The anatomical structure of the venous system of the lower limbs is characterized by great variability.Knowledge of the individual characteristics of the structure of the venous system plays an important role in evaluating the data of instrumental examination and choosing the correct treatment method.
The veins of the lower limbs are divided into superficial and deep.The superficial venous system of the lower extremities begins from the venous plexuses of the toes, forming the venous network of the dorsum of the foot and the dorsal cutaneous arch of the foot.The medial and lateral marginal veins originate from it, which channel into the large and small saphenous veins respectively.The great saphenous vein is the longest vein in the body, contains 5 to 10 pairs of valves, and its normal diameter is 3-5 mm.It originates in the lower third of the leg in front of the medial epicondyle and ascends into the subcutaneous tissue of the leg and thigh.In the inguinal area the great saphenous vein drains into the femoral vein.Sometimes the great saphenous vein of 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 can ascend above the popliteal fossa and flow into the femoral vein, the great saphenous vein 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, 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 merge to form the popliteal vein, which lies lateral and slightly posterior to 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 flows into the femoral vein 6-8 cm below the inguinal crease.Above the inguinal ligament, this vessel receives the epigastric vein, the deep vein surrounding 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 join 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 torso, abdominal organs and small pelvis.
Perforating (communicating) veins connect the deep veins with the superficial ones.Most of them are equipped with valves located suprafascial and thanks to which the blood moves from the superficial to the deep veins.There are direct and indirect perforating veins.The direct ones directly connect the deep and superficial venous networks, 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 rather than the trunk of the great saphenous vein.Incompetence of the perforating veins of the medial surface of the lower third of the leg is found in 90% of patients.In the lower leg, incompetence of the perforating veins of Cockett is most often observed, which connects the posterior branch of the great saphenous vein (Leonardo's vein) with the deep veins.In the middle and lower third of the thigh, 2-4 permanent perforating veins (Dodd, Gunter) are usually found, 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 third, lower leg and in the area of the lateral malleolus are more often observed.
Clinical course of the disease
Mostly, varicose veins occur in the system of the great saphenous vein, less often in the system of the small saphenous vein, and begin with 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, patients may not be bothered by anything.Subsequently, if timely treatment is not carried out, complaints of heaviness, leg fatigue and swelling begin to appear after physical activity (long walks, standing) or in the afternoon, especially in the hot season.Most patients complain of pain in the legs, but after a thorough examination it is possible to reveal that it is indeed a feeling of fullness, heaviness and fullness in the legs.Even with a short rest and an elevated position of the limb, the severity of 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 (artery 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 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 the perforating veins, trophic disorders are limited to any surface of the leg (lateral, medial, posterior).Trophic disorders in the initial stage are manifested by local hyperpigmentation of the skin, then a thickening (hardening) of the subcutaneous adipose tissue occurs until 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.The typical place of onset of venous trophic ulcers is the area of the medial malleolus, but the localization of the ulcers on the lower leg can be different and multiple.In the phase of trophic disorders, severe itching and burning occur in the affected area;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 leg become constant.
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 on his 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) and ultrasound data on the first pathological changes in the venous system.
All this can lead to failure to meet the 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 does it become 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, the correct interpretation of all his complaints, a detailed analysis of the history of the disease and the maximum possible information on the state of the venous system of the legs obtained using the most modern equipment (instrumental diagnostic methods).
Duplex scanning is sometimes performed to determine the exact location of the perforator veins, identifying venovenous reflux in a color code.In case of valve insufficiency, their valves stop closing completely during the Valsava maneuver or compression tests.Valvular insufficiency leads to the appearance of veno-venous reflux, up through the incompetent saphenofemoral junction, and down through the incompetent perforating veins of the leg.Using this method it is possible to record the reverse flow of blood through the prolapsed leaflets of an incompetent valve.This is why the diagnosis is multistage or multilevel.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 performed in stages.
