The main method of treatment for varicose veins (VV) remains surgery. The purpose of the operation is to remove the symptoms of the disease (including cosmetic defects) and prevent the progression of the varicose transformation of the saphenous veins. Today, none of the existing surgical methods alone satisfy all the pathogenetic principles of treatment, which is why the need for their combination becomes obvious. Different combinations of individual operations primarily 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 with classes C2-C6. A combined operation may include the following steps:
- Estuary ligation and crossing of GSV and/or SVC with all tributaries (crossectomy);
- Removal of GSV and/or SSV trees;
- Removal of varicose tributaries GSV and SSV;
- Crossing incompetent perforating veins.
This body of work has been developed over decades of scientific and practical research.
Crossectomy of the great saphenous vein. The optimal approach for ligation of the GSV is through the inguinal fold. The suprapinguinal approach has some advantages only in patients with recurrent disease because of the remaining pathologic stump of the GSV and the high location of the postoperative scar. The GSV must be tied strictly parietal to the femoral vein; all estuarine tributaries, including the superior (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 removal of the GSV, it is necessary to take 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 the leg. Removal of GSV along its entire length (total removal) is accompanied by a significantly higher incidence of saphenous nerve damage compared to removal of GSV from the mouth to the upper third of the leg (short removal) - 39% and 6. 5%, respectively. At the same time, the frequency of recurrence of varicose veins does not differ significantly. The remaining segment of the vein can be used in the future for reconstructive vascular surgery
In this regard, the basis of intervention in the GSV basin should be a short dismantling. Removal of the entire length of the trunk is permitted only if it is reliably confirmed that it is inoperable and that it has expanded significantly (more than 6 mm in the horizontal position).
When choosing a saphenectomy method, preference should be given to intussusception techniques (including PIN removal) or cryophlebectomy. Although a detailed study of these methods is still ongoing, their advantages (less traumatic) compared to the classic Babcock technique are undoubted. However, Babcock's method is effective and can be used in clinical practice, but it is recommended to use olives of small diameter. 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, whose technique includes antegrade vein removal.
Crossectomy of the small saphenous vein. The structure of the terminal part of the small saphenous vein is very variable. As a rule, the SVC joins the popliteal vein a few centimeters above the knee flexion line. In this regard, the approach for crossectomy of the SVC must be moved proximally, taking into account the localization of the sapheno-popliteal anastomosis (before the operation, it is necessary to clarify the localization of the anastomosis by ultrasound scanning).
Removal of the trunk of the small saphenous vein. As with GSV, the vein should be removed only to the extent that reflux is found to be present. In the lower third of the leg, reflux along the SVC is very rare. Intussusception methods should also be used. SVC cryophlebectomy has no advantages over these techniques.
Comment. Intervention on the small saphenous vein (crossectomy and trunk removal) should be performed with the patient in the supine position.
Thermoobliteration of the main saphenous veins. Modern endovasal techniques - laser and radiofrequency - can eliminate brainstem reflux and therefore, in terms of their functional effect, can be called an alternative to crossectomy and stripping. Morbidity of thermoobliteration is significantly lower than with stem phlebectomy, and the cosmetic result is significantly higher. Laser and radiofrequency obliteration is performed without ligation of the ostium (GSV and SSV). Simultaneous crossectomy practically eliminates the advantages of thermoobliteration, and the cost of treatment increases.
Endovasal laser and radiofrequency obliteration have limitations in application, are accompanied by specific complications, are significantly more expensive and require mandatory intraoperative ultrasound control. The reproducibility of the technique is low, so it should only be performed by experienced specialists. The long-term results of use in broad clinical practice are still unknown. In this sense, thermoobliteration methods require further study and still cannot completely replace traditional surgical interventions for varicose veins.
Removal of varicose veins. During the elimination of varicose tributaries of superficial trunks, preference should be given to their removal using miniphlebectomy instruments through skin punctures. All other surgical methods are more traumatic and lead to worse cosmetic results. In agreement with the patient, it is possible to leave some varicose veins that are subsequently removed with sclerotherapy.
