Thrombosis of the superficial veins of the lower extremities, symptoms, treatment. Thrombophlebitis of the superficial veins of the lower extremities: signs, features and treatment methods

Thrombophlebitis of the saphenous veins lower extremities or superficial thrombophlebitis is a disease in which blood clots appear in the lumen of the saphenous veins. Since the veins are located close to the skin, this phenomenon is accompanied by inflammation - redness of the skin, pain, local swelling.

Essentially, thrombophlebitis saphenous vein is a "double" disease. Because, firstly, the venous walls themselves become inflamed. And secondly, in a vein it is formed blood clot- thrombus.

Superficial thrombophlebitis in the vast majority of cases, it manifests itself as an acute disease.

More often, varicose-transformed tributaries of the large (and / or small) saphenous vein, as well as perforating veins, are thrombosed. But if untreated, thrombosis extends to the great (small) saphenous vein itself, and further to the deep veins.

Causes of thrombophlebitis of superficial veins

The cause of any thrombosis is a combination of three factors:

• change in the configuration of the vein (for example, varicose transformation) and, as a result, "swirls" of blood in the lumen of the vessel;
• "thickening" of the blood - a tendency (hereditary or acquired) to thrombosis;
• damage to the vein wall (injection, trauma, etc.).

Main and most common cause the occurrence of superficial thrombophlebitis is considered varicose veins. Also, the most common risk factors are:

• genetic predisposition;
• pregnancy and childbirth;
• obesity, hypodynamia;
• endocrine and oncological diseases.

Superficial thrombophlebitis: symptoms and manifestations

In the initial stages, superficial thrombophlebitis of the lower extremities may not be very noticeable in the manifestations. slight redness skin, burning, insignificant swelling - many patients simply do not pay attention to all this. But the clinical picture changes very quickly, and signs of thrombophlebitis of superficial veins become noticeable and very uncomfortable:

• the appearance of "nodules" and seals in the vein;
• edema;
• sharp pain;
• local increase in temperature;
• discoloration of the skin in the area of ​​​​the inflamed vein.

Treatment of superficial thrombophlebitis

For the treatment of thrombophlebitis of superficial veins, different methods and their combinations are used.

More often it can be conservative treatment:

• compression therapy - wearing compression stockings, special elastic bandaging;
• taking non-steroidal anti-inflammatory and analgesic drugs;
• locally, in the area of ​​inflammation - cold;
• according to indications - taking drugs that "thinn" the blood.

Emergency surgical treatment acute thrombophlebitis saphenous veins is prescribed, as a rule, in cases where thrombosis does not affect the tributaries, but directly the large or small saphenous veins. So, with ascending thrombophlebitis of a large or small saphenous vein, the trunk of the main saphenous vein is thrombosed directly. With the spread of thrombosis of the great saphenous vein to the thigh, thrombophlebitis is considered ascending. For the small saphenous vein, this is the middle and upper third of the lower leg.

In this case (if technically possible), either endovenous laser obliteration or crossectomy is used - ligation of the large (small) saphenous vein along with its tributaries.

If ascending thrombophlebitis has already led to the penetration of a blood clot into deep veins, this is fraught with the occurrence pulmonary embolism- separation of a blood clot and blockage pulmonary artery. This situation occurs when thrombosis spreads from the saphenous veins into the deep (“muscular”) veins.

In this situation (if technically possible), a thrombus is removed from the deep veins and a crossectomy is performed - ligation of the saphenous vein at the mouth.

Acute thrombophlebitis is an inflammation of a vein with the formation of blood clots inside it.

Symptoms of acute thrombophlebitis of superficial veins and its diagnosis. The most typical signs of acute thrombophlebitis of the superficial veins of the upper and lower extremities are symptoms of a general inflammatory reaction, hyperemia, skin integument, infiltrates along the thrombosed veins, lymphadenitis and lymphangitis. Patients are concerned about an increase in body temperature up to 39 ° C, chills, weakness, malaise. Hyperemia and edema of the skin are noted along the affected vein. However, the swelling is minor. The diameter of the limb practically does not change. Movements in the joints remain free, but somewhat painful due to the presence of inflammation zones in the subcutaneous tissue. In the area of ​​the thrombosed vein, a painful infiltrate with clear boundaries, soldered to the surrounding tissues, is palpated. In the initial period of the course of the disease lymphatic system not involved in the inflammatory process. Subsequently, especially with suppuration of thrombosed veins, lymphangitis and lymphadenitis are observed.

With localized thrombophlebitis, signs of the inflammatory process are determined only in a small area of ​​\u200b\u200bthe saphenous veins. Migrating thrombophlebitis is characterized by the presence of many small foci of thrombosis in different segments of the limb. Ascending thrombophlebitis is accompanied by a gradual spread of the process with distal departments saphenous veins to the proximal ones.

Acute thrombophlebitis after a few days becomes subacute, followed by either a complete cure or the formation of chronic inflammation. Subacute thrombophlebitis is characterized by the absence of general inflammatory reactions, the disappearance of pain and flushing of the skin over the affected vein. However, pain does not occur during palpation of thrombosed veins, but periodically and independently. In persons with chronic thrombophlebitis, a continuous or bead-like cord is formed at the site of a thrombosed vein. Its palpation or physical activity is accompanied by the appearance of minor soreness. The prolonged existence of chronic thrombophlebitis of superficial veins contributes to the development of trophic tissue disorders.

When the effects of inflammation are stopped, the thrombosed superficial vein in most cases recanalizes, but loses its anatomical and physiological properties: it expands unevenly, its valvular apparatus is destroyed. The skin above it becomes hyperpigmented and indurated. With migrating thrombophlebitis, there are practically no violations of skin trophism.

