What are varicose veins?

Varicose veins are pathological and irreversible changes in the walls of peripheral veins with inefficiency of the valve apparatus and impaired blood flow.Veins from various locations are subject to varicose transformation, but most often the vessels of the superficial venous network in the legs are affected, therefore varicose veins usually mean venous disease in the lower part of the legs.

How do varicose veins appear?

With varicose veins, only peripheral superficial venous channels undergo pathological transformation - this is due to the structural characteristics of the walls and the physiology of the outflow of blood from the legs.This pathogenetic moment is decisive.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 vein endothelium and then spreads throughout the thickness of the vessel.The trigger mechanism in most cases is a slowdown in blood flow;there are parietal groups of blood cellular elements with rolling leukocytes - groups and "rolling" of leukocytes along the surface of the endothelium.Over time, there is a tendency for them to adhere, which provokes the release of inflammatory mediators.At this stage there are no more external changes.
2. Reconstruction of the venous wall and superficial valves. Leads to changes in density and elasticity.This is facilitated by aseptic inflammation, genetically determined defects in connective tissue proteins, micromechanical damage to 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 vein. These changes were initially quite localized;subsequently, the pathological process spreads not only along one vessel, but also involves other components of the peripheral venous network.
4. Compensatory lengthening of the affected vein with the formation of obvious pathological bends. A characteristic bulging node is formed, which gives the name to the disease: "varix" is translated from Latin as "swelling".
5. The development of valve insufficiency. Failure of valve function in the lumen of superficial veins affected by reverse blood flow (vertical reflux).Initially, it is relative and manifests itself only with a significant increase in peripheral venous pressure.After that, the failure becomes absolute - the valve wall does not close completely under any circumstances.Venous stasis (blood stagnation) appears with the formation of venous insufficiency.
6. Involvement of the perforating vein in the process.They are also called communicants or commissars.Their pathological development is also accompanied by a lack of valves, which contributes to pathological blood flow from the deep venous network to the superficial one (horizontal reflux).Increased venous insufficiency.

All these changes are irreversible and persist even with the complete elimination of provoking and predisposing factors, therefore it is impossible to cure varicose veins that have already developed using conservative methods;it is only possible to offset part of the disturbance for a while.

Causes of varicose veins

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

• Hereditary factors.
• Low mobility, long sitting position.
• In women - changes in hormonal status during pregnancy, taking oral contraceptives, and performing hormone replacement therapy.
• Conditions accompanied by partial compression of the pelvic veins: pregnancy (especially multiple pregnancy or occurs with polyhydramnios), the formation of a mass in the abdominal cavity, some intestinal diseases.Constipation and chronic lung disease with cough, which leads to increased intra-abdominal pressure, leads to venous outflow disorders at the pelvic level.
• Weight gain.

Everyone is prone to the development of varicose veins.This is due to the vertical position of the body, in which, under the influence of gravity, the blood tends to the distal part of the lower leg, and the veins experience increased pressure and are more easily deformed.

Symptoms and manifestations of varicose veins

Symptoms of varicose veins in the superficial veins of the thighs and legs include:

• Significant changes in the affected veins.Varicose veins are tortuous, overly contoured, dark, visible through the skin and bulging.Pulse is not their characteristic.As the disease progresses, local nodular protruding formations appear on the legs, which often form a whole conglomerate and do not disappear completely in the supine position.In patients with increased body weight, changes in veins often remain invisible for a long time, masked by excess subcutaneous fat.
• Swelling of the legs and feet after standing and sitting for a long time, in the evening, when staying in a high ambient temperature.Such venous edema is not accompanied by cyanosis in the distal part, which can be observed in heart failure.They decrease and even disappear after rest (including night sleep), when keeping the leg in a high position, after doing 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 without obvious swelling.Such complaints appear in conditions that promote the pathological deposition of blood in the distal part of the lower leg.Discomfort is most often observed in the evening and after a long stay in an upright position with little physical activity.
• Signs of ischemia of the muscles of the limbs affected by varicose veins: increased muscle fatigue, sometimes cramps.
• Unpleasant sensations in the legs, usually intensifying with increased swelling due to the reaction of soft tissues and peripheral nerve branches of the legs to compression by an excessive amount of intercellular fluid.Another possible cause of paresthesia is dysmetabolic trophic disorders.
• Trophic disorders of the skin and underlying soft tissue.This can be dry dermatitis or eczema, hyperpigmentation, lipodermatosclerosis (thickening, hardening of the dermis and tissue), ulcers.

