Varicose veins of the lower extremities (varicose veins)

Varicose veins, varicose veins, varicose veins(from Latin varix, varicis - expansion, swelling of veins)- persistent irreversible changes in the veins, characterized by:

• uneven increase in the lumen and length of the veins,
• the formation of nodes in areas of thinning of the veins due to pathological changes in the venous walls, their thinning, stretching, reduced tone and elasticity,
• functional failure of the venous valves and impaired blood flow.

Varicose veins are a fairly common disease. Varicose veins and their complications are diagnosed in 25% of the population, with women suffering 2-3 times more often than men. In women, the first signs of the disease are often observed at a young age, most often associated with pregnancy and childbirth. In older age, an increase in morbidity is observed in both men and women, and the frequency of complicated forms also increases. At the age of 70, the disease occurs 6-10 times more often than at the age of 30. However, recently, the manifestation of varicose veins is often observed in very young people, even teenagers. That is why identifying all possible causes of the disease and preventing venous disorders is becoming an increasingly urgent task.

How varicose veins occur and develop

To understand how varicose veins occur, let's briefly explain the physiology of the venous system of the lower extremities. Venous outflow in the legs is provided by two interconnected mechanisms - central and peripheral. The central mechanism is related to the heart, lungs, diaphragm, and the peripheral mechanism is directly related to the functioning of the venous system of the lower extremities, surrounding the vessels of the muscles and tissues.

The initial signs of varicose veins are impaired capillary blood circulation, swelling, a feeling of heaviness in the legs, the appearance of cobwebs and cobwebs. These changes are reversible, but if preventive measures are not taken in time, the problems will increase.

As a rule, more than a year passes from the first signs of varicose veins of the lower extremities to the formation of varicose nodes and the appearance of pronounced symptoms of varicose veins. Developing gradually, varicose veins lead to impaired blood flow and chronic venous insufficiency. Stagnation of blood in the veins can lead to phlebitis (inflammation of the veins), thrombophlebitis (inflammation of the veins with the formation of blood clots), phlebothrombosis (thrombosis with additional inflammation of the veins), non-healing dermatitis (inflammation of the skin), trophic ulcers.

Types and forms of varicose veins

There are primary (true) and secondary (symptomatic) varicose veins.

Primary varicose veins are an independent disease of the venous system (varicose veins). It develops gradually over several years. Varicose enlargement of the great saphenous vein is most often observed (70-85%), less often - the small saphenous vein (5-12%). In varicose veins, 50-70% of vein damage is bilateral.

Secondary varicose veins are a symptom and consequence of diseases in which there are obstacles to the outflow of blood through the deep veins of the lower limbs (post-thrombotic disease, tumors, scars, inflammatory processes, aplasia and dysplasia of the deep veins, arteriovenous fistulas, etc. ). Secondary varicose veins are quite rare.

Varicose veins most often affect the saphenous veins of the lower extremities, which are part of the great saphenous vein system. Branches of the small saphenous vein suffer from varicose veins much less often.

Classification of the types of varicose veins

Until recently, doctors in our country classified varicose veins according to several types of classifications. The staged clinical classification of V. S. Savelyev was used, reflecting the degree of violation of venous blood circulation in the limb and the ability of the body to resist these violations and compensate for them, as well as classification according to the forms of varicose veins and the complications caused by them.

But the main one at the moment is the CEAP international classification, based on clinical (C - clinic), etiological (E - etiology), anatomical (A - anatomy) and pathogenetic (P - pathogenesis) characteristics of the disease.

6 clinical classes ("C") are arranged in increasing severity of disease from telangiectasias (TAE) to trophic ulcers.

The etiologic section ("E") indicates whether the process is primary or not.

The anatomical part of the classification ("A") divides the venous system of the lower extremities into 18 relatively separate segments, which allows to indicate the localization of the affected area of the venous system.

The pathophysiological section ("P") characterizes the presence of reflux and/or obstruction in the affected venous segment.

Symptoms of varicose veins

The symptoms of varicose veins depend on the stage of the disease, i. e. on the degree of changes in blood vessels and disruption of the venous system. Depending on the stage, a prognosis can be given for the further development of the disease.

The initial stage of varicose veins - varicose veins of the 1st degree

In the initial stage, when the pathology of the veins is not yet clearly expressed, visible signs of varicose veins may be absent. Patients complain of a feeling of heaviness and discomfort in the legs, too fast fatigue, a feeling of heat, paresthesia (numbness, burning, tingling). Symptoms worsen towards the end of the day, as well as under the influence of heat - in summer, or when wearing warm shoes indoors in winter. Swelling of the foot and ankle appears, which disappears after a short rest. Night cramps of the calf muscles are sometimes possible, but patients attribute them to overfatigue.

