Esophageal varices are the term given to venous dilatations in the lower part of the esophagus that result from disruption of blood flow in the portal vein and therefore the gastroesophageal plexus by excessive amounts of leaking blood seeking outflow from the heart.
Due to the fact that varicose veins of the esophagus correspond to cirrhosis of the liver in 90% of cases, yellowing of the skin and whites of the eyes, loss of appetite, weight loss, ascites, abdominal pain and nausea may occur.
The most dangerous symptom of this disease is associated with hemoptysis, vomiting mixed with blood, tarry stools and weakness.
Varicose veins of the esophagus in its lower section occur due to congestion in the portal vein system of the liver, which appears with thrombosis and cirrhosis of the liver. The cause of this disease in the upper part is a malignant goiter. The liver veins constrict, making it difficult for blood to flow through them. Phlebectasia of the esophagus also appears as a complication of heart and spleen diseases.
Factors causing this disease:
Varicose veins of the esophagus most often occur in the following categories of patients:
The appearance of bleeding is affected not so much by the level of pressure as by its sharp fluctuations. The risk of rupture is also high in those patients who suffer from vascular diseases that negatively affect the structure of the walls of blood vessels.
The classification of the disease of varicose veins of the esophagus has changed several times, however, the version from 1997 for the veins of the esophagus is now used, dividing the disease into degrees:
If varicose veins of the esophagus do cause internal bleeding, then according to statistics, only 50% of patients survive after it. More than half of patients who survive bleeding experience a relapse of this disease within 1-3 years and are forced to start treatment again.
The clinical picture is poorly expressed. The patient has virtually no complaints. During the examination, it is observed: the dilatation of the veins is not strong up to 3 mm, there is no ectasia of the veins, or only sporadic, the lumen is not filled. Diagnosed only by endoscopy. In the first degree, it is important to start treatment as quickly as possible.
The unevenness of the vessels is clearly visible, and there are also nodules whose size exceeds 3 millimeters. In this case, the mucous membrane of the esophagus remains intact, without any violation of its integrity.
When conducting a study, large vascular protrusions can be diagnosed. Treatment must be carried out in a timely manner; this is the only way to get rid of the unpleasant symptoms of the disease at the initial stage. Bleeding is not typical at this stage.
The most common diagnosis. The patient has severe symptoms. As a rule, in this case, surgery is prescribed. The veins are very swollen, the nodes are clearly visible, constantly dilated, occupy 2/3 of the esophagus, the mucous membrane of the esophagus is greatly thinned. Gastroesophageal reflux occurs.
This degree of disease is determined when numerous vein nodules are detected in the esophagus, not collapsing and with a thinned surface. Numerous erosions are found on the mucous layer. Patients register, in addition to signs of esophagitis, a salty taste in the mouth. The fourth degree most often leads to spontaneous bleeding.
For the first few years, varicose veins of the esophagus may occur without visible symptoms. Sometimes there are rare attacks of heartburn, slight heaviness in the chest, and belching. Some patients complain of difficulty swallowing food.
Symptoms of advanced disease usually appear several days before bleeding begins. Their signs consist of severe heaviness in the chest and a deterioration in the general well-being of the patient. In other patients, symptoms may include ascites.
In addition, symptoms of esophageal vein disease can manifest as the appearance of “jellyfish head”. This phenomenon is a certain pattern that is quite clearly visible on the anterior wall of the abdominal cavity by various pathologically formed convex vessels or veins.
After the veins rupture, severe bleeding occurs, accompanied by characteristic symptoms:
With minor bleeding, a person may feel some weakness, malaise, and symptoms of anemia. Esophageal varicose veins are diagnosed using laboratory tests, ultrasound examination of the abdominal organs, and, if necessary, X-ray examinations and esophagoscopy are performed.
The diagnosis is made on the basis of complaints, external examination, and identification of primary diseases. Instrumental studies include:
When making a diagnosis, all possible causes must be taken into account and excluded, only then will it be possible to finally and accurately determine the root cause of bleeding and changes in the veins of the esophagus.
If symptoms of varicose veins of the esophagus occur, treatment is carried out only in the intensive care unit or intensive care unit. The main classification of non-surgical procedures is aimed at preventing and eliminating bleeding (hemostatic therapy) by reducing pressure in the vessels:
In cases where the listed methods are not enough to thoroughly stop the bleeding and there is a risk of repeated damage to the vessels in the near future, they resort to surgery:
There is also currently significant experience in the use of minimally invasive endoscopic interventions to eliminate bleeding from dilated esophageal veins. There are 2 ways to perform endoscopic sclerotherapy of the esophagus:
The intravasal method of administering sclerosant involves the development of connective tissue at the location of the thrombosed varicose vein. With the paravasal method, when the sclerosant is injected into the submucosal layer, scarring of the paravasal tissue occurs and subsequent compression of the dilated veins of the esophagus. This method is more gentle and has fewer complications.
Patients need to follow a strict diet throughout their lives, regardless of their health:
Alcohol, carbonated drinks, and beer are strictly contraindicated.
In order to prevent healthy veins of the esophagus from turning into pathological varicose veins, it is first necessary to monitor the condition of the liver and promptly treat all its diseases. To do this, experts advise regularly contacting them for advice and following all recommendations.
Unfortunately, esophageal varices are incurable. However, in case of timely diagnosis, adequate supportive treatment will significantly improve the patient’s quality of life and help prevent a terrible condition - bleeding.
The mortality rate for existing bleeding from varicose veins of the esophagus is more than 50% and depends on the severity of the underlying disease and the condition of the body as a whole. In patients who survive bleeding, 75% of cases experience a relapse within the next 1-2 years.
In general, the prognosis for long-term survival of patients with this disease remains low, which is mainly due to the underlying severe liver disease.
Varicose veins are a well-known cosmetic problem that worries many women, because a pronounced venous network appears on the legs. This disease not only makes the legs ugly, but also causes a lot of inconvenience and constantly worries the patient.
It is important to understand that an advanced form of the disease can provoke serious complications, so treatment of varicose veins should begin in the first stages of the disease. Timely and correct therapy will help avoid surgery and reduce the manifestations of the disease.
Varicose veins are a chronic disease; with varicose veins, the veins increase in size, become deformed, and blood circulation in the tissues is disrupted. As a result, nodes appear under the skin, as well as a visible venous network and blue stars. Typically, varicose veins occur in the lower extremities, but sometimes the disease also affects internal organs.
