The anatomical structure of the venous system of the lower extremities is highly variable. Knowledge of the individual characteristics of the structure of the venous system plays an important role in evaluating the data of the instrumental examination in order to choose the correct method of treatment.
The veins of the lower extremities are divided into superficial and deep. The superficial venous system of the lower extremities starts from the venous plexuses of the toes, which form the venous network of the dorsum of the foot and the dorsal arch of the skin of the foot. From it originate the medial and lateral marginal veins, which pass into the greater and lesser saphenous veins, respectively. The great saphenous vein is the longest vein in the body, it contains 5-10 pairs of valves, its diameter is normally 3-5 mm. It originates in the lower third of the lower leg anterior to the medial epicondyle and rises in the subcutaneous tissue of the lower leg and thigh. In the groin, the great saphenous vein empties into the femoral vein. Sometimes a large saphenous vein in 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 lower leg along its lateral surface. In 25% of cases it empties into the popliteal vein in the region of the popliteal fossa. In other cases, the small saphenous vein may rise above the popliteal fossa and empty into the femoral veins, the great saphenous vein, or the deep vein of the thigh.
The deep veins of the dorsum of the foot begin with the dorsal metatarsal veins of the foot and empty into the dorsal venous arch of the foot, from where the 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, which lies lateral to and somewhat posterior to the popliteal artery. In the region of the popliteal fossa, the small saphenous vein, the veins of the knee joint, empty into the popliteal vein. The deep thigh vein usually empties into the femoral vein 6-8 cm below the inguinal crease. Above the inguinal ligament, this vessel receives the epigastric vein, the deep vein that surrounds 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 join to form the inferior vena cava. It is a large valveless vessel, 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 extremities, the lower torso, the abdominal organs, and the small pelvis.
Perforating (communicating) veins connect the deep veins with the superficial ones. Most of them have valves located suprafascially and through which blood moves from the superficial to the deep veins. There are direct and indirect perforating veins. Direct lines directly connect the deep and superficial venous networks, indirect lines connect indirectly, that is, they first flow into the muscular vein, which then flows into the deep one.
The vast majority of perforator veins originate from tributaries and not from the trunk of the great saphenous vein. In 90% of patients, the perforating veins of the medial surface of the lower third of the leg are incompetent. In the lower leg, the most common failure of Cockett's perforating veins, which connects the posterior branch of the great saphenous vein (Leonardo's vein) with deep veins. In the middle and lower thirds of the thigh, there are usually 2-4 of the more permanent perforating veins (Dodd, Gunther), which directly connect 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 area 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 small saphenous vein system, and begins with the tributaries of the trunk of the vein in the lower leg. The natural course of the disease in the early stage is quite favorable, the first 10 years or more, in addition to a cosmetic defect, patients may not feel bothered by anything. In the future, if timely treatment is not carried out, complaints of heaviness, fatigue in the legs and their swelling begin to join after physical exertion (a lot of walking, standing) or in the evening, especially in the warm season. Most patients complain of pain in the legs, but a detailed questioning reveals that it is precisely the feeling of fullness, heaviness and fullness in the legs. Even with a short rest and an elevated position of the limb, the severity of the sensations decreases. It is these symptoms that characterize venous insufficiency at this stage of the disease. If we talk about pain, it is necessary to exclude other causes (arterial insufficiency of the lower extremities, acute venous thrombosis, joint pain, etc. ). Further progression of the disease, in addition to an increase in the number and size of dilated veins, leads to the appearance of trophic disorders, most often due to the addition of insufficiency of the perforating veins and the appearance of valvular insufficiency of the perforating veins. deep veins.
With insufficiency of the perforating veins, trophic disorders are limited to any of the surfaces of the lower leg (lateral, medial, posterior). Trophic disorders in 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 ulcerous-necrotic defect, which can reach a diameter of 10 cm or more and extend deep into the fascia. A typical place of occurrence of venous trophic ulcers is the region of the medial malleolus, but the location of ulcers in the lower leg can be different and multiple. At the stage of trophic disorders, severe itching, burning in the affected area join; some patients develop microbial eczema. The pain in the area of the ulcer may not manifest itself, although in some cases it is intense. At this stage of the disease, the heaviness and swelling of 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 on the legs.
