VARICOSITY
The varicose veins is the disease which is characterized by nonreversible progressing changes in superficial, perforating and deep veins, and clinically manifests by the dilation of superficial veins of the inferior extremities.
Etiology and pathogenesis
Among the etiological factors of the development of varicosity an important role plays hereditary factors, hormono-endocrine abnormal changes, particularly pregnancy, various physiological and pathological factors, that cause elevation of intraabdominal pressure.
In the inherited or acquired structural weakness of a venous wall and valves the abnormal reflux of venous blood occurs: from superficial veins of leg the blood flows into deep, rises upward to saphenofemoral juncture, where the second part returns to superficial veins and as a result of the valvular incompetence dumps downwards. This mechanism results in elevating of venous pressure and varicose transformation.
Pathology
Macroscopicly the veins are tortuous, irregularly dilated, protruded, and sometimes are filled with thrombi. Walls of veins thickened, and vice versa, in the places of protruding are thinned. Microscopically at the onset of the disease a focal hyperplasia of elastic fibers and hypertrophy of longitudinal and circular muscle fibers are revealed. Further a focal plasmorrhagia, fibroelastosis and sclerosis develop. There comes an atrophy of muscular fibers. The expansion of the lumen of veins tends to functional incompetence of valves. On the skin (particularly of legs) a hyperpigmentation and trophic ulcers appear.
Classification
I) According to etiological factors:
– Primary (essential) and secondary varicosity;
2) According to anatomy:
– Varicosity of a great saphenous vein;
– Varicosity of a small saphenous vein;
– Varicosity of superficial veins;
3) According to the form of varicosity:
– Cylindrical form;
– Diffuse, tortuous form;
– Mixed form;
4) According to stages of the development of disease:
– Compensated;
– Subcompensated;
– Decompensated;
5) According to state of the valves of veins:
– Without valvular incompetence;
– With valvular incompetence;
6) According to manifestation of incompetence of a venous stasis
– I, ІІ, III degree.
Symptomatology and clinical course
The compensated varicosity usually does not manifest. Some patients after an physical exertion feel a heavy, dull sensation in legs. At inspection of such patients in a standing position it is possible to note a little bit expressed varicose veins of tributaries of great and small saphenous veins. At functional examination the valves are not affected.
In the stage of subcompensation the patients complain usually of a heavy sensation and fatigability of legs, their swelling or edema, burning pain in the region of varicosity and night cramps of tibial muscles. During examination of the patient in standing position it is possible to note a considerable varicosity of superficial veins of the inferior extremities. The skin of lower legs more often is not changed. The functional examination of the valves reveals valvular incompetence of superficial or perforating veins.
In the stage of decompensation the chief complaints of a constant gravity in legs, pain, prompt fatigue, edema and cramps of tibial muscles. This is associated with pigmentation, induration and trophic ulcer with localization in the lower third of leg. A large protruding veins are common for these patients. At functional examination it is possible to determine valvular incompetence of superficial, perforating and deep veins.
The insufficiency of a venous circulation of the first degree is common for varicosity in the stage of compensation. The manifestations of venous incompetence of II degree take place in a subcompensated varicose. For chronic venous insufficiency of II degree are evident manifestations of a decompensation with trophic changes of soft tissues such as induration, hyperpigmentation, hemosiderosis, dermatitis of the skin etc.
The III degree of chronic venous insufficiency, which develops in the stage of expressed clinical forms of decompensation, beside above described changes manifests by vasotrophic ulcers, with usual localization in the inferior third of leg.
Tests for definition of valvular incompetence of superficial veins
Troyanov-Trendelenburg’s test. The patient lies supine with the elevated extremity, and superficial veins is emptied. A rubber tourniquet is applied around the upper third of thigh. The patient stands up. If in a vertical position (with a tourniquet and after its releasing) the veins are slowly filled from below upward, the test is considered as negative. At prompt filling of veins mainly from above downward the test is positive.
