Primary deep venous valve insufficiency in the lower extremities often coexists with primary superficial saphenous valve insufficiency. According to the survey, primary deep vein valve insufficiency is present in up to 58.10% of patients with severe varicose veins.
Since the veins of lower limbs are divided into superficial veins and deep veins, superficial veins consist of large saphenous veins and small saphenous veins, and their valve insufficiency is superficial vein valve insufficiency of lower limbs; deep veins also have valves, and their valve insufficiency is deep vein valve insufficiency of lower limbs. The venous wall is composed of three layers, which are the outer membrane, the middle layer and the inner membrane. The outer membrane is mainly composed of collagen fibers and contains nerve fibers, while the inner membrane is endothelial cells and the folds of the inner membrane form the venous valves. The middle layer is the muscle layer, which is the main factor to determine the strength of the vein wall, but there is no elastic fiber, so in the case of venous hypertension, the trunk vein diameter is thickened, the muscle layer is thickened, but there will be no elasticity, and the branches of the trunk, which are poorly developed, are often caused by the high pressure factor, and the deep veins of the calf branch into sinuous veins.
In both superficial and deep venous systems of the lower limbs, valves are present, and the position of the valves is variable, but there are constant valves at the branches of the trunk veins. Most of the valves are double-valved and only a few are triple-valved. The function of the valves is to ensure unidirectional flow of venous blood to prevent regurgitation. Valve insufficiency causes venous blood reflux disorders in the lower extremities, venous hypertension, and venous stasis. The base of the valve is attached to the venous wall parts, there are valve concave, that is, the valve sinus, this venous sinus often cause thrombosis, especially the calf deep vein valve parts. Deep vein valves, from distant to near, gradually decrease. In the lower leg, there are many valves in the tibial and peroneal veins, almost every 2.5 cm should have a pair of valves, while in the femoral vein, there are only 5 pairs of valves on average. The deep vein valves ensure that blood can return to the heart in any part of the lower extremity, and the calf deep vein valves ensure the role of the gastrocnemius muscle pump. When the deep venous valves are not functioning, the high pressure reverse flow in the deep veins of the lower extremities will flow backward into the superficial veins through the traffic branches unimpeded, resulting in secondary superficial varicose veins.
The traffic between the superficial and deep veins of the lower extremities is also connected to each other. The traffic branches between the superficial and deep veins in the thigh are mainly located in three places: under the suture muscle, the adductor canal and the knee, and in the lower leg, the inner ankle traffic vein branch and the outer ankle traffic vein branch are the most important. There are 3 branches of the internal ankle traffic vein, which drain the venous blood of the lower 1/3 of the lateral side of the calf and cross the fascia directly into the peroneal vein. With deep venous hypertension in the lower extremities due to deep venous valve insufficiency, venous blood passes through these branches causing clinical symptoms of stasis and even stasis dermatitis and ulcers.
Under normal conditions, venous blood from the lower extremities flows back to the heart, relying on the diastolic force generated by the heartbeat, the pumping action of the muscles surrounding the veins, the negative pressure suction in the thoracic cavity during respiratory movements, and the venous valves to keep the blood flowing to the heart.
The return of venous blood to the lower extremities is different when the person is in prone or standing. In the prone position, the lower extremities are in the same plane as the heart, and all superficial and deep venous blood can return to the heart. When standing at rest, a hydrostatic pressure is formed between the heart and the veins of the lower extremities, which is approximately equal to the distance between the heart and the venous plane (cmH2O). The farther the veins are centrifuged, the higher the pressure is, and only when the muscles of the lower limbs play the role of effective pump, that is, when the muscles contract, the deep veins between the muscles are squeezed to return the blood to the heart; when the muscles are relaxed, the pressure in the deep veins drops suddenly, and the blood in the superficial veins can be sucked into the deep veins in order to promote the deep veins to return the blood to the heart, so when standing, the ankle veins bear the highest pressure, and the inner and outer ankles are often prone to depressed symptoms.
1.Etiology pathology.