The vessels are designed in a special way; they contain valves that allow blood to pass only upward; this is necessary so that it circulates normally and does not stagnate. If the valves for any reason stop working normally, blood stops flowing normally, the vessels dilate and lengthen.
Varicose veins are divided into several types, depending on where the pathology was discovered:
According to the location of the veins, the following types of varicose veins are divided:
Reticular or cosmetic varicose veins are benign, they do not cause complications and usually bother young girls and women. It is characterized by the appearance of a noticeable vascular network, which usually occurs due to hormonal changes, for example, during puberty.
Reticular varicose veins do not pose a serious danger, but it is still necessary to be examined when a venous network appears, since such a symptom often indicates a real pathology. It is also worth noting that such a cosmetic problem can also worsen, with the veins becoming more pronounced and itching appearing in them.
Reticular varicose veins are removed using surgery, laser or injection with a special substance, this procedure is called foam sclerosis. In the initial stages, you can get rid of a cosmetic defect with the help of exercises, massage and folk remedies, but it is better to immediately visit a doctor.
There are a number of reasons that can provoke varicose veins of the lower extremities:
It is important to understand that almost all causes of varicose veins can be circumvented if you lead the right lifestyle, because they primarily depend on the patient himself. Perhaps it is difficult to fight a hereditary predisposition, but such a pathology is quite rare, and it can be overcome if you raise a child in a healthy atmosphere.
The disease usually occurs in several stages, which are accompanied by characteristic symptoms:
In order for the treatment prognosis to be as positive as possible, it is necessary to consult a doctor as soon as pain and unusual leg fatigue appear. In this case, treatment of varicose veins will not take much time; massage and a course of physiotherapy will help. But if the disease has already reached the stage when vascular networks or nodes have appeared, treatment can take a long time, often even requiring surgical intervention.
Varicose veins are dangerous mainly due to their complications, since during the course of the disease the patient may not even feel pronounced symptoms for a long time. This pathology often provokes vascular inflammation and the appearance of blood clots; also, if enlarged veins are damaged, a trophic ulcer and bleeding can form, and over time, chronic venous insufficiency occurs.
This pathology is characterized by the appearance of dense clots in the superficial veins, which disrupt blood flow, causing non-infectious inflammation of the venous walls, and the blood becomes viscous and stops moving normally through the vessels and is retained in the tissues.
This complication of varicose veins is manifested by the following symptoms:
Thrombophlebitis is very dangerous; it can cause an abscess that quickly spreads through the affected vein. If the blood clot is not firmly attached, it can break off with a sudden movement or impact, then the clot moves through the vessels to the lungs or heart, causing the death of the patient.
Therefore, thrombophlebitis cannot be delayed; at the first signs of such a pathology, you need to fix the sore leg or other part of the body and call an ambulance or carefully take the patient to the hospital. Such pathology begins to be treated immediately, most often with the help of surgery; any delay can be very dangerous for the life and health of the patient.
This pathology develops in the saphenous veins; it represents a violation of blood flow. If left untreated, blood clots, trophic ulcers, and erysipelas of the lower leg may occur. Due to poor circulation, rashes often appear on the skin and mental activity is impaired.
Often, chronic venous insufficiency is accompanied by a general deterioration in the patient’s condition, he feels weak, and a feeling of anxiety appears. Inhibition of thinking appears, a person cannot move or work normally, and psychological problems often arise against the background of such disorders. A timely visit to the doctor helps prevent complications.
Ulcers usually appear in the most advanced forms of varicose veins, when blood clots and chronic circulatory disorders may appear. With any, even the smallest injury to the affected area of the vein, a trophic ulcer may occur.
First, a kind of hyperpigmentation forms on the affected area, this is due to excessive vascular permeability when red blood cells with hemosiderin come out of it. Thanks to hemosiderin, which has a yellow-brown color, the spots acquire a characteristic shade. Over time, the spots become denser, the skin acquires a whitish tint, and then a painful ulcer appears in this place.
Treatment of trophic ulcers is complex and long-term; the patient will have to remain in bed for at least 2 weeks. Typically, therapy is carried out in a hospital setting, since it is necessary to ensure timely administration of medications and sterile dressings, in addition, doctors regularly clean the trophic ulcer to prevent the occurrence of purulent complications and fungal infection. It is also worth mentioning that in some cases, trophic ulcers can degenerate into malignant tumors.
A phlebologist diagnoses and treats varicose veins on the legs; he is a specialist in the field of veins. Most often, this doctor is visited in cases where the pathology is obvious and the vascular network has already appeared on the skin, until then no one knows about him. And this is in vain, since the following categories of patients must visit a phlebologist every year:
It is important not only to regularly visit a doctor if you have at least one risk factor described above, but also to choose competent and experienced specialists. After all, vein diseases are very specific and need to be treated correctly, so you shouldn’t go to the first doctor you come across; you need to check whether you have a diploma and experience.
It is best to treat varicose veins in clinics that have repeatedly proven themselves. If there is such an opportunity, you need to look for reviews about the doctor and the clinic, ask friends and relatives who may have sought help from such a specialist. It is important to understand that timely diagnosis and treatment by an experienced specialist will help not only eliminate fatal complications, but also prevent cosmetic defects without resorting to surgery.
When visiting a phlebologist, first of all, the patient will have to answer several questions, share his complaints, and remember whether relatives have had varicose veins. The presence of various chronic diseases in patients also plays an important role; it is often necessary to visit several more specialized specialists.
The doctor can clarify what kind of lifestyle the patient leads, whether he plays sports, where and for whom he works. You need to be frank with a specialist, even if you are embarrassed to admit something, honest answers will help you quickly identify the cause of the pathology and eliminate it, so as not to worsen the condition even further.
Signs of varicose veins are usually obvious, the doctor immediately sees swelling, enlarged veins, the nodes are easily palpated. Therefore, it seems possible to establish a preliminary diagnosis already at the first appointment with a competent doctor. To confirm the diagnosis and clarify the stage of the disease, it will be necessary to undergo an examination. The following studies are usually prescribed:
This is an ultrasound examination, in which the doctor can see how good the blood flow is in the required area, he measures the speed of blood flow, its direction, the performance of the valves, detects the presence of blood clots, atherosclerotic plaques, if any.
Ultrasound scanning is divided into several types:
The doctor decides which study will be carried out in a particular case. All of them are quite effective in diagnosing varicose veins and its complications.
