The main treatment method 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 by itself meets all the pathogenetic principles of treatment; as a result, the need for their combination becomes obvious. Various combinations of certain operations primarily depend 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 classes C2-C6. A combined operation may include the following steps:
- Estuary ligation and intersection of the GSV and/or SVC with all tributaries (crossectomy);
- Removal of GSV and/or SSV trunks;
- Removal of varicose tributaries of the GSV and SSV;
- Crossing of incompetent perforating veins.
This scope of operation has been developed over decades of scientific and practical research.
Crossectomy of the great saphenous vein. The optimal approach for ligating 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 a high location of the postoperative scar. The GSV must be ligated strictly parietal to the femoral vein; all estuarine tributaries, including the superior one (superficial epigastric vein) must be ligated. There is no need for suturing of the oval window or subcutaneous tissue after crossectomy of the GSV.
Removal of the trunk of the great saphenous vein. When determining the extent of GSV stripping, 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 (total stripping) 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 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 in the future for reconstructive vascular operations
In this regard, the basis of intervention in the GSV basin should be short stripping. Removal of the entire length of the trunk is permissible only if it is reliably confirmed to be incompetent and has significantly expanded (more than 6 mm in a horizontal position).
When choosing a safenectomy method, preference should be given to intussusception techniques (including PIN stripping) or cryophlebectomy. Although detailed study of these methods is still underway, their advantages (less traumatic) in comparison with the classical Babcock technique are undoubted. 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 traction from top to bottom, i. e. , 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 merges with the popliteal vein a few centimeters above the knee bend line. In this regard, the approach for crossectomy of the SVC must be shifted proximally, taking into account the localization of the sapheno-popliteal anastomosis (before the operation, the localization of the anastomosis should be clarified using ultrasound scanning).
Removal of the trunk of the small saphenous vein. As with the GSV, the vein should be removed only to the extent that reflux is determined to be 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.
A comment. Intervention 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 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 higher. Laser and radiofrequency obliteration is carried out without ostial ligation (GSV and SSV). Simultaneous crossectomy virtually eliminates the benefits of thermoobliteration, and the cost of treatment increases.
Endovasal laser and radiofrequency obliteration have limitations in their 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 performed by experienced specialists. Long-term results of use in widespread clinical practice are still unknown. In this regard, thermoobliteration methods require further study and cannot yet completely replace traditional surgical interventions for varicose veins.
Removal of varicose veins. When eliminating varicose tributaries 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. By agreement with the patient, it is possible to leave some varicose veins, which are subsequently eliminated using 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 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 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 assigned to vertical discharge through the saphenous veins, and the failure of perforators is associated with the increasing 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 into the deep veins), which is primarily 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 CEAP clinical class. These data are partly confirmed by studies in which, after interventions on the superficial venous system and elimination of reflux, a significant proportion of perforators become solvent.
However, in patients with trophic disorders, from 25. 5% to 40% of perforators remain incompetent and their further impact on the course of the disease is not clear. Apparently, with varicose veins of classes C4-C6 after the 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 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 ligation of perforators must be made individually by the surgeon, depending on the clinical picture and instrumental examination data. In this case, dissection should be carried out only if 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 perforating veins (ESDPV). Numerous studies indicate its undeniable advantages compared to 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.
A 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 concurrent saphenous vein surgery in most patients. 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 us to draw final conclusions regarding the use of certain methods of surgical treatment.
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 rate of recurrence of ulcers 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 were also obtained. However, the likelihood 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 from small (up to 1 cm) incisions and even from skin punctures using miniphlebectomy instruments.
Correction of deep vein valves. Currently, in this section of surgical phlebology there are more questions than answers. This is due to existing contradictions regarding such aspects as the significance of deep vein reflux and its impact on the course of CVI, determining indications for correction, and assessing the effectiveness of treatment. 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 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 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 itself, since these interventions are in most cases performed in combination with operations on the superficial and perforating veins. Isolated elimination of reflux through the femoral vein either does not affect venous hemodynamics at all, or leads to minor temporary changes in only some parameters. On the other hand, only the elimination of reflux along the GSV in varicose veins in combination with incompetence of the femoral vein leads to the restoration of valve function in this venous 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, 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), angioscopically assisted extravasal valvuloplasty, and percutaneous installation of corrective devices.
The issue of correction of deep vein valves should be raised only in patients with recurrent or non-healing trophic ulcers (class C6), primarily 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 lifelong prescription of compression hosiery, surgery may be performed for severe edema and C4b. The decision to operate should be made on the basis of clinical status, but not on data from special studies, since symptoms may not correlate with laboratory parameters. Surgeries to correct deep vein valves should only be performed 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 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 on the subcutaneous venous system
In many patients, the saphenous veins perform a collateral function in PTB, and their removal can lead to a 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 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 tests (ultrasound, radionuclide).
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 the deep veins for PTB have not gone beyond the scope of clinical experiments.
Bypass interventions
In the second half of the last century, for occlusions of deep veins, two shunt interventions were proposed, 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 the femoral vein to another (healthy) limb in case of occlusioniliac veins (Palma-Esperon method). Only the second method demonstrated clinical effectiveness. This type of operation is not only effective, but also today the only way to create an additional pathway 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 issue include a small number of patients with ambiguous 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 the venous outflow in the opposite limb. In addition, functional indications for surgery arise only with the 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 shows good success in the immediate months after surgery. Usually, superficial veins of the upper limb are used, which are transplanted to the position of the femoral vein. The limitations of the method are due to the difference in vein diameters. 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. 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 possible from a technical point of view may be transposition of the superficial femoral vein into the deep vein of the femur, cannot be recommended for widespread clinical practice due to their complexity and the casuistic rarity of optimal conditions fortheir 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 accompanied by the highest level of venous hypertension and the most severe manifestations of CVI compared with reflux or occlusion alone. Proximal occlusion, especially of the iliac veins, is more likely to lead to CVI than involvement of distal segments. As a result of iliofemoral thrombosis, only 20-30% of the iliac veins are completely recanalized; in other cases, residual occlusion and the formation of more or less pronounced collaterals are 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 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. Occlusion of the iliocaval segment and associated anomalies can be diagnosed with 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. Among the factors contributing to thrombosis or restenosis in the stenting area 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 dilatation and iliac vein stenting was 68%; no relapse 2 years after the intervention was noted in 62% of cases. The severity of swelling and pain has decreased significantly. The proportion of limbs with swelling decreased from 88% to 53%, and with pain - from 93% to 29%. Analysis of questionnaires of patients after venous stenting showed a significant improvement in all main 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, no distribution of patients into groups depending on the etiology of occlusion, acute or chronic pathology, etc. ). The technique of vein stenting has appeared relatively recently, and therefore the period of observation 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 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 vein conglomerates is performed in order to reduce local venous stagnation.
Surgeries for CVD can be performed in the departments of vascular or general surgery by specialists trained in phlebology. Some types of interventions (reconstructive: valvuloplasty, bypass surgery, transposition, transplantation) should be performed only in specialized centers according to strict indications.