Эндовенозная лазерная терапия варикоза

Хроническая венозная недостаточность (ХВН) нижних конечностей вызывается  венозной гипертензией, которая обычно является результатом рефлюкса, то есть обратного заброса  крови в одной или нескольких

до лечения

до лечения

подкожных венах и их первичных притоках. Варианты лечения у пациентов с недостаточностью подкожной вены включают консервативное, то есть лекарственное лечение или устранение этих проблем с помощью эндовенозных методов или хирургии. На изображении ниже показано варикозное расширение вен перед лечением эндовенозной лазерной терапией.

Хотя консервативное лечение компрессионной терапией может улучшить симптомы хронической венозной недостаточности, оно не излечивает ее. Исторически сложилось так, что хирургическое вмешательство считалось лучшим способом устранить венозную недостаточность.  Для этого использовалось лигирование подкожной вены, то есть ее перевязка и последующее удаление аномальных сегментов подкожной вены. За последние 10-15 лет лечение существенно изменилось. Теперь используютсяЭндовенозная лазерная терапия варикоза, ее еще называют чрескожной эндовенозной термической абляцией. Существуют два типа термической абляции:

  1. эндовенозная лазерная абляция ,
  2. радиочастотная абляция (РА).

Обе процедуры связаны с высокими показателями успешных результатов и низкими уровнями осложнений.

после лечения

после лечения

Процедуры обычно выполняются амбулаторно с местной анестезией и обычно не требуют седации. Пациенты идут домой после лечения, а время восстановления короткое.

Показания к применению

Перед применением радиочастотной абляции доктор узнает у пациента историю болезни, проводит физическое обследование и дуплексное ультразвуковое исследование .  Показания для лечения следующие:

I Симптомы хронической венозной недостаточности, влияющие на качество жизни:

  1. Боль,
  2. Тромбозы,
  3. Местное повышение температуры,
  4. Усталость,
  5. Ночные судороги,
  6. Местный зуд,
  7. Спонтанное кровоизлияние.

II Изменения кожи, связанные с хронической венозной гипертензией, следующие:

  1. Выпячивание вен, экзема и пигментация,
  2. Липодерматосклероз,
  3. Атрофия,
  4. Изъязвления на коже,
  5. Водянка,
  6. Поверхностный флебит в варикозных венах

III Косметологические проблемы также являются показаниями к лечению.

IV Анатомические показания:

  1. Значительный рефлюкс, который подтверждается УЗИ-исследованием (рефлюкс> 0,5 секунды),
  2. Прямая вена,
  3. Внутрифасциальный сегмент эпифасциальной вены , который можно отделить от кожи с использованием местного анестетика,
  4. Имеется рефлюкс, приводящий к венозной гипертензит, что приводит к клиническим аномалиям.

Противопоказания

Противопоказания к эндовенозному лечению приведены ниже:

  1. Пациентки, которые беременны или кормят грудью (могут возникнуть проблемы, связанные с использованием анестетиков и нагревание крови, которая затем может проходить через плаценту к плоду)
  2. Поврежденная глубокая венозная система, которая не восстановится для поддержки венозного возврата после радиочастотной абляции,
  3. Дисфункция печени или аллергия делают невозможным использование местного анестетика (холодный солевой раствор может быть полезен в качестве альтернативы)
  4. Аллергия на местные анестетики и амидные и сложные эфиры (холодный солевой раствор может быть альтернативой)
  5. Тяжелая некорректируемая коагулопатия (РА безопасна при использовании варфарина)
  6. Выраженная повышенная свертываемость крови (где риск лечения перевешивает потенциальную пользу, несмотря на профилактический прием антикоагулянтов)
  7. Невозможность полноценно двигаться после процедуры
  8. Рефлюксная вена
  9. Тромбы или синехии в вене или извилистой вене, делающие прохождение эндовенозного устройства невозможным (если не выбраны множественные точки доступа)

Обезболивание

Необходимо использование больших объемов разбавленных анестезирующих растворов, которые проникают в 40.2фасциальное пространство обрабатываемых вен. Обоснование использования большого объема фасциальной  анестезии – его способность опорожнять вену для максимального контакта теплового устройства и обеспечения защитного теплоотведения вокруг обработанной вены для минимизации нагревания соседних тканей.

