The incidence of varicose veins in the lower extremities has now reached about 5% of the total population in cities. Based on such a high incidence, vascular surgery has sprung up all over the country in recent years. Varicose veins of the lower extremities have become the leading disease in vascular surgery clinics or wards everywhere.
Traditionally, varicose veins are treated mainly by sclerotherapy and saphenous vein trunk tapping.
Traditional aspiration makes the patient’s hospital stay generally about a week due to the long incision, trauma and pain. In addition, the traditional anesthesia also makes patients have more adverse reactions after surgery and require long periods of bed rest.
Sclerotherapy injection does not require anesthesia, no incision, low cost, as early as in the 1970s in China’s primary hospitals widely used. Sodium cod liver oil acid is the most commonly used sclerosing agent. However, there are great risks associated with sclerosing agent injection; first, if the sclerosing agent injection solution leaks, it can lead to skin necrosis. Second, once the sclerosing agent flows into the deep vein, it can lead to thrombosis, and in serious cases, pulmonary embolism. In recent years, the international sclerosing agent injection has made a series of improvements, such as: the emergence of microfoam technology (microfoam), which can make the occlusion effect better while reducing the concentration and dosage of sclerosing agent, greatly avoiding the past complications. However, sclerotherapy is a poor and risky treatment for the saphenous vein trunk, resulting in a high recurrence rate in clinical practice. Some small medical institutions package sclerosing agent injection as “the latest therapy” “thrombolysis” “interventional conduction” “nano therapy “and so on, with a certain degree of deception. At present, I think sclerotherapy is more reasonable for capillary dilation, postoperative residual or as an adjunct to surgery.
In the last decade, various minimally invasive treatments for varicose veins have gradually emerged.
Endovenous laser closure (EVLT) is a procedure that uses a special wavelength laser to intervene in the saphenous vein trunk through fiber optics and then perform vein closure. This technique avoids to some extent some of the complications associated with aspiration of the saphenous vein. For example, hematoma and saphenous nerve injury. The first report of semiconductor laser treatment in China was by the vascular team of Jiang Mier, Department of Vascular Surgery, Shanghai Ninth People’s Hospital. Then, Zhang Qiang vascular team was the first to report holmium laser treatment of varicose veins in China, treating hundreds of cases.
Since the laser emits energy from the head end, there are cases such as vein perforation or incomplete closure. In addition, in clinical practice, conditions such as inexperience of the surgeon and large caliber of the saphenous vein can lead to a high recurrence rate after the procedure.
The subcutaneous aspiration technique (Trivex) is designed for patients with extensive varicose veins in the lower leg, using a subcutaneous light source to locate the varicose vein and then a suction system to remove the varicose vein. This technique solves the problem of extensive varicose veins in the lower leg by making only 2 incisions in the lower leg.
However, the aspiration technique does not apply to the trunk of the saphenous vein and therefore cannot be performed as a stand-alone technique and requires other means. Also, the planar aspiration is not strictly minimally invasive, as it appears to be a small incision, but the subcutaneous trauma is greater, with more postoperative subcutaneous bruising and a greater risk of nerve damage.
The CHIVA procedure is the least invasive and least painful of all minimally invasive surgeries, which is short for Cure Conservatrice et Hemodynamique de l′Insufficience Veineuse en Ambulatoire in French. in contrast to the destructive and disposable surgical principles of the past, the CHIVA procedure is performed through preoperative analysis of venous hemodynamics to reroute blood flow. the advantages of CHIVA are obvious.
(1) The body’s saphenous vein trunk is preserved and can be used for venous flow, which can be used as vascular graft material needed for other future diseases.
(2) It can be performed under local anesthesia, and the patient can walk below the ground after surgery without the need for hospitalization for observation.
(3) Since most of the blood vessels are preserved, the postoperative period is almost painless, and the problems of nerve and lymphatic reflux damage that may exist in other surgeries are avoided.
However, CHIVA is not suitable for severely dilated veins and has a high recurrence rate. Therefore, it is currently limited to patients with early varicose veins (saphenous veins less than 5 mm in diameter, elderly patients) with diabetes, hypertension, heart failure, etc. who cannot tolerate traditional anesthesia and surgery.
Endovenous radiofrequency precision closure (Venefit) is currently the most widely used treatment method internationally. Its operating principle is similar to that of laser surgery, but its peripheral release of energy makes the closure of the vein appear more reliable. A special swelling solution is injected around the vein under ultrasound guidance, which basically solves the problems of postoperative pain and incomplete closure.
