Chronic venous insufficiency: causes of development, symptoms and treatment. What is chronic venous insufficiency? Venous insufficiency syndrome

07.11.2019 -

Venous insufficiency of the legs is the most frequent illness peripheral vessels. Blood stagnates in the limbs, the valves weaken and do not fulfill their role as a pressure regulator.

It should be distinguished that venous insufficiency and varicose veins are not the same thing. Varicose veins are the cause and sometimes a symptom of insufficiency.

Principle of disease development

Veins are distinguished between deep and subcutaneous-superficial. The main volume of blood from lower limbs, about 80-90%, flows through the deep venous system.

The walls of the superficial veins have smooth muscle fibers that help blood flow.

The flow of blood in the deep veins is ensured by a combination of factors:

intra-abdominal pressure;
venous-muscular pump, which works during muscle contraction - ensures pumping of the main volume (about 75%) of blood;
breathing, and as a consequence of this - the movement of the diaphragm;
pressing on the plantar venous system when walking;
blood pressure, which affects the sources of venous blood;

Blood flow also depends on the person’s position in space.

At horizontal position it happens passively. The vertical flow of blood to the heart is ensured by a muscular-venous pump.

When the valve system is weakened and venous hypertension occurs, the outflow of blood is disrupted. Venous insufficiency of the lower extremities develops.

Causes

AVI occurs suddenly and can be caused by deep vein thrombosis, drug, food or chemical poisoning. Appear as a result of a blood clotting disorder or serious illnesses, such as cirrhosis of the liver.

Chronic venous insufficiency often occurs latently, without pronounced symptoms.

Many reasons lead to the disease:

lack of physical activity;
long static positions, standing or sitting, due to the nature of the profession. Cashier, salesperson, assembly line worker or office worker;
excess weight;
fluctuations hormonal levels, the ratio of estrogen and progesterone in women;
pregnancy - the growing uterus compresses the peritoneal veins, increasing pressure in the venous vessels;
heavy physical exercise- lifting weights, playing some sports - wrestling, lifting weights, shot put;
heredity - congenital weakness of blood vessels and valves;
varicose veins, thrombophlebitis.

Both OVN and CVI can develop as a result of injury to the vein, its compression (during tumor growth, for example) or blockage of the vein lumen by a blood clot.

Classification of acute and chronic forms. Stages and degrees
According to the domestic classification, VN is divided into 4 degrees:

0 - at this stage there are no symptoms, but the patient has a predisposition and a combination of provoking factors.
1 - there is swelling and heaviness in the legs.
2 - this degree is characterized by skin pigmentation, persistent swelling, eczema, lipodermatosclerosis.
3 - appearance of trophic ulcers.

The international CEAP system classifies VN according to clinical signs, the cause of the pathology, and the location of the lesion.

Degrees

The cipher consists of large and small Latin letters and Arabic numerals. The letter C denotes the class of the disease based on clinical signs.

VN degrees by clinical classification CEAP:

C0 - visual examination and palpation do not reveal symptoms of the disease.
C1 - spider veins and dilation of the thin saphenous veins are observed.
C2 - varicose veins are diagnosed.
C3 - swelling appears;
C4a - the skin becomes pigmented, venous eczema appears;
C4b - the skin thickens, excessive pigmentation or white skin atrophy begins;
C5 - in addition to pigmentation, self-healing wounds are observed;
C6 - open trophic ulcers and accompanying skin changes.

Index E is assigned due to the occurrence (etiology):

Ec - VL developed due to a hereditary tendency;
Ep - the reason remains unclear;
Es - the cause has been established - consequences of injury, varicose veins.

The letter A indicates the affected area (anatomical classification):

As - the disease affected the superficial veins;
Ap - damage to the communicating (connecting) veins;
Ad - pathology of deep veins;
An - no visible changes were detected.

The P index groups the disease according to the type of lesion (pathophysiological sign):

Pr—valvular damage;
Po—complete occlusion of the vein lumen (occlusion);
Pr,o - a combination of both pathologies;
Pn—outflow disturbances have not been established.

The code includes numbers from 1 to 18, which indicate the area venous system. There may be several of them.

Based on the symptoms, the patient’s performance is determined and described in stages from 0 to 3.

Stage zero is assigned to patients without severe symptoms and complaints. The functionality is completely preserved.

At the first stage of CVI, the first signs of pathology are noted, performance is preserved, and medication is not required.

In the second stage, performance is maintained thanks to drug support.

