Varicose veins on the thighs. Anatomy of the venous system

Many people confuse the concepts of vein and artery. Let's see how these two elements of the human circulatory system differ from each other before moving on to reviewing a specific part of it.

Heart

Signs of superficial femoral vein thrombosis are:

1. Swelling and pain in the legs, from the groin down.
2. Blueness of the skin on the legs.
3. The so-called petechial rash in the form of small red dots.
4. An increase in body temperature as a result of phlebitis - inflammation of the walls of the vessel.

With deep vein thrombosis, two stages are distinguished: white and blue phlegmasia. At the initial stage, due to impaired blood circulation, the skin of the leg becomes pale, cold to the touch, with severe pain.

Blue phlegmasia is a sign of overcrowding of venous vessels with blood. With it, the skin may darken, and swellings appear on its surface, which contain hemorrhagic fluid. With such symptoms, thrombosis risks flowing into acute gangrene.

Causes of deep vein thrombosis

Most often, deep vein thrombosis occurs when a vessel is compressed for a long time by a tumor or bone fragment during a fracture. Another reason for the formation of cork is a violation of blood circulation in certain diseases. Poorly circulating blood leads to stagnation and, accordingly, blood clots. The key causes of clogged veins are:

1. Decrease in the rate of blood circulation in the vessels.
2. Increased blood clotting time.
3. Damage to the walls of blood vessels.
4. Prolonged immobility, such as in severe illness.

Some professional activities have a negative impact on the condition of the veins. Sellers, cashiers, pilots, international drivers have a hard time. They are forced to stand or sit in one position for a long time. Therefore, they are at risk. Frequently recurring diseases that lead to dehydration, such as acute intestinal infections, accompanied by diarrhea and vomiting, chronic diseases of the intestines and pancreas. It also occurs against the background of excessive intake of drugs with a diuretic effect. Dangerous pathologies that cause an imbalance of fats and proteins, including diabetes, atherosclerosis, cancer. To increase the likelihood of platelets sticking together, bad habits lead: smoking, alcohol abuse.

Why is a femoral vein catheterization necessary? More on that below.

Diagnosis and treatment

Needless to say, the importance of timely diagnosis and medical or other intervention for DVT. To make an accurate diagnosis, it is necessary to do an ultrasound or dopplerography of the femoral vein. Such diagnostics will help determine the exact location of the thrombus and the degree of its fixation to the vessel wall. In other words, to understand whether it can come off and clog the vessel, and also cause pulmonary embolism or not. Also, when detecting DVT, the phlebography method is used - an x-ray with a contrast agent. However, the most accurate method to date is angiography. On the eve of the procedure, you must observe strict bed rest. Sometimes a puncture of the femoral vein is performed.

Treatment for DVT depends on the cause of the disease and the individual patient. If the vessel is not completely clogged and a thrombus is unlikely to break off, then conservative therapy is indicated. It is necessary to restore the patency of the veins, prevent the violation of the integrity of the thrombus and avoid vascular embolism. To achieve the above goals, special medicines, ointments, and compression therapy are used, for example, it is recommended to wear special compression stockings.

If the patient is in a satisfactory condition, but drug treatment is contraindicated for him, then surgical methods for the treatment of deep thrombosis are used. The operation is carried out on the latest equipment and is high-tech. Thrombectomy is prescribed when the risk of separation of a blood clot and blockage of the main vessels is not excluded. This plug is removed through a small incision by inserting a special catheter. During the operation, the “clogged” vessel is completely cleared, but recurrence is not ruled out.

To avoid thrombosis, you need to follow some rules and completely reconsider your lifestyle. It is recommended to give up bad habits, eat right, lead a physically active lifestyle, try to avoid injuries to the lower extremities, etc. We examined the femoral arteries and veins. Now you know how they differ and what they are.

Protruding veins on the legs are most often a sign. In women, the disease occurs more often than in men, which is explained by more frequent hormonal changes throughout life. I must say that this is not a cosmetic, but a medical problem, so treatment should not be limited to the elimination of ugly nodes. It is important to slow down the progression of the disease, which, unfortunately, is irreversible, and try to avoid severe complications.

I must say that if a vein on the leg came out, then this is not the earliest sign of varicose veins. Surely, before that, the first signals had already been received in the form of pain, heaviness in the legs, swelling in the evening, night cramps.

Why do leg veins protrude?

There are several reasons for this phenomenon, and it is not always a sign of illness. Sometimes the veins are visible in a healthy person: in this way the body can respond to certain loads. But most often the veins protrude due to pathological changes in the vessels.

• The most common cause is varicose veins, which are characterized by varicose veins and incompetence of the valvular apparatus. In the course of the disease, the walls of the veins lose their elasticity, become thinner, and stretch. Gradually, the vessels become tortuous, form knots that are translucent and protrude under the skin. Why varicose veins develop is not exactly known. It is believed that it is associated with weak veins and valves from birth, in addition, with age, natural wear and tear of tissues occurs.
• hereditary predisposition. If parents have varicose veins, it is likely that the pathology will be in children.
• Veins may be visible in overweight people. It affects the increased load on the vessels, due to which pathological changes occur.
• Pregnancy. During the period of gestation, many women complain that a vein has come out on their leg. This is due to the fact that the unborn child strongly presses on the vessels, as a result of which blood stagnates in them and varicose veins develop.
• There are risk factors in life. This applies to people who, by occupation, have to sit or stand for a long time (surgeons, hairdressers, salespeople, accountants, drivers, programmers, and others). The sitting position negatively affects the vessels of the lower extremities.
• With constantly high physical exertion (athletes, porters).
• Bad habits can also adversely affect the veins.

Pregnant women often find protruding veins

Treatment of protruding veins

As already mentioned, most often ugly knots on the legs are a symptom of varicose veins. To date, it is impossible to completely get rid of the disease, so treatment will be limited to curbing the progression and preventing complications that can lead to disability.

If a person has protruding veins on the lower extremities, he will live with this problem all his life, which means that you need to learn how to keep the disease under control. Only complex treatment can help in this, which includes:

• Lifestyle change.
• Elimination of harmful factors.
• Proper nutrition.
• Compression therapy.
• Medical treatment.
• folk methods.
• Operational intervention.
• Modern minimally invasive methods.

Medical therapy

For the treatment of varicose veins, drugs are prescribed for internal and local use. These are venotonics and anticoagulants. Of the tablets most often prescribed:

• Detralex;
• Venarus;
• Troxerutin;
• Troxevasin.

Phlebodia is a popular and effective drug for varicose veins

Of the external agents, the most effective are:

• heparin ointment;
• gel Lyoton;
• Troxevasin;
• Troxerutin.

These remedies will not get rid of protruding veins, but they will help to stop the disease. They strengthen the vascular walls, relieve swelling, improve microcirculation, and normalize blood circulation.

ethnoscience

Many people prefer to use folk remedies, because they are considered natural, and therefore harmless. For the treatment of varicose veins at an early stage, decoctions and infusions are used for internal use and for compresses. They are prepared on the basis of plants such as chestnut, acacia, birch buds, nettle.

Apple cider vinegar is considered an effective remedy, which is mixed with water in a ratio of 1 to 10 and wiped with sore spots.

