The anatomical structure of the venous system of the lower extremities is characterized by great variability.When assessing instrumental examination data and choosing the right method of treatment, knowledge of the individual characteristics of the structure of the venous system plays a major role.
The veins of the lower extremities are divided into superficial and deep veins.The superficial venous system of the lower extremities begins at the venous plexuses of the toes and forms the venous network of the dorsum of the foot and the cutaneous arch of the dorsum of the foot.The medial and lateral marginal veins originate from it and merge into the great saphenous vein and the lesser saphenous vein.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 arises in the lower third of the leg in front of the medial epicondyle and originates in the subcutaneous tissue of the leg and thigh.In the groin area, the great saphenous vein flows into the femoral vein.Sometimes the great saphenous vein on 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 popliteal area.In other cases, the small saphenous vein may protrude beyond the popliteal fossa and flow into the femoral vein, the great saphenous vein, or the deep femoral vein.
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 tibial vein and posterior tibial vein merge to form the popliteal vein, which lies laterally and slightly behind the artery of the same name.In the popliteal area, the small saphenous vein and the veins of the knee joint flow into the popliteal vein.The deep femoral vein usually flows into the femoral vein 6-8 cm below the inguinal fold.Above the inguinal ligament, this vessel receives the epigastric vein, the deep vein that surrounds the ilium, and merges with the external iliac vein, which merges into 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 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 trunk, abdominal organs and small pelvis.
Perforating (communicating) veins connect the deep veins with the superficial ones.Most of them have suprafascial valves through which blood flows from the superficial veins into the deep veins.There are direct and indirect perforating veins.Direct ones connect the deep and superficial venous network directly, indirect ones connect indirectly, that is, they first open into the muscular vein, which then flows into the deep vein.
The vast majority of perforating veins arise from tributaries rather than from the trunk of the great saphenous vein.In 90% of patients there is insufficiency of the perforating veins of the medial surface of the lower third of the leg.In the lower leg, insufficiency of the Cockett perforator vein 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 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 varicose vein transformation of the small saphenous vein, insufficient connecting veins in the middle and lower third of the leg and in the area of the lateral malleolus are most commonly observed.
Clinical course of the disease
Varicose veins usually occur in the system of the great saphenous vein, more rarely in the system of the small saphenous vein, and begin in the tributaries of the venous trunk on the legs.The natural course of the disease in the initial stages is quite favorable;For the first 10 years or more, patients may not be bothered by anything other than a cosmetic defect.If timely treatment is not provided, complaints of heaviness, fatigue in the legs and their swelling appear subsequently after physical activity (long walking, standing) or in the afternoon, especially in the hot season.Most patients complain of pain in the legs, but upon closer questioning, it can be determined that this is precisely 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 the sensations decreases.It is these symptoms that characterize venous insufficiency at this stage of the disease.When it comes to pain, other causes (arterial insufficiency of the lower extremities, acute venous thrombosis, joint pain, etc.) must be excluded.The later progression of the disease, in addition to an increase in the number and size of dilated veins, leads to the appearance of trophic disorders, often due to the addition of insufficient perforating veins and the appearance of valvular insufficiency of the deep veins.
With insufficiency of the perforating veins, the trophic disorders are limited to all surfaces of the leg (lateral, medial, posterior).Trophic disorders are manifested in the initial stage by local hyperpigmentation of the skin, then thickening (hardening) of the subcutaneous fatty tissue occurs until cellulite develops.This process ends with the formation of an ulcerative-necrotic defect, which can reach a diameter of 10 cm or more and extends deep into the fascia.The typical place of occurrence of venous trophic ulcers is the area of the medial ankle, however, the localization of ulcers on the lower leg can be different and varied.In the stage of trophic disorders, there is severe itching and burning in the affected area;Some patients develop microbial eczema.Pain in the area of the ulcer may not be pronounced, although in some cases it is intense.In this stage of the disease, there is a constant feeling of heaviness and swelling in the leg.
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 the legs.
In such patients, the diagnosis of varicose veins of the legs is incorrectly rejected, despite the presence of symptoms of varicose veins, evidence 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 missing 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 is it possible to prevent pathological changes in the venous system of the legs through minimal therapeutic effects on varicose veins.
Avoiding various diagnostic errors and establishing a 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 history of the disease and the greatest possible information about the condition of the venous system of the legs using the most modern equipment (instrumental diagnostic methods).
