With the accumulation of anatomical knowledge and the improvement of diagnostic tools, the progress of understanding the role of venous valves in the venous system of the lower extremities, the relationship between their morphology and function, and the abnormalities of venous hemodynamics has caused a change in the traditional concept of varicose veins in the lower extremities, and the gradual recognition that varicose veins in the lower extremities are not an independent disease but a clinical manifestation of chronic venous insufficiency (CVI) of the limbs. Because of this, the treatment of varicose veins in the lower extremities must be individualized.
To choose the appropriate treatment, it is necessary to have a detailed understanding of the diagnosis of varicose veins in the lower extremities, and only on the premise of a clear diagnosis can we talk about individualized treatment.
First of all, let’s understand the clinical manifestations of varicose veins in the lower limbs.
1, superficial varicose veins: this is one of the most common and characteristic clinical manifestations. It is the first to be recognized because it is superficial and easily recognizable. Superficial varicose veins show varying degrees of tortuosity, dilatation, twisting and massing.
2. Soreness, pain and heaviness: Soreness, pain and heaviness vary from person to person, with different degrees of severity of performance. This group of symptoms is the characteristic manifestation of venous hypertension, due to the increase of venous pressure, superficial venous dilatation and stimulation of venous outer membrane receptors, weakness, soreness and swelling of lower limbs, pain, soreness and heaviness are mostly seen after standing or walking, and can be relieved or disappeared after resting or elevating the limbs.
3.Limb swelling: nearly half of the patients may have different degrees of edema in the limbs, mainly after activity, and the edema is obvious after a day’s activity or a long period of standing or walking, while the edema is slight or disappears in the morning, i.e. “light in the morning and heavy in the evening”.
4, lower limb skin trophic lesions: due to the continuous increase of venous pressure in the affected limb, skin pigmentation, dermatitis, eczema, ulcers and other skin trophic lesions will appear in the lower leg after a period of time, due to the anatomical characteristics of rich venous network, weak venous walls and little subcutaneous tissue in the foot and shoe area, skin trophic lesions are mostly seen in the foot and shoe area.
5.Thrombotic superficial phlebitis: the blood flow in the varicose veins is relatively slow, so it is easy to stimulate thrombosis after slight trauma, and then infectious phlebitis and perivenous inflammation can occur. The most typical symptom is the sudden pain of the affected limb, and the serious person can’t walk, and the performance of redness, swelling, heat and pain suddenly appears in the superficial varicose vein, and the local hard nodes and even lumps can be touched, and the serious one can be accompanied by fever and other systemic symptoms.
6.Ruptured varicose vein bleeding: Most of them occur in the foot and ankle area, because of the high pressure of the vein and fast bleeding, so they need emergency treatment.
Not every patient has all the above clinical manifestations, because of this, the treatment choice of varicose veins in lower limbs must be individualized. For patients with varicose veins of the lower extremities, the CEAP classification system is used internationally, which was confirmed at the 2nd Pan-Pacific Symposium on Venous Disorders (1997).The CEAP classification system consists of four components: clinical manifestations (C), etiology (E), anatomy (A) and pathophysiology (P). See the table below for details.
Classification
Clinical manifestations
C0: absence of signs of venous disease (pain, swelling, heaviness).
C1: dilated capillaries or reticular veins.
C2: superficial varicose veins.
C3: venous edema.
C4: trophic skin changes (hyperpigmentation, eczema, etc.).
C5: skin changes + healed ulcers.
C6: skin changes + active ulcers.
Specific explanation
C0: simply speaking, we can’t see the varicose vein mass, but there are clinical symptoms of venous insufficiency of lower limbs, including soreness and heaviness of limbs after activity, fatigue and weakness, commonly known as “restless legs”. This level is especially easy to be ignored or misdiagnosed.
C1: There are three different manifestations.
① capillary dilation, persistent dilated small intra-dermal veins, red, less than 1mm in diameter, linear or filiform.
(ii) Reticular veins, persistently dilated small intra-dermal veins, blue in color, greater than 1mm in diameter and less than 3mm in diameter, usually twisted and different from normal small intra-splenial veins.
③Coronary venous dilatation, a dilated intra-dermal capillary in the medial and lateral sides of the foot near the inner and outer ankle, fan-shaped arrangement, consistent with the site of ulcer predilection, often a clinical manifestation of progressive chronic venous insufficiency.
C2, C3, C5 and C6 are better understood and can be seen in the clinical presentation above.
C4: Nutritional changes of the skin, which most commonly have three manifestations.
① pigmentation, early skin changes as light black pigmentation, commonly around the ankle, which may extend to the lower legs and feet.
②Eczema, manifested as erythema, blistering, oozing or scaly erythema, which can involve the whole lower limb in severe cases, also known as bruising dermatitis.
③ lipid scleroderma, manifesting as limited sclerosis of the skin of the affected limb, which may be accompanied by scarring, contracture, involving skin, subcutaneous tissue, and even fascia, is a serious skin lesion, with acute subcutaneous histitis, localized skin redness and tenderness.
The diagnosis and classification of varicose veins of the lower extremities are not an independent disease, and the diversity of clinical manifestations also determines the diversity of treatment, and standardized diagnosis and classification can help to further rationalize the choice of treatment for venous diseases. The specific treatment is described in the introduction of surgical and non-surgical treatment of varicose veins in the lower extremities.