RU2740468C1 - Method for total stripping of a greater saphenous vein in acute varicothrombophlebitis of lower extremities - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to phlebology. Great saphenous vein (GSV) suction is performed within 10 days from onset of disease. Prior to probing through graft GSV superfascial dressing of perforating veins and thrombotic vein phlegbosis is performed with evacuation of thrombotic masses. Then, after flexible vein extractor is introduced through GSV lumen first into fascial box of vessel from medial malleolus to upper third of shin to area of knee joint is introduced 100-150 ml of normal saline, depending on the depth of GSV and the soft tissue volume of the shin in a specific patient. Then, after selection of the corresponding olive, the value of which depends on the width of GSV, and preliminary tying of the vein on the probe, antegrade stripping of GSV is performed in the direction from the medial malleolus to the groin. When tensioning GSV tributaries during stripping, traction is stopped and tributary with barrel is disconnected by isolating influx from mini-puncture with the help of Mueller hook. Proximal end of the inflow is cut off with further continuation of traction, the distal end is twisted by means of clamps and / or ligatured. After removal of GSV for 5-7 minutes, manual compression of the GSV bed is performed all along for haemostasis. Before the sutures are applied in the place of the incisions with the tightly rolled tampon, the blood clots are evacuated from the wound, after which the wound is closed and the bandage is elasticly bandaged to the groin.

EFFECT: method allows to increase the results of surgical treatment of acute varicothrombophlebitis of lower extremities (AVTP), due to total antegrade stripping of GSV, as well as to reduce the rate of developing neurological disorders and postoperative lymphorrhea.

1 cl, 2 ex

Description

The invention relates to the field of surgery, in particular to phlebology, and can be used in operations for thrombosis of varicose veins of the lower extremities.

The issue of treatment of acute varicothrombophlebitis (OVTF) remains open today. According to Kirienko A.I., Matyushenko A.A., Andriyashkin V.V. With the help of full-scale surgical intervention on varicose and perforating veins of the lower extremities in varicothrombophlebitis in many cases, the main therapeutic tasks can be solved with high reliability: prevention of deep vein thrombosis, rapid relief of the disease and prevention of its recurrence [1]. A radical operation not only quickly cures thrombophlebitis, but also eliminates the very cause of its occurrence - varicose veins, thereby guaranteeing the patient from recurrence of the disease and from the progression of chronic venous insufficiency.

Di Nisio M. et al. after a systematic review of the treatment of this disease, it was concluded that in most cases, anticoagulant therapy with fondaparinux for 45 days is acceptable. However, on the other hand, they note the need for an adequately planned study to determine the role of topical therapy, as well as surgical treatment of this pathology [2]. It should be noted that recurrence of OVTF in the long-term follow-up after conservative therapy develops in 7.5-20% of patients, and in 14.3% thrombosis from the saphenofemoral anastomosis spreads to the femoral vein, which can cause the development of venous thromboembolic complications [3].

Radical surgical treatment for OVTF involves the removal of all varicose veins (thrombosed and non-thrombosed), as well as dissection of insufficient perforators, which eliminates the need for further treatment of varicose veins and practically negates the likelihood of recurrence of OVTF [1, 3, 4]. However, in up to 50% of cases after radical phlebectomy, damage to the cutaneous nerves occurs, and besides, the intervention on the thrombosed veins can be traumatic, requiring general or regional anesthesia [5]. The issue of surgical treatment of OVTF should be considered only after a thorough ultrasound assessment of the affected limb, including a scrupulous assessment of all large perforating veins [4].

A fairly standard volume of radical phlebectomy for acute varicothrombophlebitis in the GSV basin is crossectomy and GSV stem venectomy on the thigh [1, 3, 4]. However, in a significant part of patients with OVTF, it is necessary to remove the GSV trunk and on the lower leg.

The purpose of the invention is to improve the results of surgical treatment of lower extremity OVTF by developing a technique for total antegrade stripping of GSV, characterized by low frequencies of neurological disorders and postoperative lymphorrhea.

