What are varicose veins?

Varicose veins are a pathological and irreversible change in the walls of peripheral veins with incapacity of the valve apparatus and impaired blood flow.Veins of various locations are subject to varicose transformation, but the vessels of the superficial venous network in the legs are most often affected, therefore varicose veins usually mean diseases of the veins of the lower extremities.

How do varicose veins appear?

With varicose veins, only superficial peripheral venous vessels undergo pathological transformation - this is due to the structural features of the walls and the physiology of blood flow from the extremities.It is these pathogenetic moments that are crucial.All other predisposing factors affect the entire vascular system, but do not lead to characteristic changes in central veins and arteries of any caliber.

Let's consider the pathogenesis of varicose veins:

1. Aseptic inflammation. It starts from the endothelium of the veins and then spreads throughout the thickness of the vessel.The triggering mechanism in most cases is a slowing of blood flow;there is a parietal grouping of the cellular elements of the blood with rolling of leukocytes - grouping and "rolling" of leukocytes along the surface of the endothelium.Over time, a tendency to stick is observed, which provokes the release of inflammatory mediators.At this stage there are no external changes yet.
2. Remodeling of superficial vein walls and valves. It leads to changes in density and elasticity.This is facilitated by aseptic inflammation, genetically determined defects in connective tissue proteins, mechanical microdamage of the endothelium and several other factors.In affected vessels, the ability to reversibly compensate for fluctuations in venous pressure is significantly reduced and they become rigid.
3. Continuous and progressive expansion of the lumen of the affected veins. These changes are initially quite local;then, the pathological process spreads not only along the length of a vessel, but also includes other components of the peripheral venous network.
4. Compensatory extension of the affected vein with the formation of pronounced pathological curves. Characteristic swollen nodes are formed, which give the name to the disease: "varix" is translated from Latin as "swelling".
5. Development of valvular insufficiency. Functional failure of valves in the lumen of superficial veins affected by reverse blood flow (vertical reflux).Initially, it is relative in nature and manifests itself only with a noticeable increase in peripheral venous pressure.Then the failure becomes absolute - the valve walls do not close completely under any conditions.Venous stasis (blood stagnation) occurs with the formation of venous insufficiency.
6. Involvement of perforating veins in the process.They are also called communicators or commissioners.Their pathological expansion is also associated with valvular insufficiency, which contributes to the pathological flow of blood from the deep venous network to the superficial one (horizontal reflux).Increased venous insufficiency.

All these changes are irreversible and continue even with the complete elimination of provoking and predisposing factors, therefore it is impossible to cure already developed varicose veins using conservative methods;it is only possible to partially compensate for the disorders for a while.

Causes of varicose veins

Varicose veins are a polyetiological disease, the development of which is triggered by external and internal (endogenous) factors.The main reasons for the development of varicose veins:

• Hereditary factor.
• Low mobility, prolonged sitting position.
• In women - changes in hormonal status during pregnancy, taking oral contraceptives and performing hormone replacement therapy.
• Conditions associated with partial compression of the pelvic veins: pregnancy (especially multiple pregnancy or occurring with polyhydramnios), massive formations of the abdominal cavity, some intestinal diseases.Constipation and chronic lung diseases with cough, leading to increased intra-abdominal pressure, lead to interruption of venous outflow at the level of the pelvis.
• Increase in body weight.

All people are predisposed to developing varicose veins.This is due to the vertical position of the body, due to which, under the influence of gravity, the blood tends to the distal parts of the lower extremities, and the veins experience increased stress and deform more easily.

Symptoms and manifestations of varicose veins

Symptoms of varicose veins of the superficial veins of the thigh and leg include:

• Visible changes in the affected veins.Varicose veins are tortuous, overly contoured, dark, visible through the skin, and bulging.Pulsation is not characteristic for them.As the disease progresses, prominent local nodular formations appear on the legs, which often form whole conglomerates and do not disappear completely in the lying position.In patients with increased body weight, changes in the veins often remain practically invisible for a long time, masked by excess subcutaneous fat.
• Swelling of feet and legs after long standing and sitting, in the evening, when standing in conditions of elevated ambient temperature.Such venous edema is not accompanied by cyanosis of the distal extremities, which can be observed in heart failure.They decrease and even disappear after rest (including night sleep), when you keep your legs in an elevated position, after performing special gymnastics to activate the "muscle pump" of the lower leg.Swelling is one of the first signs of chronic venous insufficiency with varicose veins.
• A feeling of heaviness and fullness in the legs, even in the absence of visible swelling.Such complaints appear in conditions that promote pathological deposition of blood in the distal parts of the lower extremities.Discomfort is most often observed in the evening and after a long stay in a vertical position with little physical activity.
• Signs of muscle ischemia of the limbs affected by varicose veins: increased muscle fatigue, sometimes cramps.
• Unpleasant sensations in the leg usually intensify with increasing swelling due to the reaction of the soft tissues and peripheral nerve branches of the leg to compression by an excessive amount of intercellular fluid.Another possible cause of such paresthesias are dysmetabolic trophic disorders.
• Visible trophic disorders of the skin and soft tissues in it.These can be dry or eczematous dermatitis, hyperpigmentation, lipodermatosclerosis (thickening, hardening of the dermis and tissues), ulcers.

