Vein diseases

Phlebitic syndrome is a symptom complex that develops with the development of venous disease.

Varicose veins are all diseases of the veins characterized by an uneven increase in their lumen, distorted course of the vessels with the development of nodules and protrusions of thinned walls, their functional insufficiency and vicious blood flow.

The process may involve superficial, perforating and deep veins. The classification of varicose veins is based on this principle.

1. Varicose veins only superficial;
2. Varicose veins of the superficial and perforating;
3. Varicose veins of the superficial, perforating and deep:
   • without chronic venous insufficiency;
   • with chronic venous insufficiency:
     • without signs of decompensation;
     • with signs of decompensation.

Diagnosis of varicose veins is not difficult, as dilated and tortuous superficial venous vessels are visible to the eye, they increase with physical exertion, prolonged standing, decrease in the lying position and can generally: disappear with a raised limb. The feeling of fatigue in the legs is disturbing, swelling appears in the evening.

To identify signs of venous disease and chronic venous insufficiency, many techniques have been proposed, which can be divided into 3 groups.

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Techniques for detecting venous disease and valve insufficiency

Troyanov-Trendelenburg test - lying on his back, the patient lifts his leg up to empty the venous vessels. At the mouth, the superficial vein is pressed with a finger and the patient is asked to stand up. The finger is quickly removed and the filling of the vessels is observed; there may be three pictures:

1. the vessels are filled from the distal side for more than 2 s - the valve system is preserved;
2. the vessels are filled from the distal side in less than 2 s - there is insufficiency of the valves of the collateral vessels;
3. filling of the vessels occurs from above - valve insufficiency occurs.

McCulling and Heyerdahl's test - in a standing position, "listening" fingers are placed on varicose veins, nodes on the thigh, neck, shin, and light blows are applied to the vessel in the area of the oval fossa - the transmission of a wave-like impulse indicates valve insufficiency.

Hackenbruch's test - in a standing position, place your hand on the place where the subcutaneous vein enters the femoral vein, ask the patient to cough - if the valves are insufficient, the cough impulse is transmitted through the vessel.

Techniques for detecting varicose veins and valve insufficiency

Burrow-Sheinis test (three-tourniquet, five-tourniquet can be used) - allows to detect valvular insufficiency of not only superficial venous vessels, but also perforating ones - in a supine position with a raised limb and emptied vessels, 3 venous tourniquets are applied (to the upper, lower third of the thigh, middle third of the shin). The patient gets up. Rapid filling of the vessels before removing the tourniquet in one of these areas indicates valvular insufficiency. With a step-by-step removal of the tourniquets, by the retrograde blood flow, areas of the superficial venous vessel with valvular insufficiency are determined. Talman test - in a supine position with a raised leg, the limb is bandaged with a rubber tube from top to bottom to the foot, leaving a distance of 5-6 cm between the tourniquets. The patient gets up, the appearance of varicose areas between the tourniquet tourniquets indicates areas with perforating veins that have valvular insufficiency.

Techniques for determining varicose veins and patency of deep vessels

The Delbe-Perthes test (march) allows you to determine the patency of a deep vein - in a standing position, a venous tourniquet is applied to the thigh and the patient walks for 5-10 minutes. If the deep veins are passable and the valves function normally, the superficial vein becomes empty. In the case of persistent varicose veins, clarifying studies are necessary; it is easier to conduct a five-tourniquet test

• venous tourniquets are applied to the upper and lower third of the thigh, the upper, middle and lower third of the shin in a standing position, and marching is performed - if at least one of the zones between the tourniquets has collapsed the superficial vessels
• the deep vein is passable, and in areas where collapse has not occurred, there is insufficiency of the valves of the perforating veins. Mayo's test - in a lying position with a raised limb, a venous tourniquet is applied to the thigh, and then the leg from the toes to the groin is bandaged with a rubber bandage to squeeze the superficial vessels. If after a long walk (at least half an hour) pain in the leg, swelling and cyanosis of the folds appear, the deep vein is impassable. Pratt's test - after measuring the circumference of the shin, the patient is laid on his back with a raised leg, which is bandaged with an elastic bandage for reliable compression of the subcutaneous vein. They are asked to walk actively for 10 minutes. If during this time pain in the shin appears and the circumference of the shin increases after removing the tourniquet, then the deep vein is impassable. Phlebography is performed to confirm and document the diagnosis.

Signs of decompensation of varicose veins, depending on the severity of the disturbance of microcirculation and metabolic processes, are:

1. dermatitis, which is a hyperpigmented area of dry and atrophic skin in the lower third of the leg, ring-shaped;
2. local trophic ulcer of the lower third of the leg;
3. an extensive, usually annular, trophic ulcer of the leg.

