RU2526271C1 - Method of scleroobliteration of perforant veins of shin - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: visualisation of a perforant by means of ultrasonic examination is carried out. Before introduction of a sclerosant by means of a syringe performed is circular subfascial introduction of a physiological solution in the paravasal space around the perforant vein until the lumen of the perforant vein reduces to a diameter smaller than 1 mm. 3-5 minute exposure is performed, local compression in the place of echo-controlled scleroobliteration is carried out, which is performed in a continuous mode for 2 days.

EFFECT: method increases efficiency of echo-controlled scleroobliteration of the perforant veins due to hydrocompression of the perforant, absence of the washing away effect and results in more intensive impact of the sclerosant on the wall of the affected vein, reduces risk of thrombosis of deep veins.

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Description

The present invention relates to medicine, namely to surgery, and can be used in the treatment of varicose veins of the lower extremities.

The prevalence of varicose veins of the lower extremities in the United States and Western Europe reaches 25% (Phlebology. A guide for doctors. Edited by Savelyev V.S. - Moscow, "Medicine", 2001. P. 438). In Russia, more than 30 million people suffer from various forms of varicose veins (Diseases of the main veins. Savelyev V.S., Dumpe E.P., Yablokov E.G. - Moscow, 1972. p. 440), of which 15% have trophic frustration. Today, varicose disease is characterized not only by an increase in the number of cases, but also by the tendency for varicose veins in young people.

High prevalence, rapid rejuvenation, as well as a significant number of relapses make the problem relevant, which requires the development of new technologies for the treatment of varicose veins.

In the pathogenesis of the terminal stage of venous insufficiency in varicose veins of the lower extremities, the defeat of perforating veins of the lower leg plays an important role. In addition, perforating veins preserved during surgical treatment are often the cause of recurrence of varicose veins even during prophylactic treatment in the postoperative period.

One of the principles of surgical treatment of varicose veins is the elimination of pathological reflux of blood from deep veins to the saphenous (Fundamentals of Clinical Phlebology. Edited by Shevchenko Yu.L., Stoyko Yu.M., Lytkina MI - Moscow, Medicine Publishing House , 2005. pp. 144-145).

A large number of surgical methods for dissociating perforants have been proposed, many of which are of historical value only [R. Linton 1938, 1953], and the rest confidently lose their position under the onslaught of minimally invasive treatments.

The general principle of surgical treatment is the physical destruction and ligation of a perforating vein using special instruments through a skin incision. Good results were achieved with endoscopic dissection of perforants (Fundamentals of Clinical Phlebology. Edited by Shevchenko Yu.L., Stoyko Yu.M., Lytkina MI - Moscow, Publishing House Medicine, 2005. P. 164-170). The known method provides a reduction in surgical injury due to the possibility of 1-2 cuts to clip or coagulate several failed perforating veins.

However, the known method is complicated in execution and requires the use of expensive endoscopic equipment. It is characterized by high invasiveness and low cosmetic outcome due to the formation of scars. Most often, such interventions are performed under general or regional anesthesia, which requires hospitalization of the patient with further prolonged temporary disability. The known method is not applicable for outpatient practice.

Attempts to bring therapy closer to outpatient conditions led to the use of the miniflebectomy method under local anesthesia. But in the known method, the operation is performed in the “blind” punch area - through a minimum skin puncture in the region of the punch marked in advance. It is necessary with a microsurgical hook to pick up the desired vein in the thickness of the tissues and pull it out of the wound for processing. However, in order to be sure that this is a perforating vein, it is necessary to see the site of perforation of the fascia (Fundamentals of clinical phlebology. Edited by Shevchenko Yu.L., Stoyko Yu.M., Lytkina MI - Moscow, Publishing House “Medicine”, 2005. P. 171-172).

Obviously, such “blind” methods are not able to absolutely guarantee the dissection of labeled perforant, and can also be accompanied by significant trauma to the lymphatic pathways and nerve fibers. As a consequence, the classic complications of the early postoperative period of the known method are paresthesia and lymphorrhea. In addition, the perforating vein is often destroyed before it leaves the wound. This is accompanied by bleeding from a dangling perforant and the development of hematomas. Also, cases of suppuration of postoperative wounds when working in the area of trophic disorders are not uncommon (ibid., P. 474).

