Varicose veins, varicose veins, varicose veins(from Latin varix, varicis - dilation, swelling in the veins)- persistent irreversible change in the veins, characterized by:
- irregular increase in the lumen and length of the veins,
- the formation of knots in the areas of thinning of the veins due to pathological changes in the venous walls, their thinning, stretching, decreased tone and elasticity,
- functional insufficiency of the venous valves and alteration of blood flow.
Varicose veins are a fairly common disease. Varicose veins and their complications are diagnosed in 25% of the population, and women suffer from them 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 old age there is an increase in incidence in both men and women and the frequency of complicated forms 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 has often been 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 arise and develop
To understand how varicose veins are formed, we 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 related to the functioning of the venous system of the lower extremities surrounding the vessels of muscles and tissues.
The first signs of varicose veins are disorders of capillary circulation, swelling, feeling of heaviness in the legs, appearance of varicose veins and varicose veins. These changes are reversible, but if preventive measures are not taken in time, problems will increase.
As a rule, more than a year passes from the initial 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 formation of blood clots), phlebothrombosis (thrombosis with further 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 large saphenous vein is observed (70-85%), less often - of the small saphenous vein (5-12%). In varicose veins, 50-70% of venous damage is bilateral.
Secondary varicose veins are a symptom and consequence of diseases in which obstructions to the outflow of blood occur through the deep veins of the lower limbs (post-thrombotic disease, tumors, scars, inflammatory processes, aplasia and dysplasia of the deep veins, varicose veins, 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 different types of classification. The phased clinical classification of V. S. Savelyev was used, which reflects the degree of disturbance of venous circulation in the limb and the body's ability to resist these disorders and compensate for them, as well as classification according to the forms of varicose veins and complications caused by them.
But the main one currently is the international CEAP classification, based on the clinical (C - clinical), etiological (E - etiology), anatomical (A - anatomy) and pathogenetic (P - pathogenesis) characteristics of the disease.
6 clinical classes ("C") are organized in order of increasing disease severity from telangiectasias (TAE) to trophic ulcers.
The etiology 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 you 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
Symptoms of varicose veins depend on the stage of the disease, e. g. on the degree of changes in blood vessels and disruption of the venous system. Depending on the stage a prognosis for the further development of the disease can be given.
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 rapid fatigue, sensation 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 appears in the foot and ankle, which disappears after a short rest. Night cramps in the calf muscles are occasionally possible, but patients attribute these to overwork.
After prolonged physical activity, 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 can vary. These may be single, barely noticeable growths on the lower leg, which appear more clearly in the evening or after physical activity. The appearance of varicose veins is also observed in this phase of varicose veins.
If at this stage you start the simplest conservative treatment and follow preventive measures, you can prevent the development of the disease by eliminating almost all symptoms.
Symptoms of 2nd degree varicose veins, compensation phase
At this stage of the disease, changes in the large subcutaneous vessels become evident. The veins become deformed, swollen, the outflow of blood is interrupted, and noticeable swelling appears in the feet and ankles. Swelling increases with prolonged physical activity in the legs, but disappears after a night's rest. Calf muscle cramps are common at night. Paresthesia is observed: a temporary loss of sensitivity in the legs, numbness in the legs, burning, "goosebumps". As the disease progresses, pain appears, which intensifies in the evening.
This subcompensation phase, as a rule, lasts for several years, and at this time the development of the disease can even be stopped if treatment is started in a timely manner. Otherwise, the disease will inevitably progress to a more severe stage.
Symptoms of 3rd degree varicose veins - decompensation stage
In this phase of varicose veins, a significant increase in symptoms is noted, the pain, heaviness in the legs are more intense and there is a disturbance of peripheral blood and lymphatic circulation (chronic venous insufficiency). The swelling does not disappear even after 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, as a result of which 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, pain complaints in the heart area, shortness of breath, headaches and deterioration of the musculoskeletal function of the affected limb may appear.
Although the decompensation stage is already a very significant manifestation of the disease, with adequate treatment the patient's condition can be maintained at a satisfactory level for quite a long period, maintaining working capacity and preventing the transition to the stage of complications.