Hackenbruch’s test. In upward position, the great saphenous vein is compressed with fingers and the patient is asked to cough. In incompetence of venous valves, particularly ostial, it is possible to feel a retrograde wave of a blood, which is transmitted by vessel below the finger.
Tests for evaluation of a valvular incompetence of perforating veins
Pratt’s test. After the veins have been emptied the patient lie supine and elevating the lower limb vertically the elastic bandage is applied from toes to groin. The superficial veins are compressed with a rubber tourniquet in the upper third of thigh. The patient stands up. The imposed bandage is released gradually from above downward, and simultaneously another elastic bandage is applied from inguinal region downward thus between them there is a space 5-
Sheinis‘ test. Around the leg, after the emptying of superficial veins by elevating the extremity, three tourniquets are applied: around the thigh just below oval fossa, above the knee and around upper leg. The patient is recommended to stand up. The veins are gradually filled up by a blood. If the vein in any region is promptly dilated, in this place it is necessary to consider the incompetence of valves of perforating veins.
Talman’s test is the modification of previous. For performance of this test a rubber tourniquet of 2-
Tests for estimation of deep veins patency
Mayo-Pratt’s test. In a laying position of the patient around the upper third of thigh of the elevated extremity a tourniquet is applied and superficial veins are compressed. Then the extremity is imposed by elastic bandage from toes to the groin. The patient is asked to stand up. If after that he feels the pain in leg, sense of compressing and fullness, it is possible to think, that deep veins are obstructed.
Delbet-Perthes‘ test (march test). At the patient, that stands, for the stopping of blood flow in superficial veins above the knee joint a rubber tourniquet is applied. After that, he is recommended to walk during 3-5 min. If the superficial veins after are constricted, it reveals satisfactory patency of deep veins.
Variants of clinical course and complications
The signs of chronic venous insufficiency of II – III degree superimpose the clinical manifestations of varicosity. First of all it is edema and itching of the skin, that are promptly progressing and constantly troubling the patient. Further the trophic disturbances such as induration, hyperpigmentation, alopecia and induration of subcutaneous fat superimpose. Very often this pathology is accompanied by phlebothrombosis, eczema, erypsipelas etc.
Nevertheless the most often of all complications of varicose veins of the inferior extremities should be considered an acute thrombophlebitis and static ulcers.
The diagnostic program
I. Anamnesis
2. Objective examination
3. General blood and urine analyses
4. Coagulogram
5. Functional tests for definition of the state of a valvular system of superficial, deep and perforating veins
6. Sonography
7. Dopplerography
8. Phlebography
Differential diagnostics
Some difficulties may occur at differential diagnostics of varicosity of superficial veins with arterio-venous fistulas. The latter could be inherent or acquired (most frequently after traumas). Besides other signs, the traumatic fistulas manifest by trembling and systolic murmur above the place of the previous trauma. Later edemas and induration of tissues develop. Furthermore cardiomegaly with the subsequent heart failure occurs. In inherent arterio-venous fistulas these changes occur much later. Diagnostics of arterio-venous fistulas should be based on clinical signs and supplemented by data of a gas composition of arterial and venous blood and arteriography.
Differential diagnostics with anomalies of the development of deep veins (venous angiodysplasia) should be based on the anamnestic data of manifestations of the disease, particularly in young age, nevertheless the basic method of recognition should be the phlebography.
Tactics and choice of treatment
The surgical treatment is indicated in: 1) decompensation of varicosity with incompetence of valves of superficial and perforating veins; 2) varicosity complicated by acute thrombophlebitis of superficial veins.
The contraindication to surgical treatment may be an obstruction of deep veins, decompensative heart failure, diseases of a liver and kidneys with considerable disturbances of function, obesity of III degree. To relative contraindications it is necessary to refer dermatites, trophic ulcers, eczema etc.
Technique of operation on great saphenous system
Troyanov-Trendelenburg’s operation. A great saphenous vein just at saphenofemoral juncture is ligated and cut. Previously before this management in the same way three veins are followed up widely and ligated in the place of their draining into a great saphenous vein: superficial external pudendal, circumflex iliac, inferior epigastric tributaries.