Абляцию обычно проводят с разбавленным в физрастворе обезболивающим раствором лидокаина с адреналином или без него.  Зачастую буфером служит бикарбонат натрия (обычно используют 0,1% лидокаина со средним объемом около 5-10 мл / см обработанной вены ). Раствор вводят под ультразвуковым контролем в подкожную оболочку вены. В итоге вена окружена вдоль всей обрабатываемой длины анестезирующей жидкостью, как показано на изображении. При использовании адреналина показано использование ЭКГ-мониторинга.

Расположение пациента

Доступ к целевой вене должен выполняться у пациента в положении лежа на спине. Рекомендуется использовать обратную позу Тренделенбурга (ноги вниз), чтобы увеличить давление в оперируемой вене и увеличить вероятность успешного прокола, особенно в случаях с венами малого диаметра. В момент ведения проводника пациент расположен ровно, а затем в положении Тренделебурга. Позиция Тренделенбурга помогает опорожнить жилу и улучшить передачу энергии от волокна к стенке вены. Это особенно важно на верхнем конце большей подкожной вены, где диаметр вены больше, а вена менее восприимчива к спазму.

Осложнения

Неблагоприятные события после абляции могут быть, но почти все они незначительны. Эхимоз над обработанным участком часто встречается и обычно длится 7-14 дней. Примерно через неделю после операции 40.3может возникнуть ощущение напряжения мышцы. Этот преходящий дискомфорт, вероятно связан с воспалением в сегменте обработанной вены. Устраняется с помощью использования нестероидных противовоспалительных препаратов (НПВП) и компрессионных чулок.

Поверхностный флебит – еще один необычный побочный эффект. Наблюдается после лечения примерно у 5% пациентов. Поверхностный флебит, по-видимому, чаще образуется в варикозных венах большего диаметра или в варикозных венах, которые имеют приток и отток

Более значимые побочные явления, сообщаемые после лазерной терапии, включают в себя повреждения нервов, ожоги кожи. Частота этих осложнений выше в венах с небольшим объемом, чем у вен с большим объемом. В результате повреждения нерва появляется парестезия или дизестезия, что является временным явлением. Встречается максимум у 10% пациентов. Повреждения нерва могут возникать при введении катетера, во время фасциальной анестезии или в результате термического воздействия, связанного с нагреванием тканей. Риск венозной тромбоэмболии выше у пациентов с предшествующим флебитом.

Послеоперационный период

Послеоперационный уход предназначен для повышения эффективности и минимизации побочных эффектов и риска осложнений. Сразу после операции почти все врачи рекомендуют какую-то форму компрессии. Наиболее 40.4распространенная рекомендация – использование компрессионных чулок класса II (30-40 мм рт. Ст.). Они надеваются сразу после процедуры и носятся в течение 1-2 недель. Клиническая пациенты чувствуют себя лучше с использованием компрессии, особенно во вторую неделю, когда возникает напряжение мышц.

Пациентам рекомендуется ходьба  в течение как минимум 30-60 минут непосредственно сразу же после операции и не менее 1-2 часов в день в течение 1-2 недель. Необходимо повременить с горячими ваннами, бегом, прыжками, тяжелой атлетикой 1-2 недели. НПВС могут быть приняты по мере необходимости для снятия дискомфорта и болевого синдрома.

Через 1 месяц после процедуры нужно показаться доктору для оценки результатов путем клинического обследования и УЗИ. Также необходимо повторное УЗИ примерно через 9-12 месяцев после процедуры лазерного лечения, что в конечном итоге определяет анатомический успех абляции.

Общие выводы: Абляция безопасно и эффективно выполняется с использованием местной анестезии в амбулаторной обстановке (без госпитализации пациента). Длительность операции составляет 45-90 минут. Время процедуры зависит от количества одновременно обработанных вен, длины обработанного сегмента, выполняются ли вспомогательные процедуры, такие как амбулаторная флебэктомия. Сообщается, что в целом процент положительных отзывов пациентов очень высок. Кроме того, по стоимости процедура лазерного лечения выгоднее, чем операция. А частота положительного исхода составляет 93-100%.

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