Leg Swelling

Leg Swelling

Swelling of the legs may result from many causes, with vein and lymph problems being two of them. In essence, any swelling may often result in poor lymph drainage, but this does not necessarily mean that one has lymphoedema. Occasionally, there is more than one cause.

Often we have to treat the underlying cause and then manage the lymph system which has been overloaded and becomes sluggish. There are clues as to where swelling is coming from.

One leg involved Other symptoms
Leg veins • Swelling worse on standing
• Swelling relieved by leg elevation
• Leg symptoms: heavy, tired, throbbing, aching leg.
• May have skin changes (pigmented skin, eczema, hardened skin)
• May have wounds
Pelvic vein compression • Swelling when exercising
• Thigh swelling
• Bursting sensation
• Unknown cause of thrombosis
Lymphoedema • Heavy leg, tired leg.
• Swelling goes down on elevation but with time swelling remains.
• Skin changes (thickened, warty skin).
• May have wounds
Pelvic or abdominal obstruction from a mass – benign or malignant • Pelvic or gynae symptoms
• No symptoms at all in the pelvis

 

Both legs Other symptoms
Leg veins • Swelling worse on standing
• Swelling relieved by leg elevation
• Leg symptoms: heavy, tired, throbbing, aching legs.
• May have skin changes (pigmented skin, eczema, hardened skin)
• May have wounds
Pelvic vein compression • Swelling when exercising
• Thigh swelling
• Bursting sensation
• Unknown cause of thrombosis
Lymphoedema • Heavy leg, tired leg.
• Swelling goes down on elevation but with time swelling remains.
• Skin changes (thickened, warty skin).
• May have wounds
Pelvic or abdominal obstruction from a mass – benign or malignant • Pelvic or gynae symptoms
• No symptoms at all in the pelvis
Cardiac failure • Shortness of breath
• Difficulty lying flat
Renal failure • May have blood pressure problems
• May have nausea
Thyroid dysfunction • Weight gain
• Lethargy
• Intolerance to cold
Liver failure • May have jaundice
• May have fluid in the abdomen
Protein losing condition • May have swelling of face and body as well

In order to work out where swelling is coming from, a thorough history must be undertaken and investigations done.

Investigations may include:

  • Blood tests
  • Urine tests
  • X-rays
  • Duplex doppler ultrasound scans
  • Pelvic ultrasound
  • CT scans

Remember, although in some patients it is obvious why they have swelling, in others, it may take time to work out where the swelling is coming from, and we do this in a stepwise progression. Sometimes there is more than one cause.

Phlebolymphoedema: Venous Oedema

Venous oedema refers to leg swelling that happens from veins. Veins carry blood that is low in oxygen out of the legs and back to the heart and lungs to get more oxygen. If one has varicose veins or chronic venous disease, then the veins do not carry this blood properly and there is ‘backflow’ of blood. The veins then distend and fluid seeps out of the veins into the tissue resulting in leg swelling.

Veins carry blood against gravity, thus, if they are not working properly applying gravity puts more strain on them – hence swelling results from standing for long periods, and elevating the legs relieves the swelling.

Leg swelling is problematic from a health concern:

Firstly, it is uncomfortable for a patient and symptoms such as a bursting sensation, burning, numbness, itching, throbbing and heaviness can be described. Leg swelling has been shown to affect quality of life.

Additionally, if there is fluid retention for a prolonged period, the body sensing this as a pathological process and reacts by bringing in inflammatory cells. Pigment (haemosiderin) is laid down in the skin and can cause irreversible pigmentation; Mast cells release histamine which can cause itchiness and venous eczema, scar tissue is laid down causing the skin to become hardened and not able get properly oxygenated, and then the damaged skin can be broken down forming wounds known as venous ulceration. Venous ulceration is very difficult to heal. This cycle of inflammation and scar formation is ongoing until the cause is treated. Thus this process needs to be stopped and early ulcers prevented.

Lymphatics also drain fluid out of a leg, however, lymph vessels work on negative pressure. Thus, if there is fluid retention from veins, the pressure in the legs goes up and the lymphatics are unable to drain properly, thus aggravating the fluid and in some cases aggravating inflammation and conditions such as eczema.

This is what is known as phlebolymphoedema (secondary lymphoedema from veins). This is why, when fluid has been present for a long period, we work closely with lymphoedema therapists to ‘kickstart’ the lymphatics to work again, only once we have treated the vein problem. Veins and lymphatics always need to be looked at hand in hand.

Whole Leg swelling – thigh swelling or pain in exercise

Some patients – often see in active individuals, or athletes, may get leg swelling that involves the thigh as well. This is often aggravated by exercise and a patient will describe the leg as wanting to ‘burst’ after exercise. This is known as venous claudication. Typically, this occurs on the left hand side. This is related to vein obstruction in the pelvis.

There may be narrowing of the veins, where the veins lie against the spine and where the arteries cross over the veins. Athletes, spinal surgery, pregnancy and age may all result in some additional pelvic change which causes this narrowing to become significant and not allow venous blood to drain from the leg.

This narrowing can cause leg swelling – typically on the left, but occasionally the compression/narrowing is on the right. It may also cause extensive acute deep vein thrombosis in some patients.

In this case, the veins need to be scanned, sometimes with a CT scan and a vein stent inserted to keep the narrowing open.

Vein Stenting

Vein stenting is a procedure used to open up narrowings (stenosis) or blockages (occlusions) in veins. The typical area for vein narrowing is in the pelvis on the left side. However, it can be in the abdomen as well and may also affect the right side.

The vein is often compressed between the bony spine and an artery. Changes in abdominal and pelvic structure can aggravate this narrowing and cause symptoms such as swelling and thrombosis.

This may occur after spinal operations, after pregnancy, in athletes and sometimes just spontaneously. Imaging modalities have improved and we now actively look for it and treat it.

How do we treat vein lesions?
  • The diagnosis will be suspected on duplex doppler ultrasound imaging.
  • Thereafter a CT Venogram or MR Venogram may be performed to more accurately delineate anatomy.
  • However, of note, is that these imaging modalities may still miss lesions.
  • The most accurate diagnosis is by IntraVascular UltraSound (IVUS)
How is Vein Stenting performed?

The patient will need to go to theatre for vein stenting. A general anaesthetic will be given and a venogram performed. This is a small puncture in the groin inserting a sheath (small cannula) into the femoral vein. A venogram is then performed – this is the same idea as a coronary angiogram for the coronary arteries. However, we are looking at blood vessels in the pelvis.

Venogram

The IVUS catheter will then be inserted to look directly inside the vein and assess for any narrowing. This will be marked with the venogram. The IVUS is accurate in measurement and will help determine what size stent is necessary.

Balloon being inflated

Thereafter a balloon will be used to inflate the area of narrowing and prepare the vessel for the stent.

Stent deployed

The stent will then be inserted and deployed. This will result in clinical improvement of symptoms. Treating symptomatic vein lesions is important. If they are not treated they can lead to thrombosis as well as swelling and chronic leg changes such as skin pigmentation, skin damage and wound formation.
Thereafter a venogram and IVUS will be done again to ensure the stent has opened nicely and blood is flowing well.

OptiVein’s International Vein & Lymphatic Network
Dr Redman is connected to world experts on an academic, clinical and personal level via the International Vein Network.

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Leg Swelling