Simplex varicose veins of the lower extremity are superficial veins of the lower extremity with incomplete valve closure. The superficial veins are elongated, dilated and flexed, which mostly occur in people who are permanently engaged in standing work and physical labor.
1.Etiology
Congenital weakness of the venous wall and poor venous valve structure are the main causes of the disease. Heavy physical labor, prolonged standing and increased abdominal pressure caused by various reasons can make the valves bear excessive venous pressure, which can lead to incomplete valve closure and blood regurgitation in the case of poor valve structure. Due to the thin muscle layer of the superficial venous wall and the lack of surrounding connective tissue, the regurgitation of blood can cause the veins to grow and thicken, resulting in varicose veins. Due to the increased venous pressure in the lower extremities, a large number of capillary hyperplasia and increased permeability can occur in the boot area, resulting in hyperpigmentation and liposclerosis. Due to the accumulation of large amounts of fibrinogen, the exchange between capillaries and surrounding tissues is obstructed, which can lead to nutritional changes in the skin and subcutaneous tissues.
Pathogenesis
The main hemodynamic changes in varicose veins occur during the systole of the calf muscle, when the venous valves protecting the unidirectional flow of blood are destroyed and the blood from the deep veins flows backwards into the superficial venous system, creating deep venous pressures as high as 20-26.7 kPa during muscle contraction. This results in the growth and thickening of the veins and the appearance of varicose veins.
Barnandl and Browse showed that in the pigmented and liposclerotic areas of varicose veins in the lower extremities, there is a large amount of capillary hyperplasia. And due to the increase of the pore size between capillary endothelial cells, it leads to the large leakage of osmotically active particles, especially fibrinogen, and the fibrinolytic ability of veins decreases at this time, so a large amount of fibrin accumulates into sheaths around capillaries, which hinders the exchange of oxygen and nutrients between capillaries and their surrounding normal tissues, so there are trophic changes in skin and subcutaneous tissues.
2.Clinical manifestations
Clinical symptoms
At the beginning of the disease, because the venous epithelium feels stimulation, the patient mostly has the feeling of soreness, swelling and pain, the nature of the pain is mostly dull pain, at the same time there is a feeling of heaviness of the limbs, easy fatigue and weakness. Patients mostly feel worse after standing for a long time or in the afternoon, but when lying down, limb elevation or wearing elastic stockings, it is obviously reduced, sometimes accompanied by calf muscle spasm. In some patients, there is no significant discomfort. Later stages of the disease are dominated by varicose veins and the complications they cause. The damaged veins are bulging, dilated, and tortuous, especially in the area of the saphenous vein stroke in the lower leg. In longer cases, the skin of the lower leg, especially the ankle, often shows nutritional changes, including skin atrophy, desquamation, pruritus, hyperpigmentation, hardening of the skin and subcutaneous tissue, and even eczema and ulcer formation, sometimes complicated by bleeding and thrombophlebitis. It is worth pointing out that simple superficial varicose veins are mostly not accompanied by edema, and even if they exist, they are only located at the back of the ankle and foot and are relatively mild. In case of severe lower limb edema, other causes such as primary deep vein valve insufficiency or deep vein thrombosis should be considered.
Physical examination
Percussion test: In obese patients, especially the main trunk of the saphenous vein above the knee, varicose veins are often not easily seen by the naked eye because of the thick subcutaneous fat coverage. In this case, a venous percussion test can be performed along the stroke of the saphenous vein to determine the diagnosis. During the examination, the doctor taps the vein below the knee with the right hand and gently touches the entrance of the saphenous vein in the groin with the left hand, and when the impact sensation can be transmitted to the left hand, it means that the varicose vein trunk above the knee has occurred.
Venous valve function test (modified Brodie-Trendelenburg test): The patient lies on his back, elevates the lower extremity so that the varicose vein is emptied of blood, wraps a tourniquet around the lower groin, compresses the great saphenous vein, and compresses the proximal end of the small saphenous vein with the thumb at the N fossa, then tells the patient to stand and observes the degree of filling of the superficial vein and the If the vein fills at once when the tourniquet is released (without relaxing the thumb), it means that the saphenous vein valve is not fully closed; if the vein fills at once when the thumb is relaxed (without releasing the tourniquet), it means that the small saphenous vein valve is not working. If both are not relaxed, and the emptied vein fills up within half a minute, it means that there is incomplete closure of the traffic vein valve between the deep and superficial group of veins. At this point, the tourniquet or thumb is relaxed, and if the degree of filling of the vein increases again, it means that the valves of both the superficial group of veins and the traffic veins are not functioning.
