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 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, the need for their combination becomes obvious. Different combinations of certain operations depend mainly on the severity of the pathological changes in the venous system of the lower extremities.
The indication for surgery is the presence of blood reflux from the deep veins to the superficial veins in patients with classes C2-C6. A combined operation may include the following steps:
- Connection of the estuary and crossing of GSV and/or SVC with all branches (crossectomy);
- Removal of the trunk of the GSV and/or SSV;
- Removal of varicose branches of GSV and SSV;
- Crossing of incompetent perforating veins.
This field of action 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 due to the residual pathologic trunk of the GSV and the high location of the postoperative scar. The GSV must be strictly connected parietal to the femoral vein; all ostial branches, including the superior one (superficial epigastric vein) should be ligated. There is no need for suturing of the oval window or subcutaneous tissue after GSV crossectomy.
Removal of the trunk of the great saphenous vein. When determining the extent of stripping of the GSV, it is necessary to take into account that in the vast majority of cases (80-90%), reflux along the GSV is registered only from the mouth to the upper third of the leg. Removal of the GSV along its entire length (total stripping) is associated with a significantly higher incidence of saphenous nerve damage compared to removal of the GSV from the mouth to the upper third of the leg (short stripping) - 39% and6. 5 %, respectively. At the same time, the frequency of relapses of varicose veins does not change 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 short stripping. Removal of the entire length of the trunk is allowed only if it is reliably confirmed that it is disabled and has expanded significantly (more than 6 mm in the horizontal position).
When choosing a safectomy method, preference should be given to intussusception techniques (including PIN removal) or cryophlebectomy. Although the detailed study of these methods is still underway, their advantages (less traumatic) compared to the classical Babcock technique are undoubted. However, the Babcock method is effective and can be used in clinical practice, but the use of small diameter olives is advised. When choosing the direction of vein removal, preference should be given to traction from top to bottom, d. m. th. , retrograde, with the exception of cryophlebectomy, the technique of which involves antegrade removal of the vein.
Crossectomy of the small saphenous vein. The structure of the terminal section 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 the crossectomy of the SVC should 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 scanning).
Removal of the trunk of the small saphenous vein. As with GSV, the vein should be removed only to the extent that it is determined that reflux is 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 advantage over these techniques.
A comment. Intervention in the small saphenous vein (crossectomy and removal of the trunk) should be performed with the patient in the prone 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. The morbidity of thermoobliteration is significantly lower than that of trunk phlebectomy, and the cosmetic result is significantly higher. Laser and radiofrequency obliteration is performed without ostial connection (GSV and SSV). Simultaneous cruciectomy practically eliminates the benefits of thermoabliteration and the cost of treatment increases.
Endovasal laser and radiofrequency obliteration have limitations in their use, are associated with specific complications, are much 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 results of use in widespread clinical practice are still unknown. In this regard, thermoblistering methods require further studies and still cannot completely replace traditional surgical interventions for varicose veins.
Removal of varicose veins. When eliminating the varicose branches of the superficial trunks, priority 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. By agreement with the patient, it is possible to leave some varicose veins, which are then eliminated using sclerotherapy.
Dissection of perforating veins. The main controversial issue in this subsection is determining the indications for intervention, as 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 veins. A number of authors generally question the fact that incompetent perforating veins may 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 failure of the perforators is associated with an increased load on them to drain the reflux blood from the superficial venous system to the deep one. As a result, they increase in diameter and have bidirectional blood flow (mainly in deep veins), which is determined mainly by the severity of vertical reflux. It should be noted that bidirectional blood flow through the perforators is observed even in healthy people without signs of CVD. The number of incompetent perforating veins is directly related to the CEAP clinical grade. These data are partially confirmed by studies in which, after interventions in the superficial venous system and elimination of reflux, a significant part of the perforators become solvent.
However, in patients with trophic disorders, from 25. 5% to 40% of perforators remain disabled and their further influence on the course of the disease is not clear. Apparently, with 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 subcutaneous and/or deep veins, irreversible changes occur in a certain part of these vessels and the reverse blood flow through them takes on 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 connect the perforators should be made individually by the surgeon, 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 show its undeniable advantages compared to the open subtotal subfascial ligation of the previously widely used perforators (Linton 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, the indicators of venous hemodynamics and the frequency of relapses are comparable.
A 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 unclear 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 patients with C4-C6 who did not undergo perforator vein interventions, but only phlebectomy, does not yet allow us to draw definitive conclusions regarding the use of certain surgical treatment methods.
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 against the background of varicose veins. The rate of ulcer recurrence after phlebectomy combined with ESDPV varies from 4% to 18% (follow-up period 5-9 years). In this case, complete recovery occurs in approximately 90% of patients within the first 10 months.
