Varicose veins

Varicose veins of the lower limbs - an expansion of the superficial veins, accompanied by failure of the valves and a violation of blood flow. Primary varicose veins are associated with weakness or functional impairment of the venous wall. Contribute to the development of the disease pregnancy, obesity, prolonged stay in the field standing, congenital weakness of connective tissue, wearing a stocking with tight elastic bands. Secondary varicose dilatation occurs as a result of venous outflow, for example, in postthrombophlebitis syndrome, failure of deep vein valves, tumors, and trauma.

Physiology of venous circulation of the limb. The current of venous blood to the heart is provided by contraction of the muscles of the shank and thigh (muscular pump) and pulsation of the arteries. When the muscles of the lower leg and thigh are contracted, the deep veins of the limb are compressed, and the blood from them enters the proximal limb and pelvic veins. The rich valves of the communicating veins do not allow blood to penetrate into the superficial venous system. With the relaxation of the muscles, provided that the valves of the deep veins are well-suited, there is no return of blood from the veins of the pelvis, deep blood flows from the superficial system through the communicating veins and from the system of the calf muscles. With varicose veins, increasing the pressure in the veins leads to a deficiency in the valves of the communicating veins, as a result of which, with muscle contractions, blood under high pressure comes from the deep system to the surface. Local venous hypertension arises, more pronounced in the lower third of the shin, where communicative veins are the most powerful. Increased pressure in the superficial veins leads to their expansion. At the same time, increased pressure in the venous section of the microcirculation leads to the appearance of edema and diapedesis of erythrocytes (with prolonged increase in pressure there is induration and skin pigmentation), as well as the opening of arteriovenous shunts. This causes a significant reduction in blood flow in the capillaries, a decrease in perfusion, tissue hypoxia and the occurrence of ulcers.

Symptoms, course. The main symptom in the beginning of the disease is varicose veins; With compensation of venous circulation, there may not be other complaints. As the disease progresses, fatigue, a feeling of heaviness in the legs, raspiranie, cramps in the calf muscles, especially in the evening, and sometimes at night, paresthesia. Swelling usually occurs in the evening, especially after a prolonged standing, after an overnight rest, swelling completely disappears. Over time, along with the progression of varicose veins, there are trophic disorders, most often localized on the inner surface of the lower third of the tibia: induration, pigmentation, dermatitis, then-trophic ulcer, which is not amenable to treatment.

The diagnosis is made on the basis of complaints, anamnesis of the disease, examination of the limb and conduct of functional tests. The purpose of the functional study: to exclude secondary varicose veins, to reveal the inconsistency of the remaining valve of the large saphenous vein, to determine the functional state of the communicating veins, to determine the permeability of the deep venous system.

The state of the valve apparatus of the surface system can be judged from the Troyanov-Trendelenburg and Gakkenbruch tests. Troyanov-Trendelenburg Symptom: the patient, who is in a horizontal position, raises his aching leg; After the desecration of the superficial venous system, the surgeon transmutes a large subcutaneous vein at the site of its entry into the deep. The patient gets up. After releasing the hand with the failure of the ostial valve, a marked reverse blood wave is noted. Gakkenbruch symptom: in the upright position of the patient, the surgeon puts his hand on the varicose nodules and asks the patient to cough - in the failure of the valves, the hand feels a push of blood.

The condition of the communicating veins and their valves is assessed using Pratt-2 and the three-jaw sample of Sheinis. Pratt-2 trial: the patient lies; After emptying the superficial veins, the patient is given an elastic bandage on the shin and the lower third of the thigh. Below the navel ligament (5-6 cm above the already imposed bandage tour) a second elastic bandage tour is imposed. The patient gets up. By releasing the tour of the first bandage, immediately impose a tour of the second, the distance between the bandages remains constant 5-6 cm. At the site of localization of communicating veins with insolvent valves, after removing the tour of the first bandage, varicose veins appear immediately. The three-jaw sample of Sheinis is produced almost similarly, but with 3 bundles, the level of overlapping of which can be changed. After the patient gets up, the zone of insolvent valves of communicating veins is determined by the appearance of varicose nodules.

Localization of the communicating veins can be determined palpatory-in the failure of valves the communicating vein is expanded and stretches the surface fascia, in which it is sometimes possible to detect a defect.

The penetration of deep veins is determined with the help of the Delbe-Perthes test: the patient in the vertical position is put on the thigh tourniquet, after which the patient walks in place for 30 seconds. With the patency of deep veins, there is a decrease or decrease in the tension of varicose veins.

At clinical and functional research even at skilled experts the erroneous diagnostics of patency of deep veins (almost 15%) is possible. Therefore, in case of doubt in the patency of deep veins, especially the presence of trophic disorders, phlebography is indicated.

Complications of varicose veins: acute thrombophlebitis, rupture of the varicose node with bleeding, chronic venous insufficiency with the development of trophic ulcers.

Stages of varicose enlargement: I stage - no complaints, only cosmetic disorders; II stage - a feeling of heaviness, raspiraniya, cramps at night, paresthesia; III stage - drainage, feeling of raspiraniya, induration of the skin and subcutaneous tissue, pigmentation; IV stage - the formation of ulcers.

Treatment. Conservative treatment consists in wearing elastic stockings or bandages. It is indicated for varicose veins in pregnant women, because after birth it can disappear or decrease. Conservative treatment is also performed when the patient refuses the operation. According to the indications to it, you can add drugs that improve microcirculation (veururton), increase capillar resistance (vitamin C), disaggregants (preparations of salicylic acid), diuretics. Sclerotherapy as an independent method of treatment is rarely used, as it often gives a relapse of the disease. Carrying out sclerotherapy is indicated for blocking the lateral branches of the saphenous vein, as well as for reticular forms of varicose veins. Complications of sclerotherapy: deep vein thrombophlebitis of the extremity, necrosis of the skin and subcutaneous tissue after paravenous administration of the drug.

Operative treatment consists in dressing the large saphenous vein at the site of its entry into the deep (operation of Troyanov-Trendelenburg), excision of varicose-dilated veins and bandaging of untenable communicative veins. After the operation for 4-6 weeks, bandage of the limb is made with an elastic bandage. With segmental varicose veins, partial removal of veins is permissible.

The prognosis is favorable.