hypertension<\/a>, 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.\u00a0<\/span><\/p>\nInsufficiency 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 <\/span>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.<\/p>\nWhen 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.\u00a0<\/span><\/p>\nIn 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.\u00a0 This results in\u00a0<\/span>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.\u00a0<\/span><\/p>\nIn 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.\u00a0\u00a0<\/span><\/p>\n<\/span>Symptoms of Varicose veins<\/span><\/h2>\nThe main clinical symptoms of varicose veins are as follows:\u00a0<\/span><\/p>\n\u2714 <\/span>heaviness in the legs;\u00a0<\/span><\/p>\n\u2714 <\/span>leg fatigue;\u00a0<\/span><\/p>\n\u2714 the <\/span>appearance of “spider veins” (dilated capillaries);\u00a0<\/span><\/p>\n\u2714 a <\/span>feeling of fullness in the calf muscles;<\/span><\/p>\n\u2714 <\/span>burning, soreness in the lower extremities;\u00a0<\/span><\/p>\n\u2714 <\/span>periodic, later – constant swelling of the feet, legs;\u00a0<\/span><\/p>\n\u2714 <\/span>night cramps in the calf muscles;\u00a0<\/span><\/p>\n\u2714 <\/span>visible dilated veins;\u00a0<\/span><\/p>\n\u2714 <\/span>sharp or aching leg pain;\u00a0<\/span><\/p>\n\u2714 <\/span>general cyanosis or darkening of the skin of the lower extremities;\u00a0<\/span><\/p>\n\u2714 <\/span>age spots, etc.\u00a0<\/span><\/p>\nThe 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.<\/span><\/p>\n![\"lower](\"https:\/\/i0.wp.com\/lavascular.com\/wp-content\/uploads\/lower-extremity-varicose-veins.jpg?resize=377%2C333&ssl=1\")
\u00a0\u00a0<\/span>Early symptoms include the feeling of a heavy leg and the need to elevate the legs.\u00a0 Shoes may become tight due to minimal swelling that occurs early on.\u00a0 These symptoms can become more pronounced in\u00a0 those wearing high-heeled shoes.\u00a0 These symptoms come on earlier in females and those who are<\/span> overweight or flat-footed, as well as those who are sedentary or spend a large amount of time sedentary.<\/p>\nThese 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.<\/span><\/p>\nThe 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.\u00a0 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.\u00a0<\/span><\/p>\n<\/span>Stages of varicose veins<\/b><\/span><\/h2>\nIn the development of varicose veins of the lower extremities, 4 stages are distinguished: <\/span><\/p>\n1st stage (compensation). Small cosmetic defects (spider veins) are present, no physical complaints.\u00a0<\/span><\/p>\n2nd stage. There are twisted dilated veins, slight swelling of the ankles, mild night pains.\u00a0<\/span><\/p>\n3rd stage (subcompensation). Reporting, nocturnal cramps in the calves, fatigue of the legs, a feeling of muscle distention, skin pigmentation are observed. <\/span><\/p>\n4th 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.<\/span><\/p>\n<\/span>Diagnosing Varicose veins<\/span><\/h2>\nExamination of the patient is carried out in an upright position. Enlarged varicosities as well as skin discoloration or skin ulcers are noted.<\/span><\/p>\nThis 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.\u00a0<\/span><\/p>\nA 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.\u00a0 <\/span>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.\u00a0<\/span><\/p>\nDoppler 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.\u00a0<\/span><\/p>\nTriplex 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\u00a0\u00a0<\/span>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 perfor<\/span>ating veins. <\/span><\/p>\n![\"incompetent](\"https:\/\/i0.wp.com\/lavascular.com\/wp-content\/uploads\/incompetent-veins-with-reflux.jpg?resize=523%2C258&ssl=1\")
(Ultrasound triplex scan of the lower extremities) Left: saphenous varicose veins. Right: reflux of blood through an incompetent perforating vein<\/p><\/div>\n
<\/span>Classification\u00a0 of varicose veins<\/span><\/h2>\n![\"progression](\"https:\/\/i0.wp.com\/lavascular.com\/wp-content\/uploads\/progression-of-varicose-veins.jpg?resize=870%2C230&ssl=1\")
progression of varicose veins and chronic venous insufficiency<\/p><\/div>\n
Currently, there are several classifications, including clinical, etiological, anatomical and based on pathophysiological signs.\u00a0<\/span><\/p>\nThe most common classification method is the International Classification of Varicose Disease – CEAP (C – clinic, E – etiology, A – anatomy, P – pathophysiology):\u00a0<\/span><\/p>\nArt. 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.\u00a0<\/span><\/p>\nArt. 2 Varicose veins.\u00a0<\/span><\/p>\nArt. 3 Swelling of the lower extremities in the evening.\u00a0<\/span><\/p>\nArt. 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.<\/span><\/p>\nSpecific changes in the lower extremities are characteristic for each stage of varicose veins.\u00a0 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. <\/span><\/p>\nVenous clinical severity score<\/span>\u00a0\u2014\u00a0<\/span>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).<\/p>\nVenous disability score<\/span>\u00a0\u2014\u00a0<\/span>The venous disability score (VDS) quantifies physical limitations due to chronic venous disease. Patients are considered:<\/p>\n\u25cf<\/span>Score = 0; asymptomatic<\/p>\n\u25cf<\/span>Score = 1; symptomatic, but able to carry out usual activities without compression therapy<\/p>\n\u25cf<\/span>Score = 2; symptomatic, able to carry out usual activities only with compression therapy or limb elevation<\/p>\n\u25cf<\/span>Score = 3; symptomatic, but unable to carry out usual activities even with compression therapy or limb elevation<\/p>\nVenous segmental disease score (VSDS)<\/span>\u00a0\u2014\u00a0<\/span>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 \u00a0and 10 for obstruction.<\/p>\nVillalta scale<\/span>\u00a0\u2014\u00a0<\/span>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.<\/p>\nPoints 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.<\/p>\n
<\/span>Complications of varicose veins<\/span><\/h2>\nThe most common complications of varicose veins: <\/span>bleeding, thrombophlebitis, venous ulcer<\/span><\/i>.\u00a0<\/span><\/p>\nTrauma to the affected veins leads to severe bleeding which requires emergent attention.\u00a0\u00a0<\/span><\/p>\nThrombophlebitis 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.<\/span><\/p>\nPhlegmasia is a dreaded complication arising as a result of thrombosis of the venous system of the limb. There are 2 types of phlegmasies: whi<\/span>te (Phlegmasia Alba) and blue (Phlegmasia cerulea dolens).<\/p>\nWhite 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.\u00a0<\/span><\/p>\nBlue 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.\u00a0 Phlegmasia cerulea dolens\u00a0 quickly moves to the perineum. This is the only type of venous insufficiency that leads to gangrene and requires amputation.\u00a0<\/span><\/p>\nThe 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.\u00a0\u00a0<\/span><\/p>\nConservative 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.<\/span><\/p>\nSurgical treatment consists of removal or ablation of the altered superficial veins, excision of the ulcer along with altered tissues and dermoplasty.\u00a0<\/span><\/p>\n<\/span>Surgical Options<\/b><\/span><\/h2>\n<\/span>Phlebectomy<\/b><\/span><\/h3>\n