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 development of varicose transformation of the saphenous veins. Today, none of the available surgical methods meet all pathogenetic principles of self-treatment, as a result, the need for their combination becomes clear. Different combinations of certain operations depend primarily on the severity of pathological changes in the venous system of the lower extremities.
In patients with C2-C6 class, the presence of blood flow from deep veins to superficial veins is an indication for surgery. A combined operation may include the following steps:
- Closure of the estuary and transection of the GSV and/or SVC with all branches (crossectomy);
- Removal of GSV and/or SSV trunks;
- Removal of varicose branches of GSV and SSV;
- Intersection of incompetent perforating vessels.
This field of activity has been developed during decades of scientific and practical research.
Crossectomy of the great saphenous vein. The optimal approach for GSV closure is through the inguinal fold. The suprapinguinal approach has some advantages only in patients with recurrent disease due to the remaining part of the pathological stump of the GSV and the high location of the postoperative scar. The GSV must be strictly parietal to the femoral vein; all estuarine branches, including the upper one (superficial epigastric vein), should be ligated. There is no need to suture the oval window or subcutaneous tissue after crossectomy of the GSV.
Removal of the trunk of the great saphenous vein. When determining the degree of stripping of the GSV, it should be taken 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 the GSV along its entire length (total stripping) is accompanied by a significantly higher rate of damage to the saphenous nerves than 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 can be used for reconstructive vascular operations in the future
In this regard, short stripping should be the basis of intervention in the GSV basin. Removal of the entire length of the trunk is allowed only if its incompetence is reliably confirmed and it has expanded significantly (more than 6 mm in the horizontal position).
When choosing a saphenectomy method, preference should be given to intussusception methods (including stripping of the PIN) or cryophlebectomy. Although these methods are still being studied in detail, their advantages (less traumatic) compared to the classical Babcock technique are unquestionable. 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 top-down, i. e. retrograde traction, except for cryophlebectomy, the technique of which involves antegrade removal of the vein.
Crossectomy of the lesser saphenous vein. The structure of the terminal part of the small saphenous vein is very variable. Typically, the SVC joins the popliteal vein a few centimeters above the knee flexion line. In this regard, the approach for crossectomy of the SVC should be changed 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 lesser saphenous vein. As with GSV, the vein should be removed only to the extent that reflux is determined to be present. Reflux along the SVC in the lower third of the leg is very rare. Intussusception methods should also be used. Cryophlebectomy of the SVC has no advantages over these methods.
Comment. Small saphenous vein intervention (crossectomy and trunk removal) should be performed with the patient in the prone position.
Thermoobliteration of the main saphenous veins. Modern endovasal methods - laser and radio frequency - can eliminate brainstem reflux and therefore can be called an alternative to crossectomy and stripping surgery due to its functional effect. The morbidity of thermoobliteration 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). Simultaneous crossectomy virtually eliminates the benefits of thermoobliteration and increases the cost of treatment.
Endovasal laser and radiofrequency obliteration have limitations in their use, are accompanied by specific complications, are more expensive and require mandatory intraoperative ultrasound control. The reproducibility of the technique is low, so it should be performed only by experienced specialists. The long-term consequences of use in widespread clinical practice are still unknown. In this regard, thermoobliteration methods require further research and cannot yet completely replace traditional surgical interventions for varicose veins.
Removal of varicose veins. When removing varicose veins 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 later removed by sclerotherapy.
Dissection of perforating vessels. 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 field is associated with the lack of clear criteria for determining the incompetence of perforating vessels. A number of authors generally question whether incompetent perforating vessels may have an independent role in the development of CVD and may be a source of pathological reflux from the deep to the superficial venous system. In varicose veins, the main role is given to the vertical flow through the saphenous veins, and the failure of the perforators is associated with an increased load to empty reflux blood from the superficial to the deep venous system. As a result, they increase in diameter and have bidirectional blood flow (mainly deep veins) determined primarily by the severity of vertical reflux. It should be noted that bidirectional blood flow through perforators is also observed in healthy people without CVD symptoms. The number of incompetent perforating veins is directly related to CEAP clinical class. These data are partially supported by studies in which a significant proportion of perforators become solvent after interventions in the superficial venous system and elimination of reflux.