The course of thrombophlebitis of the saphenous veins is often complicated by suppuration of thrombosed superficial veins with the formation of subcutaneous abscesses and phlegmon, the spread of thrombosis to deep veins through the sapheno-popliteal fistula, as well as through the communicating veins. Having penetrated into the main veins, the thrombus either completely blocks their lumen, or is in a floating state (oscillates under the influence of blood flow). The separation of blood clots leads to thromboembolism of the pulmonary artery. In the case of migration of infected thrombi, metastatic lung abscesses occur.

Differential diagnosis of acute thrombophlebitis of superficial veins. Thrombophlebitis of superficial veins must be differentiated from diseases that occur with a similar clinical picture: acute deep vein thrombophlebitis, lymphangitis, erythematous form of erysipelas, soft tissue phlegmon, etc.

Treatment of acute thrombophlebitis of superficial veins. Tactics in acute thrombophlebitis of superficial veins is determined by the localization of thrombosis, the state venous vessels involved in the inflammatory process, the nature of the course of the disease.

Conservative treatment is carried out for acute thrombosis of the saphenous veins of the forearm and shoulder, as well as local thrombophlebitis of varicose veins of the lower leg and lower third of the thigh without a tendency to spread and in the absence of symptoms of pulmonary embolism; with subacute and chronic thrombophlebitis of varicose veins that are not altered, amenable to conservative measures; in severe condition of patients due to concomitant pathology.

Patients with acute thrombophlebitis of the superficial veins of the forearm and lower leg, subacute and chronic thrombophlebitis can be treated in outpatient settings. In all other situations, they are hospitalized. There is a general and local treatment. In the acute phase of the disease, conditional bed rest with an elevated position of the diseased limb is indicated. Locally applied compresses with heparin, heparoid, butadion ointments, Vishnevsky ointment, 30% dimexide solution, semi alcohol compresses etc., cold. On top of the compresses, to accelerate the outflow of blood and thereby prevent the spread of the process, elastic bandaging of the legs is performed. Prescribed drugs that improve microcirculation and rheological properties blood (trental, theonicop, flexital, etc.); inhibitory effect on the adhesive-aggregation function of platelets (aspirin, chimes, indomethacin, etc.); corrective disorders of venous blood flow (detralex, venoruton, troxevasin, aescusan, etc.); having anti-inflammatory, antipyretic, analgesic effect (butadione, reopyrin, analgin, etc.); desensitizing agents (diphenhydramine, suprastin, etc.). used in the presence of a pronounced inflammatory process.

Anticoagulant therapy for thrombophlebitis of superficial veins, as a rule, is not carried out. Only with significant hyperprothrombinemia is it possible to use both indirect (phenylin, pelentan, neodicoumarin, etc.) and direct (heparin, fraxiparin, etc.) anticoagulants.

In the phase of subsiding acute inflammation, physiotherapeutic procedures are prescribed to accelerate the resorption of blood clots and infiltrates. Effective iontophoresis of potassium iodide, proteolytic enzymes (trypsin, chymotrypsin, etc.), heparin; UHF; prolonged diathermy; solar lamp. After stopping acute thrombophlebitis, patients with varicose veins of the lower extremities are recommended to have elastic bandaging of the extremities and wearing elastic stockings for 2 months. At the same time, it is advisable to take drugs that have a phlebodynamic effect.

Surgical intervention is a radical method of treating thrombophlebitis of superficial veins, preventing the development of its complications and relapses. with thrombophlebitis of superficial veins are performed, in an emergency and planned manner.

Indications for emergency surgical intervention are: 1) acute ascending thrombophlebitis of the great saphenous vein when the objectively determined upper border of the thrombus is localized at or above the border of the upper and middle thirds of the thigh; 2) acute ascending thrombophlebitis of the small saphenous vein with the upper limit of thrombosis, located at or above the border of the middle and upper thirds of the posterior surface of the leg; 3) the presence of symptoms and the threat of repeated pulmonary embolism; 4) purulent fusion of a thrombus. If necessary, preoperative preparation and special methods examination, surgery in patients with a risk of recurrent pulmonary embolism may be delayed.

Planned operations are indicated for thrombophlebitis of varicose veins; in case of failure conservative treatment acute thrombophlebitis of varicose veins, subacute and chronic thrombophlebitis.

Contraindications to radical surgery: occlusion or hypoplasia of the main veins; heart disease with symptoms of decompensation, myocardial infarction, hypertension Stage III, suppurative processes in the lungs, inflammatory disease of the abdominal organs; skin diseases (eczema, pyoderma). A relative contraindication is the advanced age of patients.

Most often, the main trunk of the large or small saphenous vein involved in the inflammatory process is removed with the processing of its side branches.

The operation for acute thrombophlebitis of the superficial veins is performed in a certain sequence. Initially, a sapheno-femoral fistula is distinguished from an oblique or vertical incision. The oblique incision passes 3 cm below the inguinal fold and parallel to it, and the oblique incision is made on the border between the inner and middle thirds of the pupart ligament through the oval fossa or somewhat medially to the determined pulsation of the femoral artery. The fistula zone is examined. In the absence of blood clots in the area where the great saphenous vein flows into the common femoral vein, v.saphena magna and its tributaries are tied up and crossed (Troyanov-Trendelenburg operation). In the presence of a thrombus in the common femoral or external iliac vein, the external iliac, superficial and common femoral veins are initially isolated and clamped outside the zones of thrombosis. The tributaries of the great saphenous vein are ligated and crossed. Thrombectomy from its mouth is performed by transverse section of the great saphenous vein, and from deep veins - by longitudinal dissection of the rest of the valve and the wall of the common femoral vein. The effectiveness of thrombectomy is controlled visually and by the presence of retrograde blood flow from the iliac veins at the height of the Valsalva test.

