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 major role in evaluating instrumental examination data and 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 toes, forms the venous network of the back of the leg and the skin dorsal arch of the leg.It gives rise to the medial and lateral marginal veins, which pass into the great and small saphenous veins, respectively.The great saphenous vein is the longest vein in the body, consists of 5-10 pairs of valves, and its normal diameter is 3-5 mm.It arises from 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, 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 along the lateral surface of the lower third of the leg.In 25% of cases, it flows into the popliteal vein in the region of the popliteal fossa.In other cases, the lesser saphenous vein may rise above the popliteal fossa and drain into the thigh, the greater saphenous vein, or the deep vein of the thigh.
The deep veins of the hindfoot originate from the dorsal metatarsal veins of the foot, which flow into the posterior venous arch of the foot, and from there 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, which is located lateral and slightly posterior to the artery of the same name.In the region 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 groin.Above the inguinal ligament, this vein 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 bowl 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 pelvis.
Perforating (communicating) veins connect deep veins with superficial veins.Most of them have valves located suprafascially, thanks to which blood moves from superficial veins to deep ones.There are direct and indirect perforating vessels.The direct ones directly connect the deep and superficial venous networks, the indirect ones are connected indirectly, that is, they flow first to the muscular vein, and then to the deep vein.
The vast majority of perforating veins arise from branches of the great saphenous vein, not from its body.90% of patients have incompetence of the perforating veins of the medial surface of the lower third of the leg.In the lower leg, incompetence of the perforating veins of Coquette, which connect the posterior branch of the great saphenous vein (Leonardo's vein) with the deep veins, is most often observed.In the middle and lower third of the thigh, there are usually 2-4 most permanent perforating veins (Dodd, Gunter) connecting the trunk of the great saphenous vein with the femoral vein.With varicose transformation of the small saphenous vein, incompetent communication veins are most often observed in the area of the middle, lower third of the foot and lateral malleolus.
Clinical course of the disease
Varicose veins mainly occur in the large vascular system, less often in the small saphenous vein system, and start from branches of the venous trunk in the legs.At the initial stage, the natural course of the disease is quite favorable;for the first 10 years or more, nothing can bother patients, except for a cosmetic defect.Later, if not treated in time, after physical activity (long walk, standing) or in the afternoon, especially in the hot season, complaints about the feeling of heaviness, fatigue and swelling in the legs begin to appear.Most patients complain of pain in the legs, but after a detailed questioning, it is possible to find out that it is exactly a feeling of fullness, heaviness and fullness in the legs.Even with a short rest and a high position of the limb, the intensity of the sensations decreases.These are the 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 extremities, acute venous thrombosis, joint pain, etc.).The further development of the disease leads to the formation of trophic disorders due to the increase in the number and size of dilated vessels, often due to the addition of incompetent perforating veins and the occurrence of valvular insufficiency of deep veins.
In the absence of perforating vessels, trophic disorders are limited to any surface of the foot (lateral, medial, posterior).At the initial stage, trophic disorders are manifested by local hyperpigmentation of the skin, then thickening (induration) of the subcutaneous fat tissue occurs until the development of cellulite.This process ends with the formation of an ulcer-necrotic defect, which can reach a diameter of 10 cm or more and extends to the depth of the fascia.The typical site of appearance of venous trophic ulcers is the area of the medial malleolus, but the localization of ulcers on the lower leg can be varied and multiple.In the stage of trophic disorders, severe itching and burning occurs in the affected area;Some patients develop microbial eczema.Although severe in some cases, the pain in the ulcer area cannot be expressed.At this stage of the disease, heaviness and swelling in the leg are permanent.
Diagnosis of varicose veins
Diagnosing the preclinical stage of varicose veins is especially difficult, because such a patient may not have varicose veins in his legs.
In such patients, the diagnosis of varicose veins of the legs is erroneously rejected, although there are ultrasound data on the symptoms of varicose veins, the presence of relatives suffering from this disease (hereditary tendency), and 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 is possible to prevent pathological changes in the venous system of the legs through minimal therapeutic effects on varicose veins.
Avoiding various types of diagnostic errors and making a 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 the maximum possible information about the state of the venous system of the legs obtained using the most modern equipment (instrumental diagnostic methods).
