Treatment of varicose veins

Definition

Varicose pathology means an affection of the superficial veins of the limbs inferior (vv large or small saphenous and / or their collateral), whose incidence affects about 30% of the population with prevalence of the female sex. The causes of these diseases can be:

- primitive (the most frequent)
- secondary (from deep venous hypertension).

The predisposing factors are represented by the familiarity, the use of oral contraceptives, pregnancies and the prolonged standing station.

Clinic and evolution of venous pathology

It is a chronic and progressive pathology characterized by the loss of functionality of the valve system of the veins that performs the action of preventing the backflow of blood in the peripheral areas; therefore the impairment of the aforesaid apparatus involves the progressive whitening of the veins themselves which become more and more evident until they manifest themselves as varicose veins.

Pathophysiology

(cfr The varices of the legs )

The vein system has valves, which, like pockets, when the blood presses to go back, fill and close the return circuit; however, it happens that the vase, for various reasons, is left untreated, so that the blood flows downwards, instead of proceeding towards the femoral, iliac and hollow vein system and therefore the heart. This causes a further dilatation of the veins that become "varicose", ie tortuous, and the valve changes cause a very slow flow with a progressive expansion and stasis that gradually affect the downstream structures. Hence the edema, responsible for most of the symptoms and complications, with alterations involving the cutaneous microcirculation of the most sloping areas, with dilatation of the capillaries around the ankle, repeated blood microcircuits and chromatic alterations (ocher dermatitis), until true infections of the skin and ulcerations. The stasis inside the veins is also responsible for the ease with which blood tends to coagulate (phlebitis and thrombosis). Fearsome, therefore, are the complications: pulmonary embolism, hemorrhages, infections, stasis eczema and leg ulcers lead not only to a worsening of symptoms, but especially to risks that are not worth running. The blood therefore does not flow properly and stagnates in the peripheral areas (legs, feet), sometimes manifesting itself as well as with the evidence of varicose veins with all the typical symptomatic outcomes of the disease, including:
heaviness, nocturnal cramps, itching and edema of lower limbs.

Progressively the pathology also compose the appearance of equally typical signs: redness, discoloration (dark spots), dry skin. Phlebitis (inflammation of the venous wall with thrombosis inside) can occur and true ulcers that are typically located in the area of the "gaiter" (lower third of the leg, ankle and foot).

Diagnosis

Diagnosis is based on clinical evidence and / or instrumental evidence (echo color doppler) of venous insufficiency.Indicazioni al trattamento

Non sempre la patologia varicosa deve essere trattata chirurgicamente. Il trattamento chirurgico della patologia varicosa ha la funzione di impedire che si determinino le complicanze sopracitate o, quando già presenti, I'estensione delle stesse.

Types of treatment

The treatment of varicose veins uses multiple methods depending on the clinical type of varicose veins, the age of the patient and his general clinical state. The most frequently used surgical techniques are:
- Isolated varicectomies, ie the simple cutaneous incision and the removal of varices
- Safenectomia, which consists in extracting (stripping) the large and / or small saphenous vein. The intervention is usually associated with varicectomies.
- Crossectomy, ie the ligation and section of the saphena at the outlet of this in the deep venous system.
- Motorized phlebectomy for transillumination (TRIVEX), a method that grinds and aspirates extra-sympathetic varices after detaching the tissues with anesthetic solution introduced into the positive pressure subcutaneous tissue and visualizing the same for transillumination.
- C.H.I.V.A., a method of decompression of the saphenous to prevent the stagnation of blood in the superficial venous system.
- S.E.P.S., a minimally invasive endoscopic method used for ligation and disruption of diseased perforating veins.
- Intravenous obliteration with Laser method
- Intravenous obliteration with radiofrequency.
Sclerotherapy (injection of substances that close small vessels) can sometimes be associated with surgical therapy
Such interventions are usually performed with minimal hospitalization (from a few hours to one day) and sometimes outpatient with local or regional anesthesia technique, thus precluding an early ambulation. The intervention can involve even if performed in full respect and knowledge of the most current and standardized strategies and surgical techniques, multiple complications distinguishable in early and late. The main of which are, though not unique.

Immediate intraoperative and postoperative complications

In the various international cases, mortality is an event not mentioned but not zero. In fact there are sporadic episodes of mortality linked essentially
to pulmonary embolism secondary to deep vein thrombosis.
· Intraoperative hemorrhage, a condition that can be more or less severe, which rarely involves the need for blood transfusion with the associated risks.
· Injury of the femoral or popliteal vein with possible deep venous thrombosis.
· De-cure, sepsis and blood or lymphatic collections in surgical wounds that do not always regress with adequate conservative and / or surgical treatment. '
· Deep vein thrombosis and pulmonary embolism.

Late complications even after years

· Recurrence, or the reappearance of varices even with correctly performed interventions.
· Discrimination in the scar area.
· Cheloids in the scar area (exuberant scars).
· Injury of the saphenous nerve with consequent paresthesia and / or pain along its course which can persist for years.
· Lymphedema, ie lymphatic stasis that causes edema (swelling of the operated limb) sometimes of considerable magnitude and which may not completely regress.
Furthermore, verifiable conditions intraoperatively may lead to changes in the proposed operative technique.
It is reiterated that what has been outlined emerges from the current state of the art and therefore other events not described may occur.

Why undergo surgery?

It is evident that the surgical treatment represents the most effective strategy if medical therapy is no longer able to prevent or limit the evolution of the disease and any complications of the disease to which we have previously mentioned.
In particular, for the varicose pathology the data in the literature now agree that all those pharmacological / physical (elasto-compression) devices currently available to us are capable of improving the functionality of the compromised venous system, but less effectively than surgical treatment.
Once the intervention is over, it is essential that the patient follows the recommended therapy, which is not only represented by the use of prescribed drugs but also by an adequate lifestyle. It should be remembered that venous insufficiency is rarely completely curable with surgery, which presents the possibility of relapse even if correctly treated and that the symptoms present before surgery do not always disappear with the operation itself.

index topic on varicose veins