The main method of treatment 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 progression of varicose veins of the saphenous veins. Today, none of the existing surgical methods alone meets all the pathogenetic principles of treatment, so the need for their combination becomes obvious. Various 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 backflow of blood from deep veins into superficial veins in patients of classes C2-C6. A combined operation can include the following steps:
- Orifical ligation and crossing of the GSV and/or SVC with all tributaries (crossectomy);
- removal of GSV and/or SSV strains;
- removal of varicose veins of the GSV and SSV;
- Crossing of insufficient perforating veins.
This range of functions was developed over decades of scientific and practical research.
Crossectomy of the great saphenous vein. The optimal approach to ligation of the GSV is the inguinal fold. The suprapenguinal approach has some advantages only in patients with recurrent disease due to the remaining pathological stump of the GSV and a high position of the postoperative scar. The GSV must be ligated strictly parietal to the femoral vein; all orifice tributaries, including the superior one (superficial epigastric vein), must be ligated. No suturing of the oval window or subcutaneous tissue is required after GSV crossectomy.
Removal of the trunk of the great saphenous vein. When determining the extent of GSV stripping, it must be taken into account that in the vast majority of cases (80-90%), reflux along the GSV is only recorded from the mouth to the upper third of the leg. Removal of the GSV along the entire length (total stripping) is associated with a significantly higher incidence of damage to the saphenous nerve than removal of the GSV from the mouth to the upper third of the leg (short stripping) - 39% and 6. 5, respectively%, respectively. At the same time, the frequency of relapses of varicose veins does not differ significantly. The remaining vein section can be used for reconstructive vascular operations in the future
In this context, the basis of the intervention in the GSV basin should be a short excavation. Complete removal of the trunk is permissible only if its incompetence is reliably confirmed and it has expanded significantly (more than 6 mm in a horizontal position).
When choosing a safenectomy method, preference should be given to the intussusception technique (including PIN stripping) or cryophlebectomy. Although a detailed study of these methods is still ongoing, their advantages (less traumatic) compared to the classic Babcock technique are undisputed. However, the Babcock 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, the traction from top to bottom, i. e. retrograde, should be preferred, with the exception of cryophlebectomy, in which the technique involves antegrade removal of the vein.
Crossectomy of the small saphenous vein. The structure of the end section of the small saphenous vein is very variable. As a rule, the SVC flows into the popliteal vein a few centimeters above the knee flexion line. In this regard, the approach to crossectomy of the SVC must be moved proximally, taking into account the location of the sapheno-popliteal anastomosis (before the operation, the location of the anastomosis should be clarified using ultrasound).
Removal of the trunk of the small saphenous vein. As with GSV, the vein should only be removed to the extent that reflux is detected. In the lower third of the leg, reflux along the SVC is very rare. Intussusception methods should also be used. Cryophlebectomy of the SVC has no advantages over these techniques.
A comment. The procedure on the small saphenous vein (crossectomy and removal of the trunk) should be carried out with the patient in the prone position.
Thermoobliteration of the main veins. Modern endovascular techniques - laser and radiofrequency - can eliminate brainstem reflux and can therefore be described as an alternative to crossectomy and stripping in terms of their functional effect. The morbidity of thermoobliteration is significantly lower than that of truncal phlebectomy and the cosmetic result is significantly higher. Laser and radiofrequency obliteration is performed without ostial ligation (GSV and SSV). Simultaneous crossectomy virtually eliminates the benefits of thermal obliteration and increases treatment costs.
Endovascular laser and radiofrequency obliteration have limitations in their application, are associated with specific complications, are significantly more expensive and require mandatory intraoperative ultrasound control. The reproducibility of the technique is low, so it should only be carried out by experienced specialists. Long-term results of use in broad clinical practice are still unknown. In this regard, thermoobliteration methods still need further study and cannot yet fully replace traditional surgical interventions for varicose veins.
Removal of varicose veins. When eliminating varicose veins of the 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 consultation with the patient, it is possible to leave some varicose veins, which will then be eliminated using sclerotherapy.
