The varicose vein (from Old High German krimpfan , 'to bend') or varices (literally varix , plural varices , older varices , from Latin varix ) is a nodular, enlarged (superficial) vein (blood vein). The disease in the presence of such local vein extensions called in the jargon varicose veins or varicose veins .
Classification and frequency
Depending on the origin, the disease is divided as follows:
- Primary idiopathic varicosis, caused by genetic disposition (approx. 95% of cases), familial disposition
- Secondary varicosis as a result of other venous diseases such as deep vein thrombosis , with the creation of a bypass circuit via the superficial venous system (approx. 5% of cases)
According to estimates by the European specialist societies, every second European is said to suffer from varicose veins. Around 60 percent of adults worldwide are affected. In> 80% small varicose veins ( spider veins ) should appear and up to 30% have a varicose vein. The incidence of the disease ( prevalence ) increases with advancing age and every third woman and every fourth man are affected.
(Adapted from guidelines for diagnosis and therapy of varicose veins )
The clinical manifestation of the changes associated with varicose veins (varicose veins) can be divided according to different classifications. In everyday clinical practice, the following classification, based on the Widmer classification (303, 322), has been common (Tab. 1).
Table 1: Classification of the clinical manifestation of varicose veins based on the classification of chronic venous insufficiency (CVI) according to Widmer (303), modified according to Marshall (322)
- Grade 1 varicose veins: no (noteworthy) complaints; no complications.
- Grade 2 varicose veins: complaints (dysesthesia, itching, feeling of heaviness, feeling of tension, slight tendency to swell, leg cramps, pain, etc.); no complications.
- Grade 3 varicose veins: symptoms (like Grade 2, more pronounced); Complications: trophic skin disorders (induration, pigmentation, dermatitis, eczema, atrophy); Varicophlebitis.
- Grade 4 varicose veins: discomfort (like Grade 3); Complications (such as grade 3, more pronounced); florid ulcus cruris.
Today, the clinical classification according to the CEAP classification (158, 239, 267) has established itself internationally (Tab. 2).
Table 2: Classification of the clinical manifestation of varicose veins according to the CEAP classification (158)
- C0 No visible signs of venous disease
- C1 spider veins and reticular varices
- C2 Varicose veins with no signs of CVI
- C3 Varicose vein with edema
- C4 varicose veins with skin changes
- C4a varicose veins with pigmentation, eczema
- C4b Varicose disease with dermatoliposclerosis, atrophy blanche
- C5 Varicosis with scar of a leg ulcer
- C6 Varicosis with florid leg ulcer
C1 - C6 additionally A = asymptomatic S = symptomatic
In addition, etiological (E), anatomical (A) and pathophysiological (P) criteria can be taken into account in the CEAP classification.
The cause of idiopathic varicose veins is controversial. A family disposition and the volume overload of the lower extremities caused by gravity play a decisive role. The importance of other factors such as warmth, crossing (crossing) the legs, height, weight, sport, high heels, pregnancy, standing or sitting jobs are overestimated. The blood from the legs is mainly transported to the heart against gravity by the calf muscle pump . Any form of movement is therefore beneficial. To prevent backflow into the leg, nature has built sail valves into the veins.
The superficial veins lie in the subcutaneous fatty tissue, which builds up little pressure, so that due to lack of movement of the legs, e.g. B. by standing or sitting for long periods of time, more blood sinks into the legs. The veins are stretched until they are so widened that the venous valves can no longer close - comparable to a leaky air lock gate. The blood then flows following gravity towards the foot, instead of to the heart. This leads to a volume overload of the veins. The phenomenon continues for years, so that the doctor speaks of chronic venous insufficiency. The superficial leg veins fill and meander, creating a varicose vein / curved vein.
A secondary varicose vein occurs when the blood in the deep leg veins can no longer flow freely. This is usually caused by a thrombus (blood clot) in a deep guide vein, very often the popliteal vein . This occurs very often after long air travel or after orthopedic surgery on the hip or knee. In order to compensate for the disturbed blood flow, a bypass circuit develops over the superficial veins, which are thereby expanded.
Complications of varicose veins
Varicose veins are not just a " blemish ", they also have a significant disease value. As the disease progresses, severe damage to the leg, especially in the area of the distal lower leg, occurs as a result of the impaired blood flow and the increased peripheral venous pressure . The pathological change usually manifests itself initially only in discrete and unspecific symptoms, such as (one-sided increased) leg swelling, heaviness, itching or nocturnal calf cramps. The scarring of the skin, subcutis and fascia (dermato-lipo-fascio-sclerosis) as well as the deposition of hemosiderin in the context of congestive dermatitis (congestive eczema), inflammation of the superficial veins ( thrombophlebitis ) up to the ulcus cruris varicosum ("open leg") then already severe, sometimes irreparable symptoms. The risk of a thrombosis with consecutive pulmonary embolism is comparatively low. An injury to the previously damaged skin can cause threatening variceal bleeding after a minor injury. The only thing that helps here is consistent compression and elevation up to the point of medical assessment.
