| Venous Diseases |
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There are three types of blood vessels in the body namely arteries, veins and lymphatic vessels. The arteries carry oxygenated blood from the heart to the tissues. The veins bring back the deoxygenated blood from the tissues along with carbon dioxide and metabolic waste products.
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Man is the only animal with an upright posture. Hence, the blood has to be returned to the heart against gravitational force. To aid this process, the calf muscles propels the blood upwards during motion. There are valves in the veins which prevent the blood from going downwards again. The veins are thin walled and the valves are very delicate. Thin walls in the veins allow for expansion rapidly and large quantity of blood can be handled by it because of this. In certain condition like Venous thrombosis, the valves can get damaged and the veins became dialated due to stasis of the blood in dependant parts of body. This condition if present for a long time is known as Chronic Venous Insufficiency.
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| What are Varicose Veins? |
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"Varicose Veins" is the popular term for tortous and dilated veins in the subcutaneous tissues. The cause of these formations may be primary, for example Weak vessel walls and is known to run in families. Secondary Varicose Veins is a term referred to when it is formed due to other causes like obesity, damage to valves, obstruction to flow of blood in veins, liver disease, cardiac disease, direct connection between arteries and veins ( arterio - venous fistula ), structural abnormalities( venous malformations) etc.
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| What is Chronic Venous Insufficiency? |
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| Figure 1: POST PHLEBITIC LEG CAUSED BY CHRONIC VENOUS INSUFFICIENCY |
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Whenever there is damage to a valve in deep veins or perforator veins ( veins connecting deep and superficial veins) blood flow back towards the heart is reduced as the blood which ascends upwards against gravity during contraction of the calf muscles returns is downwards back again as the valves are damaged. When this happens there is accumulation of blood in the veins in the deeper tissues. This can manifest in the early stages as oedema around the ankle increasing towards the evening and disappearing in the morning after a night's sleep with the foot in an elevated position. Chronic Venous Insufficiency may occur due to cardiac, liver, renal and rheumatoid disorders. It is very important to investigate ankle oedema as it may be the earliest indicator of the above diseases.
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| What are the sequelae and consequences of Chronic Venous Insufficiency and Varicose Veins? |
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| Figure 2: Figure showing Normal and abnormal blood flow in the veins of calf |
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Many of these patients complain of dull aching or cramping pains. A few complain of severe shooting pains in the spinal muscles of the back and buttocks area. This type of pain along with ankle oedema and calf muscle pain often restricts physical activity leading to obesity. Obesity, in turn, may lead to arthritis of hip and knee, hypertension and diabetes. The dull aching pain is related to the stretching of the smooth muscle fibres. Postural changes in these patients lead to secondary effects. Ankle fibrosis, joint derangement of the foot etc is common. Small muscles may undergo degeneration, ligaments of smaller joints of the foot may fibrose, contract or may become lax, all these lead to limitation of free movements of the foot .Calf muscle hypotrophy and fibrosis in these unfortunate patients accelerates the severity of symptoms and hampers mobility leading to reduction in venous return. Ulcers soon develop and make life for these patients miserable and pose a challenge for the vascular surgeon who is treating them.
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| Primary Treatment is Prevention |
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The primary treatment for varicose veins consists of exercises to stimulate calf muscle pump by walking and flexion extension movement of the foot and ankle in individuals exposed to venous stasis during day. ie. waiters, guards, peons etc.. They are encouraged to wear compression stockings to facilitate the venous blood to return to the heart.Seconday prevention is done in people who have ankle oedema and diffuse varicose veins, skin changes, discolouration etc, to prevent ulcer formation. This is usually done by Sclerotherapy, life style advice exercises and Class II or Class III Compression Stockings and footwear. Tertiary prevention is for patients with calf muscle, ankle fibrosis and recurrent ulcers .All these treatments are highly specialized today and require a team which includes a vascular specialist, a podiatric specialist, foot care technicians and orthotic specialists. Technical details of these treatments of venous disease is beyond the scope of this article, however one must realize that unlike previously one need not go abroad for treatment anymore and this is available here in India by trained personnel. Even many medical specialists are not aware of this.
