When your heart beats it pumps the blood around the body through the circulatory system which consists of hollow living tubes. These tubes are of three types – the arteries carrying oxygenated blood away from the heart and veins carrying deoxygenated blood towards the heart. The third type is the lymphatics.
Veins are flexible hollow tubes with flaps within them called valves. Blood return to the heart is passive and assisted by the movement of the muscles of the arms and the legs. When your muscles contract these thin veins the blood moves by opening these valves and when the muscles relax the valves close to allow blood to move in one direction through these veins. The veins become progressively larger as they go towards the heart. The largest ones are the superior vena cava bringing blood from your head and neck and arms back to the heart while the inferior vena cava brings blood from the lower limbs and abdomen back to the heart.
If these valves within the veins get damaged due to any reason, the blood flows in both the directions as they leak backward.
The wall of the leg veins deteriorate and the valves get damaged and become incompetent leading to all the multiple diseases they cause. This allows the blood to flow back towards the foot in the superficial or the deep venous systems. It is called reflux. When the superficial veins become damaged and severely dilated the blood flows back towards the foot and thus much of the blood has to go by the deep system towards the heart.
The excess blood makes the deep system dilate and thus this also becomes incompetent. When the blood is not pumped effectively back to the heart it pools in the legs and does not reduce walking thus increasing the static pressure. This is called chronic venous insufficiency (CVI) leading to edema, skin changes and ulceration.
Normally in all of us during circulation small amounts of fluids and proteins leak from the arteries and veins. Lymphatic veins bring this protein risk fluid back into circulation
These fall into two broad categories – Blockage from a blood clot (thrombus) and inadequate venous drainage (insufficiency)
The clot in the vein blocks it and this causes back pressure in the vein which leaks fluid into the tissue causing swelling. The clot itself produces inflammation, redness, and tenderness.
Though clots in the legs occur quite commonly, the condition is not dangerous but should they break free when they travel via the blood to the lungs giving rise to the fatal condition – pulmonary embolism(PE). Without treatment, 25% of the clots will break free and travel via the circulation to the lungs. The complications of PE are shortness of breath, marked exercise limitation and death.
The diagnosis is made on ultrasound and is very reliable above or at the knee which is the commonest site to send off an embolus to the lung. Below knee, ultrasound is not very reliable because the venous anatomy is not very reliable. If needed an MRI or a venogram is done.
The treatment is anticoagulation which dramatically reduces the chances of PE. We start with injectable heparin and then turn onto oral anticoagulation (warfarin). It should be continued for 3-6 months and needs frequent monitoring of blood thinning levels. This treatment reduces the incidence of PE from 25 – 5% over the first year but the chances of bleeding increase from 2-3%.
1) Thrombolysis (clot-dissolving therapy)
2) use of blood thinners for clots in a calf
Thrombolysis carries a serious risk of bleeding and is only recommended in very serious cases. In the second case, most prescribe blood-thinning drugs for calf clots.
It is characterized by pooling of the blood, chronic leg swelling, increased pressure in the legs, increased leg pain. Increased pigmentation or discoloration of the skin and leg ulcers called stasis ulcers. The swelling increases on dependency and improves on elevation. It is worse in warm weather and during menstruation.
Skin color changes are due to leakage, destruction, and deposition of red blood cells in the skin. These changes are not dangerous but depict severe long term process.
Treatment is aimed at improving the blood return to the heart and decreasing fluid escape from the veins. Leg elevation, compression stockings, specialized care of ulcers and occasional use of diuretics constitutes the therapy. There are hardly any surgical options.
Obesity, pregnancy, prolonged standing, sedentary life may be responsible.
Symptoms of pain, swelling and heaviness are less severe in the morning and increase as the day progresses.
In neglected they may progress to color changes in the skin and leg ulcers, skin infection, blood clots, and spontaneous bleeding.
Standard treatment is weight loss in obese, exercise, blood pressure control and stockings
The stockings are worn in the morning when the veins are empty. After getting ready elevate the legs in bed for a few minutes to empty the veins. The veins are elevated above the level of the heart