Symptoms
In venous insufficiency, the normal return flow of venous blood to the heart is disturbed due to various causes. The following symptoms occur on the legs, especially the ankle and lower leg:
- Superficial venous dilatation: Varicose veins, spider veins, varicose veins.
- Pain and heaviness, tired legs
- Fluid retention, swelling, “water in the legs”.
- Calf cramps
- Itching, changes in sensation, tightness, tingling, restlessness, burning sensation.
- Skin changes: Pigmentation due to the storage of hemosiderin, stasis eczema, tissue changes such as hardening, fibrosis (lipodermatosclerosis), atrophy blanche.
- Ulcerations (lower leg ulcer), mostly at the ankle.
Complaints such as pain and swelling occur mainly when standing and sitting and improve during lying down and at night.
Causes
The peripheral venous system in the legs serves as a reservoir and conduit system to carry blood back to the heart. Venous blood is carried to the heart against gravity by muscle contractions in the feet, calf, and thigh. The numerous venous valves ensure that there is no backflow in the opposite direction to the feet. The main cause of the symptoms is considered to be a backlog of blood in the veins and a resulting overpressure. This is triggered by insufficiently functioning venous valves, venous obstruction, malfunction of the muscle pump or combinations of these factors. The excess pressure leads to, among other things, vasodilatation and damage, changes in microcirculation, inflammatory processes, and damage to the smallest vessels. Most venous symptoms are primarily idiopathic (cause unknown) or arise secondarily as a result of disease, usually after deep vein thrombosis. In rarer cases, the problem exists from birth (congenital).
Complications
Dilated superficial veins are cosmetically bothersome and can be an aesthetic and psychosocial problem that negatively affects quality of life. Lower leg ulcers require a long period of treatment and may recur chronically after healing. They can be a severe disability in everyday life. Other complications include poor mobility, delayed wound healing, infection, and inflammation of the subcutaneous cellular tissue (cellulitis)
Risk factors
- Age
- Female gender
- Pregnancy (progestogens)
- Heredity
- Obesity
- Body size
- Smoking
- Previous leg injuries, deep vein thrombosis, inflammation of venous vessels.
- Environmental factors such as standing or sitting for long periods (occupation), little exercise and sports.
- Living in industrialized countries
Differential diagnoses
- Acute new complaints: Deep vein thrombosis
- Kidney disease
- Liver diseases
- Heart failure
- Endocrine diseases
- Adverse effects of medications such as dihydropyridines (calcium channel blockers), NSAIDs, and antidiabetics.
- Local discomfort, such as a hematoma of the connective tissue.
- Other
Non-drug treatment
Compression therapy with compression stockings is the 1st-line treatment. Compression stockings have been shown to be effective against the discomfort and complications of venous insufficiency if worn frequently enough. In case of mild symptoms, stockings with low compression are sufficient (class 1), in case of more severe symptoms, skin changes or ulcerations, stockings with higher compression should be applied (class 2, 3). Compression stockings are also used to prevent venous disorders and to prevent recurrence of ulcerations. Compliance is a problem especially in summer (warmth, tightness). Dressing can also be difficult, especially for older people, if they suffer from arthritis or muscle weakness, for example. Lower leg ulcers should first be covered with a dressing before the stockings are put on. Supportive measures:
- Elevate the legs above heart level several times a day.
- Move more and exercise to activate the muscle pump.
- Do not stand or sit for too long.
- Reduce the increased weight.
- Stop smoking.
- Avoid heat and cool the legs.
- Drink enough fluids.
Pain occurs mainly when standing and sitting and improves when wearing support stockings, walking, lying down and elevating the legs. Some patients therefore also sleep with their legs slightly elevated. Various (minimally) invasive methods:
- Sclerotherapy (sclerotherapy), e.g. with polidocanol.
- Laser treatment
- Surgical procedures, e.g. vein removal.
Drug treatment
Topical and oral vein medications (vein therapeutics, phlebotonics) are designed to seal and strengthen the vessels, reduce increased permeability, inhibit inflammation, improve wound healing, and reduce oedema. Applied topically as a gel, cream, or ointment, they also have a cooling or skin-conditioning effect, and rubbing them in also has a short-term symptom-relieving effect:
- Oxerutin, troxerutin, diosmin and hesperidin (flavonoids).
- Butcher’s broom extracts
- Bilberry extract
- Horse chestnut extracts and aescin
- Red vine leaf extract
- Sweet clover, buckwheat (contains rutin), tannins, arnica.
- Heparins
- Calcium dobesilate
- Naftazone
- Pentoxifylline
- Polidocanol 600 is used for sclerotherapy
- Other vein remedies are on the market, for example, various cosmetics
Painkillers:
- Such as NSAIDs, acetaminophen, or opioids are taken for symptomatic treatment of pain. They should not be used regularly if possible because of the adverse effects.
Topical glucocorticoids:
- Are anti-inflammatory and are used to treat eczematous skin conditions.
Skin care products:
- For skin care in case of skin lesions.
Wound treatment:
- Treatment of ulcers with modern wound dressings such as hydrocolloids and alginates. The use of topical disinfectants and topical antibiotics is discouraged in the literature because they can cause local adverse effects and delay wound healing. Oral antibiotics should be used only when ulcerations are obviously infected.
Diuretics:
