Krysa and Krysa: Selection of Treatment Techniques for Lower Extremity Varicose Vein Disease



Introduction

Lower extremity varicose vein disease (LEVVD) tend to be a chronic disease with constantly progressing flow which is characterized by misperfusion in the venous system and causes irreversible changes in the venous wall and surrounding tissues. VVD cause aesthetic and general discomfort, local tissue changes, contribute to thrombophlebitis and thrombosis, which can threaten life. However, treatment of VVD is considered a safe procedure, although it is often combined with significant complications, recurrence, and treatment becomes not only surgical, but also economic and legal problem. Incorrect diagnosis and treatment are the main causes of unsatisfactory results. Therefore, the development and reasonable implementation of new innovative solutions can significantly improve the results of treatment [1, 6, 16].

Etiology

The pathology is common in society and, according to epidemiological data, its different forms are diagnosed in 26-28% of women and 10-18% of men of working age. It is worth emphasizing that varicose affection of the saphenous veins often develops in people who attend fitness centers excessively.

According to available literature VVD is linked with heredity, being female, obesity, hormonal changes (pregnancy, oral estrogen), deep vein thrombosis in anamnesis, sedentary lifestyle, occupations associated with prolonged standing and static load [8].

Symptoms

VVD is accompanied by various clinical manifestations, such as unsightly bulging veins, tiredness in the legs, heavy legs and leg swelling in the afternoon and when standing for long periods, pain and spastic cramps in the leg muscles, throbbing pain in the legs. There is increased pressure in the lower extremity venous system, which is 20-25% leads to changes in tissue and skin, including hyperpigmentation, lipodermatosclerosis, paratrophic eczema, chronic weeping ulcers. Alongside with varicose vein upstream 70-80% of patients develop thread veins and telangiectasia [15].

Diagnosis

Diagnosisis based on physical data, namely visual and investigatory palpatory examination, which consume little time together with history taking. Demands of modern phlebology dictate the need for accurate data on surgical anatomy of the lower extremity veins, as well as information how blood outflow works in normal and pathological conditions.

Detailed surgical anatomy of the venous bed is studied by ultrasonography. 7.5-10-MHz linear transducer can help find out patency and state of the deep veins, position the perforator veins, determine the structure of the saphenous veins and faulty valves, register hemodynamic disorders in different parts of the venous system in real time. Permanent hardware and software improvements of ultrasound devices caused an increase in the extent and quality of diagnostic information.

An important aspect that affects the extent of intervention is to determine the range of the damage to the saphenous veins as well as to map perforators. Ultrasound scanning allows to determine the presence or absence of reflux when identifying perforators and to provide its quantitative characteristics. Diagnostic value of ultrasound dominates the performance of all other methods, so today vascular ultrasonography is the best method of venous system examination. Properly performed preoperative diagnosis allows choosing surgical intervention, which is the most effective, aesthetically reasonable and focused on the nature of saphenous veins pathology [3].

Treatment

Highly dynamic modern life, need to stay healthy for a long time, desire to be physically attractive force patients to choose treatment options that at moderate financial cost enable rapid return to normal life and have a good aesthetic effect.

If different techniques are used to treat surgical pathology, the issue of their comparative characteristics arises naturally. The following criteria are standard when choosing effective treatment approach to LEVVD:

  • its suitability to the maximum number of patients;

  • incidence of complications;

  • recurrence rate in the early and remote periods;

  • possibility to combine different treatment techniques;

  • cost of treatment.

The era of “deep incision” in lower extremity vein surgery has become outdated. Focusing on minimally invasive technologies in various fields of surgery found its way in vascular surgery as well. Currently, in view of call of the time - maximal radicalism alongside with minimal invasiveness - low-impact technologies are increasingly included into the complex of surgical treatment of VVD. These techniques are developing towards reducing trauma intervention, decreasing operational risk, the number of postoperative complications, duration of rehabilitation, reliable removal of abnormal saphenous veins from blood circulation and improving the aesthetic effect of surgery alongside with moderate financial cost of treatment and social and economic benefits to the patient and society.

The development of new endovascular techniques, improved tools and accurate ultrasound preoperative marking of affected zones of the venous system and incompetent perforators or performing surgery under constant ultrasound control enable achievement of excellent results, making interventions an instrument of so-called “office surgery” when patients can leave the medical center on their own and proceed with their usual activities in a short time.

