The Significance of Valvular Insufficiency of Perforating Veins and Minimally Invasive Surgical Methods of Its Correction in Patients with Varicose Disease of the Lower Extremities

The research is dedicated to studying the significance of valvular insufficiency of perforating veins in varicose disease of the lower extremities and developing rational algorithms for minimally invasive surgical correction of this condition. The work analyzes modern diagnostic methods, including ultrasonic examination and computer thermography, and evaluates the effectiveness of combining endoscopic subfascial dissection, suprafascial ligation of perforating veins, venectomy, and compressive phlebosclerotherapy. Special attention is given to the application of echo-sclerotherapy and thermographic investigation in assessing treatment outcomes.

Relevance of the problem. Varicose disease of the lower extremities is one of the most prevalent forms of vascular pathology. Up to 25% of the population in developed countries suffer from this disease (Aleksandrov G.N., 1938; Vedenskiy A.N., 1983; Vil'yanskiy M.P. et al., 1988; Askerkhanov G.R., 1995; Savel'ev B.C. et al., 2001). Some authors note the prevalence of the disease at a level of 80 - 90% (Madar G. et al., 1986). Trophic changes of the skin and subcutaneous fat tissue complicate the course of varicose disease in 40 - 50% of patients (Savel'ev B.C., 1996; Kiriенко A.I. et al., 2000; Kuznetsov N.A. et al., 2000). In Russia, more than 30 million people suffer from various forms of this disease, of whom 15% have trophic disorders (Savel'ev B.C. et al., 1972; Konstantinova G.D. et al., 1978; Savel'ev B.C. et al., 2000). Retrograde blood flow through perforating veins is detected in patients with chronic venous insufficiency of 2-6 classes according to the CEAP classification with a frequency ranging from 12.3% (Kiriенко A.I. et al., 2004) to 74.7% (Les'ko V.A., Efimovich V.A., 2001). Trophic ulcers occur in 23 - 40% of these patients (Askerkhanov R.P., 1969; Coleridge Smith P.D., 2000; Vin F., 2001).

Given the fact that the majority of patients are individuals of the most active working age (20 - 50 years) and the frequency of disability due to the development of severe trophic disorders amounts to 10 - 67%, treatment of this pathology represents an actual socio-economic problem (Askerkhanov R.P., 1973; Vas'yutkov V.Ya., Protsenko N.V., 1997; Savel'ev B.C. et al., 2000; Mayberry J., 1991; Jimenez Cossio J.A., 1995; Ruckley C., 1995).

The only radical measure of assistance for patients with pronounced trophic disorders is surgical intervention (Askerkhanov R.P., 1969; Savel'ev B.C. et al., 1972; Vedenskiy A.N., 1983; Yablokov E.G. et al., 1999). Complete elimination of perforating reflux is considered an obligatory component of radical intervention in varicose disease. Preservation of perforating insufficiency, in the opinion of S.G. Darke, C. Penfold (1992), is the cause of disease recurrence in 47% of observations. The most significant results in this area were achieved in the 1930s-1950s of the 20th century thanks to the works of Cockett, Linton, and Felder. Having thoroughly studied the pathogenesis of trophic complications of chronic venous insufficiency, they developed and introduced original methods for eliminating horizontal venous reflux in the zone of trophic disorders through subtotal ligation of perforating veins of the leg from a subfascial and suprafascial access (Linton R.R., 1938; Cockett F.B., Jones E.E., 1953; Felder D. et al., 1955). The effectiveness and radical nature of these interventions led to their widespread application worldwide and the development of numerous modifications (Knyazev M.D. et al., 1973; Tserkovnyy V.A., 1974; Kozlova M.A. et al., 1977; Savel'ev B.C. et al., 1981; Vedenskiy A.N., 1983; Lipnitskiy E.M., 1986; Bogdanov A.E., 1993; Vas'yutkov V.Ya., Protsenko N.V., 1997).