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| What is a Compression Stocking? |
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| Figure 3 Action of compression stockings |
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A Compression Stocking is a device that is the main stay of mechano-prophylaxis of the venous disorders. These are specially made stockings which give a high compression pressure at the ankle and progressively reduced compression as we move from calf to the knee and then to the thigh. The stockings improve the mechanical efficiency of the calf muscle pump and prevent stasis at the ankle. They also help in deep venous thrombosis prophylaxis and management. There are various classes (I, II, III) offering different pressures at the ankle from 10 to 40 mm Hg (mercury) pressure. These must be prescribed by qualified vascular specialist and by fitting done after measurement by a podiatric or vascular technician. Wrongly prescribed stockings, poorly taken measurements and ill-fitting stockings could cause severe harm to the patient's legs. This is the commonest cause for non-compliance from the patients, leading to lack of confidence in the treatment programme. European and imported stockings generally do not measure upto the Indian anthropometric sizes.
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| Foam Sclerotherapy For varicose veins, Chronic Venous insufficiency and vascular malformations |
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| Figure 4 : Foam sclerotherapy for varicosity |
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| Figure 5 Foam being injected |
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Traditionally open surgery for varicose veins and chronic venous insufficiency was considered harmful by patients and doctors alike. Painful surgery was not appreciated by the patients and they usually refused surgery as recurrence was common. Sometimes sequelae of surgery leads to serve morbidity. This prevented surgeons from attempting surgery and drove patients away from modern medical treatment. Laser and ultrasound treatments which were promoted as alternatives met with problems of high cost and are unsuitable in severe venous disease. Traditional Sclerotherapy using various solutions had high recurrence rate and incidence of deep venous thrombosis and skin necrosis. Foam Sclertherapy is the latest and most successful form of treatment in varicose veins and chronic venous dieases. It is also the mode of treatment for venous disease of high severity previously thought to be not treatable. It is minimally invasive and generally done under ultrasound guidance by trained vascular surgeon. Pain is minimal. Compression stockings are given in the post procedure period to accelerate the recovery. As the use of drugs and anesthesia is minimal, it can be used to treat venous disease in patients with liver and kidney disease and elderly. Further details regarding this revolutionary procedure can be gained from the author at www.dynamictechnomedicals.com
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| Deep vein Thrombosis: |
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| Figure 6 Colour doppler depicting vein thromboses |
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Thrombosis is the medical term for the formation of a clot inside the blood vessels. Traditionally research, media and popular imagination revolved around arterial thrombosis (clot formation) in the coronary tree (blood vessels carrying blood to heart muscles) and the cerebrovascular tree (blood vessels carrying blood to the brain). The popular imagination was ignited because of the dramatic and eventful turn (heart-attack, stroke) in a person afflicted with this condition. There is a less insidious but no less dangerous condition where the clots form in the deep veins of the leg. Probably this disease claims an equally great number of lives and inflicts a greater toll in terms of social and economic burden. In this condition clots forms in the veins of the calf muscles and propagates or breaks away upwards the heart . Migration of clot to the lung is known as pulmonary embolism. Pulmonary embolism may result in death ,if the clot is big enough to occlude the main blood vessels. Diseases like Varicose veins, Diabetes, malignancy, Congestive cardiac failure, septicemia, prolonged illness, hospitalization etc are often associated with deep vein thrombosis and pulmonary embolism. Treatment methods include prevention by mobilization, physiotherapy and regular active and passive exercise, mechanical prophylaxis with compression stockings and chemoprophylaxis with anticoagulant drugs like heparin and warfarin. Obesity is often associated with this condition because it may precipitate chronic venous insufficiency, stasis with edema and deep vein thrombosis. Established pulmonary embolism is a serious condition with high mortality. Every effort must be undertaken to prevent this condition .More frequent and widespread use of compression stockings and anticoagulation .in hospitalized patients will reduce its incidence. People on long flights and journeys must take periodic short walks and drink plenty of water and take medical advice for thromboprophylaxis.
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| Figure 7 Steps to prevent Deep Vein Thromboses during work or travel |
| Author: Dr.Roy Varghese MS, Dip.NB, Ph.D, FSVS(USA), Vascular Surgeon |
