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Abstract: The treatment of saphenous varicose veins is usually individualized in clinical practice according to the patient’s specific situation. This patient had varicose veins for 5 years and was always treated conservatively. Recently, she developed swelling in her right calf, frequent twitching at night, and slight pigmentation in her leg, so she came to our hospital and was diagnosed with saphenous varicose veins after a series of examinations. After individualized surgical treatment with medication, the varicose veins in the lower limbs disappeared and the patient resumed normal work.
Basic information】Female, 33 years old
Disease Type】Saphenous varicose vein
Hospital】Zhejiang Hospital of Traditional Chinese Medicine
Date of consultation】November 2021
Treatment plan】Surgery (minimally invasive surgery for saphenous varicose vein) + medication (Diosmin tablets, mucopolysaccharide polysulfate cream)
Treatment period】Discharge from hospital 2 days after surgery, 1 week follow-up
Treatment effect] The varicose veins in the lower limbs disappeared, the treatment effect was good, and the patient resumed normal work
I. Initial consultation
The patient was a 33-year-old woman who was admitted to the hospital because of “earthworm protrusion of the right lower extremity for 5 years, accompanied by discomfort and itching of the lower leg for half a year”. Due to the reluctance to wear elastic stockings in hot weather, the veins on the legs became more and more serious, and recently the right calf became edematous and heavy, and the lower limb twitched frequently at night when sleeping, which affected the sleep, and the originally fair legs began to be slightly pigmented, so he was worried that he had “old rotten legs”, so he came to our hospital for consultation.
Through communication with the patient, we learned that the patient had no history of hypertension, diabetes, hyperlipidemia and other diseases. The patient’s physical examination showed that he was not obese and his body mass index was 18.0. After observing his legs, he found that he had a worm-like bulge and distortion on the medial side of his right calf, with bruises on his inner ankle and dorsalis pedis, and skin pigmentation in the vicinity without ulcer symptoms. The patient’s dorsalis pedis artery pulsation was normal and the bilateral ankle-brachial index was 1.0. The patient reported that the left calf would be mildly swollen after lunch and had acupressure depression, so the patient’s calf circumference was measured and the results showed that the left calf circumference was 35 cm and the right calf circumference was 36.5 cm.
The patient’s right saphenous vein was found to be dilated, tortuous and refluxed in the main trunk, with a localized tumor-like dilatation in the proximal end and a tortuous dilatation in the calf genus branch, and a penetrating vein with an open diameter of 0.3 cm was seen 13 cm above the inner calf ankle. A diagnosis of right saphenous varicose vein with CEAP grade 3 was made.
(Ultrasound)
II. Treatment
The patient’s indexes were integrated and the decision was made to perform minimally invasive surgery for saphenous varicose vein under local anesthesia, which was divided into seven steps, as follows.
1.Mapping the veins: this step relies on preoperative examination to clarify the etiology through color ultrasound and to precisely trace the main trunk, the penetrating branches and the varicose branches of the saphenous vein for the patient.
2.Ultrasound-guided high ligation: Under ultrasound guidance, a small 0.8 cm incision is made in the patient’s groin in a private area, which results in a smaller and more discreet postoperative scar.
3.Swelling anesthesia: This type of anesthesia is a modified local anesthesia, which reduces the patient’s pain during the operation and shortens the operation time.
4.Minimally invasive stripping: combined with jerking techniques to disconnect the branches of the saphenous vein in the direction of the main stem.
5.Ultrasound-guided sclerosing agent injection: this is a safe and minimally invasive adjunctive treatment at present, we can carefully observe the direction of sclerosing agent and whether the sclerosing agent fills the varicose vein through ultrasound during the operation, and avoid the sclerosing agent from entering the deep vein.
6.Point stripping: intraoperative use of specially designed vein hooks to deal with twisted into a mass of venous branches to reduce the patient’s postoperative venous sclerosis.
7.Pressure bandage: the patient’s right lower limb was wrapped with elastic bandage with pressure for 2 days after surgery to promote venous reflux in the lower limb.
III. Treatment effect
After the above-mentioned surgical treatment, the patient was immediately out of bed after the surgery with elastic bandage, given oral diosmin tablets to improve venous activity, and given mucopolysaccharide polysulfate cream for the lower leg to reduce edema, and the diseased saphenous vein was successfully stripped after the surgery with only a small 0.8 cm incision. On the second postoperative day, the patient did not show any symptoms such as bleeding or oozing from the wound, so he was discharged from the hospital to recuperate and was asked to come for follow-up 1 week after surgery. When the patient came for follow-up 1 week after surgery, the varicose veins disappeared and there was no swelling in the lower extremities, which achieved a more satisfactory treatment effect. In conclusion, the patient’s saphenous varicose vein disappeared, the treatment effect is good, and he has resumed normal work.
IV. Notes
I am glad that after a series of treatments, the patient’s saphenous varicose vein disappeared and achieved a more satisfactory treatment effect. However, since the patient had a surgery after all, there is still a certain recovery period after the surgery, so the following points still need to be noted after discharge.
1.You can walk or stand normally in daily life, but you should avoid prolonged standing, sitting, weight bearing and heavy physical labor.
2.Strenuous activities or other behaviors that can cause a lot of sweating should be avoided within 7 days after surgery, and bathing should be avoided, and appropriate bathing should be allowed only 10 days after surgery.
3.Patients can wear varicose veins stockings for 10 days after discharge, and adjust the wearing time appropriately according to the review situation. Elastic stockings can be worn daytime for at least 1 month. If long time standing is needed, varicose veins stockings should always be worn during standing to promote venous reflux in lower limbs and reduce venous pressure in lower limbs.
V. Personal insight
Minimally invasive surgery for saphenous varicose veins is less traumatic and quicker to recover. Patients have less pain and better experience during treatment, and there are no scars after surgery. In this case, the patient underwent this type of surgery, and strictly followed the doctor’s instructions for daily care after surgery, so the postoperative recovery was faster and the treatment effect was better.
In the current clinical practice, the cuffing catheter is a relatively new surgical procedure, which has changed the existing anesthesia and philosophy to optimize the minimally invasive surgery through the innovation from traditional involution to cuffing. And we, as vascular surgeons, should strive to improve ourselves in the face of continuous innovation of surgical modalities, not only to master surgical skills and minimally invasive concepts, but also to master ultrasound techniques and interventional techniques to lay a solid foundation for treatment.