The main method of treating varicose veins (VV) remains surgery. The purpose of the operation is to eliminate the symptoms of the disease (including cosmetic defects) and prevent the progression of varicose transformation of the saphenous veins. Today, none of the existing surgical methods alone meets all the pathogenetic principles of treatment, so the need for their combination becomes obvious. Various combinations of certain operations mainly depend on the severity of pathological changes in the venous system of the lower extremities.
The indication for surgery is the presence of blood reflux from deep veins to superficial veins in patients of classes C2-C6. A combined operation may include the following steps:
- Ligation of the estuary and intersection of the GSV and/or SVC with all tributaries (crossectomy);
- Removal of GSV and/or SSV trunks;
- Elimination of varicose tributaries of GSV and SSV;
- Crossing of incompetent perforating veins.
This field of action has been developed over decades of scientific and practical research.
Crossectomy of the great saphenous vein. The optimal approach to ligating the GSV is through the inguinal fold. The suprapinguinal approach only has some advantages in patients with recurrent disease due to the remaining pathological stump of the GSV and high localization of the postoperative scar. The GSV must be ligated strictly parietal to the femoral vein; all estuarine tributaries, including the upper (superficial epigastric vein) must be ligated. There is no need to suture the oval window or subcutaneous tissue after GSV crossectomy.
Removal of the trunk of the great saphenous vein. When determining the extent of stripping of the GSV, it should be taken into account that in the vast majority of cases (80-90%), reflux along the GSV is recorded only from the mouth to the upper third of theleg. Removal of the GSV along its entire length (total stripping) is accompanied by a significantly higher incidence of saphenous nerve damage compared to removal of the GSV from the mouth to the upper third of the leg (short stripping) - 39% and 6. 5%, respectively. At the same time, the frequency of relapses of varicose veins does not differ significantly. The remaining segment of the vein may be used in the future for reconstructive vascular operations
In this regard, the basis of intervention in the GSV basin should be short stripping. Removal of the entire length of the trunk is allowed only if it is reliably confirmed to be incompetent and has expanded significantly (more than 6 mm in a horizontal position).
When choosing a safenectomy method, preference should be given to intussusception techniques (including PIN stripping) or cryophlebectomy. Although the detailed study of these methods is still in progress, their advantages (less traumatic) compared to the classic Babcock technique are indisputable. However, the Babcock method is effective and can be used in clinical practice, but it is advisable to use small diameter olives. When choosing the direction of ablation of the vein, preference should be given to traction from top to bottom, that is to say retrograde, with the exception of cryophlebectomy, the technique of which involves anterograde ablation of the vein. .
Crossectomy of the small saphenous vein. The structure of the terminal section of the small saphenous vein is very variable. Typically, the SVC merges with the popliteal vein a few centimeters above the line of curvature of the knee. In this regard, the approach to SVC crossectomy must be shifted proximally, taking into account the location of the saphenopopliteal anastomosis (before the operation, the location of the anastomosis must be clarified by ultrasound).
Removal of the trunk of the small saphenous vein. As with GSV, the vein should only be removed to the extent that reflux is detected. In the lower third of the leg, reflux along the SVC is very rare. Intussusception methods should also be used. SVC cryophlebectomy has no advantage over these techniques.
A comment. The intervention on the small saphenous vein (crossectomy and ablation of the trunk) must be carried out with the patient in a supine position.
Thermoobliteration of the main saphenous veins. Modern endovasal techniques - laser and radiofrequency - can eliminate brainstem reflux and can therefore, in terms of functional effect, be called an alternative to crossectomy and stripping. The morbidity of thermoobliteration is significantly lower than that of stem phlebectomy, and the aesthetic result is significantly superior. Laser and radiofrequency obliteration is performed without ostial ligation (GSV and SSV). Simultaneous crossectomy virtually eliminates the benefits of thermoobliteration and the cost of treatment increases.
Endovasal obliteration by laser and radiofrequency has limitations of use, is accompanied by specific complications, is much more expensive and requires obligatory intraoperative ultrasound control. The reproducibility of the technique is low, so it should only be performed by experienced specialists. The long-term results of its use in widespread clinical practice are still unknown. In this regard, thermoobliteration methods require further study and cannot yet completely replace traditional surgical interventions for varicose veins.
