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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47
Chapter6—
Treatment
Thepatientwithvaricoseveinsobviouslywantstoknowwhattreatmentsareavailable.Insomecases,theveinsarebestleftalone.Otherchoicesaretheuseof
supportstockings,injectiontreatment,lasertreatmentandsurgery.Theprosandconsofeachofthesearediscussed.
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Whenyouconsultyourdoctoraboutvaricoseveins,hewillofferyouoneoffourcoursesoftreatment:
1.Donothingatall.(notreatment).
2.Wearelasticstockings.
3.Haveinjectiontreatment.
4.Lasertreatment.
5.Havesurgery.
NoTreatment
Ifyouhaveonlyverymildvaricoseveinsthatgivelittle,ifany,trouble,yourdoctorwillusuallyadviseyoutoleavewellalone.Varicoseveinsdonotsuddenlybecome
muchworse,andminordegreesofswollenveinsarenotsubjecttothevariouscomplicationssetoutinChapter8.Often,adoctorfindsthatthereissomeunderlying
anxi
Mediventhighlengthinblackwithlace
topbandavailableincompressionclasses
1and2.Otherlenghtsareavailable.
Inpregnancymaternitytightsarehelpful
inpreventingvaricoseveins.
IllustrationscourtesyofmediUKLtd.
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Thighlengthstockinginflesh
tone,notethesheerappearance.
Longhandledeasescorrectapplicationof
compressionstockings.Theshorthandled
optionisfornurseuse.
IllustrationscourtesyofmediUKLtd.
etybehindapatient'srequestfortreatment.Thismaybebecausearelative,veryoftenthemother,hasbeenplaguedwithalltheburdensofabadleg(probablya
varicoseulcer)formanyyears.Itisperfectlyreasonableforherchildren,discoveringthefirsttraceofavaricosevein,toimaginethatheorshe,too,israpidlygoingto
developsevereulceration.
Perhapsyouareoneofthoseyoungwomenwhohavechubbylegsorthickanklesandwhohopethattreatmentofoneortwotinyveinsinthelegmightimproveyour
appearance.Anytherapyforyourvaricoseveinsisonlygoingtoproducedisappointment,asChapter5willtellyou.
Youmaybelongtoathirdcategoryofpatientswhoeitherdonotsufferfromvaricoseveinsatallorwhoseminorvaricoseveinssimplydisguiseothercausesofaching
anddiscomfortinthelegs(seeChapter8).Here,obviously,yourdoctorwillneedtofindouttherealcauseofthesymptomsandtouseappropriatetreatment.
Now,ifyourveinsarecosmeticallyunpleasantorareproducingsymptomsofdiscomfort,oriftherehavebeenanyofthecomplicationsthatsometimesaccompany
varicoseveins(seepages98110),thenthetimehascometodecideonactivetreatment.Theaimofallformsoftreatmentistokeeptheaffectedveinsemptyof
blood.
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ElasticStockings
Theveinsinyourlegscanbesupportedandcompressedbyelasticstockings,butthesewillnotbythemselvescurevaricoseveins.Thestockingsare,however,
extremelyusefulinanumberofcategories.Theyareveryhelpfultoelderlypatientswhosegeneralhealthisnotgoodenoughforeventhesafeandfairlyminor
treatmentsusedtocurevaricoseveins.Thestockingsarealsousefulingivingtemporaryrelieftoveryoverweightpatientswhiletheyslimthemselvesdownin
preparationformorespecifictreatment.AswesawinChapter4,supportstockingsarealsovaluableforvaricoseveinsduringpregnancy.
Awholerangeofelasticstockingsisnowavailableforvaricoseveinsufferers.Youwillfindthatcosmeticallytheyarequiteacceptable,andindeedordinarystockings
canbewornoverthemtoimprovetheirappearancestillfurther.Itisimportanttorememberthat,withrepeatedwashing,elasticstockingslosetheirelasticityand,
whenthishappens,youwillneednewones.Normally,stockingslastabout34months,sothatyouwillneedthreetofourpairseachyear.
Thestockingsaremosteffectivewhentheyareappliedtoveinsthatarealreadycollapsed.Therefore,youshouldkeepthembyyourbedandputthemonbeforeyou
getoutofbedinthemorning,i.e.beforeyouputyourfootonthefloor.Ifyoutrytoapplythestockingafteryouhavegotoutofbed,youaretryingtocompressveins
whicharealreadyfullofblood.Thesestockingsapplyagraduatedpressuretotheleg,whichisgreatestattheankleandwhichdecreasessteadilysothatitisleastat
thetopoftheleg.Thisforcesvenousbloodoutoftheleg.DonotuseTubigrip.Thisappliesthesamepressuretoallpartsoftheleg,sothatitwillbegreatestwhere
thelegisthickest,i.e.atthetop.Tubigripwillthereforeactasatourniquetkeepingbloodinthelegandincreasingthevenousstasis,thusmakingvenousproblems
worse.
