Surgery to remove leg veins: its types, how it goes

Varicose veins - the defeat of the superficial venous lower limbs, characterized by a malfunction of the valves and blood regurgitation. Such changes lead to impaired blood circulation and the occurrence of typical symptoms: burning and heaviness in the legs, sometimes there are night cramps in the calf muscles. In severe cases, there is swelling, hyperpigmentation of the skin and lipodermatosclerosis.

The term “varicose veins” is derived from lat. varix, genus P. varicis - “bloating”.(According to wikipedia.org)

For the treatment of the disease most often resort to surgery to remove the veins in the legs. Before surgery, examinations are necessarily carried out that help to assess the general state of human health, and it is possible to identify concomitant diseases. It is also important to know the basic principles of postoperative care and the complications that may occur after the operation.

Video: Laser Treatment For Varicose Veins - Laser Laserska operacija vena 2015

Main indications

• Surgical removal or obliteration of varicose veins is most often performed for cosmetic purposes.
• Non-cosmetic indications include the treatment of symptomatic varicosity with such manifestations as pain, fatigue, heaviness, recurrent superficial thrombophlebitis, bleeding.
• Conservative treatment with stockings and external compression is an acceptable alternative to surgery, but the worsening of skin manifestations or symptoms, despite these measures, usually requires surgical intervention over time.
• The desire of the patient to surgical treatment with the ineffectiveness of a conservative effect or only for cosmetic purposes is a reasonable relative indication for surgery.
• Patients with obstruction of venous outflow should not remove varicose vessels or do it partially, because these veins are important workarounds that allow the flow of blood around the obstruction.
• Those patients who cannot remain active enough to reduce the risk of postoperative deep vein thrombosis (DVT) should not be subjected to surgery.
• Surgery during pregnancy is contraindicated, because many dilated veins after childbirth spontaneously regress after delivery.

The treatment of varicose veins has developed over the centuries and the tendency to its decrease is not considered yet. Less invasive methods continue to improve, but long-term efficacy should always be tested according to the criteria of the main surgical intervention, safenectomy.

To select the correct operation for the removal of leg veins, various types of diagnostics are used, for example:

• Determination of venous pressure
• Reflective rheography
• Duplex sonography + color mapping
• Plethysmography.

Basics of surgical treatment

Surgical treatment of varicose veins is at a stage of formation more than 2000 years, but until this era, relatively small importance was attached to a purely cosmetic focus of treatment. Modern methods of exposure become less invasive and lead to more successful recovery of the patient, but long-term results have not yet been accurately determined.Therefore, today therapy is aimed at removing the superficial venous system using the following methods of exposure:

• Surgery
• Endovenous ablation
• Sclerotherapy

In 90% of cases, when venous hypertension develops due to superficial and perforator reflux, removal or obliteration of the great saphenous vein (GSV) can help improve the condition of a patient with venous hypertension. In the remaining 10%, additional treatment of incompetent (insolvent) perforating veins is sometimes required. In addition, if serious deep venous incompetence exists, treatment of only GSV usually does not contribute to resolving venous hypertension.

In both cases, additional interventions can be used, for example:

• Subfascial endoscopic perforating operation (SEPO)
• Ablation of perforation vein
• Venous reconstruction.

At this time, procedures for the removal of the superficial venous system, starting with the most invasive and ending with the least invasive, will be considered. Historical perspectives, advantages and disadvantages of each method will also be evaluated. However, before any intervention, duplex ultrasonography (DUSH) is required, which allows for a thorough study of all the main pathways of reflux. Additionally, a marker pigment is used to designate all surface vessels to be removed.

Open access technique

The Rindfleisch-Friedel method, known since the early 1900s, was based on a single incision to the deep fascia that runs around the leg six times, creating a spiral-shaped groove that drives more surface veins previously ligated. The wound created was left open until granulation healed.

The Linton method, developed in the late 1930s, was based on a large linear median incision of the leg, which deactivated all superficial and perforating leg veins. Incompetent superficial veins were removed, and perforating veins were interrupted.

In the late 1800s, Trendelenburg presented the mid-dressing of the GSV. The results were variable, and this procedure was later modified by Trendelenburg's student Perthes, who advocated cutting the groin and ligating the GSV at the level of the saphenofemoral anastomosis (SPS).

Later, more successful results were obtained when, instead of a single ligation, a ligation safenectomy was performed.In a randomized study, two-thirds of patients who were ligated without safenektomii, needed repeated surgical intervention for 5 years as a result of the development of recurrent reflux due to recanalization or the formation of side effects around the ligated area.

Removing BPV

The history of surgical removal of GSV begins with large open incisions to less invasive desorption. The original removal methods used various devices and variations of the technique.

