The main treatment method for varicose veins (VV) remains surgery. The purpose of the operation is to eliminate the symptoms of the disease (including cosmetic defects) and prevent the development of saphenous vein varicose transformation. Today, no existing surgical method by itself fulfills all the principles of pathogenetic treatment; consequently, the need for their combination becomes clear. Various combinations of certain operations depend mainly on the severity of pathological changes in the venous system of the lower leg.
The indication for surgery is the presence of blood reflux from the deep vein to the superficial vein in patients with C2-C6 class. Combined operations may include the following steps:
- Ligation of the mouth and junction of GSV and/or SVC with all tributaries (crossectomy);
- Removal of GSV and/or SSV stems;
- Removal of GSV and SSV varicose tributaries;
- Inefficient vena cava crossing.
This scope of operations 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 has some advantages only in patients with recurrent disease due to the residual GSV pathological stump and high postoperative scar location. The GSV must be tied tightly 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 degree of GSV stripping, it is necessary to take into account that in most 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 stripping) is accompanied by a higher incidence of damage to the saphenous nerve than removal of GSV from the mouth to the upper third of the leg (short stripping) - 39% and 6. 5 %, respectively. At the same time, the recurrence frequency of varicose veins does not differ significantly. The remaining vein segments can 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 as inefficient and has grown significantly (more than 6 mm in the horizontal position).
When choosing a saphenectomy method, preference should be given to intussusception techniques (including PIN stripping) or cryophlebectomy. Although detailed studies of this method are still underway, their advantages (less traumatic) compared to the classic Babcock technique are not in doubt. 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 vein removal, preference should be given to traction from top to bottom, that is, retrograde, with the exception of cryophlebectomy, a technique involving antegrade removal of the vein.
Small saphenous vein crossectomy. 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 bend of the knee. In this case, the approach for SVC crossectomy must be moved proximally, taking into account the localization of the sapheno-popliteal anastomosis (before the operation, the localization of the anastomosis should be clarified using 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 determined to be present. In the lower third of the leg, reflux along the SVC is very rare. The invagination method should also be used. SVC cryophlebectomy has no advantages over this technique.
One comment. Interventions on the small saphenous vein (crossectomy and stem removal) should be carried out with the patient in the supine position.
Thermoobliteration of the main saphenous vein. Modern endovascular techniques - laser and radiofrequency - can eliminate brainstem reflux and therefore, in terms of its functional effect, can be called an alternative to crossectomy and stripping. Morbidity of thermoobliteration is significantly lower than stem phlebectomy, and cosmetic results are significantly higher. Laser and radiofrequency ablation are performed without ostial ligation (GSV and SSV). Simultaneous crossectomy almost eliminates the benefit of thermoobliteration, and treatment costs increase.
Endovasal laser and radiofrequency ablation have limitations in their use, are accompanied by certain complications, are much more expensive, and require mandatory intraoperative ultrasound control. The reproducibility of the technique is low, so it should only be performed by experienced specialists. Long-term results of use in widespread clinical practice are still unknown. In this regard, the thermoobliteration method requires further study and cannot yet completely replace traditional surgical intervention for varicose veins.
Removal of varicose veins. When eliminating varicose tributaries on the shallow trunk, priority should be given to their removal using a miniphlebectomy instrument through a skin puncture. All other surgical methods are more traumatic and lead to worse cosmetic results. By agreement with the patient, it is possible to leave some varicose veins, which are then eliminated using sclerotherapy.
Perforated vein surgery. The main controversial issue in this subsection is the determination of indications for intervention, because the role of perforators in the development of chronic venous disease and its complications requires clarification. The inconsistency of many studies in this field is associated with the lack of clear criteria for determining the incompetence of perforated veins. A number of authors generally question the fact that an inefficient perforated vein 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 given to the vertical discharge through the saphenous vein, and the failure of perforators is associated with an increased load on them to drain reflux blood from the superficial to the deep venous system. As a result, they increase in diameter and have two-way blood flow (mainly into deep veins), which is mainly determined by the severity of vertical reflux. It should be noted that bidirectional blood flow through the perforator is also observed in healthy people without signs of CVD. The number of incompetent vena cava is directly related to CEAP clinical class. These data are partially confirmed by studies in which, after intervention on the superficial venous system and elimination of reflux, the majority of perforators become solvent.
