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 transformation of the saphenous veins. Today, none of the existing surgical methods alone meets all the pathogenetic principles of treatment, therefore the need for their combination becomes obvious. Various combinations of certain operations depend mainly on the severity of pathological changes in the venous system of the lower extremities.
The surgical indication is the presence of blood reflux from deep veins to superficial veins in patients with classes C2-C6. A combined operation may include the following steps:
- Ligation of the estuary and intersection of the VSM and/or VCS with all tributaries (crossectomy);
- Removal of GSV and/or SSV trunks;
- Removal of varicose veins from GSV and SSV;
- Crossing of incompetent perforating veins.
This scope of operation has been developed over decades of scientific and practical research.
Great saphenous vein crossectomy. The ideal approach to ligate the GSV is through the inguinal fold. The suprapinguinal approach has some advantages only in patients with recurrent disease due to the remaining pathological stump of the GSV and the elevated location of the postoperative scar. The GSV must be connected strictly parietal to the femoral vein; all estuarine tributaries, including the superior one (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 extent of removal of the GSV, it is necessary to take into account that in the vast majority of 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 (full removal) is accompanied by a significantly higher incidence of damage to the saphenous nerves compared to removal of the GSV from the mouth to the upper third of the leg (short removal) - 39% and 6, 5%, respectively. At the same time, the frequency of recurrences of varicose veins does not differ significantly. The remaining segment of the vein can be used in the future for reconstructive vascular operations
In this sense, the basis of intervention in the GSV basin should be short stripping. Removal of the entire length of the trunk is only permitted if it is reliably confirmed that it is incompetent and has expanded significantly (more than 6 mm in a horizontal position).
When choosing a saphenectomy method, preference should be given to intussusception (including PIN removal) or cryophlebectomy techniques. Although detailed study of these methods is still ongoing, 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, although 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 cryoplebectomy, whose technique involves anterograde removal of the vein.
Small saphenous vein crossectomy. The structure of the terminal section 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 approach to SVC crossectomy should be shifted proximally, taking into account the location of the saphenopopliteal anastomosis (before the operation, the location of the anastomosis should be clarified by ultrasound).
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. Invagination methods should also be used. Cryophlebectomy of the SVC has no advantages over these techniques.
One comment. Intervention on the small saphenous vein (crossectomy and removal of the trunk) must be performed with the patient in the prone position.
Thermobliteration 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 stem phlebectomy and the cosmetic result is significantly greater. Laser and radiofrequency obliteration is performed without ostial ligation (GSV and SSV). Simultaneous crossectomy practically eliminates the benefits of thermoobliteration and the cost of treatment increases.
Endovasal laser and radiofrequency obliteration have limitations in use, 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 carried out by experienced specialists. The long-term results of use in widespread clinical practice are still unknown. In this sense, thermoobliteration methods require further studies and cannot yet completely replace traditional surgical interventions for varicose veins.
Removal of varicose veins. When eliminating varicose tributaries from the superficial trunks, preference should be given to their removal with miniphlebectomy instruments using 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 later eliminated with sclerotherapy.
Dissection of perforating veins. The main controversial point 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 associated with the lack of clear criteria for determining the incompetence of perforating veins. Several authors generally question the fact that incompetent perforating veins can have an independent significance 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 attributed to the vertical discharge through the saphenous veins, and the failure of the perforators is associated with the 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 bidirectional 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 perforators is also observed in healthy people without signs of CVD. The number of incompetent perforating veins is directly related to the CEAP clinical 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 solvent.
However, in patients with trophic disorders, 25. 5% to 40% of perforators remain incompetent and their further impact on the course of the disease is unclear. Apparently, with varicose veins of classes C4-C6 after elimination of vertical reflux, the possibilities of restoring normal hemodynamics in perforating veins are limited. As a result of prolonged exposure to pathological reflux of subcutaneous and/or deep veins, irreversible changes occur in a certain part of these vessels, and the reverse flow of blood through them acquires 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 on perforator ligation must be made individually by the surgeon, depending on the clinical picture and data from the instrumental examination. In this case, dissection should only be performed if its failure is reliably confirmed.
If the location of trophic disorders precludes the possibility of direct percutaneous access to an incompetent perforating vein, the operation of choice is endoscopic subfascial perforating vein dissection (ESDPV). Numerous studies indicate its undeniable advantages in comparison with the previously widely used open subtotal subfascial ligation of 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, indicators of venous hemodynamics and the frequency of relapses are comparable.
One comment. Numerous studies indicate 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 concomitant 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, 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 recurrence rate of ulcers after phlebectomy combined with ESDPV ranges from 4% to 18% (follow-up period 5 to 9 years). In this case, complete cure occurs in approximately 90% of patients within the first 10 months.
When using other minimally invasive techniques to eliminate perforating veins, such as scleroobliteration with microfoam and endovasal laser obliteration, good results were also obtained. However, the likelihood of success with their use directly depends on the doctor's qualifications and experience, therefore, for now, they cannot be recommended for widespread use.
In patients with clinical classes C2-C3, ESDPV should not be used, as the elimination of perforating reflux can be successfully performed using small incisions (up to 1 cm) and even skin punctures with miniphlebectomy instruments.
