For quotation: Klimova E.A. Chronic venous insufficiency and methods of its treatment // Breast cancer. 2009. No. 12. P. 828

Chronic venous insufficiency (CVI) lower limbs- a syndrome characterized by disturbances of venous outflow, which lead to disorganization of the regional microcirculation system. CVI is a common disease, occurring in 10-15% of the adult population. This is a syndrome that develops with a polyetiological disease - varicose veins of the lower extremities. Thus, a group of leading Russian phlebologists developed a capacious definition: “Varicose veins of the lower extremities is a polyetiological disease, in the genesis of which heredity, obesity, disorders hormonal status, lifestyle features, as well as pregnancy. The disease is manifested by varicose transformation of the saphenous veins with the development of CVI syndrome.” The disease is characterized by high prevalence. Thus, in the USA and Western European countries, about 25% of the population suffers from various forms varicose veins.

Etiology
However, the etiology of CVI is currently still a debated issue. Modern studies of the functions of the endothelium indicate the dominant role of venules in this pathological syndrome. In the lower extremities, the surface area of ​​the venules in contact with blood is greater than in all other venous vessels combined. Endothelial cells, due to their location at the interface between blood and other tissues, are responsible for maintaining vascular homeostasis. They regulate the passage of plasma and leukocyte contents from the bloodstream into the interstitium. These properties of the endothelium are associated with the presence of specific molecules - membrane receptors, adhesion molecules, intracellular enzymes and a special configuration of the cytoskeleton. Also, endothelial cells synthesize various substances that regulate platelet functions - platelet-activating factor, prostaglandins; leukocytes - interleukin-1, interleukin-8, granulocyte-macrophage colony-stimulating factor; smooth muscle cells - endothelin, growth factors. Inflammatory or other pathological processes in the inner wall of venules activate endothelial cells. The activated endothelium releases inflammatory mediators, which leads to the influx, adhesion and activation of polymorphonuclear neutrophils and platelets. If this process becomes chronic, T-lymphocytes and monocytes attach to the surface of the endothelium, which release highly reactive radicals, ultimately leading to the destruction of the endothelial barrier of the venules. Contact that occurs between plasma coagulation factors and tissue factor located in the extravascular space, and especially on the pericytes of adjacent capillaries, can trigger intravascular coagulation.
Until recently, in the domestic literature one could find various forms of classification of varicose veins of the lower extremities and CVI. In 2000, at a meeting of experts, “Standards for the diagnosis and treatment of varicose veins of the lower extremities” were adopted. Based on these standards, our country currently operates the classification presented in Table 1.
Pathogenesis
The leading place in the pathogenesis of CVI is occupied by the “valve” theory. Valvular insufficiency of various parts of the venous bed of the lower extremities leads to the appearance of pathological, retrograde blood flow, which is the main factor in damage to the microvasculature, which was proven using X-ray contrast venography, and then using non-invasive ultrasound methods. Indirect confirmation of the “valve” theory of CVI were the results of well-known epidemiological studies, conducted in Germany and Switzerland, on the basis of which it was concluded that the primary need for correction of valvular insufficiency of the venous bed using elastic compression or surgery. However, the question remained about the cause of the development of valve insufficiency itself as a trigger for the development of CVI. Thus, a large number of patients were found with complaints characteristic of CVI in the absence of valve pathology. In this case, the use various options Plethysmography recorded a violation of the tone of the venous wall of varying degrees of severity. Thanks to this, the hypothesis was put forward that CVI is not a valve disease, but a pathology of the vein wall.
It has now been proven that if there is various factors risk and under the influence of gravity in the venous knee of the capillary, the pressure increases, reducing the arteriovenular gradient necessary for normal perfusion of the microvasculature. The consequence is first periodic and then constant tissue hypoxia.
TO the most important factors The risk of developing CVI includes:
1) Pregnancy and childbirth.
2) Heredity.
3) Excess body weight.
4) Chronic constipation.
5) Hormonal contraception.
6) Systematic sports activities.
In addition, constant changes in body position and uneven load on various departments the venous bed of the lower extremities triggers another little-studied mechanism, called mechanotransduction, or shear force. This means that under the influence of pressure constantly changing in strength and direction, a gradual loosening of the connective tissue frame of the venule wall occurs. Disruption of the normal intercellular relationships of the endothelium of venous capillaries leads to the activation of genes encoding the synthesis of various adhesion molecules.
The main symptoms that occur with CVI are: heaviness in the legs, pain in calf muscles, which is caused by a decrease in venous tone and hypoxemia; cramps, swelling of the lower extremities in the evening, which is caused by overload lymphatic system, increased capillary permeability and inflammatory reactions; constant itchy skin. More often these symptoms are combined.
Treatment
Commonly accepted treatments for CVI include pharmacotherapy, compression therapy, and surgical methods treatment. The mechanical method of therapy, which is effective only during its application, does not affect the significantly increased permeability of the venule endothelium. This effect can only be achieved through pharmacotherapy, using a drug that binds to the endothelium of venules and has the ability to suppress or prevent inflammation, leading to a decrease in the permeability of small vessels and, as a consequence, a decrease in edema.