Phlebectomy of thrombosed veins on the thigh and lower leg is performed from separate incisions 4-6 cm long (Narata operation by tunneling (F.K Sidorina operation) or by a continuous skin incision from the inguinal fold to the medial malleolus (Madelung operation). Babcock operation (removal of veins from using probes) is acceptable for phlebectomy of non-thrombotic vessels.In severe phlebitis and panniculitis, the thrombosed trunk is removed from the bordering incisions along with tissue and skin flap(operation by R.L. Askerkhanov). The communicants are bandaged subfascially (but according to Linton) or suprafascially (according to Cocket) only after preliminary removal of blood clots from their lumen.

The sapheno-subcutaneous anastomosis is exposed from a transverse, vertical or B-shaped access similar to the isolation of the sapheno-femoral anastomosis. The trunk of the small saphenous vein is removed by one of the methods described above. Small tributaries of the great and small saphenous veins are sutured according to Sheda (percutaneous suturing of the veins with tying the ends of the threads on the skin) or according to Sokolov-Klapp (intradermal suturing of the veins).

In severe patients with ascending thrombophlebitis of the saphenous veins of the lower extremities, only the intersection and ligation of the great saphenous vein and tributaries at the saphenofemoral (Troyanov-Trendelenburg operation) is performed, and the small saphenous vein is performed at the sapheno-popliteal fistula.

Phlebectomy of thrombosed veins of the upper extremities is performed according to Marat or Askerkhanov. AT postoperative period to improve regional blood circulation in the limb, to prevent recurrence of thrombophlebitis, continuation of antiplatelet therapy (10-15 days), bandaging the limb or wearing an elastic stocking for 3 months is indicated.

For citation: Kiyashko V.A. Thrombophlebitis of superficial veins: diagnosis and treatment // RMJ. 2003. No. 24. S. 1344

D This type of pathology is a very common disease of the venous system, which is faced by a doctor of any specialty.

Currently, in medical practice, terms such as phlebothrombosis and varicothrombophlebitis are also often used. All of them are legal to use, but the following points should be considered. Phlebothrombosis is considered as an acute obstruction of a vein as a result of hypercoagulation, which is the leading mechanism. But at the same time, after 5-10 days, the thrombus that has arisen causes reactive inflammation of the tissues surrounding the vein with the development of phlebitis, that is, phlebothrombosis is transformed into thrombophlebitis .

The term "varicothrombophlebitis" clearly indicates the actual cause of thrombosis that occurs against the background of varicose veins already present in the patient.

The pathology of the venous system listed above in the vast majority of clinical cases occurs in the large system and much less often in the system of the small saphenous vein.

Thrombophlebitis of the veins on the upper extremities are extremely rare, and the main provoking factors for their occurrence are multiple punctures for the introduction medicines or prolonged placement of the catheter in a superficial vein.

Particular attention should be paid to patients with spontaneously occurring blood clots in the upper and lower extremities, not associated with iatrogenic exposure. In such cases, the phenomena of thrombophlebitis can be suspected as a manifestation of a paraneoplastic reaction due to the presence of an oncological pathology in the patient, requiring an in-depth multifaceted examination.

Thrombus formation in the system of superficial veins is provoked by the same factors that cause thrombosis of the deep venous system of the lower extremities. These include: age over 40 years, the presence of varicose veins, cancer, severe cardiovascular disorders vascular system(cardiac decompensation, occlusion of the main arteries), hypodynamia after major operations, hemiparesis, hemiplegia, obesity, dehydration, banal infections and sepsis, pregnancy and childbirth, oral contraceptives, limb injury and surgical interventions in the area of ​​passage of the venous trunks.

Thrombophlebitis can develop in any part of the superficial venous system , with the most frequent localization on the lower leg in the upper or middle third, as well as the lower third of the thigh. The overwhelming number of cases of thrombophlebitis (up to 95-97%) was noted in the basin of the great saphenous vein (Kabirov A.V. et al., Kletskin A.E. et al., 2003).

Further development of thrombophlebitis can actually go in two ways:

1. Relatively favorable course diseases , against the background of the ongoing treatment, the process stabilizes, thrombus formation stops, inflammation subsides, and the process of thrombus organization begins, followed by recanalization of the corresponding section of the venous system. But this cannot be considered a cure, because. there is always damage to the initially altered valvular apparatus, which further aggravates the clinical picture of chronic venous insufficiency.

Clinical cases are also possible when a fibrous thrombus densely obliterates a vein and its recanalization becomes impossible.

2. most unfavorable and dangerous option in terms of the development of local complications - ascending thrombosis along the great saphenous vein to the oval fossa or the transition of the thrombotic process through the communicating veins to the deep venous system shins and thighs.

The main danger of the course of the disease according to the second option is the threat of developing such complications as pulmonary embolism (PE), the source of which can be a floating thrombus from the system of a small or large saphenous vein, as well as secondary deep vein thrombosis of the lower extremities.

It is quite difficult to judge the frequency of thrombophlebitis among the population, but if we take as a basis the position that among those hospitalized in surgical departments more than 50% of patients with this pathology had varicose veins, then taking into account the millions of patients with this pathology in the country, this figure looks very impressive and the problem is of great medical and social importance.

The age of patients ranges from 17 to 86 years and even older, and average age is 40-46 years old, that is, the able-bodied contingent of the population.

Given the fact that with thrombophlebitis of the superficial veins, the general condition of the patient and well-being, as a rule, do not suffer and remain quite satisfactory, this creates the illusion of relative well-being and the possibility of various self-treatment methods for the patient and his relatives.

As a result, this behavior of the patient leads to late accessibility for the provision of qualified medical care, and often the surgeon is already faced with complicated forms of this “simple” pathology, when there is a high ascending thrombophlebitis or deep vein thrombosis of the limb.

