Особенности рецидива варикозной болезни нижних конечностей и его оперативной коррекции

Несмотря на бурное развитие и стремительное распространение за последнее время малоинвазивных методик в хирургическом лечении хронических заболеваний вен, частота рецидивов с учетом срока послеоперационного периода продолжает оставаться высокой. В настоящее время отсутствует единый алгоритм хирургического лечения пациентов с рецидивами варикозной болезни нижних конечностей. Поэтому обсуждение вопросов хирургической тактики с учетом индивидуальной клинико-анатомической формы рецидива заболевания представляет актуальную проблему. В статье представлен обзор современной отечественной и зарубежной литературы по частоте встречаемости, этиологии, патогенезу, диагностике и вариантам хирургического лечения рецидива варикозной болезни нижних конечностей. Приведены современные классификации REVAS и PREVAIT, используемые для оценки рецидива варикозной болезни нижних конечностей. Детально отражены современные гипотезы об основных причинах, приводящих к его возникновению. Проведен анализ частоты рецидива после применения различных методов хирургической коррекции первичного заболевания. В обзоре дана характеристика как классических, так и современных методов коррекции рецидива варикозной болезни нижних конечностей. Акцентирована роль ультразвукового дуплексного ангиосканирования вен нижних конечностей как оптимального диагностического метода, позволяющего с высокой точностью выявить основные патоморфологические и гемодинамические причины развития рецидива заболевания. Оперативные вмешательства по поводу рецидива должны выполняться только в специализированных отделениях и высококвалифицированными хирургами. При оперативном лечении рецидива варикозной болезни нижних конечностей необходимо проводить коррекцию венозного кровотока во всех отделах мышечно-венозной помпы, а не ограничиваться простым удалением варикозно расширенных вен.

1. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML et al. Society for Vascular Surgery; American Venous Forum. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5 Suppl.):2S-48S. https://doi.org/10.1016/j.jvs.2011.01.079.

2. Rabe E, Guex JJ, Puskas A, Scuderi A, Fernandez Quesada F; VCP Coordinators. Epidemiology of chronic venous disorders in geographically diverse populations: results from the Vein Consult Program. Int Angiol. 2012;31(2):105–115. Available at: https://pubmed.ncbi.nlm.nih.gov/22466974.

3. Whing J, Nandhra S, Nesbitt C, Stansby G. Interventions for great saphenous vein incompetence. Cochrane Database Syst Rev. 2021;8(8):CD005624. https://doi.org/10.1002/14651858.CD005624.pub4.

4. Shmelev K, Gupta R. Choosing the Best Treatment Approach for Axial Vein Reflux: Thermal versus Nonthermal Approaches. Semin Intervent Radiol. 2021;38(2):209–214. https://doi.org/10.1055/s-0041-1729155.

5. Раскин ВВ, Семенов АЮ, Кургинян ХМ. Эндовенозная лазерная облитерация в профилактике развития рецидива варикозной болезни в бассейне передней добавочной подкожной вены. Профилактическая медицина. 2020;23(3):98–103. https://doi.org/10.17116/profmed20202303198.

6. Bush RG, Bush P, Flanagan J, Fritz R, Gueldner T, Koziarski J et al. Factors associated with recurrence of varicose veins after thermal ablation: results of the recurrent veins after thermal ablation study. Scientific World Journal. 2014;2014:505843. https://doi.org/10.1155/2014/505843.

7. Perrin MR, Labropoulos N, Leon LR Jr. Presentation of the patient with recurrent varices after surgery (REVAS). J Vasc Surg. 2006;43(2):327–334. https://doi.org/10.1016/j.jvs.2005.10.053.

8. Eklof B, Perrin M, Delis KT, Rutherford RB, Gloviczki P; American Venous Forum; European Venous Forum; International Union of Phlebology; American College of Phlebology; International Union of Angiology. Updated terminology of chronic venous disorders: the VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg. 2009;49(2):498–501. https://doi.org/10.1016/j.jvs.2008.09.014.

