A B S T R AC T S
Simposio Internazionale di Flebologia • International Symposium of Phlebology • Simposio Internacional de Flebología
28 - 29 Marzo • March • Marzo
Sclerotherapy
Sheraton Firenze Hotel & Conference Center - Florence
Supported by
Associazione Flebologica Italiana
(ITALY)
Sclerotherapy
Presentazione • Introduction • Presentación
Sono passati due anni e ancora una volta è arrivato il momento per una nuova edizione di Sclerotherapy. Per chi lavora tutti i giorni praticando la
flebologia questo congresso è diventato rapidamente un appuntamento irrinunciabile di confronto scientifico e di aggiornamento. Anche questa volta
lo spazio più ampio sarà dato alle forme di ablazione venosa, sia fisica che chimica anche se cercheremo di proporre tutte le più importanti novità in
flebologia invitando esperti da tutto il mondo. Come per le altre edizioni anche questa si terrà in tre lingue con traduzione simultanea (italiano, inglese
e spagnolo) in modo da sottolineare una volta di più il carattere internazionale del meeting. Sclerotherapy 2014 ospiterà anche quest’anno il congresso
nazionale dell’AFI, l’Associazione Flebologica Italiana che ha continuato a crescere moltissimo in questi ultimi due anni grazie all’importante contributo
dei coordinatori regionali e dei suoi associati. Questo sarà il mio ultimo anno di presidenza dell’AFI e permettetemi di rivendicare con orgoglio il lavoro che
abbiamo fatto tutti insieme: l’AFI è diventata in poco tempo il riferimento più significativo e affidabile per il flebologo italiano e per le aziende che operano
in questo settore. Per questo voglio ringraziare tutti per il conseguimento di questo grande obiettivo che si è concretizzato nel creare una comunità di
flebologi prima di tutto, con interessi e scopi comuni.
Two years have passed and once again the time has come for a new edition of Sclerotherapy. For those who work every day practicing Phlebology
this conference has quickly become a key event for scientific confrontation and update. This time a wider relevance will be given to the forms of venous
ablation, both physical and chemical although we will introduce the most important news in Phlebology inviting experts from around the world. As with
the other editions this one too will be held in three languages with simultaneous translation (English, Italian and Spanish) in order to emphasize once more
the international character of the meeting. Sclerotherapy 2014 will also host this year’s national convention of AFI, the Italian Pthlebological Association
that has continued to grow a lot in the past two years thanks to the important contribution of regional coordinators and its associates. This will be my last
year as the AFI president and let me proudly claim the work we have been doing all along: the AFI has quickly become the most significant and reliable
reference for the Italian phlebologist and for the companies operating in this sector. I want to thank everyone for the great achievement of this goal, which
has mainly resulted in creating a community of phlebologists, with common interests and goals.
Dos años han pasado y una vez más ha llegado el momento de una nueva edición de Sclerotherapy. Para los que trabajan todos los días practicando Flebología esta conferencia se ha convertido rápidamente en un evento clave para comparación científica y actualización. También esta vez se le dará
el mayor espacio a las formas de la ablación venosa, tanto físicos como químicos, aunque vamos a tratar de proponer todas las noticias más importantes
de Flebología invitando a expertos de todo el mundo. Al igual que con las otras ediciones también esta se llevará a cabo en tres idiomas con traducción
simultánea (Inglés, italiano y español) con el fin de subrayar una vez más el carácter internacional del simposio. Sclerotherapy 2014 también será la
casa de la convención nacional de la AFI, la Asociación Febológica Italiana que ha ido creciendo mucho en los últimos dos años gracias a la importante
contribución de los coordinadores regionales y sus socios. Este será mi último año como presidente AFI y qui siera afirmar con orgullo el trabajo que
hemos estado haciendo desde el principio: la AFI ha convertido rápidamente en la referencia más importante y confiable para los flebologos italianos y
de las empresas que operan en este sector. Quiero dar las gracias a todos por el gran logro de este objetivo, que se ha traducido en la creación de una
comunidad de flebólogos en primer lugar, con los intereses y objetivos comunes.
Dr. Alessandro Frullini
Presidente AFI • AFI President • Presidente AFI
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Sclerotherapy
1 SESSIONE 1
ANATOMIA VENOSA DELL’ARTO INFERIORE: ANALISI DEI QUADRI PIÙ FAVOREVOLI ALLA SCLEROTERAPIA.
Ricci S.*[1]
[1]studio Medico Ricci
Lo studio dell’anatomia venosa degli arti inferiori, che comunque non deve essere disgiunto dallo studio funzionale, ha trovato nell’ecografia (e nel
Color Doppler) il mezzo ideale per un progresso di conoscenza che ha rivoluzionato il trattamento,. Le innumerevoli variabili anatomiche una volta
considerate “misteriose” oggi possono essere comprese utilizzando criteri semplici e facilmente comprensibili, quali i “segni di identificazione” dei
principali tronchi safenici (segnodell’occhio, dell’allineamento, dell’angolo Tibio-Gastrocnemio, ecc) indipendentementi dal loro calibro e dalla loro
emodinamica. Quasi sempre il rapporto fra vene e fascia superficiale è in causa, tale fascia, con la sua forte ecogenicità, risultando uno dei criteri
più facili da individuare.
La distinzione di vene sopra e sottofasciali, il loro calibro, l’origine e la forma delle perforanti, la presenza di circuiti alternativi (V. di Giacomini), la
forma e la funzione delle giunzioni condizionano comprensibilmente il tipo di terapia, in una alternativa fra asportazione o sclerosi, con una possibile
opzione anche per la terapia conservativa. Per quanto riguarda più particolarmente la sclerosi dei tronchi safenici, un notevole contributo può venire
dalla conoscenza dei migliori punti di accesso, delle aree con minori rischi di puntura arteriosa, della selezione dei punti di occlusione.
Da ricordare infine lo studio di quadri particolari quali: la Safena Accessoria Anteriore, il sistema venoso della c.d. Lamina Linfatica della Giunzione Safeno Femorale, e la perforante del cavo popliteo, le vene pelviche e glutee, tutte tipicamente coinvolte nelle recidive post trattamento delle
rispettive aree.
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GIACOMINI VARICOSE VEINS ORIGINATING FROM THE POPLITEAL FOSSA
Ermini S.*[1]
[1]Studio Flebologico ~ Firenze ~ Italy
Giacomini varicose veins can originate from escape points placed above or below the visible varicose veins and can have different hemodynamic
patterns. This work analyzes those patterns originating from the popliteal fossa, where an escape point gives origin to a centripetal flow in the Giacomini vein during muscle contraction. This centripetal flow can describe different hemodynamic patterns and may or may not feed varicose veins.
This work classifies these different patterns, the possible hemodynamic solutions and the early outcomes of CHIVA treatment.
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Sclerotherapy
DAILY SCLEROTHERAPY PRACTICE ACCORDING TO THE NEW EUROPEAN GUIDELINES ON SCLEROTHERAPY IN CHRONIC VENOUS DISORDERS
Guggenbichler S.*[1], Breu F.[2]
[1]Monaco di Baviera, [2]Tegernsee
Since the first Consensus Meeting, which was held at Tegernsee, Germany in 2003,several new technical recommendations have been given in
order to treat varicose veins with sclerotherapy in a safe and efficacious way. In May 2012 a European group of experts discussed and updated
the second European Tegernsee consensus on sclerotherapy from 2006 . The new guidelines on sclerotherapy were adopted by 23 European
phlebology societies and provide for the first time evidence-based recommendations on sclerotherapy that are valid throughout Europe. They
take into account the extensive scientific findings on the effectiveness of liquid and foam sclerosants and give practical advice on how to perform
sclerotherapy. We will show
• the integration of the updated parameters in our daily sclerotherapy practice by combining the new recommendations with our practical experience of many years. We will point out indications, pre sclerotherapy mapping, technical aspects of puncture and injection.
• the updated recommendations for foam volumes and concentrations for the treatment of all types of varicose veins by chemical endovenous
ablation.
• our way of applying the post treatment recommendations in daily practice such as compression therapy, mobilization of the patient and also the
assessment of the outcome after sclerotherapy.
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Sclerotherapy
TREATMENT OF INSUFFICIENT PERFORATING VEINS WITH PERCUTANEOUS LASER UNDER ECHO DOPPLER COLOR
CONTROL.
Pietravallo A.*[1],
[1]University of the Salvador - Buenos Aires - Argentina
BACKGROUND: First publications of this technique in our country were done by two groups of work: 1- Jorge Soracco – Jorge López D’ambola,
published in the year 2000 in Phlebology Magazine, Official Organ of diffusion of Argentina Society of Phlebology and Lymphology and International
Union of Phlebology. 2- Oscar Bottini – Oscar Gural, beginning of the method in the year 2004. Published in Argentina Magazine Forum of Phlebology and Lymphology in May, 2006. We began to effect the first cases in the year 2004 and since then because of the obtained efficiency we
develop this technique in systematic way up to the current. We use this technique only in insufficient perforating veins that with their reflux produce
secondary varicose veins or trophic disorders. TECHNIQUE: We use a 980 laser, laser fiber 400 or 600 micras. For fiber of 400 micras we realize the
puncture with needle 18 G x 1 ½” and for fiber of 600 micras we use an Abbocath 14G. 1- The patient must be studied with a precise topography
of insufficient perforating veins indicating with abscissas and arranged the exact point of the aponeurotic ostium of the perforating to be treated.
2- In operating room is located accurately insufficient perforating vein with patient in supine position with slight flexion of the knee downward leg in
Trendelenburg invested with an angle of 45 ° down. Indeed, look for the perforating vein with Echo Doppler and its respective function respecting
this angle is essential because many perforating decrease its flow and therefore its diameter in the supine position. For this reason we accurately
diagnose days or weeks before with the patient standing but we do again the marking in operating room with this angle. 3- In intraoperative Doppler
image the insufficient perforating vein is found and we see how the needle reach to that perforating under the guidance of Echo Doppler. 4- The
laser fiber is carried through the lumen of the needle 18 G x 1 ½ “or Abbocath 14 G which is the one we used for the puncture. 5- Once the needle
is inside the perforating vein laser discharge shows us the image of the “bubble” in the light of the perforating. 6- They are downloads 3”, power
of 4 watts. It corresponds to 36 joules. 7- Echo Doppler image shows how the perforating vein is closed to that level. 8- Making pressure on the
calf muscle is found that the reflux is stopped in the closed perforating vein. Percutaneous laser to treat insufficient perforating veins of more than
4 mm., 4 to 6 mm with demonstrated reflux: Used powers in our experience and recommended for effective closure without secondary effects:
1- 4 watts in 3 series of 3 seconds each one: 36 joules 2- Powers effective range without drilling: 8 watts in 3 series of 3 seconds. Total = 72 joules
3- From 72 joules = 8% of perforations 4- 10 watts in 3 series of 3 seconds = 90 joules = 24% of perforations Operated cases since 2004 to June
2012= 367 cases Recurrence= 13 cases Recurrence rate= 3.6% RESULTS: We present the results of three years in each group of patients in
the three periods that make up our series. We believe that it’s enough to get an accurate assessment of the results because in all series of other
authors consulted confirmed that recurrences occur in the first 6 months post-treatment. First serie 2004-2005-2006: operated cases: 142. Evaluated cases:138. Recurrences: 5 % Second serie 2007-2008-2009: operated cases:128. Evaluated cases: 115. Recurrences: 4 % Third serie 2010
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Sclerotherapy
to June 2012: operated cases:97. Evaluated cases: 97. Recurrences: 2 % In the first 367 cases: Recurrence rate: 3.6 % Up to December 2012:
operated cases:47. Evaluated cases: 47. Recurrences were not detected until the present Total of cases operated: 414 CONCLUSIONS: 1- High
percentage of confirmed closure of the perforating. 2- Excellent aesthetic result. Just leave a scar punctate that over a week to ten days tends to
go unnoticed. 3- Minimally invasive technique. 4- The postoperative period is short, comfortable and painless allowing ambulation from the next
day. 5- We have not registered inflammatory or indurative signs in the area of the puncture
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Sclerotherapy
THE EAST EUROPEAN ENDOVASCULAR METHOD
Bihari I.*[1], Dragic P.[2], Zernoviczky F.[3], Ayoub G.[1], Bihari P.[1]
[1]Budapest, [2]Novi Sad, [3]Bratislava
Objective. At the beginning of our laser surgery the recurrency rate was unacceptably high: 13.8 % a year. This is the reason why several modifications were performed. Now the Hungarian experience with the East European Endovascular Method (EEEM) will be presented.
