TREATMENT OF TROPHIC ULCERS IN PATIENTS WITH CHRONIC VENOUS INSUFFICIENCY USING PHOTHOTHERAPY AND HETEROTRANSPLANT

Summary. Purpose. The improvement of the treatment effect of patients with a decompensated form of the chronic venous insufficiency. Reduction of the reatment period in a hospital by application of the complex treatment. Materials and methods. The work was based on the studies of 24 patients who had trophic ulcers on the lower leg. All patients have undergone combined treatment, including scleroobliteration of perforating veins, phototherapy, platelet-derived growth factor, the use of wound closure with a heterograft. Results and discussion. The combined use of phototherapy and platelet-derived growth factor has significantly reduced the duration of all phases of the wound process. The ultrasound-controlled scleroobliteration has helped to remove a pathological reflux in the insolvent tibial perforators. The studies have shown that the use of phototherapy in the treatment of trophic ulcers with the application of the heterograft has contributed to the rapid cleansing of wounds, accelerating the appearance of granulations and epithelialization, has reduced the need for antibacterial therapy and is an alternative to autodermoplasty. Conclusions. The use of the offered technique allows to reach optimum restoration conditions of the affected fabrics trophism, leads to the decrease in the number of complications and reduces the hospitalization period.

CLINICAL ANATOMY OF THE PERFORATING VEINS OFTHE PROXIMAL LOWER LIMBS

Objective. To clarify the topographic and anatomical feature of the perforating veins (PVs) in the proximal part of the lower extremity. Methods. 70 amputated lower extremities from the patients with severe ischemia were subjected to sectional anatomical study; 2800 patients with varicose disease underwent lower extremity sonography. Results. PVs were primarily located on the medial surface of the thigh. In the upper third of the thigh PVs drain into superficial femoral vein. It was detected that one or two PVs occur sin the lower third of the hip draining into superficial femoral vein and originating from the great saphenous vein in 73.6% cases. All PVs were accompanied by an arterial branch from the superficial femoral artery. Anatomical sectional study revealed that a nervous branch accompanied PVs in the lower third of the thigh. Two or four PVs were detected on the lateral surface of the thigh. PVs in the popliteal fossa could be referred to as “atypical” due to their rare occurence (0.4% of cases at sonography) in combination with absent typical sapheno-popliteal junction. PVs in this area were not supported by the intermuscular septa. PVs drained laterally into popliteal vein of the lower limb in 100% cases, while small saphenous vein drained into great saphenous vein in the upper third of the leg or into the intersaphenous vein. Conclusion. Perforating veins constitute perforating bundles (PV, arterial branch, nervous branch), which are predominantly located along the intermuscular septa, which create a constant and strong orientation along the direction of the great vessels. This ensures stable hemodynamics of great vessels and perforating complexes and does not allow squeezed tham togeter during physical exertion. What this paper adds For the first time it has been proved that the perforating veins of the gluteal region pass through the fascia and the thickness of the gluteus maximus muscle and enter the superior and inferior gluteal veins, being transmuscular perforating veins. For the first time it has been established that the location of the femoral perforating veins along the intermuscular septa allows preserving the hemodynamics of the perforating complexes without any squeezed in physical exertion.

Anatomy of Perforating veins of the lower limb

ZusammenfassungDie Perforansvenen (PV) der unteren Extremitäten sind nicht nur gerade und direkte Verbindungen zwischen den tiefen und oberflächlichen Venennetzen, sondern bilden gemeinsam ein weit verzweigtes Netz. Trotz ihrer starken anatomischen Variabilität ist ihre Position bemerkenswert konstant und prognostizierbar. Dies ist durch ihre enge Beziehung zu den Muskelvenen bedingt und durch die hämodynamischen Ebenen entlang der Extremität zu erklären. Sie sind bei der Beurteilung durch Ultraschalluntersucher in der täglichen Praxis eine Hilfe.Der anatomische Inhalt dieses Artikels stammt aus folgenden Quellen: Anatomische Präparationen von C. Gillot nach Latex-Injektion und anschließender farblicher Unterteilung von über 400 Extremitäten. Dreidimensionale Rekonstruktionen von CT-Venografien von 1200 Extremitäten und präoperativen Hautvenenvermessungen von 25 000 Extremitäten.Es wird Folgendes beschrieben: Referenzpunkte der Extremität, Perforansvenen des Fußes, Beins und Sprunggelenks, der Wade, Anastomosen zwischen den Perforansvenen, Begleitarterien der Bein-PVs und Oberschenkel-PVs.

Perforating veins incompetence. Clinical aspects and evaluation mode

This manuscript represents a literature review on evaluation mode of perforating vein incompetence and its clinical impact on chronic venous disease development. Perforating veins (PV) serve as a complex anatomical and functional structure which incompetence indicates possible pathological processes in superficial and deep veins. PV almost never become a reflux source and though never require to be treated to abolish its incompetence. At the same time accurate diagnostic evaluation of PV condition must be performed to distinguish PV incompetence from PV compensatory changes that correct effects of vertical venous refluxes.