Compression therapy can improve the activity of the muscle-venous pump of the leg, reduce swelling and relieve heaviness and bursting pain in the legs. The greatest comfort for the patient and optimal physiological pressure distribution is achieved using special therapeutic knitwear.
Surgical treatment: the initial form of varicose veins (telangiectasia and reticular varicose veins) is only a cosmetic problem, and all its external manifestations can be eliminated using modern techniques such as sclerotherapy. Main goal surgical treatment is to eliminate the mechanism of the disease, namely, pathological veno-venous discharges. This is achieved by crossing and ligating insufficient perforating veins, sapheno-femoral and sapheno-popliteal anastomosis. With the development of modern minimally invasive technologies, old ideas about venectomy as a voluminous and traumatic operation are a thing of the past.
Drug treatment
Among the main drugs used at all stages of the disease, the most widely used are venotonics, or phleboprotectors. These are a variety of pharmacological drugs that share a common property - stabilization. structural components venous wall and increasing its tone. Of the main venotonics, the best studied are g-benzo-pyrones - flavonoids, preparations based on micronized diosmin. In severe forms of CVI, accompanied by disruption of the hemostatic system with the development of hyperviscosity and hypercoagulation syndromes leading to thrombosis, as a remedy basic therapy anticoagulants are used. Among the anticoagulants, low molecular weight heparin is the most convenient to use, which causes a lower incidence of hemorrhagic complications, rare thrombocytopenias, has a longer duration of action and no need for frequent laboratory monitoring compared to unfractionated heparin. Subsequently, indirect oral anticoagulants, represented by coumarin and phenidine derivatives, are used; their dose is individually selected depending on the value of the international normalized ratio. To specifically improve hemorheology and microcirculation, platelet disaggregants are used. The most commonly used are low molecular weight dextrans, dipyridamole and pentoxifylline. In recent years, the possibility of using clopidogrel has been studied, which appears to be more appropriate.
Also, auxiliary, symptomatic agents are used to treat CVI. For example, antibacterial and antifungal agents - for infected venous trophic ulcers or in the case of the development of erysipelas. Anti-histamine drugs are prescribed for the treatment of such common complications of CVI as venous eczema and dermatitis. In cases of severe edematous syndrome, it is advisable to use potassium-sparing diuretics. NSAIDs are used for severe pain and convulsive syndromes, as well as for aseptic inflammation of the skin of the lower leg - acute indurative cellulite. Also, do not forget about the use of acetylsalicylic acid (ASA), which is perhaps the only representative of NSAIDs actively used in phlebological practice. Under the influence of ASA, the aggregation response of platelets to various thrombogenic stimuli is weakened. In addition, ASA suppresses the synthesis of vitamin K-dependent coagulation factors, stimulates fibrinolysis, and suppresses the lipoxygenase pathway of arachidonic metabolism in platelets and leukocytes. The usual dosage is 125 mg ASA per day. Corticosteroids are used in the most severe forms of CVI, accompanied by acute indurative cellulite, venous eczema, hemosiderosis, lamellar dermatitis, etc.
Topical medications (ointments and gels) occupy an important place in the treatment of CVI and are very popular among both doctors and patients. This is due to the fact that the cost of these drugs is relatively low, and their use is not associated with any difficulties. Ointments and gels based on venoactive drugs, along with some distracting effects, can have veno- and capillary-protective effects. An example of the highest quality drug presented on the Russian pharmaceutical market is Venitan gel or cream for external use. Active substance Venitana escin - active ingredient Chestnut fruit extract is a mixture of triterpene saponins. Escin has anti-inflammatory, angioprotective properties, improves microcirculation, reduces capillary permeability, prevents the activation of lysosomal enzymes that break down proteoglycan, reduces the “fragility” of capillaries and increases the tone of the venous wall, which helps reduce stagnation in the venous bed and fluid accumulation in the tissues, thereby preventing the appearance of edema (Fig. 1).
The most favorable effect of using this drug is achieved when using Venitan on initial stages development of chronic venous insufficiency.
Of particular note new uniform the drug - Venitan Forte, which in addition to escin includes heparin, this combination acts not only on the venous wall, but also on the blood flow inside the vessel. Venitan Fotrte also contains dexpanthenol and allantoin, which improve the absorption of heparin and escin through the skin, promote tissue regeneration and improve skin condition. The drug is used not only for initial degree development of chronic venous insufficiency, but also with severe symptoms venous insufficiency (II, III degree): swelling, feeling of heaviness, fullness and pain in the legs, for the complex treatment of varicose veins and thrombophlebitis of the superficial veins. The mechanism of action of the drug Venitan Forte is presented in Table 2.
The doctor should not forget that the treatment of chronic venous insufficiency is complex measures aimed at both the pathogenetic mechanisms of the development of the disease and various etiological factors. For successful treatment it is necessary to rationally and balancedly use the existing arsenal of drugs, compression stockings and surgical methods of treatment.

