The anatomical structure of the venous system of the lower leg is characterized by great variability.Knowledge of the individual characteristics of the structure of the venous system plays a large role in evaluating instrumental examination data and in choosing the right treatment method.
The lower veins are divided into superficial and deep.The superficial venous system on the lower part of the leg starts from the venous plexus of the toes, forming the venous network of the dorsum of the leg and the dorsal cutaneous arch of the leg.From it originates the medial and lateral marginal veins, which respectively enter the greater and lesser saphenous veins.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 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 of the thigh and leg can be represented by two or three trunks.The small saphenous vein begins in the lower third of the leg along its lateral surface.In 25% of cases, it drains 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 femoral, great saphenous vein, or into the deep vein of the thigh.
The veins in the dorsum of the foot begin with the dorsal metatarsal vein of the foot, which drains into the dorsal venous arch of the foot, from where blood flows into the anterior tibial vein.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 slightly posterior to the artery of the same name.In the area of the popliteal fossa, the small saphenous vein and the vein of the knee joint drain into the popliteal vein.The vein in the thigh usually drains into the femoral vein 6-8 cm below the inguinal fold.Above the inguinal ligament, this vessel receives the epigastric vein, an internal vein that surrounds the ilium, and enters the external iliac vein, which joins the internal iliac vein at the sacroiliac joint.The paired common iliac veins begin 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 legs, lower body, abdominal organs, and small pelvis.
Perforated veins (communicating) connect deep veins with superficial ones.Most of them have a valve located in the suprafascial and thanks to which the blood moves from the superficial veins to the deep ones.There are direct and indirect perforating veins.The direct directly connect the network of deep and superficial veins, the indirect connect indirectly, that is, they first flow into the muscular veins, which then flow into the deep veins.
Most of the vena cava arise from tributaries rather than from the trunk of the great saphenous vein.In 90% of patients, there is incompetence of the perforating vein of the medial surface of the lower third of the foot.In the lower part of the leg, incompetence of the perforating vein of Cockett, which connects the posterior branch of the great saphenous vein (vein of Leonardo) with the deep vein, is most often observed.In the middle and lower third of the thigh there are usually 2-4 perforating veins that are the most permanent (Dodd, Gunter), directly connecting the trunk of the great saphenous vein with the femoral vein.With varicose transformation of the small saphenous vein, inefficient communicating veins in the middle, lower third of the leg and in the area of the lateral malleolus are most often observed.
The clinical course of the disease
Most often, varicose veins occur in the great saphenous vein system, less often in the small saphenous vein system, and begin with tributaries of the venous trunk in the legs.The natural course of the disease in the early stages is quite good;for the first 10 years or more, apart from cosmetic defects, the patient may not be bothered by anything.After that, if timely treatment is not carried out, complaints of heaviness, fatigue in the legs and their swelling after physical activity (long walks, standing) or in the afternoon, especially in summer, begin to appear.Most patients complain of pain in the legs, but after questioning in detail it is possible to reveal that this is precisely a feeling of fullness, heaviness, and fullness in the legs.With a short rest and a high position of the limb, the severity of the sensation decreases.These symptoms characterize venous insufficiency at this stage of the disease.If we talk about pain, it is necessary to exclude other causes (lack of arteries in the lower leg, acute venous thrombosis, joint pain, etc.).The subsequent development of the disease, in addition to an increase in the number and size of dilated veins, leads to the occurrence of trophic disorders, often due to the inefficient addition of perforated veins and the occurrence of valve insufficiency in the deep veins.
In the case of perforating vein deficiency, trophic disorders are limited to any surface of the foot (lateral, medial, posterior).Trophic disorders in the early stages are shown by local hyperpigmentation of the skin, then thickening (induration) of subcutaneous fat 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 extends deep into the fascia.The usual site of venous trophic ulcers is the area of the medial malleolus, but the localization of ulcers on the lower legs can be different and multiple.At the stage of trophic disorders, severe itching and burning in the affected area occurs;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 legs become constant.
Diagnosis of varicose veins
It is very difficult to diagnose the preclinical stage of varicose veins, because such patients may not have varicose veins on the legs.
In such patients, the diagnosis of varicose veins of the legs is mistakenly rejected, despite the presence of varicose vein symptoms, signs that the patient has relatives suffering from this disease (hereditary tendency), and ultrasound data on early pathological changes in the venous system.
