The anatomical structure of the venous system of the lower extremities is very variable. Knowing the individual characteristics of the structure of the venous system plays an important role in evaluating the instrumental examination data in choosing the appropriate treatment method.
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 back of the foot and the arch of the dorsal skin of the foot. The medial and lateral marginal veins originate from it, 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 begins 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 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 flows 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 drain into the femoral, great saphenous, or deep femoral veins.
The deep veins of the dorsal plantar 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 join 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, drain into the popliteal vein. The deep femoral vein usually drains 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 joins the internal iliac vein at the sacroiliac joint. The paired common iliac vein begins after the union 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 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 pelvis.
Perforating (communicating) veins connect the deep and superficial veins. Most of them have valves located superficially and due 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 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 branches, rather than 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 disabled. In the lower leg, the most common failure of the perforating veins of Cockett, which connects the posterior branch of the great saphenous vein (Leonardo's vein) with the 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 to 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 more often observed.
Clinical course of the disease
Basically, varicose veins occur in the system of the great saphenous vein, less often in the system of the small saphenous vein and begin with the branches of the trunk of the vein in the lower part of the leg. The natural course of the disease in the initial stage is quite favorable, the first 10 years or more, except for a cosmetic defect, patients may not be bothered by anything. In the future, if the treatment is not carried out in time, complaints about the 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 question reveals that this is precisely the feeling of fullness, heaviness and satiety in the legs. Even with a short rest and an elevated position of the limbs, the severity of the sensations decreases. These are the 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 the increase in the number and size of dilated veins, leads to the appearance of trophic disorders, most often due to the increase in the disability of the perforating veins and the appearance of valvular insufficiency of the deep veins.
With insufficiency of perforating veins, trophic disorders are limited to any surface of the lower leg (lateral, medial, posterior). Trophic disorders in the initial stage are manifested by local hyperpigmentation of the skin, then thickening (hardening) of subcutaneous fat increases until 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 site of venous trophic ulcers is the region of the medial malleolus, but the localization of ulcers in the lower part of the leg can be different and multiple. In the stage of trophic disorders, severe itching, burning in the affected area come together; some patients develop microbial eczema. Pain in the ulcer area may not be pronounced, although in some cases it is intense. At this stage of the disease, heaviness and swelling in the legs 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 changes in the venous system.
All this can lead to missing 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 establishing the correct diagnosis is possible only after a complete 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 for the condition of the venous system of the legs (instrumental diagnostic methods).
Duplex scanning 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. The insufficiency of the valves leads to the occurrence 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 prolapsing leaflets of an incompetent valve. That is why our diagnosis has a multi-phase or multi-level character. In a normal situation, the diagnosis is made after ultrasound diagnostics and examination by a phlebologist. However, in particularly difficult cases, the examination should be carried out in stages.
- first, a complete examination and questioning by a phlebological surgeon is performed;
- if necessary, the patient is referred for additional instrumental research methods (duplex angioscan, phleboscintigraphy, lymphoscintigraphy);
- patients with concomitant diseases (osteochondrosis, varicose eczema, lymphovenous insufficiency) are invited to consult the main specialist consultants for these diseases) or additional research methods;
- all patients who need surgery are consulted in advance by the operating surgeon and, if necessary, by the anesthesiologist.
Treatment
Conservative treatment is mainly indicated for patients who have contraindications for surgical treatment: according to the general condition, with a slight expansion of the veins, causing only cosmetic concerns, in case of refusal of surgical intervention. Conservative treatment aims to prevent 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, to periodically give the legs a horizontal position, to perform special exercises for the leg and the lower part of the leg (bending andstretching of the ankle and knee joints). to activate the musculo-venous pump. Elastic compression accelerates and increases 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 start in the morning, before you get out of bed. The bandage is applied with a slight tension from the toes to the thigh with the obligatory grip of the joint of the heel and the ankle. Each subsequent round of the bandage should overlap by half with the previous one. The use of certified therapeutic hosiery with an individual selection of the degree of compression (from 1 to 4) should be recommended. Patients should wear comfortable shoes with strong soles and low heels, avoid long standing, heavy physical work, work in hot and humid areas. If, due to the nature of the productive activity, the patient has to sit for a long time, then the legs should be given an elevated position, replacing a special posture of the required height under the feet. It is recommended that every 1-1. 5 hours you walk a little or stand up on your toes 10-15 times. The resulting contractions of the calf muscles improve blood circulation, increasing venous flow. During sleep, the legs should be raised in an elevated position.
