The anatomical structure of the venous system of the lower limbs is highly variable. Knowledge of the individual characteristics of the structure of the venous system plays an important role in evaluating the data of the instrumental examination in choosing the right method of treatment.
The veins of the lower limbs are divided into superficial and deep. The superficial venous system of the lower limbs starts from the venous plexuses of the toes, which form the venous network of the dorsum of the foot and the dorsal cutaneous arch of the foot. From it originate the medial and lateral marginal veins, which pass respectively into the great and small saphenous veins. 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 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 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 flow into the femoral vein, the great saphenous vein, or the deep thigh vein.
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 merge to form the popliteal vein, which is located laterally and a little behind the homonymous artery. In the region of the popliteal fossa, the small saphenous vein, the veins of the knee joint, flow 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 surrounding the ileum, 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 vase, 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, the lower torso, the abdominal organs and the small pelvis.
Perforating (communicating) veins connect deep and superficial veins. Most of them have valves located suprafascially and thanks to which the blood moves from the superficial to the deep veins. There are direct and indirect perforating veins. The direct lines directly connect the deep and superficial venous networks, the indirect ones connect indirectly, that is, they flow first into the muscle vein, which then flows into the deep one.
The vast majority of perforating veins come from tributaries and not 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, the most common subsidence of Cockett's perforating veins, which connects 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), which directly connect 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 third 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 great saphenous system, less often in the small saphenous system, and begins with the tributaries of the vein trunk on the lower leg. The natural course of the disease in the initial stage is quite favorable, the first 10 years or more, 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 a feeling of heaviness, fatigue in the legs and their swelling after physical exertion (long walks, standing) or in the afternoon, especially in hot weather, begin to appear. Most patients complain of pain in the legs, but a detailed interrogation 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 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 limbs, 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 onset of trophic disorders, most often due to the addition of incompetence of the perforating veins and the occurrence of valvular insufficiency of the deep veins.
With the insufficiency of the 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 the thickening (hardening) of the subcutaneous fat adds 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 onset of venous trophic ulcers is the region of the medial malleolus, but the location 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 ulcer area may not be expressed, 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 incorrectly 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 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 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 on the state of the venous system of the legs (instrumental diagnostic methods).
Duplex scanning is sometimes performed to determine the exact location of the perforating veins, clarifying the veno-venous reflux in a color code. In case of failure of the valves, their flaps cease to close completely during the Valsava test or the compression tests. Valvular insufficiency leads to 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 prolapsed flaps of an incompetent valve. That is why our diagnostics have a multistage or multilevel character. 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 to further instrumental research methods (duplex angioscanning, phleboscintigraphy, lymphoscintigraphy);
- patients with concomitant pathologies (osteochondrosis, varicose eczema, lymphovenous insufficiency) are advised to consult the main specialized consultants on these diseases) or further research methods;
- all patients requiring surgery are previously consulted by the operating surgeon and, if necessary, by the anesthetist.
Treatment
Conservative treatment is mainly indicated for patients who have contraindications to surgical treatment: depending on the general condition, with a slight dilation of the veins, it causes only aesthetic discomfort, in case of refusal of surgical intervention. Conservative treatment is aimed at preventing further development of the disease. In such 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 of the joints of the ankle and knee) to activate the musculo-venous pump. Elastic compression accelerates and improves blood flow in the deep veins of the thigh, reducesthe 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 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 is 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, strenuous 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, the legs should be placed in an elevated position, replacing a special support of the required height under the feet. It is recommended every 1-1. 5 hours to walk a little or to stand up on tiptoes 10-15 times. The resulting contractions of the calf muscles improve blood circulation, improve venous outflow. During sleep, the legs must be betrayed in an elevated position.
Patients are advised to limit water and salt intake, normalize body weight, periodically take diuretics, drugs that improve the tone of the veins / According to indications, drugs are prescribed that improve microcirculation in the tissues. For treatment, the use of non-steroidal anti-inflammatory drugs is recommended.
An essential role in the prevention of varicose veins belongs to physical therapy. In simple forms, water procedures are useful, especially swimming, hot foot baths (not higher than 35 °) with a 5-10% solution of edible salt.
Compression sclerotherapy
The indications for injection therapy (sclerotherapy) for varicose veins are still under discussion. 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. they 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 between and it makes sense that young women with the early stages of the disease use an injection method of treatment. The only thing is that they need to be warned about the possibility of relapse (more than surgery), about the need to constantly wear a fixing compression bandage for a long time (up to 3-6 weeks), about the likelihood of several sessions.
