In recent years, with the gradual improvement of living standard, the change of people’s lifestyle and the aging of population, peripheral vascular diseases are rapidly increasing and have a high incidence and disability rate. In vascular surgery, the incidence of varicose veins in lower limbs ranks first among peripheral vascular diseases, and is a common and frequent disease, mostly occurring in workers engaged in manual labor or permanent standing staff. According to statistics, the proportion of varicose veins in the lower extremities of people over 15 years old is about 10%, and there is a trend of gradual increase.
Pathological changes
The presence of leukocyte aggregation in the lower extremities of this group of patients has been recognized. Leukocyte infiltration and activation may be the initial cause of venous insufficiency in the lower extremities, and this leukocyte activation in areas of high venous pressure in the ankle may be associated with sclerotic lesions of the skin. Activation of leukocytes causes an increase in the expression of adhesive glycoproteins, which allow leukocytes to adhere readily to the endothelium, mesenchymal connective tissue, and other cells. Activated leukocytes and endothelial cells produce harmful factors that cause lipid peroxidation and eventually apoptosis and necrosis of mesenchymal cells and certain connective tissues.
Clinical manifestations
Some patients may experience no significant discomfort. Some patients often feel heavy, sore, swollen, and fatigued in the lower extremities, and even experience muscle spasms in the lower legs. Superficial veins can be seen in the anterior medial calf of the affected limb, which are elevated, meandering, or even curled into a mass with venous tumor-like changes, especially when standing up. In long-standing cases, the skin of the lower leg and ankle often has nutritional changes, including hyperpigmentation, desquamation, and eczema formation.
Some of the varicose veins are prone to thrombophlebitis, and the local skin appears red, swollen, and painful. Ulcers are most commonly found above the medial ankle and are usually solitary or occasionally multiple. The base of the ulcer is dark red unhealthy granulation tissue, and the surface may be oozing with hyperpigmentation, hardening of the surrounding skin, or eczema-like dermatitis. If the ulcer does not heal over time, the edges are elevated, cratered or lycopodium-shaped, bleeding easily when touched, and the discharge is foul-smelling, it suggests the possibility of malignant transformation.
Clinical diagnosis
Medical history
Most often occurs in workers engaged in manual labor or prolonged standing. The affected limbs are mostly heavy, sore, and weak, and may have superficial varicose veins, hyperpigmentation, dermatitis, swelling, and persistent ulcers.
Physical examination
The superficial varicose veins can be seen on the anterior medial side of the affected limb, which is obvious when standing up. In some patients, hyperpigmentation and ulcer formation can be seen in the skin of the lower calf and ankle. Occasionally, the varicose veins are prone to thrombophlebitis, and the local skin shows redness, swelling and hardness.
Ancillary tests
Laboratory tests are performed to clarify the patient’s general condition and coagulation status. Ancillary tests such as vascular ultrasound and angiography are used to clarify the diagnosis and its reflux classification.
Differential diagnosis
1, post-deep vein thrombosis syndrome of the lower limbs.
2, lymphedema.
3, Klippel-Trenaunay syndrome.
Treatment
Non-surgical treatment: The principle is to reduce the pressure in the venous cavity of the lower extremity, including elevating the affected limb, appropriate activities, applying elastic stockings or elastic bandages, etc. Oral medications such as Mizarin to promote venous reflux can also be taken to reduce the symptoms of edema. It is suitable for patients with simple varicose veins of lower extremities with mild symptoms in early stages or for women with varicose veins of lower extremities during pregnancy. However, this method cannot cure varicose veins, but can only relieve the symptoms, and can be used as an allopathic treatment or as an adjuvant treatment before and after surgery.
Surgical treatment: varicose veins of lower extremities can be treated by different surgical methods according to the degree of lesion.
1.Sclerotherapy injection: It is the injection of sclerosing agent into the vein to destroy the endothelial cells and cause the formation of thrombosis and fibrosis due to the inflammatory reaction of blood vessels, so as to eliminate varicose veins. But it is only applicable to the residual and local recurrence of varicose veins after surgery or those with mild symptoms of varicose veins in lower limbs. The method has a high recurrence rate and its side effects include allergies, local pain, skin necrosis and pigmentation, deep vein thrombosis and other complications, and it is rarely used alone.