Traffic vein valve function test (Pratt test): specifically used to detect traffic vein valve function. The patient is placed supine, the lower limb is elevated so that the superficial veins are empty, a tourniquet is tied at the fossa ovalis, the first elastic bandage is tied from the toe up to the N fossa, then the second elastic bandage is tied from the tourniquet down, the patient is allowed to stand, the first elastic bandage is untied downward while the second elastic bandage continues to be tied downward, and any varicose veins appearing in the gap between the two bandages means that there is incompetent traffic vein. This will identify and mark any valvularly incompetent traffic veins.
Deep vein patency test (Perthes test, also known as kick test): the patient is instructed to take a standing position and compress the vein below the groin with a tourniquet, after the varicose vein fills, the patient quickly stretches the knee with force 20 times, if the filled varicose vein disappears rapidly or is significantly reduced and there is no lower limb cramping, it means that the deep vein is patented and the traffic branch vein is intact, which is negative. On the contrary, if the varicose vein increases and the lower limb is swollen and uncomfortable, it means that the deep vein is embolized and it is positive. In addition, the leg wrap test can also be used, first elevate the lower limb, after emptying the venous blood, wrap the lower leg with bandage pressure, and ask the patient to walk freely for 2~3h, if the swelling and pain is reduced, it means the deep vein is open.
3.Complications
Thrombophlebitis: The blood flow in varicose veins is slow and easy to form thrombus with non-infectious inflammation. Sometimes infectious inflammation can also be caused by bacterial invasion of the foot. The patient’s legs become red, swollen, and feverish, and the veins become streaky and painful to touch. The patient should be advised to rest in bed, elevate the affected limb, and apply anti-infective treatment such as penicillin and cephalosporin when moving. Local wet dressing of 75% ethanol or 50% magnesium sulfate can be applied. After the inflammation is controlled, surgical treatment is performed.
Ulcers: The upper ankle boot area is a site of high venous pressure and has constant penetrating veins, and the skin is poorly nourished. Treatment includes bed rest, elevation of the affected limb, compression therapy during activity, anti-infection therapy, etc. Since varicose ulcers are difficult to heal on their own, once the infection is controlled and the granulation tissue on the ulcer surface is fresh, surgery should be performed at the right time, and if necessary, ulcer implantation is feasible.
Bleeding: The varicose veins have thin walls and minor trauma can cause rupture and bleeding which is difficult to stop on its own. The affected limb should be elevated and bandaged with elastic bandage to stop the bleeding, and if necessary, sutures can be applied to stop the bleeding, and then surgical treatment can be done later.
4.Check
For patients with suspected post-formation syndrome of deep vein thrombosis and primary deep vein valve insufficiency, vascular ultrasound, volumetric tracing and venography can be performed to clarify the degree of deep vein patency and valve function.
5.Diagnosis
Superficial varicose veins of lower limbs have obvious morphological characteristics, so it is not difficult to diagnose. The percussion test, venous valve function test and traffic vein valve function test can provide a comprehensive understanding of the condition and provide a basis for determining the treatment plan.
6.Differential diagnosis
Primary lower extremity superficial varicose veins are distinguished from the following diseases.
Primary lower extremity deep vein valve insufficiency: primary lower extremity deep vein valve insufficiency is secondary to lower extremity superficial varicose vein, but its clinical manifestation is heavier, the patient has distending pain and obvious swelling when standing for a long time, and when making lower extremity superficial vein pressure measurement, the rate of pressure decrease after standing activity is reduced, generally within 30%, the most reliable differentiation test is lower extremity venography.
Post-deep vein thrombosis syndrome of lower limbs: superficial varicose veins of lower limbs are mostly a compensatory symptom of this syndrome. In the early stage of the disease, the patient has uniform and consistent swelling of the limb, pain with fever, and obvious pressure pain in the femoral triangle and gastrocnemius muscle, and pain in the gastrocnemius muscle when bending to the dorsal side with force (Homans’ sign positive), then the deep vein of the lower limb is blocked by thrombus, forming reflux obstruction, and the Perthes test is positive. At the later stage of the disease, the thrombus is reopened after mechanization, the venous valve is destroyed and becomes reflux lesion, the patient shows superficial varicose veins of lower limbs, lower limb edema, redness or cyanosis of lower limb skin when standing, and heavy and swollen limbs or soreness and nutritional changes, and lymphedema of affected limbs can be secondary, at this time it is difficult to distinguish from primary deep venous valve insufficiency, and deep venography can help to make a clear diagnosis.
Arteriovenous fistula: Most often occurs after trauma, especially penetrating injuries, and occasionally congenital. Tremors and continuous vascular murmurs can be detected at the site of the arteriovenous fistula, and the proximal limb is thickened and warm, hairy and sweaty, while the distal limb is cold and may be edematous. When the limb is elevated, the blood in the varicose veins of the lower extremity is not easily emptied, and the venous pressure is significantly increased, with bright red oxygenated blood when the vein is punctured.
