Abstract In order to observe the hemodynamic changes of the deep veins in the lower limbs after saphenous vein ligation and stripping, 38 limbs with varicose veins and deep venous valve insufficiency were treated surgically. The results showed that high saphenous vein ligation and stripping had a certain improvement effect on the primary lower limb deep venous valve insufficiency.
Saphenous varicose vein is a common disease, and patients diagnosed with simple saphenous varicose vein should be treated surgically if they can tolerate surgery after having obvious clinical symptoms and signs. The traditional surgical approach is a high saphenous vein ligation and stripping with excision of the meandering, dilated geniculate branches [1]. We treated 38 lower limbs with varicose saphenous vein and deep venous valve insufficiency with high saphenous vein ligation and stripping + varicose vein spinotomy, and compared the preoperative and postoperative femoral vein internal diameter, femoral venous blood flow velocity, maximum superficial femoral venous valve regurgitation velocity, and regurgitation time by high-resolution ultrasound examination. The results are reported as follows.
1.Data and methods
1.1 Clinical data Case selection criteria: clear history of lower limb superficial varicose veins, and color Doppler ultrasound examination confirmed the patency of deep veins, with varying degrees of femoral venous valve regurgitation (grade I-III). 29 patients (38 affected limbs) had obvious signs of saphenous varicose veins, 17 men, 12 women, 22 left lower limbs, 16 right lower limbs, maximum age 72 years, minimum age 41 years old, average age 51.3 years old, 13 cases (7 lower limbs) had soreness and weakness of the affected limbs, 8 cases (9 lower limbs) had pigmentation and nutritional disorder changes in the affected limbs, and 7 cases (7 lower limbs) had ulcers in the foot and shoe area.
1.2 Treatment method Preoperative routine examination and preparation, application of Pioneer V to prevent infection, continuous epidural anesthesia, high saphenous vein ligation and stripping + varicose vein spinotomy (Trivex spinotomy for varicose branch veins), root ligation, severing the main trunk of the saphenous vein, ligation of two superficial branches of the medial and lateral femoral veins. After the operation, the affected limb was wrapped with an elastic bandage from the foot to the thigh with pressure for 48-96 hours, the affected limb was elevated, and subcutaneous low molecular heparin calcium anticoagulation therapy was given, and the venous ultrasound of the lower limbs was reviewed 12 days after the operation.
1.3 Observation methods and indexes The Acuson Aspen color Doppler ultrasonograph with a probe frequency of 7-10MHz was used to routinely examine the femoral vein, saphenous vein and superficial femoral vein, including the internal diameter of the femoral vein and blood flow velocity, and to perform the Valsalva maneuver and calf squeeze test, and to record the maximum regurgitation velocity of the superficial femoral vein valve, regurgitation time and other indexes.
1.4 Statistical methods SPSS13.0 statistical analysis software was used for data processing. The measured values of each index were expressed as ± s. If the data obeyed normal distribution, the t test was used for measurement data; if the data did not obey normal distribution, the rank sum test was used for measurement data.
2.Results
2.1 Femoral vein internal diameter: it did not obey normal distribution, and the rank sum test (Wilcoxon paired method) was used. p=0.0413<0.05, the femoral vein internal diameter was significantly thicker after surgery than before surgery.
2.2 Femoral venous blood flow velocity: obeyed normal distribution, using t-test of paired data. p=0.9290>0.05, no significant change in blood flow velocity after surgery compared with preoperative.
2.3 Maximal regurgitation velocity of superficial femoral vein valve: did not obey normal distribution, using rank sum test (Wilcoxon paired method). p=0.0002<0.05, maximal regurgitation velocity of superficial femoral vein valve was significantly lower after surgery than before surgery.
2.4 Superficial femoral vein valve regurgitation time: obeyed normal distribution, using t-test of paired data. p=0.0005<0.05, the superficial femoral vein valve regurgitation time after surgery was significantly shorter than before surgery.