Patients. EEEM was performed on 855 limbs, with various wavelengths of laser instruments. The age range was between 17 and 82 years. The
diameter of the veins was between 4 and 32 mm. In the last 3 years classic varicose vein surgery has not been performed, which means every
saphenous stem varicosity case without selection was included in this survey. A high percentage (43 %) of our material are so-called „non-study
cases”: recurrent varicosity (79), double saphenous stem (41), saccular ectasia (4), acute varicophlebitis (22), BMI >35 (45), later pregnancy (6),
older than 70 (91), CVI (74), crural ulcer (29). Other diseases (diabetes mellitus, hypertension, hyperthyreosis, hypothyreosis, thrombophilia, coronary stent, myasthenia gravis) in 21 % were present.
Methods. EEEM is as follows: (1) the distance of the tip of the laser fibre is 0.5 cm from the femoral vein (2) delivered energy is more than 100 J/cm
(3) more energy is given to the proximal part than to the distal part of the saphenous stems (4) the amount of cooled tumescent anaesthetic solution
given is 5 ml/cm (5) the tumescent solution compresses the SFJ (6) insufficient perforator veins are treated (7) propofol anaesthesia is administered
and (8) LMWH prophylaxis is given.
Manual pullback was employed. To remove side branches and perforator veins along the limb, foam sclerotherapy, Varady’s hook and the saw-knife
were used. Heparin prophylaxis was not given in the first 216 cases, but after one slight pulmonary embolism without deep venous thrombosis,
LMWH was administered in every subsequent case.
Results. Every treated vein occluded (100 %) and there was a 2.3 % recurrent varicosity rate in this 6 year period. Recurrent cases were from the
following cohorts: CVI, overweight and earlier operated cases. None of our patients developed recurrency during pregnancy. A questionnaire was
completed in 60 cases regarding post-operative complaints: 79 % of patients did not take any painkillers, and 66 ???% of them were back at work
within a week. There was some degree of suffusions in 88 % of cases. Complications: 2 pulmonary embolisms, and in 7.2 % there were some minor
and temporary neurological complaints in the region of the laser treatment.
Conclusions. According to our study, EEEM is recommended instead of crossectomy, stripping and ligature of perforator veins in every type of
varicosity.
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Sclerotherapy
QUALE CHIRURGIA NEL TRATTAMENTO DELLA VENA GRANDE SAFENA?
Pavei P.*[1], Ferrini M.[1], Nosadini A.[1], Spreafico G.[1], Piccioli A.[2], Giraldi E.[1], Baccaglini U.[1]
[1]PADOVA, [2]VICENZA
INTRODUZIONE
Negli ultimi anni sempre più si discute sulla validità della chirurgia tradizionale, cioè di crossectomia radicale e stripping, nel trattamento delle varici
degli arti inferiori. L’approccio tradizionale si è sempre più modificato ed ha lasciato spazio a trattamenti meno invasivi guidati dallo studio emodinamico.
MATERIALI E METODI
Dal 2009 al giugno 2013 sono stati trattati con metodica “conservativa” 63 pazienti con insufficienza della vena grande safena. I pazienti sono stati
tutti sottoposti a crossectomia conservativa con piccola incisione all’inguine, preservazione delle collaterali prossimali ed eventuale legatura delle
collaterali distali, se refluenti all’ecocolordoppler.Di questi pazienti 37 presentavano una competenza della valvola terminale. Il diametro del tronco
safenico era compreso tra 5 e 15 mm (media 7mm). 59 pazienti sono stati sottoposti a crossectomia conservativa, safenectomia e flebectomia,
mentre 4 hanno eseguito solo safenectomia. In 4 casi è stata effettuata la legatura della vena di Giacomini refluente ed in 4 casi della collaterale
antero-laterale. I pazienti sono stati trattati in 27 casi in anestesia generale, sedazione e maschera laringea in 4 casi e negli ultimi 32 casi in anestesia
locale tumescente eseguita sotto guida ecografica. La classificazione CEAP era compresa tra C2 e C5
RISULTATI
Al controllo clinico-strumentale eseguito nel settembre 2013 nessun paziente presentava varici clinicamente evidenti. Il follow up era così distribuito:
12 pazienti < 12 mesi; 15 pazienti con follow up a 12 mesi; 10 pazienti a 24 mesi; 26 paziente a 36 mesi. Il controllo ecografico ha dimostrato in 20
dei 26 pazienti con incompetenza preoperatoria della valvola terminale, una ripresa della continenza della stessa (crosse IIbC). In 6 casi persisteva
l’incontinenza della valvola terminale alla manovra di Valsalva. In 1 di questi pazienti abbiamo osservato lo sviluppo di neoangiogenesi all’ecocolordoppler, non associato a quadro clinico.
In 8 casi l’ecocolordoppler di controllo ha evidenziatola presenza di una collaterale antero-laterale continente, già evidenziata nel preoperatorio
e che andrà monitorata nel tempo. In 3 casi i pazienti presentavano anche varici perineali refluenti, già evidenti nella valutazione preoperatoria e
trattate a distanza di 3 mesi con scleroterapia. Il dolore post-operatorio è stato molto modesto: 28 pazienti non hanno assunto alcun farmaco per
il dolore, 22 hanno assunto 1 g di paracetamolo la sera dell’intervento, 12 pazienti la sera dell’intervento e la mattina successiva ed in 1 caso il
paziente ha assunto ibuprofene per 2 gg. I pazienti hanno eseguito profilassi eparinica per 4-7giorni in base alla classe di rischio ed indossato un
monocollant della II classe per 30 giorni. Non abbiamo avuto TVP, né tromboflebiti.
DISCUSSIONE
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Sclerotherapy
Negli ultimi 10 anni anche la chirurgia tradizionale ha subito numerose modifiche con uno spostamento verso tecniche sempre meno aggressive ed
eseguibili in ambulatorio. Tutto ciò grazie ad una sempre più accurata diagnosi preoperatoria e alla comparsa di lavori in letteratura che confermano
un’incidenza di recidive con le tecniche mininvasive (trattamenti endovascolari e CHIVA) anche inferiore rispetto alle tecniche tradizionali di crossectomia radicale e stripping. La nostra piccola esperienza conferma la bontà degli approcci più conservativi con risultati non inferiori a quelli classici.
CONCLUSIONI
La chirurgia delle varici per stare al passo con le nuove metodiche mininvasive, scleroterapia e tecniche endovascolari, deve essere guidata da un
accurato esame ecocolordoppler, essere mininvasiva, a basso costo e possibilmente effettuabile in un ambulatorio protetto.
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Sclerotherapy
VASCULAR ULCERS OF THE LOWER LIMBS: THE EFFECT OF AMINAPHTONE IN AN IN VITRO MODEL OF WOUND-HEALING
Di Stefano R.*[1], Felice F.[1], Dal Pozzo E.[2], Belardinelli E.[1], Frullini A.[3]
[1]Cardiovascular Research Laboratory, Department of Surgical, Medical and Molecular Pathology and Critic Area, University of Pisa, Pisa, Italy, [2]Department of
Pharmacy, University of Pisa, Pisa, Italy, [3]Studio medico Flebologico
Background. Failure to re-epithelialize is the major clinical problem in venous ulcers. The wound repair process within chronic venous ulcers is ineffective. Initially, fibroblasts must migrate to and proliferate in the wound. They must also respond appropriately to cytokines and other factors that
modulate and direct the production of extracellular matrix and the process of wound contracture.
Aim. Evaluate the effect of aminaphtone (AMNA) on wound healing process in fibroblast subjected to normal condition and hypoxic stress.
Material and Methods. Dermal fibroblast were isolated from normal thigh skin. After confluences, the wound healing assay was performed to study
cell migration and cell interactions. In particular, cells were treated in two different way: a) cells were pre-treated with different concentration of
AMAN (6 and 10 µg/ml) for 24h. AMNA was than removed and cells were scratched by a pipette tip, simulating a wound; b) cells were scratched
by a pipette tip to simulate a wound and AMNA (6 and 10 µg/ml) were added for 24h. Wound-healing process were evaluated at 0 and after 24
h under a Nikon microscope at 4x magnification. Four images per treatment were analyzed using an AxioVision program, and results reported as
mean ± SD. Treatment under hypoxic conditions (1% O2 for 12 h and 24 h), are in progress.
Results. Pre-treatment with 10 µg/ml AMNA for 24 h improves wound healing process (90%) compared to control (untreated cells) and cell pretreated with 6 µg/ml AMNA. Moreover, pre-treatment results more effective than the treatment after scratch (70% wound healing).
Conclusion. AMNA improve wound healing process in a time and concentration-dependent manner.
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Sclerotherapy
SCLEROTHERAPY COMPLICATIONS – IS IT REALLY ALWAYS AN EASY AND SAFE TREATMENT METHOD?
Urbanek T.*
The wide implementation of the sclerotherapy lead to the common use of this treatment modality in ambulatory settings. Despite the growing experience concerning the use of this kind of treatment, sclerotherapy is still not free from, sometimes serious, complications.
Even, if in the majority of cases only temporary and self healing complications can be observed, in some patients clinically significant problems
are present. In the paper, based on the literature overwiew as well as on the own material, the possible sclerotherapy complications with potential
risk factors as well as proposed treatment solutions will be presented. The examples of the registered own local complications (including matting,
hyperpigmentation, skin necrosis) as well as more severe clinical conditions such as visual disturbances (including temporary complete blindness),
deep vein thrombosis or peripheral leg ischemia related to the sclerotherapy use will be presented and discussed.
The knowledge concerning the possible complications related to the sclerotherapy use, should always be discussed with the potential patient – this
in turn requires the proper physican education in the field of the potential risk factor evaluation as well as in the proper treatment implementation.
The relatively common presence of matting (1-25%), hyperpigmentation (10-30%), skin necrosis (0-1,5%) as well as the low frequent occurrence of
the more severe clinical complications should be always taken into consideration and requires the careful patient follow up after each sclerotherapy
session. The proper physican experience, anatomy and injection technique knowledge as well as the use of the minimal volume of the sclerosant,
needle placement control technique and an avoidance of the deep vein system injury by sclerosant should be always taken into account as well as
should be an important part of the sclerotherapy training.
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Sclerotherapy
SCLEROTHERAPY TECHNIQUE USING ENDOVENOUS INCLUSIONS
Radu D.*[1], Ivan V.[1], Ivan C.D.G.[2]
[1]*Surgical Clinic 1, County Hospital Timis, University of Medicine and Pharmacy “V.Babes” Timisoara ~ Timisoara ~ Romania, [2]Surgical Clinc 1 County Emergency
Hospital Timis ~ Timisoara ~ Romania
Background
Sclerotherapy is a conservative method for varicose diseases, recommended method for the small and middle caliber varicose veins or remaining
varicose veins after saphenous veins ablation. Sclerotherapy uncombined with the surgical interruption of the pathologic reflux is ineffective, for that
reason we use often sclerotherapy and surgical method.
Method
In the Surgical Clinic 1, a personal technique of sclerotherapy (Brinzeu), is represented by the sclerotherapy with surgical wire, through endovenous
intraaoperatory inclusion with a good therapeutically effect. The histological changes subsequent to this sclerotherapy method: a thrombogenous effect on the circulatory blood and destructive action on the venous endothelium, tunica media and venous endothelium are replaced by a fibrous layer.
Perivenously, an unspecific limphoplasmocitary invasion process occurs. The advantages of the method: easy to perform, shortens the treatment time
because all the varices may be treated in one session, reduced costs, ensures the morphological, pathophysiological and esthetic objectives in the
inferior limb treatment.