Venous malformation bone hypertrophy syndrome (Klippel-Trénaunay syndrome): This disease is caused by congenital arteriovenous communication or congenital venous malformation (deep vein compression, high degree of stenosis or occlusion). Varicose veins are widespread, not limited to the main trunk of the saphenous or small saphenous vein, but often on the lateral thighs, and there are also obvious varicose veins on the posterior side, and the affected limb often hinges on the thickening and growth of the healthy side, and there are also large reddish-brown vascular nevus-like changes, which some people call “wine spots”. According to the above triad of signs, it is easy to identify.
7.Treatment
The treatment of simple varicose veins of lower limbs can be divided into conservative treatment, surgical treatment and sclerotherapy.
Conservative treatment
Conservative treatment is unsatisfactory for most patients and is only applicable to early mild varicose veins, women in pregnancy and patients who have difficulty in tolerating surgery; while it is effective for those with venous ulcers of lower limbs.
General treatment: the patient rests in bed appropriately, avoids standing for a long time, and elevates the affected limb during rest: the foot is higher than the knee in sitting position and higher than the heart in lying position.
Compression therapy: Compression therapy during walking or standing can reduce superficial venous hypertension in the lower extremities, while increasing the tension of the subcutaneous tissue space to counteract capillary hyperpermeability and reduce soreness and edema in the lower extremities. The appropriate compression stocking is usually chosen according to the extent of the lesion. The pressure of compression stockings is usually 4-5.33 kPa (30-40 mmHg), with a decreasing pressure gradient from the bottom up. In the absence of elastic stockings, elastic bandages can be used, but the wrapping pressure is difficult to control. It should be noted that it is contraindicated in the presence of concomitant ischemic manifestations in the lower extremities.
Drug therapy: Drug therapy is only suitable for reducing symptoms and promoting ulcer healing, but has no effect on valve function and varicose veins. There are many kinds of drugs, such as drugs to reduce capillary permeability, such as hesperidin; drugs to improve blood rheology, such as hexanone cocaine; drugs to improve microcirculation, such as prostaglandin E1, etc., but in general, the efficacy is not satisfactory.
Surgical treatment
Surgical treatment is feasible for those who have incompetent valves in the superficial and penetrating veins of the lower extremities and have open deep veins. The procedure should be minimally invasive to strip the varicose veins and eliminate the cause of the superficial lower extremity hypertension – the femoral vein or the through vein regurgitation. Depending on the patient’s condition, there are several surgical options.
High saphenous vein ligation + varicose vein stripping.
high ligation of the saphenous vein + sclerotherapy of the varicose vein.
varicose vein stripping alone. In about 2/3 of patients, preoperative examination reveals reflux in the saphenous vein, so high saphenous vein ligation + varicose vein stripping is more often advocated.
Surgery.
Preoperative preparation: The patient is instructed to stand and mark the varicose vein with a marker before surgery. If possible, Doppler ultrasound can be used to mark the penetrating vein.
Anesthesia: Lumbar or epidural anesthesia is used.
Surgical steps.
Supine position with mild external rotation of the affected limb. Disinfection is performed from the level of the umbilicus to the toe of the affected foot. The blood is expelled from the dorsum of the foot upward, and the expulsion band is tied to the mid-thigh.
A parallel incision of 4-5 cm is made 0.5-1 cm below the inguinal ridge, which facilitates ligation of the branches of the saphenous vein. Especially the superficial medial femoral vein. A parallel incision 1 cm above the skin line can also be chosen to reveal the saphenofemoral junction.
The superficial fascia is incised, the main trunk of the saphenous vein is exposed and the branches are ligated, and the saphenous vein is cut about 0.5 cm from the junction point of the saphenofemoral vein, and the proximal end is ligated and sutured. During the operation, attention should be paid to the anatomical level, and the saphenous vein and femoral vein should be correctly identified, and if the femoral vein is damaged, it should be repaired in time. The ligation of the saphenous vein should be 0.5 cm from the femoral vein, too long may leave a residual branch leading to recurrence, too short may narrow the femoral vein. In case of small saphenous varicose vein, a transverse incision can be made at the N fossa to reveal the small saphenous vein and its branches and cut and ligated at its entry into the N vein.
A stripper is inserted into the distal saphenous vein and led out near the knee joint, and the stump of the vein is tied to the head of the stripper and slowly withdrawn. The trunk of the vein is stripped to the medial ankle in the same manner. Care should be taken not to leave the trunk of the vein under the skin, as this may cause local cord-like nodules after surgery.
