These include the following conditions:

  • Deep Venous Thrombosis
  • Deep Venous Insufficiency
  • May Thurner’s Syndrome
  • Pelvic Congestion Syndrome
  • Varicocele
  • Nutcracker Syndrome

DEEP VENOUS THROMBOSIS

Overview

Deep vein thrombosis (DVT) is a blood clot that develops within a deep vein in the body, usually in the leg.

Blood clots that develop in a vein are also known as venous thrombosis.

DVT usually occurs in a deep leg vein, a larger vein that runs through the muscles of the calf and the thigh.

It can cause pain and swelling in the leg and may lead to complications such as pulmonary embolism. This is a serious condition that occurs when a piece of blood clot breaks off into the bloodstream and blocks one of the blood vessels in the lungs (see below).

DVT and pulmonary embolism together are known as venous thromboembolism (VTE).

Symptoms of DVT

In some cases, there may be no symptoms of DVT. If symptoms do occur they can include:

  • pain, swelling and tenderness in one of your legs (usually your calf)
  • a heavy ache in the affected area
  • warm skin in the area of the clot
  • red skin, particularly at the back of your leg below the knee
  • DVT usually (although not always) affects one leg. The pain may be worse when you bend your foot upward towards your knee.
Pulmonary embolism

If left untreated, about 1 in 10 people with a DVT will develop a pulmonary embolism. A pulmonary embolism is a very serious condition that causes:

  • breathlessness – which may come on gradually or suddenly
  • chest pain – which may become worse when you breathe in
    sudden collapse
  • Both DVT and pulmonary embolism require urgent investigation and treatment.
  • Seek immediate medical attention if you have pain, swelling and tenderness in your leg, and you develop breathlessness and chest pain.
  • Read more about the complications of DVT.
What causes DVT?

Each year, DVT affects around 52 person in every 100,000 in Australia.

Anyone can develop DVT, but it becomes more common over the age of 40. As well as age, there are also a number of other risk factors, including:

  • having a history of DVT or pulmonary embolism
  • having a family history of blood clots
  • being inactive for long periods – such as after an operation or during a long journey
  • blood vessel damage – a damaged blood vessel wall can result in the formation of a blood clot
  • having certain conditions or treatments that cause your blood to clot more easily than normal – such as cancer (including chemotherapy and radiotherapy treatment), heart and lung disease, thrombophilia and Hughes syndrome
  • being pregnant – your blood also clots more easily during pregnancy
    being overweight or obese

The combined contraceptive pill and hormone replacement therapy (HRT) both contain the female hormone oestrogen, which causes the blood to clot more easily. If you’re taking either of these, your risk of developing DVT is slightly increased.

Diagnosing DVT

See your GP as soon as possible if you think you may have DVT – for example, if you have pain, swelling and a heavy ache in your leg. They’ll ask you about your symptoms and medical history.

D-dimer test

It can be difficult to diagnose DVT from symptoms alone, so your GP may advise that you have a specialised blood test called a D-dimer test.

This test detects pieces of blood clot that have been broken down and are loose in your bloodstream. The larger the number of fragments found, the more likely it is that you have a blood clot in your vein.

However, the D-dimer test isn’t always reliable because blood clot fragments can increase after an operation, injury or during pregnancy. Additional tests, such as an ultrasound scan, will need to be carried out to confirm DVT.

Ultrasound scan

An ultrasound scan can be used to detect clots in your veins. A special type of ultrasound called a Doppler ultrasound can also be used to find out how fast the blood is flowing through a blood vessel. This helps doctors identify when blood flow is slowed or blocked, which could be caused by a blood clot.

Venogram

A venogram may be used if the results of a D-dimer test and ultrasound scan can’t confirm a diagnosis of DVT.

During a venogram, a liquid called a contrast dye is injected into a vein in your foot. The dye travels up the leg and can be detected by X-ray, which will highlight a gap in the blood vessel where a clot is stopping the flow of blood.

Treating DVT

Treatment for DVT usually involves taking anticoagulant medicines, which reduce the blood’s ability to clot and stop existing clots getting bigger.

