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 assessing 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 extremities begins from the venous plexuses of the toes, which form the venous network of the dorsum of the foot and the skin dorsal arch of the foot. From it originate the medial and lateral marginal veins, which pass into the great and small saphenous veins, respectively. The great saphenous vein is the longest vein in the body, contains from 5 to 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 rises in the subcutaneous tissue of the lower leg and thigh. In the groin, the great saphenous vein drains 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 lower leg along its lateral surface. In 25% of cases, it flows into the popliteal vein in the region of the popliteal fossa. In other cases, the small saphenous vein can rise above the popliteal fossa and flow into the femoral, great saphenous veins, or into the deep vein of the thigh.
The deep veins of the dorsal foot begin with the dorsal metatarsal veins of the foot, flowing 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, which is located laterally and somewhat behind 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 usually flows into the femoral 6-8 cm below the inguinal fold. 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 extremities, lower torso, abdominal organs, and small pelvis.
Perforating (communicating) veins connect deep veins with superficial ones. Most of them have valves located suprafascially and due to which blood moves from the superficial veins to the deep ones. 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 one.
The vast majority of perforating veins originate from tributaries, and not from the trunk of the great saphenous vein. In 90% of patients, perforating veins of the medial surface of the lower third of the leg are incompetent. On the lower leg, the most common failure of the perforating veins of Cockett, connecting 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 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 area of the lateral malleolus are most often observed.
Clinical course of the disease
Basically, varicose expansion occurs in the system of the great saphenous vein, less often in the system of the small saphenous, and begins with the tributaries of the trunk of the vein 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, the patients may 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 walking, standing) or in the afternoon, especially in the hot season, begin to join. Most patients complain of pain in the legs, but a detailed questioning reveals that this 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 are talking about pain, it is necessary to exclude other causes (arterial insufficiency of the lower extremities, acute venous thrombosis, joint pain, etc. ). The subsequent progression of the disease, in addition to an increase in the number and size of dilated veins, leads to the occurrence of trophic disorders, more often due to the addition of incompetence of perforating veins and the occurrence of valvular insufficiency of deep veins.
With insufficiency of perforating veins, trophic disorders are limited to any 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 the subcutaneous fat is added up to the development of cellulite. This process ends with the formation of an ulcerative-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 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 join; some patients develop microbial eczema. Pain in the area of the ulcer may not be expressed, although in some cases it is intense. At this stage of the disease, 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 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 venous system.
All this can lead to missed 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 becomes possible to prevent pathological changes in the venous system of the legs through a minimal therapeutic effect on varicose veins.
Avoiding various kinds 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 possible information obtained on the most modern equipment about the state of the venous system of the legs (instrumental diagnostic methods).
Duplex scanning is sometimes performed to determine the exact localization of 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. Valve 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 register the reverse flow of blood through the prolapsing leaflets of an incompetent valve. That is why our diagnostics is multi-stage or multi-level. In a normal situation, the diagnosis is made after ultrasound diagnostics and examination by a phlebologist. However, in particularly difficult cases, the examination must be carried out in stages.
- first, a thorough examination and questioning by a phlebologist surgeon is performed;
- 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 on these diseases) or additional research methods;
- all patients requiring surgery are consulted in advance by the operating surgeon and, if necessary, by the anesthesiologist.
Treatment
Conservative treatment is indicated mainly for patients who have contraindications to surgical treatment: according to the general condition, with a slight dilation of the veins, causing only cosmetic 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 (flexion and extension in the ankle and knee joints) to activate the musculo-venous pump. Elastic compression accelerates and enhances blood flow in the deep veins of the thigh, reduces the amount of blood in the saphenous veins, prevents the formation of edema, 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 ankle joint. Each subsequent round 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, then the legs should be given an elevated position, substituting a special stand of the required height under the feet. It is advisable every 1-1. 5 hours to walk a little or rise on your toes 10-15 times. The resulting contractions of the calf muscles improves blood circulation, enhances venous outflow. During sleep, the legs must be betrayed in an elevated position.
Patients are advised to limit the intake of water and salt, normalize body weight, periodically take diuretics, drugs that improve the tone of the veins / According to indications, drugs are prescribed that improve microcirculation in tissues. For treatment, we recommend the use of non-steroidal anti-inflammatory drugs.
An essential role in the prevention of varicose veins belongs to physical therapy. In uncomplicated forms, water procedures are useful, especially swimming, warm (not higher than 35 °) foot baths with a 5-10% solution of edible salt.
