Varicose veins (varicose veins) are a disease in which the superficial veins are enlarged or swollen. The disease in most cases occurs in people over the age of 30. In the vast majority of cases, it is observed on the lower limbs. Varicose veins are characterized by an expansion of the lumen of the veins with a simultaneous change in their wall. The saphenous veins are well shaped, the direction of their course becomes "serpentine". Usually the great saphenous vein is affected, less often the small saphenous vein, and even less their saphenous anastomoses.
Causes of varicose veins
The theories proposed to explain the causes and mechanisms of the onset of the disease can be reduced to three groups.
The theories of the first group explain the origin of varicose veins by the anatomical features of the location and structure of these vessels of the lower extremities. The veins have valves that prevent the centrifugal flow of blood and therefore its excessive flow from the subcutaneous to the deep veins of the leg. With insufficiency of the valves in the saphenous veins, more blood is deposited, which leads to their expansion.
The theories of the second group on the development of varicose veins attach importance to the stagnation of blood in the pelvis during pregnancy, constipation, the consequences of inflammatory processes, and also during a prolonged stay on the legs.
The theories of the third group, which explain the origin of varicose veins from a constitutional predisposition, weakness of the mesenchyme, are the least proven.
With varicose veins, for various reasons, their walls change, become thinner, so increased pressure leads to swelling of the walls. It first manifests itself in the form of nodes and, at the same time, compaction areas resulting from excessive growth of connective tissue are also noted. Mechanical factors contribute only to the development of the pathological process in the veins, but they are in no way the main point of the pathogenesis, etiology and causes of varicose veins of the lower extremities.
Symptoms of varicose veins
With the expansion of the veins, patients usually experience a feeling of fullness and heaviness in the lower limbs. Sometimes there is a convulsive, short-term nature of the pain. There is often swelling. The feeling of fullness and heaviness in the limbs increases in the evening, as edema usually increases at this point. Itching appears, there are often scratches on the legs. In the later stages of the disease, ulcers are formed, usually located in the lower third of the lower leg on the inner side.
The main objective symptom of the disease is visible varicose veins. Examination of the patient to identify this symptom is performed in a standing position. At the same time the dilated saphenous veins are clearly visible; on the lower leg they appear more prominent, more twisted; on the thigh the veins are generally dilated only along the course of the main vascular trunk. Sometimes there is a varicose vein on the thigh almost at the confluence of the largest saphenous vein in the femoral vein. Such a knot may be mistaken for a femoral hernia, but the softness of the knot, its rapid filling with blood after taking the examiner's hand away, and the presence of dilated veins on the lower leg provide a basis for establishing the correct diagnosis.
There are a number of symptoms that indicate the presence of expansion of the venous trunk of the great saphenous vein. These include a symptom in which the patient is placed in a horizontal position, the leg is given an elevated position. Carefully stroking the leg from the periphery to the center, the subcutaneous venous system is emptied, the place where the largest saphenous vein flows into the femoral vein is pressed firmly with a finger and, holding the finger, the patient is transferred to the standing position. If the filling of the veins occurs only after the removal of the finger, this is a positive symptom. In these cases, the anastomoses between the superficial and deep venous network are poorly expressed, and the operation can have a positive effect. If, in an upright position in a patient, the veins in the periphery still begin to fill slowly, this indicates a significant development of anastomosis, a negative symptom. In this case, the venous ligation operation will not be successful.
The Delbe-Perthes symptom indicates how pronounced the emptying of the saphenous veins into the deep ones is through the anastomoses. An elastic bandage is applied to the patient in a standing position on the edge of the middle and lower thirds of the thigh, then they are offered to walk lightly. If the tension of the dilated veins decreases significantly, this indicates the presence of anastomoses developed between the superficial and deep veins.
Other symptoms of varicose veins include swelling, eczematous skin changes, and ulcers. Swelling is different: from a slight mess to pronounced edema, when the skin loses its usual pattern and appears shiny, the circumference of the lower leg increases noticeably. Of the eczematous manifestations dryness, peeling and, finally, eczematous rashes are observed. The skin on the lower leg is usually affected. These changes occur due to trophic disorders.
Prevention and treatment of varicose veins
Prevention of varicose veins comes down to a change of profession, if it is associated with prolonged standing, taking measures for regular bowel movements, bandaging the legs with an elastic bandage or using an elastic stocking. Bandaging the legs or wearing a stocking must be done while lying down. For several minutes, the leg is held in an elevated position, and only after making sure that the veins are empty, a bandage or stocking is applied. The bandage begins to be applied from the bottom and continues upwards, avoiding any stretching and crushing that cause stagnation.
There are several methods of surgical treatment. The operation of ligation of the great saphenous vein in Scarpov's triangle where it flows into the femoral vein is palliative. After this operation, relapses are often observed. Therefore, it is used only in conjunction with other surgical interventions.
During the Bebcock operation, a skin incision is made at the lower end of the dilated great saphenous vein, separated and ligated. Over the dressing, it is opened and a long belly probe is inserted into the lumen. A second small skin incision is made over the upper end of the dilated vein. Its central end is tied and crossed, under the intersection the vein is tightly tied above the probe, after which it is carefully removed through the lower incision. At the same time, the probe extracts a vein that has been inverted from the intima. The disadvantage of this method is that hematomas form at the site of the torn anastomoses.
During the Madelung operation, the dilated veins are removed completely. Of all the operations, this surgery is the most radical, giving the best long-term results.
Complications of varicose veins
The most common and most difficult to treat complications of varicose veins are varicose ulcers. These ulcers usually occur in the elderly. They are located on the inner surface, less often on the outer one, of the lower third of the leg. These ulcers are the result of chronic tissue malnutrition. They are usually deep, have a necrotic, foul-smelling drainage bottom and high, callused margins. Ulcers can reach large sizes, surround the entire lower leg. The skin around them is pigmented, sometimes inflamed, with eczematous irritation.
Varicose ulcers must be differentiated from syphilitic ones. Syphilitic ulcers are usually found in the upper third of the lower leg, most often on the anterior surface. Also, with syphilitic ulcers, other signs of syphilis can be detected. Tuberculosis of the skin (lupus) is more common on the face, much less often on the extremities. Lupus begins as isolated lumps which then ulcerate; in the future, deeper tissue damage occurs, sometimes with the formation of smooth scars that tighten neighboring tissues.
Given that varicose ulcers develop against the background of circulatory and trophic disorders, their treatment must be persistent and long. The constant position of the patient with the leg raised in most cases leads to rapid improvement. A bandage with a 0. 5% solution of potassium permanganate, penicillin ointment or balsamic liniment should be applied to the ulcer. When the wound has cleared and the swelling around it disappears, it is recommended that the veins be removed. Only a radical intervention to remove the altered veins eliminates the risk of ulcer recurrence.
As the disease progresses and varicose nodes increase, their walls and the skin attached to them become thinner. As a result, usually during walking (when the knots are particularly tight), one of the knots can break and venous bleeding can occur. Although such bleeding can be significant, they do not pose a great danger, as they stop quickly if the patient is lying down and the leg is raised. In this position, negative pressure is created in the veins, they subside and the bleeding stops. A light aseptic bandage is applied to the wound. Due to the fact that the bleeding can be repeated, surgery is recommended for the excision of the veins or their ligation and the removal of the thinnest knots. With bleeding from compensatory dilated veins, any operation associated with ligation of the main trunk of the vein is categorically contraindicated.