venous-disorder - Lymphedema Treatments in Mumbai by Board Certified Plastic Surgeon of Mumbai

Venous Disorders

Venous disorders especially varicose veins (enlarged veins) form a very important reason for leg swelling. In general, venous disorders can cause a lot of severe problems as well as long term problems. Venous disorders can be classified as varicose veins and its associated problems, others namely – Deep Vein Thrombosis and acute venous obstruction.

What are veins?

Veins are part of the circulatory system. Arteries carry good oxygenated blood from the heart to the various tissues and then the oxygen transport happens through the capillaries and then the deoxygenated blood (means after the exchange the blood which has left its oxygen) is carried back to the heart and then to the lungs for oxygenation / re-oxygenation again.

This carrying vessel of the blood which does not have much oxygen content is carried back through the structures which are called veins. Veins are commonly seen at the back of the hand or legs. Essentially, there are two types of venous systems. One is superficial – near to the skin and other is deep in the deep tissues, in between the muscles and around the muscles. Both have got different importance and thus different problems if they become abnormal.

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One very important aspect of veins is that veins have valves which transport the blood only in one direction i.e. towards the heart.

Heart is the center from which the arteries come. Arteries do not have any valve; they flow because of the pressure generated from the pumping action of the heart.

Once they go and the oxygen is given, the pressure drops in the capillaries. There is a low capillary pressure system which carries the blood back due to low pressure system along with the dependent position of our limbs. We as human beings have learnt to walk and stand straight. So the hands and legs are pointing down. Blood has to flow back to the heart against the gravity and the pressure is also not very high. So it is basically a push mechanism. Lot of fluids enters the capillaries and they are pushing the fluid higher up. When they go up there is always a chance that when the pressure is low the fluid can come down. To prevent that, we have valves that allow the blood to flow only in one direction. That means any blood cannot come back from top to bottom or from proximal to the distal part. This is common to all veins.

The superficial veins are just close to the skin and the deep veins are deep in. There are multiple channels between the superficial veins and the deep veins which again have a valve which allow the flow in one direction and that is from the superficial to the deep. So no blood flows from the deep to the superficial. These are the body mechanisms so that no blood accumulates in the superficial system.

In the deep veins, apart from the valves there are muscles which pump the blood in the proximal direction, which empty the veins. Once the veins are emptied there is a vacuum created and the blood also sucks in. This is how the blood finally reaches from smaller veins to a little bigger veins, much bigger veins and then finally to the heart.

So venous disorders can be abnormality of the vein valves, which are the most common venous disorders in which the valves become incompetent or non-functional. What it means is that there is a reflux from the proximal to the distal part of the vein. Especially if you are standing for long there is a column of blood and there is always a pressure on the valves to hold that column of blood. Finally, they give way and thus the valve becomes incompetent and the fluid can come down. When the fluid comes down, there is lot more fluid in the lower part of the limb and that finally leaks out in the tissue and causes swelling.

Similarly if the valves from the superficial to the deep system become incompetent then there is a blood backflow from the deep system to the superficial system which ultimately again gives rise to swelling in the leg.

It is not just fluid filled collection causing swelling but the fluid also has iron component which can cause discoloration or pigmentation as well as over a period of time, wounds and ulcers can develop in the leg because of high pressure on the veins. So wound appears because of lot of pressure and because of the iron content and all that which an irritant, a wound can develop in the leg and which are very difficult to heal unless special measures are taken and they get cured once the vein valve problems are solved through various mechanisms.

The second problem is Deep Vein Thrombosis which occurs in the deep system.

This happens if you are immobile for quite some time, person is lying on the bed for quite some time because there is no muscle activity, but blood stagnates and can clot / coagulate. Also, when the coagulation profile is abnormal and there is more clotting tendency and in elderly. In such cases the blood can clot and the clot can dislodge and get lodged in the heart or in the lung veins which can cause breathlessness and clot to travel to the lungs and cause pulmonary embolism which is a life threatening condition and which leaves with a very important message that Deep Vein Thrombosis need to be taken seriously, if possible prevent it.