In such patients, the diagnosis of varicose veins of the legs is mistakenly rejected, although there are symptoms of varicose veins, indications that the patient has relatives suffering from this disease (hereditary predisposition), ultrasound data on initial pathological changes in the system venous.
All this can lead to non-compliance with the deadlines for the optimal start of treatment, the formation of irreversible changes in the venous 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 is possible to prevent pathological changes in the venous system of the legs through 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 and the maximum information possible obtained on the most modern equipment on the state of the venous system of the legs (instrumental diagnostic methods).
Sometimes a duplex scan is performed to determine the exact location of the perforating veins, clarifying the veno-venous reflux in a color code. In case of valve insufficiency, their leaflets fail to close completely during the Valsava test or compression tests. Valvular insufficiency leads to the appearance of veno-venous reflux, high, through the incompetent saphenofemoral fistula, and low, through the incompetent perforating veins of the leg. Using this method, it is possible to record the reverse flow of blood through the prolapsed leaflets of an incompetent valve. That is why our diagnosis has a multistage or multilevel character. In a normal situation, the diagnosis is made after ultrasound diagnosis and examination by a phlebologist. However, in particularly difficult cases, the examination must be carried out in stages.
- first, a full examination and questioning is carried out by a phlebologist surgeon;
- if necessary, the patient is referred for additional instrumental research methods (duplex angioscanning, phleboscintigraphy, lymphoscintigraphy);
- patients with concomitant diseases (osteochondrosis, varicose eczema, lymphovenous insufficiency) are invited to consult leading specialist consultants in these diseases) or additional research methods;
- All patients requiring surgery are previously consulted by the operating surgeon and, if necessary, by the anesthesiologist.
Treatment
Conservative treatment is indicated mainly for patients who have contraindications for surgical treatment: depending on the general condition, with a slight dilation of the veins, causing only aesthetic discomfort, in case of rejection 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 bring the legs to a horizontal position, perform special exercises for the foot and lower leg (flexion and extension in ankle and knee joints) to activate the musculo-venous pump. Elastic compression accelerates and improves blood flow in the deep veins of the thigh, reduces the amount of bloodin the saphenous veins, it prevents the formation of edema, improves microcirculation and contributes to the normalization of metabolic processes in the tissues. The bandage should start in the morning, before getting out of bed. The bandage is applied with slight tension from the toes to the thigh with the obligatory capture of the heel and ankle joint. Each subsequent round of the bandage should overlap the previous one by half. The use of certified therapeutic knitwear with an individual selection of the degree of compression (from 1 to 4) should be recommended. 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, then the legs should be placed in a raised position, replacing them with a special support of the required height under the feet. It is recommended every 1-1, 5 hours to walk a little or stand on tiptoe 10-15 times. The resulting contractions of the calf muscles improve blood circulation and increase venous flow. During sleep, the legs should be betrayed in an elevated position.
Patients are recommended to limit the intake of water and salt, normalize body weight, periodically take diuretics, drugs that improve the tone of the veins / According to the indications, drugs that improve microcirculation in the tissues are prescribed. For treatment, we recommend the use of non-steroidal anti-inflammatory drugs.
An essential role in the prevention of varicose veins belongs to physiotherapy. In simple forms, water procedures are useful, especially swimming, warm (no more than 35 °) foot baths with a 5-10% solution of edible salt.
compression sclerotherapy
The indications for injection therapy (sclerotherapy) for varicose veins are still being 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. does 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 the middle, 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 (greater than with surgery), the need to constantly wear a fixative compression bandage 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 telangiectasias ("spider veins") and reticular dilation of small saphenous veins, since the causes of these diseases are identical. In this case, together with sclerotherapy, it is possible to performpercutaneous laser coagulation, but only after exclusion of injuries to the deep and perforating veins.
Percutaneous laser coagulation (PCL)
This 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 lack of contact of this technology. The focusing attachment focuses the energy on the blood vessel in the skin. Hemoglobin in a glass 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 gluing of the vessel walls.
The efficiency of the PLC directly depends on the depth of penetration of the laser radiation: the deeper the container, the longer the wavelength must be, so the PLC has rather limited indications. For vessels with a diameter greater than 1. 0-1. 5 mm, microsclerotherapy is the most effective. Given the widespread and branching spread of spider veins on the legs, the variable diameter of the vessels, a combined method of treatment is currently actively used: at the first stage, sclerotherapy of veins with a diameter of more than 0 , 5 mm, then a laser is used to remove the remaining "asterisks" of a smaller diameter.
