Varicose veins, varicose veins, varicose veins(from Latin varix, varicis - dilation, swelling in the veins)- persistent irreversible change in veins, characterized by:
- uneven increase in the lumen and length of veins,
- the formation of nodes in areas of thinning veins due to pathological changes in the venous walls, their thinning, stretching, decreased tone and elasticity,
- functional insufficiency of venous valves and impaired blood flow.
Varicose veins are a fairly common disease. Varicose veins and its complications are diagnosed in 25% of the population, with women suffering 2-3 times more often than men. In women, the first signs of the disease are often observed at a young age, most often associated with pregnancy and childbirth. At older ages, there is an increase in incidence in both men and women, and the frequency of complicated forms increases. At 70 years of age, the disease occurs 6-10 times more often than at the age of 30 years. However, recently, the manifestation of varicose veins is often observed in very young people, even teenagers. Therefore, identifying all possible causes of the disease and preventing venous disorders is becoming an increasingly urgent task.
How varicose veins arise and develop
To understand how varicose veins occur, let us briefly explain the physiology of the venous system of the lower extremities. Venous outflow in the legs is provided by two interconnected mechanisms - central and peripheral. The central mechanism is associated with the heart, lungs, diaphragm, and the peripheral mechanism is directly related to the functioning of the venous system of the lower extremities surrounding the vessels of muscles and tissues.
The initial signs of varicose veins are impaired capillary circulation, swelling, a feeling of heaviness in the legs, the appearance of spider veins and spider veins. These changes are reversible, but if preventive measures are not taken in time, problems will increase.
As a rule, more than one year passes from the initial signs of varicose veins of the lower extremities to the formation of varicose nodes and the appearance of pronounced symptoms of varicose veins. Developing gradually, varicose veins lead to impaired blood flow and chronic venous insufficiency. Stagnation of blood in the veins can lead to phlebitis (inflammation of the veins), thrombophlebitis (inflammation of the veins with the formation of blood clots), phlebothrombosis (thrombosis with further inflammation of the veins), non-healing dermatitis (inflammation of the skin), trophic ulcers.
Types and forms of varicose veins
There are primary (true) and secondary (symptomatic) varicose veins.
Primary varicose veins are an independent disease of the venous system (varicose veins). It develops gradually over several years. Most often, varicose dilatation of the great saphenous vein is observed (70-85%), less often - the small saphenous vein (5-12%). With varicose veins, 50-70% of vein damage is bilateral.
Secondary varicose veins are a symptom and consequence of diseases in which there are obstructions to the outflow of blood through the deep veins of the lower extremities (post-thrombotic disease, tumors, scars, inflammatory processes, aplasia and dysplasia of the deep veins, arteriovenous fistulas, etc. ). Secondary varicose veins are quite rare.
Most often, varicose veins affect the saphenous veins of the lower extremities, which are part of the great saphenous vein system. The branches of the small saphenous vein suffer from varicose veins much less frequently.
Classification of types of varicose veins
Until recently, in our country, doctors classified varicose veins according to several types of classifications. V. S. Savelyev’s staged clinical classification was used, reflecting the degree of disturbance of venous circulation in the limb and the body’s ability to resist these disturbances and compensate for them, as well as classification according to the forms of varicose veins and the complications caused by them.
But the main one at present is the international classification CEAP, based on clinical (C - clinic), etiological (E - etiology), anatomical (A - anatomy) and pathogenetic (P - pathogenesis) features of the disease.
6 clinical classes ("C") are arranged in increasing severity of the disease from telangiectasias (TAE) to trophic ulcers.
The etiological section ("E") indicates whether the process is primary or not.
The anatomical part of the classification ("A") divides the venous system of the lower extremities into 18 relatively separate segments, which makes it possible to indicate the localization of the affected area of the venous system.
The pathophysiological section ("P") characterizes the presence of reflux and/or obstruction in the affected venous segment.
Symptoms of varicose veins
The symptoms of varicose veins depend on the stage of the disease, i. e. on the degree of changes in blood vessels and disruption of the venous system. Depending on the stage, a prognosis for the further development of the disease can be given.
The initial stage of varicose veins - varicose veins of the 1st degree
In the initial stage, when the pathology of the veins is not yet clearly expressed, visible signs of varicose veins may be absent. Patients complain of a feeling of heaviness and discomfort in the legs, fatigue too quickly, a feeling of warmth, paresthesia (numbness, burning, tingling). Symptoms worsen towards the end of the day, as well as under the influence of heat - in the summer, or when wearing warm shoes indoors in winter. Swelling appears in the foot and ankle, which disappears after a short rest. Occasionally, nighttime cramps of the calf muscles are possible, but patients attribute them to overwork.
