Shrinking the Swollen Leg

Shrinking the Swollen Leg

One of the most vexing problems for patient and physician alike is the persistently swollen leg that sometimes occurs after a blood clot. This is sometimes referred to as chronic venous insufficiency or post-phlebitic syndrome.

This basically occurs because the leg veins have valves that become stiffer and less compliant after the inflammatory process of a blood clot has subsided. Persistent clots that scar and never quite go away also contribute to the process. As a result, blood that is attempting to return from the feet and leg has difficulty making it through the damaged vein valves back to the heart and tends to reflux (pool) in the leg, causing unsightly skin changes and uncomfortable chronic swelling of the leg. This can lead to further complications, such as ulcers and varicose veins on the skin of the legs.

An article recently appeared in the New England Journal of Medicine reviewing this subject. The authors, Drs. Seshadri Raju and Peter Neglen, gave an update on the subject and reviewed evaluation and treatment of this problem

The physical examination by a physician can give a pretty good idea of what is going on, but imaging of the veins with venography is the gold standard in terms of finding out where the blocked sites are. In particular, the iliac veins (located in the lower abdomen and pelvis) are often involved, and need to be visualized.

Treatment for chronic venous insufficiency first and foremost involves graduated compression with stockings. Low pressure stockings can help control edema (swelling) but higher compression stockings, with pressures of 35 mm Hg or higher are needed to prevent things like ulcers and stasis dermatitis. Lifelong compression is recommended for a person who has had an ulcer.

Drug therapy with pentoxifylline may provide modest benefits.

Laser therapy and sclerosing therapy my help in ablating unsightly or uncomfortable varicose veins or “spiders”. Radiofrequency ablation (RFA) may also helping in place of “stripping” procedures. Other techniques, such as stenting and valve reconstruction may be useful, especially in re-opening blocked iliac veins.

The treatment of chronic venous insufficiency has developed much in recent years, almost becoming a specialty of its own. When confronted with this problem, it is wise to consult with physicians who have a special expertise in its management, including vascular surgeons, interventional radiologists and hematologists.

p.s. Due to other distractions this is my first post in quite some time and I intend to be more regular with the blog in the future. Thank you for your interest.