Heparin and warfarin are 2 types of anticoagulant often used to treat DVT. Heparin is usually prescribed first because it works immediately to prevent further clotting. After initial treatment, you may also need to take warfarin to prevent another blood clot forming.

A number of anticoagulants, known as directly acting oral anticoagulants (DOACs), or NOACs (for Novel or Newer -) may also be used to treat conditions such as DVT. These medications include rivaroxaban and apixaban, and they’ve been shown to be as effective as heparin and warfarin with less serious side effects.

Preventing DVT

If you need to go into hospital, a member of your care team should assess your risk of developing a blood clot when you’re admitted to hospital, whatever type of treatment you’re having.

If you’re at risk of developing DVT, there are a number of things you can do to prevent a blood clot occurring, both before you go into hospital, such as temporarily stopping taking the combined contraceptive pill, and while you’re in hospital, such as wearing compression stockings.

When you leave hospital, your care team may also make a number of recommendations to help prevent DVT returning or complications developing. These may include:

  • not smoking
  • eating a healthy, balanced diet
  • taking regular exercise
  • maintaining a healthy weight or losing weight if you’re obese

There’s no evidence to suggest that taking aspirin reduces your risk of developing DVT.

See your GP before embarking on long-distance travel if you’re at risk of getting DVT, or if you’ve had DVT in the past.

When taking a long-distance journey (6 hours or more) by plane, train or car, you should take steps to avoid getting DVT, such as drinking plenty of water, performing simple leg exercises and taking regular, short walking breaks.

Assessing risk

Surgery and some medical treatments can increase your risk of getting DVT. It’s estimated that around 25,000 people who are admitted to hospital die from preventable blood clots each year.

All patients admitted to hospital should be assessed for their risk of developing a blood clot, whatever type of treatment they’re having, and, if necessary, given preventative treatment.

Chronic venous insufficiency

Chronic venous insufficiency and leg ulcers affect approximately 1-2 people per 1000 of the general population, with approximately 10-20 people per 1000 developing ulcers during their lifetime. Ulcer healing rates can be poor with up to 50% of venous ulcers present and unhealed for 9 months. Ulcer recurrence rates are worrying with up to one third of treated patients on their fourth or more episode. Leg ulcer treatment is costly and affects the quality of life of affected individuals.

What is chronic venous insufficiency?

Chronic venous insufficiency is a term used to describe the changes that can take place in the tissues of the leg, due to longstanding high pressure in the veins. This high pressure in the veins usually occurs because blood flow in the veins is abnormal, secondary to valvular incompetence, causing reflux (reverse flow) in the veins. High venous pressure may also occur if the veins in the legs become blocked, but this is much less common. In many patients varicose veins will also be present in conjunction with chronic venous insufficiency, but this is not always the case. There are many patients with typical changes of chronic venous insufficiency, but no obvious problem with their superficial veins. These patients may have abnormalities in the deeper veins which will only be apparent on ultrasound scans.

The prolonged high pressures in varicose veins appear to lead to low level chronic inflammation in the surrounding tissues and to ultimately produce the clinical changes described below.

There are some factors which appear to predispose patients to chronic venous insufficiency. Correctable factors include being overweight, physically inactive and smoking. Age and a family history of venous disease cannot be altered but do increase your risk. A study in San Diego study also found that hours standing was a risk factor in women (San Diego study).

What are the changes that occur in chronic venous insufficiency?

Chronic venous insufficiency is a general term which encompasses a number of different changes that can occur in the gaiter area of the leg (the lower half of the leg above the ankle and around the ankle). The classical changes are described below.

Pigmentation
A brown discolouration of the skin can develop in the gaiter area (just above the ankle) and is a typical sign of venous disease. The brown discolouration occurs when blood cells leak out of the blood vessels. Haemoglobin from the red blood cells is broken down into a compound called haemosiderin, which is then permanently deposited in the tissues. This can commonly occur after a significant injury to the leg and will be made worse by an underlying problem in the veins.