Primary lower extremity deep vein valve insufficiency often coexists with saphenous vein and small saphenous varicose vein, mainly due to weak vein wall and venous valve malformation or defect, which is a manifestation of weak systemic supporting tissues, and is related to genetic factors, and people with this disease usually have superficial venous valve insufficiency syndrome first. In addition to the main congenital factors, acquired factors must also be considered, such as people engaged in strong physical labor (loaders, porters and tricycle workers) when the pressure in the abdominal cavity rises during weight bearing, lower limb venous reflux is blocked, venous pressure can also increase, long-term venous hypertension, making the valve relaxation, prolapse, resulting in venous valve insufficiency. In the formation of primary venous valve insufficiency, venous wall, venous valve weakness and venous pressure increase play an interactive role. In individuals with weakly developed venous walls and valves, clinical symptoms appear early, even shortly after puberty. In people with sound venous valves, clinical symptoms appear later, often after the age of 60.
According to traditional Chinese medicine, deep vein insufficiency in the lower extremities is mostly caused by heavy loads and standing for a long time, which hampers the operation of local qi and blood, and by external causes such as insect bites that break the skin of the lower extremities, resulting in external invasion of dampness and toxicity, stasis of the meridians and channels, and the development of sores; qi and blood are not transported, the essence is not distributed, and the sores are not guarded, which eventually leads to sores that do not heal for a long time or are prone to recurrence after healing.
2.Clinical manifestations and signs
The clinical symptoms of patients with primary femoral vein valve insufficiency present saphenous varicose vein disease.
(1) Discomfort and pain: This is the main symptom of primary femoral vein valve insufficiency, which often occurs when standing at rest and gradually worsens. It is comfortable after a little walking and reappears after a long time walking. It is comfortable at rest and not only i swollen but also painful when standing for a long time. The reason for these symptoms is that the pressure in the vein increases when standing, the wall of the vein expands, and the receptors of the sensory nerve endings in the outer membrane of the vessel are stimulated. When walking or flexing, the gastrocnemius muscle plays the role of pump, and the venous blood returns to the heart, which makes the symptoms of intravenous pressure disorder relieved, and these are the early symptoms.
(2) swelling: early most of this symptom, the late stage of the disease with the traffic branch valve insufficiency of patients, often long standing, after a long walk, the calf ankle area swelling, swelling often in the evening thickening, after a night’s rest is reduced or subside, which is obviously due to the increase in venous pressure, local pressure, so that the fluid in the blood extravasation.
(3) Pigmentation: In the late stage of this disease, the color of the inner side of the ankle to the lower part of the calf changes from brownish-brown to obvious purpura, and even ulcers. This is due to deep venous hypertension, insufficiency of traffic branch valves, venous blood overflow, subcutaneous stasis, pigmentation, followed by local malnutrition, resulting in rupture and failure to heal.
(4) Signs: The main signs of this disease are caused by saphenous vein valve insufficiency, primary femoral vein valve insufficiency has very few signs and the conscious symptoms are not severe. Many patients come to the clinic because they develop complications and then come to the clinic. These complications are the same as saphenous varicose veins, such as trophic changes in the skin (skin atrophy, flaking, itching, hyperpigmentation), eczema, and ulcers. The main cause of these these changes is venous hypertension. Blood from the veins of the lower extremities overflows and depresses under the skin through the traffic branches with incompetent valves, and the oxygen content of the blood decreases, and degenerative changes occur in the skin, manifesting as sweat hair loss, light thinning and flaking of the skin. Due to the rupture of capillaries, resulting in hyperpigmentation. Due to the weakened local resistance, it is easy to be infected into cellulitis. The main manifestation is in the supra-ankle area, mostly on the medial side, a few on the lateral or bilateral side, with pigmented areas of varying size, further forming eczema and ulcers on the basis of pigmentation. In the pigmented area and the base of the ulcer, there are incompetent traffic branch valves. If they cannot tolerate the venous high pressure when standing or suffer minor injury, they will pierce the skin and bleed, and this bleeding is difficult to stop by itself because the ankle is far from the heart and the venous pressure of the limb is high, plus the venous wall is inelastic and contracted.
