Varicose veins are a common and frequent disease, especially in the lower limbs, and if left untreated may develop into ulcers in the legs, bringing a heavy burden to the patient’s body and mind. For this reason, I had the honor of interviewing Dr. Mao, Deputy Chief Physician of the Vascular Surgery Group of General Surgery Department of Shanghai First People’s Hospital. Dr. Mao’s patient and detailed explanation is more like a popular science class, making abstract medical knowledge vivid, graphic and interesting, so that people not only know what they know but also know why they know it, I believe you will benefit from Dr. Mao’s explanation as much as I did.
Scientific Life: Before I interviewed you, I also read some information, which said that varicose veins are caused by excessive pressure on the veins, so is the pressure on the veins the same thing as the blood pressure we usually talk about?
The arterial system and the venous system are both part of the human circulatory system. In short, arteries are a channel through which blood is transported from the heart to the organs of the body and into the tissues, and it is the arterial system that goes from the heart to the tissues. Then, after the exchange of substances and oxygen in the tissues, the blood flows back to the heart through capillaries, and this channel back to the heart is called the venous system.
What we usually call blood pressure is actually the arterial pressure, often measured in the brachial artery pressure of the upper limbs. The vein, in fact, also has pressure, it is a hydraulic system, the blood vessel is a tube, filled with blood, the liquid must have a pressure on the wall of the tube, called hydraulic pressure. But the venous pressure is much lower than the arterial pressure. Let me draw an analogy, the venous pressure we commonly use is the central venous pressure, that is, the inferior vena cava or superior vena cava immediately returns to the heart in the place called central vein, its pressure is generally 4-12 cm water column, while the artery is 90-140 mm Hg, it can be seen that the venous pressure is much lower than the arterial pressure.
The venous pressure in different parts of the body also varies considerably. The lower it is, let’s say the venous pressure in the lower extremities must be higher than the venous pressure in the upper extremities or in the head. The amount of venous pressure depends more on the height of the fluid injection. So the varicose veins that we usually see basically occur in the lower extremities.
Scientific Life: One of the major causes of varicose veins is due to a poorly functioning valve, so what does this valve do?
This starts with understanding venous reflux. Venous blood flows back from the tissues to the heart, so for the lower extremities, the blood in the lower extremities must flow against the direction of gravity. We often say that water flows downward, so why can blood flow from the bottom to the top? This relies mainly on the pumping action of the heart. The heart has two different periods: systole and diastole. The systolic period is to beat out the arterial blood, diastolic period is to suck the venous blood to the atrium, so the power of blood flowing from the bottom to the top is entirely by the pumping action of the heart, by the negative pressure generated by the pumping suck up.
So what is the function of the venous valves mentioned earlier? Although the heart is sucking blood upward, the heart alternates between systole and diastole. If there is no venous valve, blood will be sucked up in diastole and knocked down in systole, which is like doing an ineffective exercise, and blood will never be sucked up. So in addition to the vein acting as a conduit, it has many valves. The valve is like a valve, and it’s a one-way valve. It can only open in one direction, blood flowing from the bottom to the top, the valve can be opened to let the blood through to go, but if the blood flows down in the opposite direction, the valve closes in the opposite direction. That is to say, once the blood is sucked up, when the heart contracts again, it is impossible to flow back, but is topped off by a section of the valve. In this way, the venous blood from the lower extremities can flow back up to the heart in a steady stream.
Scientific Life: What you said above is the normal return of venous blood, but is there a problem with the return of varicose veins?
Varicose veins in the lower extremities are in fact largely a reflux disease. The blood in the lower extremities should flow from the bottom to the top, and in patients with varicose veins or venous insufficiency, the main problem is the damage of the valve function. After the blood is sucked up, it flows back down again, and even some patients lose the valve function completely, which causes the reflux obstacle. At the same time, arterial blood is constantly rushing downward, so the pressure in the lower tissues and veins becomes higher. When the valves are damaged, the pressure in the veins of the lower extremities increases, which is the basis for the disease varicose veins.
