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The swollen leg of distrubed venous outflow

, : The swollen leg of distrubed venous outflow. S African Med J 38(34): 793-800

The chronic swollen leg of venous stasis is due not only to deep-vein thrombosis with consequent venous incompetence but is also the result of disordered hemodynamics of the venous outflow of the leg, owing to a variety of causes. Review of the anatomy and the hemodynamics of the veins of the leg revealed that the venous circles of Edwards are potential pathways for the return of blood after its retrograde flow down the ilio-femoral vein, the peculiarities in the course of the left iliac vein may contribute to the marked prevalence of ilio-femoral thrombosis on the left side, distension of veins is the result of raised intramural pressure and not of the reactivity of the vien wall, and that raised intramural pressure is caused by increased inflow through the capillary bed and through the arteriovenous fistulae (more important) or by decreased outflow as a result of backpressure due to obstruction or incompetence of the major outflow tract. There are indications that the arteriovenous shunts play a more important role in health and disease than has been suspected up to now. The major causes of disturbed venous outflow from the leg are: Obstruction [long dash] (1) Thrombophlebits, (2) Disruption of continuity, (3) Occlusionby tumor or fibrosis. Incompetence [long dash] (1) Postphlebitic, Traumatic with valve rupture, Idiopathic. The retrograde thrombosis, which is a common occurrence in the proximal veins of the leg, cannot be explained by the prevailing concept of mechanical hydrostatic factors. In acute thrombophlebitis, the major lymph vessels of the leg are involved in the peri-venous inflammation and, with the combination of venous and lymphatic obstruction, edema results. Venous obstruction by itself does not usually cause edema. Thrombophlebitis is but a later phase of phlebothrom-bosis. Treatment: Acute (ilio-femoral) thrombophlebitis thrombectomy; Chronic obstruction[long dash]bypass venous graft; Incompetence[long dash]restoration of valvular competence to the most proximal valve in the legby replacement with autogenous valve-bearing vein segments or repair or valvular tears.


PMID: 14203669

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