Varicose veins in the lower extremities are one of the common diseases of peripheral blood vessels and have a high incidence in the population, 15% for men and 25% for women according to the literature, and they occur mostly in men who are engaged in permanent standing work and physical labor, while in women they are mostly related to the compression of bilateral iliac vessels by the fetus during pregnancy. The traditional treatment method is high saphenous vein ligation and stripping, but it has the disadvantages of large surgical trauma, many wounds, affecting the aesthetics and postoperative complications, which discourage many patients. In recent years, with the increasing maturity of minimally invasive technology and the continuous development of medical equipment, minimally invasive treatment methods for varicose veins of lower limbs are gradually applied in clinical practice. Saphenous vein laser closure (endovenouslasertreatment, EVLT) is one of the minimally invasive methods. The surgery department of a hospital was the first to carry out this procedure in Chengdu area, and summarized 32 cases and 50 legs of saphenous varicose veins treated by high ligation combined with endovenous laser from April 2008 to April 2009, which is reported as follows.
1.The principle of EVLT treatment
The principle of EVLT treatment is to deliver 980nm wavelength semiconductor laser in the vein by fiber optics, and through the high-energy thermal effect generated by the laser, the blood in the vein lumen boils and produces steam bubbles, which acts on the surrounding vessel wall, causing endothelial cell degeneration and necrosis, adjacent tissue charring and endothelial tearing, thus leading to thrombosis in the lumen of the vein, and then the wall shrinks and fibrosis, resulting in permanent occlusion of the lumen. Since the penetration of laser in the blood is only 0.3mm, the damage to the surrounding tissues is not significant.
2.High ligation combined with intracavitary laser treatment purpose
Blood reflux caused by saphenous vein valve insufficiency is the most important pathophysiological basis of varicose veins in the lower extremities. In this study, we know from the principle of EVLT treatment that it induces venous thrombosis by the high-energy thermal effect of laser, so there is a possibility of recanalization under the impact of regurgitated blood flow. The location of the starting point of laser treatment is an important factor affecting postoperative recurrence and is not easy to control. If the starting point is too high, it may cause damage to the femoral vein and lead to deep vein thrombosis. If the starting point is too low, the branch vessels of the saphenous vein may not be occluded, and under the action of the saphenous vein reflux, varicosities and saphenous vein thrombosis may occur in the branch vessel area. Therefore, we advocate high ligation of the saphenous vein to effectively ensure the surgical effect and reduce recurrence, as well as to prevent the formation of deep vein thrombosis in the lower extremity and the inflow of thrombus from the superficial veins into the deep veins.
3.The indications of high ligation combined with endovenous laser treatment
The authors experienced the following points in the treatment process.
1.For patients with mild to moderate saphenous varicose veins or with grade I or II deep vein valve insufficiency, high ligation combined with intravitreal laser therapy is feasible.
2.Severe varicose vein masses (vessel diameter >1cm) above and below the femur and knee should be combined with local stripping. Three patients in this group had recurrence which was caused by not doing local stripping. So partial debridement is very necessary for more serious varicose vein cases.
3.For patients with recurrent localized phlebitis and thrombosed veins, because of vascular fibrosis and endothelial inflammation, the walls are thickened and the vessels become continuously dilated, and varicose veins and discomfort will remain after laser treatment, so local debridement should also be performed.
4.For patients with deep venous valve insufficiency grade III and IV, EVLT treatment alone without solving the serious regurgitation of deep veins may aggravate the stasis of lower limbs and increase the chance of recurrence of superficial veins, so joint deep venous valve repair is needed.
4.The superiority of high ligation combined with endovenous laser treatment
High ligation combined with intracavitary laser treatment has obvious advantages compared with traditional surgical methods.
1.Less incision in the affected limb, less bleeding, shorter operation time.
2.Faster recovery and shorter hospitalization time.
3. Relatively fewer postoperative complications.
4.Low recurrence rate.
5.Meets the modern requirements of aesthetics. The differences between the above indicators and traditional surgical methods were statistically significant (P<0.05).
5.Complications of high ligation combined with intracavitary laser treatment
The common complications of high ligation combined with intracavitary laser treatment include subcutaneous bruising, local numbness in the lower leg, and skin burns. Reducing complications is important to improve the quality of care. In our group, there were 9 patients with subcutaneous hemorrhage, most cases appeared in the early stage of performing EVLT, and the site was mainly in the lower leg. Since the depth of laser damage to blood vessels is related to the vessel diameter, finer vessels are prone to penetrating injury. By adjusting the laser power to 12-15W above the knee and 1O-12W below the knee, the cases of subcutaneous bleeding were significantly reduced. The local numbness of the lower leg was observed in 6 cases in this group, which was due to the saphenous nerve running along with the saphenous vein in the anterior tibial area, and the thermal effect of the laser was likely to cause injury to the adjacent saphenous nerve and abnormal sensation in the corresponding distribution area. The thermal effect can also cause skin burns due to the small amount of subcutaneous fat in the anterior tibia. By reducing the laser power, applying sterile ice pack and topical moist burn cream, the local numbness and skin burns of the lower leg can be significantly reduced.
In conclusion, high ligation combined with endovenous laser treatment of saphenous varicose veins is a safe and effective treatment method, which has obvious advantages compared with traditional surgery, but still has some limitations. Since EVLT has not been applied for a long time in China and there is still little experience, its long-term efficacy still needs further observation.