Results
As a co-treatment, we have associated sclerotherapy with inclusions in the case of 206, out of 2662 patients, diagnosed with chronic venous insufficiency CEAP III-V operated on between 2003-2013. As a complementary treatment method, the endovariceal inclusion has been used in the case of
736 patients (11,30% out of the varicose treated ulcers during 2003 – 2013) out of which 178 cases (24,18%) as a single therapy. Potential incidents,
accidents and complications: perivenous hemorrhagic suffusion, gradually resorbing under compressive bandage. Few patients presented violet microscars, 1-2 mm long, on a period of maximum 11-12 months. 2 years after, the scars were pale, hardly obvious.
Discussions
Starting with 1962, when Pius Brinzeu introduced sclerotherapy with endovenous inclusions, this method has been performed as a complementary
peroperatory therapy for the remaining or relapsing varices. In CEAP C VI, in the presence of the calf ulcer, sclerotherapy represents a complementary
treatment method, used more often in the varicose ulcer, than in the posttrombotic ulcer. This method completes the pathological reflux interruption
surgery, by resolving the restant ulcers. The sclerosing treatment may suppress the reflux of the perforating veins having a small, or medium flow, which
cannot be used in massive refluxes.
Conclusion: Sclerotherapy through endovenous inclusion is an alternative method of chemical sclerosis, safe, efficient, faster and shorter in terms of
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Sclerotherapy
treatment duration and recuperation. It is a Romanian technique imagined and implemented by Timisoara’s Phlebology School. The surgical and sclerosing therapies are pathogenical treatment methods, and not etiological methods as, only the consequences of the varicose disease are removed.
PHLEBOLOGIC REHABILITATION
Chunga Prieto J.A.*[1]
[1]Lima
1) OBJECTIVE: To establish the clinical benefits of the exercises we teach our patients of venous ulcer by improving the range of ankle movement
(ROAM), and demonstrate the benefits in wound healing. 2) METHODS: + Study Design: Case series. + Year(s)/Month(s) Study Conducted: April
2012 to December 2012 + Disease/Condition Studied: patients with leg ulcers caused by venous insufficiency that came to our practice. + Subjects
Studied: 27 patients with venous leg ulcers (9 males, 18 females); 35 limbs; 42 active leg ulcers. Sizes of the ulcers: 20 cm2. to 100 cm2. (Media
of 60 cm2). + Setting in Which Subjects Studied: We teach our patients and a family member a series of exercises in our private practice, to be
performed at home or at workplace. + Intervention(s): Series of exercises perform which include: 15 minutes work 3 times per day; alongside with
compression therapy and sclerotherapy. +Outcome Measurement(s): ROAM, Wound healing time. 3. RESULTS: ROAM was reduced in all patients
with venous leg ulcers (22°+-5) and patients with long time ulcers, showed lower levels of ROAM. After doing this exercises as scheduled, patients
improve their ROAM (30°+-5) and also has a lesser time in healing their ulcer (1 to 4 months with a media of 2 months). The exercises are better
performed with elastic compression. Patients with venous leg ulcers are often told to rest in bed, when we tell them to do this exercises and walk,
they feel better with themselves becoming our best allies in healing their ulcers 4. CONCLUSION: The objective of the study was to demonstrate our
exercises program improves healing rates in patients with venous leg ulcers. In conclusion this research has shown that phlebologic rehabilitation
improves ROAM and alongside sclerotherapy and compression therapy heals venous leg ulcers faster and also improves our patient’s psychology
because they can walk and be efficient again.
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TREATMENT OF INSUFFICIENT PERFORATING VEINS WITH ULTRASOUND GUIDED SCLEROTHERAPY
Pietravallo A.*
Background: This one is the procedure that is performed by more frequency of agreement to the international bibliography.
The method was described by Knight et al in 1989 and the first prospective study was realized by Thibault and Lewis from Australia in 1992:
1- Knight R.M., Vin F., Zygmunt J.A.: Ultrasonic guidance of injection into the superficial venous system. In: Davy R., Stemmer R. John Libbey
Eurotext Ltd. Phlebologie 1989; 339-41.
2- Thibault P.K., Lewis W.A.: Recurrent varicose veins. Part 2: Injection of incompetent perforating veins using ultrasound guidance. J. Dermatol.
Surg. Oncol. 1992; 18: 895-900
Between the first works they are:
3- Nicolaides A.: “Venous disease and phlebotherapy. A new approach”, Phlebology. Supp. 2, Springer Internacional, 1992, vol. 7
4- Issacs MN: Duplex guided sclerotherapy. Dermatol. Surg., 1997; 23: 309
5- Schadek M.: Sclerotherapie des perforantes jambieres. Phlebologie, 1997. 50 (4): 683-688
6- Guex J.J.: Ultrasound guides sclerotherapy (USGS) for perforating veins (PV). Hawaii Med. J. 2000; 59: 261-2
7- Puggioni A., Lurie F., Masuda E., Eklof B., Kistner R.: Ultrasound-guided sclerotherapy of incompetent perforators: Technique and duplex
follow-up. Pacific Vascular Symposium on Venous Disease. Kona-Hi. Nov. 2002
8- Eklof B.: “Are perforators a real issue?” Revista Phlebologie, Julio-Septiembre 2004, año , Nº 3, págs. 285 – 287.
Indications: Insufficient perforating veins of more than 4 mm of diameter that produce secondary varicose veins to their reflux, varicose recurrence
or trophic disorders.
Technique:
1- All the procedure is with ultrasound guidance.
2- The insufficient perforating vein to be treated forms part of a program to effecting as it exists insufficiency GSV or SSV, insufficient tributaires
and the perforating veins to be treated.
3- In operating room we realize Echo-marking.
4- We locate and mark the perforating vein to be treated with dermographic pencil according to coordinates (abscissas from the latero-internal
edge of the tibia and arranged from sole). This is saved in the clinic history of the patient and then we can do next following to 3 days, 3 months,
6 months, 1 year and 3 years.
5- Patient in supine position with slight flexion of the knee downward leg in Trendelenburg invested with an angle of 45 ° down.
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Sclerotherapy
6- The secondary varicose Gulf is punctured to the output of fascial ostium.
7- 2 to 3 cm3 of foam of Polidocanol 1% is injected slowly.
8- We check with Echo Doppler that foam is inside the perforating vein and its gradual closure. Image is showed in video.
9- Then we put a chiffon square in the point of the perforating treated, on this White bandage and elastic bandage. The bandage is is removed
at 3 days when the first Eco Doppler control is effected.
10- Wandering from 12 hours.
Clinic Recurrence Concept: Recurrences are more frequent in first year. Las recidivas son más frecuentes en el curso del primer año. When Echo
Doppler demonstrates reflux and a epifascial varicose vein it is recurrence.
Echographic Recurrence Concept: From January 2007 to October 2013 178 cases were operated: women 76% and men 24%. Between 35 and
67 years old.
Outcomes: clinical recurrences18%. 16% cases were reoperated with new puncture. 2% of the patients didn’t come back to control.
Echographic Recurrence: Clinical follow-up was carried out without further treatment.
Minor complications:
a- Hematomas at the puncture site: 7%
b- Ecchymosis: 4%
c- Pain during the first week: 6%
Complications of medium importance:
d- Posterior tibial thrombophlebitis: 2% (Good evolution with anticoagulant therapy)
Complications of major importance:
e- There was no thromboembolism or skin lesions
Conclusions: This is an excellent therapeutic resource for insufficient perforating veins that with its reflux generate secondary varicose veins, with
few complications and excellent aesthetic result.
One of the main advantages of this procedure is that if clinical recurrences are detected the percutaneous puncture can be repeated under Echo
Doppler control, close the perforating vein and void its reflux.
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Sclerotherapy
CONSIDERATIONS ABOUT THE VALVE COMPETENCE TESTS
Ermini S.*[1]
[1]Studio Flebologico ~ Firenze ~ Italy
The venous flow speed is always lower than that visible with the US. For this reason we need maneuvers to increase this velocity.
With the exception of some places, we don’t know where the venous valves are located. So, when we detect a flow with an inverse direction to the
valve’s orientation, we are checking a flow in a vessel and not only a valve competence. To increase venous flow speed, we must create a pressure
gradient.
A pressure gradient is a vector that joins two points with different pressure values and has one direction:
• the point where the force works (i.e. point A )
• the low energy reference point ( i.e point B )
• the vector between A and B and its direction.
In a vertical gradient the hydrostatic pressure must always be considered.
The direction of the flow is the same as the gradient and its speed is in relation to the gradient intensity.
Between points A and B a continuity must exist, otherwise the gradient is null (i.e. a retrograde flow can only exist if there is a valve incompetence
and a re-entry point that represents the communication with a low energy point)
Referring to the Doppler check-up of valve incompetence, we must consider that when we create a maneuver to increase venous flow speed, the
detection point must be placed on the gradient line that is between point A and point B.
The test to check-up the valve competence may be divided into:
• hypertensive tests (Valsalva Test)
• gravitational aspirative tests
Valsalva Test.
The Valsalva maneuver involves an expiration against a closed airway such as blowing into a closed straw, or a forced inspiration such as that of a
bowel movement or weight bearing. This inverts the pressure gradient from a cardio to peripheral directional flow
The distribution of abdominal hypertension to the lower legs occurs in 2 different ways:
• By direct distribution of the flow that originates from the abdomen squeezing in every segment without valves (anatomical absence or
pathologic incompetence)
• By the creation of a “clamp effect” in the valved segments where the pressure increases proportionally to the residual venular flow and to the
muscle pump activity if the patient is in standing position. The clamp effect also occurs in case of valve absence, when the abdomen vein squeezing
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Sclerotherapy
is finished but the Valsalva systole continues.
The clamp effect is demonstrated by an increase of the saphenous arc or of the superficial femoral vein in a normal subject.
We also have a systolic and a diastolic phase in the Valsalva maneuver.
In the systolic phase if the system is competent the increase in pressure stops the antegrade flow in the superficial and deep system. During diastole
the flow restarts, and this phase gives us the confirmation that the maneuver has been well executed.
If there is an incompetent escape point connected to a system with low energy between the abdomen and the doppler detection site, we find a
reverse flow doppler signal in this site.
The Valsalva maneuver is a good test for the escape points (compartment jumps), but its gradient is sometimes very high and valves can appear
incompetent where they appear competent with other tests. The reversal flow in an escape point occurs due to a direct distribution of the flow if
there is no competent valve between the abdomen and the escape point, and due to the “ clamp effect” in the other situation. This involves a different latency between the maneuver and flow detection and explains the Valsalva positivity in a site far from abdomen, i.e. an incompetent SPJ
during the Valsalva maneuver in a patient with healthy deep veins.
The Valsalva maneuver can be done in a lying or in a standing position. In a standing position the abdominal gradient evoked by the maneuver has
the same direction of the hydrostatic pressure, and is more effective. In a lying position the empty volume of the leg veins, mostly in the case of
valve incompetence, is reduced and the Valsalva gradient is increased, but the displacement of abdomen organs over the pelvic floor is reduced.
This means that if the maneuver is well executed, its sensibility is highest in a lying position.
The “Clamp Effect” may be responsible not only for an outward flow in an escape point (compartment jump) but also for a retrograde flow in an
network connected to another competent vein of the same network level, i.e. in a situation where there is no compartment jump.
Gravitational aspirative tests:
• Static test , the calf compression , or squeezing test
• Dynamic test , muscle contraction still in place
These tests must be done only in standing position because to run the hydrodynamic energy is necessary.
The squeezing test mobilizes blood mainly in superficial system and in minor part in deep veins.
The compression phase of the squeezing test ( or the systolic phase ) mobilizes blood upward because in the leg downward resistance are higher
. During the relaxation ( or diastole ) we empty the veins in the compression site and this create a gradient pressure between this point and the
incompetent vein above placed. The gradient is in this case an aspirative gradient, between the upper point of the incompetent system and the
compressed site, where now pressure is lower. The site of doppler detection is between these two points , that represent the extremes of the gradient. Otherwise if I test with a squeezing test the function of a perforator, the detection Doppler site is out of the gradient line.
