Iliac vein disease can cause long term swelling of the leg
Often, we come across patients who have a long-standing swelling of the lower limb or a non-healing ulcer for months – years. These patients are often subject to repeated surgeries for these ulcers and spend a significant part of their lifetime tolerating pain and heaviness in their legs. All of this is just because of the lack of information among the physicians about the cause of this problem. In this blog, I would focus on the cause of this problem and what we can do to heal those ulcers or reduce their pain/heaviness.
What is the cause of this problem?
In the leg, blood comes from the heart to the foot through the arteries and goes back through vessels called as veins. Iliac veins are those veins that travel from groin upwards in the pelvis. These veins are the main highways through which, blood travels from the lower limbs into the abdominal veins. Any narrowing in these highways can cause obstruction to traffic of the blood.
This narrowing of these veins can happen in two ways. May Thurner syndrome is one such entity. In this disease, the iliac vein is compress by the iliac arteries (arteries carry pulsatile blood from the heart at high blood pressure; hence, it can compress the low-pressure veins). This causes a narrowing of the iliac veins over time. This happens more commonly in women, usually on the left side.
The other mechanism by which the narrowing of Iliac veins can happen is by a trauma that forces the patient to undergo bed rest for a couple of days to a couple of weeks or more. Immobile patient’s veins are very prone to clotting which is often unrecognize. These clots are dissolve with time; however, they leave behind very narrowed and diseased iliac veins, which still, although not obstructed, cause significant slow down of blood flow.
Once these veins get narrow and diseased by either of these mechanisms, blood flow upstream towards the abdomen gets slow down because of which, venous pressure increases and causes swelling in the leg and further changes eg skin pigmentation, venous ulcers, and pain/heaviness.
These patients are often manage with multiple dressings, debridements (cleaning surgeries of the wound), limb elevation during the night and various types of compression garments. Because of increase venous pressure, some of these patients also develop varicose veins (big bluish tortuous visible veins in the thigh and leg). Therefore, these patients often undergo laser procedure or other procedure for these varicose veins. However, this procedure is not very helpful until and unless we treat the iliac veins.
How do we treat these patients?
The simple answer is that we have to widen the diseased iliac veins which will improve the blood flow from the lower limbs to the abdomen and therefore, will reduce swelling of the leg and help in the healing of the ulcers. But its easier said than done. This is done by doing angioplasty of the veins(balloon expansion of the iliac veins to increase their diameter). Often, the narrowing may recur after the angioplasty.
In these conditions, stenting of the diseased segment of the iliac veins may be done. Nowadays, dedicate venous stents are available to be used in these veins, thus significantly increasing the success of these procedures. Apart from the angioplasty and stenting procedures, properly applied compression garments and dressing play a great role in relieving the pain/heaviness, swelling and helping in ulcer healing.
To conclude, there needs to be awareness among the general public as well as their first contact physicians regarding this disease and its treatment so that these patients can get appropriate and correct treatment at the earliest and there can be a tremendous increase in the quality of life of these patients.
All patients who have chronic swelling of one / both the legs should be evaluate by a vascular surgeon to detect the presence of venous disease and treat it so that, the disease does not worsen into a non-healing ulcer. All patients with non-healing ulcers should also be evaluate by a vascular surgeon so as to help them heal the ulcer and lead a normal life.
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