Causes

Why does it happen?

There are two basic causes of venous hypertension :

  • Blockage of the veins
  • Incompetence of the valves within the veins.
  Superficial veins  Deep veins
  Blockage  phlebitis  Deep vein thrombosis (DVT)
  Incompetence  Varicose veins  Chronic venous insufficiency (CVI)

How do they present?

  • Dull Ache
  • Swelling
  • Heaviness
  • Night cramps
  • Leg tiredness
  • Restless legs

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.

Who is more prone to venous hypertension?

  • Age – incidence increases with age
  • DVT – Causes dilatation of the vein due to blockage leading to increased venous pressure.
  • Sedentary life – By this, the pump action of the calf muscles is minimized causing stagnation of blood and thus venous hypertension.
  • Obese women – it is commoner.
  • Prolonged standing jobs – lead to increased venous pressure.
  • Smoking – Higher incidence in male smokers.
  • Pregnancy – is an important causative factor.

How common is it?

  • 2 – 5% of all adult population suffers from CVI
  • Varicose veins present in 7 – 60% of the adult population and 40% of them have venous reflux.
  • Venous stasis is seen in 3% of the population
  • Hospital admission for CVI is 92/100,000
  • The incidence of CVI is higher in industrialized nations than in developing countries due to differences in lifestyle and activity.

What is the sequence of events in venous hypertension?

  • Venous hypertension increases the morbidity and disability of patients with venous disease. If no treatment is done the condition only worsens due to the progression of a disease. The skin eventually breaks down and venous ulcers result. These ulcers are recurrent. This is preceded by thickening of the skin or lipodermatosclerosis.
  • Chronic non-healing ulcers increase the morbidity and only heal if the reflux is totally eliminated.
  • Tissue atrophy and colour changes are not reversible.

Why are there colour changes and ulcers around the ankle?

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.

How do you diagnose venous hypertension?

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.

  • Colour Doppler study

    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

  • Venography

    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.

  • Venous Plethysmography

    here infra-red light assesses the capillary filling during exercise. An increased capillary filling is indicative of venous reflux and thus incompetent veins.

  • Physiologic venous function tests

    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.

    Maximum venous overflow (MVO)

    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.

    Muscle Pump Ejection Fraction (MPEF)

    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.

What happens if I do not treat venous hypertension?

  • There is an increased lifetime risk of DVT and PE.
  • Amputation is needed in 1.2% of the people
  • Overall mortality is 1.6%
  • 50% of patients with untreated varicose veins develop thrombophlebitis at some time.
  • 45% of patients with superficial phlebitis have unrecognized DVT.
  • The risk of DVT is 3 times higher in Varicose veins patients.
  • Venous hypertension patients on bed-rest and allied illnesses are prone to DVT.
  • Phlebitis develops in 60% venous hypertension patients and 50% of these patients develop DVT.
  • The incidence of PE is higher in venous hypertension patients developing DVT (50%) and the death rate is also 1 in 3 from PE.
  • Venous Hypertension patients die from haemorrhage due to bleeding varices.