What are varicose veins?

Varicose veins are a pathological and irreversible change in the walls of peripheral veins with incompetence of the valvular apparatus and alteration of blood flow.Veins of various localizations are subject to varicose transformation, but most often the vessels of the superficial venous network of the legs are affected, so 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 flow from the extremities.It is these pathogenic moments that are decisive.All other predisposing factors affect the entire vascular system, but do not cause characteristic changes in the 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 subsequently extends throughout the thickness of the vessel.The triggering mechanism in most cases is a slowdown in blood flow;there is a parietal grouping of cellular elements of blood with leukocytes rolling - grouping and "rolling" of leukocytes along the surface of the endothelium.Over time, they tend to stick together, causing the release of inflammatory mediators.At this stage there are still no external changes.
2. Remodeling of the walls of superficial veins and leaflets. It leads to changes in density and elasticity.This is facilitated by aseptic inflammation, genetically determined defects in connective tissue proteins, mechanical microdamage to the endothelium and some other factors.In affected vessels, the ability to reversibly compensate for venous pressure fluctuations is significantly reduced and they become rigid.
3. Persistent and progressive expansion of the lumen of the affected veins. These changes are initially quite local;Subsequently, the pathological process spreads not only along one vessel, but also involves other components of the peripheral venous network.
4. Compensatory elongation of the affected vein with the formation of pronounced pathological curves. The characteristic swollen nodes form, which give the disease its name: "varix" is translated from Latin as "swelling."
5. Development of valve insufficiency. Functional failure of the valves in the lumen of the affected superficial veins with reverse blood flow (vertical reflux).Initially, it is relative 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 circumstances.Venous stasis (blood stagnation) appears with the formation of venous insufficiency.
6. Involvement of the perforating veins in the process.They are also called communicating or commissural.Its pathological expansion is also accompanied by valve insufficiency, which contributes to pathological blood flow from the deep to the superficial venous network (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 already developed varicose veins with conservative methods;It is only possible to partially compensate for disorders for a time.

Causes of varicose veins

Varicose veins are a polyetiological disease whose development is facilitated 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 hormone replacement therapy.
• Conditions accompanied by partial compression of the pelvic veins: pregnancy (especially multiple pregnancy or with polyhydramnios), massive formations of the abdominal cavity, some intestinal diseases.Constipation and chronic lung diseases with cough, which cause an increase in intra-abdominal pressure, cause an interruption of venous flow at the pelvic level.
• Increase in body weight.

All people are predisposed to the development of varicose veins.This is due to the vertical position of the body, therefore, under the influence of gravity, blood tends to the distal parts of the lower extremities and the veins experience greater tension 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.Varicose vessels are tortuous, excessively contoured, dark, visible through the skin and bulging.The pulsation is not characteristic of them.As the disease progresses, local nodular protuberant formations appear on the legs, which often form entire conglomerates and do not completely disappear in the supine position.In patients with higher body weight, changes in the veins often remain practically imperceptible for a long time, masked by excess subcutaneous fat.
• Swelling of the feet and legs after standing and sitting for a long time, at night, when staying in conditions of high ambient temperature.This venous edema is not accompanied by cyanosis of the distal extremities, which may be seen in heart failure.They decrease and even disappear after rest (including night 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 with varicose veins.
• Feeling of heaviness and fullness in the legs, even in the absence of obvious swelling.Such complaints appear in conditions that promote pathological blood deposition in the distal parts of the lower extremities.The discomfort is most often observed at night and after a long stay in an upright position with little physical activity.
• Signs of ischemia of the muscles of the limb affected by varicose veins: increased muscle fatigue, sometimes cramps.
• Unpleasant sensations in the legs, which usually intensify with increased swelling due to the reaction of soft tissues and peripheral nerve branches of the leg to compression by 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 may 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 a timely manner.The order in which new features are added may be different.In some patients, a cosmetic defect is initially observed 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: 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 - venous crown of the foot;
• 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.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 notice serious trophic alterations.