9. Kostas T, Ioannou CV, Touloupakis E, Daskalaki E, Giannoukas AD, Tsetis D, Katsamouris AN. Recurrent varicose veins after surgery: a new appraisal of a common and complex problem in vascular surgery. Eur J Vasc Endovasc Surg. 2004;27(3):275–282. https://doi.org/1-0.1016/j.ejvs.2003.12.006.

10. Покровский АВ, Игнатьев ИМ, Бредихин РА, Градусов ЕГ. Послеоперационные рецидивы варикозной болезни. Ангиология и сосудистая хирургия. 2015;21(4):118–126. Режим доступа: https://angiolsurgery.org/magazine/2015/4/13.htm.

11. Rasmussen L, Lawaetz M, Bjoern L, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation and stripping of the great saphenous vein with clinical and duplex outcome after 5 years. J Vasc Surg. 2013;58(2):421–426. https://doi.org/10.1016/j.jvs.2012.12.048.

12. Lee KH, Chung JH, Kim KT, Lee SH, Son HS, Jung JS et al. Comparative Study of Cryostripping and Endovenous Laser Therapy for Varicose Veins: Mid-Term Results. Korean J Thorac Cardiovasc Surg. 2015;48(5):345–350. https://doi.org/10.5090/kjtcs.2015.48.5.345.

13. O’Donnell TF, Balk EM, Dermody M, Tangney E, Iafrati MD. Recurrence of varicose veins after endovenous ablation of the great saphenous vein in randomized trials. J Vasc Surg Venous Lymphat Disord. 2016;4(1):97105. https://doi.org/10.1016/j.jvsv.2014.11.004.

14. Зубрицкий ВФ, Чернооков АИ, Кузнецов МР, Кандыба СИ, Долгов СИ, Атаян АА и др. Оптимизация хирургической тактики лечения пациентов с рецидивами варикозной болезни нижних конечностей. РМЖ. Медицинское обозрение. 2023;7(4):225–231. https://doi.org/10.32364/2587-6821-2023-7-4-225-231.

15. Савельев ВС, Кириенко АИ, Золотухин ИА, Андрияшкин АВ. Неадекватная перевязка устья большой подкожной вены как причина повторного развития варикозной болезни. Ангиология и сосудистая хирургия. 2007;13(3):73–77. Режим доступа: https://angiolsurgery.org/magazine/2007/3/10.htm.

16. Гавриленко АВ, Вахратьян ПЕ. Современные методы комплексного ведения пациентов с рецидивом варикозной болезни после хирургических вмешательств. Ангиология и сосудистая хирургия. 2012;18(2):97–100. Режим доступа: https://angiolsurgery.org/magazine/2012/2/15.htm.

17. Смирнов АА, Куликов ЛК, Привалов ЮА, Соботович ВФ. Рецидив варикозного расширения вен нижних конечностей. Новости хирургии. 2015;23(4):447–451. https://doi.org/10.18484/2305-0047.2015.4.447.

18. Садриев ОН, Калмыков ЕА, Гаибов АД, Иноятов МС. Рецидив варикозной болезни после флебэктомии. Российский медикобиологический вестник имени академика И.П. Павлова. 2016;24(1):86–90. https://doi.org/10.17816/PAVLOVJ2016186-90.

19. Бокерия ЛА, Абдулгасанов РА. Современные принципы лечения хронической венозной недостаточности нижних конечностей (новые направления в флебологии). Грудная и сердечно-сосудистая хирургия. 2011;(1):44–49. Режим доступа: http://elib.fesmu.ru/Article.aspx?id=247311.

20. Pittaluga P, Chastanet S, Rea B, Barbe R. Midterm results of the surgical treatment of varices by phlebectomy with conservation of a refluxing saphenous vein. J Vasc Surg. 2009;50(1):107–118. https://doi.org/10.1016/j.jvs.2008.12.067.

21. Gauw SA, Lawson JA, van Vlijmen-van Keulen CJ, Pronk P, Gaastra MT, Mooij MC. Five-year follow-up of a randomized, controlled trial comparing saphenofemoral ligation and stripping of the great saphenous vein with endovenous laser ablation (980 nm) using local tumescent anesthesia. J Vasc Surg. 2016;63(2):420–428. https://doi.org/10.1016/j.jvs.2015.08.084.

