Venous Reflux Disease

Venous reflux disease, also known as venous insufficiency, is a medical condition affecting the circulation of blood in the lower extremities. The tiny valves that normally force blood back up towards the heart no longer function, causing blood to pool up in the legs, and the veins of the legs become distended.

Venous reflux disease commonly produces varicose veins, the abnormally swollen and discolored superficial leg veins that affect more than 25 million Americans. Varicose veins can range from small, thin purple lines just under the skin (known as “spider veins”) to thick, bulging veins that can protrude well beyond the skin surface. In any form, varicose veins serve as indicators of venous reflux, a progressive disease that can cause significant circulatory problems as it worsens.

Venous Reflux Patient Demographics

Ten times more patients suffer from venous insufficiency than peripheral arterial disease in the United States. Although often mistaken as a cosmetic problem, venous insufficiency can produce a number of clinical problems for the patient.

Venous insufficiency can significantly impact a person’s lifestyle, especially when the person’s job requires extended standing. Market research indicates that over 2 million workdays are lost annually in the US and $1.4 billion is spent each year on this common medical condition.

Of the 25 million Americans with venous insufficiency, approximately 7 million exhibit serious symptoms such as edema, skin changes and venous ulcers. It is estimated that in America, 72% of women and 42% of men will experience varicose veins by the time they are in their 60s. Prevalence is highly correlated to age and gender.

Venous System Anatomy

The veins in the lower limbs are classified into two systems:

• Superficial Veins (including saphenous)
  
• Deep Veins

The two systems are connected by perforating veins that pass through the deep fascia

Three factors influence the return of blood back to the heart:

• Respiration - the movement of the diaphragm creates a negative pressure that assists the return of blood from the legs to the heart
  
• Vein Valves - healthy valves close, preventing blood from refluxing or pooling
  
• Calf Muscle Pump - action of the calf muscle helps to force blood upward

Common Symptoms Of Venous Reflux

In the absence of other symptoms, patients with cosmetic concerns due to the presence of varicose veins might be evaluated with only a physical examination. However, patients presenting with other symptoms of venous insufficiency, such as those listed below, should also undergo an in-depth evaluation, including a duplex ultrasound study.

• 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 (edema)
  
• Color and texture changes of the skin
  
• Open wounds (skin ulcers)

Varicose Veins

Varicose veins are typically found in the superficial venous system and often involve the main trunk veins - the great and small saphenous veins - as well as tributaries.

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 cusps from closing properly resulting in reflux. Alternatively, a lack of competent valves can also cause dilation of the vein. As one valve fails, increasing pressure is exerted on each more distal valve until it, too, becomes incompetent. Diameters of varicose veins can range from 3 mm to > 8 mm.2

Edema & leg or ankle swelling with and without skin changes

Edema and swollen ankles are the next progressive states of venous insufficiency and occur as the result of venous hypertension forcing fluid into the lymphatic and interstitial spaces.

This can cause leg or ankle swelling and changes in skin pigmentation. Severe pain and discomfort are typical of these conditions, particularly in the lower leg (calf & ankle) where proximity of nerves exacerbates the situation. In addition to superficial involvement, these stages often include some portion of the perforating or deep vein systems.

Active & Healed Venous Ulcers

Venous ulcers indicate the most severe forms of venous insufficiency and typically involve both the deep (including perforators) and superficial vein systems. Extreme reflux and venous hypertension result in changes in the microcirculation of the skin eventually leading to severe ulceration.

Anatomic involvement at these stages generally involves the saphenous system3, the perforators (typically the Cockett perforators), and the deep system (typically the femoral, superficial femoral and/or the profunda)Why do we mention deep system and list superficial femoral? A smaller subset of the population has deep system-only involvement (<5%) and an even smaller portion perforator-only incompetence.

What is the Great Saphenous Vein?

The greater saphenous vein is a large superficial leg vein running from the foot to the groin, roughly in parallel with the short or lesser saphenous vein, which runs up the back of the leg from the ankle to the knee. These are the principal vessels of the superficial venous system in the leg.

The greater saphenous vein delivers oxygen-depleted blood from the ankle, lower leg and thigh vessels to the femoral vein, the primary deep vein in the leg. The propulsion of blood up such a significant length of the body is heavily dependent on the function of the one-way valves that prevent backflow down the vein. When those valves fail, the resultant venous reflux causes blood to back up into the smaller veins closer to the skin, distending them and initiating the condition known as varicose veins.

Venous insufficiency, also known medically as venous reflux disease, in the greater saphenous vein is a primary underlying cause of varicose veins. The great saphenous is also therefore the superficial vein most frequently treated with radiofrequency ablation to restore healthy circulation and eliminate varicose veins.