Clinical picture

The clinical picture of the disease is quite typical in the form of local pain in the projection of the saphenous veins at the level of the lower leg and thigh with the involvement of the tissues surrounding the vein in the process, up to the development of a sharp hyperemia of this zone, the presence of seals not only of the vein, but also subcutaneous tissue. The longer the zone of thrombosis, the more pronounced pain in the limb, forcing the patient to restrict its movement. Hyperthermic reactions in the form of chills and an increase in temperature up to 38-39 ° C are possible.

Quite often, even a banal acute condition becomes a provocative moment for the occurrence of thrombophlebitis respiratory disease especially in patients with varicose veins of the lower extremities.

Inspection is always carried out from two sides - from the foot to inguinal zone. Attention is drawn to the presence or absence of pathology of the venous system, the nature of the discoloration of the skin, local hyperemia and hyperthermia, swelling of the limb. Severe hyperemia is typical for the first days of the disease, it gradually decreases by the end of the first week.

With the localization of thrombophlebitis in the small saphenous vein, local manifestations expressed to a lesser extent than with damage to the trunk of the great saphenous vein, which is due to the peculiarities of the anatomy. The superficial sheet of the own fascia of the lower leg, covering the vein, prevents the transition inflammatory process to the surrounding tissues. The most important point is to find out the period of appearance of the first symptoms of the disease, the speed of their increase, and whether the patient has attempted to influence the process with medication.

So, according to A.S. Kotelnikova et al. (2003), the growth of a thrombus in the system of the great saphenous vein goes up to 15 cm per day. It is important to remember that in almost a third of patients with ascending thrombosis of the great saphenous vein, its true upper limit is located 15-20 cm above the level determined by clinical signs (V.S. Savelyev, 2001), that is, this fact should consider each surgeon when consulting a patient with thrombophlebitis of a vein at the level of the thigh, so that there is no unreasonable delay in the operation aimed at preventing PE.

It should also be considered inappropriate to locally administer anesthetics and anti-inflammatory drugs to the area of ​​a thrombosed vein on the thigh, since, by stopping pain, this does not prevent the growth of a thrombus in the proximal direction. Clinically, this situation becomes difficult to control, and duplex scanning can really only be used in very large medical institutions.

Differential Diagnosis should be carried out with erysipelas, lymphangiitis, dermatitis of various etiologies, nodular erythema.

Instrumental and laboratory diagnostics

Highly long time The diagnosis of thrombophlebitis of the superficial veins was made by a physician on the basis of clinical symptoms diseases, since there were virtually no non-invasive methods for characterizing venous blood flow. Implementation into practice ultrasonic methods diagnostics opened a new stage in the study of this common pathology. But the clinician must know that among the ultrasound diagnostic methods venous thrombosis Duplex scanning plays a decisive role, since only with its help it is possible to determine a clear boundary of thrombosis, the degree of organization of a thrombus, the patency of deep veins, the state of the communicants and the valvular apparatus of the venous system. Unfortunately, the high cost of this equipment still sharply limits its practical use in outpatient and inpatient settings.

This study is indicated primarily for patients with suspected embologenic thrombosis, that is, when there is a transition of a thrombus from the superficial venous system to the deep one through the sapheno-femoral or sapheno-popliteal fistula.

The study can be carried out in several projections, which significantly increases its diagnostic value.

Phlebographic study

The indication to it is sharply narrowed. The need for its implementation arises only in the case of a blood clot spreading from the great saphenous vein to the common femoral and iliac vein. Moreover, this study is performed only in cases where the results of duplex scanning are doubtful and their interpretation is difficult.

Laboratory diagnostic methods

In normal clinical analysis blood draws attention to the level of leukocytosis and the level of ESR.

Research is desirable C-reactive protein, coagulograms, thrombelastograms, the level of the prothrombin index and other indicators characterizing the state of the coagulation system. But the scope of these studies is sometimes limited by the capabilities of the laboratory service of a medical institution.

Treatment

One of the important points that determine the outcome of the disease and even the fate of the patient is the choice of tactics for the optimal treatment option for the patient.

With the localization of thrombophlebitis at the level of the lower leg, the patient can be treated on an outpatient basis, being under the constant supervision of a surgeon. Under these conditions, it is necessary to explain to the patient and his relatives that if signs of the spread of thrombosis to the level of the thigh appear, the patient may need to be hospitalized in a surgical hospital. Delay in hospitalization is fraught with the development of complications, up to the occurrence of PE.

In cases where thrombophlebitis at the level of the lower leg, treated for 10-14 days, does not regress, there should also be a question of hospitalization and more intensive therapy for the disease.

One of the main issues in the treatment of patients with thrombophlebitis of superficial veins is the discussion the patient's need for strict bed rest .

Currently accepted fact is that strict bed rest is indicated only for patients who already had clinical signs of PE or have clear clinical data and results instrumental research indicate the embologenic nature of thrombosis.

The motor activity of the patient should be limited only by severe physical activity (running, lifting weights, performing any work that requires significant muscle tension limbs and abdominals).

General principles for the treatment of thrombophlebitis of superficial veins

These principles are indeed common for both conservative and surgical treatment of this pathology. The main goals of treatment these patients are:

• To act as quickly as possible on the focus of thrombosis and inflammation to prevent its further spread.
• Try to prevent the transition of the thrombotic process to the deep venous system, which significantly increases the risk of developing PE.
• Treatment should be a reliable method of preventing recurrent thrombosis of the venous system.
• The method of treatment should not be strictly fixed, since it is determined primarily by the nature of the ongoing changes in the limbs in one direction or another. That is, the transition or addition of one treatment method to another is quite logical.

Undoubtedly, conservative treatment shown to the vast majority of patients with "low" superficial thrombophlebitis of the saphenous veins.

Once again, it should be emphasized that reasonable physical activity the patient improves the function of the muscle pump, which is the main determining factor in ensuring venous outflow in the system of the inferior vena cava.

The use of external compression (elastic bandage, stockings, tights) in the acute phase of inflammation can cause some discomfort, so this issue should be addressed strictly individually.