Patients are advised 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.
An essential role in the prevention of varicose veins belongs to physical therapy. In uncomplicated forms, water procedures are useful, especially swimming, warm foot baths (not higher than 35 °) with a 5-10% solution of food salt.
Compression sclerotherapy
The indications for injection therapy (sclerotherapy) for varicose veins are still being debated. The method consists in introducing a sclerosing agent into the dilated vein, its further compression, destruction and sclerosis. Modern drugs used for these purposes are quite safe, d. m. th. 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 completely reject the method. Most likely, the truth lies 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 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 several sessions.
The group of patients with varicose veins should include patients with telangiectasia ("spider veins") and reticular dilatation of the small saphenous veins, as the causes of these diseases are identical. In this case, together with sclerotherapy, it is possible to performpercutaneous laser coagulation, but only after excluding lesions of 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 different substances of the body. A feature of the method is contactless of this technology. The focusing plug concentrates the energy on the blood vessels of the skin. Hemoglobin in a container selectively absorbs laser rays 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 adhesion of the walls of the vessel.
The efficiency of the PLC directly depends on the depth of penetration of the laser radiation: the deeper the vessel, the longer the wavelength should be, so the PLC has rather limited indications. For vessels with a diameter exceeding 1. 0-1. 5 mm, microsclerotherapy is more effective. Given the wide spread and branching of spider veins in the legs, the variable diameter of the vessels, a combined method of treatment is currently actively used: in the first stage, sclerotherapy of veins with a diameter of more than 0, 5 mm, then a laser is used to remove the remaining "stars" with a smaller diameter.
The procedure is practically painless and safe (no skin coolers and anesthetics are used) because of the lightapparatusesrefers to the visible part of the spectrum, and the wavelength of light is calculated so that the water in the tissue does not boil and the patient does not burn. Patients with high sensitivity to pain are recommended to apply a cream with a local anesthetic effect beforehand. 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 people with light skin, the changes are almost invisible, but in patients with dark skin or strong tanning, 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 due to the unique "square" shape of the light pulse of the device, 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 extremities. The purpose of the operation 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 non-communicating veins.
The treatment of varicose veins with surgery has a hundred-year history. Previously, and many surgeons still used large incisions along the course of varicose veins, general or spinal anesthesia. The traces after such a "miniphlebectomy" remain an eternal memory of the operation. The first operations on 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 came up with a method of plucking the saphenous veins using a strong metal probe with an olive and vein plucker. In an improved form, this method of surgery to remove varicose veins is still used in many public hospitals. Varicose veins are removed with special incisions, as suggested by surgeon Narat. Thus, the classic phlebectomy is called the Babcock-Narata method. Phlebcock-Narath phlebectomy has disadvantages - large postoperative wounds and impaired skin sensitivity. The ability to work decreases by 2-4 weeks, which makes it difficult for patients to accept surgical treatment of 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 veins are removed by inversion stripping, which involves minimal intervention through mini-incisions (from 2 to 7 mm) of the skin, which practically leave 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 union of the trunk 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).
Actuallyminiphlebectomycame to replace the method of removing varicose branches of the main veins according to Narata. Previously, skin incisions from 1-2 to 5-6 cm were made along the course of the varix, through which the veins were identified and removed. The desire to improve the cosmetic result of the intervention and to be able to remove 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 aminimal 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 with a fairly large diameter (for example, a needle used to take venous blood for analysis with a diameter of18G). Ideally, the trace of a piercing 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 a minimal observation in the clinic after the operation, the patient can be allowed to go home on his own. In the period after the operation, 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 from 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 a component of the combined treatment of varicose veins, combined with laser vein treatment and sclerotherapy. The application tactic is determined individually, always taking into account the results of the duplex ultrasound scan of the patient's venous system. Microphlebectomy is used to remove veins of various locations that have changed for various reasons, including those on the face. Professor Varad from Frankfurt developed his useful 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 work, almost jewelry.
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 lymphatic flow 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 stitches, as these are only punctures, there is no pain sensation and damage to the skin nerves has not been 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.