Varicose Veins

Clinical Anatomy of Vessels of Popliteal Region

INTRODUCTION: A modern standard for noninvasive diagnostics of the vascular system is duplex scanning. The knowledge of variability of vascular anatomy is essential for ultrasound doctors. AIM: To clarify variants of the clinical anatomy of vessels of the popliteal region using duplex scanning and anatomical preparation. MATERIALS AND METHODS: The work used data of duplex scanning of the arteries and veins of the lower extremities of patients without pathology of the vascular system of the lower extremities, who underwent examination of the vascular system: 200 patients aged from 18 to 92 years. As control, the data of anatomical preparation of 50 amputated lower extremities were taken, with preliminary filling the venous system with a blue synthetic gel. RESULTS: In the course of anatomical preparation, two trunks of the popliteal vein were identified in the distal popliteal region in 86.0% of observations. A typical drain of the small saphenous vein with formation of the saphenopopliteal junction was encountered in 60.0% of cases. In duplex scanning, a high bifurcation of the popliteal artery was detected in 1.9% of observations. The two trunks of the popliteal vein in the distal part of the popliteal region were encountered in 82.4% of cases, and the medial trunk was almost always larger than the lateral one. The small saphenous vein drained into the popliteal vein in 63.0% of cases. In 7.2% of observations, it drained into one of the intramuscular veins. In 0.95% of observations, a perforator vein was identified in the popliteal region. The sural veins were identified in all the patients — two on the medial and lateral surface positioned at the sides of the two trunks of the sural arteries, forming a single trunk before confluence with the popliteal vein. CONCLUSIONS: TThe study revealed the following anatomic variants of vessels of the popliteal region: two trunks of the popliteal vein below the knee joint cleft in 85.7% to 86.0% of observations; a high bifurcation of the popliteal artery in 1.9%; saphenopopliteal junction in 60.0% to 63.0%; perforator veins of the popliteal region in 0.95% of observations; upon that, the small saphenous vein does not form the saphenopopliteal junction.

The Reasonability of Using Complex Medical Prescriptions for Tumescent Anesthesia When Performing Endovenous Laser Obliteration of Varicose Veins

   INTRODUCTION. Despite the widespread use of methods for thermoobliteration of varicose veins, there are no standards for prescribing solutions for tumescent anesthesia when performing these operations. Existing prescriptions can be difficult, both in terms of finding the necessary components in a certain concentration, and in terms of correct dilution of the components in saline.

   AIM OF STUDY. To determine the reasonability of using complex medicinal prescription solutions for tumescent anesthesia when performing endovenous laser obliteration of varicose veins of the lower extremities.

   MATERIAL AND METHODS. The prospective study included 64 patients who underwent endovenous laser obliteration of the great or small saphenous vein. The operations were performed in accordance with the standard protocol on a device with a wavelength of 1,940 nm and radiation power from 5.0 to 6.0 W. Tumescent anesthesia was created using an automatic infiltration pump using 21 G needles with a length of 120 mm. Group I included patients (n = 34) who were anesthetized with a 0.1 % lidocaine solution at room temperature. Group II included patients (n = 30), for whom the anesthesia solution was prepared according to Klein’s standard prescription for tumescent anesthesia. The distribution of patients into groups was carried out using random sampling. Evaluation criteria: the presence or absence of complaints of pain during surgery and the level of pain assessed using a visual analogue scale.

   RESULTS. The groups did not differ statistically significantly in terms of main clinical and demographic indicators (p < 0.05). Complaints of pain or burning during surgery were made by 2 patients (5.9 %) in group I and 5 patients (16.7 %) in group II (p = 0.0023). The average pain value according to the visual analogue scale in group I was 0.75 cm [0.30; 1.44], in group II – 1.85 cm [0.85; 2.72], p = 0.0017, while in group I the maximum number of patients — 24 (70.6%) were distributed in the range of 0–1 cm, in group II the maximum number of patients, 17 (56.7 %) were distributed in the range of 1.5–3 cm according to a visual analogue scale.

