Varicose veins (varicose veins) is a disease in which the superficial veins are enlarged or swollen. The disease occurs in most cases in people over 30 years old. 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 profiled, the direction of their course becomes "serpentine". The great saphenous vein is most often affected, less often the small saphenous vein, and even less often their saphenous anastomoses.
Causes of varicose veins
The theories proposed to explain the causes and mechanisms of occurrence 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 outflow from the subcutaneous into the deep veins of the leg. With the insufficiency of the valves in the saphenous veins, more blood is deposited, which leads to their expansion.
The theories of the second group in the development of varicose veins attach importance to the stagnation of blood in the pelvis during pregnancy, constipation, the consequences of inflammatory processes, as well as during a long stay on the legs.
The theories of the third group, which explain the origin of varicose veins by a constitutional predisposition, weakness of the mesenchyme, are the least supported.
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 knots, and at the same time, areas of compaction resulting from excessive growth of connective tissue are also noted. Mechanical factors only contribute to the development of the pathological process in the veins, but are by no means 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 feel a feeling of fullness and heaviness in the lower extremities. Sometimes there is a short-term, convulsive nature of the pain. There is often swelling. The feeling of fullness and heaviness in the limbs increases in the evening, since the edema usually increases at this time. Itching appears, there is often scratching on the legs. In the later stages of the disease, ulcers form, usually located in the lower third of the lower leg, on its inner side.
The main objective symptom of the disease are visible varicose veins. Examination of the patient to identify this symptom is carried out in a standing position. At the same time, dilated saphenous veins are clearly visible; on the lower leg, they appear more prominent, more convoluted; on the thigh, the veins are usually 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 greater saphenous vein into the femoral vein. Such a knot can be mistaken for a femoral hernia, but the softness of the knot, its rapid filling with blood after removing the examiner's hand, and the presence of dilated veins on the lower leg provide a basis for making the correct diagnosis.
There are a number of symptoms indicating the presence of an 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 placed in an elevated position. Carefully stroking the leg from the periphery to the center, the subcutaneous venous system is emptied, the place where the greater saphenous vein flows into the femoral vein is firmly pressed with a finger, and, holding the finger, the patient istransferred to a standing position. If the filling of the veins occurs only after the removal of the finger, this is a positive symptom. In such 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 peripheral veins nevertheless begin to fill slowly, this indicates a significant development of anastomoses - a negative symptom. In this case, the vein ligation operation will fail.
The Delbe-Perthes symptom indicates how pronounced the emptying of the saphenous veins into the deep veins is through the anastomoses. An elastic bandage is applied to the patient in a standing position on the edge of the middle and lower third of the thigh, then he is offered to walk a little. If the tension of the dilated veins decreases significantly, this indicates the presence of developed anastomoses between the superficial and deep veins.
Other symptoms of varicose veins include swelling, eczematous skin changes, and ulcers. Puffiness is different - from a slight pulp to a pronounced edema, when the skin loses its usual pattern and looks shiny, the circumference of the lower leg increases significantly. Eczematous manifestations include dryness, scaling and, finally, eczematous eruptions. The lower leg skin is usually affected. These changes occur as a result of trophic disturbances.
Prevention and treatment of varicose veins
Prevention of varicose veins is reduced to a change of profession, if combined with prolonged standing, taking measures for regular bowel movements, bandaging the legs with an elastic bandage or wearing elastic stockings. Binding the legs or putting on a stocking must be done in a lying position. For several minutes, the leg is held in a raised position, and only after making sure that the veins are empty, they apply a bandage or put on a stocking. The bandage begins to be applied from below and continues upwards, avoiding any stretching and compression that causes stagnation.
There are several methods of surgical treatment. The operation to ligate the great saphenous vein in Scarpov's triangle where it empties into the femoral vein is palliative. After this operation, relapses are often observed. Therefore, it is used only in combination with other surgical procedures.
During Bebcock's operation, a skin incision is made at the lower end of the dilated great saphenous vein, it is separated and ligated. Above the dressing it is opened and a long ventral probe is inserted into the lumen. A second small skin incision is made above the upper end of the dilated vein. Its central end is tied and crossed, below the intersection the vein is tightly tied over the probe, after which it is carefully removed through the lower incision. At the same time, the probe pulls a vein returned through the intima. The disadvantage of this method is that hematomas form at the site of torn anastomoses.
During the Madelung operation, dilated veins are excised everywhere. Of all the operations, this intervention is the most radical, giving the best long-term results.
Complications of varicose veins
The most common and difficult to treat complications of varicose veins are varicose ulcers. These ulcers usually occur in older people. They are located on the inner surface, less often on the outer surface, of the lower third of the lower leg. These ulcers are the result of chronic tissue malnutrition. They are usually deep, have a necrotic, foul-smelling bottom of discharge, and high, calloused margins. Ulcers can reach large sizes, encircle the entire lower leg. The skin around them is pigmented, sometimes inflamed, with eczematous irritation.
Varicose ulcers should be differentiated from syphilitic. Syphilitic ulcers are usually located in the upper third of the lower leg, more often on the front side. Also, along 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 nodules which then ulcerate; in the future, deeper tissue damage occurs, sometimes with the formation of smooth scars that tighten nearby tissues.
Since varicose ulcers develop against a background of circulatory and trophic disorders, their treatment should be persistent and long. The constant position of the patient with a raised leg in most cases leads to rapid improvement. A dressing with a 0. 5% solution of potassium permanganate, with penicillin ointment or balsamic liniment should be applied to the ulcer. When the wound is cleansed and the swelling around it disappears, it is recommended to excise the veins. Only a radical operation to remove the altered veins eliminates the risk of recurrence of ulcers.
As the disease progresses and the 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 may rupture and venous bleeding may occur. Although this bleeding can be severe, it does not present a great danger, as it quickly stops if the patient is lying down and the leg is raised. In this position, negative pressure is created in the veins, they calm down and the bleeding stops. A light aseptic dressing is placed over the wound. Due to the fact that bleeding can be repeated, surgical intervention is recommended for the excision of veins or their ligation and removal of the most thinned nodes. In case of bleeding from the compensatory dilated veins, any operation associated with the ligation of the main trunk of the vein is categorically contraindicated.