The anatomical structure of the venous system of the lower limbs is very variable. Knowledge of the individual characteristics of the structure of the venous system plays an important role in evaluating the data of instrumental examination in choosing the right method of treatment.
The veins of the lower extremities are divided into superficial and deep. The superficial venous system of the lower limbs starts from the venous plexuses of the toes, which form the venous network of the dorsum of the foot and the dorsal cutaneous arch of the foot. The medial and lateral marginal veins arise from it, which pass into the great and small saphenous veins respectively. The great saphenous vein is the longest vein in the body, contains 5-10 pairs of valves, normally its diameter is 3-5 mm. It originates in the lower third of the lower leg in front of the medial epicondyle and ascends into the subcutaneous tissue of the leg and thigh. At the level of the groin, the great saphenous vein empties into the femoral vein. Sometimes a large saphenous vein on the thigh and lower leg can be represented by two or even three trunks. The small saphenous vein begins in the lower third of the leg along its lateral surface. In 25% of cases, it empties into the popliteal vein at the level of the popliteal fossa. In other cases, the lesser saphenous vein may rise above the popliteal fossa and drain into the femoral, greater saphenous, or deep thigh veins.
The deep veins of the dorsal foot begin with the dorsal metatarsal veins of the foot, draining into the dorsal venous arch of the foot, from where blood flows into the anterior tibial veins. At the level of the upper third of the lower leg, the anterior and posterior tibial veins merge to form the popliteal vein, located laterally and somewhat posterior to the artery of the same name. In the region of the popliteal fossa, the small saphenous vein, the veins of the knee joint, flow into the popliteal vein. The deep vein of the thigh generally empties into the femur 6 to 8 cm below the inguinal crease. Above the inguinal ligament, this vessel receives the epigastric vein, the deep vein surrounding the ilium, and passes into the external iliac vein, which merges with the internal iliac vein at the sacroiliac joint. The paired common iliac vein begins after the confluence of the external and internal iliac veins. The right and left common iliac veins merge to form the inferior vena cava. It is a large vessel without valves, 19-20 cm long and 0. 2-0. 4 cm in diameter. The inferior vena cava has parietal and visceral branches, through which blood flows from the lower limbs, lower torso, abdominal organs and small pelvis.
The perforating (communicating) veins connect the deep veins to the superficial veins. Most of them have valves located suprafascially and thanks to which the blood moves from the superficial veins to the deep veins. There are direct and indirect perforating veins. Direct lines directly connect the deep and superficial venous networks, indirect ones connect indirectly, that is, they first flow into the muscular vein, which then flows into the deep vein.
The vast majority of perforating veins arise from tributaries, not from the trunk of the great saphenous vein. In 90% of patients, the perforating veins of the medial aspect of the lower third of the leg are incontinent. On the lower leg, the most common failure of the perforating veins of Cockett, connecting the posterior branch of the great saphenous vein (Leonard's vein) with the deep veins. In the middle and lower thirds of the thigh there are usually 2-4 of the most permanent perforating veins (Dodd, Gunther), directly connecting the trunk of the great saphenous vein with the femoral vein. With varicose transformation of the small saphenous vein, incompetent communicating veins of the middle and lower thirds of the lower leg and in the region of the lateral malleolus are most often observed.
Clinical course of the disease
Basically, varicose expansion occurs in the great saphenous vein system, less often in the lesser saphenous system, and begins with the tributaries of the vein trunk on the lower leg. The natural course of the disease at the initial stage is quite favorable, the first 10 years or more, in addition to a cosmetic defect, patients can not be bothered by anything. In the future, if timely treatment is not carried out, complaints of a feeling of heaviness, fatigue in the legs and their swelling after physical exertion (long walk, standing) or in the afternoon, especially in the warm season, begin to manifest themselves. Most patients complain of pain in the legs, but a detailed examination reveals that it is precisely the feeling of fullness, heaviness and fullness in the legs. With even a short rest and an elevated position of the limb, the severity of sensations decreases. It is these symptoms that characterize venous insufficiency at this stage of the disease. If we talk about pain, we must exclude other causes (arterial insufficiency of the lower limbs, acute venous thrombosis, joint pain, etc. ). The subsequent course of the disease, in addition to an increase in the number and size of dilated veins, leads to the occurrence of trophic disorders, most often due to the addition of incompetence of perforating veins and the occurrence ofvalvular insufficiency of the deep veins.
