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 the evaluation of instrumental examination data and in choosing the appropriate 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 fingers, forming the venous network of the back of the foot and the dorsal cutaneous arch of the foot.The medial and lateral marginal veins originate from it, which pass into the great and small saphenous veins, respectively.The great saphenous vein is the longest vein in the body, contains from 5 to 10 pairs of valves and its normal diameter is 3-5 mm.It begins 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 great saphenous vein of the femur 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 drain 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 somewhat 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 drain into the popliteal vein.The deep femoral vein usually drains into the femoral vein 6-8 cm below the inguinal fold.Above the inguinal ligament, this vessel 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 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 pelvis.
Perforating (communicating) veins connect the deep and superficial veins.Most of them have valves located superficially and thanks to which blood moves from the superficial veins to the deep ones.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 branches 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 observed in 90% of patients.In the lower part of the leg, incompetence of the perforating veins of Cockett, which connects the posterior branch of the great saphenous vein (Leonardo's vein) with the deep veins, is most often observed.In the middle and lower thirds of the thigh, there are usually 2-4 more permanent perforating veins (Dodd, Gunter), which directly connect the trunk of the great saphenous vein to the femoral vein.With varicose transformation of the small saphenous vein, incompetent communicating veins of the middle, lower third of the 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 branches of the leg vein trunk.The natural course of the disease in the initial stage is quite favorable;for the first 10 years or more, except for a cosmetic defect, patients may not be bothered by anything.Then, if the treatment is not carried out in time, complaints about the 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 after detailed questions it is possible to find out that this is precisely a feeling of fullness, heaviness and satiety in the legs.Even with a short rest and elevated position of the limbs, the severity of the sensations decreases.It is these symptoms that characterize venous insufficiency at this stage of the disease.If we are talking about pain, it is necessary to exclude other causes (arterial 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 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 thickening (hardening) of the subcutaneous fatty 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 site of venous trophic ulcers is the area of the medial malleolus, but the localization of ulcers in the lower part of the leg can be different and multiple.In 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 pronounced, although in some cases it is intense.At this stage of the disease, heaviness and swelling in the legs 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 in the legs.
In such patients, the diagnosis of varicose veins of the legs is wrongly 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 initial pathological changes in the venous system.
All this can lead to the loss of 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 becomes 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 establishing an accurate diagnosis is possible only after a complete 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 about the condition 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 perforating veins, identifying venous reflux in a color code.In case of valve insufficiency, their valves stop closing completely during the Valsava maneuver or compression tests.Insufficiency of the valves leads to the occurrence 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 record the reverse flow of blood 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 ultrasound diagnostics and examination by a phlebologist.However, in particularly difficult cases, the examination should be carried out in stages.
- First, there is an examination and questioning by a phlebological surgeon;
- if necessary, the patient is sent for additional instrumental research methods (duplex angioscan, phleboscintigraphy, lymphoscintigraphy);
- patients with accompanying diseases (osteochondrosis, varicose eczema, lymphovenous insufficiency) are offered consultation with the main specialist consultants for 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 for surgical treatment: due to their general condition, with slight dilatation of the veins causing only cosmetic concerns, or if surgical intervention is refused.Conservative treatment aims to prevent further development of the disease.In these cases, patients should be advised to bandage the affected area with an elastic bandage or wear elastic stockings, periodically place the legs in a horizontal position and perform special exercises for the leg and the lower part of the leg (flexion and extension at the ankle and knee) to activate the muscular-venous pump.Elastic compression accelerates and increases 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 normalize metabolic processes in tissues.Bandaging should start in the morning, before you get out of bed.The bandage is applied with light tension from the toes to the thigh, with mandatory tightening of the heel and ankle joint.Each subsequent round of the bandage should overlap by half with the previous one.It is recommended to use medically certified hosiery with individual selection of the degree of compression (from 1 to 4).Patients should wear comfortable shoes with strong 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 legs.It is recommended to walk a little every 1-1.5 hours or stand 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 the indications, medications are prescribed that improve microcirculation in the 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 foot baths (not higher than 35°) with a 5-10% solution of table salt.
Compression sclerotherapy
The indications for injection therapy (sclerotherapy) for varicose veins are still being debated.The method consists in introducing a sclerosing agent into the dilated vein, its further compression, destruction and sclerosis.Modern drugs used for these purposes are quite safe, i.e.do not cause necrosis of the skin or subcutaneous tissue when administered extravasally.Some specialists use sclerotherapy for almost all forms of varicose veins, while others completely reject the method.Most likely, the truth lies 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 that they should be warned about the possibility of relapse (higher than with surgical intervention), the need to constantly wear a fixing 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 veins.
