Varicose veins are a disease accompanied by thinning of the venous wall, an increase in the lumen of the veins and the formation of aneurysm-like nodular extensions. Usually, when talking about varicose veins, they mean an independent disease – varicose veins of the lower extremities. Varicose veins are manifested by a feeling of heaviness in the legs and their fatigue, swelling of the feet and shins, nocturnal cramps in the legs, visual subcutaneous expansion of veins with the formation of venous nodes. The main way to diagnose varicose veins and its complications is Doppler ultrasound. Treatment can be conservative (drug therapy, sclerotherapy) or operative.
ICD 10
I83 Varicose veins of the lower extremities
Meaning
Varicose veins is a pathology of the veins, manifested in their expansion, convolution, destruction of the valve apparatus. The initial manifestations are the formation of vascular asterisks, swelling of subcutaneous veins, the formation of nodes, vein soreness, heaviness in the legs. With the progression of the disease, signs of chronic insufficiency of venous circulation are added: swelling of the feet and lower leg, cramps in the calf muscles, trophic ulcers, thrombophlebitis, ruptures of varicose veins. According to various studies in the field of clinical phlebology, varicose veins affect from 30 to 40% of women and from 10 to 20% of men over the age of 18.
Causes of varicose veins
Varicose veins are a polyethological disease. There are several factors that increase the risk of developing varicose veins:
- Genetic predisposition due to vascular wall weakness due to connective tissue insufficiency.
- Pregnancy. It is believed that varicose veins develop during pregnancy due to an increase in the volume of circulating blood and compression of retroperitoneal veins by the pregnant uterus.
- Overweight. Obesity is a proven risk factor for varicose veins. If the body mass index increases to 27 kg / m2, the risk of developing the disease increases by 33%.
- Lifestyle. The risk of developing varicose veins increases with prolonged sitting or standing, constant static loads, especially those associated with lifting weights. An adverse effect on the course of the disease is caused by corsets that increase intra-abdominal pressure and tight clothing that squeezes the main veins in the inguinal folds.
- Nutrition features. The probability of developing varicose veins increases with a low content of fruits and raw vegetables in the diet. The deficiency of coarse fiber leads to chronic constipation, and the lack of some useful substances leads to a violation of the restoration of the structure of the venous wall.
- Hormonal balance disorders. A certain influence on the prevalence of the disease has a wide distribution of hormonal contraceptives and hormonal drugs that are used in the treatment of osteoporosis and menopausal syndrome.
Under certain conditions (some diseases, congenital pathology), not only the veins of the lower extremities can expand. So, portal hypertension can cause the expansion of the veins of the esophagus. With varicocele, varicose veins of the spermatic cord are detected, with hemorrhoids – dilation of veins in the anal opening and the lower part of the rectum. Regardless of the localization of the process, there is a hereditary predisposition to the development associated with congenital weakness of the vascular wall and insufficiency of venous valves.
Pathogenesis
The veins of the lower extremities form an extensive network, which consists of subcutaneous and deep veins connected by perforant (communicating) veins. Through the superficial veins there is an outflow of blood from the subcutaneous tissue and skin, through the deep – from the rest of the tissues. Communicating vessels serve to equalize the pressure between deep and superficial veins. Blood normally flows through them only in one direction: from the superficial veins to the deep ones.
The muscular layer of the venous wall is weakly expressed and cannot force the blood to move upwards. The blood flow from the periphery to the center is carried out due to the residual blood pressure and the pressure of the tendons located next to the vessels. The most important role is played by the so-called muscle pump. During physical exertion, the muscles contract and the blood is squeezed upwards, since the venous valves prevent downward movement. The maintenance of normal blood circulation and constant venous pressure is affected by venous tone. The pressure in the veins is regulated by the vasomotor center located in the brain.
Insufficiency of valves and weakness of the vascular wall lead to the fact that blood under the action of a muscle pump begins to flow not only up, but also down, exerting excessive pressure on the walls of blood vessels, leading to the expansion of veins, the formation of nodes and the progression of valvular insufficiency. The blood flow through the communicating veins is disrupted. Reflux of blood from deep vessels to surface vessels leads to a further increase in pressure in the superficial veins. Nerves located in the walls of veins send signals to the vasomotor center, which gives the command to increase venous tone. The veins cannot cope with the increased load, gradually expand, lengthen, become sinuous. Increased pressure leads to atrophy of the muscle fibers of the venous wall and the death of nerves involved in the regulation of venous tone.
Classification of varicose veins
There are several classifications of varicose veins. This diversity is due to the polyetiology of the disease and the many variants of the course of varicose veins.
Classification by forms
The following forms of varicose veins are distinguished:
- Segmental lesion of subcutaneous and intradermal vessels without reflux.
- Segmental venous lesion with pathological discharge through superficial or communicative veins.
- A common lesion of veins with pathological discharge through superficial or communicative veins.
- Common venous lesion with pathological discharge through deep veins.
