Varicose veins in the lower limbs (varicose veins)

varicose veins, varicose veins, varicose veins(from Latin varix, varicose vein - dilated, swollen veins)- Persistent irreversible changes in the veins, characterized by:

• Uneven increase in vein lumen and length,
• Due to pathological changes in the vein wall, the veins become thinner, stretched, and their tension and elasticity decrease, forming nodules in the thinned areas of the veins.
• Venous valve insufficiency and impaired blood flow.

Varicose veins are a fairly common condition. 25% of the population is diagnosed with varicose veins and their complications, with women being 2-3 times more likely to suffer from varicose veins and their complications than men. In women, the first signs of the disease usually appear at a young age, usually in connection with pregnancy and childbirth. The incidence increases with age in both men and women, and the frequency of complex forms increases. At age 70, the incidence of the disease is 6-10 times higher than at age 30. Recently, however, manifestations of varicose veins are often observed in very young people, even teenagers. Therefore, identifying all possible causes of disease and preventing venous disease is becoming an increasingly urgent task.

How varicose veins develop

In order to understand how varicose veins occur, let us briefly explain the physiology of the venous system of the lower limbs. Venous outflow from the legs is provided by two interrelated mechanisms - the central mechanism and the peripheral mechanism. The central mechanism is related to the heart, lungs, and diaphragm, and the peripheral mechanism is directly related to the function of the venous system of the lower limbs surrounding the muscles and tissue vessels.The first symptoms 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 promptly, problems will increase.Generally speaking, it takes more than a year from the initial symptoms of varicose veins in the lower limbs to the formation of varicose vein nodules and the emergence of obvious varicose vein symptoms. Varicose veins develop gradually, leading to 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 and the formation of blood clots), venous thrombosis (the formation of blood clots and the formation of further inflammation of the veins), non-healing dermatitis (inflammation of the veins of the skin), Nutritional ulcer.

Types and forms of varicose veins

There are primary (true) and secondary (symptomatic) varicose veins.Primary varicose veins are a separate disease of the venous system (varicose veins). It developed gradually over several years. The most common is varicose dilation of the great saphenous vein (70-85%), and less commonly the small saphenous vein (5-12%). With varicose veins, 50-70% of venous injuries are bilateral. Secondary varicose veins are the symptoms and consequences of diseases in which the outflow of blood from the deep veins of the lower limbs is obstructed (post-thrombotic diseases, tumors, scars, inflammatory processes, hypoplasia and hypoplasia of the deep veins, arteriovenous thrombosis). fistula, etc. ). Secondary varicose veins are very rare.Most commonly, varicose veins affect the saphenous vein of the lower limbs, which is part of the great saphenous venous system. Branches of the small saphenous vein develop varicose veins much less frequently.

Types of varicose veins

Until recently, in our country, doctors classified varicose veins according to several types. The staging clinical classification of V. S. Savelyev is adopted, which reflects the degree of venous circulation disorders of the limbs and the body's ability to resist these disorders and compensate, and is classified according to the form of varicose veins and the complications caused.But the main one currently is the international classification CEAP, based on the clinical (C - clinical), etiological (E - etiology), anatomical (A - anatomy) and pathological (P - pathogenesis) characteristics of the disease.There are 6 clinical categories ("C") based on the severity of the disease ranging from telangiectasias (TAE) to trophic ulcers.The etiology section ("E") indicates whether the process is primary.The anatomical part of the classification ("A") divides the venous system of the lower extremities into 18 relatively independent segments, which makes it possible to indicate the localization of affected areas of the venous system.The pathophysiology section ("P") characterizes the presence of reflux and/or obstruction in the affected venous segment.

Symptoms of varicose veins

Symptoms of varicose veins depend on the stage of the disease, that is, the extent of blood vessel changes and destruction of the venous system. Depending on the stage, a prognosis for further progression of the disease can be given.

The initial stage of varicose veins - 1st degree varicose veins

In the initial stages, when the pathology of the veins has not yet been clearly expressed, there may be no obvious signs of varicose veins. The patient complained of heaviness and discomfort in the legs, rapid fatigue, warmth, and paresthesia (numbness, burning, tingling). Symptoms worsen at the end of the day and when wearing thermal shoes indoors under the influence of heat (in summer) or in winter. Swelling may occur in the feet and ankles, which will subside after a short rest. Sometimes, calf muscles may cramp at night, but patients attribute this to overexertion.After prolonged physical activity, veins can become swollen and the network of veins can be easily seen through the skin. They are especially noticeable on the thighs, calves and foot areas. The number of such veins and their degree of dilation may vary. These may be single and less noticeable formations on the lower legs that appear more noticeable at night or after physical activity. Also at this stage of varicose veins, the appearance of spider veins is observed. If the simplest conservative treatment is started at this stage, and preventive measures are taken, then the development of the disease can be prevented by eliminating almost all symptoms.