Compression sclerotherapy
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, i. e. do not cause necrosis of the skin or subcutaneous tissue when extravasally administered. Some specialists use sclerotherapy for almost all forms of varicose veins, while others reject the method completely. Most likely, the truth lies somewhere in between, and it makes sense for young women with the initial stages of the disease to use an injection method of treatment. The only thing is that they must be warned about the possibility of recurrence (higher than with surgery), the need to constantly wear a fixing compression bandage for a long time (up to 3-6 weeks), the likelihood that severalsessions.
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, along with sclerotherapy, it is possible to carry outpercutaneous laser coagulation, but only after the exclusion of lesions of 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 contactlessness of this technology. The focusing attachment concentrates the energy in the blood vessel of the skin. Hemoglobin in the 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 gluing of the walls of the vessel.
The efficiency of the PLC directly depends on the depth of penetration of laser radiation: the deeper the vessel is, the longer the wavelength should be, thus the PLC has rather limited readings. For vessels with a diameter exceeding 1. 0-1. 5 mm, microsclerotherapy is the most effective. Given the extended and branched 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 is performed, 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 lightapparatusrefers to the visible part of the spectrum, and the wavelength of the light is calculated so that the water in the tissues does not boil, and the patient does not get burned. Patients with high pain sensitivity are recommended to pre-apply a cream with a local anesthetic effect. Erythema and edema subside 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 people with fair skin, the changes are almost imperceptible, but in patients with dark skin or a strong tan, the risk of such temporary pigmentation is quite high.
The number of procedures depends on the complexity of the case - the blood vessels are 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 needed. The maximum result in such a short time is achieved due to the unique "square" shape of the device’s light pulse, which increases its efficiency compared to other devices, while also 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 purpose of the operation is to eliminate pathogenetic mechanisms (veno-venous reflux). This is achieved by removing the main trunks of the great and small saphenous veins and ligating the incompetent communicating veins.
Treatment of varicose veins by surgery has a hundred-year 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 harm from them exceeded the harm from varicose veins.
In 1908, an American surgeon came up with a method of saphenous vein plucking using a hard metal probe with an olive and vein plucking. In an improved form, this method of surgery for the removal of varicose veins is still used in many public hospitals. Varicose tributaries are removed by separate incisions, as suggested by the surgeon Narat. Thus, the classic phlebectomy is called the Babcock-Narata method. The Bebcock-Narath phlebectomy has disadvantages - large scars after the operation and impaired skin sensitivity. The ability to work is reduced by 2-4 weeks, which makes it difficult for patients to agree to surgical treatment of varicose veins.
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 removed by inversion stripping, which involves minimal intervention through mini-incisions (from 2 to 7 mm) of the skin, which practically do not leave 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 confluence of the trunk of the great saphenous vein into the deep venous system
- Stripping - removal of a varicose fragment of a vein. Only the varicose-transformed vein is removed, and not the entire vein (as in the classic version).
Actuallyminiphlebectomycame to replace the method of removal of varicose tributaries of the main veins according to Narata. Previously, along the course of the varix, skin incisions were made from 1-2 to 5-6 cm, through which the veins were identified and removed. The desire to improve the cosmetic result of the intervention and to be able to remove veins not through traditional incisions, but through mini-incisions (punctures), forced doctors to develop tools that allow them to do almost the same through a minimal skin defect. So there were sets of phlebectomy "hooks" of various sizes and configurations and special spatulas. And instead of the usual scalpel for puncturing the skin, they began to use scalpels with a very narrow blade or needles of a sufficiently large diameter (for example, a needle used to take venous blood for analysis with a diameter of 18G). Ideally, the trace of a puncture with such a needle after a while is practically invisible.
For some forms of varicose veins, we perform outpatient treatment under local anesthesia. 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 clinic after the operation, the patient can be allowed to go home on his own. In the postoperative period, an active lifestyle is maintained, active walking is encouraged. Temporary disability 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 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 an independent operation or be 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 ultrasound duplex scanning of the patient's venous system. Microphlebectomy is used to remove veins of various localizations that have been changed for various reasons, including those on the face. Professor Varadi from Frankfurt developed his handy tools and formulated the basic postulates of modern microphlebectomy. The Varadi phlebectomy method gives an excellent cosmetic result without pain and hospitalization. This is a very painstaking, almost jewelry work.
After vein 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 noticeable scars, often after a large phlebectomy there is a violation of sensitivity in the heel area.
In contrast, after miniphlebectomy, wounds do not require suturing, since these are only punctures, there are no pain sensations, and damage to the skin nerves was not observed in our practice. However, such results of phlebectomy are achieved only by very experienced phlebologists.
Making an appointment with a phlebologist
Be sure to consult a qualified specialist in the field of vascular diseases.