primary lower extremity venous insufficiency
Introduction
Primary lower extremity venous valve insufficiency Lower extremity venous valvular insufficiency is a common disease, which occurs mostly in long-term physical labor or standing workers, and has a high incidence among farmers, barbers, athletes, surgeons, etc. Lower extremity venous valve insufficiency mainly produces severe limbs, soreness, fatigue, and superficial varices, hyperpigmentation, dermatitis, swelling and long-lasting ulcers, not only the patient is suffering, but also affects the labor force. basic knowledge The proportion of illness: long-term standing work such as traffic police, teacher occupational population incidence rate is about 0.004% - 0.007% Susceptible people: persistent physical labor or standing staff Mode of infection: non-infectious Complications: dermatitis varicose veins
Cause
Primary lower extremity venous valve regurgitation
Congenital vein wall weakness, dilatation, venous valve defects, persistent increase in venous pressure, and venous wall and valvular degeneration are the main causes of venous valve insufficiency in the lower extremities.
Heavy full-time labor and long-term standing are prone to lower limb venous valve insufficiency, intra-abdominal pressure rises when weight-bearing, lower extremity venous return is blocked, and persistent standing, less muscle contraction in lower limbs, affecting venous return, vein wall and valve congenitally weak In addition, the above factors can cause the venous valve insufficiency of the lower extremity.
Due to the weak congenital vein wall, long-term blood stasis, increased venous pressure, early muscle fiber and elastic fiber compensatory thickening, late muscle fiber and weak fiber atrophy, disappear, are replaced by connective tissue, the vein wall often expands Thinning, the elastic fibers of the venous valve also degenerate, although the valve is in the form of a film, there is no sign of thickening of the valve after deep phlebitis, but the valve is incomplete, the two leaflets can not close together, resulting in valve insufficiency, blood The flow flows downward from the two drooping leaflets.
Deep valve insufficiency, blood flow to the distal deep vein, reflux, venous pressure increased, venous lumen dilation, thinning of the wall, capillary congestion, limb edema, lymphatic secondary occlusion, edema tissue fibers The swelling of the limbs is more serious. Continuous deep venous hypertension and insufficiency of the perforating veins cause the deep vein blood to flow back into the superficial vein, causing secondary varicose veins of the saphenous vein.
Lower limb blood return slows and countercurrent, causing blood flow in the lower limbs to stagnate, blood oxygen content is reduced, capillary wall is increased, red blood cells are infiltrated into the blood vessels, hemoglobin metabolite hemosiderin is deposited under the skin, often causing boots The skin of the area showed brown-black punctate pigmentation, local tissue was malnourished due to hypoxia, and the resistance was reduced, and it was easy to cause rash-like dermatitis, lymphatic vessels and ulcers.
Prevention
Primary lower extremity venous valve insufficiency prevention
Keep your mood comfortable, have an optimistic, open-minded spirit, and be confident in fighting disease.
Pay attention to maintain adequate sleep, avoid overwork, pay attention to work and rest, pay attention to the regularity of life.
Reasonable diet, diet should be light, avoid spicy spicy food.
Reduce venous pressure in valve insufficiency, including raising the affected limb, proper activity, and applying elastic bandages.
Complication
Primary lower extremity venous valve insufficiency complications Complications dermatitis varicose veins
Lower limb blood return slows and countercurrent, causing blood flow in the lower limbs to stagnate, blood oxygen content is reduced, capillary wall is increased, red blood cells are infiltrated into the blood vessels, hemoglobin metabolite hemosiderin is deposited under the skin, often causing boots The skin of the area showed brown-black punctate pigmentation, local tissue was malnourished due to hypoxia, and the resistance was reduced, and it was easy to cause rash-like dermatitis, lymphatic vessels and ulcers.
Symptom
Primary lower extremity venous valvular insufficiency symptoms Common symptoms Varicose veins lower limbs heavy,... Lower abdomen dull pain and soreness, severe pain, calf pain
1. Most of them are long-term standing and strong physical labor, or the symptoms of saphenous vein exfoliation have not improved or short-term recurrence.
2. The affected limb is swollen, and there is swelling and severe pain when standing for a long time. It has symptoms and signs of simple varicose veins of the lower extremities.
3. Intravenous pressure measurement, directional Doppler ultrasonography is helpful for diagnosis.
4. Venous angiography
1 antegrade angiography, the deep vein trunk is tubular expansion, loss of bamboo-like formation, blurred valve shadow, often accompanied by superficial vein dilation.
2 retrograde angiography, can determine the valve function: grade I - valve function is sound, calm breathing without contrast agent to the far side; II - mild valve insufficiency, a little contrast agent backflow, no more than the thigh proximal; III, IV - Moderate valvular insufficiency, contrast agent reflux, respectively, to the knee and knee, but there is still a considerable contrast agent to return to the Han; V-level - severe valve dysfunction, most or all of the contrast agent countercurrent, straight to the ankle.
