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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4087_Библиотеки_им_академика_М_И_Перельмана

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Page36
"Ghislain&MarieDaviddeLossy/theImageBank,©1999"
ifyouhaveseverevaricoseveins,youcanhavethemtreatedbyinjections
orsurgeryfromafewweeksafteryourbabyisborn.
deliveryisperfectlysatisfactoryforeitherinjectionorsurgicaltreatment,whicheverisrightforyourparticularcondition.
SpiderVeinsorSpiderNaevi
Thesetiny,dilatedbloodvesselsintheskinofthethighsoftenseemtomaketheirfirstappearanceduringpregnancy,buttheycausenoharmandshouldbeleftalone.
Weshallbedealingwiththeseinmoredetailonpage110.
VulvalVeins
Itisduringpregnancythatthesurfaceveinsofthevulva(aroundtheentrancetothevagina)andontheinnersideofthetopofthethighsometimesexpandandbecome
varicose.Indeed,theyhavebeenknowntodevelopquiterapidlyandcanbearatheralarmingsightbyaboutthethirdorfourthmonthofthepregnancy.
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Althoughugly,andindeedsometimesratherfrighteninginappearance,theseveinsveryrarelygiverisetoanytroublesuchasbleedingorclottingeitherduringthe
pregnancyorduringdelivery.Assoonasthebabyisborn,theybegintoshrinkandoftendisappearcompletely.
Notreatmentisadvisedduringpregnancy,butyoucanbeassuredthattheconditioniscompletelyharmlessandwillgreatlyimproveonceyourbabyhasbeen
delivered.Itistruethattheveinsmaystillbevisibleafteryourconfinementandmayrequiresurgicalremovalthroughoneortwotinyskinincisions.Althoughsome
doctorsrecommendinjectiontreatmentforthesevulvalvaricoseveins,mostsurgeonsconsiderthatasmalloperationismoreeffectiveandlessuncomfortableforthe
patient.Sometimesvulvalveinscanberelatedtoreflux(orbackflow)ofbloodintheovarianveins,deepinsideyourabdomen.Thesecanberelatedtoafeelingof
heavinessinthepelvisespeciallyjustbeforeaperiodisdue.Thisconditionhasbeentermedpelviccongestionsyndrome.Yourdoctormaywantsomespecialteststo
findoutexactlywhichveinsareincompetentandthesetestswillbedescribedinChapter5.
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Chapter5—
Investigations
Thediagnosisofvaricoseveinsisusuallyonlytooobvious,butthischapterdescribessomeofthesophisticatedinvestigationswhicharenowavailableandwhich
enablethesurgeontoobtainanaccuratepictureofthedistributionofthevaricoseveinsandtheirperforatorsintothedeepveinsoftheleg.
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Ifyourvaricoseveinsarestraightforward,yoursurgeonmaynotrequireanyfurtherteststofindoutwherethesitesofconnectionaretothehighpressuredeep
venoussystem.However,therearecertainconditionsthatmayrequirefurthertests.Ifyouhavehadathrombosisofthedeepveinsintheleg(adeepveinthrombosis,
orDVT)foranyreason,yourdoctormaywanttomakeabsolutelysurethatthedeepveinsinthelegareopen(patent)andthatthevalvesareworking(competent).
ThecommoncausesofaDVTareprolongedperiodsofimmobility,suchasalongjourneyincrampedconditions,astayinhospitalorpregnancy.
Anotherreasontolookattheseveinsisifyouhaveeverbrokenyourleg.Afractureofthebonesinthelowerleg(thetibiaandfibula)usuallyresultsindamagetothe
fragileveinsofthelegwhichrelyuponthesupportofthesebones.SuchdamagecanresultinaDVT,whichmaybeunrecognisedduringtheperiodofrecovery.This
isbecausethelegwillbeswollenandpainfulasaresultoftheinjuryandthebreakinthebones.Swellingandtendernessinthecalfarealsosymptomsofathrombosis
inthecalfveins,sothatunlessfurthertestsareperformedspecificallytolookatthedeepveins,thiscomplicationmaybeoverlooked.
