The initial signs of varicose veins of the lower extremities are, as a rule, telangiectasias or varicose saphenous veins. In this case, the disease is often limited to only these symptoms and the progression of the process is to increase the number of telangiectasias and reticular veins. Only after a few years or even decades, varicose veins may appear in the basin of the large or small saphenous vein.
In cases where varicose veins begin with the appearance of typical venous nodes (varixes), two variants of the development of the disease can be distinguished. The appearance of varicose veins on the lower leg, more often on its medial surface, indicates a predominant lesion of the perforating veins, which can be detected by palpation or using instrumental examination methods. The predominance of low veno-venous discharge does not mean at all that the trunks of the main saphenous veins remain intact. Reflux can also be observed along them, but, as a rule, the lines are slightly dilated, varicose are not changed, and the discharge of blood through them is segmental.
The appearance of varicose veins initially outside the zone of the usual location of the perforating veins (femur, anteromedial surface of the leg, popliteal fossa and posterior surface of the upper third of the leg) indicates the leading role of the high veno-venous discharge in the development of the disease. Reflux in the great and/or small saphenous vein can be detected using functional tests or ultrasound. The main trunks themselves are dilated and well palpated throughout, especially in thin subjects. Often you can observe a typical varicose deformation of the subcutaneous highways. A high veno-venous shunt does not exclude the presence of incompetent perforating veins, but their pathogenetic role is small. Over time, the differences in the manifestations of varicose veins are leveled out and doctors have to observe patients with both stem varicose veins and those with severe perforant shunt.
Identification of options for the development and course of varicose veins is important for solving practical problems, in particular, for determining the plan and volume of operational benefits.
The number and size of varicose veins that appear can increase over time, but sometimes the clinical picture is constant for many years. Irrespective of the type of discharge with which the disease proceeds, the addition of symptoms of CVI occurs in the same way. In most patients, after some time (on average 3-5 years) after the appearance of the first varicose veins, functional disorders are noted (complaints of a feeling of heaviness, pain in the leg, pastosity of the foot and lower leg that occur at the end of the working day).
In some cases, the disease begins precisely with these symptoms, and only later varicose veins are detected. This is commonly seen in overweight patients where the initial transformation of the superficial veins is "masked" by prominent subcutaneous adipose tissue.
The differential diagnosis of various diseases accompanied by the development of varicose syndrome is very important. At the stage of history taking and physical examination, significant difficulties are possible due to the commonality of many clinical manifestations of various pathological conditions, primarily varicose and post-thrombophlebitis diseases. In clinical practice, it is often necessary to make a differential diagnosis between these diseases and congenital venous dysplasia, since they are all accompanied by varicose transformation of the saphenous veins.
The correct determination of the type of pathology at the stage of examination of the patient allows you to optimize the diagnostic tactics and avoid the use of unnecessary examination methods. The main clinical differential diagnostic criteria for the causes of varicose syndrome are given in the table.
Modern phlebology is not only the result of the clinical experience of many generations of researchers, but primarily the result of the rapid development of medical diagnostic technologies. Indeed, many questions of the etiology and pathogenesis of venous diseases, the problems of their treatment would never have been resolved without the use of special instrumental research methods. In this chapter, we will present the most informative and currently safe methods that allow a phlebologist to obtain data on the volume and nature of damage to the venous system, to get answers to the following questions:
what is the cause of varicose veins (are deep veins affected)?
Is there reflux through the saphenofemoral and saphenopopliteal anastomoses?
where is the saphenopopliteal fistula located?
What is the condition of the valves of the great and small saphenous veins?
Is there perforant reflux and where is it localized?
The answer to all these questions determines the choice of treatment method (conservative or surgical), the determination of the scope of a possible operation or the method of vein scleroobliteration, as well as, to a large extent, the prognosis of the effectiveness of treatment and the possible progression of the disease. Currently, the main methods for diagnosing varicose veins are ultrasound and radionuclide tests.
Doppler ultrasound. This technically simple method allows you to assess the patency of the veins and the state of their valvular apparatus.
