The anatomical structure of the venous system of the lower extremities 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 extremities are divided into superficial and deep.The superficial venous system of the lower limbs originates from the venous plexuses of the toes, forming the venous network of the dorsum of the foot and the cutaneous dorsal arch of the foot.From here arise the medial and lateral marginal veins, which pass into the greater and lesser saphenous veins respectively.The great saphenous vein is the longest vein in the body, it contains 5 to 10 pairs of valves and its normal diameter is 3 to 5 mm.It originates in the lower third of the leg, in front of the medial epicondyle, and rises into the subcutaneous tissue of the leg and thigh.In the groin, the great saphenous vein flows 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 at the level of the popliteal fossa.In other cases, the small saphenous vein may rise above the popliteal fossa and drain into the large saphenous femoral 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, located laterally and slightly behind the artery of the same name.At the level 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 generally empties into the femoral vein, 6 to 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 merge to form the inferior vena cava.It is a large container without valves, 19 to 20 cm long and 0.2 to 0.4 cm in diameter.The inferior vena cava has parietal and visceral branches through which blood circulates from the lower extremities, lower torso, abdominal organs, and small pelvis.
The perforating (communicating) veins connect the deep veins to the superficial veins.Most of them have valves located suprafascially and through which blood passes from superficial veins to deep veins.There are direct and indirect perforator veins.Direct ones connect the deep and superficial venous networks directly, 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.In 90% of patients, there is incompetence of the perforating veins of the medial aspect of the lower third of the leg.At the bottom of the leg, incompetence of the perforating veins of Cockett, 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 most permanent perforator veins (Dodd, Gunter), directly connecting 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 third of the leg and in the area of the lateral malleolus are most often observed.
Clinical evolution of the disease
Most often, 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 at the initial stage is quite favorable;for the first 10 years or more, apart from a cosmetic defect, patients cannot be bothered by anything.Subsequently, if treatment is not carried out on time, complaints about a feeling of heaviness, fatigue in the legs and their swelling after physical activity (long walk, standing) or in the afternoon, especially in the hot season, begin to appear.Most patients complain of pain in the legs, but after a detailed interrogation it is possible to reveal that it 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 sensations decreases.It is these symptoms that characterize venous insufficiency at this stage of the disease.If we talk about pain, we must exclude other causes (arterial insufficiency of the lower limbs, acute venous thrombosis, joint pain, etc.).Further 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 incompetent perforating veins and the appearance of valvular insufficiency of deep veins.
In case of insufficiency of the perforating veins, the trophic disorders are limited to any one of the surfaces of the leg (lateral, medial, posterior).Trophic disorders at the initial stage are manifested by local hyperpigmentation of the skin, then thickening (induration) 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 extend deep into the fascia.The typical place of appearance 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.At the stage of trophic disorders, severe itching and burning appear 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 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 missed deadlines for the optimal start of treatment, the formation of irreversible changes in the vein 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 effect 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, 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).
A double-sided scan is sometimes performed to determine the exact location of the perforating veins, identifying venovenous reflux in a color code.If the valves fail, their valves stop closing completely during Valsava maneuvers or compression tests.Valvular insufficiency leads to the appearance of venovenous reflux, high, through the incompetent saphenofemoral junction, and low, through the incompetent perforating veins of the leg.Using this method, it is possible to record reverse blood flow through the prolapsed leaflets of an incompetent valve.This is why the diagnosis is multi-stage or multi-level.In a normal situation, the diagnosis is made after an ultrasound diagnosis and an examination by a phlebologist.However, in particularly difficult cases, the examination should be carried out in stages.
- First, a thorough examination and questioning is carried out by a phlebotomist surgeon;
- if necessary, the patient is sent for additional instrumental research methods (duplex CT angiography, phleboscintigraphy, lymphoscintigraphy);
- patients with concomitant diseases (osteochondrosis, varicose eczema, lymphovenous insufficiency) are offered consultations with leading specialist consultants in these diseases) or additional research methods;
- all patients requiring surgical intervention are consulted beforehand by the operating surgeon and, if necessary, by an anesthesiologist.
Treatment
Conservative treatment is indicated mainly in patients with contraindications to surgical treatment: due to their general condition, with slight dilation of the veins causing only an aesthetic inconvenience, or in case of refusal of surgical intervention.Conservative treatment is aimed at preventing the further development of the disease.In these cases, patients should be advised to bandage 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 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 the thigh, reduces the amount of blood in the saphenous veins, prevents the formation of edema, improves microcirculation and helps to normalize metabolic processes in tissues.The dressing should start in the morning, before getting out of bed.The bandage is applied with slight 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 work, and work in hot and humid areas.If, due to the nature of professional activity, the patient has to sit for a long time, the legs should be placed in a raised position by placing a special support of the required height under the feet.It is advisable 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 flow.While sleeping, your 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 indications, drugs are prescribed to improve microcirculation in tissues.For treatment, it is recommended to use nonsteroidal anti-inflammatory drugs.
Physiotherapy plays an important role in the prevention of varicose veins.For simple forms, water procedures are useful, especially swimming, warm (no higher than 35°) foot baths with a 5-10% solution of table salt.
