The anatomical structure of the venous system of the lower extremities is characterized by great variability.Knowing the individual characteristics of the structure of the venous system plays a big role in evaluating the data of the instrumental examination and 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 fingers, forming the venous network of the dorsum of the foot and the skin of the dorsal arch of the foot.It originates from the medial and lateral marginal veins, which pass into the greater and the lower saphenous vein.The great saphenous vein is the longest vein in the body, it contains from 5 to 10 pairs of valves, and its normal diameter is 3-5 mm.It arises in the lower third of the leg in front of the medial epicondyle and rises in the subcutaneous tissue of the leg and thigh.In the groin area, the great saphenous vein drains into the femoral vein.Sometimes the great 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 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 dorsum of the 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 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 and the veins of the knee joint flow into the popliteal vein.The deep vein of the thigh 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 thanks to which blood moves from superficial veins to deep ones.There are direct and indirect perforating veins.The direct ones directly connect the deep and superficial venous network, the indirect ones connect indirectly, that is, they first flow into the muscular vein, which then flows into the deep vein.
The vast majority of perforating veins arise from tributaries and not from the trunk of the great saphenous vein.In 90% of patients there is incompetence of the perforating veins of the medial surface of the lower third of the leg.On the lower leg, incompetence of Cockett's perforating veins, which connect the posterior branch of the great saphenous vein (Leonard's vein) with the deep veins, is most often observed.In the middle and lower third of the thigh, there are usually 2-4 permanent perforating veins (Dodd, Gunter), 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, lower third of the leg and in the area of the lateral malleolus.
Clinical course of the disease
Varicose veins mostly occur in the system of the great saphenous vein, less often in the system of the small vein, and start from the tributaries of the venous trunk on the legs.The natural course of the disease in the initial stage is quite favorable;for the first 10 years or more, apart from a cosmetic defect, the patient may not be bothered by anything.After that, if timely treatment is not carried out, complaints of a feeling of heaviness, fatigue in the legs and their swelling after physical activity (long walking, standing) or in the afternoon, especially in the hot season, begin to appear.Most patients complain of pain in the legs, but a detailed examination can reveal that it is a 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 an increase in the number and size of varicose veins, leads to the appearance of trophic disorders, often due to the addition of incompetent perforating veins and the appearance of valvular insufficiency of the deep veins.
In case of insufficiency of perforating veins, trophic disorders are limited to any of the surfaces of the leg (lateral, medial, posterior).Trophic disorders in the initial phase are manifested by local hyperpigmentation of the skin, then there is a thickening (induration) of the subcutaneous fatty tissue until the development 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 area 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 and burning occurs in the affected area;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 constant.
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 mistakenly rejected, although there are symptoms of varicose veins, indications that the patient has relatives suffering from this disease (hereditary predisposition), and 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 with 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, a correct interpretation of all his complaints, a detailed analysis of the medical history and maximum possible information about the condition of the venous system of the legs obtained with the most modern equipment (instrumental diagnostic methods).
A duplex scan is sometimes performed to determine the exact location of the perforating veins, identifying venous reflux in a color code.In the case of valvular insufficiency, their valves stop closing completely during the Valsava maneuver or compression tests.Insufficiency of the valve leads to the appearance of venous reflux, high, through the incompetent saphenofemoral junction, and low, through the incompetent perforating veins of the leg.Using this method, it is possible to image the reverse blood flow through the prolapsed leaflets of an incompetent valve.That is why the diagnosis is multi-level or multi-level.In a normal situation, the diagnosis is made after ultrasound diagnostics and an examination by a phlebologist.However, in particularly difficult cases, the review must be carried out in stages.
- First, a detailed examination and examination is performed by a surgeon-phlebologist;
- if necessary, the patient is sent for additional instrumental research methods (duplex angioscanning, phleboscintigraphy, lymphoscintigraphy);
- patients with accompanying diseases (osteochondrosis, varicose eczema, lymphovenous insufficiency) are offered consultation with leading specialists for these diseases) or additional research methods;
- all patients requiring surgery are first consulted by an operating surgeon and, if necessary, an anesthesiologist.
