Varicose veins of the lower extremities (varicose veins)

Varicose veins, varicose veins, varicose veins(from Latin varix, varicis - dilation, swelling of the veins)- persistent irreversible change in the veins, characterized by:

• uneven increase in the lumen and length of the veins,
• the formation of nodes in areas of thinned veins due to pathological changes in the venous walls, their thinning, stretching, decreased tone and elasticity,
• functional insufficiency of venous valves and impaired blood flow.

Varicose veins are a fairly common disease. Varicose veins and their complications are diagnosed in 25% of the population, and women suffer from them 2 to 3 times more than men. In women, the first signs of the disease are usually observed at an early age, and are usually associated with pregnancy and childbirth. At older ages there is an increase in incidence in both men and women, and the frequency of complicated forms increases. At 70 years of age, the disease occurs 6-10 times more often than at 30 years of age. However, recently, the manifestation of varicose veins is often observed in very young people, even in adolescents. Therefore, identifying all possible causes of the disease and preventing venous disorders is becoming an increasingly urgent task.

How varicose veins arise and develop

To understand how varicose veins occur, let's briefly explain the physiology of the venous system of the lower extremities. Venous flow in the legs is provided by two interconnected mechanisms: central and peripheral. The central mechanism is associated with the heart, lungs, diaphragm and the peripheral mechanism is directly related to the functioning of the venous system of the lower extremities that surround the vessels of the muscles and tissues.

The initial signs of varicose veins are impaired capillary circulation, swelling, a feeling of heaviness in the legs, the appearance of spider veins and spider veins. These changes are reversible, but if preventive measures are not taken in time the problems will increase.

As a rule, more than a year passes from the initial signs of varicose veins of the lower extremities to the formation of varicose nodes and the appearance of pronounced symptoms of varicose veins. Varicose veins, which develop gradually, cause impaired blood flow and chronic venous insufficiency. Stagnation of blood in the veins can lead to phlebitis (inflammation of the veins), thrombophlebitis (inflammation of the veins with the formation of blood clots), phlebothrombosis (thrombosis with additional inflammation of the veins), non-healing dermatitis (inflammation of the the veins). skin), trophic ulcers.

Types and forms of varicose veins.

There are primary (true) and secondary (symptomatic) varicose veins.

Primary varicose veins are an independent disease of the venous system (varicose veins). It develops gradually over several years. Most often, varicose dilation of the great saphenous vein is observed (70-85%), less often - the small saphenous vein (5-12%). In the case of varicose veins, between 50 and 70% of venous damage is bilateral.

Secondary varicose veins are a symptom and consequence of diseases in which there are obstructions to the flow of blood through the deep veins of the lower extremities (postthrombotic diseases, tumors, scars, inflammatory processes, aplasia and dysplasia of the deep, arteriovenous veins). fistulas, etc. ). Secondary varicose veins are quite rare.

Most often, varicose veins affect the saphenous veins of the lower extremities, which are part of the great saphenous vein system. The branches of the small saphenous vein suffer from varicose veins much less frequently.

Classification of types of varicose veins.

Until recently, in our country doctors classified varicose veins according to various types of classifications. The clinical stage classification of V. S. Savelyev was used, which reflects the degree of disturbance of venous circulation in the limb and the body's ability to resist these disturbances and compensate for them, as well as the classification according to the forms of varicose veins and complications caused by them.

But the main one today is the international CEAP classification, based on the clinical (C - clinical), etiological (E - etiology), anatomical (A - anatomy) and pathogenic (P - pathogenesis) characteristics of the disease.

They are divided into six clinical classes ("C") according to increasing severity of the disease, from telangiectasias (TAE) to trophic ulcers.

The etiological section ("E") indicates whether the process is primary or not.

The anatomical part of the classification ("A") divides the venous system of the lower extremities into 18 relatively separate segments, which makes it possible to indicate the location of the affected area of the venous system.

The pathophysiological section ("P") characterizes the presence of reflux and/or obstruction in the affected venous segment.

Symptoms of varicose veins

The symptoms of varicose veins depend on the stage of the disease, ie. on the degree of changes in blood vessels and alteration of the venous system. Depending on the stage, a prognosis can be given for the further development of the disease.

The initial stage of varicose veins: first degree varicose veins.

At the initial stage, when the pathology of the veins is not yet clearly expressed, there may be no visible signs of varicose veins. Patients complain of a feeling of heaviness and discomfort in the legs, too rapid fatigue, a feeling of heat, paresthesia (numbness, burning, tingling). Symptoms worsen towards the end of the day, as well as under the influence of heat, in summer or when wearing warm shoes indoors in winter. Swelling appears in the foot and ankle, which disappears after a short rest. Occasionally, nighttime cramps may occur in the calf muscles, but patients attribute these to overwork.

