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Swollen Legs - Lowe Limb Edema - Chronic Venous Insufficiency

Lower Limb Edema (Swollen Legs): Chronic Venous Insufficiency and Venous Hypertension

Last Updated: December 12, 2023 | Dr Reza Moazzeni

What are the main causes of swollen legs?

Video: This video highlights venous hypertension as a top cause of lower limb edema and presents interesting cases for early diagnosis and management.

Swollen legs, also known as “lower limb edema,” are among the most common findings in medical practice across various specialties. This symptom signals an underlying condition that demands further exploration. The challenge lies in the multitude of potential causes, many of which can coexist in a single patient.

Adopting a clear yet thorough approach to diagnosing lower limb edema can streamline investigations and prevent unnecessary diagnostic delays. The four primary culprits behind this swelling are Venous Hypertension, Medication side effects, Lymphedema, and Lipedema. This post will discuss venous hypertension, with subsequent posts addressing the other causes.

Venous Hypertension:

Venous Hypertension, as the name suggests, is characterized by elevated pressures within the veins of the legs. This condition predominantly arises from two main causes:

  • Chronic Venous Insufficiency (CVI): This is a condition where the venous wall and/or valves in the leg veins aren’t working effectively, making it difficult for blood to return to the heart from the legs.
  • Venous flow obstruction and stasis: This pertains to conditions where there’s a blockage or sluggish blood flow in the veins, often due to blood clots or other obstructions.
Chronic Venous Insufficiency (CVI)

Chronic Venous Insufficiency (CVI) occurs when the veins in the legs cannot efficiently return blood to the heart, leading to blood pooling in the veins. This can manifest as swelling, pain, and skin changes in the affected limbs.

Causes of CVI:

  • Valve Damage: This can result from various factors such as prolonged immobility, obesity, smoking, trauma, surgery, or a prior clot in the veins known as Deep Venous Thrombosis (DVT). The consequent reversal of blood flow towards the extremities is termed ‘Reflux’.
  • Vein Wall Weakness: Aging can lead to weakening or damage to the walls of the veins.
  • Genetics: Some individuals might have a predisposition to CVI due to their family lineage.

Symptoms of CVI include:

  • Swelling in the legs or ankles.
  • Leg pain or aching, exacerbated by prolonged sitting or standing.
  • Skin changes, such as thickening and discoloration (termed Lipodermatosclerosis, as shown in Fig-1) or the presence of varicose veins.

Treatment Options for CVI:

  • Compression Therapy: Using compression stockings or bandages to enhance leg blood flow and diminish swelling.
  • Medications: Diuretics or anticoagulants might be prescribed to alleviate symptoms.
  • Endovenous Ablation: A minimally invasive technique employing heat or lasers to close off impaired veins, diverting blood to healthier ones.
  • Lifestyle Modifications: Recommendations often include weight loss, regular exercise, and avoiding extended periods of immobility.

Venous flow obstruction and stasis

Obstruction

Venous flow obstruction, in many cases, is directly attributed to venous blood clots, also known as Deep Venous Thrombosis (DVT). These clots can form due to prolonged immobility, surgery, or genetic factors and can impede the normal flow of blood, leading to pooling in the extremities.

Besides DVT, certain conditions can lead to external compression of the major veins, particularly those located in the thigh or pelvis. Tumors, growing adjacent to veins, can exert pressure, and so can the expanding uterus during pregnancy. Both scenarios result in reduced venous return from the lower limbs, exacerbating the risk of edema.

Stasis

Heart Failure (HF) presents a unique challenge to the venous system. While HF doesn’t cause a physical obstruction in the venous pathways, it significantly impacts the efficiency of blood circulation. Due to the heart’s weakened pumping capability, blood tends to move sluggishly, especially through the vast network of veins in the lower extremities. This slow movement can lead to fluid accumulation and stasis.

Additionally, the body’s response to HF complicates matters further. With decreased cardiac output, the kidneys might perceive a lower blood volume. As a compensatory measure, they retain more fluid, aiming to support vital organs. However, this well-intended response often results in an increased, yet inefficient, intravascular volume, further contributing to edema in the lower limbs.

Lipo-dermatosclerosis
Fig-1: Lipodermatosclerosis and Hyperpigmentation
Lipo-dermatosclerosis

Lipo-dermatosclerosis is an inflammatory condition targeting the lower legs’ skin and subcutaneous fat tissue. Classified as a type of panniculitis, it falls within a spectrum of disorders that afflict the fatty layer beneath the skin. As the condition progresses, inflammation gives rise to fibrotic changes, resulting in the hardening and thickening of the skin. Patients often report symptoms such as pain, swelling, redness, and over time, the skin might adopt a discoloured (hyperpigmented) appearance and a characteristic “woody” texture. While the precise etiology remains elusive, lipo-dermatosclerosis is thought to stem from venous blood flow stasis in the legs. Notably, it has associations with Chronic Venous Insufficiency (CVI) and the resultant blood pooling.

Treatment Approaches
  • Compression Therapy: Wearing compression stockings or bandages can bolster blood circulation in the legs, alleviating swelling.
  • Medications: Anti-inflammatories like NSAIDs and corticosteroids can mitigate inflammation and relieve pain.
  • Surgery: For some individuals, surgical intervention becomes indispensable to rectify damaged veins and restore optimal leg blood flow.
  • Lifestyle Modifications: Adopting healthier habits, including weight loss, regular exercise, and circumventing prolonged sitting or standing, can fortify blood flow and thwart further vascular damage.

Lymphedema:

Various pathologies can involve the lymphatic system, leading to the accumulation of lymph in the interstitium and causing swelling and edema in affected organs. In developed countries, cancer and its treatments like chemotherapy, radiotherapy, and surgery are the leading cause of lymphedema. However, parasitic infections are the primary cause of this issue worldwide.

Lipedema:

Lipedema is a chronic disorder characterized by an excessive and abnormal accumulation of fat in the legs, thighs, buttocks, and sometimes arms that occurs almost exclusively in women and is typically symmetrical. Lipedema can cause pain, tenderness, swelling, and bruising in the affected areas. It is often misdiagnosed as obesity or lymphedema, but it is a unique condition that requires specialized treatment. The cause of lipedema is not fully understood. Still, it is thought to have a genetic component, and hormonal factors may also play a role. If you want to know more about Lipedema, please check out our recent post which includes several cases related to this condition.

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