Examine
Primary lower extremity venous valve insufficiency examination
According to clinical manifestations, some physical examinations and laboratory special examinations are needed, especially for lower extremity venography.
(1) Science examination
1. Lower limb circumference measurement
Straighten or slightly bend the lower extremities, measure the length of the knee 15cm and 15cm below the knee, generally with the lower edge of the humerus (when measuring the calf) and the upper edge of the humerus (when measuring the thigh) as the fixed point, measure the value of the healthy side and the affected side Preoperative and postoperative controls.
2. Lower extremity deep vein patency test (Perthes test)
It is used to measure the patency of deep venous return by blocking the great saphenous vein in the thigh with a tourniquet. The paralyzed patient kicks the leg vigorously or continuously for the lower jaw movement. Due to muscle contraction, the superficial venous blood flow should be returned to the deep. The veins cause the varicose veins to collapse, such as deep veins or venous pressure, and the degree of varicose veins is not alleviated or even worsened.
Whether the deep venous valve is closed or not, there is no physical examination (refer to the above manual inspection without instrument) to detect the lesion.
3. Great saphenous vein valve and calf penetrating venous valve test (Trendelenburg test)
In order to determine the position of the incomplete valve of the saphenous vein and the venous insufficiency of the valve, the patient takes the lying position, the lower limb is raised, and the affected limb is massaged upward from the ankle to make the vein empty. The examiner presses the proximal thigh with a tourniquet. Then let the patient stand, when the tourniquet is released, the saphenous vein is rapidly filled, indicating that the saphenous vein valve is incomplete; the tourniquet is not released and the saphenous saphenous vein is rapidly filled in 30 seconds, indicating that the calf is worn through the branch. Venous valve insufficiency.
(2) Laboratory without damage inspection
In recent years, Doppler ultrasound blood flow examination, electrical impedance volume map, photoelectric blood flow meter measurement, etc. to check the deep venous patency of the lower extremities and deep venous valve function until the beneficial effect, but the ascending and descending lower extremity venography It is still a method of visualizing the diagnosis of deep venous patency and venous valve function.
(three) lower extremity venography
When the limb is swollen or there is a long-term unhealed ulcer, it is best to perform venography of the lower extremity. On the one hand, it is differentiated from the syndrome of deep phlebitis. On the other hand, the degree of deep and shallow venous valve insufficiency is clearly defined, which provides a basis for formulating the surgical plan.
Generally, advanced venography is performed first, and the deep veins of the lower limbs are patency, and then the venous angiography is performed to determine whether the venous valve has lesions.
Ascending venography
It is mainly used to observe the deep venous patency of the lower extremities and the function of penetrating the venous valve. The method: the patient is supine, taking the semi-erect position, showing 45o, the sacral part is tied with a rubber tourniquet to prevent the superficial venous blood flow upward, and the percutaneous needle is directly percutaneously Puncture into the superficial vein of the foot, push 60% or 40% diatrizoate 80-120ml as soon as possible, take a picture under the guidance of the TV screen, first take the calf X-ray film, let the patient take the toe force, make a heel The concentration is preferably 40% diatrizoate, and the excessive concentration can cause superficial phlebitis. After the end of the angiography, physiological saline can be injected for vascular irrigation.
2. Downward venography
It is mainly used to observe the function of deep venous valve of lower extremity. The angiography must be performed without clearing the deep vein without obstruction. Otherwise, it often fails. Method: The patient takes 60o and a half of the upright position, and directly injects 60 needles into the inguinal femoral vein. % diatrizoate 40ml, under the guidance of the TV screen, take the X-ray of the hip, if there is a countercurrent, then take the calf X-ray.
Taheri reported that the catheter was inserted from the superficial vein of the upper extremity, through the cephalic vein, the subclavian vein to the bifurcation of the vena cava, and then into the common iliac vein, and then the contrast agent was injected. This method is more complicated and less used.
According to the level of reflux shown by descending venography, the venous valve function is divided into the following five levels:
Grade I: The valve function is good and the contrast agent has no obvious countercurrent.
Grade II: The valve is the least mildly closed, and the contrast agent is just as close as the proximal thigh.
Grade III: The valve is mildly insufficiency and the contrast agent flows back to the knee.
Grade IV: The valve is moderately insufficient and the contrast agent flows back to the knee.
Grade V: The valve is severely insufficiency and the contrast agent flows back to the calf until it is level.
Postoperative venography can be used to determine the degree of improvement in valvular muscle energy.
Raju had performed venous angiography on 14 normal symptom volunteers and found that 2 patients had mild regurgitation. For this reason, the analysis of angiographic results must be combined with clinical symptoms and signs, and the correct conclusions were drawn.
Department of Vascular Surgery, Shanghai Zhongshan Hospital, from February 1983 to February 1988, performed 120 cases of venous insufficiency (including primary and secondary) in patients with lower extremity venous angiography and/or descending venography. 66% of patients with primary venous insufficiency of deep phlebitis had severe deep venous insufficiency and blood flowed back below the knee.
The X-ray findings of primary deep venous insufficiency have the following main points.