However, in patients with trophic disorders, 25. 5% to 40% of perforators remain incompetent, and the subsequent effect on the course of the disease is unclear. Apparently, after elimination of vertical reflux with varicose veins of classes C4-C6, the ability to restore normal hemodynamics in the perforating vessels is limited. As a result of long-term exposure to pathological reflux from subcutaneous and/or deep veins, irreversible changes occur in a certain part of these vessels, and the reverse flow of blood through them becomes pathologically important.
So, today we can only talk about mandatory precautionary closure of incompetent perforating vessels in patients with varicose veins with trophic disorders (classes C4-C6). The decision to close perforators in C2-C3 clinical classes should be made individually by the surgeon depending on the clinical picture and instrumental examination data. In this case, fragmentation should be carried out only when 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 show its undeniable advantages compared to open subtotal subfascial ligation of perforators (Linton operation), which was widely used earlier. The frequency of wound complications with ESDPV is 6-7%, and 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 can be compared.
Comment. Numerous 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 not clear which of the observed effects are due to dissection and which are due to concurrent saphenous vein surgery in most patients. However, the lack of long-term results in C4-C6 patients who underwent phlebectomy but did not intervene in the perforating vessels does not yet allow for definitive conclusions regarding the use of certain surgical treatment methods.
Despite the current contradictions, most researchers still consider it necessary to combine conventional 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 phlebectomy combined with ESDPV ranges from 4% to 18% (follow-up period 5-9 years). In this case, complete recovery occurs in about 90% of patients within the first 10 months.
Good results have also been obtained when using other minimally invasive methods to eliminate perforating vessels, such as microfoam scleroobliteration, endovascular laser obliteration. However, the probability of success with their use depends directly on the doctor's qualifications and experience, so they cannot be recommended for widespread use yet.
ESDPV should not be used in patients with C2-C3 clinical classes, since elimination of perforator reflux can be successfully performed through small (up to 1 cm) incisions and even skin punctures using miniphlebectomy instruments.
Correction of deep vein valves. Currently, there are more questions than answers in this branch of surgical phlebology. This is due to the current controversy regarding aspects such as the importance of deep venous reflux and its impact on the course of CVI, determining indications for correction and evaluating the effectiveness of treatment. The failure of different segments of the deep venous system of the lower extremities causes various hemodynamic disorders, which is important to consider when choosing a treatment method. A number of studies suggest that reflux through the femoral vein plays no significant role. At the same time, damage to the deep veins of the leg can cause irreversible changes in the work of the musculo-venous pump and severe forms of CVI. It is difficult to assess the positive effect of venous reflux correction in the deep veins themselves, since these interventions are often performed together with operations on superficial and perforating veins. Isolated elimination of reflux through the femoral vein either does not affect venous hemodynamics at all or causes only small temporary changes in some parameters. On the other hand, elimination of reflux along GSV only in varicose veins leads to restoration of valvular function in this venous segment together with femoral vein incompetence.
Surgical methods of primary deep venous reflux treatment can be divided into two groups. The former involves phlebotomy and includes internal valvuloplasty, transposition, autotransplantation, creation of new valves, and the use of frozen allografts. The second group does not require phlebotomy and includes extravasal interventions, external valvuloplasty (transmural or transcommissural), angioscopically assisted extravasal valvuloplasty, and percutaneous installation of corrective devices.
The question of correction of deep vein valves should be raised only in patients with recurrent or non-healing trophic ulcers (class C6), primarily recurrent trophic ulcers and grade 3-4 deep venous reflux. knee joint) according to the Kistner classification. If conservative treatment is ineffective in young adults who do not want lifelong compression stockings, surgery may be considered for severe edema and C4b. The decision to operate should be made based on the clinical situation, but not on the data of specific studies, because symptoms may not be related to 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 with varicose veins. Thus, the recurrence rate of trophic ulcers in the first 3 years after ESDPV reaches 60%. The validity of interventions on perforating vessels 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 in the subcutaneous venous system
In many patients, the saphenous veins act as collaterals 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 necessity and possibility of removing subcutaneous vessels of this or that volume should be made on the basis of a comprehensive analysis of clinical and anamnestic data, the results of instrumental diagnostic tests (ultrasound, radionuclide).