A duplex scan is sometimes performed to determine the exact location of the perforating vessels, color-coding venovenous reflux.In the event of valve failure during the Valsava maneuver or compression tests, their valves stop closing completely.Valve insufficiency leads to the appearance of venovenous reflux, from the superior, incompetent saphenofemoral joint and inferior, through the incompetent perforating veins of the leg.Using this method, it is possible to record reverse blood flow through prolapsed leaflets of an incompetent valve.Therefore, the diagnosis is multi-stage or multi-level.In a normal case, the diagnosis is made after ultrasound diagnostics and examination by a phlebologist.However, in particularly difficult cases, the examination should be done step by step.
- First, a comprehensive examination and questioning is carried out by a phlebologist surgeon;
- if necessary, the patient is sent to additional instrumental research methods (duplex angioscanning, phleboscintigraphy, lymphoscintigraphy);
- patients with accompanying diseases (osteochondrosis, varicose eczema, lymphovenous insufficiency) are offered consultations with leading specialist consultants on these diseases) or additional research methods;
- All patients who need surgery are first consulted by an operating surgeon and, if necessary, an anesthesiologist.
Treatment
Conservative treatment is mainly indicated for patients who have contraindications to surgical treatment: due to their general condition, with a slight expansion of vessels causing only cosmetic concern, or when 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 surface with an elastic bandage or wear elastic stockings, periodically place their legs in a horizontal position, and perform special exercises for the leg and lower leg (flexion and extension in the ankle and knee joints) to activate the musculo-venous pump.Elastic compression accelerates and strengthens 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.The bandage should be started in the morning, before getting out of bed.The bandage is applied from the toes to the thigh with a slight tension, forcing the joint of the heel and ankle.Each next round of the bandage should cut 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 heels and low heels, avoid standing for a long time, heavy physical labor, and work in hot and humid places.If the patient has to sit for a long time due to the nature of work, then it is necessary to place the feet in a raised position by placing a special support under the feet at the appropriate height.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 flow.You should keep your legs elevated while sleeping.
Patients are advised to limit water and salt intake, normalize body weight, periodically take diuretics and drugs that improve venous tone.According to the indications, drugs are prescribed that improve microcirculation in the tissues.It is recommended to use non-steroidal anti-inflammatory drugs for treatment.
Physiotherapy plays an important role in the prevention of varicose veins.For uncomplicated forms, water procedures are useful, especially swimming, foot baths with a 5-10% solution of warm (not higher than 35 °) table salt.
Compression sclerotherapy
Indications for injection treatment (sclerotherapy) for varicose veins are still debated.The method consists of introducing a sclerosing agent into the dilated vessel, further compressing it, emptying it and sclerosing it.Modern drugs used for these purposes are quite safe, that is, they do not cause necrosis of the skin or subcutaneous tissue when applied extravasally.Some specialists 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 stage of the disease to use the injection method.The only thing is that they should be warned about the possibility of relapse (higher than with surgical intervention), the need to constantly wear a stabilizing compression bandage for a long time (up to 3-6 weeks), and the possibility that several sessions may be required for complete sclerosis of the vessels.
The group of patients with varicose veins should include patients with telangiectasia ("spider veins") and mesh dilatation of the small saphenous veins, because the reasons for the development of these diseases are the same.In this case, in addition to sclerotherapy, you canpercutaneous laser coagulation, but only after excluding damage to deep and perforating vessels.
Percutaneous laser coagulation (PLC)
This is a method based on the principle of selective photocoagulation (photothermolysis), which is based on the different absorption of laser energy by different substances in the body.A special feature of the method is that this technology is non-contact.The focusing head concentrates the energy on the blood vessel in the skin.Hemoglobin in the vein selectively absorbs laser rays of a certain wavelength.Under the influence of the laser, the endothelium is destroyed in the lumen of the vessel, which causes adhesion of the vessel walls.
The effectiveness of PLK directly depends on the penetration depth of laser radiation: the deeper the vein, the longer the wavelength should be, so PLK has rather limited indications.Microsclerotherapy is most effective for vessels with a diameter greater than 1.0-1.5 mm.Taking into account the wide and branched distribution of spider veins on the legs and the changing diameter of the veins, a combined treatment method is actively used: at the first stage, sclerotherapy of veins with a diameter of more than 0.5 mm is performed, then a laser is used to remove the remaining "stars" of a smaller diameter.