Elimination of varicose veins. When eliminating varicose tributaries from the superficial trunks, priority should be given to their elimination using miniphlebectomy instruments by skin puncture. All other surgical methods are more traumatic and lead to poorer aesthetic results. In agreement with the patient, it is possible to leave a few varicose veins, which will then be eliminated by sclerotherapy.
Dissection of perforating veins. The main controversial issue in this subsection is the determination of indications for intervention, since the role of perforators in the development of chronic venous disease and its complications needs to be clarified. The inconsistency of many studies in this area is associated with the lack of clear criteria for determining the incompetence of perforating veins. A number of authors generally question whether incompetent perforator veins can have an independent significance in the development of cardiovascular diseases and be a source of pathological reflux from the deep venous system to the superficial venous system. The main role in varicose veins is attributed to the vertical flow through the saphenous veins, and the failure of the perforators is associated with the increasing load imposed on them to drain reflux blood from the superficial venous system to the deep venous system. As a result, their diameter increases and their two-way blood flow (mainly in deep veins) is mainly determined by the severity of vertical reflux. It should be noted that bidirectional blood flow through the perforators is also observed in healthy people without signs of cardiovascular disease. The number of incompetent perforator veins is directly related to the CEAP clinical class. These data are partly confirmed by studies in which, after interventions on the superficial venous system and elimination of reflux, a significant proportion of perforators become solvent.
However, in patients with trophic disorders, 25. 5-40% of perforators remain incompetent, and their further impact on the course of the disease is unclear. Apparently, with varicose veins of classes C4-C6 after elimination of vertical reflux, the possibilities for restoring normal hemodynamics in the perforating veins are limited. As a result of prolonged exposure to pathological reflux from subcutaneous and / or deep veins, irreversible changes occur in a certain part of these vessels and reverse blood flow through them acquires pathological significance.
So, today we can talk about careful and obligatory ligation of incompetent perforator veins only in patients with varicose veins with trophic disorders (classes C4-C6). In clinical classes C2-C3, the decision to ligate the perforators should be made individually by the surgeon, based on the clinical picture and data from the instrumental examination. In this case, dissection should only be carried out if their failure is reliably confirmed.
If the localization of trophic disorders excludes the possibility of direct percutaneous access to an incompetent perforating vein, the operation of choice is endoscopic subfascial dissection of perforating veins (ESDPV). Numerous studies indicate its undeniable advantages over the previously widely used open subfascial ligation (Linton operation). The incidence of wound complications with ESDPV is 6-7%, while with open surgery it reaches 53%. At the same time, the healing time of trophic ulcers, indicators of venous hemodynamics and the frequency of relapses are comparable.
A comment. Numerous studies indicate that ESDPV can have a positive effect on the course of chronic venous disease, especially with regard to trophic disorders. However, it is not clear which of the observed effects are due to dissection and which are due to concomitant saphenous vein surgery in most patients. However, the lack of long-term results in patients with C4-C6, who did not undergo perforator vein interventions, but only phlebectomy, does not yet allow definitive conclusions to be drawn regarding theuse of certain surgical treatment methods.
Despite the existing contradictions, most researchers still consider it necessary to combine traditional interventions on superficial veins with ESDPV in patients with trophic disorders and open trophic ulcers against the background of varicose veins. The ulcer recurrence rate after phlebectomy combined with ESDPV ranges from 4% to 18% (follow-up period 5 to 9 years). In this case, complete recovery occurs in about 90% of patients within the first 10 months.
Using other minimally invasive techniques to remove perforator veins, such as microfoam sclero-obliteration, laser endovasal obliteration, good results have also been achieved. However, the likelihood of success of their use directly depends on the qualifications and experience of the doctor. For the moment, their widespread use cannot therefore be recommended.
In patients of clinical classes C2-C3, ESDPV should not be used, since the removal of perforator reflux can be successfully carried out from small incisions (up to 1 cm) and even from skin puncturesusing miniphlebectomy instruments.
