| BackgroundVaricose Veins of Lower Extremity (VVLE), or Lower Limb Varices, are a frequently seen disease with high incidence of occurrence. It is estimated that 25% females and 15% males are suffering functional insufficiency of superficial veins in lower limbs, mostly due to congenital vulnerability of venous wall and insufficiency of venous valve. Damage of venous valve and high pressure in deep vein lead to backflow of blood and eventually, varix, and effusion of large amount of fibrinogens constitutes an obstacle prohibiting exchange of oxygen and nutrition between capillary vessels and surrounding tissues, which causes changes of nutritional structure of skin and subcutaneous tissues. The initial stage of this disease is characterized of soreness, ache, and frequent fatigue in lower legs. Later, the patient will suffer changes of nutritional structure of skin and demonstrate symptoms such as itching, pigmentation of skin and eczema. In the late stage, the disease develops into venous ulcer, or "decay of feet", a name comes from the location of the ulcer, which persists and reoccurs repeatedly, and significantly reduces the quality of life of patients.Conventional therapies of Varicose Veins of Lower Extremity (VVLE) include palliative treatment, injection-pressurization therapy, and traditional surgical operation. The palliative treatment is only applicable for pregnant women, light VVLE patients in earlier period and the ones who are with poor systemic conditions and intolerant with surgical operation. The patient should properly rest in bed, and avoid standing for a long time or raising the affected limb. With perfect flexibility and constraint force, stretch hoses can relieve the hypertension of superficial vein caused by muscle contraction while action. Unless VVLE has developed to upper leg, commonly using stretch hoses below knee joint with a common pressure between 4.0 and 5.33Kpa can get satisfactory effect.And injection-pressurization therapy is mainly applicable for①Isolated and small VVLE.②Remained VVLE after operation.③Relapsed patients after operation.④Patients with perforating venous valvular insufficiency of the lower extremities and skin complications. The principle is to induce inflammation and adhesions of the wall of veins and blocked veins by pressure bandaging after injecting curing agent to varicose veins. As for simple superficial venous varicosis, the traditional surgery operations are high ligation and stripping. Expectant treatment is with limited indications, and can only relieve clinical symptoms and delay the course of disease. High ligation and stripping of great saphenous vein had been the supreme and classic operations for treating great sephenous varicosis in the past few decades, but high ligation is abandoned because it can only eliminate contraflow at sapheno-femoral junction and relapse frequently happens, and stripping of great saphenous vein usually causes postoperative pain, limited action, and large and unbeautiful wound, although it can thoroughly eliminate contraflow of great saphenous vein trunk and greatly reduce the opportunity of postoperative reoperation, thus, minimal invasive surgery with both effect of thorough eliminating contraflow of great saphenous vein trunk and small wound rapidly develops and becomes the chief method to treat great sephenous varicosis.To meet the requirement of minimal invasive surgery, a concept widely accepted in all areas of surgery in the last decade, researchers are seeking for a new therapy of VVLE that requires minimal invasion to patients. The latest minimal invasive treatment of superficial venous varices of lower limbs is called endovenous laser treatment (ELT), which can be carried out with local anaesthesia of patient. This treatment leaves no scar, requires less time for recovery, and the patient suffers less pain.In 1970s, doctors started using laser in treatment of telangiectasia. With the development of long-wave and pulse laser, the application of laser technology in clinical area has been widened significantly. In 1998, Carlos Boné, a Spanish phlebologist, used ELT in treatment of varices of the trunk and branches of great saphenous vein in lower limb. In 1999, some researchers from Spain and New York reported the initial clinical effects of this technology.In China, relevant reports were not seen until 2003, and such reports did not cover fundamental research related to the mechanism of ELT, or comparison between the effects of ELT and conventional surgery, or systematic studies on complications and treatment of ELT.In 2004, we started a systematic study on treatment of lower limb varices using ELT. The study can be divided into four parts.Purposes1. To study basic principle of treating VVLE with ELT.2. To compare the short-term curative effects of ELT and conventional surgery on treatment of VVLE.3. To study indications and cautions related to the treatment of VVLE using ELT.4. To study causes, prevention, and treatment of complications related to ELT treatment of VVLE.Methods1. High ligation of great saphenous vein and ELT were carried out on 20 patients with varix, and D-dimeride of all the patients were examined before and one day after the surgery. One section of the laser-burned trunk of the vein and one section of the unburned vein, each is 0.5cm in length, were left during the operation for examination under optical microscope and electron microscope.2. ELT was carried out on 20 VVLE patients (22 limbs) and conventional surgical operation was carried out on 30 VVLE patients (36 limbs). Six indices, including duration of operation, incision, post-treatment ache, complications, duration of hospitalization after operation, and 1-year relapse rate were evaluated.3. Retrospective review was carried out on 52 patients (65 limbs) treated by ELT between September of 2004 and December of 2005.Results1. There are significant differences between pre- and post-operative D-dimeride (p＜0.05); Observing the burned section of the great saphenous vein under optical microscope, congestion and buckled and obstructive blood capillary were observed, while under electron microscope, platelet aggregation, karyotin gathering at the side, shrinkage of nucleus of endothelial cells, cavitation of chondriosomes, vacuolization of cytoplasm of smooth muscular cells, and shedding of endotheliocyte observed.2. The results of ELT group are preferable on duration of operation, incision, post-treatment ache, and duration of hospitalization after operation. As for complications and 1-year relapse rate, no significant difference was observed.3. The results of one-year following-up survey showed that all patients can work and live normally. The curative effects were satisfactory and there was no relapse of varix or ulcer.Conclusions1. By observing pre- and post-treatment vascular inner membranes with laser under optical microscope and electron microscope, we first demonstrated the basic principle of ELT, and confirmed ELT can cause direct or indirect thermal damage of endothelial cells and inner membranes, which can induce formation of thrombus through the vein and eventually lead to venofibrosis and venous occlusion. 2. By establishing experiment group and control one, and comparing six indices, including duration of operation, incision, post-treatment ache, complications, duration of hospitalization after operation, and 1-year relapse rate were evaluated, we confirmed ELT group were preferable on duration of operation, incision, post-treatment ache, and duration of hospitalization after operation, while as for complications and 1-year relapse rate, no significant difference was observed, and consequently conclude that ELT is a new, safe, effective, and minimal invasive method for treatment of VVLE, and is to take the place of conventional surgical operation.3. By the retrospective review, we summarized the indications, cautions, and combined therapy of complicated ulcer of ELT, proposed prevention from some complications through experience, and achieved the purposes of reducing complication and increasing long-term curative effect. |
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