What are varicose veins?

Varicose veins are a pathological and irreversible change in the walls of the peripheral veins with incompetence of the valvular apparatus and impaired blood supply.Veins of different localization are subject to varicose transformation, but the vessels of the superficial venous network of the legs are most often affected, therefore varicose veins usually mean a disease of the veins of the lower extremities.

How do varicose veins appear?

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

Let's look at the pathogenesis of varicose veins:

1. Aseptic inflammation. It starts from the endothelium of the veins and subsequently 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 cellular elements of the blood with leukocyte rolling - grouping and "rolling" of leukocytes on the surface of the endothelium.Over time, there is a tendency for them to stick together, which provokes the release of inflammatory mediators.At this stage, there are still no external changes.
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 some other factors.In affected vessels, the ability to reversibly compensate for fluctuations in venous pressure is significantly reduced and they become rigid.
3. Constant and progressive expansion of the lumen of the affected veins. These changes are initially quite local;subsequently, the pathological process spreads not only along the length of one vessel, but also includes other components of the peripheral venous network.
4. Compensatory lengthening of the affected vein with the formation of pronounced pathological bends. Characteristic protruding nodes are formed, which give the name of the disease: "varix" is translated from Latin as "swelling".
5. Development of valvular insufficiency. Functional failure of the valves in the lumen of the affected superficial veins with reverse blood flow (vertical reflux).Initially, it has a relative character and manifests itself only with a noticeable increase in peripheral venous pressure.Subsequently, 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 in the process of perforating veins.They are also called communicating or commissural.Their pathological expansion is also accompanied by valvular insufficiency, which contributes to pathological blood flow from the deep venous network to the superficial (horizontal reflux).Increased venous insufficiency.

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

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

All people are prone to developing varicose veins.This is due to the vertical position of the body, due to which, under the influence of gravity, the blood is directed to the distal parts of the lower limbs, and the veins experience increased stress and are more easily deformed.

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.Dilated vessels are tortuous, excessively contoured, dark, visible through the skin, and bulging.Pulsation is not characteristic of them.As the disease progresses, local nodular bulging formations appear on the legs, which often form entire conglomerates and do not disappear completely in the supine position.In patients with increased body weight, changes in the veins often remain practically imperceptible for a long time, masked by excessive subcutaneous fat.
• Swelling of the feet and legs after prolonged standing and sitting, in the evening, when staying in conditions of increased 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 a night's sleep), when keeping the 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 in varicose veins.
• A feeling of heaviness and fullness in the legs, even in the absence of obvious swelling.Such complaints appear in conditions that contribute to pathological deposition of blood in the distal parts of the lower limbs.Discomfort is most often observed in the evening and after a long stay in a standing position with little physical exertion.
• Signs of ischemia of the muscles of the limbs affected by varicose veins: increased muscle fatigue, sometimes cramps.
• Unpleasant sensations in the legs, usually intensify with increasing edema due to the reaction of the soft tissues and branches of the peripheral nerves of the leg to compression from an excess amount of intercellular fluid.Another possible cause of such paresthesias are dysmetabolic trophic disorders.
• Visible trophic disorders of the skin and underlying soft tissues.This can be dry or eczematous dermatitis, hyperpigmentation, lipodermatosclerosis (thickening, hardening of the dermis and tissue), ulcers.

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

Stages

Stages of varicose veins are defined according to the CEAP classification:

• C0 - no signs of pathology;
• C1 - presence of reticular varicose veins or telangiectasias;
• C2 - varicose veins;
• C2r - recurrent varicose veins;
• C3 - swelling of the limb;
• C4a - trophic changes: hyperpigmentation or venous eczema;
• C4b - trophic changes in the form of lipodermatosclerosis or white atrophy of the skin;
• C4c - corona venosus of the foot;
• C5 - long trophic ulcer;
• C6 - open trophic ulcer.
• C6r - recurrent open trophic ulcer.

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

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

Diagnosis

The main examination to confirm the diagnosis of varicose veins of the lower extremities and clarify the extent and nature of the disorders includes:

• Clinical examination.The phlebologist determines the course and condition of the 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 study of the patient is aimed at clarifying 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 examination shows 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.
• Hemostasiogram (blood tests for a comprehensive evaluation of the coagulation system).

According to the indications, multislice 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 to a wide range of patients;the results obtained are usually not critical in determining treatment tactics.Usually, a basic examination is sufficient, which, if necessary, is supplemented by consultations with specialized specialists (endocrinologist, hematologist, cardiologist, etc.).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 think that varicose veins of the lower extremities are mainly a cosmetic problem.Indeed, often the external unattractiveness of legs with nodules, bulging blue-violet vessels or spider veins is the main reason for a visit to the doctor.