The third problem is Acute Thrombus formation which can happen because of injury or post-surgery or hypercoaguable state in such it can give rise to acute swelling in the leg.

Deep Vein Thrombosis normally does not give rise to swelling but acute thrombus will give rise to swelling and bluish discoloration of the limb. Treatment becomes very urgent because it can threaten the survival of the limb.

CAUSES OF VARICOSE VEINS INCLUDE

How do we diagnose a venous problem?

Varicose veins are the most common problems of veins and any swelling in the leg can be a reflection of varicose veins especially when one is obese in which the visible veins or the varicosities are not very prominent or appreciated.

Special investigations are required for all patients with chronic leg swelling to see if there are valve incompetency’s which are leading to varicosities or visible torturous varicose veins. Clinically, in thin or moderately built patients, on physical examination we can see torturous veins that are serpentine in nature. Sometimes small streaks of vessels are also seen are harmless known as telangiectasia.

Small to Medium size or serpentine torturous vessels means there can be valve incompetence which can be due to long standing, walking throughout the day and needs to be investigated. Acute leg swelling always needs to be investigated for acute vein problem and chronic patients lying on bed need to be investigated for Deep venous thrombosis formation. Diagnosis is done by the simple use of vascular ultrasound called Colour Doppler of arteries and veins of both the lower limbs to know the architecture and valves that can be depicted through and the site of incompetence can be mapped for further treatment.

Treatments - Non-Surgical

1. LIMB ELEVATION

The limb should be elevated as far as possible so that there is no load on the veins and no pooling of blood in the lying position.
During the day one should try and take out time to elevate the limb on a chair or on the bed.
At bed time, limb elevation should be practised by placing pillows underneath the leg so that there is dependant drainage.

2. COMPRESSION DRESSING AND GARMENT

The compression garment is a tight stocking which is given which helps in pumping the blood upwards and defies gravity. This pressure garment is best tailor made but readymade garments are also available. This should be put as soon as the patient gets up and should be ideally put on the bed.
During the day whenever the patient is moving about or sitting the pressure garment should be worn. It should be taken out whenever the person goes back to bed at night or naps in the day
Please note no non-surgical treatment can cure varicose veins, it can only be controlled. The moment these non- surgical treatments are discontinued the problem will recur.
After the surgery or laser treatment in many cases the limb elevation and pressure garments can be taken off.

Surgical Treatments

Incompetent veins are either surgically ligated or treated with lasers, both which have different advantages and disadvantages, which can be discussed with the doctors.

Perforator valve incompetence : Ligated

Endovenous laser

Both options need to be discussed with your plastic surgeon. We recommend surgical options as they are very precise as compared to endovascular lasers which are not very precise and tend to damage the surrounding veins as well which can many a times increase the swelling, unless there is a contradiction to surgery.

Sclerotherapy

If only superficial veins are involved and no deep valve incompetence is present, then (injection therapy) sclerotherapy can help. There is also an option of radio frequency treatment that can also help

Deep Venous Thrombosis when diagnosed has to be treated with urgency. The line of treatment is medical with use of anti-coagulants and pressure stockings and monitoring for pulmonary or cardiac embolism.

Acute venous thrombosis requires surgical intervention like embolectomy -removal of the thrombus, through open surgery or non-invasive vascular surgery, both options should be discussed with the patient.

We at Lymphedema and Vascular clinic, Mumbai, which treats Lymphatic and allied vascular disorders like venous disorders, we offer complete care for venous problems – both surgical and non-surgical.

Many a times the venous problems are associated with Lymphedema due to fluid stagnation. We specialize in customized treatment for each patient as each patient is different.

Many patients have successfully undergone treatments for the same.

Prognosis is quite good if timely intervention is done. Both swelling and ulcers resolves to quite an extent and we encourage you to take good skin care and venous stockings till the problem is resolved.