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 the evaluation of instrumental research data in choosing the correct treatment method.
The veins of the lower extremities are divided into superficial and deep. The superficial venous system of the lower extremities originates from the venous plexuses of the toes, which form the venous network of the dorsum of the foot and the cutaneous dorsal arch of the foot. From it originate the medial and lateral marginal veins, which pass into the great and small saphenous vein, respectively. The great saphenous vein is the longest vein in the body, contains 5 to 10 pairs of valves, and is usually 3-5 mm in diameter. It originates in the lower third of the lower leg in front of the medial epicondyle and ascends in the subcutaneous tissue of the lower leg and thigh. In the groin, the great saphenous vein empties into the femoral vein. Sometimes the great saphenous vein of 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 area of the popliteal fossa. In other cases, the lesser saphenous vein may rise above the popliteal fossa and drain into the femoral vein, the greater saphenous vein, or the deep vein of the thigh.
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, forming the popliteal vein, which is located laterally and slightly 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 femoral vein usually drains into the femur 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 valveless vessel with a length of 19-20 cm and a diameter of 0. 2-0. 4 cm. The inferior vena cava has parietal and visceral branches through which blood flows from the lower limbs, the lower part of the 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 thanks to which the 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 lines connect indirectly, that is, they first flow into the muscular vein, which then flows into the deep vein.
The majority of perforating veins originate from the tributaries rather than the trunk of the great saphenous vein. In 90% of patients, the perforating veins on the medial surface of the lower third of the leg are incompetent. On the lower part of the leg, the most common insufficiency of perforating Cockett's veins, connecting the posterior branch of the great saphenous vein (Leonardo's vein) with deep veins. In the middle and lower third 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. In varicose transformation of the small saphenous vein, incompetent communicating veins are most often observed in the middle and lower third of the lower leg and in the area of the lateral malleolus.
Clinical course of the disease
Varicose veins generally occur in the great saphenous system, less commonly in the small saphenous system, and begin with the tributaries of the lower leg vein trunk. The natural course of the disease in the initial stage is quite favorable, the first 10 years or more, in addition to the cosmetic defect, patients may not worry about anything. In the future, if timely treatment is not carried out, complaints of a feeling of heaviness, fatigue in the legs and swelling begin to join after physical exertion (prolonged walking, standing) or in the afternoon, especially in the hot season. Most patients complain of pain in the legs, but upon detailed questioning it is found 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 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. ). The subsequent progression of the disease, in addition to the increase in the number and size of varicose veins, leads to the appearance of trophic disorders, more often due to the addition of incompetence of the perforating veins and the appearance of valvular insufficiency of the deep veins.
In case of insufficiency of the perforating veins, the trophic disorders are limited to each of the surfaces of the lower leg (lateral, medial, posterior). Trophic disorders in the initial stage are manifested by local hyperpigmentation of the skin, after which thickening (induration) of subcutaneous fat tissue is added to the development of cellulite. This process ends with the formation of an ulcer-necrotic defect that can reach a diameter of 10 cm or more and extend deep into the fascia. A typical place for the occurrence of venous trophic ulcers is the area of the medial malleolus, but the localization of lower leg ulcers can be different and multiple. At the stage of trophic disorders, strong itching, burning in the affected area is added; some patients develop microbial eczema. Pain in the area of the ulcer may not be pronounced, although in some cases it is intense. At this stage of the disease, the heaviness and swelling of the leg become constant.
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, signs 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 missing 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 becomes possible to prevent pathological changes in the venous system of the legs through 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 and the maximum possible information obtained on the most modern equipment about the condition ofthe 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 the case of valve insufficiency, their leaflets stop closing 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. With the help of this method, it is possible to register the reverse flow of blood through the prolapsing leaflets of an incompetent valve. That is why our diagnosis has a multi-stage or multi-level character. In a normal situation, the diagnosis is made after ultrasound diagnosis and examination by a phlebologist. But in particularly difficult cases, the review should be carried out in stages.
- first a thorough examination and questioning by a phlebologist surgeon is carried out;
- if necessary, the patient is directed to additional instrumental research methods (duplex angioscanning, phleboscintigraphy, lymphoscintigraphy);
- patients with concomitant diseases (osteochondrosis, varicose eczema, lymphovenous insufficiency) are invited to consult leading specialists-consultants on these diseases) or additional research methods;
- all patients who need surgery are consulted in advance by the operating surgeon and, if necessary, by the anesthetist.
Treatment
Conservative treatment is indicated mainly in patients who have contraindications for surgical treatment: according to the general condition, with a slight expansion of the veins, which causes only cosmetic inconvenience, in case of refusal of surgical intervention. Conservative treatment is aimed at preventing the further development of the disease. In these cases, patients should be advised to bandage the affected surface with an elastic bandage or wear elastic socks, 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 activatethe musculo-venous pump. Elastic compression accelerates and strengthens the 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 the tissues. Bandaging should begin in the morning before getting out of bed. The bandage is applied with slight tension from the toes to the thigh with mandatory capture of the heel and ankle joint. Each subsequent round of the bandage should overlap the previous one in half. It is recommended to use certified therapeutic knitwear with an individual choice of 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 rooms. If, due to the nature of the production activity, the patient has to sit for a long time, then the legs should be raised, replacing a special stand with the necessary height under the legs. It is recommended that every 1-1. 5 hours you walk a little or rise on your toes 10-15 times. The resulting contractions of the calf muscles improve blood circulation, improve venous outflow. During sleep, the legs should be handed over in a raised position.
