In the treatment of varicose and postthrombophlebitic ulcers, it is important to distinguish between primary varicose and secondary varicose veins, since surgical tactics are different for them. To conduct functional tests to determine the condition of superficial, communication and deep veins, sufficient skill is required. The reference of some authors to the great unreliability of many functional tests is subjective. With the help of correctly performed functional tests, it is possible to determine the patency of deep veins in most patients, whereas phlebography is required to determine the level of occlusion and the extent of the thrombotic process. Carefully collected anamnesis with the skillful conduct of a complex of clinical samples makes it possible to correctly diagnose the vast majority of patients with venous pathology.
The following main clinical and functional tests are used to determine the valvular insufficiency of the superficial and communication veins of the lower extremities.
- Main part
The Brody-Troyanov-Trendelenburg test
The Brody-Troyanov-Trendelborg test is carried out in the horizontal position of the patient. By stroking an upwardly raised limb from the foot to the inguinal region, the subcutaneous veins are first emptied, and then the fingers of the hand or the application of a rubber tourniquet compress the large subcutaneous vein in the region of the oval fossa and, without taking away the fingers, invite the patient to stand up. At the same time, the veins subside, but after the removal of the tourniquet or the weaning of the fingers, blood quickly replenishes against its normal current, ie, from the top down, which indicates a failure of the valves and a positive Brody-Troyanov-Trendelenburg test.
Bernsten (1927) expanded the interpretation of the Brody-Troyanov-Trendelenburg diagnostic test and carried out it somewhat modified. After evacuation of the veins in the elevated limb, the patient is placed a tube of soft rubber to squeeze only the subcutaneous veins at the border of the upper and middle thirds of the thigh, after which they offer to stand up and, depending on the filling of the large saphenous vein, give the following functional evaluation:
- If the vein slowly fills under the rubber strand and above it, and the removal of the tourniquet does not affect its filling, – therefore, the valves of the large saphenous vein and its anastomoses are capable.
- If the vein becomes filled above the rubber strand and does not fill below it, then there is a deficiency in the ostial valve.
- If the vein fills quickly (5-10 seconds) only below the tourniquet and removal does not add anything, – there is a lack of valves of the medial crural veins, and the osteal valve functions.
- If the vein quickly fills over and under the rubber strand, as well as before and after it is removed, the valves of the large vein and the communication veins are incapacitated.
The Brody-Troyanov-Trendelenburg test makes it possible to determine the insufficiency of the valves of the subcutaneous veins in a simple and accessible way. But it can not quantify the degree of retrograde blood flow through the veins and the degree of failure of the valves.
The Alekseev-Bogdasarian test
For the quantitative determination of the degree of venous insufficiency of the superficial veins, the Alekseev-Bogdasaryan trial (1966) was proposed. The sample is carried out in an open vessel, which has the form of a boot with a drain cock in the upper part (Figure 4). The water is poured into the vessel with a temperature of + 30 ° + 34 °. The limb rises, foot movements are made to empty the veins, and a plate tourniquet is placed in the groin to stop arterial and venous blood flow. The limb is lowered into a vessel of water. The displaced water flows down the drain cock into the measuring vessel. The volume of it (V0) is equal to the submerged part of the limb to the middle third of the thigh. Then the tourniquet is removed, and blood flows down the arteries and veins. The volume of the limb increases, and for 15 seconds the amount of fluid displaced from the vessel is measured. This will be the volume of the arterial-venous influx (V1). After 20 minutes, the test is repeated in the same order, only below the tourniquet is the cuff of the tonometer, in which the pressure is maintained 70 mm Hg. Art. for compression of veins. The tourniquet is removed, and blood rushes down the artery (veins are squeezed by a cuff). Within 15 seconds, the displaced liquid is measured. This is the amount of arterial inflow (V2).
The calculation is carried out. The difference between arteriovenous inflow and arterial (V1-V2 = V3) shows the volume of reverse venous blood flow in 15 sec (V3).
Then, according to the formula S = V3 / 15 ml / s, the volumetric velocity of the reverse venous inflow in 15 sec (V3) is calculated, and the volume of this inflow per 1000 cm3 of tissue is calculated by the formula: V1000 = V3x1000 / V0. It was found that with venous insufficiency of the first degree the volume of reverse venous inflow in 15 sec ranges from 11 to 30 ml, at the second degree – from 31 to 90 ml and at the third degree – from above 90 ml. The volume velocity is from 0.7 to 2 ml / s, respectively; from 2 to 6 ml / s and above 6 ml / s; the volume of the reverse blood flow per 1000 cm3 of tissue is from 2 to 6 ml; from 7 to 12 ml and over 12 ml. In the arterial form of varicose veins, these indicators are close to those in healthy people, and when mixed form different degrees of venous insufficiency are observed.
The Alekseev-Baghdasaryan trial improves the quality of diagnostics. It is designed for patients with valvular insufficiency of superficial varicose veins and with the preservation of the functions of communication and deep veins.
In the opinion of PP Bulgakov and co-authors (1969), this trial can not be recommended for patients with post-thrombophlebitic syndrome. According to the new technique of plethysmometry proposed by PP Alekseev for patients with postthrombophlebitic syndrome, we developed the indices of this sample and conducted its further study in the clinic.