• Stripper Mayo was an extra-lumen ring that squeezed the vessel as it passed along the vein.
• Babcock's device was an intra-aluminum ring with an acorn-like head, which was folded into the vein.
• Keller's device was an intravascular wire used to pull a vein through itself, as is done today with the help of perforating-invaginating stripping (PIN-stripping).

At present, the PIN-stripping method begins with a cut from 2 to 3 cm made in the area of ​​the inguinal fold. The femoral vein and SPS undergo an autopsy, and all SPS inflows are identified and tied up to minimize the frequency of reflux relapse.

After ligation and separation of the fistula, a special tool (usually in the form of a stiff but flexible and long wire) is passed into the GSV through an incision in the groin and is passed through an incompetent vein distal to the calf muscle. The stripper is brought out through a small (≤5 mm) incision approximately 1 cm from the tibial tuberosity of the knee. The rotating head is attached to the stripper in the groin and to the proximal end of the vein. Then the vessel as it turns out, coming off from each inflow and perforating vessel, when the stripper stretches down the leg and out through the incision near the gastrocnemius muscle.

The older method of scraping to the ankle (and not just to the knee) is less popular due to the large number of complications, including damage to the saphenous nerve, which is closely adjacent to the vein below the knee.

Removal of MPV

The process of excision of the small saphenous vein (MPV) is complicated by the variable local anatomy and the risk of injury to the popliteal vein and peroneal nerve. Additionally, the safenopliteal fistula (ATP) should be assessed by duplex research before it is opened, therefore adequate direct visualization of the ATP is required.

After ligation and separation, the ATP instrument (often a stiffer stripper, which facilitates advancement) moves down to the distal part of the gastrocnemius muscle, where it is removed through a small (2-4 mm) incision. The stripper is attached to the proximal end of the vein, which turns out when it is pulled down from the knee to the ankle and removed from the bottom.

Flabectomy

For the first time, Galen was performed in the second century in the form of a phlebectomy of the feet, which is also known as an outpatient phlebectomy. In the 1960s, it began to be used again and has since gained particular popularity.This procedure is extremely useful for the treatment of residual vein clusters after safenectomy. Also suitable for removal of intervascular inflows when the saphenous vein is competent.

A micro cutter is made in a vessel using a tiny blade or a large needle, and the hook for performing phlebectomy is inserted into the micro-cut, and the vein is drawn through the incision. The vein is drawn out as long as possible and this is done until the vessel breaks or is fully stretched. Next, another micro-cutter is made, and the process is repeated again and so along the entire length of the vein that needs to be removed. Short vein segments can be removed through tiny incisions without ligatures, and then skin closure is not required.

Endovascular methods

Laser treatment

Laser fiber produces endoluminal heat, which destroys the vascular endothelium. In endovenous laser therapy of varicose veins, the Seldinger method is used to advance the long catheter along the entire length of the varicose dilated vessel, which must be removed (usually, the GSV). The horizontal laser fiber is passed through the catheter until the tip protrudes approximately 2 cm from the end of the catheter. The tip of the laser fiber is located in the SPS region, distal to the subterminal valve. The position is confirmed by ultrasound and laser guiding light.

In accordance with the current guidelines, a tumescent solution with local anesthesia is injected along the entire length of the vessel, which allows the vein to be separated from its fascial membrane. As a result, the risk of damage to neighboring structures, including nerves and skin, is reduced, and the level of pain is also more carefully controlled.

Under the force of pressure, the veins are broken around the laser fiber. Under the action of a laser, heat is released, which leads to the release of vapor bubbles inside the vessel lumen and irreversible endothelial damage and thrombosis. The fiber and catheter advance by about 2 mm and the laser starts up again. This process is repeated throughout the course of the affected vessel.

Due to the fact that during the laser exposure the vein is blocked by a thrombus, it can dissolve over time and the vessel will become open again. High temperatures can also damage the vein, which causes additional complications.

Radiofrequency ablation

In radiofrequency ablation (RFA) of varicose veins, radiofrequency (RF) thermal energy is directly applied to the vessel wall, causing protein denaturation, collagen compression, and immediate closure of the vein. Unlike endovenous laser fibers, the RF catheter actually comes into contact with the vessel walls.

A special radiofrequency catheter passes through the vessel wall and moves along the vein until its end is located near the SPS, distal to the subterminal valve. As with endovenous laser exposure, a tumescent local anesthetic is injected through the injection.

The metal fingers on the tip of the RF catheter are deployed until they come into contact with the endothelium of the vessel. Radio frequency energy is supplied both inside and around the vessel to be processed. Thermal sensors record the temperature inside the vessel and provide enough energy for high-quality endothelial ablation. The radiofrequency catheter advances a short distance, and the process repeats along the entire length of the affected vein.

