Varicose Veins and Chronic Venous Insufficiency

What is Venous Disease

Healthy blood circulation relies on good blood flow to and from the heart. This requires a strong heart and healthy blood vessels. When blood is returning to the heart via the venous system, we need healthy one-way valves too because very often this return blood flow is against gravity. The one-way valves within the veins make sure that blood is efficiently transported back to the heart rather than refluxing backwards.

Circulatory problems develop when either the heart, vessels or valves are diseased or damaged. Varicose veins and chronic venous insufficiency are problems that occur with the venous system or the blood return system.

A patient with superficial varicose veins might still have adequate blood flow out of the legs and would therefore not be diagnosed with chronic venous insufficiency. And vice versa, a patient with chronic venous insufficiency might not have any visible varicose veins. However there is frequently an overlap in these two conditions.

Chronic Venous Insufficiency (CVI) is a mechanical condition that occurs when the venous (vein) wall and/or the valves in the leg veins are not working properly. Blood that should be going efficiently back to the heart is unable to do so because the one-way valves in the vein are not closing properly and/or because the vein wall itself is out of shape. This causes the pressure within the veins to increase and blood to stagnate in the affected area.

CVI is predominantly a genetic condition aggravated by standing and sitting for long periods of time. It can also be caused by deep vein thrombosis (DVT) and injury. Our blood vessels do naturally deteriorate as we age so a certain amount of age related venous disease is normal.

Varicose veins, also a genetic condition, tend to be more superficial or closer to the surface of the skin.

Chronic Venous Insufficiency and Varicose Veins do not develop overnight but are problems that usually start when a patient is in their 30’s or 40’s. Unfortunately most patients only seek medical advise much later when they have pain, discomfort, visible changes in the skin and perhaps a wound that fails to heal normally.

Both conditions are progressive which means that without treatment they will get worse. Early diagnosis, correct treatment and good patient compliance with treatment can halt progression and maintain the health of the venous system.

Symptoms of Venous Disease

  1. Itching caused by stasis dermatitis. Why does this happen? Deoxygenated blood carrying the waste products from cell metabolism is toxic to the skin. When blood remains in the tissues rather than being returned to the heart, it causes inflammation, and breakdown in the skin. The very first signs of stasis dermatitis are scaly itchy skin and dark pigmentation to the skin between the ankle and calf muscle. Untreated, the skin becomes fragile and can weep clear fluid and form a crusty scab. No amount of cream or skin care will resolve this itching as the problem is coming from within the skin itself. It is often after scratching and removing the crusty scab that patients develop their first wound related to the CVI.
  2. Hemosideran staining is a permanent stain or brown pigmentation to the leg between the ankle and calf muscle. Why does this happen? Because our blood contains a red pigment that stains the skin when it is sitting too long in the lower leg.
  3. Varicose Veins: Superficial varicose veins affect the veins closer to the surface of the skin. A weakness in the wall of the vein causes bulging and twisting of the vein and this affects the functioning of the valves. The body can usually find alternate routes to transport the blood back to heart. It is therefore common for patients to have varicose veins safely removed or treated with sclerotherapy. Varicose veins give a good visual idea of how the structure of the vein is compromised.
  4. Painful, burning sensation and heaviness in the legs that is aggravated by sitting or standing. 
Hemosideran Staining Between Ankle and Calf Muscle
Superficial Bulging of Varicose Veins

Treatment Protocol – Compression Therapy

Compression therapy is the world standard in care for varicose veins and chronic venous insufficiency. By applying external pressure to the skin, we can improve the internal shape of the vessels and the functioning of the valves within the veins. Compression is applied using bandages and compression garments and stockings. A qualified therapist must fully assess the problem and prescribe the correct compression accordingly. Too little pressure will be ineffective and to much pressure places the patient at risk of injury. 

Patients who have had veins removed or treated with sclerotherapy are advised to wear compression to support their venous system, as a preventative treatment against future venous problems and to avoid progression of the existing weakness in the venous system. 

Untreated CVI and varicose veins eventually places a strain on the lymphatic system and patients with long-standing, inadequately treated venous disease will go on to develop chronic swelling too. This is then reclassified as phlebolymphedema. 

Types of compression.

Circular Knit Garments are seamless garments that resemble a tube of elasticated fabric. Circular knit garments resemble a fashion stocking but they are engineered to exert more pressure at the point furtherest from the body and gradually less pressure closer to the body (this applies to all graduated medical compression). Circular knit garments are ‘action’ garments and should be worn during the day when the patient is active and moving. They have a High Resting Pressure which means that when the muscles are not moving (i.e. the patient is asleep) the elasticated fabric pushes down strongly. They are therefore not prescribed for nighttime use. They are not prescibed for patients with skin folds and lobules as they tend to cut into any area of skin that is creased or crevassed. Circular knit garments tend to be very stretchy in all directions. They are ideal for travel stockings, mild-moderate venous disease and mild swelling. It takes some effort and skill to donn (put on) a circular knit garment.

Flat Knit Garments have a seam because the compression fabric is manufactured resembling a piece of flat material. It is then sewn into the desired shape. Flat knit garments are stiffer and do not stretch in all directions. They hold their shape well and tend not to band or fold. They are easier to donn and doff and are more comfortable and durable. They can be custom made to fit any shape and size. They are however more expensive that circular knit garments and they look ‘thicker’ which is visually off-putting to patients. However, once patients have experienced flat-knit compression, they tend never to go back to circular knit.

Velcro Garments are the latest in compression technology. They look good and they are very easy for the patient to apply and give great results providing the patient is able to get the compression gradient correct. They are expensive and need to be replaced often. As the velcro ages is can get noisy and loosen easily. 

Short Stretch Compression Bandage With Foam is used when the patient has swelling. The foam layer is there for comfort and to keep the compression value of the bandage applied by expanding as the swelling reduces. Without the foam a bandage will easily fall down after a few hours of swelling reduction. 

Short Stretch Compression Without Foam is used during the healing phase of treatment for patients with chronic wounds or venous stasis ulcers, providing they don’t have extensive swelling. Moist wound care is applied to the wound itself and then the compression bandages are applied last with a layer of protective cotton for comfort and protection. 

Short Stretch Compression Bandages are the most versatile and effective way to manage swelling and venous wounds. They are cost effective, easy to apply for the therapist and patient should they wish to learn. They are 100% cotton and can therefore be washed at high temperatures and reused many times. 

Elasticated Tape, more commonly known as kinetape, can be used on the fingers and toes as a short stretch compression bandage. It can also be used to wrap and compress smaller areas of swelling and if applied in a ‘fan-cut’ method, it can direct circulation in the desired direction.

How Fit Are Your Legs?

When it comes to our legs, there are many tell tale signs of venous and lymphatic stress long before the real diagnosable problems begin.

Be proactive, take the quick Vein Test below and see how you score. Prevention is better than cure.