3. Identification and treatment.
The key point of identification of this disease is to distinguish between dampness, heat and deficiency cold. The lower extremities are swollen if wet, red if hot; deficient if there is a deficit of qi and blood, the flesh buds of the wound are white or dark red after a long illness, and the sewage is foul; cold if the yang does not reach the four ends, the extremities are not warm, preferring heat and fearing cold; if the sore is ulcerated, the flesh is bright red and painful, it is easy to treat if it is hot and toxic; if the sore is dark and painless, it is difficult to treat if there is a deficit of liver and kidney.
(1) Damp-heat infiltration evidence: after exertion, when walking for a long time or sitting for a long time, the calf feels painful and swollen, and is relieved after lying down and resting, accompanied by superficial varicose veins, stagnant venous blood, and if complicated by infection, the local manifestations are red, swollen, hot and painful, or itchy first and then painful, red and swollen in patches, later breaking down and watery, forming ulcers, with a red tongue, yellow and greasy coating, and slippery pulse. The treatment is to clear heat and dampness, harmonize the camp and eliminate swelling. The formula is San Miao Wan combined with Dioscorea Z Hwa Toxin Tang plus and minus: Phellodendron, Atractylodes, Poria, Papaya, White Moss Peel, Coix Seed, Zedoary, Slippery Rock; if heat is heavy, add Shuang Hua and Dandelion; if dampness is heavy, add Qu Mai and Q Cun; if stagnation is heavy, add Red Peony, Rhubarb and Tao Ren.
(2) Qi deficiency and subsidence: swelling of the lower limbs is obvious, but the swelling subsides when lying down, the pigmentation of the lower legs is heavy, the sores do not heal for a long time, the sores are sunken, sometimes flowing sewage, or the sores are sunken, or become a jar mouth, the surrounding skin is black and stiff, the sewage stinks and is difficult to close the mouth, the tongue is red, the moss is white and thick, the pulse is floating; the treatment should be to strengthen the spleen and benefit the qi to lift, the formula is used to supplement Zhong Yi Qi Tang with San Miao Tang plus reduction: Astragalus, Ginseng, Angelica, Sheng Ma, Chai Hu The treatment is to strengthen the spleen, benefit qi and elevate it. The formula is based on Huang Qi, Ginseng, Angelica sinensis, Sheng Ma, Chai Hu, Bai Zhu, Fu Ling, Huang Bai, Niubizi, Cang Zhu; dampness, Qu Mai, Q Cun, Mu Gua; heat, Shuang Hua, Gong Ying, Di Ding; stagnation, Red Peony, Tao Ren, Da Huang.
(3) Liver and kidney yin deficiency evidence: the wound does not heal for a long time, the skin is black, the sore is sunken, sometimes flowing sewage, the face is yellow and thin, the tongue is red, the moss is thin and peeling, the pulse is sunken; treatment is appropriate to nourish the liver and benefit the kidney, the formula is used to add and subtract Tiger Qian Wan: Huang Bai, tortoise version, Zhi Mu, Shu Di, Chen Pi, Bai Shao, Lock Yang, Tiger Bone (with substitutes), Angelica, Fu Ling; stagnation is heavier add red peony, peach kernel, safflower, rhubarb, gadfly.
4.Western medicine treatment.
(1) General treatment: prepare elastic bandages, cotton elastic socks to wrap the calf or substitute with sports goods such as leg guards and ankle protectors. These supplies are mainly used in the lower leg. Because of the high venous pressure in the lower leg, the deep and superficial traffic branches are mainly in the lower leg, especially in the inner and outer ankle. The effective compression of the traffic branches of the inner and outer ankle can reduce the symptoms and control the development of the disease. Meanwhile, pay attention to proper bed rest, elevate the affected limb to the same level as the heart, and avoid standing for a long time.
(2) Surgical treatment: the use of vein wall with ring ring, ring suture, vein segment transplantation and valve repair can be used as appropriate.
5.Other therapies.
Such as traditional Chinese medicine and adult medicine for local external use, should be selected at discretion and used with caution, if used improperly, it is easy to aggravate the disease; bloodletting therapy, in the part of the inner or outer ankle rich in traffic branches, using a trigeminal needle to pierce the bloodletting, so that the traffic branch occlusion fibrosis, under certain conditions, the application of this method of treatment, but also to reduce the symptoms.