22. Дибиров МД, Шиманко АИ, Гаджимурадов РУ, Волков АС, Тюрин ДС, Магдиев АК. Радиочастотная абляция в комплексном хирургическом лечении больных с варикозным расширением вен нижних конечностей. Ангиология и сосудистая хирургия. 2018;24(1):92–96. Режим доступа: https://angiolsurgery.org/en/magazine/2018/1/10.htm.

23. van Rij AM, Jiang P, Solomon C, Christie RA, Hill GB. Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmography. J Vasc Surg. 2003;38(5):935–943. https://doi.org/10.1016/s0741-5214(03)00601-3.

24. Mouton WG, Marklewitz MM, Friedli S, Zehnder T, Wagner HE, Heim D, De Maeseneer MG. Neovascularisation after surgery for recurrent saphenofemoral incompetence: does surgical dissection technique matter? Vasa. 2011;40(4):296–301. https://doi.org/10.1024/0301-1526/a000118.

25. Recek C. Significance of Reflux Abolition at the Saphenofemoral Junction in Connection with Stripping and Ablative Methods. Int J Angiol. 2015;24(4):249–261. https://doi.org/10.1055/s-0035-1546439.

26. Garner JP, Heppell PS, Leopold PW. Thelateral accessory saphenous vein – a common cause of recurrent varicose veins. Ann R Coll Surg Engl. 2003;85(6):389–392. https://doi.org/10.1308/003588403322520744.

27. Потапов МП, Ставер ВЕ, Дякив АД, Парщенко АФ. Особенности флебогемодинамики при рецидиве варикозной болезни нижних конечностей. Здоровье и образование в XXI веке. 2017;1(19):43–46. Режим доступа: https://rucont.ru/efd/58029.

28. Zollmann M, Zollmann S, Zollmann P, Veltmann J, Kramer P, Stuecker M. Patterns of relapse 3 years after endovenous thermal ablation for insufficient saphenofemoral junctions. J Vasc Surg Venous Lymphat Disord. 2021;9(1):137–145. https://doi.org/10.1016/j.jvsv.2020.04.021.

29. Baccellieri D, Ardita V, Pannone A, Valente FBA, Lembo R, Chiesa R, Melissano G. Factors influencing recurrent varicose vein formation after radiofrequency thermal ablation for truncal reflux performed in two high-volume venous centers. J Vasc Surg Venous Lymphat Disord. 2024;12(2):101675. https://doi.org/10.1016/j.jvsv.2023.08.014.

30. Bontinis V, Bontinis A, Koutsoumpelis A, Potouridis A, Giannopoulos A, Rafailidis V. Endovenous thermal ablation in the treatment oflarge great saphenous veins of diameters > 12 mm: A systematic review meta-analysis and meta-regression. Vasc Med. 2023;28(5):449–457. https://doi.org/10.1177/1358863X231183997.

31. Vähäaho S, Halmesmäki K, Mahmoud O, Albäck A, Noronen K, Venermo M. Three-year results of a randomized controlled trial comparing mechanochemical and thermal ablation in the treatment of insufficient great saphenous veins. J Vasc Surg Venous Lymphat Disord. 2021;9(3):652–659. https://doi.org/10.1016/j.jvsv.2020.08.007.

32. Rass K, Frings N, Glowacki P, Gräber S, Tilgen W, Vogt T. Same Site Recurrence is More Frequent After Endovenous Laser Ablation Compared with High Ligation and Stripping of the Great Saphenous Vein: 5 year Results of a Randomized Clinical Trial (RELACS Study). Eur J Vasc Endovasc Surg. 2015;50(5):648–656. https://doi.org/10.1016/j.ejvs.2015.07.020.

33. Hamann SAS, Giang J, De Maeseneer MGR, Nijsten TEC, van den Bos RR. Editor’s Choice - Five Year Results of Great Saphenous Vein Treatment: A Meta-analysis. Eur J Vasc Endovasc Surg. 2017;54(6):760–770. https://doi.org/10.1016/j.ejvs.2017.08.034.

