The anatomical structure of the venous system of the lower extremities is highly variable. Knowing the individual characteristics of the structure of the venous system plays an important role in the evaluation of instrumental examination data in choosing the right 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 fingers, which form the venous network of the dorsum of the foot and the skin of the dorsal arch of the foot. The medial and lateral marginal veins depart from it and pass into the great and small saphenous vein. The great saphenous vein is the longest vein in the body, it contains from 5 to 10 pairs of valves, with a normal diameter of 3-5 mm. It arises 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 flows into the femoral vein. Sometimes the great 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 area of the popliteal fossa. In other cases, the small saphenous vein may rise above the popliteal fossa and drain into the femoral, great saphenous vein, or deep vein of the thigh.
The deep veins of the dorsal foot begin with the dorsal metatarsal veins of the foot, which flow 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 slightly behind the artery of the same name. In the area of the popliteal fossa, the small saphenous vein, the vein of the knee joint, flows into the popliteal vein. The deep femoral vein usually drains into the femoral vein 6-8 cm below the inguinal fold. Above the inguinal ligament, this vessel receives the epigastric vein, a 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 a valve, 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 pelvis.
Perforating (communicating) veins connect the deep veins with the superficial ones. Most of them have valves located suprafascially and due to which blood moves from superficial veins to deep ones. There are direct and indirect perforating veins. Direct lines directly connect the deep and superficial venous network, indirect lines connect indirectly, that is, they first flow into the muscular vein, which then flows into the deep vein.
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 of the medial surface of the lower third of the leg are incompetent. On the lower leg, failure of the perforating Cockett's veins is the most common, connecting the posterior branch of the great saphenous vein (Leonard's vein) with the deep veins. In the middle and lower third of the thigh, there are usually 2-4 permanent perforating veins (Dodd, Gunther), which directly connect the trunk of the great saphenous vein with the femoral vein. In the case of 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
Basically, the expansion of varicose veins occurs in the system of the great saphenous vein, less often in the system of the small saphenous vein, and begins with the tributaries of the trunk of the vein on the lower leg. The natural course of the disease in the initial stage is quite favorable, for the first 10 years and more, apart from the 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 examination 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 extremity, the severity of the sensation decreases. Exactly these symptoms characterize venous insufficiency at this stage of the disease. If it is pain, it is necessary to rule out 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.
With insufficiency of perforating veins, trophic disorders are limited to any surface of the lower leg (lateral, medial, posterior). Trophic disorders in the initial phase are manifested by local hyperpigmentation of the skin, and then thickening (induration) of the subcutaneous fatty tissue is added to the formation of cellulite. This process ends with the creation of an ulcerous-necrotic defect, which can reach a diameter of 10 cm or more, and extend deep into the fascia. The typical site 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. In the stage of trophic disorders, severe itching, burning in the affected area is added; some patients develop microbial eczema. The pain in the area of the ulcer may not be pronounced, 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, because such a patient may not have varicose veins on the legs.
In such patients, the diagnosis of varicose veins of the legs is rejected by mistake, 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 missing the deadlines for the optimal start of treatment, the occurrence of irreversible changes on the vein wall and the development of very serious and dangerous complications of varicose veins. Only when the disease is recognized in the early preclinical phase, it becomes possible to prevent pathological changes in the venous system of the legs through minimal therapeutic action on varicose veins.
Avoiding various types of diagnostic errors and establishing the correct diagnosis is possible only after a thorough examination of the patient by an experienced specialist, correct interpretation of all his complaints, detailed analysis of the medical history and maximum possible information obtained on the most modern equipment about the state of the venous system of the legs (instrumental diagnostic methods).
A duplex scan is sometimes performed to determine the exact localization of perforating veins, elucidating veno-venous reflux in a color code. In the case of valve insufficiency, their leaflets stop closing completely during the Valsava test or the compression test. Valve insufficiency leads to the appearance of veno-venous reflux, high, through an incompetent saphenofemoral fistula, and low, through incompetent perforating leg veins. Using this method, it is possible to register the reverse blood flow through the prolapsing valves of an incompetent valve. That is why our diagnostics has a multi-level or multi-level character. In a normal situation, the diagnosis is made after ultrasound diagnostics and an examination by a phlebologist. However, in particularly difficult cases, testing must be carried out in stages.
- first, a detailed examination and examination by a phlebologist surgeon is performed;
- if necessary, the patient is referred to additional instrumental research methods (duplex angioscanning, phleboscintigraphy, lymphoscintigraphy);
- patients with accompanying diseases (osteochondrosis, varicose eczema, lymphovenous insufficiency) are invited to consult with leading specialists for these diseases) or additional research methods;
- all patients who need surgery are consulted in advance by the operating surgeon and, if necessary, the anesthesiologist.
Treatment
Conservative treatment is indicated mainly for patients who have contraindications for surgical treatment: according to the general condition, with a slight expansion of the veins, which causes only aesthetic discomfort, 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 area with an elastic bandage or wear elastic socks, occasionally give the legs a horizontal position, perform special exercises for the foot and lower leg (flexion and extension in the ankle and knee joint) to activate the muscle-venous pump. Elastic compression accelerates and enhances 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. Dressing should start in the morning, before getting out of bed. The bandage is applied with light tension from the toes to the thigh, with the obligatory grasping of the heel and ankle joints. Each subsequent round of bandages should overlap the previous one in half. It is recommended to use certified therapeutic knitwear with 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 work, and work in warm 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, replacing a special stand of the required height under the feet. It is recommended to walk a little or stand on your toes 10-15 times every 1-1. 5 hours. The resulting contractions of the calf muscles improve blood circulation and increase venous outflow. During sleep, the legs must be raised in an elevated position.
