Venous insufficiency. Chronic venous insufficiency: causes of development, symptoms and treatment Acute venous pathology

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As a result of a prolonged increase in venous pressure, the subcutaneous veins expand with overload of the lymphatic vessels and microvasculature. As a result of circulatory disorders in the microvasculature, tissue metabolites accumulate, leukocytes and macrophages are activated, a large number of free radicals, lysosomal enzymes and local inflammatory mediators appear, which contributes to further progression of the disease.

A traditional mistake is the unambiguous identification of chronic venous insufficiency and varicose veins of the saphenous veins of the lower extremities. The fact is that varicose veins, although widespread, are far from the only disease of the veins of the lower extremities. In turn, varicose veins can be one of the manifestations of chronic venous insufficiency.

In the early stages of development, chronic venous insufficiency manifests itself symptom of heavy legs and swelling. Unlike cardiac and renal edema in pathologies of the venous system, they are localized on the foot and lower leg and are accompanied by pronounced daily fluctuations - a significant decrease or complete disappearance after an overnight rest.

In the later stages of progressive chronic venous insufficiency, the appearance of varicose, pain and convulsive syndromes is characteristic.

The most common complication of chronic venous insufficiency is progressive disorders of the trophism of the soft tissues of the leg, quickly evolving from superficial hyperpigmentation to extensive and deep trophic ulcers. Along with local complications, CVI can lead to distant reactions. As a result of the deposition of large volumes of blood (up to 2.5-3 l) in the affected veins of the lower extremities, the volume of circulating blood decreases, resulting in the development of heart failure, which is manifested by a decrease in tolerance to physical and mental stress. A large number of different tissue breakdown products, which are antigens in nature, induce a variety of allergic reactions - venous eczema and dermatitis.

What are the causes of chronic venous insufficiency?

What are the risk factors for chronic venous insufficiency?

Symptoms of the development of chronic venous insufficiency

Symptoms and treatment

What is chronic venous insufficiency? We will discuss the causes, diagnosis and treatment methods in the article by Dr. A. G. Khitaryan, a phlebologist with 34 years of experience.

Definition of disease. Causes of the disease

Chronic venous insufficiency(CVI) is a pathology that occurs as a result of disturbances in the venous outflow of blood in the lower extremities. It is one of the most common diseases related to the vascular system.

CVI affects more the female half of the population than the male half. This condition can be identified in a quarter of residents of developed countries.

CVI is often confused with varicose veins of the lower extremities, which is a misconception. CVI can exist without visible manifestations of varicose veins.

Heredity, excess weight, physical inactivity, previous diseases of the vascular system (or thrombosis), hormonal imbalances and increased intra-abdominal pressure can be the causes of impaired blood outflow in the lower extremities.

In women, the development of the disease most often begins during pregnancy and childbirth. During pregnancy, progesterone and estrogen levels increase significantly. They weaken the walls of the veins. In addition to hormonal changes, the progression of CVI may be associated with displacement of venous vessels in the pelvis, as well as with an enlarging uterus. Deterioration of the condition of the venous walls may be associated with changes in pressure in the veins during contractions during childbirth. High estrogen levels and tension in the vein walls during childbirth are the main culprits for the occurrence of the disease.

Frequent and prolonged static loads and heavy lifting lead to the onset of the disease and its progression. Patients consider the clinical manifestations of CVI to be normal and associate them with fatigue and lack of physical activity. Unfortunately, patients do not promptly contact specialists at the first symptoms of the disease. Athletes, overweight people, and pregnant women are most often susceptible to CVI.

Underestimating the seriousness of the disease usually leads to serious consequences: dilation of the veins, their inflammation, blood clots, and the formation of trophic ulcers on the lower extremities (frequent complications of CVI).

If you notice similar symptoms, consult your doctor. Do not self-medicate - it is dangerous for your health!

Clinical signs of CVI are varied and do not depend on the progression of the disease.

The initial stage is manifested by one or a complex of symptoms. The only reason to contact a specialist may be a cosmetic defect of the “star” (telangiectasia - TAE), as well as the appearance of discomfort, heaviness in the legs, which increases with prolonged standing on the legs. Much less common are muscle spasms and skin irritations, which can manifest themselves to varying degrees. There may not be varicose veins, but, as a rule, examination reveals signs of damage to the intradermal veins.

Basically, the manifestation and progression of CVI boils down to the following complaints:

• the appearance of “stars”, increased swelling of the feet and legs by the end of the day;
• muscle spasms and crawling sensations;
• decreased temperature and loss of sensation in the legs;
• the appearance of pigmentation on the legs;
• discomfort and fatigue of the lower extremities.

As pregnancy progresses in women, the incidence of these symptoms begins to increase. Their appearance decreases within a week after the baby is born.

Often people with CVI complain of a feeling of warmth in the legs, itching, burning and a feeling of heaviness. Most often, the intensity of CVI symptoms increases in the afternoon or due to an increase in air temperature.

The occurrence of pain in the lower extremities is caused by a malfunction of the valves, leading to the transition of blood flow from deep to superficial veins. Due to increased pressure in the superficial veins, pain gradually increases, swelling, dryness and hyperpigmentation of the skin occurs. Severe trophic disorders can cause the opening of ulcers.

A significant volume of circulating blood (CBV) begins to be retained in the lower extremities, which leads to dizziness, fainting and heart failure. Since the volume of blood volume decreases, people with severe CVI have difficulty coping with physical and mental stress.

