Venous insufficiency (VI) is one of the most ignored diseases. Physicians´ and people´s belief is that
- VI is mainly genetically determined,
- there is no way to prevent it
- invasive therapy should be delayed as long as possible as it has significant risks.
The introduction of endovenous modalities reduced the risks, but overall expenses for invasive treatments are rising, and patients are still not offered effective therapy until they show serious problems or at least large varices.
Current efforts are on safety and patient comfort of endovenous methods, like with the second and third generation of vein gluing, the combination of sclerotherapy and compression film bandage, perivenous hyaluronan or novel protein-enforced microfoam.
While it is good to improve ablation techniques, it may be much better to reduce the need for it, starting with the early stages. (Innovation in Phlebology / The Future of Phlebology, Johann Christof Ragg, Venous Interventions I, Main Ballroom, May 5, 2019).
So What is Chronic Venous Insufficiency (CVI)?
Veins are in charge of transporting blood uphill, back to the heart. It’s a one way system with valves at every 0.5-1cm increments.
Varicose veins indicate these valves are not closing properly, causing the pressure in the veins to increase (mainly starting in the lower legs) forcing blood into the tissues, resulting in first, a bluish discolouration on the skin as the blood pools in the tissues to later causing a brownish discolouration which indicates hemosiderin deposition. Highlighting the venous insufficiency and need for treatment.
These changes initiate a vicious cycle that causes further damage to the veins with increased valve insufficiency.
CVI is classified into different severity levels:
- Reversible oedema, dark blue skin discolouration at the medial and lateral edge of the foot.
- Irreversible oedema: hemosiderin deposit, dermatosclerosis, varicose eczema, cyanotic skin colour, severe tissue tension, and phleboedema
- Ulcus cruris (ulcers)
- Positive family history, age, and lack of exercise are considered risk factors.
What are the early signs of CVI?
What are the early signs of Chronic Venous Insufficiency?
Spider & Varicose Veins ~ Spider Veins are small damaged blood vessels. Can be caused by either sitting or standing for long periods constantly, adults of a mature age, pregnancy can be a cause or due to injury.
Varicose veins are a clear indication of damaged valves within the blood capillaries and are a clear sign of venous insufficiency.
Skin Discolouration Blue/Brown ~ The bluish skin is a sign of initial leakage into the tissues, the brownish discolouration is that of iron rich blood that has settled into the tissues (hemosiderin staining)
Some common conditions associated with hemosiderin staining include:
- trauma
- leg oedema
- diabetes
- cardiovascular disease
- high blood pressure
- venous ulcers
- venous hypertension
- vein insufficiency
Swelling ~ dynamic oedema particularly at the end of the day. Reversible by elevating your legs in early stages. If irreversible it is developing into more severe stages.
Ulcers ~ This is in fact more towards the later stages, but an identifiable reason for treatment urgently. However, treatment differs to the type of ulcer/s. Venous ulcer compression is ok, Arterial Ulcer is a definite NO for compression, until it has healed.
What is Phleboedema?
What is Phleboedema?
Long term overload of the lymphatic pathways is considered the cause of phleboedema. Particularly during the second half of the day, the patient suffers stasis and swelling in the legs. Once the tissue is chronically indurated, the lymph vessels are damaged.
A positive stemmer sign confirms lymph drainage disorder that leads to oedema. Therefore diagnosed as Phleboedema.
Stages of CVI turned Phleboedema
Stages of Chronic Venous Insufficiency (turned) Phleboedema
Stage 0 – Latent
- No symptoms
- No visible/palpable oedema
- Lymph-vascular compensation of ambulatory venous hypertension.
Stage 1
- Overnight reversible perimalleolar oedema (mild)
- Corona phlebectatica (ankle flare)
- Dynamic insufficiency of the lymphatic system
- Reduces with elevation
- Low-protein oedema
- Upon waking in the morning the limb or affected area is almost a normal size.
- Mild pitting in lower leg / ankle
Stage 2
- Persistent oedema up the middle of the lower leg
- Hyperpigmentation (purple/browning colour)
- Safety valve insufficiency of the lymphatic system
- Irreversible oedema (moderate)
- Accumulation of protein rich edema fluid
- Deep pitting oedema mostly in lower leg / ankle
- Varicosis
- Hemosiderin deposits
- Sensation of heaviness / tension / leg cramps
- Elevation of leg relieves condition
Stage 3
- Ulceration
- Compartment Syndrome
- Drop Foot
- Fibrosis and sclerosis (severe induration)
- Skin changes
- The tissue at this stage is hard (fibrotic) and will only be slightly responsive to the touch.
Complications
- Thrombosis
- Embolism
- Ulceration
- Phlebitis
- Phlebolymphoedema
Treatment for CVI / Phleboedema
Treatment for Chronic Venous Insufficiency / Phleboedema
Ultimately, treatment for Phleboedema requires a detailed study of what may be occurring beneath in your tissues, reasons why it has occurred and treating the cause not just the symptoms. An MLD massage here and there weeks apart, will likely not have an affect. Similar to Lymphoedema but
Treatment may include:
- Manual Lymph Drainage (if acute thrombosis must wait 4-6 weeks)
- Compression
- Bandaging in oedema reduction phase
- Circular knit garment in maintenance phase
- Elevation of limb
- Muscle pump exercises
- Surgery for varicose veins
- Treatment of eczema and ulcers
If left untreated , it can cause painful swelling, ulcers and open sores, which can lead to infection, or progress to a life-long painful condition called Post Thrombosis Syndrome with continued high risk of other thrombosis.
Treatment options available in clinic with Sal
- (MLD) Manual hands-on lymphatic Drainage
- Combined (MLD) & Pneumatic Compression Pump
- Pneumatic Compression Pump only sessions (45mins)
- Decongestive Therapy – Bandaging & Garment prescription
- Scar & fibrosis management
- Low Level Laser Therapy
- Muscle & Myotherapy treatments (see muscle pages for details)
Garment Recommendations
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