Reticular veins is a chronic disease of the venous system, accompanied by a weakening of tone and an increase in the lumen of small subcutaneous vessels. Thin convoluted veins in the form of a mesh appear on the skin of the lower extremities, which usually do not bring subjective discomfort and are exclusively a cosmetic defect. Diagnosis is carried out according to clinical data and by ultrasound examination of veins (duplex scanning, Dopplerography). Treatment is carried out by conservative methods with the use of medications, compression therapy, microsclerotherapy and laser therapy.
Reticular (intradermal) veins is a pathological condition characterized by dilation of subcutaneous veins with a diameter of 1 to 3 mm. Currently, the disease is considered as an independent nosological unit, and not a stage of development of varicose veins of the lower extremities, as previously thought. Mesh varicose veins are common in the population and are characteristic of 30-50% of women of working age. In pregnant women, a defect of the superficial venous network is detected in 80-85% of cases. Men suffer from any form of chronic phlebopathology half as often.
The etiopathogenesis of reticular veins is still being discussed and is subject to further investigation. If the secondary process is caused by arteriovenous fistulas and thrombosis of the overlying parts of the vascular system, accompanied by an increase in pressure in the intradermal network, then the primary (essential) is initiated by a complex of internal and external factors. Among them , the most important are:
- Hereditary predisposition. The risk of expansion of the reticular bed is 6 times higher in the presence of a family history of varicose veins, due to a number of genetic mutations affecting the remodeling of connective tissue. For a child with both parents suffering from varicose veins, the probability of developing pathology in adulthood is almost 90%.
- The number of pregnancies. Women who have several pregnancies complain of subcutaneous varicose veins 5 times more often than those who have not given birth. The defect becomes noticeable already in the first trimester of gestation, increasing as the gestation period increases. An aggravating factor is the existence of such problems even before pregnancy.
- Increased load on the legs. Prolonged standing or sitting position, due to the peculiarities of the profession (surgeons, teachers, salesmen, flight attendants, office workers) or lifestyle, is an independent risk factor. By the evening, the efficiency of venous blood flow in people engaged in “sedentary” work or being on their feet all day decreases.
- Frequent and long-term air travel. Staying more than 4 hours in the cabin and sleeping in a chair reduce the efficiency of reticular blood flow by 40%. Due to frequent changes in atmospheric pressure, the venule wall becomes thinner and loses its tone. In a sitting position, many muscles of the lower extremities are relaxed, and the dry air in the cabin provokes dehydration and blood thickening.
Other causes of varicose veins include overweight and obesity, endocrine diseases, bad habits (smoking). Prolonged (over 3 months) use of estrogen-gestagenic contraceptives by women leads to phlebopathy caused by degenerative processes in the inner layer of the vascular wall. Due to the increase in hydrostatic pressure in the veins of the lower extremities, the risk of pathology increases with congenital disorders – absence (agenesis) or underdevelopment (hypoplasia) of the ilio-femoral valve. Limited mobility of the foot, which occurs when wearing tight shoes with high heels, is also important in the pathogenesis of varicose veins.
Pathological shifts in intradermal varicose veins cover the veins of the reticular bed in the area of the mesh layer of the dermis. Vessels expand due to disturbances in their wall – type III collagen replaces type I fibers, which leads to increased rigidity and preservation of residual deformation after volume loading. Increased destruction of elastin and extracellular matrix proteins by enzymes (metalloproteinases) provokes thinning of the vascular wall. But this form of pathology passes without nodal transformation, structural changes of the endothelium and cellular reactions of an inflammatory nature.
Hemodynamic disorders are an important aspect of the development of reticular veins. Prolonged stagnation of blood leads to stretching of the walls of subcutaneous vessels and deformation of their valve apparatus. In women, such processes are mediated by hormonal influence. An increase in the concentration of progesterone in pregnant women contributes to a decrease in the tone of the smooth muscles of the vascular wall, provokes degenerative-dystrophic changes in the structure of collagen and elastin fibers. High levels of estrogens, stimulating the synthesis of clotting factors and reducing the plasma content of antithrombin, increase coagulation and provoke stagnation.
Reticular veins are part of the structure of chronic venous diseases. According to the CEAP classification, which is the most recognized and used in clinical phlebology, consisting of several sections (C – clinical, E – etiological, A – anatomical, P – pathophysiological), the following categories are assigned to pathology:
- C (clinical status of the patient): C1 – telangiectasia or reticular veins (S – with the presence of subjective symptoms; A – without complaints from the patient).
- E (origin of changes): Ec – congenital condition; Ep – primary; Es – secondary with a known cause; En – the cause has not been identified.
- A (lesion localization): As – surface vessels.
- P (presence of disorders of reticular blood flow): Pr – reflux; Po – occlusion; Pr, o – reflux and occlusion; Pn – changes cannot be detected.
The presented classification is basic. The extended version involves the enumeration of all subjective signs of class C1S and the indication in section P of the segment of the venous bed with reflux or occlusion (1 – reticular vessels).
The clinical picture consists of objective and subjective signs. The disease begins gradually, with prolonged exposure to causal factors on the body. Often, the only symptom is dilated veins on the back and side of the shins. They have a bluish color, look thin and twisted, creating a mesh pattern of various shapes on the skin. The objective picture in many patients is complemented by telangiectasia – the expansion of intradermal venules with a diameter of up to 1 mm.
