Variceal ulcer of lower extremities (VULE) is a common clinical peripheral vascular disease that occurs in the lower part of the lower leg, especially in the inner ankle. The main cause of VULE is venous hypertension and regurgitation of blood caused by the insufficiency of traffic branch valves in the lower extremities. Subfascial endoscopic perforating surgery (SEPS) and endovenous laser treatment (EVLT) are minimally invasive, safe and complete, and have become important tools for the management of lower extremity venous and superficial venous reflux. It has become an important tool for the management of venous and superficial reflux in the lower limbs.
1.Data and methods
1.1 General data From January 2007 to December 2008, 27 patients (29 affected limbs) with varicose veins of lower extremities combined with venous ulcers were admitted to our hospital, including 17 men (19) and 10 women (10), aged 40~81(56±10.6) years. The duration of superficial varicose veins in the lower limbs ranged from 6 to 50 (15.4±9.3) years, and the duration of ulceration ranged from 1 to 10 (3.8±1.2) years. All presented with significant superficial varicose veins, hyperpigmentation, and active ulcers (grade C6) in the lower leg, with ulcer diameters of approximately 1-10 cm in size. Twenty-one were treated initially, six relapsed after conventional surgery, and two relapsed after sclerotherapy. All affected limbs were indicated by lower extremity cis-venous angiography or color Doppler ultrasound exploration for patency of the deep venous trunk and exclusion of deep venous thrombosis.
1.2 Treatment modalities
1.2.1 SEPS surgical method After epidural anesthesia, the affected limb was elevated l0~l5° in the flat position. Disinfect the operative field and spread the towel. With the knee flexed, a transverse incision of about 1.0 cm was made 6 cm below the tibial ramus and 3-4 cm medial to the tibia, the deep fascia was incised, the subfascial space was bluntly separated, the Trocar and lumpectomy were inserted, and the pressure was maintained at 12-15 mm Hg. An incision of about 0.5 cm was made 3-4 cm medial to the lower side of the first incision to place the Trocar, and a separation rod was inserted to separate the deep subfascial space under lumpectomy guidance. Under lumpectomy guidance, the subfascial loose connective tissue was separated, reaching anteriorly to the tibia and posteriorly to the midline until near the medial ankle. The traffic vein is freed and dissected after cautery and electrocoagulation with an electrocoagulation hook, and for vessels larger than 3 mm in diameter, they can be closed with a titanium clip and then dissected. Generally, three to six traffic veins can be seen intraoperatively, and the traffic branches are mostly located near the medial tibia and are thicker near the ulcer. After disconnecting the deep subfascial veins of the calf one by one, the instruments are withdrawn, the C02 is driven away, and the incision is sutured to end the SEPS procedure.
1.3.2 Endovenous laser treatment method The saphenous vein is punctured at the inner ankle of the affected limb with an 18G trocar needle, a super-slip guidewire is inserted, a 5F angiographic catheter is introduced, the guidewire is withdrawn, and a 600-μm laser fiber is replaced. If the puncture is unsuccessful, a small skin incision (0.5 cm) can be made to cannulate the saphenous vein. The ARC.Surgilas semiconductor laser is connected and the tip of the fiber is placed 1~2 cm below the inguinal ligament. The root of the saphenous vein was ligated at a high level according to the location of the indicated light point. In intermittent pulse mode, the firing power is set at 12 W. The progressive and regressive laser treatment is performed in the lumen of the saphenous vein trunk at a speed of 0.5 to 1.0 cm/s until the puncture is removed. In case of severe varicose veins in the lower leg or segmental occlusion of the main trunk of the saphenous vein due to sclerotherapy injection, laser cauterization after segmental incision is used if the fiber cannot be introduced into the predetermined location at one time. In the case of branch varicose veins in the lower leg, the fiber is introduced at multiple points and the power is set at 10W for cauterization. Visibly dilated vein clusters were removed with small incisions, which were closed intradermally with absorbable sutures. Necrotic tissue on the surface of the ulcer was scraped off with a blade and the wound was wrapped with iodoform gauze. After the operation, an elastic bandage was applied along the path of the saphenous vein, and after 72h, the elastic bandage was removed and replaced by medical elastic stockings for 3 months.
2.Results
The soreness and heaviness of the lower extremity of the affected limb were gradually reduced, the local itching and trauma pain were relieved, the varicose vein branches and venous masses disappeared, and the incision was healed in one stage. The ulcer surface exudation gradually decreased and granulation tissue grew in 2~3 days after surgery, and the patients were discharged from the hospital 4~10 days after surgery. All cases were followed up for 4 to 18 months, and there was no varicose vein formation or recurrence of ulcers. Some patients felt a subcutaneous tugging sensation within 1 month after surgery; 4 cases had numbness in the medial calf skin, which disappeared within 3 months.