Dynamic tests : were introduced in venous cartography by Claude Franceschi in Paranà- Argentine, 1998. The most important maneuver described
by Claude take its name from the city. The importance of these tests is that we use the muscle pump activity to mobilize blood in deep and superficial system, simulating what happens when the patient walk. Only with this kind of tests we can mobilize an important volume of blood in deep
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system.
The dynamic tests are very important in check-up of the deep system in postphlebitic syndrome and of the perforators. In this case the detection
doppler site always is on the line of the pressure gradient.
Otherwise, if a stenosis, functional or organic, or a complete obstruction of the deep system exists, only the mobilization of blood in the deep system
like happens with a muscle contraction, can point out a compensative system and a related systolic outward flow while a hand calf compression
(squeezing) may evidence only a short retrograde flow.
There are many kinds of maneuver to perform a dynamic test. The most frequently used in my daily practice are :
• The Paranà maneuvre, both from anterior and posterior side
• The flexo-extension of the knee.
To perform this test and the venous mapping , the position of the operator and of the patient are most important.
To compare manual calf compression (or squeezing test) with the Paranà manouvre the following calculations have been taken into consideration:
1. The ascending time from zero to the maximum speed, and the time from the maximum speed to zero (descending time) in 20 healthy popliteal
veins the maximum speed,
2. The maximum speed of the propulsive and relaxation flow and their times in 13 incompetent SFJ, in 13 incompetent saphenous trunks and in
11 re-entry perforators
The mathematic analysis of these data confirms that the Paranà test is more reliable and more effective then the squeezing test.
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VENOUS CARTOGRAPHY: A SIMPLE YET EFFECTIVE WEB TOOL
Figueiredo M.*[1], Figueiredo M.[1]
[1]Sociedade Brasileira de Angiologia e Cirurgia Vasclar - SBACV ~ Uberlandia ~ Brazil
The goal is to present to the medical community the web-based app Vascular Cartography. It’s primary function is the crafting of ultrasonographic
reports, containing drawings of the patients vascular pathologies as well as pictures of the ultrasonographic exam. No installation is required, since
it’s a web-base app. The user can create, edit and visualize exams from anywhere through a device, such as notebooks and tablets, connected
to the Internet.
Metod:
The vascular cartography is a software on line with three basic functions.
Clinical cartography – Upon the clinical examination of the patient with venous insufficiency in the lower limbs having been made, draw the main
varicose veins (micro varicose veins, reticular, trunk veins), schematize the ochre dermatitis, draw an ulcer or scar, recording the patient’s physical
examination. It is also provided with accessory tools for the change of colors, rubber to erase or undo arrow, free brush in three sizes and arrows
to make notes in the scheme.
Venous ultrasonographic cartography – It permits the issue of ultrasonographic reports of the venous mapping and research of thrombosis of the
lower limbs, and the cava vein and the iliac veins. Tools of a specific nature permit drawing into the scheme the recent or late thrombus, reflux,
aneurysms,stents – thus recording the report in one scheme. It is also provided with accessory tools for the change of colors, rubber to erase or
undo arrow, free brush in three sizes and arrows to make notes in the scheme.
Arterial ultrasonographic cartography – It permits the issue of ultrasonographic reports of the carotid and vertebral arteries, abdominal aorta and
iliac veins, lower and upper extremities, digestive tract arteries. It uses specific tools that permit drawing in the scheme an atheroma plaque, stents,
aneurysms (sacular, fusiform, or pseudoaneurysm) and fistulas. And it is also provided with accessory tools for the change of colors, rubber to erase
or undo arrow, free brush in three sizes and arrows to make notes in the scheme.
To acess: www.vascularcartography.com
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Sclerotherapy
LA TECNICA L.A.F.O.S. NEL TRATTAMENTO DELL’INSUFFICIENZA SAFENICA INTERNA
Gerardi G.A.*[1]
[1]OSPEDALE S MARGHERITA ~ CORTONA (AREZZO) ~ Italy
INTRODUZIONE
La ricerca della Tecnica migliore per il trattamento delle Safene Insufficienti è l obiettivo che tutti gli Specialisti del settore si pongono.
Lo sforzo è quello di identificare una metodica che sia efficace; Miniinvasiva; Pain less ; Sicura; Economica e Standardizzabile ovvero universalmente
riproducibile indipendentemente dalla perizia dell’ Operatore.
Ciò è ancor più necessario in un periodo in cui il taglio alle spese sanitarie impone una riduzione dei costi alle Aziende Ospedaliere.
La Tecnica L.A.F.O.S. presenta a nostro avviso tutte le prerogative per essere annoverata come il trattamento obliterativo per la correzione dell’
Insufficienza Safenica più economico, di semplice e rapida esecuzione, indolore, di minimo impegno temporale e gestionale per il paziente e di pari
efficacia nei risultati se confrontato alle altre metodiche mini invasive demolitive.
MATERIALI E METODI
In questo Studio Non Randomizzato abbiamo trattato con Tecnica L.A.F.O.S. (Laser Assisted Foam Sclerotherapy) dieci pazienti (sette donne e tre
uomini) di età compresa tra 40 e 65 anni affetti da Insufficienza della Safena Interna ( C2EPAS2-3-5PR).
L’insufficienza della Safena Interna è stata documentata ambulatorialmente tramite ecocolordoppler con sonda lineare 10 Mhz in ortostatismo considerando significativa la durata >1 sec. del reflusso venoso Safenico durante manovra iperpressiva di Valsalva e gravitazionale dinamica di Paranà
alla cross con la vena femorale. Il diametro delle Safene Interne trattate alla Cross è stato determinato per ogni paziente (9 mm diametro medio).
I pazienti sono stati pre trattati il giorno precedente l’ intervento con Eparina BPM .
Il giorno dell’ Intervento (effettuato in ambulatorio in anestesia locale) è stato ritirato il Consenso Informato discusso, argomentato e distribuito ai
pazienti durante la visita di arruolamento, tenutasi almeno un mese prima di eseguire l’ operazione.
L’ incannulamento della Safena Interna è stato praticato in tutti i casi in corrispondenza del ginocchio dove la Safena Interna decorre più superficialmente, in clinostatismo,sotto guida ecografica previa anestesia locale del punto cutaneo di incannulamento della Safena effettuato mediante
agocannula 17 G.
Attraverso la cannula è stata inserita la fibra laser Ho:YAG 2100 nm di di 550 micron di diametro di produzione Techlamed® fino a raggiungere la
distanza di due centimetri dalla cross della Safena Interna con la Femorale sempre distalmente all’origine della vena epigastrica. La progressione e
il posizionamento del tip sono stati effettuati sotto guida ecografica.
La Fluenza utilizzata è compresa in un range tra 150 e 350 J per impulso in relazione al diametro della vena trattata e della sua distanza dalla cute
con tempo di erogazione di un secondo.
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Sclerotherapy
La PRF (Frequenza di Ripetizione degli Impulsi) utilizzata è pari a 7 Hz con impulsi brevi della durata di 350 micro sec e tempi di t- off pari a 142 ms.
La retrazione manuale della sonda centimetro per centimetro è stata effettuata solo dopo aver raggiunto la riduzione del 50% del diametro del lume
di ogni segmento Safenico trattato (evento eco graficamente valutato)
Al termine del Trattamento Laser è stata iniettata tramite la medesima ago cannula di 17G la schiuma sclerosante prodotta con Atossisclerol® 3%
e aria in proporzioni di 1:4 secondo tecnica Tessari per un volume di 5ml totali1-2
Si è praticata compressione eccentrica lungo il decorso Safenico con garze ed concentrica tramite collant di grado compressivo classe II e si è
invitato il paziente a camminare per circa trenta minuti dal termine della seduta e successivamente per mezz’ora al giorno per i seguenti sette-dieci
giorni.
Il Follow up ecocolordoppler dei pazienti è stato effettuato a sette giorni dal trattamento, un mese; tre mesi e sei mesi.
RISULTATI
L’ Occlusione totale della Safena interna con scomparsa di reflusso a valle dell’ origine della vena epigastrica nei dieci pazienti a sei mesi è del 100%
dei casi senza necessità per nessuno di retrattamento.
Nessun paziente ha lamentato dolore perioperatorio e nei casi in cui la vena Safena presentava decorso più superficiale la Fluenza del Laser è stata
regolata al limite basso di erogazione (150J).
Il dolore postoperatorio investigato anamnesticamente con scala 1:10 in tutto il periodo postoperatorio di F.up è stato mediamente pari a 3 e solo
nelle prime 24 ore.
I pazienti lamentavano prevalentemente algia urente lungo il percorso Safenico e solo per un giorno.
Algia peraltro risolta con prescrizione di antalgici minori (Tachipirina 500 gr 1X2 /die).
L’ Ipercromia cutanea lungo il tratto Safenico cutaneo si è manifestato in due pazienti in cui il decorso della vena era più superficiale ed è stato risolto
con applicazioni topiche di Lattoferrina NLT.
Non vi sono stati casi di complicanze maggiori quali TVP (Tutti i pazienti hanno proseguito la terapia con Eparina BPM per10 giorni dopo l’ intervento).
DISCUSSIONE
Le tecniche demolitive obliterative miniinvasive per il trattamento dell’ Insufficienza Safenica più comuni sono quelle chimiche e quelle indotte da
laser e radiofrequenza.3-4-5
Obiettivo del lavoro non è quello di promuovere una tecnica che ormai è collaudata e la cui efficacia è stata dimostrata con coorte di pazienti e
lunghezza di follow up riportati in letteratura da autorevoli Autori ben più significativi di quelli qui presentati 2
Ci si propone viceversa di porre l’attenzione sulle importanti peculiarità che la tecnica L.A.F.O.S. presenta.
La metodica infatti presenta una versatilità unica che abbinata al suo costo relativo (prevalentemente il costo per la sonda laser),alla sua reale mini
invasività,alla sua semplice applicabilità e all’assenza di dolore percepito dal paziente, la rendono tecnica di eccellenza tra le obliterative mini invasive.
La mancanza di dolore percepito durante il trattamento rende superflua l’esecuzione di anestesia tumescente lungo il decorso safenico, momento
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Sclerotherapy
necessario nelle altre tecniche obliterative che prolunga il timing operatorio di almeno dieci minuti rispetto alle Tecnica L.A.F.O.S.
L’ assenza di questo tempo operatorio contribuisce nel permettere alla L.A.F.O.S. di essere effettuata in Ambulatorio senza necessità di Sala Operatoria garantendo gli stessi risultati finali delle altre tecniche.
Questo particolare è di notevole importanza se si considera che l’atteggiamento gestionale delle Aziende Sanitarie Pubbliche di questa patologia
per motivi di spending review è passata da tempo a regime di day surgery e dovrà trasformarsi rapidamente in regime ambulatoriale possibilmente
con utilizzazione del più basso numero di mezzi e personale medico-infermieristico disponibile.
CONCLUSIONI
La nostra esperienza L.A.F.O.S. ancorché limitata per numero di pazienti reclutati e per il breve Follow up vuole contribuire a porre l’ attenzione sulla
sua validità e la sua maggiore versatilità rispetto alle altre tecniche obliterative mini invasive in considerazione del fatto che i risultati finali raggiunti
sono paritetici a quelli ottenibili con le altre tecniche (100% di occlusione Safenica Interna a sei mesi).3
Pertanto la Tecnica L.A.F.O.S. non è tecnica superiore ma sicuramente valida alternativa con qualche prerogativa in più considerando la sua semplicità d’esecuzione unita al basso costo e all’ ottima compliance che garantisce al paziente trattato.
Bibliografia
1. CavezziA., Frullini A. Preliminary experience with a new sclerosino foam in the treatment veins. Dermatol.Surg.2001;27:58-60.
