Chronic venous insufficiency is a disease of the leg veins. It usually shows up on the lower legs and ankles. Heralds are small visible veins on the inside and outside of the ankles and swelling that goes away when you put your legs up or overnight. If left untreated, the swelling can last until the skin on the lower leg turns brown, white patches appear and the tissue hardens more and more.
In the worst case, chronic venous insufficiency can lead to open lower leg ulcers that heal slowly. Chronic venous insufficiency is generally treated with compression stockings and compression bandages.
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Chronic Venous Insufficiency Causes And Risk Factors
Veins (except for the pulmonary veins) take the deoxygenated blood from the tissues and transport it back to the heart. They often have to work against gravity, e.g. in their legs. Muscle pumps help them to still be able to carry out the transport task: for example, if the calf muscles contract, they press the blood in the leg veins upwards towards the heart. At the same time, venous valves, which work like non-return valves, prevent blood from flowing back when the muscles relax again.
If the muscle pump no longer works properly or if there is a – perhaps congenital – weakness in the connective tissue in the vein walls, they relax over time and widen. As a result, the flaps can no longer close properly. The blood sags down the legs and collects there. The back pressure puts pressure on the blood vessels: first the superficial veins deform, then the venous connections to the inner veins, and then the deep veins too.
If the backwater persists, the tissue is not sufficiently supplied with oxygen and nutrients, and metabolic products, e.g. iron pigment from the blood, cannot be properly removed. This leads to the typical brownish-red discoloration, stasis eczema, hardening of the tissue and, in the worst case, to an open ulcer.
Risk factors
Vein problems on the legs are promoted by a whole range of risk factors:
- Hereditary factors: The frequency of vein disorders in certain families suggests that varicose veins, a tendency to thrombosis or chronic venous insufficiency are often hereditary.
- Female gender: Because of the special structure of their connective tissue, women are more often affected by venous insufficiency. Hormonal influences, e.g. during pregnancy, also play a role. The birth control pill is also said to increase the risk of vein problems.
- Age: The elasticity of the connective tissue decreases with age. In addition, many older people exercise less than in previous years.
- Overweight: The heavier a person is, the more strain is placed on the leg veins.
- Occupational situation: Standing and sitting activities promote venous insufficiency because the muscle pump is not activated enough and gravity impedes the backflow of blood.
- Lack of exercise: Lack of exercise causes the muscles to become slack and the muscle pump no longer works properly.
- Lifestyle: Smoking has a negative effect on blood circulation throughout the body and increases the risk of thrombosis. Heavy alcohol consumption can lead to cirrhosis of the liver, varicose veins in the esophagus and stomach.
- Certain diseases: Heart failure or cirrhosis of the liver are two of the diseases that can lead to increased pressure in the veins.
Chronic Venous Insufficiency Symptoms
Do you have brown discoloration on your lower legs or ankles?
Does your skin on your lower legs feel as inelastic as cigarette paper?
These skin changes are typical of chronic venous insufficiency. After signs such as a dull, pulling pain in the legs - especially after standing or walking for a long time - still disappear and the swelling initially improves by putting the legs up or overnight, the brown discoloration on the lower legs and ankles will eventually persist. If the skin also becomes less and less elastic due to the weakness of the veins, small wounds quickly develop that heal poorly. Because the tissue under the skin hardens more and more, these wounds can subsequently develop into chronic ulcers. This increases the risk of a "spread leg" (technical term: ulcus cruris).
The following symptoms are characteristic of chronic venous insufficiency:
- Swelling that initially goes away with elevating your legs or overnight
- Small visible veins on the inside and outside of the feet and dilated skin veins (technical term: calf veins).
- Brownish darkening (technical term: purpura jaune d'orcre), usually in the ankle area, on the lower legs and on feet
- Stasis eczema (also: stasis dermatitis) with reddened, weeping, scaly skin on the congested lower leg, combined with burning itching, often in the vicinity of varicose veins
- Tissue changes (technical terms: dermatosclerosis, lipodermatosclerosis, dermatoliposclerosis) with inelastic skin that can no longer be lifted in folds, becomes like cigarette paper and tears more easily, with the tissue underneath the skin hardening more and more
- White patches (technical term: atrophie blanche) above the hocks, clearly demarcated and often circular
- Lower leg ulcer (technical term: venous leg ulcer) as an open wound, usually behind and above the ankle on the inside of the leg, also known as an "open leg" (technical term: leg ulcer).
