Primary lower extremity deep venous valve insufficiency and femoral vein ringing
I. What is primary lower extremity deep venous insufficiency
Primary lower extremity deep venous insufficiency belongs to the lower extremity venous blood backflow disease, which is a kind of lower extremity varicose vein class disease, and it was only gradually recognized in 1980s, before that this disease has been treated as lower extremity varicose vein, and it is a common disease and multiple diseases, which can account for about 80% of the lower extremity varicose vein lesions. In order to better understand this disease, it is necessary to firstly understand briefly the anatomical characteristics of the veins of the lower limbs.
The main function of lower limb vein system is to transport blood from distal limb back to heart, it is divided into two groups of deep veins and superficial veins, there are traffic veins connected between deep and superficial veins, superficial veins are veins that are usually visible to naked eyes on lower limbs, divided into large and small saphenous veins; while deep veins are divided into common femoral vein, superficial femoral vein, deep femoral vein, N vein, etc., which are located in deep tissues, most of them travel between muscle gaps. so they cannot be seen. No matter deep, superficial or traffic veins, there are many pairs of venous valves in their lumen, and these valves are open in one direction, which only allow blood to flow back to the heart under normal conditions, and do not allow backflow. When these valves are damaged due to various factors, they lose their one-way open function, and blood will flow backwards due to gravity, i.e., backflow to the distal limb, thus causing venous reflux disease, resulting in lower limb venous system stasis and high pressure, and leading to a series of clinical symptoms and signs. Among these venous valves, there is a pair of valves with the most important role, that is, the first pair of valves of the superficial femoral vein, this pair of valves can normally withstand the greatest pressure strength, up to 350-420 mmHg, which is also the limit of its resistance to reverse pressure.
Once the function of this pair of valves is destroyed, the blood will be damaged in sequence due to the gravitational effect of the vertical blood column, so that the blood flows backward to the distal end of the limb, and the pressure in the deep veins of the lower limbs will be increased, so that the deep veins of the lower limbs will be dilated and the two leaves of the valves will not be able to come together, which will further aggravate the insufficiency of the valves, and the blood of the lower limbs will lose the normal one-way centripetal reflux function, so that the venous blood will be stagnant and the pressure in the veins of the lower limbs will be further increased. The pressure in the veins of the lower extremities will be further increased, which will certainly affect the traffic veins and superficial veins between the deep and superficial veins, and the valves in the traffic veins and superficial veins can withstand much less pressure than the valves in the deep veins, so they can easily lose their function in the case of increased pressure in the deep veins, thus causing the superficial veins to bulge, that is, varicose veins, or aggravating the original varicose veins in the lower extremities, which is the clinical blood backflow This is the principle of the formation of clinical blood backflow disease.
Therefore, the so-called primary lower extremity deep vein valve insufficiency means that the free edge of the valve in the deep vein elongates, relaxes and sags under the action of many factors, so that it loses the role of one-way opening, coupled with the expansion of the lumen of the deep vein, it cannot make the two opposing valve leaves close together in the lumen, so that the blood in the deep vein flows backwards, causing high pressure and blood stagnation in the venous system of the lower extremity, and causing a series of clinical symptoms and signs. The symptoms and signs.
Second, what are the clinical manifestations of primary lower limb deep vein valve insufficiency?
The clinical manifestations of this disease are similar to varicose veins of lower limbs, but much more obvious and serious than saphenous varicose veins.
1. Superficial varicose vein
This is the earliest pathological change that appears. Mostly, the superficial veins along the saphenous vein and/or small saphenous vein distribution location are dilated and elongated, while the stroke is sinuous and tortuous, and some of them may appear globular dilated and varicose veins may be combined with infection due to slow blood flow, leading to thrombotic superficial phlebitis.
2. Swelling, distension and pain
This is a characteristic manifestation of deep venous valve insufficiency and venous hypertension. There is obvious weakness, soreness and swelling or distension in the lower limbs, and sometimes there may be twitching of calf muscles. The lower legs are uniformly swollen and there may be acupressure edema in front of the shins. The symptoms are aggravated in the afternoon and when walking, and can be relieved in the morning, after resting or elevating the affected limb.
3. Nutritional changes of the skin
These changes include skin atrophy, desquamation, pruritus, hyperpigmentation, sclerosis of skin and subcutaneous tissue, eczema, and even ulcers. The dilated superficial vein wall becomes thin and easily complicates hemorrhage due to trauma or self-piercing, and it is difficult to stop by itself.