An infusion is prepared from nettles, which is drunk three times a day. Two tablespoons of chopped herbs require a glass of boiling water. After insisting, the infusion must be filtered and cooled. Nettle has contraindications, so it is undesirable to use folk remedies on your own, you need to consult a doctor.

Another popular remedy is an alcohol tincture of chestnut. To prepare it, you need to take 50 grams of fruits with a peel, chop and pour vodka (0.5 l). Insist for a week in a dark place. When the tincture is ready, take 10 drops four times a day.

For the treatment of varicose veins, tinctures, decoctions, ointments, foot baths are prepared from chestnut

How to remove protruding veins

Conservative methods help to stop the disease and eliminate unpleasant symptoms, but they cannot get rid of the veins that appear under the skin.

Non-surgical methods

To remove varicose veins, you need to resort to other methods. Sclerotherapy is considered one of the most common and effective methods today. The essence of the procedure is the introduction of a sclerosing drug into the affected vessel, which destroys it, and gradually it resolves. As a rule, several sessions are required.

Sclerotherapy rarely leads to complications and is the most accessible to most patients, therefore it remains the most commonly used method of dealing with varicose veins.

Surgery

Today, classical surgery is performed only in the most extreme cases. Doctors try to use minimally invasive methods.

Phlebectomy is now done less and less, it has been replaced by a less traumatic operation - miniphlebectomy, during which the affected vein is removed through punctures. After treatment, no scars remain, patients recover quickly.

Another less traumatic method is laser coagulation. The treatment consists in introducing a light guide into the vessel and exposing the affected vein to a laser beam, after which it closes, and blood does not circulate through it.

With the help of short stripping, not the entire vein is removed, but only the affected area. The operation is done through two incisions, the recovery of the patient takes only a few days.

Miniphlebectomy is less traumatic than classical varicose vein surgery

Prevention

It is very important, especially if there are relatives with varicose veins or the first signs of the disease have already appeared. Prevention involves compliance with the following rules:

1. Engage in physical education and sports (a sedentary lifestyle is detrimental to blood vessels).
2. Eat right, include in the diet more foods rich in vitamins A, C, E.
3. During sedentary work, try to get up periodically, and also do a simple exercise: raise your legs and bend them at the ankle joint alternately towards yourself and away from you.
4. Choose comfortable, not tight shoes and refuse high heels.
5. Use compression stockings or pantyhose for long flights or car rides.
6. If possible, try to sit or lie down, raising your legs above the level of your heart.
7. Rinse your feet with cool water.
8. Refuse to visit baths and saunas, do not take hot baths, do not put your feet in direct sunlight.
9. Do not sit cross-legged.

Conclusion

If veins began to protrude on the legs, you need to contact a phlebologist as soon as possible. Early diagnosis and timely treatment will help prevent the progression of the disease, which most often leads to severe complications: thrombophlebitis, phlebitis, thrombosis.

According to statistics, varicose veins are more related to the female sex, especially if it concerns women of the most interesting age after 40 years. However, despite this, young women should also be more careful, especially since the disease is getting younger. Often its appearance is preceded by pregnancy, long-term use of hormonal drugs, including contraceptives.

In addition to the fact that the disease is accompanied by pain, it frightens precisely with its cosmetic effect. This refers to the fact that varicose veins do not spare the most important part of the body of any woman, namely the legs. Women try to keep them in shape, but varicose veins can ruin them for many years. Especially often, varicose veins affect the upper part of the legs - the thigh. Varicose veins of the thigh are the most common and cause the most inconvenience.

These are very tender places, and if treatment is not done in a timely manner, then a disease that begins quite harmlessly can lead to very serious consequences. Therefore, try to identify if you have varicose veins in the early stages, when it can be easily and often completely painless treatment.

At this stage, you can overcome the disease even without surgery. The main thing is to find out in time. If you often have to stand still, for example, if you work as a salesman, or if you have to work at a computer, when you come home in the evening, you need to listen to your feelings. Pain in the legs, heaviness when walking may already indicate that varicose veins are somewhere nearby.

At first, this is exactly how it manifests itself and does not have any external manifestations. If you have not missed this moment, then you are already lucky. Considering that varicose veins in itself is not a terrible disease, treatment in your case will be limited to the use of inexpensive medicines, diet and rational physical activity will not be superfluous. Varicose veins on the hips manifest themselves in different ways at different stages.

In the first, initial stages, as mentioned above, it manifests itself only in the form of pain in the limbs. It goes away after a short rest or taking a warm bath.

If you are unlucky and time is lost for some reason, the next stage of varicose veins will already appear visually in the form of an ugly blue grid. A lot of still thin veins lie, as it seems to us, on top. It usually occurs on the inner thigh. With this, too, local therapy, ointments, compresses and compression underwear can most often cope.

The next stage may be the appearance of seals, swelling of the veins, which is manifested by the formation of nodes of various lengths and shapes. At this stage, your hips will be helped by sclerotherapy or laser photocoagulation. Both methods are painless and able to cope with the disease.

If this happened, and you started the treatment of the disease in the initial stages, the skin can weaken and the result of this can be the appearance of varicose ulcers, which cause a lot of trouble, especially when it comes to the delicate inner surface of the thigh.

The most common cause of protruding veins, and not only on the legs, is varicose veins. Women are more susceptible to the negative effects of the disease than men, so 7 out of 10 patients are girls. This is due to changes in hormonal levels and strong pressure in the intra-abdominal cavity during pregnancy. The problem has not only a cosmetic manifestation, but also means serious deviations in health, the state of health worsens significantly, and in some cases causes a fatal outcome. At the initial stages, it is most important to slow down the progress of varicose veins, then bulging veins on the legs will not appear for a long time.

If the veins on the legs bulge out - this is the first sign of varicose veins, you should take this symptom with sufficient seriousness and make an appointment with a doctor.

Symptoms and causes of protruding veins in the legs

There are a lot of reasons why leg veins protrude, some depend on lifestyle and can be eliminated without much difficulty, others are caused by genetic changes in the structure of the body and require treatment. If the veins on the legs protrude, then the causes most often come down to certain pathological abnormalities in the body and are triggered by an unhealthy lifestyle.

1. The most common cause is varicose veins, which are characterized by varicose veins due to any deficiencies in the vascular valves. During the course of the disease, the walls lose their elasticity, can become significantly thinner, which leads to an increase in their volume. If the veins protrude on the legs, then knots have probably already formed, the veins have become tortuous, and deviations are observed in the membranes. Most experts point to congenital causes of pathology;
2. hereditary factor. It is highly likely that if the veins on the legs of the parents stand out, the children will also suffer from this disease;
3. Obesity. In overweight people, vessels appear much more often, as excess pressure is created on the veins;
4. Pregnancy creates many reasons for the veins in the legs to show through. The load on the legs increases, and quite significantly. Also, due to the difficulty of maintaining an active lifestyle, many spend time sitting or standing on their feet, which creates static loads. A large pressure is formed in the abdominal cavity, which inevitably affects the vessels of the legs. Often the placenta presses on certain veins, which slows down the blood flow in it. The hormonal background plays an important role;
5. Job. Some types of work provoke a long stay in one place in a sitting or standing position, then veins protrude on the legs due to a lack of blood circulation, which provokes a reverse, or stagnation;
6. Strong physical loads;
7. Destructive influence from bad habits.