Graduatedelasticatedcompressionstockingsareusuallysuppliedfromhospitalsatthesurgicalappliancesdepartment.Theycomeinvariousclasseswhichapply
differentdegreesofpressuretotheleg.Thisisleastwithgrade1andgreatestwithgrade4.Uncomplicatedvaricoseveinsmayneedgrade1or2compression.
Patientswithlargesymptomaticveinsmayrequiregrade2or3,andveinswhichhavecausedvenousulcersmayrequiregrades3or4.Itisveryimportantthatthe
arterialsupplytoyourlegisassessedbeforestockingsareapplied.Ifthepulsesinyourlegarepalpablethenthearterialsupplyisadequate.Ifnopulsescanbefound,
thencompressionstockingsmaycompromisethe
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arterialsupplyandmakeanyvascularproblemworse.Yourdoctormayaskforteststoseehowgoodthearterialsupply.Thesimplesttestistoplaceacuffaround
theankle,andtoplaceaDopplerprobetopickupthearterialflowinthearteriesinthefoot.TheaudibleDopplersignalwilldisappearwhenthepressureinthecuffis
highenoughtooccludethearterialflow.Thepressureinthearterialsystemneedstobeatleast50mmHghigherthanthatgeneratedbythestockingforadequate
perfusionofthetissues.Falselyelevatedpressuresmayberecordedinpatientswhohavecalcifiedarterieswhicharenowflexibleenoughtobecompressedbythe
cuff.Suchcalcifiedarteriesarecommoninpatientswithdiabetesandinthosewithrenalfailure.
WhatdoElasticStockingsdo?
Theiractionissimplytocompresstheswollenveinsonthesurfaceofyourleg,emptyingthemintothedeepveinsystemwherethemusclepumpcanreturntheblood
totheheart.Togetthemaximumbenefitfromthestockingsremembertwosimplerules:
1.Oncethelegiswellsupported,youshouldwalkaboutasmuchaspossible.Theelasticstockinggentlybutfirmlypressestheswollensurfaceveinsandsqueezesthe
bloodinthembackintothedeepmusclepump.Theactionofthemusclesistoreturnthebloodtotheheartandthis,ofcourse,istremendouslyincreasedbyexercise.
Agood3mile(5kilometre)walkeachdaywillworkwonders!
2.Keepthelegraisedwhenyouarenotwalkingandthemusclepumpisnotinuse.Takeoffthestockingsatnight;thereisnoneedtoweartheminbed.Onceinbed,
however,theveinsshouldbekeptemptybysleepingwithyourheelraisedaboveyourkneeandyourkneeaboveyourhip.Thiscanbeachievedeitherwithoneor
twopillowsplacedunderyourlegsorelsebygettingthefootofthebedraiseduponastrongbox,onsomebricksorwithanyothertechniquethatyouoryourfamily
candevise.Wewillgivesomemoreadviceaboutwearingelasticstockingsinpages9396.
InjectionTreatment
Injectiontreatmentofvaricoseveinsiswellover100yearsold.Asolutionofironchloridewasthefirstsubstancetobeusedtoproducetheseeminglyparadoxical
healingprocessesofclottingandinflammation
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1.Thevaricoseveinsare
markedoutontheleg.
2.Withthelegelevated,thefailedperforator
valveislocated.
3.Thepatientstandsandthe
surgeonpressesonthe
perforatorvalvetoconfirm
thatthisnowcontrolsthe
varicosevein.Theinjectionis
carriedoutatthissite.
4.Thelegisbandagedfromthetoestojustbelow
thesiteofinjection.
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5.Theperforatorvalveisinjectedusinga
veryfineneedle—thisshouldbealmost
painless!
6.Apadisplacedovertheinjectionsite.
7.Thebandageiscontinueduptotheknee.
8.Finally,thelegissupportedbyanelastic
stockingoverthebandage.
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intheveins.Thiswasfollowedbyaweaksolutionofphenol,thensodiumsalicylateandthenamixtureofquinineandurethane.Althoughsuccesseswereachieved,the
body'sreactiontothesesubstanceswasoccasionallysevereandthelongtermresultswerenotparticularlygood.
HowDoesitWork?
MuchcreditgoestoProfessorGeorgeFeganofDublinfortheinjectiontherapyweusetoday.Asayoungsurgeonin1950hewasputinchargeofthevaricosevein
clinicatthefamousDublinmaternityhospital,theRotunda.Hefoundhimselffacedwithsome30newpatientseachweek,butwithnohospitalbedsforoperative
treatment.Hethereforeresolvedtorefinewhathad,untilthen,beenaratherhitandmissinjectionmethodandthetechniquehedevisedformsthebasisofthe
treatmentgiveninmostvaricoseveinclinicsthroughouttheworldtoday.
ProfessorFegan'smethodisbasedongoodphysiologicalandanatomicalprinciples.First,thesurgeonhastofindthepointsalongyourlegwherethevaricoseveins
penetratethroughthesheathoffibroustissuethatsurroundsthelegmusclesanddrainintothedeepveins.Thesepenetrating,orcommunicatingveinsarecalledthe
perforators(oftennicknamedthe`blowouts').