Third, how to diagnose primary lower limb deep vein insufficiency
The first is based on the clinical symptoms and signs of the patient’s lower extremities, as described above;
Secondly, relevant tests are done: including limb strain volume tracing (SPG) test, limb photoelectric volume tracing (PPG) test, dynamic venous pressure measurement, lower limb venous ultrasound and lower limb venography. Of these tests, the latter two are the most commonly used and valuable diagnostic methods.
Lower extremity venous ultrasound.
This is by far the most advanced non-invasive test and can replace venography to a considerable extent. It allows observation of venous valve activity, determination of the site of backflow, and determination of the amount of venous blood backflow using the blood flow spectrum. The ultrasound diagnostic report shows that the deep venous tibia is widened, the wall is smooth, not thick and continuous, and the lumen can be deflated or disappear after the probe pressure; the valve exists, but the edge is blurred and relatively short; when the Valsalva test (breath-hold test) is done, the color flow appears “reversed” and the blood flow spectrum appears continuous reverse flow. The venous reflux sign.
Lower extremity venography.
This is an invasive test but is still the “gold standard” for diagnosing venous lesions in the lower extremities. There are four types.
1. Lower extremity deep vein retrograde angiography: it is characterized by ① thickening of the main trunk of deep vein, often with obvious straight tube expansion; ② blurring or disappearance of the valve shadow, and loss of bamboo-like expansion of the venous segment there; ③ varicose state of the saphenous vein, and in severe cases local expansion in the form of a sac; ④ thickening of the traffic vein visible above the inner ankle, which is especially obvious around the ulcer.
2. Retrograde angiography of the deep veins of the lower limbs. It can determine the extent of deep venous reflux.
3.N vein cannulation angiography. It is a means of localizing the function of the deep vein valves in the lower extremities.
4. Superficial varicose vein angiography. It can clearly show the dysfunctional traffic veins of the affected limb.
What is the difference between primary lower extremity deep static valve insufficiency and secondary lower extremity deep venous valve insufficiency?
Lower extremity deep venous valve insufficiency is divided into two kinds: primary and secondary. Like varicose veins of the lower extremities, primary lower extremity deep venous insufficiency is also a common disease, accounting for about 80% of the varicose veins of the lower extremities. It can be caused by congenital weakness of the vein wall or dysplasia of the venous valves, and on the basis of this, the long-term increase in the reverse pressure of the proximal segment of the veins and the action on the deep venous valves, the venous lumen dilates and the valves lose their unidirectional opening function, which is the main factor. Secondary lower extremity deep vein valve insufficiency is caused by other lower extremity deep vein diseases, the most common cause is lower extremity deep vein thrombosis. When suffering from lower extremity deep vein thrombosis, the presence of the thrombus causes sterile inflammation in the venous lumen. In a few patients, deep vein thrombosis can be gradually absorbed, and as the thrombus is absorbed, the inflamed venous valves either disappear or shorten, losing their proper function as valves and their anti-blood backflow function.
However, the clinical symptoms are basically the same, that is, the same as the symptoms of varicose veins of lower extremities, so it is difficult to distinguish them, and it needs to be combined with medical history and ultrasound or angiography to identify them.
V. What is the difference between primary lower limb deep venous insufficiency and simple lower limb varicose vein?
Both of them can be seen clinically as varicose veins in the lower extremities, and later they both form
Therefore, it is difficult to distinguish the two by general physical examination, and necessary auxiliary examinations are needed. Ultrasound of the lower extremities and retrograde venography of the deep veins of the lower extremities are the most commonly used and most valuable tests. Ultrasound is a relatively simple, accurate and painless method of examination, which can clearly show the size of the deep vein, the intima, the direction of blood flow and the presence of blood backflow, etc. Experienced examiners can make accurate judgments based on ultrasound alone. The lower extremity venography can show the morphology, patency and valve function of the deep veins of the lower extremities more visually. The ultrasound and phlebography manifestations of primary lower extremity deep vein valve insufficiency have been described previously, while primary lower extremity varicose veins are mainly abnormal dilatation of superficial veins, while deep veins are normal.
Before 1980s, the two diseases have been confused as one disease, both considered as varicose veins of lower extremities, until after 1980, it was confirmed by Dr. Kistner after long exploration and research that primary lower extremity deep vein valve insufficiency is an independent disease and occupies a large proportion (about 80%) of lower extremity varicose veins.
Six, how to treat primary lower extremity deep venous valve insufficiency
The main purpose of treating lower extremity deep venous valve insufficiency is to restore the function of the deep venous valve and eliminate the backflow of blood. This involves reconstructing the function of the valves, and the surgical procedures include two main types: valve repair and valve replacement. Since the first pair of valves in the superficial femoral vein is in a constant position and the toughest of all venous valves, all reconstructive valve surgery is performed around the first pair of valves in the superficial femoral vein.