However, the injection of swelling solution and the use of intraoperative ultrasound are more demanding for the surgeon and require a certain learning curve. Dr. Zhang Qiang’s group introduced the technology for the first time in China in July 2015 and has already solved the pain for hundreds of varicose vein patients, and the vascular teams in Shanghai and Beijing have fully mastered the technology.
Vascular surgery across China has made great progress and achievements in the treatment of varicose veins. However, in an overview, there are still some problems in the treatment of varicose veins in China.
First, the problem of excessive medical treatment
Varicose vein surgery is a relatively common procedure, and the preoperative diagnosis should be relatively simple and clear for most patients. It should be said that for an experienced vascular surgeon, a clear diagnosis can be made by physical examination and ultrasound.
Thus, it seems that the vast majority of patients do not need a deep venogram before surgery. In fact, a significant number of providers use deep venography at every turn, putting the patient at risk for a number of complications associated with the imaging. For example, allergy to the contrast dose or thrombosis. It also significantly increases the cost of treatment for the patient and increases the waiting time for the procedure. However, for less experienced surgeons or for more difficult clinical cases, phlebography is necessary.
It is also inappropriate to use antibiotic therapy in the postoperative period. Because saphenous vein surgery without infected ulcers is a sterile procedure category, there is no indication for the use of antibiotics.
Secondly, the problem of choosing the surgical procedure
Some devices for varicose vein treatment are expensive, such as laser, radiofrequency, shaving suction, etc. But the effect of the same device in the hands of different doctors may be very different, just like the relationship between driver and car. Equipment is only a tool, the doctor’s experience and technology is the leading role. Each device has its advantages and disadvantages, and experienced doctors will choose the best way according to the patient’s specific condition.
Third, the judgment of the treatment effect
Strictly speaking, varicose veins are the clinical manifestation of many kinds of diseases. Apart from the aesthetic changes in the image, varicose veins themselves are not harmful to the body, but some complications brought about by the long-term development of varicose veins, such as thrombosis, ulcers, edema, etc., are the main factors that affect the patients’ daily life.
So the main purpose of treatment of varicose veins is to prevent these complications or for cosmetic purposes. The evaluation of the results of varicose veins should focus on the patient’s perception and improvement in quality of life, and the long-term results should be followed up.
Some providers use sclerotherapy injections to make varicose veins disappear in the short term, but most patients have a recurrence after several years due to untreated diseased trunk veins. The evaluation of laser and radiofrequency procedures has also revealed over the years the possibility of recurrence of the saphenous trunk if not performed by an experienced surgeon. Although the planar aspiration technique has only two incisions, the extent of the trauma is mostly subcutaneous, so the postoperative subcutaneous bruising is more serious and requires longer bandages, which is difficult for Chinese patients to accept the relatively slow postoperative recovery.
Fourth, exaggerating the therapeutic effect of drugs
At present, the only clinically proven effective drugs for treating varicose veins are Avalanche, Vein Spirit, and Desquamation. Other traditional Chinese medicine, topical ointment, injection “blood activation drug” etc. are all false products that fool the people. The drugs in the actual clinical use can only be used as an aid, not a substitute for surgery. Long-term use may bring adverse reactions.
Fifth, the relapse caused by missed lesions
The causes of recurrence after varicose vein surgery are as follows.
1, omission of the small saphenous vein lesion. The small saphenous vein is located at the back of the calf and is deeper, so it is easy to be overlooked if the preoperative ultrasound localization examination is not done.
2.Omission of traffic branch lesion. The ultrasound examination of the traffic vein is missed in most hospitals, and the traffic vein lesion is an important factor causing the skin lesion and ulceration of the calf.
3.Omission of saphenous vein trunk. Sclerotherapy injection and trunk position variation can lead to recurrence after surgery.
We believe that: routine preoperative ultrasound lesion localization by surgeons can avoid recurrence of most surgeries. In addition, ultrasound examination of varicose veins must be performed with the patient in the standing position. This is because when lying down, the veins are in a state of emptying and lesions are easily missed.
If one understands the above mentioned issues, one should know that one cannot blindly tell the patient what technique is best, but only what is most appropriate after examining the patient.
A high quality varicose vein treatment procedure usually takes less than a few hours of hospitalization. (Except for patients with other medical conditions, of course.) Currently. Dr. Zhang Qiang’s group routinely uses the Day Surgery model to avoid spinal puncture or tracheal intubation, allowing for early return to work and life without hospitalization, making the procedure much more convenient and safe.
With the maturation of minimally invasive techniques and changes in anesthesia, the treatment of varicose veins has become easier than ever. I anticipate that the number of varicose vein patients in vascular surgery will increase, and the demands on the specialty will become higher and higher. As a vascular surgeon, it is important to insist on scientific care and continuous innovation.