Phlebography is an x-ray of blood vessels, in which a special contrast agent is injected into a vein. This study allows you to detect the presence of blood clots in the vessels. It is used quite rarely in our time, since ultrasound examination is considered a fairly informative and convenient research method.
In rare cases, other studies may be prescribed to clarify the diagnosis, for example, computed tomography, plethysmography, etc.
All patients are usually interested in how to treat varicose veins if a phlebologist has made such a diagnosis. You can get rid of varicose veins at the initial stage, when the venous network is still poorly defined, using conservative methods.
An important role in the treatment of varicose veins is played by drugs prescribed by a specialist. It is important to understand that self-medication can be dangerous, so you should not prescribe medications yourself. The doctor selects the dosage of each drug individually.
What medications are used for varicose veins:
External agents can eliminate stagnant processes in tissues and reduce the manifestation of varicose veins at the initial stage. It is important to understand that ointments and gels are ineffective in advanced forms of the disease.
Popular creams for varicose veins:
Nowadays, there are a number of therapeutic methods that can get rid of cosmetic defects at the initial stage of the disease:
In complicated forms, surgical treatment of varicose veins in the legs is prescribed, in which surgery is performed to restore blood circulation. If necessary, blood clots and inflamed areas of blood vessels are removed, replacing them with a prosthesis.
Treatment of varicose veins is usually complex; the patient needs to reduce the influence of negative factors that worsen the condition of the veins. First of all, it is recommended to unload your feet; to do this, you need to give up tight high-heeled shoes. It is better to choose models made from natural materials that fit your legs well without squeezing them.
It is also necessary to normalize physical activity; loads should not be completely absent, but should not be excessive. You need to give your legs time to rest, but do not forget to do therapeutic exercises, especially in the morning. The exercise therapy complex will help strengthen muscles, reduce the risk of congestion in tissues and improve blood circulation. It is important to note that during the period of exacerbation you cannot engage in physical exercise.
Nutrition plays an important role in the treatment of varicose veins. It is necessary to exclude alcohol and coffee, as these drinks dilate the veins, this is dangerous for varicose veins and greatly aggravates the situation. You should not eat fatty, spicy, smoked, highly salted and other harmful foods.
Nutrition should be correct, balanced and healthy. A large amount of fruits and vegetables are introduced into the diet; they saturate the body with vitamins and help improve metabolism.
You should not attend physiotherapy during varicose veins, in particular Darsonval, without the testimony of a specialist. Such methods provoke blood flow in the tissues, and with varicose veins, the outflow is usually impaired, so physiotherapy will provoke swelling and complications.
Olga Beklemishcheva: Today - at the numerous requests of our listeners - we are talking about trophic ulcers on the legs, or on the lower extremities, as experts will correct me, and of course, about varicose veins. And I urge our radio listeners to listen carefully, because (and this was a discovery for me) trophic ulcers on the legs, unfortunately, are not only due to varicose veins. And here differential diagnosis is very important.
Our guest today is angiosurgeon and phlebologist Sergei Viktorovich Sapelkin, Candidate of Medical Sciences, he represents the Institute of Surgery named after the famous Vishnevsky.
And we begin. So, Sergei Viktorovich, it is clear that there are veins and arteries everywhere in the body. But why do problems with veins always arise in the legs?
Sergey Sapelkin: Our veins are in a very interesting position on our legs, because they are subject to the so-called hydrostatic moment. That is, the entire hydrostatic column of blood, depending on a person’s height, exerts a certain pressure on the veins mainly in the lower extremities.
Olga Beklemishcheva: That is, we are pressing with all the weight of our blood on them.
Sergey Sapelkin: Of course. Nature has rewarded us for our upright posture with such problems with the veins of the lower extremities. Therefore, the processes that we observe are pathological - either varicose veins, or thrombotic processes in the deep vein system; they are more often found in the veins of the lower extremities.
Olga Beklemishcheva: And the veins of the lower extremities, what do they look like, how are they divided, what are their varieties? You said about deep veins, obviously there are also superficial veins?
Sergey Sapelkin: Yes, of course. But right away we are talking about the presence of deep and superficial veins. And plus, we must not forget about the presence of so-called communicating or perforating veins, that is, veins communicating between the deep and superficial systems. The veins themselves are thin-walled vessels, unlike arteries, the wall of which consists of three layers. The veins have a very thin wall, less than a millimeter thick, and it is very susceptible to any traumatic influences. Therefore, any trauma, surgical manipulation of any kind on the veins, they can lead to thrombosis in these veins, so-called embologenic thrombosis, or post-traumatic thrombosis. Therefore, any interventions, even surgical ones, in other areas, if performed by gynecologists and traumatologists, should be performed in such a way that the veins are protected from trauma as much as possible.
Olga Beklemishcheva: You spoke about varicose veins and thrombotic processes in the veins of the lower extremities. Are these two different forms of disease?
Sergey Sapelkin: These are absolutely two different forms of diseases. If varicose veins are a problem associated with insufficiency of the valves of the superficial veins - varicose veins, and accordingly, here again due to the hydrostatic mechanism, the force of attraction, reflux flows arise, that is, blood rushes.
Olga Beklemishcheva: I’ll explain a little now. The fact is that in these veins (not only, of course, in the veins of the lower extremities, but in veins in general) there are pocket valves that prevent blood from flowing in the other direction. And it is precisely the insufficiency of these valves that leads to varicose veins.
Sergey Sapelkin: And reflux flows arise, that is, unnatural. With varicose veins, blood can descend from top to bottom, rather than flowing from bottom to top, as is normal, as valves should ensure. And with thrombotic processes, the veins are simply blocked by thrombotic masses. In this case, both deep and superficial veins can be affected. As a result, increased pressure occurs in the segments of the veins located below the site of occlusion - the site of thrombosis, which increases the pressure in the capillaries, and already at the level of the capillaries those inflammatory changes occur that can subsequently lead to trophic disorders. The basis of all trophic disorders in varicose veins, post-thrombotic disease, and other vascular diseases is the capillary bed. But the effect on this capillary bed is transmitted through various mechanisms.
Olga Beklemishcheva: And, naturally, the area of intervention for a doctor can only be relatively large vessels. That is, as I understand it, nothing special can be done with the capillaries.
Sergey Sapelkin: Yes, you are right. And the possibilities of surgery, they are to some extent limited by the diameter of the vessels, just like arteries and veins. The larger the vessel, the easier it is for us to perform the planned intervention. If the problem occurs on small-caliber vessels, our capabilities are technically limited, and the result, even if we suddenly performed such a unique surgical intervention, directly depends on the diameter of the vessels.