   CONCLUSIONS. When using a simple 0.1 % lidocaine solution for tumescent anesthesia, a significantly lower average pain value according to VAS was obtained in comparison with the group of patients who used the standard D. Klein solution (0.75 cm and 1.85 cm, respectively, p = 0. 0017). Also, for the study group, a significantly lower frequency of perioperative complaints and complaints of severe pain was obtained (p < 0.01). The use of complex prescriptions of solutions for tumescent anesthesia when performing endovenous laser obliteration of varicose veins is impractical. The use of a simple 0.1 % lidocaine solution at room temperature, while following the surgical protocol, provides comfortable anesthesia.

Study of variations in the anatomy of the deep femoral vein using indirect CT phlebography

Aim of the study was to evaluate the features of the anatomy of the deep vein of the femur according to CT-phlebography data. Material and methods. The data of CT-phlebography of 100 limbs of 50 patients (27 women, 23 men, mean age 39 years, age range 28–46 years) obtained in 2021–2023 were used as the basis of the work. The study was performed according to the original technique (patent of the Russian Federation N 2799023) on a 128-slice multispiral computed tomography scanner, with slice thickness of 0.5 mm, intravenous injection of contrast agent. The diameter of the femoral deep vein at different levels, the presence of additional trunks and its anastomoses with other segments of deep and superficial veins were evaluated. Results. True doubling of the femoral deep vein occurs with a frequency of 6 %, anastomoses of the femoral deep vein with the femoral-pubic segment of deep veins in 62 % cases. Variant anatomy with direct transition of the femoral or popliteal vein into the femoral deep vein occurs in 13 % of observations. Conclusions. The data on variant anatomy of the deep vein and its tributaries may be of practical importance when it is necessary to diagnose or choose the technique of surgical intervention in patients with venous diseases of the lower extremities.

Surgical Treatment of Varicose Veins of the Lower Extremities

The review presents an analysis of relevant literature on the surgical treatment of varicose veins of the lower extremities. Modern methods of surgical intervention for varicose veins are considered: open operations, methods of thermal ablation of the main veins, non-thermal non-tumescent methods, vein-preserving surgery (ASVAL), methods of treating reflux in perforating veins and recurrent varicose veins. The effectiveness of each of the surgical treatment methods used was analyzed. The frequency of relapses and the likelihood of complications of the described operations are considered. All surgical treatment methods presented in the review were developed on the basis of modern ideas about the pathogenesis of varicose veins, the mechanisms of formation of chronic venous insufficiency, and have an evidence base. These techniques are reflected in the latest clinical guidelines and are widely used in medical practice.

Current state of the problem of risk assessment and prevention of venous thromboembolic complications after thermal obliteration of superficial veins

Venous thromboembolic complications (VTEO) after modern minimally invasive superficial vein interventions are an infrequent but very dramatic event. This article presents a review of the literature, covering the issues of prevalence, prognosis and pharmacological prevention of VTEO. The performed studies demonstrate that the incidence of symptomatic thrombotic complications after endovenous thermal obliteration does not exceed 0,5%, but taking into account asymptomatic thermally induced thromboses and subclinical occlusions of the muscular veins of the lower leg, this figure can exceed 10%. There is a high heterogeneity of the data, possibly due to differences in the individual risk of VTEO. The most validated tool for assessing the latter is the Caprini Scale, which has not been sufficiently studied in the surgical treatment of varicose veins. The administration of prophylactic doses of anticoagulants after thermal obliteration of saphenous veins is widely used in routine clinical practice, despite the lack of convincing evidence for the appropriateness of this approach. In recent years, the use of direct oral anticoagulants against the official instruction (off-label) has gained great popularity as an alternative to heparin. The largest evidence base has accumulated for the use of rivaroxaban 10 mg, which is associated with high efficacy and safety. Based on completed clinical trials, it is not possible to formulate unequivocal recommendations for prophylactic anticoagulant doses after thermal obliteration of superficial veins at this time. Additional studies are required to identify patients with an individually increased risk of thrombosis in whom prophylactic doses of anticoagulants may be of maximum benefit.