Symptoms of second degree varicose veins, compensatory phase

At this stage of the disease, changes in the large subcutaneous vessels become apparent. The veins become deformed and swollen, blood flow is blocked, and the feet and ankles become significantly swollen. Swelling in the legs increases with prolonged physical activity but disappears after a night's rest. Calf muscle cramps are common at night. Paresthesia is observed - temporary loss of sensitivity in the legs, numbness, burning sensation in the legs, "goosebumps". As the disease progresses, pain develops and worsens at night.This subcompensatory phase usually lasts several years, and at this point, if treatment is started promptly, the progression of the disease can be halted. Otherwise, the condition is bound to develop into a more serious stage.

Symptoms of Third Degree Varicose Veins - Decompensation Phase

At this stage of varicose veins, symptoms are significantly aggravated, leg pain and heaviness become more intense, and peripheral blood and lymph circulation are disrupted (chronic venous insufficiency). Even after a long period of rest, the swelling does not go away and spreads to the calf. The patient is troubled by itchy skin. The skin on the legs becomes dry, loses elasticity, makes the skin easily injured, and loses the ability to regenerate quickly, causing wounds to take a long time to heal. Brown spots appear on the skin, most commonly on the inner surface of the lower third of the legs (hyperpigmentation due to subcutaneous bleeding).All these complaints are constant. In the future, symptoms of pain in the heart area, shortness of breath, headache, and worsening of musculoskeletal function of the affected limb may occur.Although the decompensation stage is already a very significant manifestation of the disease, with appropriate treatment, the patient's condition can be maintained at a satisfactory level for a considerable period of time, maintaining the ability to work and preventing the transition to the complication stage.

Degree 4 Varicose Veins - Complication Stage

This stage of the disease is characterized by marked disturbances in venous circulation. There is almost constant swelling of the legs, increased skin itching, and malnutrition of the calf skin. Advanced varicose veins are often accompanied by eczema, dermatitis and long-term damage, and because the regeneration ability of varicose skin is significantly reduced, even small wounds may develop into persistent trophic ulcers. Thin skin and vein walls can easily become injured, leading to heavy bleeding. Damaged soft tissue and open sores become pathways for infection.The most common complications of varicose veins:

• Phlebitis - inflammation of the veins;
• Thrombosis - the formation of a blood clot (thrombus) in a vein, which may cause blockage of the blood vessel;
• Trophic ulcers - form where the affected veins are unable to provide adequate blood flow from the skin, causing the tissue's nourishment (nourishment) to be destroyed.

Varicose veins may be complicated by acute (sometimes suppurative) thrombophlebitis,Dermatitis and eczema, hemorrhage, erysipelas, lymphangitis.One of the most dangerous complications of varicose veins is pulmonary embolism, which can lead to sudden death.At this stage it is no longer possible to restore the condition of the venous system, we can only talk about preventing further complications and improving the patient's quality of life as much as possible.

causes of varicose veins

There is no single cause of primary varicose veins of the lower extremities. The occurrence of this disease is usually caused by a variety of factors. But all painful symptoms of varicose veins are related to structural changes in the tissue of the blood vessel vein walls and damage to the function of the vein valves.What causes these violations?You will often come across the statement that one of the most important physiological causes of conditions such as varicose veins is upright posture. In fact, by the very nature of humans, the load on the vasculature of the lower extremities is very high. The pressure caused by gravity and high pressure within the abdominal cavity prevent blood from flowing from the veins and up to the heart. However, not everyone develops varicose veins. What factors can cause varicose veins?The main identified risk factors for developing varicose veins are:

• Genetic predisposition (heredity) - congenital weakness of vein walls, rupture of vein valves;
• Women – Women are 4-6 times more likely to develop varicose veins than men;
• hormone imbalance;
• hormonal contraception;
• Pregnancy, especially multiple gestation;
• Heavy physical activity (heavy physical labor, strength sports);
• Conditions and diseases that cause increased intra-abdominal pressure (chronic respiratory disease, constipation, etc. )
• Diseases that negatively affect blood vessels (hyperglycemia, diabetes, stress surges, etc. );
• Work characteristics - standing or sitting for long periods of time, sudden temperature changes, prolonged exposure to high or low temperatures;
• Being overweight or obese, which increases pressure on the legs and pelvic area;
• Lack of vitamin C and other beneficial substances needed by the vascular system;
• A sedentary lifestyle and bad habits can damage blood vessels and cause additional tension.

