The use of mesotherapy for varicose veins

Alexander Radionov, executive director, vice-president of the Ukrainian association of clinical and aesthetic mesotherapy “Mesotherapy of Ukraine” (Ukraine, Kiev)

Epidemiology
According to various sources, up to 30% of the working population suffers from varicose veins, and 15–20% of the population suffers from chronic venous insufficiency. Women suffer 2–3 times more often, with 60–90% of them having their onset during pregnancy.
Postoperative relapses occur, according to various sources, in 5–80% of cases and are a pressing problem in surgical phlebology today.

Etiology
Varicose veins are a multifaceted and polyetiological process, and therefore there are several theories explaining the origin of the disease.

Theory of hereditary predisposition:

• deficiency and disruption of the structure of collagen leads to disruption of the structure of the connective tissue of the venous wall, as evidenced by the frequent combination of varicose veins with hernias of the anterior abdominal wall, flat feet, dystrophies of the skin, cartilage and tendons;
• anomalies of valve development at the mouth of the great saphenous vein;
• weakness of the deep fascia of the leg.

Endocrine theory:

• decreased production or neutralization of the anterior pituitary hormone vasopressin;
• the action of endogenous (endocrine diseases, pregnancy, menopause) and exogenous (hormonal drugs, contraceptives) hormones leads to: impaired contractility of myocytes, hormone-induced restructuring of connective tissue, changes in blood rheology, imbalance of coagulation and anticoagulation systems.

Neurotrophic and neurohumoral theories:

• decreased venous tone due to disturbances in central nervous regulation;
• violation of humoral regulation (decreased production of vasoconstrictors and/or decreased sensitivity of specific receptors to them);
• disruption of innervation due to pathology of the spine and peripheral nerves, which leads to disruption of the regulation of the tone and trophism of the vascular wall.

Autoimmune theory: auto-aggression towards one’s own connective tissue leads to its structural disorders.

Pathogenesis
One of the triggering mechanisms for the development of varicose veins of the lower extremities is a violation of hemodynamics as a consequence of the action of gravity on the formed elements of blood and increased hydrostatic pressure in the vessels. By the end of the first hour of a person’s stay in an upright position, about 30% of circulating leukocytes are deposited in the distal part of the vessels. Due to the slow parietal blood flow, leukocytes “roll” along the walls of the veins, which promotes their adhesion, which triggers a cascade of biochemical processes leading to damage to the venous wall.

As a result of alteration, the synthesis of growth factors is activated - polypeptide chemical agents produced by the cells of the vessel walls (endotheliocytes, myocytes) and blood cells (platelets, leukocytes). Growth factors (PDGF - platelet-derived growth factor, TGFb - platelet growth factor, FGF - fibroblast growth factor, VEGF - vascular endothelial growth factor, etc.) regulate the processes of cell migration, proliferation and biosynthesis or breakdown of elements of the vascular wall. The imbalance of these processes leads to structural changes.

The production of prostanoids also changes - the production of thromboxane A2 and prostaglandin E2 with proaggregant proinflammatory properties increases, and the synthesis of prostacyclin with antiplatelet properties decreases. The permeability of the vascular wall increases, resulting in edema. The tone of the veins is regulated by smooth muscle cells. With varicose veins in myocytes, the number of receptors and their sensitivity to vasoconstrictors (alpha-adrenoreceptors of norepinephrine, beta-receptors of endothelin-1, receptors of angiotensin-II, etc.) are disrupted, the balance of vasomotor substances shifts towards dilatation. In addition, smooth muscle cells begin to produce large quantities of components of the intercellular substance, and the synthesis of contractile elements decreases.

Violation of the structure of connective tissue and the tone of smooth muscle cells leads to dilation of veins, deformation and functional insufficiency of the valve apparatus, which in turn further aggravates hemodynamic disturbances, tissue hypoxia, adhesion of leukocytes, production of inflammatory mediators, etc. - a “vicious circle” is formed , which must be broken as early as possible.

As a result of stretching of the venous wall, areas not covered by endothelium are formed, which, against the background of slow blood flow and hemoconcentration, leads to activation of the coagulation system and thrombus formation.

Structural changes in varicose veins are manifested by focal disorganization of the intima, disorganization of connective tissue (swelling, diffuse sclerosis, atrophy of elastic fibers, collagen abnormalities, increased content of proteoglycans), organic damage to the valves (fibroelastosis, sclerosis, hyalinosis), hypertrophy of myocytes, degenerative changes at the cellular level all layers of the venous wall.

Provoking factors are all situations in which venous pressure increases and blood flow is disrupted:

• long standing;
• improper sitting;
• obesity;
• pregnancy;
• persistent severe cough;
• sports and professions related to weight lifting;
• eating habits (overeating, constipation, flatulence);
• tight clothes, etc.

