The main method of treatment of 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 satisfies all the pathogenetic principles of treatment, as a result, 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 reflux of blood from the deep veins to the superficial veins in patients of classes C2-C6. A combined operation can 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;
- Removal of varicose tributaries of the GSV and SSV;
- Crossing of incompetent perforating veins.
This operational scope has been developed over decades of scientific research and practice.
Crossectomy of the great saphenous vein. The optimal approach to ligation of the VGS is through the inguinal crease. The suprapinguinal approach has some advantages only in patients with disease recurrence due to the residual pathological stump of the VGS and the elevated position of the postoperative scar. The VGS must be tied tightly parietal to the femoral vein; all tributaries of the estuary, including the upper one (superficial epigastric vein), must be tied. Suturing of the oval window or subcutaneous tissue is not necessary after VGS crossectomy.
Removal of the trunk of the great saphenous vein. When determining the extent of VGS stripping it is necessary to take into account that in the vast majority of cases (80-90%) the reflux along the VGS is recorded only from the mouth to the upper third of the leg. Removal of the VGS along its entire length (total stripping) is accompanied by a significantly higher incidence of damage to the saphenous nerves than removal of the VGS 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 can be used in the future for reconstructive vascular interventions
In this regard, the basis of intervention in the GSV basin should be short stripping. Removal of the entire length of the trunk is permitted only if it is reliably established that it is incompetent and has significantly expanded (more than 6 mm in a horizontal position).
When choosing a saphenectomy method, preference should be given to intussusception techniques (including PIN stripping) or cryophlebectomy. Although the detailed study of these methods is still ongoing, their advantages (less traumatic) compared to the classic Babcock technique are undoubted. The Babcock method is still effective and can be used in clinical practice, but it is advisable to use small diameter olives. When choosing the direction of vein removal, preference should be given to traction from top to bottom, that is, retrograde, with the exception of cryophlebectomy, the technique of which involves antegrade removal 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 superior vena cava merges with the popliteal vein a few centimeters above the bend line of the knee. In this regard, the approach for crossectomy of the SVC should be moved proximally, taking into account the localization of the saphenopopliteal anastomosis (before surgery, the localization of the anastomosis should be clarified by ultrasound).
Removal of the trunk of the small saphenous vein. As with GSV, the vein should be removed only to the extent that reflux is determined to be present. In the lower third of the leg, reflux along the superior vena cava is very rare. Intussusception methods should also be used. SVC cryophlebectomy has no advantages over these techniques.
A comment. The operation on the small saphenous vein (crossectomy and removal of the trunk) must be carried out with the patient in the prone position.
Thermoobliteration of the main saphenous veins. Modern endovascular techniques - laser and radiofrequency - can eliminate brainstem reflux and therefore, in terms of functional effect, can 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 higher. Laser and radiofrequency obliteration is performed without ostial ligation (GSV and SSV). Simultaneous crossectomy virtually eliminates the benefits of thermoobliteration and increases the cost of treatment.
Endovascular obliteration with laser and radiofrequency has limitations in their use, is accompanied by specific complications, is much more expensive and requires mandatory intraoperative ultrasound control. The reproducibility of the technique is low, so it should be performed only by experienced specialists. The long-term results of use in widespread clinical practice are still unknown. In this regard, thermoobliteration methods need further study and cannot yet completely replace traditional surgical interventions for varicose veins.
Removal of varicose veins. When eliminating varicose tributaries of superficial trunks, preference should be given to their removal using miniphlebectomy tools through skin punctures. All other surgical methods are more traumatic and lead to worse aesthetic results. By agreement with the patient, it is possible to leave some varicose veins, which will subsequently be eliminated by sclerotherapy.
Dissection of perforating veins. The main controversial issue in this subsection is the determination of indications for surgery, since the role of perforators in the development of chronic venous disease and its complications requires clarification. The inconsistency of numerous studies in this area is associated with the lack of clear criteria for determining the incompetence of perforating veins. Numerous authors generally question the fact that incompetent perforating veins can have an independent significance in the development of CVD and be a source of pathological reflux from the deep to the superficial venous system. The main role in varicose veins is assigned to vertical discharge through the saphenous veins, and the failure of perforators is associated with the increasing load on them to drain reflux blood from the superficial to the deep venous system. As a result, they increase in diameter and have bidirectional blood flow (mainly in the deep veins), which is primarily determined by the severity of vertical reflux. It should be noted that bidirectional blood flow through perforators is observed even in healthy people without signs of CVD. The number of incompetent perforating 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% to 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 of restoring normal hemodynamics in perforating veins are limited. As a result of prolonged exposure to pathological reflux from the subcutaneous and/or deep veins, irreversible changes occur in a certain part of these vessels, and the reverse flow of blood through them acquires pathological significance.
