Lower extremity varicose veins are the most common condition among peripheral vascular diseases With the development of diagnostic tools and clinical research, there is a new understanding of the morphology and function of lower extremity venous valves. Lower extremity varicose veins are common clinical manifestations of lower extremity venous diseases. In addition to simple lower extremity varicose veins, there are also diseases such as lower extremity deep vein valve insufficiency and lower extremity deep vein thrombosis.
I. Etiology of varicose veins of lower extremities
1.Weakness of vein wall and valve defects
Whether it is simple varicose veins of lower extremity, or the valve insufficiency of deep vein of lower extremity, the pathogenic factors are: congenital weakness of vein wall and valve defect, which leads to persistent increase of intravenous pressure.
2.Increased intravenous pressure
Usually the causes of increased venous pressure are more, such as long-term standing work, in addition to this, any factors that can make the intra-abdominal pressure increase can lead to increased intravenous pressure. Such as heavy physical labor or strenuous sports activities, chronic cough, constipation, etc., the pressure generated by closed-air force and abdominal muscle contraction can affect the venous blood return, thus damaging the valve function of the upper end of the saphenous vein and developing.
Second, the clinical performance of varicose veins of lower limbs
1.Superficial varicose veins of lower limbs: superficial varicose veins mostly occur in bilateral lower limbs, but also in unilateral lower limbs, among which the left side is more common because the left iliac vein is compressed by the right iliac artery.
2.Soreness and pain in the affected limbs: Patients mostly have soreness or swelling in the affected limbs and are easily fatigued, which mostly occurs when standing for a long time. When the limb is elevated lying down, the soreness and swelling disappears rapidly.
3, the affected limb swelling: the worse the function of deep vein valve, the more obvious the affected limb swelling. If the lymphatic vessels are involved, the swelling of the affected limb will be more obvious if it is complicated by lymphedema at the same time.
4.Complications.
Clinical diagnosis of varicose veins of lower limbs
(A) Asking medical history
1.Age: It can occur in people of any age, but it is more common in middle and old age.
2.Occupation: The incidence is higher in long-term standing workers, such as store salesmen, textile workers, teachers, hairdressers, nurses and surgeons.
3.Past history: chronic bronchitis, habitual constipation, abdominal tumor and pregnancy patients, etc.
4.Family history: varicose veins of the lower extremities are related to heredity, often more than one parent or sibling in a family suffers from this disease.
5.Onset: if varicose veins of lower limbs occur after trauma, acquired arteriovenous fistula should be excluded; if varicose vein masses are present in lower limbs since childhood and accompanied by claudication, congenital vascular malformation or congenital arteriovenous fistula should be considered; if swelling of lower limbs occurs first and then varicose vein masses appear, post-thrombotic syndrome of deep veins in lower limbs should be excluded.
6.Complications: varicose veins of lower limbs are often complicated by thrombotic superficial phlebitis, stasis dermatitis, ulcers, secondary infection and superficial vein bleeding.
(B) Physical examination
1.General condition
Attention should be paid to the patient’s development, nutritional status, physical strength and so on.
2.Limb examination
(1) Skin condition of the limbs
① Skin color and temperature Whether there is skin discoloration, pigmentation, skin redness, swelling, heat and pain, scattered red rash, accompanied by itching and exudation.
② Skin nutritional changes In the early stage of varicose veins of lower limbs, there is no obvious nutritional disorder of limb skin, with the aggravation of the disease, it mainly shows thinning, dryness and desquamation of skin in foot and boot area, pigmentation, stasis dermatitis, etc.
(2) Superficial varicose vein
The superficial veins of the affected limbs are bulging, dilated, curved, or even tortuous into lumps or earthworm shape, which is more obvious when standing. It may be accompanied by swelling of the lower leg.
(3) Thrombotic superficial phlebitis
The varicose veins show redness, hard nodules and cord-like swellings with pressure pain and increased local skin temperature.
(4) Lower limb ulcer
The advanced stage of varicose veins of lower limbs is often accompanied by stasis dermatitis, itching, and due to scratching or trauma of patients, skin breakage and secondary infection, which can cause long-lasting ulcers. The ulcers mostly occur near the inner ankle, which do not heal for a long time and are prone to secondary infection.
(5) Venous function test of lower limbs
(1) Perthes test: A positive test is not suitable for saphenous vein stripping surgery.
(ii) Saphenous vein valve function test (Trendelenburg test).
(③) Traffic vein valve function test (Prart test).
(C) Auxiliary examination
1, color ultrasound examination: simple and convenient, the first choice for clinical.
2, CT venous angiography: adapted to complex venous lesions.
3.Angiography: invasive, “gold standard”
Fourth, the diagnosis and differential diagnosis of varicose veins of lower limbs
(A) Diagnosis
1.History of prolonged standing and diseases that can lead to increased abdominal pressure (pregnancy and pelvic tumor history, chronic bronchitis, habitual constipation, etc.), and mostly family history of varicose veins of lower extremities.
2.The veins of lower limbs are obviously tortuous and dilated, which is more obvious when standing; often accompanied by thrombotic superficial phlebitis, and skin pigmentation, fibrosis and ulceration in the foot and boot area may occur in the late stage.
3.Deep vein patency test shows: deep vein patency.
4.Ultrasound Doppler examination shows: saphenous vein valve insufficiency, or accompanied by deep vein valve insufficiency.
5.Venogram shows that the saphenous vein is tortuous and dilated, with valve insufficiency, or with deep vein valve insufficiency at the same time.
6.Exclude other venous diseases.
(B) Differential diagnosis
1.Post-deep vein thrombosis syndrome of lower limb
The patient has a history of sudden lower extremity swelling, distension and pain. In the late stage of deep vein thrombosis, superficial varicose veins of the lower limbs appear, and the swelling of the affected limbs is obvious and cannot be completely relieved after rest.
2.Arteriovenous fistula of lower limbs
This disease is divided into two kinds: congenital and secondary. Congenital arteriovenous fistula should be considered if severe varicose veins appear in youth and children for no apparent reason, and vascular murmurs and tremors can be heard and palpated at the varicose veins. The diagnosis of the disease is further supported if there is also thickening, growth, hairiness, and sweating of the affected limb. Secondary arteriovenous fistula should be considered if there is first trauma and then coarse swelling and varicose veins in the affected limb.
3.Venous malformation bone hypertrophy syndrome
This disease is characterized by limb growth, thickening, abnormally thick and varicose superficial veins, and cutaneous hemangioma (wine-like spots) triad.
4.Bu-ga syndrome
The main clinical manifestations are hepatosplenomegaly, massive and persistent ascites, esophageal varices often combined with bleeding, thoracoabdominal wall varices, bilateral lower limb edema and varices, skin pigmentation, ulcers, etc.
V. Clinical treatment of varicose veins of lower extremities
The treatment principles of varicose veins of lower extremities are
1.Promote blood reflux of lower limbs and eliminate stasis of blood
2.Clear heat and anti-inflammation, control limb infection
3.Protect the affected limb and prevent trauma