The Big Picture on Vein Disease and Leg Swelling

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“Why are my legs swollen?”  In this blurb I’m going to hopefully give you the big picture on a very common complaint, leg swelling (edema) that tends to go right along with venous disease.

When I give talks on venous disease of the legs, I emphasize that I believe one of the most important things I am trying to accomplish is educating patients on the importance of recognizing signs and symptoms of problems early when treatment can produce rapid recovery and return to function.  Doing this can prevent progression to advanced stages when recovery and improvement can be lengthy.   In addition to explaining the possible health consequences that could result from ignoring serious signs of developing vein disease in their legs, I like to focus on just how effective, well tolerated and elegant that modern vein procedures really are.

In most advertising for vein clinics (mine included!), you will see some version of “leg swelling?” being asked.   The typical pattern of swelling that is associated with what I treat (venous insufficiency) usually begins around the ankle and progresses up the leg.  Usually, this swelling tends to increase during the work day and decreases overnight or with simple maneuvers such as leg elevation.  Over time, swelling is noted to occur on top of the foot as well.

From here, keeping an eye on the big picture is challenging to say the least.  Figuring out the cause of swollen legs can be a complicated affair and frustrating for patients and physicians.   It’s very much like that scary forest right outside the Emerald City on the Wizard of Oz.  The second you walk into the trees it gets dark.  And thick.  So off we go.

First of all, when I see a patient for evaluation of a swollen leg, it is usually after studies searching for urgent situations such as acute deep venous thrombosis (DVT) have already been performed.  This is not always the case however.   Sudden swelling that occurs over hours to days is termed “acute” and if from a venous cause, is usually due to either a DVT in the leg or other obstruction higher up the venous circulation in the abdomen or pelvis.  These problems are usually managed in the hospital setting.

Leg swelling that occurs over a longer period of time, weeks to months, is termed “chronic” and when a patient comes for treatment, early investigation should start.  The most important thing to remember is that the longer swelling is allowed to continue without treatment, the more likely it will potentially become permanent.

My focus at Precision Vein Therapeutics is sorting out whether or not a swollen leg is the result of a vein that is not doing its job.  I perform a thorough venous ultrasound of both deep and superficial leg veins to determine this.  This exam is noninvasive and done right in our clinic on Watermelon Road.   The amount of information about the venous circulation that can be obtained from this elegant test is truly amazing.

In the setting of saphenous vein reflux, which I detail on the vein disorders and treatment pages of this website, mild to moderate swelling that follows the pattern I mentioned above, (gets better overnight), after treatment with endovenous laser ablation, typically resolves.  Longer standing or more extensive swelling that tends to remain unchanged over night on average may improve after correction of saphenous reflux, but in a percentage of patients, will need further management to deal with.   This is where the woods get dark and deep.   In medicine, we like to blame a set of conditions on one cause.  The swollen leg is a big ugly example of the situation where there can be multiple contributing causes.   It’s very important in cases of severe edema and venous insufficiency to help patients set realistic expectations.

The lymphatic system of the body is an extremely important little machine and it doesn’t get much air play.   For all practical purposes, it is microscopic, but it is the hardest working system in the body for its’ size.  It is responsible for collecting the plasma portion of the blood that is filtered out between arteries and veins at the cellular level.  Okay, there it is, we just lost the sun.  Walk with me in the dark for just a second.

There are many different medical and structural issues that can affect the load on the lymphatic system’s fluid transport ability and when it can’t keep up, you guessed it, edema happens.  The lymphatic system itself can have abnormalities that affect its ability to function correctly.  There’s even a little roundworm that is transmitted to humans by mosquitos mostly in tropical countries that has an appetite for human lymphatic vessels and basically destroys them.  Outside of developed countries, this is the #1 cause of lymphedema in the world.  120 million people have this.  120 million.  There are effective treatments but I’d still take some Deep Woods Off if you plan to go down there.  Here’s a classic example.

 

 

 

In developed countries, the #1 cause of lymphedema is obesity.   There are even some medications that can cause lymphedema.