The clinical picture of varicose veins of the lower extremities (LVLV) depends on the location and stage of the process, the presence of chronic venous insufficiency (CVI).

VBNK classification

Clinical classification

• I Intradermal and segmental varicose veins without pathological venovenous discharge.
• II Segmental varicose veins with reflux along the superficial and/or perforating veins.
• III Common varicose veins with reflux along the superficial and perforating veins.
• IV Varicose veins in the presence of reflux in the deep veins.

Varicose veins of the lower extremities without timely and adequate treatment leads to the development of CVI. Currently, the CEAP (clinical-etiology-anatomy-physiopathology) classification has been adopted.

CEAP classification

C – clinical manifestations (in the absence of complaints, the patient is assigned to subgroup A – asymptomatic, if there are any – to group S – symptomatic):

• 0 – absence of clinical manifestations of CVI;
• 1 – telangiectasia;
• 2 – varicose veins;
• 3 – swelling;
• 4 – lipodermatosclerosis or hyperpigmentation;
• 5 – healing ulcer;
• 6 – active ulcer.

E – etiology:

• congenital CVI: clinical manifestations from birth;
• primary – unknown etiology;
• secondary – associated with postthrombophlebitic syndrome/disease, injury.

A – anatomical localization (isolated or combined):

• superficial veins - large and small saphenous veins of the leg;
• deep veins - inferior vena cava, iliac, tibial, veins of the gonads, deep and muscular veins of the lower extremities;
• perforating – perforating veins on the leg and thigh.

P – leading pathophysiological mechanism:

• reflux into the main or perforating veins;
• obstruction – acute or chronic.

The Shalimov classification takes into account the presence or absence of organic damage to the venous valves and the localization of the process.

Insufficiency of the valve apparatus:

1. Functional.
2. Organic.

Process localization:

1. Saphenous vein system.
2. Deep vein system.
3. Communicating veins.

This classification is convenient for planning conservative treatment and predicting outcome. Mesotherapy is most effective for functional insufficiency of the valve apparatus and for pathology of the superficial veins.

Treatment of VBNK

Many doctors, especially surgeons, consider only surgical treatment effective. To date, many types of operations have been developed for various variants of VBNK.

Types of surgical treatment can be divided into several areas:

1. Elimination of pathological discharge of blood from the deep venous system to the superficial (Troyanov-Trendelenburg, Cockett, Linton operations).
2. Phlebectomies (Madelung, Narat, Babcock operations).
3. Exclusion from the bloodstream and obliteration of superficial veins (ligation and dissection of veins are not currently used, but minimally invasive methods of injection sclerosing therapy, electrosurgical, radio wave, cryosurgical, laser, etc., are being developed).
4. Extravasal correction of venous valves.

Surgical treatment allows you to fight the consequences and complications of varicose veins, and not the causes.

Without a doubt, surgical treatment for certain indications is necessary and advisable, but given the frequent complications, long rehabilitation period, and frequent relapses, conservative treatment continues to be the most relevant. In addition, all surgical treatment options, with the exception of valve correction, are not organ-saving, which leads to overload of veins that are not excluded from the circulation, and causes the progression of varicose veins and frequent relapses. Another disadvantage of surgical treatment is the formation of scars at the site of removed or sclerotic veins, which also need to be treated.

Treatment of any pathology should be comprehensive: etio-pathogenetic, symptomatic and preventive. Only with this approach, a combination of all available methods of treatment and prevention, can maximum success be achieved.
The methods of general and local pharmacotherapy are most widely used in the treatment of VLNC today. But they, unfortunately, are limited to only a few groups of drugs, including phlebotonics and angioprotectors, anticoagulants and antiplatelet agents, drugs to improve trophism and microcirculation.

Of the non-drug methods, compression therapy using elastic bandages or special underwear is most often used, hardware methods are pneumopressing, electrical stimulation, etc.

Doctors pay little attention to the psychological state of patients, changing their lifestyle, getting rid of bad habits, using the healing power of cold water, using the devices available today for physiotherapy at home (darsonval, electrotherapy, magnetic therapy, cryomassage, Lyapko applicator, hydromassage and much more) . Manual techniques (correction of the spine, venous-lymphatic drainage, vacuum massage, etc.) are very effective.
Treatment of VBNC using injection techniques is also effective.

