RU2812293C1 - Method of total striping of great sabacutaneous vein for varicose veins of lower extremities complicated by prior thrombophlebitis - Google Patents

Abstract

FIELD: medicine; surgery; vascular surgery; phlebology.

SUBSTANCE: after placing a flexible vein extractor in the lumen of the great saphenous vein and fixing the proximal and distal sections of the trunk of the great saphenous vein to the corresponding ends of the probe, paravasal injection is performed along the fascial sheath along the great saphenous vein from the medial malleolus to the level of the upper third of the leg of 150–250 ml of a solution containing 250 ml of 0.9% sodium chloride and 0.25 ml of 0.1% epinephrine. 5 minutes after administration of the solution, traction of the great saphenous vein, fixed to the probe, is performed in the antegrade direction. After stripping, compression is applied along the removed trunk of the saphenous vein. Next, the inguinal access is sutured with a cosmetic suture, an aseptic bandage is applied, and elastic bandaging is completed to the level of the groin.

EFFECT: method allows to improve treatment results by reducing the severity of postoperative hematoma and increasing the cosmetic result.

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Description

The invention relates to medicine, namely to surgery, vascular surgery, phlebology, and can be used in the surgical treatment of varicose veins of the lower extremities, complicated by thrombophlebitis of the saphenous veins of the lower extremities.

Chronic venous diseases are widespread among working groups of the population, often becoming a cause of incapacity and sometimes disability. According to a Russian clinical study, symptoms of chronic venous diseases (CVD) of the lower extremities were detected in 69.3% of 703 examined over the age of 18 years [Zolotukhin IA, Seliverstov EI, Shevtsov YN, Avakiants IP, Nikishkov AS, Tatarintsev AM, Kirienko AI . Prevalence and Risk Factors for Chronic Venous Disease in the General Russian Population. Eur J Vase Endovasc Surg. 2017; 54(6):752-758]. Modern medicine has a wide choice of treatment methods for this group of patients: from local conservative therapy to surgical intervention, which is necessary when conservative methods cannot show a good positive effect and patients note a decrease in quality of life. Surgical treatment shows better results in reducing the symptoms of CVD, better cosmetic effect, as well as in satisfaction and self-perception of the quality of life of patients compared with conservative treatment [Michaels JA, Campbell WB, Brazier JE, Macintyre JB, Palfreyman SJ, Ratcliffe J, Rigby K. Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial). Heal Technol Assess. 2006; 10(13):1-196]. Despite the emergence of endovasal methods for the treatment of varicose veins (VV) of the lower extremities, their effectiveness is comparable to the open method of surgical treatment, subject to the technique of intussusception stripping and in the absence of large incisions [Kamaev A.A., Bulatov V.L., Vakhratyan P.E., Volkov A.M., Volkov A.S., Gavrilov E.K., Golovina V.I., Efremova O.I., Ivanov O.O., Ilyukhin E.A., Katorkin S.E., Konchugova T.V. , Kravtsov P.F., Maksimov S.A., Mzhavanadze N.D., Pikhanova Zh.M., Pryadko S., Smirnov A.A., Sushkov S.A., Chabbarov R.G., Shimanko A.I. , Yakushkin S.N., Apkhanova T.V., Derkachev S.N., Zolotukhin I.A., Kalinin R.E., Kirienko A.I., Kulchitskaya D.B., Pelevin A.V., Petrikov A.S., Rachin A.P., Seliverstov E.I., Stoiko Yu.M., Suchkov I.A. Clinical recommendations. Phlebeurysm. Phlebology. 2022; 16(1):41-108. https://doi.org/10.17116/flebo20221601141]. According to Russian clinical guidelines, thermal obliteration of vein segments with fresh thrombotic masses in the lumen is not recommended in patients with CVD. A full surgical intervention aimed at eliminating pathological reflux and varicose superficial veins is recommended during the period of subsided thrombophlebitis [Stoiko Yu.M., Kirienko A.I., Ilyukhin E.A., Lobastov K.V., Chabbarov R.G. ., Parikov M.A., Khorev N.G., Zolotukhin I.A., Andriyashkin V.V., Karpenko A.A., Fokin A.A., Sushkov S.A., Sapelkin S.V., Suchkov I .A., Krylov A.Yu., Ignatiev I.M. Diagnosis and treatment of thrombophlebitis of the superficial veins of the extremities. Recommendations of the Association of Phlebologists of Russia. Phlebology. 2019; 13(2):78-97. https://doi.org/10.17116/flebo20191302178]. For a long time, the technique of stripping the great saphenous vein (GSV) was basic in the surgical treatment of this pathology. The length of the removed vein fragment should correlate depending on the extent of vertical reflux along the trunk of the saphenous vein. If there is reflux throughout the great saphenous vein, total stripping is recommended [Kostas TT, Ioannou CV, Veligrantakis M, et al. The appropriate length of great saphenous vein stripping should be based on the extent of reflux and not on the intent to avoid saphenous nerve injury. J Vase Surg 2007; 46: 1234-41]. The most commonly used classical technique for removing the GSV is Babcock phlebectomy. However, this method in its classical version in 20-50% of cases can be complicated by injury to the saphenous nerve, with the development of the corresponding clinical picture of neurological disorders in the postoperative period [Burleva E.P., Smirnov O.A., Tyurin S.A. On the issue of stripping the great saphenous vein. Phlebology. 2017; 11(2):76-82. [Burleva E.R., Smirnov O.A., Tyurin S.A. K question about strippinge bol'shoj podkozhnoj veny. Flebologiya. 2017; 11(2):76-82. (In Russ.)]. According to some authors, damage to the cutaneous nerves occurs in 4 to 50% of cases of radical phlebectomy, and surgical treatment of thrombosed veins after an episode of acute thrombophlebitis is quite traumatic and requires regional or general anesthesia [Pustovoit A.A., Gavrilov S. G., Zolotukhin I.A. Treatment tactics for acute ascending thrombophlebitis. Phlebology. 2011; 3:46-52. [Pustovojt A.A., Gavrilov S.G., Zolotuhin T.A. Taktika lecheniya ostrogo voskhodyashchego tromboflebita. Flebologiya. 2011; 3:46-52. (InRuss.)].