Quite controversial is the question of the use of antibiotics in this category of patients. The physician must be aware of possible complications this therapy ( allergic reactions intolerance, provocation of blood hypercoagulability). Also, the question of the advisability of using anticoagulants (especially direct action) in this contingent of patients is far from unambiguously resolved.

The doctor must remember that the use of heparin after 3-5 days can cause thrombocytopenia in the patient, and a decrease in the number of platelets by more than 30% requires discontinuation of heparin therapy. That is, there are difficulties in monitoring hemostasis, especially on an outpatient basis. Therefore, it is more appropriate to use low molecular weight heparins (dalteparin, nadroparin, enoxaparin), since they rarely cause the development of thrombocytopenia and do not require such careful monitoring of the coagulation system. Positive is the fact that these drugs can be administered to the patient 1 time per day. 10 injections are enough for a course of treatment, and then the patient is transferred to indirect anticoagulants.

In recent years, ointment forms of heparin (lyoton-gel, Gepatrombin) have appeared for the treatment of these patients. Their main advantage is rather high doses of heparin, which are delivered directly to the focus of thrombosis and inflammation.

Of particular note is the targeted effect on the area of ​​thrombophlebitic changes of the drug Hepatrombin ("Hemofarm" - Yugoslavia), produced in the form of an ointment and gel.

Unlike Lyoton, it contains 2 times less heparin, but additional components - allantoin and dexpanthenol, which are part of the Hepatrombin ointment and gel, as well as essential oils pines, which are part of the gel, have a pronounced anti-inflammatory effect, reduce the effects skin itching and local pain in the area of ​​thrombophlebitis. That is, they contribute to the relief of the main symptoms of thrombophlebitis. The drug Hepatrombin has a strong antithrombotic effect.

It is applied topically by applying a layer of ointment to the affected areas 1-3 times a day. In the presence of an ulcerative surface, the ointment is applied in the form of a ring up to 4 cm wide around the perimeter of the ulcer. Good tolerability of the drug and the versatility of its impact on the pathological focus puts this medicine to the fore in the treatment of patients with thrombophlebitis both on an outpatient basis and in hospital treatment. Hepatrombin can be used in a complex of conservative treatment or as a remedy aimed at stopping inflammation of the venous nodes after the Troyanov-Trendelenburg operation, as a method of preparing for the second stage of the operation.

The complex of conservative treatment of patients should include non-steroidal anti-inflammatory drugs also have analgesic properties. But the clinician should be mindful of extreme caution when prescribing these agents to patients with disease. gastrointestinal tract(gastritis, peptic ulcer) and kidneys.

Well proven in the treatment of this pathology is already good known to physicians and patients phlebotonics (rutoside, troxerutin, diosmin, ginkgo biloba and others) and disaggregants (acetylsalicylic acid, pentoxifylline). AT severe cases with extensive phlebitis, intravenous transfusions of 400-800 ml of rheopolyglucin intravenously are indicated for 3 to 7 days, taking into account the cardiac status of the patient due to the risk of hypervolemia and the threat of developing pulmonary edema.

Systemic enzyme therapy in practice has limited application due to the high cost of the drug and a very long course of treatment (from 3 to 6 months).

Surgery

The main indication for surgical treatment thrombophlebitis, as previously indicated, is an increase in a thrombus along the great saphenous vein above the middle third of the thigh or the presence of a thrombus in the lumen of the common femoral or external iliac vein, which is confirmed by phlebography or duplex scanning. Fortunately, the latter complication is not so common, only in 5% of patients with ascending thrombophlebitis (I.I. Zatevakhin et al., 2003). Although individual reports indicate a significant frequency of this complication, reaching even 17% in this group of patients (N.G. Khorev et al., 2003).

Anesthesia methods - possible different variants: local, conduction, epidural anesthesia, intravenous, intubation anesthesia.

The position of the patient on the operating table is of some importance - the foot end of the table must be lowered.

The generally accepted operation for ascending thrombophlebitis of the great saphenous vein is Troyanov-Trendelenburg operation .

The surgical approach used by most surgeons is quite typical - an oblique incision below the inguinal fold according to Chervyakov or the inguinal fold. But at the same time, it is important to take into account the main clinical point: if there are instrumental data or clinical signs of a thrombus moving into the lumen of the common femoral vein, then it is more advisable to use a vertical incision that provides control over the thrombosed great saphenous vein and the trunk of the common femoral vein, when sometimes it is required to clamp it on time of thrombectomy.

Some technical features of the operation:

1. Mandatory isolation, intersection and ligation of the trunk of the great saphenous vein in the area of ​​its mouth.

2. When opening the lumen of the great saphenous vein and detecting a thrombus in it that goes beyond the level of the ostial valve, the patient must hold his breath at the height of inspiration during surgery under local anesthesia (or this is done by an anesthesiologist with other types of anesthesia).

3. If the thrombus "is not born on its own", then a balloon catheter is carefully inserted through the sapheno-femoral fistula at the height of inspiration and thrombectomy is performed. Retrograde blood flow from the iliac vein and antegrade from the superficial femoral vein are checked.

4. The stump of the great saphenous vein must be sutured and ligated; it must be short, since a too long stump is an “incubator” for the occurrence of thrombosis, which poses a threat of pulmonary embolism.

In order to discuss options for this routine operation, it should be noted that some surgeons suggest performing thrombectomy from the great saphenous vein in the Troyanov-Trendelenburg operation, and then injecting a sclerosant into it. The feasibility of such manipulation is questionable.

The second stage of the operation - the removal of thrombosed varicose veins and trunks is performed according to individual indications within a period of 5-6 days to 2-3 months as local inflammation is relieved, in order to avoid suppuration of wounds in the postoperative period, especially with trophic skin disorders.

When performing the second stage of the operation, the surgeon must necessarily ligate the perforating veins after preliminary thrombectomy, which improves the healing process.