The third stage is characterized by loss of performance even with maintenance therapy.

Symptoms

Signs of AHS

In almost half of cases, AHF is asymptomatic. The only sign of venous insufficiency of the lower extremities becomes pulmonary thromboembolism- the patient is in danger fatal outcome.

In other cases, symptoms of venous insufficiency of the lower extremities increase rapidly and immediate treatment is necessary.

The limb swells, pain appears, intensifying with movement. The pain increases to an unbearable level and radiates to the genitals. The skin turns pale, then turns blue.

The temperature of the leg drops several degrees. In contrast to body temperature, which rises to 40 C.

Signs of CVI

The diagnosis of CVI is accompanied by varicose veins and swelling of the feet and legs. This type of pathology mainly affects the superficial veins.

At the onset of the disease, swelling disappears after a night's sleep or prolonged rest in a horizontal position.

The usual shoes become too small, the patient experiences discomfort when walking, and it is difficult to step on his feet in the morning. Heaviness in the legs, cramps and pain appears.

The pathology is accompanied by headaches, fainting, shortness of breath, and rapid heartbeat.

Diagnosis of pathology

Perform instrumental and laboratory research.

Blood is examined for a tendency to thrombus formation, assessing its characteristics according to general and biochemical analysis.

Ultrasound is used duplex scanning vessels. This method allows you to assess the condition of the walls of blood vessels, their wear and tear and track the nature of blood flow.

Phlebography is performed using X-ray examination. Injected into veins contrast agent to assess the condition of blood vessels and blood flow. Determination of the affected area and its duration.

IN Lately venography is performed much less frequently due to the traumatic nature of the method.

Treatment

OVN is treated with conservative and surgical methods. There are three areas of treatment:

medicinal. Anticoagulants, antiplatelet agents, and nonsteroidal anti-inflammatory drugs are prescribed. Venotonics for external and internal use, hormonal drugs from the group of glucocorticoids. The essence drug treatment consists of restoring blood flow, thinning the blood, eliminating inflammation;
compression This method is used regardless of the form, cause and stage of VN. A properly fitted compression bandage helps return blood to the heart. Healing of trophic ulcers, normalizing pressure inside blood vessels. There are several degrees of bandage pressure from very light to very strong;
surgical. This may be thrombolysis or thrombectomy, aimed at dissolving the blood clot in the vein. Restoring blood flow and integrity of venous vessels.

If acute venous insufficiency is diagnosed, the first thing to do is lie down. Place your leg above chest level and apply a cold compress.

The main difference in the treatment of AHF from the chronic form is the limitation of the patient’s mobility.

Treatment of the chronic form of the disease

Medication

For internal use, medications of the following groups are prescribed:

non-steroidal anti-inflammatory drugs - eliminate inflammatory process, which is not infectious in nature, relieves pain and spasm;
glucocorticosteroids - accelerate the healing and recovery process, help eliminate inflammation;
anticoagulants - help thin the blood;
antiplatelet agents - prevent red blood cells from sticking together, which helps prevent blood clots;
drugs against ischemia - nourish cells in conditions oxygen starvation;
antiallergic drugs - reduce the likelihood of an immune response to foods metabolic processes;
antibacterial drugs- aimed at preventing infectious lesions.

Externally used:

ointments and creams based on hormonal substances;
antiseptics;
venotonics.

Surgical

Methods surgical treatment CVI is quite diverse:

sclerotherapy is used to glue small and medium-sized veins;
laser surgery. Used for healing trophic ulcers and removing diseased veins under ultrasound control. Which eliminate from the inside laser beam. To do this, a light guide is inserted through a puncture in the skin and through it the affected area is exposed;
surgical removal of varicose veins. The intervention is performed under general anesthesia to remove large diameter vessels;
ablation It is used to remove varicose veins. A catheter with heating elements at the end is inserted into them. With their help, diseased vessels are cauterized;
phlebectomy. Conducted under local anesthesia. The essence of the treatment is to remove veins of small diameter;
endoscopic vein removal. This method is used when skin defects and ulcerations are detected. The damaged vessel is removed with visual control of the operation;
vein bypass - an artificial vessel is installed to restore blood flow bypassing the damaged area;
restoration of valve function.

Compression therapy

A compression bandage is used in the form of elastic bandages, therapeutic knitwear, or treatment is carried out using intermittent pneumatic compression devices.

Most often they manage by bandaging with medical bandages or wearing knitwear.

