Venous surgery

Anatomy of the veins of the lower limb:

The venous network serves to bring blood from the periphery to the heart.

In the lower limb it is organized into two parallel networks:

Deep vein network; In the middle of the muscles of the limb, is essential for venous drainage.

The superficial venous network; Under the skin, which consists of two main trunks: the internal saphenous vein or large saphenous vein (which extends from the ankle to the inner border and follows the internal face of the leg, the thigh, and throws itself into the femoral vein Fold of the groin), and the small saphena vein or external saphenous vein (which originates from the ankle to the external border, passes behind the calf to throw itself into the popliteal vein in the popliteal cavity).

The superficial venous network is incidental and can be removed without consequence for the limb provided the venous network is competent.

What is a varicose vein?

A varicose vein is defined by the dilation and elongation of the superficial veins of the lower limbs, more particularly on the saphenous veins and the branches which depend on them.

Depending on their size, there are:

Telangiectasias, reticular varicose veins and varicose veins (> 3mm).

It is a very common condition since after 40 years, 50% of the population is carrying telangiectasis or varicose veins, 20% are varicose vectors and 0.5% have varicose ulcers.

Varicose veins affect women more than men (3 women per 1 man). They are more frequent with age, pregnancy count and are favored by the extended standing crafts.

How varicose veins are born?

In the lower limbs in the upright position, the venous blood circulates against the laws of gravity since it circulates from the bottom upwards. This venous return is due to the heartbeat, but especially thanks to the muscles of the calf and the thigh which at each step in contracting chase the blood upwards. However between each contraction the blood would tend to naturally fall back down. Now there is a system of “valves” called the anti-reflux valves that allow the blood to circulate only from bottom to top without possible reflux.

The varicose disease is due to an abnormality of these valves which become incontinent (they no longer touch in closed position) causing in a standing position a reflux of blood from top to bottom. Consequently, in the upright position, the venous wall is subjected to a very important abnormal pressure causing an expansion of the latter. Thus is born the varicose vein.

This anomaly of continence of the valves is generally hereditary. However, in rare cases, it is due to diseases associated in particular with sequelae of deep phlebitis.

What are the symptoms of varicose veins?

The symptoms are always standing, since elongated, reflux does not exist.

The first of the symptoms is usually an aesthetic discomfort. Indeed these “clusters” of veins under the skin can be extremely unsightly.

The symptoms are very rich and are not always specific to varicose disease.

Common symptoms are heavy leg sensation, itching (pruritus), edema in the legs at the end of the day.

Sometimes a change in the pigmentation of the skin can be found: brown coloration on the ankle (ocher dermatitis) due to extravasation of red blood cells under the skin under the pressure of reflux. In the long term, venous ulcers appear, the healing of which can be complex.

What are the risks of varicose veins?

Varicose veins are not, strictly speaking, a life-threatening disease. However, they expose the patient to sometimes very troublesome complications:

  • Superficial venous thrombosis, formerly known as paraphlebitis, causes acute pain in relation to varicose veins. This becomes hard red.

Although the risk of extension to the deep vein network and pulmonary embolism is extremely low, it requires specific care from your treating angiologist.

  • Trophic disturbances: after several years of evolution, venous hyperpressure on the ankle in the standing position leads to a pain in the tissues that change colors (ocher dermatitis, sclerotic hypodermic, white atrophy) and then spontaneous ulcers appear.
  • Bleeding: when varicose veins are very bulky, they can explode as a result of trauma causing a spectacular bleeding pattern. However, venous haemorrhage is at low pressure (unlike the arteries), to stop the bleeding, to raise the leg and compress the bleeding zone with a clean cloth (attention: do not tourniquet: this would aggravate the bleeding Bleeding by venous return gene).

What should we achieve?

The diagnosis is mainly clinical. However, it is advisable in front of a table of varicose veins to have your venous angiologist carry out a venous doppler echo of the lower limbs to document the reflux, the incontinence of the valves and above all to eliminate another cause (anomaly of the deep venous network).

What are the different treatments?

  • Skin laser: is indicated for telangiectasia in the event of sclerotherapy failure and in certain indications or particular localizations.
  • Sclerosis: its principle is to inject in the dilated vein an irritating product causing a venous spasm and then a thickening of the wall which evolves rapidly towards the obliteration: the vein then becomes a fibrous cord. Its main disadvantages are the duration of the treatment (numerous sessions) and the recurrence. In fact, sclerosis, to be durable, must be repeated regularly. It is the treatment of choice of telangiectasias and some reticular varicose veins. Currently the injection of sclerosant in the form of foam seems to considerably increase the effectiveness of the sclerotherapy especially for the treatment of the large venous trunks and the recurrences after surgery. It requires ultrasound guidance (echo-sclerosis with foam). However, this technique also exposes a higher recidivism rate than surgical techniques. These techniques are carried out in consultation in the office. Complications are rare and most often benign.
  • Elastic restraint (tights, stockings, socks or bands): this is the main treatment for varicose disease. The strength of the restraint is classified in force (ranging from 1 to 4), it is the force 2 restraints that are usually prescribed. They must be put in the morning immediately after getting up. They reduce edema, slow the progression of the disease and prevent complications. Attention: if the stockings or tights of contention walk for all the reflux, the socks of contention are indicated only in case of incontinence of the small saphenous one.
  • Drugs: called veinotonic, Daflon, Ginckor strong …. While its treatments sometimes improve some patients, they have not demonstrated efficacy on the evolution of varicose veins. That is why they are no longer reimbursed by social security.
  • Endovenous techniques: whether the endovenous laser, the radiofrequency, or the hot water vapor, their aim is to deliver, via the interior of the vein, energy causing thermal destruction with fibrous reaction and retraction of The wall no longer leaving a channel for the circulation of the blood leading eventually to the disappearance of the treated vein. Only the superficial vein trunks are accessible to this type of treatment (saphenous veins). Varicose veins on the branches are treated at the same time or secondarily by surgical removal (see phlebectomies) or by sclerosis. For the time being these treatments are not reimbursed by the social security resulting in a surcharge for the patient. The advantage of these techniques is that the patient can immediately resume his professional activity. In addition, very thin patients can not benefit from this type of treatment because proximity to the skin in these patients can sometimes result in these “thermal” techniques of lesions of burns by contiguity on the facing skin.
  • Conventional surgical treatment: Stripping or Eveinage and phlebectomies. This is an intervention aimed at removing the varicose veins by small, stepwise incisions. They are, depending on the case, associated or not with a treatment of the saphenous trunks (endo-venous techniques, stripping). Isolated, they can be performed under local anesthesia on an outpatient basis and have above all an aesthetic purpose. They may allow the saphenous trunk to be retained when the saphenous trunk is poorly or not reached and thus improve the signs, symptoms and superficial venous hemodynamics.
  • Stripping or deveining: this is the ablation of the saphenous vein by surgical procedure, by 2 short incisions. This procedure is often associated with phlebectomies. This is the reference intervention, especially in cases of large varicose veins. This intervention is well codified and is controlled by many surgeons. It can be performed under local, loco-regional or general anesthesia and can in most cases be done on an outpatient basis. In general, the work stoppage is 15 days.
    The postoperative side effects are mostly minor (pain, hematoma). Surgery of the large saphenous vein can exceptionally cause a lesion of the internal saphenous nerve causing anomalies in the sensitivity of the inner face of the calf. All of these interventions are performed in the context of ambulatory surgery.