After prolonged physical activity, the veins swell and their network can be easily seen through the skin. They are especially noticeable in the thighs, calves and feet area. The number of such veins and the degree of expansion may vary. They can be single, inconspicuous formations on the lower leg, which appear more clearly at night or after physical activity. Also at this stage of varicose veins, the appearance of spider veins is observed.

If at this stage the simplest conservative treatment begins, as well as following preventive measures, then the development of the disease can be prevented by eliminating almost all symptoms.

Symptoms of second degree varicose veins, compensation stage.

At this stage of the disease, changes are noted in the large subcutaneous vessels. The veins become deformed, swollen, blood flow is disturbed, and noticeable swelling appears in the feet and ankles. Swelling increases with prolonged physical activity in the legs, but disappears after a night's rest. At night, cramps in the calf muscles are common. Paraesthesia is observed: temporary loss of sensitivity in the legs, numbness of the legs, burning, "goosebumps". As the disease progresses, pain appears, which intensifies at night.

This stage of subcompensation usually lasts several years, and at this time the development of the disease can also be stopped if treatment is started in a timely manner. Otherwise, the disease will inevitably progress to a more serious stage.

Symptoms of third degree varicose veins: decompensation stage

At this stage of varicose veins, there is a significant increase in symptoms, the pain, heaviness in the legs are more intense and there is an alteration in peripheral blood and lymphatic circulation (chronic venous insufficiency). The swelling does not go away even after prolonged rest and spreads to the lower leg. Patients are bothered by itchy skin. The skin on the legs dries out, loses elasticity, the skin is easily injured, loses the ability to regenerate quickly, which is why wounds take a long time to heal. Brown spots appear on the skin, most often on the inner surface of the lower third of the leg (hyperpigmentation due to subcutaneous hemorrhages).

All these complaints are constant. In the future, complaints of pain in the heart area, shortness of breath, headaches, and deterioration in the musculoskeletal function of the affected limb may appear.

Although the decompensation stage is already a very important manifestation of the disease, with adequate treatment the patient's condition can be maintained at a satisfactory level for a long time, preserving work capacity and avoiding the transition to the complications phase.

Fourth degree varicose veins: stage of complications.

This phase of the disease is characterized by pronounced alterations in venous circulation. Swelling of the legs becomes almost constant, skin itching intensifies, and trophic disorders appear on the skin of the lower leg. Advanced varicose veins are often accompanied by eczema, dermatitis and long-lasting lesions, and since the regenerative capacity of skin with varicose veins is markedly reduced, even a small wound can turn into a persistent trophic ulcer. The thinned skin and vein walls are easily injured, causing extensive bleeding. Damaged soft tissues and open ulcers become gateways for infection.

The most common complications of varicose veins:

• phlebitis - inflammation of a vein;
• thrombosis - the formation of a blood clot (thrombus) in a vein, which can cause blockage of the vessel;
• Trophic ulcers - are formed in the place where the affected vein cannot provide sufficient outflow of blood from the skin, as a result of which the nutrition (trophism) of the tissues is disturbed.

Varicose veins can be complicated by acute (sometimes purulent) thrombophlebitis.,dermatitis and eczema, hemorrhage, erysipelas, lymphangitis.One of the most dangerous complications of varicose veins is pulmonary embolism, which can cause sudden death.

At this stage it is no longer possible to restore the state of the venous system, we can only talk about preventing additional complications and, as far as possible, improving the patient's quality of life.

Causes of varicose veins

There is no single cause of primary varicose veins of the lower extremities. The development of this disease is usually caused by several factors. But all painful symptoms of varicose veins are associated with structural changes in the tissue of the venous walls of blood vessels and with disturbances in the functioning of venous valves.

What causes these violations?

You can often find the statement that one of the most important physiological reasons for the development of a disease such as varicose veins is an upright posture. In fact, in humans, by their very nature, the load on the vascular system of the lower extremities is very high. The flow of blood from the veins and its rise to the heart is impeded by the pressure caused by gravity, as well as by the high pressure in the abdominal cavity. However, not everyone develops varicose veins. What factors cause the development of varicose veins?

It has been established that the main risk factors for the development of varicose veins are:

• genetic predisposition (heredity): congenital weakness of the venous wall, disruption of venous valves;
• female gender: women suffer from varicose veins 4-6 times more often than men;
• hormonal disorders;
• hormonal contraception;
• pregnancy, especially multiple pregnancies;
• intense physical activity (intense physical work, strength sports);
• conditions and diseases that cause increased intra-abdominal pressure (chronic respiratory diseases, constipation, etc. )
• diseases that negatively affect blood vessels (high blood sugar, diabetes, pressure surges, etc. );
• work characteristics: standing or sedentary work, sudden changes in temperature, prolonged contact with high or low temperatures;
• overweight, obesity, which creates increased tension in the legs and increased pressure in the pelvic area;
• lack of vitamin C and other beneficial substances necessary for the vascular system;
• sedentary lifestyle, bad habits that destroy blood vessels and cause additional stress on them.

