Chronic venous insufficiency is a pathology caused by a violation of venous outflow in the lower extremities. With CVI, there are swelling and pigmented disorders of the shins, fatigue and heaviness in the legs, cramps at night. Progressive venous insufficiency causes the appearance of trophic ulcers. The diagnosis is made on the basis of ultrasound examination of veins, phlebography. Treatment is carried out by conservative (elastic bandaging, drug therapy) or surgical methods (phlebectomy, miniflebectomy).
I87.2 Venous insufficiency (chronic) (peripheral)
The wide prevalence of this pathological condition is due to upright walking, as a result of which an increased load on the veins of the lower extremities becomes almost inevitable. Often, chronic venous insufficiency is confused with varicose veins of the lower extremities. However, these states are not identical. CVI can also be detected in the absence of visible changes in the superficial veins on the legs. Chronic venous insufficiency develops as a consequence of a number of congenital and acquired pathological conditions that lead to impaired outflow through the deep veins of the lower extremities.
Chronic venous insufficiency can occur in the following conditions:
- long-term varicose veins of the lower extremities;
- post – thrombophlebitic syndrome;
- congenital pathology of deep and superficial venous systems (congenital hypo- or aplasia of deep veins – Klippel-Trenone syndrome, congenital arteriovenous fistulas – Park-Weber-Rubashov syndrome).
Sometimes chronic venous insufficiency develops after phlebothrombosis. In recent years, phlebopathy has been singled out as one of the causes leading to the development of CVI – conditions in which venous stagnation occurs in the absence of instrumental and clinical signs of pathology of the venous system. In rare cases, chronic venous insufficiency develops after injuries.
There are a number of adverse factors that increase the risk of developing chronic venous insufficiency:
- Genetic predisposition. The development of pathology is caused by a genetically determined insufficiency of connective tissue, which causes weakness of the vascular wall due to a lack of collagen.
- Female gender. The occurrence of chronic venous insufficiency is due to the high level of estrogens, increased load on the venous system during pregnancy and childbirth, as well as a longer life expectancy.
- Age. In older people, the likelihood of developing CVI increases as a result of prolonged exposure to adverse factors.
- Taking hormonal contraceptives and other hormone-containing drugs (due to an increase in estrogen levels).
- Insufficient motor activity, obesity.
- Prolonged static loads (long trips in transport, standing or sedentary work), constant lifting of heavy loads.
- Chronic constipation.
Blood from the lower extremities flows through deep (90%) and superficial (10%) veins. The outflow of blood from the bottom up provides a number of factors, the most important of which is muscle contraction during exercise. The muscle, contracting, presses on the vein. Under the influence of gravity, the blood tends downwards, but its reverse outflow is prevented by venous valves. As a result, normal blood flow through the venous system is ensured. The preservation of the constant movement of fluid against gravity becomes possible due to the consistency of the valve apparatus, the stable tone of the venous wall and the physiological change in the lumen of the veins when the body position changes.
In the case when one or more elements that ensure the normal movement of blood suffer, a pathological process consisting of several stages is triggered. The expansion of the vein below the valve leads to valvular failure. Due to the constant increased pressure, the vein continues to expand from the bottom up. Venous reflux joins (pathological discharge of blood from top to bottom). The blood stagnates in the vessel, presses on the vein wall. The permeability of the venous wall increases. Plasma through the vein wall begins to sweat into the surrounding tissues. Tissues swell, their nutrition is disrupted.
Circulatory insufficiency leads to the accumulation of tissue metabolites in small vessels, local blood thickening, activation of macrophages and leukocytes, an increase in the number of lysosomal enzymes, free radicals and local inflammatory mediators. Normally, part of the lymph is discharged through anastomoses into the venous system. An increase in pressure in the venous bed disrupts this process, leads to an overload of the lymphatic system and a violation of the outflow of lymph. Trophic disorders are aggravated. Trophic ulcers are formed.
There is an international classification of chronic venous insufficiency (CEAP system), which takes into account the etiological, clinical, pathophysiological and anatomical and morphological manifestations of CVI. Classification of CVI according to the CEAP system:
- 0 – there are no visual and palpatory signs of venous disease;
- 1 – telangiectasia;
- 2 – varicose veins;
- 3 – edema;
- 4 – skin changes (hyperpigmentation, lipodermatosclerosis, venous eczema);
- 5 – skin changes in the presence of a healed ulcer;
- 6 – skin changes in the presence of a fresh ulcer.
