Causes and mechanism of development
Acute venous insufficiency syndrome occurs exclusively when deep veins are occluded. The main causes include acute thrombosis, thrombophlebitis, mechanical injury, or surgical ligation of major venous trunks.
Important to remember: if only superficial veins are affected, acute venous insufficiency will not occur. The bulk of blood always drains through the deep veins, and the superficial network easily compensates for a local block via communicating veins (in such cases, local signs of inflammation come to the fore).
For the clinical picture to develop, occlusion must occur at the so-called critical levels:
- In the upper extremity: at the level of the axillary and subclavian veins.
- In the lower extremity: at the level of the common femoral and iliac veins.
Clinical presentation depending on the level
Symptoms directly depend on how high the thrombus is located.
- Acute femoral vein thrombosis. Patients complain of sudden or gradually increasing pain along the inner surface of the thigh. The lower limb itself noticeably swells. The skin acquires a cyanotic (bluish) tint, and an enhanced venous pattern clearly shows through the skin.
- Acute thrombosis of the major veins of the pelvis and thigh. In this case, the block is located higher, so the clinical picture is more severe. Pain is localized not only in the thigh but also in the inguinal region. A massive, pronounced edema develops, which encompasses not just the entire leg but extends to the perineum and lower abdomen on the affected side. Palpation of the inguinal and iliac regions is sharply painful. The venous pattern on the thigh is strongly enhanced.
Special forms: white and blue phlegmasia
In thrombosis of the major pelvic and thigh veins, specific severe forms — phlegmasias — may develop.
White phlegmasia (phlegmasia alba dolens). The main distinguishing feature of this form is the characteristic milk-white skin color of the affected lower limb.
Blue phlegmasia (phlegmasia caerulea dolens, or venous gangrene). This is an extremely severe condition with high mortality. The pathogenesis is based on total thrombosis of absolutely all veins of the leg and pelvis.
- Local manifestations: begins with acute, sudden pain in the groin and thigh with a feeling of severe bursting. Edema develops lightning-fast, encompassing the entire leg, buttocks, and perineum. The skin becomes cold, shiny, and cyanotic. Point hemorrhages appear, which rapidly merge into purple-blue spots. The epidermis peels off, forming blisters with hemorrhagic fluid — these are clear signs of gangrene.
- Vascular and neurological status: due to colossal edema, arteries are compressed — their pulsation disappears. Paresthesias occur on the thigh, and sensitivity decreases on the lower leg and foot.
- General condition: the patient is in an extremely severe condition. There is pronounced weakness, chills, high fever, rapid breathing, a drop in blood pressure (hypotension), and a frequent weak pulse. There is a huge risk of developing septic shock.
Epidemiological note
Venous system diseases are a major healthcare problem. In Europe, they are diagnosed in 9–20% of the adult population. People of working age — from 40 to 60 years old — are most susceptible to the pathology.
In cases where the acute process (e.g., previous deep vein thrombophlebitis) transitions into chronic venous insufficiency (post-thrombophlebitic syndrome), 0.5–2% of such patients subsequently develop severe complications in the form of trophic ulcers.
Briefly: answers to topical questions
What instrumental diagnostic methods are used to confirm acute deep vein thrombosis?
To visualize and assess the level and nature of deep vein thrombosis, the following methods are used:
- Duplex or triplex scanning of the inferior vena cava and lower extremity veins.
- Phlebography — provides the most complete information on the state of venous blood flow and deep veins.
- CT phlebography — computed tomography angiography of the lower extremity vessels.
- MR phlebography — magnetic resonance venography of a single region.
To avoid confusing phlegmasias: Alba — associated with an albino (leg white as milk). Caerulea — associated with ceruloplasmin (blue color), this is total thrombosis with purple-blue spots and gangrene.
Class and exam questions
Why does superficial vein thrombophlebitis not cause acute circulatory insufficiency?
Because the primary venous outflow from the extremities occurs precisely through the deep veins. When superficial veins are affected, blood flow is compensated via communicating veins, and local signs of inflammation predominate clinically.
Where are the critical levels of occlusion located?
For the upper extremity, the critical level is considered to be the subclavian and axillary veins. For the lower extremity — the common femoral and iliac veins.
How fast does venous gangrene (blue phlegmasia) develop?
This condition develops rapidly. Irreversible changes and venous gangrene form in just 4–8 hours from the onset of total thrombosis.
What else to study on this topic
- Pathogenesis of chronic venous insufficiency (CVI)
- Varicose veins and their role in the development of CVI
- Post-thrombophlebitic syndrome: consequences of previous thrombosis
- Mechanism of trophic ulcer formation in venous diseases
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