Olga Beklemishcheva: The larger the vessel, the easier it is to treat.
Olga Beklemishcheva: Okay. But you said that in addition to varicose veins, in addition to some kind of thromboembolic pathology in the arteries and veins, and as I understand it can already be in any type of vessel, there are other diseases that lead to trophic ulcers. That's how I understand you.
Sergey Sapelkin: Yes, absolutely correct.
Olga Beklemishcheva: What diseases are these?
Sergey Sapelkin: If we take the general statistics of trophic ulcers of the lower extremities, trophic ulcers of the legs, then varicose veins give us, conditionally, 75 percent of trophic ulcers. Three out of four ulcers are associated with varicose veins. Next comes postthrombotic disease, postthrombophlebitic syndrome - this is a condition associated with damage to the deep veins due to thrombosis. And in third place are arterial ulcers - ulcers associated with insufficient arterial inflow, about 8-10 percent.
Olga Beklemishcheva: Does this mean that if a person is hypertensive, then he may have a trophic ulcer of the lower limb?
Sergey Sapelkin: Here, with malignant arterial hypertension, which is quite severe and difficult to relieve using standard antihypertensive therapy, so-called hypertensive ulcers can occur, located in not quite typical areas - in the area of the outer ankle. And the basis of such ulcers is pronounced vascular sclerosis. That is, the wall of small capillaries of an artery and vein becomes sclerotic, it thickens to such an extent that these small vessels become rigid and not subject to the influence of nerves, and the tone in them cannot be regulated by any external influences.
Olga Beklemishcheva: Did I understand correctly, Sergei Viktorovich, that an ordinary hypertensive patient whose hypertension is under control, in general, can sleep peacefully?
Sergey Sapelkin: Yes, this, in principle, is the key to well-being from such severe complications. Of course, compensated hypertension does not lead to hypertensive ulcers.
Olga Beklemishcheva: Dear listeners, I can’t help but urge you again, if you have problems with blood pressure, then the modern point of view on them is that the pressure needs to be kept normal, that is, 130, well, maximum 135 per 80. And please achieve this.
Now, in my opinion, we have outlined, as far as we could, the pathological situations that can arise with the vessels of the lower extremities, and now, probably, we need to move on to diagnosis. This person has some problems. What should he do? And what should his doctor do?
Sergey Sapelkin: Well, as I already said, there are many reasons for the occurrence of trophic ulcers. We haven't even touched on diabetes yet.
Olga Beklemishcheva: Yes! Sorry, but this is also really very important. Remember, I told you, dear listeners, that there was a whole month dedicated to diabetic feet, because, unfortunately, this is already becoming a mass phenomenon, I mean diabetes.
Sergey Sapelkin: Well, and a number of other more or less significant conditions, but which can also lead to trophic processes, are congenital vascular diseases and diseases belonging to the group of rheumatological diseases, which can also lead to trophic defects. But all this is realized through the capillary system, through the system of arteries and veins and the capillary network. Therefore, first of all, at the first stage, when the patient comes to the doctor, when the doctor sees the patient, the question should be a differential diagnosis of trophic ulcers. As you understand, not all ulcers are associated with venous pathology. And here a carefully collected medical history from the patient, a confidential conversation between the doctor and the patient is necessary in order to clarify all aggravating factors.
Olga Beklemishcheva: Let’s imagine that you are collecting anamnesis, for example, from me. What will make the doctor be wary and decide that this is varicose veins, but this is something else? Where is the border?
Sergey Sapelkin: We always start with an inspection. And venous ulcers, as a rule, their “favorite” localization is the inner surface of the lower leg, the inner side of the ankle. Ulcers of all other localizations are suspicious for non-venous pathology. Therefore, this should be alarming, firstly. Then the presence of varicose veins. If we see dilated superficial veins, then we can say with greater confidence that the venous system is involved here. And finding out the patient’s concomitant diseases. If an elderly patient with diabetes mellitus comes to us, then, of course, we must clarify the duration of diabetes mellitus, whether it is compensated or not, what medications she receives, and clarify the origin of this trophic defect, when it appeared and where it is located. As a rule, in such patients, in rheumatological patients, the places where such ulcers appear are the interdigital spaces, the dorsum of the foot - that is, those places that are most in contact with shoes.
Olga Beklemishcheva: Is it the same for a rheumatoid patient?
Olga Beklemishcheva: For hypertensive patients, we must measure their blood pressure.
Sergey Sapelkin: For hypertensive patients – a must. We must measure the blood pressure of every elderly patient.
Olga Beklemishcheva: Okay. A choice has been made and differential diagnostics have been carried out. Are there any clarifying manipulations? After all, there is so much technology now.
Sergey Sapelkin: Differential diagnostics is at the highest level, it should include mandatory ultrasound examination. Moreover, with ultrasound, we must closely look at both arteries and veins in any patient, taking into account the fact that all these systems may be interested in the origin of trophic ulcers. This also helps us carry out differential diagnosis - what kind of pathology it is. Modern centers and modern clinics are well equipped with ultrasound equipment. These are so-called duplex scanners, ultrasonic duplex scanning, which allows diagnostics at the highest level. And here we see the functioning of the valves, the patency of blood vessels, the presence of plaques, blood clots - whatever you want.
Olga Beklemishcheva: Yes, one might say, they already see right through a person. And, nevertheless, in my opinion, laboratory methods can also add some information. Are there any markers of inflammation in this case?
Sergey Sapelkin: Well, first of all, we need laboratory diagnostics to assess congenital risk factors for the occurrence of thrombosis. Because postthrombotic syndrome very often develops in patients with existing defects in the hemostatic system. And science has literally made a big breakthrough recently, clarifying these risk factors. Modern laboratory diagnostics, even in Russia, make it possible to more likely diagnose these genetically determined defects in the hemostatic system, identify them and, accordingly, recommend one or another preventive measure to patients. Very simple preventive measures are the inclusion of certain.
Sergey Sapelkin: No, no. For venous thrombosis, Aspirin will not play a specific role here. It is still more suitable for arterial pathology. For example, there is a so-called problem with hemostasis - hyperhomocysteinemia - the content of a certain protein produced in the liver increases. This dramatically increases the risk of venous thrombosis. And to correct this pathological condition, we can recommend that the patient take B vitamins and folic acid. The usual, simple recommendations, but...
