What are varicose veins?

Varicose veins are a pathological and irreversible change in the walls of peripheral vessels due to incompetence of the valvular apparatus and impaired blood flow.The veins of various places undergo varicose transformation, but in most cases the veins of the superficial venous network in the legs are affected, therefore, varicose veins usually mean the disease of the veins of the lower extremities.

What do varicose veins look like?

With 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 flow from the extremities.It is these pathogenetic points that are decisive.All other predisposing factors affect the entire vascular system, but do not cause characteristic changes in central vessels and arteries of any caliber.

Let's consider the pathogenesis of varicose veins:

1. Aseptic inflammation. It starts from the endothelium of the vessels and later spreads throughout the entire thickness of the vessel.In most cases, the triggering mechanism is a slowing of blood flow;with the rolling of leukocytes, there is a parietal grouping of the cellular elements of the blood - the grouping and "rolling" of leukocytes along the surface of the endothelium.Over time, there is a tendency for adhesion to occur, leading to the release of inflammatory mediators.There are no external changes yet at this stage.
2. Reconstruction of the walls of superficial veins and valves. It causes 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 the affected veins, the ability to reverse changes in venous pressure is significantly reduced and they become stiff.
3. Continuous and progressive expansion of the lumen of the affected vessels. These changes are initially quite local;later, the pathological process spreads not only along the length of a vein, but also involves other components of the peripheral venous network.
4. Compensatory stretching of the affected vessel with the formation of open pathological bends. Characteristic bulging nodes are formed, which gave the name to 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 vessels with reverse blood flow (vertical reflux).Initially, it is relative in nature and manifests itself only with a significant increase in peripheral venous pressure.Subsequently, failure is inevitable - the valve walls do not close completely under any circumstances.Venous stasis (blood stagnation) occurs with the formation of venous insufficiency.
6. Involvement of perforating vessels in the process.They are also called communicants or commissioners.Their pathological expansion is also accompanied by valve failure, 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 continue even with the complete elimination of inciting and predisposing factors, so it is impossible to treat already developed varicose veins using conservative methods;it is only possible to partially compensate the disorders for a while.

Causes of varicose veins

Varicose veins are a polyetiological disease, external and internal (endogenous) factors contribute to its development.The main reasons for the development of varicose veins:

• Hereditary factor.
• Low mobility, long sitting position.
• In women - changes in hormonal status during pregnancy, taking oral contraceptives and conducting hormone replacement therapy.
• Conditions accompanied by partial compression of the pelvic vessels: pregnancy (especially occurring with multiple pregnancies or polyhydramnios), mass formation of the abdominal cavity, some intestinal diseases.Chronic lung diseases accompanied by constipation and cough cause an increase in intra-abdominal pressure, causing a violation of venous flow at the pelvic level.
• Increased body weight.

All people are prone to the development of varicose veins.This is related to the vertical position of the body, therefore, under the influence of gravity, the blood tends to the distal parts of the lower limbs, and the vessels 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 vessels.Varicose veins are curved, over-contoured, dark, visible through the skin and bulging.Pulsation is not characteristic for them.As the disease progresses, local nodular protruding formations appear on the legs, often forming entire conglomerates, which do not completely disappear in the supine position.Vascular changes in patients with increased body weight often remain practically invisible for a long time, masked by excessive subcutaneous fat.
• Swelling of the feet and legs after standing and sitting for a long time in the evening, when staying in conditions of high 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), keeping the legs in an elevated position, and 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 if there is no obvious swelling.Such complaints appear in conditions that promote pathological deposition of blood in the distal parts of the lower limbs.Discomfort is most often observed in the evening and after prolonged standing in an upright position with little physical activity.
• Signs of ischemia of limb muscles affected by varicose veins: increased muscle fatigue, sometimes cramps.
• Unpleasant sensations in the legs are usually intensified by increased swelling due to the compression reaction of the soft tissues and branches of the peripheral nerves of the leg with an excessive amount of intercellular fluid.Another possible cause of such paresthesias is dysmetabolic trophic disorders.
• Visible trophic disorders of the skin and underlying soft tissues.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 to them in time.The order in which new features are added may vary.In some patients, initially a cosmetic defect is noted in the form of clearly altered veins, 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 - 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 skin atrophy;
• C4c - coronary vein of the leg;
• C5 - elongated trophic ulcer;
• C6 - open trophic ulcer.
• C6r - recurrent open trophic ulcer.

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

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

Diagnostics

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

• Clinical examination.A phlebologist determines 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 determine 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 the usual ultrasound, but the assessment of blood flow using Doppler Doppler Ultrasound (USD).The study shows the speed of blood movement, the presence of pathological veno-venous reflux and the violation of the patency of vessels.This information is necessary for the doctor to choose the appropriate treatment regimen.
• Hemostasiogram (blood tests for a comprehensive evaluation of the coagulation system).

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

Other diagnostic methods are also used in modern medicine - plethysmography, laser Doppler flowmeter.They are not available to a wide range of patients;the obtained results are usually not critical in determining treatment tactics.Usually, a basic examination is enough, if necessary, it is supplemented with the advice of 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 clinical, etiological, anatomical and pathophysiological characteristics of work.

