The anatomical structure of the venous system of the lower extremities is highly variable. Knowledge of the individual characteristics of the venous system structure plays an important role in the evaluation of instrumental examination data in choosing 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 empty into the great saphenous and small saphenous veins, respectively. The great saphenous vein is the longest vein in the body, it contains from 5 to 10 pairs of valves, normally its diameter is 3-5 mm. It originates in the lower third of the 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 drains into the femoral vein. Sometimes a large saphenous vein in the thigh and 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 drains 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 flow into the femoral veins, great saphenous veins, 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, 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 leg, the anterior and posterior tibial veins merge to form the popliteal vein, 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, empty into the popliteal vein. The deep thigh vein usually flows into the femur 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 unite 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 trunk, abdominal organs, and small pelvis.
The perforating (communicating) veins connect the deep veins with the superficial ones. Most of them have valves located suprafascially and due to which the 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.
The vast majority of perforating veins originate from tributaries rather than from the trunk of the great saphenous vein. In 90% of patients, the perforating veins on the medial aspect of the lower third of the leg are incompetent. In the 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 more 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 leg and in the area of the lateral malleolus are most often seen.
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 at the initial stage is quite favorable, in the first 10 years or so, in addition to a cosmetic defect, patients may not be bothered by anything. In the future, if timely treatment is not carried out, complaints of heaviness, fatigue in the legs and swelling after physical exertion (long walking, standing) or in the afternoon, especially in the hot season, begin to come together. Most patients complain of leg pain, but a detailed inquiry reveals that this 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 diminishes. 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 occurrence of trophic disorders, most often due to increased 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 leg (lateral, medial, posterior). Trophic disorders in the initial stage are manifested by local hyperpigmentation of the skin, then thickening (hardening) of subcutaneous fat is added 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 site of occurrence of trophic venous ulcers is the medial malleolus region, but the location of ulcers in the lower leg can be different and multiple. In the stage of trophic disorders, intense itching, burning in the affected area come together; 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.
varicose vein diagnosis
It is especially difficult to diagnose the preclinical stage of varicose veins as this patient may not have varicose veins in their legs.
In such patients, the diagnosis of varicose veins of the legs is erroneously rejected, although there are symptoms of varicose veins, indications that the patient has relatives who suffer from this disease (hereditary predisposition), ultrasound data on early 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 types of misdiagnosis 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 as much information as possible obtained about the most modern equipment on the status of the venous system of the legs (instrumental diagnostic methods).
Duplex scanning is sometimes performed to determine the exact location of perforating veins, elucidating veno-venous reflux in a color code. In case of valve failure, their leaflets fail to close completely during the Valsalva test or compression tests. Valve insufficiency leads to veno-venous reflux, high through the incompetent saphenofemoral fistula, and low through the incompetent perforating veins of the leg. With 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 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 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 angioscan, phleboscintigraphy, lymphoscintigraphy);
- patients with concomitant diseases (osteochondrosis, varicose eczema, lymphovenous insufficiency) are invited to consult with leading consultants specializing in these diseases) or additional research methods;
- All patients requiring surgery are previously consulted by the surgeon and, if necessary, by the anesthesiologist.
Treatment
Conservative treatment is mainly indicated for patients who have contraindications to surgical treatment: according to the general condition, with slight dilatation of the veins, causing only aesthetic discomfort, in case of refusal of the surgical intervention. Conservative treatment aims to prevent the development of the disease. In such cases, patients should be advised to bandage the affected surface with an elastic bandage or use elastic stockings, periodically place the legs in a horizontal position, perform special foot and leg exercises (flexion and extension at the ankle and knee joints) to activate the muscle-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 the tissues. The bandage should start in the morning, before getting out of bed. The bandage is applied with light tension from the toes to the thigh with mandatory capture of the heel and ankle joint. Each subsequent round of dressing should overlap the previous one by half. It is recommended to use certified therapeutic meshes with individual selection of the compression degree (from 1 to 4). Patients should wear comfortable shoes with hard soles and low heels, avoid standing for a long time, heavy physical work, work in hot and humid areas. If, due to the nature of the production activity, the patient has to be seated for a long time, the legs should be given an elevated position, replacing a special support of the necessary height under the feet. It is advisable every 1-1. 5 hours to walk a little or stand on tiptoe 10-15 times. The resulting contractions of the calf muscles improves blood circulation, increases venous flow. During sleep, the legs should be pulled 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 physiotherapy. In uncomplicated forms, water procedures are useful, especially swimming, warm foot baths (not higher than 35 °) 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 of introducing a sclerosing agent into the dilated vein, its subsequent compression, desolation and sclerosis. Modern drugs used for these purposes are quite safe, that is, they do not cause necrosis of the skin or subcutaneous tissue when administered extravasally. Some experts 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 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 fixation 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, 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 the deep and perforating veins.