If the veins are painful and the skin over them is red during the period of CVI symptoms, there is a risk that they may precede thrombosis of the veins in the lower extremities.

Pathogenesis of chronic venous insufficiency

The pathogenesis of CVI is very specific. In a healthy person, blood flows out through the deep veins of the leg. Thanks to the joint work of the constantly contracting and relaxing skeletal muscles and the valve apparatus, blood is directed to the heart, where it is saturated with oxygen. In the process of this work, smooth skeletal muscles increase pressure on the veins, and the valve system, which consists of closing valves, does not allow the blood to succumb to gravity.

Due to long-term risk factors, venous hypertension occurs, and the vein wall expands and protrudes. The valve flaps diverge and cannot prevent the pathological outflow of blood. The increased volume of blood puts more pressure on the vein wall, causing the vein to expand. If treatment is not started, the vein will continue to expand. The walls of blood vessels will begin to rapidly lose their elasticity, and their permeability will increase. Blood elements and plasma will escape through the walls into the surrounding tissues. This causes swelling of the tissues, which further depletes them of oxygen. Free radicals and inflammatory mediators accumulate in tissues, and the mechanism of activation of leukocytes is triggered. This disrupts the nutrition and metabolism of tissues. The end result is the formation of “venous” trophic ulcers, which significantly reduces the patient’s quality of life.

Classification and stages of development of chronic venous insufficiency

According to clinical signs, the following stages of CVI are distinguished:

• Stage 0 - cosmetic defect, the appearance of TAE, which does not cause any clinical manifestations;
• Stage I - swelling of the legs and feet, increasing in the evening;
• Stage II - pain along the varicose vein, increasing at night. The veins may be painful on palpation;
• Stage III - constant swelling of the soft tissues, a feeling of numbness and coldness of the legs, pain increases significantly, cramps occur, which also increase at night;
• Stage IV - skin changes, pigmentation, venous eczema, lipodermatosclerosis (varicose dermatitis);
• Stage V - skin changes mentioned above and a healed ulcer. At this stage, bleeding may begin, the veins become clogged with blood clots, and thrombophlebitis occurs.
• Stage VI - skin changes mentioned above and an active ulcer.

Thrombophlebitis can only be cured through surgery.

Complications of chronic venous insufficiency

Complications of CVI include bleeding from a dilated vein, thrombophlebitis and venous ulcer. All these complications arise in the later stages of CVI with a long course of the disease.

Bleeding from a dilated vein can occur after trauma or begin spontaneously. The cause is a violation of the integrity of the ulcerated skin over the vein. Typically, these veins are located in the ankle area. This area is characterized by very high pressure in the veins, especially in an upright position of the body. Venous blood has low coagulability, so bleeding during late diagnosis can be very heavy. Emergency care consists of immediately transferring the patient to a horizontal position, placing the limbs in an elevated position and applying pressure bandages; if possible, elastic bandaging is performed. Phlebologists can stitch a bleeding vessel or glue it together with special preparations.

A trophic ulcer develops in the lower third of the leg, in the area of ​​maximum skin damage. First, brown spots appear there - pigmentation. Then whitish compactions appear in the center, reminiscent of paraffin deposits. This is considered a pre-ulcerative condition. Even the slightest injury to this area can lead to a skin defect.

The resulting skin defect begins to progressively increase, and inflammation of the skin begins around it. The ulcer becomes infected. It begins to get wet, thereby increasing the area of ​​inflammation. If the reasons that caused the formation of the ulcer persist, it occurs again and again. Therefore, the optimal treatment tactics are to first eliminate the causes of the ulcer and prevent its recurrence. Conservative treatment consists of adequate elastic compression, selection of compression hosiery for patients with trophic ulcers, and the use of special wound coverings for various stages of inflammation of a trophic ulcer.

Diagnosis of chronic venous insufficiency

It is important to know that in the treatment of any disease, the main thing is to identify it in the early stages, thereby preventing possible complications, minimizing costs and significantly reducing treatment time.

Diagnosing CVI in the early stages helps speed up treatment. When diagnosing, it is important to determine the stage of the disease. After a general clinical examination, the doctor performs a duplex angioscanning of the veins of the lower extremities to determine treatment tactics. Duplex angioscanning will help assess the condition of the vessels being studied, see the places of their narrowing or dilatation, and also identify thrombus formation.

To self-diagnose CVI, simply look at your feet. Symptoms such as swelling, pain and cramps, as well as the appearance of vascular networks and veins on the legs, are an “alarm bell” for going to a phlebologist.

One of the most accessible methods for diagnosing this disease is ultrasound, the main advantage of which is its reusability without health risks, painlessness, and the ability to identify disturbances in the current functioning of the venous system.

To obtain the best result, the examination is recommended to be carried out in the afternoon. Because it is after a day’s exercise on the legs that a more accurate assessment of the condition of the valves, the diameter of the veins and the degree of damage to the walls can be made. Treatment tactics are influenced by the presence of a blood clot in the lumen of the veins, which leads to disruption of blood flow and poses the greatest threat to the patient’s life.

Treatment of chronic venous insufficiency

There are many ways to treat CVI. In specialized clinics, the main focus is on minimally invasive treatment methods, that is, surgical interventions with minimal damage to the skin.