Symptoms of varicose veins on the lower legs appear quite early, although not all patients pay attention to them in time.The order of new features added may vary.In some patients, cosmetic defects in the form of clearly altered veins are initially observed, while in others the disease appears in the form of venous insufficiency.

level

The stage of varicose veins is determined according to the CEAP classification:

• C0—no pathological signs;
• C1—presence of reticular varicose veins or telangiectasias;
• C2 - varicose veins;
• C2r - 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 - corona venosus leg;
• C5—chronic 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.Used by phlebologists when making a diagnosis.

For example, in class C1, only a cosmetic defect is observed - the reticular vein is dilated by about 1 mm.in diameter, and with C4c it is no longer possible not to see serious trophic disturbances.

Diagnostics

Basic examinations to confirm the diagnosis of varicose veins on the lower leg and clarify the extent and nature of the disorder include:

• Clinical examination.Phlebologists determine the course 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 patient survey aims to clarify the predisposing and provoking factors, duration and characteristics of the development of the disease.
• Ultrasound examination.In the case of varicose veins, the most informative is not conventional ultrasound, but the assessment of blood flow using Doppler Doppler Ultrasound (USD).Studies show the speed of blood movement, the presence of pathological veno-venous reflux, and impaired vascular patency.This information is necessary for the doctor to choose the necessary treatment regimen.
• Hemostatiogram (blood test for a comprehensive evaluation of the coagulation system).

According to the indications, multi-slice tomography (MS CT) is performed - a high-tech study in some cases becomes the main technique to determine 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 various patients;the results obtained are usually not critical in determining treatment tactics.Usually a basic examination is sufficient, which, if necessary, is supplemented by a consultation with a specialist (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 disease, which includes case characteristics according to clinical, etiology, anatomy and pathophysiology.

The danger of varicose veins

Many people believe that varicose veins on the lower legs are primarily a cosmetic problem.In fact, it is often the external discomfort of the legs with knotted blue-purple veins, bulging or spider veins that is the main reason for a visit to the doctor.

Pathologically dilated peripheral veins are a condition that should not be underestimated.It can significantly worsen the patient's well-being and even lead to 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 in the patient's quality of life.Significant discomfort and even decreased performance with varicose veins due to heavy leg syndrome, swelling, night cramps, poor healing and recurrent ulcers.
• Changes in soft tissue with a decrease in the external traction of the foot, which is very important for women.Moreover, hyperpigmentation, lipodermatosclerosis and healing ulcer effects usually persist even after removal of the affected vein, especially if surgical treatment is carried out against the background of a developed trophic disorder.
• Bleeding from a varicose node or ruptured vein at the bottom of a trophic ulcer.
• The development of thrombosis and thrombophlebitis of superficial veins.It is fraught 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 a more dangerous condition in terms of thromboembolism.

Complications of varicose veins that have developed in the superficial veins of the thighs and legs not only have a negative impact on the patient's condition and the prognosis of the disease.They significantly reduce the possibility of obtaining a quick and adequate result even using radical treatment methods.

Is the disease always dangerous?

Varicose veins on the lower leg with a lack of saphenous vein valve is not the only possible variant of this pathology.There are also so-called "cosmetic" versions of varicose veins.According to the classification of chronic venous disease CEAP is C1, the characteristics of the form:

• Damage to small intradermal channels up to 3 mm in diameter.They may be subepidermal or reticular.
• The appearance of spider veins, reticular varicose veins in the form of a fine superficial mesh.
• Absence of vertical or horizontal pathological venovenous reflux.The affected small vessels have no valves and communicate only with small tributaries of the saphenous vein 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.