Table Comparison of femoral vein internal diameter, blood flow velocity, superficial femoral vein valve maximum regurgitation velocity and regurgitation time before and after surgery
Group Number of strips Femoral vein internal diameter Femoral vein blood flow Superficial femoral vein valve Superficial femoral vein valve
mm velocity cm/s maximal regurgitation velocity cm/s regurgitation time s
Preoperatively 38 11.513±0.695 20.400±4.263 31.185±5.761 4.093±0.898
Postoperative 38 12.307±1.087 20.220±3.852 15.323±4.007 2.368±0.734
3. Discussion
Saphenous varicose vein is a common peripheral vascular disease with a high incidence. a survey in the UK in 1969 [2] showed that 56.5% of standing workers suffered from superficial varicose veins of the lower extremities. in 1980, Kistner [3] first proposed the concept of primary deep venous insufficiency of the lower extremities, and many scholars at home and abroad have carried out a lot of research work on it. sun Jianmin [ 4] found that among 105 patients with severe symptoms of superficial varicose veins of lower extremities, there were 61 patients with lower extremity deep venous valve insufficiency. The relationship between lower extremity superficial varicose veins and lower extremity deep venous valve insufficiency has not been conclusively established, among which the hemodynamic theory is highly agreed. The venous hypertension caused by deep venous regurgitation and venous reflux obstruction not only destroys the valves of the deep venous trunk, but also destroys the saphenofemoral valves and thus causes saphenous varicose vein, which further destroys the valves of the traffic branches of the deep and superficial veins in the calf segment and puts the superficial veins in a state of high pressure and stasis, resulting in a series of clinical symptoms and signs. Therefore, simple saphenous varicose veins are not necessarily associated with deep venous valve insufficiency, but all patients with primary deep venous valve insufficiency are also associated with saphenous varicose veins [5]. The treatment of saphenous varicose vein is based on the traditional saphenous vein ligation with stripping, and other methods include suture ligation, point stripping, valvuloplasty, radiofrequency therapy, laser ablation therapy, sclerotherapy, etc. Each method has its own characteristics and limitations. The traditional high saphenous vein ligation with stripping is definitely effective.
A survey showed [6] that the accuracy of the application of high-resolution color Doppler ultrasonography to examine the deep veins of patients with saphenous varicose veins in the lower limbs was 92% compared with the results of X-ray angiography and surgery of the deep veins of the lower limbs, which fully proves that high-resolution color ultrasound can accurately respond to the situation of deep veins and can provide very useful information for the selection of treatment plans for patients with saphenous varicose veins, considering that the examination method is easy and Considering the simplicity and non-invasiveness of the examination method, it has become the preferred method for the examination and diagnosis of venous diseases of the lower extremities.
Walsh et al [7] reported that in 29 affected limbs, those with preoperative superficial femoral vein and saphenous vein backflow confirmed by bidirectional Doppler ultrasound, had thigh saphenous vein stripping and the backflow in the deep veins disappeared; this phenomenon was also confirmed by Sales et al [8]. In our clinical study, we found that after patients underwent high saphenous vein ligation and stripping + varicose vein spinotomy, their femoral vein inner diameter was significantly thickened, the maximum regurgitation velocity at the first pair of valves of the superficial femoral vein was significantly reduced, and the regurgitation time was significantly shortened.It is believed that there are two sets of venous systems for blood return in the human lower extremity, namely the superficial vein (including the great and small saphenous veins) and the deep vein, and when the main trunk of the saphenous vein was simply stripped and the When the main trunk of the saphenous vein is simply stripped and the varicose veins are removed, the same amount of blood return can only rely on the deep venous system, and the increase of blood return in the lumen of the same area causes the pressure in the deep vein to increase and the pressure against the backflow to increase at the same time, thus reducing the backflow to a certain extent. It indicates that performing high saphenous vein ligation and stripping + varicose vein spinotomy has a certain improvement effect on primary lower limb deep vein valve insufficiency (mild-moderate).