RU2137427C1 - Method for treating the cases of varicosis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves applying clips on inconsistent veins. NiTi clips possessing shape memory properties are used. Threads are conducted under the veins in the regions of maximum dilatation and length of pathologically changed vein and tied on gauze ball. Threads are conducted in perpendicular to vein direction not more than 10-15 cm distant one from another. The threads are additionally tightened every 2-3 days. Tightening is carried out 4-5 mm apart from thread exit through the skin surface. The threads are tightened to reach complete subcutaneous intersection of a vein. Ostial valve being inconsistent, clips are set on the great subcutaneous vein ostium. In 1-2 days after clips being set and veins being sutured, the veins are subjected to sclerosis. 1.5% thrombovar solution is injected into varicose vein fragments. EFFECT: accelerated treatment course; improved cosmetic results. 3 cl, 1 dwg

Description

 The invention relates to medicine, namely to vascular surgery.

 Damage to the veins of the extremities is one of the first places in the overall structure of the incidence of the cardiovascular system. According to N. Dodd, F.B. Cockett, varicose veins of the lower extremities are found in every fifth woman. The history of treatment for BPH is represented by the stages of enthusiasm only by surgical or conservative methods. Conservative treatment methods (sclerosis) in their pure form have strictly limited indications, give a large percentage of relapses after a short time. Surgical treatment for a long period of time (1.5-2 months) takes a person out of his usual lifestyle, reduces his ability to work, and there is a risk of postoperative complications. As a rule, the cosmetic effect of surgery does not satisfy patients, especially women. However, modern social conditions require physicians to create methods of treatment with minimal disability and compliance with cosmetic principles of exposure, provided that the cure for the disease is radical.

 A known method of treating varicose veins with sclerotherapy (J.P. Daudyaris, "Diseases of the veins and lymphatic system of the limbs", M., "Medicine", 1984, S. 81-87), which consists in the injection into the dilated veins of phlebosclerosing drugs, as a result, the vein is scarred and obliterated. The disadvantages of the method are that in spite of strict adherence to the technology of the sclerotherapy procedure after a short time (a year and a half), relapses develop in a large number of treated patients. In addition, the sclerosis method has strictly limited indications - local changes in the saphenous veins.

 A known method of treating varicose veins with an endoscopic method ("Varikosis und chronische Veneninsuffizienz in der Praxis", Sigvaris., 2. Auflage 1994., = 1994 by Ganzoni & Cie AG, St. Gallen / Switzerland., S. 22-23), which consists in performing in the projection of the enlarged vein small incisions through which an endoscope is inserted and pathologically altered veins are extracted. The modern endoscopic phlebectomy method has a good cosmetic effect, but the disadvantage of this method is the traumatic effect on the subcutaneous structures that does not differ from the traditional standard operation and the complexity of the intervention on perforating veins, requiring additional skin incisions, which reduces the initially expected good cosmetic effect.

 The closest way to the claimed is the method of percutaneous ligation of varicose saphenous veins (A.S. N 1618395, M.cl. A 61 17/00, 17/12 A 61 L 17/00, BI N 1, 01/07/91) consisting in the fact that the vein is stitched along its lumen and when stitching, a ligature soaked in 20% aqueous solution of ferric trichloride is used. The disadvantage of this method is the longitudinal flashing of the vein, since the preservation of even capillary blood flow in the vein lateral to the thread and maintaining the continuity of the vein sooner or later lead to its recanalization. In addition, impregnation of the filament with trichloride used as a phlebosclerosing procedure is significantly inferior to standard sclerosing preparations in its effect. Ultimately, these shortcomings lead to the rapid development of relapse of the disease.

 The objective of the present invention is to reduce the frequency of relapses in individuals with II-III degree of varicose veins with the maximum use of the principles of cosmetic effects and the fastest recovery.

 The task is achieved by the fact that before flashing on inconsistent perforating veins and in the case of an inconsistent ostial valve, NiTi clips with shape memory are applied to the mouth of the large saphenous vein, while after suturing the saphenous vein, every 2-3 days, a gradual additional tightening of the thread to complete sap vein crossings; 1-2 days after clipping and stitching of the veins, sclerosing of the dilated vein fragments with 1.5% thrombovar is additionally carried out.

