Surgical diseases of the veins

Surgical diseases of the veinsVeins are the vessels that the blood is returned to the heart and lungs to replenish its oxygen supply. Several conditions may affect the veins, thereby modifying the normal venous return.

Phlebitis means vein-inflammation. Any vein may be involved, over a short segment or its entirety. Most commonly the superficial (sur­face) veins of the lower extremity are affected. The causes of the inflammation may be several and often are unknown. Phlebitis is often a post­operative complication and is usually associated with clot formation within the inflamed lining. This has been discussed, and all of the principles and factors mentioned there apply also to phlebitis which occurs other than postoperatively. The same causes and hazards of blood clots in veins exist with all forms of phlebitis.

A blood clot attached in a vein is called a thrombus. A blood clot which floats free in the blood current to plug a vessel at another site is called an embolus (or embolism).

Thrombophlebitis means blood-clot-vein-in- flammation. The clot forms on the inflamed wall and is quite securely anchored to it. The vein is blocked but the possibility of the clot’s breaking loose to float free in the blood stream is not so likely since it is quite adhered to the inflamed lining.

Phlebothrombosis means vein-blood-clot. Here the vein is not inflamed and the clot is not securely adhered to the vessel. Detachment of the clot to float free in the blood stream is more likely and serious complications may re­sult. The cause is most often stagnation of blood in a vessel, or an increase in the blood’s ability to clot.

Treatment of phlebitis, thrombophlebitis, and phlebothrombosis is obviously best by pre­ventive measures. Stagnation of blood must be avoided by early ambulation, exercises, and avoiding compression of veins with dressings and casts. Drugs which reduce the blood’s abil­ity to clot are used in cases where thrombus is likely, and also to prevent enlargement of a clot already formed. Surgical removal of clots in certain veins may be necessary to prevent pul­monary embolus. Ligating (tying) the vein above a clot to block its pathway to the lung may be a necessary surgical means of prevent­ing pulmonary embolus.

Varicose veins are enlarged and tortuous deformities of the veins. The flow of blood in the veins is maintained in the direction back to the heart by a series of moon-shaped flaps, or valves, within the vein. These act passively to prevent back-flow of the column of blood. These valves may be injured by phlebitis or long­standing back pressure in the veins from com­pression. When the valves become incompetent the veins gradually dilate from the increased pressure within them; large bulges may occur at certain points. The involved vessel becomes enlarged and distorted.

Varicose veins occur most frequently in the thigh and leg, and the ones most affected are those which lie near the surface, especially the saphenous veins. The circulation of the foot and leg is impaired. Actually the blood is traveling the wrong direction in the involved vein, by gravity, away from the heart. The ar­terial flow to the part is therefore impeded; the oxygenated blood cannot reach the part as the venous blood does not leave. The deep veins must collect the normal amount of blood as well as the added burden of that passing down the varicosed outer veins. There results from this venous congestion swelling, discoloration of the skin from inadequate oxygen, and a lowered re­sistance to injury and infection. Clots may form. Disfigurement may be the only symptom, but pain, easy fatigue of the part, and cramps may occur.

With the deficient circulation associated with varicose veins, varicose ulcer may develop. This begins by any small break in the skin from in­jury or infection. The area will not heal and gradually enlarges.

Treatment of varicose veins must be directed at eliminating the weight of the column of blood in the veins. Elimination of this abnormal flow of blood by gravity into the part alleviates the venous congestion, and the arterial inflow is thereby enhanced. This is accomplished by sev­eral means. Compression of the entire dilated varicose vein to prevent its filling may be ac­complished by elastic bandages or elastic stockings; these and their use must be ac­curately prescribed. This method is only pallia­tive and does not cure the condition but may be an excellent temporary measure.

Definitive treatment of varicose veins may be accomplished surgically. The varicosed ves­sels may be prevented from filling by vein liga­tion, or tying, at the upper end of the diseased portion. Since there are communicating vessels between the deep and outer veins, the varicosed vessel may fill below a ligation; therefore, in many cases several ligations along the course of a varicose vein may be necessary. The surgeon can determine preoperatively just what ligations will be needed, by testing at various levels with a tourniquet. When it has been ascertained that several ligations will be needed, the surgeon may deem it advisable to remove the entire diseased section of vein. This is accomplished by vein stripping: The vein is isolated at one end of the diseased portion and a pliable long instru­ment (vein stripper) is inserted into the vein for the entire length of the varicosed portion; the vein is tied to the instrument and then pulled from its bed by gentle traction; compression bandages over the area control the bleeding un­der the skin.

Another means of treating small segments of varicose veins is by vein injection. With this method an irritating solution is injected into the diseased section; this causes chemical inflamma­tion which finally resolves into scar formation which obliterates the vein. This method is ap­plicable and meets with success in some well- selected cases.

Treatment of varicose ulcer may entail pro­longed tedious measures. Primarily, the circula­tion to the area must be improved by eliminat­ing the abnormal venous congestion from the varicose vein or veins. This may be accomplished temporarily by compression of the diseased seg­ment while local medications to the ulcer are used. Eventually, however, the varicose seg­ment with dependent blood flow must be per­manently obliterated; or the treatment of the ulcer and of the varicose vein may be done simultaneously. The vein is ligated or stripped and then local medications are used on the ulcer. Some larger ulcers may require skin grafting subsequent to, or at the time of, vein ligation or stripping. Each case requires individual sur­gical consideration.

Injuries to veins are relatively common and usually with no major sequelae. Initially, hemor­rhage may be of great concern but usually it can be controlled as a first-aid measure by man­ual or bandage compression over the bleeding site. Definitively the vessel is ligated at the time of repair of the entire wound. Except with the major veins, as in the trunk, rarely is it neces­sary to repair or replace an injured vein, since other pathways of blood back to the heart are present in most regions. Contusions caused by blunt blows which fracture veins to cause bleed­ing under the skin are usually self-limited in their bleeding and the blood is re-absorbed with­out special therapy.

Intra-abdominal vein anastomosis has in recent years been found quite valuable in the treatment of obstruction to the portal vein. The portal vein is that which absorbs the digested food elements from the intestinal tract and trans­ports them to the liver; in some diseases, such as cirrhosis of the liver, this large vein is ob­structed and large amounts of fluid accumulate in the abdomen, the condition known as ascites. The amount of blood which must flow through this diseased vein may be decreased by shunting the blood through a different route. This may be accomplished by portal-caval shunt (uniting the portal vein to the vena cava), or by spleno­renal shunt (union of the splenic vein to a kid­ney vein). The burden of the portal vein circu­lation is thereby reduced.

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