Current concepts in the management of varicose veins

Varicose veins are a very common problem, affecting women more than men. The major concern is usually the unsightly appearance of the veins. Various options to deal with this problem are discussed-- compression stockings, compression sclerotherapy and surgery. For good results and patient satisfaction, the cause and natural history of varicose veins must be understood. Depending on the type of varicose vein, different modalities of treatment are required and may need to be combined. "Cosmetic" varicosities can usually be managed conservatively with compression stockings. Sclerotherapy is best used for dilated superficial or residual varicose veins, recurrent varicosities or leg perforators. Operation should be reserved for very large varicose veins or an incompetent long or short saphenous vein. A sound understanding of the problems and discussion of anticipated results with the patient will prevent unrealistic expectations.     

Investigation and management of varicose veins

The aspects of the anatomy and physiology of the lower limb which are concerned with venous return from the leg and its disorders are explored. It is shown that an understanding of the pathophysiology of this group of disorders forms the basis of a clinical classification. Recent advances in methods of assessment of the varicose leg are considered and it is shown that these can be used to supplement clinical evaluation. Finally, the relative merits of the two main methods of treatment are discussed.     

The management of recurrent varicose veins.

Recurrent varicose veins are due to unidentified connections between the deep and superficial venous systems. Conventional clinical and radiological methods of identification are inefficient. In a series of 662 operations the rate of recurrence was over 40%. By changing to a different radiological technique, using an image intensifier, it was found that the gastrocnemius veins in the popliteal fossa were a common cause of recurrence. This radiological technique also differentiated between those recurrences that required a second operation and those which ought to be treated by Fegan's method.     

评价腔内激光闭合术治疗原发性下肢静脉曲张的效果

目的评价腔内激光闭合术治疗原发性下肢静脉曲张的效果。方法随机将2017-06—2018-01间郑州大学第二附属医院血管外科收治的50例原发性下肢静脉曲张患者分为2组。对照组(24例)行大隐静脉高位结扎+主干与曲张静脉分段剥脱术;观察组(26例)实施腔内激光闭合术。比较2组的疗效。结果观察组的治疗总有效率、踝围改善效果及皮下渗血灶面积、小腿隐神经受损导致的局部皮肤异常感觉发生率,均优于对照组,差异均有统计学意义(P0.05)。结论腔内激光闭合术治疗原发性下肢静脉曲张,可明显改善患者踝围、减少术后并发症发生率,临床疗效显著。     

Causes of telengiectasias, reticular veins, and varicose veins

Study of surgical specimens and direct observation by angioscopy has revealed that the varicose venous wall, the valvular annulus, and the valves themselves undergo profound changes. Morphologic investigations have shown dilation of the valve annulus, bulging valve leaflets, commissural dilation, leaflet stretching, and eventually complete destruction of the valves. The venous wall has been seen to undergo changes of thickening in some segments and thinning in others. Our investigations show that inflammation and subsequent remodeling of the venous valves and wall are the fundamental mechanisms underlying the observed lesions. Hemodynamic forces, such as blood pressure changes in the wall and sheer stress, as well as varying planes of laminar and turbulent flow, induce activation of leukocytes and endothelial cells. Integrins appear to act as intermediaries and expression of adhesion molecules has been observed. Breakdown of extracellular matrix of the media and adventitia through activation of matrix metalloproteases (MMP) has been observed. In particular, expressions of MMP-1, MMP-2, MMP-9, and tissue inhibitor of metalloproteinase have been studied. Telangiectasias, reticular veins, and true varicose veins appear to be a consequence of the changes induced by venous hypertension and sheer stress.     

Pathogenesis of varicose veins and implications for clinical management

Varicose veins (VVs) classically result from venous hypertension owing to incompetence of the major communications between the superficial and deep veins of the lower extremity. In a significant number of patients, there is no demonstrable truncal saphenous reflux and varicosities are the result of isolated perforating and nonsaphenous vein incompetence. The clinical and histologic features of VVs are the result of disruption of the normal architectural structure of the venous wall as a consequence of remodeling of the extracellular matrix (ECM) in response to increased venous distention and altered hemodynamic shear stress. Although a number of genes, growth factors, proteases, and their inhibitors known to modulate the ECM have been implicated in the pathogenesis of VVs, their etiology remains unknown. The complex variations in venous anatomy in patients with VVs require detailed vein mapping to determine the source and drainage locations of reflux if the rates of residual and recurrent varicosities are to be reduced. The distinct pathogenic mechanisms involved in the development of VVs have important implications for the management of VVs that include a wide spectrum of treatment modalities ranging from reassurance, alternative medicines, conservative management or compression therapy, and surgical or endovascular therapy.     

Duodenal varicose veins

Summary Duodenal varices (DV) are rare. We present a review of published cases with emphasis on the management and outcome, as illustrated by our own case, which reflects the experience reported in the literature. The diagnosis of DV must be considered in patients with gastrointestinal bleeding. Two-thirds of all reported cases have portal venous hypertension caused by hepatic cirrhosis. In the remaining one-third prehepatic portal hypertension as a consequence of either a compromised portal venous circulation (caused by perivenous tumor or inflammation) or a primary haematological disease is the underlying cause. Previously, duodenoscopy has often failed to detect and correctly interpret DV, and was similarily unsuccessful in our case. This case report demonstrates the problems and shortcomings in the management of DV and documents a hither to unreported cause. Treatment depends on the severity of bleeding. When conservative measures cannot control the haemorrhage, emergency laparotomy may be indicated. The type of surgery should be chosen according to the aetiology, site and extent of the bleeding DV. Among 112 reported cases of DV, information on outcome exists for only 35 patients who presented with haemorrhage. The aetiology was liver cirrhosis in 26 of these patients, 10 of whom had a fatal outcome, and prehepatic portal hypertension in the remaining 9, 1 of whom had a fatal outcome.     