Literature
1. Savelyeva V.S. Phlebology. Guide for doctors. M.: Medicine, 2001.
2. Kirienko A.I., Koshkina V.M., Bogacheva V.Yu. Outpatient angiology. Guide for doctors. M., 2001.
3. Becker C., Zijistra JA. New aspects of the pathogenesis of chronic venous insufficiency and the direction of action of oxyrutins. Consilium-Medicum Volume 3/N 11/2001.
4. Bogachev V.Yu. Initial forms of chronic venous insufficiency of the lower extremities: epidemiology, pathogenesis, diagnosis, treatment and prevention. Consilium-Medicum Volume 06/N 4/2004.
5. Bogachev V.Yu. Chronic venous insufficiency of the lower extremities: modern principles of treatment. Consilium-Medicum. Volume 05/N 5/2000.

Venous insufficiency is a symptom complex caused by a violation of the outflow of blood through the venous system. About 40% of adults suffer from this pathology. Venous insufficiency of the lower extremities is more common. This is explained by the upright posture of a person, as a result of which the load on the veins of the legs significantly increases, as blood flows through them, overcoming the forces of gravity. Venous insufficiency can also be observed in other parts of the body - internal organs, brain.

Swelling of veins in venous insufficiency of the lower extremities

Chronic venous insufficiency is a slowly progressive pathology that long time is practically asymptomatic, which is why patients seek medical care often already in advanced stages. This is where the insidiousness of the disease lies. According to statistics, no more than 8-10% of patients receive timely treatment.

Chronic venous insufficiency is a slowly progressive pathology that is practically asymptomatic for a long time. According to statistics, no more than 8-10% of patients receive timely treatment.

Differential diagnosis is carried out with lymphangitis, erysipelas. Acute venous insufficiency is differentiated from muscle sprain or rupture, compression of the vein from the outside by enlarged lymph nodes or a tumor, lymphedema, rupture of Baker's cyst, cellulite.

Treatment of venous insufficiency

Treatment of acute venous insufficiency begins with applying a cold compress to the affected limb. To do this, cotton fabric is soaked in ice water, squeeze out and apply to the skin. After 1.5-2 minutes, the fabric is removed and moistened in water, and then applied to the skin again. The total duration of the procedure is one hour.

Patients are provided with strict bed rest. In order to prevent further thrombus formation, heparin injections are prescribed, which are performed under the control of blood clotting time and platelet count. In the future, indirect anticoagulants are indicated. In the first days of therapy, the prothrombin index is determined daily, subsequently it is monitored once every 7-10 days for several weeks, and after stabilization of the patient’s condition - once a month for the entire duration of treatment.

In case of acute venous insufficiency of the lower extremities, caused by the formation of a floating thrombus, surgical intervention is indicated, which consists of installing a vena cava filter in the inferior vena cava below the level of the renal veins. This operation prevents the development of thromboembolic complications, including potentially life-threatening pulmonary embolism (PE).