According to Carradice D, et Chetter I. [18] in the USA the number of classical surgeries for LEVVD (crossectomy, stripping, vein ligation) has decreased since introduction of endovascular techniques 5-fold per year (from 150 to 30 thousand). However, the frequency of minimally invasive surgeries, namely radiofrequency ablation has increased from 25 to 140 thousand (almost 6-fold), and endovascular laser ablation - from 15 to 340 thousand per year (almost 23-fold!). The number of interventions has also increased from 190 to 510 thousand (2.7-fold) during this period owing to introduction of minimally invasive techniques and increase in the number of patients who decided to undergo treatment.

These statistics confirm that treatment of VVD is marked by significant increase in the number of minimally invasive surgeries with prevailing in the past decade endovascular techniques, which have become priority trends in surgical phlebology. Minimally invasive surgeries become especially topical at the initial stage of VVD development when patients find different excuses not to undergo traditional surgery paying great attention to aesthetic factors.

Notwithstanding a great amount of research dedicated to treatment of LEVVD, combination of various treatment techniques in order to achieve a better final clinical result has not been sufficiently substantiated. There are no grounded indications and contraindications for application of a certain approach depending on the nature and extent of vascular lesion, as well as their potential usage both independently and in combination with other techniques.

Clinical foundation for treatment is maximal correction of phlebohemodynamic disorders taking into account how vascular lesion works. The main objective of treatment is to exclude from blood circulation varicose saphenous veins to eliminate vertical reflux as well as to overlap incompetent perforator veins for elimination of horizontal reflux of the deep veins. This objective can be achieved by combining surgical techniques with conservative therapy.

  1. Conservative therapy, including elastic compression, phlebothropic medications, massage, therapeutic physical training, physiotherapy.

  2. Traditional surgeries, including mini-phlebectomy.

  3. Endovascular techniques, namely radiofrequency and electric welding ablation, steam thermal ablation, sclerotherapy, laser coagulation.

Conservative and medicamentous therapy does not cure VVD completely, but allows achieving temporary hemodynamics improvement. It is used to prevent complications and aggravation of the disease in risk groups, especially during pregnancy, when a serious attendant pathology is present and at an old age, during the preoperative preparation and the postoperative rehabilitation.

The main method of treatment is surgery. It affects visual manifestations of the disease as well as its genesis and development. While there are different types of surgery for VVD, their common feature is influence on key pathogenesis elements and the main objective is to eliminate or minimize faulty veins using the following:

  • ligation and transection of tributaries in the area of confluence of the saphenous veins;

  • removal of varicose trunk;

  • ligation and transection of incompetent perforator veins;

  • removal of varicose tributaries.

However, phlebectomy (extirpation, stripping) of varicose veins has a number of disadvantages, including significant trauma, bruising along the removed veins, trauma of lymphatic vessels and nerve trunks and development of infectious complications on this background. Phlebectomy is often followed by a prolonged period of disability and its cosmetic results are not always satisfactory. The incidence of postoperative complications in classical vascular surgery increases in case of severe chronic venous insufficiency, edema, trophic changes in tissues and skin. In this regard, the issue of reducing postoperative trauma, as well as shortening hospitalization and rehabilitation periods remains topical. Therefore, classical phlebectomy, which used to dominate in vascular surgery for many years, is replaced by less traumatic endovascular techniques [6].

Less invasive procedures are applied not only to win patients and pay tribute to fashion but also for some pragmatic reasons, including increasing number of ambulatory surgeries paid by insurance companies in many countries. The above mentioned also refers to vascular surgeries, performed in hospitals only in case of recurrent disease or a serious comorbid pathology.

Vein removal or any other way of excluding it from blood circulation must be aimed only at areas with abnormalities. Such approach enables preserving this autograft, indispensable in cardiovascular surgery, for the future. In this regard, varicose veins should be removed only in the area with venous reflux, which was confirmed by ultrasonography. Much attention is paid to crossectomy, i.e. thorough incision and tying off all the tributaries of the saphenous vein where it enters the femoral vein, since non-tied tributaries can often cause recurrence.

Endovascular techniques are considered minimally invasive procedures. They are aimed at creating aseptic inflammation of the venous wall, accompanied by lumen thrombotic process and occlusion of varicose veins.

Intravascular electrocoagulation with a unipolar electrode, suggested in 1972 by V.S. Savelyev was the first alternative to classical surgical techniques in historical perspective. However, electrocoagulation was not developed owing to penetrating burns of surrounding tissues and paravascular necrosis, which required long-term treatment. Recently, the technique of intravascular electric welding ablation has received a new life owing to scientific and technical elaborations by Paton Electric Welding Institute of NAS of Ukraine. Innovative technology of electric welding causes denaturation and disorganization of venous wall collagen without coagulation scab formation and paravascular tissue injury [10].