Babcock’s operation. A great saphenous vein is removed by means of a vein stripper which inserted in its distal end.
Narath’s operation. Operation is carry out as addition to Babcock’s operation in diffuse or mixed type of varicosity. The varicose tributary is exposed and removed by either stripping or excision between two incisions.
Cocket’s operation. A suprafascial ligating and cutting of perforating veins. An incision up to 2-
Linton’s operation – a subfascial ligating and cutting of perforating veins. After the skin, subcutaneous fat and fascia are incised, subfascially perforating veins are exposed, ligated and cut. The incised fascia is sewed up.
In a valvular incompetence of a femoral or popliteal deep vein the extravascular correction by means of synthetic spirals according to A.Vedensky is performed.
In postoperative period an active regimen is recommended. The patients begin to walk oext after saphenectomy day. The sutures are taken out on the 6-7th day. For aging function of venous system iew requirements, The patients are advised an elastic support of extremity during 1,5-3 months.
The indications for sclerotherapy: a compensated stage of varicosity associated with a diffuse type; smaller recurrent varicosities; contraindications to operative treatment.
Contraindications to application of sclerotherapy are the decompensative varicosity, decompensative diseases of heart, lungs, kidneys, acute infectious and purulent disease, acute thrombophlebitis of deep and superficial veins, pregnancy, bronchial asthma, obesity of III degree.
Technique of a sclerosing therapy.
The varicose vein is compressed in its distal and proximal end. After puncturing of the vein and emptying it from blood in its lumen sclerosing solution (varicocid, varicosan, thrombovar, 30 % solution of a sodium bromid etc) is injected. A compressing bandage should be used during 2-3 days.
The immediate and long-term results of a surgical treatment of a primary varicosity of the inferior extremities in majority patients are good. Nevertheless, at 5-20 % of cases is possible a recurrence of the disease. The knowledge of the causes and backgrounds of recurrent varicosity enables to prevent the development of its occurrence and to management appropriate operation.
Among the causes of such recurrence it is necessary to note stripping fails during operation of a major trunk of great or small saphenous vein, leaving of tributaries of a great saphenous vein at saphenofemoral juncture, incomplete disjuncture of systems of superficial and deep veins in the lower leg. After the establishment by clinical and instrumental methods of the diagnosis of a recurrent varicosity and the improvement of its cause, an appropriate operative treatment is managed.
POSTFLEBITIC SYNDROME (POSTTHROMBOTIC disease)
Postflebitic syndrome is a chronic disease of inferior extremities, which develops due to a deep vein thrombosis and manifests by the expressed edema, secondary varicosity of superficial veins and recurrent thromboses.
Etiology and pathogenesis
The cause of a postflebitic syndrome is the acute thrombosis of major veins of the system of inferior vena cava. At once after formation of a thrombus under the influence of the factors of a blood coagulating system there comes its retraction. Simultaneously under the influence of fibrinolysis a spontaneous lysis occurs. Depending on activity of these systems there could be such further course of the disease: in one cases a complete recanalization of the thrombus take place; and in others – complete obliteration or partial patency of the vessel could be restored. Nevertheless, despite the character, in this or that degree it always leads to incompetence of a valvular system of affected veins. It also causes a venous hypertension more distal to pathological process.
Pathology
In larger veins a considerably expressed sclerotic changes with the involvement of valves in the process are observed. Histologically revealed a sclerosis of all venous layers with the atrophy and necrobiosis of a functionally active elements (smooth muscles and elastic membranes). The intima of the such vessels is sharply and uneven thickened. Thus both sites of a hypertrophy, and zones of a sharp thinning up to the disappearance of structural elements take place. There are also revealed the lack of the valves in such veins.
Classification
1. According to the form of disease:
– Sclerotic;
– Varicose;
– Edematous;
– Ulcerative.
2. According to localization of the lesion:
– Inferior vena cava;
– Iliac vein;
– Femoral vein;
– Popliteal vein;
– Tibial veins.
3. According to spreading of the lesion:
– Isolated;
– Combined;
– Wide-spread.