All this can lead to a missed deadline for the start of optimal 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, it becomes possible to prevent pathological changes in the leg venous system through a minimal therapeutic effect on varicose veins.
Avoiding various types of diagnostic errors and making a correct diagnosis is only possible after a thorough examination of the patient by an experienced specialist, a 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 perforated vena cava, identifying venous reflux in a color code.In the case of valve insufficiency, their valves stop closing completely during the Valsava maneuver or compression test.Valve insufficiency leads to the appearance of venovenous reflux, high, through an inefficient saphenofemoral junction, and low, through an inefficient perforating vein of the leg.Using this method, it is possible to record the backflow of blood through the leaflets of the inefficient valve prolapse.That is why the diagnosis is multi-level or multi-level.Under normal circumstances, the diagnosis is made after diagnostic ultrasound and examination by a phlebologist.However, in very difficult cases, the examination must be done in stages.
- First, a comprehensive examination and interrogation is carried out by a phlebologist 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 a leading expert consultant on this disease) or additional research methods;
- all patients requiring surgery are first consulted by a surgical surgeon and, if necessary, by an anesthesiologist.
Treatment
Conservative treatment is indicated mainly for patients who have contraindications to surgical treatment: due to their general condition, with a slight vein dilatation that causes only cosmetic discomfort, or if surgical intervention is refused.Conservative treatment aims to prevent the further development of the disease.In this case, the patient should be advised to wrap the affected surface with an elastic bandage or wear elastic stockings, periodically put their feet in a horizontal position, and do special exercises for the legs and lower legs (flexion and extension in the ankle and knee joints) to activate the muscle-venous pump.Elastic compression accelerates and increases blood flow in the veins in the thigh, reduces the amount of blood in the saphenous vein, prevents the formation of edema, improves microcirculation, and helps normalize metabolic processes in tissues.Bandaging should start in the morning, before getting out of bed.The bandage is applied with slight tension from the toes to the thigh, with mandatory grip on the heel and ankle joints.Each subsequent round of wrapping should overlap the previous one by half.It is recommended to use certified medical knitwear with individual selection of the compression level (from 1 to 4).Patients should wear comfortable shoes with hard soles and low heels, avoid long 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 a high position by placing a special stand of the required height under the legs.It is advisable to walk a little every 1-1.5 hours or stand on your toes 10-15 times.The resulting calf muscle contraction increases blood circulation and increases venous outflow.While sleeping, your legs should be placed in a high position.
Patients are advised to limit water and salt intake, normalize body weight, and periodically take diuretics and drugs that increase venous tone.According to the indications, drugs are prescribed that improve microcirculation in the tissues.For treatment, it is recommended to use non-steroidal anti-inflammatory drugs.
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% table salt solution.
Compression sclerotherapy
Indications for injection therapy (sclerotherapy) for varicose veins are still debated.This method consists of inserting a sclerosing agent into the dilated vein, further compression, desolation and sclerosis.Modern drugs used for this purpose are relatively safe, i.e. they do not cause necrosis of the skin or subcutaneous tissue when administered extravasally.Some experts use sclerotherapy for almost all forms of varicose veins, while others reject the method entirely.Most likely, the truth lies somewhere in the middle, and it makes sense for young women with early stages of the disease to use injection treatment methods.The only thing is that they must 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 needed for complete sclerosis of the vein.
The group of patients with varicose veins should include patients with telangiectasias ("spider veins") and dilation of the network of small saphenous veins, because the causes of the development of these diseases are the same.In this case, along with sclerotherapy, you can toopercutaneous laser coagulation, but only after excluding damage to deep and perforated veins.
Percutaneous laser coagulation (PLC)
This is a method based on the principle of selective photocoagulation (photothermolysis), based on the absorption of different laser energy by various substances in the body.A special feature of this method is the non-contact nature of this technology.The focused head concentrates energy into the blood vessels in the skin.Hemoglobin in the vessels selectively absorbs laser beams with certain wavelengths.Under the action of the laser, the destruction of the endothelium occurs in the vessel lumen, which leads to the adhesion of the vessel wall.
