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Venous insufficiency

Veins provide the transfer of dirty blood from organs and tissues to the heart. There are three vein systems, deep, superficial and perforating. Deep veins carry 80-90% of blood and 10% of superficial blood.

These veins contain valves that allow blood to flow from the leg to the heart and prevent back-escape. It is called venous insufficiency that these valves reclaim blood for various reasons.

Figure. Deep (Upper), superficial (Lower) veins

There are two-leafed valves in the veins and they allow blood to flow only towards the heart, preventing blood from escaping. It is found in the connecting (vein: perforator) veins that allow the transition between deep and superficial veins. These have valves that only allow passage from the surface to the deep.

Figure 3.4: Vein valves

  • Superficial veins in the leg ejaculate by connecting to deep veins in the ankle, knee and above knee areas. There is always a deep blood flow through the superficial veins. In cases where deep veins are blocked, these valves break down and blood flow passes from deep to superficial veins.
  • In standing people, the muscles in the leg have an important role in sending blood to the heart. In people who stand still for a long time, blood will be deposited in the leg, since the muscles cannot act as pumping.
  • In normal individuals, when standing up in the ankle area, the pressure is around 15mmHg. This pressure remains constant as long as it is walking. However, if it waits motionless, the pressure rises up to 100-120mmHg. If we start walking, the pressure starts to decrease in the ankle area due to the pumping effect of the leg muscles at each step and the pressure decreases more than 50%.
  • The expected fall during walking in people with impairment of this valve or muscles is much lower than in normal individuals. In these, venous pressure is constantly high even during walking.
  • In order for this decline to take place effectively, deep, superficial and perforating balls that combine them must have sufficient pumping power in the leg muscle structure as well as the valves in the vessels are intact.
  • The flow of blood pumped from the leg in the abdomen and chest cavity is determined by normal spontaneous breathing movements. The diaphragm moves upward while exhaling, decreases intra-abdominal pressure and blood flow from the leg to this area is accelerated, then, by breathing, the diaphragm is pushed down, the chest cavity expands. Accordingly, intra-abdominal pressure increases, intra-chest pressure decreases and blood flow from the abdomen of the blood to the heart accelerates.
  • In the graphic below, pink represents normal individuals, individuals with leaks in the red cap. After starting to walk, normal vein pressure decreases very much in normal people, while it is seen that it decreases very little in people with leakage.

Figure 4. Vein pressure change

  • If we continue to stand still, there will be enlargement of the veins, depending on the high pressure and the blood buried in the leg. Due to the fact that deep veins surround muscle tissue, enlargements develop in superficial rather than deep veins. Accordingly, the valves in the vein will be insufficient in the enlarged vein and leakage will develop. As leaks evolve, the vessel will expand more, leading to more leaks, leading to a vicious circle.

Figure 5. Capillaries or large varicose veins due to leaks in the groin area

Capillaries or large varicose veins develop due to leaks especially in the groin area where deep and superficial veins meet.

Venous insufficiency classification

Class 0. No visible problems

Class 1. Capillaries

Class 2. Wide heirs

Class 3. Leg edema

Class 4. Ankle discoloration (darkening)

Class 5. Healed ulcer in the ankle

Class 6. Active ankle in the ankle

  • Often, capillary varices can also develop due to deep or superficial vascular leaks. These leaks must be eliminated before proceeding for these capillary varices. Otherwise, they will relapse in a short time.
  • High pressure occurs in the knee region due to the escape of blood from the valves in the veins. Depending on the effect of prolonged high pressure, varicose veins, edema, thickening of the skin and darkening in the color occur. In the advanced stages of the disease, an ulcer develops in the ankle area.

Picture. Class 1-6

  • Venous insufficiency is the main cause of vein insufficiency and varicose veins in professional groups such as long-standing hairdressers, teachers and surgeons.
  • Other factors causing vein leakage; genetically weak vascular wall, obesity and high intra-abdominal pressure, weak leg muscles, and births can cause venous insufficiency.
  • Depending on venous insufficiency, swelling in the leg, night cramps, burning at the sole of the foot, skin hardening and darkening in the ankle area are observed.

What should we do to reduce the venous insufficiency complaint?

  • For this, we should not stand still, standing still for a long time.
  • We should not put too much hot water on our legs during the shower.
  • We should avoid weight gain, and exercise more often
  • We should avoid tight clothes that will increase intra-abdominal pressure
  • We should not wear very high heels
  • We should not consume too many salty foods
  • We should rest our feet up at appropriate times during the day.
  • We should do ankle movements where we sit on long trips

What to do in the treatment of venous insufficiency?

  • The main approach to the treatment of venous insufficiency is the elimination of leakage. For this purpose, in the previous years, the removal of the vessel, which was leaking, was performed with classical surgical techniques. Laser or radiofrequency ablation (ablation: burning) methods have been replaced by the less invasive method for the last 10 years.
  • Intravenous adhesion technique, a new method, has been developed for the last few years. The literature results of this method are similar to laser and radiofrequency.
  • In patients with mild venous insufficiency, drug therapy and life course changes are of great benefit.

Perforating Vein Failure and Treatment Approaches

Deep veins travel between the muscles and travel 90% of the blood and superficial under the skin on the muscles and carry 10% of the blood. Perforating veins establish a connection between the deep and superficial veins at various levels in the leg and provide transition to superficial balls.

Perforating veins also contain valves, which only allow passage from the superficial vein to the deep.

Figure 1.2. Localization of perforating veins

Perforating veins in the knee region are the first perforating vein at the ankle level. Others are located 7-9cm above this and 10-12cm above. Other perforating vessels are located at the knee level and in the thigh area.

Various problems such as discoloration and ulcers, especially in the ankle area, develop due to the transition from deep to superficial veins due to the deterioration of these valves due to various reasons.

Perforating vein failure was also detected in approximately 55-60% of patients who developed venous ulcers due to chronic venous insufficiency.

Figure 3. Skin changes in chronic venous insufficiency.

What are the causes of this perforating vein deficiency?

  • Deep vein thrombosis (DVT) is one of the most common causes
  • Working in jobs that stand still for a long time
  • Birth
  • Genetic factors
  • Weakness in the calf muscles
  • Obesity

In general, determination of perforating vein diameter of 3.5mm and above is found as a finding in favor of failure. It also gives information about the severity of imaging and duration of the flow back in the dopp.

Figure 1.2. Enlarged perforating vein and leak in Doppler

What applications are available for treatment in perforating vein insufficiency?

The treatment methods to be applied for the perforating vein differ. Although these methods are often the same as those applied to other varicose therapies, their application techniques vary widely.

  1. Subfascial endoscopic perforator surgery (SEPS):

Connecting the perforating vein with an endoscope. It is one of the most frequently used methods in the past. It is not preferred much because it requires special tools.

Figure: SEPS

  1. Open surgical ligation: Perforating vein is connected through 1.5-2 cm incisions with local anesthesia
  2. Sclerotherapy with ultrasonographic guidance: Foam sclerosing substance is injected into the perforating vein by seeing with ultrasound.
  3. Endovenous laser and radiofrequency; The perforating vein is burned by laser or RF.


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