After prolonged physical activity, the veins swell and their network can be easily seen through the skin. They are especially noticeable in the thigh, lower leg and foot area. The number of such veins and the degree of their expansion may vary. These may be single and not very noticeable formations on the lower leg, appearing more clearly in the evening or after physical activity. Also at this stage of varicose veins, the appearance of spider veins is observed.
If at this stage you begin the simplest conservative treatment, as well as follow preventive measures, then the development of the disease can be prevented by eliminating almost all symptoms.
Symptoms of varicose veins of the 2nd degree, compensation stage
At this stage of the disease, changes in large subcutaneous vessels become noticeable. The veins become deformed, swell, the outflow of blood is disrupted, and noticeable swelling appears in the feet and ankles. Swelling increases with prolonged physical activity on the legs, but goes away after a night's rest. At night, cramps in the calf muscles are common. Paresthesia is observed - a temporary loss of sensitivity in the legs, numbness of the legs, burning, "goosebumps". As the disease progresses, pain appears, which intensifies in the evening.
This stage of subcompensation, as a rule, lasts several years, and at this time the development of the disease can also be stopped if treatment is started in a timely manner. Otherwise, the disease will inevitably progress to a more severe stage.
Symptoms of varicose veins of the 3rd degree - stage of decompensation
At this stage of varicose veins, there is a significant increase in symptoms, pain, heaviness in the legs are more intense, and there is a disturbance in peripheral blood and lymph circulation (chronic venous insufficiency). Swelling does not disappear even after a long rest and spreads to the lower leg. Patients are bothered by itchy skin. The skin on the legs becomes dry, loses elasticity, the skin is easily injured, loses the ability to quickly regenerate, as a result of which wounds take a long time to heal. Brown spots appear on the skin, most often on the inner surface of the lower third of the leg (hyperpigmentation due to subcutaneous hemorrhages).
All these complaints are constant. In the future, complaints of pain in the heart area, shortness of breath, headaches, and deterioration in the musculoskeletal function of the affected limb may appear.
Although the stage of decompensation is already a very significant manifestation of the disease, with appropriate treatment the patient’s condition can be maintained at a satisfactory level for quite a long time, maintaining ability to work and preventing transition to the phase of complications.
Varicose veins of the 4th degree - stage of complications
This phase of the disease is characterized by pronounced disturbances of venous circulation. Swelling of the legs becomes almost constant, skin itching intensifies, and trophic disorders appear on the skin of the lower leg. Advanced varicose veins are often accompanied by eczema, dermatitis, and long-lasting injuries, and since the regenerative abilities of the skin with varicose veins are noticeably reduced, even a small wound can develop into a persistent trophic ulcer. Thinned skin and venous walls are easily injured, resulting in extensive bleeding. Damaged soft tissues and open ulcers become gateways for infection.
The most common complications of varicose veins:
- phlebitis - inflammation of a vein;
- thrombosis - the formation of a blood clot (thrombus) in a vein, which can lead to blockage of the vessel;
- trophic ulcers - are formed in the place where the affected vein cannot provide sufficient outflow of blood from the skin, as a result of which the nutrition (trophism) of the tissues is disrupted.
Varicose veins can be complicated by acute (sometimes purulent) thrombophlebitis,dermatitis and eczema, bleeding, erysipelas, lymphangitis.One of the most dangerous complications of varicose veins is pulmonary embolism, which can lead to sudden death.
It is no longer possible to restore the condition of the venous system at this stage; we can only talk about preventing further complications, and, to the extent possible, improving the patient’s quality of life.
Causes of varicose veins
There is no single cause of primary varicose veins of the lower extremities. The development of this disease is usually provoked by several factors. But all the painful symptoms of varicose veins are associated with structural changes in the tissue of the venous walls of blood vessels and disruption of the functioning of the venous valves.
What causes these violations?
You can often come across the statement that one of the most important physiological reasons for the development of a disease such as varicose veins is upright posture. Indeed, in humans, by their very nature, the load on the vascular system of the lower extremities is very high. The flow of blood from the veins and its rise to the heart is prevented by pressure caused by gravity, as well as high pressure in the abdominal cavity. However, not everyone develops varicose veins. What factors provoke the development of varicose veins?
It has been established that the main risk factors for the development of varicose veins are:
- genetic predisposition (heredity) - congenital weakness of the venous wall, disruption of the venous valves;
- female gender - women suffer from varicose veins 4–6 times more often than men;
- hormonal disorders;
- hormonal contraception;
- pregnancy, especially multiple pregnancies;
- heavy physical activity (heavy physical work, strength sports);
- conditions and diseases leading to increased intra-abdominal pressure (chronic respiratory diseases, constipation, etc. )
- diseases that negatively affect blood vessels (high blood sugar, diabetes, pressure surges, etc. );
- characteristics of work - standing or sedentary work, sudden changes in temperature, prolonged contact with high or low temperatures;
- overweight, obesity, which creates increased stress on the legs and increased pressure in the pelvic area;
- lack of vitamin C and other beneficial substances necessary for the vascular system;
- a sedentary lifestyle, bad habits that destroy blood vessels and provoke additional tension in them.