The doctor prescribes underwear or bandages based on the degree of vascular damage and general condition patient.

Auxiliary therapy using traditional methods

Treatment of venous insufficiency with folk remedies is auxiliary. It consists of thinning the blood and restoring the tone of the venous vessels.

The leader among all plants for the treatment of vein diseases - horse chestnut. One hundred grams of crushed chestnut fruit requires 500 ml of alcohol.

The product is infused in a dark place for a month. Drink 10 ml of tincture diluted in a small amount of water half an hour before meals.

The tincture is used for rubbing and compresses.

Calamus root is useful. The dry rhizome is crushed and an aqueous tincture is prepared from it. Half a teaspoon of raw material is infused in a glass of boiling water until it cools.

Drink three times a day.

Calamus root is infused for 10-14 days in natural apple cider vinegar. 50 g of root per 500 ml of vinegar.

Take 2 tablespoons of tincture 2 times a day.

Preventive measures are to maintain optimal body weight and sufficient physical activity.

Helps avoid illness proper nutrition and healthy lifestyle.

Should be abandoned bad habits, especially smoking.

Food should be taken in small portions, 4-5 times a day.

Of great importance drinking regime— you need to drink up to 2.5 liters per day clean water.

Useful video: Venous insufficiency of the legs

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

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

Meet - HVN

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

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

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

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

Why does venous insufficiency occur in the legs?

Heaviness in the legs and spider veins?

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

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

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

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

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

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

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

Degrees and symptoms of CVI of the lower extremities

How does venous insufficiency manifest?

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

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

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

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

That is why special meaning diagnosis of chronic venous insufficiency, especially in the early stages, is acquired.

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

Diagnostics

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

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

But in order to make an accurate diagnosis - CVI, and choose the best way treatment must be applied additional methods research. These methods include:

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

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

It has been proven that only surgical correction diseases. But if venous insufficiency is diagnosed in the early stages, then it timely treatment may avoid surgery.

Treatment of CVI - drugs or surgery?

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

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

About compression hosiery

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

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

Drugs

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

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

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

Surgical treatment

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

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

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

About the treatment of trophic ulcers

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

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

Forecast

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

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

Chronic venous insufficiency of the lower extremities is extremely common in modern world. In Russia, more than 35 million people suffer from its various forms, and 15% of them already have trophic changes in the skin, open or recurrent trophic ulcers. Chronic venous insufficiency is a pathological condition characterized by stagnation or perversion of blood flow in the venous system of the lower extremities.

The main mechanisms of venous return from the lower extremities:

systemic blood pressure transmitted to the origins of the venous system;

systole-diastolic movement of arteries, transmitted to accompanying venous vessels;

compression of the plantar venous network that occurs periodically while walking, from which blood is evacuated into the deep and superficial veins;

muscular-venous pump of the leg and thigh, the action of which, when muscles contract, leads to the outflow of blood from the venous sinuses into the deep veins;

breathing movements of the chest and diaphragm (“suction” action).

The two main causes of chronic venous insufficiency are:

varicose veins;

postthrombophlebitic disease.

The essence varicose veins- gradual expansion of the lumen of the saphenous veins and perforators, as a result of which relative valve insufficiency develops (they remain intact, but their leaflets do not close). Venous reflux occurs from top to bottom along the saphenous veins (vertical) and from the deep veins to the superficial (horizontal).

Postthrombophlebitic disease- This clinical manifestations developing in some cases (70%) in patients after acute thrombosis deep veins and associated with the presence of venous hypertension and lymphovenous insufficiency of the lower extremities (synonyms: chronic thrombophlebitis, postthrombotic syndrome, postthrombotic disease, postthrombophlebitis syndrome). Occurs as a consequence of acute thrombosis of the veins of the lower extremities.

Classification (A.N. Vedensky 1986, V.S. Savelyev 1983):

Form: sclerotic, varicose.

Stage: I,II,III;

Localization (isolated, combined)

inferior vena cava;

iliac vein;

popliteal vein;

tibial veins.

Nature of the lesion:

occlusion;

recanalization;

Degree of venous insufficiency:

compensation;

subcompensation;

decompensation.

In the diagnosis of post-traumatic syndrome, examination methods such as vascular ultrasound and X-ray examination play an important role.

The quality of ultrasound diagnostics of pathology of the veins of the lower extremities is constantly increasing as diagnostic equipment improves. It is possible to assess and direct blood flow, localize occlusions and decompensation of communicating veins.

