Causes and mechanisms of development
The development of CVI is most commonly triggered by two main conditions:
- Varicose veins. Based on congenital weakness of the elastic-fibrous framework of the venous wall. When pressure increases (heavy labor, prolonged standing, pregnancy), deep veins dilate, and their valves cease to close properly. Blood is refluxed through communicating veins into superficial veins, causing nodular deformation.
- Post-thrombotic syndrome (PTS). Occurs after acute deep vein thrombosis. Valves are destroyed, and paravalvular fibrosis develops. The musculovenous pump fails, and venous outflow occurs through recanalized deep or collateral veins with pathological retrograde blood flow.
Regardless of the initial cause, a persistent impairment of venous outflow forms. Blood stasis leads to fluid leakage into the tissues (edema). As a result, microcirculation is disrupted: tissues are deprived of oxygen, and metabolic waste products are not removed, which triggers a cascade of trophic disorders.
Stages of trophic disorders
Chronic venous insufficiency progresses gradually, and its development can be divided into distinct stages of local changes in the skin and subcutaneous tissue:
- Stage one: the skin becomes dry and thinned.
- Stage two: sclerosis of the subcutaneous tissue develops (cellulite).
- Stage three: local skin necrosis.
- Stage four: rejection of dead tissue with the formation of an open trophic ulcer.
Clinical presentation
In the early stages of varicose veins, symptoms may be absent, with only slight dilation of soft subcutaneous veins, and the overlying skin unchanged.
In the decompensation stage, patients are troubled by:
- A feeling of heaviness and fullness in the legs, and rapid fatigue.
- Cramps and pain in the calf muscles.
- Pronounced skin itching, which is often a precursor to ulcers.
- Edema (puffiness) of the distal parts of the legs.
Upon examination, veins are tense, of elastic consistency, and sometimes adhered to the skin. Hyperpigmentation along the dilated vessels is noted. An important diagnostic sign: in varicose veins, symptoms (feeling of heaviness) resolve in a horizontal position, whereas in PTS, the edema does not subside when lying down.
Diagnostics and treatment
To assess the state of the venous system, manual techniques (finger and tourniquet tests) and instrumental methods are used:
- Contrast phlebography — provides the most accurate picture of the state of deep veins, valves, and collaterals.
- Doppler ultrasound, rheography, infrared thermography, and duplex ultrasound (DUS).
- March test — to assess deep vein patency (the onset of pain when walking with an elastic bandage indicates occlusion).
Treatment tactics:
- Conservative (in early stages): pharmacotherapy, compression hosiery or elastic bandaging, exercise therapy, sclerotherapy.
- Surgical (for established dilation): ligation and removal of subcutaneous and communicating veins. If a trophic ulcer is present, excision and defect closure with a free skin autograft are performed.
Briefly: answers to topical questions
What groups of pharmacological agents are prescribed in the conservative treatment of chronic venous insufficiency?
In the conservative treatment of varicose veins in the early stages, pharmacotherapy including escin and thiamine is used. Specific pharmacological drug groups are not specified in the source.
Conservative therapy also includes physiotherapy and exercise therapy (massage, baths, swimming), compression therapy (elastic bandaging), and sclerotherapy.
What classical surgical operations (eponymous) are performed to remove subcutaneous veins and ligate communicating veins?
To remove subcutaneous veins and ligate communicating (perforating) veins, the following classical eponymous surgical operations are performed.
- Trojanov–Trendelenburg operation — ligation of the great saphenous vein at its junction with the femoral vein.
- Babcock operation — complete removal of the great saphenous vein (v. saphena magna) using a flexible probe and vein stripper.
- Cockett operation (Cockett) — epifascial isolation and ligation of incompetent perforating veins without incising the fascia.
- Linton operation (Linton) — subfascial ligation of perforating veins, requiring incision of the deep fascia of the shin.
What is the eponym of the march test and what vein function does it evaluate?
The march test is used to assess the patency of the deep veins of the lower extremities. The eponym for this functional test is not mentioned in the provided materials.
The essence of the technique involves applying a tourniquet to the thigh, bandaging the leg with an elastic bandage, and having the patient walk for 20–30 minutes. If bursting pain occurs as a result, this indicates deep vein obstruction, as such patients completely do not tolerate elastic compression.
Class and exam questions
How to distinguish edema in varicose veins from edema in PTS?
In varicose veins, symptoms (including edema and heaviness) disappear or significantly decrease upon assuming a horizontal position. In PTS, the edema does not disappear when lying down.
Where are trophic ulcers most commonly localized in CVI?
The typical location of trophic disorders and ulcers in CVI is the lower third of the shin.
What does the march test show?
The march test detects deep vein obstruction. If bursting pain appears after applying a tourniquet, elastic bandaging, and walking, it indicates intolerance to compression due to deep vein occlusion.
What else to study on this topic
- Technique of finger and tourniquet tests to assess the valvular apparatus
- Mechanism of arteriovenular shunting in post-thrombotic syndrome
- Features of supra- and subfascial ligation of communicating veins
- Pharmacodynamics of escin and thiamine in conservative CVI therapy
- Types and techniques of skin grafting for trophic ulcers
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