Therefore, today we can talk about mandatory careful ligation of incompetent perforating veins only in patients with varicose veins with trophic disorders (classes C4-C6). In clinical classes C2-C3, the decision on perforator ligation must be made individually by the surgeon, based on the clinical picture and instrumental examination data. In this case, dissection should be performed only 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 the perforating veins (ESDPV). Numerous studies indicate its undeniable advantages over the previously widely used open subfascial perforator 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 when it comes to trophic disorders. However, it is unclear which of the observed effects are due to the dissection and which are due to concomitant surgery on the saphenous vein in the majority of patients. However, the lack of long-term results in patients with C4-C6, who did not undergo operations on perforating veins, but only phlebectomy, does not yet allow us to draw definitive conclusions regarding the use of some 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 on the background of varicose veins. The recurrence rate of ulcers after phlebectomy combined with ESDPV varies from 4% to 18% (follow-up period 5-9 years). In this case, complete healing occurs in approximately 90% of patients within the first 10 months.
Good results have also been obtained using other minimally invasive techniques to eliminate perforating veins, such as microfoam sclerobliteration and endovascular laser obliteration. However, the probability of success with their use directly depends on the qualifications and experience of the doctor, so for now they cannot be recommended for widespread use.
In patients with clinical classes C2-C3, ESDPV should not be used, since the elimination of perforating reflux can be successfully performed by small incisions (up to 1 cm) and even skin punctures using 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 on aspects such as the significance of deep venous reflux and its impact on the course of CVI, determining the indications for correction and evaluating the effectiveness of treatment. Failure of various segments of the deep venous system of the lower extremities leads to various hemodynamic disorders, which is important to consider when choosing a treatment method. Numerous studies indicate that reflux through the femoral vein plays no significant role. At the same time, damage to the deep veins of the legs can lead to irreparable changes in the functioning of the musculovenous pump and severe forms of CVI. It is difficult to evaluate the positive effects of the same correction of venous reflux in the deep veins, since these interventions are in most cases performed in combination with operations on the superficial and perforating veins. Isolated elimination of reflux through the femoral vein does not affect venous hemodynamics at all or leads to temporary minor changes in only some parameters. On the other hand, only the elimination of reflux along the VGS 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 for treating primary deep venous reflux can be divided into two groups. The first involves bloodletting and includes internal valvuloplasty, transposition, autotransplantation, the creation of new valves and the use of cryopreserved allografts. The second group does not require bloodletting and includes extravascular interventions, external valvuloplasty (transmural or transcommissural), angioscopically assisted extravascular valvuloplasty and percutaneous installation of corrective devices.
The question of correction of deep venous valves should be raised only in patients with recurrent or non-healing trophic ulcers (class C6), mainly with recurrent trophic ulcers and reflux in the deep veins of grade 3-4 (up to the level of the knee joint) according to Kistner's classification. If conservative treatment is ineffective in young people who do not want a permanent prescription of compression stockings, surgery may be performed for severe edema and C4b. The decision to operate should be made based on clinical status, but not on data from specific studies, as symptoms may not correlate with laboratory parameters. Surgical interventions to correct deep venous valves should be performed only in specialized centers with experience in such operations.
Surgical treatment of post-thrombotic disease
The results of surgical treatment of preterm patients are significantly worse than those of patients with varicose veins. Therefore, after ESDPV, the recurrence rate of trophic ulcers reaches 60% during the first 3 years. The validity of operations on perforating veins in this category of patients has not been confirmed in many 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 play a collateral function in preterm birth and their removal can lead to a worsening of the disease. Therefore, phlebectomy (as well as laser or radiofrequency obliteration) cannot be used as a routine procedure for preterm birth. The decision on the need and possibility of removing subcutaneous veins in one volume or another should be made on the basis of a thorough analysis of clinical and anamnestic information, the results of instrumental diagnostic tests (ultrasound, radionuclides).
Correction of deep venous valves
Post-thrombotic damage to the valve system in most cases is not amenable to direct surgical correction. Several dozen options for operations to form valves in deep veins for preterm birth have not gone beyond the scope of clinical experiments.