 The existing methods for examining the venous system - phleboscopy, grafting, dopplerography, which help to establish a reliable topical diagnosis of the cause, the degree of expansion and impaired venous circulation in the saphenous and deep veins of the legs, allow avoiding surgical treatment of HRV of the lower extremities and applying gentle combined techniques. In addition, the use of combined methods for the treatment of CVT of the lower leg and thigh without degrees of obstruction of deep veins, without trophic changes in the skin (when correction of blood flow along the main deep veins is not required) is possible due to the anatomical structure of the saphenous veins: in the absence of blood flow they quickly fall off. Therefore, knowing the exact reason for the development of varicose veins, it is possible not to perform a standard phlebectomy, but to target the pathologically altered sections of the vein, “fragmenting” it, turning it off from the blood circulation and achieving obliteration. With this formulation of the question, there is no need to make large skin incisions, to destroy fiber with lymphatic vessels and small blood vessels along the vein being removed. Intervention is not accompanied by blood loss, is performed on an outpatient basis, after 5-6 days, the patient restores the original working capacity and domestic behavior. A good cosmetic effect is noted. In the majority of patients, the total duration of a staged exposure to the dilated veins is within 2 weeks. Up to a month and a half, it is necessary to wear an elastic bandage or stocking, upon termination of which it is revealed, if any, non-obliterated sections of veins as a result of treatment. If necessary, an additional effect is carried out until a stable clinical effect of recovery is obtained. The invention is illustrated in the drawing, where in FIG. 1 shows a diagram of an operation.

 The essence of the method is as follows.

 After a topical orientation in the location of pathologically altered perforating veins, altered sections of the saphenous veins 1, failed valves of the saphenous veins that cause retrograde discharge of blood, the following is performed: marking the sites of intervention with a solution of diamond green; the patient is laid on a dressing table, the saphenous veins fall. At the projection points of insolvent perforating veins or valves in the saphenous veins, which are the main cause of vein expansion, local anesthesia is performed with 0.25 or 0.5% novocaine solution. Skin incisions are made up to 8-10 mm long, subcutaneous tissue is dissected with a mosquito clip, fascia is divided, and a vein is detected. A special retractor is introduced from titanium nickelide and a clip 2 is applied to the vein with a narrow hemostatic clamp, also from titanium nickelide, which interrupts the blood flow in this area. In the case of staples at the mouth of the saphenous vein 3 from one access, they are superimposed two or three over the entire length to completely stop the flow of blood from all inflows. Wounds on the skin due to their small size, lack of bleeding, it is permissible not to suture, but to reduce their edges with a band-aid. The areas of greatest expansion and length of the altered veins are “fragmented” (intersected in stages subcutaneously) by flashing at a distance of no more than 10-15 cm from each other. Perpendicular to the vein after anesthesia with a solution of novocaine at the injection and puncture site, departing from the projection of the marked vein on both sides by approximately 0.5 cm, a thick (N 8-10) sterile thread 4 is carried out under the vein with a sharp needle. strive to pass the thread just under the vein and perpendicular to its axis, but not through the vein, as this leads to the rapid recanalization of this area and the relapse of the disease. The threads carried out in this way (their number varies depending on the length and tortuosity of the dilated veins) are tied on a gauze ball 5 as tightly as possible. Knotted knots should be easily untied if necessary, due to the fact that every 2-3 days the thread is untied, the gauze ball is removed, the skin is treated with an antiseptic, a new ball is laid and the thread is tied again, but more tightly, the thread under the skin should reach the surface by approximately 4-5 mm. On the 9-10th day after holding the threads, the vein due to the periodic pulling up of the thread completely intersects and obliterates. The vein fragmented in such a way falls and starts. For the entire period of treatment, a compression bandage is applied to the limb - an elastic bandage or stocking, removed by the patient only at night. 1-2 days after the clipping and stitching of the veins, sclerotherapy of the formed fragments with thrombovar diluted to 1.5% concentration begins to reduce the manifestation of phlebitis. The injection needle is inserted into the distal part of the vein fragment in the patient’s standing position, then the patient is placed, the limb is slightly raised so that the vein is emptied as much as possible and a sclerosing drug is administered. The introduction of 2 ml is sufficient in one fragment. As a rule, only a single sclerosis of each fragment is necessary. Despite the low concentration of thrombovar, the effect is achieved due to the cessation of blood flow in the bandaged area. In total, a bandage on the limbs is worn 1-1.5 months.

Clinical example
Patient Ch. 42 years old went to the surgeon on 4.12.95. The diagnosis was made: Varicose veins of the right lower leg and lower third of the thigh. Varicose expansion suffers during the 15 years that arose after childbirth, the maximum changes in veins occurred within a year. Periodically wore an elastic stocking. Six months before coming to the surgeon, periodic pain began to appear along the dilated veins, convulsions. When bandaging the limbs feels significant relief. Objective status: in the middle third of the leg, the expanded veins are contoured in the form of four convoluted cords, 12-15 cm long, converging in the upper third of the leg to a large knot. On the thigh, the dilated vein continues with one trunk 1.5 cm in diameter, ending in the lower third along the inner surface.