However, along with the positive aspects of these operations, significant disadvantages were identified. Firstly, the necessity of wide access to perforating veins makes this operation traumatic and significantly prolongs the terms of postoperative rehabilitation of patients (Grishin I.N. et al., 1977; Borovkov S.A., 1978; Vas'yutkov V.Ya., Protsenko N.V., 1997). Secondly, performing an access in the zone of trophically altered tissues causes a high risk of developing postoperative purulent complications and marginal necroses, the treatment of which is a complex task (Hauer G., 1985; Jugenheimer M. et al., 1991; Inoue N. et al., 1992; Scuderi A., Nigri H., 1995). Thirdly, in 16 - 35% of patients, a recurrence of trophic ulcers occurs (Knyazev M.D. et al., 1973; Rzaev N.M., Kosaev D.V., 1988; Konstantinova G.D. et al., 2000).

Modern trends in revising the traditional surgical technique developed by Cockett and Linton imply increasing the radical nature of the intervention while minimizing operative trauma and cosmetic losses. No less relevant is the problem of developing technologies used for treating patients with complicated forms of varicose disease in outpatient conditions and under the "one-day hospital" program (Pyatnitskiy A.G., 2005; Chabbаров R.G., 2005; Sparks S. et al., 1997; Stuart W. et al., 1997).

The rapid development of endoscopic methods in recent years has led to attempts to apply them for eliminating low veno-venous reflux in varicose disease of the lower extremities (Nagovitsyn E.S., Balyasnikov N.P., 1989; Kiriенко A.I. et al., 1997; Pashin V.S., 2000; Shatalov A.V., 2000; Maly shev K.V. et al., 2005; Starkov Yu.G. et al., 2005; Hauer G., 1985; 1987). In this regard, an endoscopic technique for eliminating perforating reflux was developed and introduced into practice. The authors report positive immediate results of such operations (Kungurtsev V.V. et al., 2000; Zhirnova V.M. et al., 2005; Trenyov M.I. et al., 2005; Fischer R., 1991; Jugenheimer M. et al., 1991; Targonski J.S., 1992). However, there is little information about long-term results in the literature (Kiriенко A.I. et al., 2005; Losev R.Z. et al., 2005; Fischer R., 1994), which does not allow judging the true effectiveness of endoscopic operations. Moreover, the questions regarding the volume and nature of interventions on the subcutaneous venous system performed simultaneously with endoscopic dissection of perforating veins have not been finally developed.

More and more often nowadays, percutaneous sclerotherapy of insufficient perforating veins under ultrasonic control - echo-sclerotherapy - is applied (Kiriенко A.I., Bogachev V.Yu., Zolotukhin I.A., 2000; Gradusov E.G. et al., 2001; Byrikhin N.I. et al., 2005; Guzhkov O.N. et al., 2005). However, information about the possibility and advisability of using echo-sclerotherapy in the preoperative and postoperative periods to accelerate the regression of trophic disorders and its combination with endoscopic intervention, as well as with intraoperative catheter sclerotherapy of subcutaneous veins, remains ambiguous to this day.

The goal of the present study is to improve the results of treatment for patients with varicose disease of the lower extremities accompanied by valvular insufficiency of perforating veins based on the application of minimally invasive surgical methods.

Research tasks:

1. To study the features of venous hemodynamics in the presence of perforating vein insufficiency in patients with varicose disease of the lower extremities using ultrasonic research methods.

2. To study the possibility and advisability of using computer thermography in the diagnosis of varicose disease of the lower extremities and its complications, as well as in evaluating the effectiveness of comprehensive surgical treatment of this category of patients.

3. To develop a rational algorithm for combining endoscopic subfascial dissection of insufficient perforators, suprafascial ligation of perforating veins, venectomy, and compressive phlebosclerotherapy.

4. To study the possibility and effectiveness of using percutaneous phlebosclerotherapy of insufficient perforating veins, including sclerotherapy of perforating veins under ultrasonic control in the zone of pronounced trophic disorders.

5. To evaluate the effect of the combined use of minimally invasive surgical treatment methods in the presence of perforating vein insufficiency in patients with varicose disease of the lower extremities in terms of functional, aesthetic results, and terms of medical and social rehabilitation.