CHOICE OF TACTICS OF SURGICAL TREATMENT OF VARICOSE DISEASE DEPENDING ON THE VARIANT OF THE ANATOMICAL STRUCTURE OF SAPHENO-POPLITEAL ANASTOMOSIS IN DOPPLEROMETRY OF THE VENES OF THE LOWER LIMBS

Summary. The aim of the study is to determine the variants of the anatomical structure of the saphenopliteal anastomosis in ultrasound Doppler of the veins of the lower extremities, including as sources of pathological blood reflux in varicose veins of the small saphenous vein basin, and the importance of insolvent veins in the formation of insufficiency in the small saphenous vein basin to clarify the further protocol treatment. Materials and methods. The venous system of 2348 patients was studied, including both patients with various pathologies of the venous system, including those with varicose veins, and those in whom the pathology of the veins was not detected by USDG. Results and discussion. In patients with USDG, various anatomical variants of the structure of the sapheno-popliteal anastomosis were found. The anastomosis may look like a perforating vein and have a fairly sharp angle of deviation from the trunk. In these cases, it is recommended to conduct an open surgical intervention, namely: crossectomy — ligation and transection of the small saphenous vein, striping — removal of the trunk of the small saphenous vein, ligation of insolvent communicative veins, miniflebectomy - removal of varicose nodes through punctures. The smooth course of the sapheno-popliteal anastomosis was found in 58.0 % of the subjects and did not depend on the level of the anastomosis. In such cases, the option of choice for surgical intervention was minimally invasive technologies: laser coagulation, radiofrequency ablation, as well as combined phlebectomy, which includes the following stages - removal of varicose inflows of the small saphenous vein and elimination of incompetent perforating veins. Indirect variants of the anastomosis turned out to be frequent, for example, through the sural or nonsaphenic vein with the presence of additional venous vessels (up to 18.0 % of those studied). In these cases, the level of the anastomosis was also formed below the knee joint gap. According to the USDG data, the anatomical absence of the sapheno-popliteal anastomosis was found only in 142 patients, which is less than 1.0 %. In such patients, a search and elimination of pathological reflux is performed, which leads to the development of varicose veins in the system of the small saphenous vein. Its varicose inflows are removed and insolvent perforating veins are eliminated. Conclusion. The specialists’ understanding of the variants of the structure of the saphenopliteal anastomosis in normal and pathological conditions, as well as the observance of the full examination protocol for venous ultrasonography, allows providing detailed information in order to determine the most effective treatment tactics and prevention of disease recurrence.

A randomized clinical trial of the effects of saphenous and perforating veins radiofrequency ablation on venous ulcer healing (VUERT trial)

Objectives To investigate whether radiofrequency endovenous ablation (RFA) of saphenous and perforating veins increases venous leg ulcer (VLU) healing rates and prevents ulcer recurrence. Method This prospective, open-label, randomized, controlled, single-center trial recruited 56 patients with VLU divided into: compression alone (CR, N = 29) and RFA plus compression (RF, N = 27). Primary endpoints were ulcer recurrence rate at 12 months; and ulcer healing rates at 6, 12, and 24 weeks. Secondary endpoints were ulcer healing velocity; and Venous Clinical Severity Score (VCSS). Results Recurrence was lower in the RF group (p < .001), as well as mean VCSS after treatment (p = .001). There were no significant between-group differences in healing rates. Healing velocity was faster in the RF group (p = 0.049). In the RF group, 2 participants had type 1 endovenous heat-induced thrombosis (EHIT). Conclusions RFA plus compression is an excellent treatment for VLU because of its safety, effectiveness, and impact on ulcer recurrence reduction and clinical outcome. Registration: Clinicaltrials.gov, NCT03293836, clinicaltrials.gov.

Endothermal ablation for the treatment of clinically significant incompetent lower limb perforating veins: factors influencing the early outcomes

Background To review the clinical experience and early outcomes of endothermal perforator ablation. Method Retrospective review of an endovenous practice from 2007-2019. Clinically significant incompetent perforators were treated by Endovenous Laser Ablation (EVLA), or segmental radiofrequency ablation (RFA). Result Complete data were available for 110 of the 116 symptomatic incompetent perforating veins treated. Radiofrequency ablation of 20 perforators produced a 55% perforator closure rate, while 90 EVLA perforator ablations resulted in a closure rate of 80%. Closure rates with EVLA varied by location and perforator length. Closure rates for truncal ablation were 95.5% for RFA and 97.2% for EVLA. Conclusion Early closure rates following endothermal ablation of incompetent lower limb perforating veins are lower than those obtained for truncal ablation. EVLA perforator closure appears to be more effective than segmental RFA in most situations but short treatment lengths and location at the ankle are associated with the poorest outcomes.

SURGICAL TREATMENT OF CHRONIC VENOUS DEFICIENCY OF LOWER EXTREMITIES

Summary. The aim. Improving the results of treatment of patients with decompensated forms of chronic venous insufficiency in post-thrombophlebitic and varicose diseases based on the use of differentiated pathogenetically substantiated surgical tactics. Materials and methods. The basis of the work is the study of the results of surgical treatment of 102 patients not previously operated on with postthrombophlebitic disease of the lower extremities in the decompensated stage of CVI. All patients underwent combined surgical treatment, including the elimination of perforating insufficiency and various modifications of the operation on the superficial veins to eliminate vertical reflux. Results and discussion. The combined operation for clipping perforating veins allows the operation to interrupt blood circulation through insolvent perforating veins, including on an outpatient basis, minimizing tissue trauma during puncture rather than sectional access to a vein. The cosmetic effect of the operation is significantly increased, which is especially important in the treatment of women. Since the operation can be performed on an outpatient basis, the number of days of incapacity for work is significantly reduced compared to standard operations on perforating veins, which is a particularly important circumstance in modern economic conditions. Conclusion. Using the proposed method allows to achieve optimal conditions for the restoration of trophism of affected tissues, leading to a decrease in the number of complications and a reduction in hospitalization.