Varicose veins, varicose veins, varicose veins(from Latin varicose, varicis - dilation, swelling of the veins)- persistent and irreversible modification of the veins, characterized by:
- uneven increase in lumen and length of veins,
- the formation of nodes in areas of thinning of veins due to pathological changes in the vein walls, their thinning, stretching, decrease in tone and elasticity,
- functional insufficiency of 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 from them 2 to 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. At older ages, there is an increase in the incidence in both men and women, as well as the frequency of complicated forms. At 70 years old, the disease occurs 6 to 10 times more often than at 30 years old. However, recently, the manifestation of varicose veins is often observed in very young people, even adolescents. Therefore, identifying all possible causes of the disease and preventing venous disorders is becoming an increasingly urgent task.
How varicose veins appear and develop
To understand how varicose veins occur, let's briefly explain the physiology of the venous system of the lower limbs. Venous outflow in the legs is provided by two interconnected mechanisms - central and peripheral. The central mechanism is associated with the heart, lungs, diaphragm and the peripheral mechanism is directly linked to the functioning of the venous system of the lower limbs surrounding the muscular and tissue vessels.
The first signs of varicose veins are impaired capillary circulation, swelling, a feeling of heaviness in the legs, the appearance of spider veins and spider veins. 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 circulation 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 veins). 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. Most often, varicose dilatation of the great saphenous vein is observed (70-85%), less often - the small saphenous vein (5-12%). In the case of varicose veins, 50 to 70% of venous lesions are bilateral.
Secondary varicose veins are a symptom and consequence of diseases in which there are obstructions to the flow of blood through the deep veins of the lower extremities (post-thrombotic disease, tumors, scars, inflammatory processes, aplasia and dysplasia of deep veins, arteriovenous). fistulas, etc. ). Secondary varicose veins are quite rare.
Most often, varicose veins affect the saphenous veins of the lower extremities, which are part of the great saphenous vein system. The branches of the small saphenous vein suffer much less frequently from varicose veins.
Classification of types of varicose veins
Until recently, in our country, doctors classified varicose veins according to several types of classifications. The staged clinical classification of V. S. Savelyev was used, reflecting the degree of disruption of venous circulation in the limb and the body's ability to resist these disruptions and compensate for them, as well as classification according to the forms of varicose veins andthe complications they cause.
But the main one at the moment is the international CEAP classification, based on clinical (C - clinical), etiological (E - etiology), anatomical (A - anatomy) and pathogenetic (P - pathogenesis) characteristics of the disease.
6 clinical classes ("C") are classified by increasing severity of the disease from telangiectasias (TAE) to trophic ulcers.
The etiological section ("E") indicates whether the process is primary or not.
The anatomical part of the classification ("A") divides the venous system of the lower limbs into 18 relatively distinct segments, which helps indicate the location 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
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 for the further course of the disease can be given.
The initial stage of varicose veins - 1st degree varicose veins
At 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, fatigue too quickly, a feeling of heat, paresthesias (numbness, burning, tingling). Symptoms worsen at the end of the day, as well as under the influence of heat in summer, or when wearing warm shoes indoors in winter. Swelling appears in the foot and ankle, which disappears after a short rest. Sometimes night cramps in the calf muscles are possible, but patients attribute them to overwork.
After prolonged physical activity, veins swell and their network is easily visible through the skin. They are particularly visible on the thighs, lower legs and feet. The number of these veins and the degree of their expansion can vary. These may be single, inconspicuous formations on the lower leg, appearing more clearly in the evening or after physical activity. Also at this stage of varicose veins, the appearance of spider veins is observed.
If at this stage you start the simplest conservative treatment and follow preventive measures, the development of the disease can be avoided by eliminating almost all symptoms.
Symptoms of 2nd degree varicose veins, compensation stage
At this stage of the disease, changes in large subcutaneous vessels become noticeable. The veins become deformed, swell, the flow of blood is disrupted and noticeable swelling appears in the feet and ankles. The swelling increases with prolonged physical activity on the legs, but disappears after a night's rest. At night, cramps in the calf muscles are common. Paresthesias are observed - a temporary loss of sensitivity in the legs, numbness of the legs, burning, "goosebumps". As the disease progresses, pain appears, which intensifies in the evening.
This stage of undercompensation usually lasts several years and at this stage the development of the disease can also be stopped if treatment is started in time. Otherwise, the disease will inevitably progress to a more serious stage.
Symptoms of 3rd degree varicose veins - decompensation stage
At this stage of varicose veins, there is a significant increase in symptoms, pain and heaviness in the legs are more intense and there is a disruption of peripheral blood and lymphatic circulation (chronic venous insufficiency). The swelling does not go away even after a long rest and spreads to the lower leg. Patients are bothered by itchy skin. The skin on the legs becomes dry, loses elasticity, the skin is easily injured, loses the ability to quickly regenerate, which takes a long time for wounds to heal. Brown spots appear on the skin, most often on the inside 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 heart region, shortness of breath, headaches and deterioration of musculoskeletal function of the affected limb may appear.