Patients are advised to limit water and salt intake, normalize body weight, occasionally take diuretics, drugs that improve vein tone/According to indications, drugs that improve tissue microcirculation are prescribed. For treatment, we recommend the use of non-steroidal anti-inflammatory drugs.
Physical therapy plays an important role in the prevention of varicose veins. In uncomplicated forms, water procedures are useful, especially swimming, warm (no higher than 35 °) foot baths with a 5-10% solution of edible salt.
Compression sclerotherapy
Indications for injection therapy (sclerotherapy) of varicose veins are still debated. The method consists in the introduction of a sclerosing agent into the varicose vein, its further compression, destruction and sclerosis. Modern drugs used for these purposes are quite safe, ie. they do not cause necrosis of the skin or subcutaneous tissue when given extravasally. Some experts use sclerotherapy for almost all forms of varicose veins, while others completely reject this method. Most likely, the truth is somewhere in between, and for young women with the initial stages of the disease, it makes sense to use the injection method of treatment. The only thing is that they must be warned about the possibility of relapse (higher than with surgery), the need to constantly wear a 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 telangiectasia ("spider veins") and reticular dilatation of the small saphenous veins, because the causes of these diseases are identical. In this case, with sclerotherapy, it is possible to carry outpercutaneous laser coagulation, but only after exclusion of lesions of deep and perforating veins.
Percutaneous laser coagulation (PCL)
This is a method based on the principle of selective photocoagulation (photothermolysis), which is based on different absorption of laser energy by different body substances. The characteristic of the method is the non-contact nature of this technology. Focusing supplement concentrates energy into the blood vessel of the skin. Hemoglobin in the vessel selectively absorbs laser rays of a certain wavelength. Under the action of the laser in the lumen of the vessel, the endothelium is destroyed, which leads to the sticking of the vessel walls.
The effectiveness 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 greater than 1. 0-1. 5 mm, microsclerotherapy is the most effective. Due to the widened and branched spread of spider veins on the legs, the changing diameter of blood vessels, a combined method of treatment is currently actively used: in the first stage, sclerotherapy of veins with a diameter greater than 0. 5 mm is carried out, then a laser is used to remove the remaining "stars"smaller diameter.
The procedure is practically painless and safe (skin cooling and anesthetics are not used) because it is lightdeviceit refers 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 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 skin area, which then disappears. In light-skinned people, 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 area 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 thanks to the unique "square" shape of the light pulse of the device, which increases its efficiency compared to other devices, while at the same time reducing the possibility of side effects after the procedure?
Operation
Surgical intervention is the only radical treatment for patients with varicose veins of the lower extremities. The purpose of the operation is to remove pathogenetic mechanisms (venous-venous reflux). This is achieved by removing the main trunks of the great and small saphenous veins and ligation of incompetent communicating veins.
Treatment of varicose veins with 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 lifelong reminder 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 devised a method of plucking the saphenous vein using a hard metal probe with plucking of the olive and veins. 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, the classic phlebectomy is called the Babcock-Narata method. Phlebcock-Narath phlebectomy has disadvantages - large scars after surgery and impaired skin sensitivity. Working capacity decreases in 2-4 weeks, which makes it difficult for patients to agree to 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 solved by usingcombined technique. The main large varicose veins are removed by inverse stripping, which involves minimal intervention through mini-incisions (from 2 to 7 mm) on 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. Combined surgical treatment is performed under total intravenous or spinal anesthesia, and the maximum hospital stay is up to 1 day.
Surgical treatment includes:
- Crossectomy - crossing the mouth 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 version).
Actuallyminiphlebectomycame to replace the method of removing enlarged tributaries of the main veins towards Narata. Previously, skin incisions of 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 that the veins can be removed not by traditional incisions, but by mini-incisions (punctures), forced doctors to develop tools that allow them to do almost the same through a minimal skin defect. Thus, sets of phlebectomy "hooks" of different 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 sufficiently large diameter (for example, a needle used for taking venous blood for analysis with a diameter of 18G). In an ideal case, the trace of a puncture with such a needle is practically invisible after a while.
Some forms of varicose veins are treated on an outpatient basis under local anesthesia. Minimal trauma during miniphlebectomy, as well as a low risk of intervention, make it possible to perform this operation in a day hospital. After minimal observation in the clinic after surgery, 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 longer than 7 days, after which it is possible to start work.
When is microphlebectomy used?
- With the diameter of the dilated trunks of the great or small saphenous vein greater than 10 mm
- After getting over 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 an integral part of the combined treatment of varicose veins, in combination with laser treatment of veins and sclerotherapy. The tactics of application are determined individually, always taking into account the results of an ultrasound duplex 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 Varadi from Frankfurt developed his handy tools and formulated the basic postulates of modern microphlebectomy. The Varadi method of phlebectomy gives an excellent cosmetic result without pain and hospitalization. This is very painstaking work, almost jewelry.
After vein surgery
The postoperative period after the usual "classic" phlebectomy is quite painful. Sometimes large hematomas disturb, there is edema. Wound healing depends on the phlebologist's surgical technique, sometimes there is leakage of lymph and long-term 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, because they are only punctures, there are no painful sensations, and damage to skin nerves has not been observed in our practice. However, such phlebectomy results are achieved only by highly experienced phlebologists.
Scheduling an appointment with a phlebologist
Be sure to consult with a qualified specialist in the field of vascular diseases.