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THE KURSK STATE MEDICAL UNIVERSITY

Department of surgical diseases № 1

VARICOSE DISEASE

Information for self-training of English-speaking students

The chair of surgical diseases N 1 (Chair-head - prof. S.V.Ivanov)

By professor O.I. Ochotnickov

KURSK-2010

Varicous disease is the kind of chronic venous insufficiency and it’s characterized by present of sacciformis venous dilations of superficial and deep veins with haemodinamic damages and vines congestition in lower limbs.

First of all it’s necessary to remind surgical anatomy of lower limb venous system. The venous system is characterized by a lot of variants of morphological structure. But all lower limbs veins can be divided into 3 vascular systems. They are superficial, intermedium veins and deep once. Superficial veins consist of two main vessel - the long saphenous vein and the short once. There are a lot of venous junctions between them.

In ontogenesis superficial venous system changes its own structure from loop shaped to main. This transformation is connected with reduction of primary loop shaped venous net. Main venous system has formed, if the reduction has been important. In the case there are two main superficial veins - long and short saphenous without a lot of junctions.

If the reduction wasn’t so great, loop form structure of superficial vein system has preserved. It’s characterized by absence of good-looking subskinal venous mains. There are a lot of junctions between subskinal vines.

The third type of anatomical structure of subskinal vines system is intermediate. This type is more spreading. According different forms of subskinal veins anatomical structure, there are some differences in morphology of deep vines too. They are in number of junctions between main deep veins.

Usually on foot and leg there are pair main venous vessels, which are accompanied main arteries. In popliteal region and in femur main deep veins are single.

The third lower limb venous system - intermedium is. It is presented by muscular and communicating veins. It’s number and localization are connected with reduction form of subskinal venous system.

Communicating veins can be direct and indirect. In last case it connects with deep veins through muscular veins.

Distinctive peculiarity of muscular leg veins morphological structure the presence of venous sinusoides is. They are thin-wall venous vessels, which localized in gastrocnemius and soleus muscles. Size of them is about 3-5 cm lengthwise and in 1 cm width. This formations play the role of volume chambers in blood pumping. The sinusoides are connected with subskinal and deep veins due to communicating veins.

Subcutaneous, deep and communicating veins have valves. Most often they consist of two cusps. It’s structure doesn’t give possibility for active function. Venous valves work passively under influence of retrograde blood flow. Venous valves gave possibility for centripetal blood outflow .

Localization and function of valves are conditioned by mutually. These parts of veins have more number of valves, where possibility for retrograde blood outflow presences. Foot communicating veins have peculiarity. They haven’t valves. So, according muscles condition and body position blood flow directions in the veins can be different - from subskinal veins into deep and back.



Muscular pump of lower limbs.

Lower limb venous haemodinamics has sharp changes, which are depended from body position and muscular function condition. In reclining position of patient hydrostatic resistance for venous blood outflow is absent. There isn’t muscular pump function. So, in this condition venous blood outflow volume and velocity become.

In cases of muscular activity their blood supply increases in 8-10 times. In walking, increase of blood flow volume in main vein of lower limb is because of blood arriving from muscles. Venous sinusoides of gastrocnemius and soleus muscles, as blood chambers, in muscular contraction phase become empty. A large blood volume is going into main vein of lower limb.

First blood portion, which has come from muscular veins, is creating some retrograde flow and local venous hypertension. Valves are closing due to it.

General intravenous pressure includes in itself static pressure, dynamic pressure and hydrostatic once. The hydrostatic pressure is determinated as a weight of blood column under measuring level. So, hydrostatic pressure is more in foot veins then in femoral once in standing patient position.

Static pressure is determinated due to vessels and muscles tonus, microcircularitive pressure.

Dynamic portion of intravenous pressure is more important . It’s determined by kinetic energy of blood jet, going from lateral anastomosis, first of all.

Venous blood outflow is continual and in relaxing condition venous valves are opened. They are closing due to retrograde blood flow only. It’s realized in cases of quick muscular constriction, quick standing up, tussis, Valsalva test.

Valves in small veins are protecting microcicularity region from retrograde blood flow and dynamic venous hypertension. Increase of blood flow velocity in main vein is accompanied with pressure decreasing in it And this connection is direct. This peculiarity has positive influence to venous outflow from tissue veins.

Foot has two sorts of venous pumps. Muscular pump, of cause, isn’t so important that once in leg, and compressive pump. Compressive pump is realized by periodical plantar veins compression. In physiological conditions by walking and running the increase of blood flow volume is presented in main limb veins as in subskinal veins. And if the increase of main veins blood flow is depending on “muscular pump” of leg or femur, the blood flow increase in short and long scaphen veins are providing by muscular and compressive foot pump. This outflow ways are presented the shunts from foot veins to popliteal and femoral veins and in normal condition, they prevent venous hypertension in foot veins.