With insufficiency of perforating veins, trophic disorders are limited to one of the surfaces of the lower leg (lateral, medial, posterior). Trophic disorders at the initial stage are manifested by local hyperpigmentation of the skin, then thickening (induration) of subcutaneous fat is added to the development of cellulite. This process ends with the formation of an ulcero-necrotic defect, which can reach a diameter of 10 cm or more, and extend deep into the fascia. A typical place for the appearance of venous trophic ulcers is the region of the medial malleolus, but the localization of ulcers on the lower leg can be different and multiple. At the stage of trophic disorders, severe itching, burning in the affected area joins; some patients develop microbial eczema. Pain in the ulcer area may not be expressed, although in some cases it is intense. At this stage of the disease, the heaviness and swelling in the leg become permanent.
Diagnosis of varicose veins
It is especially difficult to diagnose the preclinical stage of varicose veins, since such a patient may not have varicose veins in the legs.
In such patients, the diagnosis of varicose veins of the legs is wrongly rejected, although there are symptoms of varicose veins, indications that the patient has relatives suffering from this disease (hereditary predisposition), ultrasound data on the initial pathological changesof the venous system.
All this can lead to missed deadlines for an optimal start of treatment, the formation of irreversible changes in the vein wall and the development of very serious and dangerous complications of varicose veins. Only when the disease is recognized at an early preclinical stage, it becomes possible to prevent pathological changes in the venous system of the legs due to a minimal therapeutic effect on varicose veins.
Avoiding various types of diagnostic errors and making the correct diagnosis is possible only after a thorough examination of the patient by an experienced specialist, the correct interpretation of all his complaints, a detailed analysis of the history of the disease andthe maximum possible information obtained on the most modern equipment about the state of the venous system of the legs (instrumental diagnostic methods).
Doppler ultrasound is sometimes performed to determine the exact location of the perforating veins, elucidating veno-venous reflux in a color code. In case of insufficiency of the valves, their leaflets cease to close completely during the Valsava test or compression tests. Valvular insufficiency leads to the appearance of venovenous reflux, high, by the incontinent sapheno-femoral fistula, and low, by the incontinent perforating veins of the leg. Using this method, it is possible to record reverse blood flow through the prolapsed leaflets of an incompetent valve. This is why our diagnoses have a multi-stage or multi-level character. In a normal situation, the diagnosis is made after ultrasound diagnosis and examination by a phlebologist. However, in particularly difficult cases, the examination should be carried out in stages.
- first, a thorough examination and questioning by a phlebologist surgeon is performed;
- if necessary, the patient is referred for complementary instrumental research methods (duplex angioscanning, phleboscintigraphy, lymphoscintigraphy);
- patients with concomitant diseases (osteochondrosis, varicose eczema, lymphovenous insufficiency) are advised to consult leading specialist consultants on these diseases) or additional research methods;
- any patient requiring surgery is first consulted by the operating surgeon and, if necessary, by the anesthesiologist.
Treatment
Conservative treatment is indicated mainly for patients who have contraindications to surgical treatment: depending on the general condition, with a slight dilation of the veins, causing only aesthetic inconvenience, in case of refusal of surgical intervention. Conservative treatment is aimed at preventing further development of the disease. In these cases, patients should be advised to bandage the affected surface with an elastic bandage or wear elastic stockings, periodically give the legs a horizontal position, perform special exercises for the foot and lower leg (bending andextension of the ankle and knee joints) activate the musculo-venous pump. Elastic compression accelerates and improves blood flow in the deep veins of the thigh, reduces the amount of blood in the saphenous veins, prevents the formation of edemas, improves microcirculation and contributes to the normalization of metabolic processes in tissues. Bandaging should begin in the morning, before getting out of bed. The bandage is applied with a slight tension from the toes to the thigh with the obligatory capture of the heel and the ankle joint. Each subsequent turn of the bandage should overlap the previous one by half. It should be recommended to use certified therapeutic knitwear with an individual selection of the degree of compression (from 1 to 4). Patients should wear comfortable shoes with hard soles and low heels, avoid prolonged standing, heavy physical labor, work in hot and humid areas. If, due to the nature of the production activity, the patient has to sit for a long time, the legs should be placed in a raised position, replacing a special support of the required height under the feet. It is advisable to walk a little every 1 to 1. 5 hours or stand on tiptoe 10 to 15 times. The resulting contractions of the calf muscles improve blood circulation, improve venous outflow. During sleep, the legs should be betrayed in an elevated position.