In the past decade radiofrequency ablation, i.e. thermal ablation using high-frequency current generator and closure vein treatment system (VNUS), has become widely spread. High-frequency current heats the catheter operating end to the temperature of 90-950С. Heat destructs the venous wall, which is followed by its fibrous degeneration and closure of the vein. Surgeons, using this technique, have noted satisfactory clinical and cosmetic effect, lower rate of complications associated with traditional surgery. However, radiofrequency ablation has a risk of damaging nerve fibers and paravascular tissues, alongside with limited prospects of usage in case of distorted varicose veins and apparent trophic changes in soft tissues. Problematic ambulatory application has also been noted [4].

Steam vein sclerosis (SVS). The steam heated to 120-1500С is applied into the vein through a special system, causing thermal injury and its cicatrical closure. According to the research carried out, the results are similar to those of radiofrequency ablation but the device is cheaper and uses inexpensive system and water instead of expensive one-time catheters. It currently has not been allowed for wide usage in Europe and the USA though. This technique is used by separate phlebologists.

Nowadays polidocanol foam sclerotherapy performed under ultrasound control has become widely spread. Sclerosing agent interacts with the endothelial tissue resulting in chemical necrosis of the vessel wall and lumen thrombosis. Further, under conditions of elastic compression, the clot is replaced by connective tissue.

Direct indications for sclerotherapy are lateral form of VVD and varicose transformation of the main veins tributaries and the absence of blood reflux through the trunks of the great and small saphenous veins and perforators.

Surgery is well tolerated and low-impact, which enables its wide application on an outpatient basis, however it has several disadvantages. In particular, the following complications have been noted: allergic and autoimmune response to sclerosing agent, ecchymoses, hyperpigmentation, cutaneous necrosis, Nicolau syndrome [12]. Alongside this, chemical injury to the vein wall does not always cause long-term obliteration, leading to recurrent varicose vein disease and necessitating re-sclerosing in close succession.

Sclerotherapy often causes scar degeneration of paravascular tissues, which complicates subsequent surgical treatment of recurrent varicose vein disease. Sclerosing agent can penetrate into the deep veins and lead to visual impairment in patients with passable interatrial foramen ovale [14].

Endo venous laser treatment (EVLT) is one of the latest perspective achievements in treatment of LEVVD. This technique, introduced into clinical practice at the millennia change, has been called a technology of the 21st century and is applied on its own, and as a constituent part of combined surgery.

Wide application of EVLT in treatment of VVD has become possible with introduction of portable semiconductor high-energy surgical laser devices being highly reliable, easy to use and affordable, thus, enabling delivery of laser energy via flexible light guide through blood vessels.

Laser energy causes photocoagulation of the endothelial tissue and the venous walls, thermal and photocoagulation, vaporization and carbonization of the blood in its lumen. Laser thermal effect results in primary vessel bonding in case of elastic compression of the limb after surgery. The formation of dense attached to the wall linear coagulation clot in the lumen, in case of the vein diameter exceeding 1 cm, is also possible. Further thrombotic occlusion degenerates into fibrous and the vein is replaced by scar tissue.

The era of introduction of laser energy into phlebology began with the use of wavelengths of 800-960 Nm – “universal surgical range”, which due to small dispersion and weak absorption of radiation by melanin and hemoglobin should use high energy density with light guide output capacity of 15-25 watts for EVLT. Laser beams in this range penetrate deep beyond the vessel wall and cause significant paravascular thermal injury.

In the last 6-8 years world phlebologists have switched to using laser wavelength of over 1,000 Nm (1030-1470 Nm) – “water-absorbing range”, which much less penetrates into the surrounding tissues, and requires 2.5-3 times less energy power than when using the range of 800-960 Nm, in particular 8-10 watts of light guide output capacity.

Nowadays, Ukrainian scientists began to investigate the clinical effect of a 445 Nm wavelength – “hemoglobin-absorbing range”. Intensive radiation absorption by hemoglobin in red blood cells and scattering in light tissue results in minimizing thermal damage to paravascular tissue. Varicose veins coagulation occurs when the output power is 3-6 watts [5, 9].

It should be noted that inflammatory response of tissue to laser radiation is according to the same pattern as that to thermal injuries of other etiology, although, there are some special features, namely:

  • coagulated tissue is not a source of vasoactive components, including kinins, which reduces local inflammatory response;

  • there is no bleeding of surrounding tissue in the laser impact zone;

  • pain syndrome in the laser impact zone is lower;

  • resorption of coagulated tissue by macrophages and neutrophils is slow;

  • reduction in the inflammatory response slows regeneration time.