- First, a thorough examination and interrogation by a phlebologist surgeon is carried out;
- if necessary, the patient is sent for additional instrumental research methods (duplex angioscanning, phleboscintigraphy, lymphoscintigraphy);
- patients with concomitant diseases (osteochondrosis, varicose eczema, lymphovenous insufficiency) are offered consultation with leading consultants specializing in these diseases) or additional research methods;
- all patients requiring surgery are first consulted by the operating surgeon and, if necessary, by an anesthetist.
Treatment
Conservative treatment is mainly indicated for patients who have contraindications to surgical treatment: due to their general condition, with a slight dilation of the veins causing only aesthetic inconveniences, or if surgical intervention is refused.Conservative treatment is aimed at preventing further development of the disease.In these cases it is necessary to advise the patient to bandage the affected surface with an elastic bandage or wear elastic stockings, periodically position the legs in a horizontal position and perform special exercises for the foot and lower leg (flexion and extension of the ankle and knee joints) to activate the musculovenous pump.Elastic compression accelerates and improves blood flow in the deep veins of thethigh, reduces the amount of blood in the saphenous veins, prevents the formation of edema, improves microcirculation and helps normalize metabolic processes in the tissues.Bandaging should begin 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 turn of the bandage should overlap the previous one by half.It is recommended to use certified medical 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 labor, and work in hot, humid areas.If, due to the nature of the working activity, the patient has to sit for a long time, the legs should be placed in an elevated position by placing a special support of the required height under the feet.It is recommended to walk a little every 1-1.5 hours or stand on tiptoe 10-15 times.The resulting contractions of the calf muscles improve blood circulation and increase venous outflow.During sleep, the legs should be placed in an elevated position.
Patients are advised to limit water and salt intake, normalize body weight and periodically take diuretics and drugs that improve venous tone.According to the indications, drugs that improve microcirculation in the tissues are prescribed.For treatment it is recommended to use non-steroidal anti-inflammatory drugs.
Physical therapy plays a significant role in the prevention of varicose veins.For uncomplicated forms, water procedures are useful, in particular swimming, warm foot baths (not exceeding 35°) with a 5-10% solution of table salt.
Compression sclerotherapy
The indications for injection therapy (sclerotherapy) for varicose veins are still a matter of debate.The method consists in introducing a sclerosing agent into the dilated 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 administered extravascularly.Some specialists use sclerotherapy for almost all forms of varicose veins, while others completely reject this method.Most likely, the truth lies somewhere in the middle and it makes sense that young women with the initial stages of the disease use the injection method of treatment.The only thing is that they need to be warned about the possibility of recurrence (higher than with surgery), the need to constantly wear a fixative compressive bandage for a long time (up to 3-6 weeks) and the likelihood that several sessions will be required for complete sclerosis of the veins.
The group of patients with varicose veins should include patients with telangiectasias ("spider veins") and dilation of the meshes of the small saphenous veins, since the causes of the development of these diseases are identical.In this case, together with sclerotherapy, you can also do itpercutaneous laser coagulation, but only after excluding damage to the 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 the various substances present in the organism.A special feature of the method is the non-contact nature of this technology.The focusing head focuses energy into a blood vessel in the skin.The hemoglobin in the vessel selectively absorbs laser rays of a certain wavelength.Under the action of the laser, destruction of the endothelium occurs in the lumen of the vessel, which leads to gluing of the vessel walls.
The effectiveness of PLK directly depends on the depth of penetration of the laser radiation: 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 more effective.Considering the extensive and branched distribution of varicose veins on the legs and the variable 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 is used to remove the remaining "stars" of smaller diameter.
The procedure is practically painless and safe (no skin cooling and anesthetics are used), since the light from the device belongs to the visible part of the spectrum, and the wavelength of the light is designed in such a way that the water in the tissues does not boil and the patient does not receive burns.For patients with high pain sensitivity, the preliminary application of a cream with local anesthetic effect is recommended.The erythema and swelling disappear within 1-2 days.After the course, for about two weeks, some patients may experience a darkening or lightening of the treated skin area, which then disappears.In people with light skin, 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 located at different depths, the lesions can be minor or occupy a fairly large skin surface, but usually no more than four sessions of laser therapy are needed (5-10 minutes each).The maximum result in such a short time is achieved thanks to the exclusive "square" shape of the device's light pulse;increases its effectiveness compared to other devices, also reducing 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 aim of the operation is to eliminate the pathogenetic mechanisms (veno-venous reflux).This is achieved by removing the main trunks of the great and small saphenous veins and ligating the incompetent communicating veins.
