by Dr. David Ian Rosen,MD
I have had vein troubles for many years; why did I start getting leg discoloration?
Many factors can lead to lower extremity discoloration. All such causes are too numerous to mention here. But, once we know that a patient’s leg discoloration is due to chronic vein disease, doctors have a better understanding as to why it happens and what can be done about it. First a brief into about what veins do and how things can go wrong.
What do veins do?
Think of veins as “stretchy pipes”. In their role of serving as “pipes”, they are tasked with returning blood flow back to the heart. In the lower extremities, while we stand or sit with our legs hanging, the challenge is to move flow upwards against the force of gravity.
Fortunately we have an ingenious system to accomplish this: a calf muscle “pump” that acts as a peripheral heart. The contraction of the calf muscle generates the force to propel blood that is in the leg veins upward against gravity. Most of the blood flow (about 90%) travels out of the lower extremity through Deep Veins. The remainder travels through Superficial Veins. Superficial and Deep veins often intercommunicate with each other along the journey up and out of the lower extremities.
Once the blood gets pumped upwards by the calf muscle contractions, what keeps the blood that has been moved upward from passively pooling back in the legs are one-way valves within lower extremity veins. If the valves malfunction, one-way valves can, unfortunately, become two-way and allow blood to flow downward with gravity. This wrong-way flow due to valve malfunction is known as Superficial or Deep Venous Insufficiency.
Remember the other aspect of veins? They’re stretchy. They’re made that way in order to serve another important function: acting as a reservoir to store “extra” flow while we are relaxing and then releasing the blood back to the circulation when we are actively moving around.
Ordinarily, the stretchiness factor is a good thing. However, as blood pools due to venous insufficiency, or if there is something preventing flow from moving upwards (blockages, blood clots, scars inside veins to name a few), pressure builds up (venous hypertension). This excessive pressure can lead to numerous symptoms and overt signs, including leg swelling.
Symptoms of chronic vein disease include lower extremity heaviness, fatigue, cramping, itching and even “restless legs”: the annoying feeling of having to move your legs around in order for them to feel comfortable. Given the fact that gravity makes matters worse, most patients feel worse at the end of the day vs. the morning.
Other than chronic leg swelling, venous hypertension, over the course of time, can lead to chronic inflammatory changes in the skin. The skin can become discolored, thicker and even develop ulcers (chronic wounds that can be difficult to heal). In addition, chronically inflamed veins in the legs become more “leaky”. They allow red blood cell and proteins to leak out into the surrounding tissues. When these proteins and red cells break down, they can cause staining of the skin and tissues.
Is Leg Discoloration serious?
Given the many factors that can lead to leg discoloration, there is a spectrum ranging from simple causes to serious underlying illnesses.
If your discoloration started only very recently, is in one lower extremity and is associated with discomfort , you need to seek immediate medical attention. In the medical world, this is a blood clot in a Deep vein until proven otherwise. If a physician hears about such complaints from a patient, the next step is to order an ultrasound to evaluate for clot in somewhere in the Deep venous system. Even though your symptoms are on one side, expect them to evaluate BOTH legs with an ultrasound as they can occur simultaneously and can be subtle to detect by just symptoms alone. I’m not kidding…if you are reading this and think that these descriptions apply to your current problem, you need to stop reading and seek medical attention. Just save your place in this fun and informative document and read the rest later…maybe while you are waiting for your ultrasound results!
Why are blood clots in Deep veins a serious matter?
First of all, remember that we just stated that about 90% of the flow out of your legs goes through Deep veins. Hampering that outflow can have serious immediate and long-term consequences. Deep vein clots (Deep Venous Thromboses or DVT’s in “doctor-speak”) leading to valve damage can lead to Post-thrombotic Syndrome: chronic, often life-long swelling and discomfort.
More serious still, Deep vein clots can break into pieces and embolize, or travel upwards and lodge themselves in the lungs (pulmonary embolism; potentially deadly) or, rarely, paradoxical emboli across the heart and up into the brain and the rest of the arterial circulation.
[If it sounds like I’m trying to freak you out about DVT’s, that’s because I’m trying to get you to take your body seriously…to listen to your symptoms and seek medical attention. Serious consequences of DVT’s may be prevented if caught early enough. Once its done, damage is difficult, if not impossible, to undo.]
How can I find out about the extent of my problem and what to do about it?
Assuming that your leg swelling doesn’t fit the criteria for worrying about an acute Deep vein clot, the first step is making an appointment for a consultation with a qualified primary physician. During such a visit, the physician should take a medical history and perform a thorough physical exam.
If chronic leg discoloration is your main complaint…and if you haven’t seen your primary doctor in a while, expect that routine, appropriate blood tests should be performed. Sometimes, depending on vital signs and other physical findings, other tests may be ordered.
G-d willing, all those blood tests and other tests should turn out to be normal.
Once those other possible systemic causes are ruled-out, your doctor may consider…and if she/he doesn’t, YOU SHOULD…that a cause of your chronic discoloration may relate to Superficial Venous Insuffiiciency.
The test to best evaluate for SVI is an ultrasound exam of your lower extremities. This painless test is best performed with patients standing upright. The anatomy of your leg veins is “mapped out” by using sound waves to create images in real-time. More importantly, the Doppler function of the ultrasound helps to map out the flow in your veins. Normally, flow should travel up and out of your legs rather than returning back down toward your feet. Downward flow can be measured. If it lasts longer than 500 milliseconds (half a second), it is considered abnormal. In that case, that particular vein segment has an incompetent vein valve.
Sometimes the doctor performs the test; in other cases an ultrasound tech does the study that is then evaluated formally by a physician.
Once a diagnosis of Superficial Venous Insufficiency is made, the next doctor you should see (if she/he wasn’t already the one making the diagnosis), is a physician specializing in venous disease: a Phlebologist. Phlebologists come from many different fields in medicine: surgery, primary care, Ob/Gyne, dermatology…or,like me, from Internal Medicine/Emergency Medicine. Some, like me, have taken the next step towards being an uber-overachiever and have also obtained additional board certification by the American College of Venous & Lymphatic Medicine. My guess is that I’m probably one of only 1,000 or so doctors that have done so.
Treatment options depend on the extent of disease. In general, larger relatively deeper superficial veins are treated first with endovenous ablation techniques (endovenous laser ablation, radiofrequency ablation, mechanochemical ablation and others). Once the underlying flow issue has been dealt with, patients may begin to notice an improvement in their leg swelling within the first months after their procedure(s)! Unlike the alleviation of symptoms, swelling and varicose/spider veins, chronic leg discoloration due to superficial venous insufficiency can take months to years to begin to lighten up. If you have reached the stage where skin breakdown and ulceration has occurred, definitive treatment by endovenous ablation methods has been shown to significantly decrease the time of wound healing.
For more information regarding the treatment of varicose veins and to learn more about Rosen Vein Care, visit www.RosenVeinCare.com
To schedule your 1-hour Initial Consultation appointment, call 847-272-8346. We will get you on schedule as soon as possible, typically within a few business days.
I look forward to meeting you and helping your legs to feel and look better than they have in years!
David Ian Rosen,MD
Diplomate, American Board of Venous and Lymphatic Medicine
Founder, Rosen Vein Care