Endovasal ECHO-controlled laser methods are known (Laser obliteration of veins for practicing physicians. Sokolov AL, Lyadov KV, Lutsenko MM - Moscow, Medpraktika-M, 2011. pp. 74-78). At the same time, a skin puncture of an insolvent perforating vein under ultrasound control is performed, a laser light guide is inserted through a puncture needle into the lumen of the vein, which is located at the fascia level and produces a laser effect. The entire process of laser coagulation is controlled by ultrasound.

The known method is well suited for outpatient practice and less traumatic than endoscopic ligation of perforants. However, the method is expensive, since in addition to the laser generator itself, disposable angiosurgical catheters and endovasal fibers are used. The effectiveness and safety of the method depends on the quality of the latter (Laser obliteration of veins for practicing physicians. Sokolov AL, Lyadov KV, Lutsenko MM - Moscow, Medpraktika-M, 2011. P. 27).

Another disadvantage of this method is that the visualization of the position of the fiber in the lumen of the perforating vein is often difficult due to the small size of the vein, which can lead to extravasation of the fiber and damage to surrounding tissue by laser radiation. Relatively large 16G-18G needles are used to perform percutaneous ECHO-controlled venous puncture with EVLK, which complicates the puncture process compared to thinner needles used in ECHO-controlled scleroobliteration.

In addition, the laser endovasal method has the risk of complications, for example, breaking off (with repeated use and improper processing of the fiber), migration of the fiber tip or annealing (when the fiber is moved inside the catheter) of the angiosurgical catheter, damage to the vessel wall, skin burns (Laser vein obliteration for practitioners doctors.Sokolov A.L., Lyadov K.V., Lutsenko M.M. - Moscow, Medpraktika-M, 2011. P.80-89). Due to the high radiation power necessary for guaranteed laser ablation of a perforating vein, thermal damage to surrounding tissues can occur, which leads to pain in the postoperative period. In addition, there is no guaranteed "protection" of the deep venous system from thermal injury and, as a result, from thrombosis of the sections of deep veins closest to the perforator (Laser obliteration of veins for practitioners. Sokolov A.L., Lyadov K.V., Lutsenko M. M. - Moscow, Medpraktika-M, 2011. P. 84).

For the prototype of the present invention, a well-known method for scleroobliteration of perforating veins of the leg is chosen, including visualization of the perforant using ultrasound, percutaneous puncture, introduction of a sclerosant into the perforant, ECHO control of its distribution and subsequent creation of compression in the form of a roller and the use of compression knitwear (Phlebology. Guide for doctors, edited by V. Saveliev - Moscow, “Medicine”, 2001. P. 456-463).

The known method is as follows.

The hands of the surgeon and assistant, the skin of the lower limb at the puncture site are processed as standard. For ultrasonic navigation, an ultrasonic device is used in B-mode with a digital linear sensor with a frequency of 9-11 MHz. The sensor is isolated using a sterile disposable latex nozzle. A sterile ultrasound gel is used as the ultrasonic medium. Using ultrasound (ultrasound) determine the place of puncture - the projection of the affected perforant. The linear sensor is placed longitudinally relative to the axis of the perforant, visualize its clearance. Percutaneous puncture of the perforant is performed under the control of holding the needle into the lumen of the vein using ultrasound. The puncture is carried out with a 5 ml syringe and a 24G needle. After the location of the needle cut in the lumen of the vein, a sclerosant solution is introduced in the form of a highly dispersed foam until the perforant is completely filled. Foam distribution is monitored by ultrasound. After removing the needle, an aseptic dressing with a pressure swab is applied to the puncture site. After that, compression jersey of the 2nd compression class is put on a limb.

The known method is cheaper and easier to use, well suited for outpatient practice, well tolerated by the patient, without the formation of temporary disability.