- the cause of CVI is congenital pathology (EC);
- primary CVI with unknown cause (EP);
- secondary CVI developed as a result of thrombosis, trauma, etc. (ES).
Reflects the segment (deep, superficial, communicant), localization (large subcutaneous, inferior hollow) and the level of lesion.
Classification taking into account the pathophysiological aspects of CVI:
- CVI with reflux phenomena (PR);
- CVI with obstruction phenomena (PO);
- CVI with reflux and obstruction phenomena (PR,O).
When assessing CVI according to the CEAP system, a points system is used, where each sign (pain, swelling, lameness, pigmentation, lipodermatosclerosis, ulcers, their duration, number and frequency of relapses) are estimated at 0, 1 or 2 points.
Within the CEAP system, a scale of disability reduction is also used, according to which:
- 0 – complete absence of symptoms;
- 1 – there are symptoms of CVI, the patient is able-bodied and does not need supportive means;
- 2 – the patient can work full-time only if he uses supportive means;
- 3 – the patient is incapacitated, even if he uses supportive means.
Chronic venous insufficiency can manifest itself in a variety of clinical symptoms. In the early stages, one or more symptoms appear. Patients are concerned about heaviness in the legs, which increases after a long stay in an upright position, transient swelling, night cramps. There is hyper- (less often – hypo-) pigmentation of the skin in the distal third of the lower leg, dryness and loss of elasticity of the skin of the lower legs. Varicose veins do not always appear in the initial stage of chronic venous insufficiency.
As CRF progresses, local circulatory insufficiency worsens. Trophic disorders become more pronounced. Trophic ulcers are formed. Depositing a significant amount of blood in the lower extremities can lead to dizziness, fainting, and signs of heart failure. Due to a decrease in CBV, patients with severe chronic venous insufficiency do not tolerate physical and mental stress well.
The diagnosis is made on the basis of anamnestic data, patient complaints, the results of objective and instrumental research. The conclusion about the degree of violation of venous outflow is made on the basis of ultrasound of the veins of the lower extremities and duplex angioscanning. In some cases, an X-ray contrast examination (phlebography) is performed to clarify the cause of CRF.
When determining the tactics of treatment of chronic venous insufficiency, it should be clearly understood that CVI is a systemic pathological process that cannot be eliminated by removing one or more superficial varicose veins. The aim of therapy is to restore the normal functioning of the venous and lymphatic system of the lower extremities and prevent relapses.
Treatment for CVI should be selected individually. Therapy should be a course. Some patients are shown short or episodic courses, others – regular and long-term. The average duration of the course should be 2-2.5 months. Taking medications should be combined with other methods of treating CVI. To achieve good results, the active participation of the patient is necessary. The patient must understand the essence of his illness and the consequences of deviations from the doctor’s recommendations.
The main importance in the treatment of CVI are conservative methods: drug therapy (phlebotrobial agents) and the creation of an additional framework for veins (elastic compression). Preparations for topical use: wound coatings, ointments, creams, antiseptics and creams are prescribed in the presence of appropriate clinical manifestations. In some cases, corticosteroid medications are indicated.
Surgical treatment is performed to eliminate pathological venous discharge and removal of varicose veins (phlebectomy). About 10% of patients with chronic venous insufficiency need surgical treatment. With the development of CVI against the background of varicose veins, minimally invasive miniflebectomy is often resorted to.
As the most important problem that has a negative impact on the development and progression of CVI, it should be noted that patients seek medical help later. A significant proportion of patients believe that the symptoms of chronic venous insufficiency are a normal consequence of fatigue and prolonged static loads. Some underestimate the severity of the pathology and do not realize what complications CVI can lead to. Along with the lack of information, a certain negative role is played by the advertising of “miraculous” remedies that supposedly can completely eliminate venous pathology. Currently, only about 8% of patients with CVI receive medical care.
Prevention of CVI includes exercise, regular walks, prevention of constipation. It is necessary, if possible, to limit the time spent in a static position (standing, sitting). Uncontrolled intake of hormonal drugs should be excluded. Patients at risk, especially when prescribing estrogens, are shown wearing elastic stockings.
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