4. According to the character of the lesion:
– Occlusion;
– Partial recanalization;
– Complete recanalization.
5. According to the degree of a venous insufficiency:
– Compensation;
– Subcompensation;
– Decompensation.
Symptomatology and clinical course
The postflebitic syndrome clinically manifests by a dull ache in the affected extremity, expressed edema and secondary varicosity. In the course of the disease with the change of stages a lot of new signs may occur, such as induration of tissues, hyperpigmentation of the skin, stasis dermatitis and recurrent trophic ulcers. The general state of the patient usually remains satisfactory. The clinical manifestations basically depend on pathological changes in the venous system. Due to periphlebitis all the vascular-nervous fascicle in the region of thrombosis is involved in cicatrical tissues It also causes the edemas on legs, which are mostly expressed after prolonged standing of the patient or during the latter part of the day. Some manifestations of postflebitic syndrome caused by venous insufficiency (arching pain, heaviness in legs) after recumbence or elevation of legs may considerably decrease or disappear.
The varicose veins is commonly not a permanent sign of postflebitic syndrome. It, as a rule, develops in the system of a great saphenous vein, particularly in places of perforating veins. Sometimes also the dilation of superficial veins and in inferior part of a forward abdominal wall is observed. Its degree frequently is in direct dependence on the level of localization of pathological process. The most discomfort manifestation of postflebitic disease for the patients is necessary to consider trophic ulcers. They are formed most frequently in the lower third of the leg, on its interior surface. The skin of stasis area is cyanotic or hyperpigmentative, a subcutaneous fat is firmed. The ulcers may be of various sizes, are always formed on the background of edema, heal slowly and have predisposition to recurrences. Sometimes they circulatory cover the inferior third of leg.
Despite that the pain sensation in affected extremity is a permanent signs of the disease, its intensity is almost always inappreciable. The most expressed the pain syndrome is in a phase of occlusion. In majority of patients with a postflebitic syndrome the pain is mostly expressed after prolonged standing or in the latter part of the day.
Heaviness in legs and dull ache caused by the venous stasis are localized, first of all, in the distal parts of affected extremity. The degree of expressiveness of these signs always directly depends on degree of decompensation of the venous outflow.
Postflebitic syndrome is characterized by a stage course of the disease.
I stage manifests by edema of legs without the phenomena of skin hyperpigmentation and induration of a subcutaneous fat. In these patients it is possible to note a cyanosis of the skin. After recumbence or night rest the edema completely disappears.
II stage of the disease is characterized by the edema, which decreases after 24 hours staying in bed. It might be connected with initial disturbances of a lymph flow. Further there may be a slight hyperpigmentation of the skin and indurative changes of a subcutaneous fat.
III stage is accompanied by decompensation of a lymph outflow from the extremity and transformation of a venous edema in lymphovenous. It results in the development of a testaceous fibrosis, which extends around inferior third of the leg.
Variants of clinical course and complications
The sclerotic form. Characteristic for this form is the absence of varicose veins of the extremity in I stage of the disease and moderate dilation of the tributaries of a superficial veins in the regions of localization of perforating veins in II and III stages. The main trunks of a great and small saphenous veins are without the signs of pathological dilation. The induration of a subcutaneous fat and hyperpigmentation of the leg more expressed in comparison with the other forms of postflebitic disease. In sclerotic form there is a so-called testaceous fibrosis of the fat, which as a rule, is localized in inferior third of the leg.
The varicose form. In patients the skin of legs is of a usual colouring, the edema expressed insignificantly, but the superficial veins are varicose changed. Their localization usually assigns the level of lesion of the veins. So, the involvement in the process of iliofemoral segment manifests by the simultaneous varicosity of a great and small saphenous veins and incompetence of perforating veins of lower leg. In complete occlusion of a major veins of pelvis or restricted occlusion of iliac vein the varicosity of superficial veins is localized mainly in the upper third of thigh and lower part of a forward abdominal wall. In occlusion of the distal parts of inferior vena cava the varicose veins may be observed on both legs and lateral surface of the abdomen and chest.
