Several months ago, a 39-year-old mother who had given birth a day earlier by cesarean section at Manila Doctors Hospital, was referred to us for sudden-onset shortness of breath.
It was initially thought that she might have an undiagnosed heart disease, which pushed her to heart failure. However, except for a fast heartbeat, there was nothing to indicate an existing heart problem.
On workup, she was found to have a blood clot (thrombus) in the lungs (pulmonary embolism) which most likely originated from a problem in her leg veins (chronic venous insufficiency), where the blood clot most likely developed (deep vein thrombosis or DVT).
So it started from what might have seemed as a benign longstanding swelling of the superficial and big leg veins (varicose veins), which developed blood clots, with the pregnancy and delivery as triggering risk factors. The blood clot likely chipped off, and the clotted fragments got carried by the circulation to the lungs where it blocked the arteries (pulmonary embolism).
If not treated promptly, this can lead to death of lung tissues (pulmonary infarction)—basically the same mechanism as a heart attack (myocardial infarction).
Fortunately for the patient, she responded well to the potent intravenous medicine given to dissolve the clot (thrombolytic therapy), and she and her baby went home after a few days. However, she was given maintenance medicines to improve blood flow in her diseased leg veins, and another medicine to prevent the formation of another blood clot.
She’s doing well more than six months after the life-threatening complication of her chronic vein disease.
When we say blood vessel or vascular problem, we’re referring to either the arteries, which carry oxygenated blood from the heart to the different organs, or the veins, which carry the unoxygenated blood from the various body tissues back to the heart. Heart attack and strokes are caused by blockage of the arteries, while varicosities and hemorrhoids are examples of vein disease.
The common cause for varicose veins and hemorrhoids is a slow swelling or inflammation of the vein. It is a progressive process, so we must treat these problems early on, to slow their progression to more advanced stages and prevent complications like what happened to our patient.
Chronic venous disease or insufficiency (CVI) usually presents with vague discomfort in the legs such as feeling of heaviness of the legs, progressing gradually to varicose veins, edema, discoloration of the skin (hyperpigmentation), and development of shallow wounds or ulcers. Skin on the affected part may look and feel “leathery,” and the leg pains also become more severe and intolerable.
When one remains in bed for several days, remains standing for prolonged periods, goes on a long-haul flight and hardly moves one’s legs or walks during the flight, and has any condition that can impede blood flow back to the heart (pregnancy, tumors in the pelvis), the CVI may be complicated by deep or superficial vein blood clots, which can have potentially fatal sequelae.
Chronic venous disease is a prevalent condition, with an estimated 40 to 50 percent of adults older than 50 likely to have it. In some studies, the prevalence is up to 60 percent; that means, six out of ten middle-aged or older adults might have CVI, with many not knowing it. However, it’s frequently undetected or sometimes dismissed as a benign problem that does not need treatment.
“Ay, varicose lang ’yan; malayo sa puso ’yan at hindi delikado (That’s just varicose veins, and far from the heart; so, it’s not dangerous),” a husband told his wife, who was seeing us for a separate heart problem. I had to immediately correct him, and he was surprised at the potentially life-threatening complications the vein problem might cause.
Because of the risk factors associated with CVI, women are at greater risk than men to develop it. One of two women, and one out of four men over the age of 50, would be found to have CVI if diagnostic tests are done.
When a woman is pregnant, the increasing size of the baby in the womb compresses the veins in the abdomen, partially obstructing the venous flow back from the legs. This can be aggravated by a genetic or familial disposition to develop this condition.
The veins are naturally provided with one-way valves to prevent the blood from flowing backward. In patients with CVI, the valves no longer work, so the blood may flow backward, particularly when one is standing, and blood clots could form in the varicose veins.
In untreated patients with CVI, the pressure and swelling of the varicose veins increase and will burst the tiny blood vessels in the legs called capillaries. Hence, one could note a reddish brown discoloration of the legs, especially near the ankle. Shallow wounds or ulcers could develop in these areas, which don’t heal well.
The ulcers may get infected particularly if one scratches them, and this can cause swelling of the entire leg (cellulitis), which is another life-threatening complication.
So, early recognition and treatment are important, which may consist of lifestyle changes (exercises and leg-raising), and nondrug treatment (wearing of compression stockings). Circulation-enhancing drugs such as purified flavonoids (diosmin), may also be prescribed. If the patient formed blood clots already, blood thinners called anticoagulants are also needed to prevent blood clot recurrence.
In more severe cases, surgical procedures such as sclerotherapy or venous thermal ablation may be recommended. This method uses high-frequency radio waves or a laser to heat and close the problematic vein to reroute the flow toward the healthy veins. In more advanced centers, vein repair, bypass and transplant are being done.
So, it’s best not to allow one’s chronic venous insufficiency to progress to a stage that may cause life-threatening complications, or require surgical intervention. Just like in most medical conditions, early recognition and treatment can save one a lot of trouble in the future.
Varicose veins are not as harmless as many believe they are. INQ