However, in patients with trophic disorders, from 25. 5% to 40% of perforators remain inefficient and the further effect on the course of the disease is unclear. Apparently, with varicose veins of class C4-C6 after elimination of vertical reflux, the possibility of restoring normal hemodynamics in perforated veins is limited. As a result of prolonged exposure to pathological reflux from the subcutaneous and / or deep veins, irreversible changes occur in certain parts of these channels, and the backflow of blood through them acquires pathological importance.
Therefore, today we can talk about mandatory careful ligation of inefficient perforated veins only in patients with varicose veins with trophic disorders (class C4-C6). In the clinical class C2-C3, the decision on ligation of the perforator must be made individually by the surgeon, depending on the clinical picture and instrumental examination data. In this case, surgery should be carried out only if the failure is confirmed with certainty.
If the localization of the trophic disturbance excludes the possibility of direct percutaneous access to the inefficient vena cava, the operation of choice is endoscopic subfascial dissection of the vena cava (ESDPV). Many studies show its undeniable advantages over the previously widely used open subtotal subfascial ligation (Linton's 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, venous hemodynamic indicators and recurrence frequency are comparable.
One comment. Many studies show 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 surgery and which are due to concurrent saphenous vein dissection in most patients. However, the lack of long-term results in patients with C4-C6 who did not undergo intervention on the perforated vein, but only phlebectomy, does not yet allow us to draw final conclusions about the use of certain surgical treatment methods.
Despite 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. Ulcer recurrence rates after combined phlebectomy with ESDPV ranged from 4% to 18% (follow-up period 5-9 years). In this case, complete healing occurs in about 90% of patients within the first 10 months.
When using other minimally invasive techniques to eliminate perforated veins, such as microfoam scleroobliteration, endovasal laser elimination, good results are also obtained. However, the likelihood of success with their direct use depends on the qualification 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 a small incision (up to 1 cm) and also from a skin puncture using a miniphlebectomy instrument.
Deep vein valve repair. Currently, in this field 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 CVI, determining the indications for correction, and evaluating the effectiveness of treatment. The failure of various segments of the venous system in the lower leg leads to various hemodynamic disorders, which are important to consider when choosing a treatment method. A number of studies have shown that reflux through the femoral vein does not play an important role. At the same time, damage to the veins in the legs can lead to irreversible changes in the muscle-venous pump function and a severe form of CVI. It is difficult to assess the positive effect of the correction of venous reflux in deep veins by itself, because this intervention in most cases is performed in combination with operations on superficial and perforated veins. Isolated elimination of reflux through the femoral vein either does not affect venous hemodynamics at all, or leads to small temporary changes in only a few parameters. On the other hand, only the elimination of reflux along the GSV in the varicose vein in combination with femoral vein incompetence leads to the restoration of valve function in this vein segment.
Surgical methods to treat primary urinary reflux can be divided into two groups. The first involves phlebotomy and includes internal valvuloplasty, transposition, autotransplantation, the creation of new valves and the use of preserved allografts. The second group does not require phlebotomy and includes extravasal intervention, external valvuloplasty (transmural or transcommissural), angioscopically assisted extravasal valvuloplasty, and percutaneous installation of corrective devices.
The issue of deep venous valve repair should be raised only in patients with recurrent or unhealed trophic ulcers (class C6), especially with recurrent trophic ulcers and reflux in deep veins of grade 3-4 (up to the level of the knee joint) according to the Kistner classification. If conservative treatment is ineffective in young people who do not want a lifelong prescription for compression stockings, surgery can be done for severe edema and C4b. The decision to operate should be made based on clinical status, but not based on data from special studies, because symptoms may not be related to laboratory parameters. Surgery to correct deep vein valves can only be performed in specialized centers experienced in such interventions.
Surgical treatment of postthrombotic disease
The results of surgical treatment of PTB patients are worse than those of varicose vein patients. Therefore, after ESDPV, the recurrence rate of trophic ulcers reaches 60% within the first 3 years. The validity of interventions on perforated 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.
Intervention on the subcutaneous venous system
In most patients, the saphenous vein performs a collateral function in PTB, and its removal can lead to deterioration of the disease. Therefore, phlebectomy (as well as laser or radiofrequency ablation) should not be used as a routine procedure for PTB. Decisions about the necessity and possibility of removing a subcutaneous vein in one volume or another should be made based on a comprehensive analysis of clinical and anamnestic information, the results of instrumental diagnostic tests (ultrasound, radionuclides).