Compression sclerotherapy
The indications for injection treatment (sclerotherapy) for varicose veins are still debated.The method involves introducing a sclerosing agent into the dilated vein, its subsequent compression, desolation and sclerosis.Modern drugs used for these purposes are completely 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 between, and it is logical that young women in the early stages of the disease use the injection method of treatment.The only thing is that they should be warned about the possibility of relapse (higher than in case of surgical intervention), the need to constantly wear a compressive fixation 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 meshwork of the small saphenous veins, since the causes of the development of these diseases are identical.In this case, in addition to sclerotherapy, you can alsopercutaneous laser coagulation, but only after excluding 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 present in the body.A particularity of the method lies in the contactless nature of this technology.The focusing head focuses energy into a blood vessel in the skin.Hemoglobin in the vessel selectively absorbs laser beams of a certain wavelength.Under the action of a laser, the destruction of the endothelium occurs in the lumen of the vessel, which leads to sticking of the vessel walls.
The effectiveness of PLK directly depends on the penetration depth of the laser radiation: the deeper the vessel, the longer the wavelength should be, therefore PLK has rather limited indications.For vessels with a diameter greater than 1.0-1.5 mm, microsclerotherapy is most effective.Taking into account the extensive and branched distribution of spider veins on the legs and the variable diameter of the vessels, a combined treatment method is currently actively used: first, sclerotherapy of veins with a diameter of more than 0.5 mm is carried out, then a laser is used to remove the remaining "stars" of a smaller diameter.
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 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, prior application of a cream with local anesthetic effect is recommended.Erythema and swelling disappear in 1 to 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 fair-skinned people, the changes are almost imperceptible, but in patients with dark skin or intense tans, 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 area of the skin, but usually no more than four sessions of laser therapy (5-10 minutes each).The maximum result in such a short time is achieved thanks to the unique “square” shape of the device’s light pulse;it increases its effectiveness compared to other devices, also reducing the risk of side effects after the procedure.
Surgical treatment
Surgery is the only radical treatment method for patients suffering from 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 greater and lesser saphenous vein and ligating the incompetent communicating veins.
The surgical treatment of varicose veins has a century-old history.Previously, and many surgeons still do this, large incisions along the varicose veins and general or spinal anesthesia were used.The traces left after such a “mini-phlebectomy” will remain a permanent memory of the operation.The first operations on veins (according to Schade, according to Madelung) were so traumatic that their damage exceeded that of varicose veins.
In 1908, the American surgeon Babcock invented a method for extracting subcutaneous veins using a rigid metal probe fitted 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.So, 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 is reduced for 2-4 weeks, making it difficult for patients to accept surgical treatment of varicose veins.
Phlebologists have developed a unique technology for treating varicose veins in one day.Complex cases are handled usingcombined technology.The main large varicose veins are removed by inversion stripping, which involves minimal intervention through mini-incisions (2 to 7 mm) in the skin, which leave virtually no scarring.Using a minimally invasive technique involves minimal tissue trauma.The result of this operation is the elimination of varicose veins with an excellent aesthetic result.The combined surgical treatment is carried out under total intravenous or spinal anesthesia, with a maximum hospitalization duration of one day.
Surgical treatment includes:
- Crossectomy - crossing the place where the trunk of the great saphenous vein empties into the deep venous system;
- Stripping consists of removing a fragment of varicose vein.Only the varicose vein is removed, and not the whole thing (as in the classic version).
Actuallyminiphlebectomyreplaced the Narat technique to eliminate varicose tributaries of the main veins.Previously, skin incisions of 1-2 to 5-6 cm were made along the varicose veins, through which the veins were isolated and removed.The desire to improve the aesthetic result of the intervention 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 with a minimal skin defect.This is how sets of phlebectomy “hooks” of various sizes and configurations and special spatulas appear.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 used to take venous blood for analysis with a diameter of 18G).Ideally, the mark 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, allow this operation to be carried out in a day hospital.After minimal observation in the clinic after surgery, the patient can be sent home on their own.In the postoperative period, an active lifestyle is maintained, active walking is encouraged.Temporary incapacity for work usually lasts no more than 7 days, after which it is possible to start working.
When is microphlebectomy used?
- When the diameter of the varicose trunks of the great or small saphenous vein is greater than 10 mm;
- After suffering from thrombophlebitis of the main subcutaneous trunks;
- After recanalization of the trunks after other types of treatment (EVLT, sclerotherapy);
- Elimination of very large individual varicose veins.
It can be an independent operation or part of a combined treatment of varicose veins, combined with laser vein treatment and sclerotherapy.Tactics of use are determined individually, always taking into account the results of duplex ultrasound of the patient's venous system.Microphlebotomy is used to remove veins from various locations that have changed for various reasons, including on the face.Professor Varadi from Frankfurt developed his practical instruments and formulated the basic postulates of modern microphlebectomy.The Varadi phlebectomy method allows you to obtain excellent aesthetic results without pain or hospitalization.It is very meticulous work, almost jeweler-like.
After vein surgery
The postoperative period after the usual “classic” phlebectomy is quite painful.Sometimes large bruises are cause for concern and swelling occurs.Wound healing depends on the surgical technique of the phlebologist;there is sometimes lymph leakage and long-term formation of visible scarring;Often, after a major phlebectomy, there remains a loss of sensitivity in the heel.
On the other hand, after a miniphlebectomy, the wounds do not require suturing, since they are only punctures, there is no pain and no damage to the skin nerves has been observed in practice.However, such phlebectomy results are achieved only by very experienced phlebologists.