancy, obesity, and inactivity can also influence the development of spider veins, but they can also be seen in active and thin people, even marathon runners.
They are more common in women due the effects of hormones, but men get them too.
Why do I have varicose veins?
The most common cause of varicose veins, as Dr. Artwohl often puts it, “is from our choice of parents” — that is genetics. Varicose veins often runs in families. It’s quite common for Dr. Artwohl to hear, “I’m getting legs like my mother!”
After genetics, contributing factors to developing varicose veins include prolonged standing, pregnancy, obesity, and inactivity.
Having said that, Dr. Artwohl has treated varicose veins in thin physically fit marathon runners.
Not only is getting varicose vein determined by genes, how we respond to them is also genetics. Some people can tolerate varicose vein for decades, while other can develop severe discomfort, skin changes. and even skin ulcers just a few years after developing varicose veins.
Do women really get varicose veins and spider veins more than men?
Women seek treatment for varicose vein problems more often than woman, so it seems reasonable to think the incidence of varicose veins is higher in women than in men.
There is no question that estrogen and progesterone have influence on varicose veins and conditions like pregnancy, birth control, menopause, and hormone replacement often cause their veins to become more symptomatic earlier in life.
However, as more and more men have sought treatment for varicose veins, it seems that about 80% of men and about 88% of women will develop some sort of varicose vein problems at some time in their lives. It may be that women develop problems with veins earlier in life, but over the course of a lifetime, the incidence of varicose veins may be not as different as we once thought.
Is it safe to close down veins or remove them? Don't I need them for my circulation?
We have two sets of veins in our legs: superficial veins and deep veins. The superficial veins are located just below the skin and many of them are visible. The deep veins run deep inside the legs and around surrounded by muscle. (See vein illustrations in middle column on this page.)
The superficial veins of the legs actually contribute less than 10% of venous flow back to the heart, and the deep veins carry over 90%
Dilated varicose veins with defective valves cannot properly transport the blood in the right direction (up and out of the leg) so the varicose veins are a burden on your circulation. They can also put a burden on the deep veins of the leg and on the lymphatic system.
Getting rid of defective superficial veins actually improve your circulation.
Many elite athletes wear compression sleeves (or stockings) on their legs. One of the possible ways this venous compression may help is by compressing the superficial veins and diverting blood into the deep veins, where the the pumping action of the leg muscles on the deep veins helps return blood to the heart more efficiently.
Are my restless legs or nocturnal leg cramps cause by venous insufficiency?
There is certainly a subset of patients with restless legs who benefit from having their venous insufficiency treated.
Studies suggest that the 22% of patients with restless syndrome may also have venous insufficiency. Therefore, if you have restless legs, it is reasonable to have a venous work-up, especially before one starts on a trial of expensive medicines with multiple side effects.
80% of patients with both venous insufficiency and restless legs who are treated for their venous insufficiency will have long term relief.
Should I have my varicose veins fixed before knee or hip surgery?
Surprisingly, there is little research on this question. One study published in 2012 found that patients with history of untreated varicose veins had about a three times higher risk for a deep vein thrombosis after hip replacement. There was no difference for knee replacement.
Your orthopedic surgeon should be well versed in the prevention of deep venous thrombosis. Often an orthopedic surgeon will refer their patient with varicose vein to a vein specialist prior to surgery.
Superficial thrombophlebitis can occur with higher frequency after hip or knee surgery, but this is usually not a life threatening issue.
If the knee or hip surgery is not urgent and the varicose veins are bothersome, a patient may consider have the veins problems dealth with first, since the recovery from vein procedures is much quicker than recovery from hip or knee surgery
Should I have sclerotherapy during pregnancy or while breast feeding.
With respect to pregnancy the answer is simple: absolutely not.
However, with respect to breast feeding, the answer is no one really knows. There is diverse opinion about this among vein care professionals.
Most sclerotherapy solutions clear the bloodstream rapidly and will probably not be found in any significant quantities in breast milk. At the Alaska Vein Clinic, we use Asclera (polidocanol). This is cleared from the bloodstream in about 1.5 – 3 hours and most likely, it is safe use after discarding breast milk (pump and dump) for 8 -12 hours after a sclerotherapy session.
However, it is our position that any sclerotherapy done for strictly cosmetic reasons be deferred until after breastfeeding is completed. Sclerotherapy for more clinical reasons like severe disabling discomfort, venous stasis dermatitis or ulcerations could be considered, after a thorough discussion.
Hypertonic saline, a super-concentrated saltwater solution could be used, since this is just salt and water, but this can be painful when injected and carries a potential risk of causing skin ulcers at the injections sites.
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Stages of Venous Disease
The progression of venous disease is slow, but inexorable. We don’t fully understand why some people can have varicose veins for years and not progress, but others go to develop swelling, pigmentation and scarring of the skin, and ulceration. Genetics may play a role.
Varicose veins are usually the first visible sign of venous disease, although some people can have leg swelling before they develop varicose veins.
Most patients can tolerate varicose veins for years, but others quickly evolve to swelling, pigmentation, lipodermatosclerosis, and ulceration.
The next stage of chronic venous insufficiency is most often leg swelling, although some patients will develop swelling as the first sign of venous disease and later develop varicose veins.
Leg swelling can have many other causes, including lymphedema, heart failure, obesity, and deep venous thrombosis. Sometimes, leg swelling can be caused by two or more factors.
Dr. Artwohl looks for all causes of leg swelling and makes sure the patient understands the causes and gets the proper treatment.
Pigmentation occurs in the later stages of chronic venous insufficiency. Like most of the more advanced complications of venous disorders, it is found mostly in the gaiter area of the leg.
Believe it or not, this pigmentation is not fully understood.
The accepted explanation has been that venous pressure forces red cells out into the tissues and when they are broken down, the hemoglobin gets converted into protein and iron complex called hemosiderin, which causes the discoloration and can also lead to inflammation of the skin (venous stasis dermatitis) and ulceration.
Lately, however, studies have shown that melanin can be found in the areas of discoloration of the legs. Some studies have shown that hemosiderin may stimulate melanocytes, the cells that produce melanin. Other studies have shown that phagocytes (cells that engulf harmful particles, bacteria, and dead cells), can ingest both hemosiderin and melanin.
The cause of pigmentation in venous insufficiency should still be thought of primarily as a problem of iron deposition in the skin.
After staining comes lipodermatosclerosis. This is caused by chronic inflammation of the skin and subcutaneous tissues of the gaiter leading to scarring down of the skin.
A typical sign of lipodermatosclerosis is the “wind glass” appearance. This happens because the thickened and hard skin of the gaiter area cannot stretch while the normal tissues above can stretch from the excess fluid that accumulates as a result of the chronic venous insufficiency.
Venous Stasis Ulceration
Venous stasis ulceration is the last stage of chronic venous insufficiency.
Through various factors, the skin breaks down and leave exposed subcutaneous tissue. It always occurs in the skin that has suffered from pigmentation and lipodermatosclerosis.
No one really knows why some people can suffer from varicose veins for many years and not progress to ulceration, while others can go from varicose veins to ulcerations in a few years. There seems to a genetic component.
The treatment for this condition is vigorous venous support and correction of venous insufficiency.
This patient was treated with $100,000 of hyperbaric oxygen with no beneficial result before she came to the Alaska Vein Clinic. Her ulcers quickly once the venous insufficiency was treated.
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