The course of the disease does not lead to the development of significant clinical complications.In fact, discomfort in patients is caused by cosmetic defects.But this does not mean that a person with the presence of spider veins is exempt from damage to larger caliber veins.In such cases, it is no longer C1 that is 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 minimally expressed signs of venous insufficiency.You can expect a quick onset of the expected effect, a complete regression of symptoms and a low likelihood of relapse.Advanced varicose vein treatment will not be effective.Sometimes the task is 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 on the lower leg can be divided into non-surgical (conservative) and surgical (radical).Traditionally, most patients prefer gentle techniques, delaying the decision on surgery until uncorrectable complications develop.And many of them do not consult a doctor, use self-medication.Self-medication often leads to pathological complications.

Conservative treatment

Conservative treatment regimens for varicose veins include:

• Systemic drug therapy.Aims to improve the rheological properties of blood to prevent thrombosis, achieve anti-inflammatory effects, increase the elasticity of vascular walls, and stimulate tissue regeneration.
• Local drug therapy (ointment, cream, gel).External agents aim to improve microcirculation, reduce swelling, improve vein tone, and heal trophic ulcers.
• Therapeutic exercises increase the pump efficiency of the lower leg muscles and thus increase blood flow from the legs.
• Use of compression stockings.Compression stockings and tights provide dosed compression to veins located on the surface, which reduces the tendency to deposit blood and edema, improves well-being, and reduces the possibility of thrombosis.
• Physiotherapy.They are used mainly in the absence of open trophic ulcers and beyond the acute stage of thrombophlebitis.Hardware pneumocompression, darsonvalization, galvanization, UHF therapy, UV therapy, hydrotherapy, and ozone therapy are used.The objectives of physiotherapy include increasing venous and lymphatic outflow, improving microcirculation, stimulating regeneration, and reducing the severity of discomfort.

Medicines will not restore healthy blood flow to altered veins;they will remain tortuous and wide.And even a slight increase in the tone of the vascular walls under the influence of phlebotonics will not be able to completely correct the lack of valves.

You cannot 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 patients from varicose veins and prevent further development of the disease using a conservative approach.

Surgical treatment

Invasive (surgical) methods of treating varicose veins aim to exclude the affected vessels and their main tributaries from the general blood flow (by removing them or eliminating them) and eliminate horizontal venovenous reflux.Does not worsen tissue ischemia, improves trophism by significantly reducing (or even eliminating) venous stasis.This treatment not only removes cosmetic defects, but also helps to overcome chronic venous insufficiency.

Classic surgical methods to treat varicose veins on the lower legs:

• A crossectomy is a complete transection of a large superficial vein that is ligated at the point where it drains into the deep venous network.
• Phlebectomy – removal of superficial veins affected by varicose veins (great or small saphenous).It is done by removing (pulling, pulling out) the vessel using an instrument through a small incision.Currently, it is combined with crossectomy and tributary removal.
• Miniphlebectomy – removing large perforators and tributaries through a small incision or puncture.

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

• Significant blood loss;
• Bleeding in the surgical area, sometimes requiring repeated surgery to clear the blood.
• Lymphostasis is caused by the junction of lymphatic vessels.
• Severe pain syndrome.
• Long-term disability.

A modern alternative to surgery

Endovascular techniques are considered minimally invasive interventions;they do not require incision.They are not so traumatic and are not inferior in effectiveness compared to classic operations.Complications and recurrences are less common than after surgery.

Minimally invasive methods:

• Laser destruction
• Sclerotherapy/Cryosclerotherapy
• Radio frequency elimination.

With minimally invasive methods, veins affected by varicose veins are not removed, as in classic operations.The walls are exposed from the inside with laser or radiofrequency energy, and during sclerotherapy, with sclerosant drugs.This causes "sticking together" of vessels and subsequent fibrosis and replacement with connective tissue.The closure of the vessel lumen is called obliteration.And with RFM stars, they actually evaporate under the influence of radio frequency waves.