Cairn at  the Pacific Ocean in LaPush, WashingtonChronic Venous Insufficiency

Chronic Venous Insufficiency

Chronic Venous Insufficiency or CVI is the failure of the valves inside the veins to shut fully and force the blood up to the heart.  Instead, the valves stay open and the blood falls down in the leg causing the leg to swell.  The lymphatic system helps the veins move the fluid in the system back to the heart.  Elevating the legs makes the swelling go away initially.  The lymphatics kick into overdrive or turbo and help prevent swelling in CVI, but over time (decades later) this system fails as well.

Once the lymphatics and valves of the veins have failed, the swelling no longer goes away and eventually, the skin allows fluid to accumulate which causes the skin to stretch out and the cycle continues.  The skin acts as if it says, "Come on in, there's room for more".  Eventually, the skin starts thickening and the swelling turns hard.  The skin color usually turns a reddish-brown color initially and then the color can turn purple. The skin shows more veins.  This problem is typically noted primarily below the knees.

A poorly healed thrombosis or blood clot is the most common cause of chronic venous insufficiency.   After a blood clot, the only technique beneficial in preventing edema is using the right compression.  According to Professor of Medicine, Michael Földi, M.D., of the Földi Clinic for swelling disorder treatment in Hinterzarten, Germany, with adequate compression a person will be able to control the swelling and will prevent a wound.

 

Loraine's blood clots

When I was 13, I fractured my left tibia when a boy's head smashed into my knee while he was being pulled on an inner tube behind a snowmobile machine.  The initial physician told me it was a sprain and I should walk on the leg.  However, two weeks later the second physician found the fracture and diagnosed me with blood clots in the leg.  So from the time I was 13, I have had venous insufficiency.

 

Physiology of blood vessels

A blood capillary is the very smallest blood vessel such as a vein or artery.   The blood exerts a force on the inside of the vessel wall which is known as the “Blood capillary pressure”.   This is like water exerting pressure on the inside of the garden hose when it is turned on.  Over a long time,  a stretch occurs to the wall of the blood capillary and it becomes more permeable due to increased blood capillary pressure.  The holes get bigger and more holes develop.

Signs of CVI

Due to the holes getting so big, the red blood cells can now leave the blood capillary and move out into the interstitium.  The interstitium or tissue space is the space that surrounds the vessels.   Hemoglobin can now come out to the interstitium with red blood cells.  Hemoglobin breaks down and converts to the protein hemosiderin which has iron in it.  The first sign visible of CVI is tiny red dots called petechia on the foot and lower leg.  Later a brown hemosiderin “stain” appears on the lower legs and eventually, the leg can turn red or purple.  This photo shows the petechia on my left forefoot and ankle.  The petechia makes the foot look dirty.   Notice the obvious swelling of the foot and ankle.  Typically the bones and tendons of my foot and ankle are visible but this photo shows they have fluid covering them.  If you look closely you can also see the tiny vertical lines on the forefoot from hammertoe repair surgery that was done in 1989.  The petechia started showing up at about age 45.

 

 

 

 

 

 

 

Swelling and petechiae-small red-brown                                       Less swelling after wearing compression socks

dots on forefoot indicating chronic venous insufficiency                    Petichiea are still present but lighter

Blood pressure in the lower leg

In an individual with chronic venous insufficiency, the blood pressures in the lower leg are the same as in a normal leg both when lying on your back and in standing without movement.  However, with walking, the venous pressure remains very high at 108 mm Hg (when normal is only 30 mm Hg).  The muscle pump of the calf normally helps to pump the fluid out of the leg and propel it back to the heart, which reduces the blood pressure in the lower leg.  However, instead of moving up toward the heart the increased pressure left in the leg is now forced out toward the skin which is called”blow-out”.

Damaged veins eventually result in valve insufficiency.  The valves of the veins normally close very tightly and help propel the fluid up toward the heart.  Because the muscle and joint pump of the calf are unable to cut this very high venous blood pressure in valve insufficiency a resistance or backup of fluids occurs in the venous system.  Anything blocking the venous system increases venous blood pressure and causes congestion which is similar to a traffic jam.

Development of wounds

Over time, without treatment using compression stockings this condition worsens.  Due to blow-out, skin cells eventually die and open wounds in the skin called venous stasis ulcers.  Compression is mandatory in treating chronic venous insufficiency, as compression prevents the dilation of veins under ambulatory conditions and during sitting.  Ambulatory venous hypertension is drastically reduced with compression.  Starling's Law of equilibrium basically says that the pressure on the inside and outside of the vessel wall is equal.  In other words, the body is working to prevent edema.