Since the light of the device belongs to the visible part of the spectrum, the procedure is practically painless and safe (no cooling of the skin and anesthetics are used), 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 pain sensitivity, initial application of a cream with local anesthetic effect is recommended.Erythema and swelling disappear within 1-2 days.After the course, for about two weeks, some patients may notice darkening or lightening of the treated area of the skin, which then disappears.In people with light skin, the changes are hardly noticeable, 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 work - the blood vessels are located at different depths, the lesions can be small or occupy a fairly large surface of the skin, but usually no more than four laser therapy sessions (5-10 minutes each) are needed.In such a short time, the maximum result is achieved due 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
For patients with varicose veins of the lower extremities, surgery is the only radical treatment method.The purpose of the operation is to eliminate pathogenetic mechanisms (veno-venous reflux).This is achieved by removing the main trunks of the greater and lesser saphenous vein and ligation of the incompetent communicating vessels.
Surgical treatment of varicose veins has a hundred years of history.In the past, and many surgeons still do, large incisions were made along the varicose veins and general or spinal anesthesia was used.The scars 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 was greater than the damage of varicose veins.
In 1908, the American surgeon Babcock proposed a method of drawing a subcutaneous vein using a hard metal probe with an olive.In an improved form, this surgical method to remove varicose veins is still used in many public hospitals.Varicose veins are removed through separate incisions as suggested by surgeon Narat.Thus, the classic phlebectomy is called the Babcock-Narat method.According to Babcock-Narat, phlebectomy has disadvantages - large scars after the operation and impaired skin sensitivity.The ability to work decreases within 2-4 weeks, which makes it difficult for patients to agree to surgical treatment of varicose veins.
Phlebologists have developed a unique technology for the treatment of varicose veins in one day.Complicated cases are operated usingcombined technology.The main large varicose veins are removed by inversion peeling, which involves minimal intervention through mini-incisions of the skin (between 2 and 7 mm) and leaves practically no scars.The use of minimally invasive techniques 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, the maximum length of hospital stay is up to 1 day.
Surgical treatment includes:
- Crossectomy - passing through the place where the trunk of the great saphenous vein flows into the deep venous system;
- Stripping is the removal of part of the varicose veins.Only the varicose vein is removed, not the entire one (as in the classic version).
Actuallyminiphlebectomyreplaced the Narat technique to eliminate varicose branches of major veins.Previously, skin incisions of 1-2 to 5-6 cm were made along the course of the varices, through which the vessels were isolated and removed.The desire to improve the cosmetic result of the intervention and 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 thing through a minimal skin defect.This is how sets of phlebectomy "hooks" of various sizes and configurations and special spatulas appeared.And instead of an ordinary scalpel, scalpels with a very narrow blade or needles with a fairly large diameter began to be used to pierce the skin (for example, a needle with a diameter of 18G used to take venous blood for analysis).Ideally, 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 the low risk of intervention, allows this operation to be performed in a day hospital.After the operation, the patient can be sent home on his own after minimal observation in the clinic.In the postoperative period, an active lifestyle is maintained, active walking is encouraged.Temporary incapacity for work usually does not exceed 7 days, after which it is possible to start work.
When is microphlebectomy used?
- When the diameter of varicose veins of the great or small saphenous vein is more than 10 mm;
- After suffering from thrombophlebitis of the main subcutaneous bodies;
- After recanalization of trunks after other types of treatment (EVLT, sclerotherapy);
- Removal of very large individual varicose veins.
It can be an independent operation or it can be part of the combined treatment of varicose veins 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 for a variety of reasons, including removing veins from various areas of the face that have changed.Professor Varadi from Frankfurt developed his convenient tools and formulated the basic postulates of modern microphlebectomy.The Varadi phlebectomy method provides excellent cosmetic results without pain or hospitalization.It is very painstaking, almost jewelry work.
After vascular surgery
The postoperative period after the usual "classic" phlebectomy is quite painful.Sometimes large hematomas cause discomfort, swelling occurs.Wound healing depends on the phlebologist's surgical technique;sometimes there is lymph leakage and long-term formation of visible wounds;Often after a large phlebectomy, a loss of sensation remains in the heel area.
On the contrary, after miniphlebectomy, suturing of wounds is not required, because they are only punctures, there is no pain, and in practice, damage to skin nerves is not observed.However, such results of phlebectomy are achieved only by very experienced phlebologists.