1. The deep venous valve shadow exists but is ambiguous. The contrast agent flows back through the valves. The veins displayed may sometimes be bamboo-like. The contrast agent is lighter than the section, indicating that the valve still plays a part. A portion of the blood is blocked by the valve, and a portion of the blood flows back from the sagging sagging leaflets, and the more distally, the less contrast agent is countercurrent.
2. The venous lumen is obviously enlarged.
3. There was no lesion left by thrombosis in the whole venous system. The contrast agent was partially countercurrent, and some of it was refluxed toward the proximal end.
Diagnosis
Diagnosis and diagnosis of primary lower extremity venous valve insufficiency
diagnosis
Can be diagnosed based on clinical performance and laboratory tests.
Differential diagnosis
(1) Lower extremity deep vein thrombosis syndrome
Both the disease and deep vein thrombosis syndrome have stagnation of venous blood flow in the lower extremities, and the symptoms and signs are very similar. Especially in patients with a long history of deep vein thrombosis, the condition has been memorized at the time of onset, and the deep vein thrombosis has been Re-pass, more confusing, but there are still many aspects to identify.
Differential diagnosis of primary deep venous insufficiency of lower extremity and post-deep vein thrombosis syndrome
Primary deep venous valvular insufficiency of the lower extremity Deep vein thrombosis syndrome is insidious, slow and sudden, some fever, long-term standing of the inguinal pain, strong physical labor, postpartum, after major surgery, after trauma, after cold , tumor, long-term bedridden superficial varicose veins often located in the calf, varicose into a group, protruding skin, thigh less common range, often in the lateral and lower abdominal wall of the hip, perineal can be found collateral vein, small The varicose veins of the legs are lighter, because the tissue edema does not protrude from the skin, the degree of swelling is lighter. The calves are the main part, the thighs rarely occur, and the circumference of the affected side calves is generally 1~3cm larger than the healthy side. The calves and thighs are light. It can be swollen. The circumference of the affected leg is 3~6cm larger than the healthy side. The circumference of the thigh can be 3~9cm larger than the healthy side. The pigmentation range is small. In some cases, there is no larger range. In almost all cases, there are less ulcers. More common venous tenderness without early cases, obvious tenderness, inguinal sputum, abnormal sputum and ascending venography, showing femoral vein patency, enlarged lumen showed thrombus formation in the femoral vein Shadow display femoral vein had reflux, but valve still developing some terminally ill patients will also show the presence of femoral venous reflux, but the valve had been destroyed inflammation often does not develop.
(B) lower extremity arterial venous fistula
The lower arteriovenous fistula also has superficial varicose veins, hyperpigmentation, dermatitis and ulcers, so it is also necessary to distinguish it from the disease. If it is caused by trauma, there is a history of trauma, often with a knife wound, bullet penetrating wound, sharp thorn Injury and other medical history, local sputum and persistent vascular tremor, persistent vascular murmur during auscultation; if congenital, it is found from childhood, limbs can grow thicker, skin temperature is significantly increased, but also tremor and tremor And to hear vascular murmurs, differential diagnosis is generally not difficult, if necessary, lower extremity angiography can further confirm the diagnosis.
(three) lymphedema
Some obese patients suffer from deep venous insufficiency of the lower extremities, and superficial varices may not be obvious. These patients still need to be differentiated from lymphedema. Lymphatic edema is swollen in the lower extremities, but no pigmentation and ulceration occur. The skin often thickens, calves and ankles. The swelling of the back of the foot is the most, and the swelling of the venous valve is mainly caused by the calf. The ankle, the back of the foot is rarely swollen, and the venous blood stasis of the venous valve is not obvious in the calf. The lymphedema glare occurs under the skin. The ankle, the other soft tissues of the back of the foot are less, so the tumor is obvious, if necessary, for the venous angiography, lymphatic edema patients without venous reflux.
(4) Klippel-Trenaunay syndrome
This disease may have lower extremity varicose veins and limb swelling, so it is also necessary to identify with this disease, Kilppel-Trenaunay syndrome is a congenital vascular malformation, with superficial varices, limb growth and sputum, a group of cutaneous hemangioma, often There is an increase in skin temperature, in addition to involving the calf, thigh, often involving the buttocks, ascending venography can show venous malformations, most of which are congenital atresia of the iliac vein or femoral vein, the differential diagnosis is not difficult.
(5) Simple saphenous vein valve insufficiency
According to the descending venography, the simple saphenous vein membrane closure and deep venous insufficiency can be identified. The deep venous insufficiency often combined with the great saphenous vein regurgitation and deep, superficial venous perforator valvular insufficiency, both in clinical symptoms Different from the signs on the signs, some deep venous valve insufficiency due to the compensation of the calf muscle pump, help the lower extremity venous return, the lower limbs are not swollen, through a large number of venography, the patient diagnosed as simple saphenous vein in the past About 66% are accompanied by deep venous insufficiency, so we believe that the two can be the same disease, but at different stages of the disease, or the degree of disease is different.