The closest analogue of the invention is total stripping of the great saphenous vein using the method of hydropreparation with saline solution, which consists in the fact that after passing a flexible vein extractor through the lumen of the GSV, 100-150 ml are first injected into the fascial sheath of the vessel from the medial malleolus to the upper third of the leg to the knee joint area physiological solution. Then, after selecting the appropriate olive, the size of which depends on the width of the GSV, and preliminary ligation of the vein on the probe, antegrade stripping of the GSV is performed in the direction from the medial malleolus to the groin. When tensioning the tributaries of the GSV during stripping, the traction is suspended and the tributary is disconnected from the trunk. The inflow is isolated from the mini-puncture using a Muller hook, while the proximal end of the inflow is cut off followed by continued traction. The distal portion of the inflow is unscrewed using clamps and/or bandaged. Then, after removal of the GSV, manual compression of the GSV bed is performed throughout its entire length for 5-7 minutes for the purpose of hemostasis. Before applying sutures at the incision site, a tightly rolled tampon is used to evacuate accumulated blood clots from the wound, after which the wound is sutured and elastic bandaging of the lower limb to the groin is performed [Patent RU 2726588, IPC A61 B17/00, publ. 2020]. The disadvantage of this method is that, despite the preservation of the saphenous nerve, patients may still have severe subcutaneous hematomas and cosmetic defects of the skin after surgery.

The objective of the invention is to develop a method for total stripping of the GSV for varicose veins of the lower extremities, complicated by subsided thrombophlebitis, providing improved functional and cosmetic results.

The technical result when using the invention is to improve treatment results by reducing the severity of postoperative hematoma and increasing the cosmetic result.

