Brief anatomy and physiology of the venous system of the lower extremities

The venous system, in contrast to the arterial system, functions under different conditions. In the arterial system blood is pumped from the heart under pressure to the arms, brain and lower extremities.  In the venous system by contrast the blood must return to the heart from the lower extremities (legs) while overcoming the force of gravity.  This becomes an even more difficult endeavor when someone is in a passive position (lying, sitting, standing still).  

The body has come up with methods to battle these issues.  for example when you inhaling, the pressure in the inferior vena cava system (The largest draining vein in the abdomen) rises and the blood flow slows down, and when inhaling deeply and holding the breath, it stops altogether; when exhaling, the pressure in the abdominal cavity decreases and a suction mechanism (negative pressure) is created that promotes increased blood flow. Therefore, during Doppler sonography, the venous blood flow is heard as the sound of the surf which is a classic sound of venous vascular flow. 

Another mechanism the body uses is with dynamic physical exertion.  Muscles surrouding veins help compress the vein and move the blood back up the venous tree towards the heart.  This is one reason walking and activity is so important in creasing venous blood return to the heart and protecting against blood stasis and possible clot formation.   

The mechanisms described above could not work effectively without the presence of valves that provide blood flow only in one direction – upwards and do not let blood flow in the opposite direction, increasing the efficiency of mechanisms that ensure blood return to the right heart. 

veins of the lower extremities consist of 2 systems: deep and superficial. The deep system is located under the fascia of the lower leg and thigh, the superficial – above the fascia in under the skin tissue. Both systems are connected by veins that perforate the fascia and are therefore called perforating veins. The latter also have valves that allow blood to pass only from the superficial to the deep ones. 85% of the blood flows through the deep veins, and 15% through the superficial ones. 

Varicose veins of the lower extremities is manifested by the expansion of the superficial veins of the lower extremities, valve failure, impaired systemic and regional blood flow, metabolic disorders and, ultimately, leads to the development of CVI.

Varicose Veins

Varicose veins have accompanied humanity since its inception. References to this disease can be found in the Old Testament. This is confirmed by the excavations of the Mastaba burial in Egypt (1595-1580 BC), where a mummy was found with signs of varicose veins and traces of a venous leg ulcer.  Hippocrates, Avicenna, Galen tried to treat this disease.

F. Trendelenburg, believing that the cause of varicose veins is reflux in the sapheno-femoral anastomosis, in 1880 proposed to ligate a large saphenous vein in this place.

Since then, the ligation of the great saphenous vein at the place of its confluence has been used as a treatment. 

In 1908, WW Babcock proposed to remove the great saphenous vein with a metal probe without making large incisions, which significantly reduced trauma and increased the cosmetic efficiency of the operation.

 

The next stage in the development of methods for the treatment of chronic diseases of the veins of the lower extremities was due to the development and introduction into practice of X-ray diagnostic methods. 

Ultrasound with color mapping of blood flows and made it possible to assess venous hemodynamics, study the structure of the venous wall, the state of the valves of deep, superficial and perforating veins, made it possible to diagnose blood reflux, its degree, the presence of intravascular thrombosis, its length and development dynamics.   This method made it possible to perform local targeted interventions in various parts of the venous system in order to correct the venous blood flow. 

Sclerotherapy, as a method of intravascular exposure to chemicals, appeared after the invention of the syringe by Charles-Gabriel Pravaz in 1851. Pravets injected iron sesquichloride to obtain aseptic phlebitis. Other doctors – chloral hydrate, carbolic acid, iodo-tannic solution, soda solutions. 1998-1999 the first reports by C. Boné appeared on the clinical intravascular application of a diode laser (810 nm) for the treatment of chronic venous diseases. This was the beginning of venous ablations.

Medical and social significance of varicose veins

Varicose veins of the lower extremities and CVI represent an important medical and social problem due to their associated morbidity and cosmetic concerns.  Venous stasis ulcers and other complications can even result in persistent disability. 

In the United States about 25% of the population suffers from various forms of varicose veins.   After age 70, the disease occurs in more than 70% of people. Women are effected 5x more often than men.  

Etiology and pathogenesis of varicose veins

One of the leading causes of the development of the disease is a genetic predisposition. 

At the cellular level, Varicose veins occur because pathology in the physiological balance between muscle cells, collagen and elastic fibers of the venous wall, which is confirmed by the frequent combination of varicose veins with hernias, hemorrhoids, flat feet, scoliosis, and progressive myopia. 

