Venous reflux disease, also known as venous insufficiency, is a medical condition affecting the circulation of blood in the lower extremities. Normally, one-way valves in the veins keep blood flowing toward the heart against the force of gravity. When the valves become weak and do not close properly, they allow blood to flow backward and this is a condition called reflux.
Venous reflux disease can produce a number of clinical problems for the patient and can significantly impact a person’s lifestyle, especially when the person’s job requires extended standing or sitting. The more serious symptoms include edema, skin changes, venous ulcers and venous reflux disease commonly produces varicose veins which are abnormally swollen and discolored superficial leg veins.
Venous system anatomy
The veins in the lower limbs are classified into two systems:
- Superficial veins
- Deep veins
The two systems are connected by perforating veins that pass through the deep fascia, which is a sheet of fibrous tissue that envelops the body beneath the skin and also encloses muscles and groups of muscles.
Three factors influence the return of blood back to the heart:
- Respiration – the movement of the diaphragm causes pressure changes in the chest and the diaphragm as it moves up and down causes pressure changes in the abdomen effecting venous blood flow.
- Inspiration, which decreases intrathoracic pressure increases flow from the upper extremities. With inspiration the diaphragm moves down increasing intra-abdominal pressure and decreasing venous return from the leg.
- Expiration increases intrathoracic pressure slowing flow from the upper extremities but relaxes the diaphragm and abdominal pressure. Flow goes to the heart from the leg.
- Vein Valves – healthy valves close, preventing blood from refluxing or pooling
- Venous Muscle Pump – action of the calf muscle helps to force blood upward
In the absence of other symptoms, patients with cosmetic concerns due to the presence of spider veins are usually evaluated with only a physical examination. However, patients presenting with more serious symptoms of venous insufficiency should undergo an in-depth evaluation by a vascular specialist which should include a supine and standing duplex ultrasound study. These symptoms include:
- Leg pain, aching, tired or weak legs, especially after long periods of standing or sitting
- Varicose veins
- Burning or itching of the skin
- Swollen legs and/or swollen ankles
- Color and texture changes of the skin
- Open wounds (skin ulcers)
- Recurrent thrombophlebitis (blood clots in the varicose veins)
- Spontaneous hemorrhage when the skin gets too thin and the vessel erodes through the skin
Varicose veins are superficial veins that have expanded in response to increased pressure caused by incompetent or absent valves. Progressive vein dilation eventually prevents the valve from closing properly resulting in reflux. Alternatively, a lack of competent valves can also cause dilation of the vein.
Leg or ankle swelling (edema) with and without skin changes
Edema and swollen ankles are the next progressive state of venous insufficiency and occur as the result of venous hypertension. This can cause leg or ankle swelling and changes in skin pigmentation. Severe pain and discomfort are typical of these conditions, particularly in the calf and ankle. Open ulcers do not heal if the ankle is swollen.
Active & healed venous ulcers
Venous ulcers indicate the most severe form of venous insufficiency and may involve both the deep (including perforating veins) and superficial vein systems. Extreme reflux and venous hypertension result in changes in the passage of blood in the smallest vessels (capillaries) of the skin and eventually leads to severe venous ulcers.
Diagnosis of venous reflux disease is easily made by a physician during a clinical examination and confirmed by a non-invasive ultrasound examination. The patient is examined both supine and standing as venous reflux can only be accurately diagnosed with a standing venous duplex Doppler.
Once the diagnosis is made the treatment can range from something as simple as wearing medical-grade support stockings to endovenous laser treatment of veins to prevent flow through leaky valves.
When we walk a pumping action of the feet will cause the calf venous muscle pump to force upward movement of the blood in the vein. One-way valves at multiple levels in the vein help movement of the blood against gravity. When valves in the vein are defective, the blood leaks (venous reflux) and instead of moving upward toward the heart the blood pools in the leg causing venous stasis or venous congestion, then stasis pigmentation and loss of subcutaneous tissues under the skin (atrophie blanche and lipodermatosclerosis) and then ulceration.
When sitting for long periods of time or traveling long distance, one should walk every hour or, if unable to do so, pump the feet up and down 20 times every 30 minutes. This will cause the venous muscle pump to do the work as if walking.
The use of support stockings can help but before using medical-grade compression one should be certain the arterial flow in the leg is adequate. Consultation with a vascular specialist will determine if medical-grade compression is appropriate and what strength of compression is best in your particular case.
If you have really severe problems and venous ulcers or significant skin changes, such as increased pigmentation, eczema or ulcers,you absolutely must follow this link to the water-tower effect and how it works in you. You must thoroughly understand what is in that section.
We hope the information on these pages is both informative and helpful, but it is intended for education only. Please do note that no web site, no matter how much information is shared, can replace a consultation with your doctor and a vascular specialist. Medical technology and treatment are continually improving and evolving so before making any decision on treatment, it is always advisable to see your doctor first for a comprehensive evaluation of your vascular disease and other medical conditions.
At the Vascular Center of Wichita Falls, we work closely with your other physicians. If you have concerns about your arteries or veins, contact us. A referral is not necessary to make an appointment.