Endovasal laser coagulation (EVLC)

In developed countries, up to 40% of patients suffering from this disease receive assistance using laser technology. With early diagnosis, treatment takes little time and leaves no traces. Many clinics use a phlebological water laser with a wavelength of up to 1500 nm, supporting radial light guides. This technology allows you to close veins of any diameter through a small puncture of the skin.

The sclerotherapy method is based on the introduction of a sclerosant into the lumen of the affected vessel. Thanks to this substance, the vein becomes overgrown and subsequently disappears completely. For deeper location of varicose veins, the echo sclerotherapy technique is used. For more accurate intravenous administration of the drug, the procedure is performed under ultrasound control. With this technique, replacement occurs with connective tissue, which disappears within a few months. Sclerotherapy is also used to eliminate the external cosmetic manifestations of varicose veins.

The technique of diode fluorescent sclerotherapy consists of illuminating telangiectasia (up to 0.4 mm) or reticular veins (up to 2 mm) with a fluorescent lamp, into the lumen of which a special solution is injected.

A promising direction in aesthetic phlebology is the combined use of diode laser and sclerotherapy - laser cryotherapy (ClaCS). This method allows you to eliminate reticular veins and telangiectasias without any particular discomfort.

Conservative therapy for CVI consists of:

The patient should not worry about choosing a treatment method, since the phlebologist will select an individual treatment option depending on the patient’s age and type of activity, the form of his disease and the presence of pathologies. Usually, when visiting large phlebology centers, specialists simultaneously use many methods to treat one patient. For example, for the most effective and efficient treatment of CVI, laser surgery is performed in combination with injection methods for treating veins.

Forecast. Prevention

There are several methods that help reduce the risk of developing pathology and stop the progression of CVI.

The greatest positive effect comes from increasing physical activity. Daily walking (preferably 2-3 km), race walking, running, swimming, cycling increases venous pressure. If your work is characterized by long-term orthostatic loads, then try to take 10-15 minute breaks during the working day, during which you stretch your leg muscles or take a horizontal position, with your legs elevated.

In case of CVI, taking hot baths, visiting baths and saunas is strictly contraindicated, since it causes enlargement of the veins, their overflow and disrupts the outflow of blood.

The risk of increased symptoms of CVI can be reduced by reducing the time spent in the sun and in the solarium, which reduces muscle and venous tone.

In stopping the progression of CVI, constant monitoring of body weight plays an important role, because the greater a person’s weight, the greater the load on the vessels of the legs. Fats, salt and sugar, everything hot and spicy should be excluded as much as possible from the diet. Eating spicy and salty foods causes fluid retention in the body, fat deposition and weight gain. It is necessary to consume as much coarse fiber and dietary fiber as possible.

Women are advised to wear high-heeled shoes (above 4 cm) as little as possible. Due to high heels, the muscles of the lower extremities are subject to continuous tension, thereby increasing the load on the veins. To restore natural blood flow, feet need to be rested for a few minutes, removing shoes every 2-3 hours. Remember that by choosing loose, stable and comfortable shoes, you can avoid problems with blood vessels.

People at risk of developing this pathology should wear exclusively loose clothing and socks without tight elastic. For people who are prone to CVI, it is recommended to wear compression hosiery, selected with the help of consultation with phlebologists.

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Man is an upright walking creature. And we pay for the vertical position of the body with many diseases that can be called not “diseases of civilization,” such as obesity, physical inactivity and hypertension, but diseases of “upright walking.” These include, for example, spinal osteochondrosis and CVI.

Osteochondrosis, which is the aging and wear of intervertebral discs, and the numerous complications associated with this - hernias and protrusions - have been repeatedly discussed in previous articles. And CVI - what is it?

Meet - HVN

“It is known that when a person stands and when he sits, his legs are down, and only at night, when he rests in a horizontal position, are his legs not lowered down. And during the day, it’s simply difficult for the heart to raise blood to the top, so blood stagnation occurs in the legs and heaviness appears.” This answer from a school graduate on a biology exam may seem clumsy, but it captures one of the mechanisms of impaired venous return of blood.

In scientific terms, chronic venous insufficiency (CVI) is a group of diseases that affect the veins of the lower extremities. They disrupt the functioning of the valve apparatus, which facilitates the return of blood to the heart. As a result, narrowing or obliteration of the great vessels occurs.

Venous circulation is disrupted, and then external manifestations appear: trophic changes in the skin, which ultimately lead to the appearance of ulcers, the formation of complications such as thrombophlebitis, and the addition of a secondary bacterial infection.

You should know that chronic venous insufficiency of the lower extremities is not a cause, but a consequence of the well-known varicose veins, as well as postthrombophlebitic syndrome.

Why does venous insufficiency occur in the legs?

Heaviness in the legs and spider veins?

It is known that in order for the blood to flow upward from below, active muscle contractions are needed, which “push” the blood higher and higher, and valves that are located only in the veins prevent it from going back down. If any process begins that interferes with the coordinated work of veins, valves and muscles, a pathological process develops, sooner or later leading to CVI.

Very briefly, the stages of development of CVI can be represented as 7 steps:

1. Primary dilatation (expansion of the vein) occurs under the valve;
2. There is a malfunction of the venous valve;
3. The occurrence of reflux, that is, the discharge of blood from top to bottom, through the valve;
4. Venous stagnation develops;
5. Blood pressure on the vessel wall increases;
6. An increase in the permeability of the vascular wall develops;
7. Sweating of the liquid part of the blood occurs in the tissue, with the development of edema and subsequent disruption of trophism.