2.High ligation stripping plus electrocoagulation: The principle is to strip the saphenous vein trunk and electrocoagulate the endothelium of the branch varicose veins to form thrombosis causing fibrosis, which is suitable for those who have incomplete closure of the valves of the superficial veins and the valves of the traffic branches of the lower limbs, while the deep veins are open. This method has a wide range of indications and complete treatment, but has a certain rate of recurrence. It is widely used in many hospitals because of the simplicity of the equipment. However, this method has some limitations, such as easy skin burns, large damage to the vascular bed due to stripping, long hospital stays, and high hospital costs. The common complications of this method include incisional bleeding and hematoma formation, femoral vein injury, saphenous nerve injury, deep vein thrombosis, etc.
3.Laser vein occlusion: This treatment is to send infrared laser through laser fiber in the vein, and the heat effect is produced when the end emits heat, which damages the endothelial cells and vein wall, and causes fibrosis and closure of the inner wall of the vessel. However, this method has narrow indications and can only treat the main trunk of the saphenous vein and deal with minor superficial varicose veins, while for moderate to severe superficial venous masses the treatment is poor and still requires the application of traditional stripping surgery. Laser treatment is also contraindicated for pregnant and lactating women, deep vein thrombosis in the lower extremities, and patients with hypercoagulable blood. The advantages of this procedure are simple surgery, small trauma, short operation time, little postoperative pain and short hospital stay. Adverse effects include local skin numbness, subcutaneous bruising, hard nodes can be palpated along the occluded veins, and high recurrence rate.
4.Radiofrequency ablation endoluminal closure: This method adopts radiofrequency treatment instrument and computer-controlled VNUS vein closure system, which is an endoluminal treatment technique of vein tube, when the tissue coagulation and carbonization occurs, the resistance will increase sharply and the temperature will decrease to ensure the safety of treatment. This procedure has satisfactory near-term results and a high rate of long-term recurrence. Complications include sensory abnormalities, skin burns, deep vein thrombosis, pulmonary embolism, vascular perforation, hematoma, and infection. Contraindications are patients with deep vein thrombosis or blood reflux in the lower extremities.
5.TriVex transilluminated spinotomy: TriVex spinotomy removal system, as the only spinotomy treatment for varicose veins in lower limbs, has been recognized by many experts and scholars in recent years. The system is the second generation of the Trivex system developed by Smith & Nephew in the United States and is the only extra-venous lumen treatment technique. The main principle is to remove localized varicose vein masses in the lower extremities by rotary aspiration under the condition of direct visualization of varicose veins in a liquid environment. Its features include: the procedure is performed under visualization, which is safer; the procedure has very few complications, is simple and quick to operate, and is readily accepted by both doctors and patients; the procedure has a small incision, a small number of incisions, and a good postoperative cosmetic effect. This treatment instrument can remove varicose veins far more than other minimally invasive treatment techniques, and can easily remove any curved, thick or small veins under visualization, so its treatment is complete and there is no risk of disease recurrence, which opens up a new way for treating varicose veins in lower limbs.
6.Clarivein catheter system: This system consists of micro puncture sheath, treatment handle, Clarivein catheter and so on. There is a motor on the treatment handle, and the motor can drive the guide wire to rotate at high speed to destroy the endothelial cells of the vein and cause the spasm of the main trunk of the vein at the same time. The sclerosing agent can be injected through the catheter while the guide wire is rotating to act on the proximal end of the guide wire to gradually close the main trunk of the vein. This surgical method does not require supporting expensive equipment (radiofrequency therapy instrument, laser emitter, etc.), there is no high temperature generated by laser and radiofrequency emission, there is no damage to the surrounding tissues, and at the same time, there is no need to inject paralyzing swelling solution under the skin during the operation, so the patient does not feel obvious swelling.
In conclusion, although there are various treatment methods for varicose veins of lower limbs, different treatment plans should be chosen for different patients according to their different conditions and physical status and according to the principle of individualized treatment. For patients with complex conditions, several treatment methods can be chosen to be applied in combination to achieve complete cure.