For reference

Mesotherapy is a systematic, scientifically based method of influencing the derivatives of the mesoderm by introducing drugs into the epidermis, dermis, hypodermis, muscles (including the pancreas, perivasal, perineural and periarticular spaces) locally, loco-regionally and at a distance from the affected organ with the goal of achieving maximum therapeutic effect due to: pharmacological (local, loco-regional and systemic) action of drugs, antihomotoxic action of homeopathic drugs; as well as mechanical effects of the injection device on specific receptors of the nervous, humoral and immune systems

Mesotherapy techniques

Mesotherapy is not a way to use a specific medicine. This is a system of knowledge and practical skills that allows you to use the widest arsenal of medications, taking into account the etiology, pathogenesis, symptoms of the disease, the stage of the pathological process, pathological changes in the body as a whole and local changes in the affected organs and tissues.

The treatment strategy and tactics should be based on the results of a detailed examination, taking into account the individual characteristics of the patient, general and local pathological changes, and clinical manifestations of the disease.

Everything “peripheral” is preceded by “central”. Therefore, treatment and prevention should begin with correction of the general condition of the body, effects on the central and peripheral nervous system, and only then carry out local therapy.

In this regard, various mesotherapy techniques are used:

• general mesotherapy (mesostress, mesostimulation, mesoimmunocorrection, metabolic therapy, mesoreflexotherapy);
• systemic and loco-regional mesotherapy (treatment of the spine and peripheral nervous system, vascular system and microcirculation, correction of metabolism and hemocoagulation, impact on the functional state and structure of connective tissue, etc.);
• local mesotherapy (local blood flow and lymph outflow, local inflammation and pain, processes of scar formation and resorption, effects on the structure of the connective tissue of the vascular wall, skin, pancreas, tendons and cartilage, on neuromuscular transmission and the structure of muscle tissue, treatment of lipodystrophies and much more) .

General mesotherapy

Methods of general mesotherapy allow for correction of the general condition of the patient’s body:

• treatment of stress and secondary pathologies caused by it (mental disorders - anxiety-depressive and anxiety-psychotonic syndromes, neuro-vegetative dysfunctions, muscle dysfunctions and fibromyalgia, secondary immunodeficiency, stress-related hormonal disorders, menopause, PMS, etc.);
• treatment of psychogenic pain;
• treatment of asthenic conditions;
• secondary immunodeficiencies, etc.

The choice of drugs depends on the pathology.

The main directions of general mesotherapy are blocking and stimulating:

1. Blocking mesotherapy is used in cases of psychotonia. The cocktails include local anesthetics, drugs with a sedative effect (magnesium, diazepam), muscle relaxants (thiocolchicoside, sirdalud, mydocalm), antioxidants (vitamins A, E, C, B1, B2, B6, nicotinic acid, magnesium, copper, selenium, zinc), vascular (pentoxifylline, priacetam, vinpocetine) and other drugs according to indications.
2. During stimulating mesotherapy, local anesthetics and sedatives are not used. Instead, along with vascular and antioxidants, central nervous system stimulants (caffeine, theophylline) and adaptogens (extracts of ginseng root, Leuzea, Rhodiola rosea, Eleutherococcus, Schisandra, pantocrine) are used. For anxiety and depression, anxiolytics (amitriptyline) are used.

General mesotherapy is performed using superficial techniques: epidermal, intrabasal. This treatment is practically painless; when performed skillfully, it allows the use of reflex mechanisms, creating a very superficial depot of drugs, which ensures their mild and long-lasting effect. The drug load is minimal.
The frequency of sessions may vary. It is best to perform the next session after the previous one ends. The criterion for completing a course of general mesotherapy is the achievement of stable normalization of the patient’s general condition, i.e., relief of manifestations of acute or chronic stress.

Systemic and loco-regional mesotherapy

The goal of systemic and loco-regional mesotherapy is to influence the elements of the vascular, nervous and immune systems, metabolic processes of a certain area (extremities, walls of the abdominal and thoracic cavities, mammary glands, head and neck, etc.).

To select techniques and medications, as in the case of general mesotherapy, diagnostic information is important, including the results of examination, palpation, results of laboratory and functional studies.

There is no one method for treating all patients with VLNK, and cannot exist, since each clinical case is unique. But the principles and approaches are the same.

What exactly are the links in pathogenesis and anatomical structures that can be affected using mesotherapy?