2. Frullini A,Fortuna D. Laser assisted foam sclerotherapy(LAFOS): a new approach to the treatment of incompetent saphenous veins. Phlebologie
2013;66:1p
3. Rasmussen L.H., et al. Randomized clinical trial comparing endovenous laser ablation,radiofrequency ablation,foam sclerotherapy and surgical
strippingfor great saphenous varicose veins.BrJ.Surg 2011;98:1079-87
4. Shadid N.,Ceulen R., Nelemans P., Dirksen C., Veraart J., Schurink G.W., Van Neer P.,Vd Kley J., de Haan E., Sommer A. Randomized clinical
trial of ultrasound-guided foam sclerotherapy versus surgery for incompetent great saphenous veins. Br J Surg.201291062-70
5. Figueiredo M., Araujo S., Barros N., Miranda F. Results of surgical treatment compared with ultrasound-guided foam sclerotherapy in patients
with varicose veins: a prospective randomised study. Eur J.Vasc. Endovasc. Surg.2009 Dec; 38(6):758-63
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Sclerotherapy
EVLA AND SCLEROTERAPY: COMBINED METHODS TO TREATE SUPERFICIAL VENOUS INSUFFICIENCY AND VARICES.
Baraldi C.*[1], Carelli M.[1], Spina T.[2]
[1]Tricarico Clinic ~ Belvedere Marittimo ~ Italy, [2]AMBULATORIO ANGIOLOGIA ASP COSENZA ~ CARIATI ~ Italy
Background: In the past it was common to entirely remove the GSV and SSV by surgical procedure; however, recently minimally invasive techniques
have taken over a significant number of varicose vein treatments. In recent years, endovenous laser treatment (EVLA) has been proposed to treat
incompetent great and small saphenous veins (GVS and SSV). Combined technique to EVLA as sclerotherapy, is now an important option for treatment of tributaries varices of saphenous veins. This study reports the long-term outcome of ELT combined to sclerotherapy (foam) in a series of
500 patients.
Methods: Incompetent GSV and SSV segments in 500 patients (416 women, 84 men) with a mean age of 51.4 years (range, 16 to 90 years) were
treated with intraluminal ELT using a 1470-nm diode laser (LASEmaR1500-Eufoton, Italy) with Ring fibers. The GSV and SSV diameters were measured by Duplex examination in an upright position in different segments (1.5 cm from sapheno-femoral junction, GSV trunk at the middle thigh,
1.5 cm below the sapheno-popliteal junction and sural segment). These measurements were used to determine the optimal linear endovenous
energy density (LEED) for each segment. During treatment, patients were maintained in the Trendelenburg position. In all patients, were added
sclerotherapy (foam) for treating tributaries saphenous vein varices. Patients were evaluated clinically and by duplex scanning at 1 and 8 days, 1, 3
and 6 months, and at 1, 2, and 3 years to assess treatment efficacy and adverse reactions.
Results: A total of 523 GSV/SSVs were treated. The mean diameter was 7.5 mm (range, 5.0 to 12.5) for GSV and 5 mm (range, 4.0 to 9.0) for
SSV. The LEED was tuned as a function of the initial GSV/SSV diameters measured in the orthostatic position, from 80 J/cm (4 mm) up to 140 J/
cm (11.5 mm). Sclero-foam was prepared utilizing Atoxisclerol from 0,5% to 1,5% based to vessels diameters (from 5 mm do 11,0 mm). At the
1-week follow-up, 13.6% of the patients reported moderate pain. In the immediate postoperative period, the closure rate was 99.9% and remained
constant during the 4-year follow-up to reach 99.1%. After 1 year, a complete disappearance of the GSV/SSV or minimal residual fibrous cord was
noted. Major complications have not been detected; in particular, no deep venous thrombosis. Ecchymosis was seen in 33%, transitory paresthesia
was observed in 7%, painful palpable indurations in the legs (78% post sclero-foam). There was no dyschromia (except transient dyschromia at
the leg after sclero-foam in 26% of patients), superficial burns, thrombophlebitis; palpable indurations were observed in 3% at the thigh after EVLA.
Failures never occurred.
Conclusion: EVLA of the incompetent GSV/SSV with a 1470-nm diode laser appears to be an extremely safe technique, particularly when the
energy applied is calculated as a function of the GSV/SSV diameters. It is associated with only minor effects. Currently, EVLA has become the
method of choice for treating superficial saphenous veins and has almost replaced the treatment of traditional ligation and stripping; in addition,
sclerotherapy (foam) represent a valid alternative to treat tributaries saphenous veins.
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Sclerotherapy
ELASTOCOMPRESSIONE DOPO LASERTERAPIA
Pinzetta C.*[1]
[1]Bolzano
In recent years, endovascular treatments of varicose veins have increased significantly. The published studies have shown very good results. Endovenous Laser therapy and the Closure Fast show high closure rates and the minimally invasive approach is more popular than the traditional surgical
therapy in patients . The postoperative compressiontherapy however, is not always readily accepted over a long time by the treated patients. In the
literature, there are few data about the time and type of compression after endovascular treatment. Most colleagues use compression stockings 2
° KKL over 2 weeks. Studies by Prof. H. Partsch and G. Mosti have shown that compression on the thigh has to be very high (60-70 mm Hg). Low
compression can only minimize or prevent complications (hematoma, pain, faster reabsorbtion of anesthesia-liqiud) . We have in the meantime an
experience of over 3000 endovascular laser treatments. The treatment is performed under local anesthesia and on an outpatient basis in our practice. Phlebectomy to eliminate the varicose veins is made in the same session. The control examinations were performed postoperatively after two
days, one month and six months. The postoperative compression therapy was performed with thigh-stockings class II ° and worn for two weeks.
Now we have studied a group of 30 patients. The patients wore after the first control only lower leg stockings II ° compression class for 2 weeks.
The clinical and ECD follow up to 6 months after, showed no difference to patients with thigh compression stocking. No increase in inflammation,
pain or hematoma on the thigh. The tumeszensanesthesia liquid was absorbed completely after 2 days the injection related hematoma were virtually
non-existent. The lowerleg stocking was especially very well accepted by the male patients. In some cases, however, a slight malaise at the thigh
has been specified.
We are of the opinion that a compression to the thigh for two days is sufficient to promote the reabsorption of tumeszensanesthesia. The lack of
compression of the treated LSV influenced to a period of 6 months, neither the closure rate nor still possible complications. A compression in the
lower leg is much more acceptable.
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Sclerotherapy
ANTERIOR ACCESSORY SAPHENOUS VEIN INSUFFICIENCY: PHYSIOPATOLOGY AND THERAPY
Nero G.*[1]
[1]ROMA
A failure of the anterior accessory saphenous vein ( AASV ) is not so rare (few data in scientific literature but almoast 12-15% of all the varicose
veins of the lower limbs in my experience), but is often not considered or confused with an insufficiency of the great saphenous vein with therefore,
poor therapeutic results.
An accurate diagnostic evaluation with Doppler ultrasound allows to define the hemodynamic characteristics of reflux and identify the pathophysiological mechanisms that cause the extension of the anterior accessory saphenous reflux; the pre-terminal valve of the great saphenous vein plays
a great role in this context.
The “ refluxing points “ responsible for varicose veins of the AASV may be at the level of saphenous-femoral crosse ( crosse recurrences, incontinence of terminal valve or the ostium of the saphenous vein with continence of the pre-terminal valve), primitive reflux of the ostium valve of the AASV
, venous hypertension of the crosse saphenofemoral hyperflow due to both pelvic varices (varicocele pelvic overload of the external pudendal vein)
and post- thrombotic collateral circulation (circulation of Palma) with overload of superficial epigastric, circumflex iliac medial or pudenda outside.
The extension of the reflux along the AASV follows the saphenous trunk in the splitting of the superficial fascia for a very variable length (from a
few centimeters to the entire length of the thigh) with a passage R2 -R3 that makes varices clinically visible with antero –lateral, anterior- medial
or anterior “scarf “ shape; it may be possible to observe a “ re-entry “ into the great saphenous vein with an axial reflux of the same vein for short
stretches and with new passage R2 -R3 of varicose veins of the thigh or , more frequently, of the leg.
The treatment of varicose veins by AASV is always hemodynamic and conservative with the aim of closing the refluxing point at the confluence of the
AASV in the great saphenous vein and deleting both the trunk of the AASV in the splitting of the superficial fascia and the distal veins . To achieve
this, I have personally used hemodynamic and conservative surgical techniques , sclerotherapy and a mix of the two ( surgery + sclerotherapy ) .
The results of my experience are really positive and last in a follow-up of over 10 years.
The correct identification of reflux on the AASV allows durable therapeutic solutions both on a functional and on an aesthetical point of view, with
a very low recurrence rate.
The treatment strategy should take into account morphological and hemodynamic parameters provided by an accurate Doppler ultrasound mapping with the intent, to taylor the treatment on the haemodinamic characteristics of each patient.
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TRANSILLUMINATION IN SCLEROTHERAPY OF TELANGIECTASIAS
Miranda R.*[1]
[1]Portici (NA)
Telangiectasias are often related to small-caliber varicose veins, which are called “feeding veins” but are often scantly visible. The low visibility of
these veins contrasts with the flashiness of telangiectasias and can cause unsatisfactory results of sclerotherapy or early relapses. In order to improve the results of the treatment it is useful to implement a mapping of veins that feed the telangiectasias. Venous mapping enables phlebologist
to identify the most part of venous branches in the area of interest, mostly reticular veins, to have an overview of them and therefore to develop an
appropriate operational strategy.
Transillumination ( TR ) is a method for the visualization of suprafascial vessels consisting in applying a light source in contact with the skin. Light
source should have high color temperature and minimal thermal component. Light is transmitted through the underlying tissues, reflects in the fascial plane and produces shadow images of the venous vessels that are filled with blood and immersed in the subcutaneous fat. This method does
not displays sub-fascial nor inter-fascial veins because they are covered by the reflective surface of the muscular or saphenous fascia.
The TR is exposed to two kinds of errors: parallax and positioning error. The parallax error, which is well known in metrology, is due to the possible
different point of view that an observer can assume making a measurement. In this specific case the parallax error is linked to an excessive angular
distance between the light source and the vessel in exam. The positioning error is instead a wrong marquage caused by any change of position of
the leg between the phase of TR / marquage of varicose veins and the operating position. In this case, the slippage of the subcutaneous plane can
dislocate the drawing in a different position from the reference vein.
Viewing of normal vessels is frequent and only a part of observed veins have to be treated. On the other hand not all venous vessels of interest
are viewable, for example the perforating veins, the presence of which can be only suspected by indirect signs, and the superficial veins if they are
empty at the time of the examination.
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Sclerotherapy
VIDEO:“LA SCHIUMETTA” UNA MOUSSE DELICATA NEL TRATTAMENTO DELLE VARICI RETICOLARI E DELLE TELEANGECTASIE. TECNICA PERSONAL
Scevola L.*[1]
[1]Vallod ella Lucania
Mostro, in un video, una modalità semplice e facile per realizzare una schiuma delicata che ho chiamato “SCHIUMETTA”, per differenziarla dalla
Mousse classica, che ho trovato particolarmente adatta alla sclerosi delle Teleangectasie e delle Varici reticolari. E’ una macro-schiuma, delicata,
a grosse bolle, poco compatta e stabile, facilmente degradabile, diffusibile che può coesistere con il liquido in forma di miscela. La “schiumetta” si
ottiene in modo semplice, non necessitando di devise. Servono infatti: il prodotto sclerosante, una siringa, un dito o un tappo e l’ago per iniettarla.
Come prodotti sclerosanti ho usato prevalentemente il Polidocanolo, allo 0,25 ed allo 0,5 %, il DTS (tetradecilsolfato di sodio) allo 0,1/0,2 %,ma
possono essere usati tutti gli agenti sclerosanti schiumogeni tensioattivi come per la mousse classica. La siringa ideale, quella di plastica da 2,5 e
5 cc, di buona qualità con stantuffo che deve scorrere fluidamente senza troppo attrito, L’ago quello da 27 o 30 g. Tecnicamente la “Schiumetta”
si realizza meccanicamente tirando indietro e rilasciando più volte lo stantuffo, previa occlusione del cono dell’ago con un dito o un tappo, in modo
che il ritorno sotto pressione crei la schiuma. Si effettuano tante più “stantuffate” quanto più densa vogliamo che sia la schiuma. I risultati, dopo circa
3 anni di trattamento, sono superiori, in termini di efficacia, alla sclerosi con liquido e con minori effetti collaterali in confronto alla Mousse classica.