Flaw - the difficulty of diagnosis in conditions of a large number of collateral blood flow paths, false-positive and false-negative results are possible. X-ray examination allows a more detailed study of the characteristics of blood flow in the limb, but is an invasive technique and requires the use of contrast agents.

Both antegrade and retrograde vein contrast options are possible.

The process involves all venous basins of the lower extremities. The line between thrombosis and post-thrombotic changes in deep veins is quite arbitrary. The process of transformation of blood clots consists of their adhesion to the venous wall and retraction with partial lysis (plasma and leukocyte), their germination by fibroblasts, followed by canalization and revascularization. These processes lead to restoration (at least partial) of the lumen of the main veins. Occlusive forms of postthrombophlebitic disease (deep veins are completely obstructed) are quite rare. In postthrombophlebitic disease, the integrity and function of the valves of the deep and perforating veins is never restored. Hence the conclusion: with varicose veins and postthrombophlebitic disease, there are similar mechanisms of venous outflow disturbances (vertical and horizontal reflux), which determine similar clinical symptoms.

Clinical picture of varicose veins and postthrombophlebitic disease varies at the stage of collecting the medical history.

Clinical (physical) examination of patients with chronic venous insufficiency is carried out with the patient standing. Evaluated appearance extremities: skin color, presence and localization of varicose veins of the saphenous veins, telangiectasia, presence of areas of hyperpigmentation and induration of the skin of the lower leg. Depending on the degree of decompensation of the venous outflow, external signs of the disease can range from subtle to pronounced. When examining a patient, there is no need to carry out so-called functional tests, since vertical and horizontal reflux can be reliably determined using only two clinical tests: the incompetence of the ostial valve of the great saphenous vein is determined by Hackenbruch samples – with a sharp increase in intra-abdominal pressure (coughing, straining), a retrograde wave of blood is felt by palpation under the inguinal fold in the projection of the sapheno-femoral anastomosis; this test can be repeated by moving the hand lower along the trunk of the great saphenous vein and determining the incompetence of the stem valves of this venous line; horizontal reflux determined indirectly: by palpation of defects in the aponeurosis in those places where incompetent perforators are usually localized.

Distinctive signs of postthrombophlebitic disease from varicose veins In addition to the medical history, there are significant hemodynamic disturbances in the presence of minor superficial varicose veins (or even its absence), pronounced varicose veins of the saphenous veins in the groin and pubic area.

The clinical picture of chronic venous insufficiency is very variable because it depends on its cause, the localization of venous reflux, the individual characteristics of the venous system of the lower extremities and its compensatory capabilities.

There are four degrees of chronic venous insufficiency:

0 degree of chronic venous insufficiency - the main clinical symptoms are: heavy leg syndrome, telangiectasia, reticular varicose veins.

I - main symptoms: transient swelling, varicose transformation of the saphenous veins.

II degree of chronic venous insufficiency - main clinical symptoms: persistent swelling, hyperpigmentation, lipodermatosclerosis, eczema.

III degree of chronic venous insufficiency - indurative cellulitis, trophic ulcer, secondary lymphedema.

Diagnostic principles:

To select treatment strategies and tactics for chronic venous insufficiency, it is necessary to solve the following diagnostic problems:

clarify the cause of chronic venous insufficiency (varicose or postthrombophlebitic disease);

assess the condition of the deep veins (their patency and the consistency of the valves);

detect reflux through the sapheno-femoral and sapheno-popliteal anastomosis;

determine the condition of the valve apparatus of the trunks of the great and small saphenous veins;

identify the presence and localize insufficient perforating veins.

Only an objective and accurate solution to these problems allows you to choose an adequate treatment method and guarantees against tactical errors.

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

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

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

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

There is a common misconception among patients that chronic venous insufficiency of the veins of the lower extremities and varicose veins of the venous lines of the legs are the same pathology. However, this is not true.

CVI of the lower extremities is a syndrome that includes several pathological disorders: insufficiency of venous valves in the legs, impaired blood circulation, increased thrombus formation in the patient’s vascular bed and vascular anomalies, both congenital and acquired.

General ideas about pathology

The prerequisites for the development of this pathological condition serves the ability of people to walk upright and the decrease in their physical activity every year.

In the absence of regular training of the calf muscles, the negative impact of the vertical position human body aggravated, since it is the muscle fibers surrounding the venous lines that help maintain normal elasticity and tone of the vascular walls, acting as an anatomical “corset” for the veins.