The Doppler probe is initially placed in the projection of the femoral vein at the border of the upper and middle thirds of the thigh, 7-8 cm distal to the inguinal fold (below the mouth of the deep vein of the thigh). If a retrograde blood wave is recorded at the height of the Valsalva test, this means that the patient has valvular insufficiency of the superficial femoral vein. Then the sensor of the device is displaced 3-4 cm more medially in order to locate the ostium of the great saphenous vein. If it is not possible to detect the vein immediately, it is necessary to carry out light percussion of the projection of the trunk of the great saphenous vein distal to the sensor, while slightly changing its angle of inclination. Thanks to this technique, the blood flow through the great saphenous vein increases and is recorded by the device in the form of wave-like bursts. Then the patient performs a Valsalva maneuver, listening to the noise during which indicates blood regurgitation and indicates the failure of the ostial and stem valves of the great saphenous vein.
The next stage of dopplerography is an examination of the popliteal and small saphenous veins, carried out with the patient in the prone position. In this zone, the optimal functional test that stimulates retrograde blood flow is the proximal compression of the thigh muscles in the lower third, which makes it possible to identify valvular insufficiency of the small saphenous vein. The coincidence of the projections of the ostium of the small saphenous, sural and popliteal veins can cause diagnostic errors. To exclude them, the small saphenous vein must be heard not only in the popliteal fossa, but also in the upper third of the lower leg along the midline. The greatest difficulties arise when there is a combination of valvular insufficiency of the sural and small saphenous veins. In these cases, you can resort to the following technique: clamp the ostium of the small saphenous vein (with a sensor or rubber band) and repeat the proximal compression test. The weakening of the retrograde blood wave indicates a combined lesion of the superficial and deep veins. If there is doubt about the correctness of the data obtained, the examination is repeated in the vertical position of the patient. At the same time, accurate identification of reflux in the popliteal fossa using dopplerography is possible only in the hands of a very experienced researcher, therefore, if retrograde flow is detected in this vascular region, it is advisable to perform duplex angioscanning.
The use of Doppler ultrasound for the search and localization of perforating veins with valvular insufficiency is advisable in case of pronounced changes in the trophism of the skin and subcutaneous tissue, when palpation detection of these veins is ineffective. In addition, the search for perforating veins can be carried out in the initial stages of the disease to determine the cause of varicose veins.
The technique for locating perforating veins is as follows: a rubber tourniquet or elastic bandage is applied to the upper third of the leg to block blood flow through the saphenous veins. In the area suspected of perforating discharge (areas of hyperpigmentation, induration, local varicose veins, etc.), an ultrasonic sensor is installed perpendicular to the skin. With his free hand, the researcher performs alternate compression of the calf muscles. Perforating veins with valvular insufficiency are identified by a characteristic high-frequency, pendulum-like and alternating signal. The probability of errors in the search for perforating veins using dopplerography is quite high, since they do not allow you to "see" the vessels. Often, a sound signal from a varicose inflow is regarded as a sign of a perforating vein. Therefore, preference in the diagnosis of low veno-venous shunt should be given to angioscanning.
An obligatory stage of the Doppler examination should be the determination of the ankle-brachial index. Its fall to 0.8 and below is a sign of severe atherosclerosis of the arteries of the lower extremities, the presence of which radically changes the tactics and methods of treating patients with varicose veins.
Ultrasonic duplex angioscanning with color coding of blood flows makes it possible to reliably determine anatomical and morphological changes in the venous bed and, accordingly, to choose an adequate treatment for varicose veins.
In most patients with this disease, ultrasound examination of deep veins registers their intactness, which is manifested by the presence of phasic blood flow in them, the preservation of the lumen, vascular compressibility, and the absence of reflux. At the same time, physiological reflux of blood can be recorded in the femoral vein to the level of the valve located at the mouth of the deep vein of the thigh. The duration of reflux in the norm, according to various researchers, ranges from 0.5 to 1.7 s. The results of our studies have shown that the time of retrograde blood flow through the valve in the femoral vein does not exceed 0.7 s in the vertical position and 1.7 s in the horizontal position. We detect pathological (longer) reflux only in 10% of patients with varicose veins.
In the popliteal vein with varicose veins, physiological reflux of blood can also be noted. The most successful test for its evaluation is the determination of the reflux index proposed by A. Nicolaides et al. Valvular insufficiency of the popliteal vein is considered hemodynamically significant if the index value is above 0.40. According to our data, the incidence of valvular insufficiency of the popliteal vein in varicose veins is 3.5%.