In conclusione“LA SCHIUMETTA”prontamente disponibile, di semplice e facile realizzazione, permette una maggiore completezza ed estensione
della sclerosi, una maggiore rapidità con piccole dosi e pochi effetti collaterali, si pone come metodica ideale intermedia tra lo sclerosante liquido
e la mousse classica nel trattamento delle teleangectsaie e delle Varici reticolari. BIBLIOGRAFIA 1.Cappelli M : Riflessioni di emodinamica sulle
teleangectasie. In “ Scleroterapia II° Edizione “ di F.Mariani e S.Mancini, ed Minerva Medica, Torino 2006 2.Benigni J.P., Sadoun S., Thirion V., Sica
M., Demagny A., Chahim M. Télangiectasies et varices réticulaires. Traitement par la mousse d’Aetoxisclérol a 0,25%. Présentation d’une étude pilote. Phlébologie 1999,(52) 3:283-29 3.Monfreux A. Traitement sclérosant des troncs saphènies et leurs collatérales de gros calibre par la méthode
MUS Phlébologie 1997;50(3):351-3 4.Goldman MP : My sclerotherapy technique for telangiectasia and reticular veins. Dermatol Surg. 2010 Jun;36
Suppl 2:1040-5. 5.Green D : Sclerotherapy for varicose and telangiectatic veins. Am Fam Physician. 1992 Sep;46(3):827-37.
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Sclerotherapy
LATE FOLLOW-UP OF SAPHENOFEMORAL JUNCTION LIGATION COMBINED WITH ULTRASOUND-GUIDED FOAM SCLEROTHERAPY IN PATIENTS WITH VENOUS ULCERS
Figueiredo M.*[1], Figueiredo M.[1]
[1]Sociedade Brasileira de Angiologia e Cirurgia Vasclar - SBACV ~ Uberlandia ~ Brazil
Background:
Venous ulcers are a frequent complication of venous disease, and a variety of
healing methods have been proposed for these lesions. The objective of this study was to provide late follow-up data for a group of patients with
venous ulcers who presented with advanced chronic venous insufficiency and were treated with saphenofemoral junction ligation combined with
ultrasound-guided foam sclerotherapy.
Methods:
This was a prospective study of 35 patients. Patients were classified as CEAP6 and were followed during a 45- to 68-month period. The following
variables were assessed: wound healing, ultrasound findings, and venous clinical severity scores.
Results:
The following ultrasound findings were observed: total and partial recanalization in 19 patients (treatment failure) and occlusion in 13 patients (treatment success). Two patients were lost to follow-up, and one patient died. Ulcers healed between 30 and 70 days and remained closed for a mean
period of 48 months (KaplaneMeyer method). The analysis of clinical severity scores (pain, edema, pigmentation, lipodermatosclerosis, and inflammation) revealed significant improvement when comparing pre- and post-treatment results.
Conclusion: Our preliminary findings suggest that saphenofemoral junction ligation combined with ultrasound-guided foam sclerotherapy is a feasible and simple palliative treatment method for this group of patients.
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Sclerotherapy
PHYSICAL CHARACTERISATION OF TESSARI FOAM FOR A MARKETING AUTHORISATION
Watkins M.*[1]
[1]stdpharm
Aim
To demonstrate that foam made with sodium tetradecyl sulphate was reproducible and consistent to justify the addition of foam as an indication
to the product licence.
Methods
The Tessari method was used to make foam from 3% and 1% Fibrovein with air:liquid ratios of 3:1 and 4:1. These strengths and air:liquid ratios
were chosen because they were the ones used in the key clinical papers used to justify the safety and efficacy of foam.
Foam density, stability and bubble size distribution over time were studied. For foam density and stability several people created foam seven times.
For bubble size five people made five replicates of foam and the bubble sizes were recorded over two minutes. The average results for each person
were compared using T tests.
Results
The results were very consistent with no significant differences between any of the operators for any of the tests. For bubble diameter initially there
are thousands less than 12 microns, within 30 seconds they have coalesced into hundreds at 100 microns.
Conclusion
Sodium tetradecyl sulphate foam made using the Tessari method is consistent and reproducible. The production of foam and safety and efficacy
has been assessed by the ministries of health in five European countries and is now included as an indication on the product license in those
countries.
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Sclerotherapy
COMBINING SCLEROTHERAPY WITH MULTIPLE MODALITIES (LASER, OHMIC THERMOLYSIS, OR MICRO-SURGICAL
TECHNIQUES) TO TREAT SPIDER TELANGIECTASIA
Bush R.*[1]
[1]Palm City
INTRODUCTION
Spider telangiectasias are the most common presentation of venous pathophysiology. The standard of treatment has been and continues to be
sclerotherapy. A study was designed to test the safety and efficacy of combination therapy using heat, chemical and/or surgical interventions in
treating telangiectasia.
METHOD
Thirty participants were evaluated using combination therapy for spider telangiectasia. In some patients, biopsy of the treated vein was performed.
Patients were observed for any adverse sequalae for 3 months after procedure. All treated telangiectasia were 1 mm in diameter. Ten patients had
a combination of sclerotherapy 0.2% Sotradecol preceded by treatment with a 940 nm laser. Ten patients were treated with SotradecolÒ 0.2% or
PolidocanolÒ 0.5% followed by ohmic thermolysis. The third group of ten patients were treated with SotradecolÒ 0.2% followed by the interruption
of the treated vein at ½ “ intervals using an #11 blade: Surgical Chemical Ablative Technique (SCAT).
RESULTS
In-group 1 (sclerotherapy and laser), biopsies showed loss of endothelium with vessel thrombosis and decreased lumen size. Vessel wall integrity
was maintained. Collagen showed thermal damage and squamous epithelium was disrupted for a distance of 50 microns. A subcutaneous water
blister was present. Post treatment, no adverse sequalae occurred with complete resolution of treated vein in a 3-month period. Group 2 (sclerotherapy and ohmic thermolysis), biopsies demonstrated loss of endothelium and intravascular thrombosis. Squamous epithelium was thermally
damaged for a 30-micron distance. Vessel wall integrity was maintained and collagen unaffected. No adverse effects were noted and resolution
was complete at 3 months. Group 3 (sclerotherapy and surgical technique), biopsy revealed loss of endothelium and disruption of vein. Minimal
intravascular thrombosis noted. No adverse effects were noted and resolution of treated veins occurred within 1 month.
CONCLUSION
Combination therapies with sclerotherapy, heat and/or surgical techniques are effective for the treatment of spider telangiectasia. Combination
therapy results in faster resolution with improved cosmesis. Combining sclerotherapy with micro-surgical techniques (SCAT), resulted in faster
resolution of treated veins in this series.
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Sclerotherapy
EIGHT-YEAR FOLLOW-UP OF LASER AND RADIOFREQUENCY GREAT SAPHENOUS VEIN OBLITERATION
Del Corso A.*[1], Leo M.[1], Alberti A.[1], Ferrari M.[1]
[1]Pisa
Objectives: To assess, over an 8-year follow-up period, the long-term efficacy of Endovenous Laser Therapy (EVLT) and Radiofrequency Ablation (RFA)
of the great saphenous vein.
Background: Although traditional surgery still remains the most frequently performed treatment for varicose veins in Italy EVLT and RFA are increasing
in popularity making them the most frequently requested alternative treatment models for their minimal invasiveness, less post procedural discomfort,
and shorter recovery time.
Methods: Over a 3-year period (2003-2005), we prospectively enrolled 104 patients with great saphenous vein insufficiency. Echo-color Doppler inclusion criteria were: a safeno-femoral junction reverse flow lasting more than 1 second after a Valsalva and swing test and saphenous vein diameter, at
3 cm below the epigastric vein, ranging between 7 and 12 mm.
51 patients received radiofrequency ablation (VNUS Medical Technologies, inc.) and 53 received 980-nm diode laser treatment (ELVeS, Biolitec AG
Jena,Germany). Patient exclusion criteria were:
American Society of Anesthesiologists classification score >2;Pregnancy;A saphenous vein skin distance of less than 3mm;Pacemaker bearer patients.
72 (69.3%) of the patients were female and 32 (30.7%) male. During the assessment period 2 patients received bilateral saphenous vein laser ablation
and one other bilateral radiofrequency saphenorus vein ablation. 6 patients were lost for follow-up within 6 months and not considered in the study.
Echo-color-Doppler were scheduled at 1 days and then at 1,6 and 12 month intervals and subsequently each year for the next 7 years.
Results: 1 day follow-up ablation failure occurred in 3 cases (5.6%) of laser ablation and 2 cases (4%) of radiofrequency treatment. At the 6 month
patient review following saphenous vein ablation treatment the echo color Doppler documented the complete disappearance of the great saphenous
vein at 3 cm below the epigastric vein in 40 (39.6%) cases while in the other 61(60.4%) a residual saphenous stump was detectable with an average
maximum diameter of the saphenous vein of 4.5mm. Referring to the categorization of vein occlusion status according to Merchant classification study
no patient presented a complete occlusion of the saphenous-arch because overall have the saphenous-femoral junction washed by the epigastric vein
flux. Of the total number of saphenous vein treated, at 6 month, 5 had immediate recanalisation (5%); 40 (39.6%) have no residual saphenous stamp,
arbitrarily named type 0, 50 (49.5%) veins had a recanalisation length less than 5 cm, named type 1, and 6 (5.9%) a recanalisation longer than 5 cm
, named type 2. At 8-year follow-up 55 great saphenous vein ( 54.4%) presented a type 1 recanalisation while 11 (11%) a type 2 recanalisation. No
statistical difference on recanalisation were found between laser and radiofrequency treatment
Conclusions: At the 8-year follow-up both laser and radiofrequency presented persistent benefit to the patient without statistical difference on ricanalisation. Nevertheless both technique are today really different from the past and so this conclusion may be not current. In 8-year 15 (14.8%) veins pass
from type 0 to type 1 recanalisation and 5 (5%) from type 1 to type 2 recanalisation. Except the 5 cases of immediate failure none thereafter undergone
to complete recanalisation. In all cases of recanalisation (type 1 and type 2) the average diameter of the saphenous vein were 4.5mm
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Sclerotherapy
SCLEROTERAPIA ECOGUIDATA CON SCHIUMA DELLE VARICI RECIDIVE DELLA VENA GRANDE E PICCOLA SAFENA: RISULTATI A 5 ANNI
Pavei P.*[1], Spreafico G.[1], Ferrini M.[1], Giraldi E.[1], Nosadini A.[1], Piccioli A.[1], Baccaglini U.[1]
[1]Centro Regionale Multidisciplinare per la Day Surgery Azienda Ospedaliera di Padova ~ Padova ~ Italy
INTRODUZIONE Lo scopo del trattamento delle varici recidive è il controllo della malattia varicosa e dei suoi sintomi e la prevenzione delle complicanze. I pazienti affetti da questa patologia appartengono spesso alla Classe CEAP da 3 a 6 e spesso si sottopongono malvolentieri ad un altro
trattamento attivo.
Generalmente si rivolgono al medico per la comparsa di sintomi significativi o di complicanze, quali tromboflebiti, lipodermatosclerosi , ulcere.
MATERIALI E METODI
Abbiamo suddiviso i pazienti del nostro ambulatorio valutati per varici recidive in 2 gruppi: pazienti con varici recidive da neoangiogenesi e pazienti
con varici recidive ad origine da neocrosse cavernomatosa.
Dal 2006 al 2012 sono stati trattati 142 pazienti con neoangiogenesi, 155 pazienti con cavernoma inguinale e 28 pazienti con cavernoma popliteo.