(a) Valve repair, including three types: intraluminal valve repair, extraluminal valve repair, and valve wear ring (also known as valve wrap narrowing)
(i) Superficial femoral vein valve endoluminal repair
The procedure involves multiple interrupted sutures between the free edge of the first pair of valves of the superficial femoral vein and the canal wall to shorten them and return them to their normal semi-straight state so that the free edges of the two opposing leaflets can be tightly aligned in the canal lumen to stop backflow after the valve fossa is filled with backflowing blood.
②Extravalvular repair of the superficial femoral vein
In other words, a series of interrupted sutures are made in the wall of the vein where the first pair of valves of the superficial femoral vein is located to narrow the lumen in order to restore the unidirectional opening function of the vein valves.
(iii) Femoral vein ringing (also known as femoral vein valve narrowing). This is described in a separate topic.
(ii) Valve replacement surgery, including three types: autologous valve-carrying vein segment grafting, deep vein transposition, and N vein external muscle collaterals formation.
(1) Autologous superficial femoral vein grafting with a valved vein segment
This procedure involves transplanting a segment of an autologous vein containing a functioning valve to the first pair of valves in the superficial femoral vein.
This procedure is performed by grafting a segment of the superficial femoral vein containing a functioning valve to the superficial femoral vein below the first pair of valves to prevent backflow of blood.
②Deep vein grafting of the lower extremity
The proximal segment of the incompetent superficial femoral vein is severed, the proximal segment is ligated, and the distal segment is anastomosed end-to-end with the proximal segment of the saphenous vein or deep femoral vein that has an intact valve.
(3) Formation of external muscle collaterals of the N vein
This procedure is also called “N vein valve replacement”. The principle of the operation is to select one medial and one lateral thigh flexor tendon in the N fossa of the lower extremity to form a “U” shaped muscle collaterals and place them between the N artery and vein, so that when the lower extremity moves, the muscle collaterals alternate with the leg muscles to play a valve-like role to promote blood return.
It is important to emphasize that, after performing either type of valve reconstruction, it is necessary to simultaneously treat incompetent large (small) saphenous veins, varicose superficial veins, and incompetent traffic veins to achieve satisfactory results.
In addition, during the recovery period after the surgery, it is necessary to wear elastic bandages or medical compression stockings for the affected limbs, which can promote the recovery and prevent the recurrence of the disease, at least 3-6 months, and long-term wearing of medical compression stockings is more beneficial to protect the veins of the affected limbs.
Seven, the femoral vein wear ring surgery is how
Femoral vein ringing is a kind of valve repair, which usually refers to the ringing of the first pair of valves of superficial femoral vein. The principle of the procedure is to reduce the caliber of the first pair of valves in the dilated superficial femoral vein so that the two leaflets of the valves come together to correct the valve insufficiency and prevent backflow of blood.
During surgery, a longitudinal incision is made at the root of the affected thigh to reveal the common femoral vein, superficial femoral vein and deep femoral vein, find the location of the first pair of valves in the superficial femoral vein, confirm the backflow of blood by finger tapping and squeezing, take a section of artificial repair material, generally 2 cm wide and 2/3 of the circumference of the measured vessel at the valve, wrap it with vascular sutures and suture it outside the wall of the vein at the valve to reduce The diameter of the vessel is reduced by about 1/3 and fixed with several stitches to the vessel wall. In this way, when the valve fossa fills with blood, the enlarged lumen is reduced and the loose free edges of the two leaflets are confined to the lumen and close to each other and no longer flip downward, thus stopping the backflow of blood. This surgery is less traumatic, and do not need to cut the vein lumen, so there are few surgical complications, but to achieve good results, the key is to master the degree of lumen narrowing is just right, otherwise the narrowing is too little, can not make the lesion of the valve function to restore to stop the backflow of blood, can not play a therapeutic role; and excessive narrowing, it will affect the lower limb venous blood back to the heart, resulting in reflux disorders, easy to complicate thrombosis, should cause attention.
Anyang City Vasculitis Hospital in 06 years since the operation, has treated hundreds of patients, have achieved better surgical results, filling the gap in Anyang City. When this surgery is performed, endovenous laser treatment of lower limb veins is performed at the same time, which not only solves the problem of blood backflow, but also deals with large (small) saphenous veins, superficial varicose veins and traffic branch veins, and the surgery is thorough and minimally invasive, with satisfactory clinical results.