As for the deep veins of the lower leg, it is now almost unrecognized that their valvular insufficiency is essentially a manifestation of a post-thrombotic lesion. Reflux of blood through the tibial veins in varicose veins is recognized as casuistry. According to our study of 5,000 patients, valvular insufficiency of the tibial veins in varicose veins was detected in only 2 (0.04%) patients.
Of particular importance are the data of ultrasonic angioscanning in relation to sural reflux, leading to the development of nocturnal cramps in the calf muscles in patients with varicose veins. The need for ultrasound mapping of the sural veins is due to the fact that the projections of the mouths of the sural and small saphenous veins coincide. The small saphenous vein with the solvency of the valves has a very small diameter (0.2-0.3 cm), and it is possible to determine the blood flow through it only using color mapping. To do this, it is necessary to strongly compress the lower leg in the upper third, after which a rather weak blue color signal appears. The superficial location of the small saphenous vein leads to the fact that even slight compression by the sensor blocks its lumen. In this regard, one of the sural veins can be mistaken for a small saphenous vein. Meanwhile, these veins are always accompanied by the artery of the same name, the location of which allows them to be reliably distinguished. When the thigh muscles are compressed, a retrograde blood wave is recorded through the incompetent sural veins.
When echolocation of the great saphenous vein, ultrasound scanning allows not only to reliably detect the absence or presence of reflux, but also to determine its extent. Total reflux (from the groin to the ankle) is detected in only 12% of patients with varicose veins. In 25% of observations, it extends to the middle third of the lower leg, and in 65% it captures only the thigh. At the height of the Valsalva test, in case of insufficiency of the ostial valve, the diameter of the mouth of the great saphenous vein increases by 2 times. The reason for this is a decrease in the tolerance of the affected vein to hypertension due to the loss of smooth muscle and elastic fibers by its wall. Probably, such a dilation test can be used to predict the likelihood of developing varicose veins in individuals at risk.
The echographic picture in patients with previously transferred thrombophlebitis of the great saphenous vein has its own characteristics. Depending on the duration of the disease, signs of segmental occlusion and varying degrees of recanalization may be detected. In most cases, after 6-8 months, there is an almost complete restoration of the patency of the trunk of the great saphenous vein on the thigh. The transferred thrombosis is indicated by uneven thickening of the walls of the vessel and its complete avalvation.
The variety of anatomical variants of the small saphenous vein dictates the need for careful ultrasound mapping of its mouth before surgery and changes in the surgical approach, taking into account the data obtained. The condition of the valve apparatus of the small saphenous vein is assessed using compression tests. Valve insufficiency is found in approximately 20% of patients. At the same time, reflux in the vast majority of cases is limited to the upper third of the lower leg. This is due to the peculiarity of the location of the vessel under the dense fascia. The exception is the region of the popliteal fossa, in which the fascia becomes sharply thinner. An additional extravasal frame prevents varicose vein transformation in the rest of the length.
Duplex angioscanning is recognized as the best way to accurately localize perforating veins with valvular insufficiency. The study is performed in the areas of their most frequent location: the medial surface of the lower third of the lower leg, the upper third of the posterior surface of the lower leg and the medial surface of the thigh in the lower third. In addition, it is necessary to carry out echolocation of all areas suspicious for perforating discharge (zones with impaired skin trophism, local varicose veins in the tributaries of the saphenous veins, etc.). A perforating vein with valvular insufficiency is recognized as a tubular structure with a diameter of more than 0.3 cm, which perforates the own fascia of the lower leg or thigh and flows into a deep vein. Dopplerography with simultaneous variable manual compression of the gastrocnemius muscles makes it possible to obtain a characteristic pendulum-like alternating signal, indicating transverse blood flotation in the perforating vein with valvular insufficiency. When the image is color-coded, the blue signal of normal blood flow (from superficial to deep veins) is replaced by red, characteristic of the reverse flow of blood.
The frequency of involvement in the pathological process in varicose veins of perforating veins of various localization according to the results of angioscanning of the lower extremities is presented in the table.