Per il primo gruppo di pazienti abbiamo utilizzato una schiuma sclerosante preparata con il metodo di Tessari di Polidocanolo (POL) o tetradecilsolfato di Sodio (TDS) in concentrazione compresa tra 0.3 e 1%. I pazienti sono stati sottoposti a 1-3 sedute con iniezione di un massimo di 10 cc per
seduta. 99 erano C2, 29 C3, 12 C4 e 2 C5.
Per il gruppo di varici caratterizzate da neocrosse cavernomatosa abbiamo utilizzato una schiuma sclerosante, sempre preparata con il metodo di
Tessari, ottenuta con TDS all’1% per vasi di 5mm e TDS al 3% per diametri maggiori. Anche in questa serie di pazienti sono state eseguite da 1 a
3 sedute di scleroterapia con un volume massimo per sessione di 10ml.
La classe C della classificazione CEAP era la seguente: 89 C2, 37 C3, 19 C4, 8 C5 e 2 C6
RISULTATI
Nel gruppo con neoangiogenesi i risultati a 3-5 anni sono stati di completa occlusione all’ecocolordoppler e assenza di varici nel 90.9% dei casi.
Tutti i pazienti di questo gruppo hanno completato il follow up. Nel gruppo dei pazienti con cavernoma inguinale 4 pazienti sono stati persi al follow
up nel primo anno. Ad 1 anno di follow up l’87% dei pazienti presentava una completa occlusione all’ecocolordoppler, senza evidenza clinica di
varici; a 2 anni 98 pazienti hanno completato il follow up con un 85% di buoni risultati; a 3-5 anni 75 pazienti hanno completato il follow up con un
80.79% di buoni risultati.
Nel gruppo di 28 recidive poplitee da cavernoma a 3-5 anni abbiamo avuto un 60 % di occlusioni complete all’ecodoppler senza varici clinicamente
evidenti; nel 13% dei pazienti abbiamo osservato una ricanalizzazione con reflusso all’ecodoppler senza varici evidenti; nel 27 % dei casi una ricanalizzazione all’esame duplex associata a varici clinicamente evidenti.
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Sclerotherapy
Le complicanze rilevate sono state: trombosi delle vene del gastrocnemio 0.2%, complicanze neurologiche minori 0.1% , tromboflebiti superficiali
2.8 %, pigmentazioni 3,8% e dolore post trattamento nel 16,5% dei casi.
DISCUSSIONE
Dalla valutazione dei nostri risultati emerge che varici recidive originanti da fenomeni di neoangiogenesi ben si prestano al trattamento sclerosante
con buoni risultati a medio termine. Inoltre sono varici a parete sottile, difficilmente trattabili con la chirurgia, e non adatte ad una procedura endovascolare.
Per quanto riguarda le varici ad origine da un grosso ramo recidivo proveniente da una crosse già operata i risultati sono soddisfacenti a medio
termine, anche se sembra che i risultati siano meno buoni nei pazienti con vasi di maggior diametro. In questi gruppi di pazienti potrebbe essere
utile associare una flebectomia.
CONCLUSIONI
La scleroterapia ecoguidata con schiuma è una tecnica sicura, ben accettata anche dai pazienti affetti da varici recidive. Ha discreti risultati a medio
termine e nei casi più impegnativi, caratterizzati da voluminose varici, può essere associata ad un trattamento di flebectomia in anestesia locale.
34
Sclerotherapy
DIFFERENT MOLECULE OF ‘SODIUM TETRA DECYL SULFATE’ AS CAUSE OF ALLERGY
Patel M.*[1]
[1]Ahmedabad
Over the last decade, foam sclerotherapy has gained popularity for treatment of superficial venous reflux. Some cases of allergic and adverse reactions including death have been reported in peer reviewed journals and some at conferences and small gatherings.
Most adverse reactions have been reported when Sodium Tetradecyl Sulfate (STS) solution was used and impurities were responsible for them.
They are rare and occur sporadically but can be serious if impurities get in into STS or if impure solutions of STS are used.
At Sclerotherapy 2012, I reported one death that occurred in 2008, following which I started to use carbon-dioxide instead of air but we did not
test the STS at that time.
Last year three patients developed adverse reactions within three days after use of STS foam. One developed skin rashes about 30 minutes after
treatment. He was treated with antihistamines and short acting corticosteroids. Another developed vasovagal syncope 30 minutes after treatment.
The third patient developed sweating and chest heaviness 15 minutes after treatment. Both these patients were placed supine and observed.
All three made complete recoveries within an hour.
After the relatively frequent development of allergic reactions I started use of polidocanol.
30 ampoules of the same batch of STS were sent to UK for testing on the assumption that some new kind of impurity/impurities in that batch of
STS could be responsible for the adverse reactions. STD Pharma helped in this process and it was reported that the STS tested, was different from
the STS molecule as prescribed by the British Pharmacopoeia. It also exceeded acceptable endotoxin levels.
The local company which supplied the STS ampoules sources the bulk drug from another country and sells it as Sodium Tetradecyl Sulfate in India.
Since we do not know where this bulk drug may come from, we strongly recommend use of STS only from manufacturers whose bulk drug purchase is also subject to intense and thorough testing, in this case as per British Pharmacopoeia.
35
Sclerotherapy
TRATTAMENTO LASER ENDOVENOSO DELLA SAFENA ACCESSORIA ANTERIORE R2-R3 CON FIBRE 600 E 200 MICRON
Loparco O.W.*[1]
[1]casa di cura villa san marco ~ ascoli piceno ~ Italy
Il trattamento laser endovasale, con laser diodo 1470 e fibra radiale 600 micron viene utilizzato, prevalentemente, per la safena interna,esterna e in
percentuale minore per la SAA. La SAA drena la parte antero-laterale della coscia. Può confluire nella cross safeno femorale, direttamente nella vena
femorale sotto o sopra la cross; oppure in una vena collaterale della cross. Uno studio su cadavere ha rivelato la presenza della SAA nel 50%. Un
reflusso isolato della SAA è presente nel 10% dei pz con varici sintomatiche. Spesso è presente in pz con varici recidive sottoposti a crossectomia
e stripping. Lo studio ECD è molto importante per evidenziare il decorso della SAA in R2 ed R3 ed il tipo di confluenza. Una SAA competente presenta un calibro di circa 3 mm fino a circa 30 mm in caso di incompetenza. La metodica laser endovasale per l’R2 della SAA è la stessa della safena
interna. Sotto controllo ecografico si incannula la SAA nel punto più distale del reflusso. Si posiziona la fibra fino a 1 cm circa, dalla confluenza e si
lavora in continuo con 6-7 watt, l’anestesia è locale per infiltrazione. Quando presente l’R3 si utilizza un ago cannula 23G e introducendo la fibra
200 micron si esegue l’ablazione con una lenta retrazione, lavorando fra 1 max 3 watt.
Nella mia esperienza ho utilizzato tale metodica da 4 anni con risultati ottimi dal punto di vista estetico e per la possibilità di eseguirli ambulatorialmente.
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Sclerotherapy
ENDOVENOUS TREATMENT OF INCOMPETENT ANTERIOR ACCESSORY SAPHENOUS VEINS WITH A 1540 NM DIODE
LASER
Cavallini A.*[1]
[1]Padova
OBJECTIVE: to show the short-term result of endovenous laser treatment (EVLT) with a ball-tipped fiber and a 1540 nm diode laser of the anterior
accessory saphenous vein (AASV) with preservation of a competent great saphenous vein (GSV). PATIENTS AND METHOD: 9 incompetent AASV
veins in 8 patients (6 female) were treated. The gravity of chronic venous disease was determined according to the CEAP classification and the
severity of symptoms was scored according to the revised Venous Clinical Severity Score. Patient satisfaction was assessed by a 0 to 3 scale.
RESULTS: The average linear endovenous energy density was 60.5 J/cm vein (SD: 7.5). Patients return to daily activities after a mean of 3.8 days
(SD: 1.4). 5 patients (63%) have had pain but of mild intensity. No Patients developed paresthesia or phlebitis reactions in the treated area. Postoperative ecchymoses are frequent (89%). During the follow-up period (mean 13 months, range: 7-17 months) all the veins were occluded. The
VCSS improved drastically from a mean of 3.2 (SD: 1.3) pre-interventional to 0 (SD: 0.38) at 17 months. All patients were satisfied or very satisfied
with the method. No severe complications occurred. CONCLUSION: EVLT of an incompetent AASV with a 1540 nm diode laser is a safe and efficient therapy option, with a high success rate and with no evidence of GSV neo-reflux or recurrent varicosities during the follow-up period.
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Sclerotherapy
ULTRASOUND-GUIDED FOAM SCLEROTHERAPY IN THE TREATMENT OF CHRONIC VENOUS ULCERS
Ceratti S.*[1], Macedo Okano F.[1], Salvetti M.[1]
[1]Brasile
Aims: To determine the healing rate of chronic venous ulcers treated with ultrasound-guided foam sclerotherapy and assess patient satisfaction
with treatment. Methods: The medical records of chronic venous ulcer patients treated by Ultrasound-Guided Foam Sclerotherapy (UGFS) between
2006 and 2012 in a private clinic in Brazil were reviewed. The procedures were performed by a radiologist with experience in interventional procedures, and a vascular surgeon together. Patients were assessed by color Doppler ultrasound after 15 days after the procedure and the follow-up
ranged from 4 to 84 months. The ulcers with re-epithelialization and total lack of drainage, were considered healed. Recurrence were defined as
epithelial rupture. Results: The analysis of the characteristics of the sample showed a predominance of females (73.1%) and older than 60 years
(53.8%). The mean duration of ulcers was 5 years. The saphenous vein was treated vessel in 96.2% of cases, other tax were. The complete healing rate was 61.1% in the first reassessment and 81.8% in the second reassessment. The healing time was 1 to 3 months in 70.6% of cases.
Assessment of satisfaction with treatment showed that 94.7% of patients felt that the treatment produced improvement or much improvement.
Conclusion: The foam guided sclerotherapy was found to be an effective method for the treatment of chronic venous ulcers. The healing rate was
very good and the healing time was brief. There was improvement of symptoms and associated patient satisfaction with treatment. Few adverse
effects were observed
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Sclerotherapy
TITLE: PERCUTANEOUS FOAM SCLEROTHERAPY FOR VENOUS ULCERS
Bush R.*[1]
[1]Palm City
Background
Foam sclerotherapy is extremely effective for the treatment of venous ulcers. Directing treatment to the underlying venous network is the primary
objective. Recently the technique of percutaneous foam sclerotherapy has been described to enable precise targeting of these vessels.
Method
In 15 patients, foam sclerotherapy was delivered via a 25-gauge scalp needle. The vessels cannulated were cutaneous vessels in close proximity
of the ulcer. If chronic skin changes were present and no vessels could be identified, then injection was carried out by cannulation of a vein directly
under the ulcer bed, using ultrasound guidance.
Results
There were no complications. No instances of skin damage from the injections were noted. Rapid healing in less than 2 months occurred in twelve
patients. Prolonged healing from 3-5 months occurred in 3 patients with deep venous obstruction or reflux and marked lipodermatosclerosis. Discomfort from the procedure was minimal as reported by the patients. The average number of treatments was 2.3 per patient.
Conclusion
Foam sclerotherapy delivered percutaneously is safe and well tolerated. Foam delivered in close proximity to the venous network underlying the
ulcer bed insures less deactivation before the target is reached. The percutaneous technique using foam for ulcers is easily performed and is associated with minimal discomfort. In many cases if an ultrasound is not available, this procedure may also be done.
