The main method of treating varicose veins (VV) remains surgical. The purpose of the operation is to eliminate the symptoms of the disease (including cosmetic defects) and to prevent the progression of the varicose transformation of the saphenous veins. Today, none of the existing surgical methods by itself meets all the pathogenetic principles of treatment, as a result of which the need for their combination becomes obvious. Different combinations of certain operations depend primarily 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 deep veins into superficial veins in patients with class C2-C6. The combined operation may include the following steps:
- Estuarine ligation and transection of GSV and/or SVC with all tributaries (crossectomy);
- Removal of GSV and/or SSV trunks;
- Removal of varicose veins of GSV and SSV;
- Transection of incompetent perforating veins.
This scope has been developed over decades of scientific and practical research.
Crossectomy of the great saphenous vein. The optimal approach for GSV ligation is through the inguinal fold. The suprapinguinal approach has some advantages only in patients with recurrent disease because of the residual pathologic stump of the GSV and the high location of the postoperative scar. The GSV should be ligated strictly parietal to the femoral vein; all estuarine tributaries should be ligated, including the superior (superficial epigastric vein). 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 removal of the GSV, it is necessary to take into account that in the majority of cases (80-90%) reflux on the GSV is recorded only from the mouth to the upper third of the leg. Removal of the GSV along its entire length (total stripping) is accompanied by a significantly higher frequency of damage to the saphenous nerves 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 recurrence rate of varicose veins did 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 exposure. Removal of the entire length of the trunk is permissible only if it is reliably confirmed that it is incompetent and significantly expanded (more than 6 mm in the horizontal position).
When choosing a safe removal method, preference should be given to intussusception techniques (including PIN removal) or cryophlebectomy. Although the detailed study of these methods is still in progress, their advantages (less traumatic) compared to the classical Babcock technique are undoubted. However, Babcock's method is effective and can be used in clinical practice, but it is recommended to use small diameter olives. When choosing the direction of vein removal, preference should be given to traction from top to bottom, i. e. retrograde, with the exception of cryophlebectomy, the technique of which involves 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 merges with the popliteal vein a few centimeters above the knee flexion line. In this regard, the SVC crossectomy approach should be shifted proximally, taking into account the location of the sapheno-popliteal anastomosis (before the operation, the location of the anastomosis should be clarified using an ultrasound scan).
Removal of the trunk of the small saphenous vein. As with GSV, the vein should be removed only to the extent that reflux is established. In the lower third of the leg, SVC reflux is very rare. Intussusception methods should also be used. SVC cryophlebectomy has no advantages over these techniques.
Comment. The intervention of the small saphenous vein (crossectomy and removal of the body) should be performed with the patient in the supine position.
Thermoobliteration of the main saphenous veins. Modern endovasal techniques - laser and radio frequency - can eliminate brainstem reflux and therefore, in terms of their functional effect, can be called an alternative to crossectomy and stripping. The morbidity of thermal obliteration is significantly lower than that of trunk phlebectomy, and the cosmetic result is significantly higher. Laser and radiofrequency obliteration are performed without ostial ligation (GSV and SSV). Concomitant crossectomy virtually eliminates the benefits of thermal obliteration, and the cost of treatment increases.
Endovasal laser and radiofrequency obliteration have limitations in their application, are accompanied by specific 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. The long-term results of use in general clinical practice are not yet known. In this regard, thermal obliteration methods require further study and cannot yet completely replace traditional surgical interventions for varicose veins.
Removal of varicose veins. When eliminating varicose veins of superficial trunks, preference should be given to their removal with the help of miniphlebectomy instruments through skin punctures. 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 subsequently 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 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 assigned to the vertical discharge through the saphenous veins, and the damage of the perforators is associated with the increasing load on them for the outflow of reflux blood from the superficial to the deep venous system. As a result, they increase in diameter and have two-way blood flow (mainly in the deep veins), which 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 CVD. The number of incompetent perforating veins is directly related to the clinical CEAP 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 perforators became soluble.
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 classes 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 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 a pathological significance.
Thus, 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 to ligation of perforators should be made individually by the surgeon, depending on the clinical picture and the data of the instrumental examination. In this case, dissection should be performed only if their malfunction 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 have shown its undeniable advantages compared to the previously widely used open subtotal subfascial ligation of perforators (Linton operation). The frequency 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 the frequency of relapses are comparable.
Comment. Numerous studies have shown that ESDPV can have a positive effect on the course of chronic venous disease, especially when it comes to trophic disorders. However, it is not clear which of the observed effects are due to dissection and which are due to simultaneous saphenous vein surgery in most patients. However, the lack of long-term results in patients with C4-C6 who did not undergo perforating vein interventions, but only phlebectomy, still does not allow us to draw definitive conclusions about the use of certain methods of surgical treatment.
Despite the existing controversies, most researchers still consider it necessary to combine traditional superficial vein interventions 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.