Varicose veins can be accompanied by complications in the form of thrombophlebitis and phlebothrombosis, intra-tissue bleeding from thinned vessel walls and erosive bleeding from ulcers, and the addition of infection.

Phlebitis is an acute or subacute inflammatory disease of the veins until a thrombus forms and the process turns into thrombophlebitis or phlebosclerosis. By localization, there are:

Endophlebitis is a disease of the veins, the main cause of which is trauma to the venous wall or prolonged presence of needles, catheters, the introduction of sclerosing drugs, usually ending in sclerosis of the vein; periphlebitis develops mainly when inflammation passes to the vein from surrounding tissues, more often from abscesses, mainly the process turns into phlebothrombosis; panphlebitis has various etymologies, but is most often the initial stage of thrombophlebitis.

The clinical picture of venous disease can be observed only in the initial stages of the process, mainly when localized in the lower extremities: acute pain along the vein, the skin above them is hyperemic, the vein is palpated as a dense and painful cord, with periphlebitis, a painful infiltrate is detected along the vein.

Mondor's syndrome - occurs as a subacute form of the disease of the veins of the lateral surface of the chest, manifested by the formation of one or more painful cord-like strands of veins, along the course of which a burning sensation is determined, the skin above it is not changed. The disease lasts 3-4 weeks, after which all phenomena disappear, but skin pigmentation and hyperesthesia may remain.

Phlebitis of internal organs forms certain symptom complexes: Chiari - a disease of the liver veins, ending with their obliteration and the development of portal hypertension; metrothrombophlebitis - a disease of the uterine veins, more often after childbirth; pylephlebitis - thrombosis or thrombophlebitis of the portal vein, as a complication of appendicitis and cholecystitis, with the development of jaundice and liver failure.

Thrombophlebitis is a vein disease characterized by inflammation of the vein walls and thrombosis of the vessel. Depending on what is primary, there are: thrombophlebitis, when inflammation develops first, followed by thrombosis, and phlebothrombosis, when thrombosis is primary, and then inflammation joins. But basically, this is only important in the initial stages of the development of vein disease, since subsequently the process is uniform.

The causes of thrombophlebitis development are varied: the state of the body's reactivity, endocrine, autoimmune and neurotrophic disorders, vascular damage, slowing of blood flow and venous stasis, exposure to infection, etc. It often develops with varicose veins. The veins of the lower extremities and small pelvis are most often affected, but thrombophlebitis of the veins of the upper extremities, brain, portal vein, etc. can develop.

Thrombophlebitis is distinguished only as acute, the outcome of which is sclerosis of the vein and the development of chronic venous insufficiency (post-thrombophlebitic syndrome), against the background of which relapses of the vein disease may occur. There is no concept of chronic thrombophlebitis. The duration of the acute period of the disease is up to 20 days, subacute - from 21 to 30 days from the onset of the vein disease.

Thrombophlebitis of superficial (subcutaneous) vessels in most cases develops against the background of varicose veins with the usual localization on the foot, shin, thigh, or all subcutaneous veins are affected. Pain in the area of the thrombosed vein suddenly appears, when examining the limb, the skin above it is hyperemic, shiny, an infiltrate is visible along the vein, the vein is palpated as a painful, dense cord. There is no swelling of the limb. The general condition changes little, a feverish state is rare.

Deep vein thrombophlebitis of the lower leg begins with pain in the calf muscles that intensifies and spreads retrogradely, a feeling of distension appears. On examination, the skin is unchanged or has a cyanotic tint, by the 2nd-3rd day of the disease, dilated subcutaneous veins are detected: Slowly increasing edema of the lower leg is characteristic, which distinguishes it from thrombophlebitis of the superficial vessels. Palpation of the gastrocnemius muscle is sharply painful in depth, but the abdomen itself is slightly painful. The skin temperature of the limb is elevated. The general condition is disturbed, proceeds with purulent-resorptive fever. Characteristic symptoms of venous disease are revealed: Homans' symptom - the appearance or increase of pain in the gastrocnemius muscle with dorsiflexion of the foot; Moses' symptom - pain when squeezing the lower leg in the anteroposterior direction and absence when squeezing from the sides (has differential significance with myositis); positive Lowenberg test - a cuff from a tonometer is placed on the middle third of the shin; normally, pain in the calf muscle appears at a pressure of over 180 mm Hg; with thrombophlebitis, sharp pain occurs already at a pressure of 60-150 mm Hg.