Varicose veins of the 4th degree - stage of complications
This stage of the disease is characterized by pronounced disturbances of venous circulation. Swelling of the legs becomes almost constant, itching of the skin intensifies, and trophic disorders appear on the skin of the lower leg. Advanced varicose veins are often accompanied by eczema, dermatitis and long-lasting lesions, and since the regenerative capabilities of the skin with varicose veins are greatly reduced, even a small wound can develop into a persistent trophic ulcer. The thinned skin and vein walls are easily damaged, causing extensive bleeding. Damaged soft tissues and open ulcers become gateways for infection.
The most common complications of varicose veins:
- phlebitis: inflammation of a vein;
- thrombosis: 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 outflow of blood from the skin, as a result of which the nutrition (trophism) of the tissues is disrupted.
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.
In this phase it is no longer possible to restore the conditions 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 painful symptoms of varicose veins are associated with structural changes in the tissue of the venous walls of blood vessels and disruption of the functioning of venous valves.
What causes these violations?
We often come across the statement that one of the most important physiological reasons for the development of a disease such as varicose veins is upright posture. Indeed, in humans, by their very nature, the load on the vascular system of the lower limbs is very high. The flow of blood from the veins and its return to the heart is prevented by the pressure caused by gravity, as well as by high pressure in the abdominal cavity. However, not everyone develops varicose veins. What factors cause 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, disruption of venous valves;
- female gender: women suffer from varicose veins 4-6 times more often than men;
- hormonal disorders;
- hormonal contraception;
- pregnancy, especially multiple pregnancies;
- heavy physical activity (heavy physical work, strength sports);
- conditions and diseases that lead to increased intra-abdominal pressure (chronic respiratory diseases, constipation, etc. )
- diseases that negatively affect blood vessels (high blood sugar, diabetes, changes in blood pressure, etc. );
- work characteristics - standing or sedentary work, temperature changes, prolonged contact with high or low temperatures;
- overweight, obesity, which creates greater stress on the legs and greater pressure in the pelvic area;
- 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, diagnosing varicose veins is not difficult. A clinical examination, including a physical examination (examination and palpation), a survey of the patient, a collection of complaints and anamnesis (information about the course of the disease, characteristics of life and work, past and current diseases) for severe varicose veins of usually makes it possible to make a diagnosis without instrumental examination. Exceptions are situations where, with excessive development of the subcutaneous adipose tissue of the lower extremities, varicose changes may be difficult to notice.
Currently, duplex ultrasound scanning (USDS) has become widely used to study lower extremity veins. This method allows you to determine the localization of changes in the veins and the nature of the disturbance in venous blood flow. However, it is necessary to know 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 particular medical institution. When determining therapeutic tactics, they are guided primarily by clinical examination data.
Duplex scanning is performed when planning invasive treatment of varicose veins of the lower extremities. Additionally, X-ray contrast venography, magnetic resonance venography, and CT venography can be used.
All these methods allow you to clarify the localization, nature and extent of venous lesions, to clearly see disturbances in venous hemodynamics, to evaluate the effectiveness of prescribed therapy 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, reducing 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 the specific situation, such as:
- conservative treatment– recommendations for prevention and lifestyle changes, pharmacotherapy, compression therapy;
- invasive non-surgical procedures- sclerotherapy, ecosclerotherapy, foam sclerotherapy (Foam-form Therapy), etc. ;
- surgery- phlebectomy, thermal obliteration, stripping, combined methods and operations of greater complexity for complications of varicose veins and treatment of trophic ulcers of the lower extremities.
These methods allow you to improve blood circulation in the lower extremities, including microcirculation, eliminate many cosmetic defects caused by varicose veins and relieve the patient of 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 areas:
- lifestyle changes;
- pharmacological therapy;
- compression therapy.
It's no coincidence that lifestyle changes happen first. It is necessary, if possible, to eliminate sludge at least to reduce the influence of unfavorable factors.
One of them is long-term static loads in a standing or sitting position, which lead to blood stagnation. To activate the musculovenous pump of the lower leg, you need to regularly stretch your legs and walk more. During work, you can periodically perform exercises with alternating contraction and relaxation of the muscles of the lower leg (lifting on tiptoes).
It is advisable to find time to practice outdoor sports that are not associated with the risk of leg injuries (athletics or Nordic walking, exercise bike, treadmill, swimming, cycling and walking).