It is worth consulting a doctor after the first symptoms of the disease are detected. At the beginning, small manifestations are observed or they are completely absent. In the future, the veins stand out and protrude strongly over time. Even at the first stages of the course of the disease, you need to know which doctor to contact - this is a vascular surgeon or a phlebologist.

If the primary symptoms are ignored on the legs, then a feeling of heaviness, increased tension begins. Seizures often occur at night. Then comes a noticeable stage of the disease, the veins begin to protrude, while they bend and increase in diameter. The presence of protruding vessels is a good reason to start treating varicose veins, otherwise pain will begin to appear over time.

Protruding veins are a stage of varicose veins

The causes and treatment of protruding veins largely depend on the type of disease. In fact, few diseases have a similar specific manifestation and it is impossible to confuse varicose veins with other diseases. For reliability, you can study the photo. When the veins begin to stand out, it is important to know what to do in this case, what kind of disease this is - varicose veins.

Varicose veins are characterized by an increase in the volume of blood vessels. This is provoked due to stagnation of blood or increased pressure on the vessels. As the load on the veins increases, they become larger, as the walls lose some of their properties. With a significant expansion, the formation of blood clots in the lumen of the affected vein is possible, especially often observed due to the strong density of the blood. In other cases, trophic ulcers may appear.

People seek help not only because of an aesthetically ugly appearance, but also to prevent the development of the disease. If you start treatment in the initial stages, then it is possible to eliminate the disease without surgical intervention or prevent the onset of serious consequences.

Treatment methods for varicose veins

There are several basic methods for removing varicose veins, it greatly depends on the stage of the disease and the type of complications.

1. conservative approach. Medications are used, usually tablets or creams. This option for dealing with protruding veins is used in the light and medium stages of the course. It can significantly alleviate symptoms and prevent further development of the disease. The expansion of the vein itself is irreversible, therefore, if you want to completely eliminate the vein, you will have to do an operation;
2. surgical approach. It is used at advanced stages, the conclusion about the appropriateness of the technique is made by a specialist;
3. Folk remedies. They are often only added to therapy or used when only a little vein is oozing out.

External preparations

Women experience severe discomfort in the presence of diseases of the feet, legs and hips, as they greatly deteriorate the aesthetic appearance of the legs. In such cases, manifestations can be reduced through a simple approach - applying creams.

1. Phlebotonics improve the quality of blood vessels and relieve unpleasant symptoms of the disease. Among the best niche drugs can be identified

   Varius, Detralex, Troxevasin and Venoruton;

2. Anticoagulants prevent the formation of blood clots in stagnant, swollen veins. At the same time, the blood liquefies, which improves its outflow and eliminates the formation of edema. Recommended for use -

   Varius, Venolife, Curantil, Heparin ointment, Lyoton 1000;

3. Anti-inflammatory drugs are prescribed to eliminate the infection. The drugs Indomethacin and Diclofenac are used.

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Preparations

For the treatment of varicose veins, special agents are indicated for use, they are used as soon as a vein begins to appear or certain pathologies are detected. Of the tablets, venotonics and anticoagulants are most often prescribed. Trade marks:

1. Detralex has an angioprotective effect, while it belongs to phlebotonics. It has no contraindications, except for allergies. It is used 2 tablets per day, which are used 1-2 times;
2. Phlebodia has a venotonic effect and helps to reduce congestion in the body, increases vascular tone. Used 1 tablet 1 time per day, drink in the morning on an empty stomach. Course 2 months;
3. Venarus includes the properties of angioprotectors and phlebotonics. Contraindicated for use in lactation. Apply 1-2 tablets 2 times a day;
4. Troxevasin acts as an angioprotector. It should not be used for ulcers in the gastrointestinal tract, gastritis, I trimester of pregnancy. Drink 1 pill three times a day.

Surgical intervention in the classical view today is carried out only in extreme cases. In most cases, preference is given to minimally invasive methods of treatment. A facilitated operation to remove a vein today can be performed through punctures - this is a miniphlebectomy. After the procedure, even scars do not remain and general anesthesia is not required.

Laser coagulation allows you to clog the vessel by introducing a small LED. Heat acts on the blood, and it clogs the vein, which prevents the circulation of fluid and gradually eliminates the external manifestation of the vessel. The radio frequency method has an approximately similar appearance, only a different device is introduced.

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Treatment methods for the advanced stage

Treatment of the disease in an advanced stage is not an easy task, because with the growth of symptoms and manifestations, it is possible to attach other life-threatening or health manifestations. The great danger lies in the high risk of complications, for example, thrombophlebitis, trophic ulcers. In this case, the treatment must be carried out under the supervision of a physician.

It is much easier to carry out therapy in the initial stages, since the use of creams or tablets is sufficient. At the advanced stages, you will have to combine many drugs at once, sometimes there is nothing left but expensive drugs. If necessary, an operation is performed, capsules, creams, diets, physical education and wearing compression underwear are used.

Often used tablets with a venotonic effect and anticoagulants, such as Detralex and Troxevasin.

Treatment with folk remedies

For treatment, make a tincture or decoction of acacia, nettle, chestnut, birch buds. 2 tbsp raw materials are used for 0.5 liters of vodka and infused for 2 weeks. Such lotions are laid at night.

Apple cider vinegar is considered an effective remedy, diluted with water 1 to 10 and you can both drink it and wipe the skin.

You can prepare a decoction of nettles: 2 tbsp. plants in 1 cup boiling water. Drink 50 ml twice a day.

Prevention

1. Physical education, gymnastics;
2. Diet;
3. Perform warm-ups at work;
4. Take vitamins;
5. Wear comfortable clothes and shoes;
6. Use compression stockings;
7. Periodically throw your legs up for a few minutes;
8. To refuse from bad habits;
9. Do not use hot baths, saunas, baths.

Do you still think that getting rid of varicose veins is difficult?

The advanced stage of the disease can cause irreversible consequences, such as: gangrene, blood poisoning. Often the life of a person with an advanced stage can only be saved by amputation of a limb.

In no case should you start the disease!

PhD V.A. Kiyashko

This type of pathology is a very common disease of the venous system, which is faced by a doctor of any specialty.

Currently, in medical practice, terms such as phlebothrombosis and varicothrombophlebitis are also often used. All of them are legal to use, but the following points should be considered. Phlebothrombosis is considered as an acute obstruction of a vein as a result of hypercoagulation, which is the leading mechanism. But at the same time, after 5–10 days, the thrombus that has arisen causes reactive inflammation of the tissues surrounding the vein with the development of phlebitis, that is, phlebothrombosis is transformed into

The term "varicothrombophlebitis" clearly indicates the actual cause of thrombosis that occurs against the background of varicose veins already present in the patient.

The pathology of the venous system listed above in the vast majority of clinical cases occurs in the large system and much less often in the system of the small saphenous vein.

Thrombophlebitis of the veins in the upper extremities is extremely rare, and the main provoking factors for their occurrence are multiple punctures for the administration of drugs or a long stay of the catheter in a superficial vein.

Particular attention should be paid to patients with spontaneously occurring blood clots in the upper and lower extremities, not associated with iatrogenic exposure. In such cases, the phenomena of thrombophlebitis can be suspected as a manifestation of a paraneoplastic reaction due to the presence of an oncological pathology in the patient, requiring an in-depth multifaceted examination.