In a randomized study, it was found that compared with the usual high ligation and desorption, it took more time to perform RFA for varicose veins, but patients returned to their normal activities much earlier and had less pronounced pain after the operation.

Pasting of vessels

Endovenous treatment of varicose veins with N-butylcyanoacrylate is becoming more interesting and shows promising medium-term results. The technique is based on the introduction of a special catheter into the varicose vein, through which cyanoacrylic glue is delivered in portions and so along the entire length of the vessel. As a result, the lumen of the vessel is reduced, and due to the effect of glue on the vein wall, inflammation develops with subsequent fibrosis. To control the quality of the procedure, an ultrasound examination is performed. Approximately four months after the procedure, a connective tissue cord is detected, which eventually dissolves.

Minimally invasive methods

Electrodegradation

This is an old technique associated with electrical cauterization of small vessels. Because of the disfiguring trauma of the skin today it is rarely used.

Sclerotherapy

Chemical sclerosis of varicose veins has been less and less used since the late 1800s. Modern sclerosants with an acceptable degree of risk became widely available in the 1930s, and since then their sphere of involvement has expanded. Initially, sclerotherapy was used as a surgical adjunct after safenectomy for the treatment of residual varicose veins, reticular veins or telangiectasias. Currently, the method is used to treat GSV and major tributaries.

The sclerosing substance is injected into the abnormal vessels to stimulate endothelial damage. This is followed by the formation of a fibrous cord and the possible reabsorption of all vascular tissue layers.

Local treatment of superficial manifestations of venous insufficiency is less successful if the above-mentioned reflux points are not found and processed. Even when the patient only has primary telangiectasia, and the initial treatment is successful, relapses will occur very quickly if reflux is not detected in large subsurface vessels.
In this regard, utmost caution should be exercised when using sclerosing agents.

An improperly administered injection into arteriovenous malformation (AVM) or directly into an unspecified artery can cause extensive tissue necrosis or loss of the entire limb. Inadvertent injection of concentrated sclerosans into the deep venous system can cause deep vein thrombosis, pulmonary embolism and death .

The sclerosants most commonly used today are polidocanol and sodium tetradecyl sulfate. Both are known as detergent sclerosants, since they are amphiphilic substances that are inactive in a dilute solution, but biologically active when they form micelles. These agents have never been submitted to the FDA for approval, but they are available in some countries of the world.

Postoperative care

After treating large varicose veins using any of the above methods, a 30-40 mm gradient compression humidification Hg is used. Patients are advised to maintain or increase their level of normal physical activity. Most medical practitioners also recommend the use of compression stockings with an appropriate pressure gradient, even after treating spider veins and small tributary veins.

In clinical practice, it was found that a compression bandage for 24 hours, followed by the use of thromboembolic restraints for the remaining 14 days, gives results comparable to a compression bandage for 5 days. In a randomized study in patients undergoing foam sclerotherapy for the treatment of primary uncomplicated varicose veins, there was no significant difference in venous occlusion, phlebitis, skin discoloration or pain after 2 and 6 weeks using two methods. [1 - O'Hare JL; Stephens J; Parkin D; Earnshaw JJ. Sclerotherapy for varicose veins. Br J Surg. 2010; 97 (5): 650-6]

Do not use acetone wraps or other long bandages. Such elastic bandaging does not provide adequate compression for more than a few hours. They are often slid or incorrectly tolerated by patients, resulting in a tourniquet effect that causes distal leg swelling and also increases the risk of deep vein thrombosis.

The activity of the patient is especially important after treatment with any method, because all methods of eliminating varicose veins can potentially increase the risk of vascular thrombosis. Physical exercise is a strong protective factor against venous stasis. The activity is so important that most phlebologists do not undertake to treat a patient who cannot remain active after treatment.

Complications

The correct diagnosis of superficial venous insufficiency is important. Veins should be treated surgically if they are incompetent or if the normal collateral pathway does not function as intended. Removal of the saphenous vein with a competent ending will not help in the management of pathological varicose formations.

Under conditions of deep obstruction of the varicose circulatory system, the superficial vessels are hemodynamically beneficial because they provide a workaround for venous return. Therefore, in such cases, varicose veins should not be removed or sclerosed. Ablation of these varicosities will lead to the rapid emergence of pain and swelling of the extremities, which ultimately will cause the formation of new bypass varicose pathways.

The most annoying, albeit minor, complications of any venous surgery are dyesthesia from nerve damage or the subcutaneous nerve.

Subcutaneous hematoma is a common complication, regardless of the method of treatment used. To cope with the problem, you can use a warm compress, nonsteroidal anti-inflammatory drugs (NSAIDs), or when using aspiration.