The reflux of venous blood causes an increase in the pressure in the veins of the lower extremities. Because the vein wall is very thin, unlike the artery wall which is very thick, the middle layer of the artery wall is smooth muscle layer, which is very strong and looks round and solid; while the vein wall is very thin, even sometimes it looks translucent, the blood inside can be seen, and there is no smooth muscle inside the middle layer of the vein wall, so its ability to bear the pressure is very poor. When the pressure of the vein increases, the wall expands, so we can see that the vein is dilated and tortuous. The damage of the valve and the reflux constitute a vicious circle: because the valve is attached to the wall, when the wall is dilated, the valve is not closed properly, which causes the reflux to be more serious.
The valves are arranged one by one in the vein, and when the top valve is damaged, the pressure is transmitted to the next valve, causing the next valve to be damaged as well, just like dominoes, one after the other. The most common varicose vein is the saphenous vein, which is located in the inner part of the thigh and calf. What we usually see like a worm is not a saphenous vein, but a branch of it, which we call a genus, and the saphenous vein usually only dilates but not tortuously. The most vulnerable valves are the pair of valves at the root of the saphenous vein, where it joins the femoral vein in the groin.
Scientific Life: As you said, the most easily damaged valves are the pair of valves at the root of the saphenous vein in the thigh, but the most obvious site for varicose veins is in the calf, so how does this happen?
Although the valves are broken from the top to the bottom, the top valves do not show varicose veins in the thighs when they are broken; when varicose veins appear in your calves, most of the time the top valves have been damaged and transmitted to the bottom valves. There are, of course, exceptional cases where the upper valve is not broken, but the lower one can develop varicose veins because there is an abnormal “through branch” between the superficial and deep veins, and this through branch returns from the deep vein to the superficial vein. This is another reason, most of the time the valve breaks down from top to bottom one by one and varicose veins appear in the lower leg.
There are two sets of reflux veins in our lower limbs, one is the superficial veins: the great saphenous vein and the small saphenous vein, which are under the subcutaneous tissue and above the muscles. There is also a deep vein system, which is deep in the muscle, and this deep vein is usually not damaged because it is supported by the muscle around it.
Scientific Life: What are the symptoms of varicose veins and what happens if the disease progresses?
There is a change of concept here, the previous understanding was divided according to the degree of the disease, called primary saphenous varicose vein and primary small saphenous varicose vein; now this concept has changed, it is considered wrong to completely separate the deep vein and superficial vein problems, now the consensus is that both deep and superficial veins are venous system, if there is reflux disease, it is often deep and superficial veins If reflux disease occurs, it is often the deep and superficial veins that have reflux at the same time, but different patients have different performance. For example, some patients have heavy deep venous reflux, but the varicose veins are not obvious, but their legs are swollen; some patients have mainly superficial venous reflux, so they often show varicose veins, and the swelling is not necessarily very strong. Nowadays, the international term for this type of disease is CVI, i.e. chronic venous insufficiency. There is a grading according to the degree of severity, the most used is based on the clinical manifestations of grading, from C0 to C6 into 7 levels.
In C0, there are no obvious symptoms or positive signs, but ultrasound may reveal some changes, such as reflux, etc. In C1, some patients have capillary dilation, i.e., the capillaries under the skin of the patient are a little thicker than the average person, and they look red and flaky, some of them are red with purple or blue inside, which is the earliest varicose vein. In C3, the patient has edema in combination. After the development of C4, the patient will have skin color changes, which is clinically called sebaceous scleroderma, pigmentation and eczema.
Scientific Life: Could you please explain to us why varicose veins have skin problems?
When the venous pressure is high, it causes changes in the skin. This is because the blood from the capillaries, which is supposed to collect slowly in the venous system, returns to the capillary network when the venous pressure is high. When the capillary pressure rises, the plasma inside will penetrate to the outside of the capillary, and there is a lot of fibrinogen in the plasma, and after these substances reach the surrounding tissues, the fibrinogen will become fibrin deposits in that place, forming a “protein rust”, that is, fibrin deposits around the lumen of the capillary, so that A layer of things like a cover isolates the capillaries from the surrounding tissues. Originally, the nutrients from the capillaries should penetrate into the tissues and exchange with them, but this barrier prevents the skin from absorbing the nutrients, so the skin slowly deteriorates.
