Contents
Ligation of a perforating vein is an important step aimed at restoring natural blood flow without significant discomfort for a person. Unlike surgery on large veins like the femur, perforator surgery is truly a piece of jewelry.
This statement is explained by the fact that such veins are much smaller in diameter. They are designed to connect superficial veins with deep ones, which makes them an important connecting link, without which the circulatory system quickly fails. Under normal conditions, such “threads” have dimensions of no more than 2 mm.
Due to their size, they are difficult to see even with the use of high-precision imaging technologies such as duplex scanning. Because of this, doctors have to conduct many ancillary studies in order to identify not only the source of their destabilization, but also the overall degree of damage.
How to find the source of the problem
In an average person, blood, along with nutrients and oxygen, moves along the perforating path according to the principle: from a superficial vessel to deep ones. But if the victim becomes a victim of varicose veins, then the valves of the vascular connective system cease to function according to the algorithm laid down by nature.
As soon as the victim is diagnosed with valvular insufficiency, he will immediately be offered to use a radical technique to correct the clinical picture. We are talking about the ligation of perforating “veins”. Otherwise, the blood flow will “get used” to moving in the opposite direction, which will significantly undermine the patient’s health.
As soon as blood begins to flow from the deep vein to the superficial one, the pressure in the external venous system increases. Due to this imbalance, the given volume of blood enhances the development of varicose veins. It will be possible to eliminate the unnatural algorithm only by tightening problematic vessels.
To deal with those who cannot do without bandaging, and who else can try their luck in treatment with alternative methods, the doctor prescribes a series of tests. First, the patient is sent for a physical examination or ultrasound diagnosis. With insufficient visualization of the potentially affected area, doctors add radiopaque phlebography.
But since the survey format presented is already considered somewhat outdated, many experts recommend adopting:
- functional tests;
- stereophlebography;
- dopplerography;
- duplex scanning.
The price of a preparatory set of examinations will directly depend on how many tests were prescribed for a particular victim. But if the doctor sent to take almost all of them, then you should follow the instructions, since it is not always possible to consider the severity of the lesion the first time.
Doctors believe that functional tests have become obsolete due to low information content. But this will only work if the subject is obese or the lower extremities are swollen. Sometimes you can’t do without classical radiopaque phlebography, since it is it that allows you to draw up a schematic picture of what is happening in the perforating zone. It is almost always prescribed before surgery.
When the collected information is not enough, the patient is sent for stereophlebography. Such a diagnosis is especially relevant for minor lesions of the connecting “veins”, where a single intervention with particular accuracy is required.
With the help of stereophlebography, it is possible to see a three-dimensional image, which helps in studying the complex anatomy of the perforating system with localization in the lower extremities.
Some ordinary people confuse dopplerography with duplex scanning, believing that when assigning one diagnosis, the second is a waste of time and money. But the first technique is only suitable for determining the boundaries of blood flow without subsequent visualization of the alleged damaged vessel.
Although the diagnostic measure is safe and relatively inexpensive, it only helps to identify relatively simple forms of varicose veins. This is due to the high resolution. But the search for individual perforators using dopplerography tools is another task.
Against this background, it is easier for phlebologists who suspect complex forms of varicose veins in their wards who need immediate surgery to issue a referral for duplex scanning. Manipulation has an increased sensitivity, which, together with color mapping, allows you to accurately assess the viability of perforating vessels, the diameter of which does not exceed 2 mm.
In especially advanced cases, or at the initial stage of the development of the disease, diagnostics with energy mapping helps to detect even vessels with a diameter of about 0,4 mm.
Thanks to increased clarity, the doctor will be able to identify:
- the location of the affected areas;
- vessel sizes;
- the structure of the diseased junction.
The collected information helps the doctor to establish a specific diagnosis, to figure out whether venous insufficiency is acquired or congenital. Information becomes the basis for choosing a specific type of dressing, the amount of future work. The results of the analyzes are also necessary to draw up a correct recovery program.
Dressing classification
After the varicose veins are confirmed, the doctor will immediately suggest bandaging the perforating veins so as not to aggravate the clinical situation. This is to prevent the spread of valve failure.
Difficulties are added by the fact that there are no stable zones where such veins are located in the body. But, according to statistics, the shin area most often falls under the scope of valve insufficiency. Most of all goes to the lower third of the medial surface.
In addition to it, the following fall under attack:
- the middle third of the anterior medial surface;
- the middle third of the back surface;
- top third.
Another 10% of cases of varicose veins occur in areas of the hidden femoral surface. And most rarely, the disease is diagnosed in the region of the lateral level of the lower leg and the posterior femoral surface.
After the specialist understands the specific location of the pathology, he will decide on the preferred type of intervention:
- suprafascial;
- subfascial.