I mention all of this mainly because of what I mentioned earlier.  Expectations. There is no question that venous insufficiency can cause or contribute to leg edema.  If I’m asking in my advertising if you have swollen legs then you might have venous disease, I better know what your next stop needs to be if you don’t.

The good news is that for patients clinically diagnosed with lymphedema, there are treatments available to help manage the disease.   There are lymphedema clinics that specialize in this very issue.

This brings us right back around to what I mentioned at the beginning of this.  Job #1 for me is providing education and awareness of the resource that Precision Vein Therapeutics can offer patients in terms of thorough evaluation for the presence of treatable venous disease, and then offering those definitive, effective outpatient treatments in the same office-based setting.  For those patients with a family history of venous disease, living with chronic leg and ankle edema, thinking it is just a sign of aging, working too hard or it’s something that just “runs in my family”, understand that waiting can be a very bad thing.   Make an appointment and get treatment.

That’s the big picture.

Michael R. Barlow MD, RPhS

Precision Vein Therapeutics

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Pregnancy and Varicose Veins

Let’s Get Started

I wanted my first entry into the Precision Vein Therapeutics website blog to focus on the topic for which I receive the most questions.  Without a doubt, it’s pregnancy and varicose veins. It’s a great place to start because this is pretty much where all things bad with veins in women begins.  

First of all, we know that heredity is the most important risk factor for developing venous problems, for men and women.  “It’s baked in the cake” as my old friend and mentor Dr. Michael Manning would say. For women though, there’s no denying that pregnancy is a very close second place.  Population studies have found only 12% of women with varicose veins have never been pregnant.  It’s a double whammy at this point for women.

What is it about pregnancy that causes vein problems and varicose veins?  

Hormonal factors are primarily to blame.  Of patients that develop varicose veins during pregnancy, 70-80% appear during the first trimester when the uterus is only slightly enlarged.  Only 1-5% of patients will develop them in the third trimester. Circulating hormones increase distensibility of the vein walls and soften vein valve leaflets which does accommodate the natural increase in blood volume, but also allows blood to collect in the leg veins, increasing the venous pressure, and resulting in dilated “varicose” or spider veins at the surface.  Late in pregnancy, the enlarged uterus compresses the inferior vena cava, further increasing venous pressure, and contributing to the distention.

If I develop varicose or spider veins during pregnancy, should I get treatment?

Most sources dance around this issue. The newest recommendations state that Interventional treatment for varicose veins during pregnancy should only be carried out in exceptional circumstances.  Other sources suggest avoiding treatment during pregnancy except for unavoidably urgent cases. Good luck finding examples of these circumstances or urgent cases. In this country it’s all about medico-legal issues.  In general, physicians stay away from elective (non-emergency) procedures during pregnancy primarily due to the concern for premature labor. In addition, pregnancy by itself is well recognized as increasing the risk for deep vein thrombosis (DVT) and pulmonary embolism (PE).  In the event a pregnant patient treated with sclerotherapy developed a DVT or a PE, the treating physician would be in a difficult position due to the uncertainty of what caused it; pregnancy itself, or the sclero. Short answer: No, not with sclerotherapy or endovenous laser ablation.  There are effective conservative treatments which I will discuss below.

What if I discover I become pregnant in the midst of treatment?   

Having said all of that in the last paragraph, here’s the good news.  Thousands of women have been safely treated with sclerotherapy during pregnancy and physicians around the world continue this practice.  There currently is no evidence that this is unsafe or harmful in any way. In the US, treatment would be discontinued but the patient would be reassured that almost certainly there would be no impact on her pregnancy.  

The current recommendation is that interventional treatment including sclerotherapy is to be avoided in any patient known to be pregnant, who has indicated that she is actively attempting to become pregnant, or who has been pregnant in the last three months.  

Is there anything that can be done?  I’m miserable!

More good news.  Wearing compression hose dramatically reduces symptoms and swelling due to the effects of pregnancy on the venous circulation.  Compression minimizes dilation of superficial veins and maintains the vein valvular competence, reducing the likelihood of permanent damage.  It can also reduce or slow the process in future pregnancies.