However, in the known method of ECHO-controlled scleroobliteration of perforating veins of the lower leg, the introduction of a sclerosant directly into the perforating vein has the risk of casting it into the deep venous system and, as a consequence, its thrombotic lesion. In addition, the known method may be ineffective as a result of rapid "flushing" of the sclerosant with pathological blood flow in the affected perforant. These negative factors are more often observed in perforating veins of small length (Cauquette group). That is why ECHO-controlled scleroobliteration is considered to be insufficiently radical and reliable way to separate insolvent perforants (Phlebology. A manual for doctors. Edited by V. Savelyev - Moscow, “Medicine”, 2001. Page 464).

Thus, the known method cannot guarantee both the performance of reliable ECHO-controlled scleroobliteration of the perforating bed and the absence of sclerosant casting into the deep vein system, which is fraught with thrombosis.

The task of the invention is to develop a method for scleroobliteration of perforating veins of the leg.

The problem is solved in that in the known method of sclerobliteration of perforating veins of the lower leg, including visualization of the perforant using ultrasound, percutaneous puncture, introduction of a sclerosant into the perforant, ECHO control of its distribution and the subsequent creation of local compression in the form of a roller and the use of compression knitwear, before the introduction of sclerosant with a syringe, a subfascial injection of physiological sodium chloride solution into the paravasal space of the wok is performed circularly a circle of a perforating vein until a reduction in the clearance of the perforating vein to a diameter of less than 1 mm is achieved, the exposure is maintained for 3-5 minutes, local compression is created at the site of ECHO-controlled scleroobliteration, which is continued continuously for 2 days.

The present invention meets the criteria of the invention of "novelty" and "inventive step", since in the process of conducting patent information research, no sources of scientific, technical and patent information have been identified that would discredit the novelty of the proposed method, as well as technical solutions with essential features of the invention .

The proposed method when used allows to obtain the following technical effect.

To date, the proposed method in the conditions of the Center for Phlebology conducted 12 ECHO-controlled scleroobliteration of perforating veins. Basically, according to the ultrasound data, damaged perforating veins with a diameter of 1.5 to 3.5 mm were found. In all cases, using the proposed method, it was possible to achieve complete obliteration of the perforant from the first session. There were no thrombotic complications in the deep vein system. Larger diameter perforators were obliterated without the development of thrombotic complications from the deep venous system, but there were cases of recanalization in the delayed period. Thus, the proposed method reduces the risk of deep vein thrombosis with ECHO-controlled scleroobliteration of perforating veins of the lower leg, regardless of the diameter of the damaged vessel. According to ultrasound, to achieve a stable obliteration effect, it is most advisable to use the proposed method with a damaged vessel diameter of 1.5-3.5 mm.

Thus, the proposed method improves the efficiency of ECHO-controlled sclerobliteration of perforating veins, due to the fact that when applying subfascial hydrocompression of the shin perforant, the lumen of the affected vessel is substantially narrowed or completely blocked, due to which the blood flow velocity in the vessel decreases sharply. This leads to an increase in the residence time of the sclerosant in the affected vein (the absence of the “flushing” effect) and, as a result, to a more intense effect of the sclerosant on the wall of the affected vein.

The proposed method reduces the risk of deep vein thrombosis. Due to the narrowing or complete overlap of the subfascial section of the perforant. With the help of hydrocompression, the blood flow from the affected perforant to the deep vein system is stopped and, as a result, the sclerosant is thrown in them. This leads to a significant reduction in the possibility of damage to the deep vein wall by a sclerosant and the development of acute deep vein thrombosis against the background of ECHO-controlled scleroobliteration of perforating leg veins.

The proposed method allows to reduce the period of temporary disability in outpatient treatment of varicose veins of the lower extremities, as well as reduce the cost of outpatient treatment due to the lack of the use of expensive equipment and supplies.

Thus, the proposed method allows to increase the efficiency of ECHO-controlled scleroobliteration of perforating veins of the lower leg and reduce the risk of casting sclerosant into the deep vein system.

The proposed method is as follows.