Usually, mesh varicose veins are only a cosmetic defect, without bringing physical discomfort. But a number of patients also have subjective signs confirming the likelihood of a chronic disease. By the end of the day or after an increased load on the legs, fatigue, heaviness and aching pains in the calf muscles begin to bother. Unpleasant symptoms may be supplemented by slight itching and burning in the area of dilated vessels.
In young women, symptoms worsen on the background of menstruation or before them. The condition improves after rest, walking, staying in a horizontal position (with slightly raised lower limbs). There are no obvious symptoms of chronic venous insufficiency (edema, trophic disorders) in patients with reticular veins.
According to research, pathology almost never transforms into a nodular variant of varicose veins and is rarely accompanied by complications. A persistent cosmetic defect that occurs due to subcutaneous extensions is the most unpleasant consequence for women. The need to hide it behind clothes, the inability to wear dresses and skirts negatively affect the level of emotional comfort. Wide surface vessels are sometimes subjected to mechanical damage, which creates a risk of venous bleeding, especially in elderly people.
The preliminary diagnosis is based on the analysis of anamnestic information, identification of patient complaints and objective changes. Of the additional methods clarifying the nature of the pathological process in reticular veins, the main role is assigned to ultrasound examination:
- Duplex vein scanning. Allows to simultaneously assess the morphology of the vascular wall, the condition of the valve apparatus and hemodynamic parameters in the subcutaneous network, revealing pathophysiological changes (reflux, obstruction). Vein management is a reliable method of verifying the diagnosis and planning treatment tactics.
- Dopplerography. It makes it possible to determine the presence or absence of blood flow and assess its direction. Like duplex scanning, vein ultrasound requires performing functional tests – Valsalva (breath retention with straining), distal compression (with an inflated cuff), imitation of walking.
Differential diagnosis of reticular veins is performed with other forms of chronic venous pathology (including telangiectasia), post-phlebitic syndrome, phlebothrombosis. Vascular malformations (Klippel-Trenone syndrome), reticular or tree-like livedo should be excluded. Pathology requires consultation of a phlebologist (vascular surgeon).
Therapeutic tactics for mesh varicose veins involves a complex effect of conservative and minimally invasive methods. General measures are reduced to the elimination of factors that provoke the expansion of subcutaneous vessels: the fight against overweight and physical inactivity, adequate physical exertion (gymnastics, sports, swimming), wearing comfortable shoes, etc. Specific treatment is carried out in the following ways:
- Compression therapy. It plays a key role in the conservative therapy of mesh varicose veins, eliminating retrograde blood flow and pathological venous capacity. It is carried out by prescribing elastic bandaging or wearing compression knitwear (knee socks, stockings, tights). When expanding the subcutaneous bed, products with compression class A (preventive) and I (therapeutic) are suitable.
- Pharmacotherapy. The main role belongs to venoactive (phlebotropic) drugs, which are basic medications that eliminate subjective symptoms, but not external manifestations. They increase the tone of the superficial veins, reduce the permeability of the walls, improve microcirculation and lymph flow. In clinical practice, diosmin, troxerutin, escin, extracts (horse chestnut, needles), calcium dobezilate are used.
- Phlebosclerosis. It consists in obliteration (blockage) of mesh vessels by injecting liquid or foamy substances-sclerosants (polydocanol, sodium tetradecyl sulfate, ethoxysclerol) into their lumen. Microsclerotherapy is the most effective method of eliminating a cosmetic problem. The indication for the procedure is the presence of a defect and the patient’s desire to get rid of it.
- Laser therapy. It is based on point processing of extensions with a concentrated beam of light (in the short-wave zone of infrared radiation). But the effectiveness of laser exposure to the subcutaneous bed is lower, in comparison with telangiectasias, so the procedure is usually prescribed after microsclerotherapy sessions to eliminate smaller defects.
A mandatory component of the rehabilitation program after injection and laser correction is compression therapy, which improves blood outflow and eliminates stagnation. Physiotherapy, reflexotherapy, therapeutic gymnastics are of auxiliary importance in complex treatment.
Prognosis and prevention
The expansion of superficial veins for most patients is only a cosmetic problem, and therefore does not bring any negative consequences. Transformation into a typical varicose disease is unlikely, although its parallel occurrence cannot be ruled out. Subjective symptoms are completely eliminated with adequate therapy, the prognosis is favorable in all cases. In order to prevent it, it is recommended to eat right, maintain a sufficient level of physical activity, eliminate static loads on the legs, and regularly undergo preventive examinations by a doctor.
- Davies Huw O.B., Popplewell Matthew, Bate Gareth, Ryan Ronan P., Marshall Tom P., and Bradbury Andrew W. Analysis of Effect of National Institute for Health and Care Excellence Clinical Guideline CG168 on Management of Varicose Veins in Primary Care Using the Health Improvement Network Database // European Journal of Vascular and Endovascular Surgery. — 2018; 56 (6): 880-884.
- Eklöf B., Rutherford R., Bergan J., et al. Revision of the CEAP classification for chronic venous disorders: Consensus statement // J Vasc Surg. — 2004; 40 (6): 1248-1252.
- Gloviczki P. Handbook of Venous Disorders Guidelines of the American Venous Forum. 4rd ed. // Hodder Arnold Publishers. — 2017; 838.
- Nicolaides A., Kakkos S., Eklof B., Perrin M., Nelzen O., Neglen P., Partsch H., Rybak Z. Management of chronic venous disorders of the lower limbs — guidelines according to scientific evidence // Int Angiol. — 2014; 33 (2): 87-208.