 When retrograde phleboscopy with a tourniquet applied in the upper third of the thigh with the introduction of 40 ml of a 30% urographin solution, it was found that the shape and degree of expansion of the saphenous veins coincided with a visual assessment. In the lower third of the thigh and upper third of the lower leg between the dilated large saphenous vein of the popliteal, femoral vein, there are direct, unsuccessful communicants. Valves in the large saphenous vein and its tributaries throughout all the enlarged areas are untenable - there is a retrograde blood flow and a "pendulum-like" blood movement in pathologically altered veins. In the middle, upper third of the thigh, the ostial valve of the mouth of the great saphenous vein is wealthy, patency of the deep veins of the lower leg and femoral vein is not impaired, their valve apparatus is preserved. Evacuation of contrast medium from deep veins within 30 seconds.

 Dopplerography was performed, with the help of which the projection of insolvent communicative veins in the n \ 3 thighs and in the \ 3 tibia was determined and marked on the skin of the lower leg and thigh. The projection of sections of the large saphenous vein with the largest number of failed valves was revealed.

 In the dressing room in the patient’s supine position (the dilated veins collapsed), local anesthesia with 0.5% novocaine solution (10-15 ml in each area) was performed at the marking points. Above insolvent communicative veins in the transverse direction, the skin is cut up to 1 cm in length. With a mosquito clip, subcutaneous fatty tissue is stupidly distributed, the thigh's own fascia is divided, and the desired perforating veins are found. A retractor was introduced and clips placed on the veins, single nodal sutures on the skin. The limb is raised above the table for the most complete emptying and subsidence of the dilated saphenous vein and its tributaries. In this position, the foot is laid on a raised platform. In marked areas, the vein is "sheathed" with threads: two on the thigh and four on the shin. The threads are tightly tied on gauze balls. Elastic foot bandage from the foot to the inguinal ligament.

 The patient is recommended to take analgesics for pain, restriction of the motor regime and she is allowed to go home. After two days, the condition is satisfactory. The feeling of moderate pulling pain in the area of the conducted threads was significantly reduced. Slightly limp. No swelling of the legs. At home, in a day, she did the usual work. On examination, the dilated veins are collapsed, a large trunk is slightly contoured in the area of the knee joint and in the c \ 3 lower leg. At the distal points of these sites, 3 ml of a 1.5% thrombovar solution were punctured. Gauze balls are replaced and threads are tied more tightly. Elastic bandage. Subsequent tightening of the threads after another 3 days. In the injection zone of the sclerosing drug, moderate local edema and hyperemia.

 On the 9th day from the moment of the "fragmentation", the threads were removed. All dilated veins are asleep. There is moderate hyperemia, swelling of the skin along their course and slight pain on palpation. Veins are felt in the form of dense cords. There is no feeling of bursting pain in the limb when wearing an elastic bandage. There is no swelling of the limb, it doesn’t limp when walking, and on the 6th day from the beginning of treatment I started to work (works as an economist). Indications for the additional introduction of sclerosing substance into any parts of the vein were not found. It is recommended to continue elastic bandaging of the limb during the day for another 2-3 weeks, periodically showing the surgeon for dynamic monitoring of the condition.

 The patient was examined after a year. He feels well, has no complaints. Leads a familiar lifestyle. The limb does not swell. Previously dilated veins are not visualized or palpated. In some areas, moderate hyperpigmentation of the skin persists. No recurrence of varicose veins was detected.

 Thus, the described outpatient treatment of varicose veins of the II-III degree allows you to achieve a stable good effect comparable to the effect of surgical phlebectomy, eliminating the trauma of the latter, to achieve a high cosmetic result and a quick recovery of disability in the patient.

Claims (3)

 1. A method of treating varicose veins, characterized in that NiTi clips with shape memory are applied to insolvent perforating veins, then at the sites of greatest expansion and the length of the altered veins at a distance of no more than 10-15 cm from each other perpendicular to the veins under the vein the threads are tied on a gauze ball, after which every 2-3 days a gradual additional tightening of the thread is carried out so that the thread comes to the surface by 4-5 mm until the subcutaneous vein crosses completely.  2. The method according to p. 1, characterized in that in the event of osteal valve insolvency, NiTi clips with shape memory are applied to the mouth of a large saphenous vein.  3. The method according to claims 1 and 2, characterized in that 1-2 days after clipping and stitching of the veins, sclerosing of the dilated vein fragments with a 1.5% thrombovar solution is additionally carried out.