Localization of perforating veins with valvular insufficiency in varicose veins
Information about the localization of perforating veins with valvular insufficiency, which determine the development of trophic ulcers, is extremely important for surgeons. As a rule, incompetent perforating veins are not detected directly under the trophic ulcer; they are usually located along its upper semicircle.
Radionuclide phleboscintigraphy. With varicose veins, this method is advisable to use in the following cases:
if a multiperforant veno-venous shunt is suspected, when it takes a lot of time and effort to search for perforating veins with valvular insufficiency using angioscanning;
with an open trophic ulcer, when contact of the ultrasonic sensor with its surface is undesirable;
with significant lymphatic edema (associated lymphedema, hyperplasia of the lymphoid tissue).
With varicose veins, all deep veins are visualized, the speed of blood movement through them is somewhat reduced - up to 5-7 cm / s (normally 8-9 cm / s). The reasons for the slowdown in venous outflow are the disorganization of the work of the musculo-venous pump of the lower leg, a pronounced perforating reset, and sometimes insufficiency of deep vein valves. A characteristic scintigraphic sign of the disease is the contrasting of perforating veins with valvular insufficiency, through which superficial venous lines and their tributaries are filled. In addition, in conditions of complete valvular insufficiency of the great saphenous vein, its filling with a radiopharmaceutical from top to bottom is detected. Reflux through the dilated orifice of the small saphenous vein can also be registered using this method. The linear and volumetric blood flow velocity is reduced by 2 times or more compared to the norm.
Additional methods of instrumental examination. Occlusal plethysmography makes it possible to determine the tonoelastic properties of the venous wall based on changes in the evacuation volume of blood and the time of its evacuation or recurrent blood filling (depending on the research technique).
Photoplethysmography and reflective rheography make it possible to estimate the time of recurrent blood filling, which indicates the degree of venous congestion. These methods on an outpatient basis can help determine the state of the deep venous system and exclude its post-thrombophlebitis lesion. In addition, multiple repetition of the procedure allows you to study the dynamics of changes in the tonoelastic properties of the venous wall and parameters of venous circulation during treatment. This is especially true in cases of varicose veins with trophic disorders, i.e., when a course of conservative therapy is necessary before surgery.
Direct phlebotonometry with the measurement of venous pressure in one of the veins of the dorsal foot in a static position and during physical activity has long been considered the "gold standard" in assessing the function of the musculo-venous pump of the leg. The invasive nature of the study, as well as the emergence of methods for indirect assessment of functional parameters, led to the almost complete replacement of phlebotonometry from clinical practice.
X-ray contrast phlebography used to be considered the main method of instrumental diagnosis of varicose veins. Its data made it possible to judge the state of the deep venous system, trunks of the saphenous veins, as well as accurately localize incompetent perforating veins. Currently, X-ray phlebography for varicose veins is practically not used, since similar information can be obtained using ultrasound without the risk of any complications.
Generalized data on the possibilities of certain diagnostic methods and indications for their use in varicose veins are presented in the table below. Various instrumental methods come to the fore depending on the nature of the diagnostic tasks. Assessing in general their diagnostic significance in varicose veins, Doppler ultrasound should be recognized as a screening method. Ultrasound duplex angioscanning is most often used as the main method, and radionuclide phlebography serves as an additional method. In the diagnostic reserve, radiopaque phlebography remains, which should usually be refrained from.
In most cases, the recognition of primary varicose veins of the lower extremities does not present great difficulties. Diseases that clinically resemble varicose veins should be excluded. First of all, it is necessary to exclude secondary varicose veins due to hypoplasia and aplasia of deep veins (Klippel-Trenaunay syndrome) or previous deep vein thrombosis, the presence of arteriovenous fistulas in Parkes Weber-Rubashov disease.
Post-thrombotic disease is characterized by: an increase in the volume of the limb due to diffuse edema; the skin of the limb has a cyanotic hue, especially in the distal sections; dilated saphenous veins have a loose appearance, and their pattern is more pronounced on the thigh, in the inguinal region and on the anterior abdominal wall.