The goal is achieved by the fact that in the method of performing total antegrade stripping of the great saphenous vein (GSV) in acute varicothrombophlebitis (OVTF) of the lower extremities, stripping is performed within 10 days from the onset of the disease, before passing the probe through the GSV trunk, suprafascial ligation of the perforating veins and venouscentesis of thrombosed with the evacuation of thrombotic masses, and then after passing a flexible venextractor through the lumen of the GSV, 100-150 ml of saline is injected into the fascial case of the vessel from the medial ankle to the upper third of the leg to the knee joint area, depending on the depth of the GSV and the volume of soft tissues of the lower leg in a specific patient; 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 ankle to the groin; when pulling the BPV inflows during stripping, the traction is suspended and the inflow is disconnected from the trunk, separating the inflow from the mini-puncture using the Muller hook, while the proximal end of the inflow is cut off with the subsequent continuation of traction, the distal end is unscrewed with clamps and / or tied; then, after removal of the GSV, manual compression of the GSV bed is performed for 5-7 minutes for the purpose of hemostasis; before suturing at the site of incisions with a tightly rolled tampon, the accumulated blood clots are evacuated from the wound, after which the wound is sutured and elastic bandaging of the lower limb is performed to the groin.

The method is implemented as follows:

With OVTF of the lower extremities, we performed a one-stage radical phlebectomy, which consisted in carrying out radical surgical treatment within 10 days from the onset of the disease. Before passing the probe through the GSV trunk, if necessary, we performed suprafascial ligation of perforating veins and phlebocentesis of thrombosed veins with evacuation of thrombotic masses. When performing antegrade total stripping of GSV during OTRF, saline is preliminarily introduced into the fascial case of GSV along the length of the leg. This creates the effect of hydro-preparation, in which the GSV is separated from the saphenous nerve and lymphatic tracts and the likelihood of damage to these structures due to total stripping decreases.

The proposed method was used in 23 patients with OVTF. The development of a technique for total antegrade stripping of GSV makes it possible to perform radical phlebectomy for varicose transformation and valvular insufficiency of the GSV trunk along the entire length in patients with PRRF of the lower extremities. During the application of this method, the minimum percentage of complications was noted (17.4%):

случаев рефрактерной парестезии голени, гнойных осложнений отмечено не было;

cases of refractory paresthesia of the lower leg, purulent complications were not observed;

преходящие (до 3 месяцев) нарушения чувствительности отмечены у 3 больных с ОВТФ;

transient (up to 3 months) sensitivity disorders were noted in 3 patients with OVTF;

лимфоррея из послеоперационных ран отмечалась у 1 больного. Купирована консервативно, без дополнительного прошивания тканей.

lymphorrhea from postoperative wounds was observed in 1 patient. Cropped conservatively, without additional stitching.