After prolonged physical exertion, the veins swell and their network is easily visible through the skin. They are especially noticeable in the thigh, lower leg and foot area. The number of such veins and the degree of their expansion may vary. These can be single and not particularly noticeable formations on the lower leg, appearing more clearly in the evening or after physical exertion. Also at this stage of varicose veins, the appearance of cobwebs is observed.

If at this stage you start the simplest conservative treatment, as well as follow preventive measures, then the development of the disease can be prevented by eliminating almost all symptoms.

Symptoms of varicose veins of the 2nd degree, stage of compensation

At this stage of the disease, changes in the large subcutaneous vessels are noticeable. Veins are deformed, swollen, blood flow is disturbed, noticeable swellings appear in the legs and ankles. Swelling increases with prolonged physical activity of the legs, but disappears after a night's rest. At night, calf muscle cramps are common. Paresthesia is observed - temporary loss of sensation in the legs, numbness of the legs, burning, "goosebumps". As the disease progresses, pains appear, which intensify in the evening.

This stage of subcompensation, as a rule, lasts for several years, and during this time the development of the disease can also be stopped if treatment is started promptly. Otherwise, the disease will inevitably progress to a more severe stage.

Symptoms of varicose veins of the 3rd degree - stage of decompensation

In this stage of varicose veins, a significant intensification of symptoms is observed, pain, heaviness in the legs are more intense, and a violation of peripheral blood and lymph circulation (chronic venous insufficiency) is observed. The swelling does not disappear even after a long rest and spreads to the lower leg. Patients are worried about itchy skin. The skin of the feet becomes dry, loses elasticity, the skin is easily injured, loses its ability to regenerate quickly, as a result of which the wounds take a long time to heal. Brown spots appear on the skin, most often on the inner surface of the lower third of the leg (hyperpigmentation due to subcutaneous hemorrhages).

All these complaints are constant. In the future, complaints of pain in the region of the heart, shortness of breath, headache and deterioration of the musculoskeletal system of the affected limb may appear.

Although the stage of decompensation is already a very significant manifestation of the disease, with appropriate treatment, the patient's condition can be maintained at a satisfactory level for quite a long time, maintaining the ability to work and preventing the transition to the phase of complications.

Varicose veins 4th degree - stage of complications

This phase of the disease is characterized by pronounced disorders of venous circulation. Swelling of the legs becomes almost constant, itching of the skin intensifies, and trophic disorders of the skin of the lower leg appear. Advanced varicose veins are often accompanied by eczema, dermatitis and long-term injuries, and since the regenerative abilities of the skin with varicose veins are significantly reduced, even a small wound can develop into a persistent trophic ulcer. Thinned skin and vein walls are easily injured, leading to profuse bleeding. Damaged soft tissues and open sores become entry points for infection.

The most common complications of varicose veins:

• phlebitis - inflammation of a vein;
• thrombosis - the formation of a blood clot (thrombus) in a vein, which can lead to blockage of the vessel;
• trophic ulcers - are formed in the place where the affected vein cannot provide sufficient blood flow from the skin, as a result of which the nutrition (trophism) of the tissues is disturbed.

Varicose veins can be complicated by acute (sometimes purulent) thrombophlebitis,dermatitis and eczema, bleeding, erysipelas, lymphangitis.One of the most dangerous complications of varicose veins is pulmonary embolism, which can lead to sudden death.

At this stage, it is no longer possible to restore the state of the venous system, we can only talk about preventing further complications and, as far as possible, improving the patient's quality of life.

Causes of varicose veins

There is no single cause of primary varicose veins of the lower extremities. The development of this disease is usually provoked by several factors. But all the painful symptoms of varicose veins are associated with structural changes in the tissue of the venous walls of blood vessels and dysfunction of the venous valves.

What causes these disorders?

You can often come across the statement that one of the most important physiological reasons for the development of a disease such as varicose veins is the upright posture. In fact, in humans, by its nature, the load on the vascular system of the lower extremities is very high. The flow of blood from the veins and its rise to the heart is impeded by the pressure caused by gravity, as well as by the high pressure in the abdominal cavity. However, not everyone develops varicose veins. What factors provoke the development of varicose veins?

It has been established that the main risk factors for the development of varicose veins are:

• genetic predisposition (heredity) - congenital weakness of the venous wall, violation of the venous valves;
• female gender - women suffer from varicose veins 4-6 times more often than men;
• hormonal disorders;
• hormonal contraception;
• pregnancy, especially multiple pregnancy;
• heavy physical activity (heavy physical work, strength sports);
• conditions and diseases leading to increased intra-abdominal pressure (chronic respiratory diseases, constipation, etc. )
• diseases that negatively affect blood vessels (high blood sugar, diabetes, pressure spikes, etc. );
• work characteristics - standing or sedentary work, sudden changes in temperature, prolonged contact with high or low temperatures;
• overweight, obesity, which creates increased load on the legs and increased pressure in the pelvic area;
• lack of vitamin C and other useful substances necessary for the vascular system;
• sedentary lifestyle, bad habits that destroy blood vessels and provoke additional tension in them.