It is important to know that this mechanism starts faster in the presence of aggravating factors. These include:

• Hereditary weakness of connective tissue, in which “defective” valves are formed due to a lack of collagen;
• Fair sex. High levels of estrogen, pregnancy, which is a test for blood vessels, and simply a long life expectancy lead to an increased incidence of CVI;
• Elderly age;
• The use of drugs containing sex hormones. These include oral contraceptives;
• Presence of obesity and physical inactivity;
• Prolonged sitting or standing. This can be either driving or standing.

Considering that predisposing factors are very common, as a result, the incidence of various forms of CVI in civilized countries can reach even 50%, subject to careful and comprehensive diagnosis in the early stages.

How does venous insufficiency manifest, and what types does it happen?

Degrees and symptoms of CVI of the lower extremities

How does venous insufficiency manifest?

There are many different classifications of chronic venous insufficiency, but the most popular is the classification according to which any doctor, not being a vascular surgeon, can make a preliminary diagnosis of the patient based on complaints and visible signs, without resorting to instrumental methods. It includes four degrees:

• Stage zero includes conditions in which there is some discomfort in the legs, which intensifies in the evening, there is a burning sensation, muscle fatigue, and bloating in the legs. The appearance of edema is typical, but also minor. At this stage there is no pain yet;
• The first stage is characterized by the appearance of night muscle cramps, and a noticeable pain syndrome occurs. On the skin of the legs and thighs, you can notice single areas of enlarged saphenous veins, as well as the appearance of spider veins, or telangiectasia;
• The second stage is the “blooming” of CVI, in which there are still no pronounced trophic disorders. With CVI of the second degree, the pain is often disturbing, it is stronger, the veins protrude in numerous areas, and they are more than 5 cm long, varicose nodes appear;
• At the third stage, the above signs are joined by focal hyperpigmentation of the skin over the altered veins. You may sometimes read that this condition is called “varicose dermatitis.” This condition means that if urgent measures are not taken, skin defects will appear;
• The fourth stage is the formation of trophic ulcers, which are difficult to treat because blood supply and microcirculation are impaired.

If anyone thinks that the fourth stage is the final, then this is wrong. Usually a secondary infection occurs, thrombophlebitis may occur, and infected emboli can reach the right side of the heart, causing pulmonary embolism. However, much more often, patients experience septic complications, and death is possible due to sepsis and multiple organ failure.

Thus, the main symptoms of chronic venous insufficiency in the initial stages are discomfort in the legs, swelling, cramps, and the appearance of pain. In the advanced stage, visible contours of veins and nodes are added, and in the later stages ulcers develop, which are difficult, long, and, of course, expensive to treat.

That is why the diagnosis of chronic venous insufficiency, and especially in the early stages, is of particular importance.

There are other classifications of CVI. It is necessary to indicate the international classification CEAP, which phlebologists around the world are focused on. It is divided into 6 stages. Stage zero is the absence of external signs, at the first stage spider veins are noticeable, at the third stage there are varicose veins visible to the eye. At the fourth stage there are skin changes (pigmentation, or hyperkeratosis). The fifth stage is the presence of a healed ulcer, and the sixth stage is the presence of an active ulcer.

Diagnostics

There is nothing complicated in the above classification: every doctor can determine the stage of CVI. To do this, it is imperative to carry out the examination with the patient standing, be sure to examine and compare both legs, and carefully palpate.

Vascular surgeons and phlebologists conduct additional functional tests (Troyanova-Trendelenburg with a tourniquet or cuff, Pratt test), which show the failure of the venous system and valvular insufficiency.

But in order to make an accurate diagnosis - CVI, and choose the optimal treatment method, you need to use additional research methods. These methods include:

• Ultrasound - Dopplerography. With its help, you can see how strong the valve apparatus is, how passable the veins are, and get a direct picture of blood flow rates and its volume. This is the main method of instrumental diagnostics;
• Ultrasound – angioscanning, or “color Doppler”. This is an additional “plug-in” to conventional ultrasound, which shows the features of changes in the venous bed and allows you to choose the most favorable type of treatment;
• Phlebography. This is an X-ray examination in the form of a series of images of the venous system of the lower extremities, with the introduction of a contrast agent;
• Rheovasography. Shows the functional state of blood vessels and is an auxiliary research method.

After making an accurate diagnosis, it is necessary to choose the type of treatment. In the case of the second stage and above, conservative treatment does not lead to recovery, but only temporarily delays the progression of the disease, although it can cause lasting improvement.

It has been proven that only surgical correction of the disease can lead to recovery. But if venous insufficiency is diagnosed in the early stages, then its timely treatment can avoid surgery.

Treatment of CVI - drugs or surgery?

Before using drugs to treat CVI, it is necessary to pay due attention to non-drug methods, which are, perhaps, leading in the early, subclinical stages. These include:

• Modification of risk factors. It is necessary to lose excess weight and eliminate long periods of time sitting or standing. You need to take daily walks and give up bad habits;
• Physiotherapy. A special set of exercises, most of which are performed “with your legs up,” allows you to normalize the outflow from the superficial veins into the deep ones, which prevents swelling of the extremities;
• Swimming. While swimming, a person makes various movements with his legs, using different muscles than when walking. At the same time, his body is horizontal, which has a very good effect on the normalization of blood outflow;
• Finally, it is useful to sometimes rest with your feet up.

