I. Disease Overview
Varicose veins of the lower extremities are the most important disease of the venous system and one of the most common diseases of the vascular disorders of the extremities. Usually, varicose veins and their comorbidities, especially ulcers, are commonly seen in most cases of vascular disease of the extremities. Varicose veins can be divided into two categories: primary and secondary.
II. Disease description
Varicose veins of lower extremities belong to the category of “tendon tumor” in Chinese medicine. It is recorded in the book of “Surgery” that “the tendon tumor is firm and purple, the base is green, the coiled is even, the knot is like earthworm.” Varicose veins of the lower limbs with ulcers belong to the category of “polyposis”. In the “Spiritual Pivot”, it is said that “Polyposis is the result of wind-heat and dampness, and there is a difference between the old and the new, and between the inside and the outside.” In the book of Surgery, it is said that “Polyposis, women are the mouth of the skirt and pants ……” and in the book of Surgery, it is said that “Polyposis is born in two polyposis, the initial swelling, long rotten or itchy, broken and pus dripping ……” all describe in detail the clinical manifestations of varicose veins and their complications in the lower limbs. It has far-reaching guiding significance for later generations to understand this disease.
Third, etiology
Inadequate venous valve closure leads to venous blood reflux and venous vasodilation
1, venous wall weakness and valve defects: the relative weakness of the venous wall, under the action of venous pressure can expand, the expansion at the valve sinus leads to the original venous valve without close closure, the occurrence of valve function is relatively incomplete, blood reflux. 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 walls and valves gradually lose their 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 that the tension of the superficial veins of the extremities is reduced during pregnancy, making them easy to dilate, a condition that can be restored after delivery.
Fourth, pathophysiology
Under normal circumstances, the venous reflux of lower extremities relies on the diastolic force generated by the pounding of the heart, the pumping action of the muscles surrounding the deep veins within the deep fascia, and the synergistic effect of the negative pressure attraction in 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. Long-term 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 become hypoxic and less resistant to damage, thus making them prone to infection and ulceration.
V. Symptoms and signs
Patients with primary varicose veins mostly have no local symptoms in the early stage, but the following clinical manifestations may appear gradually.
1.The affected limbs often feel soreness, dullness, swelling and pain, easy fatigue and weakness.
2.The superficial veins of the affected limbs are bulging, dilated, varicose, or even tortuous or lumpy, which is more obvious when standing up.
3.Swelling: slight edema may appear in the ankle and dorsum of the foot, and mild edema may also appear in the lower part of the calf in severe cases.
4.Complications.
(1) Nutritional changes of the skin: thinning of the skin, flaking, itching, pigmentation, eczema-like dermatitis and ulcer formation.
(2) Thrombotic superficial phlebitis: pain at varicose veins, presenting red, hard nodules and striae with pressure pain.
(3) Bleeding: acute bleeding due to trauma or spontaneous rupture of varicose veins or small veins.
VI. Diagnostic examination
The diagnosis of simple varicose veins of lower limbs is not difficult, and the diagnostic criteria are summarized as follows according to clinical practice.
1.History of prolonged standing and elevated abdominal pressure, or family history of varicose veins in lower limbs.
2.The veins of lower limbs are obviously tortuous and dilated, which is more obvious when standing.
3.The deep vein is patent, the saphenous vein valve is incompetent, and there may be traffic branch vein valve incompetence.
4.Ultrasound Doppler or venography shows tortuous dilatation of saphenous vein and valve insufficiency.
5.Complications such as hyperpigmentation, ulceration, thrombotic superficial phlebitis, bleeding and ulceration may be associated.
VII. Treatment methods
There are three kinds of treatment methods for varicose veins in lower limbs, including: compression therapy, varicose vein sclerotherapy and surgical treatment. So far there is no drug that can completely cure varicose veins of lower limbs. Wearing medical sequential decompression elastic stockings is the most effective method of compression therapy.
1, compression therapy method: use medical elastic stockings, medical sequential decompression elastic stockings in the ankle to establish the highest support pressure, gradually decreasing upward along the leg. In the calf belly to reduce to 70%-90% of the maximum pressure value, in the thigh to reduce to 25%-45% of the maximum pressure value. This decreasing change in pressure allows venous blood flow back to the lower extremities, effectively relieving or improving the pressure on the veins and valves of the lower extremities. It is best to wear the compression stockings in the early morning before getting up, and then take them off at night after going to bed.
2.Sclerotherapy: High tension solution (such as high concentration saline or sclerosing agent) is injected into the varicose veins to destroy the endothelium and make them disappear after sealing. However, only small varicose veins can be treated, and there may be severe pain, pigmentation, inflammation, redness, swelling, ulceration and other sequelae in the treatment, and it is easy to recur and difficult to deal with after recurrence, so it is only applicable to a small number of patients.
3.Surgical removal surgery: An incision is made in the groin and the saphenous vein is cut and ligated or withdrawn, which requires semi-body or general anesthesia and 2-3 days of hospitalization. If the varicose vein is too strong, several small cuts may be required to remove the varicose vein in one section. The treatment is complete but has the disadvantage of subcutaneous bruising and painful wounds. Extracorporeal laser or pulsed light: The same principle as the laser cosmetic treatment for blemish removal, the advantage is that only local anesthesia is needed, the treatment time is short, the pain is low, the wound is quite small, no unsightly scars will be left, and you can walk immediately. However, it is only for microscopic spider varicose veins, and it requires several sessions at your own expense to be effective.
Eight, lower limb varicose veins patients daily attention 12 matters
1.Avoid standing or sitting for a long time, you should always let your feet do elevation and lowering exercise, or take a small walk if possible.
2, should make the habit of wearing elastic socks to exercise legs for one hour every day, such as walking, brisk walking, cycling, running or treadmill, etc.
3, the right amount of exercise can promote venous blood flow back to the lower extremities 3. should develop several times a day to lie down and raise the legs higher than the heart posture, so as to promote the venous circulation of the legs.
4, maintain normal weight can not be overweight, because overweight will make the leg vein burden increase.
5, avoid lifting more than 20 pounds (about 10 kg) of heavy objects.
6.Do not use high temperature water above 40°C for a long time to soak your feet.
7.Keep your feet and legs clean, and avoid trauma that may cause skin breakdown.
8.If the skin of your legs is already dry, please follow the doctor’s instructions to apply medicine.
9.Check your legs every night to see if they are swollen.
10.Every night when you go to bed, put your leg up about 6 ⒈ 3 simply to make sure that you are not swollen.
11, insist on wearing progressive compression stockings, because leg swelling, usually occurs a few minutes after getting out of bed and standing. Please put on the stockings every morning before you get up and get out of bed.
12. Keep the stockings clean and pay attention to whether the elasticity of the stockings changes. When the elasticity of the stocking is lost, replace it immediately.