Sergey Sapelkin: Very effective, literally leveling out the genetic pathology that we identified.
Olga Beklemishcheva: Lord! If only everything were so good. If only you could take vitamins for any occasion – and.
Sergey Sapelkin: Well, these cases need to be identified, proven, we need to know and think about it. And a good diagnostic program helps us, where we have to think with our own heads and use ultrasound techniques and biochemical capabilities.
Olga Beklemishcheva: Yes, and no one canceled the head.
Sergey Sapelkin: Never. And we need to start with this.
Olga Beklemishcheva: And this is wonderful! But, for example, there is already some confidence in the diagnosis. What can you advise a person? At what point, relatively speaking, does surgery become inevitable?
Sergey Sapelkin: Although we belong to a group of surgeons, we always start with conservative therapy.
Sergey Sapelkin: Firstly, eliminating the risk factors that are present in the patient and influencing these risk factors can provide tremendous assistance to the patient in terms of ulcer healing. The second point is still the presence of pathology of large arterial and venous vessels. As I already said, modern surgical interventions make it possible to level out this in case of varicose veins. This is an intervention performed in the system of superficial, communicating veins.
Olga Beklemishcheva: Communicating veins, I remind you, are those that connect the superficial and deep veins.
Sergey Sapelkin: And this eliminates venous hypertension, increased pressure in the superficial vein system and leads to a good improvement in the state of microcirculation in the area of trophic disorders.
We must not forget about compression. For venous pathology, the main treatment is compression therapy, that is, the use of an elastic bandage or special compression products.
Olga Beklemishcheva: That is, we are thus trying to compensate for this hemodynamic pressure on the diseased vein.
Sergey Sapelkin: Yes, exactly. This is compensation.
Olga Beklemishcheva: But this is not treatment, this is compensation. You don’t go through your whole life bandaged...
Sergey Sapelkin: This is treatment. And for those patients for whom this treatment is indicated for life, it should be conveyed to their consciousness that without elastic compression, unfortunately, this situation can repeat itself. We are not talking about a radical cure for post-thrombotic syndrome, post-thrombophlebitic syndrome - this is the serious condition that arose in the patient after suffering thrombosis.
Olga Beklemishcheva: So this still cannot be completely cured?
Sergey Sapelkin: The blood clots are recanalized, but the valves that are in the thrombosis zone suffer, they no longer function.
Olga Beklemishcheva: And they will not recover.
Sergey Sapelkin: And they are not restored, of course. Surgery of the deep veins to restore their valve function, at the present stage, cannot ensure their complete restoration. This is a definite palliative intervention.
Olga Beklemishcheva: But if, say, thank God, a person has not yet reached the point of an ulcer, some serious blood clot in the lower extremities, at the stage when his external veins are simply dilated and deformed, can this be completely cured?
Sergey Sapelkin: In the case of pathology of the superficial veins, today we can say that surgical intervention completely eliminates this system of impaired blood flow, and in addition to the recommended compression, to the recommended drug therapy, it can completely eliminate the risk of the appearance and progression of trophic disorders. If the deep veins are involved, then it is impossible to say unequivocally about a radical cure. And even in these patients, adherence to a certain regimen is required for a long time, and sometimes for many years - a compression treatment regimen and a course of venotonic drugs.
Olga Beklemishcheva: We will definitely tell you in more detail about venotonic drugs. But now I would like to kind of round it off and summarize. I will express my conclusions, and you will correct me, Sergei Viktorovich. That is, if the problem is in the superficial veins, and it has not yet descended into the deep veins, then, in principle, it can be dealt with quite easily.
Olga Beklemishcheva: If the deep veins are already affected, then, of course, modern medicine is able to alleviate the condition, but it is impossible to guarantee healing.
Sergey Sapelkin: It is impossible to guarantee healing forever, and a person is required to follow certain recommendations to stabilize this condition.
Olga Beklemishcheva: But a strong-willed person can actually maintain their quality of life if they follow all the recommendations. This is true?
Sergey Sapelkin: Now people’s literacy is growing.
Sergey Sapelkin: Yes. And when we explain to patients the mechanisms of occurrence of these trophic disorders and tell them that it is impossible to completely correct this, many of them understand this whole problem, and no difficulties arise in implementing our recommendations. We observe many patients for years, decades, and we see how.
Olga Beklemishcheva: . that they live normally despite quite serious pathology.
Olga Beklemishcheva: And finally, here is a remark that, in my opinion, is very important - this is that trophic ulcers on the legs can occur due to other disorders, not just venous ones. And it is very important to carry out a competent differential diagnosis, to understand why the ulcer arose. And even, say, our respected diabetics, who are accustomed to thinking that an ulcer is exclusively caused by diabetes, we can say that, on the one hand, they think correctly, but, probably, a diabetic may also have a varicose ulcer.
Sergey Sapelkin: A combination of similar problems is possible. Therefore, an examination by a vascular surgeon in the presence of any trophic ulcer, I believe, is necessary, and examination of all vessels - both arterial and venous - using duplex scanning is also the “gold standard” today.
Olga Beklemishcheva: How accessible is this “gold standard” outside Moscow?
Sergey Sapelkin: Most regional clinics are already quite well equipped with these devices. And communicating with our colleagues, we see that not only Moscow, but also the periphery is switching to providing angiological care according to the most modern standards.
Olga Beklemishcheva: This is very good, because in fact, of course, many people have questions about “what should we do if we do not live in Moscow?” Well, I would like to say again and again, dear listeners, in Russia there are a number of legislative acts that actually guarantee you, firstly, the provision of necessary medical care, secondly, its free nature, thirdly, your right , if you are not satisfied with the situation that has developed at your local level, contact a higher level. In general, no one forbids a patient, if he has such a need, to request a consultation in a more powerful clinic, with better equipment, with more experienced surgeons. Of course, in general, it is difficult for a sick person to get his license, but maybe there are some relatives who can do this for you. In any case, don’t give up, which is very important. Because I once observed a woman who, with a trophic ulcer on her legs, continued to work in a flower shop. And to all my calls to take care of myself and go to the doctor, she said that “oh well, I’ll live anyway.” This was, I think, a completely wrong attitude towards my health. And so it must be overcome. She was quite a young woman, about 55 years old, and for some reason she was in this mood.
And now Dmitry Nekhezin will introduce you to medical news.
