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 in the legs are affected, therefore varicose veins usually mean disease of the veins of the lower extremities.

How do varicose veins appear?

With 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 outflow 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 the 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 subsequently spreads 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 the blood with leukocyte rolling - grouping and “rolling” of leukocytes along the surface of the endothelium.Over time, there is a tendency for them to adhere, which provokes the release of inflammatory mediators.At this stage 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 spreads not only along the length of one 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: “varix” is translated from Latin as “swelling”.
5. Development of valvular insufficiency. Functional failure of the valves in the lumen of the affected superficial veins with reverse blood flow (vertical reflux).Initially, it is relative in nature and manifests itself only with a noticeable increase in peripheral venous pressure.Subsequently, the failure becomes absolute - the valve walls do not close completely under any conditions.Venous stasis (blood stagnation) appears with the formation of venous insufficiency.
6. Involvement of perforating veins in the process.They are also called communicant or commissural.Their pathological expansion is also accompanied by valve insufficiency, which contributes to pathological blood flow from the deep venous network to the superficial one (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 position.
• 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 pregnancy or occurring with polyhydramnios), mass formations of the abdominal cavity, some intestinal diseases.Constipation and chronic lung diseases with cough, 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, 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 the affected veins.Varicose vessels are tortuous, excessively contoured, dark, visible through the skin and bulging.Pulsation is not characteristic of them.As the disease progresses, local nodular protruding formations appear on the legs, which often form entire conglomerates and do not completely disappear in the supine position.In patients with increased body weight, changes in the veins often remain practically unnoticeable for a long time, masked by excessive subcutaneous fat.
• Swelling of the feet and legs after prolonged standing and sitting, in the evening, when staying in conditions of elevated 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), when keeping the legs in an elevated position, after performing special gymnastics to activate the “muscle pump” of the lower leg.Swelling is one of the first signs of chronic venous insufficiency with varicose veins.
• A feeling of heaviness and fullness in the legs, even in the absence of obvious swelling.Such complaints appear in conditions that promote 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 muscles of the limb affected by varicose veins: increased muscle fatigue, sometimes cramps.
• Unpleasant sensations in the legs, usually intensifying with increasing swelling due to the reaction of the soft tissues and branches of the peripheral nerves of the leg to compression by an excess amount of intercellular fluid.Another possible cause of such paresthesias is dysmetabolic trophic disorders.
• Visible trophic disorders of the skin and underlying soft tissues.These can be dry or eczematous dermatitis, hyperpigmentation, lipodermatosclerosis (thickening, hardening of the dermis and tissue), ulcers.

Symptoms of varicose veins of the lower extremities appear quite early, although not all patients pay attention to them in a timely manner.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 debuts in the form of venous insufficiency.

Stages

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

• C0—no signs of pathology;
• C1—presence of reticular varicose veins 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 - corona venosus of the foot;
• C5—protracted 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.

Diagnostics

A basic examination to confirm the diagnosis of varicose veins of the lower extremities 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 features 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 comprehensive assessment of the coagulation system).

According to indications, multislice 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 available to a wide range of patients; the results obtained are usually not critical in determining treatment tactics.Usually a basic examination is sufficient, which, if necessary, is supplemented by consultations with specialized specialists (endocrinologist, hematologist, cardiologist and others).Previously, several stages of varicose veins of the legs were distinguished.Currently, when making a diagnosis, phlebologists use the CEAP classification of chronic venous diseases, which includes characteristics of the case according to clinical, etiological, anatomical and pathophysiological characteristics.

The danger of varicose veins

Many people believe that varicose veins of the lower extremities are mainly a cosmetic problem.Indeed, it is often the external unattractiveness of the 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.It can significantly worsen the patient’s well-being and even lead to potentially life-threatening complications.And this is primarily 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 and even decreased performance with varicose veins are caused by heavy leg syndrome, swelling, night cramps, poorly healing and recurrent ulcers.
• Changes in soft tissues with a decrease in the external attractiveness of the legs, which is especially important for women.Moreover, 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 ruptured varicose nodes or veins at the bottom of trophic ulcers.
• Development of thrombosis and thrombophlebitis of superficial veins.It is fraught not only with local hemodynamic disorders and inflammation, but also with distant thromboembolism with infarctions of various organs and acute life-threatening conditions.
• Deep vein thrombosis is an even more dangerous condition 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 obtaining a quick and sufficient result even when using radical treatment methods.

Is the disease always dangerous?

Varicose disease of the lower extremities with valvular insufficiency of the saphenous veins is 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 may 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 small tributaries of the saphenous veins using a feeding pedicle.They collect blood from individual sectors of the dermis and drain it into 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, the discomfort in patients is due to a cosmetic defect.But this does not mean that a person with the presence of spider veins is excluded from damage to veins of larger caliber.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 begin not with the development of complications, but at the stage of primary changes and minimally expressed signs of venous insufficiency.You can expect a rapid onset of the expected effect, complete regression of symptoms and a low likelihood of relapse.Treatment of advanced varicose veins will not be as effective.Sometimes its task will only be to reduce the rate of disease progression, 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).Traditionally, most patients prefer gentle techniques, postponing the decision on surgery until complications that cannot be corrected develop.And many of them do not even consult a doctor, resorting to self-medication.Self-medication often leads to complications of the pathology.

Conservative treatment

The conservative treatment regimen for varicose veins includes:

• Drug systemic therapy.Aimed at improving the rheological properties of blood to prevent thrombosis, achieving an anti-inflammatory effect, increasing the elasticity of the vascular wall, and stimulating tissue regeneration.
• Local drug therapy (ointments, creams, gels).External agents are intended to improve microcirculation, reduce swelling, increase vein tone, and heal trophic ulcers.
• Therapeutic exercise increases the efficiency of the lower leg muscle pump and thereby improves the outflow of blood from the legs.
• Use of compression stockings.Compression stockings and tights provide dosed compression of superficially located veins, which reduces the tendency to deposit blood and edema, improves well-being, and reduces the likelihood 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 objectives of physiotherapy include improving venous and lymphatic outflow, improving microcirculation, stimulating regeneration, and reducing the severity of discomfort.

Medications will not return healthy blood flow to already altered 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 from conservative treatment.It will reduce pain and swelling, reduce the risk of thrombosis and improve the healing of trophic disorders.But it is impossible to save the patient from varicose veins and prevent further 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 it or obliterating it) and eliminating horizontal venovenous 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 ligated large superficial vein at the point where it flows into the deep venous network.
• Phlebectomy – removal of the superficial vein affected by varicose veins (great or small saphenous).It is performed by stripping (pulling, pulling out) 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, their disadvantages:

• Significant blood loss;
• Hemorrhages in the surgical area, sometimes requiring repeated surgery to evacuate the blood.
• Lymphostasis due to the intersection of lymphatic vessels.
• Severe pain syndrome.
• Long-term disability.

Modern alternative to surgery

Endovascular techniques are considered minimally invasive interventions; they do not require incisions.They are not so traumatic and are not inferior in effectiveness to classical operations.Complications and relapses after them are less common than after operations.

Minimally invasive methods:

• Laser obliteration
• Sclerotherapy/Cryosclerotherapy
• Radiofrequency obliteration.

With minimally invasive methods, the vein affected by varicose veins is not removed, as in classical operations.Its wall is exposed from the inside with laser or radiofrequency energy, and during sclerotherapy, with a sclerosant drug.This provokes “sticking together” of the vessel and its subsequent fibrosis and replacement with connective tissue.This closure of the lumen of the vessel is called obliteration.And with RFM of stars, they are actually evaporated under the influence of radio frequency waves.