Thrombus formation in the system of superficial veins is provoked by the same factors that cause thrombosis of the deep venous system of the lower extremities. These include: age over 40 years, the presence of varicose veins, cancer, severe disorders of the cardiovascular system (cardiac decompensation, occlusion of the main arteries), physical inactivity after major operations, hemiparesis, hemiplegia, obesity, dehydration, banal infections and sepsis, pregnancy and childbirth, taking oral contraceptives, trauma to the limbs and surgical interventions in the area of ​​passage of the venous trunks.

Thrombophlebitis can develop in any part of the superficial venous system . with the most frequent localization on the lower leg in the upper or middle third, as well as the lower third of the thigh. The overwhelming number of cases of thrombophlebitis (up to 95–97%) was noted in the basin of the great saphenous vein (Kabirov A.V. et al. Kletskin A.E. et al. 2003).

Further development of thrombophlebitis can actually go in two ways:

1. Relatively favorable course of the disease . against the background of the treatment, the process stabilizes, thrombus formation stops, inflammation subsides, and the process of thrombus organization begins, followed by recanalization of the corresponding section of the venous system. But this cannot be considered a cure, because. there is always damage to the initially altered valvular apparatus, which further aggravates the clinical picture of chronic venous insufficiency.

Clinical cases are also possible when a fibrous thrombus densely obliterates a vein and its recanalization becomes impossible.

2. The most unfavorable and dangerous option in terms of the development of complications of a local nature - ascending thrombosis along the great saphenous vein to the oval fossa or the transition of the thrombotic process through the communicating veins to the deep venous system of the lower leg and thigh.

The main danger of the course of the disease according to the second variant is the threat of developing such a complication as pulmonary embolism (PE), the source of which can be a floating thrombus from the system of a small or large saphenous vein, as well as secondary deep vein thrombosis of the lower extremities.

It is quite difficult to judge the frequency of thrombophlebitis among the population, but if we take as a basis the position that among the patients hospitalized in the surgical departments with this pathology, more than 50% had varicose veins, then taking into account the millions of patients with this pathology in the country, this figure looks very impressive and the problem is of great medical and social importance.

The age of patients ranges from 17 to 86 years and even older, and the average age is 40–46 years, that is, the working-age population.

Given the fact that with thrombophlebitis of the superficial veins, the general condition of the patient and well-being, as a rule, do not suffer and remain quite satisfactory, this creates the illusion of relative well-being and the possibility of various self-treatment methods for the patient and his relatives.

As a result, such behavior of the patient leads to late accessibility for qualified medical care, and often the surgeon is faced with already complicated forms of this “simple” pathology, when there is a high ascending thrombophlebitis or deep vein thrombosis of the limb.

Clinical picture

The clinical picture of the disease is quite typical in the form of local pain in the projection of the saphenous veins at the level of the lower leg and thigh with the involvement of the tissues surrounding the vein in the process, up to the development of a sharp hyperemia of this zone, the presence of seals not only in the vein, but also in the subcutaneous tissue. The longer the zone of thrombosis, the more pronounced the pain in the limb, which forces the patient to limit its movement. Hyperthermic reactions in the form of chills and an increase in temperature up to 38-39 ° C are possible.

Quite often, even a banal acute respiratory disease becomes a provocative moment for the occurrence of thrombophlebitis, especially in patients with varicose veins of the lower extremities.

Inspection is always carried out from two sides - from the foot to the inguinal zone. Attention is drawn to the presence or absence of pathology of the venous system, the nature of the discoloration of the skin, local hyperemia and hyperthermia, swelling of the limb. Severe hyperemia is typical for the first days of the disease, it gradually decreases by the end of the first week.

With the localization of thrombophlebitis in the small saphenous vein, local manifestations are less pronounced than with damage to the trunk of the great saphenous vein, which is due to the peculiarities of the anatomy. The superficial sheet of the own fascia of the lower leg, covering the vein, prevents the transition of the inflammatory process to the surrounding tissues. The most important point is to find out the period of appearance of the first symptoms of the disease, the speed of their increase, and whether the patient has attempted to influence the process with medication.

So, according to A.S. Kotelnikova et al. (2003), the growth of a thrombus in the system of the great saphenous vein goes up to 15 cm per day. It is important to remember that in almost a third of patients with ascending thrombosis of the great saphenous vein, its true upper limit is located 15–20 cm above the level determined by clinical signs (V.S. Savelyev, 2001), that is, this fact should consider each surgeon when consulting a patient with thrombophlebitis of a vein at the level of the thigh, so that there is no unreasonable delay in the operation aimed at preventing PE.

It should also be considered inappropriate to locally administer anesthetics and anti-inflammatory drugs to the area of ​​a thrombosed vein on the thigh, since, by stopping pain, this does not prevent the growth of a thrombus in the proximal direction. Clinically, this situation becomes difficult to control, and duplex scanning can really only be used in very large medical institutions.

Differential Diagnosis should be carried out with erysipelas, lymphangitis, dermatitis of various etiologies, erythema nodosum.

Instrumental and laboratory diagnostics

For a very long time, the diagnosis of thrombophlebitis of superficial veins was made by a doctor on the basis of only the clinical symptoms of the disease, since in fact there were no non-invasive methods for characterizing venous blood flow. The introduction of ultrasound diagnostic methods into practice has opened a new stage in the study of this common pathology. But the clinician must know that among the ultrasound methods for diagnosing venous thrombosis, duplex scanning plays a decisive role, since only with its help it is possible to determine the clear boundary of thrombosis, the degree of thrombus organization, the patency of deep veins, the state of the communicants and the valvular apparatus of the venous system. Unfortunately, the high cost of this equipment still sharply limits its practical use in outpatient and inpatient settings.

This study is indicated primarily for patients with suspected embologenic thrombosis, that is, when there is a transition of a thrombus from the superficial venous system to the deep one through the sapheno-femoral or sapheno-popliteal fistula.

The study can be carried out in several projections, which significantly increases its diagnostic value.

Phlebographic study

The indication to it is sharply narrowed. The need for its implementation arises only in the case of a blood clot spreading from the great saphenous vein to the common femoral and iliac vein. Moreover, this study is performed only in cases where the results of duplex scanning are doubtful and their interpretation is difficult.

Laboratory diagnostic methods

In a routine clinical blood test, attention is drawn to the level of leukocytosis and the level of ESR.

It is desirable to study C-reactive protein, coagulogram, thrombelastogram, the level of the prothrombin index and other indicators characterizing the state of the coagulation system. But the scope of these studies is sometimes limited by the capabilities of the laboratory service of a medical institution.

One of the important points that determine the outcome of the disease and even the fate of the patient is the choice of tactics for the optimal treatment option for the patient.

With the localization of thrombophlebitis at the level of the lower leg, the patient can be treated on an outpatient basis, being under the constant supervision of a surgeon. Under these conditions, it is necessary to explain to the patient and his relatives that if signs of thrombosis spread to the level of the thigh appear, the patient may need to be hospitalized in a surgical hospital. Delay in hospitalization is fraught with the development of complications, up to the occurrence of PE.

In cases where thrombophlebitis at the level of the lower leg, treated for 10-14 days, does not regress, there should also be a question of hospitalization and more intensive therapy for the disease.

One of the main issues in the treatment of patients with thrombophlebitis of superficial veins is the discussion the patient's need for strict bed rest .