ThelongtermoutcomeofaDVTisdamagetothevalvesintheveins,whichwillmakethemincompetent.Anotherreasontoperforminvestigationsisifyouhaveever
hadpreviousvaricoseveinsurgery.Thetestsshouldbeabletotellthesurgeonwherethesiteofconnectionbetweenthedeepandsuperficialsystemsare,sothatthey
canbedealtwith.Sometimes,newveinscangrowatthesiteofprevioussurgerysothatthisareaneedstobeexploredagainsurgically;ortheremaybenew
connectionsawayfromthesiteofprevioussurgerywhichneedtobeidentifiedanddealtwithifgoodresultsaretobeobtainedfromintervention.
Onelastreasonisthatsometimesthesiteofentryofthesuperficialveinintothedeepvenoussystemisveryvariable.Thesurgeonmaywanttoconfirmthissitesothat
theincisioncanbeaccuratelyplacedovertheexactplace.Themostcommonplaceforthistypeofvariableconnectionisbehindthekneewheretheshortsaphenous
systemjoinsthedeepvenoussystem(thepoplitealvein;seediagramonpage15).
Themostcommoninvestigationperformedonvaricoseveinsisanultrasoundtestusingaduplexmachine.Thiscombinestwotypesofultrasound:Bmodeimaging,
whichgivesananatomicalviewoftheleg.Thisisthesortofultrasoundusedtolookatbabiesinthewomb.Thisallowstheoperatortoidentifythevascularstructures
intheleg,thatisthearteriesandtheveins.Thesecondtypeofultrasoundisa
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ModernDopplerscanningapparatus
Dopplerscanwhichisusedtolookatthebloodflowwithinthesevessels.Mostduplexmachineshavetheabilitytocolourcodethebloodflowtohelptheoperator
seetheflow,sothatflowawayfromthescanningprobeismadeonecolourandflowtowardstheprobeisanother.Thecolourschosenareusuallyredandblue.
Thismeansthatflowinthearteriestakingbloodfromtheheartouttotherestofthebodyperipheryisdifferenttothatintheveinswhichbringbloodbacktotheheart.
However,iftheveinsareincompetent(thatis,thevalvesintheveinsarenotfunctioningproperly)thenthecolourintheincompetentveinwillbethesameasinthe
arteries.You
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Thehandheldultrasoundprobe
canseehowduplexscanningcanquicklyandeasilyidentifyreflux,orbackflow,ofbloodintheveins.Amajoradvantageisthatitdoesnothurtbecauseitisnon
invasiveandnoneedlesareused.ThereisalsonoexposuretoionizingradiationsuchasyouwouldreceivewithanXray.Theonlythingthatneedstobeappliedto
yourbodyissomegelontheskinsurface,toensureagood`connection'betweentheultrasoundprobeandtheskin.Thisiseasilywipedoffattheendofthe
procedure.
Allultrasoundtestsrelyupontheskilloftheoperatortobesuccessful,butincompetenthandsthetestcantellthesurgeonallthatneedstobeknownaboutthe
patencyandcompetenceoftheveins,togetherwiththesiteofanyperforatingveinswhichconnectthedeepvenoussystemtothesuperficialsystem.Yoursurgeon
maywantthesiteoftheveintobemarkedontheskinjustbeforeyouroperation,sothatthistestmaybeperformedjustbeforesurgery.Onedisadvantageisthatit
canbeverytimeconsuming,soyouwillhavetobepatient!Ifalltheveinsinbothlegsneedtobeassessed,thiscantakeaskilledoperatorabout90minutesDuplex
scanningcanalsoassesstheveinsinsideyourabdomen,suchastheovarianveins,toseeifthesearealsoincompetent
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Scanningthesaphenopoplitealjunctionbehind
theknee(patientstanding)
(seealsothefigures,whichshowtheduplexmachineandsomesamplescansofnormalandincompetentveins).