3.Discussion
Venous ulcers of lower limbs are mostly caused by deep and superficial venous and traffic branch venous insufficiency, among which traffic branch venous insufficiency has the closest relationship with the occurrence of ulcers. On the one hand, when superficial venous reflux occurs, if the function of the traffic branch vein is normal, the blood flow to the deep venous system increases, causing venous hypertension and deep venous dilatation, and then deep venous insufficiency occurs. On the other hand, if the venous function of the communication branch is not complete, the venous reflux to the superficial veins of the lower extremities causes venous stasis in the lower legs, local microcirculation changes, skin nutrition disorders, and the appearance of long-lasting ulcers. Traditional high saphenous vein ligation with stripping often fails to remove all the traffic branches, and fails to effectively resolve the backflow of traffic branches, which often leads to unhealed or recurrent ulcers after surgery. In 1985, Hauer et al. first introduced the lumpectomy technique to the treatment of lower extremity veins (SEPS procedure), because it was performed by making an incision in the skin away from the lesion and using endoscopic techniques to disconnect the traffic branch veins. This effectively solves the problem of postoperative incisional complications. Compared with the Linton procedure, the SEPS procedure has a small incision, light trauma, and is far away from the lesion skin, which can effectively reduce incisional complications; the traffic branch can be clearly displayed intraoperatively, the dissection and ligation are accurate and reliable, and the postoperative ulcer heals quickly.
Wang Wentong et al. examined the lower limb venous system of 168 lower limb venous ulcer affected limbs in 105 cases by Doppler ultrasound technology and found that 162 (96%) of them had superficial venous reflux, which shows that superficial venous reflux plays a very important role in the formation of venous ulcer. One of the newest minimally invasive methods of superficial varicose vein treatment is endovenous laser therapy (EVLT), the main principle of which is to deliver laser light through fiber optic in the venous cavity, resulting in the absorption of energy by the hemoglobin around the fiber and the production of vapor bubbles, causing extensive thermal damage and contraction of the endothelium, which eventually leads to occlusion, fibrosis and absorption of the vein, thus achieving the purpose of treatment. This procedure is safe, reliable, less invasive, quick recovery, no scarring, and low recurrence rate of varicose veins, which has replaced traditional surgery. In this group of cases, EVLT was used in combination with SEPS surgery for superficial varicose veins, and laser treatment was also used in cases of recurrence of traditional surgery for residual trunk of saphenous vein. All cases were followed up for 4 to 18 months without varicose vein formation or ulcer recurrence, which shows that the combined application of these two minimally invasive treatment methods can achieve more satisfactory clinical results.
To summarize the experience of this group of cases, we believe that we should pay attention to.
(1) The selection of the SEPS incision is the key to the smooth implementation of the operation. The first incision was chosen 6 cm below the tibial ridge and 3-4 cm medially, and the second incision was located 3-4 cm medially below the first incision, so that the incision was far from the tibial crest, which was conducive to the separation of the deep subfascial space and intraoperative lumpectomy adjustment to fully expose the operative field. The incision should not be made anteriorly or laterally on the tibia, because it may lead to poor healing of the incision and difficulty in exposing the communication vein after surgery.
(2) The traffic branch vein should be handled in a “hanging” manner to avoid collateral damage. Especially when electrocoagulation and electrocautery are used, direct contact with muscle, deep fascia and skin can cause local tissue damage, and blind cautery should not be used when the field of vision is unclear.
(3) For those with larger ulcer diameters, autologous free skin grafting can be performed to accelerate the healing of the ulcer after local drug exchange treatment and fresh granulation tissue.
(4) Treatment of the traffic branch first and then the superficial veins. The treatment of superficial veins in the lower extremities may damage the deep fascia, make the SPES operation unclear or leak to form subcutaneous emphysema, and bring potential contamination of the skin to the deep subfascia, causing subfascial infection.
(5) The pressure of subfascial gas injection should not be too high, generally not exceeding 15 mmHg, otherwise it may increase the risk of subcutaneous emphysema and gas embolism. In case of large venous bleeding, the operation should be terminated in time to expel the gas to prevent gas embolism.
(6) The treated saphenous vein should be compressed when withdrawing the fiber during EVLT to better allow for intravenous thrombosis, but compression of the luminous spot should be avoided to avoid perforating the vein wall and causing subcutaneous bleeding or petechiae.
(7) The laser power used for the branch varicose veins of the calf should be appropriate (about 10W), otherwise it may damage the medial dermal nerve of the calf causing numbness and local skin burns.
(8) Postoperative compression bandage is used to prevent recurrence of varicose veins; at the same time, the gastrocnemius muscle is massaged to prevent deep vein thrombosis.
In conclusion, lumpectomy deep subfascial traffic branch dissection combined with endovenous laser treatment can effectively block the abnormal reflux of superficial venous system and traffic branch venous system, and the treatment of varicose venous ulcer of lower limbs is less invasive, easy to operate, safe and reliable, and the efficacy is determined, which has good clinical application value.