All conglomerates of varicose veins are to be removed in order to avoid the development of gross trophic disorders in the future.

Surgical treatment of this group of patients is carried out by a very wide range of general surgeons and angiosurgeons. The seeming simplicity of treatment sometimes leads to tactical and technical errors. Therefore, this topic is almost constantly present at scientific conferences.

Thrombophlebitis of the superficial veins of the lower extremities is a disease characterized by the formation of blood clots on the wall of these vessels and blockage of their lumen. The disease leads to circulatory disorders, muscle weakness and dysfunction of the lower limb. Pathology should not be ignored, since there is a risk of developing serious complications. Consider what superficial thrombophlebitis is - the nature of the pathology and methods of treatment.

How pathology develops

For the development of thrombosis of superficial veins in the legs, a change in blood viscosity is necessary, a violation of the vital activity of white blood cells, reduced blood flow and damage to the venous wall. In a certain area, a precipitate forms, which gradually thickens and forms a clot that closes the lumen of the vessel. Later, inflammation joins, and signs of the disease appear. Sometimes a blood clot breaks off and forms.

Interesting!

According to ICD 10, this pathology is assigned the code "I 80".

Etiology

Superficial thrombophlebitis is complex pathology progressing gradually. For its development, a single pathological chain is needed, to which the following reasons can lead:

• Deep vein thrombosis of the leg - when blood clots appear in these areas, they can migrate with the blood flow to the superficial vessels;
• Limb injuries - any damage to the skin, muscles and other tissues destroys the integrity of the wall of the saphenous vein and can lead to the development of thrombosis;
• Burdened heredity - according to scientific data, there is a genetic predisposition to increased "gluing" of white blood cells and the formation of blood clots;
• Varicose veins - with this pathology, stagnation occurs in the venous bed, which can provoke thrombophlebitis;
• Infections - when the body is infected with microbial agents, complex defense mechanisms rapid formation of blood clots at sites of cell damage;
• Allergy - can provoke an autoimmune attack of white blood cells;
• overeating and excess weight- in this case the concentration of substances that increase its viscosity increases in the blood;
• Operations - when interfering with the internal environment of the body, the risk of blood clots and damage to blood vessels increases;
• Pregnancy period - change hormonal background can negatively affect the regulation of the tone of the vascular system and qualitative composition blood.

In addition to the reasons described, the side effects of certain drugs during treatment can lead to impaired local blood flow in the lower extremities, different kinds poisoning. Increased blood viscosity can also develop when taking contraceptives, plasma transfusions. The vascular wall is damaged by frequent drips or during intravenous injections.

Disease classification

In addition to ICD, thrombophlebitis is divided into several forms depending on the severity of symptoms and the nature of local changes.

By severity clinical signs distinguish:

• Acute thrombophlebitis is characterized by rapid progression and severity of symptoms: pain appears sharply, rapidly increases, swelling of the lower limb progresses, its function is impaired. This state requires urgent treatment;
• Chronic thrombophlebitis - develops slowly, moderate symptoms are present, it may take several months for the patient's condition to completely deteriorate.

Depending on the pathogenesis, two forms of thrombosis of the veins of the lower limb are distinguished:

• Purulent thrombophlebitis - characterized by the involvement of microbes and the development purulent inflammation. Highly dangerous state requiring additional antibiotic treatment;
• Nonpurulent thrombophlebitis - classic version pathology, proceeds with signs of circulatory disorders in the lower limb.

If the patient has a purulent variant of the pathology and there is no open injury, in parallel with the ongoing treatment, it is necessary to be examined for the presence of chronic focus infections.

Clinical picture

The first signs of the disease usually develop gradually, when the thrombus slowly increases in size and clogs the lumen of the saphenous vein, causing circulatory disorders in the lower limb. If - an acute condition occurs that requires immediate treatment.

Classical symptoms of thrombophlebitis of superficial veins:

• Pain in the affected area, aggravated by movement or touch;
• Under the skin, the outline of the vein is visible along the “inflated” contour and the characteristic cyanotic color - this indicates its blockage when it increases under pressure;
• Subcutaneous red nodules appear along the vessel;
• Edema of the lower limb develops, an increase in local temperature;
• With a long course of thrombosis, ulcers appear that bleed and hurt.

Often these lesions are called ascending thrombophlebitis, as the saphenous veins rise up to the heart and swell.

The most common two types of thrombophlebitis of the lower limb:

• Ascending thrombophlebitis of the great saphenous vein (GSV) is characterized by edema mainly on the inner side. Under the skin, you can find a seal rising up, around which redness forms, later ulcers appear. Thrombosis of the great saphenous vein of the thigh develops quite often, requires special attention of the attending physician;
• Thrombophlebitis of the small saphenous vein - the symptoms are more blurred than in the previous case. It is characterized by classic manifestations of the disease and lesions upper divisions lower limb.

Interesting!

At varicose veins thrombosis of the GSV on the right is very often observed.

Establishing diagnosis

For diagnosis, it is necessary to visit the attending physician - the doctor will conduct an external examination and detect subcutaneous changes. You can also recognize blood clots on your own if you look at the photo of superficial thrombophlebitis of the lower extremities - swelling and discoloration of the skin will be noted in the picture, swollen cyanotic outlines can be seen along the vein.

For further detection of thrombosis, relevant following methods research;

• Doppler ultrasound;
• Reovasography;
• Ultrasonic duplex angioscanning;
• Venography;
• contrast radiography.

Treatment

Treatment of superficial thrombophlebitis of the lower extremities involves strict bed rest and limited mobility. This rule should be followed to reduce the risk of thrombus detachment from the wall of the subcutaneous vessel. For the same purpose, the use of an elastic bandage is shown to reduce congestion.