The effectiveness of PLK directly depends on the depth of penetration of the laser beam: the deeper the vessel, the longer the wavelength should be, therefore PLK has a rather limited indication.For vessels with a diameter greater than 1.0-1.5 mm, microsclerotherapy is most effective.Given the widespread and branched distribution of spider veins on the legs and the variable diameter of the vessels, combined treatment methods are being 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 remove the remaining "stars" of smaller diameter.
This procedure can be said to be painless and safe (skin cooling and anesthetics are not used), because 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 receive burns.For patients with high pain sensitivity, the initial use of a cream with a local anesthetic effect is recommended.Erythema and swelling subside within 1-2 days.After the course, for about two weeks, some patients may experience darkening or lightening of the treated skin area, which then disappears.In people with fair skin, the changes are almost invisible, but in patients with dark or tanned skin, the risk of 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 relatively large surface of the skin, but usually no more than four laser therapy sessions are required (5-10 minutes each).The maximum result in a short time is achieved due to the unique "square" shape of the light pulse of the device;it increases its effectiveness compared to other devices, also reduces the possibility of side effects after the procedure.
Surgical treatment
Surgery is the only radical treatment method for patients with varicose veins on the lower leg.The purpose of the operation is to eliminate the pathogenetic mechanism (veno-venous reflux).This is accomplished 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 hundred years of history.Previously, and many surgeons still do, a large incision along the varicose vein and general or spinal anesthesia was used.Traces after such a "mini-phlebectomy" remain a reminder for the lifetime of the operation.The first operation on the vein (according to Schade, according to Madelung) is so traumatic that the harm from it exceeds the harm from varicose veins.
In 1908, the American surgeon Babcock came up with a subcutaneous vein extraction method using a rigid metal probe with an olive.In its improved form, this surgical method to remove varicose veins is still used in many public hospitals.Varicose veins are removed using a separate incision, as suggested by surgeon Narat.Therefore, the 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, which makes it difficult for patients to agree to surgical treatment of varicose veins.
Phlebologists have developed a unique technology to treat varicose veins in one day.Complex cases are handled usingcombined technology.Large main varicose veins are removed with inversion stripping, which involves minimal intervention through mini-incisions (from 2 to 7 mm) of the skin, which leave almost no scars.The use of minimally invasive techniques involves minimal tissue trauma.The result of this operation is the elimination of varicose veins with excellent aesthetic results.Combined surgical treatment is performed under intravenous or total 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 varicose vein debris.Only varicose veins are removed, and not the whole (as in the classic version).
Actuallyminiphlebectomyreplaces the Narat technique to remove tributaries of the main varicose veins.Previously, a skin incision from 1-2 to 5-6 cm was made along the course of the varixes, where the veins were isolated and removed.The desire to improve the cosmetic results of interventions 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 minimal skin defects.This is how phlebectomy sets of "hooks" of various sizes and configurations and special spatulas appeared.And instead of an ordinary scalpel, a scalpel with a very narrow blade or a needle with a relatively large diameter began to be used to pierce the skin (for example, the needle used to take venous blood for analysis with a diameter of 18G).Ideally, the puncture mark with such a needle can be said to be 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, 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 postoperative period, 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 large or small saphenous vein varicose trunk is more than 10 mm;
- After experiencing thrombophlebitis on the main subcutaneous stem;
- After trunk recanalization after other types of treatment (EVLT, sclerotherapy);
- Removal of very large individual varicose veins.
It can be an independent operation or be a component of the combined treatment of varicose veins, combined with vein laser treatment and sclerotherapy.The 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 veins of various locations that have changed for various reasons, including on the face.Professor Varadi from Frankfurt developed his simple instrument and formulated the basic postulates of modern microphlebectomy.The Varadi phlebectomy method provides excellent cosmetic results without pain or hospitalization.This is very meticulous, almost jewelry work.
After vein surgery
The postoperative period after the usual "classic" phlebectomy is quite painful.Sometimes a large hematoma is a concern, and swelling occurs.Wound healing depends on the phlebologist's surgical technique;sometimes there is lymph leakage and long-term formation of significant scars;often after primary phlebectomy there is still a loss of sensitivity in the heel area.
On the other hand, after miniphlebectomy, the wound does not need stitches, because this is only a puncture, there is no pain, and no damage to the skin nerves has been observed in practice.However, such phlebectomy results can only be achieved by highly experienced phlebologists.