Klippel-Trenaunay syndrome, caused by aplasia or hypoplasia of deep veins, is very rare, manifests itself in early childhood, gradually progresses with the development of severe trophic disorders. Varicose veins have an atypical localization on the outer surface of the limb. On the skin there are age spots in the form of a "geographic map", hyperhidrosis is pronounced.
Parkes Weber-Rubashov disease is characterized by: elongation and thickening of the limb, atypical localization of varicose veins; veins often pulsate due to the discharge of arterial blood; there is hyperhidrosis, hypertrichosis, the presence of age spots according to the type of "geographic map" over the entire surface of the limb, often on the outer surface of the pelvis, on the abdomen and back, hyperthermia of the skin, especially over dilated veins, arterialization of venous blood. The disease manifests itself in early childhood.
Pratt Piulaks and Vidal-Barraque distinguish "arterial varicose veins", in which the varicose veins are the result of the functioning of multiple small arteriovenous fistulas. These fistulas are congenital in nature and open during puberty, pregnancy, after injury or excessive physical exertion. Dilated veins are localized more often along the outer or back surface of the lower leg or in the popliteal fossa. After surgery, varicose veins quickly recur, and, as a rule, radical treatment of this form of varicose veins is not possible.
Aneurysmal expansion of the great saphenous vein at the mouth must be differentiated from a femoral hernia. The venous node above the pupart ligament disappears when the leg is raised, sometimes a vascular murmur is heard over it, which is not observed with a femoral hernia. The presence of varicose veins on the side of the lesion often speaks in favor of the venous node.
|
sign |
P. thrombotic disease |
Elephantiasis |
Varicose veins |
|
Etiological factors |
acute deep phlebothrombosis |
Heredity, info.zab-I |
Heredity |
|
Acute onset after surgery, trauma |
gradual development |
gradual development |
|
|
Constant with trophic disorders |
Is absent |
while walking, towards the end of the day |
|
|
softish |
not expressed |
||
|
Varicose veins |
Usually available | ||
|
ulcers, eczema |
most have |
Is absent |
at a later date |
|
Changed only in the field of trophic disorders |
Thickened all over |
Changed in later stages |
|
|
Symmetry |
characteristic |
Most often, thromboembolism is observed in the system of the inferior vena cava. Three conditions are necessary for the occurrence of thrombosis in a vein:
Slow down blood flow
Change in its composition
Damage to the vascular wall.
Classification and stages of development of the thrombotic process
Since the etiology, pathogenesis, localization and distribution of the thrombotic process remain in some cases not entirely clear, the exact classification of thrombophlebitis is difficult. According to the clinical course, acute, subacute thrombophlebitis, post-thrombotic disease are distinguished. The most commonly used classification is L.I. Klioner (1969), which takes into account a number of the most important features:
The most frequent localizations of the primary thrombotic process and the ways of its distribution in both venous systems,
The main etiological points
The most typical clinical stages of the course,
The degree of trophic and hemodynamic disorders,
According to the localization of the primary thrombotic effect and the way it spreads:
1.Inferior vena cava system:
a) veins that drain the muscles of the leg,
b) iliac-femoral segment,
c) segments of the inferior vena cava,
d) combined cava-ileofemoral department,
e) combined total thrombosis of the entire deep venous system or lower limb.
2.Superior vena cava system:
a) segments
b) only the trunk of the superior vena cava,
c) the combination of the trunk of the superior vena cava and the innominate veins is one- or two-sided,
d) axillary-subclavian segment,
e) combined total thrombosis of the entire deep venous network of the upper limb
Etiologically:
Thrombosis developing as a result of:
a) infections, b) injuries, c) operations, d) childbirth, e) varicose veins, f) allergic or metabolic disorders, g) intravasal congenital or acquired formations, h) extravasal congenital or acquired formations.
By clinical course:
a) acute thrombophlebitis,
b) subacute thrombophlebitis, after 1-2 months
c) post-thrombotic disease,
d) acute thrombophlebitis on the background of postthrombophlebitic disease.
According to the degree of trojanic disorders and hemodynamic disorders:
a) easy
b) moderate
c) heavy.
The clinic of acute thrombosis of the deep veins of the lower leg is rather poor, since due to a significant number of them, there are no pronounced hemodynamic disorders. Disturbed by pain in the calf muscles, aggravated by movements in the ankle joints. There may be a slight swelling of the lower leg.