Therapy for chronic venous insufficiency, as a systemic pathological process, is aimed not only at restoring normal venous blood flow, but also at preventing relapses of the disease.

Drug treatment of venous insufficiency in its chronic form is carried out with drugs that reduce blood clotting (acetylsalicylic acid, indirect anticoagulants) and phlebotropic agents. Besides drug therapy, the elastic compression method is used (bandaging the limb with elastic bandages, wearing compression hosiery).

Patients often confuse varicose veins and venous insufficiency of the lower extremities. These two pathologies have a lot in common in symptoms, but still are not identical.

In case of chronic venous insufficiency, according to indications, perform surgical removal varicose veins, or replace the operation with sclerosing therapy - a special drug is injected into the pathologically altered vein, which causes inflammation of its walls, and subsequently their adhesion to each other.

Possible consequences and complications

Complications of chronic venous insufficiency are:

• deep vein thrombophlebitis;
• pulmonary embolism;
• streptococcal lymphangitis.

Acute venous insufficiency can cause the development of white or blue painful phlegmasia, which, in turn, can lead to gangrene of the limb, hypovolemic shock (due to significant deposition of blood in the limb). Another complication this state a purulent melting of the blood clot may occur, with the development of an abscess, phlegmon, and in the most severe cases even septicopyemia.

Chronic venous insufficiency of the brain leads to, causes irreversible changes in nervous tissue, and can cause permanent disability.

Forecast

At timely diagnosis and active treatment of venous insufficiency, the prognosis is generally favorable.

Prevention

Prevention of acute venous insufficiency includes:

• early activation of patients after surgical interventions;
• use of elastic stockings;
• performing periodic compression of the lower leg on a bedridden patient;
• drug prophylaxis of thrombus formation at its increased risk.

Preventive measures aimed at preventing the formation of chronic venous insufficiency:

• preventing constipation;
• active lifestyle (sports, walks in the fresh air, morning exercises);
• avoiding prolonged stay in a static position (sitting, standing);
• during replacement hormone therapy Women receiving estrogens are advised to wear elastic stockings and the prothrombin index is regularly monitored;
• refusal to wear shapewear or outerwear with a tight collar;
• fight against excess weight;
• refusal to regularly wear high-heeled shoes.

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Chronic venous insufficiency of the lower extremities is the most common disease peripheral vessels. The prevalence of this disease among the working population is 40-50 percent. In this connection, chronic venous insufficiency is a very important medical and social problem.

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 pathology 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?

If high venous pressure persists in the lower extremities, chronic venous insufficiency may develop over time. Another reason for the development and progression of chronic venous insufficiency is deep vein thrombosis and phlebitis (inflammation of the vein wall), in which obstruction (blockage) of the veins develops, which leads to increased venous pressure and disruption of the function of the underlying veins (more about deep vein thrombosis and its complications of pulmonary embolism, see separate section). Phlebitis (inflammation of the vein wall) most often develops in the superficial veins and is manifested by swelling of the adjacent soft tissues, pain and inflammation. Inflammation, in turn, contributes to the formation of blood clots (thrombosis), including deep veins, and the progression of venous insufficiency.

What are the risk factors for chronic venous insufficiency?

Risk factors for chronic venous insufficiency include having any of your immediate family members varicose veins veins, overweight, pregnancy, lack of physical activity, smoking, the need to maintain a stationary position (sitting or standing) for a long time. However, not everyone develops chronic venous insufficiency. The risk of developing chronic venous insufficiency increases with age, develops more often in women, and appears most often over the age of 50 years.

Symptoms of the development of chronic venous insufficiency

Chronic venous insufficiency can also lead to edema due to increased venous pressure and impaired venous outflow. If you have chronic venous insufficiency, you may experience swelling in your ankles and legs, and you may also feel like your shoes are getting too small. Important symptoms Chronic venous insufficiency also includes a feeling of heaviness in the legs, rapid fatigue, anxiety, and cramps. Unpleasant pain may occur while walking or immediately after stopping.

Content

Poor venous circulation, accompanied by pronounced symptoms, leads to a disease called venous insufficiency of the lower extremities - its symptoms, treatment and prevention are aimed at restoring blood flow inside the vein. The disease is associated with a sedentary lifestyle and genetic predisposition, and at certain stages is accompanied by varicose veins.