Currently, it is a recognized fact that strict bed rest is indicated only for patients who already had clinical signs of PE or have clear clinical data and instrumental findings indicating the embologenic nature of thrombosis.

The motor activity of the patient should be limited only by severe physical activity (running, lifting weights, performing any work that requires significant muscle tension in the limbs and abdominals).

General principles for the treatment of thrombophlebitis of superficial veins

These principles are indeed common for both conservative and surgical treatment of this pathology. The main goals of treatment these patients are:

· As quickly as possible to act on the focus of thrombosis and inflammation to prevent its further spread.

· Try to prevent the transition of the thrombotic process to the deep venous system, which significantly increases the risk of developing PE.

Treatment should be a reliable method of preventing recurrent thrombosis of the venous system.

The method of treatment should not be strictly fixed, since it is determined primarily by the nature of the ongoing changes in the limb in one direction or another. That is, the transition or addition of one treatment method to another is quite logical.

Undoubtedly, conservative treatment shown to the vast majority of patients with "low" superficial thrombophlebitis of the saphenous veins.

Once again, it should be emphasized that reasonable motor activity of the patient improves the function of the muscle pump, which is the main determining factor in ensuring venous outflow in the system of the inferior vena cava.

The use of external compression (elastic bandage, stockings, tights) in the acute phase of inflammation can cause some discomfort, so this issue should be addressed strictly individually.

Quite controversial is the question of the use of antibiotics in this category of patients. The doctor should be aware of the possible complications of this therapy (allergic reactions, intolerance, provocation of blood hypercoagulability). Also, the question of the advisability of using anticoagulants (especially direct action) in this contingent of patients is far from unambiguously resolved.

The doctor must remember that the use of heparin after 3-5 days can cause thrombocytopenia in the patient, and a decrease in the number of platelets by more than 30% requires discontinuation of heparin therapy. That is, there are difficulties in monitoring hemostasis, especially on an outpatient basis. Therefore, it is more appropriate to use low molecular weight heparins (dalteparin, nadroparin, enoxaparin), since they rarely cause the development of thrombocytopenia and do not require such careful monitoring of the coagulation system. Positive is the fact that these drugs can be administered to the patient 1 time per day. 10 injections are enough for a course of treatment, and then the patient is transferred to indirect anticoagulants.

In recent years, ointment forms of heparin (lyoton-gel, Gepatrombin) have appeared for the treatment of these patients. Their main advantage is rather high doses of heparin, which are delivered directly to the focus of thrombosis and inflammation.

Of particular note is the targeted effect on the area of ​​thrombophlebitic changes of the drug Hepatrombin ("Hemofarm" - Yugoslavia), produced in the form of an ointment and gel.

Unlike Lyoton, it contains 2 times less heparin, but additional components - allantoin and dexpanthenol, which are part of the Hepatrombin ointment and gel, as well as pine essential oils, which are part of the gel, have a pronounced anti-inflammatory effect, reduce the effects of skin itching. and local pain in the area of ​​thrombophlebitis. That is, they contribute to the relief of the main symptoms of thrombophlebitis. The drug Hepatrombin has a strong antithrombotic effect.

It is applied topically by applying a layer of ointment to the affected areas 1-3 times a day. In the presence of an ulcerative surface, the ointment is applied in the form of a ring up to 4 cm wide around the perimeter of the ulcer. The good tolerability of the drug and the versatility of its impact on the pathological focus puts this drug at the forefront in the treatment of patients with thrombophlebitis both on an outpatient basis and in hospital treatment. Gepatrombin can be used in a complex of conservative treatment or as a means aimed at stopping inflammation of the venous nodes after the Troyanov-Trendelenburg operation, as a method of preparing for the second stage of the operation.

The complex of conservative treatment of patients should include non-steroidal anti-inflammatory drugs . also have analgesic properties. But the clinician must remember to exercise extreme caution when prescribing these drugs to patients with diseases of the gastrointestinal tract (gastritis, peptic ulcer) and kidneys.

Well-established in the treatment of this pathology is already well known to doctors and patients phlebotonics (rutoside, troxerutin, diosmin, ginkgo biloba and others) and disaggregants (acetylsalicylic acid, pentoxifylline). In severe cases, with extensive phlebitis, intravenous transfusions of 400–800 ml of rheopolyglucin intravenously are indicated for 3 to 7 days, taking into account the patient's cardiac status due to the risk of hypervolemia and the threat of pulmonary edema.

Systemic enzyme therapy in practice has limited application due to the high cost of the drug and a very long course of treatment (from 3 to 6 months).

Surgery

The main indication for surgical treatment of thrombophlebitis, as previously mentioned, is the growth of a thrombus along the great saphenous vein above the middle third of the thigh or the presence of a thrombus in the lumen of the common femoral or external iliac vein, which is confirmed by phlebography or duplex scanning. Fortunately, the latter complication is not so common, only in 5% of patients with ascending thrombophlebitis (I.I. Zatevakhin et al. 2003). Although individual reports indicate a significant frequency of this complication, reaching even 17% in this group of patients (N.G. Khorev et al. 2003).

Anesthesia methods - different options are possible: local, conduction, epidural anesthesia, intravenous, intubation anesthesia.

The position of the patient on the operating table is of some importance - the foot end of the table should be lowered.

The generally accepted operation for ascending thrombophlebitis of the great saphenous vein is Troyanov-Trendelenburg operation .

The surgical approach used by most surgeons is quite typical - an oblique incision below the inguinal fold according to Chervyakov or the inguinal fold itself. But at the same time, it is important to take into account the main clinical point: if there are instrumental data or clinical signs of a thrombus moving into the lumen of the common femoral vein, then it is more advisable to use a vertical incision that provides control over the thrombosed great saphenous vein and the trunk of the common femoral vein, when sometimes it is required to clamp it on time of thrombectomy.

Some technical features of the operation:

1. Mandatory isolation, intersection and ligation of the trunk of the great saphenous vein in the area of ​​its mouth.

2. When opening the lumen of the great saphenous vein and detecting a thrombus in it that goes beyond the level of the ostial valve, the patient must hold his breath at the height of inspiration during surgery under local anesthesia (or this is done by an anesthesiologist with other types of anesthesia).

3. If the thrombus "is not born on its own", then a balloon catheter is carefully inserted through the saphenofemoral fistula at the height of inhalation and thrombectomy is performed. Retrograde blood flow from the iliac vein and antegrade from the superficial femoral vein are checked.

4. The stump of the great saphenous vein must be sutured and tied up; it must be short, since a too long stump is an “incubator” for the occurrence of thrombosis, which creates a threat of PE.

In order to discuss options for this routine operation, it should be noted that some surgeons suggest performing thrombectomy from the great saphenous vein in the Troyanov-Trendelenburg operation, and then injecting a sclerosant into it. The feasibility of such manipulation is questionable.

The second stage of the operation - the removal of thrombosed varicose veins and trunks is performed according to individual indications in terms of 5-6 days to 2-3 months as local inflammation is relieved, in order to avoid suppuration of wounds in the postoperative period, especially with trophic skin disorders.

When performing the second stage of the operation, the surgeon must necessarily ligate the perforating veins after preliminary thrombectomy, which improves the healing process.

All conglomerates of varicose veins are to be removed in order to avoid the development of gross trophic disorders in the future.

