What are varicose veins?

Varicose veins are an irreversible pathological change in the peripheral vein wall, resulting in valvular organ dysfunction and impaired blood flow.Varicose veins can occur in veins in different locations, but most commonly the vessels in the superficial venous network of the legs are affected, so varicose veins usually indicate venous disease of the lower extremities.

How do varicose veins appear?

In the case of varicose veins, only peripheral superficial venous vessels undergo pathological transformation - this is due to the structural characteristics of the vessel wall and the physiology of blood outflow from the extremities.It is these pathogenic moments that are decisive.All other predisposing factors affect the entire vasculature but do not cause characteristic changes in central veins and arteries of any caliber.

Let’s first understand the pathogenesis of varicose veins:

1. Aseptic inflammation.It starts in the vein endothelium and subsequently spreads throughout the thickness of the blood vessel.In most cases, the triggering mechanism is slowed blood flow.Cellular components of the blood accumulate in the parietal layer, accompanied by leukocyte rolling - leukocytes aggregate and "roll" along the endothelial surface.Over time, they have a tendency to adhere, triggering the release of inflammatory mediators.There are no external changes at this stage.
2. Remodeling of superficial vein walls and valves.Causes changes in density and elasticity.This process is facilitated by sterile inflammation, genetically determined defects in connective tissue proteins, mechanical microtrauma to the endothelium, and several other factors.In the affected vessels, the ability to reversibly compensate for venous pressure fluctuations is significantly reduced, and they become stiff.
3. There is persistent and progressive dilation of the lumen of the affected vein.These changes are initially quite localized; subsequently, the pathological process spreads not only along the length of one vessel but also involves other components of the peripheral venous network.
4. The affected veins are lengthened compensatoryly, forming obvious pathological curvatures.Characteristic raised nodes are formed, which give the disease its name: "varix" translates from Latin as "swelling".
5. Development of valvular insufficiency.The valves in the affected superficial vein lumen fail and blood flow reverses (vertical reflux).Initially, it is relative in nature and manifests itself only with a significant increase in peripheral venous pressure.Subsequently, the failure becomes absolute - the valve walls do not completely close under any conditions.Venous stasis (stagnant blood) occurs with the development of venous insufficiency.
6. Perforating veins participate in this process.They are also called communicators or connecters.Their pathological dilation is also accompanied by valvular insufficiency, which results in pathological blood flow from the deep to the superficial venous network (horizontal regurgitation).Venous insufficiency worsens.

All these changes are irreversible and persist even if predisposing and predisposing factors are completely eliminated, so it is impossible to cure already developed varicose veins with conservative methods; for the time being only partial compensation of these diseases is possible.

causes of varicose veins

Varicose veins are a multi-etiological disease whose development is promoted by external and internal (endogenous) factors.The main causes of varicose veins:

• genetic factors.
• Difficulty moving and sitting for long periods of time.
• Women - whose hormonal status changes during pregnancy, take oral contraceptives, and undergo hormone replacement therapy.
• Diseases associated with partial compression of the pelvic veins: pregnancy (especially multiple pregnancy or polyhydramnios), abdominal mass, certain intestinal diseases.Constipation and chronic lung disease with cough can lead to increased intra-abdominal pressure, resulting in disruption of venous outflow at the pelvic level.
• Weight gain.

All people are prone to developing varicose veins.This is because the body is in a vertical position, and under the influence of gravity, blood flows to the distal parts of the lower limbs, which increases the pressure on the veins and makes them more susceptible to deformation.

Symptoms and manifestations of varicose veins

Symptoms of superficial varicose veins in the thighs and legs include:

• There are noticeable changes in the affected veins.Varicose blood vessels are tortuous, overly contoured, dark, visible through the skin, and bulging.Pulsation is not a characteristic of them.As the disease progresses, localized nodular protrusions appear on the legs, often forming complete aggregates that do not completely disappear in the supine position.In patients who gain weight, venous changes are often virtually unnoticeable for long periods of time, masked by excess subcutaneous fat.
• Feet and legs can swell after long periods of standing and sitting, at night, and when ambient temperatures rise.This venous edema is not accompanied by cyanosis of the distal extremities, which may be observed in heart failure.They decrease or even disappear after rest (including night sleep), keeping the legs in a higher position, performing special gymnastics to activate the "muscle pump" of the calves.Swelling is one of the first symptoms of chronic venous insufficiency with varicose veins.
• Even if there is no obvious swelling, the legs may feel heavy and full.This complaint occurs in conditions that promote pathological deposition of blood in the distal lower limbs.Discomfort is most common at night and after remaining in an upright position for long periods of time with little physical activity.
• Signs of ischemia in the muscles of the limbs affected by varicose veins: increased muscle fatigue and sometimes cramps.
• An unpleasant sensation in the legs, usually worsened by increased swelling, due to the reaction of the soft tissues and peripheral nerve branches of the legs to compression by excess interstitial fluid.Another possible cause of this paresthesia is metabolic and nutritional disorders.
• Nutritional disorders can be seen in the skin and subcutaneous soft tissues.These may be dry or eczematous dermatitis, hyperpigmentation, lipodermatosclerosis (thickening and hardening of the dermis and tissue), ulcers.