Symptoms of varicose veins of the lower extremities appear quite early, although not all patients pay attention at the right time.The order in which new features are added may vary.In some patients, a cosmetic defect is first noticed in the form of clearly altered veins, while in others the disease debuts in the form of venous insufficiency.

stages

The stages of varicose veins are determined according to the CEAP classification:

• C0 - there are no signs of pathology;
• C1-presence of reticular or telangiectatic varicose veins;
• C2 - varicose veins;
• C2r - veins with recurrent varicose veins;
• C3 - limb swelling;
• C4a - trophic changes: hyperpigmentation or venous eczema;
• C4b - trophic changes in the form of lipodermatosclerosis or white skin atrophy;
• C4c - venous corona of the leg;
• C5-prolonged trophic ulcer;
• C6 - open trophic ulcer.
• C6r – recurrent open trophic ulcer.

The CEAP classification was created in 1994 and is now international and generally accepted.It is used by phlebologists when making a diagnosis.

For example, in class C1, only one cosmetic defect is observed - dilated reticular veins of about 1 mm.in diameter, and with C4c it is no longer possible not to observe serious trophic disturbances.

Diagnosing

A basic examination to confirm the diagnosis of varicose veins of the lower extremities and to clarify the degree and nature of the disorders includes:

• Clinical examination.The phlebologist determines the flow and condition of visible superficial veins, changes in the skin and soft tissues, and the presence of edema.Functional tests are performed to assess vertical reflux and identify the approximate level of horizontal reflux.The survey of the patient aims to clarify the predisposing and provoking factors, the duration and features of the development of the disease.
• Ultrasound examination.In the case of varicose veins, the most informative is not a conventional ultrasound, but an assessment of blood flow using Doppler ultrasound (USD).The study shows the speed of blood movement, the presence of pathological venous-venous reflux and the weakening of vascular permeability.This information is necessary for the doctor to choose the necessary treatment regimen.
• Hemostasiogram (blood tests for a comprehensive evaluation of the coagulation system).

According to indications, multi-slice computed tomography (MS CT) is performed - a high-tech study in some cases becomes the main technique for determining the picture of damage to the venous system.

In modern medicine, other diagnostic techniques are also used - plethysmography, laser Doppler flowmetry.They are not available for a wide range of patients;the results obtained are usually not critical in determining treatment tactics.A basic examination is usually enough, which, if necessary, is supplemented by consultations with specialized specialists (endocrinologist, hematologist, cardiologist and others).Previously, several stages of varicose veins of the legs were distinguished.Currently, when making a diagnosis, phlebologists use the CEAP classification of chronic venous diseases, which includes case characteristics according to clinical, etiological, anatomical and pathophysiological characteristics.

The danger of varicose veins

Many people believe that varicose veins of the lower extremities are mainly a cosmetic problem.Indeed, it is often the lack of traction on the outside of the legs with nodular vessels, swollen blue-purple or spider veins that is the main reason for a visit to the doctor.

Pathologically enlarged peripheral veins are a condition that should not be underestimated.It can significantly worsen the patient's well-being and even lead to potentially life-threatening complications.And this is mainly due to the development of chronic venous insufficiency due to continuous and progressive hemodynamic disorders.Other unpleasant consequences are also possible.

Consequences of advanced varicose veins:

• Significant deterioration of the patient's quality of life.Significant discomfort and even reduced performance with varicose veins is caused by severe leg syndrome, swelling, night cramps, poor healing and recurrent ulcers.
• Changes in soft tissues with a decrease in the external traction of the legs, which is especially important for women.In addition, hyperpigmentation, lipodermatosclerosis and traces of healed ulcers usually persist even after the removal of the affected veins, especially if the surgical treatment was performed against the background of pronounced trophic disorders already developed.
• Bleeding from rupture of varicose nodes or veins at the bottom of trophic ulcers.
• The development of thrombosis and thrombophlebitis of superficial veins.It is filled not only with local hemodynamic disorders and inflammation, but also with distant thromboembolism with infarction of various organs and acute life-threatening conditions.
• Deep vein thrombosis is an even more dangerous condition in terms of thromboembolism.

Already developed complications of varicose veins of the superficial veins of the thigh and leg not only negatively affect the patient's condition and the prognosis of the disease.They significantly reduce the likelihood of obtaining a quick and sufficient result even when radical treatment methods are used.

Is the disease always dangerous?