Palvator-percussion test of Schwartz
With abundant fatty tissue on the hips, which is more common in women, it is not always possible to determine the course of the main trunk of a varicose dilated large saphenous vein. For this, the Schwarz’s palpation-percussion test is used. It is carried out as follows. One hand (“listening”) lies on the upper end of the large saphenous vein, and the fingers of the second arm are struck by visible varicose veins. Sensible jerks of the arm at the top of the thigh confirm the presence of the projection of the large saphenous vein.
The Myers compression test is also performed with the only difference that a large subcutaneous vein is pressed against the inner condyle of the hip, while the other is located at the top of the thigh or lower on the shin and perceives a push.
These samples make it possible to determine the main trunk of the large saphenous vein on the lower leg, which only 10-12% of patients can be expressed and twisted by the varicose process, and in other cases its branches that lie on the fascia in the connective tissue vagina are poorly contoured or contoured.
Cough symptom of Gakkenbruch
To determine the deficiency of the ostial valve of the large saphenous vein, the cough symptom of Gakkenbruch is used. For this purpose, an arm is applied in the area of the saphenic-femoral anastom, and after coughing of the patient with insufficient osteal valve under the fingers, a retrograde impulse of venous blood from the inferior vena cava due to contraction of the diaphragm is felt.
The Valsalva test
With valvular insufficiency of the deep veins of the thigh and drumstick, the Valsalva test is valuable. It consists in the fact that when the patient strains, the filling of varicose veins of the lower leg upwards comes quickly, as a result of phlebocytotension and perverted venous blood flow from the “valveless” deep veins through the perforation to the subcutaneous ones.
Valsalva test. Bulging of swelling on the neck with coughing and straining, i.e. with an exhaled exhalation with a closed glottis. It is used for the detection of a chesty goiter. At the same time, a deep fainting is possible, from which the patient is difficult to withdraw.
Pratt (1941) conducts the following test to determine the lack of communication veins. In the position of the patient lying on the raised limb after the subcutaneous veins fall, a rubber bandage Bira is placed in the form of turns from the fingers to the inguinal area, which squeezes the superficial veins and completely covers the limb. Then a rubber band is applied over the bandage (in the groin) to squeeze the large saphenous vein below the sapheno-femoral anastom. The patient rises, the rubber bandage is gradually removed at a distance of 6-8 cm from the bundle. In the same way, a second rubber bandage is applied from above. After that, the lower bandage unfolds further, and the upper bandage folds so that there is a gap of 5-6 cm between them. When a full varicose node appears indicating a deficiency of the perforating vein, a blue mark is made in this place.
VN Sheinis (1954), Barrow (1957) modified Pratt’s sample and used three bundles instead of the rubber bandage of Bir, so the sample is called a three-clotted sample. To conduct its tourniquets superimposed in the elevated position of the limb: one below the saphenous-femoral anastom, the other above the knee and the third below the knee. The patient is asked to get up. If there is a swelling of veins on any site, then there are communication veins with incompetent valves. Then, by moving the bundles to this area, the sample is repeated several times. However, it is laborious and time-consuming.
The Mayo-Pratt test
To determine the patency of deep veins, there are a number of functional tests that can be widely used in the daily work of the surgeon, especially where phlebographic examination methods are not yet available.
The Mayo-Pratt test. The authors define the function of deep veins in the following way. On the sublime limb after emptying the subcutaneous veins, a tourniquet is placed on the upper third of the thigh before the suppression of the superficial veins. After that, the limb is bandaged with a rubber bandage from the fingers to the inguinal fold or a rubber stocking is applied and the patient is offered to walk for 30-40 minutes. If there are pains or worse, deep veins are impassable.
To establish the patency of deep veins, V. Ivanov proposed a trial, which consists in the following. The patient is placed in a horizontal position, the limb rises at an angle to such a level that there is a complete collapse of the subcutaneous veins. This will be the “compensation angle”. Then, in the vertical position of the patient in the upper third of the shin, a tourniquet is applied only to squeeze the subcutaneous veins. The veins are filled below the harness. Then the patient lies down and lifts the leg with the tourniquet to the former level of the “compensation angle”. If the veins below the tourniquet subside – deep veins are considered passable. If the veins do not fall off and the patient experiences a feeling of bursting into the lower leg, deep veins are considered impassable.
The Delbe-Pertesa trial
To determine the function of deep veins of the lower extremities, the Delbe-Perthes test (“march test”) was widely used in surgical practice. It consists in determining the filling or shedding of subcutaneous varicose veins below the tourniquet after walking for 3-5 minutes. If the subcutaneous veins collapse – consider that the deep passable (Figure 5). If the subcutaneous veins swell, then the deep veins are impassable. In assessing this sample errors are allowed, which served as an excuse for some authors to question its reliability
There are other ways to determine arteriovenous anastomoses, for example, comparison of venous blood by oxygen level, a sample with radioactive isotopes, determination of blood flow velocity by intravenous administration of chemicals. A more reliable method is serial arteriography.
To determine deep vein thrombophlebitis, other diagnostic methods are also used. Thrombophlebitis of the deep veins is often accompanied by pain along the course of the main vessels, so when palpating in the femoral, popliteal and tibial veins, the projection of the pain sensation may correspond to the level of the thrombotic process.
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