Bypass interventions
In the second half of the last century, two shunt operations for deep venous occlusions were proposed, one of which was aimed at diverting blood from the popliteal vein to the VGS in case 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 is also today the only way to create an additional path for the outflow of venous blood, which can be recommended for wide clinical use. Autogenous femoro-femoral cruciate venous shunts are characterized by lower thrombogenicity and better patency than artificial ones. However, available studies on this topic include a small number of patients with ambiguous periods of clinical and venographic follow-up.
The indications for femorofemoral bypass surgery are unilateral occlusion of the iliac vein. Prerequisite is the absence of obstructions to the venous outflow in the opposite limb. Furthermore, functional indications for surgical intervention emerge only with the constant progression of CVI (to clinical classes C4-C6), despite adequate conservative treatment for several (3-5) years.
Vein transplant and transposition
Transplantation of venous segments containing valves shows good success 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 the diameters of the veins. The intervention is physiopathologically poorly justified: the hemodynamic conditions of the upper and lower limbs differ significantly, and therefore the transplanted venous segments expand with the development of reflux. Furthermore, replacement of 1-2-3 valves with extensive damage to the deep venous system cannot compensate for impaired venous outflow.
Methods of transposition of recanalized veins "under the protection" of valves of intact vessels, of which the most possible from a technical point of view can be the transposition of the superficial femoral vein into the deep vein of the femur, cannot be recommended for a extensive clinical practice. practice due to their complexity and the rarity of optimal conditions for their implementation. The limited number of observations and the lack of long-term results do not allow us to draw any conclusions.
Endovascular interventions for stenosis and occlusion of deep veins
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, 1% to 6% of patients have this pathology. In 17% of cases the occlusion is associated with reflux. It should be noted that this combination is accompanied by the highest level of venous hypertension and more severe manifestations of CVI than reflux or occlusion alone. Proximal occlusion, especially of the iliac veins, is more likely to lead to CVI than involvement of the distal segments. Following iliofemoral thrombosis only 20-30% of the iliac veins are completely recanalized; in other cases more or less pronounced residual occlusion and collateral formation are observed. The main goal of the surgery is to remove or eliminate the occlusion or provide additional pathways for venous outflow.
Directions. Unfortunately, there are no reliable criteria for "critical stenosis" in the venous system. This is the major obstacle in determining indications for treatment and interpreting results. X-ray contrast venography is a standard method for visualizing the venous bed, allowing the determination of areas of occlusion, stenosis and the presence of collaterals. Intravascular ultrasound (IVUS) is superior to venography in evaluating the morphological characteristics and extent of iliac vein stenosis. Iliocaval segment occlusion and associated anomalies can be diagnosed with MRI and spiral CT venography.
Femoroiliac stent. The introduction of percutaneous balloon dilation of the iliac vein and stent into clinical practice has significantly expanded the therapeutic options. This is due to their high efficiency (restoration of segment patency in 50-100% of cases), the low incidence of complications and the absence of deaths. Among the factors contributing to thrombosis or restenosis in the stent area in patients with postthrombophlebitic disease, the main ones are thrombophilia and long stent length. In the presence of these factors, the restenosis rate after 24 months reaches up to 60%; in their absence the stenosis does not develop. The healing rate of trophic ulcers after balloon dilation and iliac vein stenting was 68%; no recurrence 2 years after surgery was observed in 62% of cases. The severity of the swelling and pain decreased significantly. The percentage of limbs with swelling decreased from 88% to 53% and with pain from 93% to 29%. Analysis of questionnaires from patients undergoing venous stenting showed significant improvement in all major aspects of quality of life.
Published studies on venous stents often have the same limitations as reports on open surgery (small number of patients, lack of long-term results, no distribution of patients into groups according to the etiology of the occlusion, acute pathology or chronic, etc. ). The venous stent technique appeared relatively recently and therefore the period of observation of patients is limited. Since the long-term results of the procedure are not yet known, continuous monitoring for several years is required to evaluate its effectiveness and safety.
Surgical treatment of phlebosplasia
There are no effective methods for radical correction of hemodynamics in patients with phlebosplasia. The need for surgical treatment arises when there is a risk of bleeding from dilated and thinned saphenous veins or from trophic ulcers. In these situations, excision of the venous conglomerates is performed in order to reduce local venous stagnation.
Operations for cardiovascular diseases can be performed in vascular or general surgery departments by specialists trained in phlebology. Some types of operations (reconstructive: valvuloplasty, bypass surgery, transposition, transplant) should only be performed in specialized centers according to strict indications.