The proposed method of total stripping of the GSV for varicose veins of the lower extremities, complicated by subsided thrombophlebitis, is carried out as follows:

1. After passing the flexible vein extractor through the lumen of the great saphenous vein, it is fixed to the vein extractor in the area of the proximal and distal ends.

2. Next, under digital control of the location of the probe along the GSV, from 150 to 250 ml of a solution containing 250 ml of 0.9% sodium chloride and 0.25 ml of 0.1% epinephrine are injected paravasally along the fascial sheath. The solution is injected from the level of the medial ankle to the upper third of the leg to achieve the effect. The effect of hydropreparation of the great saphenous vein reduces the likelihood of damage to a nearby cutaneous nerve, and the content of epinephrine causes vasospasm in the injection area, which reduces the severity of postoperative hematomas. Above the level of the knee joint, introducing a solution for hydropreparation of the great saphenous vein is not advisable, due to the different localization of the saphenous nerve, which is why the likelihood of its injury is minimal [Hadzic A. Hadzic's peripheral nerve blocks and anatomy for ultrasound-guided regional anesthesia. 2nd ed. New York, N.Y.: McGraw-Hill Education LLC. 2012; p 430].

3. 5 minutes after administration of the solution, the GSV is stripped in the antegrade direction - from the ankle towards the groin. In the course of identifying the departure of tense tributaries of the GSV, the traction of the probe is stopped, the tributary is isolated and separated. The distal part of the GSV inflow is cut off and removed, or bandaged, the proximal part is bandaged, the skin access is immediately sutured cosmetically, and accentuated compression is performed along the removed vein with elastic bandaging in the antegrade direction, to the level of the distal head of the probe. Then continue stripping.4. After completion of stripping of the GSV, hemostasis in the inguinal access area is monitored for 5 minutes. Accented compression is continued along the removed trunk of the saphenous vein. Next, the inguinal access is sutured with a cosmetic suture, an aseptic bandage is applied, and elastic bandaging is completed to the level of the groin.

The essence of the invention is illustrated by the following clinical examples

Example 1

Patient P., 54 years old, was admitted as planned with a diagnosis of varicose veins of the lower extremities C2EsAsPr,o on the left. Complaints upon admission: varicose dilated saphenous veins of the left lower limb, periodic pain along the course of varicose veins at the level of the upper and middle third of the leg. From the anamnesis: 6 months ago she suffered an episode of thrombophlebitis of the great saphenous vein with the upper border of a thrombus at the level of the middle third of the thigh, she was treated as an outpatient. Ultrasound duplex scanning before admission revealed valvular incompetence of the saphenofemoral anastomosis on the left, vertical reflux to the level of the lower third of the thigh along the great saphenous vein and incompetence of its tributaries on the thigh and lower leg. In the lumen of the great saphenous vein at the level of the upper third of the leg there is hyperechoic content, with recanalization up to 40%. The valve apparatus of the deep veins is wealthy. No concomitant pathology was identified. The operation was performed using the proposed method under spinal anesthesia. The surgical field was processed, the great saphenous vein was isolated in the groin area, crossed with clamps, and the proximal stump of the great saphenous vein was ligated with an additional ligature at the point of its confluence with the femoral vein. The tributaries of the great saphenous vein were divided and ligated. In the lower third of the leg in front of the medial malleolus, the distal section of the great saphenous vein is isolated with a linear incision, crossed, and the distal end is ligated. A probe was inserted into the proximal end of the trunk of the great saphenous vein, passed along the entire length of the GSV trunk, the proximal and distal sections were fixed to the probe. Hydropreparation of 150 ml of solution obtained from 250 ml of 0.9% sodium chloride and 0.25 ml of 0.1% epinephrine was performed, exposure time was 5 minutes. Next, stripping was performed with excision and ligation of the tributaries of the great saphenous vein, followed by suturing of the completed accesses with a cosmetic suture. Accented compression along the removed trunk of the great saphenous vein with intraoperative bandaging. Control of hemostasis of the proximal access for 5 minutes, suturing with a cosmetic access suture, aseptic bandage, elastic bandage of the lower limb to the groin level. The duration of the operation is 1 hour 20 minutes. The patient was discharged from the hospital after 2 days. Control examination on the day of surgery after 8 hours, on the 1st day, on the 7th day and after 1 month. The sutures were removed on the 7th day after surgery. There were no subcutaneous hematomas, the sutures healed by primary intention. During follow-up examinations, the patient had a good cosmetic effect and no neurological changes in the limb.