Surgical treatment of this group of patients is carried out by a very wide range of general surgeons and angiosurgeons. The seeming simplicity of treatment sometimes leads to tactical and technical errors. Therefore, this topic is almost constantly present at scientific conferences.

Literature:

5. Revskoy A.K. "Acute thrombophlebitis of the lower extremities" M. Medicine 1976

6. Saveliev V.S. Phlebology 2001

7. Khorev N.G. "Angiology and Vascular Surgery" No. 3 (Appendix) 2003, pp. 332-334.

& Garbuzenko Dmitry Victorovich, Doctor of Medicine, professor

Diseases of the veins of the lower extremities

Chronic venous disease is a collective term that includes all morphological and functional disorders of the venous system. The main nosological forms of chronic venous diseases are varicose veins of the lower extremities, reticular varicose veins and/or telangiectasias, post-thrombotic disease of the lower extremities, angiodysplasia (phlebodysplasia).

Epidemiology

Chronic venous disease is the most common pathology of peripheral vessels. According to various epidemiological studies, they suffer from 20% (at a young age) to 80% (in older age groups) of the population. Complications of chronic venous diseases. which include trophic disorders of the skin and subcutaneous fat, as well as thrombophlebitis of superficial veins, are recorded in 15-20% of patients.

The term "chronic venous insufficiency" is currently used to refer to situations accompanied by a significant dysfunction of the venous system with the development of venous edema and trophic disorders (hyperpigmentation, lipodermatosclerosis, trophic ulcer) in patients with chronic venous diseases. The frequency of chronic venous insufficiency in relation to all cases of chronic venous pathology ranges from 10-15% (trophic disorders) to 40% (edema).

Classification

In international and Russian phlebological practice, the CEAP classification of chronic vein diseases, created in 1994 by a group of experts from the American Phlebological Forum, is used. It includes clinical, etiological, anatomical and pathophysiological sections. In everyday work, the first section of the classification is most actively used, which allows a detailed description of the patient's status.

CEAP is an abbreviation consisting of the first letters of the names of sections of the classification.

C - clinical class of the disease:

C0 - no visible or palpable signs of venous disease.

C1 - telangiectasias and reticular varices. Telangiectasias are dilated intradermal venules less than 1 mm in diameter. Reticular veins - from 1 to 3 mm. They are usually tortuous. The exception is normal visible veins in people with thin, translucent skin.

C2 - varicose saphenous veins with a diameter of 3 mm or more.

C3 - swelling of the lower limb, often at the level of the ankle, but may spread to the lower leg and thigh.

C4a Hyperpigmentation or eczema. Hyperpigmentation is characterized by a characteristic brownish discoloration of the skin, usually in the ankle area, but may extend to the lower leg. Eczema is an erythematous dermatitis that can progress to blisters, weeping eczema, delamination and damage to the integrity of the skin of the lower leg.

C4b - lipodermatosclerosis - in the area of ​​chronic inflammation, fibrosis of the skin and subcutaneous tissues of the leg is formed. Sometimes white skin atrophy develops, which is manifested by localized round or stellate areas of ivory skin surrounded by dilated capillaries, and sometimes with areas of hyperpigmentation. This is a sign of a severe violation of the venous outflow.

C5 - healed trophic ulcer.

C6 - open trophic ulcer - a local defect of the skin throughout the entire thickness, most often in the ankle area, which do not heal spontaneously.

If the patient has subjective manifestations of chronic venous diseases (pain, heaviness, fatigue, feeling of swelling, etc.), the letter S (symptomatic course) is added to the disease class, for example, C2S. In the absence of complaints, add A (asymptomatic course).

When describing the clinical status, you can use both an abbreviated (for example, C4aS - the most pronounced objective sign of the disease in this case is skin hyperpigmentation, in addition, the patient has subjective symptoms), and an extended version of the classification (C,2,3,4aA - in the patient found varicose saphenous veins, edema and trophic disorders, no subjective symptoms). The use of an extended version of the classification makes it possible to most fully describe the clinical status of the patient, and after the treatment, evaluate its changes in the dynamics.

E - the etiology of the disease:

Es is a congenital disease.

Ep is primary.

Es - secondary - violations of the venous outflow, as a result of another pathology, for example, after venous thrombosis or trauma.

En - if the origin of the venous disease is not established.

A - anatomical localization of the disease:

As - superficial veins, which are contained in the subcutaneous tissue of the lower extremities.

Ap - perforating veins - connecting superficial and deep veins.

An - no changes in the venous system.

P - pathophysiology, indicates the type of disorder:

Pr - venous reflux - damage to the venous valves.

Po - venous obstruction - obstruction or complete cessation of flow in a vein.

Pr, o - combination of venous reflux and obstruction.

Pn - violations of the venous outflow was not detected.

The number indicates the corresponding anatomical segment. There are 18 of them in total: 1 - telangiectasia and reticular veins; 2 - a large saphenous vein on the thigh; 3 - a large saphenous vein on the lower leg; 4 - small saphenous vein; 5 - changes outside the basin of the great and small saphenous veins; 6 - inferior vena cava; 7 - common iliac vein; 8 - internal iliac vein; 9 - external iliac vein; 10 - pelvic veins; 11 - common femoral vein; 12 - deep vein of the thigh; 13 - superficial femoral vein; 14 - popliteal vein; 15 - tibial and peroneal veins; 16 - muscular veins (sural sinuses, etc.); 17 - perforating veins of the thigh; 18 - perforating veins of the leg.

The variety of forms of chronic venous diseases requires an individual approach to the choice of treatment. An accurate diagnosis is possible on the basis of ultrasound diagnostics of the veins.

SURGICAL ANATOMY OF THE LOWER LIMB VEINS

The anatomical structure of the venous system of the lower extremities is highly variable. Knowledge of the individual characteristics of the structure of the venous system plays an important role in assessing the data of instrumental examination in choosing the right method of treatment.

The veins of the lower extremities are divided into superficial and deep.

Superficial veins of the lower limb

The superficial venous system of the lower extremities begins from the venous plexuses of the toes, which form the venous network of the dorsum of the foot and the skin dorsal arch of the foot. From it originate the medial and lateral marginal veins, which pass into the great and small saphenous veins, respectively. The plantar venous network anastomoses with the deep veins of the fingers, metatarsus, and with the dorsal venous arch of the foot. Also, a large number of anastomoses are located in the area of ​​the medial malleolus.

The great saphenous vein is the longest vein in the body, contains from 5 to 10 pairs of valves, normally its diameter is 3-5 mm. It originates in front of the medial epicondyle and rises in the subcutaneous tissue behind the medial edge of the tibia, wraps around the medial femoral condyle behind and passes to the anterior medial surface of the thigh, parallel to the medial edge of the sartorius muscle. In the region of the oval window, the great saphenous vein pierces the ethmoid fascia and flows into the femoral vein. Sometimes a large saphenous vein on the thigh and lower leg can be represented by two or even three trunks. From 1 to 8 large tributaries flow into the proximal part of the great saphenous vein, of which the most constant are: the external genital, superficial epigastric, posteromedial, anterolateral veins and the superficial vein surrounding the ilium. Usually tributaries flow into the main trunk in the region of the oval fossa or somewhat distally. In addition, muscle veins can flow into the great saphenous vein.

