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
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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
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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
microcircularitive pressure.
due
to
vessels
and
muscles
tonus,
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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
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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.
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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
 Early beginning and quick development of the disease
 Pain and leg oedema after physical efforts
 Trophic changes presence
 Disseminative or untypical varicous transformation of subskinal veins.
 Lesions of short subskinal vein
 Muscular part volume increase of the leg
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.
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Usually, angiodisplasia has appeared in early childhood. Presence of arteriovenous 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 /ClippelTrenonie 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.
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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.
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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
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 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
 compensation
 subcompensation @
 decompensative without trophic lesions
 decompensative with trophic changes
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”
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 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.