At present, most medical institutions in China adopt the method of stripping the trunk of great saphenous vein and injecting sclerosing agent.
The traditional stripping of great saphenous vein has a history of 100 years. From 65438 to 0890, Friedrich Trendelenburg, a professor of surgery at Bonn University, Germany, began to popularize high ligation of great saphenous vein and superficial vein stripping, which are still in use today. 1907, babcock, a professor of surgery at Temple University in the United States, developed an endoluminal dissector, which is a slender metal body with an olive-shaped expansion at the head end, which is convenient for doctors to dissect veins.
Because of the long incision, great trauma and much pain, the traditional stripping of great saphenous vein usually makes the patient stay in hospital for about one week. In addition, traditional general anesthesia or spinal anesthesia also causes many postoperative adverse reactions, which requires long-term observation and bed rest. Postoperative patients have extensive subcutaneous hematoma, obvious pain, getting out of bed late and prone to deep vein thrombosis. In recent decades, stripping tools and methods have also been improved. However, the principle of stripping treatment has not changed in essence.
Later, many scholars thought that the simple stripping of great saphenous vein had poor effect and high recurrence rate, so they advocated "completely" stripping varicose veins on the calf. At that time, before the appearance of vascular ultrasound, extensive surgical stripping or sealing varicose veins in legs with sclerosing agent was considered as a "thorough treatment", but the terrible thing is that this concept has been used to this day. In fact, the postoperative recurrence rate of varicose veins after "radical treatment" is still high, and the literature reports that it is about 20~50%.
Injection of sclerosing agent for varicose veins is earlier than stripping of great saphenous vein. As early as 1835, Massachusetts state hospital tried injection therapy, but it could not be popularized because of its poor effect. In 1950s, due to the appearance of sodium morrhuate as sclerosing agent, sclerosing therapy was applied again. Because it doesn't need anesthesia, surgery and low cost, it was widely used in primary hospitals in China as early as the 1970 s, but injecting sclerosing agent is very risky. First of all, if the sclerosing agent is injected and extravasated, it will lead to skin necrosis. Second, once sclerosing agent flows into deep vein, it can lead to thrombosis, and in severe cases, pulmonary embolism occurs. Third, patients leave different degrees of pigmentation after treatment, which affects their appearance. The fourth is temporary nerve damage or visual impairment. Fifth, very few patients have anaphylactic shock.
The application of micro-foam technology in 1980s can not only make the plugging effect better, but also reduce the concentration and dosage of hardener and reduce the incidence of complications in the past. However, sclerosing agent injection for the treatment of great saphenous vein trunk has poor curative effect and high risk, and the clinical recurrence rate is high. Literature reports that the recurrence rate is more than 20% within two years, 80% within ten years, and the incidence of deep vein thrombosis is high.
Some medical institutions package sclerosing agents into "latest therapy", "thrombolytic therapy", "interventional therapy" and "nano-therapy", which is deceptive to some extent. At present, sclerosing agent is mostly used for telangiectasia, postoperative residue or as an auxiliary treatment of surgery.
Subcutaneous aspiration technique (Trivex)
The principle similar to "liposuction" is designed for patients with varicose veins in the lower leg. Locate varicose veins with subcutaneous light source, and then remove varicose veins with curettage system. This technique only needs to make two incisions on the calf, which solves the aesthetic problem of large varicose veins in the calf. In 2004, Zhang Qiang's vascular team carried out TRIVEX combined with endovascular laser surgery for varicose veins for the first time in China.
Scraping and aspiration technology is not suitable for the treatment of great saphenous vein trunk, and can not be implemented as a separate technology, and other means are needed. There is also planing and aspiration, which is not minimally invasive in the strict sense. It seems that there are fewer and smaller incisions, but the subcutaneous trauma is greater, and there will be more subcutaneous congestion after operation, and the risk of nerve injury is also greater. At present, TRIVEX is gradually fading out of the market.
Endoscopic transvenous devascularization
The serious lesion of communicating vein is an important factor in the formation of venous ulcer of lower limbs. Due to the malnutrition of skin around ulcer, the incidence of incision complications in the past surgical method of direct incision of deep fascia for vein ligation (LINTON operation) was high.
1988, Dr. Hauer of Germany first reported the use of endoscopic technique to puncture the subfascular vein. 1992, Dr. Antonel of the United States used subfascular CO2 inflation to expand the surgical field of vision. From 65438 to 0997, Dr. Zhang Qiang reported SEPS for the first time at the annual meeting of Asian endoscopy, and cut off the perforating vein with ultrasonic scalpel.
The advantages of SEPS operation are small incision, avoiding diseased skin and complete vein disconnection. However, the disadvantage is that vascular surgeons must master laparoscopic technique skillfully, which is difficult to operate and highly dependent on equipment.