A duplex scan is sometimes performed to determine the exact location of perforating veins and to identify venovenous reflux using a color code.In the event of valve insufficiency, their valves no longer close completely during the Valsava maneuver or compression tests.Valvular insufficiency leads to the occurrence of venovenous reflux, high, through the incompetent saphenofemoral junction and low, through the incompetent perforating veins of the leg.With this method it is possible to record the backflow of blood through the prolapsed leaflets of an insufficient valve.That is why the diagnosis is multi-stage or multi-stage.Normally, 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 is carried out by a phlebological surgeon;
- if necessary, the patient is sent for further instrumental research methods (duplex angioscanning, phleboscintigraphy, lymphoscintigraphy);
- Patients with concomitant diseases (osteochondrosis, varicose eczema, lymphovenous insufficiency) are offered advice from leading specialists on these diseases or additional research methods;
- All patients requiring surgery are initially consulted by the operating surgeon and, if necessary, by an anesthesiologist.
Treatment
Conservative treatment is indicated primarily in patients who have contraindications to surgical treatment: due to their general condition, in cases of slight dilatation of the veins, which causes only cosmetic inconvenience, or when surgical intervention is refused.The aim of conservative treatment is to prevent further development of the disease.In these cases, patients should be recommended to bandage the affected surface with an elastic bandage or wear elastic stockings, periodically bring the legs into a horizontal position and perform special exercises for the foot and lower leg (flexion and extension in the ankle and knee joints) to activate the muscular-venous pump.The elastic compression accelerates and improves blood flow in the deep veins of the thigh, reducingthe amount of blood in the saphenous veins, prevents the formation of edema, improves microcirculation and helps to normalize metabolic processes in tissues.The bandage should be started in the morning before getting up.The bandage is applied with a slight pull from the toes to the thigh, with the obligatory support of the heel and ankle.Each subsequent round of 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, hard-soled shoes with low heels, avoid prolonged standing, heavy physical labor, and working in hot and humid areas.If the nature of the work activity requires the patient to sit for a long time, the legs should be placed in an elevated position by placing a special stand under the feet at the required 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 drainage.While sleeping, your legs need to be placed in an elevated position.
Patients are recommended to limit water and salt intake, normalize body weight, and regularly take diuretics and drugs to improve venous tone.Depending on the indications, drugs are prescribed that improve microcirculation in the tissues.The use of non-steroidal anti-inflammatory drugs is recommended for treatment.
Physiotherapy plays an important role in preventing varicose veins.For uncomplicated forms, water treatments are useful, especially swimming, warm (not higher than 35°) foot baths with a 5-10% saline solution.
Compression sclerotherapy
The indications for injection therapy (sclerotherapy) for varicose veins are still being debated.The method consists of introducing a sclerosing agent into the dilated vein, further compressing it, obliterating it and obliterating it.Modern drugs used for these purposes are quite safe, i.e.h.do not cause necrosis of the skin or subcutaneous tissue when administered extravascularly.Some specialists use sclerotherapy for almost all forms of varicose veins, others reject the method completely.Most likely, the truth lies somewhere in the middle, and for young women in the initial stages of the disease it makes sense to use the injection method of treatment.You just need to be warned about the possibility of relapse (higher than with surgical intervention), the need to constantly wear a fixing compression bandage for a long period of time (up to 3-6 weeks) and the likelihood that several sessions may be required for complete sclerosis of the veins.
The group of patients with varicose veins should include patients with telangiectasia (“spider veins”) and network expansion of the small saphenous veins, as the causes for the development of these diseases are identical.In this case, treatment is possible in addition to sclerotherapypercutaneous 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) and is based on the differential absorption of laser energy by different substances in the body.A special feature of the process is the contactless nature of this technology.The focusing head concentrates the energy in a blood vessel in the skin.Hemoglobin in the vessel selectively absorbs laser beams of a specific wavelength.Under the influence of a laser, the endothelium in the lumen of the vessel is destroyed, which leads to the vascular walls sticking together.
The effectiveness of PLK directly depends on the depth of penetration of laser radiation: the deeper the vessel, the longer the wavelength should be, therefore PLK has rather limited indications.Microsclerotherapy is most effective for vessels with a diameter of more than 1.0-1.5 mm.Given the extensive and branched distribution of spider veins on the legs and the variable diameter of the vessels, a combined method of treatment is currently being actively used: in the first step, sclerotherapy of veins with a diameter of more than 0.5 mm is carried out, then the remaining “stars” of smaller diameter are removed using a laser.