Deep vein valve repair
Postthrombotic damage to the valve apparatus in most cases cannot allow direct surgical correction. Several dozen options for the operation to form a valve in the deep vein for PTB do not go beyond the scope of clinical experiments.
Bypass intervention
In the second half of the last century, for deep vein occlusion, two shunt interventions were proposed, one of which aims to divert blood from the popliteal vein to the GSV in case of femoral occlusion (Warren-Tyre method), the other - from the femoral vein to another limb(healthy) in case of iliac vein occlusion (Palma-Esperon method). Only the second method shows clinical effectiveness. This type of operation is not only effective, but also today the only way to create an additional path for venous blood outflow, which can be recommended for wide clinical use. Autogenous femoral-femoral cross-venous shunt is characterized by lower thrombogenicity and better patency than artificial. However, the available studies on this issue include a small number of patients with periods of clinical equivocation and venographic follow-up.
The indication for femorofemoral bypass surgery is unilateral iliac vein occlusion. A prerequisite is the absence of obstruction to venous outflow in the opposite limb. In addition, functional indications for surgery arise only with stable CVI progression (to clinical class C4-C6), despite adequate conservative treatment for several (3-5) years.
Transplantation and transposition of veins
Transplantation of the vein segment containing the valve shows good success in the months after surgery. Usually, the superficial vein of the upper limb is used, which is transferred to the position of the femoral vein. The limitation of the method is due to the difference in vein diameter. The intervention is pathophysiologically unwarranted: the hemodynamic conditions in the upper and lower legs are significantly different, and therefore the transplanted vein segment develops with the development of reflux. In addition, replacement of 1-2-3 valves with extensive damage to the deep venous system cannot compensate for the impaired venous outflow.
The method of transposition of the recanalized vein "under the protection" of an intact vessel valve, which is most likely from a technical point of view to be transposition of the superficial femoral vein into the deep vein of the femur, cannot be recommended for widespread clinical use. practice due to its complexity and rarely casuistic optimal conditions for its implementation. The small number of observations and the lack of long-term results do not allow us to draw any conclusions.
Endovasal intervention 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 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 degree of venous hypertension and the most severe manifestations of CVI compared to reflux or occlusion alone. Proximal occlusion, especially of the iliac vein, is more likely to lead to CVI than distal segment involvement. As a result of iliofemoral thrombosis, only 20-30% of the iliac veins are completely re-aligned; in other cases, residual occlusion and more or less clear collateral formation are observed. The main goal of the intervention is to remove or eliminate the occlusion or provide an additional path for venous outflow.
Guidance. 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 the results. X-ray contrast venography serves as a standard method for visualizing the venous bed, allowing one to determine areas of occlusion, stenosis and the presence of collaterals. Intravascular ultrasound sonography (IVUS) is superior to venography in assessing the morphological characteristics and degree of iliac vein stenosis. Iliocaval segment occlusion and associated anomalies can be diagnosed with MRI and spiral CT venography.
Femoroiliac 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 efficiency (restoration of segment patency in 50-100% of cases), low incidence 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, the main ones are thrombophilia and long stent length. With the presence of these factors, the rate of restenosis after 24 months is up to 60%; if absent, stenosis does not develop. The healing rate of trophic ulcers after balloon dilatation and iliac vein stenting is 68%; no relapse 2 years after intervention was noted 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 with pain - from 93% to 29%. Analysis of patient questionnaires after venous stenting showed a significant improvement in all major aspects of quality of life.
Published studies on venous stents often have the same shortcomings as reports on open surgical intervention (a small number of patients, lack of long-term results, no distribution of patients into groups depending on the etiology of occlusion, acute or chronic pathology, etc. ) . The technique of venous stenting has appeared relatively recently, and therefore the period of patient observation is limited. Since the long-term results of the procedure are not yet known, continued monitoring for several more years is needed to assess its effectiveness and safety.
Surgical treatment of phlebodysplasia
There is no effective method for radical hemodynamic correction in patients with phlebodysplasia. The need for surgical treatment arises when there is a risk of bleeding from the saphenous vein or a trophic ulcer that widens and thins. In this situation, venous conglomerate excision is performed to reduce local venous stasis.
Surgery for CVD can be performed in the vascular department or general surgery by a specialist trained in phlebology. Some types of intervention (reconstructive: valvuloplasty, bypass surgery, transposition, transplantation) should be performed only in specialized centers according to strict indications.