Superficial Venous System – GSV (Great Saphenous Vein)

• Longest vein in body
• Areas of aplasia/hypoplasia common in lower thigh, knee and calf
• Often runs a superficial subcutaneous course from mid thigh-knee
• May enter and exit the saphenous sheath at various locations
• Closely associated with saphenous nerve below mid-calf
• Often duplicated (25% in the calf; 8% in thigh)
• Numerous normal variants at Saphenofemoral junction (SFJ)

Superficial Venous System – SSV (Small Saphenous Vein)

• Within the fascial space (saphenous sheath)
• Begins posterior to the lateral malleolus
• Travels up calf between two heads of gastrocnemius muscle
• May have thigh extension
• Usually drains into the Saphenopopliteal Junction (SPJ)

Types of Leg Swelling

Venous Edema: Venous edema occurs when blood flow in the veins is impaired, leading to fluid accumulation in the lower legs. This type of swelling is often caused by conditions like chronic venous insufficiency or varicose veins, where the veins are unable to efficiently return blood to the heart, causing fluid to leak into surrounding tissues.

Lymphatic Edema: Lymphatic edema is due to a disruption in the lymphatic system, which impairs the drainage of lymph fluid from the tissues. This type of swelling typically results from conditions that affect lymphatic vessels, such as lymphatic obstruction or damage, leading to fluid buildup primarily in the extremities.

Lipedema: Lipedema is a condition characterized by abnormal fat deposition in the legs and sometimes the arms, leading to swelling and a disproportionate appearance. Unlike venous or lymphatic edema, lipedema primarily affects the fat tissue and is often associated with tenderness and pain in the swollen areas.

Common Causes of Edema

Unilateral Swelling: When swelling happens in just one leg, it might be due to problems like blood clots (deep vein thrombosis) or issues with vein function (venous insufficiency).

Bilateral Swelling: When both legs are swollen, it could be due to issues with veins (venous insufficiency), heart problems (heart failure), or certain medications. Other causes might include unknown reasons (idiopathic edema), hormonal changes before your period (premenstrual edema), issues with the lymphatic system (lymphedema), or high blood pressure in the lungs (pulmonary hypertension).

Medications Causing Edema

• Calcium channel blockers (up to 50% of patients will develop edema)
• NSAID (up to 5% of patients will develop edema)
• Other antihypertensives: beta blockers, clonidine, hydralazine, minoxidil, methyldopa
• Hormones: corticosteroids, estrogen, progesterone, testosterone
• Other drugs: monoamine oxidase inhibitors, rosiglitazone, pioglitazone

Less Common Causes of Edema

Unilateral Swelling:

• Ruptured Bakers cyst: a fluid-filled sac behind the knee that can burst
• Cellulitis: an infection in the skin, can also cause swelling
• Secondary lymphedema: this occurs if a tumor, radiation, or surgery affects the lymphatic system.
• Pelvic mass or tumor can press on the veins and cause one leg to swell.
• Reflex sympathetic dystrophy
• Post-thrombotic syndrome

Bilateral Swelling: 

• Bilateral deep vein thrombosis
• Renal disease (kidney problems)
• Liver disease
• Secondary lymphedema (tumor, radiation, surgery)
• Dependent edema
• Preeclampsia: a pregnancy-related condition
• Anemia: a condition where you don’t have enough red blood cells
• Post-thrombotic syndrome

Less Well Known Causes of Edema

Unilateral Swelling:

• Primary Lymphedema: This is a condition where the lymphatic system doesn’t work properly from birth or develops later in life, leading to swelling in the legs.
• Vascular Malformations: These are unusual or abnormal blood vessels that can cause swelling in the legs.
• May-Thurner Syndrome: This is a condition where one of the veins in the pelvis is compressed by another vein, which can lead to swelling in the leg.

Bilateral Swelling:

• Primary Lymphedema
• Malabsorption and Malnutrition: Problems with absorbing nutrients or a lack of essential nutrients can cause swelling in the legs due to fluid imbalances.Restrictive Pericardial Disease: This occurs when the sac around the heart becomes thickened and stiff, which can affect how blood flows and cause swelling in the legs.

Primary Lymphedema

Congenital Lymphedema: This condition appears at birth or by the age of 2 and is often due to a genetic issue.