Varicose disease of the lower extremities with valvular insufficiency of the saphenous veins is not the only possible variant of this pathology.There is also a so-called "cosmetic" version of varicose veins.According to the classification of chronic venous diseases CEAP is C1, the features of the form:

• Damage to small intradermal vessels up to 3 mm in diameter.They can be subepidermal or reticular.
• The appearance of spider veins, reticular varicose veins in the form of a fine surface network.
• Absence of vertical or horizontal pathological venous reflux.The affected small vessels have no valves and communicate only with small branches of the saphenous veins using a feeding pedicle.They collect blood from individual sectors of the dermis and drain it into larger and deeper vessels.Impaired blood flow at this level does not contribute to the development of chronic venous insufficiency.

This course of the disease does not lead to the development of clinically significant complications.In fact, the discomfort in patients is due to a cosmetic defect.But this does not mean that a person with the presence of spider veins is excluded from the damage of larger caliber veins.In such a situation, C1 is no longer diagnosed, but C2 and subsequent classes according to the CEAP classification.

Treatment of varicose veins

Treatment of varicose veins should begin not with the development of complications, but at the stage of primary changes and minimal expressed signs of venous insufficiency.You can expect a quick onset of the expected effect, complete regression of symptoms and a low probability of relapse.Treatment of advanced varicose veins will not be as effective.Sometimes his task will be only to reduce the rate of disease progression, create conditions for the healing of trophic ulcers and reduce the severity of chronic venous insufficiency.

In general, all methods of treating varicose veins of the lower extremities can be divided into non-surgical (conservative) and surgical (radical).Traditionally, most patients prefer gentle techniques, postponing the decision for surgery until uncorrectable complications develop.And many of them do not even consult a doctor, resorting to self-medication.Self-medication often leads to complications of the pathology.

Conservative treatment

The conservative treatment regimen for varicose veins includes:

• Systemic drug therapy.Aimed at improving the rheological properties of blood to prevent thrombosis, achieving an anti-inflammatory effect, increasing the elasticity of the vascular wall and stimulating tissue regeneration.
• Local drug therapy (ointments, creams, gels).External agents aim to improve microcirculation, reduce swelling, increase vein tone and heal trophic ulcers.
• Therapeutic exercise increases the pump efficiency of the lower leg muscles and thus improves blood flow from the legs.
• Use of compression stockings.Compression stockings and tights provide dosed compression of superficially located veins, which reduces the tendency to deposit blood and edema, improves well-being and reduces the possibility of thrombosis.
• Physiotherapy.They are mainly used in the absence of open trophic ulcers and outside the acute phase of thrombophlebitis.Hardware pneumocompression, darsonvalization, galvanization, UHF therapy, UV therapy, hydrotherapy and ozone therapy are used.The objectives of physiotherapy include improving venous and lymphatic flow, improving microcirculation, stimulating regeneration and reducing the severity of discomfort.

Medications will not restore healthy blood flow to already altered veins;they will remain twisted and expanded.And even a slight increase in the tone of the vascular wall under the influence of phlebotonics will not be able to completely correct valvular insufficiency.

You should not expect high results from conservative treatment.It will reduce pain and swelling, reduce the risk of thrombosis and improve the healing of trophic disorders.But it is impossible to save the patient from varicose veins and prevent further progression of the disease using a conservative approach.

Surgical treatment

An invasive (surgical) method of treating varicose veins aims to exclude the affected vessel and its main branches from the general blood flow (by removing or eliminating it) and eliminating horizontal venous reflux.It does not worsen tissue ischemia, improves trophism by significantly reducing (or even eliminating) venous stasis.This treatment not only eliminates the cosmetic defect, but also helps to cope with chronic venous insufficiency.

Classical surgical methods for the treatment of varicose veins of the lower extremities:

• Crossectomy is the complete transection of a large ligated superficial vein at the point where it empties into the deep venous network.
• Phlebectomy – removal of the superficial vein affected by varicose veins (great or small saphenous vein).It is performed by removing (retracting, withdrawing) the vessel using instruments through small incisions.Currently, it is combined with crossectomy and branch removal.
• Miniphlebectomy – removal of perforators and large branches through small incisions or punctures.

For a long time, the main method of surgical treatment was open surgery, their disadvantages:

• Significant blood loss;
• Hemorrhages at the surgical site sometimes require repeated surgery to evacuate the blood.
• Lymphostasis due to the intersection of lymphatic vessels.
• Severe pain syndrome.
• Long term disability.

The modern alternative to surgery

Endovascular techniques are considered minimally invasive interventions;they do not require cutting.They are not so traumatic and are not inferior in effectiveness to classical operations.Complications and relapses after them are less common than after operations.

Minimally invasive methods:

• Laser ablation
• Sclerotherapy/Cryosclerotherapy
• Radio frequency extinction.

With minimally invasive methods, the vein affected by varicose veins is not removed, as in classic operations.Its wall is exposed from the inside with laser or radiofrequency energy and during sclerotherapy with a sclerosing drug.This provokes "sticking" of the vessel and its subsequent fibrosis and replacement with connective tissue.This closure of the lumen of the vessel is called obliteration.And with RFM of stars, they actually vaporize under the influence of radio frequency waves.