34. Flessenkämper IH, Stenger D, Hartmann M, Hartmann K, Roll S. Two-year results of a prospective randomised controlled multicenter trial to compare open operative therapy vs. endoluminal venous laser therapy with and without high ligation for the therapy of varicose greater saphenous veins. Zentralbl Chir. 2015;140(1):27–34. https://doi.org/10.1055/s-0033-1360347.

35. Anwar MA, Idrees M, Aswini M, Theivacumar NS. Fate of the tributaries of sapheno femoral junction following endovenous thermal ablation of incompetent axial vein – A review article. Phlebology. 2019;34(3):151–155. https://doi.org/10.1177/0268355518783635.

36. Wallace T, El-Sheikha J, Nandhra S, Leung C, Mohamed A, Harwood A. Long-term outcomes of endovenous laser ablation and conventional surgery for great saphenous varicose veins. Br J Surg. 2018;105(13):1759–1767. https://doi.org/10.1002/bjs.10961.

37. Eggen CAM, Alozai T, Pronk P, Mooij MC, Gaastra MTW, Ünlü Ç. Ten-year follow-up of a randomized controlled trial comparing saphenofemoral ligation and stripping of the great saphenous vein with endovenous laser ablation (980 nm) using local tumescent anesthesia. J Vasc Surg. 2022;10(3):646-653.e1. https://doi.org/10.1016/j.jvsv.2021.08.008.

38. Hong KP. Prognosis of reflux of the below-knee great saphenous vein after surgical or endovenous treatment of reflux of the above-knee great saphenous vein. J Vasc Surg Venous Lymphat Disord. 2020;8(4):629–633. https://doi.org/10.1016/j.jvsv.2019.11.009.

39. Mendes CA, Martins AA, Fukuda JM, Parente JB, Munia MA, Fioranelli A. Randomized trial of radiofrequency ablation versus conventional surgery for superficial venous insufficiency: if you don’t tell, they won’t know. Clinics. 2016;71(11):650–656. https://doi.org/10.6061/clinics/2016(11)06.

40. Bootun R, Davies AH. Long-term follow-up for different varicose vein therapies: is surgery still the best? Phlebology. 2016;31(1 Suppl.): 125–129. https://doi.org/10.1177/0268355516632438.

41. Nesbitt C, Eifell RK, Coyne P, Badri H, Bhattacharya V, Stansby G. Endovenous ablation (radiofrequency andlaser) and foam sclerotherapy versus conventional surgery for great saphenous vein varices. Cochrane Database Syst Rev. 2011;5(10):CD005624. https://doi.org/10.1002/14651858.CD005624.pub2.

42. Erben Y, Vasquez I, Li Y, Gloviczki P, Kalra M, Oderich G. A multi-institutional review of endovenous thermal ablation of the saphenous vein finds male sex and use of anticoagulation are predictors oflong-term failure. Phlebology. 2021;36(4):283–289. https://doi.org/10.1177/0268355520972923.

43. Whing J, Nandhra S, Nesbitt C, Stansby G. Interventions for great saphenous vein incompetence. Cochrane Database Syst Rev. 2021;8(8):CD005624. https://doi.org/10.1002/14651858.CD005624.pub4.

44. Balint R, Farics A, Parti K, Vizsy L, Batorfi J, Menyhei G, Balint IB. Which endovenous ablation method does offer a better long-term technical success in the treatment of the incompetent great saphenous vein? Review. Vascular. 2016;24(6):649–657. https://doi.org/10.1177/1708538116648035.

45. Gao RD, Qian SY, Wang HH, Liu YS, Ren SY. Strategies and challenges in treatment of varicose veins and venous insufficiency. World J Clin Cases. 2022;10(18):5946–5956. https://doi.org/10.12998/wjcc.v10.i18.5946.

46. Shrestha O, Basukala S, Thapa N, Karki S, Pant P, Paudel S. Endovenous laser ablation versus conventional surgery (ligation and stripping) for primary great saphenous varicose vein: a systematic review and meta-analysis. Ann Med Surg. 2023;85(9):4509–4519. https://doi.org/10.1097/MS9.0000000000001095.

47. Anwar MA, Idrees M, Aswini M, Theivacumar NS. Fate of the tributaries of sapheno femoral junction following endovenous thermal ablation of incompetent axial vein – A review article. Phlebology. 2019;34(3):151–155. https://doi.org/10.1177/0268355518783635.