• Familial Form: Milroy disease is a hereditary type of congenital lymphedema that runs in families and is present from an early age.

Lymphedema Praecox: This is the most common type of lymphedema, typically occurring between ages 2 and 35. It affects women more frequently than men, with a ratio of 10 females to 1 male. It usually affects one leg (unilateral) and often involves swelling in the foot and calf.

Lymphedema Tarda: This type of lymphedema presents after the age of 35, developing later in life rather than from birth or early childhood.

Important Things to Know in Edema Evaluation

1. What is the duration? (acute < 72 hours or longer)
2. Is the edema painful?
3. Patient on any medication?
4. Does edema improve overnight or worse in evenings?
5. Any history of abdominal/pelvic neoplasm or radiation?
6. Is there any history consistent with sleep apnoea?

Evaluating Leg Edema

History: This involves gathering information about the patient’s symptoms, medical background, family history, and any relevant lifestyle factors. It helps in understanding the onset, duration, and nature of the swelling, and in identifying possible causes or contributing factors.

Physical Examination: This includes a thorough check-up by a healthcare provider to assess the swelling, look for signs of other conditions, and evaluate the affected areas. It helps in determining the extent of the edema and other physical manifestations.

Lab Tests/ECG: Laboratory tests may include blood tests to check for markers of inflammation, infection, or other underlying conditions. An ECG (electrocardiogram) measures the electrical activity of the heart to identify any heart-related issues that could be contributing to the swelling.

Imaging: Various imaging techniques, such as ultrasound, MRI, or CT scans, are used to visualize the internal structures, identify the cause of the swelling, and assess the condition of veins, lymphatic vessels, or other affected areas.

Most important imaging is vascular ultrasound scan of the leg, which can be done in a supine and standing position. CT venogram done from feet up to diaphragm is an extremely useful test in certain patients. It can be combined with CT pulmonary angiogram to assess the pulmonary arteries in patients with relevant history. MRI is useful in occasional patients.

What is a Doppler Ultrasound?

According to Mayo Clinic, a Doppler ultrasound is a noninvasive test that can be used to estimate the blood flow through your blood vessels by bouncing high-frequency sound waves (ultrasound) off circulating red blood cells. This is different from a regular ultrasound, which uses sound waves to produce images and does not show blood flow.

This test may be done as an alternative to more-invasive procedures, such as angiography, which involves injecting dye into the blood vessels so that they show up clearly on X-ray images. A Doppler ultrasound test may also help our doctor check or to monitor certain treatments to your veins. There are more several types of venous diseases we offer to treat different problems including varicose veins and spiders veins as well as deep vein thrombosis. Thanks to the latest innovations have led to more precise assessment and better informed treatment plans. Read more about  “Tomorrow’s Varicose Veins Treatments” with varicose vein specialist, Dr. Manish Taneja.

Venous Causes of Leg Swelling

Deep Vein Thrombosis (DVT): A blood clot in a deep vein, usually in the leg, that can cause swelling and pain.

Post-Thrombotic Syndrome: A condition that can occur after DVT, leading to long-term symptoms like swelling, pain, and skin changes due to vein damage.

Chronic Venous Insufficiency: A condition where veins in the legs cannot efficiently return blood to the heart, leading to persistent swelling and discomfort.

Varicose Veins: Enlarged, twisted veins near the surface of the skin that cause swelling and discomfort due to poor blood flow.

Extrinsic Venous Compression: Swelling caused by external pressure on the veins from surrounding structures, such as tumors or enlarged organs.

Ischemic Reperfusion: Swelling resulting from the return of blood flow to tissues after a period of restricted blood supply, causing inflammation and fluid buildup.

Arteriovenous Malformation: An abnormal connection between arteries and veins that can disrupt normal blood flow and cause swelling.

Venous Malformation: Abnormal growths of veins that can lead to localized swelling and discomfort.

Klippel-Trenaunay Syndrome: A rare condition characterized by a combination of varicose veins, abnormal blood vessel growth, and limb overgrowth, leading to swelling and other issues.

May-Thurner Syndrome: A condition where the left iliac vein is compressed by the right iliac artery, leading to swelling in the left leg.

Popliteal Vein Compression Syndrome: Compression of the popliteal vein behind the knee, causing swelling and pain in the lower leg.