Patients are advised to limit water and salt intake, normalize body weight, periodically take diuretics, drugs that improve the tone of veins / According to indications, drugs are prescribed to improve microcirculation intissues. For treatment, we recommend the use of nonsteroidal anti-inflammatory drugs.
An essential role in the prevention of varicose veins belongs to physical therapy. In simple forms, water procedures are useful, especially swimming, warm foot baths (not more than 35 °) with a 5-10% solution of edible salt.
Compression sclerotherapy
The indications for injection therapy (sclerotherapy) for varicose veins are still debated. The method consists in the introduction of a sclerosing agent into the dilated vein, its further compression, desolation and sclerosis. Modern drugs used for these purposes are quite safe, that is, do not cause necrosis of the skin or subcutaneous tissue when administered extravasally. Some specialists use sclerotherapy for almost all forms of varicose veins, while others reject the method altogether. Most likely, the truth lies somewhere in between, and it makes sense for young women in the early stages of the disease to use an injection method of treatment. The only thing is that they should be warned about the possibility of recurrence (higher than with surgery), the need to constantly wear a compression bandage fixing for a long time (up to 3-6 weeks), the probability of several sessions.
The group of patients with varicose veins should include patients with telangiectasia ("varicose veins") and reticular dilation of the small saphenous veins, since the causes of these diseases are identical. In this case, in parallel with sclerotherapy, it is possible to carry outpercutaneous laser coagulation, but only after excluding deep and perforating vein lesions.
Percutaneous laser coagulation (PCL)
It is a method based on the principle of selective photocoagulation (photothermolysis), based on the different absorption of laser energy by various body substances. A feature of the method is the contactless nature of this technology. The focusing attachment focuses energy into the blood vessel in the skin. Hemoglobin in a vessel selectively absorbs laser beams of a certain wavelength. Under the action of a laser in the lumen of the vessel, the destruction of the endothelium occurs, which leads to the sticking of the walls of the vessel.
The effectiveness of the PLC depends directly on the depth of penetration of the laser radiation: the deeper the vessel, the longer the wavelength must be, thus the PLC has rather limited indications. For vessels with a diameter greater than 1. 0-1. 5 mm, microsclerotherapy is most effective. Given the extensive and branching spread of spider veins on the legs, the variable diameter of the vessels, a combined treatment method is currently actively used: at the first stage, sclerotherapy of veins with a diameter of more than 0. 5 mm is carried out, then a laser is used to remove the remaining "asterisks" of a smaller diameter.
The procedure is virtually painless and safe (skin cooling and anesthetics are not used) because the lightdevicerefers to the visible part of the spectrum, and the wavelength of light is calculated so that the water in the tissues does not boil and the patient does not get burned. Patients who are very sensitive to pain are recommended to first apply a cream with a local anesthetic effect. Erythema and edema disappear after 1-2 days. After the course, for about two weeks, some patients may experience darkening or lightening of the treated area of the skin, which then disappears. In fair-skinned people, the changes are almost imperceptible, but in patients with dark skin or a pronounced tan, the risk of such temporary pigmentation is quite high.
The number of procedures depends on the complexity of the case - blood vessels are at different depths, lesions can be insignificant or occupy a fairly large area of skin - but usually no more than four laser therapy sessions (5-10minutes each) are required. The maximum result in such a short time is obtained thanks to the unique "square" shape of the light pulse of the device, which increases its efficiency compared to other devices, while reducing the possibility of side effects afterthe procedure?
Operation
Surgical intervention is the only radical treatment for patients with lower limb varicose veins. The aim of the intervention is to eliminate the pathogenic mechanisms (veno-venous reflux). This is achieved by removing the main trunks of the great and small saphenous veins and ligating the incontinent communicating veins.