About compression hosiery

A very important stage in the treatment of CVI and varicose veins is compression underwear (stockings, stockings, tights). You need to purchase it only in specialized orthopedic salons. The underwear is graduated in millimeters of mercury and, according to the pressure created, has several compression classes.

The first, weakest class, can be used at the zero stage and even in healthy people, for example, during pregnancy and during prolonged stays in bed for the prevention of venous thrombosis. Underwear of the highest compression classes is usually prescribed by prescription and prescribed by the attending physician - a phlebologist. Compression hosiery is put on in the morning, while lying in bed, and removed in the evening, also while lying down. When trophic ulcers appear, wearing compression stockings no longer makes sense.

Drugs

Currently, there are many different drugs that are tried to treat CVI. The main group is venotonics, which do not allow the veins to expand and disrupt the valve mechanism of blood outflow. The most well-known drugs include Detralex, Phlebodia and their numerous analogues containing diosmin and hesperidin. Horse chestnut extract is effective, on the basis of which a whole family of drugs has been created - “Aescusan” and its derivatives.

In addition to venotonics, the following are used in treatment:

• NSAIDs for relief of inflammation and pain relief (meloxicam, ketoprofen);
• Antispasmodics that relieve vascular spasm (papaverine and “No-spa”);
• Means to improve microcirculation (aspirin, pentoxifylline, clopidogrel);
• Vitamins of various groups and especially derivatives of rutin, which strengthens the wall of blood vessels (Anavenol, Venoruton, Troxevasin, Troxerutin);
• Preparations containing heparin and its derivatives: heparin ointment;
• Physiotherapeutic techniques (various electrophoresis sessions).

Surgical treatment

Currently, the “gold standard” is endovascular laser correction, in which the large saphenous vein is punctured under ultrasound guidance and a miniature disposable flexible probe with a laser LED at the end is passed through it. It releases heat and “seals” the lumen of the vein, and after a few weeks it resolves, thereby restoring blood flow through the deep veins and stopping reflux.

• The operation is quick and painless, without general anesthesia, incisions and stitches: the patient leaves “on his own two feet”.

This is a wonderful alternative to classic “bloody” operations, which mostly involve the removal of the great saphenous vein of the thigh. But sometimes (for example, with severe tortuosity and the impossibility of inserting a catheter), it is necessary to resort to these interventions.

About the treatment of trophic ulcers

Perhaps this is the most difficult problem, especially if the ulcers exist against the background of severe general pathology: diabetes mellitus, nutritional deficiency, severe atherosclerosis. Most often, trophic ulcers, for example, with varicose veins, occur in the area of ​​the inner or medial ankle.

In the treatment of trophic ulcers, enzymes (Wobenzym) and reparants (Panthenol, methyluracil ointment) are used. Necrectomy, or excision of dead tissue, surgical debridement, and antiseptics (chlorhexidine, miramistin, hydrogen peroxide) are performed.

Forecast

CVI of the lower extremities is a disease that is a “litmus test” of how a person relates to his health. It is bitter to admit, but almost 80% of patients with trophic ulcers simply did not pay the necessary attention to their condition. After all, during this disease there are several “alarm bells”: if you don’t do gymnastics and don’t change your lifestyle, you need conservative treatment, medications, compression stockings. If you ignore it, then only surgery can cure it. Finally, if ulcers have formed, then there is no point in performing the operation.

Thus, after reading this article, it’s worth thinking: “do I have heaviness and discomfort in my legs?” And if you answer yourself in the affirmative, sign up for an ultrasound scan of the vessels of the lower extremities and visit a phlebologist or vascular surgeon. If everything is in order, then you can simply check the condition of the blood vessels annually and be calm about your future.

Chronic venous insufficiency is a pathology characterized by impaired blood outflow from the vessels located under the skin of the lower extremities. In women, such vein damage occurs much more often than in men.

The chronic form of venous insufficiency is an extremely dangerous disease, since in the early stages it is rarely accompanied by significant symptoms, and in the later stages it causes severe complications that are extremely difficult to treat.

Causes

The appearance of chronic venous insufficiency (CVI) is the result of a decrease in the intensity of blood flow through the vessels, which develops due to disruption of the venous-muscular pump. This is a subtle mechanism that prevents backflow and helps push fluid up toward the heart. A similar effect is achieved through the coordinated operation of the valves, contraction of the muscles in the legs and the pressure created in the system by the work of the heart.

The most unfavorable conditions for pushing blood upward are created when a person is in a sitting or standing position, but does not make movements that would properly involve the leg muscles. This provokes blood stagnation, gradual failure of valves, increased intravascular pressure and expansion of the diameter of blood vessels. Factors that increase the risk of developing chronic venous insufficiency include:

• hormonal disorders;
• congenital anomalies of vascular structure;
• obesity;
• lifting weights;
• taking certain types of drugs;
• increased static loads;
• elderly age;
• chronic constipation and colitis;
• low physical activity.

Various inflammatory vascular pathologies can provoke chronic venous insufficiency. With this course, blood clots often form. This causes acute venous insufficiency, which eventually becomes chronic.

Chronic venous insufficiency. Causes, symptoms, treatment of CVI

VARICOSE. Treatment of chronic venous insufficiency without drugs!

Chronic venous insufficiency

Hereditary predisposition also matters. Many people with chronic venous insufficiency have close blood relatives who have similar health problems. In most cases with a family history, a reduced level of collagen in the structure of the fibers that form the blood vessels is determined.