Accidental treatment of the femoral vein by improper placement of a radiofrequency or laser catheter, proliferation of a sclerosant, or improper surgical ligation can damage the endothelium in the deep vein, causing thrombosis of the vessel with the potential for pulmonary embolism and even death.

Other complications, such as postoperative infection and trauma to the artery, are less common and can be minimized by carefully performing the necessary procedures.

Endovenous treatment methods (radiofrequency and laser therapy) have the potential to overheat the tissue, which can lead to skin burns. This problem can be eliminated if a sufficient amount of tumescent anesthesia is administered, which allows you to remove the skin from the vein.

Reviews of leg vein surgery

There are many different opinions, it is useful or harmful to remove varicose veins. The best thing, of course, is to obey a competent angiosurgeon, who after all examinations will be able to say exactly how necessary surgical intervention is.But if the testimony is nevertheless clearly defined and medical evidence of the need for an operation is obtained, then reviews of people who have already had to go through this can help to create the most complete picture of the previous test. Therefore, it is an analysis of the most popular reviews, mostly women, who had to undergo an operation and draw certain conclusions useful for other potential patients of vascular surgeons.

• It does not hurt

The pain threshold for all people is different, but with the correct implementation of the surgical intervention pain in the postoperative period is minimal. Much, of course, depends on the volume of the operation, how large the cuts are. Also, a lot depends on the severity of varicose veins.

It is important to note that painkillers are necessarily given to eliminate pain after surgery, and that during the procedure there is no discomfort, local anesthesia is done.

There may be pain during wound healing, but most often they are not very pronounced, especially if small punctures were made. Still undesirable right before the operation to watch various realistic videos about the operation to remove the veins in the legs. They only horrify and set up a very strong pain. Therefore, it is better to read the literature of interest and get more information about proper foot care during the postoperative period.

• It is better not to postpone

Varicose veins today are increasingly common in young girls, especially among those who like shaping and other fashionable sports trends. But then to come at the age of 26 to get a surprise in the form of a bunch on the legs from the dilated veins, which do not feel normal. That is why you should not postpone treatment for later.

Varicose veins may not manifest immediately, and the first symptoms are most often subtle, therefore, in the early stages, patients rarely come to the doctor. But at first, less traumatic procedures such as hardening or laser therapy can be used. Also in such cases, the postoperative period is smoothed out, which becomes less painful, and the person returns to normal life more quickly.

A full surgical operation requires special attention from both the surgeon and the patient. In particular, before the intervention, it may be necessary to take detralex, keep a sore leg (or both legs) from bruises and avoid bath procedures. After the operation, tight bandaging is often used, which also at first will not allow wearing such clothes as dresses and skirts. Such moments must be negotiated with your doctor and, if necessary, you must first prepare for them.

• Veins are removed once and for all

In some cases, this is true, especially when using those techniques that make the vessel into a connective tissue cord, which is absorbed with time. The use of other techniques sometimes involves opening the vein, which can lead to the re-operation.

As some women who have undergone surgery to remove varicose veins indicate, the disease may return with time, especially if pregnancy occurs. It is also noted that there is no guarantee for complete elimination of varicose veins, if the pathology is inherited. Symptoms may still appear over time, especially after another pregnancy.

In particular, for pregnant women with varicose veins it is better not to ignore the recommendations of doctors about wearing special compression hosiery. Sometimes it is necessary to wear it even during childbirth, it all depends on the progress and severity of the disease. In such cases, compression clothing will slow down the course of varicose veins and improve well-being.

• Good makeup, but not for long

Varicose veins do not allow a woman to feel attractive, wear open clothes and enjoy the beach season with pleasure.That is why today the operation to remove leg veins is widely used for cosmetic purposes. If there are direct indications for this, the surgeons perform the intervention unconditionally. The only effect of beautiful legs is often enough for a short time.

According to one patient who underwent an operation, it took about three months to walk in bandages. Removal of veins was performed on two legs, with an interval of a week. But after a year, almost nothing was noticeable. The condition was almost perfect, but eight years passed, one child was born and everything returned. Not to such a pronounced degree, but nevertheless the grids have become noticeable, so you should know that a single operation is not an absolute solution for eliminating varicose veins.

• The disease is not treated, but only aggravated.

Some patients who underwent leg vein surgery believe that such an intervention should be done only at stage 4 of the disease. This is due to the fact that the first three stages can be successfully treated in a conservative way, only it will take more time than with an instant operation. Additionally, the removal of superficial veins can lead to an overload of the deep vein system, which causes corresponding complications. Therefore, the best option is to engage in non-surgical treatment, and only in critical cases to resort to the removal of veins.

Video: Varicose vein surgery