Treatment
Conservative treatment is indicated mainly for patients who have contraindications for surgical treatment: due to the general condition, with a slight expansion of the veins that causes only aesthetic discomfort, or if surgical intervention is refused.Conservative treatment is aimed at preventing further development of the disease.In these cases, patients should be advised to wrap the affected area with an elastic bandage or wear elastic socks, occasionally put their legs in a horizontal position and perform special exercises for the foot and lower leg (flexion and extension in the ankle and knee joints) in order to activate the muscle-venous pump.Elastic compression accelerates and enhances blood flow in the deep veins of the thigh, reduces the amount of blood in the saphenous veins, prevents edema, improves microcirculation and helps normalize metabolic processes in tissues.Dressing should be started in the morning, before getting out of bed.The bandage is applied with light tension from the toes to the thigh, with the obligatory grip of the heel and ankle joint.Each subsequent round of bandages should overlap the previous one in half.It is recommended to use certified medical 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, heavy physical work and work in hot and humid areas.If, due to the nature of the work activity, the patient has to sit for a long time, then the legs should be placed in an elevated position by placing a special stand of the required height under the feet.It is recommended to walk a little every 1-1.5 hours or stand on your toes 10-15 times.The resulting contractions of the calf muscles improve blood circulation and increase venous outflow.During sleep, your legs should be in an elevated position.
Patients are advised to limit water and salt intake, normalize body weight and occasionally take diuretics and drugs that improve venous tone.According to indications, drugs are prescribed that improve microcirculation in tissues.For treatment, the use of non-steroidal anti-inflammatory drugs is recommended.
Physical therapy plays an important role in the prevention of varicose veins.For uncomplicated forms, water procedures are useful, especially swimming, warm (no more than 35°) foot baths with a 5-10% solution of table salt.
Compression sclerotherapy
Indications for injection therapy (sclerotherapy) of varicose veins are still debated.The method consists of introducing a sclerosing agent into the varicose vein, its further 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 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 the middle, and it makes sense for young women with the initial stages of the disease to use the injection method of treatment.The only thing is to warn them about the possibility of relapse (greater than with surgical intervention), the need to constantly wear a compression bandage for a long time (up to 3-6 weeks) and the probability that several sessions will be needed for complete vein sclerosis.
Patients with telangiectasia ("spider veins") and network dilatation of small saphenous veins should be included in the group of patients with varicose veins, because the causes of the development of these diseases are identical.In this case, with sclerotherapy, you can alsopercutaneous laser coagulation, but only after ruling out damage to deep and perforating veins.
Percutaneous laser coagulation (PLC)
This is a method based on the principle of selective photocoagulation (photothermolysis), based on the different absorption of laser energy by various substances in the body.A special feature of the method is the non-contact nature of this technology.The focusing head concentrates energy into a blood vessel in the skin.Hemoglobin in the vessel selectively absorbs laser rays of a certain wavelength.Under the action of the laser, the endothelium in the lumen of the vessel is destroyed, which leads to the adhesion of the vessel walls.
The effectiveness of PLK directly depends on the depth of laser radiation penetration: the deeper the vessel, the longer the wavelength should be, so PLK has rather limited indications.For vessels with a diameter greater than 1.0-1.5 mm, microsclerotherapy is the most effective.Due to the extensive and branched distribution of spider veins on the legs and the variable 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 the remaining "stars" of smaller diameter are removed with a laser.