Obesity is a proven risk factor for varicose veins among women of reproductive and menopausal age. 

inactivity, static loads of a constant nature, including professional ones – in a standing position (surgeons, salespeople, wig makers, lecturers, librarians) and sitting (office, scientific and other workers), contribute to the development of varicose veins.  Long-term walking in high heels (more than 4 cm), pregnancy can lead to varicose veins of the lower extremities in women. 

A lower consumption of raw vegetables and fruits leads to a relative decrease of plant fibers which is associated with increased risk of varicose veins.  This is because low fiber consumption is generally  associated with chronic constipation, increasing intra abdominal pressure and hindering the outflow of blood from the veins of the lower extremities. 

Venous hypertension, which is the main cause of venous dilatation, develops as a result of valvular insufficiency and the appearance of reverse blood flow – reflux. This process can begin simultaneously in the deep and superficial veins. 

Insufficiency of deep vein valves leads to vertical reflux of blood and venous hypertension not only in the deep veins, but also damages the valves of the perforating veins, which leads to their failure. Blood from deep vein begins to flow under pressure into superficial veins. At the same time, the work of the musculo-venous pump, due to the incorrect function of the valves of the perforating veins, increases the pressure in the superficial veins. Horizontal reflux occurs, aggravating venous hypertension in the superficial veins. Primary varicose veins develops – one of the main symptoms of varicose veins.

When the blood flow slows down, leukocytes (white blood cells) attach to the venous endothelium, activating the process of inflammation. The same process takes place on the venous valves. Over time, this process extends to the entire depth of the venous wall. 

In the latter stages venous hypertension causes an increase in capillary permeability first to water. One of the earliest and main symptoms of venous insufficiency appears – edema. At first, it is easy to eliminate it: either walk or raise your legs just above the level of the pelvis. With progressive venous hypertension, protein begins to enter the matrix, which causes pericapillary infiltration with leukocytes (Schwarzman’s phenomenon). This protein is hyalinized, the capillary bed becomes rigid, capillary blood flow is impeded.  This results in tissue ischemia, stimulating the formation of xanthine oxidase and the formation, in turn, of free radicals that destroy phospholipids of cell membranes. Clinical symptoms of trophic disorders appear in the form of dermatitis, paravenous eczema. 

In the lower third of the lower leg – in the region of the medial ankle, where the lower perforating veins are localized and venous hypertension is most pronounced, a thickening of the cellulose (induration) appears. With the progression of these phenomena, hyperpigmentation appears in the same area due to increased permeability for erythrocytes and inflammation. At end stages, a chronic venous ulcer occurs in this area.  

Symptoms of Varicose veins

The main clinical symptoms of varicose veins are as follows: 

heaviness in the legs; 

leg fatigue; 

✔ the appearance of “spider veins” (dilated capillaries); 

✔ a feeling of fullness in the calf muscles;

burning, soreness in the lower extremities; 

periodic, later – constant swelling of the feet, legs; 

night cramps in the calf muscles; 

visible dilated veins; 

sharp or aching leg pain; 

general cyanosis or darkening of the skin of the lower extremities; 

age spots, etc. 

The severity of the symptom complex is greater in the evening, after physical exertion, and in hot weather. If swelling and discoloration of the skin is constantly observed, this indicates the development of CVI.

lower extremity varicose veins  Early symptoms include the feeling of a heavy leg and the need to elevate the legs.  Shoes may become tight due to minimal swelling that occurs early on.  These symptoms can become more pronounced in  those wearing high-heeled shoes.  These symptoms come on earlier in females and those who are overweight or flat-footed, as well as those who are sedentary or spend a large amount of time sedentary.

These symptoms can sometimes be confused with the manifestations of “restless legs”, which is more often manifested at night, while in “heavy legs” related to venous insufficiency the symptoms are improved at night.

The first form of varicosities is seen in the small reticular veins often called spider veins (telangiectasia). These spider veins may be the first indication and the first reason for patients to visit their physician.  These spider veins often occur in women during pregnancy and childbirth, and gradually progress in the form of increased fatigue in the legs, the appearance of edema in the evening, a feeling of swelling, burning, pain along the veins, and sometimes night cramps in the calf muscles. 

Stages of varicose veins

In the development of varicose veins of the lower extremities, 4 stages are distinguished:

1st stage (compensation). Small cosmetic defects (spider veins) are present, no physical complaints. 

2nd stage. There are twisted dilated veins, slight swelling of the ankles, mild night pains. 