The procedure is practically painless and safe (skin cooling and anesthetics are not used), since the light from the device belongs to the visible part of the spectrum and the wavelength of light is designed so that the water in the tissue does not boil and the patient does not suffer burns.For patients with high pain sensitivity, it is recommended to use a cream with a local anesthetic effect beforehand.Erythema and swelling resolve within 1-2 days.After the treatment, some patients may experience darkening or lightening of the treated area of skin for about two weeks, which then disappears.In people with fair skin, the changes are hardly noticeable, 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 minor 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 achieved due to the unique “square” shape of the device's light pulse;It 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 aim of the operation is to eliminate pathogenetic mechanisms (veno-venous reflux).This is achieved by removing the main trunks of the large and small saphenous veins and ligating the insufficient connecting veins.
The surgical treatment of varicose veins has a hundred-year history.In the past, and many surgeons still do this today, large incisions were made along the varicose veins and general or spinal anesthesia was performed.Traces after such a “mini-phlebectomy” remain a lifelong memory of the operation.The first vein operations (after Schade, after Madelung) were so traumatic that the damage from them exceeded the damage from varicose veins.
In 1908, American surgeon Babcock developed a method of drawing subcutaneous veins using a rigid metal probe with an olive.This surgical method for removing varicose veins is still used in an improved form in many public hospitals today.Varicose veins are removed through separate incisions, as suggested by surgeon Narat.Therefore, the classic phlebectomy is called the Babcock-Narat method.Babcock-Narat phlebectomy has disadvantages – large scars after surgery and impaired skin sensitivity.The ability to work is limited for 2-4 weeks, making 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.Complex cases are also operated oncombined technology.The main large varicose vein trunks are removed by inversion stripping, which requires minimal intervention through small incisions (from 2 to 7 mm) in the skin, leaving practically no scars.The use of a minimally invasive technique requires 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 hospital stay of up to 1 day.
Surgical treatment includes:
- Crossectomy – crossing of the point where the trunk of the great saphenous vein flows into the deep venous system;
- Stripping involves the removal of a fragment of a varicose vein.Only the varicose vein is removed and not the whole thing (as with the classic variant).
ActuallyMiniphlebectomyreplaced the Narat technique for removing varicose veins of the main veins.Previously, skin incisions of 1-2 to 5-6 cm were made along the course of the varicose veins, through which the veins were isolated and removed.The desire to improve the cosmetic result of the procedure and be able to remove veins not through traditional incisions, but through mini-incisions (punctures), forced doctors to develop instruments that allow them to do almost the same thing with a minimal skin defect.This resulted in sets of phlebectomy “hooks” of various sizes and configurations, as well as special spatulas.And instead of a regular scalpel, scalpels with a very narrow blade or needles with a fairly large diameter for piercing the skin were used (for example, a needle for taking venous blood for analysis with a diameter of 18 G).Ideally, the puncture site with such a needle will be practically invisible after some time.
Some forms of varicose veins are treated on an outpatient basis under local anesthesia.The minimal trauma during miniphlebectomy and the low risk of the procedure allow this operation to be carried out in a day clinic.After minimal observation in the clinic after the operation, the patient can be sent home independently.In the postoperative period, an active lifestyle is maintained and active walking is encouraged.Temporary incapacity to work usually lasts no longer than 7 days, after which it is possible to start work.
When is a microphlebectomy used?
- If the diameter of the varicose trunks of the large or small saphenous vein is more than 10 mm;
- After 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 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 examination of the patient's venous system.Microphlebetomy is used to remove veins in various places that have changed for various reasons, including the face.Professor Varadi from Frankfurt developed his practical instruments and formulated the basic postulates of modern microphlebectomy.The Varadi phlebectomy method provides excellent cosmetic results without pain or hospitalization.This is a very laborious, almost decorative job.
After vein surgery
The postoperative period after the usual “classic” phlebectomy is very painful.Sometimes large hematomas cause concern and swelling occurs.Wound healing depends on the phlebologist's surgical technique;sometimes there is a leakage of lymph and, in the long term, the formation of noticeable scars;A loss of sensitivity in the heel area often remains after a major phlebectomy.
In contrast, wounds following a miniphlebectomy do not require stitches because they are merely punctures, there is no pain, and no damage to the cutaneous nerves has been observed in practice.However, such results of phlebectomy are achieved only by very experienced phlebologists.