Although the decompensation stage is already a very significant manifestation of the disease, with appropriate treatment the patient's condition can be maintained at a satisfactory level for a fairly long period, maintaining working capacity and avoiding the passagein the complication phase.
4th degree varicose veins - stage of complications
This phase of the disease is characterized by pronounced disorders of venous circulation. Swelling of the legs becomes almost constant, skin itching intensifies, and trophic disorders appear on the skin of the lower leg. Advanced varicose veins are often accompanied by eczema, dermatitis and long-term injuries, and since the regenerative capabilities of the skin with varicose veins are noticeably reduced, even a small wound can turn into a persistent trophic ulcer. Thinned skin and vein walls are easily injured, leading to heavy bleeding. Damaged soft tissues and open ulcers 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 cause the vessel to become blocked;
- Trophic ulcers - form in the place where the affected vein cannot provide sufficient outflow of blood from the skin, which leads to disruption of nutrition (trophism) of tissues.
Varicose veins can be complicated by acute thrombophlebitis (sometimes purulent),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 point, it is no longer possible to restore the condition of the venous system; we can only talk about preventing further complications and, wherever possible, improving the patient's quality of life.
Causes of varicose veins
There is no single cause of primary varicose veins of the lower limbs. The development of this disease is usually caused by several factors. But all painful symptoms of varicose veins are associated with structural changes in the tissues of the venous walls of blood vessels and disruption of the functioning of venous valves.
What are the causes of these violations?
We often hear that one of the most important physiological reasons for the development of a disease such as varicose veins is vertical posture. Indeed, in humans, by its very nature, the load on the vascular system of the lower limbs is very high. The flow of blood from the veins and its rise to the heart is prevented by the pressure caused by gravity, as well as 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 vein wall, disruption 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 pregnancies;
- intense physical activity (intense physical work, strength sports);
- conditions and diseases leading to increased intra-abdominal pressure (chronic respiratory diseases, constipation, etc. )
- diseases that negatively affect blood vessels (hyperglycemia, diabetes, water hammer, etc. );
- work characteristics - standing or sedentary work, sudden temperature changes, prolonged contact with high or low temperatures;
- overweight, obesity, which creates increased stress on the legs and increased pressure in the pelvic region;
- lack of vitamin C and other beneficial substances necessary for the vascular system;
- a sedentary lifestyle, bad habits that destroy blood vessels and cause additional tension in them.
Diagnosis of varicose veins
Most often, the diagnosis of varicose veins is often not difficult. A clinical examination, including a physical examination (examination and palpation), a survey of the patient, a collection of complaints and anamnesis (information on the course of the disease, life and work characteristics, past illnessesand current) for severe varicose veins generally makes it possible to make a diagnosis without instrumental examination. The exceptions are situations where, with excessive development of subcutaneous adipose tissue of the lower extremities, varicose changes may be difficult to notice.
Currently, duplex ultrasound (USDS) has become widely used to study the veins of the lower extremities. This method makes it possible to determine the localization of changes in the veins and the nature of the violation of venous blood flow. However, it should be known that the results of ultrasound 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 guided primarily by clinical examination data.
Double-sided scanning is performed when planning invasive treatment of varicose veins of the lower extremities. Additionally, X-ray contrast venography, MRI venography, and CT venography can be used.
All these methods make it possible to specify the location, nature and extent of venous lesions, to clearly visualize venous hemodynamic disorders, 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:
- eliminate or reduce the severity of symptoms that cause particular discomfort in patients - pain, swelling, cramps;
- restoration and improvement of the functioning of blood vessels - from capillaries to deep veins, improvement of the functioning of valves, restoration of damaged vascular walls, increasing their elasticity and strength;
- improve the rheological properties of blood, reduce its viscosity;
- improve the functioning of the lymphatic system.
- prevent further development of the disease and complications;
- improve 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 a given situation, such as:
- conservative treatment– recommendations for prevention and lifestyle modification, drug therapy, compression therapy;
- non-surgical invasive procedures- sclerotherapy, echosclerotherapy, foam sclerotherapy (Foam-form Therapy), etc. ;
- surgery- phlebectomy, thermal obliteration, stripping, combined methods and operations of increased complexity for 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, eliminate many aesthetic defects caused by varicose veins, and relieve the patient of a significant part of the painful manifestations of the pathology.
Conservative methods of treating varicose veins
Modern conservative therapy of varicose veins offers an integrated approach to treatment and includes several areas:
- lifestyle changes;
- pharmacological therapy;
- compression therapy.
It’s no coincidence that lifestyle changes take priority. It is necessary, if possible, to remove sludge at least to reduce the influence of unfavorable factors.
One of them is long-term static loads while standing or sitting, which lead to blood stagnation. To activate the musculovenous pump in 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 (rising on tiptoes).
