Varicose veins in the lower extremities are one of the four most common surgical conditions, mostly seen in people who work long hours in standing positions and heavy physical labor. They can develop in youth, but are generally most common in middle age. In Europe and the United States, the prevalence rate is as high as 20% to 40%, while in tropical Africa it is only 0.1%. Zhang Peihua et al. found that the prevalence rate in China is 8.6% in people over 15 years old and 16.4% in people over 45 years old. Therefore, surgeons believe that the incidence of the disease may be on the rise as people’s living standards continue to improve, society becomes industrialized, and the population ages.
The traditional treatment of varicose veins in the lower extremities is based on surgery, which has a positive effect. However, due to excessive and long surgical incisions, trauma and slow postoperative recovery, it brings unsatisfactory results to patients. In recent years, with the research on the etiology and pathology of varicose veins in the lower extremities by surgical scholars, especially the research on the pathophysiology of saphenous vein, many new treatment methods have emerged. Such as sclerotherapy injection, circumferential suture, electrocoagulation, laser therapy, radiofrequency ablation, transilluminated spinotomy, etc., the corresponding minimally invasive procedures are selected at different stages of lesion development. Thus the surgical treatment of varicose veins of lower extremities has developed from the traditional one to the modern hundred, and the emphasis on minimally invasive and cosmetic has become a new trend for surgeons to choose the procedure. This paper focuses on the surgical treatment of varicose veins of lower extremities as follows.
1.Traditional surgery
High saphenous vein ligation with stripping is a classic procedure for the treatment of varicose veins, which has been continued to this day. This procedure includes ligation of the main trunk of the saphenous vein at the point where the saphenous vein joins the femoral vein, ligation of the five major branches respectively, and stripping of the lower varicose saphenous vein. In recent years, some people have used high ligation + stripping with three major branches or five major branches to treat saphenous varicose veins, and achieved better long-term results. Wu Kaizhu reported 65 cases with 94 limbs using high ligation and stripping with three major branches, and no recurrence after surgery. According to Liu Weifan, it is feasible to preserve the secondary high ligation of the five major branches for those whose clinical symptoms and signs are confined to the lower leg or the middle and lower thighs, and who do not have varicose veins in the five major branches.
Long-term clinical practice has confirmed that the surgical treatment of saphenous varicose vein with high ligation and stripping is definitely effective and applicable to all levels of hospitals. However, there are defects such as more and longer incisions, more trauma, more bleeding, longer hospital stay, serious impact on the morphology of the affected limb, permanent or temporary damage to the saphenous nerve in up to 23%-60% and lymphatic vessel injury edema. Foreign reports show that the short-term efficiency of high ligation + stripping is 94%, but the long-term results are poor and the recurrence rate is high. Recent study showed that saphenous vein stripping was performed from the groin to the ankle level, the saphenous nerve damage was 58%, the patients had saphenous nerve damage conscious symptoms was 40%, and only 6.7% of the patients would have their quality of life affected by saphenous nerve damage.
2.Sclerotherapy injection
Sclerotherapy was first proposed by Cassaigness in 1853. This method is to inject sclerosing agents, such as 5% sodium cod liver oil acid and phenol glycerol, into varicose veins to cause sterile inflammatory changes in the endothelial cells of the vessels. The cells are crumpled due to enzymatic metabolic disorders and nutritional disorders and are eventually replaced by fibrous connective tissue and the veins are fibrously occluded to achieve atrophy of the varicose veins. The advantages of sclerotherapy are simple operation, low patient pain, no hospitalization and low cost, especially for the treatment of limited varicose veins, which can meet the psychological needs of patients who do not want surgery and consider limb “cosmetic”. The disadvantage is that it cannot block the backflow of the trunk veins and the traffic veins at a high level and has a high recurrence rate, which can lead to serious complications such as deep vein thrombosis and pulmonary embolism.
As early as half a century ago, some scholars proposed to combine injection therapy and high ligation therapy, and use both to complement each other, which has been recognized by many scholars. At present, many scholars in China have obtained better results when implementing varicose vein sclerotherapy injection, supplemented by pressure bandaging to make direct contact and occlusion of the vein lining. The author believes that the therapeutic effect of sclerotherapy is a temporary method, which only treats the symptoms but not the root cause, and the local vascular inflammatory reaction causes skin lesions, which will bring lifelong regret to the patient.