Diagnosis of varicose veins

In most cases, diagnosing varicose veins is usually not difficult. Clinical examination of severe varicose veins, including physical examination (inspection and palpation), patient investigation, collection of chief complaints and medical records (information about the course of the disease, life and work characteristics, past and current diseases), usually leads to the diagnosis of severe varicose veins. Diagnosis can be made without instrumentation. The exception is that varicose vein changes may be difficult to notice due to excessive development of subcutaneous fat tissue in the lower limbs.Currently, duplex ultrasound scanning (USDS) has been widely used to study the veins of the lower extremities. This method allows you to determine the location of changes in the veins and the nature of the disturbance in venous blood flow. However, you need to know that the results of an ultrasound scan are largely subjective and depend largely not only on the experience and knowledge of the researcher, but also on the strategic approach to treating venous disease adopted by a particular medical institution. In determining treatment strategies, they were primarily guided by clinical examination data.When planning invasive treatment of varicose veins in the lower extremities, a duplex scan is required. Additionally, X-ray contrast venography, MRI venography, and CT venography may be used.All of these methods can clarify the location, nature, and extent of venous lesions, clearly visualize venous hemodynamic disturbances, assess the effectiveness of prescribed treatments, and predict the course of the disease.

Treatment of varicose veins - modern technology

The doctor's main tasks in treating varicose veins are:

• Eliminate or reduce the severity of symptoms - pain, swelling, cramping - that cause particular discomfort to the patient;
• Restore and improve blood vessel function - from capillaries to deep veins, improve valve function, restore damaged blood vessel walls, and increase their elasticity and strength;
• Improve the rheological properties of blood and reduce its viscosity;
• Improves the function of the lymphatic system.
• Prevent the further development of diseases and complications;
• Improve patients' quality of life.

Depending on the stage of the disease and the extent of blood vessel damage, your doctor may prescribe the best treatment for your specific situation, such as:

• Conservative treatment– Advice on prevention and lifestyle changes, medication, stress treatment;
• non-surgical invasive procedures- Sclerotherapy, echo sclerotherapy, foam sclerotherapy (foam form therapy), etc. ;
• Surgery- Combination approaches and procedures for phlebectomy, thermal obliteration, stripping, more complex varicose complications and treatment of trophic ulcers of the lower limbs.

These methods can improve blood circulation in the lower limbs, including microcirculation, eliminate many cosmetic defects caused by varicose veins, and relieve patients of most of the painful manifestations of the pathology.

Conservative approach to treating varicose veins

Modern conservative treatment of varicose veins provides a comprehensive treatment approach that includes the following aspects:

• lifestyle changes;
• medical treatement;
• Compression therapy.

It’s no coincidence that lifestyle changes come first. If possible, at least eliminate sludge to reduce the impact of adverse factors.One of these is allostatic load from standing or sitting for long periods of time, which causes blood stagnation. To activate the muscle venous pumps in your calves, you need to stretch your legs regularly and walk more. While working, you can regularly perform exercises that alternate contraction and relaxation of your calf muscles (lifting your toes).It is recommended to make time for outdoor sports (athletics or Nordic walking, exercise bikes, treadmills, swimming, cycling and walking) that are not associated with the risk of leg injury.If you have varicose veins, you should not overheat your legs; you will have to refuse visits to bathhouses and saunas.People with varicose veins need to monitor their weight. It is understood that a body mass index exceeding 27 kg/m²The likelihood of varicose veins increases by 30%. Being overweight is often associated with elevated blood sugar levels, which can lead to 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 medications or after surgery and sclerotherapy.The effectiveness of compression therapy can be explained by reducing reverse blood flow and, to some extent, reducing the pathological ability of the veins to dilate, thereby reducing swelling, improving capillary blood flow, and reducing varicose vein symptoms.In addition to bandages and knits, there is also hardware compression therapy, which is particularly effective for chronic venous edema and trophic ulcers.In the early stage of varicose veins, it is recommended that drug treatment be the main treatment, supplemented by elastic compression treatment when necessary. Medications are also used to prepare for surgical treatment or during the postoperative period to speed recovery and prevent complications.The following groups of drugs are used to treat venous disease:

• Venoconstrictors and vasoprotectants;
• anticoagulants and thrombolytics;
• anti-inflammatory and analgesics;
• Vascular regeneration agent.

