A. Etiology and pathophysiology
1, weak vein wall and valve defects: the vein wall is relatively weak and can expand under the action of venous pressure, the expansion at the valve sinus leads to the original venous valve can not close closely, the valve function is relatively incomplete, blood backflow. Valve dysplasia or absence, also can not play an effective role in preventing backflow, leading to the onset.
2, venous pressure persistently elevated: venous blood itself due to the role of gravity, a certain pressure on the valve, under normal circumstances will not cause damage, but when the venous pressure continues to rise, the valve will withstand excessive pressure, gradually relaxation, prolapse, so that the closure is incomplete. This is mostly seen in long-term standing work, heavy physical labor, pregnancy, chronic cough, long-term constipation, etc.
3, followed by age, gender: because the limb venous pressure only in the body length up to the highest when the highest pressure, the body before puberty is not high, so the caliber of veins is small, all can prevent venous dilation, so although there are suffering from serious varicose veins before 30 years old, but most of them are with age, the vein wall and valve gradually lose its tension, the symptoms increase forcing patients to seek medical attention.
Varicose veins are more common in women, probably because pregnancy can trigger or exacerbate them. However, in women without pregnancy, the incidence is higher than in men (male:female=1:3), probably because of the wider pelvis, the excessive curvature of the vascular structures and the increased congestion of the veins in the pelvis during menstruation, pregnancy and menopause. Another reason why varicose veins are prone to occur during pregnancy is because the tension of the superficial veins of the extremities is reduced during pregnancy, making them prone to dilation, a condition that can be restored after delivery.
Under normal conditions, venous reflux in the lower extremities is based on the synergistic effect of the diastolic force generated by the *heartbeat, the pumping action of the muscles surrounding the deep veins within the deep fascia, and the negative pressure attraction within the thoracic cavity during respiratory movements. The venous valves act as a one-way restriction in blood return. If there is a valve defect, the unidirectional restriction is lost and causes additional impact on the next level of venous valves by backflow of blood, which in time leads to the destruction of the next level of venous valves. The destruction of the valves in the vein makes the backflow of blood to the vein wall to produce huge pressure, which can cause dropsy in the relatively weak part of the vein. Long-term standing, heavy physical labor, pregnancy, chronic cough, long-term constipation, etc. can increase the pressure in the veins, which further intensifies the impact of blood on the valves and the pressure on the vein walls, leading to varicose veins. Prolonged varicose veins and blood stagnation eventually produce stasis dermatitis, hyperpigmentation and chronic sclerosing cellulitis or ulcer formation.
The pathological changes in varicose veins occur mainly in the middle layer of the vein wall. In the early stages, both the elastic and muscular tissues of the middle layer thicken, a change that can be considered a compensatory response to increased venous pressure. In the late stage, both muscle and elastic tissues atrophy and disappear and are replaced by fibrous tissues, and the vein wall thins and loses elasticity and dilates. The venous valves also become atrophied and sclerotic. The microcirculation of the tissues surrounding the diseased vein is also impaired by the increase in venous pressure, causing malnutrition and fibroblast proliferation. The subcutaneous tissue of the lesion is diffusely fibrous and edematous, and the edematous fluid contains a large amount of proteins, which in turn can cause fibroblastic proliferation. The lymphatic reflux is blocked by venous stasis, and the large amount of proteins in the lymphatic fluid aggravates the tissue fibrosis. As a result of this vicious circle, the local tissues are hypoxic, and the resistance to damage is reduced, so that infection and ulceration can easily occur.
Second, clinical manifestations
Progressively aggravated superficial veins of the lower extremities are dilated, bulging and tortuous, with the inner calf being the most obvious. In the early stage of the disease, it is often accompanied by soreness and swelling of the affected limb, as well as heaviness and weakness of the limb, which can be reduced after lying down or elevating the limb, and swelling of the affected limb can also appear, which can subside after rising in the morning. Some patients have no obvious discomfort. For longer duration of the disease, dystrophic changes may appear in the lower leg, especially the ankle, including skin atrophy, desquamation, hyperpigmentation, skin and subcutaneous tissue sclerosis, eczema and refractory ulcers, sometimes complicated by thrombophlebitis.
Diagnosis and differential diagnosis
Most of the patients with varicose veins can be diagnosed clearly by medical history, simple physical examination and imaging diagnosis.
1.Deep vein patency test (Perthes test): It is used to determine the deep vein reflux, which is often patency in varicose veins of lower limbs. The method is to block the saphenous vein stem with a tourniquet in the thigh and ask the patient to kick the leg or squat continuously with force, because of the movement of lower limb, the muscle contraction, the superficial vein blood flow back through the deep vein and make the varicose vein atrophy and empty. If the deep vein is inaccessible or there is backflow to increase the venous pressure, the varicose vein pressure will not be reduced, and even the varicose is more significant.
2, saphenous vein valve function test (Trendelenburg test): used to determine the function of saphenous vein valve, simple varicose veins of lower limbs patients with loss of saphenous vein valve function. The method involves the patient lying in a flat position with the lower limbs elevated, emptying the blood from the superficial veins and tying a tourniquet at the base of the thigh below the fossa ovalis. The patient is then allowed to stand and the tourniquet is released within 10 s. Immediate filling of the saphenous vein column from the top down is indicative of saphenous valve insufficiency. The lesion is most likely located at the level of the fossa ovalis, where deep venous blood drains into the superficial venous system through the saphenofemoral venous junction. A slow (more than 30s) and gradual filling of the superficial veins is normal and is the result of blood flowing back into the veins from the capillaries. If the superficial vein below the tourniquet fills up rapidly after the patient stands up and the tourniquet is not untied, it means that the blood returning to the vein comes from the small saphenous vein or some dysfunctional traffic vein.
3, traffic vein valve function test (Pratt test): patient lying down, elevate the affected limb, tie a tourniquet at the root of the thigh, first from the toe up to the rouge fossa, tie the first elastic bandage, then from the tourniquet down, tie the second elastic bandage, while down to untie the first elastic bandage, while down to continue to tie the second elastic bandage, if the varicose appears in the gap between the two elastic bandages If there is a varicose vein in the gap between the two bandages, it means that there is an incompetent traffic vein there.
The impact diagnosis includes color ultrasound and venography, usually color ultrasound, and venography if there is a high suspicion of deep vein pathology.
The differential diagnosis includes: lower extremity deep vein valve insufficiency, lower extremity deep vein thrombosis sequelae syndrome, arteriovenous fistula, and K-T syndrome.
IV. Treatment
1.Conservative treatment
Only for early mild varicose veins, pregnant women and patients who have difficulty to tolerate surgery. It includes compression therapy with circulatory drive stockings, medication, etc. Drug treatment can only relieve the symptoms.
2.Surgical treatment
Surgery is the fundamental treatment for varicose veins in the lower extremities, and it is effective. Traditional surgical methods mainly include.
①High ligation of saphenous or small saphenous vein.
② stripping of the main trunk of saphenous or small saphenous vein and varicose vein.
(iii) ligation of incompetent traffic veins, which is especially important for those with hyperpigmentation or ulcers. With the development of technology, new minimally invasive treatments such as laser and radiofrequency have emerged, but the aim of all these treatments is to remove or occlude the diseased vessels. The efficacy of these new methods is relatively certain, and they are complementary to the traditional methods. The actual application of the treatment method needs to be selected according to the specific situation of the patient and the technical development of the hospital.