Ulceration
In some patients damage to the tissues can become so bad that an area of skin can be lost. When an area of skin is lost the raw area left behind is called an ulcer. Ulcers can vary from being very small to very large. Some patients become very worried when they hear they have an ulcer. Ulcers can certainly be very troublesome, but the term ulcer only means that an area of skin has been lost. It does not have any more serious underlying connotations.

Lipodermatosclerosis (LDS or liposclerosis)
This refers to a thickening in the tissues underneath the skin. It can only be detected by feeling the leg. It is a very obvious change in the tissues. They become hard and woody and lose all their normal suppleness. It is particularly obvious in some patients with varicose veins. This is because it can be easy to feel the difference between the relatively soft and compressible vein and the surrounding hard, incompressible tissues.

Varicose eczema
When this develops, the skin becomes red, wet and scaly. It can vary from a relatively small localised area with very mild changes, to a situation where the whole of the lower leg is involved and the skin can appear very angry and inflamed.

Abnormal appearance to the shape of the leg (inverted champagne bottle)
An inverted champagne bottle aptly describes the appearances of some legs with chronic venous insufficiency. The leg is very narrow at the ankle and just above, but then becomes much fatter in the upper part of the calf below the knee. This is commonly associated with pigmentation around the ankle and sometimes with varicose veins.

Swelling
Swelling around the ankle, foot and lower leg especially of a mild degree can occur in many patients with venous problems. If it becomes more severe and is only present in one leg, then it can be a sign that investigation and treatment of the venous system is required.

How is venous insufficiency diagnosed?

Your doctor will want to do a physical examination and take a complete medical history to figure out if you have venous insufficiency. They may also order some imaging tests to pinpoint the source of the problem. These tests may include a venogram or a duplex ultrasound.

Venogram
During a venogram, your doctor will put an intravenous (IV) contrast dye into your veins. Contrast dye causes the blood vessels to appear opaque on the X-ray image, which helps the doctor see them on the image. This dye will provide your doctor with a clearer X-ray picture of your blood vessels.

Duplex ultrasound
A type of test called a duplex ultrasound may be used to test the speed and direction of blood flow in the veins. A technician will place some gel on the skin and then press a small hand-held device (transducer) against your skin. The transducer uses sound waves that bounce back to a computer and produce the images of blood flow.

How is Chronic venous insufficiency treated?

Treatment will depend on many factors, including the reason for the condition and your health status and history. Other factors your doctor will consider are:

  • your specific symptoms
  • your age
  • the severity of your condition
  • how well you can tolerate medications or procedures

The most common treatment for venous insufficiency is prescription compression stockings. These special elastic stockings apply pressure at the ankle and lower leg.

They help improve blood flow and can reduce leg swelling. Compression stockings come in a range of prescription strengths and different lengths. Your doctor will help you decide what the best type of compression stocking is for your treatment.

Treatment for venous insufficiency can include several different strategies:

Improving blood flow

Some tips to improve your blood flow include:

  • Keep your legs elevated whenever possible.
  • Wear compression stockings to apply pressure to your lower legs.
  • Keep your legs uncrossed when seated.
  • Exercise regularly.

Medications:

There are also a number of medications that may help those suffering from this condition. These include:

  • diuretics: medications that draw extra fluid from your body that is then excreted through your kidneys
  • anticoagulants: medications that thin the blood

Surgery

Sometimes more serious cases of venous insufficiency require surgery. Your doctor may suggest one of the following surgery types:

Surgical repair of veins or valves
Removing (stripping) the damaged vein
Minimally invasive endoscopic surgery: The surgeon inserts a thin tube with a camera on it to help see and tie off varicose veins.
Vein bypass: A healthy vein is transplanted from somewhere else in your body. This procedure is generally used only when the upper thigh is affected and only for very severe cases after nothing else has worked.
Vein ablation surgery: This relatively new treatment uses lasers or Radiofrequency waves to either fade or close the damaged vein with heat in a small, specific place. It involves no surgical cuts.

Ambulatory phlebectomy
This outpatient procedure (you won’t have to spend the night in the hospital) involves your doctor numbing certain spots on your leg, and then making small pricks and removing smaller varicose veins.