Symptoms

For a long time, the symptoms of chronic venous insufficiency remain vague, so many patients do not pay attention to them. As the pathology progresses, complaints arise about:

• heaviness in the legs;
• transient or persistent swelling;
• varicose veins;
• muscle weakness;
• pain;
• night cramps;
• the appearance of pigmentation.

Due to venous insufficiency, the skin becomes dry and loses its elasticity. In the later stages of the pathology, signs of progression of trophic changes in the soft tissues of the lower extremities begin to clearly appear.

The retention of a large volume of blood in the dilated vessels of the legs can cause symptoms of heart failure, attacks of dizziness and fainting.

With moderate physical activity, symptoms may worsen.

Degrees of the disease

In medical practice, several classifications of the severity of pathology are used, the parameter of which is the presence of signs. The most popular are the assessment systems according to V. S. Sevel’ev and the international CEAP scale. Many doctors use the simpler first version of the classification. It distinguishes 4 degrees of development of chronic venous insufficiency.

Zero

It is no coincidence that this degree has been identified by clinicians. Severe symptoms do not bother the patient, and palpation of the legs does not reveal characteristic changes. Only during the study are signs of valve dysfunction and dilation of the walls of blood vessels determined.

First

With stage 1 chronic venous insufficiency, patients complain of heaviness and pain in the extremities, which clearly manifest themselves during prolonged standing. Incoming swelling is observed, disappearing after a short period of rest. The patient may be bothered by isolated cases of night cramps. Multiple spider veins are visible on the surface of the skin.

Second

With stage 2 chronic venous insufficiency, complaints of severe arching pain in the lower leg appear. Edema becomes chronic. These symptoms intensify even after minor exertion. Thinning of the skin is observed over the areas of the affected veins. The appearance of itching and the first manifestations of hyperpigmentation are often noted.

Third

With grade 3 pathology, there is a worsening of all previously present symptoms. Venous insufficiency, which occurs in a chronic form, provokes an increase in trophic changes in soft tissues. The course of the disease is accompanied by the development of complications.

This system for assessing the course of chronic venous insufficiency is based on a number of parameters. Depending on the severity of clinical manifestations, 6 stages are distinguished, including:

• 0 – there are no subjective or palpable symptoms of venous lesions;
• 1 – spider veins are present;
• 2 – the lumens of the veins expand; Main classification of CVI
• 3 – chronically persistent edema;
• 4 – increasing skin changes;
• 5 – skin changes against the background of a healed ulcer;
• 6 – presence of trophic changes and fresh ulcers.

Depending on the cause of its occurrence, the pathology can be congenital, idiopathic and secondary, developing as a result of injury, thrombosis, etc. Depending on the anatomical segment affected, venous insufficiency, which occurs in a chronic form, can be deep, communicative and superficial.

There are large subcutaneous and inferior hollow forms of the pathology. Depending on the pathophysiological aspects, venous insufficiency, which occurs in a chronic form, may be accompanied by a reflex, obstruction, or both phenomena simultaneously. CEAP has a scale of decreased ability to work:

• 0 – no restrictions on activities;
• 1 – continued ability to work without maintenance therapy;
• 2 – ability to work full-time with the use of supportive means;
• 3 – disability even with the use of supporting means.

According to the CEAP classification, the intensity of all existing symptoms is assessed from 0.1 to 2 points.

Diagnostics

If any signs of this disease appear, you should contact a vascular surgeon or phlebologist. Anamnesis is collected and existing complaints are assessed, and the affected areas are examined. Subsequently, a coagulogram is performed, which allows you to determine coagulation indicators. General and biochemical blood tests are required. If there are signs of damage to the veins of the lower extremities, an ultrasound scan is performed.

Often, duplex scanning is required to clarify the diagnosis. This study allows you to determine the condition of deep, perforating and superficial veins. It helps to assess vascular patency and blood flow speed. Phlebography is often performed, which allows you to visualize blood vessels in a separate area of ​​the body and identify certain damage that disrupts the normal flow of blood.

Treatment methods

Treatment of chronic venous insufficiency is carried out comprehensively. As part of prevention and to eliminate the manifestations of the initial stages of pathology, medications and some types of physiotherapy can be used. In addition, drug therapy is used to normalize the condition in the postoperative period. In the later stages of the disorder, surgical intervention is required.

Compression therapy

Often, to eliminate the manifestations of chronic venous insufficiency, elastic bandages and special knitwear are used to create pressure on the affected areas. Such products can have varying degrees of compression on the legs. Such therapy can improve the functioning of the muscular-venous pump, reduce the severity of edema and relieve discomfort.

Physiotherapy

In the treatment of chronic venous insufficiency, various methods of physiotherapy can be used. When treating venous insufficiency, the following are used:

• dynamic currents;
• electrophoresis;
• magnetotherapy.

After the condition has stabilized, a special massage is prescribed. It should only be done by a specialist, as it can cause harm if used incorrectly. Hirudotherapy, i.e. the use of medicinal leeches, helps thin the blood and improve microcirculation.

Medicines

In the treatment of chronic venous insufficiency, drugs from the following groups are used to stabilize microcirculation, correct blood flow disorders, increase the tone of vascular walls, and improve lymph flow:

• venotonics;
• anticoagulants;
• fibrinolytics;
• NSAIDs;
• antihistamines;
• antibiotics;
• vitamin complexes;
• local painkillers.