C5 to C6, skin ulcers will appear, C5 is called healing ulcers, that is, after the patient produces ulcers, slowly may also heal, with 3 months as the boundary, within 3 months ulcers healed, this is called C5, if more than 3 months ulcers do not heal is called C6, if there is no treatment at this time, then the ulcer may be with the patient for life. At the same time, the ulcer will also be secondary to infection, forming old rotten feet, non-stop infection, the infection of bacteria may be streptococcus, anaerobic bacteria and other bacteria, so the smell is very bad, and the ulcer surface will become larger and larger, all these cause great pain and burden to the patient psychologically and physically.
Scientific Life: Is this ulcer very painful then?
If it is over time, it may not even hurt because the surrounding nerve endings will also rot away together and the patient may not even feel it anymore. In the most extreme case, if the infection is too long, the ulcer develops deeper and can even cause complications such as chronic osteomyelitis. Of course this is less common because it is, after all, an inaugurated wound and the main exudate of the infection is going outside.
Scientific Life: Both C5 and C6 are ulcers, why do some heal and some don’t?
It still depends on the extent of the disease. C5 is relatively mild, and some patients may change their medication and get better after a while, while some time later they may relapse. If we don’t intervene, the process must be irreversible, it must go in a serious direction and become more and more powerful, it is a disease without any self-limiting.
Scientific Life: I read some information that varicose veins are one of the four common diseases in surgery, is that right?
We have four common diseases in surgery, namely appendicitis, inguinal hernia, varicose veins and hemorrhoids. Of these four diseases, the incidence of varicose veins is quite high, and the approximate statistic is that 1 in 11 people in China suffer from varying degrees of chronic venous insufficiency.
Scientific Life: So what triggers varicose veins?
The cause of any disease is internal + external, and the external causes work through the internal causes. The cause of varicose veins is the high pressure in the venous system of the lower extremities. The increased pressure causes the destruction of the valves, the dilatation of the lumen and the tortuousness of the veins. Previously, it was thought that venous hypertension was related to occupation, such as teachers, salesmen, including our surgeons, operating room nurses and other occupations that stand for a long time are prone to this disease. Because when standing, the hydrostatic pressure of lower limb venous system is the highest, and this problem will easily appear in the long run, so it is said that varicose veins are related to the body position they are often in.
Science of Life” You mentioned earlier that standing is prone to varicose veins, but modern people, especially white-collar workers, often sit still, so is the frequent sitting position also prone to varicose veins?
Sitting is definitely better than standing, but sitting itself is not a good thing. Because when sitting, legs are hanging, generally not moving, and muscles are not much contracted, and the contraction and diastole of the muscles themselves will help the pulsation of veins. If the leg is always hanging down and not moving, because after all, the leg is lower than the heart, also bear some pressure, so it is not very good. Xuanqi Mao, Department of Vascular Surgery, Shanghai First People’s Hospital
The above mentioned is the external cause. Nowadays, research has found that internal causes are also very important. The external cause is the high pressure, but the internal cause is the weakness of the vein wall itself, the vein wall itself or the valve itself in patients with CVI is not strong enough, that is, it is not strong enough, the wall tends to dilate and the valve tends to close incompletely. Research in this area is just now being advanced. It is believed that the toughness and strength of the wall and valve tissue depends on the composition of the collagen fibers inside. There are four types of collagen, and the tissue interstices are filled with these four types of collagen, and the normal composition of these collagen components ensures the normal strength of the tissue. We now find that the ratio of collagen type 1 to collagen type 3 is inverted in patients with varicose veins compared to normal people, which leads to the lack of toughness and strength of the veins and valves of these patients and makes them prone to problems. Let me use an analogy, my clothes are thicker, and your weave is less strong, then the same tear, maybe my one is not broken, your one is broken.
Scientific Life: Does your collagen theory suggest that varicose veins are to some extent genetic?
Because the synthesis of protein must be genetically determined. In fact, we find in our clinical practice that many of this disease is familial. Think about it, there are so many teachers who are people’s teachers, and not every teacher gets varicose veins. So, the endogenous cause of varicose veins is susceptibility to get this disease, and if the exogenous cause is then engaged in an occupation that involves a lot of standing, it will promote the formation of this disease even more.