The small saphenous vein begins behind the lateral malleolus, then it rises in the subcutaneous tissue, first along the lateral edge of the Achilles tendon, then along the middle of the posterior surface of the lower leg. Starting from the middle of the lower leg, the small saphenous vein is located between the sheets of the fascia of the lower leg (N.I. Pirogov's canal), accompanied by the medial cutaneous nerve of the calf. That is why varicose veins of the small saphenous vein are much less common than the great saphenous vein. In 25% of cases, the vein in the popliteal fossa pierces the fascia and flows into the popliteal vein. In other cases, the small saphenous vein can rise above the popliteal fossa and flow into the femoral, great saphenous veins, or into the deep vein of the thigh. Therefore, before the operation, the surgeon must know exactly where the small saphenous vein flows into the deep one in order to make a targeted incision directly above the anastomosis. The constant tributary of the small saphenous vein is the femoral-popliteal vein (vein of Giacomini), which flows into the great saphenous vein. Many cutaneous and saphenous veins flow into the small saphenous vein, most in the lower third of the lower leg. It is believed that the small saphenous vein drains blood from the lateral and posterior surface of the lower leg.

Deep veins of the lower limb

The deep veins begin with the plantar digital veins, which pass into the plantar metatarsal veins, then flow into the deep plantar arch. From it, through the lateral and medial plantar veins, blood flows into the posterior tibial veins. The deep veins of the dorsal foot begin with the dorsal metatarsal veins of the foot, flowing into the dorsal venous arch of the foot, from where blood flows into the anterior tibial veins. At the level of the upper third of the lower leg, the anterior and posterior tibial veins merge to form the popliteal vein, which is located laterally and somewhat behind the artery of the same name. In the region of the popliteal fossa, the small saphenous vein, the veins of the knee joint, flow into the popliteal vein. Further, it rises in the femoral-popliteal canal, already called the femoral vein. The femoral vein is subdivided into the superficial, located distal to the deep vein of the thigh, and the common, which is located proximal to it. The deep vein of the thigh usually flows into the femoral 6-8 cm below the inguinal fold. As you know, the femoral vein is located medially and behind the artery of the same name. Both vessels have a single fascial sheath, sometimes there is a doubling of the trunk of the femoral vein. In addition, the medial and lateral veins surrounding the femur, as well as muscle branches, flow into the femoral vein. The branches of the femoral vein anastomose widely with each other, with superficial, pelvic, and obturator veins. Above the inguinal ligament, this vessel receives the epigastric vein, the deep vein surrounding the ilium, and passes into the external iliac vein, which merges with the internal iliac vein at the sacroiliac joint. This section of the vein contains valves, in rare cases, folds and even septa, which leads to frequent localization of thrombosis in this area. The external iliac vein does not have a large number of tributaries and collects blood mainly from the lower limb. Numerous parietal and visceral tributaries flow into the internal iliac vein, carrying blood from the pelvic organs and pelvic walls.

The paired common iliac vein begins after the confluence of the external and internal iliac veins. The right common iliac vein, somewhat shorter than the left, runs obliquely along the anterior surface of the fifth lumbar vertebra and has no tributaries. The left common iliac vein is somewhat longer than the right and often receives the median sacral vein. The ascending lumbar veins drain into both common iliac veins. At the level of the intervertebral disc between the IV and V lumbar vertebrae, the right and left common iliac veins merge to form the inferior vena cava. It is a large vessel that does not have valves, 19-20 cm long and 0.2-0.4 cm in diameter. In the abdominal cavity, the inferior vena cava is located retroperitoneally, to the right of the aorta. The inferior vena cava has parietal and visceral branches, through which blood flows from the lower extremities, lower torso, abdominal organs, and small pelvis.

Venous system of the lower extremities.

1 - skin; 2 - common femoral vein; 3 - muscles; 4 - aponeurosis; 5 - a large saphenous vein;

6 - vein-perforator; 7 - superficial femoral vein; 8 - popliteal vein; 9 - small saphenous vein; 10 - sural veins; 11 - deep system of communicating veins; 12 - veins-perforators between the small saphenous and deep veins.

Perforating (communicating) veins connect deep veins with superficial ones. Most of them have valves located suprafascially and due to which blood moves from the superficial veins to the deep ones. About 50% of the communicating veins of the foot do not have valves; therefore, blood from the foot can flow both from the deep veins to the superficial ones, and vice versa, depending on the functional load and physiological conditions of outflow. There are direct and indirect perforating veins. Direct lines directly connect the deep and superficial venous networks, indirect ones connect indirectly, that is, they first flow into the muscular vein, which then flows into the deep one.

The vast majority of perforating veins originate from tributaries, and not from the trunk of the great saphenous vein. In 90% of patients, perforating veins of the medial surface of the lower third of the leg are incompetent. On the lower leg, the most common failure of the perforating veins of Cockett, connecting the posterior branch of the great saphenous vein (Leonardo's vein) with the deep veins. In the middle and lower thirds of the thigh, there are usually 2-4 most permanent perforating veins (Dodd, Gunther), directly connecting the trunk of the great saphenous vein with the femoral vein.

With varicose transformation of the small saphenous vein, incompetent communicating veins of the middle and lower thirds of the lower leg and in the region of the lateral malleolus are most often observed. In the lateral form of varicose veins, the localization of perforating veins is very diverse.

Options for connecting the superficial and deep veins of the lower extremities according to S. Kubik.

1 - skin; 2 - subcutaneous tissue; 3 - superficial fascial sheet; 4 - fibrous jumpers; 5 - connective tissue sheath of the subcutaneous main veins; 6 - own fascia of the lower leg; 7 - saphenous vein; 8 - communicating vein; 9 - direct perforating vein;

10 - indirect perforating vein; 11 - connective tissue sheath of deep vessels;

• Arterial pressure;
• breathing movements;
• intra-abdominal pressure;
• Muscle contractions of the limbs - the so-called "muscular-venous pump";
• vein valves;
• venous tone;
• Suction action of the heart;
• Pulsation of the arteries adjacent to the veins.

VARICOSE VEINS OF THE LOWER LIMB

Varicose veins of the lower extremities are a polyetiological disease, in the genesis of which heredity, obesity, hormonal status disorders, lifestyle habits, and pregnancy are important. The disease is manifested by varicose transformation of the saphenous veins with the development of chronic venous insufficiency syndrome. Chronic venous insufficiency is a syndrome manifested by impaired venous outflow from the lower extremities, the development of which is most often associated with varicose or post-thrombophlebitis (consequences of deep vein thrombosis) diseases, as well as congenital anomalies in the structure of the venous system. Much less often, the cause of chronic venous insufficiency can be systemic diseases of the connective tissue (scleroderma, systemic lupus erythematosus), obesity, dyshormonal conditions, tumors of the small pelvis.

With all the recent progress in the treatment and diagnosis of varicose veins of the lower extremities, the latter remains the most common disease of the peripheral vascular bed.

At the turn of the 70-80s in England, 10-17% of the population suffered from varicose veins, in the USA - 20-25%, in the USSR - 15-17% of the population (about 40 million people).

According to M.I. Kuzin and O.S. Shkroba (1967), in Moscow in 1966, 300,000 patients with venous disease were registered; sick every 22nd Muscovite.

