Varicose veins of the lower extremities are a common disease, with a prevalence of more than 10%. The recurrence rate of surgical treatment is very high, reaching 20 to 30 percent according to foreign authorities. What should I do if the varicose veins in my legs have recurred after surgery?
Why are varicose veins prone to recurrence after surgery?
Let’s first understand how varicose veins are created. There are three external forces that push the car upward, one is the thrust of the calf muscle contraction that squeezes upward; one is the suction of blood upward when a person inhales; and the other is the suction of blood upward when the heart is diastolic. These three forces will drive the blood car up the hill, but people in the whistle and heart contraction, there is no suction on the blood, so the blood car will be affected by gravity to slide down, and there is a structure similar to the brake in the blood vessels to stop the car to slide, this structure is the venous valve. It is like a one-way valve, the blood is open when it goes up and closed when it goes down. But if the patient’s blood vessels become thicker, the vein valve which was just able to close completely is now unable to close tightly, or the vein valve becomes less elastic and unable to close tightly, the blood will flow backwards, and the blood will accumulate in the lower limbs to form varicose veins. The toxic substances and metabolic wastes inside these veins are not excreted and stagnate on the patient’s legs, resulting in swelling and itching for a long time.
In varicose vein patients, the entire saphenous vein from the root of the thigh to the neck of the foot may have blood reflux, but it may not always show varicose throughout. If the pressure in the veins of the legs is compared to the pressure in sea water, then the pressure in the veins of the thighs is like the pressure at sea level, which is smaller, so the varicose is not obvious; while the pressure in the veins of the calves is like the pressure at the bottom of the sea, which is larger, and the varicose is more obvious, and the calves are more likely to have symptoms such as swelling and itching. Therefore, if the varicose veins are not treated thoroughly during the first surgery, or if you choose minimally invasive surgery and only deal with a part of the main saphenous vein, and other branch vessels are not treated, and the remaining part of the vessels become thicker or the vein valves become less elastic, it is still very easy for varicose veins to appear again.
Is the recurrence rate of saphenous vein stripping surgery lower than that of minimally invasive surgery?
Saphenous vein stripping surgery is to remove all the vessels of the saphenous vein from the root of the thigh to the neck of the foot, and then ligate the five branches of the saphenous vein, and also remove the varicose veins on the calf, so there are more incisions and larger incisions during the surgery, and the patient will recover more slowly after the surgery, and more scars will be left. If the operation is strict, the recurrence rate is very low. Minimally invasive surgery generally does not have a large incision, but only closes the varicose veins in various ways, which is less invasive and the patient can be discharged on the same day. However, the problem of saphenous vein trunk is not solved, so it is easy to recur after surgery.
In some patients, the saphenous vein is stripped directly after the first surgery, how can it still recur?
In some patients, the branch vessels are as thick as the saphenous vein, so it is easy for the surgeon to distinguish them during the surgery, and they do not strip the saphenous vein, and varicose veins will appear again.
What are the causes of recurrence after surgery?
There are three main causes of post-operative recurrence.
1. Incomplete treatment of the saphenous vein trunk.
The left leg in the picture is the complete vein distribution, the surgery should remove or completely close the saphenous vein from the root of the thigh all the way to the neck of the foot, if the surgery is not completely clean, there are still residual saphenous veins in the thigh, the varicose veins will easily recur.
As the picture shows, there is no saphenous vein from the root of the right leg to the middle of the thigh, but the saphenous vein below the middle is not treated, and blood can flow into the remaining saphenous vein again through other blood vessels, causing varicose veins.
2, varicose veins appear in the traffic branch.
Some patients may have the saphenous vein trunk treated very thoroughly, but it still recurs after surgery, and the varicose veins are concentrated in this section of the calf, what is going on? As shown in the CT examination result below, the saphenous vein on the right side has been treated cleanly and invisible, but many curved worm-like vessels in the calf are found, which are small vessels (also called traffic branches) connecting the deep and superficial veins of the thigh, and they have dilated, causing the varicose veins in the lower limbs to recur.
3.Misdiagnosis.
Misdiagnosis of other diseases as varicose veins, such as KT syndrome, post-thrombotic syndrome, primary deep vein valve insufficiency, Buga syndrome, and small saphenous varicose veins.
KT syndrome: As shown in the picture, the patient will also have superficial varicose veins, while the varicose leg will thicken and grow with a large erythema on the outer side of the leg.
Post thrombotic syndrome: The veins of the leg have deep and superficial veins, as shown in the picture, the patient has thrombosis in the deep veins and a large amount of blood can only flow from the thinner superficial veins, which thickens the superficial veins and forms the varicose veins. In such a patient, if the thrombus is still present, then superficial vein stripping will result in leg swelling after surgery; if the thrombus is no longer present, it is possible to do deep vein valve repair surgery plus superficial vein stripping surgery.
Primary deep vein valve insufficiency: In this case, CTV phlebography is required to detect deep vein reflux. The doctor will use the CTV findings to determine which procedures are needed. If the reflux reaches only the mid-thigh, the patient can undergo a vein stripping procedure and the symptoms of deep venous reflux will be relieved. However, if the reflux reaches the knee, a valve repair is required in addition to the vein stripping.
Buga syndrome: These patients not only have varicose veins on their legs, the color of their legs is darker, but the patient will also have visible blood vessels on their stomach, and varicose vein surgery alone will not solve the problem in this case.
Saphenous varicose vein: As shown in the picture, the patient will also have varicose veins in the lower leg, but they are caused by the small saphenous vein, which is two different vessels from the great saphenous vein. If the surgery is done to completely strip or close the great saphenous vein, but the small saphenous varicose vein is still there and will recur again.
How can I know which kind of recurrence I have?
If you have a recurrence after surgery, you need to see your doctor to identify the cause of the recurrence. The patient can have a venous CTV test (as shown in the picture, venous imaging with CT), and the images will clearly show the cause of the recurrence, which is a recurrence caused by incomplete treatment of the traffic branch, along with a small saphenous varicose vein.
At what point do recurrent varicose veins progress to the point where surgery is required?
The guidelines classify the severity of varicose veins into 7 levels, from 0 to 6, and the severity of varicose veins varies from level to level.
In grade 0, the skin of the leg looks normal, but the patient will have a distinct feeling of soreness and swelling after standing for a long time; in grade 1 varicose veins, the blood vessels can be seen bulging in the leg, but it is not very serious, somewhat like “spider legs”; in grade 2 varicose veins, the typical “earthworm legs” can be seen. If the varicose is grade 3, the patient’s leg will become edematous after standing for a long time; grade 4 varicose patients’ skin will become nutritionally impaired, and the skin will become black; when grade 5 is reached, the patient’s skin will ulcerate; grade 6 will develop a stubborn ulcer, and no change of medication will cure the old rotten foot. Simple memory as level 1 small spider, level 2 small earthworm, 3 swollen 4 black 5 broken 6 rotten.
As shown in the picture, if the patient’s condition is similar to the picture of level 1, 2, 3, you can choose conservative treatment (taking medicine, wearing elastic stockings), or you can choose surgery; but if the condition is close to that of level 4, 5, 6, it is recommended that the patient do surgery.