3rd stage (subcompensation). Reporting, nocturnal cramps in the calves, fatigue of the legs, a feeling of muscle distention, skin pigmentation are observed.

4th stage (decompensation). Severe swelling of the feet, ankles, a sharp increase in the width of the veins, acute pain, itching, severe convulsions. Signs of thrombophlebitis and venous ulcers often appear.

 

Diagnosing Varicose veins

Examination of the patient is carried out in an upright position. Enlarged varicosities as well as skin discoloration or skin ulcers are noted.

This is followed by examining the patient on their back with the leg raised vertically, At this point the varicosities should collapse signifying unimpeded outflow of blood from the limb into the i. In the same position, palpation along the great and small saphenous veins can reveal holes in the fascia through which the incompetent perforating veins pass. 

A cough exam should also be performed: With the leg in a vertical position, the index and middle fingers of the hand are applied to the examined segment of the vein (At LA vascular we also use doppler sonography) and the physician asks the patient to cough.  If at this moment if the physician notes blood moving past the finger, it means that above the point of pressure of the vein, the venous valves are incompetent and there is vertical reflux. 

Doppler ultrasound allows you to assess the functional state of the venous system. Doppler sonography determines venous blood flow with a noise that is synchronized with breathing and similar to the surf: when you exhale, the sound increases, and when you inhale, it gradually fades away. Reflux in the saphenous veins can be easily identified with this method. 

Triplex ultrasound provides a reliable method to determine the anatomical and morphological changes in the venous bed and to choose an adequate method of treating varicose veins, to determine the indications for surgery, the optimal approach of surgery, the possibility of using certain technical means and methods during operations, to assess the condition of the  walls and valves of the superficial and deep veins, their patency, functional state using the Valsalva test (straining during inhalation), the length of reflux, the state and function of the perforating veins.

incompetent veins with reflux

(Ultrasound triplex scan of the lower extremities) Left: saphenous varicose veins. Right: reflux of blood through an incompetent perforating vein

 

 

 

 

 

 

 

 

 

 

Classification  of varicose veins

progression of varicose veins

progression of varicose veins and chronic venous insufficiency

Currently, there are several classifications, including clinical, etiological, anatomical and based on pathophysiological signs. 

The most common classification method is the International Classification of Varicose Disease – CEAP (C – clinic, E – etiology, A – anatomy, P – pathophysiology): 

Art. 0 Absence of symptoms of the disease on examination and palpation, but upon questioning you are complaining of heaviness in the legs and the shoes become tight in the evening. Art. 1 Telangiectasias and / or reticular veins. 

Art. 2 Varicose veins. 

Art. 3 Swelling of the lower extremities in the evening. 

Art. 4 Skin trophic changes (pigmentation, venous eczema, induration). Art. 5 Skin changes progress around scars from healed venous ulcers. Art. 6 Skin changes around an open venous ulcer.

Specific changes in the lower extremities are characteristic for each stage of varicose veins.  However, CEAP classification is recognized by most surgeons as rather cumbersome and not very useful in routine use, especially in outpatient practice given that CEAP scores do not directly correlate with severity of disease. Its use is more justified in clinical trials and other scientific activities, when there is a need to analyze a large data set on a large sample of patients’ population.

Venous clinical severity score — The venous clinical severity score (VCSS) is a disease-specific instrument that is complementary to the CEAP classification. It has both physician-determined and patient-reported elements. Ten clinical parameters (pain, varicose veins, venous edema, pigmentation, inflammation, induration, number of active ulcers, duration of active ulcers, size of active ulcers, and compliance with compression therapy) are graded from zero to three depending upon severity (None = 0, Mild = 1, Moderate = 2, Severe = 3).

Venous disability score — The venous disability score (VDS) quantifies physical limitations due to chronic venous disease. Patients are considered:

Score = 0; asymptomatic

Score = 1; symptomatic, but able to carry out usual activities without compression therapy

Score = 2; symptomatic, able to carry out usual activities only with compression therapy or limb elevation

Score = 3; symptomatic, but unable to carry out usual activities even with compression therapy or limb elevation

Venous segmental disease score (VSDS) — The venous segmental disease score (VSDS) combines the anatomic and physiologic components of CEAP. Major venous segments are evaluated for the presence of reflux and/or obstruction. The relative importance of each anatomic segment is weighted, with a maximum score of 20, 10 for reflux  and 10 for obstruction.