Etiology of varicose disease

In base of varicose disease congenital disbalance between elastin and collagen in vascular wall lies. Because of, the vascular wall becomes disresistant to normal intravenous blood pressure and it leads to vein dilation.

Second factor of varicous disease congenital or acquired valves insufficiency is. Only on background of congenital venous incompetence venous hypertension and retrograde blood flow are leading to varicous disease.

Valves incompetence can be anatomical and functional. The last sort of it is developing due to venous dilation in valve area.

Most of all pathological venous dilation of lower limbs appears due to retrograde blood flow. Deep veins are defended by fascies and muscles, so their dilation is even. In superficial veins subskinal fatty tissue cann’t defend them equal, so varicies are appearing. Pathomorphological changes in varicous veins are definited as phlebosclerosis.

Clinical picture

Diagnosis of varicose disease is based on patients complaints and results of general examination.

There are tree stages of the disease: compensation, decompensative without trophic lesions and decompensative with trophic changes.

In compensative stage there are two levels. The first - varicous disease without varicose transformation. In this case patients complain to some pain in region of typical communicating veins localization, they fell discomfort in legs after working day. But there are no any varicies and oedema.

Second level of compensative stage is characterized by varicies presence without any other clinical manifestations. And only cosmetic problems have leaded patients to doctor.

In stage of decompensation without trophic changes patients have such complications, as varicies presence, transitional leg oedema after working day, night cruralgia.

In stage of decompensation with trophic changes pigment areas and trophic ulcers appear, first of all, in lower leg one/third.

Besides tree stages of varicose disease there are two clinical forms of the disease. They are ascending and descending.

Anamnesis of the disease must include in itself the following:


  • when did first symptoms appear ?

  • in what region they did appear ?

  • what is their dynamic ?

  • has patient ever had thrombophlebitis ?

  • has patient ever had any venous diseases before ?

General examination should be realized in standing patient position and include in itself both lower limbs, abdominal wall and chest examination. Skin color, trophic changes presence and varicies localization are exposed.

General examinations includes some functional tests. But now its importance has increased due to wide spread phlebography.

There are two sorts of phlebography - proximal and distal. Proximal phlebography gives information about valves competence in main lower limbs veins.

Distal once is necessary for finding incompetent communicating veins and deep veins passability.

Besides X-Ray examination great importance is belonged to US- examination. It gives possibility to find not only subskinal and deep lower extremities veins, but communicating veins and their valves.

Among all patients with varicous disease there is group with clinical syndrome of functional deep veins incompetence.

It consists of


Different diagnose

Early stage of varicous disease is too difficult for correct diagnosis because of the main clinical sign of the disease - varicies appearance is absent. The disease is exposing on base of presence such sings, as increase fatiguability of lower limbs, some pain syndrome in exception any other causes of it. The symptoms aren’t specific. They can be found in cases of acute arterial impassability, platypodia, osteochondrosis. In conditions of any varicies absence in accompany with nonspecific signs of varicous disease correct diagnosis can be created by proximal phlebography. On X-Ray pictures it can be found initial signs of relative deep valves incompetence.

Subskinal veins dilation is meeting in cases of congenital venous diseases and postthrombotic disease.

Usually, angiodisplasia has appeared in early childhood. Presence of arterio-venous shunts leads to quick limb increase. Capillary haemangiomes appear on skin of lower extremities. Veins dilation connects with direct arterial blood shunting into veins /Pratt-Veber disease/ due to congenital impassability of deep veins /Clippel-Trenonie disease/.

Difficulties in different diagnose between varicous disease and postthrombotic disease are connected with possibility of postthrombotic disease appearance on background of varicous disease or predisposition for it. Besides, postthrombotic disease and without varicous disease has the same clinical signs of chronic venous insufficiency. Correct diagnosis may be created on base of anamnesis and dystal phlebography.

Treatment of Varicous disease

For today the most effective mode of varicous disease management surgical is. But, it should remember, that there isn’t finally method for radical correction of the disease, because of it’s, first of all, congenital disease. So, the main aim of all kinds of varicous disease management is complications prevention, first of all - trophic ulcers.

Main purposes of surgical treatment are following:


  • Removal of up and down veno-venous shunts. It’s realized by ligation of junctions between femoral vein and long scaphen vein, so as the once between short scaphen vein and popliteal. Second part of the purpose reaching is obligative ligation of incompetent communicating veins.

  • Ablation of varicose transformed subskinal veins.

  • Surgical correction of deep veins valves incompetence.

The first principle can has been reached by Troianov-Trendelenburg procedure. It’s including long scaphen vein opening and its 3-5 main branches.