It is recommended to find time to practice outdoor sports that are not associated with a risk of leg injury (sports or Nordic walking, exercise bikes, treadmills, swimming, cycling and walking).
If you have varicose veins, you should not overheat your legs, you will have to refuse visiting public baths and sauna.
Patients suffering from varicose veins should monitor their weight. We know that with a body mass index above 27 kg/m2the risk of varicose veins increases by 30%. Excess weight is often associated with high sugar levels, leading to problems healing venous ulcers and risk of recurrence.
Compression therapyfor varicose veins, it can be used alone or in combination with pharmaceutical products, as well as after surgery and sclerotherapy.
The effectiveness of compression therapy is explained by the possibility of reducing reverse blood flow, some reduction in the pathological capacity of dilated veins, which leads to a decrease in swelling, improvement of capillary blood flow and a decrease invaricose veins symptoms.
In addition to bandages and knitwear, there is hardware compression therapy, which is especially effective for chronic venous edema and trophic ulcers.
Drug treatment can be recommended in the early stages of varicose veins as the main type of treatment, supplemented, if necessary, with elastic compression. Pharmaceutical products 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 angioprotectants;
- anticoagulants and thrombolytics;
- anti-inflammatories and analgesics;
- vascular regeneration agents.
For the systemic treatment of varicose veins, mainly venotonics and angioprotectors based on bioflavonoids, rutin derivatives, saponins, etc. are used. . These drugs increase the elasticity and tone of veins, increase the resistance of blood vessels, improve lymphatic flow and reduce lymphatic pressure. . If there is a risk of thrombosis, anticoagulants are prescribed. Anti-inflammatory drugs and analgesics are used for complications of varicose veins - inflammation of the veins, severe pain, trophic damage to 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 the veins of the lower limbs
Venous sclerotherapy is an outpatient medical procedure in which a special substance, a sclerosant, is injected into a problem capillary or vein using a fine needle. The vessel is then compressed using a latex pad or elastic bandage. The walls of the vessel "stick together", blood flow in the vessel stops. The stuck walls usually grow together, form a scar, and the scar disappears. 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 you to eliminate cosmetic defects. A series of treatments may be necessary to achieve results.
Foam therapy (foam sclerotherapy)
It is distinguished by a special sclerosant. As with sclerotherapy, a sclerosing substance is injected into the injured vein in the form of a fine foam, which quickly "closes" the affected large 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 if the sclerosant enters the arteries and nervous tissues. The procedure should be performed by an experienced phlebologist.
Absolute contraindications to sclerotherapy - allergy to the drug, deep vein thrombosis, pregnancy, breastfeeding
Surgical treatment of varicose veins
As a rule, surgical treatment is recommended in severe and 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;
- reduction and prevention of the development of venous edema;
- reduction of manifestations and prevention of the development of hyperpigmentation, lipodermatosclerosis;
- acceleration of healing and prevention of relapses of venous trophic ulcers.
According to clinical guidelines, the goals of surgical treatment are:
- elimination of vertical and/or horizontal pathological reflux;
- elimination of saphenous varicose veins.
Before performing surgical operations of any type, the risk of developing venous thromboembolism complications (VTEC) is assessed.
There are several surgical methods that can be used depending on the specific situation:
Venectomy (phlebectomy) and safenectomy- traditional operations to eliminate varicose veins.Venectomy- This involves the surgical removal of diseased venous areas.Safenectomy- a special case of phlebectomy, used in serious and advanced cases of the disease. The essence of safenectomy is the removal of the damaged central trunks of the saphenous veins in a minimally invasive way - through incisions on the venous trunk and insertion of a probe. During this operation, a ligation of the perforating veins is also performed, connecting the saphenous veins to the deep veins.
Short stripping– 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 by skin pricks with a needle using special phlebectomy hooks (vein extractors).
Vascular cryosurgery (cryosclerosis)– methods of treating venous diseases by applying cold (liquid nitrogen) to damaged vessels.
Venous suturing involves placing multiple sutures on a damaged vein, which prevent blood from flowing through the vessel. As a result, blood clots form and the vein gradually degenerates.
Thermal Obliteration Methods– thermocoagulation and laser coagulationare considered minimally invasive operations.Thermocoagulation(or RFO - Radiofrequency Venous Obliteration) - a very short exposure, of a fraction of a second, to a high frequency electrical current.Laser coagulation(EVLO or EVLK – endovasal laser obliteration (coagulation) of the veins of the lower extremities) - exposure to a laser beam on pathologically dilated vessels. In both cases, following a local increase in temperature, a destruction of the container occurs, which is called "wall sticking" or "sealing".
It is important to remember that surgery is not a permanent cure, but rather the elimination of symptoms. After surgery, conservative treatment is also necessary, and throughout life, and this must be explained to patients.
Depending on the stage of varicose veins, symptoms, concomitant diseases and the general health of the patient, the doctor selects specific recommendations to achieve maximum possible improvements as quickly as possible.