Description of the condition

Edema of the lower extremities is one of the more common presenting symptoms in people with venous disease. It is estimated to occur when there is an excessive accumulation of fluid in the tissues. It should be remembered that oedema clinically occurs when fluid retention in the tissues exceeds 2-3 litres. Venous oedema can be unilateral or bilateral, and the distribution of the oedematous lesions can also vary. In typical venous oedema, the changes start from the foot and are visible around the ankle. Later - as the venous disease progresses - the oedema covers the higher parts of the shin and then the thigh. Patients presenting to the phlebologist, present traces of knee socks or socks imprinted on the skin as evidence of swelling in the legs. Swelling is noticed when it gives painful symptoms or makes it impossible to put on shoes.

Typical swellings caused by venous insufficiency are usually mild to moderate in nature and increase gradually. They tend to increase throughout the day, especially in situations where the person is standing or sitting for long periods of time and has significantly limited sporting activity. Venous oedema can be exacerbated in obese people with excess visceral fat. In these people, especially when sitting, there is a mechanical impairment of venous outflow from the level of the venous drainage at the level of the groin. Mild and simple forms of venous oedema usually resolve or decrease after resting with the legs elevated. Patients with venous oedema (grade C3) also feel better in the morning and increasingly worse as the day progresses.

In the more advanced stage of venous insufficiency, increased intraluminal pressure causes significant impairment of capillary filtration (at the level of small capillaries), resulting in extracellular fluid retention and overloading of the lymphatic vessels that support the venous vessels. Patients who develop bruising in addition to oedema usually already have visible varicose veins and trophic changes resulting from long-term venous blood stasis. In these patients, the use of phlebotropic drugs and compression therapy is sometimes no longer effective. Most often, they already need to be treated surgically.

Typical oedema in venous insufficiency progresses quite slowly. It should be distinguished from emergency oedema (occurs overnight), which occurs in the course of venous thrombosis. Patients with varicose veins are more likely to have superficial thrombophlebitis, resulting from excessive venous blood stasis. It is also important to remember the cause of the rarer, but more dangerous, deep vein thrombosis, which can also occur in Patients who have not previously presented symptoms of venous insufficiency.

Patients with venous oedema may co-exist with other subjective symptoms (subjectively experienced by the patient), such as a feeling of heaviness and/or fatigue in the legs, pain in the calves, and muscle cramps, especially at night.

Mechanism of venous oedema formation

Venous oedema is an important clinical sign that occurs in the course of various venous disorders. Its formation is a complex pathophysiological process that varies depending on the primary cause. Oedema in chronic venous insufficiency usually arises from overloading of the venous bed with blood secondary to the pelvic venous insufficiency (overload). This leads to dilatation of the lower limb veins, secondary venous valve insufficiency and perpetuation of retrograde blood flow. Increased hydrostatic pressure in the veins causes descending dilatation of the venous vessels. Consequently, there is an increase in vascular endothelial permeability and seepage of fluid into the intercellular space. All this activates the inflammatory process in the vessel wall, further increasing its permeability and the migration of leukocytes into the surrounding tissues. This, of course, has its consequences, typically seen in venous disease at grades: C4-C6.

Venous thrombosis usually generates swelling with a more violent course. The thrombus forming in the lumen of the venous vessel, in addition to the local inflammatory process, causes partial or complete occlusion (closure) of the outflow vessel. The progression of the thrombosis causes a progressive obstruction of venous blood outflow from the limb and an increasing increase in intravenous pressure. Everything, of course, progresses much more rapidly than in simple venous insufficiency. Ultimately, there is increased seepage of fluid into the intercellular space and inflammatory damage to the vascular endothelium and deeper layers of the vascular wall.

Oedema in venous compression syndromes (e.g. in uncomplicated venous thrombosis May-Thurner syndrome) arises by a mechanism of impaired venous blood outflow from the pelvis. Its dynamics are much slower. In this syndrome, pelvic venous insufficiency occurs over time due to impaired outflow and redistribution of blood flow. This eventually leads to congestion of the venous bed, both the deep system veins and the superficial system veins. Over time, venous stasis increases and the lower limb (left limb first) begins to swell as a whole. The development of the collateral circulation causes the venous disease to spread to the other lower limb as well and generates oedema there.

Precise identification of the mechanism of venous oedema allows targeted treatment to be implemented.

Treatment methods

Successful treatment of venous oedema is based on a combination of different methods, tailored to the patient's individual needs, the specific clinical situation and the severity of the condition.

The first step in treating venous oedema is always to compression therapyor compression therapy. The use of appropriately selected compression products helps to reduce oedema, improves microcirculation and venous outflow. In typical venous oedema, we use high-stretch products (knee-length socks, stockings or tights made to measure, available in different compression classes CCL1-4), multi-layer bandages or medical adaptive systems such as CircAid. Compression devices must be precisely selected for the individual patient and tailored to their oedema. It is important to put the compression devices on in the morning when swelling is at its lowest.

Equally important in reducing oedema is lifestyle modification. Regular physical activity and exercises that activate the muscular-articular pump significantly improve venous blood outflow from the legs. Our phlebologists particularly recommend the following to their patients: walking, Nordic walking, swimming or cycling. We try to discourage Patients with venous problems from exercise sports that put excessive strain on the venous system.

Phlebotropic drugs are used more as an adjunctive treatment to compression therapy. Used alone, they rarely lead to a significant reduction in venous oedema.

In cases where there is obvious venous insufficiency, it is always necessary to treat the cause and reduce venous congestion in the lower limbs. Nowadays, minimally invasive treatment methods are most commonly used to treat pelvic venous insufficiency and limb venous insufficiency.