Understand that in even severe cases of varicose veins during pregnancy, most will completely clear spontaneously after birth.  There is a catch however.  We know that with each successive pregnancy, the risk for developing ongoing varicose veins increases.  There is a study that looked at 400 women with varicose veins. Out of the 400 pairs of legs, 13% had been pregnant once.  30% of them had been pregnant twice. 57% of them had been pregnant 3 times.  Ouch.

We recommend that to reduce the likelihood and severity of varicose veins, all pregnant patients should use graduated compression hose as tolerated.  It’s important to get measured by a trained fitter for proper fit and purchase a good quality hose as they will be somewhat easier to put on and more comfortable.  Inexpensive compression hose typically has fabric with less stretch and will just make you more miserable! At Precision Vein Therapeutics, we stock Juzo brand compression garments and all of our staff are trained fitters.  

The regimen we recommend is at the first indication of pregnancy, 20-30 mmHg graduated stockings as thigh highs or panty hose should be fitted.  In patients with multiple pregnancies, or those with previous history of varicose veins, stronger 30-40 mmHg compression stockings should be worn.  In women with large legs or those who are unable to tolerate the higher pressure 30-40mmHg stockings, calf-length 20-30mmHg can be worn over 20-30mmHg thigh highs or panty hose.  

Here in the South, we have to live in the real world come July-November.  Combine this with a third trimester pregnant Alabama girl and you can get critical load on the power grid.  Who cares about varicose veins when you are in close orbit around the Sun. In that situation, even lighter 25mmHg stockings can reduce significantly the discomfort and ankle edema during the third trimester of pregnancy.  

We are trying to slow down the clock here and make the ride easier.  Understand that there’s no way to completely prevent varicose veins but we know that you can delay or slow progression.

Other helpful conservative measures are staying active, exercise as recommended by your OB/GYN and elevating your legs when you can.  

Hey these varicose and spider veins are not going away like you said they should.   How long do I have to wait before I get them fixed and would it be better to wait until I’m completely done with having babies?  

We approach the evaluation of residual varicose veins after pregnancy the same way as any patient, male or female, with venous disease.  In addition to a careful history and physical, a duplex ultrasound exam is done to evaluate the lower extremity veins to determine underlying cause of the dilated veins or spider veins.   After delivery, at Precision Vein Therapeutics, we recommend a full 6 months prior to evaluation and treatment of ongoing varicose veins. This allows time for natural postpartum improvement to occur and for enhanced effects of pregnancy on the clotting system to normalize.    

We know that spontaneous clearing can occur for up to a full year after delivery but important factors such as severity of symptoms, risk of superficial thrombophlebitis, potential of hemorrhage from exposed varicosities and overall decrease in quality of life must be considered and patients are counseled concerning these issues.  

At Precision Vein Therapeutics, if major reflux is noted in the superficial saphenous system after pregnancy and continues for 6 months, interventional treatment with endovenous laser ablation and/or sclerotherapy is typically performed.  This will prevent reflux in the treated saphenous vein in future pregnancies.

Can I have sclerotherapy if I am still breastfeeding at 6 months?  

There is no factual evidence as to the safety during breast feeding of modern sclerosant agents to treat varicose or spider veins.  Even having patients use a breast pump and discarding an amount while waiting a period of time to resume breastfeeding should be avoided because the true half-life of sclerosants in breast milk is unknown.  Sclerotherapy is generally not performed while a patient is breast feeding.

I have a varicose vein on my leg that seemed to have come up over a couple of days.  Is this normal?

As I stated earlier, pregnancy itself is a risk factor for deep vein thrombosis.   The sudden onset of a dilated varicose vein could indicate the presence of an obstruction to the outflow of blood from the leg, producing a back-pressure effect on superficial veins.  This obstruction could potentially be a deep vein thrombosis and the sudden onset of the varicose vein at the surface might be the only sign. Certainly, any pregnant patient who reports acutely changing varicosities or varicosities associated with leg pain or swelling should have a duplex ultrasound examination to look for DVT.  

I hope this information is helpful.  If you would like to schedule an appointment for evaluation, please call our clinic at 205-710-3800.  We look forward to meeting you!

Michael R. Barlow MD

Precision Vein Therapeutics, Inc.