A small incision of approximately 5 mm in length is made in the preoperatively marked varicose vein and the vein is stripped subcutaneously in sections using a striated vascular clamp. For eczema and ulcers, the penetrating vein underneath should be stripped. The incision should be made parallel to the skin line and fully utilized to reduce the number of incisions and achieve aesthetic results. When stripping varicose veins, the accompanying saphenous nerve should be avoided as much as possible to avoid postoperative sensory disturbances in the calf and medial foot.
The inguinal incision is sutured and the small incision is covered with sterile gauze. An elastic bandage is applied with pressure from the dorsum of the foot upward to the groin.
Postoperative management: The patient was encouraged to move around as early as possible after surgery, and could generally walk out of bed on the second postoperative day and remove the stitches on the seventh day. Wear elastic stockings for 2 to 4 weeks after surgery.
Postoperative complications.
Incisional bleeding and hematoma formation: mostly caused by dislodgement of the ligature at the proximal end of the saphenous vein or insufficient compression of the elastic bandage. If necessary, reoperate to find the broken end and re-ligature.
Femoral vein injury: It is a serious complication that can cause serious complications such as limb swelling and necrosis, so the femoral surgical incision should not be too deep, and the saphenous vein should be correctly identified and the technique should be gentle and accurate so as not to tear the saphenous vein at its confluence with the femoral vein. Ligation of the saphenous vein should be 0.3-0.5 cm from the femoral vein; if it is too short, it is easy to ligate part of the femoral vein causing femoral vein stenosis, and if the femoral vein is damaged, it should be repaired in time.
Saphenous nerve injury: after saphenous nerve comes out of the internal collecting muscle canal and goes down with saphenous vein, so when stripping the varicose vein in this area, the action must be gentle, accurate and careful, once it is injured, it can cause sensory disorder in the calf and medial foot.
Precautions should be taken during surgery to prevent recurrence of varicose veins.
Carefully identify the main trunk of the saphenous vein and its branches to avoid mistaking the dilated branches for the saphenous vein ligation.
The saphenous stump should not be kept too long, but should be 0.3-0.5 cm, so that the blood does not flow backwards through the branches and lead to recurrence.
All branches of the saphenous vein should be separated and found during surgery so that they are not missed. Occasionally, the lateral femoral vein converges directly into the femoral vein, and its upper segment is located under the fascia, which is difficult to find intraoperatively and may cause recurrence after surgery if it is missed.
Preoperatively, the traffic branches with incomplete valve closure are carefully checked and marked out, and then carefully ligated and cut off during surgery.
Sclerotherapy
Sclerotherapy for varicose veins in the lower extremities was introduced in 1864, initially with procoagulant drugs, but not until the early 20th century with sclerosing agents that destroy endothelial cells. Sclerotherapy is indicated for varicose veins with no significant reflux in the superficial venous trunk or where reflux has been corrected, and indications include
Capillary dilation.
Reticular varicose veins.
Isolated varicose veins.
postoperative residual and recurrent varicose veins.
Those who have difficulty tolerating surgery. The principle of treatment is to inject a sclerosing agent into the varicose vein and then apply pressure to the vein wall to cause an inflammatory reaction and occlusion.
Currently the most used sclerosing agents are sodium cod liver oil acid, sodium tetradecyl sulfate and hypertonic saline, which can cause destruction of endothelial cells and secondary fibrosis. The patient is treated in a standing or reclined position to fill the vein, and after puncturing the vein with a fine needle, the patient is placed in a lying position with the affected limb elevated at 45° to facilitate the emptying of the vein. For varicose veins of 3-8 mm in diameter, 5% sodium cod liver oil acid, 0.5%-1.0% sodium tetradecyl sulfate or 23.4% hypertonic saline can be used, while the concentration is halved for capillary dilation and reticular varicose veins. Inject 0.5~1ml of sclerosing agent at each site and observe whether there is pain or burning sensation and other manifestations of sclerosing agent extravasation, once it happens, the injection should be stopped immediately. After 1 min of injection at each site, local compression with gauze pad. Subsequently, an elastic bandage should be applied from the dorsum of the foot upward to 10 cm above the highest injection point, and an elastic stocking may be added. Immediately after surgery, the patient should be encouraged to move actively and avoid prolonged standing. The duration of the compression bandage is controversial, ranging from 1 week to 6 weeks. Histologically, it takes 12 days for moderate varicose veins to reach fibrosis occlusion.
Sclerotherapy has a high recurrence rate, often requiring repeated injections, and also has certain complications, such as allergic reactions to sclerosing agents, thrombophlebitis, hyperpigmentation, and extravasation of sclerosing agents leading to subcutaneous fat necrosis and refractory ulcers, which limit the clinical application.