Spine and peripheral nerves
When examining the patient, changes are detected in certain segments of the spine, which are characterized by the presence of local pain, changes in muscle tone and skin sensitivity, impaired blood circulation and soft tissue structure, the so-called. zones of dermoneurodystrophy.
A detailed examination usually reveals areas of irradiation of pain, paresthesia, hyper- or hypoesthesia, which should also be affected.
It is advisable to combine superficial and deep types of injections and techniques. Deeper administration of drugs allows you to quickly relieve pain and inflammation in the area, relieve muscle hypertonicity, and superficial administration of drugs allows you to obtain a powerful reflex and prolonged medicinal effect.
The arsenal of treatments for the spine is quite wide. The cocktails usually include a local anesthetic (lidocaine, novocaine), an anti-inflammatory agent (meloxicam, dexketoprofen, piroxicam, ketoprofen, calcitonin, etc.), a vasoactive drug (pentoxifylline, nicotinic acid, etamsylate, calcitonin), antioxidants (vitamins C, group B ). After relief of pain and inflammation, trophic therapy should be carried out (alflutop, extra erbisol, glycosaminoglycans, chondroitin, solcoseryl, vitamin C, etc.). For neurological deficits, cholinesterase blockers and neurotropic vitamins (prozerin, neuromidin, milgamma, neurorubin) are used.
If it is impossible to carry out full treatment of the spine, it is necessary, at a minimum, to perform stimulus therapy, in the case of varicose veins of the lower extremities - in the lumbar spine.

Main vessels
After examination and functional tests, taking into account data from laboratory and functional research methods, treatment tactics are determined. The goal of therapy is to influence the tone of the great vessels and the structure and functional state of the vascular wall.
The impact on the great vessels is carried out by introducing vasoactive drugs along their course and projection. The depth of administration can vary from epidermal to deep hypodermal and depends on the depth of the vessel, the drug and the required speed of action. For acute processes and complications - deeper injection (from 4 to 20 mm). In chronic processes and uncomplicated cases, in remission and for prevention - more superficial (0.5–4 mm).
The choice of medications depends on the clinical picture and most often includes a local anesthetic (lidocaine, novocaine), phlebotonics, angioprotectors and antioxidants (etamsylate, pentoxifyline, escin, ascorbic acid, retinol, troxerutin, tocopherol, etc.).

Local impact

Local mesotherapy has its own spheres of influence.
Local blood flow, microcirculation, lymph flow
The purpose of mesotherapy is to regulate the tone of peripheral vessels, improve microcirculation, strengthen vascular walls, stimulate lymphatic drainage, correct rheology of blood and lymph, influence the coagulation system, correct tissue metabolism and repair processes, relieve pain and inflammation.
The principles for choosing the depth of injections and drugs are described above. In case of venous stasis, severe edema, threat or presence of thrombotic complications, as well as for their prevention, it is necessary to use anticoagulants (heparin, fraxiparin).
For inflammatory processes - anti-inflammatory drugs (meloxicam, piroxicam, dexketoprofen, diclofenac, dexamethasone, etc.), for infectious complications - antibiotics, taking into account the sensitivity of microorganisms to them.

Skin and fatty acids
General obesity and local lipodystrophy are pathogenetic factors of VLNK. Increased intra-abdominal pressure, hypertrophy and swelling of the pancreas disrupt the outflow of blood and lymph from the lower extremities. Flabby and stretched skin ceases to perform a frame function, which also contributes to the development of varicose veins.
To solve these problems, lipolytic therapy and mesolifting techniques are used.
The choice of methods and drugs for lipolysis is individual; it is necessary to take into account the causes of obesity, hormonal status, indications and contraindications for certain drugs. It is advisable to use metabolic drugs (caffeine, theophylline, aminophylline, adrenomimetics, triiodothyronine), which enhance metabolism and lipolysis in adipocytes. Direct lipolytics (phosphatidylcholine, deoxycholate) have a damaging necrotizing effect. At the site of necrosis, edema and fibrosis inevitably develop, which further disrupt the outflow of blood and lymph and themselves require treatment.
Among lifting drugs, preference should be given to low-molecular ones (ascorbic acid, silicon, alflutop, extra erbisol, solcoseryl, etc.), since, unlike large-molecular ones (hyaluronic acid, chondroitin, collagen, elastin), they penetrate from the perivasal space into the vessel wall and have a metabolic and restructuring effect on it.

Summary
Mesotherapy is an effective method of treatment and prevention for uncomplicated and complicated course of VLNK and CVI.
Mesotherapy is used as the main method for uncomplicated variants of the course of varicose veins of the superficial veins without organic damage to the valve apparatus.
As an additional method - for all types of varicose veins and its complications, providing a regulatory effect on the body as a whole, a normalizing effect on the central and peripheral nervous system, main blood flow and microcirculation, improving the rheology of blood and lymph, normalizing metabolic processes, strengthening and restructuring the walls of blood vessels, stopping thrombotic complications and inflammatory processes, creating a dermal compression bandage.
However, it is important to remember: for many drugs there are features of mesotherapeutic use that need to be known and taken into account.

First published: KOSMETIK international journal, 2009