• Heparin - relieves swelling and inflammation, prevents thrombosis. Rubbed three times a day, quickly absorbed and acts on the subcutaneous tissue;
• Gel Lyoton - has similar properties, is applied 2 times a day;
• Cream Ketonal - treatment should be carried out twice a day to relieve local symptoms and anesthesia in the affected area.

The second stage of treatment is to strengthen the walls of the subcutaneous vessels. For this purpose, venotonics are used:

• Phlebodia - you should drink 1 tablet per day for 2-3 months;
• Venarus - used three times a day, perfectly strengthens the venous wall;
• Troxevasin - treatment is allowed both with tablets and the application of ointments to strengthen the superficial veins of the lower limb;
• Venoruton - effective drug, available as capsules or gel.

To increase the effectiveness of drug treatment of thrombosis, use is allowed, but only under the supervision of the attending physician.

Physiotherapy

This type of treatment is more likely to prevent the formation of blood clots in the saphenous veins of the lower limb and is aimed at strengthening their walls. For this purpose, the following is shown:

• Medicinal electrophoresis with therapeutic ointments;
• warming up;
• laser treatments;
• magnetotherapy;
• Shock wave therapy.

Surgical treatment

Surgery is indicated in case of poor effectiveness of conservative treatment or the presence of serious complications from thrombosis of the superficial vessels of the lower limb. To remove a thrombus, the following types of operations are shown:

• Crossectomy - ligation of the saphenous vein;
• radical intervention. complete removal subcutaneous veins;
• Palliative surgical treatment - removal of a thrombus from the lumen of the vessel.

Forecast

The formation of blood clots in the superficial veins leads to thrombosis, and in the presence of inflammation, to thrombophlebitis of the subcutaneous vessels of the lower limb. In most cases, the pathology develops gradually and requires examination. Don't delay treatment early stages it is very efficient.

One of the common complications of varicose veins is thrombophlebitis of the superficial veins of the lower extremities. This pathology develops against the background of blockage of the superficial vessels of the legs and can cause a lot of dangerous and unpleasant symptoms. In the early stages, the pathology is successfully amenable to drug treatment, but with a neglected form, a surgical operation is most often prescribed. How to suspect a pathology and how does it differ from varicose veins? Who is at risk and what treatment is needed for this disease?

What causes disease

Superficial thrombophlebitis of the lower extremities develops against the background of inflammation of the wall of superficial vessels. As a result, a thrombus may occur, which reduces the patency of the vessel or completely blocks it. Many doctors are sure that thrombophlebitis is a complication of varicose veins, but there are those who are sure that the disease can also occur as an independent pathology.

The main causes of superficial vein thrombosis are:

• Varicose disease.
• genetic predisposition.
• Injuries.
• Injections.
• Oncological diseases.
• Heart disease.
• Dehydration.
• Infection.

The insidiousness of the disease lies in the asymptomatic course in the early stages. Characteristic features diseases appear already at the moment when the disease has already affected a large section of the vein. often on late stages drug treatment not efficient.

It is worth considering that thrombosis of the superficial veins of the legs more often affects women over the age of 40 years.

Today, doctors note that there are a number of risk factors that contribute to the development of pathology, namely:

• Passive lifestyle.
• Postoperative period with bed rest.
• Pregnancy.
• Obesity.
• Having bad habits.
• Elderly age.

All people at risk of developing pathology need to more carefully monitor their condition, and at the first sign of blockage in the superficial veins of the legs, an urgent need to consult a doctor. It is especially important to treat any inflammatory diseases and vascular pathology. Patients with varicose veins must strictly follow the recommendations of the doctor.

Disease classification

Thrombophlebitis of the saphenous veins is divided according to the type of course and the causes of the disease. Today, doctors distinguish several main types of thrombosis:

• Acute thrombophlebitis of superficial veins.
• Chronic superficial phlebitis.
• Post-injection phlebitis.
• Thrombosis as a consequence of varicose veins.
• Thrombophlebitis during childbearing.
• Wandering thrombophlebitis.

The treatment schedule is developed individually for each patient, depending on the type and severity of the pathology. The main goal of thrombophlebitis therapy is to restore blood circulation in the limb. It should be remembered that the formation of a thrombus is dangerous not only by a violation of blood flow, but also by the possibility of developing thromboembolism.

Symptoms of the disease

Only the acute form of the disease has clear symptoms, which is characterized by the onset of sudden severe pain in the direction of blood flow in the leg, blue skin, swelling, limited movement of the limb and fever with a cold limb. The acute form of thrombophlebitis can often lead to complications such as thromboembolism, gangrene, phlegmasia. At initial symptoms acute pathology need to call emergency care. Before the arrival of specialists, the patient can not carry out any self-treatment.

Other forms of pathology of the saphenous veins of the lower extremities in the early stages are manifested only by minor swelling on the surface of the skin, a feeling of fatigue in the legs, pain after physical activity. It is these vague symptoms that often do not frighten patients and do not force them to seek help in a timely manner. Over time, the symptoms increase, the manifestations of the disease become brighter, and only in this case the patient goes to see a doctor.

Treatment of certain forms of thrombophlebitis

Medical or surgical therapy is prescribed individually for each patient, depending on the form, stage and severity of the disease. Also, when prescribing treatment, it is important to take into account the presence of concomitant diseases, because the treatment of thrombophlebitis of superficial veins should begin with the treatment of the disease that caused the development of this disease. So, how is subcutaneous thrombophlebitis treated?

Acute pathology. Treatment of acute thrombophlebitis should occur exclusively in stationary conditions. If there is a danger of developing thromboembolism, blockage of a superficial vein in the middle or upper thigh, or in the presence of a purulent process, urgent surgical intervention is indicated. Of particular danger is the ascending form of thromboembolism, because with such a pathology there is a very high risk of a blood clot breaking off and moving upward to the cardiac or pulmonary arteries.