Sclerotherapy
This treatment method is generally reserved for advanced venous insufficiency. In sclerotherapy, a chemical is injected into the damaged vein so that it’s no longer able to carry blood adequately. Blood will return to the heart through other veins, and the damaged vein will eventually be absorbed by the body. Sclerotherapy is used to destroy small to medium veins. A chemical is injected into the damaged vein so that it’s no longer able to carry blood.

Catheter Cynoacrylate procedure
In certain cases, your doctor can use a catheter procedure for larger veins. They’ll insert a catheter (a thin tube) into the vein, heat the end of it, and then remove it. The heat will cause the vein to close and seal as the catheter is taken out.

How to prevent venous insufficiency

If you have a family history of venous insufficiency, there are steps you can take to lessen your chances of developing the condition:

  • Don’t sit or stand in one position for long stretches of time; get up and move around frequently.
  • Don’t smoke, and if you do smoke, quit.
  • Get regular exercise.
  • Maintain a healthy body weight.

May Thurner Syndrome

What Is May-Thurner Syndrome?

In May-Thurner syndrome, the right iliac artery (which carries blood to your right leg) squeezes the left iliac vein (which brings blood out of your left leg toward your heart) when they cross each other in your pelvis. Because of that pressure, blood can’t flow as freely through the left iliac vein. It’s a bit like stepping part way down on a hose.

The result: You’re more likely to get a deep vein thrombosis (DVT) in your left leg. A DVT is a type of blood clot that can be very serious. It’s not just that it can block blood flow in your leg. It can also break off and cause a clot in your lung. That’s called a pulmonary embolism, and it’s life-threatening.

Causes

May-Thurner syndrome is random. It’s not something in your genes that you get from your parents.

The crossover of those blood vessels is normal. But in some cases, they are positioned in a way that the right iliac artery presses the left iliac vein against the spine. That added pressure leaves a narrower opening. It can also lead to scars in the vein.

Symptoms

You likely won’t even know you have it unless you get a DVT. You might get pain or swelling in your leg, but usually, there aren’t any warning signs.

With a DVT, your left leg may show symptoms such as:

  • Changes in skin color, with it looking more red or purple than normal
  • Heaviness, tenderness, or throbbing
  • Pain that feels like a cramp or charley horse
  • Skin that’s warm to the touch
  • Swelling
  • Veins that look larger than usual

If the DVT clot breaks off and moves to your lungs (Pulmonary Embolism), you’ll notice:

Chest pain that’s worse when you breathe in
Coughing up blood
Heartbeat that’s faster than normal
Passing out
Shortness of breath or other problems breathing

Diagnosis

Your doctor will first do a physical exam to look for signs and symptoms of a DVT. From there, you may need imaging, such as:

  • CT or MRI
  • Ultrasound
  • Venogram, a type of X-ray that uses a special dye to show the veins in your leg
Treatment

There are two goals: to treat any clots you already have and to keep new ones from forming.

Your doctor may talk to you about several options, including:

Blood thinners:
These drugs are commonly used to treat DVT. They can prevent new clots and keep ones you already have from getting bigger. Your doctor may call these medicines anticoagulants.

Clot busters:
Your Doctor may use these to treat more serious clots. You might also hear this treatment called thrombolytic therapy. Your doctor uses a thin tube, called a catheter, to send the medication right to the site of the clot. The drug breaks it down in anywhere from a few hours to a few days.

Angioplasty and a stent:
This is a common treatment for May-Thurner syndrome. First, your doctor uses a small balloon to expand the left iliac vein. Then, you get a device called a stent. It’s a tiny cylinder, made of metal mesh, that keeps the vein open wide so blood can flow normally.

Vena cava filter:
You might get this if you can’t take blood thinners or if they don’t work well for you. Your doctor places a filter in your vena cava, a large vein in your belly. Although the filter won’t prevent clots from forming, it will catch them before they end up in your lungs.

Bypass surgery:
Your doctor builds a new path for blood to flow. You can think of it as a detour around the part of the left iliac vein that’s getting squeezed.
Surgery to move the right iliac artery:
This operation shifts the position of the artery so it sits behind the left iliac vein and no longer presses on it.