When using other minimally invasive techniques to eliminate perforating veins, such as microfoam scleroobliteration, endovasal laser obliteration, good results are also obtained. However, the probability of success with their use depends directly on the qualification 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 perforator reflux can be successfully performed from small (up to 1 cm) incisions and even from skin punctures using miniphlebectomy instruments.
Correction of deep vein valves. There are currently more questions than answers in this section of surgical phlebology. This is due to the existing controversies regarding such aspects as the importance of deep vein reflux and its influence on the course of CVI, determining indications for correction and evaluating the effectiveness of treatment. The 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. A number of studies have shown 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 irreparable changes in the functioning of the musculo-venous pump and severe forms of CVI. It is difficult to evaluate the positive effects of the correction of venous reflux in the deep veins itself, since these interventions in most cases are 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 insignificant temporary changes only in some parameters. On the other hand, only elimination of GSV reflux in varicose veins in combination with femoral vein incompetence leads to restoration of valve function in this venous segment.
Surgical methods for the treatment of 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 correcting the valves of the deep veins 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). becoming) according to Kistner's classification. If conservative treatment is ineffective in young people who do not wish to be prescribed life-long compression hosiery, surgery may be performed for severe edema and C4b. The decision to operate should be made on the basis of clinical status and not on data from special studies, as symptoms may not correlate with laboratory parameters. Operations to correct deep vein valves should only be performed in specialized centers with experience in such interventions.
Surgical treatment of postthrombotic disease
Surgical outcomes 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% in 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 informed that surgical treatment of PTB carries a high risk of failure.
Interventions of the subcutaneous venous system
In many patients, the saphenous veins perform 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 necessity 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 studies (ultrasound, radionuclides).
Correction of deep vein valves
Post-thrombotic damage to the valvular apparatus in most cases is not subject to direct surgical correction. Several dozen options for operations to form flaps in the deep veins for PTB have not gone beyond the scope of clinical experiments.
Bypass interventions
In the second half of the last century, two shunt interventions were proposed for deep venous occlusions, one of which aimed to divert blood from the popliteal vein to the GSV in case of femoral occlusion (Warren-Tyre method), the other from a femoral vein to another(healthy) limb in case of iliac vein occlusion (Palma-Esperon method). Only the second method showed 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 that can be recommended for wide clinical use. Autogenous femoral-femoral cross venous shunts are characterized by lower thrombogenicity and better patency than artificial ones. However, the available studies on this matter include a small number of patients with unclear periods of clinical and venographic follow-up.
Indications for femorofemoral bypass are unilateral iliac vein occlusion. A mandatory condition is the absence of obstructions to the venous outflow in the opposite limb. In addition, functional indications for surgery arise only with stable progression of CVI (up to clinical classes C4-C6), despite adequate conservative treatment for several (3-5) years.
Transplantation and transposition of veins
Transplantation of venous 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 place of the femoral vein. The limitations of the method are due to the difference in the diameters of the veins. The intervention is pathophysiologically poorly justified: the hemodynamic conditions in the upper and lower extremities differ significantly, and therefore the transplanted venous segments expand with the development of reflux. In addition, 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 technically feasible may be the transposition of the superficial femoral vein into the deep vein of the femur, cannot be recommended for widespread clinical practicedue to their complexity and the casuistic rarity of optimal conditions for their implementation. The small number of observations and the lack of long-term results do not allow conclusions to be drawn.
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 result in 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 areas of occlusion, stenosis, and the presence of collaterals. Intravascular ultrasound sonography (IVUS) is superior to venography in assessing the morphological features and degree of iliac vein stenosis. Iliocaval segment occlusion and associated abnormalities can be diagnosed with MRI and spiral CT venography.
Femoral stenting. The introduction of percutaneous balloon dilatation of the iliac vein and stenting into clinical practice has greatly expanded treatment options. This is due to their high efficiency (restoration of patency of the segment in 50-100% of cases), low frequency of complications and lack of deaths. Among the factors contributing to thrombosis or restenosis in the area of stenting in patients with postthrombophlebitis disease, the main ones are thrombophilia and long stent length. In the presence of these factors, the degree of restenosis after 24 months is up to 60%, in their absence, stenosis does not develop. The rate of healing of trophic ulcers after balloon dilatation and stenting of the iliac vein is 68%, there is no recurrence 2 years after the intervention in 62% of cases. The severity of swelling and pain has decreased significantly. The proportion of limbs with edema 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, lack of 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. Because 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 are no effective methods for radical correction of hemodynamics in patients with phlebodysplasia. The need for surgical treatment arises when there is a risk of bleeding from dilated and thinned saphenous veins or trophic ulcers. In these situations, excision of venous conglomerates is performed to reduce local venous stasis.
CVD operations can be performed in the vascular or general surgery departments by specialists trained in phlebology. Certain types of interventions (reconstructive: valvuloplasty, bypass, transposition, transplantation) should only be performed in specialized centers for strict indications.