Correction of deep venous valves. Currently, in this section of surgical phlebology there are more questions than answers. This is due to contradictions in aspects such as the importance of deep venous reflux and its impact on the course of CVI, in determining indications for correction and in evaluating the effectiveness of treatment. Failure of several 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. Several studies indicate that reflux through the femoral vein does not play any significant role. At the same time, damage to the deep veins of the leg can lead to irreparable changes in the functioning of the musculovenous pump and severe forms of CVI. It is difficult to assess the positive effects of the correction of venous reflux in deep veins itself, since these interventions are, in most cases, carried out in combination with operations on superficial and perforating veins. Isolated elimination of reflux via the femoral vein does not affect venous hemodynamics in any way or leads to small, temporary changes in only a few parameters. On the other hand, only the elimination of reflux along the GSV in varicose veins combined with the incompetence of the femoral vein leads to the restoration of valve function in this venous segment.
Surgical methods for treating 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 use of cryopreserved 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), mainly with recurrent trophic ulcers and reflux in deep veins of grade 3-4 (up to the level of the knee joint) according to Kistner classification. If conservative treatment is ineffective in young people who do not wish to be prescribed lifelong compression stockings, surgery may be performed for severe edema and C4b. The decision to operate should be made based on the clinical state, but not on data from special studies, since symptoms may not correlate with laboratory parameters. Surgeries to correct deep venous valves should only be performed in specialized centers with experience in these interventions.
Surgical treatment of post-thrombotic disease
The results of surgical treatment of patients with BPD 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 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 in the subcutaneous venous system
In many patients, the saphenous veins play a collateral role 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 need and possibility of removing the subcutaneous tissue in one or another volume must be made on the basis of a thorough analysis of clinical and anamnestic information, the results of instrumental diagnostic examinations (ultrasound, radionuclide).
Correction of deep vein valves
Post-thrombotic 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 did not go beyond the scope of clinical experiments.
Ignore interventions
In the second half of the last century, two shunt interventions for deep vein occlusions were proposed, one of them with the aim of diverting blood from the popliteal vein to the GSV in case of femoral occlusion (Warren-Tyre method), the other - from the femoral to another (healthy) limb in case of iliac vein occlusion (Palma-Esporon method). Only the second method demonstrated clinical efficacy. This type of operation is not only effective, but today it is the only way to create an additional route for the outflow of venous blood, which can be recommended for wide clinical use. Autogenous crossed femoral-femoral 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 ambiguous clinical and venographic follow-up periods.
Indications for femorofemoral bypass surgery are unilateral occlusion of the iliac vein. A prerequisite is the absence of obstructions to venous flow in the opposite limb. Furthermore, functional indications for surgery arise only with steady progression of CVI (to clinical classes C4-C6), despite adequate conservative treatment for several (3-5) years.
Vein transplantation and transposition
Transplantation of vein segments containing valves has good success in the immediate months after surgery. Superficial veins from the upper limb are generally used, which are transplanted to the position 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 vein segments expand with the development of reflux. Furthermore, 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 possible from a technical point of view may be the transposition of the superficial femoral vein into the deep vein of the femur, cannot be recommended for widespread clinical practice due to its complexity and the rarity of 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 interventions for deep vein stenosis and occlusion
Deep vein occlusion or stenosis is the main cause of CVI symptoms in approximately one-third of patients with DVT. In the structure of trophic ulcers, from 1% to 6% of patients have this pathology. In 17% of cases, occlusion is associated 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 lead to CVI than involvement of the distal segments. As a result of iliofemoral thrombosis, only 20-30% of the iliac veins are completely recanalized, in other cases residual occlusion and more or less pronounced collateral formation are observed. The main objective of the intervention is to remove or eliminate the occlusion or provide additional pathways for venous flow.
Indications. Unfortunately, there are no reliable criteria for "critical stenosis" in the venous system. This is the main obstacle in determining treatment indications and interpreting its results. X-ray contrast venography serves as a standard method for visualizing the venous bed, allowing areas of occlusion, stenosis and the presence of collaterals to be determined. Intravascular ultrasound (IVUS) is superior to venography in evaluating the morphological features and extent of iliac vein stenosis. Iliocaval segment occlusion and associated anomalies can be diagnosed with magnetic resonance imaging and spiral computed tomography venography.
Femoriliac stent implantation. The introduction of percutaneous balloon dilation of the iliac vein and stent implantation into clinical practice has significantly expanded treatment options. This is due to its high efficiency (restoration of segment patency in 50-100% of cases), low incidence of complications and absence of deaths. Among the factors that contribute to thrombosis or restenosis in the area of stent implantation in patients with post-thrombophlebitis disease, the main ones are thrombophilia and the long length of the stent. In the presence of these factors, the restenosis rate after 24 months is up to 60%; in their absence, stenosis does not develop. The cure rate of trophic ulcers after balloon dilation and iliac vein stent implantation was 68%; no recurrence 2 years after intervention was observed in 62% of cases. The severity of the swelling and pain 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 stent implantation showed a significant improvement in all main aspects of quality of life.
Published studies on venous stent implantation often have the same shortcomings as reports on open surgical interventions (small number of patients, lack of long-term results, no distribution of patients into groups depending on the etiology of the occlusion, acute or chronic pathology, etc. ) . The technique of venous stent implantation emerged relatively recently and, therefore, the observation period for patients is limited. Since the long-term results of the procedure are not yet known, continued monitoring is needed for a few more years to assess its effectiveness and safety.
Surgical treatment of phlebodysplasia
There are no effective methods for radical correction of hemodynamics in patients with phlecorpoplasia. 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 stagnation.
Surgeries for CVD can be performed in the vascular or general surgery departments by specialists trained in phlebology. Some types of interventions (reconstructive: valvuloplasty, bypass surgery, transposition, transplant) should be carried out only in specialized centers and according to strict indications.