Correction of deep venous valves. Currently, in this section of surgical phlebology, there are more questions than answers. This is due to existing contradictions regarding aspects such as the importance of deep venous reflux and its impact on the course of IVC, determination of indications for correction and evaluation of treatment effectiveness. Failure of various segments of the deep venous system of the lower extremities leads to various hemodynamic disorders, which are important to consider when choosing a treatment method. A number of studies indicate that reflux through the femoral vein plays no significant role. At the same time, damage to the deep veins of the leg can lead to irreparable changes in the functioning of the musculovenous pump and severe forms of IVC. It is difficult to assess the positive effects of correction of venous reflux in the deep veins itself, since these interventions in most cases are carried out in combination with operations on superficial and perforating veins. Isolated elimination of reflux through the femoral vein either does not affect venous hemodynamics at all, or leads to minor temporary changes in only some parameters. In contrast, only the elimination of reflux along the GSV in varicose veins in combination with the incompetence of the femoral vein leads to the restoration of valve function in this venous segment.
Surgical methods of treating primary deep venous reflux can be divided into two groups. The first involves phlebotomy and includes internal valvuloplasty, transposition, autotransplantation, creation of new valves and the use of cryopreserved allografts. The second group does not require phlebotomy and includes extravasal interventions, external valvuloplasty (transmural or transcommissural), angioscopy-assisted extravasal valvuloplasty and percutaneous installation of corrective devices.
The question of correction of deep venous valves should only arise in patients with recurrent or non-healing trophic ulcers (class C6), primarily with recurrent trophic ulcers and reflux into deep veins of grade 3-4 (up to knee level). joint) according to the Kistner classification. If conservative treatment proves ineffective in young people who do not want a lifetime prescription for compression stockings, surgical intervention can be performed in cases of severe edema and C4b. The decision to operate should be made based on the clinical condition, but not based on data from special studies, since the symptoms may not correspond to laboratory parameters. Surgical procedures to correct deep vein valves should only be performed in specialized centers experienced in such procedures.
Surgical treatment of postthrombotic disease
The results of surgical treatment of patients with PTB are significantly worse than those of patients with varicose veins. Thus, after ESDPV, the recurrence rate of trophic ulcers reaches 60% during the first 3 years. The validity of perforator vein interventions in this category of patients has not been confirmed in numerous studies.
Patients should be informed that surgical treatment of PTB carries a high risk of failure.
Interventions on the subcutaneous venous system
In many patients, the saphenous veins serve a collateral function in PTB and their removal can lead to worsening of the disease. Therefore, phlebectomy (as well as laser or radiofrequency obliteration) cannot be used as a routine procedure for PTB. The decision about the need and possibility of ablation of subcutaneous veins in one volume or another should be made on the basis of a thorough analysis of clinical and anamnestic information, results of instrumental diagnostic tests (ultrasound, radionuclide).
Correction of deep vein valves
In most cases, postthrombotic damage to the valve apparatus is not amenable to direct surgical correction. Several dozen options for operations aimed at forming valves in deep veins for PTB have not gone beyond the scope of clinical experiments.
Circumventions
In the second half of the last century, for deep vein occlusions, two shunt interventions were proposed, one aimed at diverting blood from the popliteal vein to the GSV in cases of femoral occlusion (Warren-Tyre method). , the other - from the femoral vein to another (healthy) limb in case of occlusion of the iliac veins (Palma-Esperon method). Only the second method has demonstrated clinical effectiveness. This type of operation is not only effective, but also today the only way to create an additional route for venous blood outflow, which can be recommended for wide clinical use. Autogenous transvenous femoral-femoral shunts are characterized by lower thrombogenicity and better patency than artificial shunts. However, available studies on this issue include a small number of patients with ambiguous clinical and venographic follow-up periods.
The indications for femorofemoral bypass are unilateral occlusion of the iliac vein. A prerequisite is the absence of obstruction of venous outflow in the opposite limb. In addition, functional indications for surgery appear only with constant progression of IVC (towards clinical classes C4-C6), despite adequate conservative treatment for several (3-5) years.