Correction of deep vein valves
Postthrombotic damage to the valvular apparatus is not amenable to direct surgical repair in most cases. Several dozen options for operations to form valves in deep veins for PTB have not gone beyond the scope of clinical experiences.
Wrong interventions
In the second half of the last century, two shunt interventions were proposed for deep vein occlusion, one aimed at diverting blood from the popliteal vein to the GSV during femoral occlusion (Warren-Tyre method) and the other from the vein. femoral vein to the other (healthy) limb in case of iliac vein occlusion (Palma-Esperon method). Only the second method demonstrated its clinical effectiveness. This type of operation is not only effective, but also the only way to create an additional path for venous blood outflow that can be recommended for widespread clinical use today. Autogenous femoral-femoral cross venous shunts are characterized by lower thrombogenicity and better patency than artificial ones. However, the available studies on this issue included small numbers of patients with uncertain periods of clinical and venographic follow-up.
Indications for femorofemoral bypass surgery are unilateral iliac vein occlusion. A prerequisite is the absence of obstructions to venous flow in the opposite periphery. In addition, functional indications for surgery arise only with persistent progression of CVI (to C4-C6 clinical classes) despite adequate conservative treatment over several (3-5) years.
Vascular transplantation and transposition
Transplantation of vascular segments with valves shows good success immediately after surgery. Usually, the superficial veins of the upper limb are used, which is transferred to the position of the femoral vein. The limitations of the method are related to the difference in the diameters of the vessels. The intervention is poorly justified pathophysiologically: the hemodynamic conditions in the upper and lower extremities differ significantly, and therefore the transplanted vascular segments expand with the development of reflux. In addition, replacement of 1-2-3 valves, which cause extensive damage to the deep venous system, cannot compensate for impaired venous outflow.
Techniques for transposition of recanalized veins "under the protection" of valves of intact veins, which may technically be the most feasible transfer of the superficial femoral vein to the deep femoral vein, cannot be recommended for widespread clinical studies. experience due to their complexity and the random rarity of optimal conditions for their implementation. The small number of observations and the lack of long-term results do not allow any conclusions to be drawn.
Endovasal interventions for stenosis and occlusion of deep vessels
Deep vein occlusion or stenosis is the main cause of CVI symptoms in approximately one-third of patients with PVT. From 1% to 6% of patients have this pathology in the structure of trophic ulcers. Occlusion is combined with reflux in 17% of cases. 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, particularly of the iliac veins, is more likely to cause 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 there is residual occlusion and the formation of more or less noticeable collaterals. The main goal of the intervention is to relieve or remove the obstruction or provide additional pathways for venous exit.
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 the standard method for visualizing the venous bed, allowing to identify areas of obstruction, stenosis, and the presence of collaterals. Intravascular ultrasonography (IVUS) is superior to venography in assessing the morphologic features and extent of iliac vein stenosis. Iliocaval segment occlusion and associated anomalies can be diagnosed by MRI and helical CT venography.
Femoroiliac stenting. The application of percutaneous balloon dilatation of the iliac vein and stenting to clinical practice has greatly expanded the possibilities of treatment. This is due to their high efficiency (recovery of segment opening in 50-100% of cases), few complications and no mortality. In patients with post-thrombophlebitis, thrombophilia and long stent length are the main factors contributing to thrombosis or restenosis at the stenting site. When these factors are present, the rate of restenosis after 24 months is up to 60%, in their absence, stenosis does not develop. The healing rate of trophic ulcers after balloon dilatation and stenting of iliac veins was 68%; 2 years after the intervention, no recurrence was observed in 62% of cases. Swelling and pain intensity have decreased significantly. The proportion of limbs with swelling decreased from 88% to 53%, 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 stenting often have the same shortcomings as reports on open surgical interventions (small number of patients, lack of long-term results, not dividing patients into groups depending on the etiology of obstruction, acute or chronic pathology, etc. ). The technique of vascular 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, several more years of continuous monitoring are needed to assess its effectiveness and safety.
Surgical treatment of phlebody dysplasia
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 cases, excision of vascular conglomerates is performed to reduce local venous congestion.
Surgery for cardiovascular diseases can be performed by specialists trained in phlebology in vascular or general surgery departments. Some types of interventions (reconstructive: valvuloplasty, bypass surgery, transposition, transplantation) should be performed only in specialized centers according to strict instructions.