Example 1

Patient G., 58 years old, independently went to the clinic with complaints of pain in the right lower extremity, reddening of the skin of the medial surface of the leg and thigh, the presence of a painful cord-like cord along the varicose vein, skin edema in the vein projection. According to the words, pain appeared 3 days before going to the hospital. She notes the presence of a small injury to the medial surface of the lower leg, after which the next day a cordlike painful thickening appeared at the site of the injury. History of varicose veins of the right lower extremity for about 10 years, was treated independently. The day before the visit, he began to notice the appearance of edema and hyperemia of the skin, the spread of the cord-like cord along the vein above the knee to the lower third of the thigh. On examination of the right lower limb, there is hyperemia and edema of the skin from the middle third of the leg to the lower third of the thigh in the projection of the trunk of the great saphenous vein. On palpation, pain is noted at the site of the lesion, the presence of a cord-like cord from the middle third of the lower leg and lower third of the thigh, and local hyperthermia. Palpation of the leg muscles is painless. With ultrasound duplex angioscanning of the right lower extremity, deep veins (common femoral vein, popliteal vein, venous sinuses of the leg, deep veins of the leg) are passable, when compressed by a sensor, the walls are completely compressible, during the Valsalva test there are no signs of valve failure (reflux less than 0.5 sec) , the blood flow through the veins is phase, coupled with breathing. The volumetric blood flow velocity in the common femoral vein is 7.2 ml / sec. The great saphenous vein is varicosely transformed along its entire length, expanded to 15 mm at the thigh, up to 11 mm at the lower leg. When examining the great saphenous vein, signs of occlusive thrombosis of its trunk and medial varicose transformed tributaries from the middle third of the leg to the upper third of the thigh are noted, the proximal end of the thrombus is located 10 cm from the saphenofemoral fistula; when compressed by the sensor, the walls are not compressible. The perforating veins (3) of the lower leg of the Cockett zone are passable, there are no signs of thrombosis, the presence of pathological reflux is noted for more than 1 sec. The small saphenous vein is passable throughout, well-to-do. At typical points of echolocation of the main arteries, the main blood flow is noted, there are no data for stenoses. Diagnosis: acute varicothrombophlebitis of the GSV trunk and tributaries of the right lower limb. Given the high risk of developing venous thromboembolic complications, the occurrence of thrombophlebitis against the background of long-term varicose veins of the lower extremities, early from the moment of thrombosis, the patient underwent an urgent radical phlebectomy under general anesthesia with total antegrade thrombosis of the great saphenous vein and after removal of phlebectomy according to the proposed method. The postoperative period was without complications, without disturbances in sensitivity and lymphorrhea. The stitches were removed on day 9, with primary wound healing. The patient was examined after 6 and 12 months. - there are no data for relapse of varicose veins and thrombophlebitis.

Clinical example No. 2

Patient K., 67 years old, was admitted to the clinic on January 20, 2016 with complaints of pain along the varicose veins on the right thigh and right leg, the presence of redness of the skin and swelling in this area, malaise, weakness. She fell ill acutely 3 days ago when the above complaints appeared. A history of more than 40 years of the presence of varicose veins of the lower extremities, which appeared during pregnancy and childbirth. She was treated independently, conservatively. For about 10 years, transient edema of the legs has been disturbing.Status localis: when examining the right lower limb, there is hyperemia and edema of the skin from the middle third of the lower leg to the upper third of the thigh in the projection of the trunk of the great saphenous vein, as well as varicose medial tributaries. On palpation, there is marked local pain, the presence of a cord-like cord from the middle third of the leg and lower third of the thigh, and hyperthermia. Palpation of the leg muscles is painless. There are no trophic disorders. The pulsation is distinct at all points.

With ultrasonic duplex angioscanning of the right lower extremity, deep veins (common femoral vein, popliteal vein, venous sinuses of the leg, deep veins of the leg) are passable, when compressed by a sensor, the walls are completely compressible, during the Valsalva test, there are no signs of valve failure (reflux less than 0.5 sec. ), phase blood flow through the veins, coupled with respiration. The greater saphenous vein varicosely transformed all the way to the medial ankle, expanded to 21 mm at the thigh, up to 12 mm at the lower leg. In the study of the great saphenous vein, signs of occlusive thrombosis of its trunk and medial varicose transformed tributaries from the middle third of the leg to the upper third of the thigh are noted, the proximal end of the thrombus is located in the saphenofemoral junction, with the presence of a floating head 5 cm long.No leakage or thrombosis of perforating veins was revealed ... The small saphenous vein is passable throughout, well-to-do. At typical points of echolocation of the main arteries, the main blood flow is noted, there are no data for stenoses. Diagnosed with acute ascending varicothrombophlebitis of the GSV trunk and tributaries of the right lower limb. Given the high risk of developing venous thromboembolic complications, the occurrence of thrombophlebitis against the background of long-term varicose veins of the lower extremities, early from the moment of thrombosis, the patient underwent an urgent right under general anesthesia under general anesthesia. A 5-cm cut along the right inguinal fold revealed the GSV trunk. Varicose transformation of the near-mouth section of the GSV up to 2.0 cm in diameter. The GSV trunk is occlusively thrombosed to the point of confluence with the common femoral vein. The peri-osteoarthritis of the GSV was isolated over a length of 8 cm, taken on holders, an oblique transverse venectomy 1.5 cm was performed 2 cm before the SPS - a floating thrombus of the sapheno-femoral anastomosis 6 × 1.5 cm was removed. Treatment of the Delbe's beam. At the medial malleolus, a 1.5 cm incision was made to reveal the source of the GSV trunk - loose thrombotic masses in the lumen. A flexible probe is inserted inside the lumen and is fixed. Antegrade stripping of the thrombosed GSV trunk was performed throughout the entire length (after preliminary hydropreparation in the form of injecting 150 ml of saline into the fascial case of GSV along the leg). Miniflebectomy of thrombosed medial varicose tributaries on the right thigh was performed using Müller hooks from separate mini-skin punctures 3-4 mm long. Layer-by-layer closure of wounds. Tight aseptic bandage. Elastic bandage. The postoperative period was without complications, without disturbances in sensitivity and lymphorrhea. In the postoperative period, antibiotic therapy was carried out (parenteral cephalosporins for 5 days), phlebotonics, antiplatelet agents were prescribed (thrombosis 100 mg once a day). Round-the-clock elastic compression was carried out with a high elongation bandage on the right lower limb, and a compression stocking of the II degree of compression on the left lower limb. The stitches were removed on day 9, with primary wound healing. The patient was discharged on the 9th day. The patient was examined after 6 and 12 months. - there are no data for relapse of varicose veins and thrombophlebitis.