Medicines and their dosages are selected by the doctor individually. In the treatment regimen for venous insufficiency, the basic ones are venotonics, which help improve the condition of the walls of the blood vessels of the lower extremities. The most commonly used means of this type include:

1. Detralex.
2. Venarus.
3. Phlebodia.

In chronic venous insufficiency, an increase in blood viscosity is almost always observed, so the use of anticoagulants is a necessary measure. Drugs of this type that are often used for venous insufficiency include:

1. Heparin.
2. Warfarin.
3. Fraxiparine.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to relieve severe pain, swelling and other signs of inflammation. When a venous trophic ulcer becomes infected, antibiotics are prescribed. In addition, in the treatment of venous insufficiency, various ointments and gels are often used to help eliminate symptoms. Other drugs are introduced into the treatment regimen if indicated.

Surgery

There are several intervention options available for chronic venous insufficiency, including:

• miniphlebectomy;
• venous bypass;
• Troyanov-Trendelenburg procedure;
• Linton's operation;
• sclerotherapy.

Microphlebectomy is used in the treatment of chronic venous insufficiency, when the problem can be eliminated by removing the affected area of ​​the blood vessel through a small puncture. Venous bypass grafting involves removing the affected area and creating a bypass path by transplanting a healthy area.

During the Troyanov-Trendelenburg operation, the first step is to eliminate a group of veins affected by the pathological process. In addition, the junction of the saphenous vein and the femoral vein is ligated. During the Linton operation, ligation of the perforating and communicating veins is performed. The procedure is performed through a small incision in the thigh.

Sclerotherapy involves the introduction of a special drug into the cavity of the affected vein. This type of intervention is used mainly in cases where the diameter of dilated veins does not exceed 2-3 mm.

Stenting of vessels of the lower extremities

Sclerotherapy - treatment of varicose veins without surgery

In the treatment of chronic venous insufficiency, other types of surgical interventions can be used. A combination of surgical treatment methods is often used.

Preventive measures

To reduce the risk of developing chronic venous insufficiency, you should avoid wearing constrictive and too tight clothing. It is not advisable to wear high-heeled shoes every day. It is imperative to monitor your diet and prevent excess body weight. As part of the prevention of chronic venous insufficiency, it is advisable for people with a hereditary predisposition to avoid visiting a solarium and avoid prolonged exposure to direct sunlight.

To prevent overloading of blood vessels, it is advisable to reduce visits to baths and saunas to a minimum. As part of the prevention of chronic venous insufficiency, it is recommended to take a contrast shower every day. Regular dosed physical activity helps preserve the venous system. It is necessary to perform special gymnastics for the legs. Existing vascular diseases should be promptly identified and treated.

Consequences and complications

The development of chronic venous insufficiency becomes the cause of extremely severe complications. This pathology creates a springboard for the development of thrombophlebitis. This condition is an inflammatory lesion of the veins, accompanied by the formation of blood clots in their lumens.

With this pathology, patients develop acute complaints of acute pain. Often, against the background of chronic venous insufficiency, the development of trophic ulcers is observed. Such defects on the skin occur when soft tissues begin to suffer from a lack of oxygen and nutrients.

Thrombosis often occurs against the background of chronic venous insufficiency. This pathological condition is accompanied by the formation of blood clots that clog the lumens of the vessel. In the future, postthrombophlebitis syndrome may develop, and a detached blood clot can provoke pulmonary embolism.

Features of the course in pregnant women

Women over 35 years of age have an extremely high risk of developing venous insufficiency during pregnancy. This is due to the fact that during this period the body experiences severe stress due to hormonal changes and increased pressure in the abdominal cavity.

This condition can cause severe complications. During pregnancy, it is not recommended to take strong medications. And surgery is impossible due to anesthesia. Drug therapy can be started only in the last trimester.

is a pathology caused by a violation of the venous outflow in the lower extremities. With CVI, swelling and pigmentary disorders of the legs, fatigue and heaviness in the legs, and cramps at night are noted. Progressive venous insufficiency causes the appearance of trophic ulcers. The diagnosis is made on the basis of ultrasound examination of the veins and phlebography. Treatment is carried out using conservative (elastic bandaging, drug therapy) or surgical methods (phlebectomy, miniphlebectomy).

ICD-10

I87.2 Venous insufficiency (chronic) (peripheral)

General information

Pathogenesis

Blood from the lower extremities flows through deep (90%) and superficial (10%) veins. The outflow of blood from bottom to top is ensured by a number of factors, the most important of which is muscle contraction during physical activity. The muscle contracts and presses on the vein. Under the influence of gravity, blood tends downward, but its reverse outflow is prevented by venous valves. As a result, normal blood flow through the venous system is ensured. Maintaining a constant movement of fluid against gravity becomes possible thanks to the consistency of the valve apparatus, the stable tone of the venous wall and the physiological change in the lumen of the veins when the body position changes.

In the case when one or more elements that ensure normal blood flow suffer, a pathological process begins, consisting of several stages. Dilatation of the vein below the valve leads to valvular incompetence. Due to constant increased pressure, the vein continues to expand from bottom to top. Venous reflux occurs (pathological discharge of blood from top to bottom). Blood stagnates in the vessel, pressing on the wall of the vein. The permeability of the venous wall increases. The plasma begins to sweat through the vein wall into the surrounding tissue. The tissues swell and their nutrition is disrupted.