The most severe form of venous disease is thrombophlebitis of the main vessels of the pelvis and the femoral vein to the point of its division into superficial and deep - ileofemoral thrombophlebitis. In the course of this venous disease, 2 stages are distinguished: compensation (prodromal) and decompensation (pronounced clinical manifestations). The compensation stage develops with preserved venous blood flow in the limb, or with a small parietal thrombus, or with a developed collateral venous network. Clinical manifestations of venous disease are poorly expressed: a characteristic pain syndrome develops, dull aching pain in the lumbosacral region, lower abdomen and lower limb on the affected side. The general condition suffers little. The duration of this stage is from 1 to 28 days and depends on the state of the collateral network, the process may end at this stage. With decompensation of venous disease, pronounced hemodynamic disturbances in the limb occur. The pains increase sharply, localized in the groin area, thigh and calf muscles. The swelling is pronounced, spreading to the entire limb, perineum, anterior abdominal wall (distinguishes from anaerobic by slower development, absence of crepitus). The skin is cyanotic-violet, cold, or can be milky white with severely impaired lymph drainage. A picture of psoitis develops: pain in the iliac region with maximum flexion of the hip, flexion contracture in the hip joint. If blood flow is not restored within 1-2 days, venous gangrene may develop, a sign of its onset is an increase in the volume of the limb by 2-3 times, the absence of pulsation of arterial vessels on the foot due to compression, the development of intoxication syndrome, up to septic shock.

Paget-Schroetter syndrome is a thrombosis of the subclavian vein associated with trauma and compression in the costoclavicular space. Paget-Schroetter syndrome should be distinguished from thrombophlebitis of the subclavian vein of other genesis: catheterization, ascending thrombosis of the upper limb, tumor invasion and compression, etc.

These venous diseases often develop in young men with developed muscles, and are more often localized on the right side. Pathogenetically, the diseases are associated with physical stress on the shoulder girdle, sudden and one-time, when there is direct trauma to its inner lining with the development of spasm and thrombosis, or with repeated monotonous movements associated with work or stress. The disease begins acutely. The earliest symptom of venous disease is the appearance of pronounced edema of the entire upper limb, which reaches a maximum by the end of the first day, but the intensity of its increase is not the same as with gas gangrene: the entire arm is tense, there is a sharp thickening of the tissue, when pressing with a finger, no indentation is formed, since the edema is determined not by the exudation of plasma into the tissue, but by the overflow of venous and lymphatic vessels. Cyanosis of the limb is most pronounced in the distal parts of the upper limb, the veins are significantly dilated and tense, a collateral network is revealed. In the first hours after thrombosis, the pain is sharp, sometimes burning, then it subsides somewhat and intensifies with physical activity and movements. The duration of the acute period is 3 weeks, after which all phenomena subside, but exacerbations are clearly associated with physical activity. The diagnosis of venous disease is confirmed by phlebography.

Given the threat of acute thrombophlebitis due to thrombus detachment and the development of thromboembolism of the arterial trunks, especially the pulmonary artery, all patients, at least for the first 2 weeks, should be hospitalized in a surgical hospital.

Postthrombophlebitic syndrome - develops in patients who have had deep vessel thrombophlebitis, but with unrecovered venous blood flow and insufficient collateral circulation. A picture of chronic venous insufficiency develops, mostly due to the failure of the valves of perforating vessels and the development of reflux from deep vessels to subcutaneous ones, with the formation of secondary varicose veins. Dysfunction of the muscular-venous pump is accompanied by venous and lymphostasis, increased venous pressure, which leads to the opening of arteriovenous shunts, desolation of capillaries, tissue ischemia with atrophic changes in them.

The clinical picture of venous disease depends on the state of blood flow compensation. The patients are bothered by bursting pains, a feeling of fatigue, heaviness in the shin, swelling of the foot and shin, which intensify in the evening, and varicose veins of the subcutaneous veins. In the stage of decompensation of venous disease, brown pigmentation and induration of the skin appear, located in the lower third of the shin, initially along the medial surface, then increasingly acquiring a ring-shaped form, capturing the entire surface of the shin: the skin is thinned, immobile, does not gather into a fold, and is devoid of hair. After a minor injury, scratching, an ulcer is formed, initially small in size on the medial surface of the shin, amenable to conservative treatment. As venous insufficiency increases, the trophic ulcer becomes chronic, expands, acquiring a ring-shaped form; it is difficult to treat conservatively, quickly recurs after healing, often becomes purulent, and causes erosive bleeding. Tactics: treatment of venous disease is long-term, conservative, outpatient, by a general surgeon or vascular surgeon.