Scientific novelty. A method for treating patients with varicose disease of the lower extremities accompanied by valvular insufficiency of perforating veins of the leg and the great saphenous vein has been developed. The effectiveness of various minimally invasive methods of surgical correction of valvular insufficiency of perforating veins in varicose disease of the lower extremities has been studied. Ultrasonic criteria for the effectiveness and safety of performing echo-sclerotherapy of insufficient perforating veins have been developed for the first time, and indications for this treatment method have been formulated. A rational algorithm for combining endoscopic dissection of perforating veins, suprafascial ligation of perforators, venectomy, and compressive phlebosclerotherapy has been developed. Thermographic investigation has been used for the first time to evaluate the effectiveness of minimally invasive surgical treatment methods for varicose disease of the lower extremities.

Practical significance. The use of a complex of non-invasive research methods, including ultrasonic angioscanning and computer thermography, increases the effectiveness of the diagnosis of varicose disease of the lower extremities. Rational application of minimally invasive surgical methods of correction of valvular insufficiency of perforating veins in varicose disease of the lower extremities allows improving the functional and aesthetic results of treatment, ensuring its high radical nature, and reducing the terms of medical and social rehabilitation of this category of patients.

Propositions for defense:

1. The leading role in detecting valvular insufficiency of superficial, deep, and perforating veins in varicose disease of the lower extremities is played by ultrasonic research methods.

2. For evaluating the effectiveness of the conducted treatment and the dynamics of manifestations of chronic venous insufficiency, the use of thermographic investigation is advisable.

3. Comprehensive surgical treatment of varicose disease of the lower extremities accompanied by valvular insufficiency of perforating veins should include endoscopic subfascial dissection, suprafascial crossing of perforators, and various techniques of phlebosclerotherapy, including echo-sclerotherapy. The treatment tactic in each case should be individual and differentiated.

4. The rational combination of minimally invasive surgical methods of correction of valvular insufficiency of perforating veins in varicose disease of the lower extremities provides optimal clinical and cosmetic results.

Presentation of the material. The materials of this research were presented at the second conference of the Association of Phlebologists of Russia (Moscow, 1999); the IV All-Russian Congress of Surgeons (Volgograd, 2000); the third conference of the Association of Phlebologists of Russia (Rostov-on-Don, 2001); the scientific-practical conference "Actual Questions of Treatment and Cosmetic Correction of Early Stages of Varicose Vessel Changes" (St. Petersburg, 2002); the international surgical congress "Actual Problems of Modern Surgery" (Moscow, 2003); the scientific-practical conference dedicated to the 90th anniversary of the department of hospital surgery of SGMA (Saratov, 2003); the 14th (XVIII) international conference of the Russian Society of Angiologists and Vascular Surgeons "New Trends in Vascular Surgery and Phlebology" (Rostov-on-Don, 2003); the V conference of the Association of Phlebologists of Russia (Moscow, 2004); the international surgical congress "New Technologies in Surgery" (Rostov-on-Don, 2005); the Volga Interregional Conference of Surgeons "Hospital-replacing Technologies in Surgery" (Saratov, 2005); the city practical conference "Actual Questions of Phlebology" (Saratov, 2006); the scientific surgical society (Saratov, 2006); the joint meeting of the departments of hospital surgery of the therapeutic faculty, hospital surgery of the pediatric faculty, faculty surgery of the therapeutic faculty, general surgery, faculty surgery of the pediatric faculty, operative surgery, and topographic anatomy of SGMA (Saratov, 28.04.2006).

Implementation into practice. On the topic of the dissertation, 25 scientific works have been published, 7 certificates for rationalization proposals have been obtained, 1 patent for a utility model, and 1 patent for an invention. The main scientific provisions and practical recommendations have been implemented in the therapeutic and pedagogical work of the clinic of hospital surgery of the therapeutic faculty of Saratov State Medical University, the surgery department of the medical center "Zdorovye", and the surgery department of the medical center "Akkson".

Structure and volume of the work. The dissertation consists of an introduction, 5 chapters, conclusion, conclusions, practical recommendations, and a list of references. The work is presented on 167 pages of typed text, illustrated with 18 tables and 75 figures. The list of references includes 196 literary sources, of which 99 are domestic and 97 are foreign.