According to the data carried out in 1997-1998. The World Organization of Angiologists multicentric study of the prevalence of venous disease in Europe, among persons aged 30 to 70 years, patients with venous diseases account for approximately 25-50%, and most patients are quite young, their average age is 45.5 years. Varicose veins are more often manifested in women, and in the period from 20 to 35 years, the sex ratio is 6:1, at the age of 65 to 75 years - 1.5:1. Another interesting fact of this study is the increase in the prevalence of venous disease with age. In persons aged 70 years, varicose veins occur 6-10 times more often than in persons aged 30 years.

Varicose veins are much more common in industrialized countries: in France - 24%, in the UK - 17%, in the USA - 20%, in Japan - 8.6%, in Tanzania - 8%, in India - 1.7% .

These disappointing data remain stable despite some progress in the treatment of varicose veins. So, in the USA and countries of Western Europe, almost 25% of the population suffer from varicose veins. In our country, more than 30 million people suffer from various forms of varicose veins, and 15% of them have trophic disorders. Various forms and stages of this disease occur in 26-38% of women and 10-20% of men, while among both men and women the prevalence of varicose veins increases with age. In addition, the annual increase in this disease for both sexes reaches 4%, and there is a tendency to rejuvenate the disease. So, according to J. Jimenez Cossio (1995), 10-15% of schoolchildren aged 12-13 years have superficial venous reflux.

After analyzing all of the above, one cannot but agree with the statement of J. Van Der Stricht that varicose veins are “humankind’s payment for the possibility of upright walking”.

Etiology and pathogenesis of chronic venous insufficiency

The development of chronic venous insufficiency is based on a violation of the normal venous outflow from the lower extremities, due to the development of valvular insufficiency in all parts of the venous bed, and in some cases (post-thrombophlebitic syndrome, aplasia and compression of the veins) due to impaired patency of deep veins. Provocative moments are all factors that cause an increase in venous pressure. These may include pregnancy, prolonged static loads, weight lifting, diseases of the bronchi and lungs, chronic constipation. All of them cause venous hypertension, which is the cause of vessel dilatation and the development of valvular insufficiency as a result.

Regardless of the immediate cause, common mechanisms are involved in the development of primary chronic venous disease. The initial link in the pathogenesis, most likely, is the remodeling of the venous wall, the causes of which have not yet been established. Immunohistochemical studies of altered veins show the presence of leukocytes in the wall layers, which suggests a possible role of metalloproteinases produced by them at the initial stages of the disease. As a result of changes in the venous wall, blood reflux is formed along the superficial veins.

In secondary chronic venous disease (post-thrombotic disease), the starting point of pathological changes is deep vein thrombosis and subsequently developing recanalization or occlusion, leading to a significant difficulty in venous outflow. There is a deposition of excess blood volumes, reaching maximum values ​​in the lower leg (up to 1.5 liters by the end of the day). The combination of bone, muscle, fascial and venous structures of this segment of the limb is called the musculo-venous pump of the leg. Its activity is the main factor in venous return, and the deposition of blood that occurs during venous reflux leads to an overload of the pump and a decrease in its efficiency. Phlebostasis develops, resistance at the venous end of the capillary bed increases. As a result, the volume of interstitial fluid increases, which in turn contributes to the overload of the lymphatic channel. Edema is formed, plasma proteins and leukocytes expressing inflammatory mediators and metalloproteinases enter the perivascular tissue. A chronic inflammatory process occurs, which can be aggravated by the development of infection after the addition of pathogenic microflora.

Clinic and diagnosis of chronic venous insufficiency

and varicose veins of the lower extremities

Examination of patients with pathology of the veins of the lower extremities begins with the collection of anamnesis, examination, palpation, setting tourniquet samples and measuring the circumference of the limb. Then, as necessary, instrumental and laboratory studies are carried out.

It is necessary to examine the lower part of the patient's body up to the waist in good light in a vertical and horizontal position on the couch. Pay attention to color, temperature, changes in pigmentation, skin trophism, limb volume, dilation of veins, capillaries, the presence of pulsating vessels, angiomas, aneurysms, etc. Be sure to compare the symmetrical sections of both limbs.

On examination, convoluted, translucent through the skin or even protruding trunks and conglomerates of varicose veins are visible. Due to the dense network of small dilated veins, the area of ​​​​the ankles and feet thickens and acquires a bluish color. In a horizontal position, the cyanosis disappears.

With the help of a centimeter tape, they find out how much at different levels the diseased limb is thicker than the healthy one.

On palpation, the trunks of dilated veins and their filling are determined. It is usually possible to feel dilated veins and holes of incompetent perforators in the aponeurosis of the leg in the subcutaneous fatty tissue or in the scar tissue.

With decompensation of varicose veins, pain and swelling of the limb increase, sweating and itching appear, which intensifies at night, which is a harbinger of trophic complications. In the future, dry or wet eczema appears, the skin of the lower limb becomes dark brown, shiny, easily vulnerable.

Venous hypertension, microcirculation disorders, thrombosis of small vessels and inflammation dramatically disrupt the nutrition and oxygenation of tissues, which leads to their necrobiosis and the formation of varicose ulcers. Most often, ulcers occur on the inner surface of the lower leg above the ankle.

To identify hidden incompetent venous trunks in the subcutaneous adipose tissue, it is advisable to use the Hackenbruch test. It is as follows. The patient, standing on the couch, is asked to cough at the moment when the venous trunks on the thigh are gently palpated with the fingers. When the valves fail, the back wave of blood with a cough push through the skin is transmitted to the palpating fingers.

Hackenbruch cough test.

Thrombophlebitis of superficial veins

Superficial veins are called those veins that are under the skin in adipose tissue no deeper than two to three centimeters. All other veins located among the muscles are considered deep. The disease is very often a complication of varicose veins.

But at the same time thrombophlebitis of superficial veins can also occur in apparently unchanged veins. It is characterized by inflammation of the venous walls and thrombosis. First, inflammation may occur, then thrombosis, or vice versa: thrombosis will appear, and subsequently inflammation. These two processes are inextricably linked, and the appearance of one becomes the cause of the other.

The occurrence of thrombophlebitis of the superficial veins leads to stagnation of blood with varicose changes in the walls of the veins. Blood ceases to be an ordered flow in such veins, eddies appear, which contributes to the formation of blood clots. Leg injuries, various viral infections, physical inactivity, hereditary genetic predisposition can also lead to this condition. As a rule, phlebitis is manifested by redness of an early dilated vein, local swelling, and thickening is noted. Nearby tissues (periflebitis) may also be involved in the inflammatory process. Thrombophlebitis is manifested by vein thrombosis, redness does not appear along the vein, but the vein is palpated as a painless cord. Diagnosis of the disease is difficult in the event of phlebitis in a vein, which lies quite deep in fatty tissue - this is the insidiousness of the disease.

Thrombosis in a vein can spread very quickly (up to 20 cm / day). When femoral vein thrombosis is detected, surgery is often necessary. Sometimes ligation of the vein is sufficient to prevent the migration of a blood clot, but in some cases, surgery is required to remove varicose veins. If phlebitis is found without thrombosis, then the treatment is anti-inflammatory in nature with compression.

Against the background of varicose veins, there are several variants of the course of thrombophlebitis of superficial veins: inflammation and thrombosis can be “frozen” at the same level, thrombosis can grow up or down.