One of the causes of impaired phlebohemodynamics in varicose disease of the lower extremities is the failure of perforating veins. She is given great importance in the development of trophic disorders and relapses after surgical treatment.
For the first time this pathology described
According to modern terminology, it is customary to call communicative vessels connecting the superficial and deep veins, distinguishing among them straight – flowing into the main trunks of the deep veins, and indirect – into their muscular inflows. Since communicative veins pass through the fascia (perforating it), they are also called perforating.
In anatomical studies, the number of perforating veins detected on one lower limb ranges from 20 to 112, which can be explained by different types of venous system structure. The number of direct perforating veins is small – from 3 to 10, they are more significant in terms of the development of chronic venous insufficiency and its surgical treatment. A detailed description of the location of the perforating veins is given by J. Van Limborg and R. May.
The greatest number of perforating veins on the legs. They begin, as a rule, with one or several trunks from the secondary branches of the great and small saphenous veins. Before perforation, the fascia’s perforating veins merge into one trunk, and in the subfascial space they can again be divided into several branches. Perforator veins of the medial and lateral surfaces, as a rule, are drained directly into the trunks of the deep veins, and the posterior group into the muscle veins.
The perforating veins of the medial surface of the lower leg were studied by Cockett. They connect the posterior arcuate vein (inflow of the great saphenous vein) with the tibial veins and are located at a distance of 7, 12–13.5 and 18–18.5 cm from the apex of the medial ankle, which is located distal to the straight foaming perforator.
Boyd’s perforating veins are located below the knee joint, which connect the trunk of the great saphenous vein and the posterior tibial veins. The perforating veins of the medial surface of the femur at the border of the middle and lower third of it (Dodd perforators) pass through the Hunter canal and connect the trunk of the great saphenous vein with the superficial femoral vein.
Sapheno femoral and sapheno poplitialnoe fistula are considered as the largest direct perforating veins.
Normally, perforating vein valves of the thigh and lower leg direct blood from the superficial veins to the deep ones. On the foot, most of the perforants do not have valves, and blood flow through them is possible in both directions, and in 36.6% of cases it is oriented from the deep veins to the superficial. Valve dysfunction leads to retrograde blood flow in both indirect and direct perforating veins.
The number of failed perforating veins for varicose veins according to duplex scanning ranges from 0 to 8 on one leg, averaging 2.4. In patients with impaired blood flow through the deep veins, their number increases by more than 2 times. Perforator failure increases according to the degree of chronic venous insufficiency, however, in the 4-6th clinical stages of varicose disease (according to the CEAP classification) there were no statistically significant differences, and therefore this indicator cannot serve as a marker of the severity of chronic venous insufficiency.
The literature data on the frequency of insolvent perforating veins in varicose veins varies depending on the contingent of patients. So, in the general group it is 50-58%, and in patients with telangiectasias and (or) reticular veins, which corresponds to the 1st clinical stage according to the CEAP classification – 15%. As a rule, incompetent perforating veins are detected in the presence of active or healed ulcer (5th and 6th stages of CEAP) or recurrence of varicose veins: 66 and 90%, respectively. At the early stage of varicose disease (local expansion of the saphenous veins up to 1 cm in diameter, normal skin condition, history up to 5 years and uncomplicated course) insufficiency of the perforating veins of the lower leg during duplex scanning is detected in 29.6% of cases, while in other cases – at 79.2%.
On the basis of anatomical, phlebographic and operational data, diagrams of the location of insolvent perforating veins are drawn up. However, they differ significantly, which is explained by the variability of localization of perforating veins and emphasizes the need to clarify it in each case. The most often insolvent perforating veins are located in the medial foraging region.
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Baeshko A. A., Popchenko A. L. BSMU. Published: Medical panorama № 4, June 2002.