What are varicose veins?

Varicose veins are a pathological and irreversible change in the walls of peripheral veins with incompetence of the valve apparatus and compromised blood flow.Veins of various locations are subject to varicose transformation, but most often the vessels of the superficial venous network of the legs are affected, therefore varicose veins often mean diseases of the veins of the lower extremities.

How do varicose veins appear?

With varicose veins, only peripheral superficial venous vessels undergo pathological transformation - this is due to the structural features of the walls and the physiology of blood flow in 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 central veins and arteries of any caliber.

Let's consider the pathogenesis of varicose veins:

1. Aseptic inflammation. It begins in the endothelium of the veins and subsequently spreads throughout the entire thickness of the vessel.The triggering mechanism, in most cases, is a slowdown in blood flow;there is a parietal grouping of blood cellular elements with rolling leukocytes - grouping and “rolling” of leukocytes along the surface of the endothelium.Over time, there is a tendency for adhesion, which causes the release of inflammatory mediators.At this stage there are no external changes yet.
2. Remodeling of the walls of superficial veins and valves. 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 fluctuations in venous pressure 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 lengthening of the affected vein with the formation of pronounced pathological curves. Characteristic protruding nodules form, which give the disease its name: “varix” is translated from Latin as “swelling”.
5. Development of valve insufficiency. Functional insufficiency of the valves in the lumen of superficial veins affected with reverse blood flow (vertical reflux).Initially, it is relative in nature 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 condition.Venous stasis (blood stagnation) appears with the formation of venous insufficiency.
6. Involvement of perforating veins in the process.They are also called communicants or commissurals.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, making it impossible to cure already developed varicose veins using conservative methods;it is only possible to partially compensate for the disturbances for a while.

Causes of varicose veins

Varicose veins are a polyetiological disease whose development is promoted 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 taking 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.Colds and chronic lung diseases with cough, leading to increased intra-abdominal pressure, lead to interruption of venous flow at the pelvic level.
• Increase in body weight.

Everyone is predisposed to developing varicose veins.This is due to the vertical position of the body, due to which, under the influence of gravity, the 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 veins are tortuous, excessively contoured, dark, visible through the skin and prominent.The pulse is not characteristic of them.As the disease progresses, local protruding nodular formations appear on the legs, which often form entire conglomerates and do not completely disappear in the supine position.In patients with increased 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 high ambient temperature conditions.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 nighttime sleep), when keeping the legs in an elevated position, after performing special exercises to activate the “muscle pump” of the 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 deposition of blood in the distal parts of the lower extremities.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, usually intensified with increasing swelling due to the reaction of soft tissues and branches of peripheral nerves 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 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 a timely manner.The order in which new features are added may differ.In some patients, a cosmetic defect is initially noted in the form of clearly altered veins, while in others the disease begins in the form of venous insufficiency.

Internships

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 - corona venosa 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 disturbances.

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 tests are performed to evaluate vertical backflow and identify the approximate level of horizontal backflow.Examination 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 Doppler ultrasound (USD).The study shows the speed of blood circulation, the presence of pathological venous-venous reflux and impaired vascular permeability.This information is necessary for the doctor to select the necessary treatment regimen.
• Hemostasiogram (blood tests for a comprehensive assessment of the coagulation system).

According to 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.A basic examination is usually sufficient, which, if necessary, is complemented by consultations with specialized specialists (endocrinologist, hematologist, cardiologist and others).Previously, several stages of varicose veins on the legs were distinguished.Currently, to make the 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 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 protruding blue-violet vessels or knotty vessels 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 potentially fatal 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 with 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 often 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 from nodules or ruptured varicose veins at the bottom of trophic ulcers.
• Development of thrombosis and thrombophlebitis of superficial veins.It is fraught not only with local hemodynamic disturbances and inflammation, but also with distant thromboembolism with multi-organ infarctions and acute life-threatening conditions.
• Deep vein thrombosis is an even more dangerous condition in terms of thromboembolism.

The 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 disease of the lower extremities with valvular insufficiency 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 is C1, characteristics of the form:

• Damage to small intradermal vessels up to 3 mm in diameter.They can be subepidermal or reticular.
• Appearance of spider veins, reticular varicose veins in the form of a fine superficial mesh.
• Absence of pathological vertical or horizontal venovenous reflux.The affected small vessels do not have valves and communicate only with small tributaries of the saphenous veins through 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 spider veins is excluded from damage to larger veins.In this situation, it is no longer C1 that is diagnosed, but C2 and subsequent classes according to the CEAP classification.

Varicose veins treatment

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 quick onset of the expected effect, complete regression of symptoms and a low probability of relapse.Treatment for advanced varicose veins will not be as effective.Sometimes your task will only be to reduce the rate of disease progression, create conditions for healing 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, delaying the decision about surgery until complications arise that cannot be corrected.And many of them don't even consult a doctor, resorting to self-medication.Self-medication often leads to complications of pathology.

Conservative treatment

The conservative treatment regimen for varicose veins includes:

• Systemic drug therapy.It aims to improve the rheological properties of the 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 agents aim to improve microcirculation, reduce swelling, increase vein tone and heal trophic ulcers.
• Therapeutic exercise increases the efficiency of the leg muscle pump and thus improves leg blood flow.
• Use of compression stockings.Compression stockings and tights provide dosed compression of superficially located veins, which reduces the tendency for blood to deposit 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 phase 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 altered 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.

You should not 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 the patient from varicose veins and prevent the progression of the disease with a conservative approach.

Surgical treatment

An invasive (surgical) method of treating varicose veins aims to exclude the affected vessel and its main tributaries from the general blood flow (by removing or obliterating it) and eliminating horizontal venovenous reflux.It does not worsen 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 treating varicose veins of the lower extremities:

• Crossectomy is the complete intersection of a large superficial vein ligated at the point where it flows into the deep venous network.
• Phlebectomy – removal of the superficial vein affected by varicose veins (saphena great or parva).It is performed by denuding (pulling, pulling) the vessel using instruments through small incisions.It is currently combined with crossectomy and tributary removal.
• 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;
• Bleeding in the surgical area, sometimes requiring repeated surgeries to evacuate the blood.
• Lymphostasis due to the 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 so traumatic and are not inferior in effectiveness to classical operations.Complications and relapses after them are less common than after operations.

Minimally invasive methods:

• Laser Obliteration
• Sclerotherapy/Cryosclerotherapy
• Radio frequency 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 sclerosing medication.This causes the vessel to “adhere” and its subsequent fibrosis and replacement by connective tissue.This closure of the vessel lumen is called obliteration.And with the RFM of stars, they actually evaporate under the influence of radio frequency waves.