Patients are recommended to limit water and salt intake, normalize body weight, periodically take diuretics, drugs that improve vein tone / According to indications, drugs that improve microcirculation in tissues are prescribed. For treatment, we recommend the use of non-steroidal anti-inflammatory drugs.
Physiotherapy plays a major role in the prevention of varicose veins. In uncomplicated forms, water procedures are useful, especially swimming, warm (not higher than 35 °) foot baths with a 5-10% solution of food 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, destruction and sclerosis. Modern drugs used for these purposes are quite safe, i. e. they do not cause necrosis of the skin or subcutaneous tissue with extravasal administration. Some specialists use sclerotherapy for almost all forms of varicose veins, while others completely reject the method. Most likely, the truth is somewhere in the middle, 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 should be warned about the possibility of relapse (higher than with surgery), the need to constantly wear a fixing compression bandage for a long time (up to 3-6 weeks), the likelihood of several sessions.
The group of patients with varicose veins should include patients with telangiectasias ("spider veins") and reticular dilatation 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 lesions of the deep and perforating veins.
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 different body substances. A feature of the method is the non-contact nature 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 adhesion of the walls of the vessel.
The effectiveness of the PLC directly depends on the depth of penetration of the laser radiation: the deeper the vessel, the longer the wavelength must be, which is why the PLC has rather limited readings. For vessels with a diameter of more than 1. 0-1. 5 mm, microsclerotherapy is most effective. Given the wide and branched distribution 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 is performed on veins with a diameter of more than 0. 5 mm, then a laser is usedto remove the remaining "stars" with a smaller diameter.
The procedure is practically painless and safe (no skin cooling or anesthetics are 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 burn. In patients with high sensitivity to pain, prior application of a cream with a local anesthetic effect is recommended. Erythema and swelling 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 people with light 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 necessary. The maximum result in such a short time is achieved 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 after the procedure?
surgery
Surgical intervention is the only radical treatment in patients with varicose veins of the lower extremities. The purpose of the operation is to eliminate the pathogenetic mechanisms (veno-venous reflux). This is accomplished by removing the main trunks of the great and small saphenous veins and ligation of the incompetent communicating veins.
Surgical treatment of varicose veins has a hundred-year history. Before and many surgeons still used large incisions along the course of varicose veins, general or spinal anesthesia. The scars after such a "miniphlebectomy" remain a reminder of the operation for life. The first operations on 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 proposed a method of severing the saphenous vein using a hard metal probe with an olive and withdrawing the vein. In an improved form, this method of surgery to remove varicose veins is still used in many public hospitals. Varicose veins are removed through separate incisions as suggested by surgeon Narath. Thus, the classic phlebectomy is called the Babcock-Narata method. Phlebcock-Narath phlebectomy has disadvantages - large scars after the operation and impaired skin sensitivity. Working capacity is reduced by 2-4 weeks, which makes it difficult for patients to consent to surgical treatment of varicose veins.
Phlebologists from our network of clinics have developed a unique technology for the treatment of varicose veins in one day. Difficult cases are handled with the help ofcombined technique. The main large varicose veins are removed by inversion stripping, which involves minimal intervention through mini-incisions (from 2 to 7 mm) in the skin that leave virtually no scars. The use of minimally invasive techniques involves minimal tissue trauma. The result of our operation is the removal of varicose veins with an excellent aesthetic result. We perform combined surgical treatment under complete venous or spinal anesthesia, and the maximum hospital stay is up to 1 day.
Surgical treatment includes:
- Crossectomy - cutting the inflow of the trunk of the great saphenous vein into the deep venous system
- Stripping - removal of a varicose vein fragment. Only the varicose-transformed vein is removed, not the entire vein (as in the classic variant).
In factminiphlebectomycame to replace the method of removing the enlarged tributaries of the main veins according to Naratha. Previously, skin incisions of 1-2 to 5-6 cm are made along the course of the varix, through which the veins are 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. Thus, phlebectomy "hooks" and special spatulas sets of different sizes and configurations appeared. And instead of the usual scalpel for piercing the skin, they began to use scalpels with a very narrow blade or needles with 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 is practically invisible after a while.
We treat some forms of varicose veins on an outpatient basis with 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, after which it is possible to start work.
When is microphlebectomy used?
- With a diameter of the dilated trunks of the great or small saphenous vein more than 10 mm
- After spent 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 part of the combined treatment of varicose veins, combined with laser treatment of veins and sclerotherapy. The tactic of administration is determined individually, always taking into account the results of the ultrasound duplex scan of the patient's venous system. Microphlebectomy is used to remove veins that have changed for various reasons with different localizations, 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 very painstaking, almost jeweler 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 phlebologist's surgical technique, sometimes there is lymph leakage and long-term formation of noticeable scars, often after a large phlebectomy there is a violation of sensitivity in the heel area.
Conversely, after miniphlebectomy, the wounds do not require suturing, since these are only punctures, there is no sensation of pain, and in our practice no damage to the skin nerves is observed. However, such phlebectomy results are achieved only by very experienced phlebologists.
Make an appointment for a phlebologist
Do not forget to consult a qualified specialist in the field of vascular diseases.