48. Blomgren L, Johansson G, Dahlberg-Åkerman A, Norén A, Brundin C, Nordström E, Bergqvist D. Recurrent varicose veins: incidence, risk factors and groin anatomy. Eur J Vasc Endovasc Surg. 2004;27(3):269–274. https://doi.org/10.1016/j.ejvs.2003.12.022.

49. Хрыщанович ВЯ, Третьяк СИ, Романович АВ. Рецидив варикозной болезни: неадекватное хирургическое лечение попрежнему остается проблемой? Флебология. 2010;4(3):71–73. Режим доступа: https://www.mediasphera.ru/issues/flebologiya/2010/3/031997-69762010312.

50. Чернооков АИ, Кандыба СИ, Сильчук ЕС, Долгов СИ, Атаян АА, Лебедева ЮН, Рамазанов АА. Применение эндоваскулярной лазерной коагуляции при рецидиве варикозной болезни нижних конечностей. Лазерная медицина. 2022;26(2):8–14. https://doi.org/10.37895/2071-8004-2022-26-2-8-14.

51. Cavallini A, Marcer D, Ferrari Ruffino S. Endovenous laser treatment of groin and popliteal varicose veins recurrence. Phlebology. 2018;33(3):195–205. https://doi.org/10.1177/0268355516687865.

52. Гаибов АД, Неъматзода О, Буриева ШМ, Калмыков ЕЛ. Опыт применения механохимической склерооблитерации в лечении рецидива варикозной болезни вен нижних конечностей. Российский медико-биологический вестник имени академика И.П. Павлова. 2020;28(1):57–66. https://doi.org/10.23888/PAVLOVJ202028157-66.

53. Pavei P, Ferini M, Spreafico G, Nosadini A. Ultrasound guided foam sclerotherapy of recurrent varices of the great and small saphenous vein: 5-year follow up. Veins and Lymphatics. 2014;3(2):46–55. https://doi.org/10.4081/vl.2014.4655.

54. Theivacumar NS, Gough MJ. Endovenous laser ablation (EVLA) to treat recurrent varicose veins. Eur J Vasc Endovasc Surg. 2011;41(5):691–696. https://doi.org/10.1016/j.ejvs.2011.01.018.

55. van Groenendael L, van der Vliet JA, Flinkenflögel L, Roovers EA, van Sterkenburg SM, Reijnen MM. Treatment of recurrent varicose veins of the great saphenous vein by conventional surgery and endovenous laser ablation. J Vasc Surg. 2009;50(5):1106–1113. https://doi.org/10.1016/j.jvs.2009.06.057.

56. Hwang JH, Park SW, Chang IS, Kim KH, Kang JH. Endovenous Thermal Ablation of Recurrent Varicose Veins due to Residual Great Saphenous Venous Insufficiency After Saphenous Venous Surgery: A Comparative Study. Dermatol Surg. 2018;44(10):1287–1294. https://doi.org/10.1097/DSS.0000000000001543.

57. Bradbury AW, Bate G, Pang K, Darvall KA, Adam DJ. Ultrasound-guided foam sclerotherapy is a safe and clinically effective treatment for superficial venous reflux. J Vasc Surg. 2010;52(4):939–945. https://doi.org/10.1016/j.jvs.2010.04.077.

58. Hernando LL, Bielsa AA, Lacayo JCF. Treatment of Recurrent Symptomatic Saphenous Trunk Reflux with Catheter Directed Foam Sclerotherapy and Tumescent Anaesthesia. EJVES Vascular Forum. 2022;55:1–4. https://doi.org/10.1016/j.ejvsvf.2022.01.008.

59. Rodriguez Santos F, Loson V, Coria A, Marquez Fosser C, Dotta M, Katsini R. Secondary Ablation of Recanalized Saphenous Vein after Endovenous Thermal Ablation. Ann Vasc Surg. 2020;68:172–178. https://doi.org/10.1016/j.avsg.2020.04.017.