The group of patients with varicose veins should include patients with telangiectasias ("spider veins") and reticular dilatation of the small saphenous veins, since the causes of these diseases are identical. In this case, together with sclerotherapy, it is possible to carry outpercutaneous laser coagulation, but only after the exclusion of deep and perforating vein lesions.
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 various bodily substances. A feature of the method is the contactlessness of this technology. The focusing attachment focuses the energy in the blood vessel of the skin. Hemoglobin in a 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 vessel walls.
The efficiency of the PLC directly depends on the depth of penetration of the laser radiation: the deeper the vessel, the greater 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. Given the extensive and branching spread of varicose veins on the legs, the varying diameter of the vessels, a combined treatment method is currently actively used: in the first stage, sclerotherapy of veins with a diameter of more than 0. 5 mm is performed, then a laser it is used to remove remaining "asterisks" of smaller diameter.
The procedure is practically painless and safe (skin cooling and anesthetics are not used) because of the lightapparatusrefers 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 pain sensitivity are recommended to apply a cream with local anesthetic effect. The 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 skin area, 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 a 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 skin surface - but usually no more than four laser therapy sessions (5-10 minutes each) are required . The maximum result in such a short time is obtained thanks to the unique "square" shape of the light pulse of the device, which increases its efficiency compared to other devices, also reducing the possibility of side effects after the procedure?
Surgery
Surgery is the only radical treatment for patients with varicose veins of the lower limbs. The purpose of the operation is to eliminate the pathogenetic mechanisms (veno-venous reflux). This is achieved by removing the main trunks of the large and small saphenous veins and ligating the incapable communicating veins.
The surgical treatment of varicose veins has a centuries-old history. Previously, and many surgeons still used large incisions along the course of varicose veins, general or spinal anesthesia. Traces after such a "miniflebectomy" remain a lifelong reminder of the operation. The first operations on the veins (according to Schade, according to Madelung) were so traumatic that the damage from them outweighed the damage from varicose veins.
In 1908, an American surgeon devised a method of plucking the saphenous vein using a hard metal probe with an olive and a vein plucker. In an improved form, this surgical method of varicose vein removal is still used in many public hospitals. Varicose tributaries are removed by separate incisions, as suggested by the surgeon Narat. Therefore, classic phlebectomy is called the Babcock-Narata method. Phlebcock-Narath phlebectomy has disadvantages: large scars after surgery and reduced skin sensitivity. The ability to work is reduced by 2-4 weeks, which makes it difficult for patients to accept surgical treatment of varicose veins.
Phlebologists from 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 reverse stripping, which involves minimal intervention through mini-incisions (2 to 7 mm) of the skin, which leave practically no scars. The use of minimally invasive techniques results in minimal tissue trauma. The result of our intervention 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 1 day.
Surgical treatment includes:
- Crossectomy: crosses 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 transformed varicose vein is removed and not the entire vein (as in the classic version).
In realityminiflebectomycame to replace the method of removing varicose tributaries of the main veins according to Narata. Previously, along the course of the varices, skin incisions from 1-2 to 5-6 cm were made, through which the veins were identified and removed. The desire to improve the aesthetic result of the surgery and to be able to remove the veins not through traditional incisions, but through mini-incisions (punctures), has forced doctors to develop tools that allow them to do almost the same through a minimal defect. cutaneous. This is how sets of "hooks" for phlebectomy 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 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 treat on an outpatient basis under local anesthesia. The slightest trauma during miniflebectomy, as well as a small risk of surgery, allow you to perform this operation in the day hospital. After minimal observation in the clinic after the operation, the patient may be allowed to go home alone. In the postoperative period, an active lifestyle is maintained, active walking is encouraged. Temporary disability usually does not exceed 7 days, so it is possible to start work.
When is microflebectomy used?
- With a diameter of varicose trunks of a large or small saphenous vein greater 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 be a component of the combined treatment of varicose veins, combined with laser vein treatment and sclerotherapy. The tactic of application is determined individually, always taking into account the results of the ultrasound duplex scan of the patient's venous system. Microflebectomy 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 practical tools and formulated the basic postulates of modern microflebectomy. The Varadi phlebectomy method gives an excellent aesthetic result without pain and hospitalization. This is a very painstaking work, almost of 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 surgical technique of the phlebologist, sometimes there is lymph loss and prolonged formation of noticeable scars, often after a large phlebectomy there is a violation of sensitivity in the heel area.
On the contrary, after miniflebectomy, the wounds do not require suturing, since it is only punctures, there are no pain sensations, and in our practice no damage to the nerves of the skin has been observed. However, such results of phlebectomy are achieved only by very experienced phlebologists.
Make an appointment with a phlebologist
Be sure to consult with a qualified specialist in the field of vascular diseases.