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The Interventions

Vascular Surgery

Dr. Russo carries out various interventions in the field of vascular surgery using his proven experience and professionalism. His methodology of diagnosis and care has become well-known in the La Spezia province, having played an important role and leadership in healthcare facilities in vascular surgery departments.

 Lower Limb Varicose Veins

What are varicose veins?
They are superficial vein dilations and are an expression of the venous blood's difficulty to flow in the right direction, i.e. from the feet to the heart, resulting in a stagnation of blood in the legs. The most common cause of this condition is a structural change to the valves in the two main superficial veins in the legs: the large saphenous vein and the small saphenous vein.

What damage do they cause?
Varicose veins often do not give any significant symptoms and represent an exclusively aesthetic problem. If they are present, symptoms are characterised by a feeling of heaviness, tension, itching and burning, especially at the end of the day, which can be associated with night-time cramps and the feeling of restlessness in the legs. However, if the varicose veins are not properly treated, the symptoms may be more serious because they may be related to a complication.

How do they manifest themselves?
Varicose veins usually develop slowly over time and manifest themselves as elongated, tortuous, very palpable, blue-ish coloured exaggerations at the level of the under the skin of the legs.
These signs may associate with the oedema, or swelling of the leg, which is usually located at the ankle level. In the most advanced cases, there may be alterations in the skin's colouration, especially in the lower leg, which are signs of skin fragility: in such areas it is possible for an ulcer to form that represents the most important skin complication due to varicose disease.

Who does it affect and why?
Varicose veins are a frequent disease affecting about 10-30% of the adult population, with a slight prevalence for the female. Most varieties are called "primitive" because of unknown causes but a genetic aspect certainly has an important role in their development. Incidence increases with age, although varicose veins are not uncommon in the young, and overweight, sedentary, and prolonged standing or sitting are also important factors contributing to the onset of the disease.

Complications
As already mentioned, a skin ulcer may develop as a complication of varicose veins, and when formed, involves long healing times and a high incidence of recurrences. Another major complication is thrombophlebitis: it is an acute occlusion of one or more varicose veins and this occlusion is caused by the formation of a thrombus that can propagate in other superficial and deep veins. Finally, the appearance of a haemorrhage due to a rupture of a varicose vein is another possible complication of the disease: the clinical picture often frightens the patient and the family, but it is actually a benign and easily controllable complication done by placing the leg for drainage and squeezing the bleeding point.

How can they be cured?

Varicose can be controlled satisfactorily but a definitive cure does not exist because of the chronic, progressive, genetic component. Disease control can be accomplished through medical or surgical therapy. Medical therapy basically consists in wearing an elastic stocking during daytime hours, the degree of compression is in relation to the severity of the disease. In addition to an elastic stocking, it is important to stick to an appropriate lifestyle, reducing body weight, in the case of overweight or obesity, to avoid a sedentary life and to carry out healthy sports activities for the veins such as
due mani che tengono una gamba di un uomo sdraiato
swimming. Surgery is an alternative to elastic compression for aesthetic reasons, when there are signs the disease is advanced, or when the patient is intolerant of the elastic stocking. In recent years, surgical techniques have profundly changed and mini-invasive methods are increasingly used in comparison to classical saphenous stripping surgery.

Surgery

Saphenous stripping

Until a few years ago, this is the surgical technique considered the most effective for treating varicose veins. It involves the "stripping", that is, the removal of a small or larger length of the saphenous vein by a probe called a "stripper"; In the same session, flebectomies are then performed, i.e. the removal of varicose veins through the use of specific hooks. This type of surgery usually requires a spinal anesthesia, followed by a surgical incision at the root of the thigh or the poplite cavity (depending on whether it is the large or small saphenous vein) and micro-incisions at the thigh level or leg at the varices to be removed. Such surgical technique is well-established and effective, but inevitably involves the removal of an unnecessary vein. Therefore, where possible, the use of mini-invasive techniques (radiofrequency, laser, sclerotherapy) is preferable, which, with similar results, intervenes on the saphenous system in a much more targeted and conservative manner.