Dissection of perforating veins. The main point of contention in this subsection is the determination of the indications for intervention, since the role of perforators in the development of chronic venous diseases and their complications requires clarification. The inconsistency of numerous studies in this area is associated with the lack of clear criteria for determining perforator vein incompetence. A number of authors generally doubt that insufficient perforating veins have an independent significance for the development of cardiovascular diseases and can be a source of pathological reflux from the deep to the superficial venous system. The main role in varicose veins is played by the vertical outflow through the saphenous veins, and the failure of the perforating veins is associated with the increasing load on these veins in the drainage of reflux blood from the superficial to the deep venous system. As a result, they increase their diameter and have bidirectional blood flow (mainly to the deep veins), which is primarily determined by the severity of vertical reflux. It should be noted that even in healthy people without signs of cardiovascular disease, bidirectional blood flow through the perforators is observed. The number of insufficient perforating veins is directly related to the clinical CEAP class. These data are partially confirmed by studies in which after interventions in the superficial venous system and elimination of reflux, a significant proportion of perforators become capable of dissolving.
However, in patients with trophic disorders, 25. 5% to 40% of perforators remain incompetent and their further influence on disease progression is unclear. Apparently, in varicose veins of classes C4-C6, after elimination of vertical reflux, the possibilities for 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 blood flow through them acquires pathological significance.
Therefore, today we can talk about mandatory careful ligation of insufficient perforating veins only in patients with varicose veins with trophic disorders (classes C4-C6). In clinical classes C2-C3, the decision about perforator ligation must be made individually by the surgeon depending on the clinical picture and instrumental examination data. In this case, dissection should only be performed if its failure is reliably confirmed.
If the location of trophic disorders excludes the possibility of direct percutaneous access to an insufficient perforating vein, endoscopic subfascial dissection of perforating veins (ESDPV) is the operation of choice. Numerous studies prove its undeniable advantages over the previously widely used open subtotal subfascial perforator ligation (Linton operation). The incidence of wound complications is 6-7% with ESDPV and 53% with open surgery. 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 influence on the course of chronic venous diseases, especially trophic diseases. However, it is unclear which of the effects observed in most patients are due to the dissection and which are due to concurrent saphenous vein surgery. However, the lack of long-term results in patients with C4-C6 who did not undergo interventions on the perforating veins, but only phlebectomy, does not yet allow conclusive conclusions to be drawn regarding the use of specific surgical treatment methods.
Despite the existing contradictions, most researchers still consider it necessary to combine traditional interventions on the superficial veins with ESDPV in patients with trophic disorders and open trophic ulcers against the background of varicose veins. The recurrence rate of ulcers after combined phlebectomy with ESDPV is between 4% and 18% (follow-up period 5–9 years). Around 90% of patients experience complete healing within the first 10 months.
Good results have also been achieved using other minimally invasive techniques to remove perforating veins, such as microfoam scleroobliteration or endovascular laser obliteration. However, the chances of success of their use directly depend on the qualifications and experience of the doctor, so they cannot currently be recommended for widespread use.
In patients with clinical classes C2-C3, ESDPV should not be used because elimination of perforator reflux can be successfully performed through small (up to 1 cm) incisions and even through skin punctures with miniphlebectomy instruments.
Correction of deep venous valves. Currently, there are more questions than answers in this area of surgical phlebology. This is due to existing contradictions regarding the importance of deep venous reflux and its impact on the course of CVI, determining the indications for correction and assessing the effectiveness of treatment. Failure of various sections of the deep venous system of the lower extremities leads to various hemodynamic disorders, which must be taken into account when choosing a treatment method. Several studies suggest that femoral vein reflux does not play a significant role. At the same time, damage to the deep leg veins can lead to irreparable dysfunction of the muscular-venous pump and severe forms of CVI. The positive effects of correcting venous reflux in the deep veins themselves are difficult to assess, since in most cases these procedures are performed in combination with operations on the superficial and perforating veins. The isolated elimination of reflux through the femoral vein either has no effect on venous hemodynamics or leads to only minor transient changes in some parameters. On the other hand, only the elimination of reflux along the GSV in varicose veins in combination with insufficiency of the femoral vein leads to the restoration of valve function in this vein segment.
Surgical methods for treating primary deep vein 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 cryopreserved allografts. The second group does not require phlebotomy and includes extravascular procedures, external valvuloplasty (transmural or transcommissural), angioscopically assisted extravascular valvuloplasty, and percutaneous installation of corrective devices.
The question of correction of the deep venous valves should only be raised in patients with recurrent or non-healing trophic ulcers (class C6), especially with recurrent trophic ulcers and reflux in the 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 of compression stockings, surgery can be performed for severe edema and C4b. The decision to undergo surgery should be made based on the clinical status, but not on the basis of data from special studies, since symptoms may not correlate with laboratory parameters. Operations to correct deep venous valves should only be performed in specialized centers with experience in such procedures.