3.Circular suture ligation method
Suture ligation method is a method of using high ligation of saphenous vein and suture ligation of varicose vein (including varicose branches of saphenous vein) across the skin. This is done by entering the needle from the skin of one side of the vein, bypassing the deep side of the vein and exiting from the opposite side for conventional ligation; the ligation is repeated at 1-2 cm intervals according to the degree and density of varicose veins, and the sutures are removed on the 21st day without elastic bandages after surgery. Lv Pengfei et al. reported that percutaneous superficial vein circumferential suture ligation treated 83 cases of varicose veins in lower limbs with satisfactory results. Cai Qiang et al. treated 220 patients with superficial varicose veins of lower extremities by applying interrupted circumferential suturing of superficial percutaneous veins and achieved good results with no recurrence at follow-up.
The scholars who advocate the suture ligation method believe that: the varicose saphenous veins are involved due to the pressure of stagnant blood, and after solving the obstacle of blood return, it is not necessary to dig out these involved vessels, and the dilated vessels remain in the body; the recurrence of varicose veins after surgery is mostly due to the incompetence of deep vein valves or traffic branch valves of the affected limbs, and the sequelae of deep vein thrombosis, not due to the existence of these superficial veins. It is not caused by the presence of these superficial veins; high ligation+stitching is in line with the principle of minimally invasive treatment, reducing trauma and fast recovery after surgery, but recurrence and recanalization make it difficult for surgeons to evaluate its long-term efficacy.
4.Point aspiration
Firstly, high ligation of the saphenous vein is routinely performed and the trunk is stripped, and multiple punctiform incisions (about 5mm) are made at the varicose branch veins, and then the diseased vein is excised or aspiration is performed with mosquito forceps. The incision is not sutured and the patient can get out of bed early, with less intraoperative bleeding, shorter operation time and lower local recurrence rate.
In recent years, many scholars in China have reported that this method is ideal for treating superficial varicose veins of lower limbs. Foreign Bergan research shows that point stripping can not only correct the lesion of superficial venous system, but also help to improve the function of deep venous system.
5.Electrocoagulation method
Electrocoagulation is the use of electrocoagulation to destroy the endothelium of varicose veins, assist local compression to occlude the lumen, and then form thromboembolism and fibrosis to occlude the lumen, to achieve the purpose of eliminating varicose veins. Although the saphenous vein trunk is not stripped by electrocoagulation, its occlusion has the same effect as stripping, while the damage to its branches and traffic branches is reduced, and the subcutaneous hematoma and bruising that often occur during stripping is avoided. Feng Lixin et al. reported 30 patients treated by electrocoagulation with an average follow-up of more than 10 months, and the original symptoms disappeared and the ulcer healed without recurrence. Zhang Deshou et al. followed up 72 patients treated with electrocoagulation for 2 months to 4 years, and only 5 cases had local recurrence of superficial varicose veins in the calf.
Electrocoagulation method has been carried out more in China, and most scholars now take continuous electrocoagulation method (electrocoagulation output power 40-50W, slow and uniform receding electrocoagulator, about 1cm/s) in dealing with the saphenous vein trunk; some scholars also advocate intermittent electrocoagulation method (electrocoagulation every 1cm, duration about 1s) in dealing with the saphenous vein trunk, and believe that this method can reduce the degree of damage to the saphenous nerve and burn the perivenous tissue. The method is believed to reduce the degree of damage to the saphenous nerve and burned perivenous tissue.
6.Radiofrequency ablation
Intracavitary radiofrequency ablation was performed by the VNUS Medical Center laboratory in 1996. The principle is that the heat released by the radiofrequency probe causes the vein to collapse and the structure to disintegrate and carbonize. The heat released by the radiofrequency probe is mainly confined to the lumen of the vein and very little heat is released through the wall to the surrounding tissues without causing thermal damage to the surrounding tissues.
Weiss et al. performed radiofrequency ablation on 140 varicose veins of the lower extremities in 120 cases and found that 98% (137/140) of the veins closed at 1 week after the procedure and only 3 patients had recanalization of the saphenous vein at 6 months after the procedure. merchant et al. reported a 90% closure rate of the saphenous vein at 5 years after radiofrequency treatment. It is now generally accepted that intraoperative pain, bruising, and hematoma, as well as early postoperative clinical indicators and quality of life, are significantly better with radiofrequency ablation than with high-grade ligation stripping.