The danger of CVI is that patients do not always focus on the triggering of pathogenic mechanisms and seek treatment specialized assistance only with a significant aggravation of the pathology, when it turns into chronic form and is characterized by severe insufficiency of the valve apparatus of the vascular lines. At the same time, development pathological process can be localized not only in the lower extremities, but also in the brain.

What can trigger the development of the disease

The causes of venous insufficiency of the lower extremities are the disruption of blood circulation in the vessels of the peripheral parts of the body and the formation of stagnation in them. Against the background of weakening muscle tone in the legs, the walls of the veins gradually weaken and are unable to maintain constant intravascular pressure.

The continuous influence of increased pressure inside the venous lines over time leads to deformation of sections of the veins and the formation of an expansion of the lumen in them. The veins become like a deformed rubber tube - thinned and elongated, unable to maintain a constant shape.

Due to the presence of congestion, the first signs of venous insufficiency of the lower extremities are a gradual increase in leg fatigue. Patients note in evening time heaviness in the legs, slight swelling may form on the feet. With absence specific treatment pathological disorders worsen over time, and they are accompanied by a violation of the trophism of the tissues of the lower legs.

The causes of venous insufficiency of the lower extremities are as follows:

Thrombosis of deep venous lines of the lower extremities.
Decompensated stage of varicose veins in the legs.
Genetic predisposition to structural weakness of the vein walls or hereditary abnormalities of vascular development.
Various leg injuries.
Hormone therapy.
Gender: pathology is diagnosed in women several times more often than in men. This is due not only to the increased content of certain hormones in the blood, but also to the functions assigned to female body- pregnancy and childbirth.
Increased load on the venous lines of the legs, which increases significantly during pregnancy not only due to increasing body weight, but also as a result of compression of the vessels by the growing uterus.
Excess body weight.
Physical inactivity.
Age-related changes affecting the condition and functionality of the vascular bed.
Regular high physical overload both during sports and when performing heavy physical work.
Tendency to constipation.
Forced standing or sitting long time(at hairdressers, surgeons).

What forms of pathological condition exist?

In the 90s of the last century, an attempt was made for the first time to systematize the pathologies of the veins of the lower extremities. After numerous modifications, it was created International Classification venous insufficiency CEAP, which is used throughout the world in differentiated diagnostics.

The abbreviation CEAP reflects the changes that occur in the vascular bed during the development of the pathological process:

C – clinical manifestations of the disease:

Grade 0 is characterized by the patient’s absence visible signs vein lesions;
at grade 1, abnormally dilated small vessels (venules and arterioles) in the form of spider veins or meshes form on the skin;
with grade 2 on the legs, upon examination, a specialist can identify areas of unstable dilated veins; when the patient’s position changes and the load on the lower extremities is reduced, the veins return to normal;
at 3rd degree peripheral parts persistent swelling of the legs;
at grade 4, signs of impaired tissue trophism appear in the lower parts of the legs;
at grade 5, disruption of metabolic processes in the tissues of the peripheral parts of the lower extremities leads to the formation of healing ulcers;
at grade 6, trophic ulcers are difficult to treat and do not heal.

E – etiology of the disease:

EU – the disease is caused by genetic factors;
EP – the causes of pathological disorders cannot be determined;
ES – the provoking factor is a previous injury or a tendency to increased thrombus formation.

A – localization and depth of pathological changes:

damage to the subcutaneous, connecting or deep veins;
damage to the inferior vena cava or great saphenous vein.

P – pathophysiological changes accompanying the development of the disease:

CVI with the presence of reflux;
CVI with the development of obstruction;
CVI, combining both of the previous symptoms.

In addition to the CEAP system, domestic phlebology has developed a systematization of venous insufficiency based on such characteristics as the severity of damage to the vascular bed and the nature of the development of the disease.

Depending on the stage of development of the pathological process and the presence/absence of complications, there are the following degrees of chronic venous insufficiency of the lower extremities:

CVI grade 0 – despite the presence of telangiectasia, clinical picture progression of the disease is not determined.
CVI stage 1 – increased fatigue of the legs develops, unstable swelling periodically occurs.
Chronic venous insufficiency of the lower extremities of the 2nd degree - swelling becomes stable, the color of the skin of the legs changes, eczema may develop.
Stage 3 CVI – the surface of the skin of the lower extremities becomes ulcerated. Complications arise in the form of bleeding of varying intensity and thrombophlebitis.