Endovascular treatment of varicose veins
Laser endovascular occlusion (EVLT) is a kind of laser with special wavelength, which intervenes in the trunk of great saphenous vein through optical fiber and then thermally seals the vein.
The earliest laser used to treat varicose veins was 8 10nm, which was first proposed by new york doctor Robert. Later, Diomed introduced 9 10nm laser, and named the operation method EVLT. To some extent, this technique avoids a large number of complications such as subcutaneous hematoma and saphenous nerve injury caused by great saphenous vein stripping. However, literature review reports that the incidence of postoperative cord-like induration and phlebitis is as high as 50%. In addition, there are also cases of doctors being injured by lasers without protective covers.
200 1 The first report on semiconductor laser therapy in China was Jiang Vascular Team of Vascular Surgery of Shanghai Ninth People's Hospital. In 2002, Zhang Qiang's vascular team first reported the treatment of varicose veins with Holmium laser in China, and nearly a thousand cases were treated.
Because the laser emits energy at the head end, there will be venous perforation or incomplete closure. In addition, in clinic, doctors' inexperience and large caliber of great saphenous vein will lead to high postoperative recurrence rate. In recent years, the application of ring laser has alleviated the defects of laser therapy to some extent.
Intracavitary radiofrequency ablation (ClosureFast) was first introduced to Chinese mainland by Dr. Zhang Qiang's team on 20 15, and hundreds of cases were successfully performed. Its working principle is similar to laser surgery, but the way of releasing energy around it makes the effect of closing the trunk of great saphenous vein more reliable. Under the guidance of ultrasound, special swelling fluid was injected around the vein, which basically solved the problems of postoperative pain and insufficiency.
However, in clinic, the injection of swelling fluid and the use of intraoperative ultrasound have higher requirements for doctors and require a certain learning curve. The doctor's inexperience may lead to the failure of the operation and even the formation of deep venous thrombosis. In addition, injecting swelling fluid during operation will bring pain.
VenaSeal produced by Medtronic has the advantage of avoiding the injection of expansion liquid required by RF technology. Its principle is to use catheter to inject adhesive into vein to achieve the effect of sealing vein. At present, the mainland has not been listed, and the long-term effects and complications have yet to be verified.
ClariVein catheter uses a high-speed rotating guide wire to disperse the sclerosing agent 360 degrees on the vein wall. It is suitable for closing the trunk of large-caliber great saphenous vein. The advantages are no thermal damage, no need to use expansion liquid injection, and relatively reliable closure. At present, it has not been listed in Chinese mainland, and its complications are similar to sclerosing agent injection.
New trend: blood flow correction method for protecting vein
CHIVA operation is the least traumatic and painful of all minimally invasive operations. It was first introduced to China by Dr. Zhang Qiang on 20 1 1. At the beginning of 20 17, Dr. Zhang Qiang announced that CHIVA would completely replace other methods. CHIVA is the abbreviation of French Cure Conservation et Hemo Dynamique de l 'Assurance Veine Use en Ambulatory. This therapeutic concept was founded by French doctor F'ranceschi. CHIVA operation is contrary to the principle of destructive and abandoned operation in the past. Through detailed analysis of venous hemodynamics before operation, blood flow correction operation is carried out.
CHIVA has obvious advantages: (1) the trunk of great saphenous vein is preserved, which reduces trauma and can be used as a vascular graft material for other diseases in the future; (2) local anesthesia can be performed, and patients can walk below after operation without hospitalization; (3) Most of the veins are preserved, and there is almost no pain after operation, which avoids the injury of nerve and lymphatic reflux that may exist in other operations.
Cochrane released the results on 20 15. The recurrence rate of CHIVA operation is significantly lower than other traditional destructive operations, and the treatment effect and experience are better.
However, CHIVA has the following disadvantages: (1) It needs a professional intravenous doctor to personally evaluate the patient's ultrasonic hemodynamics, which takes at least 20 minutes. (2) The theoretical system is complex, the training period is long, and the number of doctors who master this technology is very small, which limits its popularization. (3) Outpatients must be equipped with ultrasonic equipment, which increases the cost. (4) Some doctors use nonstandard techniques to impersonate CHIVA by "segmental ligation", taking patients from their work units to private hospitals outside to earn extra money, which leads to ineffective treatment and subsequent complications, bringing great pain to patients and their families.
Future prospects
The safe, personalized, relaxed and happy treatment concept will gradually replace the traditional destructive surgery. How to deeply understand the individualized essence of hemodynamics and the therapeutic logic behind it will become the proposition of a new generation of venous surgeons.