A frequent and important symptom is an increase in the skin temperature of the leg due to the acceleration of blood flow through the superficial veins. The most typical clinical sign is pain on palpation of the leg muscles. With combined thrombosis of the veins of the lower leg, popliteal and femoral veins, the clinical picture becomes more distinct, as arching pains, swelling of the lower leg and knee joint area, dilatation of the saphenous veins of the lower leg and thigh appear.
The clinic of acute iliofemoral thrombosis depends on the stage of the disease. In the compensation stage, hemodynamic disturbances do not occur. Usually there is an unreasonable increase in temperature, pain in the lumbosacral region, lower abdomen or lower limb on the side of thrombosis. One of the formidable symptoms is pulmonary embolism. AT
the stages of decompensation of pain increase sharply, are localized either in the inguinal region, or on the medial surface of the thigh and in the calf muscles. Swelling is pronounced, capturing the entire lower limb up to the inguinal fold. The color of the skin on the affected limb rarely changes. The saphenous veins may be dilated.
Treatment of acute venous thrombosis of the main veins is far from being fully defined and unified. Conservative methods tend to give poor results. Although, a number of drugs have an undoubted positive effect. The arsenal of such treatment includes anticoagulant therapy, novocaine blockades, oil-balsamic dressings, elastic bandaging, and drugs that have an anti-inflammatory effect.
Reopoliglyukin - well eliminates peripheral vascular spasm, significantly improves microcirculation and significantly increases the fibrinolytic activity of the blood. It is prescribed at the rate of 10 ml per 1 kg of weight. Of the physiotherapeutic methods of treatment, long-term magnetotherapy has a good effect. It should be noted that the treatment of such complications should be carried out in a hospital setting.
Conservative treatment of post-thrombotic disease is indicated:
In the initial stage of development of PTF in the first 2-3 years after acute deep vein thrombosis,
Pronounced inflammatory phenomena in the affected limb,
A slowly progressive form of the disease, when compensatory-adaptive mechanisms sufficiently provide venous outflow from the affected limb,
Severe condition of patients associated with violations of vital functions, the presence of chronic purulent infection, allergies, advanced age,
Refusal of patients from surgical intervention.
The complex of conservative treatment and rehabilitation measures in patients should primarily provide compensation for venous insufficiency by improving the functions of the peripheral heart and influencing the mechanisms that regulate microcirculation in the affected limb. Also included are drugs that relieve inflammation, allergic reactions, reduce tissue hypoxia and improve their trophism. In addition, drugs are prescribed aimed at normalizing metabolic and trophic processes and venous circulation in the affected limb.
Differential diagnosis of varicose veins is primarily aimed at cutting off as a diagnosis of post-thrombophlebitic syndrome.
Despite the significant progress made in the diagnosis of lower extremity vein disease, and at present, many surgeons, after examining a patient with vein damage, often make a symptomatic diagnosis of saphenous varicose veins and, without finding out its cause, perform surgical treatment. Such treatment does not lead to recovery, and in a number of patients after an unreasonable operation, severe complications occur that aggravate the course of the disease. Removal of dilated saphenous veins in post-thrombophlebitic syndrome of the iliac-femoral segment deprives the surgeon of the opportunity to perform autovenous bypass bypass operations.
Varicose veins and post-thrombophlebitic syndrome have different pathogenesis. Comparison of causal factors allows to differentiate the triggers of diseases.
If in the occurrence of post-thrombophlebitic syndrome the leading pathogenetic factor is persistent venostasis with impaired function of all systems that provide venous hemodynamics, then with varicose veins, only the function of the saphenous vein system first suffers, and subsequently the communicating and deep veins are affected.
Based on a clinical examination of patients using additional methods, Russian doctors drew clinical parallels between varicose veins and post-thrombophlebitic syndrome of the lower extremities.
The main complaints of patients with post-thrombophlebitic syndrome are pain in the limb, fatigue, a feeling of heaviness and fullness, aggravated after long walking and standing and decreasing in a horizontal position or with an elevated position of the limb. Pain is usually localized in the lower leg and ankles. When the iliac-femoral segment is affected, it spreads to the thigh, and sometimes to the labia.