When using other minimally invasive techniques for eliminating perforating veins, such as microfoam scleroblading, endovascular laser ablation, good results were also achieved. However, the possibility of success with 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 classes C2-C3, ESDPV should not be used, since the elimination of perforator reflux can be successfully performed through small incisions (up to 1 cm) and even through skin punctures using miniphlebectomy instruments.
Correction of deep vein valves. Currently, there are more questions than answers in this section of surgical phlebology. This is due to the 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 deep venous system of the lower extremities leads to various hemodynamic disorders, which are important to consider when choosing a treatment method. A number of studies show that reflux through the femoral vein does not play an important role. At the same time, damage to the deep veins of the leg can lead to irreparable changes in the functioning 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 the deep veins themselves, since 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 small temporary changes only in some parameters. On the other hand, only the elimination of reflux along the GSV in the varicose veins in combination with the incompetence of the femoral vein leads to the restoration of the valve function in this venous segment.
Surgical methods for the treatment of primary deep vein 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 intervention, external valvuloplasty (transmural or transcommissural), extravasal valvuloplasty with angioscopic assistance, 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 degree 3-4 (up to the level ofknee joint) according to the Kistner classification. If conservative treatment is ineffective in young people who do not want the lifelong prescription of compression stockings, surgery can be performed for severe edema and C4b. The decision to operate should be made on the basis of clinical status, but not on the basis of data from separate studies, since symptoms may not correlate with laboratory parameters. Operations to correct 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 in 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 in the subcutaneous venous system
In many patients, the saphenous veins perform a collateral function in PTB, and their removal can lead to an exacerbation of the disease. Therefore, phlebectomy (as well as laser or radiofrequency ablation) cannot be used as a routine procedure for PTB. The decision on the need and possibility of removing the subcutaneous veins in one volume or another should be made on the basis of a complete analysis of clinical and anamnestic information, the results of instrumental diagnostic tests (ultrasound, radionuclides).
Correction of deep vein valves
Postthrombotic damage to the valve apparatus in most cases is not amenable to direct surgical correction. Several dozen options for operations to form valves in deep veins for PTB have not gone beyond the scope of clinical experiments.
Bypassing interventions
In the second half of the last century, two shunt interventions were proposed for deep vein occlusions, one of which was aimed at diverting blood from the popliteal vein to the GSV in case of femoral occlusion (Warren-Tyre method), the other -from the 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 route for venous blood outflow, which can be recommended for widespread 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 issue include a small number of patients with unclear clinical and venographic follow-up periods.
Indications for femorofemoral bypass surgery are unilateral iliac vein occlusion. A prerequisite is the absence of obstruction to venous flow in the opposite limb. Moreover, 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.
Transplantation and transposition of veins
Transplantation of valve-containing vein segments shows good success in the immediate months after surgery. Superficial veins of the upper limb are usually used, which are transplanted in the position of the femoral vein. The limitations of the method are due to the variation 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 segments of the transplanted veins 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 flow.
Methods of transposition of recanalized veins "under the protection" of valves of intact vessels, of which the most feasible from a technical point of view may be the transposition of the superficial femoral vein to the deep femoral vein, cannot be recommended for widespread clinical use. . practice due to their complexity and the occasional 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 associated with a higher level of venous hypertension and more 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 the formation of more or less prominent collaterals are observed. The main goal of the intervention is to remove or eliminate the occlusion or provide additional routes 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 one 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 extent of iliac vein stenosis. Iliocaval segment occlusion and associated abnormalities can be diagnosed by MRI and spiral CT venography.
Femoroiliac stenting. The introduction of percutaneous iliac vein balloon dilation 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 lack of deaths. 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%, in their absence, stenosis does not develop. The healing rate of trophic ulcers after balloon dilation and stenting of the iliac veins was 68%; no relapse was observed 2 years after the intervention in 62% of cases. The severity of swelling and pain is significantly reduced. The percentage 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 stenosis 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 in groups depending on the etiology of occlusion, acute or chronic pathology, etc. . ) . The technique of vein stenting has appeared relatively recently, and therefore the observation period of patients is limited. Since the long-term results of the procedure are not yet known, continued monitoring for several more years is necessary to assess its effectiveness and safety.
Surgical treatment of phlebodysplasia
There are no effective methods for the 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 from trophic ulcers. In these situations, removal of vein conglomerates is performed to reduce local venous stagnation.
Surgeries for CVD can be performed in vascular or general surgery departments by specialists trained in phlebology. Some types of intervention (reconstructive: valvuloplasty, bypass surgery, transposition, transplant) should be performed only in specialized centers according to strict indications.