Chronic venous disease or varicose veins of the lower limbs

Varicose veins of the lower limbs are characterized by the presence of varicose, tortuous dilatations of the subcutaneous veins, the so-called venous ectasia (Fig. 1 and 2).

It can be primary or secondary. Secondary varicose veins appear after deep thrombosis. In the etiology of primary varicose veins, orthostatic venous hypertension is involved. This, alongside gravity and other favorable factors, produces alterations of the valve mechanism (of the ostial valve – of the great saphenous vein and the other valves). These led to the stagnation of the blood column in the superficial venous system, continuing with the dilatation of the subcutaneous veins, later becoming tortuous, sinuous, and visible under the skin.

Clinically, varicose veins have a slow, insidious onset:
• painful embarrassment,
• calf weight
Firstly, these symptoms appear only after standing up or sitting for a long time and disappear while resting. They can also be accompanied by malleolar edema (swelling of the ankles). Sometimes varicose veins appear suddenly, without noticeable warning signs. Once they develop, venous ectasias appear in the form of cords, with an irregular path, located mainly on the inner side of the calf or under the knee, protruding under the skin.
The evolution without treatment leads towards complications:
Complications, such as ruptures of the varicose veins with minor trauma and venous thrombosis can occur as well.
The untreated condition progresses, venous stasis leading to trophic lesions of the skin and subcutaneous cellular tissue. Firstly, they appear at perimalleolar level, then progresses to the entire distal half of the calf.
The evolution of these trophic lesions is irreversible, varicose disease being a chronic, disabling condition.
From a morphopathological point of view, characteristic lesions appear:

• change in skin color: confluent brown spots, up to permanent hyperpigmentation, (Fig. 5 and 6)
• infiltrative sub-tegumentary edema, the disappearance of suppleness of the teguments up to fibro-sclerosis lesions (lipodermatosclerosis),
• even the most advanced complication of CVI, which is an atonic wound with no tendency to spontaneous healing, the calf ulcer. (Fig. 7-8 and 9)
Superficial venous thrombophlebitis (phlebitis and periphlebitis) is a local complication of varicose veins (Fig. 10).
The physiopathological mechanism underlying this complication is stasis-thrombosis-infection of the superficial vein.
From a morphopathological point of view, the alterations begin by altering the endothelium, and then progresses into the entire venous wall (endophlebitis and phlebitis); the injury quickly progresses to the neighboring tissues (periphlebitis). When the local defense mechanisms are overcome, infection occurs, leading to suppurative thrombophlebitis.
Local signs: dilated, hardened venous veins, covered and surrounded by infiltrated, warm, red skin.
General signs: fever, tachycardia, even functional impotence.
Alongside the extension of the thrombosis through the communicating veins, it leads to
Deep thrombophlebitis (Fig. 11), in which:
• the edema is generalized to the whole limb,
• circular distribution,
• violet coloration,
• difficulty in walking
and the evolution of the disease without treatment is serious, with acute complications:
• distant (pulmonary) embolism or
• chronic complications: post-thrombotic syndrome

The treatment of venous diseases of inferior limbs
Being a chronic, evolving condition, the treatment includes the set of prophylactic, curative and maintenance medical and surgical therapeutic measures that are applied throughout the life of patients with IVC.
At the beginning, the treatment is simple, but it becomes more difficult and with unsatisfactory results as the condition evolves and irreversible damage occurs to both the venous system and the tegument and sub-integument tissues.

The goal of the treatment is to suppress pathological reflux and morphologically altered varicose veins that represent a local «irritating spine».
• Combating venous stasis and edema
• Combating the high pressure from the superficial degenerate varicose system,
• Improvement of local trophic disorders
Depending on the stage of the condition, established according to the CEAP clinical classification, the applicable treatment protocols provide:
• external elastocompressive measure, which is made with an elastic bandage or elastic stockings customized by individual measurement.
• external elastocompressive measure is applied at different pressures depending on the stage of the condition.
The assessment of effectiveness is carried out by:
• phlebographic exploration (invasive method)
• doppler ultrasonography (non-invasive scan)
The elastocompressive measure is also applicable and useful in the case of ulcerative complications, atonic wounds on the level of the calves-CALF ULCER.
Elastic stockings, customized by correct measurements, and depending on the stage of the disease, (graded compression stockings) ensure:
• effective prevention of venous stasis,
• healing atonic lesions,
• prevention of varicose veins recurrence
• The declination cure refers to the supine position (lying down) with the leg raised at 15 degrees, a position that must be maintained for 1-2 hours during the day.
• Physiotherapy, performed by specialized staff,
• Phlebotonic and anti-inflammatory medication, both local and systemic
• Sclerotherapy, for certain stages.
Surgical treatment addresses the CVI or its complications, the superficial, deep or communicating venous system.
For the superficial and communicating venous system, surgical techniques are performed:

• Saphenectomy by stripping and layered stripping,
• Chiva intervention,
• Phlebectomies
• Ligation of perforating veins,
• Valvular reconstructive interventions

The interventions of choice regarding CVI are considered the ligatures of perforating veins associated with the extirpation of the superficial degenerated varicose system. For the deep venous system, the following surgical techniques are frequently used:
• Intervention to disconnect the perforating veins
• Subfascial ligation of perforating veins
• Endoscopic ligation of perforating veins
• phlebolysis,
• phlebectomy,
• valvuloplasty,
• Replacement interventions
• Reconstruction interventions etc.
The attitude is complex in the post-thrombotic syndrome with phenomena of chronic venous insufficiency, the surgical treatment addresses both the superficial and deep venous system, as well as the system of communicating veins.
Surgical interventions regarding the deep venous system are more difficult and even if the immediate results are good, they are considered palliative interventions.
The results obtained in the complex treatment of varicose veins are good. They depend on the early diagnosis, the surgical treatment and the nature of the varicose veins (primary or secondary).
Varicose recurrence occurs in the presence of the persistence of favorable factors or in the absence of preventive measures for varicose recurrence:
• avoiding orthostatism and prolonged sitting position,
• physical therapy and gymnastics depending on the stage of the condition,
• elastocompressive therapy, with efficiency in situations of prolonged orthostatism,
• prophylactic treatment of thrombosis,
• maintenance drug treatment, venous trophic, micronized flavonoids,
• correct treatment of skin lesions of the lower limbs,
• compliance with the indications for periodic control,
• the appropriate, early treatment of varicose recurrence.

Sports that are recommended to be practiced:

• swimming,
• rowing and
• cycling
that favorably influences the venous return by increasing the action of the muscle pump.

In conclusion, early diagnosis, with indication of treatment and correct surgical technique (removal of pathologically modified superficial venous system) with adjuvant treatment (sclerotherapy), removal of favorable factors (prolonged orthostatism, elastic restraint), correct monitoring, lead to the absence of the relapse of the varicose disease.
In medical practice, we insist on the early recognition of the condition by both the doctor and the patient. Moreover applying early treatment, before the appearance of disabling complications, depending on the clinical stage are the keys to treat and cure without sequels.