Villalta scale — The Villalta scale is a validated clinical measure for post-thrombotic syndrome (PTS) that includes both patient symptoms and physician-observed signs of chronic venous disease.

Points are awarded for six physician-observed clinical signs (skin induration, pretibial edema, redness, hyperpigmentation, pain with calf compression, and venous ectasia) and five patient symptoms (itching, paresthesia, pain, cramps, and heaviness) with each valued from 0 (not present) to 3 (severe). A patient is considered to have PTS if a venous ulcer is present or the score is >5. Mild PTS is signified by scores of 5 to 9 and moderate disease by a score of 10 to 14, with a score >15 indicating severe PTS. The Villalta score may help in identifying and treating patients earlier in the course of developing the syndrome. While the Villalta score has been used as an outcome measure in major clinical trials of venous disease, the ability of the Villalta scale to detect meaningful differences between groups, as well as its ability to distinguish chronic underlying primary venous disease from post-thrombotic syndrome, has been questioned.

Complications of varicose veins

The most common complications of varicose veins: bleeding, thrombophlebitis, venous ulcer

Trauma to the affected veins leads to severe bleeding which requires emergent attention.  

Thrombophlebitis of deep and superficial veins is a dangerous complication of varicose veins, which can lead to thromboembolism of clot from the lower extremity to the pulmonary artery and its branches resulting in a pulmonary embolism.

Phlegmasia is a dreaded complication arising as a result of thrombosis of the venous system of the limb. There are 2 types of phlegmasies: white (Phlegmasia Alba) and blue (Phlegmasia cerulea dolens).

White phlegmasia occurs when there is preserved outflow of venous blood from the limb through the visceral veins of the pelvis. In some clinical manifestations, it is similar to arterial embolism: severe ischemic pain, pallor of the skin, absence of pulsation in the peripheral vessels, but, unlike arterial embolism, the limb is edematous, moist, warm. Errors in the diagnosis of this form of the disease lead to unjustified intervention on the arterial system and aggravate the course of the process. 

Blue phlegmasia occurs due to a complete blockage of venous outflow from the limb and is the more severe form of phlegmasia. In this case, the limb acquires a dark blue color, is a precursor to frank venous gangrene which can be life threatening.  Phlegmasia cerulea dolens  quickly moves to the perineum. This is the only type of venous insufficiency that leads to gangrene and requires amputation. 

The development of chronic venous insufficiency – CVI can eventually lead to the formation of venous ulcers, which do not heal on their own and are very difficult to treat. Treatment of venous ulcers presents significant difficulties, and without treatment of the of the underlying aberrant venous blood flow, can lead to debilitating ulcers.  

Conservative treatment is considered as a preoperative treatment and consists in long-term bandaging with elastic bandages, compression stockings, elastic knitwear, drugs that improve macro- and microcirculation, vitamins with trace elements, enzyme therapy, etc.

Surgical treatment consists of removal or ablation of the altered superficial veins, excision of the ulcer along with altered tissues and dermoplasty. 

Surgical Options

Phlebectomy

Phlebectomy is a surgical procedure to remove varicose veins . Modern phlebectomy is a combined intervention and includes four stages:

  • elimination of the source of reflux through the sapheno-femoral anastomosis or sapheno-popliteal anastomosis
  • removal of the great saphenous vein
  • removal of varicose tributaries
  • elimination of reflux in incompetent perforating veins

Laser ablation of varicose veins

Endovenous laser ablation (obliteration) of varicose veins (EVLT) is a modern minimally invasive method of treating varicose veins. The method is performed through a single 1cm incision and is performed on an outpatient setting (No hospitalization needed).  Newer methods including Venaseal ablation is even more minimally invasive requiring only one injection as opposed to EVLT which requires multiple injections to surround the vein to be ablated with tumescent fluid to protect surrounding areas from injury during ablation of the varicose vein.

Radiofrequency ablation and Venaseal ablation of varicose veins

Radiofrequency ablation of varicose veins (RFA)/Venaseal  are methods of endovenous treatment of varicose veins of the lower extremities, the purpose of which is to eliminate reflux along the great and / or small saphenous vein. The procedure for radiofrequency coagulation or gluing of varicose veins with venaseal is performed under ultrasound guidance, under local anesthesia, without large incisions and without hospitalization.

Sclerotherapy 

A modern way to eliminate varicose veins , which consists in injecting a special drug into the vein, which scars the interior of the vein . Sometimes performed under ultrasound guidance.