Diagnosis of varicose veins.

In most cases, diagnosing varicose veins is usually not difficult. A clinical examination, including a physical examination (examination and palpation), an examination of the patient, a collection of complaints and anamnesis (information about the course of the disease, life and work characteristics, past and current diseases) for the veins severe varicose veins is usually sufficient. A diagnosis can be made without instrumental examination. The exceptions are situations when, with excessive development of the subcutaneous adipose tissue of the lower extremities, varicose changes may be difficult to notice.

Currently, duplex ultrasound (USDS) has been widely used to study the veins of the lower extremities. This method allows you to determine the localization of changes in the veins and the nature of the disturbance in venous blood flow. However, you should know that ultrasound results are largely subjective and largely depend not only on the experience and knowledge of the researcher, but also on the tactical approaches to the treatment of venous diseases adopted in a given institution. medical. When determining treatment tactics, they are primarily guided by data from clinical examinations.

Duplex scanning is performed when invasive treatment of varicose veins of the lower extremities is planned. Additionally, X-ray contrast venography, magnetic resonance venography, and computed tomography venography may be used.

All these methods make it possible to clarify the location, nature and extent of venous lesions, clearly see disturbances in venous hemodynamics, evaluate the effectiveness of the prescribed therapy and predict the course of the disease.

Treatment of varicose veins - modern techniques

The main tasks of the doctor in the treatment of varicose veins are:

• eliminate or reduce the severity of symptoms that cause particular discomfort in patients: pain, swelling, cramps;
• restoration and improvement of the functioning of blood vessels, from capillaries to deep veins, improving the functioning of valves, restoring damaged vascular walls, increasing their elasticity and strength;
• improve the rheological properties of blood, reducing its viscosity;
• improving the functioning of the lymphatic system.
• prevent further development of the disease and complications;
• improving the patient's quality of life.

Depending on the stage of the disease and the degree of vascular damage, the doctor can prescribe the most optimal treatment methods for the given situation, such as:

• conservative treatment– recommendations for prevention and lifestyle changes, pharmacotherapy, compression therapy;
• non-surgical invasive procedures- sclerotherapy, ecosclerotherapy, foam sclerotherapy (foam therapy), etc. ;
• surgery- phlebectomy, thermal obliteration, stripping, combined methods and more complex operations for complications of varicose veins and the treatment of trophic ulcers of the lower extremities.

These methods make it possible to improve blood circulation in the lower extremities, including microcirculation, eliminate many cosmetic defects caused by varicose veins and relieve the patient of a significant part of the painful manifestations of the pathology.

Conservative methods for treating varicose veins.

Modern conservative therapy for varicose veins provides an integrated treatment approach and includes several areas:

• Changes in lifestyle;
• pharmacological therapy;
• Compression therapy.

It is no coincidence that lifestyle changes come first. It is necessary, if possible, to remove sludge, at least to reduce the influence of unfavorable factors.

One of them is prolonged static loads when standing or sitting, which cause blood stagnation. To activate the muscle-venous pump of the lower leg, it is necessary to regularly stretch your legs and walk more. While working, you can periodically perform exercises alternating contraction and relaxation of the muscles of the lower leg (rising on tiptoe).

It is recommended to find time to practice outdoor sports that are not associated with the risk of leg injuries (athletics or Nordic walking, stationary cycling, treadmill, swimming, cycling and walking).

If you have varicose veins, you should not overheat your legs, you will have to refuse visiting the bathhouse and sauna.

Patients with varicose veins should control their body weight. It is known that with a body mass index greater than 27 kg/m²the probability of having varicose veins increases by 30%. Excess weight is often associated with high sugar levels, which causes problems with the healing of venous ulcers and the risk of their recurrence.

Compression therapyFor varicose veins it can be used alone or in combination with pharmaceutical products, as well as after surgery and sclerotherapy.

The effectiveness of compression therapy is explained by the possibility of reducing reverse blood flow, a certain reduction in the pathological capacity of dilated veins, which leads to a decrease in swelling, an improvement in capillary blood flow and a decrease in varicose symptoms.

In addition to bandages and knitwear, there is hardware compression therapy, which is especially effective for chronic venous edema and trophic ulcers.

Drug treatment can be recommended in the early stages of varicose veins as the main type of therapy, supplemented, if necessary, with elastic compression. Pharmaceutical products are also prescribed to prepare for surgical treatment or in the postoperative period to accelerate rehabilitation and prevent complications.

The following groups of drugs are used to treat vein diseases:

• phlebotonics and angioprotectors;
• anticoagulants and thrombolytics;
• anti-inflammatories and analgesics;
• Vascular regenerative agents.