Incompetent communicating veins are removing through local skin incisions by Narat and Cocett procedures. In patients with a lot of incompetent communicating veins and severe manifestations of chronic venous insufficiency Linton-Felder procedure is indicated. It includes neartotal ablation of communicating veins on leg through subfascial posterior longitudinal incision.

The second principle is realized by removing of main subskinal veins by special olive-end probe device, was invented by Babcok. Some varicies are ligating through small additional incisions by Narat. Some of them can be sewed by vertical sutures by Clapp or Sokolov.

The third principle of treatment has been being reached by different surgical procedures on deep veins by relative valves incompetence relieving. There are extra-, intra- and extra-intra vascular modes of correction. The last type is more effective. Reached results are being controlled by retrograde phlebography.

In cases of decompensive varicous disease with trophic ulcers some modes of posterior tibial veins resection or occlusion may be applied. The sense of it is contained in ablation of retrograde blood flow from deep leg veins into small vessels in trophic changes area.

Conservative treatment of varicous disease has additional importance only. Among them there are the use of elastic compressive bandage and sclerotherapy. Elastic bandage can be realized by special bandages and stocking. Elastic bandage traditionally is using in postoperative period.

For treatment of trophic leg ulcers zinc-gelatin dressing is using. This dressing improves skin blood supply due to vent effect stimulation. During muscles contraction skin venous rate is pressed between muscles and dressing and is empty. During muscle relaxation dressing pressure is decreasing and skin veins begin to be filled up from microcirculative area. It leads to increase arterial blood supply of the skin and relieves blood congestition in ulcer area.

For today it is rational to use combined mode for varicous disease treatment - surgical and sclerotherapy. This may may be accompanied with dissection and ligation of varicous subskinal veins by Narat, Clapp, Sokolov.

The main shot-coming of sclerosing therapy is unstable results and early recurrence of phlebectasia. As an independent management mode it can be used in small patient groups with initial signs of varicous disease and in cases of critical-ill patients.

TEST-QUESTIONS


1. All lower limbs veins can be divided into 3 vascular systems. They are following, except

  • superficial

  • communicating @

  • intermedium

  • deep

2. Intermedium veins system includes following

  • the long scaphen vein

  • communicating veins @

  • deep veins

  • muscle veins @

  • the shot scaphen vein

3. Superficial veins consist of :

  • the long saphenous vein

  • communicating veins @

  • the short saphenous vein

4.Сorrect the following expression “Subcutaneous, deep and communicating veins have valves. Their structure gives possibility for active function” /doesn’t/

5. Valves are localized in all following veins, except



  • communicating veins

  • foot veins @

  • deep leg veins

  • superficial leg veins

6. Venous valves defend microcirculative bed from :

  • hydrostatic blood pressure

  • retrograde blood flow @

  • dynamic blood pressure

7. Intravenous blood pressure includes in itself all following, except

  • hydrostatic pressure

  • dynamic pressure

  • kinetic pressure @

  • hydrodinamic pressure

8. Muscular-venous pump includes in itself following, except:

  • venous sinusoides

  • communicating veins

  • leg muscles

  • tibia bone @

  • deep veins segment

9. In base of varicose disease there are following factors:

  • congenital disbalance between elastin and collagen in vascular wall .

  • congenital or acquired valves insufficiency

  • venous hypertension @

  • retrograde blood flow @

10. There are tree stages of the disease except

11. In....... stage patients have such complications, as varicies presence, transitional leg oedema after working day, night cruralgia.

  • compensation

  • decompensative without trophic lesions @

  • decompensative with trophic changes

12. In ............ stage pigment areas and trophic ulcers appear, first of all, in lower leg one/third.

  • compensation

  • decompensative without trophic lesions

  • decompensative with trophic changes @

13. Add following expression “ ......phlebography gives information about valves competence in main lower limbs veins”

  • proximal @

  • distal

14. Add following expression “ ................ is necessary for finding incompetent communicating veins and deep veins passability.

  • proximal phlebography

  • distal phlebography @

15. Among all patients with varicous disease there is group with clinical syndrome of functional deep veins incompetence.

It consists of following except



  • Early beginning and quick development of the disease

  • Pain and leg oedema after physical efforts

  • Quick leg tiredness @

  • Trophic changes presence

  • Disseminative or untypical varicous transformation of subskinal veins.

  • Lesions of short subskinal vein

  • Muscular part volume increase of the leg

16. Main purposes of surgical treatment of varicose disease are following, except

  • Removal of up and down veno-venous shunts.

  • Restoration of blood outflow in superficial veins @

  • Ablation of varicose transformed subskinal veins.

  • Surgical correction of deep veins valves incompetence.


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