Example 2

Patient G., 44 years old, was admitted as planned with a diagnosis of varicose veins of the lower extremities C3EsAs,pPr,o on the right. Complaints upon admission: varicose veins on the right lower limb, swelling of the right lower limb at the level of the lower third of the leg and foot in the late afternoon, disappearing after a night's sleep, frequent evening and night cramps in the calf muscles of both legs. From the anamnesis: according to the words, about 3 months ago there was an episode of sharp redness of the skin in the area of the right shin, with thickening and pain in this area. I did not seek medical help due to working on a rotational basis. Ultrasound duplex scanning before admission revealed valvular incompetence of the saphenofemoral anastomosis on the right, vertical reflux to the level of the upper third of the leg along the great saphenous vein and incompetence of its tributaries on the thigh and lower leg. In the lumen of the great saphenous vein at the level of the upper and middle third of the right leg, hyperechoic thrombotic masses and signs of recanalization of up to 50% were detected. The valve apparatus of the deep veins is wealthy. Among the accompanying pathologies, a fracture of the tibia and fibula of the right leg was noted about 10 years ago.

The operation was performed using the proposed method under spinal anesthesia. The surgical field was processed, the great saphenous vein was isolated in the groin area, crossed with clamps, and the proximal stump of the great saphenous vein was ligated with an additional ligature at the point of its confluence with the femoral vein. The tributaries of the great saphenous vein were divided and ligated. In the lower third of the leg in front of the medial malleolus, the distal section of the great saphenous vein is isolated with a linear incision, crossed, and the distal end is ligated. A probe was inserted into the proximal end of the trunk of the great saphenous vein, passed along the entire length of the GSV trunk, the proximal and distal sections were fixed to the probe. A hydropreparation of 250 ml of a solution containing 250 ml of 0.9% sodium chloride and 0.25 ml of 0.1% epinephrine was performed with an exposure time of 5 minutes. Next, stripping was performed with excision and ligation of the tributaries of the great saphenous vein, followed by suturing of the completed accesses with a cosmetic suture. Accented compression along the removed trunk of the great saphenous vein with intraoperative bandaging. Control of hemostasis of the proximal access for 5 minutes, suturing with a cosmetic access suture, aseptic bandage, elastic bandage of the lower limb to the groin level. The duration of the operation is 1 hour 15 minutes. The patient was discharged from the hospital after 2 days. Control examination on the day of surgery after 8 hours, on the 1st day, on the 7th day and after 1 month. The sutures were removed on the 8th day after surgery. There were no subcutaneous hematomas, the sutures healed by primary intention. At follow-up examinations, the patient's cosmetic result was better; no neurological changes were noted in the limb.

Claims (1)

A method for performing total antegrade stripping of the great saphenous vein (GSV) for varicose veins of the lower extremities, complicated by previous thrombophlebitis, including placing a venous extractor in the lumen of the GSV, fixing the proximal and distal sections of the GSV trunk to the corresponding ends of the probe, hydropreparation by introducing a solution into the fascial sheath of the vessel along the course of the GSV from the medial ankle to the upper third of the leg, traction of the GSV fixed to the probe in the antegrade direction with simultaneous suturing of the skin access and elastic bandaging, characterized in that from 150 to 250 ml of a solution containing 250 ml of 0.9 are administered as a solution % sodium chloride and 0.25 ml of 0.1% epinephrine, the skin access is sutured cosmetically, and before bandaging, additional compression is performed along the removed vein.