For the systemic treatment of varicose veins, venotonics and angioprotectors based on bioflavonoids, rutin derivatives, saponins, etc. are mainly used. . These drugs increase the elasticity and tone of veins, increase the resistance of blood vessels, improve lymphatic flow and reduce lymphatic pressure. . If there is a threat of thrombosis, anticoagulants are prescribed. Anti-inflammatories and analgesics are used for complications of varicose veins: inflammation of the veins, severe pain, trophic lesions of the veins.

In addition to systemic ones, local medications are used: ointments and gels based on venoactive active substances, heparin, non-steroidal anti-inflammatory drugs and ointments with corticosteroids.

Non-surgical invasive procedures

Sclerotherapy of veins of the lower extremities.

Venous sclerotherapy is an outpatient medical procedure in which a special substance, a sclerosant, is injected into a problematic capillary or vein with a fine needle. The vessel is then compressed with a latex pad or elastic bandage. The walls of the vessel "stick together", the blood flow in the vessel stops. The stuck walls usually grow together, heal and the scar disappears. It is used to treat varicose veins of small superficial veins. The method is effective in the early stages of the disease, only in cases where varicose veins are located only in small veins and allows you to eliminate cosmetic defects. A series of treatments may be required to achieve results.

Foam therapy (foam sclerotherapy)

It is distinguished by a special sclerosant. As with sclerotherapy, a sclerosing substance is injected into the damaged vein in the form of a thin foam that quickly "closes" the large affected veins. The method does not require numerous procedures and provides high results. It is important to know that the procedure, although rare, can have side effects: visual impairment. It is also dangerous for the sclerosant to penetrate the arteries and nervous tissue. The procedure must be performed by an experienced phlebologist.

Absolute contraindications for sclerotherapy: drug allergy, deep vein thrombosis, pregnancy, lactation.

Surgical treatment of varicose veins.

As a rule, surgical treatment is recommended in severe and advanced cases, as well as if conservative methods fail to stop the development of the disease.

Surgical intervention for varicose veins has the following objectives

• elimination of cosmetic defects;
• reduction of subjective symptoms (pain, burning, paresthesia, feeling of heaviness in the legs, etc. );
• prevention of deterioration of saphenous veins;
• prevention of bleeding from varicose veins;
• prevention of thrombophlebitis;
• reduction and prevention of the development of venous edema;
• reduction of manifestations and prevention of the development of hyperpigmentation, lipodermatosclerosis;
• acceleration of healing and prevention of relapse of venous trophic ulcers.

According to Clinical Guides, the objectives of surgical treatment are:

• elimination of vertical and/or horizontal pathological reflux;
• Removal of saphenous varicose veins.

Before performing surgical operations of any type, the risk of developing venous thromboembolic complications (VTEC) is evaluated.

There are several surgical methods that can be used depending on the specific situation:

Venectomy (phlebectomy) and saphenectomy- traditional operations to eliminate varicose veins.Venectomy- This is the surgical removal of diseased areas of the veins.Saphenectomy- a special case of phlebectomy, used in severe and advanced cases of the disease. The essence of saphenectomy is the removal of the central trunks of the damaged saphenous veins in a minimally invasive way, through incisions in the trunk of the vein and the insertion of a probe. During this operation, the ligation of the perforating veins is also performed, connecting the saphenous veins with the deep ones.

short peeling– rapid removal of the affected area of the saphenous vein in the thigh or leg through small incisions using special small and thin probes.

Microphlebectomy (miniphlebectomy) -removal of varicose veins by punctures of the skin with a needle using special hooks for phlebectomy (vein extractors).

Vascular cryosurgery (cryosclerosis)– methods of treating vein diseases by applying cold (liquid nitrogen) to damaged vessels.

Venous suturing is the placement of multiple sutures in a damaged vein, preventing blood flow through the vessel. As a result, blood clots form and the vein gradually degenerates.

Thermal destruction methods.– thermocoagulation and laser coagulationThey are considered minimally invasive operations.Thermocoagulation(or RFO - Radio Frequency Vein Obliteration): A very short, fraction of a second exposure to a high-frequency electrical current.Laser coagulation(EVLO or EVLK – endovasal laser obliteration (coagulation) of the veins of the lower extremities) - exposure to a laser beam in pathologically dilated vessels. In both cases, as a result of a local increase in temperature, the destruction of the glass occurs, which is called "sticking of walls" or "sealing".

It is important to remember that surgery is not a definitive cure, it is the elimination of symptoms. Conservative, lifelong treatment is also required after surgery, and this should be explained to patients.

Depending on the stage of varicose veins, symptoms, concomitant diseases and the general state of health of the patient, the doctor selects specific recommendations to achieve the maximum possible improvement as quickly as possible.