Diagnosis of varicose veins

Most often, diagnosing varicose veins is often not difficult. Clinical examination, including physical examination (examination and palpation), examination of the patient, collection of complaints and history (information about the course of the disease, characteristics of life and work, past and present diseases) for severe varicose veins usually makes it possible to placediagnosis without instrumental examination. Exceptions are situations when, with excessive development of the subcutaneous fatty tissue of the lower limbs, varicose changes can be difficult to notice.

Currently, duplex ultrasound scanning (USDS) has become widely used to examine the veins of the lower extremities. This method allows you to determine the localization of changes in the veins and the nature of the violation of venous blood flow. However, you should know that the results of the ultrasound scan are largely subjective and largely depend not only on the experience and knowledge of the researcher, but also on the tactical approaches to the treatment of venous diseases adopted in a given medical institution. When determining treatment tactics, they are primarily guided by the data from the clinical examination.

Duplex scanning is performed when planning invasive treatment of varicose veins of the lower extremities. Additionally, X-ray contrast venography, MRI venography, and CT venography may be used.

All these methods make it possible to clarify the location, nature and degree of venous lesions, to clearly see the disturbances in venous hemodynamics, to evaluate the effectiveness of the prescribed treatment and to predict the course of the disease.

Treatment of varicose veins - modern techniques

The main tasks of the doctor in the treatment of varicose veins are:

• eliminating or reducing the severity of symptoms that cause particular discomfort to patients - pain, swelling, spasms;
• restoring and improving the functioning of blood vessels - from the capillaries to the deep veins, improving the functioning of the valves, restoring the damaged vessel walls, increasing their elasticity and strength;
• improving the rheological properties of blood, reducing its viscosity;
• improving the functioning of the lymphatic system.
• prevention of further development of the disease and complications;
• improving the patient's quality of life.

Depending on the stage of the disease and the degree of vascular damage, the doctor can prescribe the most optimal treatment methods for the given situation, such as:

• conservative treatment- recommendations for prevention and lifestyle change, pharmacotherapy, compression therapy;
• non-surgical invasive procedures- sclerotherapy, echosclerotherapy, foam-form therapy, etc. ;
• operation- phlebectomy, thermal obliteration, stripping, combined methods and operations of increased complexity in complications of varicose veins and treatment of trophic ulcers of the lower extremities.

These methods make it possible to improve blood circulation in the lower extremities, including microcirculation, to eliminate many cosmetic defects caused by varicose veins, and to free the patient from a significant part of the painful manifestations of the pathology.

Conservative methods for the treatment of varicose veins

Modern conservative therapy for varicose veins provides an integrated approach to treatment and includes several directions:

• lifestyle changes;
• pharmacological therapy;
• compression therapy.

It's no coincidence that lifestyle changes come first. It is necessary, if possible, to remove the sediment at least to reduce the influence of adverse factors.

One of them is long-term static loads in a standing or sitting position, which lead to blood stagnation. To activate the musculo-venous pump of the lower leg, you need to regularly stretch your legs and walk more. While working, you can periodically perform exercises with alternating contraction and relaxation of the muscles of the lower leg (toe lifts).

It is recommended to find time for outdoor sports that are not associated with the risk of foot injury (athletic or Nordic walking, exercise bike, treadmills, swimming, cycling and walking).

If you have varicose veins, you should not overheat your legs, you should avoid visiting baths and saunas.

Patients with varicose veins should monitor their body weight. It is known that with a body mass index over 27 kg/m²the likelihood of varicose veins increases by 30%. Being overweight is often associated with elevated sugar levels, which leads to problems with the healing of venous ulcers and the risk of their recurrence.

Compression therapyfor varicose veins it can be used alone or in combination with drugs, as well as after surgery and sclerotherapy.

The effectiveness of compression therapy is explained by the possibility of reducing reverse blood flow, a certain reduction in the pathological capacity of varicose veins, which leads to a decrease in edema, improvement of capillary blood flow and a reduction in the symptoms of varicose veins.

In addition to bandages and knitwear, there is hardware compression therapy, which is particularly effective in chronic venous edema and trophic ulcers.

Drug treatment can be recommended in the early stages of varicose veins as the main type of therapy, supplemented, if necessary, with elastic compression. Pharmaceutical preparations are also prescribed in preparation for surgical treatment or in the postoperative period to speed up rehabilitation and prevent complications.

The following groups of drugs are used to treat venous diseases:

• phlebotonics and angioprotectors;
• anticoagulants and thrombolytics;
• anti-inflammatory and analgesic;
• means for regenerating vessels.