For systemic treatment of varicose veins, intravenous supplements and vascular protectants based on bioflavonoids, rutin derivatives, saponins, etc. are mainly used. These drugs increase the elasticity and tension of veins, increase the strength of blood vessels, and improve the flow of lymph fluid. outflow, reducing lymphatic pressure. Anticoagulants are prescribed if there is a threat of thrombosis. Anti-inflammatory drugs and analgesics are used to treat complications of varicose veins - inflammation of the veins, severe pain, venous trophic lesions. In addition to systemic drugs, topical drugs are also used - ointments and gels based on intravenous active substances, heparin, NSAIDs, corticosteroid ointments.

non-surgical invasive procedures

Venous sclerotherapy of lower limbsVenous sclerotherapy is an outpatient medical procedure in which a special substance (sclerotherapy) is injected into the capillaries or problem veins using a fine needle. A latex pad or elastic bandage is then used to compress the blood vessel. The walls of the blood vessels "stick together" and the blood in the vessels stops flowing. Glued walls often grow together, scarring, and then the scar disappears. For the treatment of small superficial varicose veins. This method is effective in the early stages of the disease only if the varicose veins are limited to small veins and can eliminate cosmetic defects. A series of treatments may be needed to achieve results.Foam form therapy (foam sclerotherapy)It features a special hardener. As with sclerotherapy, the sclerosing substance is injected into the damaged vein in the form of a fine foam, quickly "closing" the large affected vein. This method does not require extensive procedures and provides high results. It is important to know that this surgery, although rare, may have a side effect - visual impairment. Sclerosing agents can also be dangerous if they get into arteries and nerve tissue. This procedure should be performed by an experienced phlebologist.Absolute contraindications to sclerotherapy - allergy to drugs, deep vein thrombosis, pregnancy, breastfeeding

Surgical treatment of varicose veins

Generally, surgical treatment is recommended for severe, advanced cases and when conservative methods fail to halt the progression of the disease.Surgical intervention for varicose veins has the following goals

• Eliminate appearance defects;
• Reduce subjective symptoms (pain, burning, paresthesia, leg heaviness, etc. );
• Prevent saphenous vein deterioration;
• Prevent varicose bleeding;
• Prevention of thrombophlebitis;
• Reduce and prevent the development of venous edema;
• Reduces manifestations and prevents the development of hyperpigmentation, lipodermatosclerosis;
• Accelerates healing of venous trophic ulcers and prevents recurrence.

According to clinical guidelines, the goals of surgical treatment are:

• Eliminate pathological vertical and/or horizontal reflux;
• Eliminate great saphenous varicose veins.

Before any type of surgical procedure, the risk of developing venous thromboembolic complications (VTEC) is assessed.The following surgical methods can be used depending on the specific situation:Phlebectomy (phlebectomy) and safe excision- Traditional surgery to remove varicose veins.phlebectomy- This is the surgical removal of the diseased area of veins.safe resection- Special case of phlebectomy, used in severe and advanced cases of the disease. The essence of a safe resection is the minimally invasive removal of the central trunk of the damaged saphenous vein - by making an incision in the trunk and inserting a probe. During this procedure, perforating vein ligation is also performed to connect the saphenous vein to the deep vein.Short stripped wire– The affected area of the saphenous vein of the thigh or leg is quickly removed through a small incision using a special, thin probe.Microphlebectomy (resection of small veins) -Varicose veins are removed through skin puncture using a special phlebectomy hook (vein extractor).Vascular cryosurgery (cryosclerosis)– A method of treating venous disease by applying cold (liquid nitrogen) to damaged blood vessels.A venous suture is the placement of multiple sutures on a damaged vein to stop the flow of blood through the vessel. As a result, blood clots form and the veins gradually degenerate.heat removal method– Thermal coagulation and laser coagulationConsidered a minimally invasive procedure.thermal coagulation(or RFO - radiofrequency veno-occlusion) - very short momentary exposure to high-frequency electrical current.laser coagulation(EVLO or EVLK – Endovascular laser occlusion (coagulation) of lower extremity veins) – Exposure to a laser beam on pathologically dilated blood vessels. In both cases, destruction of the container, so-called "sticking" or "sealing", occurs due to localized temperature increases.It is important to remember that surgery is not a final cure, but rather an elimination of symptoms. Conservative treatment is also required after surgery and is lifelong, which must be explained to the patient.Based on the stage of varicose veins, symptoms, concomitant diseases, and the patient's overall health, doctors choose specific recommendations to achieve maximum improvement as quickly as possible.