Tofindthesitesoftheperforatingveins,thesurgeonwillmakeyoustandupandthenmarkwithapenthegeneraldistributionofthevaricoseveinsonyourleg.Hewill
thenaskyoutoliedownontheexaminationcouchandyourlegwillberaisedtoemptytheveins.Thesurgeonwillthencarefullyfeelalongthelegtofindthelittle
defectsthatmarkthespotswherethesurfaceveinspenetratethroughthefibroussheathofthelegintothedeepveins.Thesepointsoftencorrespondtoparticularly
largebulgesinthevaricoseveinsthemselves.
Thesurgeonwillthenusehispentomarkthesepointsontheskin.Henextpresseseachoftheseperforatorswithhisfingersandyouwillthenbeaskedtostandup
again.Itisatthispointthatthesurgeondiscoversifhissearchhasbeensuccessful,foritwillbeobviousinthestandingpositionthattheveinsarecontrolledatthese
pointsofpressure.Whenhetakeshisfingeroffoneofthesepoints,thevaricoseveinbeingfedfromthispointwillthenbeseentofillwithbloodandtoswell.Ifthe
veinfillsbeforehehastakenhisfingeroffthenherealisesthathehasmissedaperforatorandrepeatsthetestuntilalltheblowoutsarelocalizedandmarked.
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Theclotformedbytheinjectionclosesofftheflowofbloodinto
thevaricoseveinandsoreducedtheswelling.
Aninjectionofanirritantsolutionwillbegivenintothesesites,whichwillsetupanintensebutcontrolledinflammation.Theideaisthatthebody'sdefenceandhealing
mechanismwillimmediatelystarttocloseofftheblowoutbythecreationofscartissue,thusstoppingthehighpressurebackflowofbloodthroughthevaricosevein
andsoreducetheswelling.Tomakesurethatthereactiondoesnotspreadtonearbyhealthyveins,theinjectionwillbegivenintothevein,whichisemptiedofblood
byraisingyourlegduringtheinjection.Yourlegwillthenbefirmlybandagedfromthetoesuptoabovethesiteoftheinjectionandthebandageshouldbekeptonand
renewedforseveralweeks—ProfessorFeganrecommends6weekswhilescartissueformsatthepointofinjection.Toencouragetheflowofbloodfromtheleg
andtopreventtheslightriskofanyextensiveclottingofstagnantbloodwithintheveinsoftheleg,youwillbeinstructedtowalkbrisklyatleast3miles(5kilometres)
everyday,startingwiththe
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dayofinjection.Itisalsowisetokeepyourlegraisedinbedatnightonacoupleofpillows.
Thereareanumberofchemicalsolutionswecanusetoinjectintoveins.Currentpreferencefavourssodiumtetradecylsulphate,whichisdissolvedinanalcoholic
solution.Thematerialhas,infact,thepropertiesofadetergent.Itprobablycombineswiththeproteinofthecellsliningthewallofthevein,damagingthemandcausing
abrisklocalinflammation.Itissohighlyeffectivethatonlyasmallamount(0.51milliletre)isnecessaryatanypointofinjection.
WhenInjectionTreatmentisNotPossible
Veinsthatextendupthethightothegroinaredifficult,andinmanycasesimpossible,tocompressbybandaging,whichisanessentialpartofinjectiontherapy.Insuch
casessurgeonsusuallyadvisesurgicaltreatment,whichwillbedescribedbelow.
Veryobesepatientsarealmostimpossibletotreatbyinjectionbecauseitisdifficulttofindtheirperforatorsandevenmoredifficulttobandagetheirlegssatisfactorily
tokeeptheveinscompressedandempty.Seriouslyoverweightpatientsareusuallyputonavigorousreducingdiet.Thepromisethattheywillbeabletohavetheir
veinstreatedsatisfactorilyoncetheyhavelostweightisusuallyagreatincentivetothesesufferers.Wewilldealwiththesubjectofobesityandlosingweightmorefully
inChapter7.
Thereisnodoubtthathavingyourlegbandagedforseveralweeksisanuisance,andthisisparticularlyduringsummer.Theidealtimetocarryouttreatmentiswhen
theweatheriscooler.
Patientswhotaketheoralcontraceptivepillshouldprobablynothavetheirveinsinjected.ItisbettertostopthepillaltogetherthantoriskthedevelopmentofaDVT
whichmaycauseapulmonaryembolus.Youmustdiscussthisriskwithyourdoctorperformingtheinjections.
Followup
Onceyouhavehadtheinjection(orinjections)youwillbeexpectedtogotoyourdoctoraweeklater.Thebandageswillberemovedandthelegexamined.Atthis
stageitisusuallypossibletoseeifagoodresultisgoingtobeachieved.Itmaybe,however,thattheinjectiondidnotcreatetherightamountofinflammationandso
thetreatmentwillhavetoberepeated.Sometimeswefindthatoneormoreperforatorshavebeen
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