What is venous insufficiency of the lower extremities

Venous insufficiency of the lower extremities ranks first in prevalence among vascular pathologies. More often it affects women, and in total, according to statistics, almost a third of the adult population is affected. When, for a number of reasons, including due to increased load, the functioning of the venous valves that regulate the blood circulation process is disrupted, a constant outflow of blood begins in the lower extremities downwards, against the upward movement, towards the heart, the first symptom appears - a feeling of heaviness in the legs.

If the disease develops, the pressure on the walls of blood vessels constantly increases, which leads to their thinning. Blockages of the veins can form, and if timely therapy is not started, trophic ulcers of the tissues surrounding the venous vessels can occur. Symptoms of varicose veins appear - swelling of the lower extremities, cramps at night, a clear venous pattern at the surface of the skin.

Symptoms

Symptoms of venous insufficiency depend on the form in which it occurs - acute (AVI) or chronic (CVI), severity, and stage of the disease. ROV of the lower extremities develops rapidly, accompanied by severe pain, swelling, and the appearance of a venous pattern on the skin. The main symptoms of CVI of the lower extremities are:

• systematic feeling of heaviness in the legs;
• muscle cramps at night and during rest;
• swelling;
• hypo- or hyperpigmentation skin, venous dermatitis;
• trophic ulcers, dryness, redness on the skin;
• dizziness, fainting.

Causes

The medical group of causes, that is, diseases and conditions due to which chronic venous insufficiency of the lower extremities develops, are diseases in which the functioning of the venous-muscular pump system is disrupted:

• phlebothrombosis;
• thrombophlebitis;
• congenital pathologies vascular system;
• injuries and serious damage to the lower extremities.

There are secondary, so-called non-modifying factors that are not the cause of AVI and CVI, but are at risk and can contribute to the development of the disease or worsening the patient’s condition. These include:

• genetic predisposition to illness;
• gender – women suffer from CVI on average three times more often than men, due to higher levels of the hormone estrogen;
• pregnancy, labor - the load on the venous vessels is increased, the hormonal levels in the woman’s body change;
• elderly age;
• overweight;
• low physical activity;
• regular hard physical work, heavy lifting.

Forms

There are acute and chronic forms of venous insufficiency of the lower extremities (there is also venous insufficiency of the brain). OVN is formed as a consequence of occlusion of the deep veins of the lower extremities, during thrombosis or injury to the legs. The subcutaneous vessels are not affected. The main symptom of AHF is severe pain, stopping after applying a cold compress, since cold reduces the volume of blood in the vessels.

CVI, on the contrary, affects veins located close to the surface of the skin, and is therefore accompanied by degenerative and pigmentation changes in the skin - dark spots, trophic ulcers. If treatment is delayed, the occurrence of vascular abnormalities such as pyoderma, blood clots, and ankle joint traffic pathologies becomes inevitable.

Classification of CVI

Exists international system CEAP classification of venous insufficiency. According to this system, there are three stages of CVI:

• CVI of the 1st degree – accompanied by pain, swelling, convulsions, the patient is bothered by a feeling of heaviness in the legs;
• CVI stage 2 – accompanied by eczema, dermatosclerosis, hyperpigmentation;
• CVI stage 3 – trophic ulcers on the skin of the lower extremities.

Diagnostics

To clarify clinical picture disease, establishing an accurate diagnosis and providing assistance, after an external examination, the doctor directs the patient to undergo the following tests:

• Ultrasound of the lower extremities;
• general analysis and blood biochemistry;
• phlebography.

Treatment of venous insufficiency of the lower extremities

Disturbance of the venous outflow of the lower extremities, called venous insufficiency, is treated with complex therapy, including:

• eliminating risk factors;
• drug therapy;
• correction of the patient's physical activity using therapeutic exercises;
• physiotherapy;
• surgical intervention;
• elastic compression method.

Drugs

Mechanism of treatment of CVI medicines produced depending on the stage of development of the disease. For the first degree of CVI, sclerotherapy is used - intravenous injection a drug that significantly reduces blood flow in the deformed area of ​​the vessel. During the second stage, therapy with drugs is used that increase the overall tone of the venous vessels and improve the circulation of adjacent tissues. In this case, the main results are achieved only after 3-4 months of treatment, and the total duration of the course is 6-8 months.