Bacteriological examination of the material from the surface of purulent wounds, treated by a surgical laser, reveals complete sterility in 62% of cases, and in other cases the number of microorganisms is below the critical level. Reduced microbial contamination of the laser wound, coagulating nature of thermal necrosis and thrombosis of blood vessels in the area of necrosis contribute to lower exudative inflammation component [7].

Despite the advantages of EVLT compared to classic surgery, the technique is far from being perfect. It should be optimized in several directions:

  • to standardize surgery protocol;

  • to choose optimal wavelength;

  • to choose optimal surgery procedure for various types of varicose veins;

  • to combine EVLT with other treatment techniques.

Nowadays, no technique has been recognized as universally applicable. Each patient requires his/her own optimal treatment. The ability to determine indications for the choice of the method for a particular patient and mastery of different treatment techniques is an important indicator of medical skills. The indications and contraindications to use various techniques remain the subject of debate. However, main groups of patients have been determined, for which application of EVLT on its own or in combination with other techniques has not been denied [13, 22].

Independent application of EVLT:

  • estuary and trunk veins varication according to ultrasonography in upright patient does not exceed 10 mm;

  • the number of varicose tributaries is insignificant;

  • the varicose vein trunk is straight.

Combination of EVLT with other techniques:

  • crossectomy in case of estuary vein diameter less than 10 mm;

  • short stripping at the thigh in case of alimentary obesity;

  • surgical removal of horizontal vascular refluxes;

  • miniphlebectomy of twisted varicose tributaries;

  • closure of varicose tributaries by foam sclerotherapy.

General contraindications:

  • serious malfunction of vital organs and systems;

  • acute system and infectious diseases;

  • hemostasis disorders, thrombophilia;

  • hematological and oncological diseases;

  • lower extremity ischemia;

  • recently suffered or current pulmonary thrombo-embolism;

  • limbs lymphatic insufficiency, elephantiasis;

  • impossible early activation after the procedure;

  • impossible adequate compression in obese patients.

Local contraindications:

  • inflammation nidus in the operation zone, non-sanitized ulcers, microbal eczema;

  • previous trunk sclerotherapy;

  • intolerance to elastic compression.

Special warnings:

  • EVLT is not desirable in case of pregnancy, lactation and breast-feeding;

  • it should be performed with special care in patients with poor skin wound healing, as well as inclination to kelloidal and hyperplastic scars formation;

  • application should be limited in patients with pigmented and sunburnt skin;

  • application should be limited in patients with skin diseases;

  • in doubtful situations an alternative treatment should be suggested [17, 22].

EVLT is nowadays a priority trend in treatment of LEVVD. The reason is that it is less traumatic, has a good aesthetic effect and a shorter rehabilitation period. Therefore, EVLT has become an alternative to classic surgery and even started being idealized as an immaculate method of treating VVD. However, available literature analysis as well as the author’s own experience proves that there are a number of complications inherent to laser technologies, particularly, segmental thrombophlebitis, ecchymoses, skin hyperpigmentation over the coagulated vein, neurological disorders, skin burns. Some patients mention headache, dizziness, nausea, heavy breathing, and general weakness in early postoperative period. These symptoms are observed for 6-7 days after surgery and aggravate the course of the postoperative period [4, 11].

Scientific and practical literature discusses a number of issues concerning various aspects of laser technologies application; their solution promotes efficiency and safety of EVLT, namely:

  • application of lasers with various wavelengths;

  • choice of minimal energy density of laser radiation, sufficient for adequate vein coagulation;

  • optimal configuration of light guide working end - butt end or lens, radial, double radial, carbonized, etc.;

  • indications for EVLT application in case of various diameters of varicose veins;

  • expedience of crossectomy alongside with EVLT [11, 19, 20].

Conclusions

The aforementioned treatment methods, based on joint experience, are not strictly regulated and can change depending on the surgeon’s experience and technical provision of the clinic. Available literature analysis shows that treatment techniques should not be considered as rivals. All techniques have their advantages and disadvantages, indications and contraindications, and, in our opinion, have no grave clinical differences in direct and remote results when applied independently or combined according to competent regulation. It should be emphasized that nowadays most foreign and Ukrainian surgeons apply various integrated techniques when treating LEVVD. Combination of minimally invasive surgical and endovascular treatment technologies, as well as mastery of all treatment techniques with consideration to their peculiarities, enables them to achieve better clinical results than when aiming at a single technique [2, 17, 21]. The main criterion to choose a treatment technique is preoperative vascular ultrasonography, which determines anatomic and morphological peculiarities of varicose veins, special features of hemodynamic disorders and optimal treatment options.

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Copyright (c) 2017 Vasyl Mykhailovych Krysa, Bohdan Vasylovych Krysa

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