The symptoms of varicose veins in the lower limbs appear quite early, but not all patients can pay attention to them in time.The order in which new features are added may vary.In some patients, defects in the appearance of markedly altered veins are initially noticed, while in others the disease manifests itself in the form of venous insufficiency.

stage

The stage of varicose veins is determined according to the CEAP classification:

• C0 - no signs of pathology;
• C1—Presence of reticular varicose veins or telangiectasia;
• C2 - varicose veins;
• C2r—recurrent varicose veins;
• C3 - limb swelling;
• C4a - nutritional changes: hyperpigmentation or venous eczema;
• C4b - nutritional changes in the form of lipodermatosclerosis or leukoderma atrophy;
• C4c - coronary vein of foot;
• C5—persistent trophic ulcer;
• C6 - Open trophic ulcer.
• C6r – Recurrent open trophic ulcer.

The CEAP classification was created in 1994 and has become an internationally recognized classification.Used by phlebologists in diagnosis.

For example, in grade C1, only a cosmetic defect is noted - a dilated reticular vein of approximately 1 mm.diameter, and with C4c, it is no longer possible to not notice serious nutritional disorders.

diagnosis

Basic tests to confirm the diagnosis of varicose veins in the lower extremities and clarify the extent and nature of the disease include:

• Clinical examination.The phlebologist determines the course and condition of visible superficial veins, changes in the skin and soft tissue, and the presence of edema.Functional testing is performed to assess vertical reflux and determine the approximate level of horizontal reflux.The purpose of patient surveys is to identify the predisposing factors, predisposing factors, duration, and characteristics of disease progression.
• Ultrasound examination.For varicose veins, the most informative test is not traditional ultrasound but rather the assessment of blood flow using Ultrasound Doppler (USD).The study showed the velocity of blood flow, the presence of pathological venous return, and impaired vascular patency.This information is necessary for doctors to choose the necessary treatment options.
• Hemostatogram (blood test used to comprehensively evaluate the coagulation system).

When indicated, a multislice computed tomography (MS CT) scan is performed - in some cases, this high-tech study becomes the primary technique for determining damage to the venous system.

In modern medicine, other diagnostic techniques are also used - plethysmography, laser Doppler flowmetry.They are not applicable to a wide range of patients; the results obtained are often not important for determining treatment strategies.Usually a basic examination is sufficient, which can be supplemented, if necessary, by consultation with a specialized specialist (endocrinologist, hematologist, cardiologist, etc.).Previously, varicose veins in the legs were divided into several stages.Currently, phlebologists use the CEAP classification of chronic venous disease when making diagnoses, which includes case characteristics based on clinical, etiological, anatomical, and pathophysiological features.

Dangers of varicose veins

Many people believe that varicose veins in the lower limbs are primarily a cosmetic problem.In fact, oftentimes, unsightly legs with nodules, bulging blue-purple blood vessels, or spider veins are the main reasons to see a doctor.

Pathological peripheral venous dilation is a disease that should not be underestimated.It can significantly worsen a patient's health and even lead to potentially life-threatening complications.This is primarily due to chronic venous insufficiency due to persistent and progressive hemodynamic impairment.Other unpleasant consequences are also possible.

Consequences of advanced varicose veins:

• The patient's quality of life deteriorated significantly.Severe discomfort and even reduced performance from varicose veins are caused by leg heaviness syndrome, swelling, nighttime cramps, poor healing and recurring ulcers.
• Soft tissue changes occur and the external attractiveness of the legs decreases, which is especially important for women.Furthermore, hyperpigmentation, lipodermatosclerosis, and traces of healed ulcers often remain even after excision of the affected vein, especially when surgical treatment is performed in the setting of already obvious nutritional disease.
• The varicose nodules or veins at the base of trophic ulcers rupture and bleed.
• Development of superficial vein thrombosis and thrombophlebitis.It is not only fraught with local hemodynamic disturbances and inflammation but is also associated with distant thromboembolism, various organ infarctions, and acute life-threatening conditions.
• In terms of thromboembolism, deep vein thrombosis is more dangerous.

Already developed complications of superficial varicose veins of the thighs and legs have a negative impact not only on the patient's condition and the prognosis of the disease.Even with radical treatments, they significantly reduce the likelihood of rapid and adequate results.

Is this disease always dangerous?