In the third stage, the patient needs complex treatment main symptoms and complications. Drugs are prescribed general spectrum actions and ointments for topical use. During the course of complex therapy, it is necessary to prescribe phlebotonics, non-steroidal anti-inflammatory drugs, anticoagulants, disaggregants and antihistamines. Preparations for external use are selected from the group of drugs containing corticosteroids.

It is important to prescribe the correct physiotherapeutic procedures and select a complex of therapeutic exercises. In most cases they are prescribed;

• electrophoresis;
• balneotherapy;
• diadynamic current.

Trophic ulcers accompanying the third stage are of a very dangerous type skin diseases, fraught nearby severe complications and the occurrence of infections. The patient is prescribed bed rest, prolonged antibacterial therapy, regular local hygienic treatment using antiseptics. To speed up the process, products containing natural herbal antiseptics - propolis, sea buckthorn - and wearing medical knitwear are recommended.

Folk remedies

In the initial stages of venous insufficiency of the lower extremities and as preventive measures to improve blood circulation and reduce painful sensations resort to folk remedies. Helps against illness:

• horse chestnut infusion;
• chamomile oil;
• alcohol tincture of fragrant rue;
• tincture of silver wormwood;
• compresses from thistle - thistle;
• wraps with whey;
• alcohol tincture of Kalanchoe.

To prevent venous insufficiency of the lower extremities, it is important to follow a dietary diet - avoid fried and fatty foods. It is recommended to eat foods that have anticoagulant properties:

• figs;
• seaweed;
• onion;
• tomatoes.

Compression therapy

Treatment with the elastic compression method involves two main points - wearing compression garments (strongly recommended for pregnant women) and bandaging the lower extremities with an elastic bandage. With the help of compression therapy, a significant improvement in the condition of a patient with venous insufficiency of the lower extremities is achieved according to the following signs:

• reduction of swelling;
• restoration of normal operation of the muscle-valve pump;
• improvement of tissue microcirculation and venous hemodynamics.

Bandages lose their elasticity after several washes, so they should be replaced on average every two to three months, and alternate with wearing compression stockings or long johns. Compression bandaging of the lower extremities is carried out according to the following rules:

• produced before lifting;
• the legs are bandaged from bottom to top, from the ankle to the middle of the thigh;
• The bandage should be tight, but pain and compression should not be felt.

Surgical intervention

When a patient comes to late stage development of venous insufficiency of the lower extremities, the doctor may prescribe the following type of surgery:

• sclerotherapy;
• laser irradiation;
• phlebectomy;
• abelation.

Prevention

To prevent venous insufficiency, it is practiced to reduce risk factors by maintaining an active lifestyle, adjusting eating habits, quitting smoking and alcohol, uncomfortable shoes and tight clothing. If there is a medical history and a genetic predisposition, it is recommended to undergo preventive ultrasound examinations veins for detection pathological symptoms and timely treatment of venous insufficiency.

Video: Chronic venous insufficiency

Attention! The information presented in the article is for informational purposes only. The materials of the article do not call for self-treatment. Only a qualified doctor can make a diagnosis and make treatment recommendations based on individual characteristics specific patient.

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Man is an upright walking creature. And we pay for vertical position 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. In the event that any process begins that interferes with the coordinated work of veins, valves and muscles, it develops pathological process, 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 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 various classifications chronic venous insufficiency, but the classification that has gained the most popularity is that any doctor, not being a vascular surgeon, can diagnose preliminary diagnosis to 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, the appearance pain syndrome. In the expanded stage, visible contours of veins and nodes are added, and at 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 absence 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 carry out additional functional tests(Troyanova-Trendelenburg with application of 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 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 functional state 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 diseases. But if venous insufficiency is diagnosed in the early stages, then it timely treatment may 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. Need to reset excess weight, eliminate long periods of time sitting or standing. Need to do daily hiking, and give up bad habits;
• Physiotherapy. Special complex exercises, most of which are carried out “with your legs up,” help normalize the outflow from the superficial veins to the deep ones, which prevents swelling of the limbs;
• 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 at healthy people, for example, during pregnancy and during prolonged stays in bed to prevent 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, 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 yes to yourself, 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.