Blood circulates from the heart through the body and back via a complex vascular network, pumping out from the heart through arteries and back from distant organs and muscles through veins. When this constant flow is disrupted at any point, problems will arise, and may lead to serious complications.
Most commonly, blood flow returning through the heart from the lower body may be disrupted due to a variety of conditions that affect veins and limit their ability to transport blood. The results of venous insufficiency can range from varicose veins to very serious blood clots that originate in the legs and can travel to major organs such as the lungs.
In this episode of Kentucky Health, Dr. Wayne Tuckson speaks with a Louisville vascular surgeon to learn more about the various types of venous disease, the effects of venous disease on the cardiovascular system, and treatment options for patients.
Dr. David Lipski is a vascular surgeon with KentuckyOne Health Vein Care Associates in Louisville. He began his medical career focusing on arterial disease, but a few years back switched his concentration to vascular disease and is one of Kentucky’s leading experts in that specialty.
Lipski says the majority of people who come to see him with venous disease have problems in their legs. Specifically, they are having weakness, throbbing, and pain due to the inability of their veins to properly push blood upwards toward the vena cava, which are the two main veins that lead from the lower and middle body to the heart.
“You may wonder, ‘How does your body get blood to flow uphill?’” Lipski says. “Well, there are a couple of things, but one of the more important things is, we have a series of one-way valves on the inside of our veins. The vein valves open to allow the blood to pass upward, in the correct direction, and then they close to prevent the blood from flowing backwards in the incorrect direction.
“When everything works well, the system is fine,” he adds. “But when those vein valves fail, the veins tend to get big, they dilate and become varicose, and then that can lead to either symptoms or unsightly veins.”
Pumping Difficulties Lead to Blood Backup
Lipski explains that although heart muscle contractions drive blood away from the organ through the arteries and into the tiny capillaries throughout the body, the heart rhythm is not forceful enough to pump blood from veins in the lower body back up to complete the cardiovascular cycle. Instead, the calf muscles in our legs contract and push the blood through the veins. Vascular physicians use the term the “calf muscle pump.”
“That’s a very important mechanism, and it becomes obvious in people who, for a number of reasons, can’t move their legs,” he says. “Maybe they’re in a wheelchair, or they’re weakened, or they get an ankle fusion surgery, and their calf muscles don’t work, and they often get swelling because of it.”
Roughly 90 percent of the blood carried upwards to the heart is done so via deep veins embedded in the leg muscles, Lipski says. These deep veins are the primary area where a blood clot can form due venous insufficiency – what is called a deep vein thrombosis. If such a clot breaks free and makes its way up to the lungs, it can cause a pulmonary embolism, which is potentially a life-threatening event.
“A pulmonary embolism is just a fancy name for a blood clot that started somewhere and traveled, in this case, to the lungs,” Lipski says. “And it’s the deep veins that are larger, and they’re the ones that are really involved with the health of the leg, and so when people get clots in the deep veins, they need blood thinner medicine.”
There are many other veins in the legs – called superficial veins, ones that are visible – that may also be affected by venous insufficiency. The two most common conditions are spider veins, which form within tiny capillaries in the skin itself, and varicose veins, which form in larger veins just underneath the skin.
Both of these conditions are, for most people, unsightly and an aesthetic concern at worst. But for some people, they may present symptoms such as throbbing, leg weariness, and pain. Varicose veins may also be an indication of more serious cardiovascular problems.
Spider veins appear as tiny, twisting, purplish lines on the surface of the skin. In extreme cases, the backup of blood in these tiny veins can burst through the skin, but the main symptoms are itching and a burning sensation.
Varicose veins are bluish and bulge from underneath the skin in what Lipski terms a “snake under the blanket” appearance. He says that 60 to 70 percent of patients who consult him for treatment for either spider veins or varicose veins have them on their inner thigh or upper calf.
As for the primary cause of venous disease, Lipski says, “We really don’t know.” Genetics and age are factors, as is obesity, he explains. Many people have one or both conditions but feel no discomfort, he adds, and he also says the threat of developing blood clots from either spider veins or varicose veins is very low, and is not by itself a sufficient reason to perform surgery.
Treatments for Peripheral Venous Disease
Lipski says spider veins are treated by an outpatient procedure called sclerotherapy. Using a very small needle, the physician injects medicine into the spider vein, which seals it. Sclerotherapy is a minor procedure with good results in both improving the cosmetic appearance of a patient’s leg and alleviating pain.
Sclerotherapy can also be used to treat varicose veins, and other options are laser or radiofrequency surgery. Overall, if a patient chooses to undergo treatment, the outlook is good, Lipski says.
“There are a number of tricks that we have up our sleeve that we will use to correct that vein problem, and which one we use often depends upon the pattern of vein abnormality, and a person’s preference,” he says. “They are not particularly painful procedures, they’re not disabling, they’re not risky, they work, and generally speaking, once we do the procedure, people’s risk of having veins come back is low, but not zero.”
Lipski also recommends the use of compression stockings for patients with spider and/or varicose veins, usually as a first step. He says that they will relieve discomfort but will not eliminate the veins or prevent more from forming. With regards to sitting for long periods, as happens often during air travel, he advises people to wear compression stockings and to do small foot exercises to get the calf muscles pumping.
Other conditions associated with peripheral venous disease in the leg include dermatitis (when pressure in varicose veins causes inflammation on the skin), hyperpigmentation (when over-pressured veins cause blood to be released and metabolized outside of the vein, resulting in a brownish coloring), and ulcers (which may indicate the present of a blood clot).
Lymphedema is swelling in the legs caused by a backup in the lymphatic system. Lipedema is swelling caused by an uneven fat distribution that most commonly manifests itself in severely enlarged leg calves. Lipedema is very diet-resistant, Lipski says, and mainly affects women.
