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 extremities starts 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.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, containing 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 ascends in the subcutaneous tissue of the leg and thigh.In the groin area, the great saphenous vein empties 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 empties 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 flow into the femoral vein, great saphenous vein, or deep thigh vein.
The deep veins of the dorsum of the foot begin with the dorsal metatarsal veins of the foot, which empty into the dorsal venous arch of the foot, from where blood flows to the anterior tibial veins.At the level of the upper third of the leg, the anterior and posterior tibial veins fuse to form the popliteal vein, which is located lateral and somewhat 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 empties into the femoral vein 6 to 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 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 fuse to form the inferior vena cava.It is a large glass 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.
The perforating (communicating) veins connect the deep veins with the superficial ones.Most of them have valves located suprafascially and thanks to which blood passes 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 perforator veins arise from tributaries and not from the trunk of the great saphenous vein.In 90% of patients there is incompetence of the perforating veins of the medial surface of the lower third of the leg.Insufficiency of Cockett's perforating veins, which connect the posterior branch of the great saphenous vein (Leonardo's vein) with the deep veins, is most commonly observed in the lower leg.In the middle and lower third of the thigh there are usually 2 to 4 more permanent perforator veins (Dodd, Gunter), 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 are most often observed in the middle and lower third of the leg and in the area of the lateral malleolus.
Clinical course of the disease.
Mainly, varicose veins occur in the great saphenous vein system, less frequently in the small saphenous vein system and begin in the tributaries of the trunk of the vein in 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 a feeling of heaviness, fatigue in the legs and their swelling begin to appear after physical activity (long walks, standing) or during the day, especially in the hot season.Most patients complain of pain in the legs, but upon detailed questioning it can be revealed that this is precisely a feeling of fullness, heaviness and fullness in the legs.Even with a short rest and 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.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 subsequent 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 the deep veins.
In case of insufficiency of the perforating veins, trophic disorders are limited to any 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 adipose tissue occurs up to 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 appearance of venous trophic ulcers is the area of the medial malleolus, but the localization of ulcers in the lower leg can be different and multiple.At the stage of trophic disorders, severe itching and burning occur in the affected area;Some patients develop microbial eczema.The 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 in the legs.
In such patients, the diagnosis of varicose veins in 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 the initial pathological changes in the venous system.
All this can lead to non-compliance with 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 in an early preclinical phase is it possible to prevent pathological changes in the venous system of the legs by 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 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 veins, identifying venovenous reflux in a color code.In case of valve insufficiency, its valves stop closing completely during the Valsava maneuver 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.With this method, it is possible to record the reverse flow of blood through the prolapsed leaflets of an incompetent valve.That is why the diagnosis is multistage or multilevel.In a normal situation, the diagnosis is made after ultrasound diagnosis and examination by a phlebologist.However, in especially difficult cases, the examination should be carried out in stages.
- First, a thorough examination and questioning is performed by a phlebological surgeon;
- 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 surgeon and, if necessary, by an anesthesiologist.
Treatment
Conservative treatment is indicated mainly in patients who have contraindications for surgical treatment: due to their general condition, with a slight dilation of the veins that causes only cosmetic discomfort, or if surgical intervention is rejected.Conservative treatment is aimed at preventing 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 ofblood in the saphenous veins, prevents the formation of edema, improves microcirculation and helps to normalize metabolic processes in tissues.Bandaging should begin in the morning, before getting out of bed.The bandage is applied with light tension from the fingers to the thigh, with mandatory gripping of the heel and ankle joint.Each subsequent round of the bandage should overlap the previous one by half.It is recommended to use certified medical knitwear with individual selection of the compression degree (from 1 to 4).Patients should wear comfortable shoes with hard soles and low heels, avoid prolonged standing, heavy physical labor, and working in hot, humid areas.If, due to the nature of 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 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.During sleep, the legs should be in an elevated position.
Patients are recommended to limit water and salt intake, normalize body weight and periodically take diuretics and medications that improve venous tone.According to indications, drugs are prescribed that improve microcirculation in the tissues.For treatment, it is recommended to use non-steroidal 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 more than 35°) foot baths with a 5-10% solution of table salt.