Varicose disease of the lower extremities with saphenous valvular insufficiency is not the only possible variant of this pathology.There is also a so-called "cosmetic" version of varicose veins.According to the CEAP classification of chronic venous disease, it is C1. Its form and characteristics are:

• Injury to small intradermal blood vessels up to 3 mm in diameter.They may be subepidermal or reticular.
• Spider veins appear as thin, shallow web-like reticular varicose veins.
• There is no vertical or horizontal pathological venous return.The affected small vessels have no valves and communicate only with small tributaries of the saphenous vein through the supplying pedicle.They collect blood from various parts of the dermis and drain it into larger, deeper vessels.Impaired blood flow at this level does not lead to the development of chronic venous insufficiency.

The course of the disease does not lead to the development of clinically significant complications.In fact, the patient's discomfort is due to a cosmetic defect.But that doesn’t mean people with spider veins aren’t susceptible to damage from larger-caliber veins.In this case, it is no longer C1 that is diagnosed, but C2 and subsequent categories according to the CEAP classification.

Treatment of varicose veins

Treatment of varicose veins should not begin at the onset of complications, but at the stage of the primary lesion and the mildest symptoms of venous insufficiency.You can expect rapid onset of action, complete resolution of symptoms, and a low likelihood of recurrence.Treatment of advanced varicose veins will not be as effective.Sometimes its task is simply 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 in the lower extremities can be divided into non-surgical (conservative) and surgical (radical).Traditionally, most patients have preferred gentle techniques, deferring surgical decisions until uncorrectable complications develop.Many of them do not even consult a doctor and self-medicate.Self-medication often leads to pathological complications.

Conservative treatment

Conservative treatment options for varicose veins include:

• Drug systemic treatment.It aims to improve blood rheological characteristics, prevent thrombosis, achieve anti-inflammatory effects, increase blood vessel wall elasticity, and stimulate tissue regeneration.
• Topical medication (ointments, creams, gels).Topical medications are designed to improve microcirculation, reduce swelling, increase venous tone, and heal trophic ulcers.
• Therapeutic exercises can increase the efficiency of the calf muscle pump, thereby improving blood flow through the legs.
• Use compression stockings.Compression stockings and compression garments deliver a dose of compression to superficial veins, thereby reducing the tendency for blood deposits and edema, improving health and reducing the likelihood of thrombosis.
• physiotherapy.They are mainly used in the absence of open trophic ulcers and outside the acute phase of thrombophlebitis.Use hardware barotherapy, Dalzon therapy, electroplating therapy, UHF therapy, UV therapy, hydrotherapy and ozone therapy.The goals of physical therapy include improving venous and lymphatic outflow, improving microcirculation, stimulating regeneration, and reducing the severity of discomfort.

Medications will not restore healthy blood flow to altered veins; they will remain tortuous and dilated.Even a slight increase in the tension of the vessel wall under the influence of venous constriction does not completely correct the valvular insufficiency.

You should not expect good results with conservative treatment.It will reduce pain and swelling, reduce the risk of blood clots and improve healing of nutritional diseases.But it is impossible to save a patient with varicose veins and prevent further progression of the disease using conservative methods.

surgical treatment

Invasive (surgical) methods of treating varicose veins aim to exclude the affected vessel and its major tributaries from the general blood flow (by removing or occluding them) and to eliminate horizontal venous venous return.Does not exacerbate tissue ischemia and improves nutrition by significantly reducing (or even eliminating) venous stasis.This treatment not only eliminates cosmetic imperfections but also helps cope with chronic venous insufficiency.

Classic surgical methods for treating varicose veins of the lower limbs:

• Cross resection is the complete crossing of the large superficial veins by ligation at the point where they drain into the deep venous network.
• Phlebectomy – removal of superficial veins (great or small saphenous vein) affected by varicose veins.It is performed by using instruments to peel (pull, pull out) blood vessels through small incisions.Currently, it is combined with transection and shunt resection.
• Phlebectomy – Removal of large perforators and tributaries through small incisions or punctures.

For a long time, the main method of surgical treatment has been open surgery, which has the following disadvantages:

• heavy blood loss;
• Bleeding from the surgical area sometimes requires repeated surgery to drain the blood.
• Lymphatic stasis due to crossing of lymphatic vessels.
• Severe pain syndrome.
• Long-term disability.

Modern alternatives to surgery

Endovascular techniques are considered minimally invasive interventions; they do not require incisions.They are not as invasive and are no less effective than traditional surgeries.Complications and recurrence are less common after surgery than after surgery.

Minimally invasive method:

• laser elimination
• Sclerotherapy/Cryosclerotherapy
• RF elimination.

Using a minimally invasive approach, veins affected by varicose veins are not removed like traditional surgery.Its walls are exposed from the inside with laser or radiofrequency energy, and sclerotherapy drugs are used during sclerotherapy.This causes blood vessels to "stick together" and their subsequent fibrosis and replacement of connective tissue.This closing of the lumen of a blood vessel is called occlusion.In the case of RFM of stars, they actually evaporate under the influence of radio frequency waves.