Scientists and doctors continue to discuss ways to counter a possible pandemic caused by mutations of avian and human influenza viruses. Following the February meeting of the American College of Preventive Medicine in Miami and exercises in France, under the auspices of the UN, an international conference “Pandemic Influenza Preparedness: An International Assessment” was held in St. Petersburg. Academician Oleg Kiselev, director of the Influenza Research Institute of the Russian Academy of Medical Sciences, said that in Russia over the past 25 years, the incidence of influenza has decreased by 1.3 times. Scientists explain this circumstance by the fact that long-term circulation of similar strains of the virus has formed stable immunity in most of the population. At the same conference, Professor Alan Hay from the London Institute of Medical Research said that the likelihood of a new influenza pandemic in the coming years is extremely high. At the same time, the pandemic will not necessarily be caused by a recombinant strain of the bird flu virus, but if this happens, the pandemic will give between 57 and 132 million cases of the disease in industrialized countries alone.
On March 15, at 11 p.m., 51-year-old Inmaculada Echevarria was pronounced dead in Madrid. For several months, through the courts, she sought the right to be disconnected from the artificial respiration device. The Spanish woman suffered from a progressive form of muscular dystrophy and spent the last twenty years in a hospital bed. The patient sought deactivation based on a law passed in 2002 allowing conscious patients to refuse treatment. The shutdown was approved by the Spanish Medical Ethics Commission. However, conservatives and the Catholic Church demand that doctors be held accountable, considering their actions an analogue of euthanasia, which is prohibited in Spain. At the same time, the left, led by the socialists, now in power, is going to legalize euthanasia and hopes that the Inmanculada case will push parliamentarians to immediate action.
This week, the Central District Court of Voronezh issued a decision that opens a new era in the relationship between doctors and patients in Russia. A city resident infected with HIV in a maternity hospital was awarded compensation in the amount of 3.5 million rubles. The woman was transfused with plasma, which was taken from the blood of an HIV-infected donor, and the specialists at the blood transfusion station knew that the blood was contaminated, but for unknown reasons they did not reject it, but sent it to the maternity hospital. The woman accidentally found out that she had the virus six months later. And another 208 Voronezh patients, who could hypothetically be given contaminated plasma, could sue if they discover they have HIV infection. Experts say that 3.5 million rubles is the entire volume of the regional hospital’s extra-budgetary fund. So the regional health department may not be able to withstand the following claims. Perhaps this decision will serve as the beginning of the creation in Russia of a professional risk insurance system for doctors.
Canadian scientists report that the rate of spread of diabetes is already exceeding the forecasts of the World Health Organization. WHO experts have warned that the prevalence of diabetes will increase by almost 40 percent in the first 30 years of the 21st century. And according to epidemiological observations of 12 million residents of Ontario, a province of Canada with a large ethnic diversity of the population, the prevalence of diabetes has increased by 27 percent in just 5 years of the 21st century. The researchers believe this important information will help national health services be better prepared to treat and care for patients as one in 10 people in developed countries become diabetic.
Olga Beklemishcheva: And we continue. Sergey Viktorovich, we have already listed the possible causes of trophic ulcers and varicose veins. And they started talking about treatment. You talked about conservative methods, about the need to treat the underlying disease if it is not a varicose ulcer, but some other one. But there are probably some general venotonics, extremely popular creams, and so on. Is this how you feel about them?
Sergey Sapelkin: Venotonic drugs, they are mostly created to eliminate the subjective signs of chronic venous insufficiency.
Olga Beklemishcheva: That is, they do not treat, but alleviate?
Sergey Sapelkin: They alleviate the patient’s condition, yes, reducing swelling to some extent and eliminating the main subjective symptoms - a feeling of heaviness, swelling and discomfort. Only a few drugs have shown their effectiveness in the treatment of trophic ulcers in large, randomized studies.
Sergey Sapelkin: Well, this is micronized Diosmin. In recent years, large-scale studies have been conducted both in Europe and the Russian Federation, which have confirmed that this drug from the group of venotonics does significantly improve the healing statistics of trophic ulcers. The time for venous ulcer closure also decreases, and the total number of patients who benefit from this drug when prescribed, again as part of complex therapy, increases. Without compression, not a single drug, even the best, works.
Olga Beklemishcheva: Dear radio listeners, take note of this.
And a listener from St. Petersburg called us - this is Konstantin. Hello, Konstantin.
Listener: Hello. I have a question. I am 31 years old, I weigh 119 kilograms and I am 193 centimeters tall. When I was young, I played sports professionally. And now veins have appeared on my leg, like varicose veins, bulging like a rope around my leg. But they don’t bother me at all, they don’t hurt. But maybe there is something I need to do, please tell me? Thank you.
Olga Beklemisheva: Thank you. Sergey Viktorovich, please.
Sergey Sapelkin: I understood your situation, Konstantin. Well, given the presence of already signs of varicose veins - what you outlined, the presence of risk factors - a weight of over 100 kilograms, of course, we urgently need to do something and act according to the algorithm that we have already talked about. That is, you need to see a vascular surgeon. There is an excellent vascular school in St. Petersburg, excellent angiosurgeons. Perform an ultrasound examination, diagnose which veins are affected, assess the condition of the deep and superficial veins. Perhaps, after a thorough examination, you will be recommended a preventive or surgical intervention that will improve the condition of the venous outflow from the lower extremities. This will guarantee that trophic disorders that are not yet present in your situation will not appear.
Olga Beklemishcheva: That is, I draw the attention of listeners to the fact that the external sign of varicose veins - dilated veins - is already a rather serious symptom. That is, if you don’t pay attention, if you think “Well, just think, it’s ugly, I won’t pay attention to it,” then, unfortunately, you can very seriously accelerate the process of developing trophic ulcers in yourself.
Sergey Sapelkin: In obese patients, trophic disorders occur about an order of magnitude more often, that is, approximately 10 times, this is approximately the frequency.
Olga Beklemishcheva: So please think about it.
And the next listener is Claudius Mikhailovich from Moscow. Good afternoon.
Listener: Good afternoon. I have a recurring ulcer. The first time the ulcer was on a bone, on the foot, the bone was on the right. She was there for about two months, and to this day some signals are going up the nerve from her. And now you have a rash on your shins, on your right leg?
Olga Beklemishcheva: Outside or inside?
Listener: External ulcers. But the most important thing that worries me is that they seem to be going away now, they are starting to dry out, but lymph is being released.
Olga Beklemishcheva: Klavdiy Mikhailovich, what is your blood pressure?