The surgical treatment of varicose veins has a century-old history. Previously, and many surgeons still used large incisions along the path of varicose veins, general or spinal anesthesia. The traces after such a "miniphlebectomy" remain a permanent reminder of the operation. The first operations on the veins (according to Schade, according to Madelung) were so traumatic that their damage exceeded the damage caused by varicose veins.
In 1908, an American surgeon proposed a method of saphenous vein harvesting using a hard metal probe with olive and vein harvesting. In an improved form, this method of surgery for the removal of varicose veins is still used in many public hospitals. The varicose tributaries are removed through separate incisions as suggested by surgeon Narat. Thus, the classic phlebectomy is called the Babcock-Narata method. Phlebcock-Narath phlebectomy has drawbacks - large scars after surgery and impaired skin sensitivity. Working capacity is reduced by 2-4 weeks, which makes it difficult for patients to accept surgical treatment for varicose veins.
The phlebologists of our network of clinics have developed a unique technology for the treatment of varicose veins in one day. Difficult cases are handled usingcombined technique. The main large varicose trunks are eliminated by inversion stripping, which involves minimal intervention through mini-incisions (2 to 7 mm) in the skin, which leave practically no scars. The use of minimally invasive techniques involves minimal tissue trauma. The result of our operation is the elimination of varicose veins with an excellent aesthetic result. We perform a combined surgical treatment under total intravenous or spinal anesthesia, and the maximum duration of hospitalization is 1 day.
Surgical treatment includes:
- Crossectomy - crossing the confluence of the trunk of the great saphenous vein into the deep venous system
- Stripping - removal of a varicose fragment from a vein. Only the vein transformed into a varicose vein is removed, and not the entire vein (as in the classic version).
Reallyminiphlebectomycame to replace the method of removing varicose tributaries from the main veins according to Narata. Previously, along the varicose vein, skin incisions were made from 1-2 to 5-6 cm, through which the veins were identified and removed. The desire to improve the aesthetic result of the intervention and to be able to remove the veins not by traditional incisions, but by mini-incisions (punctures), forced doctors to develop tools allowing them to do almost the samething through minimal skin defect. This is how sets of phlebectomy "hooks" of various sizes and configurations and special spatulas appear. And instead of the usual scalpel for piercing the skin, they began to use scalpels with a very narrow blade or needles of a sufficiently large diameter (for example, a needle used for taking venous blood for analysis with a diameter of18G). Ideally, the trace of a puncture with such a needle after some time is practically invisible.
For some forms of varicose veins, we treat on an outpatient basis under local anesthesia. Minimal trauma during the miniphlebectomy, as well as a low risk of intervention, allow this operation to be performed in a day hospital. After minimal observation in the clinic after the operation, the patient may be allowed to go home alone. In the postoperative period, an active lifestyle is maintained, active walking is encouraged. Temporary incapacity usually does not exceed 7 days, then it is possible to start working.
When is microphlebectomy used?
- With a diameter of the varicose trunks of a large or small saphenous vein greater than 10 mm
- After suffering from thrombophlebitis of the main subcutaneous trunks
- After recanalization of the trunk after other types of treatment (EVLK, sclerotherapy)
- Removal of very large individual varicose veins.
It can be an independent operation or a component of the combined treatment of varicose veins, combined with laser vein treatment and sclerotherapy. The tactics of application is determined individually, always taking into account the results of duplex ultrasound of the patient's venous system. Microphlebectomy is used to remove veins from various locations that have been altered for various reasons, including those in the face. Prof. Varadi from Frankfurt developed his practical tools and formulated the basic postulates of modern microphlebectomy. The Varadi method of phlebectomy gives an excellent aesthetic result without pain or hospitalization. It is a very meticulous work, almost jewellery.
After venous surgery
The postoperative period after the usual "classic" phlebectomy is quite painful. Sometimes large hematomas are disturbing, there is edema. Wound healing depends on the surgical technique of the phlebologist, sometimes there is lymph leakage and prolonged formation of visible scars, often after a large phlebectomy there is a violation of sensitivity in the heel area.
In contrast, after miniphlebectomy, the wounds do not require suturing, since these are only punctures, there are no painful sensations, and cutaneous nerve damage has not been observed inour practice. However, such phlebectomy results are only achieved by very experienced phlebologists.
Make an appointment with a phlebologist
Be sure to consult a qualified specialist in the field of vascular diseases.