Recurrent varicose veins

When Doppler ultrasound was introduced for the assessment of patients with varicose veins, a more accurate clinical appraisal of the pathophysiology of this condition became possible. In particular, it enabled identification of those patients with recurrent varicose veins who had had inappropriate or inadequate initial treatment. It facilitated planning of appropriate further treatment. The more widespread use of radiology, in particular varicography, as a means of preoperative assessment of recurrent varicose veins has enabled a more accurate definition of the abnormal anatomical features. The extension of this principle to the operating room has made surgery for recurrent varicose veins more precise. Patients with varicose veins secondary to deep venous disease remain a problem. When both superficial and deep venous disease are present, superficial venous disease should be treated as appropriate. Deep venous insufficiency will require continued supervision of support maintained by bandages or graduated elastic stockings.

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Resumen Con la introducción del Doppier de ultrasonido para la valoración de pacientes con venas varicosas se hizo posible determinar en forma más precisa la fisiopatología de esta entidad. Específicamente, se ha logrado la identificación de aquellos pacientes con venas varicosas recurrentes que habían tenido un tratamiento inicial inapropiado o inadecuado. También vino a facilitar la planeación de adecuado tratamiento ulterior.El más amplio uso de la radiología, y de la varicografía en particular, como método preoperatorio de valoración de las venas varicosas recurrentes, ha hecho factible una más precisa definición de la patología anatómica, y la aplicación de este método en el quirófano ha aportado mayor precisión a la cirugía de las várices recurrentes.Los pacientes con várices secundarias a patología venosa profunda continÚan siendo un problema. Cuando se conjugan la enfermedad venosa superficial y la enfermedad venosa profunda, la primera debe ser tratada con la operación indicada, en tanto que la insuficiencia venous profunda requiere continuada supervisión de soporte mediante vendas o medias elásticas de compresión graduada.

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Résumé Lorsque le Doppler a été introduit pour étudier les varices, une méthode d'investigation plus précise d'appréciation de la physiopathologie de cette affection est devenue possible. En particulier, elle a permis l'étude des varices qui ont récidivé après un traitement inapproprié ou inadéquat. Elle permet de planifier la nouvelle intervention.L'emploi large de la radiologie, en particulier de la varicographie, a permis une définition plus précise de l'anatomie pathologique des varices. La pratique de cette exploration en salle d'opérations a rendu la chirurgie des récidives variqueuses plus efficace.Les varices secondaires à la thrombose veineuse profonde posent un problème thérapeutique tourjours difficile. Quand cette condition pathologique est présente un traitement adéquat des varices superficielles doit Être mis en oeuvre. L'insuffisance veineuse profonde impose une surveillance attentive du traitement exercé par bandage ou compression progressive par bas élastiques.

     

Glycosaminoglycans of normal veins and their alterations in varicose veins and varicose veins complicated by thrombophlebitis

The aim of the study was to examine the content and molecular differentiation of glycosaminoglycans (GAGs) in the wall of varicose veins. The studied material consisted of normal, varicose veins and varicose veins complicated by thrombophlebitis collected during operations on 26 patients. In the wall of varicose veins the mean GAGs' content as well as the content of sulphated GAGs, except heparan sulphate was increased, whereas the amount of hyaluronic acid was decreased. Furthermore, the increased quantitative ratio between sulphated and nonsulphated GAGs was demonstrated. The results indicate an evident extracellular matrix remodelling in the wall of varicose veins particularly those complicated by thrombophlebitis, that is characterised by alterations in the content and molecular differentiation of GAGs.     

Endoscope-assisted management of varicose veins in the posterior thigh, popliteal fossa, and calf area.

Varicose veins of the posterior thigh, popliteal fossa, and calf area were managed with the assistance of endoscopic surgery in 136 patients. Patients were divided into four types according to the normal veins involved in varicosities. With good illumination and magnified monitor viewing by means of a surgical endoscope, the main channel, tributaries of varicosities, incompetent perforating veins, and healthy veins could be clearly visualized and identified. Even though these varicosities had aberrant and tortuous courses, they could be completely dissected, divided, and then removed through one or more access incisions (2.5-3.0 cm in length). The incompetent perforating veins were also dissected and divided. The mean number of access incisions for each lower extremity was 2.2, 1.9, 1.3, and 1.0 for types I, II, III, and IV respectively. In all cases, the mean number of incisions was 1.6 in each lower limb. The most frequent morbidity was maceration of the access incision. Three wounds in 3 patients required debridement and resuturing, but the other wounds healed satisfactorily. Transient discoloration caused by bruising and numbness may present at the dissected area. There was no hematoma formation. Ischemic change with bleb formation of the dissected skin occurred in 1 patient. Subsequent secondary healing resulted in slight scarring in this area. With the assistance of endoscopic surgery, all the varicosities and the incompetent perforating veins could be completely dissected and removed. Accomplishment of removal of varicosities was double-checked between the preoperative skin marks of varicosities and the endoscopic findings. There is very little possibility for recurrence, because there were no residual varicosities or incompetent perforating veins after this operation. There was no recurrence in follow-up at least 2 months postoperatively. Patients were satisfied with the minimal surgical scarring and the complete absence of disfiguring varicosities.