The procedure is practically painless and safe (skin cooling and anesthetics are not used), since the light of the device belongs to the visible part of the spectrum, and the wavelength of the light is designed so that the water in the tissues does not boil and the patient does not get burned.For patients with high sensitivity to pain, a preliminary application of a cream with a local anesthetic effect is recommended.Erythema and swelling disappear within 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 may be smaller or occupy a fairly large area of the skin, but usually no more than four sessions of laser therapy (5-10 minutes each) are required.The maximum result in such a short time is achieved thanks to the unique "square" shape of the light pulse of the device;increases its effectiveness compared to other devices, and also reduces the possibility of side effects after the procedure.
Surgical treatment
Surgery is the only radical treatment method for patients with varicose veins of the lower extremities.The purpose of the operation is to remove pathogenetic mechanisms (veno-venous reflux).This is accomplished by removing the main trunks of the great and small saphenous veins and ligating the incompetent communicating veins.
Surgical treatment of varicose veins has a hundred-year history.In the past, and many surgeons still do, large incisions along the varicose veins and general or spinal anesthesia were used.Traces after such a "mini-phlebectomy" 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, the American surgeon Babcock devised a method of withdrawing subcutaneous veins using a rigid metal probe with an olive.In an improved form, this method of surgery to remove varicose veins is still used in many public hospitals.Varicose veins are removed through special incisions, as suggested by surgeon Narat.Therefore, the classic phlebectomy is called the Babcock-Narat method.Phlebectomy according to Babcock-Narat has disadvantages - large scars after surgery and impaired skin sensitivity.Work capacity decreases in 2-4 weeks, which makes it difficult for patients to agree to surgical treatment of varicose veins.
Phlebologists have developed a unique technology for treating varicose veins in one day.It is used to operate complex casescombined technology.The main large varicose veins are removed by inverse stripping, which involves minimal intervention through mini cuts (from 2 to 7 mm) on the skin, which practically do not leave scars.Application of the minimally invasive technique involves minimal tissue trauma.The result of this operation is the elimination of varicose veins with an excellent aesthetic result.Combined surgical treatment is performed under total intravenous or spinal anesthesia, with a maximum hospitalization period of up to 1 day.
Surgical treatment includes:
- Crossectomy - crossing the place where the trunk of the great saphenous vein flows into the deep venous system;
- Stripping is the removal of a fragment of varicose veins.Only the varicose vein is removed, not the whole one (as in the classic version).
Actuallyminiphlebectomyreplaced the Narat technique for the removal of enlarged tributaries of major veins.Previously, incisions were made on the skin from 1-2 to 5-6 cm along the course of the varix, through which the veins were isolated 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 thing through a minimal skin defect.Thus, sets of phlebectomy "hooks" of different sizes and configurations and special spatulas appeared.And instead of an ordinary scalpel, scalpels with a very narrow blade or needles with a rather large diameter began to be used to pierce the skin (for example, a needle used to take 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 sent home independently.In the postoperative period, an active lifestyle is maintained, active walking is encouraged.Temporary incapacity for work usually does not last longer than 7 days, after which it is possible to start working.
When is microphlebectomy used?
- When the diameter of the enlarged trunk of the great or small saphenous vein is greater than 10 mm;
- After you got over thrombophlebitis of the main subcutaneous trunks;
- After trunk recanalization after other types of treatment (EVLT, 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 use are determined individually, always taking into account the results of an ultrasound duplex scan of the patient's venous system.Microphlebotomy is used to remove veins of various locations that have changed for various reasons, including on the face.Professor Varadi of Frankfurt developed his handy instruments and formulated the basic postulates of modern microphlebectomy.The Varadi method of phlebectomy gives excellent cosmetic results without pain and hospitalization.This is very painstaking, almost jewelry work.
After vein surgery
The postoperative period after the usual "classic" phlebectomy is quite painful.Sometimes large hematomas are worrisome and swelling occurs.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 remains a loss of sensitivity in the heel area.
In contrast, after miniphlebectomy, wounds do not require suturing, because they are only punctures, there is no pain, and in practice no damage to skin nerves has been observed.However, such phlebectomy results are achieved only by highly experienced phlebologists.