The procedure is virtually painless and safe (no skin cooling or anesthesia is used) because the lightapparatusrefers 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 burn. Patients with high sensitivity to pain are recommended to previously apply a cream with a local anesthetic effect. The erythema and edema disappear after 1 or 2 days. After the course, for about two weeks, some patients may experience a darkening or lightening of the treated area of the skin, which then disappears. In people with fair skin, the changes are almost imperceptible, but in patients with dark skin or a strong tan, the risk of temporary pigmentation is quite high.
The number of procedures depends on the complexity of the case: the blood vessels are located at different depths, the lesions can be insignificant or occupy a fairly large surface of the skin, but usually no more than four sessions of laser therapy (5-10 minutes). each) are required. The maximum result in such a short time is achieved thanks to the unique "square" shape of the device's light pulse, which increases its efficiency compared to other devices, while reducing the possibility of side effects after the procedure.
Surgery
Surgical intervention is the only radical treatment for patients with varicose veins of the lower extremity. The goal of the operation is to eliminate the pathogenic mechanisms (veno-venous reflux). This is accomplished by removing the main trunks of the greater and lesser saphenous veins and ligating the incompetent communicating veins.
The treatment of varicose veins by surgery has a centuries-old history. Previously, and many surgeons still used large incisions along the course of varicose veins, general or spinal anesthesia. Traces after such a "miniphlebectomy" remain a lifelong reminder of the operation. The first operations on the veins (according to Schade, according to Madelung) were so traumatic that the damage from them exceeded the damage from varicose veins.
In 1908, an American surgeon devised a method of stripping the saphenous vein using a hard metal probe with an olive and stripping the vein. In an improved form, this method of varicose vein removal surgery is still used in many public hospitals. 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 disadvantages: large scars after surgery and impaired skin sensitivity. The ability to work is reduced for 2 to 4 weeks, making it difficult for patients to accept surgical treatment of varicose veins.
Phlebologists in 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 removed 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 combined surgical treatment under total intravenous or spinal anesthesia, and the maximum hospital stay is up to 1 day.
Surgical treatment includes:
- Crossectomy - crossing the trunk confluence of the great saphenous vein into the deep venous system
- Stripping: removal of a varicose fragment of a vein. Only the transformed 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 path of the varicose vein, skin incisions of 1-2 to 5-6 cm were made, through which the veins were identified and removed. The desire to improve the cosmetic result of the intervention and to be able to eliminate the veins not through traditional incisions, but through mini-incisions (punctures), forced doctors to develop tools that allow them to do almost the same thing through minimal skin defect. This is how sets of phlebectomy "hooks" of various sizes and configurations and special spatulas appeared. 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 for taking venous blood for analysis with a diameter of 18G). Ideally, the trace of such a needle prick after a while is practically invisible.
For some forms of varicose veins, we treat on an outpatient basis with local anesthesia. The minimal trauma during miniphlebectomy, as well as a small risk of intervention, allow this operation to be performed in a day hospital. After minimal observation in the post-op clinic, the patient may be allowed to go home on their own. In the postoperative period, an active lifestyle is maintained, active walking is encouraged. Temporary incapacity is usually no more than 7 days, then it is possible to start work.
When is microphlebectomy used?
- With a diameter of varicose trunks of a large or small saphenous vein of more than 10 mm.
- After suffering thrombophlebitis of the main subcutaneous trunks
- After trunk recanalization after other types of treatment (EVLK, sclerotherapy)
- Removal of very large individual varicose veins.
It can be a stand-alone operation or be a component of combined varicose vein treatment, combined with laser vein treatment and sclerotherapy. Application tactics are 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 changed for various reasons, including those on the face. Professor Varadi from Frankfurt developed his useful tools and formulated the basic tenets of modern microphlebectomy. The Varadi phlebectomy method gives an excellent cosmetic result without pain or hospitalization. This is a very meticulous work, almost jewelry.
After vein surgery
The postoperative period after the usual "classical" phlebectomy is quite painful. Sometimes large bruises are annoying, 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 sensations of pain, and in our practice no damage to the skin nerves was observed. However, such results of phlebectomy are achieved only by very experienced phlebologists.
Make an appointment with a phlebologist
Be sure to consult a qualified specialist in the field of vascular diseases.