What is the vascular system?
Our vascular system includes blood vessels (including veins, arteries, and smaller blood vessels) as well as the heart. Arteries carry blood away from the heart towards the body and veins return blood from the body back towards the heart.
What if the veins are not functioning correctly?
When the veins are not functioning correctly, the blood will not flow back to the heart appropriately. The veins in the legs are particularly susceptible to the effect of gravity. Especially when standing or sitting for a prolonged time, gravity tends to pull the blood towards the feet. The veins in the legs have valves that help prevent blood from flowing backwards towards the feet. The valves may become damaged as the result of aging, extended sitting or standing, or a combination of aging and reduced mobility. If the blood does not flow back to the heart normally, pooling of blood in the legs can occur.
A definition of terms helps us understand the implications of venous disease.
Varicose veins: the veins (most commonly in the legs) dilate or enlarge. Varicose veins may or may not cause discomfort. Spider veins - small, dilated vessels of the venous system - are a mild variation of varicose veins. Additional information about varicose veins can be found on this page of the Mayo Clinic’s website.
Venous insufficiency: a condition in which the blood does not flow forward normally in the legs and, therefore, tends to pool in the legs causing edema (swelling) and possibly discomfort.
Venous stasis: a condition in which inflammation occurs in the skin, due to chronic venous insufficiency. This may lead to stasis dermatitis which can include change in skin color, itching, discomfort, sores (ulcers), and thickening of the skin.
Hemosiderin staining: a condition in which pigmentation occurs (usually in the lower legs) due to chronic venous insufficiency. The staining may be yellow, brown, or black with a bruise-like appearance. Venous insufficiency can cause some red blood cells to “leak” out of the veins. A protein in the red blood cells called hemosiderin deposits in the tissue and causes the pigmentation.
In summary, as the venous disease progresses, the veins can dilate, and swelling and discomfort can occur. With progression, skin changes can occur due to inflammation and leaking of red blood cells from the veins.
What is the significance of venous disease in people with Down syndrome?
In our experience, venous disease seems to be more common in people with Down syndrome. People with Down syndrome are more likely to have some of the risk factors for venous disease (as explained below). People with Down syndrome also have differences in connective tissue which may contribute.
Risk factors for venous disease (including varicose veins) include age, sex (female), pregnancy, family history, obesity, and prolonged standing or sitting. Some of these risk factors may contribute to a greater degree in people with Down syndrome.
Age: People with Down syndrome have issues associated with early aging and it can result in several conditions occurring at a younger age (e.g., Alzheimer’s dementia, cataracts, osteoarthritis). Whether early aging impacts venous disease is not clear.
Obesity: People with Down syndrome have higher rates of being overweight and obese.
Prolonged sitting and standing: Some individuals with Down syndrome tend to be sedentary or have jobs in which they sit with their feet dependent (hanging down). Some have jobs or participate in activities in which they stand in one position for prolonged times. To further complicate the issues of prolonged sitting, some individuals with Down syndrome are very flexible and can sit with their legs tucked under their body, which can further restrict blood flow back to the heart from the legs.
Connective tissue differences: We think Down syndrome it itself is likely a contributor. We note that people with Down syndrome have several conditions in which the connective tissue (the tissue that holds us together) is apparently impaired. Conditions like hernias, keratoconus, and joint subluxation all have some degree of decreased connection of tissues and are more common in people with Down syndrome. We speculate that a similar factor could play a role in the tissue of the veins or valves of the veins in people with Down syndrome; but this has not been demonstrated in research that we are aware of.
What are the treatments for venous disease?
- Avoiding long periods of standing or sitting
- Exercising regularly.
- Losing weight if you are overweight.
- Elevating your legs above the level of your heart while sitting and lying down
- Wearing compression stockings.
- Taking antibiotics as needed to treat skin infections.
- Practicing good skin hygiene.
The main goals to reduce the pooling of blood and prevent pain and leg ulcers.
If those treatments are not sufficient, surgery to close or remove the dilated vein is an option. Unfortunately, after treating, removing, or closing one vein, another vein will dilate in some people. The Cleveland Clinic's website has additional information about treatment options.
Are there specific issues for people with Down syndrome?
For many people with Down syndrome, varicose veins, and venous disease, in general, do not cause discomfort, ulcers, or concerning problems. In those cases, we recommend avoiding prolonged sitting and standing, exercising regularly (walking or dancing are good examples), weight loss, elevation of the legs, and good skin hygiene, especially moisturizers.
When there are symptoms, we consider compression stockings or compression wraps. These help the blood in the veins return to the heart. While compression stockings and compression wraps can be quite beneficial, we do recommend caution. We have seen some individuals with Down syndrome develop sores due to the stockings. Most commonly this has occurred on the top of the foot where it meets the ankle. The stockings can bunch up at that location and can cause increased pressure and/or rubbing. Many individuals with Down syndrome have a higher pain tolerance and we suspect they are not aware of the pressure, rubbing, or the developing sore until it becomes problematic.
For treatment for hemosiderin staining, we first discuss that it is not typically a problem beyond the cosmetic affect. Therefore, consider the benefits and risks of treating. It may be difficult to eliminate hemosiderin staining completely. In our experience, the darkened skin may lighten with weight loss and other treatments as noted above. These don’t typically eliminate the color change. Other treatments include certain topical creams or gels or laser treatment. They may lessen the staining but don’t always eliminate it. If desired, we recommend an evaluation by a dermatologist.