If varicose veins are caught at an early stage of development, when various side effects have not yet formed, then a suprafascial strategy is better suited.
Subfascial ligation
Most often, the presented operation is performed with the identified post-thrombophlebitic syndrome or primary varicose veins. Sometimes the subfascial technique is also called the Linton operation, but their meaning is identical.
Manipulation is carried out both as a monotherapy and as an addition to the combined removal of not only communicative veins.
The course of radical tactics first involves an allergic test for the components of anesthesia in order to exclude the possibility of a possible development of anaphylactic shock. Then the doctor chooses the position of the patient, based in this on the type of access:
- with the medial type of a person, they are laid on their back with lower leg supination;
- with the posterior type of a person, they are transferred to the stomach.
As anesthesia in the absence of an allergic reaction, classic drugs of anesthesia or epidural anesthesia are used, depending on the circumstances.
The subfascial technique with medial access involves making an incision along the inner surface of the lower leg. And with a posterior approach – from the posterior surface from the lower point of the popliteal fossa to the upper level of the medial malleolus.
The opening occurs according to the common fascia of the posterior muscle group along the incision line of the skin layer with subcutaneous tissue. This is followed by the separation of muscle fibers with the intersection on medical clamps and the ligation of perforating vessels, which are found in the resulting space.
Sometimes the manipulation protocol requires mandatory removal of the great or small saphenous vein. But here all situations are considered purely individually based on images obtained during duplex scanning or other diagnostics. The very extraction of the affected vessels is carried out through incisions in the common fascia, which are carried out additionally.
The final stage involves suturing the wound of the lower leg in layers, but tightly. The intervention ends with the application of aseptic dressings.
Suprafascial bandage
If the subfascial area takes into account the distance from the fascia to the subfascial vein, then the suprafascial zone takes into account the distance from the fascia to the saphenous vein. It follows that the suprafascial version of the operation includes the obligatory pulling of the “vein” over the window in the fascia.
To realize our plans, we will have to adopt the results of an ultrasound examination. The image is marked with marks of perforating points that were susceptible to disease.
The most radical method of treatment begins with an incision in the skin about one and a half centimeters long, guided by the resulting marking. Then the edges of the wound are moved apart with a medical grip and the nearest vein is pulled out, overcoming the subcutaneous fat layer.
The surgeon here requires accuracy and increased accuracy, since it will be necessary to crank out the plan at a small distance. There you will first have to select a communicative vessel, and then cross between the installed clips. Before this, it will be necessary to rid the venous ends of the tissues surrounding them in advance.
The end must be pulled to the top until it is fixed by a vein, and the “vein” itself must go deep into the scar. Next to go down to the fascia.
After a window appears, where the connecting element is clearly visible, the surgeon performs a final check to make sure that the affected path is found.
A clip is placed on the problematic vein next to the fascia, and then the vessel is crossed to securely bandage the stump.
The size of the “vein” should match as closely as possible in size with that which was found during scanning or ultrasound examination. Only strict adherence to a predetermined scheme based on detailed visualization will protect the victim from increased risks of recurrence at almost the same place.
Very rarely there is a double defeat. This means that another vein is hiding next to the detected vessel, which poses a threat to stable blood flow. With such suspicions, it will be more effective to double-check the other end of the communication path in order to play it safe once again.
If the radical approach was the result of emergency assistance to the victim without a preliminary ultrasound, then the surgeon will never be 100% sure that he removed the diseased area. We will have to double-check under more favorable circumstances with the help of concomitant diagnostics.
Even worse, if, due to inexperience or because of an insufficiently clear picture, a site was removed that did its job quite well. This is due to the close proximity of many veins, where only one of them suffers from valvular insufficiency.
If only one vessel is tied up, then the second one, which is responsible for ejection into the superficial part of the system, can provoke an aggravation of the disease. The progress of varicose veins of the lower extremities will not be long in coming.
Proper rehabilitation
It is worth preparing in advance for the fact that any format of dressing means a rather long and at the same time painful stage of recovery. To improve well-being at this stage, you need to follow medical recommendations and take analgesics.
The exact dosage and list of drugs is prescribed by the attending physician, based on the current state of his ward. Puffiness at first is quite a common occurrence, as are extensive hematomas.
Occasionally, the patient may be followed by the outflow of lymph, but this is also not a sign of a significant anomaly. We have to come to terms with the fact that the formation is a protracted process, the duration of which directly depends on the surgical technique used.
Some patients complain of a violation of sensitivity in the operated area near the heel. But this is a temporary discomfort, since with standard dressing, damage to the skin nerves is not observed.
In order to get back on your feet as soon as possible, literally and figuratively, you will need to be patient and follow medical recommendations for recovery and prevention of relapse.