Diagnosis of varicose veins
Most often, diagnosing varicose veins is often not difficult. A clinical examination, including a physical examination (examination and palpation), a survey of the patient, collection of complaints and anamnesis (information about the course of the disease, life and work characteristics, past and current diseases) for severe varicose veins usually makes it possible to make a diagnosis without instrumental examination. Exceptions are situations when, with excessive development of subcutaneous fatty tissue of the lower extremities, varicose changes may be difficult to notice.
Currently, duplex ultrasound scanning (USDS) has become widely used to study the veins of the lower extremities. This method allows you to determine the localization of changes in the veins and the nature of the disturbance in venous blood flow. However, you need to know that the results of ultrasound scanning are largely subjective and largely depend not only on the experience and knowledge of the researcher, but also on the tactical approaches to the treatment of venous diseases adopted in a given medical institution. When determining treatment tactics, they are guided primarily by clinical examination data.
Duplex scanning is performed when planning invasive treatment of varicose veins of the lower extremities. Additionally, X-ray contrast venography, MRI venography, and CT venography can be used.
All these methods make it possible to clarify the location, nature and extent of venous lesions, to clearly see disturbances in venous hemodynamics, to evaluate the effectiveness of prescribed therapy, and to predict the course of the disease.
Treatment of varicose veins - modern techniques
The main tasks of the doctor in the treatment of varicose veins are:
- eliminating or reducing the severity of symptoms that cause particular discomfort in patients - pain, swelling, cramps;
- restoration and improvement of the functioning of blood vessels - from capillaries to deep veins, improving the functioning of valves, restoring damaged vascular walls, increasing their elasticity and strength;
- improving the rheological properties of blood, reducing its viscosity;
- improving the functioning of the lymphatic system.
- preventing further development of the disease and complications;
- improving the patient's quality of life.
Depending on the stage of the disease and the degree of vascular damage, the doctor may prescribe the most optimal treatment methods for the given situation, such as:
- conservative treatment– recommendations for prevention and lifestyle changes, pharmacotherapy, compression therapy;
- non-surgical invasive procedures- sclerotherapy, echosclerotherapy, foam sclerotherapy (Foam-form therapy), etc. ;
- surgery- phlebectomy, thermal obliteration, stripping, combined methods and operations of increased complexity for complications of varicose veins and treatment of trophic ulcers of the lower extremities.
These methods make it possible to improve blood circulation in the lower extremities, including microcirculation, eliminate many cosmetic defects caused by varicose veins, and relieve the patient from a significant part of the painful manifestations of the pathology.
Conservative methods of treating varicose veins
Modern conservative therapy for varicose veins provides an integrated approach to treatment and includes several areas:
- lifestyle changes;
- pharmacological therapy;
- compression therapy.
It is no coincidence that lifestyle changes come first. It is necessary, if possible, to eliminate sludge at least to reduce the influence of unfavorable factors.
One of them is long-term static loads in a standing or sitting position, which lead to blood stagnation. To activate the muscle-venous pump of the lower leg, you need to regularly stretch your legs and walk more. While working, you can periodically perform exercises with alternate contraction and relaxation of the lower leg muscles (raising on your toes).
It is recommended to find time to engage in outdoor sports that are not associated with the risk of leg injury (athletic or Nordic walking, exercise bikes, treadmills, swimming, cycling and walking).
If you have varicose veins, you should not overheat your legs; you will have to refuse to visit the bathhouse and sauna.
Patients with varicose veins need to monitor their body weight. It is known that with a body mass index of more than 27 kg/m2the likelihood of varicose veins increases by 30%. Excess weight is often associated with elevated sugar levels, which leads to problems with the healing of venous ulcers and the risk of their recurrence.
Compression therapyfor varicose veins it can be used either alone or in combination with pharmaceuticals, as well as after surgery and sclerotherapy.
The effectiveness of compression therapy is explained by the possibility of reducing reverse blood flow, some reduction in the pathological capacity of dilated veins, which leads to a decrease in swelling, improved capillary blood flow and a decrease in varicose symptoms.
In addition to bandages and knitwear, there is hardware compression therapy, which is especially effective for chronic venous edema and trophic ulcers.
Drug treatment can be recommended in the early stages of varicose veins as the main type of therapy, supplemented, if necessary, with elastic compression. Pharmaceuticals are also prescribed to prepare for surgical treatment or in the postoperative period to speed up rehabilitation and prevent complications.