Ablation of the Saphenous vein:
Radiofrequency and laser saphenous ablation involve the occlusion of only the incontinent saphenous tract through radio frequency or laser. Both methods, using the same form of energy, work on the walls of the saphenous vein causing its complete closure. The surgical technique, is always performed under local anaesthesia and under ultrasound guidance, is identical for both methods: the radio frequency or laser catheter is inserted into the the saphenous vein via a small hole in the skin and, once properly positioned, "burns" the affected part of the saphenous vein. As for the varices, these can be treated during the same session, or at a later time. Indeed, the occlusion of the diseased part of the saphenous vein in many cases results in the reduction and sometimes disappearance of varices without any additional treatment. If it is decided to treat them, they can be removed, either in the same session or later, by surgical flebectomy or by "scratching" with sclerotherapy.

Sclerotherapy
The occlusion of the saphenous vein can also be achieved by sclerotherapy. The technique involves the injection of a mixture of sclerosing fluid and air (sclerosing foam) into the vessel causing it to be occluded. In this case, surgery also needs to be performed under local anaesthesia and ultrasound guidance. Such a method is also extremely effective in treating veins relapsing after surgical or ablative treatment and in case there are particular pathological refluxes: incontinence of a saphenous ancillary or a perforated vein.

Recommendations after surgery

Elastic or bandage

- At the end of the surgery, in the case of mini-invasive treatment (laser, radiofrequency, sclerotherapy), a class 2 elastic sock is worn and must be kept on day and night for 48 hours and thereafter only during the day;
- In the case of classic stripping, a compression bandage is provided to be worn day and night up to the first outpatient check-up.

Duration of hospitalization

- In the post operative, a short rest period should be observed in bed if spinal anaesthesia has been performed. After a few hours, when the feeling has returned to the limb , you can get up and start walking;
- Where local anaesthesia has been performed, it is important to have early mobilazation immediately after surgery. The health care team, after successfully evaluating your overall condition and that of the treated leg, will discharge you.

Do's and don'ts after the surgery

- On the day of surgery the patient should not drive and must be accompanied; they can walk but not long distances and must avoid excessive effort, such as lifting weights;
- During the next few days, the patient can take short walks several times a day, always avoiding excessive effort; they can now drive. - It may be useful to sleep with the foot of the bed raised ca 10-15 cm and place the limb in a relaxed position several times during the day, making sure that all the leg, from the foot to the knee, is resting on a pillow, keeping the knee slightly bent;
- It is important not to wet any surgical wounds until after the first outpatient check-up.

Word of warning

- During the first few days, it is common that the elastic stocking or bandage becomes soiled with small blood spots: this is normal and should not be a concern;
- Any swelling, secretion and redness of the surgical wound or the sudden onset of pain and swelling at the lower limb should not to be underestimated and the patient should immediately contact the physician, using the contact numbers given on discharge.

Post-operative care

The first outpatient check-up is usually programmed one week on: on this occasion, any surgical wounds are checked and suture points removed. If a bandage has been used after surgery, at the time of discharge, this will be removed. It is advisable to continue with compression elastic for at least another week and, if possible, until any haematomas are reabsorbed. Finally, it is advisable to wear a preventative stocking with 18 mmHg, especially for those where work activities involve long periods of standing or sitting.

Future Care

As already mentioned, varices are a chronic and evolutionary disease to a genetic component. Surgical treatment, therefore, whatever it is, is only aimed at controlling the disease and not for its definitive cure. Recurrences are frequent and can occur in up to 20% of cases. From the data available in medical literature, however, it seems that mini-invasive treatments have a recurrence rate lower than classic stripping surgery. It is therefore important to undergo periodic check-ups after discharge, both to check the success of the surgery and to plan any further surgical treatments.
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