Transplantation and vein transposition
Transplantation of vein segments containing valves gives good results in the months immediately following surgery. Usually the superficial veins of the upper limb are used, which are transplanted to the location of the femoral vein. The limitations of the method are due to the difference in vein diameter. The intervention is pathophysiologically poorly justified: the hemodynamic conditions in the upper and lower limbs differ significantly, and therefore the transplanted venous segments dilate with the development of reflux. In addition, replacement of 1-2-3 valves in case of significant damage to the deep venous system cannot compensate for impaired venous outflow.
Methods of transposition of recanalized veins "under protection" of intact vessel valves, of which the most technically possible may be the transposition of the superficial femoral vein into the deep vein of the femur, cannot be recommended forgeneralized clinical studies. practical due to their complexity and the casuistic rarity of optimal conditions for their implementation. The small number of observations and the absence of long-term results do not allow conclusions to be drawn.
Endovasal interventions for deep vein stenosis and occlusion
Deep vein occlusion or stenosis is the primary cause of CVI symptoms in approximately one third of patients with DVT. In the structure of trophic ulcers, from 1 to 6% of patients have this pathology. In 17% of cases, the occlusion is associated with reflux. It should be noted that this association is accompanied by the highest level of venous hypertension and the most severe manifestations of CVI compared to reflux or occlusion alone. Proximal occlusion, particularly of the iliac veins, is more likely to lead to CVI than involvement of the distal segments. Following iliofemoral thrombosis, only 20 to 30% of the iliac veins are completely recanalized; in other cases, residual occlusion and the formation of more or less pronounced collaterals are observed. The main goal of the procedure is to remove or eliminate the occlusion or provide additional pathways for venous outflow.
Indications. Unfortunately, there is no reliable criterion for "critical stenosis" of the venous system. This is the main obstacle to determining the indications for treatment and interpreting its results. X-ray contrast venography is a standard method for visualizing the venous bed, allowing areas of occlusion, stenosis and the presence of collaterals to be determined. Intravascular ultrasound (IVUS) is superior to venography for evaluating the morphologic features and extent of iliac vein stenosis. Iliocaval segment occlusion and associated abnormalities can be diagnosed by MRI and spiral venography.
Femoro-iliac stenting. The introduction of percutaneous balloon dilation of the iliac vein and stenting into clinical practice has significantly expanded treatment options. This is due to their high effectiveness (restoration of segment patency in 50 to 100% of cases), their low incidence of complications and the absence of deaths. Among the factors contributing to thrombosis or restenosis in the stent area in patients with post-thrombophlebitis disease, the main ones are thrombophilia and stent length. In the presence of these factors, the restenosis rate after 24 months can reach 60%; in their absence, stenosis does not develop. The healing rate of trophic ulcers after balloon dilation and stenting of the iliac vein was 68%; no relapse 2 years after the intervention was observed in 62% of cases. The severity of swelling and pain has decreased significantly. The proportion of limbs with swelling decreased from 88% to 53% and that of painful limbs from 93% to 29%. Analysis of patient questionnaires after venous stenting showed significant improvement in all major aspects of quality of life.
Published studies on venous stenting often have the same shortcomings as reports on open surgical procedures (small number of patients, lack of long-term results, no division of patients into groups according to the etiology of the occlusion, theacute or chronic pathology, etc. ). The venous stenting technique appeared relatively recently and the patient observation period is therefore limited. Since the long-term results of the procedure are not yet known, continued monitoring for several more years is necessary to evaluate its effectiveness and safety.
Surgical treatment of phlebodysplasia
There are no effective methods for radically correcting hemodynamics in patients with phlebodysplasia. The need for surgical treatment arises when there is a risk of bleeding due to dilated and thinned saphenous veins or trophic ulcers. In these situations, excision of venous conglomerates is performed to reduce local venous stagnation.
Surgical interventions for cardiovascular diseases can be performed in vascular or general surgery departments by specialists trained in phlebology. Certain types of interventions (reconstructive: valvuloplasty, bypass, transposition, transplantation) should only be carried out in specialized centers according to strict indications.