Dissection of perforating veins. The main controversial issue in this subsection is determining the indications for intervention, because 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 related to the lack of clear criteria for determining the incompetence of perforating veins. A number of authors generally question the fact that incompetent perforating veins can have an independent importance 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 attributed to vertical emptying through the saphenous veins, and the failure of the perforators is associated with an increasing burden on them to drain reflux blood from the superficial to the deep venous system. As a result, they increase in diameter and have a two-way blood flow (mainly into deep veins), which is primarily determined by the severity of vertical reflux. It should be noted that bidirectional blood flow through perforators is also observed in healthy people without signs of CVD. The number of incompetent perforating veins is directly related to the CEAP clinical class. These data are partially confirmed by studies in which, after interventions on the superficial venous system and elimination of reflux, a significant part of the perforator becomes solvent.
However, in patients with trophic disorders, from 25. 5% to 40% of perforators remain incompetent and their further influence on the course of the disease is unclear. Obviously, in varicose veins of class C4-C6 after elimination of vertical reflux, the possibilities of 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 the reverse blood flow 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 surgeon must make the decision on ligation of the perforator individually, depending 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 precludes 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 subtotal subfascial ligation of the perforator (Linton's operation). The incidence of wound complications in ESDPV is 6-7%, while in open surgery it reaches 53%. At the same time, the healing time of trophic ulcers, indicators of venous hemodynamics and frequency of recurrence are comparable.
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 is due to the dissection and which is due to the simultaneous operation of the saphenous vein in most patients. However, the lack of long-term results in patients with C4-C6 who did not undergo interventions on perforating veins, but only phlebectomy, still do not allow us to draw final conclusions about the application of certain methods of surgical treatment.
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 rate of ulcer recurrence after combined phlebectomy with ESDPV ranges 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.
Using other minimally invasive techniques to eliminate perforating veins, such as microfoam scleroobliteration, endovasal laser obliteration, also achieved good results. However, the probability of success of 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 class C2-C3, ESDPV should not be used, because the elimination of perforator reflux can be successfully performed from small (up to 1 cm) incisions and even from skin punctures using miniphlebectomy instruments.
Correction of valves of deep veins. There are currently more questions than answers in this area of surgical phlebology. This is due to existing contradictions regarding aspects such as the importance of deep venous reflux and its influence on the course of CVI, determining 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 show that reflux through the femoral vein does not play a significant role. At the same time, damage to the deep veins of the legs can lead to irreversible changes in the work of the muscular-venous pump and severe forms of CVI. It is difficult to assess the positive effects of the correction of venous reflux in deep veins alone, because these interventions are in most cases performed 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 only in some parameters. On the other hand, only elimination of reflux along the GSV in varicose veins in combination with incompetence of the femoral vein leads to 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 implantation of corrective devices.
The question of deep vein valve correction should be asked only in patients with recurrent or incurable trophic ulcers (class C6), primarily with recurrent trophic ulcers and reflux in deep veins grade 3-4 (up to the knee level). joint) according to the Kistner classification. If conservative treatment is ineffective in young people who do not want life-long prescription of compression stockings, surgery can 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. Operations for the correction of deep vein valves should be performed only in specialized centers with experience in such interventions.
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 interventions on perforating veins in this category of patients has not been confirmed in many studies.
Patients should be advised that surgical treatment of PTB carries a high risk of failure.
Interventions on the subcutaneous venous system
In many patients, saphenous veins have 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 on the need and possibility of removing subcutaneous veins in this or that volume should be made on the basis of a detailed analysis of clinical and anamnestic data, results of instrumental diagnostic tests (ultrasound, radionuclide).
Correction of valves of deep veins
In most cases, post-thrombotic damage to the valvular apparatus is not amenable to direct surgical correction. Several dozen options for surgery to form valves in deep veins for PTB have not gone beyond the scope of clinical experiments.
Circumventive interventions
In the second half of the last century, two shunt interventions were proposed for deep vein occlusions, one of which aimed to divert blood from the popliteal vein to the GSV in case of femoral occlusion (Warren-Tyre method), and the other - from the popliteal vein to the GSV. femoral veins to the other (healthy) extremity in case of iliac vein occlusion (Palma-Esperon method). Only the second method has shown clinical efficacy. This type of operation is not only effective, but today it is the only way to create an additional path for the outflow of venous blood, which can be recommended for wide clinical use. Autogenous femoral-femoral cross-venous shunts are characterized by less thrombogenicity and better patency than artificial ones. However, the available studies on this issue include a small number of patients with unclear periods of clinical and venographic follow-up.