Valve insufficiency

There will not necessarily be significant swelling present with CVI.  Valves that are insufficient in veins do not close fully.  With varicosities, the valves do not even come close to touching due to the increased size of the vessel.  Valve insufficiency is present but no edema is seen initially secondary to the safety valve function of lymphatics and their ability to compensate.  The lymphatic safety valve function is basically a revving up of the lymphatics to accommodate a greater lymphatic load.  This carries more fluid back to the heart and out of the tissue spaces, which prevents edema.

After CVI is present for a long time, the lymphatic system that has worked in overdrive fails and fluid pools stretching the skin.  When the lymphatic system fails the lymphatic system becomes insufficient which leads to a problem called lymphedema. The main job of the lymphatic system is to move the protein molecules out of the interstitium back inside the vessels to go back to the heart.  When the protein molecules are left outside of the vessel in the interstitium it causes congestion.  Imagine a plate of refried beans left out on a plate overnight.  They get hard and crunchy.  Without compression on the leg, the same thing happens, called fibrosis of the skin.  Fibrosis is the hardening of the skin and development of scar tissue.  Dr. Földi prefers the term “DERMATO-LYPO-SCLEROSIS”:  Dermato=skin; Lypo=fat; Sclerosis=hardening. The tissue can feel waxy due to the fatty deposits.   Fibrosis=tissue is much harder than normal.

CLINICAL STAGES OF CVI

       STAGE I:  Venous insufficiency-CVI

       STAGE II:  Phlebolymphodynamic insufficiency-lymphatics are healthy but unable to handle load

       STAGE III:  Phlebo lymphostasis-increased load and damaged vessels-safety valve insufficiency.

 

TREATMENT

In stage 1 the only treatment necessary is compression with adequate compression stockings.  These should be worn daily.  The patient does not need to wear these to bed at night.  Only when up walking around.

In stages 2 and 3 of chronic venous insufficiency, treatment with Complete Lymphedema Therapy (CLT) is beneficial to mobilize the protein molecules in the interstitium.  These protein molecules cause scar tissue which causes skin changes and fibrosis.  The first phase of CLT treatment has four components.  The most important part is skincare with good cleansing and moisturizing using lotion.  A second part is doing Manual Lymphatic Drainage (MLD) which is a specialized massage technique.  Specialized foams and short-stretch compression bandages made in Germany provide adequate compression to break up the fibrosis and force the fluid back inside the vessels is another part of CLT.  And finally, proper exercise helps stimulate the lymphatic system to pull the fluid back up to the heart and to help break up the fibrosis by contracting the muscle inside while the bandages are putting force from the outside which traps the lymphatic vessels between these forces.  

 

Following the phase of decongestion treatment with CLT, the patient is fitted with compression stockings or appropriate long-term compression products, which are worn lifelong.  Once lymphedema has developed, the skin loses elasticity and without compression, the swelling will return within 3 days, according to Dr. Földi.  Research shows that a venous stasis ulcer or wound will return within 36 months of not wearing adequate compression.

 

Handout:  

Handout:  

 

Loraine's venous insufficiency

After breaking my left tibia and developing blood clots at age 13, I was set to develop chronic venous insufficiency.  I had several sports injuries in my youth which further caused swelling that would always resolve with an ace wrap and elevation.  As I turned 44, I noted that if I wore my compression stockings, it would prevent swelling and also prevent knee pain.  There are times that I like to go without my compression stockings.  When I do this for too long, I get swelling in my feet and lower legs just as the photo above shows.  I am noticing that the older I get, now I am 53, the faster the swelling comes on.  When I was 44, I could go for two weeks without the compression stockings before I started noting the swelling and knee pain.  Now I notice the swelling within 3 days and the knee pain after one week without compression.

Compression options:  

Mild to moderate swelling below-knee                 Mild to moderate swelling above the knee

        

Difficulty putting socks on:  

  Mild swelling              Moderate Swelling             Severe swelling   Swelling above knee      Swelling in foot

  below knee                 below knee                       below knee

Aids to help put compression socks on or take them off:

Mediven 2 in 1                    Juzo Slippie Gator Pad

helps make the foot               Holds the sock in place

slipperier to get the               while sliding it on

heel in or out of sock             or off

 

Contact:  Loraine@doctorlovejoyevans.com

 

© Dr. Loraine Lovejoy-Evans, DPT