LITERATURE

1. Kirienko A.I. Acute thrombophlebitis / A.I. Kirienko, A.A. Matyushenko, V.V. Andriyashkin - M .: Litterra, 2006 .-- 108 p.

2. Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database of Systematic Reviews 2018, Issue 2. Art. No .: CD004982.

3. Tsarev O.A., Anisimov A.Yu., Prokin F.G., Zakharov N.N., Lobanov A.V., Senin A.A. Acute varicothrombophlebitis: current state of the problem (review). Saratov Journal of Medical Scientific Research 2018; 14 (1): 87-94. [Carev O. A., Anisimov A. YU., Prokin F. G., Zaharov N. N., Lobanov A. V., Senin A. A. Ostryj varikotromboflebit: sovremennoe sostoyanie problemy (obzor). Saratovskij nauchno-medicinskij zhurnal 2018; 14 (1): 87-94. (In Russ.)].

4. Blattler W., Schwarzenbach B., Largiader J. Superficial vein thrombophlebitis - serious concern or much ado about little? VASA 2008; 37: 31-38 https://doi.org/10.1024/0301-1526.37.1.31.

5. 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 LA. Taktika lecheniya ostrogo voskhodyashchego tromboflebita. Flebologiya. 2011; 3: 46-52. (In Russ.)].

Claims (1)

A method for performing total antegrade stripping of the great saphenous vein (GSV) in acute varicothrombophlebitis (OVTF) of the lower extremities, characterized in that stripping is performed within 10 days from the onset of the disease, suprafascial ligation of the perforating veins and venouscentesis of thrombosed veins are performed before the probe is passed through the GSV trunk evacuation of thrombotic masses, and then, after passing a flexible venextractor through the lumen of the GSV, 100-150 ml of saline is injected into the fascial case of the vessel from the medial ankle to the upper third of the leg to the knee joint area, depending on the depth of the GSV and the volume of soft tissues of the lower leg in a particular sick; 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 ankle to the groin; when pulling the BPV inflows during stripping, the traction is suspended and the inflow is disconnected from the trunk, separating the inflow from the mini-puncture using the Muller hook, while the proximal end of the inflow is cut off with the subsequent continuation of traction, the distal end is unscrewed with clamps and / or tied; then after removal of the GSV for 5-7 minutes, manual compression of the GSV bed is performed along the entire length for the purpose of hemostasis; before suturing at the site of incisions with a tightly rolled tampon, the accumulated blood clots are evacuated from the wound, after which the wound is sutured and elastic bandaging of the lower limb is performed to the groin.