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 impaired 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 usually mean 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 features of the walls and the physiology of blood flow from 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 starts from the endothelium of the veins and then extends to the entire 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 leukocyte 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 point, 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 not only spreads along a vessel, but also involves other components of the peripheral venous network.
4. Compensatory lengthening of the affected vein with the formation of pronounced pathological bends. Characteristic bulging nodes are formed, which give the name to the disease: “varicose veins” is translated from Latin as “swelling”.
5. Development of valvular insufficiency. Functional failure of valves in the lumen of affected superficial veins with reversed blood flow (vertical reflux).Initially, it is relative in nature and is manifested only by a notable increase in peripheral venous pressure.Subsequently, the failure becomes absolute - the valve walls do not close completely, regardless of conditions.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 commissioners.Their pathological expansion is also accompanied by valve insufficiency, which contributes to pathological blood flow from the deep venous network to the superficial 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 using conservative methods;it is only possible to partially compensate for the disorders for a while.

Causes of varicose veins

Varicose veins are a polyetiological disease, the development of which is promoted by external and internal (endogenous) factors.The main reasons for the development of varicose veins:

• Hereditary factor.
• Low mobility, prolonged sitting.
• In women - changes in hormonal status during pregnancy, taking oral contraceptives, and performing hormone replacement therapy.
• Conditions accompanied by partial compression of the pelvic veins: pregnancy (especially multiple pregnancies or occurring with polyhydramnios), massive formations of the abdominal cavity, some intestinal diseases.Constipation and chronic lung diseases accompanied by coughing, leading to increased intra-abdominal pressure, lead to disruption of venous outflow at the pelvic level.
• Increased body weight.

All people are predisposed to the development of 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 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 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 protruding nodular formations appear on the legs, which often form whole conglomerates and do not completely disappear when lying down.In patients with high body weight, changes in the veins often remain practically invisible for a long time, masked by excess subcutaneous fat.
• Swelling of the feet and legs after prolonged standing or sitting, 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 night sleep), keeping the legs in an elevated position, after performing particular gymnastics to activate the “muscle pump” of the lower leg.Swelling is one of the first signs of chronic venous insufficiency accompanied by varicose veins.
• A feeling of heaviness and fullness in the legs, even when there is no obvious swelling.Such complaints appear in conditions that favor pathological deposition of blood in the distal parts of the lower extremities.Discomfort is most often observed in the evening and after a long stay in an upright position with little physical activity.
• Signs of ischemia of the limb muscles affected by varicose veins: increased muscle fatigue, sometimes cramps.
• Unpleasant sensations in the legs, usually intensifying 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.This may include 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 be different.In some patients, a cosmetic defect in the form of clearly altered veins is initially noted, while in others the disease begins in the form of venous insufficiency.

Steps

The stages of varicose veins are determined according to the CEAP classification:

• C0: no signs of pathology;
• C1—presence of reticular varices 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 a cosmetic defect is noted - 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 limbs 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 assess vertical reflux and identify the approximate level of horizontal reflux.The patient survey is aimed at clarifying the predisposing and provoking factors, duration and characteristics of the development of the disease.
• Ultrasound examination.In 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 movement, the presence of pathological veno-venous reflux, and impaired vascular patency.This information is necessary for the doctor to select the necessary treatment regimen.
• Hemostasiogram (blood tests for a complete assessment 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 accessible to a wide range of patients;the results obtained are generally not essential in determining treatment tactics.Usually, a basic examination is enough, which, if necessary, is supplemented by consultations with specialized specialists (endocrinologist, hematologist, cardiologist and others).Previously, there were several stages of varicose veins of the legs.Currently, when making a diagnosis, phlebologists use the CEAP classification of chronic venous diseases, which includes the characteristics of the case according to clinical, etiological, anatomical and pathophysiological features.

The danger of varicose veins

Many people think that varicose veins of the lower limbs are primarily a cosmetic problem.Indeed, it is often the external unattractiveness of legs with knotty, bulging blue-violet vessels or spider veins that is the main reason for a visit to 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 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, or even a reduction in performance in the case of varicose veins, is caused by heavy leg syndrome, swelling, nocturnal 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 from rupture of varicose lymph nodes or veins at the bottom of trophic ulcers.
• Development of thrombosis and thrombophlebitis of superficial veins.It involves not only local hemodynamic disorders and inflammation, but also remote thromboembolism with infarction of various organs and acute potentially fatal conditions.
• Deep vein thrombosis is an even more dangerous pathology 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 achieving a quick and sufficient result, even using radical treatment methods.

Is the disease still dangerous?

Varicose veins of the lower limbs with valvular insufficiency of the saphenous veins are 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, 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 superficial mesh.
• Absence of vertical or horizontal pathological venovenous reflux.The affected small vessels do not have valves and communicate only with the small tributaries of the saphenous veins using a feeding pedicle.They collect blood from individual areas of the dermis and drain it to 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, patient discomfort is due to an aesthetic defect.But this does not mean that a person with spider veins is excluded from damage to larger caliber veins.In such a situation, it is no longer C1 that is diagnosed, but C2 and subsequent 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 minimal signs of venous insufficiency.You can expect a rapid 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 its task will be only to reduce the rate of progression of the disease, 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) methods.Traditionally, most patients prefer gentle techniques, postponing the surgical decision until the appearance of irremediable complications.And many of them don’t even consult a doctor, resorting to self-medication.Self-medication often leads to complications of pathology.

Conservative treatment

Conservative treatment regimen for varicose veins includes:

• Systemic drug therapy.Intended 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 therapy (ointments, creams, gels).External agents are aimed at improving microcirculation, reducing swelling, increasing venous tone and healing trophic ulcers.
• Therapeutic exercise increases the efficiency of the lower leg muscle pump and thus improves the flow of blood from the legs.
• Use of compression stockings.Compression stockings and tights provide metered compression of superficially located veins, which reduces the tendency to blood deposits and edema, improves well-being and reduces the risk of thrombosis.
• Physiotherapy.They are used mainly 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 physiotherapy include improving venous and lymphatic flow, improving microcirculation, stimulating regeneration and reducing the severity of discomfort.

Medications will not restore healthy blood flow to already compromised 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 valvular insufficiency.

You should not expect high results with conservative treatment.It will reduce pain and swelling, reduce the risk of thrombosis and improve recovery from trophic disorders.But it is impossible to save the patient from varicose veins and prevent the 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 removing or obliterating it) and eliminating horizontal venous reflux.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 treating varicose veins of the lower extremities:

• Crossectomy is the complete intersection of a large superficial vein ligated where it empties into the deep venous system.
• Phlebectomy – removal of the superficial vein affected by varicose veins (greater or lesser saphenous vein).It is performed by stripping (pulling, tearing) the vessel 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, with its disadvantages:

• Significant blood loss;
• Bleeding in the surgical area, sometimes requiring repeated surgeries to drain 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 procedures;they do not require incisions.They are not so traumatic and are not inferior in effectiveness to classic operations.Complications and relapses after these are less common than after operations.

Minimally invasive methods:

• Laser obliteration
• Sclerotherapy/Cryosclerotherapy
• Radio frequency cancellation.

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 “sticking” of the vessel, then its fibrosis and its 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.