At the same time, only 34% of patients with primary varicose veins complain of pain in the affected limb. In most women, it occurs after a long stay in an upright position, is segmental in nature and is localized in the area of incompetent communicating veins. Pain quickly disappears in a horizontal position or after applying a compression bandage.
In 86.4% of women with post-thrombophlebitis syndrome, extensive edema of the limb is noted, the localization of which depends on the nature and extent of the thrombotic process. The more proximal the vascular occlusion is, the more massive the edema; they occupy the entire limb and pass to the shins in indurated edema. Usually, after the patient stays in a horizontal position, the edema decreases somewhat, but reappears when walking and never, unlike varicose veins, completely disappear.
Edema is observed only in 4.5% of women with varicose veins. They are usually minor and quickly pass in a horizontal position. In some patients with varicose veins, thickening of the limb is due to atonic dilatation of the saphenous veins, which is mistaken for edema. The circumference is measured in the elevated position of the limb, when the varicose veins subside, the tissues are freed from the deposited blood and the limb takes its usual size.
In patients with post-thrombophlebitis syndrome, complaints are persistent and of the same type, while in patients with varicose veins they appear as the disease progresses and complications develop.
More than 70% of patients with post-thrombophlebitis syndrome indicate past deep vein thrombosis, and only in 27.6% it was latent.
Varicose veins usually occur in young women or after childbirth and gradually progresses; 62% of patients indicated the expansion of the saphenous veins in their parents. A carefully collected anamnesis in patients with venous lesions helps to resolve many issues of differential diagnosis of varicose veins and post-thrombophlebitic syndrome.
In 90.1% of patients with post-thrombophlebitic syndrome, saphenous vein dilation is observed with severe tortuosity of multiple anastomoses and small-caliber vessels, and when occlusion is localized in the iliac-femoral segment, varicose veins are also determined in the pubis, anterior abdominal wall and iliac wing.
With varicose veins, first of all, the main vessels of the system of the large and small saphenous veins expand.
Dystrophic changes in the skin and underlying tissues in post-thrombophlebitis syndrome are characterized by the appearance in the distal parts of the lower leg, more often from the medial surface, indurative edema, thickening of the skin and subcutaneous tissue with severe pigmentation and the appearance of a post-thrombophlebitis ulcer in the center.
Clinical observations show that post-thrombophlebitic ulcers often occur in the area of long-term skin pigmentation, even if there are no external signs of saphenous varicose veins. In post-thrombophlebitic disease, pigmented and indurated skin is often covered with crusts, hyperkeratosis, cellulitis, and dermatitis occur. Post-thrombophlebitic ulcer is initially small, 1-2 cm in diameter, deep, with flaccid granulations, purulent plaque, sharply painful on palpation. Such ulcers do not tend to epithelialize and are not amenable to conservative treatment. The occurrence of ulcers depends on the duration of the disease, the extent of the thrombotic process, the localization and degree of recanalization of the thrombosed vessel. Already 1-3 years after thrombosis, they occur in 32.5% of patients on the background of indurative edema, skin pigmentation and dermatitis, and after 10 years - in 73.2%.
With varicose veins, dystrophic changes in tissues are less pronounced. They occur late against the background of varicose saphenous veins in one or both lower extremities. Ulcers are observed in 24% of patients, pigmentation - in 15%, induration - in 19.4%. The degree of varicose veins does not significantly affect their occurrence. The development of an ulcer is preceded by thrombophlebitis, erysipelas, trauma, perivasal phlebosclerosis, edema and allergies. With varicose expansion of the system of the great saphenous vein, ulcers are more often localized at the medial malleolus, and with damage to the system of the small saphenous vein - at the lateral and posterior or lower third of the leg. Varicose ulcers usually occur along the course of an enlarged vein, more often in the area of its thrombosis or incompetent communicant. They are not painful, surrounded by unchanged tissues, and after a long stay of patients in a horizontal position, they usually heal.
It is often difficult to distinguish between complicated varicose veins and post-thrombophlebitic varicose veins, especially when the morphological signs of the disease characteristic of post-thrombophlebitic syndrome are superimposed. In this case, the anamnesis, phlebography and other research methods are of decisive importance.
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