Indications for femorofemoral bypass surgery are unilateral iliac vein occlusion. A prerequisite is the absence of obstacles to venous outflow in the opposite limb. In addition, functional indications for surgery arise only with stable progression of CVI (in clinical classes C4-C6), despite adequate conservative treatment for several (3-5) years.
Vein transplantation and transposition
Transplantation of vein segments containing valves shows good success in the immediate months after surgery. Superficial veins of the upper extremity are usually used, which are transplanted in the position of the femoral vein. The limitations of the method are due to the difference in the diameter of the veins. The intervention is pathophysiologically poorly justified: the hemodynamic conditions in the upper and lower extremities differ significantly, so the transplanted vein segments expand with the development of reflux. In addition, 1-2-3 valve replacement with extensive damage to the deep venous system cannot compensate for impaired venous flow.
Methods of transposition of recanalized veins "under the protection" of valves of intact blood vessels, of which the most technically possible is the transposition of the superficial femoral vein into the deep vein of the femur, cannot be recommended for a widespread clinical picture. practices due to their complexity and casuistic rarity of optimal conditions for their implementation. The small number of observations and the lack of long-term results do not allow us to draw any conclusions.
Endovasal interventions for stenosis and occlusion of deep veins
Occlusion or stenosis of the deep veins is the main cause of CVI symptoms in approximately one-third of patients with PVT. In the structure of trophic ulcers, from 1% to 6% of patients have this pathology. In 17% of cases, occlusion is combined with reflux. It should be noted that this combination is accompanied by the highest level of venous hypertension and the most severe manifestations of CVI compared to reflux or occlusion alone. Proximal occlusion, especially of the iliac veins, is more likely to lead to CVI than involvement of the distal segments. As a result of iliofemoral thrombosis, only 20-30% of iliac veins are completely recanalized, in other cases, residual occlusion and formation of more or less pronounced collaterals is observed. The main goal of the intervention is to remove or eliminate the occlusion or provide additional pathways for venous outflow.
Indications. Unfortunately, there are no reliable criteria for "critical stenosis" in the venous system. This is the main obstacle in determining the indications for treatment and interpreting its results. X-ray contrast venography serves as a standard method for visualizing the venous bed, allowing to determine the area of occlusion, stenosis and the presence of collaterals. Intravascular ultrasound sonography (IVUS) is superior to venography in assessing the morphological characteristics and extent of iliac vein stenosis. Iliocaval segment occlusion and associated anomalies can be diagnosed by MRI and helical CT venography.
Femoroiliac stent. The introduction of percutaneous balloon dilatation of the iliac vein and stenting into clinical practice has significantly expanded treatment options. This is due to their high efficiency (restoration of segment patency in 50-100% of cases), low frequency of complications and absence of death. Among the factors that contribute to thrombosis or restenosis in the area of stenting in patients with post-thrombophlebitis disease, the main ones are thrombophilia and long stent length. In the presence of these factors, the rate of restenosis after 24 months is up to 60%, and in their absence, stenosis does not develop. The healing rate of trophic ulcers after balloon dilatation and stenting of the iliac vein was 68%, and relapse 2 years after the intervention was not recorded in 62% of cases. The severity of the swelling and pain decreased significantly. The proportion of limbs with swelling decreased from 88% to 53%, and with pain - 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 interventions (small number of patients, lack of long-term results, non-distribution of patients into groups depending on the etiology of occlusion, acute or chronic pathology, etc. ). The technique of vein stenting appeared relatively recently, and therefore the observation period of patients is limited. Since the long-term results of the procedure are not yet known, continuous follow-up for several more years is needed to evaluate its effectiveness and safety.
Surgical treatment of phlebodysplasia
There are no effective methods for radical hemodynamic correction in patients with phlebodysplasia. The need for surgical treatment arises when there is a risk of bleeding from enlarged and thinned saphenous veins or trophic ulcers. In these situations, excision of venous conglomerates is performed to reduce local venous stagnation.
CVD operations can be performed in vascular or general surgery departments by specialists trained in phlebology. Some types of interventions (reconstructive: valvuloplasty, bypass surgery, transposition, transplantation) should be performed only in specialized centers according to strict indications.