Before the procedure, the patient undergoes a detailed ultrasound duplex examination of the venous system of the lower extremities in orotostasis to identify all failed perforating veins. Identified flawed veins mark on the skin. After this, the patient is transferred to a horizontal position, the skin at the site of the proposed puncture is treated with standard non-staining antiseptics. For visualization using an ultrasonic device in B-mode with a digital linear sensor with a frequency of 10. '.. Hz. The sensor is isolated with a disposable sterile nozzle, and a sterile gel for ultrasound is used as the ultrasonic medium. An ECHO-graphic picture of the zone of the altered perforant is displayed with a clear visualization of the entire length of the perforating vein. Then, under ultrasonic control, using a disposable syringe with a capacity of 20 ml produce subfascial injection of physiological solution of sodium chloride into the paravasal space around the perforating vein. The introduction is carried out circularly around the perforating vein until the subfascial sodium chloride infiltrate reaches the “pillow” compressing the non-perforant. In this case, a reduction in the lumen of the perforating vein is achieved to a diameter of less than 1 millimeter. Only after achieving subfascial hydrocompression of the perforating vein, sclerosant is introduced in the form of a highly dispersed foam under the control of ultrasound into its lumen. After an exposure of 3 to 5 minutes, when the limb is motionless, a bandage is applied to the leg in the form of compression jersey of the 2nd compression class with local additional compression in the form of a latex roller at the site of ECHO-controlled scleroobliteration. After completion of the procedure, the patient is recommended to walk for 30 minutes. The compression effect in a continuous mode lasts for 2 days, in the future it is allowed to remove the bandage for hygiene procedures 2 times a day, control ultrasound examination after 1 week.

Clinical example

Patient J., born in 1975, turned to the Center for Phlebology with complaints of recurrent pain, heaviness, fatigue, swelling in the legs that occur in the evening after a long stay on the legs. More pronounced symptoms on the right. From the anamnesis: considers herself a patient for ten years, when she first felt the described symptoms. At the same time, she drew attention to the appearance of varicose veins on the right. In the future, the symptoms increased, the number of altered vessels increased. A patient in childhood suffered osteomyelitis of the right femur, was treated surgically, and complete remission was achieved.

From the data of an objective examination: respiratory organs without pathology, cardiac activity without pathology, hemodynamic, no disturbances were detected, abdominal organs without features, neurological status without features.

In local status: on the right thigh, a large number of retracted postoperative scars along the outer, anterior and inner surface is determined. Varicose nodes without signs of inflammation and telangiectasia are commonly defined.

According to the data of ultrasound examination of the venous system of the lower extremities: on the right is determined the failure of BPV (average diameter 4.5 mm), starting from the anastomosis, insolvent perforant of the middle third of the inner surface of the right thigh (diameter 4.2 mm), multiple and wealthy inflows of the BPV on the hip and lower legs.

It was decided to remove the BPV with its tributaries by ECHO-controlled scleroobliteration.

At the initial visit, under the control of ultrasound, puncture was introduced into the trunk of the BPV in the lower third of the thigh of the Fibro-Vane solution 3% - 2 ml in the form of foam.

A week later, with repeated ultrasound, obliteration was determined by the BPV trunk distal to the perforant of the thigh, the perforating vein itself and the proximal section of the BPV were passable. Fibro-vane solution 3% - 2 ml was introduced in the form of foam under the control of ultrasound directly into the perforant and the proximal section of the BPV trunk.

After another week, the same obliteration of the perforant was not achieved. Therefore, the introduction of a solution of Fibro-Vane 3% - 3 ml into the lumen of a perforant previously subjected to hydrocompression with a solution of sodium chloride 0.9% -6 ml by the proposed method. When the control ultrasound after 7 days revealed a complete obliteration of the perforant and the proximal section of the BPV. The deep venous system remained without signs of thrombosis.

Claims (1)

A method for scleroobliteration of perforating veins of the lower leg, including visualization of the perforant using ultrasound, percutaneous puncture, introduction of a sclerosant into the perforant, ECHO control of its spread and subsequent creation of local compression in the form of a roller and the use of compression knitwear, characterized in that before the introduction of sclerosant with using a syringe, a subfascial injection of a physiological solution of sodium chloride into the paravasal space around the perforating vein is circularly performed until reduce the clearance of the perforating vein to a diameter of less than 1 mm, withstand exposure in 3-5 minutes and create local compression at the site of ECHO-controlled scleroobliteration, which is continued continuously for 2 days.