The theory of collagen is more mature, there are some new theories, one of them is called matrix metalloproteinase theory, matrix metalloproteinase is a group of proteins, about dozens of species, the abbreviation is MMP. research found that several of the MMP has a degrading effect on the collagen fiber of the tissue, can destroy its tissue, which makes the strength of the lumen decreased. This theory is derived from the disease “abdominal aortic aneurysm”. The abdominal aorta is one of the thickest arteries in the body, and as blood pressure rises, its arterial wall expands like a balloon, bulging out a round thing that gets bigger and bigger like this, and the wall gets thinner and thinner, and finally “pops” and breaks. Later, after testing, it was found that the wall of the aneurysm had an increased amount of matrix metalloproteinase, which caused the expansion of the wall. Because they are all dilated diseases, some scholars have transferred this theory to varicose veins, and the results show that there are several enzymes in the tissue of the vein walls of these patients that are really high, but of course this theory is not very mature.
Scientific Life: Since the internal cause is from some collagen deficiency, is it useful if we supplement some collagen in food later on?
I’m afraid this won’t work. The genes control the composition of the ratio, the composition of each part of the composition, and it has nothing to do with what you eat.
Scientific Life: So does exercise help with varicose veins?
Exercise is not a significant help for CVI, which is manifested in varicose veins, mainly in superficial veins. Because the superficial veins are outside the muscles, the pumping effect of muscle contraction and diastole will speed up the blood flow in the deep veins, which will indirectly speed up the blood flow in the superficial veins as well. However, the exercise of walking and running will not reduce the incidence of varicose veins. Many patients in our clinic are very strong and muscular men, including martial arts instructors, who have also had surgery, so the effect of exercise is not obvious.
Rather, taking some protective measures when standing, walking and other exercises can be very effective in preventing or delaying this disease. What is the method? It is the use of “medical elastic socks”, or “sequential elastic socks”, this elastic socks in the process of knitting, elasticity is a pressure gradient, the regular medical elastic socks, five toes can be exposed, from the back of the foot has been wearing up. There are two types of stockings, long and short. Short socks are worn up to the knee joint, while long socks are worn up to the upper mid-thigh. The pressure gradient is reflected in the fact that the further down you go, the greater the pressure, and the further up you go, the more the pressure decreases in a little bit of a sequence. The purpose is to help pressure the blood from the distal end to the proximal end, if the opposite is not true, then the bottom of the leg swells up, so you can not buy indiscriminately. Many patients in the clinic, when I say they need to wear elastic stockings, the patient says, I have ah, and then takes out something like a knee brace and puts it on there. This kind of thing doesn’t work at all, so you have to go to a regular pharmacy and buy it, and it’s best to buy it on the advice of your doctor, or show your doctor that it’s this thing, right?
Scientific Life: Which stage of C0 to C6 are elastic stockings suitable for patients?
This involves the choice of treatment. Generally speaking, patients with C0 and C1 are not considered for surgical treatment, they are too light for surgery to make sense. C2 and above are relative indications for surgery, and it is reasonable if surgery is chosen, but with so many patients, it is impossible to operate on every patient. And above C4, once the skin nutrition changes, it is necessary to operate, otherwise it may develop into an ulcer. Some patients have symptoms, such as feeling very sore and painful legs every day, and cramps in the calf muscles when they sleep at night, so we still tend to operate in this case, while some patients have no symptoms, or have symptoms but cannot operate for some time for various reasons, and these patients are most suitable for wearing elastic stockings.
Scientific Life: Do you need to wear compression stockings 24 hours a day and what do you need to pay attention to in the process of wearing them?
Patients usually report that their feet are swollen during the day, especially in the evening, but when they wake up in the morning, they are fine; some people have swollen feet, but they are not swollen in the morning. Because the feet are lying flat when sleeping, the height of the feet is on the same plane as the heart, so the reflux is good and the symptoms are gone. While standing and sitting during the day, the pressure is high, and the symptoms become obvious. Therefore, we recommend that you do not need to wear elastic stockings when you go to bed at night, and when you get up in the morning, put on elastic stockings before you get out of bed, because your feet are theoretically the least swollen at this time. If you get out of bed and walk around, it’s possible that your legs will swell up, and it’s not as convenient to wear them, they’re tighter, and after all, they already constitute a certain amount of damage.
There is also the size of the elastic stockings or very careful. Generally, the outside is divided into large, medium, small, and in some cases, extra large. This is a more generalized division. You should first measure the caliber of several, the most important one is the circumference of the calf muscle in this place, measuring the circumference of the thickest part of the calf. There is also the circumference of the ankle joint. After measuring these two caliber values, you can go to the place that sells elastic stockings, and there is usually a table that corresponds to this set of values.