Depending on the nature of the pathological process, 2 types of pathology are distinguished.

Acute venous insufficiency – develops rapidly and consists of obstruction of the patency of deep veins. Specific symptoms include a change in the color of the skin of the affected leg in a very short time (they acquire a bluish tint), the occurrence of constant acute pain along the vein, and the leg quickly swells. Relieving this form of venous insufficiency does not create difficulties. First aid is applying cold to the affected limb and urgent hospitalization in a specialized institution.

Chronic – Clinical signs They appear gradually and differ from patient to patient. When this venous insufficiency of the lower extremities develops, the symptoms are mainly the following:

increased fatigue of the legs, pronounced heaviness in them after forced long stay in a vertical position;
formation of persistent edema;
the appearance of cramps in the calf muscles at night;
change in skin coloration;
the appearance of signs of impaired trophic tissue of the lower extremities - skin dry out and lose elasticity;
ulceration of the surface of the skin;
attacks of dizziness, possible loss of consciousness.

If a person notices at least one of the listed signs, he needs to contact the medical institution for specialist consultation.

Diagnostic measures

During differentiated diagnostics, the phlebologist prescribes the following laboratory and instrumental examination:

clinical blood test - to determine, first of all, the properties of blood clotting;
biochemical blood test;
general urine analysis;
ultrasound examination of the venous lines of the lower extremities using Dopplerography;
phlebography – contrast method X-ray examination;
if necessary, appointment of consultations with related specialists.

Having the results of an in-depth examination of the patient, the phlebologist can develop individual health measures that have the maximum therapeutic effect.

Therapeutic measures

When diagnosing chronic failure treatment of venous lines of the lower extremities involves an integrated approach.

Drug therapy consists of the use of specific medicines belonging to the group of venotonics:

tablets for venous insufficiency of the lower extremities reduce the intensity of pain, eliminate swelling, increase the elasticity of the vascular wall, and produce an anti-inflammatory effect (Troxevasin Neo, Troxerutin, Flebonorm, Detralex and others);
ointments for venous insufficiency of the lower extremities have the same properties as tablet forms of venotonics, but have local action and do not affect other human organs and systems (heparin, troxevasin ointments, Lyoton gel and others);
other medications for venous insufficiency of the lower extremities are medications, improving the flow properties of blood (aspirin and its derivatives, for example, Cardiomagnyl), non-steroidal anti-inflammatory drugs (Meloxicam, coxibs), strengthening the immune system (multivitamin complexes);
drugs for venous insufficiency of the lower extremities can be synthesized not only from chemical compounds, but also have vegetable origin(Antistax, Shungite balm).

Traditional medicine recommends the use of various fruits and herbs for venous insufficiency of the lower extremities (cinnamon, nutmeg, horse chestnut, nettle, hop cones, garlic). When choosing folk remedies For treatment, you need to consult your doctor.

Nutrition for venous insufficiency of the lower extremities must be balanced, containing in sufficient quantities all the necessary useful material and microelements.

It is useful to include seaweed and juice in your usual diet. chokeberry. Therapeutic diet provides for limiting the consumption of excessively fatty, hot, spicy, smoked foods, canned foods, marinades, alcoholic and carbonated drinks.

The use of physiotherapy and therapeutic exercises help enhance the positive effect conservative treatment. Physical exercise for venous insufficiency of the lower extremities, they are selected individually and help maintain the tone of the calf muscles, normalize blood circulation in the vascular bed, and eliminate stagnation in the peripheral parts of the legs.

In the absence of positive results conservative methods treatment, specialists prescribe surgical treatment.

Preventive actions

Following certain recommendations can significantly reduce the risk of pathology of the venous vessels of the legs or slow down the development of an emerging pathological condition.

Prevention of venous insufficiency of the lower extremities is as follows:

organization healthy image life - normalization of work and rest schedules, allocating sufficient time for sleep, developing a balanced diet, getting rid of bad habits And so on;
Carrying out regular walks, performing specially selected physical exercises;
selection of the right shoes - not too narrow, with low heels;
refusal of tight clothes;
limiting exposure to the open sun and visits to the solarium;
constant wearing of individually selected compression hosiery;
normalization of weight.

Timely contacting specialists to conduct a detailed examination and implement adequate therapeutic measures helps eliminate pathological manifestations in a relatively short time and prevent the formation of severe complications. Patient's visit to early stages development of the disease significantly increases the effectiveness of specific treatment.