International classification
There is a recognized international classification of varicose veins used by doctors in many countries of the world:
- Class 0. There are no signs of varicose veins. Patients complain of heaviness in the legs.
- Class 1. The veins and vascular asterisks (telangiectasia) are visually determined. Some patients have muscle cramps at night.
- Class 2. When examining the patient, dilated veins are visible.
- Class 3. There are swelling of the feet, ankles and shins that do not disappear after a short rest.
- Class 4. Examination reveals signs of lipodermatosclerosis (dermatitis, hyperpigmentation of the shins).
- Class 5. Predyazv are formed.
- Class 6. Persistent trophic ulcers develop.
Symptoms of varicose veins
Clinical manifestations of the disease depend on the stage of varicose veins. Some patients, even before the appearance of visual signs of the disease, complain of heaviness in the legs, increased fatigue, local pain in the lower legs. The appearance of telangiectasias is possible. There are no signs of impaired venous outflow. Often, the disease in the compensation stage is asymptomatic, and patients do not seek medical advice. Physical examination may reveal local varicose veins, most often in the upper third of the lower leg. The dilated veins are soft, fall off well, the skin above them is not changed.
Patients with varicose veins in the subcompensation stage complain of transient pain, swelling that occurs during prolonged stay in an upright position and disappears in the supine position. Physically (especially in the afternoon), pasty or minor swelling in the ankle area may be detected.
Patients with varicose veins in the decompensation stage complain of constant heaviness in the legs, dull pains, increased fatigue, night cramps. Skin itching, more pronounced in the evening, is a harbinger of trophic disorders. An external examination reveals pronounced venous dilation and a global violation of venous hemodynamics. Depositing a large volume of blood in the affected extremities in some cases can lead to dizziness and fainting due to a drop in blood pressure.
The expanded, strained, tight-elastic veins are determined by palpation. The walls of the affected veins are soldered to the skin. Local depressions in the area of adhesions indicate a transferred periphlebitis. Hyperpigmentation of the skin, foci of cyanosis are visually revealed. Subcutaneous tissue in the areas of hyperpigmentation is compacted. The skin is rough, dry, it is impossible to take it in a fold. There are dyshydrosis (more often – anhidrosis, less often – hyperhidrosis). Trophic disorders especially often appear on the anterior-inner surface of the lower leg in the lower third. Eczema develops in the altered areas, against the background of which trophic ulcers are subsequently formed.
Diagnostics
Diagnosis is not difficult. To assess the severity of hemodynamic disorders, duplex angioscanning, ultrasound of the veins of the lower extremities is used. Rengenological, radionuclide research methods and rheovasography of the lower extremities can be used.
Treatment of varicose veins
Three main methods are used in the treatment of patients with varicose veins:
Conservative therapy
Conservative therapy includes general recommendations (normalization of motor activity, reduction of static load), physical therapy, the use of elastic compression (compression knitwear, elastic bandages), treatment with phlebotonics (diosmin + hesperidin, horse chestnut extract). Conservative therapy cannot lead to a complete cure and restore already dilated veins. It is used as a preventive measure, during the preparation for surgery and when surgical treatment of varicose veins is impossible.
Compression sclerotherapy
With this method of treatment, a special drug is injected into the dilated vein. The doctor inserts elastic foam into the vein through a syringe, which fills the affected vessel and causes its spasm. Then the patient is put on a compression stocking that holds the vein in a dormant state. After 3 days, the vein walls are glued together. The patient wears a stocking for 1-1.5 months until dense adhesions form. Indications for compression sclerotherapy are varicose veins, not complicated by reflux from deep vessels to superficial ones through communicative veins. In the presence of such a pathological reset, the effectiveness of compression sclerotherapy decreases sharply. Modern types of sclerotherapy are foam Foam-form sclerotherapy, cryosclerotherapy.
Surgical treatment
In the initial stage of varicose veins, photocoagulation or removal of vascular asterisks with a laser is performed. The main method of treatment of varicose veins complicated by reflux through communicative veins is surgery. A variety of surgical techniques are used to treat varicose veins, including microsurgical techniques, radiofrequency and laser coagulation of affected veins, and adhesive obliteration.
With pronounced varicose veins, phlebectomy is indicated – removal of altered veins. Currently, this operation is increasingly performed using less invasive techniques – miniflebectomy, cryophlebectomy. In cases where varicose veins are complicated by vein thrombosis throughout its entire length and the addition of infection, the Troyanov-Trendelenburg operation is indicated.
Prevention of varicose veins
An important preventive role is played by the formation of correct behavioral stereotypes (lying is better than sitting and walking is better than standing). If you have to stay in a standing or sitting position for a long time, it is necessary to periodically strain the muscles of the shins, give the legs an elevated or horizontal position. It is useful to engage in certain sports (swimming, cycling). During pregnancy and during hard work, it is recommended to use elastic compression products. When the first signs of varicose veins appear, you should contact a phlebologist.
Literature
- 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. link
- 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. link
- 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.