Listener: My blood pressure is somewhere from 115 to 130 - that’s the pressure.
Listener: And I smoked for about fifty years.
Sergey Sapelkin: Well, I think, Klavdiy Mikhailovich, given your attitude towards smoking, given your age, you still need to pay attention to the arterial system and do a study of the arterial system. It looks like your problems are related specifically to impaired arterial inflow. Ulcers may be of arterial origin.
Olga Beklemishcheva: Yes. And if my memory serves me correctly, not so long ago this was one of the main reasons for amputation of the lower extremities, and this was precisely against the background of long-term smoking, failure of the arterial system of the lower extremities and inevitable gangrene and amputation. Yes?
Sergey Sapelkin: Yes. Moreover, ulcers, as the listener describes to us, they either close or appear again, and this is the same area, that is, the lower parts of the leg and foot, that is, those areas that always experience a lack of blood circulation when the arteries are blocked.
Olga Beklemishcheva: Aggravated by smoking. So, please pay attention, Klavdiy Mikhailovich.
And we listen to Nadezhda Nikolaevna from the city of Dubna. Hello, Nadezhda Nikolaevna.
Listener: Hello. I have a question. I’m calling from Dubna now, but in general I live in the Western District of Moscow. Question one. Seoshey Viktorovich, please tell me, if we don’t have a phlebologist in our clinic, a vascular surgeon, is it possible to get a consultation and examination at your Center? Because I’m already many years old, and these veins that are bulging, I’ve had them for a long time, well, about 20 years. And now in front, under the knee, they are so bulging, and they began to hurt. But now the pain has gone under my knee, and I have difficulty walking. Tell me, please, is there anything you can do to help me?
Sergey Sapelkin: You should show up either with us or at the Clinical Diagnostic Center number 4, Molodezhnaya metro station, Krylatskie Hills Street - this is the Clinical Diagnostic Center that serves the Western Administrative District. There is a good angiosurgeon there, I know him personally. But you can also show up with us by taking a referral from your clinic to the Vishnevsky Institute of Surgery. All consultations with us upon referral from clinics are free.
Olga Beklemishcheva: Again and again I urge our dear listeners, as soon as you notice some problems in yourself, still look for a doctor, because advanced cases are much worse treated.
And we listen to Galina Alekseevna from Moscow. Hello, Galina Alekseevna.
Listener: Hello. Sergey Viktorovich, please, a little consultation. My daughter is 50 years old, about six months ago or a little more ago she had an inflamed vein on her legs, she is, however, large, she has a lot of weight. And she was sent to the hospital. The leg was treated for a couple of days. And they tied a wreath in her groin. Nothing bothers her at all, everything is quiet now. Does she need to remove this ligated vein or can she leave it like that for now?
Sergey Sapelkin: Everything here will depend on the ultrasound examination performed. If disturbances in the valvular function of the superficial veins persist, then it is necessary to think about planned surgical intervention, which will completely eliminate the threat of similar complications in the future.
Olga Beklemishcheva: Planned surgical intervention - what does it mean?
Sergey Sapelkin: Planned surgical intervention - removal of the affected veins, superficial veins, in which this thrombophlebitis occurred. Thrombophlebitis most often occurs in the affected veins - in those veins that are narrower.
Olga Beklemishcheva: . were somehow harmed.
Sergey Sapelkin: Yes, incompetent. There, the blood flow is sharply weakened, the speed indicators are low, and there is a high probability of thrombophlebitis. Which is what happened in this case.
Olga Beklemishcheva: And if this vein is already diseased and its function is weakened, then, in principle, the fact that it is removed will not make the body any worse.
Sergey Sapelkin: In general, the body will be even better. The blood flow will be reorganized into working veins with normal valves, and the overall condition of the venous outflow will only improve.
Olga Beklemishcheva: And we listen to Tamara Ivanovna from Moscow. Hello, Tamara Ivanovna.
Listener: Hello. I have no obvious pathology, although I have heredity - my mother had such ulcers. But I watch my feet. I have no obvious bulging veins. But I have a nagging pain in my right leg. I should be wary, right?
Sergey Sapelkin: Well, we need to understand why it arises. Of course, the data you provided is clearly not enough to make a diagnosis. Of course, you need to look at you with your own eyes, conduct a vascular examination and conduct certain neurological tests in order to clarify the origin of your pain. Because joints, muscles, and the nervous system may be involved here.
Olga Beklemishcheva: And especially if there were any injuries in the anamnesis in this area.
Olga Beklemishcheva: So you need to see a doctor.
And we listen to Ada Antonovna from Moscow. Hello, Ada Antonovna.
Listener: Hello. I am 75 years old and have hypertension. I don’t have bulging veins, but I have more and more blue mesh, almost blue, and kind of bruises. Doctor, please tell me, what is this? And should I see a doctor?
Sergey Sapelkin: I think that you need to show up for our general peace of mind, but we can assume that this mesh will still have fewer problems than large veins. These are spider veins that appear most often in women. And with age they seem to slowly slide down. That is, they appear more often in the lower extremities.
Olga Beklemishcheva: Even if at first they were, say, on the upper thigh, right?
Sergey Sapelkin: Yes, on the thigh, in the area of the knee joint. This is more typical for some dishormonal disorders. But with age, they appear more often in the lower sections. The element of increased venous pressure here also has a certain significance. If these veins do not protrude too much above the surface of the skin, then they should not lead to trophic ulcers. Although the largest of them can be a source of bleeding in case of trauma, this also happens. The main treatment here is again the compression that we talked about, wearing compression products or elastic bandaging of the limbs.
Olga Beklemishcheva: It’s so painful to constantly bandage. Probably, now there are still a lot of all sorts of stockings, knee socks...
Sergey Sapelkin: Yes, the possibilities of modern compression therapy are already based on more aesthetic compression products that are more comfortable for the patient.
Olga Beklemishcheva: But is it possible to somehow improve the situation with medication?
Sergey Sapelkin: In terms of relieving subjective manifestations, and if these veins hurt, then venotonics, which we have already talked about, various drugs, their choice is quite wide, the use of creams and ointments is also relieving subjective manifestations. Unfortunately, none of the medications can remove either large veins or small, intradermally dilated veins. Neither ointment forms, nor tablet preparations, nor drops have this property.
Olga Beklemishcheva: But a good angiosurgeon has this “property”.
And the next listener is Vladimir from Moscow. Hello, Vladimir.