The edematous form. This form develops at once after the acute phenomena of a deep venous thrombosis and is characterized by pain, edema and moderate cyanosis.
Pain is usually of segmental character, and localized along the nerves, vascular fascicle of the leg and thigh. Nevertheless, if the patient is recumbent with elevated extremity, the pain and heaviness in affected extremity gradually disappears. The degree of the edema directly depends on the gravity of hemodynamic changes in larger veins. Thus in restricted lesion of a femoral and popliteal segment, a moderate enlargement of the leg and small edema of the lower third of thigh is observed. But the spread of the process on the iliofemoral segment sharply enlarges the volume of entire extremity, and results in edema on nates. In complete or restricted occlusion of pelvic veins also there may be a diffuse edema of the extremity. In case of the lesion of distal parts of inferior vena cava the extremely expressed edema of both extremities up to the elephantiasis is observed. But in this form of the disease the varicosity is absent.
In satisfactory state of compensation of venous outflow the edematous form of the disease sometimes disappears in several months. In a few patients the compensation of venous outflow is so well developed, that there is no visual base for establishing of the diagnosis of postflebitic disease, though in deep veins there is a segmental obliteration.
The ulcerative form. In patients with this form of the disease it is possible to find out all named above signs, which are sharply expressed. The edema of leg even after prolonged stay of the extremity in rest completely does not disappear; the degree and volume of varicose veins is enlarged, the hyperpigmentation and infiltration of a subcutaneous fat occurs, with diffuse spreading on all inferior half of leg. The trophic ulcers, which are usually formed on a medial surface of inferior third of the leg, are accompanied by itching and trophic changes of the skin and subcutaneous fat.
The diagnostic program
1. Anamnesis and physical examination.
2. Carrying out of functional tests for the definition of valvular incompetence of superficial, deep and of perforating veins.
3. General blood and urine analyses.
4. Coagulogram.
5. Sonography of vessels and dopplerography.
6. Phlebography.
Differential diagnostics
The most difficult for the differential diagnostics is the varicosity of inferior extremities and the varicose form of postflebitic disease.
Varicose disease of inferior extremities more often occurs in women, it is characterized by unnoticeable onset and slowly progressing, involves both legs above and below the knee joint and may be of a cylindrical, sacciform, type, the edemas in the stage of compensation decrease after recumbence. The function of valves of deep veins is preserved. The trophic ulcers are the signs of a stage of decompensation of a venous circulation.
In the varicose form of postflebitic disease an acute deep vein thrombosis with evident edema precedes the dilation of superficial veins. The incompetence of valves of deep veins and prompt development of sclerotic changes of subcutaneous fat and trophic changes of the skin is observed.
The particular difficulties may be in the differential diagnostics with a lymphostasis. In patients with a lymphostasis the edema is diffuse, dense, involves the ankle, back of a foot, and spreads to the leg and the thigh. The edema of elastic character and decreases after recumbency. It is important that the signs of lymphostasis mostly occur after erypsipelas. In postflebitic disease the edemas are tense with localization on the leg and thigh and they rarely develop on foot. They slightly decrease after rest and, as a rule, are combined with the trophic changes of skin.
In II stage of postflebitic disease mainly on a medial surface of inferior third of the leg, there occur a hyperpigmentation of skin and induration of subcutaneous fat. In this stage the trophic changes develop in association with dermatitis. Sometimes, the localization of skin changes is not always typical. Therefore, it is necessary to distinguish the postflebitic disease from such dermal diseases, as indurative erythema and different types of neuropathy.
Tactics and choice of treatment
Conservative therapy is applied in: а) a grave state of the patient caused by associated diseases; б) in edematous form of the disease; в) in expressed incompetence of the venous outflow on larger veins.
The following agents should be included into a complex of conservative treatment:
– Direct (heparin), and indirect anticoagulants (phenilin, pelentan);
– Antiaggregants (aspirin, curantyl, rheopolyglucin);
– The agents, which improve the microcirculation (niacin, xantinol, trental, sermion);
– The agents, which raise the tonus of a venous wall (indomethacin, methindolum, troxevasin, venoruton);
– Antiinflammatory therapy (antibiotics, nonsteroid antiinflammatory agents).