The following groups of drugs are used to treat vein diseases:
- phlebotonics and angioprotectors;
- anticoagulants and thrombolytics;
- anti-inflammatory and painkillers;
- vascular regenerating agents.
For systemic treatment of varicose veins, venotonics and angioprotectors based on bioflavonoids, rutin derivatives, saponins, etc. are mainly used. These drugs increase the elasticity and tone of the veins, increase the strength of blood vessels, improve lymph outflow and reduce lymphatic pressure. If there is a threat of thrombosis, anticoagulants are prescribed. Anti-inflammatory and painkillers are used for complications of varicose veins - inflammation of the veins, severe pain, trophic lesions of the veins.
In addition to systemic ones, local drugs are used - ointments and gels based on venoactive active substances, heparin, non-steroidal anti-inflammatory drugs, corticosteroid ointments.
Non-surgical invasive procedures
Sclerotherapy of veins of the lower extremities
Vein sclerotherapy is an outpatient medical procedure in which a special substance, a sclerosant, is injected into a capillary or problematic vein using a thin needle. The vessel is then compressed using a latex pad or elastic bandage. The walls of the vessel "stick together", the blood flow in the vessel stops. The glued walls usually grow together, scar, and the scar resolves. Used to treat varicose veins of small superficial veins. The method is effective in the early stages of the disease, only in cases where varicose veins are localized only in small veins, and allows cosmetic defects to be eliminated. A series of treatments may be required to achieve results.
Foam-form therapy (foam sclerotherapy)
It is distinguished by a special sclerosant. As with sclerotherapy, a sclerosing substance is injected into the damaged vein in the form of fine foam, which quickly "closes" the large affected veins. The method does not require numerous procedures and provides high results. It is important to know that the procedure - although rare - may have side effects - visual impairment. It is also dangerous for sclerosant to get into arteries and nerve tissue. The procedure should be performed by an experienced phlebologist.
Absolute contraindications to sclerotherapy - allergy to the drug, deep vein thrombosis, pregnancy, breastfeeding
Surgical treatment of varicose veins
As a rule, surgical treatment is recommended in severe, advanced cases, and also if conservative methods fail to stop the development of the disease.
Surgical intervention for varicose veins has the following goals
- elimination of cosmetic defects;
- reduction of subjective symptoms (pain, burning, paresthesia, feeling of heaviness in the legs, etc. );
- prevention of deterioration of the saphenous veins;
- prevention of bleeding from varicose veins;
- prevention of thrombophlebitis;
- reduction and prevention of the development of venous edema;
- reduction of manifestations and prevention of the development of hyperpigmentation, lipodermatosclerosis;
- acceleration of healing and prevention of relapse of venous trophic ulcers.
According to Clinical Guidelines, the objectives of surgical treatment are:
- elimination of pathological vertical and/or horizontal reflux;
- elimination of varicose saphenous veins.
Before performing surgical operations of any type, the risk of developing venous thromboembolic complications (VTEC) is assessed.
There are several surgical methods that can be used depending on the specific situation:
Venectomy (phlebectomy) and safenectomy- traditional operations to remove varicose veins.Venectomy- This is the surgical removal of diseased areas of veins.Safenectomy- a special case of phlebectomy, used in severe and advanced cases of the disease. The essence of safenectomy is the removal of the central trunks of damaged saphenous veins in a minimally invasive way - through incisions on the vein trunk and insertion of a probe. During this operation, ligation of perforating veins is also performed, connecting the saphenous veins with the deep ones.
Short stripping– rapid removal of the affected area of the saphenous vein on the thigh or leg through small incisions using special small thin probes.
Microphlebectomy (miniphlebectomy) -removal of varicose veins through skin punctures with a needle using special phlebectomy hooks (vein extractors).
Vascular cryosurgery (cryosclerosis)– methods of treating vein diseases by applying cold (liquid nitrogen) to damaged vessels.
Vein suturing is the placement of multiple sutures on a damaged vein, which prevent blood flow through the vessel. As a result, blood clots form and the vein gradually degenerates.
Thermal obliteration methods– thermocoagulation and laser coagulationare considered minimally invasive operations.Thermocoagulation(or RFO - Radiofrequency vein obliteration) - a very short, split second, exposure to high-frequency electric current.Laser coagulation(EVLO or EVLK – endovasal laser obliteration (coagulation) of the veins of the lower extremities) - exposure to a laser beam on pathologically dilated vessels. In both cases, as a result of a local increase in temperature, destruction of the vessel occurs, the so-called "sticking of walls" or "sealing".
It is important to remember that surgery is not a final cure, it is the elimination of symptoms. After surgery, conservative treatment is also required, and lifelong, and this must be explained to patients.
Depending on the stage of varicose veins, symptoms, concomitant diseases and the general health of the patient, the doctor selects specific recommendations to achieve the maximum possible improvements as quickly as possible.