At first, varicose veins are often only discreetly noticeable with a feeling of tension or heaviness in the legs. Itching of the skin over a large varicose vein and nocturnal leg cramps can also occur. In warm weather, the symptoms are usually worse because of the increased arterial blood flow and the comparatively poor outflow in an upright posture. At an advanced stage, the thickened veins can be seen in their typical tortuous and branched shape through the skin. Water is stored in the tissue and edema develops . The skin can turn brown and change like parchment. Occasionally, mycosis of the skin ( tinea pedis ) or of the toenails ( onychomycosis ) is found. Varicose veins rarely cause specific pain, although they are already very advanced.
Depending on which veins in the legs are affected, a distinction is made between different forms:
- Truncal varicose vein: dysfunction of the large and small superficial trunk veins (great saphenous veins , small saphenous veins )
- Lateral branch varicose veins: dysfunctional side branches of the great saphenous veins
- Perforative varicose veins: dysfunctional connecting veins between the superficial and deep venous system (also blow out )
- reticular varicose veins: dysfunctional small veins just under the skin (1–3 mm in diameter)
- Spider veins -Varikose: dysfunctional smallest veins in the skin
Non-invasive color-coded duplex sonography is considered to be the imaging method of choice. Other examination methods often used for expert opinions are hemodynamic methods, such as:
- Photoplethysmography (PPG) and light reflection rheography (LRR)
- Vein occlusive plethysmography (VVP)
- Phlebodynamometry (PD)
The main prerequisite for an invasive rehabilitation of the varicose vein is the proven patency and functionality of the deep venous system, ie that an old or fresh deep vein thrombosis must be excluded.
Today, invasive therapy focuses on minimally invasive surgical procedures worldwide , the so-called endovenous thermal and non-thermal procedures and sclerotherapy (sclerotherapy) of varicose veins. The stripping operation is considered internationally only as a replacement method. The endovenous-thermal procedures include laser ablation or radio frequency ablation. The endovenous, non-thermal processes include cyanoacrylate bonding and mechano-chemical ablation. The above procedures are recommended in the medical guidelines for treating varicose veins. The domain of sclerotherapy is the treatment of all types of varicose veins excluding trunk varicosis, i.e. side branch varicosis, perforating varicosis, reticular varicosis and, in particular, spider vein varicosis. The endovenous procedures can also be combined with sclerotherapy, so that the trunk veins are treated endovenously and the side branches and smaller varicose veins with sclerotherapy.
In the past, varicose veins were removed by opening the entire leg, for example using the spiral cut according to Rindfleisch and Friedel . In the mid-1940s, operative methods such as stripping became established . Pulling the diseased saphenous veins with an inserted probe according to the Babcock method developed by William Wayne Babcock - including crossectomy is still the most widely used form of therapy in Germany. Around the world, minimally invasive endovenous procedures have largely replaced stripping. The fact that the surgical method with ligation and removal of the varicose veins still counts around 250,000 operations every year in the Federal Republic of Germany is solely due to the remuneration structure of the statutory health insurance companies.
With the operative Babcock method , the varicose veins are removed under anesthesia and then a compression stocking must be worn because of the mechanical tissue damage. In contrast, endovenous laser therapy and endovenous radiofrequency therapy with high temperatures of 120 ° Celsius thermally destroy the inner lining of the affected veins (the endothelium ) so that the vein is permanently closed by the body's own remodeling processes. Due to the high temperatures, the tissue needs to be cooled by means of regional anesthesia , tumescent local anesthesia , and usually also anesthesia. Post-treatment is carried out with compression stockings. Mechanochemical ablation is performed using a rotating catheter that destroys the vein wall in combination with sclerotherapy of the vein. Anesthesia and compression therapy are common. The treatment of the varicose vein with the vein glue is non-thermal, non-tumescent and leads to a remodeling and degradation process of the varicose vein via a closure of the vein with a medical glue, the N-butyl-2-cyanoacrylate . The vein and cyanoacrylate are completely absorbed by the body. Anesthesia or compression treatment are not required.
In the less common CHIVA method, veins are specifically tied off at individual points so that the pathological backflows responsible for the varicose veins are avoided. Existing varicose veins can regress within a few weeks.
Ideally, the patients are informed about all procedures in accordance with the Patient Rights Act in order to provide them with a therapy that is as tailored to their needs as possible. Procedures that require anesthesia cannot be used on patients at risk of anesthesia.
The use of compression or support stockings has a preventive and soothing effect, but the causes of varicose veins cannot be eliminated.
Regardless of the form of therapy a diagnosis is made, superficial veins can be removed without hesitation, with a few exceptions. The blood circulation does not suffer because the superficial venous system transports a maximum of 5 - 10% of the total amount of blood from the leg to the heart. The main venous blood flow occurs in the deep leg vein system (90 - 100%) and can easily increase the capacity.
- Esophageal varices
- Portal hypertension
- Venous ulcer
- Varicocele (varicose vein on the testicle )
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