|Deep vein thrombosis (DVT)
|Chronic venous insufficiency (CVI)
18% are continuous symptoms while 50% are episodic.
Episodic pain due to varicose veins may be hormonal. Half the pregnant women with varicose veins have pain in the legs and 17% are unable to remain straight for 1-2 hours at a stretch due to the severity of pain.
Walking and leg elevation bring relief along with compression stockings. Warmth aggravates the pain and cold relieves it.
Leg pain may be present much before varicose veins present.
The dilated veins stagnate the return of blood causing the pooling of cells mainly WBC which release proteolytic enzymes which damage the lining of the thin capillary veins. This allows the fibrinogen to pass out into the tissue and form a wall which prevents tissue around to starve of oxygen and thus they break down. The colour changes are due to the deposit of the deposition of hemosiderin from the RBC into the tissue.
Misdiagnosing venous occlusion may be lethal but venous insufficiency is slowly progressive leading to reduced quality of life.
Blood for D-dimer is always elevated due to recurrent venous thrombosis but it reduces the usefulness of detecting DVT.
It is the investigation of choice. It tells us about any dilatation, blockage and can predict venous hypertension. It is non-invasive.
Link showing venous refluxhttps://www.youtube.com/watch?v=P15g-Oewbys
MR Venography is most sensitive and specific for venous disease of the legs and pelvis. It can detect unsuspected non-vascular causes of leg pain and edema.
here infra-red light assesses the capillary filling during exercise. An increased capillary filling is indicative of venous reflux and thus incompetent veins.
These predict the severity of venous insufficiency. The parameters used are:
a) Venous Refilling time (VRT)
b) Maximum Venous Overflow (MVO)
c) Calf Muscle pump Ejection Fraction (CMEF)a) Venous Filling Time (VRT)
The patient is made to lie down and the calf muscles are emptied of blood using a calf muscle pump. This is done as thoroughly as possible. Now the patient is made to sit and the filling of the veins in the calf occurs by the arterial blood and takes over 2 minutes or 120 secs. If this filling takes place between 40 – 120 secs it means there is mild venous reflux across early leaky valves. If this venous filling takes place between 20 – 40 secs then there is sufficient venous insufficiency due to a failure of the valves in the superficial and the perforating venous systems. These patients have leg cramps, restless legs, burning leg pain, and premature leg fatigue. Should the VRT be less than 20 secs? It shows high venous reflux from the superficial, perforating and the deep veins. These patients are symptomatic. Patients with VRT less than 10 seconds mostly have venous ulcers.
This detects the obstruction to the venous outflow in the leg irrespective of the cause. The results show the speed with which blood flows out of a maximally congested leg when an occluding tight tourniquet is suddenly removed. It detects occlusions in the calf veins, iliac veins, and IVC where colour Doppler and venography are insensitive. The test is not very sensitive with partial obstruction and reflux-induced venous insufficiency. A normal MVO does not rule out DVT categorically.
It detects the failure of the calf muscle pump to expel blood from the lower leg. The patient stands on the toes 10 – 20 times or dorsiflexes the ankle. The change in blood volume within the calf muscles is recorded as the calf muscle is pumped. Normally in 10 – 20 ankle dorsiflexions the calf muscles empty. In patients with calf muscle pump failure or severe proximal obstruction or severe deep venous insufficiency, there is little effect on the calf muscles.
Content Reviewed by – Dr. Jaisom Chopra