The presence of trophic ulcers requires:
а) Sanation of the surface of trophic ulcer: bactericidal and bacteriostatic agents of a local action (furacilin, polymyxin, UVR, photoradiotherapy);
б) Stimulation of regenerative processes in the wound by methyluracil, lorinden, flucinar).
During conservative therapy it is always necessary to take into account, that the patients who take anticoagulants and fibrinolytic agents, should be under the dynamic monitoring of a blood coagulating system.
The special attention is paid to the application of elastic bandage and organization of a rational regimen of physical exertion. The appropriate regimen of workload manifests by decreasing of the degree of edema of the extremity.
For maintaining of obtained effect it is desirable to use the sanatorium treatment.
Taking into account, that the clinical course of the disease always has the progressing character, by method of choice should be the surgical treatment. The recanalization of thrombosed veins and the development of collateral blood flow usually ends in 6-8 months after the acute thrombosis. This period, as a rule, determine the form of the disease. Therefore the surgical treatment for such patient should be applied after 6-8 months from the beginning of the disease. The purpose of such operative approach is the partial or complete liquidation of incompetence of venous flow in deep veins.
In I stage of postflebitic disease the operative treatment is rarely applied. In sclerotic form of this stage due to the absence of veins that are suitable for bypass grafting, the surgical treatment is impossible, nevertheless in the varicose form there is actual opportunity for performance of operation. For this purpose is used a great saphenous vein of a healthy extremity. The later is exposed from saphenofemoral juncture down to inferior third of thigh. The distal end of the vein is ligated, and the proximal one is provided above pubis and anastomosticated with femoral vein below place of its occlusion.
It is necessary to mean, that the postthrombotic occlusion of the femoral vein in I stage of the disease is the contraindication for removing of a great saphenous vein od the affected extremity. Nevertheless the operation of cross-bypass may be applied by means of great saphenous vein of healthy extremity.
The II stage of the development of postflebitic disease usually requires the removing of dilated veins, and ligating of perforating veins. In this stage there is an actual possibility of a wide application of plastic and reconstructive operations.
In III stage of the disease the surgical treatment is indicated even more often, nevertheless in this situation it is much more hardly to receive satisfactory results because of the pathological changes of lymphatic system and subcutaneous fat.
The main purpose of the operative treatment is to improve a venous hemodynamic by means of making additional pathways of the outflow.
The
In restricted occlusion of the iliofemoral segment the anastomosis of the popliteal vein with a great saphenous vein of the thigh is formed.
The operations, which improve the blood flow in deep veins include a thrombintimectomy, bougienage of the occluded part of the vein, plastics of a deep fascia of the leg (Ascor operation).
The Ascor operation is performed as follows: a deep fascia of a back surface of the leg is cut by a longitudinal incision and sutured as duplicature.
There are lot of operations, which purpose is to form the artificial valves in veins. The most popular are: the creation of the valves by means of a fold suturing of a venous wall inside the lumen; and by invaginating of a tributary stump inside the vein.
For the extravascular correction of the valvular incompetence the lavsan spirals are applied, which after the arrangement on the vein approach the walls of incompetent valve and restitute its function.
In order to make external muscle valve a tendon of a gentle muscle of thigh is provided in the transverse direction between a popliteal artery and vein and sutured to the tendon of biceps muscle of a thigh.
Also possible the replacement of the segment of a recanalized femoral vein by the graft of a great saphenous vein with functioning valve.
Operations, which reduce hydrostatic pressure in different levels of a venous system of inferior extremity:
– resection of popliteal vein;
– resection of femoral vein;
– resection of posterior tibial vein;
Operations, which prevent the pathologic reflux of a blood in varicose superficial veins: removing, electrocoagulation and sclerotherapy of varicose veins and the ligating of perforating veins by Kocket-Linton method.