Pathologically enlarged peripheral veins are a condition that should not be underestimated.This can significantly worsen the patient's well-being and even lead to potentially life-threatening complications.And this is primarily due to the development of chronic venous insufficiency due to persistent 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 work capacity in varicose veins are caused by heavy leg syndrome, swelling, night cramps, poorly healing and recurring ulcers.
• Changes in soft tissues with a decrease in the external attractiveness of the legs, which is especially important for women.In addition, hyperpigmentation, lipodermatosclerosis and traces of healed ulcers usually persist even after removal of the affected veins, especially if the surgical treatment was performed against the background of already developed pronounced trophic disorders.
• Bleeding from ruptured dilated nodes or veins at the bottom of trophic ulcers.
• Development of thrombosis and thrombophlebitis of superficial veins.It is filled not only with local hemodynamic disturbances and inflammations, but also with remote thromboembolism with infarctions 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 probability of obtaining a quick and sufficient result even when using radical methods of treatment.

Is the disease always dangerous?

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

• Damage to small intradermal vessels up to 3 mm in diameter.They can be subepidermal or reticular.
• The appearance of cobwebs, 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 the small tributaries of the saphenous veins by means of a feeder leg.They collect blood from individual sectors of the dermis and drain it into larger, 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, patient discomfort is due to a cosmetic defect.But this does not mean that a person with the presence of spider veins is excluded from damage to veins of a larger caliber.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 minimally expressed signs of venous insufficiency.You can expect a rapid onset of the expected effect, complete regression of symptoms and a low likelihood of relapse.Treatment of advanced varicose veins will not be as effective.Sometimes his task will be only to reduce the rate of progression of the disease, 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 sparing techniques, postponing the decision to operate until complications develop that cannot be corrected.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 regimen of conservative treatment of varicose veins includes:

• Drug systemic therapy.Aimed at improving the rheological properties of blood to prevent thrombosis, achieve an anti-inflammatory effect, increase the elasticity of the vascular wall and stimulate tissue regeneration.
• Local drug therapy (ointments, creams, gels).External means are designed to improve microcirculation, reduce edema, increase vein tone and treat trophic ulcers.
• Therapeutic exercises increase the efficiency of the lower leg muscle pump and thus improve blood flow from the legs.
• Using compression stockings.Compression stockings and tights provide dosed compression of superficial veins, which reduces the tendency to pool blood and edema, improves well-being and reduces the likelihood of thrombosis.
• Physiotherapy.They are used mainly in the absence of open trophic ulcers and outside the acute stage of thrombophlebitis.Apparatus pneumocompression, darsonvalization, galvanization, UHF therapy, UV therapy, hydrotherapy and ozone therapy are used.The goals of physical therapy include improving venous and lymphatic drainage, improving microcirculation, stimulating regeneration, and reducing the severity of discomfort.

Medicines will not restore healthy blood flow to already altered veins;they will remain curved 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 the valvular insufficiency.

You should not expect high results from conservative treatment.This 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 is aimed at excluding the affected vessel and its main tributaries from the general blood flow (by removal or obliteration) and eliminating horizontal venous reflux.Does not worsen tissue ischemia, improves trophicity by significantly reducing (or even eliminating) venous stasis.This treatment not only removes the cosmetic defect, but also helps to cope with chronic venous insufficiency.

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

• A crossectomy is a complete transection of a ligated large superficial vein at the point where it empties into the deep venous network.
• Phlebectomy - removal of a superficial vein affected by varicose veins (great or small saphenous vein).It is performed by stripping (pulling, pulling) the vessel using instruments through small incisions.It is currently combined with crossectomy and removal of tributaries.
• Miniphlebectomy – removal of large perforators and tributaries through small incisions or punctures.

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 reoperation to evacuate the blood.
• Lymphostasis due to crossing 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 incisions.They are not so traumatic and are not inferior in efficiency to classical operations.Complications and recurrences after them are rarer than after operations.

Minimally invasive methods:

• Laser obliteration
• Sclerotherapy/Cryosclerotherapy
• Radiofrequency ablation.

In minimally invasive methods, the vein affected by varicose veins is not removed, as in classical operations.Its wall is irradiated from the inside with laser or radio frequency 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 in the RFM of stars, they actually evaporate under the influence of radio frequency waves.