Percutaneous laser coagulation (PCL)
This is a method based on the principle of selective photocoagulation (photothermolysis), based on the differential absorption of laser energy by various substances in the body. A characteristic of the method is the absence of contact with this technology. The focusing accessory focuses energy on the skin's blood vessel. Hemoglobin in a vessel selectively absorbs laser beams of a particular wavelength. Under the action of a laser in the vessel lumen, the endothelium is destroyed, which leads to the bonding of the vessel walls.
The efficiency of the PLC directly depends on the penetration depth of the laser radiation: the deeper the vessel, the longer the wavelength, therefore, the PLC has very limited indications. For vessels with a diameter greater than 1. 0-1. 5 mm, microsclerotherapy is the most effective. Given the extended and branching spread of spider veins on the legs, the variable diameter of the vessels, currently a combined method of treatment is 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 practically painless and safe (no skin cooling and anesthetics are 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 with high sensitivity to pain are recommended to previously 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 skin, which then disappears. In fair-skinned people, the changes are barely noticeable, but in patients with dark skin or a strong tan, the risk of this 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 may be insignificant or occupy a fairly large surface area 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 in relation to other devices, in addition to 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 pathogenic mechanisms (veno-venous reflux). This is accomplished by removing the main trunks of the great and lesser saphenous veins and ligating the incompetent communicating veins.
The treatment of varicose veins by surgery has a hundred-year history. Previously, many surgeons still used large incisions along the course of varicose veins, general or spinal anesthesia. Traces after such a "miniphlebectomy" remain a lifetime reminder of the operation. The first operations on the veins (according to Schade, according to Madelung) were so traumatic that their damage outweighed the damage of varicose veins.
In 1908, an American surgeon came up with a method of saphenous vein harvesting using a carbide probe with an olive and vein plucking. In an improved form, this method of surgery to remove varicose veins is still used in many public hospitals. Varicose tributaries are removed through separate incisions as suggested by surgeon Narat. Thus, classical phlebectomy is called the Babcock-Narata method. Phlebcock-Narath phlebectomy has disadvantages - large scarring after surgery and impaired skin sensitivity. Work capacity is reduced in 2-4 weeks, which makes it difficult to accept surgical treatment of varicose veins.
The phlebologists in our network of clinics have developed a unique technology for treating 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) in the skin, which leave virtually 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 spinal 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
- Pickling - removal of a varicose fragment from a vein. Only the vein transformed into varicose veins is removed, not the entire vein (as in the classic version).
Actuallyminiphlebectomycame to replace the method of removing varicose tributaries from the main veins according to Narata. Previously, along the course of the varicose veins, 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 remove the veins not through traditional incisions, but through mini-incisions (punctures), forced doctors to develop tools that allowed them to do almost the same through a minimum defect of skin. This is how sets of phlebectomy "hooks" of various sizes and configurations and special spatulas came about. And instead of the usual scalpel for piercing the skin, they started using scalpels with a very narrow blade or needles of a sufficiently large diameter (for example, a needle used to draw 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 treat them on an outpatient basis 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 go home alone. In the postoperative period, an active lifestyle is maintained, active walking is encouraged. Temporary disability is usually not longer than 7 days, then it is possible to start work.
When is microphlebectomy used?
- With a diameter of varicose trunks of a great or small saphenous vein greater 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 standalone operation or be 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 scan ultrasound of the patient's venous system. Microphlebectomy is used to remove veins from various locations that have changed for a variety of reasons, including those on the face. Professor Varadi 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 meticulous, almost jeweler's job.
After vein surgery
The postoperative period after the usual "classical" phlebectomy is quite painful. Sometimes large bruises are disturbing, there is edema. Wound healing depends on the surgical technique of the phlebologist, sometimes there is lymph leakage and prolonged visible scarring, often after a major phlebectomy there is a violation of sensitivity in the heel area.
In contrast, after miniphlebectomy, the wounds do not require suturing, as they are just punctures, there is no sensation of pain, and damage to the skin nerves was not observed in our practice. However, such phlebectomy results 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 disease.