Surgical treatment of post-thrombotic diseases
The results of surgical treatment of patients with PTB are significantly worse than those of patients with varicose veins. The recurrence rate of trophic ulcers after ESDPV reaches 60% in the first three years. The validity of perforating vein interventions 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 perform a secondary function in PTB and their removal can lead to an exacerbation 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 one volume or another should be made on the basis of a thorough analysis of clinical and anamnestic information, as well as the results of instrumental diagnostic tests (ultrasound, radionuclide).
Correction of deep venous valves
In most cases, post-thrombotic damage to the valve system cannot be corrected directly with surgery. Several dozen options for operations to form valves in the deep veins for PTB have not gone beyond the scope of clinical experiments.
Bypass procedures
In the second half of the last century, two shunt procedures for deep vein occlusions were proposed, one of which was aimed at diverting blood from the popliteal vein to the GSV in the event of femoral occlusion (Warren-Tyre method), the other aimed at diverting blood from theTo divert popliteal vein into the GSV femoral vein to another (healthy) limb when occluding the pelvic veins (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 the outflow of venous blood, which 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 topic include a small number of patients with unclear periods of clinical and venographic follow-up.
Indications for femorofemoral bypass surgery are unilateral occlusion of the iliac vein. The prerequisite is that the venous drainage in the opposite extremity is not obstructed. Furthermore, functional indications for surgery only emerge with the steady progression of CVI (into clinical classes C4–C6), despite adequate conservative treatment over several (3–5) years.
Vein transplantation and transposition
Transplantation of vein sections with valves shows good results in the immediate months after the operation. As a rule, superficial veins of the upper extremity are used, which are transplanted into the site of the femoral vein. The limitations of the method are due to the different vein diameters. The procedure has little pathophysiological justification: the hemodynamic conditions in the upper and lower extremities differ significantly, which is why the transplanted vein sections expand with the development of reflux. In addition, when there is significant damage to the deep venous system, replacement of 1-2-3 valves cannot compensate for impaired venous outflow.
Methods of transposition of recanalized veins "under the protection" of valves of intact vessels, of which from a technical point of view the most likely is the transposition of the superficial femoral vein into the deep femoral vein, cannot be recommended for widespread clinical practice due to their complexity and casuistic natureRarity 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.
Endovascular procedures for stenosis and occlusion of deep veins
In approximately one-third of patients with PVT, deep vein occlusion or stenosis is the primary cause of CVI symptoms. In the structure of trophic ulcers, this pathology is present in 1 to 6% of patients. In 17% of cases, the occlusion is accompanied by reflux. It should be noted that this combination is associated with the highest levels 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 result in CVI than involvement of distal segments. As a result of iliofemoral thrombosis, only 20–30% of pelvic veins are completely recanalized; in other cases, residual occlusions and the formation of more or less pronounced collaterals are observed. The main goal of the procedure is to eliminate the obstruction or provide additional pathways for venous outflow.
Hints. 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 and allows determining areas of occlusion, stenosisand 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 abnormalities can be diagnosed using MRI and spiral CT venography.
Femoroiliac stenting. 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 incidence of complications and absence of deaths. The factors that contribute to thrombosis or restenosis in the stent area in patients with post-thrombophlebitis disease primarily include thrombophilia and long stent length. When these factors are present, the restenosis rate is up to 60% after 24 months without stenosis developing. The healing rate of trophic ulcers after balloon dilatation and iliac vein stenting was 68%, and two years after the procedure, no recurrence was noted in 62% of cases. The severity of the swelling and pain has decreased significantly. The proportion of limbs with swelling fell from 88% to 53% and the proportion of limbs with pain fell from 93% to 29%. Analysis of questionnaires from patients after venous stenting showed a significant improvement in all important aspects of quality of life.
Published studies on venous stenting often have the same shortcomings as reports on open surgical procedures (small number of patients, lack of long-term results, failure to divide patients into groups according to the etiology of the occlusion, acute or chronic pathology, etc. ). . The technique of venous stenting has only been on the market for a relatively short time and therefore the duration of observation of patients is limited. Because the long-term results of the procedure are not yet known, further monitoring over several 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, removal of venous conglomerates is performed to reduce local venous stagnation.
Operations for cardiovascular diseases can be performed in the vascular or general surgery departments by specialists trained in phlebology. Some types of procedures (reconstructive procedures: valvuloplasty, bypass surgery, transposition, transplantation) should be performed only in specialized centers according to strict indications.