Diagnosis

A basic 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 visible superficial veins, changes in the skin and soft tissues, and the presence of edema.Functional testing is performed to evaluate vertical reflux and identify the approximate level of horizontal reflux.The patient survey is aimed at clarifying the predisposing and provoking factors, the duration and characteristics 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 veno-venous reflux and impaired vascular permeability.This information is necessary for the doctor to select the necessary treatment regimen.
• Hemostasiogram (blood test 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 to a wide range of patients;The results obtained are usually not critical in determining treatment tactics.Normally a basic examination is sufficient, which, if necessary, is complemented by consultations with specialized specialists (endocrinologist, hematologist, cardiologist and others).Previously, several stages of varicose veins of the legs were distinguished.Currently, when making the diagnosis, phlebologists use the CEAP classification of chronic venous diseases, which includes characteristics of the case according to clinical, etiological, anatomical and pathophysiological characteristics.

The danger of varicose veins

Many people believe that varicose veins of the lower extremities are primarily a cosmetic problem.In fact, it is often the external unattractiveness of the legs with bulging and knobby blue-violet vessels or spider veins that are the main reason for visiting 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 persistent 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 in varicose veins are caused by heavy 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.In addition, hyperpigmentation, lipodermatosclerosis and traces of healed ulcers usually persist even after removal of the affected veins, especially if surgical treatment was carried out against the background of already developed pronounced trophic disorders.
• Bleeding due to rupture of varicose nodes or veins at the bottom 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 distant 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 likelihood of obtaining a quick and sufficient result even when using radical treatment methods.

Is the disease always dangerous?

Varicose veins of the lower extremities with valvular insufficiency of the saphenous veins are 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, characteristics 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 superficial mesh.
• Absence of pathological vertical or horizontal venovenous reflux.The small affected vessels do not have valves and communicate only with small tributaries of the saphenous veins by a feeding pedicle.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, patients' discomfort is due to a cosmetic defect.But this does not mean that a person with the presence of spider veins is excluded from suffering damage to larger veins.In such a situation, C1 is no longer diagnosed, but rather C2 and later classes according to the CEAP classification.

Treatment of varicose veins

Treatment of varicose veins should not begin 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, a complete regression of symptoms and a low probability of relapse.Treatment of advanced varicose veins will not be as effective.Sometimes your 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 to operate until complications develop that cannot be corrected.And many of them do not even go to the doctor and resort to self-medication.Self-medication often leads to complications of pathology.

Conservative treatment

The conservative treatment regimen for varicose veins includes:

• Systemic pharmacological 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.
• Therapy with local medications (ointments, creams, gels).External agents are intended to improve microcirculation, reduce swelling, increase vein tone and heal trophic ulcers.
• Therapeutic exercise increases the efficiency of the lower leg muscle pump and therefore improves blood outflow from the legs.
• Use of compression stockings.Compression stockings and stockings provide dosed compression of superficially located veins, which reduces the tendency to deposit blood and edema, 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 stage of thrombophlebitis.Hardware pneumocompression, darsonvalization, galvanization, UHF therapy, UV therapy, hydrotherapy and ozone therapy are used.The goals of physical therapy include improving venous and lymphatic flow, improving microcirculation, stimulating regeneration, and reducing the severity of discomfort.

Medications will not return healthy blood flow to already disrupted veins;They will remain tortuous and dilated.And even a slight increase in the tone of the vascular wall under the influence of phlebotonics will not be able to completely correct valve insufficiency.

Good results should not be expected from conservative treatment.It will reduce pain and swelling, reduce the risk of thrombosis and improve 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 eliminating or obliterating 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 eliminates the cosmetic defect, but also helps to cope with chronic venous insufficiency.

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

• Crossectomy is the complete intersection of a large superficial vein ligated at the point where it empties into the deep venous network.
• Phlebectomy – removal of the superficial vein affected by varicose veins (greater or lesser saphenous).It is done by peeling (pulling, removing) the glass using instruments through small incisions.Currently it is 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, its disadvantages:

• Significant blood loss;
• Hemorrhages in the surgical area, sometimes requiring repeated surgeries to evacuate the blood.
• Lymphostasis due to intersection of lymphatic vessels.
• Severe pain syndrome.
• Long-term disability.

Modern alternative to surgery.

Endovascular techniques are considered minimally invasive interventions;They do not require incisions.They are not as traumatic and are not inferior in effectiveness to classic operations.Complications and relapses after them are less common than after operations.

Minimally invasive methods:

• laser obliteration
• Sclerotherapy/Cryosclerotherapy
• Radiofrequency obliteration.

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 causes the "sticking" of the vessel and its subsequent fibrosis and replacement by connective tissue.This closure of the lumen of the vessel is called obliteration.And with the RFM of stars, they actually evaporate under the influence of radio frequency waves.