Circulatory insufficiency leads to the accumulation of tissue metabolites in small vessels, local thickening of the blood, activation of mactophages and leukocytes, an increase in the number of lysosomal enzymes, free radicals and local inflammatory mediators. Normally, part of the lymph is discharged through anastomoses into the venous system. An increase in pressure in the venous bed disrupts this process, leading to overload of the lymphatic system and disruption of lymph outflow. Trophic disturbances are getting worse. Trophic ulcers form.

Classification

Currently, Russian phlebologists use the following classification of CVI:

• Degree 0. There are no symptoms of chronic venous insufficiency.
• Degree 1. Patients are bothered by leg pain, a feeling of heaviness, transient swelling, and night cramps.
• Degree 2. The swelling becomes persistent. Hyperpigmentation, lipodermatosclerosis, dry or weeping eczema are visually determined.
• Degree 3. Characterized by the presence of an open or healed trophic ulcer.

Grade 0 was not identified by clinicians by chance. In practice, there are cases when, with pronounced varicose veins, patients do not present any complaints, and the symptoms of chronic venous insufficiency are completely absent. The management tactics for such patients differ from the treatment tactics for patients with similar varicose veins, accompanied by grade 1 or 2 CVI.

There is an international classification of chronic venous insufficiency (CEAP system), which takes into account the etiological, clinical, pathophysiological and anatomical and morphological manifestations of CVI. Classification of CVI according to the CEAP system:

Clinical manifestations:

• 0 – there are no visual or palpable signs of venous disease;
• 2 – varicose veins;
• 3 – swelling;
• 4 – skin changes (hyperpigmentation, lipodermatosclerosis, venous eczema);
• 5 – skin changes in the presence of a healed ulcer;
• 6 – skin changes in the presence of a fresh ulcer.

Etiological classification:

1. the cause of CVI is congenital pathology (EC);
2. primary CVI of unknown cause (EP);
3. secondary CVI, which developed as a result of thrombosis, trauma, etc. (ES).

Anatomical classification.

Reflects the segment (deep, superficial, communicating), localization (greater subcutaneous, inferior hollow) and level of the lesion.

Classification taking into account the pathophysiological aspects of CVI:

1. CVI with reflux symptoms (PR);
2. CVI with symptoms of obstruction (PO);
3. CVI with symptoms of reflux and obstruction (PR, O).

When assessing CVI using the CEAP system, a scoring system is used, where each sign (pain, swelling, lameness, pigmentation, lipodermatosclerosis, ulcers, their duration, number and frequency of relapses) is scored 0, 1 or 2 points.

The CEAP system also applies a disability scale, according to which:

• 0 – complete absence of symptoms;
• 1 – symptoms of CVI are present, the patient is able to work and does not need supportive measures;
• 2 – the patient can work full time only if he uses supportive measures;
• 3 – the patient is unable to work, even if he uses supportive measures.

Symptoms of CVI

Chronic venous insufficiency can manifest itself with a variety of clinical symptoms. In the early stages, one or more symptoms appear. Patients are concerned about heaviness in the legs, which increases after a long stay in an upright position, transient swelling, and night cramps. There is hyper- (less commonly, hypo-) pigmentation of the skin in the distal third of the leg, dryness and loss of elasticity of the skin of the legs. Varicose veins do not always appear in the initial stage of chronic venous insufficiency.

As chronic renal failure progresses, local circulatory failure worsens. Trophic disturbances become more pronounced. Trophic ulcers form. Deposition of a significant volume of blood in the lower extremities can lead to dizziness, fainting, and signs of heart failure. Due to a decrease in blood volume, patients with severe chronic venous insufficiency do not tolerate physical and mental stress well.

Diagnostics

The diagnosis is made on the basis of anamnestic data, patient complaints, results of objective and instrumental research. A conclusion about the degree of disturbance of venous outflow is made on the basis of ultrasound scanning of the veins of the lower extremities and duplex angioscanning. In some cases, to clarify the cause of chronic renal failure, an X-ray contrast study (phlebography) is performed.

Treatment of CVI

When determining treatment tactics for chronic venous insufficiency, it should be clearly understood that CVI is a systemic pathological process that cannot be eliminated by removing one or more superficial varicose veins. The goal of therapy is to restore normal functioning of the venous and lymphatic systems of the lower extremities and prevent relapses.

Treatment for CVI should be individualized. Therapy should be a course. Some patients are shown short or occasional courses, others – regular and long ones. The average course duration should be 2-2.5 months. Taking medications must be combined with other methods of treating CVI. To achieve good results, the active participation of the patient is necessary. The patient must understand the essence of his illness and the consequences of deviations from the doctor’s recommendations.

Conservative methods are of primary importance in the treatment of CVI: drug therapy (phlebotrobic agents) and the creation of an additional frame for the veins (elastic compression). Topical preparations: wound dressings, ointments, creams, antiseptics and creams are prescribed in the presence of appropriate clinical manifestations. In some cases, corticosteroid drugs are indicated.

Surgical treatment is performed to eliminate pathological venous discharge and remove varicose veins (phlebectomy). About 10% of patients with chronic venous insufficiency require surgical treatment. When CVI develops against the background of varicose veins, minimally invasive miniphlebectomy is often used.

Prevention

Prevention of CVI includes exercise, regular walks, and prevention of constipation. It is necessary, if possible, to limit the time spent in a static position (standing, sitting). Uncontrolled use of hormonal drugs should be avoided. Patients at risk, especially those prescribed estrogen, are advised to wear elastic stockings.