Compression sclerotherapy
The indications for injection therapy (sclerotherapy) for varicose veins are still under debate.The method consists of introducing a sclerosing agent into the dilated vein, its subsequent compression, desolation and sclerosis.Modern drugs used for these purposes are quite safe, that is, they do not cause necrosis of the skin and subcutaneous tissue when administered extravasally.Some specialists use sclerotherapy for almost all forms of varicose veins, while others reject the method altogether.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 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 mesh dilation 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 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 in the body.A special feature of the method is the contactless nature of this technology.The focusing head focuses the energy on a blood vessel in the skin.The hemoglobin in the vessel selectively absorbs laser rays of a certain wavelength.Under the action of a laser, the destruction of the endothelium in the lumen of the vessel occurs, which leads to gluing 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 greater than 1.0-1.5 mm, microsclerotherapy is the 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: at the first stage, sclerotherapy of veins with a diameter of more than 0.5 mm is performed, then a laser is used to eliminate the remaining "stars" of a smaller diameter.
The procedure is practically painless and safe (no skin cooling or 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 so that the water in the tissues does not boil and the patient does not suffer burns.For patients with high pain sensitivity, preliminary application of a cream with a local anesthetic effect is recommended.The erythema and swelling disappear in 1 or 2 days.After treatment, for approximately two weeks, some patients may experience 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 deep tan, the risk of suffering from temporary pigmentation of this type 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 to 10 minutes each).The maximum result in such a short time is achieved thanks to the unique "square" shape of the light pulse of the device;It 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 objective 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 veins and ligating the incompetent communicating veins.
The surgical treatment of varicose veins has a history of one hundred years.Previously, and many surgeons still do, large incisions along the varicose veins and general or spinal anesthesia were used.The traces of such a “miniphlebectomy” remain a lifelong reminder of the surgery.The first operations on the veins (according to Schade, according to Madelung) were so traumatic that the damage caused by them exceeded the damage from the varicose veins.
In 1908, the American surgeon Babcock devised a method of removing subcutaneous veins using a rigid metal probe with an olive.This surgical method to remove varicose veins is still used in an improved form in many public hospitals.Varicose veins are removed through separate incisions, as suggested by surgeon Narat.Therefore, 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 to 4 weeks, making it difficult for patients to accept surgical treatment of varicose veins.
Phlebologists have developed a unique technology to treat varicose veins in one day.Complex cases are operated usingcombined technology.The main large varicose trunks are removed by inverted stripping, which involves minimal intervention through mini-incisions (2 to 7 mm) of the skin, which leave practically no scars.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.The 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 empties 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 from major veins.Previously, along the varicose veins, skin incisions of 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 eliminate 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.Thus, sets of phlebectomy “hooks” of various sizes and configurations and special spatulas emerged.And instead of a normal scalpel, scalpels with a very narrow blade or needles of a fairly large diameter began to be used to pierce the skin (for example, a needle used to extract venous blood for analysis with a diameter of 18G).Ideally, the mark from 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.The minimal trauma during miniphlebectomy, as well as the low risk of intervention, allow this operation to be performed 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 and 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);
- Removal of very large individual varicose veins.
It can be a stand-alone operation or be part of a combined varicose vein treatment, combined with laser vein treatment and sclerotherapy.The tactics of use are determined individually, always taking into account the results of duplex ultrasound of the patient's venous system.Microphlebetomy 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 provides excellent cosmetic results without pain or hospitalization.This is a very meticulous work, almost jewelry.
After vein surgery
The postoperative period of the usual “classic” phlebectomy is quite painful.Sometimes large bruises are a cause for concern and swelling occurs.Wound healing depends on the phlebologist's surgical technique;sometimes there is lymph leakage and prolonged formation of visible scars;Often, after a major phlebectomy, there remains a loss of sensation in the heel area.
On the contrary, after a miniphlebectomy the wounds do not require suturing, since they are only punctures, there is no pain and in practice no damage to the cutaneous nerves has been observed.However, these phlebectomy results are only achieved by very experienced phlebologists.