Venotonics and angioprotectors based on bioflavonoids, rutin derivatives, saponins, etc. are mainly used for systemic treatment of varicose veins. . These drugs increase the elasticity and tone of veins, increase the strength of blood vessels, improve lymphatic drainage and reduce lymphatic pressure. . If there is a risk of thrombosis, anticoagulants are prescribed. Anti-inflammatory and pain relievers are used in complications of varicose veins - inflammation of the veins, severe pain, trophic lesions of the veins.

In addition to systemic drugs, local drugs are used - ointments and gels based on venoactive active substances, heparin, nonsteroidal anti-inflammatory drugs, corticosteroid ointments.

Non-surgical invasive procedures

Sclerotherapy of lower limb veins

Vein sclerotherapy is an outpatient medical procedure in which a special substance, a sclerosant, is injected into a capillary or problematic vein using a fine needle. The vessel is then compressed using a latex pad or elastic bandage. The walls of the vessel "stick", the blood flow in the vessel stops. Glued walls usually heal, form a scar, and the scar disappears. It is used to treat varicose veins of small superficial veins. The method is effective in the early stages of the disease, only in cases where varicose veins are localized only in small veins and allows to eliminate cosmetic defects. A series of treatments may be required to achieve results.

Foam therapy (foam sclerotherapy)

It is characterized by a special sclerosant. As with sclerotherapy, a sclerosing substance is injected into the damaged vein in the form of a fine foam, which quickly "closes" the large affected veins. The method does not require many procedures and gives high results. It is important to know that the procedure - although rare - can have side effects - visual impairment. It is also dangerous for the sclerosant to get into the arteries and nerve tissue. The procedure should be performed by an experienced phlebologist.

Absolute contraindications for sclerotherapy - allergy to the drug, deep venous thrombosis, pregnancy, breastfeeding

Surgical treatment of varicose veins

As a rule, surgical treatment is recommended in severe, advanced cases, as well as if conservative methods fail to stop the development of the disease.

Surgical intervention for varicose veins has the following goals

• elimination of cosmetic defects;
• reduction of subjective symptoms (pain, burning, paresthesia, feeling of heaviness in the legs, etc. );
• prevention of deterioration of the saphenous veins;
• prevention of bleeding from varicose veins;
• prevention of thrombophlebitis;
• reducing and preventing the development of venous edema;
• reducing the manifestations and preventing the development of hyperpigmentation, lipodermatosclerosis;
• acceleration of healing and prevention of recurrence of venous trophic ulcers.

According to the Clinical Guidelines, the goals of surgical treatment are:

• elimination of pathological vertical and/or horizontal reflux;
• elimination of enlarged saphenous veins.

Before performing any type of surgery, the risk of developing venous thromboembolic complications (VTE) is assessed.

There are several surgical methods that can be used depending on the specific situation:

Venectomy (phlebectomy) and saphenectomy- traditional operations to remove varicose veins.Venectomy- This is surgical removal of diseased areas of veins.Saphenectomy- a special case of phlebectomy, used in severe and advanced cases of the disease. The essence of saphenectomy is the removal of the central trunks of the damaged saphenous veins in a minimally invasive way - through incisions of the vein trunk and introduction of a probe. During this operation, ligation of perforating veins connecting the saphenous veins with the deep veins is also performed.

Short undressing– rapid removal of the affected area of the saphenous vein of the thigh or leg through small incisions using special small thin probes.

Microphlebectomy (miniphlebectomy) -removal of varicose veins through skin punctures with a needle using special phlebectomy hooks (vein extractors).

Vascular cryosurgery (cryosclerosis)– methods of treating vein diseases by applying cold (liquid nitrogen) to damaged vessels.

Vein suturing is the placement of multiple sutures on a damaged vein that prevent blood from flowing through the vessel. As a result, blood clots form and the vein gradually degenerates.

Thermal erasure methods– thermocoagulation and laser coagulationare considered minimally invasive surgeries.Thermocoagulation(or RFO - Radiofrequency vein obliteration) - very short, for fractions of a second, exposure to high-frequency electric current.Laser coagulation(EVLO or EVLK - endovasal laser obliteration (coagulation) of the veins of the lower extremities) - impact of a laser beam on pathologically dilated vessels. In both cases, as a result of a local increase in temperature, the destruction of the vessel occurs, the so-called "gluing of the walls" or "sealing".

It is important to remember that surgery is not a definitive cure, but an elimination of symptoms. After the operation, conservative treatment is also necessary, at that for life, and this should be explained to the patients.

Depending on the stage of the varicose veins, the symptoms, concomitant diseases and the general state of health of the patient, the doctor chooses specific recommendations to achieve the maximum possible improvements as quickly as possible.