Health & Disease Info
All You Wanted to Know About ... Chronic Venous Disease

What is Chronic Venous Disease?
While there are many potential causes for this problem, the most common is a history of blood clots having formed in the veins usually in years past and many times without the knowledge of the patient or physician involved. The net result is an elevated pressure within the veins due to faulty valve function. The function of the veins is to carry blood back to the heart.

Since man walks in a vertical position, the flow of blood in returning to the heart has to proceed against the forces of gravity. The forward direction is maintained by forces of the muscle pump in the extremities squeezing the blood vessels, and forcing the blood to proceed upwards toward the heart. This is aided by the presence of valves within the veins which act as one way doors allowing the blood to proceed upward, but then closing with any backward movement of blood and preventing blood from going back into the distal veins again.

When veins dilate the valves can no longer oppose properly, or when blood clots or phlebitis has occurred and the valves have been destroyed, there is loss of valvular function. This results in increased pressure within the veins in the distal part of the extremities. This is most significantly noted in the areas below the knee. It usually presents with symptoms of aching, swelling, skin discoloration, scaly, itchy skin, and even ulcer formation. Many times a peculiar brownish discoloration will also occur under the skin.

Of course the most common cause of chronic venous insufficiency is loss of valvular function in the deep venous system deep within the muscular compartments of the leg. With the chronic high pressures in the venous system, fluid, and protein leak out of the capillary bed and are deposited in the skin. This causes the skin to become thickened and firm but more importantly the extra protein blocks the transport of oxygen to the skin so that the skin becomes "ischemic", or suffering from the lack of oxygen. This can lead to skin breakdown and ulcer formation. The peculiar brownish discoloration which is seen on the skin in many cases represents the deposition of iron from breakdown of the blood cells that are leaked through the capillaries so that actually there is evidence of rust within the tissues. This is a very reliable sign of chronic high pressure in the venous system. The net result of all this causes a spectrum of disease which is referred to as chronic venous insufficiency.

How is Venous Stasis Disease Diagnosed?
The primary tool in establishing this diagnosis is a careful history and physical examination. There are very few tests that can be done to establish the diagnosis with any more certainty than a history and physical examination. If there is a consideration of blood clots

being present at this time, then duplex examination using an electronic stethoscope and imaging device will usually give us a firm answer excluding this possibility. If the duplex scan is not satisfactory, then a venogram can to be done to either confirm or deny the presence of clots within the veins.

What Treatments are Available for Venous Stasis Disease?
Unless it can be determined that the entire cause for the chronic venous insufficiency is an incompetent saphenous system requiring removal of the saphenous vein and varicosities, the backbone of treatment of chronic venous stasis disease is medical. Since the disease is caused by high venous pressure within the leg, the two most useful treatments are elevation of the legs well above the head and heart so that the pressure within the veins is significantly reduced, as well as application of elastic bandages or support stockings so that the high internal pressure is balanced by pressure from the outside. Occassionally air compression pumps are needed to force the stagnant fluid out of the tissues. Conscientious and frequent skin care must be used with application of moisturizing creams and close observation to prevent damage to the skin. Since infections will develop more frequently and more rapidly in damaged areas, this must be constantly observed and antibiotics will be necessary should infections develop.

If ulcerations develop, there are a number of medications that are available, but there is no one treatment that works in every patient and many different regimens are available to be tried. The vast majority of venous ulcerations can be healed with conservative techniques so that resection of an ulcer with application of a skin graft is rarely necessary but remains a long term possibility should conservative measures fail.

In the unusual case of an ulcer that just will not heal after prolonged medical attempts and use of many modalities, the ulcer can be widely debrided and excised and a split thickness skin graft can be applied to the surface. The skin may be applied immediately or may be delayed in order to allow a good granulating base to develop within the excised ulcer bed. As stated before, a surgical approach to chronic venous insufficiency is unusual and should we have to resort to one of these techniques a more thorough discussion will be held at that time.

Remember that these problems have developed over a period of many years, and the effects that they have had on the body tissues are not easily reduced, and the time required for full healing to occur may be prolonged.

General Recommendations:

1. Exercise legs regularly even when lying in bed or traveling. The calf muscle pumps blood in the direction of the heart.

2. Avoid standing or sitting in one position for a long period of time since it causes pooling of blood in the legs.

3. Wear elastic supports whenever legs are dependant.

4. Raise up on toes several times an hour, or shift weight from foot to foot when having to stand in one place without walking.

5. Elevate legs several times a day for at least 10 to 15 minutes. If working, set aside regular rest periods for leg elevation.

6. Raise legs higher than the level of heart. This can be done by lying on the floor with legs on a chair or against the wall.