The surgical treatment of varicose veins has a centuries-old history.Previously, 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 memory of the operation for life.The first operations on the veins (according to Schade, according to Madelung) were so traumatic that their damage exceeded the damage of varicose veins.
In 1908, the American surgeon Babcock invented a method of extracting subcutaneous veins using a rigid metal probe with an olive.In an improved form, this surgical method of removing varicose veins is still used in many public hospitals.Varicose veins are removed using separate incisions, as suggested by surgeon Narat.Therefore, classical phlebectomy is called the Babcock-Narat method.Phlebectomy according to Babcock-Narat has disadvantages: large scars after surgery and reduced skin sensitivity.Work capacity is reduced for 2-4 weeks, which makes it difficult for patients to accept surgical treatment of varicose veins.
Phlebologists have developed a unique technology for the treatment of varicose veins in one day.Complex cases are handled usingcombined technology.The main large varicose trunks are removed by inversion stripping, which involves minimal intervention through miniincisions (from 2 to 7 mm) of the skin, which leave practically no scars.The use of a minimally invasive technique results in 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: crosses the point where the trunk of the great saphenous vein flows into the deep venous system;
- Stripping is the removal of a fragment of varicose vein.Only the varicose vein is removed and not all of it (as in the classic version).
Actuallyminiphlebectomyreplaced the Narat technique for removing varicose tributaries of the main veins.Previously, skin incisions from 1-2 to 5-6 cm were made along the course of varicose veins, through which the veins were isolated and removed.The desire to improve the aesthetic result of the operation and to be able to remove 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 are born.And instead of an ordinary scalpel, to pierce the skin they began to use scalpels with a very narrow blade or needles of a fairly large diameter (for example, a needle with a diameter of 18G used to take venous blood for analysis).Ideally, the sign of a puncture with such a needle is practically invisible after some time.
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, allow this operation to be performed in day hospital.After minimal observation in the clinic after surgery, the patient can be sent home alone.In the postoperative period, an active lifestyle is maintained and active walking is encouraged.Temporary incapacity for work usually lasts no more than 7 days, after which you can start working.
When is microphlebectomy used?
- When the diameter of the varicose trunks of the large or small saphenous vein is more than 10 mm;
- After suffering thrombophlebitis of the main subcutaneous trunks;
- After recanalization of the trunks after other types of treatment (EVLT, sclerotherapy);
- Removal of very large individual varicose veins.
It can be an independent operation or be part of a combined treatment of varicose veins, combined with laser treatment of veins and sclerotherapy.The tactics of use are determined individually, always taking into account the results of the duplex ultrasound scan of the patient's venous system.Microphlebetomy is used to remove veins of various locations that have changed for various reasons, including on the face.Professor Varadi from Frankfurt developed his convenient instruments and formulated the fundamental postulates of modern microphlebectomy.The Varadi phlebectomy method provides excellent aesthetic results without pain or hospitalization.This is a very scrupulous, almost jewelery-like job.
After vein surgery
The postoperative period after the usual “classic” phlebectomy is quite painful.Sometimes large hematomas are a cause for concern and swelling occurs.Wound healing depends on the phlebologist's surgical technique;sometimes there is a loss of lymph and the long-term formation of noticeable scars;often after a major phlebectomy there remains a loss of sensation in the heel area.
In contrast, after a miniphlebectomy, the wounds do not require suturing, since these are just punctures, there is no pain, and no damage to the cutaneous nerves has been observed in practice.However, such results of phlebectomy can only be achieved by very experienced phlebologists.