In this case, doctors can tie off the section of the saphenous vein where it connects to the deep vein so that the blood clot does not penetrate the vital arteries.

If there is no threat to the patient's life, doctors carry out local treatment, which consists in taking medications to thin the blood and relieve inflammation. After emergency care in the hospital, the patient can continue treatment at home, regularly visiting the attending physician.

chronic pathology. Treatment of the chronic form of superficial vein thrombophlebitis is most often medical. For therapy, ointments, tablets, physiological procedures and special dressings are used. In the chronic form of the disease, it is very important to identify the root cause of the development of the pathology and eliminate it. So if the patient increased viscosity blood, he will be prescribed anticoagulants, if high cholesterol is to blame for the formation of blood clots, he will have to drink statins and stick to a diet. Treatment should be selected by a doctor, taking into account age and general condition patient. Chronic thrombophlebitis may worsen periodically. At this current diseases, it is important to remove acute attack, and treat the chronic form in accordance with the recommendations of doctors.

Thrombophlebitis after injections. On the legs, post-injection thrombophlebitis is rare. This mainly happens when doctors are forced to infuse drugs into the veins of the leg. Pathology manifests itself acute symptoms and requires immediate treatment. The therapy is based on the removal of the inflammatory process and the dissolution of the thrombus.

Usually this phenomenon does not require surgical intervention.

Varicose veins complicated by thrombophlebitis. Varicose thrombosis is the most common form of acute superficial thrombophlebitis. Delayed treatment varicose disease invariably leads to the development of an inflammatory process and the formation of a blood clot in the superficial vessels of the legs. The complication is characterized severe pain along the course of the vein, swelling of the vessels, swelling and redness of the leg.

Patients experience pain with any movement and when touching a damaged vessel. The danger of a complication lies in the possibility of damage to deep veins, which leads to thromboembolism and other life-threatening conditions. Treatment of this type of disease is anti-inflammatory therapy. Surgery may be indicated if indicated. It must be remembered that the treatment of varicose veins cannot be postponed so that complications do not develop.

Thrombophlebitis during pregnancy. Often during pregnancy, women experience circulatory disorders in the lower extremities. in the early stages are similar to signs of varicose veins. At the first manifestations of the disease expectant mother you need to see a doctor urgently. Treatment should be prescribed by a specialist, because pregnant women are not allowed to use all medications.

Usually, treatment during pregnancy is local in nature, and prevention of complications during this period is also important.

Wandering thrombophlebitis. This form of the disease is characterized by inflammation of the veins in different places. It can be both chronic and sharp shape. It is important that wandering phlebitis can often signal the presence of oncology, for this reason an urgent need to consult a doctor. Treatment is prescribed by a doctor after a thorough diagnosis.

Disease danger

The danger of acute thrombophlebitis of the superficial veins of the lower extremities lies in the possible detachment of the thrombus and its migration into the deep veins. However, this complication is quite rare. But, despite this, every person should know that blockage of the veins of the lower extremities, the symptoms of which are always painful, has other dangers.

First of all, this is, of course, a deterioration in the quality of life. The patient cannot fully work, move and live. It hurts him to perform even elementary actions.

Surgery

Treatment of venous blockage surgical methods is prescribed only when there is a risk of deep vein damage. The operation, as a rule, is prescribed in the later stages of the disease, when conservative methods can no longer cope with the disease.

Today, to prevent thromboembolism and other dangerous complications the following surgical interventions are used:

• Pulling of a large superficial vein.
• Crossectomy.
• Extensive phlebectomy.

Modern methods of surgical treatment make it possible to remove blood clots from vessels under local anesthesia. Operations on open vessels are extremely rare. Most often, after minimally invasive surgery, the patient can return home the very next day. After any treatment for thrombophlebitis, it is important to follow preventive measures that are aimed at preventing the formation of new blood clots.

ethnoscience

Alternative methods of treatment used in conjunction with traditional therapy help to relieve inflammation of the veins much faster and return to a normal lifestyle. One of effective recipes is a cabbage leaf wrap. To relieve swelling and inflammation, you need to take cabbage leaf, lubricate the skin with apple cider vinegar and wrap the cabbage all night to the affected area. The recipe does not side effects and applied as needed.

Also, with superficial thrombophlebitis, Kalanchoe tincture can be used. This plant has antiseptic and anti-inflammatory, vasoconstrictive and tonic properties. To prepare the tincture, you need to take kalanchoe leaf, grind it in a meat grinder and dilute with vodka in a ratio of 1: 1. You need to insist the mixture for 7 days. The resulting tincture is rubbed into the affected areas of the legs.

The course of treatment is 4 weeks.

It must be remembered that any folk remedy may have contraindications. For this reason, you should consult your doctor before use. This is especially true for patients who have accompanying illnesses. In this case, the treatment, both with medicines and folk remedies, should be selected by a doctor, because it should be primarily aimed at eliminating the underlying disease.

Prevention

Preventive measures include the following actions for the patient:

• Timely treatment of all diseases of the blood, heart, blood vessels.
• Regular preventive examinations.
• Control of the underlying disease that caused the complication.
• Adequate physical activity.
• Proper nutrition.
• Weight loss.
• Rejection of bad habits.
• Application folk recipes to strengthen the walls of blood vessels.
• Wearing compression underwear.
• Controlling your condition.
• Contacting a doctor at the first symptoms of the disease.

It should be noted that today the treatment of acute thrombophlebitis of the superficial veins of the lower extremities most often does not cause difficulty. In the arsenal of specialists there are a lot of anti-inflammatory, thrombolytic and vasoconstrictive agents. If necessary, physicians may prescribe unconventional methods treatments such as herudotherapy, mud therapy, body wraps and massages. Thrombophlebitis of the external veins, of course, is not as dangerous as the pathology of deep vessels. However, we must not forget that if left untreated, the pathology can become deadly.

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