Heavy legs may be due to chronic venous insufficiency

Chronic venous insufficiency or CVI?

It doesn’t seem to ring a bell. CVI sounds more like a car model than anything else but it is actually a disease as prevalent as diabetes or high blood pressure. It is much less recognized though and its symptoms, consisting mainly of leg edema or simply "heavy legs," are frequently passed off as a normal consequence of too much salt in the diet.

Upon closer examination though, the physician may note bluish, tortuous, dilated but non-tender superficial veins on both legs. There are usually no signs of inflammation or infection although occasionally, superficial wounds or skin ulcers may be present.

CVI is a disease of the veins due to the destruction of the valves which are the blood-flow regulator inside the veins. The hampered circulation causes pooling of the blood in the ankles and legs.

Studies show that CVI occurs more frequently in females than in males and its incidence rises substantially with age. Genetics also play an important role in its occurrence. History of deep vein thrombosis (DVT), which renders venous valves incompetent, causing backflow and increased venous pressure, is also an important risk factor.

Occupations that involve standing for long periods predispose individuals to increased venous pressure in the dependent lower extremities. When one stands continuously for hours everyday, the veins below the knee endure this increase in pressure. Smoking also brings about higher incidence of CVI, especially in men.

The chief clinical manifestations or symptoms of CVI are dilated veins, leg pain, edema and skin changes. The frequency is related to the severity of the disease. Heaviness and swelling may develop after prolonged standing or sitting. Edema or the accumulation of an excessive amount of watery fluid in cells, tissues or serous cavities, may be the first manifestation of early CVI.

Patients suffering from CVI initially note that the swelling is mild and limited to the area just above the shoe line around the ankle. The edema usually resolves with bed rest, particularly if the legs are elevated during sleep. As swelling increases, the skin over the ankles may show red spots or brownish tinge. The skin may start to feel leathery and may start to itch. If edema is not controlled, blood pools in the ankles and fluid leaks into the surrounding tissues. The tissues eventually break down and an ulcer forms.

However, not all patients with CVI may experience pain most commonly felt at the calf area after prolonged standing. Aside from the pain, skin changes can also be observed. The brown discoloration is due to hemosiderin deposits which are the yellow-brown insoluble iron pigments found especially in the liver.

Frequently eczematous skin lesions are noted and most commonly the reason for occasional referral to a skin specialist. In general, this manifestation is a sign of long-standing venous insufficiency.

What can patients with CVI do?

Lying down with elevation of the limb relieves limb heaviness within a short period. Elevation helps return blood to the heart and reduces fluid build-up in the legs. This helps keep the increased blood flow from pooling in the legs. Active leg muscles squeeze blood up the veins toward the heart.

CVI patients should avoid prolonged sitting and standing and keep their blood moving by performing foot exercises at least every half-hour. To improve overall circulation, they can spend part of their day engaging in brisk exercises such as swimming, jogging or some aerobic exercises.

Increasing blood flow back to the heart reduces the risk of developing skin ulcers. If standing and sitting in one place is unavoidable, wiggling the toes, or shifting body position would help keep the blood moving.

There is also the option of wearing compression stockings. First described by Jobst in 1940, compression stockings produce graded pressures from the foot to the knee or thigh to decrease edema and minimize venous hypertension. By binding the legs, elastic compression stockings keep the veins from sagging. As a result, less blood pools in the legs and swelling is reduced.

Doctors may also prescribe drugs such as diosmin-hesperidin (Daflon) which can improve the venous tone. Aside from its phlebotonic effect, Daflon has been reported to also have a protective effect on the blood vessels.

The next time one feels that one’s legs are heavier in the afternoon than early in the morning, one may have to think of CVI, and treat the problem properly before it becomes much more complicated.

(Dr. Garcia is the chief of cardiovascular and peripheral vascular surgery at the Philippine Heart Center and the current president of the Venous Forum of the Philippines. He is also a member of the advisory board of Charter, a non-stock, non-profit research foundation headed by Dr. Castillo and based at the Manila Sanitarium Hospital.)