The danger of varicose veins

Many people believe that varicose veins of the lower extremities are mainly a cosmetic problem.Indeed, the external appeal of legs with often knotty, bulging blue-purple veins or spider veins is the main reason to visit the doctor.

Pathologically dilated 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.

The consequences of advanced varicose veins:

• Significant deterioration of the patient's quality of life.Varicose veins cause significant discomfort and even reduced performance due to severe leg syndrome, swelling, night cramps, poor healing and recurrent ulcers.
• Changes in soft tissues with a decrease in the external attractiveness of the legs, which is especially important for women.Moreover, hyperpigmentation, lipodermatosclerosis and traces of healed ulcers usually persist even after the removal of the affected vessels, especially if the surgical treatment was carried out against the background of already developed trophic disorders.
• Bleeding from ruptured varicose nodes or veins at the base of trophic ulcers.
• Development of thrombosis and thrombophlebitis of superficial veins.It is fraught not only with local hemodynamic disorders and inflammation, but also with heart attacks of various organs and remote thromboembolism, which is acutely life-threatening.
• Deep vein thrombosis is a more dangerous condition in terms of thromboembolism.

Advanced complications of varicose veins of the superficial veins of the thigh and leg not only have a negative impact on the patient's condition and the prognosis of the disease.Even when using radical treatment methods, they significantly reduce the probability of obtaining a quick and sufficient result.

Is the disease always dangerous?

Varicose disease of the lower extremities with valvular deficiency 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 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 spider veins, reticular varicose veins in the form of a fine surface mesh.
• Absence of vertical or horizontal pathological venovenous reflux.Affected small veins 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, deeper vessels.Disruption of 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 caused by patients is caused by a cosmetic defect.However, this does not mean that a person with spider veins is exempt from damage to larger caliber veins.In such a case, not C1, but C2 and subsequent classes according to the CEAP classification are diagnosed.

Treatment of varicose veins

Treatment of varicose veins should begin at the stage of initial changes and minimally expressed signs of venous insufficiency, not with the development of complications.You can expect a rapid onset of action, complete regression of symptoms, and a low likelihood of relapse.Treatment of advanced varicose veins will not be very effective.Sometimes its task will be only to reduce the rate of disease development, 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 a gentle approach, postponing the decision to have surgery until unremediable complications arise.And many of them resort to self-treatment and do not even consult a doctor.Self-treatment often leads to complications of the pathology.

Conservative treatment

The conservative treatment regimen of varicose veins includes the following:

• Drug systemic therapy.It aims to improve 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 treatment (ointments, creams, gels).External agents are designed to improve microcirculation, reduce swelling, increase vascular tone, and heal trophic ulcers.
• Therapeutic exercise increases the efficiency of the muscle pump of the lower part of the legs, thereby improving blood flow through the legs.
• Use of compression stockings.Compression stockings and tights provide dosed compression of superficial vessels, which reduces the tendency for blood and edema to settle, improves well-being and reduces the likelihood of thrombosis.
• Physiotherapy.They are mainly used in the absence of open trophic ulcers and outside the acute phase of thrombophlebitis.Apparatus pneumocompression, darsonvalization, galvanization, UHF therapy, UV therapy, hydrotherapy and ozone therapy are used.The goals of physiotherapy include improving venous and lymphatic flow, improving microcirculation, stimulating regeneration and reducing the severity of anxiety.

Medicines will no longer restore healthy blood flow to altered vessels;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 deficiency.

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

Surgical treatment

The invasive (surgical) method of treating varicose veins is aimed at removing the affected vein and its main branches from the general blood flow (by removing or destroying it) and eliminating horizontal venovenous reflux.It does not aggravate tissue ischemia, improves trophism by significantly reducing (or even eliminating) venous stasis.This treatment not only removes the cosmetic defect, but also helps to overcome chronic venous insufficiency.

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

• Crossectomy is the complete transection of an occluded large superficial vein at the point where it drains into the deep venous network.
• Phlebectomy - removal of a superficial vein (greater or lesser saphenous vein) affected by varicose veins.It is performed by stripping (stretching, removing) the vein using tools through small incisions.Currently, it is combined with crossectomy and arm removal.
• Miniphlebectomy - removal of large perforators and arms through small incisions or punctures.

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

• Significant blood loss;
• Bleeding at the surgical site sometimes requires reoperation to drain the blood.
• Lymphostasis due to the crossing of lymphatic vessels.
• Severe pain syndrome.
• Long term disability.

A modern alternative to surgery

Endovascular methods are considered minimally invasive interventions;they do not require incision.They are not so traumatic and are not inferior to classical operations in terms of effectiveness.After them, complications and relapses after operations are less.

Minimally invasive methods:

• Laser obliteration
• Sclerotherapy/Cryosclerotherapy
• Obliteration of radio frequencies.

With minimally invasive methods, the vein affected by varicose veins is not removed as in classical operations.Its wall is exposed from the inside with laser or radiofrequency energy, and during sclerotherapy with a sclerosant drug.This causes the vessel to "stick together" and its subsequent fibrosis and replacement by connective tissue.Closing the lumen of the vessel in this way is called obliteration.With the RFM of stars, they actually evaporate under the influence of radio frequency waves.