If you have varicose veins, you should not overheat your legs, you will have to refuse to visit the bathhouse and sauna.
Patients with varicose veins should monitor their body weight. It is known that with a body mass index above 27 kg/m2the probability of varicose veins increases by 30%. Excess weight is often associated with high sugar levels, which leads to problems with the healing of venous ulcers and the risk of recurrence.
Compression therapyfor varicose veins it can be used both alone and 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 dilated veins, which leads to a decrease in swelling, an improvement in capillary blood flow and a decrease in varicose symptoms.
In addition to bandages and knitwear, there is hardware compression therapy, which is especially effective for chronic venous edema and trophic ulcers.
Pharmacological treatment may be recommended in the initial stages of varicose veins as the main therapy, integrated, if necessary, with elastic compression. Drugs 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-inflammatories and painkillers;
- vascular regenerating agents.
For the systemic treatment of varicose veins, venotonics and angioprotectors based on bioflavonoids, rutin derivatives, saponins, etc. are mainly used. . These drugs increase the elasticity and tone of the veins, increase the strength of blood vessels, improve the outflow of lymph, and reduce lymph pressure. If there is a risk of thrombosis, anticoagulants are prescribed. Anti-inflammatories and painkillers are used for complications of varicose veins: inflammation of the veins, intense pain, trophic lesions of the veins.
In addition to systemic ones, local drugs are used: ointments and gels based on vasoactive active ingredients, heparin, nonsteroidal anti-inflammatory drugs, corticosteroid ointments.
Invasive non-surgical 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 capillary or problem vein using a thin 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. The glued walls usually grow together, heal, and the scar resolves. Used to treat varicose veins of small superficial veins. The method is effective in the initial 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 needed to achieve results.
Foam therapy (foam sclerotherapy)
It is distinguished by a special sclerosant. As in sclerotherapy, a sclerosing substance in the form of fine foam is injected into the damaged vein, which quickly "closes" the affected large veins. The method does not require numerous procedures and provides high results. It is important to know that the procedure, although rare, can have side effects: vision problems. It is also dangerous for the sclerosant to penetrate the arteries and nervous tissue. The procedure must be performed by an experienced phlebologist.
Absolute contraindications to sclerotherapy: drug allergy, deep vein thrombosis, pregnancy, breastfeeding
Surgical treatment of varicose veins
As a rule, surgical treatment is recommended in severe and advanced cases and also if conservative methods fail to stop the development of the disease.
Surgery for varicose veins has the following objectives
- elimination of aesthetic 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 development of hyperpigmentation, lipodermatosclerosis;
- acceleration of healing and prevention of recurrence of venous trophic ulcers.
According to the Clinical Guidelines, the objectives of surgical treatment are:
- elimination of vertical and/or horizontal pathological reflux;
- elimination of saphenous varicose veins.
Before performing surgery of any type, the risk of developing venous thromboembolic complications (VTEC) 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 the surgical removal of diseased areas of the 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 on the venous trunk and insertion of a probe. During this operation, the ligation of the perforating veins is also performed, connecting the saphenous veins with the deep ones.
Brief stripping– rapid removal of the affected area of the saphenous vein on the thigh or leg through small incisions using special 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 venous diseases by applying cold (liquid nitrogen) to damaged vessels.
Venous suturing is the placement of multiple sutures over a damaged vein, which prevent blood flow through the vessel. As a result, blood clots form and the vein gradually degenerates.
Thermal obliteration methods– thermocoagulation and laser coagulationthey are considered minimally invasive interventions.Thermocoagulation(or RFO – Radiofrequency Vein Obliteration) – a very brief exposure, in a fraction of a second, to high frequency electrical current.Laser coagulation(EVLO or EVLK – endovascular laser obliteration (coagulation) of the veins of the lower extremities) - exposure to a laser beam on pathologically dilated vessels. In both cases, as a result of a local increase in temperature, destruction of the vessel occurs, the so-called "wall sticking" or "sealing".
It is important to remember that surgery is not a definitive cure, but the elimination of symptoms. Lifelong conservative treatment is also necessary after surgery and this must be explained to patients.
Depending on the stage of varicose veins, symptoms, concomitant diseases and the patient's general health status, the doctor selects specific recommendations to achieve the greatest possible improvements as quickly as possible.