There are also levels of strength of the stockings, from one to five, the higher the level, the higher the pressure. So it is divided into preventive and therapeutic. Let’s say our nurse in the operating room is very beautiful, she is afraid of getting varicose veins, but she is always standing, what should she do? She can then buy relatively less pressure; while C2 and C3 patients will need to buy therapeutic ones. But this treatment is also in quotation marks, it doesn’t mean that if I wear elastic stockings, varicose veins will be cured, it just makes them develop more slowly.
Scientific Life: You said earlier that if you get to C4 you need surgery, what are the indications that indicate the need for surgery?
There are several significant signs of C4. One is itchy skin, which gets a little worse when it’s cold, but never because of dry skin in winter. In varicose veins, the itchiness is visible to the naked eye, and the redness of the skin surface is actually eczema. There is also hyperpigmentation, where the skin color darkens to brown, dark brown, and later to dark brown. In particular, the skin of the area with hyperpigmentation and eczema will become particularly thin and hard to the touch, just like leather. This is the result of increasingly poor skin nutrition. The ulcers often appear where the skin turns dark brown, and they tend to grow near the ankle joint.
In general, from the beginning of the disease to the end, it develops slowly and then fast, at first it develops slowly, some patients may have varicose veins all their life, and there is no big change; but in the later stage, especially after C4, it develops faster and faster, so it is necessary to operate at this stage of C4, otherwise it will develop into ulcer soon.
Scientific Life: Generally speaking, varicose veins are more obvious in the inner calf, but the ulcers are not in the calf, but in the ankle joint, why?
This is because the ankle joint is located in a relatively lower position, which is subject to more pressure, and the skin and subcutaneous tissue in this place are the thinnest, we can feel our ankle joint, there is only one layer of skin, its blood supply is worse than the inner calf, so the ankle joint is especially prone to ulcers.
Scientific Life: So what approach is used for varicose vein surgery to solve this problem?
The history of varicose vein surgery is very long, about 100 years, during this period there are only some technical improvements, basically not much change, so the surgery is very mature. But in the last 10 years, the surgery has been revolutionized. The traditional procedure is called “saphenous vein ligation + stripping”, which is one of the most common surgical procedures, and the results are very good, and the recurrence rate is also very low. An incision is made in the groin to cut and ligate the saphenous vein that runs through the entire lower limb, and then a stripper is used to reach down through the lumen and pull out the vein. Finally, a small incision is made on each branch of the varicose vein and the subcutaneous varicose vein is withdrawn.
More than a decade ago, in 1999, Italian doctors started to use laser to do this procedure, which is to extend the laser fiber into the lumen of the vein and use the laser energy to cauterize the lining of the vein, and then with compression, the lumen becomes solid and striated. The amount of bleeding in laser surgery is basically controlled to less than 5 ml, unlike traditional surgery where the bleeding is very high. Compared to traditional surgery, the short and medium-term results of laser surgery are similar to traditional surgery, and data on long-term results are not yet available because this surgery has only been performed for about ten years. The advantage of laser surgery is that there is less bleeding, fewer incisions, and smaller evisceration wounds, and the operation time is greatly reduced, only one-third of the time of traditional surgery, 30 to 40 minutes on average. Generally speaking, you can get off the ground the day after the surgery, and the hospital stay is short, and you can be discharged after one or two days of observation.
Scientific Life: Is this surgery suitable for patients who have already developed ulcers, and will the ulcers heal after surgery?
For more serious patients a combination of traditional surgery and laser surgery may be used. For patients with local ulcers, there are often abnormal penetrating branches on the deep side of the ulcer, so in order to treat the ulcer, in addition to getting rid of the main stem, the penetrating branches below must also be removed, so that there is no communication between the deep and superficial veins, then the local pressure can be lowered, which is the basis for the ulcer to heal, otherwise, even if the medication is changed frequently, it will not help. After surgical or laser treatment, most patients’ ulcers can heal, but for larger ulcers, generally speaking, ulcers with a caliber greater than 2 cm, the epidermal defect is too large for epidermal cells to grow over, and implants may be needed in this case. Therefore, patients should try to treat early so as not to delay the treatment until the end.