Listener: Hello. Sergey Viktorovich, do I understand correctly that venous pathologies occur not only in the legs, but, say, in other areas? In particular, I am concerned about the issue of venous dysfunction in the brain, venous circulation of the brain. And the second question is in the intestinal area, hemorrhoidal cones. As I understand it, this also applies to veins. If possible, tell us something about this.
Sergey Sapelkin: I’ll say literally two words, because veins are everywhere.
Olga Beklemishcheva: And they can get sick everywhere.
Sergey Sapelkin: Yes. As for venous dysfunction of the brain, this is still the prerogative of neurologists. And together with him, we are now examining patients with such problems more thoroughly, and all the i’s have not yet been dotted, given that it is very difficult to carry out these examinations, it is a very delicate system of interconnection of the veins that ensure the outflow of blood from the brain. And it is still difficult to draw any hasty conclusions. While scientific developments in this regard continue.
As for the second problem you described, this, as I understand it, is hemorrhoids. Hemorrhoids are the prerogative of proctologists. And it’s not really the veins that are interested there. This is, after all, the hemorrhoidal plexus, a special vascular system that does not relate purely to venous pathology. We are faced with this. The basic principles of treatment are similar, in principle, to the treatment of chronic venous insufficiency, that is, they can be used.
Olga Beklemishcheva: Remove everything that gets in the way.
Sergey Sapelkin: Yes, remove everything that interferes and relieve inflammation, prescribe venotonic drugs that help the veins of the lower extremities and help eliminate the manifestations of acute hemorrhoids.
Olga Beklemishcheva: And I can say that we talked a little about hemorrhoids, we had such a program. There, of course, there is a problem, but there, as I understand it, they remove, in general, not the vessel itself, but precisely this hemorrhoidal lump, that is, a whole complex of tissues.
And the next listener is Nina from Tula. Hello Nina.
Listener: Good afternoon. I would like to ask this question. Now there are a lot of articles appearing, perhaps about treatment or improving the condition of varicose veins with the help of stem cells. Sergey Viktorovich, what could you tell us about this?
Sergey Sapelkin: Work both in cardiology and in vascular surgery for arterial insufficiency, as well as in vascular surgery associated with phlebology, is still of an initial nature. Science has not yet formed a clear opinion regarding stem cells. And it would be very simple to expect that the use of stem cells will solve all the problems of phlebology. But some points that are very relevant here are the use of such crops to close extensive trophic ulcers - this is a very important topic. And, indeed, Russia already has some developments, its own, and not just some Western technologies.
Olga Beklemishcheva: Who tried it on a large trophic ulcer?
Sergey Sapelkin: Well, the use of fibroblast cultures. The same fibroblasts that are used to close large burn wounds can also be used to close large trophic venous ulcers.
Olga Beklemishcheva: That is, in burn centers, right?
Sergey Sapelkin: Yes, in burn centers, those laboratories that cultivate these fibroblasts.
Olga Beklemishcheva: And I would like to draw the attention of our listeners to the fact that stem cells at the current stage of development of medical science, they are not used as completely pluripotent, but those that have already chosen their direction in life in a certain way - they have become fibroblasts, osteoblasts. And what I, at least, know concerns those cells that can be classified as very, very young, but still already have some kind of tissue differentiation of their own. Because otherwise, it would probably still be dangerous, because such cells that have not yet chosen their path in life can turn into completely different ones.
And Nina still has a question.
Listener: Please tell me, is there such a disease as obliterating endarteritis? I still want to know about stem cells, whether there are any developments. Are there any developments in this area?
Sergey Sapelkin: I just mentioned to you that the first work on using stem cells to accelerate the growth of new blood vessels with the help of stem cells has begun. But for now I am not going to comment on these works unequivocally. I don't say either for or against.
Olga Beklemishcheva: Very little time has passed, very few experiments have been done.
Sergey Sapelkin: Although, of course, with such a disease, the appearance of new vessels from stem cells, pluripotent, which can, as it were, reproduce vessels anew, is, of course, a vascular surgeon’s blue dream. That is, we don’t need to sew prosthetics, think about where to let the blood come from and where, we launched stem cells - and new vessels grew. Of course, in a fairy tale it looks very beautiful, but in reality there is not enough work yet.
Olga Beklemishcheva: And the next listener is Valentina Mikhailovna from Moscow. Hello, Valentina Mikhailovna.
Listener: Hello. Sergey Viktorovich, I have a question for you. It’s been ten years since I was diagnosed with varicose veins. I regularly take all medications and ointments, as they say, I support myself. But for the last year and a half, on the inside of my left foot, right where, as you said, the ulcer most often occurs, there are three dilated, purple, very bulging veins, right with redness around it. But I have a specific question. Because of angina, for two or three weeks I limited myself, as they say, in an upright position - I walked less, stood less. And after I felt better, I began to walk, stand and do things, something incomprehensible happened to me. On both legs the swelling is very strong at the level of the toes, only the toes remain white, and everything else is bright pink. And the skin is stretched as if it is about to burst. And I don’t understand whether this is due to varicose veins or is this simply an expression of edema. Neither I nor my relatives have ever had anything like this.
Olga Beklemishcheva: I see, Valentina Mikhailovna.
Sergey Sapelkin: The combination of cardiac pathology, it is clearly present here, heart failure, functional angina, class 2-3, at least, the presence of cardiac edema and the presence of venous pathology are factors that aggravate each other. And in this situation we can already talk about a serious condition associated with the appearance of trophic disorders due to both venous pathology and heart failure. That is, most likely, we are talking about the development of cellulite, that is, inflammation of the subcutaneous tissue due to venous inflammation.
Sergey Sapelkin: Yes, disturbances of trophism and venous stagnation, blood stasis.
Olga Beklemishcheva: Actually, cellulite is always some kind of purely cosmetic problem, it seemed to me, but it turns out it’s not.
Sergey Sapelkin: The suffix “-itis” is inflammation. It’s just that this term has already migrated to plastic surgery to evaluate a completely different condition. Although, in fact, it should be used in case of inflammatory changes in the subcutaneous fat tissue.
Olga Beklemishcheva: And what should Valentina Mikhailovna do?
Sergey Sapelkin: Be sure to see a cardiologist and a vascular surgeon, and together with them it is necessary to prescribe the treatment that would compensate for both of these problems. Maybe we will talk about prescribing diuretics, compression and modern phlebotonics are a must.
Olga Beklemishcheva: Sergey Viktorovich, I thank you for coming and telling everything so interestingly.