Salles et al. found that failure to ligate the saphenous vein in high position during radiofrequency ablation increases the rate of recanalization of the saphenous vein after the procedure, thus causing an increase in recurrence rate. Many medical centers in China report that the average follow-up period is 4.7 months and the recanalization rate is 10%, among which the recanalization rate is 13% for those who use radiofrequency ablation alone and 5% for those who use saphenous vein ligation in combination.
7.Laser therapy
Laser therapy was carried out by Carlos, a Spanish phlebologist, in 1998. The principle is: the laser produces thermal effect in the blood vessel, the vapor bubble produced by the boiling of blood causes thermal damage to the vein wall, the thermal damage causes the blood coagulation state to rise so that extensive thrombosis in the vein, the damaged vein wall fibrosis repair, contraction and closure, and finally occlusion of the vein to achieve the purpose of treatment. At present, foreign scholars mostly set the laser emission power as 12W, pulse time as 1s, interval 1s, laser fiber backward speed about 2-6mm/s. In China, some scholars advocate using high power (15-22W) continuous emission mode, backward speed 0.5~1.0cm/s.
Laser treatment of superficial varicose veins of lower limbs has good effect, and foreign countries report that 97% of varicose veins are closed 1 week after laser treatment, and 99% of veins are closed 6 months after surgery; the recanalization rate is 5%-7% 3 years after treatment. Domestic Mei Jiacai et al. treated 450 cases (606 limbs) of varicose veins of lower extremities with endovenous laser treatment, with an average follow-up of 16 months, and the results were very satisfactory, and the recurrence rate was only 0.8%; laser treatment reduces the complications of traditional stripping, has the advantages of small trauma, light pain, no scars after treatment, short operation time, and can keep normal activities after surgery. Its adverse reactions are rare, including local skin numbness, subcutaneous bruising, subcutaneous hard nodes, and thrombophlebitis.
8.Trivex transillumination spinotomy
Trivex surgery was first carried out in Europe and the United States and has become the definitive procedure for the treatment of varicose veins in the lower extremities.
① Direct vision operation under the guidance of cold light source, the planer head directly planes and sucks the diseased vein without residue, and the treatment is complete.
②Submerged insertion from normal tissue, avoiding direct operation over diseased tissue such as eczema, dermatitis, pigment, ulcer, etc., avoiding delayed healing of incision.
Trivex can insert the planer tip directly into the thrombosed tissue and spin out the diseased tissue thoroughly to achieve the treatment purpose.
Since the saphenous vein needs to be stripped throughout and the accompanying saphenous nerve may be injured, and the varicose vein can be removed under visual conditions, the accompanying saphenous nerve branches are still injured, so some patients have abnormal sensation and numbness in the lower leg, which usually do not need special treatment and most of the symptoms disappear within 3-6 months. Others have subcutaneous bruising and subcutaneous sclerosis, but no lower extremity deep vein thrombosis or other complications.
A prospective study by Aremu et al. comparing transilluminated vein spinning with conventional stripping found that transilluminated spinning had a small incision and short operative time, while there was no significant difference in postoperative pain and bleeding. Nearly 2000 patients have been treated by this method in China-Japan Friendship Hospital with satisfactory results. The incidence of postoperative subcutaneous bruising is about 30%, which is usually completely absorbed in 3-10 weeks after surgery.
In conclusion, laser, radiofrequency, electrocoagulation (trunk) and endorectal stripping are suitable for varicose veins with main trunk reflux of saphenous vein, but if the diameter of the vein is too large, the effect of laser, radiofrequency and electrocoagulation is poor and there is a risk of venous thrombosis. Fluoroscopic direct-view spinotomy is suitable for the treatment of varicose vein masses, especially for severe and extensive varicose vein masses. For the management of small or limited varicose masses, direct surgical excision, percutaneous circumferential suturing, electrocoagulation (branching), or sclerotherapy injections can be used. The operator should select the most appropriate surgical approach for the specific varicose vein lesion in order to achieve the best treatment results.