Graduation
Based on the visible and palpable skin changes, doctors divide chronic venous insufficiency into three degrees:
- Grade I: small visible veins on the inside and outside of the feet (technical term: corona phlebectatica paraplantaris), swellings that disappear when you put your feet up or overnight (technical term: reversible oedema), dilated skin veins (technical term: perimalleolar capillary veins)
- Grade II: persistent swelling, brown discoloration of the lower legs, white spots above the ankles, eczema, itchy skin rashes, dermatosclerosis
- Grade IIIa: healed venous leg ulcer (ulcer scar)
- Grade IIIb: strongly developed (florid) ulcus cruris
Chronic Venous Insufficiency Treatment
The specialist for chronic venous insufficiency is a phlebologist who is familiar with the treatment of vascular diseases. Based on skin and tissue changes, he can already see whether it is a matter of chronic venous insufficiency. Sometimes it can make sense to take a closer look at the condition of the vein walls or vein valves and how far the vein weakness has progressed. An arterial disease may also have to be ruled out, as it requires a completely different treatment, or even the treatment of venous insufficiency in arterial vascular diseases leads to a worsening of the symptoms.
The most important examination method is duplex or Doppler sonography, in which two different ultrasound images are superimposed to connect flow conditions and structural changes in the veins. An X-ray examination with contrast medium (technical term: ascending pressure phlebography) is considered to be the most meaningful diagnostic tool, but it is expensive. Before the X-ray is taken, a contrast medium is injected into the vein on the back of the foot using a cannula.
Therapy
The treatment a doctor recommends depends on the symptoms and the stage of the chronic venous insufficiency. The aim of all therapeutic measures, in addition to relieving the symptoms, is for the venous valves to close better again and for the blood to be able to move on (see causes).
Compression devices such as stockings or bandages that squeeze veins together (technical term: compress) and thus prevent the blood from backing up are suitable as a basic treatment. If these are not sufficient or if the vein weakness has exceeded a certain degree, the doctor may recommend additional medication, for example to relieve the swelling. The drugs can either drain (technical term: diuretics), seal the veins (technical term: oedema-protective agents) or increase the elasticity of the veins (technical term: tonic).
If open leg ulcers have already formed, they must be cleaned and disinfected regularly. Antiseptic poultices ensure that the wound remains germ-free. Moist compresses with saline solution are suitable for heavily exuding wounds. Chronic wounds also heal better with moist wound treatment. Modern wound dressings no longer stick to the open wound, so changing the dressing is generally painless. It is important in moist wound treatment that the dressings remain moist over the long term. So-called hydroactive wound dressings are particularly suitable for this purpose. Closing (technical term: occlusive) wound dressings can remain on the wound for days and give it a so-called wound rest.
- Compression devices: The most important therapy for chronic venous insufficiency are compression devices with rubber compression stockings or elastic bandages. The fine-meshed tissue compresses the leg veins, increases the blood flow speed in the vessels, increases blood return transport and makes the work of the venous valves easier. Less fluid can sag and swelling will decrease.
- Vessel-sealing and vein-toning drugs: In order to make the vein walls less permeable or to reduce the vein cross-section, there are both synthetic (e.g. heparin) and purely herbal remedies that are applied locally as a gel, cream or ointment. Herbal remedies are e.g. extracts from horse chestnut seeds (Latin: aescin), butcher's broom (Latin: ruscogenine), rhizome, blueberry or grape leaves (e.g. flavonoids, oxerutin, troxerutin).
- Diuretics: Medications that flush water out to reduce swelling are called diuretics. In the case of chronic venous insufficiency, diuretics should only be taken after consultation with the doctor treating you, and they should only be taken for a short period of time, otherwise stopping the medication can lead to increased edema formation. Herbal remedies for flushing out are e.g. birch leaves and nettle herb.
- Curettage: During curettage, the doctor removes the wound covering with a sharp spoon and then cleans the wound.
- Wound cleansing with fly larvae (technical term: Lucilia sericata): A very effective treatment for leg ulcers is bio-enzymatic wound cleansing with fly larvae. The maggots are used loosely as so-called free-runners or welded into bags (technical term: biobags) in the wound. They feed on dead tissue, the larvae do not attack living tissue. They are removed again after four days.
- Hydroactive and occlusive wound dressings: Special wound dressings ensure moist wound healing under closed conditions for days. This not only improves wound healing, but also reduces the risk of infection. Depending on the type of wound or wound healing progress, there is a whole range of wound dressings.
- Surgical procedures: Sometimes conservative treatment does not lead to healing of a leg ulcer. Then the doctor may recommend surgery. The surgeon will excise the ulcer and the diseased layer of tissue and remove any tissue that cannot be saved. Healthy skin is then transplanted or industrially manufactured biological wound dressings are used.
A role that should not be underestimated in the treatment of chronic wounds lies with those affected themselves. Their active participation contributes to a large extent to the healing of the wound. It is therefore highly recommended to seek detailed advice on the purpose and necessity of the individual treatment steps. Because often only consistent implementation of the treatment, such as compression therapy, helps. And if you really understand why a treatment – sometimes unpleasant – makes sense, you will be able to endure it better.
Post-treatment
There is always a risk of recurrence with a venous leg ulcer. In order to prevent the ulcer from recurring, those affected should carry out follow-up treatment consistently. In addition to compression therapy, this includes more exercise: just half an hour a day activates the muscle vein pump and keeps the legs healthy (see also prevention).