The group of patients with varicose veins should include patients with telangiectasia ("spider veins") and network expansion of the small saphenous veins, since the causes of the development of these diseases are identical.In this case, along with sclerotherapy, you can alsopercutaneous laser coagulation, but only after excluding injuries 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 different substances in the body.A special feature of the method is the non-contact nature of this technology.The focused head concentrates the energy on a blood vessel in the skin.Hemoglobin in the container selectively absorbs laser rays of a certain wavelength.Under the action of a laser, the destruction of the endothelium occurs in the vessel lumen, which leads to adhesion of the vessel walls.
The effectiveness of PLK directly depends on the depth of penetration of laser radiation: the deeper the vessel, the longer the wavelength should be, so PLK has rather limited indications.For vessels with a diameter exceeding 1.0-1.5 mm, microsclerotherapy is more effective.Taking into account the wide and branched distribution of spider veins in the legs and the variable diameter of the vessels, a combined method of treatment 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" with a smaller diameter.
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 tissue does not boil and the patient does not get burned.For patients with high sensitivity to pain, prior application of a cream with a local anesthetic effect is recommended.Erythema and swelling go away within 1-2 days.After the course, for about two weeks, some patients may experience darkening or lightening of the treated area of the skin, which then disappears.In fair-skinned people, the changes are almost unnoticeable, 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 case - the blood vessels are 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.The maximum result in such a short time is achieved due to the unique "square" shape of the light pulse of the device;increases its effectiveness compared to other devices, also reducing the possibility of side effects after the procedure.
Surgical treatment
Surgery is the only radical method of treatment for patients with varicose veins of the lower extremities.The purpose of the operation is to eliminate the pathogenic mechanisms (veno-venous reflux).This is achieved by removing the main trunks of the great and small saphenous vein and ligating the non-communicating veins.
Surgical treatment of varicose veins has a hundred-year history.Previously, and many surgeons still do, large incisions along the varicose veins and general or spinal anesthesia were used.The traces after such a "mini-phlebectomy" remain an eternal memory 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 came up with a method of retracting subcutaneous veins using a rigid metal probe with an olive.In an improved form, this surgical method for removing varicose veins is still used in many public hospitals.Varicose veins are removed using special incisions, as suggested by surgeon Narat.Thus, the classic phlebectomy is called the Babcock-Narat method.Phlebectomy according to Babcock-Narat has disadvantages - large postoperative wounds and impaired 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 treating varicose veins in one day.Complex cases are operated usingcombined technology.The main large varicose veins are removed by inversion stripping, which involves minimal intervention through mini-incisions (from 2 to 7 mm) of the skin, which practically leave no trace.The use of a 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 veins are removed and not all of them (as in the classic version).
Actuallyminiphlebectomyreplaced the Narat technique for removing varicose branches of major veins.Previously, during the course of varicose veins, skin incisions from 1-2 to 5-6 cm were made, through which the veins were isolated and removed.The desire to improve the cosmetic result of the intervention and to be able to remove veins not through traditional incisions, but through mini-incisions (punctures), 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 a regular 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 18 G).Ideally, the mark of a puncture with such a needle is practically invisible after some time.
Some forms of varicose veins are treated on an outpatient basis with 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 minimal observation in the clinic after surgery, the patient can be sent home on his own.In the period after the operation, an active lifestyle is maintained, active walking is encouraged.Temporary incapacity for work usually lasts no more than 7 days, then it is possible to start work.
When is microphlebectomy used?
- When the diameter of the varicose trunks of the great or small saphenous vein is more than 10 mm;
- After suffering from 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 a component of a combined treatment of varicose veins, combined with laser treatment of veins and sclerotherapy.Tactics of use are determined individually, always taking into account the results of duplex ultrasound scanning of the patient's venous system.Microphlebotomy is used to remove the veins of various places that have changed for various reasons, including on the face.Professor Varad from Frankfurt developed his own suitable instruments and formulated the basic postulates of modern microphlebectomy.The Varadi phlebectomy method offers excellent cosmetic results without pain or hospitalization.This is a very painstaking work, almost jewelry.
After vein surgery
The postoperative period after the usual "classic" phlebectomy is quite painful.Sometimes large hematomas are disturbing and swelling occurs.Wound healing depends on the phlebologist's surgical technique;sometimes there is a flow of lymph and the long-term formation of visible scars;often after a large phlebectomy remains a loss of sensation in the heel area.
In contrast, after a miniphlebectomy, the wounds do not require stitches, since these are only punctures, there is no pain and no damage to the skin nerves has been observed in practice.However, such results of phlebectomy are achieved only by very experienced phlebologists.