60. Turtulici G, Furino E, Dedone G, Sartoris R, Zawaideh J, Fischetti A, Silvestri E et al. Percutaneous treatment with radiofrequency ablation of varicose veins recurring after vein stripping surgery A preliminary study. Ann Ital Chir. 2017;6:438–442. Available at: https://pubmed.ncbi.nlm.nih.gov/29197190.

61. Hager ES, Washington C, Steinmetz A, Wu T, Singh M, Dillavou E. Factors that influence perforator vein closure rates using radiofrequency ablation, laser ablation, or foam sclerotherapy. J Vasc Surg Venous and Lymphat Disord. 2016;4(1):51–56. https://doi.org/10.1016/j.jvsv.2015.08.004.

62. Mordhorst A, Yang GK, Chen JC, Lee S, Gagnon J. Ultrasound-guided cyanoacrylate injection for the treatment of incompetent perforator veins. Phlebology. 2021;36(9):752–760. https://doi.org/10.1177/02683555211015564.

63. Jimenez JC, Lawrence PF, Pavlyha M, Farley SM, Rigberg DA, DeRubertis BG, Woo K; UCLA Gonda (Goldschmied) Venous Center. Endovenous microfoam ablation of below knee superficial truncal veins is safe and effective in patients with prior saphenous treatment across a wide range of CEAP classes. J Vasc Surg Venous Lymphat Disord. 2022;10(2):390–394. https://doi.org/10.1016/j.jvsv.2021.08.015.

64. Frings N, Nelle A, Tran P, Fischer R, Krug W. Reduction of neoreflux after correctly performed ligation of the saphenofemoral junction. A randomized trial. Eur J Vasc Endovasc Surg. 2004;28(3):246–252. https://doi.org/10.1016/j.ejvs.2004.05.015.

65. Mitschang C, Mühlberger D, Goerge T. Pros and cons of classic crossectomy with stripping compared to endoluminal treatment: Competition or team play? Hautarzt. 2020;71(1):6–11. (In German.) https://doi.org/10.1007/s00105-019-04515-z.

66. Winterborn RJ, Earnshaw JJ. Randomised trial of polytetrafluoroethylene patch insertion for recurrent great saphenous varicose veins. Eur J Vasc Endovasc Surg. 2007;34(3):367–373. https://doi.org/10.1016/j.ejvs.2007.03.019.

67. Kundu S, Lurie F, Millward SF, Padberg FJr, Vedantham S, Elias S. American Venous Forum; Society of Interventional Radiology. Recommended reporting standards for endovenous ablation for the treatment of venous insufficiency: joint statement of The American Venous Forum and The Society of Interventional Radiology. J Vasc Surg. 2007;46(3):582–589. https://doi.org/10.1016/j.jvs.2007.05.025.

68. Gloviczki P, Lawrence PF, Wasan SM, Meissner MH, Almeida J, Brown KR et al. The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine. J Vasc Surg Venous Lymphat Disord. 2024;12(1):101670. https://doi.org/10.1016/j.jvsv.2023.08.011.

69. Harlander-Locke M, Jimenez JC, Lawrence PF, Derubertis BG, Rigberg DA, Gelabert HA. Endovenous ablation with concomitant phlebectomy is a safe and effective method of treatment for symptomatic patients with axial reflux andlarge incompetent tributaries. J Vasc Surg. 2013;58(1):166–172. https://doi.org/10.1016/j.jvs.2012.12.054.

70. Izumi M, Ikeda Y, Yamashita H, Asaoka Y, Fujishiro M, Shin M, Abo Y. Safety and Effectiveness of Endovenous Laser Ablation Combined With Ligation for Severe Saphenous Varicose Veins in Japanese Patients. Int Heart J. 2016;57(1):87–90. https://doi.org/10.1536/ihj.15-282.

71. Huang Y, Zhang D, Zhou C, Zhang Y, Shi C, Chen Q. The first meta-analysis research on the effects of endovenous laser ablation combined with sapheno-femoral junction high ligation of the great saphenous vein. Lasers Med Sci. 2023;38(1):175. https://doi.org/10.1007/s10103-023-03833-y.

72. Singh A, Gattani R. A Narrative Review of Advancements in Understanding and Treating Varicose Veins. Cureus. 2023;15(11):e48093. https://doi.org/10.7759/cureus.48093.