Occasionally,ultrasoundexaminationmaynotgivethesurgeonalltheinformationrequired,andavenogrammaybeneeded.ThisisanXraytestthat,inessence,
involvesplacinganeedleintotheveins,havingaliquidinjectedandtakingpicturesoftheoutcome.Youmustnothavethisdoneifthereisanychanceyoumay
bepregnant.Thedyethatisusedtooutlinetheveinscontainsiodine,sothatyoumustalsonothavethisperformedifyouareallergictoiodine.Youshould
beaskedbothofquestionsbeforehand,butitismuch
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Scanningthesaphenopoplitealjunction(patientlyingfacedown)
safertovolunteerthisinformationbeforehandtoavoidadisaster.Ifyouhaveasthma,youhaveahigherchancethannormalofdevelopingareactiontothedye,and
youmayrequiretreatmentwithsteroids.DiabeticpatientstakingmetformincanalsodevelopseriousproblemswithXraycontrastmedia,andtheymustinformthe
radiologist(thedoctorperformingthetest)thattheyusethismedication.
Sometimesthetestwillbeperformedtolookatthedeepveinsintheleg.Acuffwillbeplacedaroundthelowercalfandthedyeinjectedintotheveinsonthebackof
thefoot.Usually,thesiteofconnectionofthevaricoseveintothedeepvenoussystemneedstobeidentified,andtheneedleisthenplacedwithinthevaricosity(a
varicogram).Ifthetestisdonetolookatwhetherthevalvesinthelegareworking,theneedlemaybeplacedeitherinthefootorinthegroin,andthetablewillbe
tiltedtoseeifthedyepassesbackwardsthroughthevalves.
Rarely,thesurgeonwillaskfortestslookingathowwelltheveinsareperformingintakingbloodawayfromthelegtotheheart.Ifthereisaproblemwiththevenous
function,thenteststhatlookatthevolumeofthelegmayberequested.Thetwomainproblemswithveins
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ExamplescansproducedbytheDopplerultrasoundprobe.
(a)Colourflowimage;blueindicatesnormalflowdirectioninthe
poplitealandshortsaphenousveins(SSV)duringcalfsqueezing.
(b)RedindicatesrefluxflowfromtheSSVindicatingsaphenopopliteal
incompetence
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isthateithertheyarethrombosed(blockedorpartiallyblocked)sothatbloodisnotcarriedoutofthelegproperly—asocalledoutflowobstruction;orthatthe
valvesareincompetentandareallowingbloodbackintotheleg—calledvenousreflux.Bothoftheseproblemswillincreasethevolumeofthelegwhenthelegis
exercised,forinstancebystandingrepeatedlyontiptoe.Theywillalsocauseadelayintheoutflowofbloodfromthelegwhenitistemporarilyblockedbyaninflated
cuffplacedaroundthethigh.Thetermforthesetestsis`plethysmography'andtherearevarioustypes:forinstance,theycanlookatthevolumeofeitherairorwater
displacedbythelegduringthesemanoeuvres,orthinmetalstrips(usuallyofmercuryinsilicone)wrappedaroundthelegcanmeasurethechangeindiameteroftheleg
(astraingauge).Anothernoninvasivemethodusesalaserlighttolookatthebloodflowintheskin(laserDopplerflowmetry).
However,thelatteraresophisticatedtestsonlyperformedinafewcentresbyvenousspecialists,usuallyinpatientswithcomplexvenousproblems.Thevastmajority
ofpatientswithvaricoseveinswillrequireeithernotestsoronlyavenousduplexscan.Thesetestswillallowthesurgeontodecidethebesttreatmentforyourveins.
Thewholequestionoftreatmentofvaricoseveinsisanimportantone,ofcourse,andinChapter6weshallbeconsideringtheprosandconsofthedifferentmethods.
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