39
Sclerotherapy
DAY SURGERY RADICAL ENDOVENOUS TREATMENT OF EXTENSIVE VARICOSE VEINS UNDER LOCO-REGIONAL ANESTHESIA
Morales Conca G.*
Day surgery radical endovenous treatment of extensive varicose veins under loco-regional anesthesia Aim: Over the last years, endothermal ablation techniques under local anesthesia have become the gold standard for treatment of truncal varicose veins. But sometimes venous disease
can be extensive (bilateral, extensive collateral, etc) and local anesthesia may hinder a complete treatment of all varicose veins. In this study we
present our experience using radiofrequency ablation (RFA) and ambulatory phlebectomy (AP) with radical intention (the most in a single session)
under regional anesthesia in day surgery regimen. Methods. Open monocentre prospective study. Between 2011-2013, 103 consecutive patients
with extensive varicose veins, (69% women) whose average age was 51,1 (22-80) years were treated with a VNUS ClosureFAST procedure under
regional anesthesia (101 patients) or local anesthesia (2 patients). Prior, all patients were evaluated of venous valvular reflux of saphenous veins (SVs)
with duplex ultrasound scanning. Most of our patients had extensive disease difficult to treat with foam sclerosis: 73% had bilateral varicose veins,
77% had SV diameter > 10 mm and the mean number of incompetent SVs per patient was 2 (1-4). Simultaneously to the RFA we carried out AP of
all collateral varicose veins more than 3 mm, and interruption of perforating veins using the Müller technique. The mean number of AP per patient
was 22.8 (0-45). Collateral less than 3 mm were treated sclerotherapy with 0.5% polidocanol-foam (Tessari method). An elastic compression was
constantly applied with an cohesive bandage for 24-36 hours and subsequently an elastic stocking for one week. In any case a low-molecularweight heparin prophylaxis was performed for 7 days. All patients were controlled with duplex ultrasound scanning on the 4th postoperative day, 1st
,3rd, 12th month, and then yearly following the treatment. The patients were asked to indicate pain on a daily basis using a Visual Analogue Scale
(VAS) from 0 to 10 and to record intake of analgesics, as well as the exact date of return to work, and if any neurological symptoms (paraesthesia)
or other complicaction had occurred after the procedure. Result: No patients were lost to follow-up. The total number of incompetent SVs treated
were 201. The average duration of surgery was 99 minutes (48-153). All patients were discharged from hospital within 12 hours after surgery:
mean 6.5 hours (4-12). No complications occurred related to regional anesthesia. Procedures and their postoperative course were uneventful and
particularly well tolerated: mean pain score was 2 for first day and 1 for fourth day after the procedure (VAS 0-10,max=10). Only 28 patients (27%)
required analgesia with paracetamol after the first 48 hours (especially in relation with the amount of AP made). 25 patients (24%) did not need to
take any analgesic treatment. Average incorporation to work (excluding weekends days) was 2.5 days (range 1-14). Complications observed were
skin pigmentation (6%), phlebitis (6%) and paraesthesia (5%). No serious complications were observed. Average follow-up was 15,9 months (135). The occlusion rate of SVs was 94 % and reflux free rate was 97%. 91 patients (88%) have not required further treatment. 6 patients with reflux
needed foam sclerosis of refluxing SVs, and other 6 patients foam sclerosis of residual collateral. Conclusion: In many our patients the varicose
disease is very extensive (bilateral, large diameter, several SVs affected, large collaterals, etc.) so your treatment with endovenous surgery under
local anesthesia or foam sclerosis requires several sessions. A radical combined treatment of RFA and AP under locoregional anesthesia brings
about a more complete and definitive result, along with an obviously better tolerability for the patients, who can solve their functional problems with
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Sclerotherapy
one treatment only.SCLEROTHERAPIE À LA MOUSSE - Etude rETROSPECTIVE SUR 5000 SESSIONS
Reis Bastos F.*[1]
[1]Belo Horizonte
Objectifs:
La Sclérothérapie est née il y a 170 ans. C’est actuellement une méthode de plus en plus utilisée, et pour la méthode mousse, depuis 20 ans.
Les connaissances récentes sur la physiopathologie veineuse nous ont poussés, avec l’apport des nouvelles technologies comme l’écho-Döppler,
la transillumination à LED et la sclérothérapie à la mousse vers des méthodes de traitements moins invasifs de la Maladie Veineuse Chronique
(MVC). Nous avons réalisé la sclérothérapie à la mousse au Brésil d’ après les protocoles validés par les Sociétés Françaises de Phlébologie. Le
stripping du tronc saphène et les autres techniques chirurgicales n’ont pas toujours été couronnées de succès, et l’échodoppler nous a appris que
parfois ce sont les collatérales qui sont incompétentes et non pas les saphènes.
Nous disposons actuellement de nombreuses techniques interventionnelles (ablations) pour traiter les MVC : la phlébectomie, la crossectomie, les
valvuloplasties et le stripping. L’ablation thermique (Laser et Radiofréquence) peut être utilisée mais le coût est plus élevé.
Jusqu’à ces dernières années, toutes ces techniques étaient réalisées sous anesthésie générale ou péridurale et ceci excluait un certain nombre
de malades du traitement interventionnel.
L’échosclérothérapie à la mousse a révolutionné notre pratique car presque tous les malades peuvent en bénéficier, même les patients très âgés
ou ceux présentant une pathologie associée sévère, comme par exemple des ulcères veineux.
Méthodes :
Nous avons testé plusieurs méthodes mais la ponction directe échoguidée des veines malades s’est avérée être un abord plus facile et efficace
pour atteindre les réservoirs variqueux à traiter.
Résultats:
. Les cas sévères de la maladie variqueuse où la chirurgie est souvent difficile et décevante sont précisément ceux qui peuvent bénéficier de la
sclérotherapie à la mousse. Ceci élargit des indications des traitement par Sclérothérapie. Les résultats que nous présenterons, se superposent à
ceux de la littérature européenne. L’échosclérothérapie à la mousse est une méthode qui allie la sécurité et l’efficacité et peut donner à une partie
de la population variqueuse, qui était jusqu’alors sans véritable solution efficace, un espoir d’améliorer sa qualité de vie.
Parmi les complications, les mêmes que celles retrouvées dans la littérature de langue francaise, les hyperpigmentations peuvent survenir autour
de 20 %.
Conclusion :
Notre expérience, basée sur plus de 5000 sessions de sclérotherapie à la mousse au Brésil, nous permet conclure que cette méthode pourra
remplacer dans le futur les autres techniques encore actuellement utilisées. Une série des photos montrent notre expérience. Il est nécessaire de
colliger d’autres études pour conclure que la méthode est la moins onéreuse, efficace, la moins invasive et la plus simple à mettre en œuvre
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Sclerotherapy
SCLEROMOUSSE DEI TRONCHI SAFENICI CON CATETERE E TUMESCENZA: STANDARDIZZAZIONE DELLA TECNICA E
FOLLOW UP A 24 MESI
Cristiani A.*[1]
[1]Imperia
Gli autori illustrano la metodica di scleromousse con catetere e tumescenza del compartimento safenico, nel trattamento della grande e piccola
safena. Vengono riportati oltre 60 casi, con follow up a 24 mesi, In termini di obliterazione del tronco safenico e di incidenza di complicanze. Vengono standardizzate alcune particolarita tecniche nella preparazione della mousse sclerosante e nella esecuzione della metodica, con particolare
riferimento alle miscele di gas e liquido sclerosante, alle siringhe da utilizzare alla esecuzione della tumescenza e alla associazione o meno delle
varicectomie nello stesso atto operatorio. I risultati sono incoraggianti, con alto tasso di obliterazioni del tronco safenico, sovrapponibile alle altre
metodiche di obliterazione endovasale dei tronchi safenici, e scarsa o quasi nulla incidenza di complicanze. Il vantaggio della metodica e’ soprattutto di natura economica, considerato il basso costo dei materiali utilizzati. L’ invasivita’ e’ senz ‘ altro inferiore alle tecniche tradizionali (stripping)
e applicabile anche a tronchi safenici di calibro superiore a 10 mm. grazie all’effetto di riduzione del calibro vasale determinnato dalla tumescenza.
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EXTREMELY DILATED TRUNCAL VARICOSE VEINS TREATED WITH ENDOVENOUS LASER
Kaspar S.*
Background: Endovenous laser ablation represents well established technique of radical therapy of varicose veins of lower extremities with excellent mid and long-term results. However, the laser ablation of extremely dilated truncal veins is not commonly used in everyday practice because of
possible higher failure rate. This study assesses the efficacy of these unusual procedures.
Material and Methods: In total, 268 procedures were assessed . Diameter of treated veins was defined as more than 15mm for great saphenous
vein (GSV) (n=156, 15-28,8mm) and more than 10mm for short saphenous vein (SSV) and anterior accessory GSV (AAGSV) (n=112, 10-24,8mm).
Before surgery, all patients were assessed with colour flow duplex ultrasonography and reflux pattern and diameter of the truncal vein were recorded. The endovenous procedures were performed using 980nm and 1470nm diode or 1320nm Nd:YAG lasers. In the follow-up ( 1 to 72 months
post op) patients were asssessed clinically and with duplex ultrasound.
Results: No deep venous thrombosis, nor pulmonary embolism were recorded. In majority of patients we found bruising and/or indurations along
the treated veins which resolved within 2 to 3 weeks. In SSV patients, the paresthesias were quite frequent ( in 7%) just after the procedures but
they resolved spontaneously within 2 months in majority of cases. Once, the neovascularisation was found in the popliteal fossa and the total occlusion rate was 96,87%.
Conclusion: Even if extremely dilated, nearly all truncal veins can be treated successfully and safely with endovenous laser ablation comparably to
well established ablation of GSV
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Sclerotherapy
SAVE AND RESORE THE SAPHENOUS VEIN: PRESENT AND FUTURE
Nero G.*[1], Fornasetti A.[1]
[1]ROMA
“Saphenous vein or not “ that is the question that should be addresses by all the ones dealing with varicose veins of the lower limbs . For too long
and too often the saphenous vein is doomed even before being processed. The main reason lies in a too hasty “ investigation “: in other words, the
assessment of Doppler ultrasound is not performed with the proper attention and specificity (hemodynamic cartography) .
What then could be said to “save” the saphenous today and, at the same time, to offer the patient a solution both functional ( symptom relief, protection from disease progression ) and aesthetic ( resolution of varicose veins ) ?
The saphenous vein reflux along the axis is determined by an incontinence or an incompetence of the valve system; the valves of the vein wall ,
however, are structures often anatomically well preserved but may be incontinent only for a dilation of the vein wall itself. Is it possible throught a
reduction of this dilatation, to restore the valvular continence? The external banding valvuloplasty (Gore ) has pursued this goal with positive results.
In the hemodynamic conservative surgical treatments ( FEC, ASVAL , CHIVA ... ) or sclerosing technique ( ESEC ) with reclamation of the peripheral
saphenous varices and reconstruction of a drainage system , have often showed over time that the recovery of a smaller caliber allows the saphenous trunk to also regain the valve continence.
Unfortunately , even following the correct indications , it is not always so. The Achilles’s heel of all conservative treatments is the restarting of a
segmental varicose from the saphenous residual reflux.
A further limitation, as far as the indications of conservative treatment concerns, is the state of dilatation and reflux of the saphenous vein that, in
these conditions , lead to demolitive or ablative solutions.
How to “ reshape “ the state of dilatation of the saphenous vein and, perhaps, to restore its valvular continence considering that the valve structure
is often well preserved and the reflux is related to a wall expansion that prevents a fluid motion of the flaps of valves with “ a swallow’s nest”shape ?
A potential solution could be to combine the usual conservative technique with a “ remodeling “ treatment that should be minimally invasive, without
side effects, low costs and performed in a single session.
In this regard, in a very limited number of patients, we have tried, in the last year, the Holmium laser with short pulse , to get a compressive effect
on the vein wall above the point of expansion of the same vein: we present the hemodynamic ( extent of reflux ) and morphological (size segmental
saphenous ) results in these cases.
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Sclerotherapy
TRATTAMENTO DELLE R3 INCONTINENTI CON SCHIUMA SCLEROSANTE (FLEBECTOMIE ADDIO?)
Gerardi G.A.*[1]
[1]OSPEDALE S MARGHERITA ~ CORTONA (AREZZO) ~ Italy
INTRODUZIONE
L’Insufficienza Venosa Cronica e le manifestazioni varicose ad essa relate,sono condizione clinica rilevante sia epidemiologicamente che per le
importanti ripercussioni socio-economiche che ne conseguono.
Nei Paesi occidentali sono note le conseguenze della loro elevata prevalenza, i costi dell’iter diagnostico e del programma terapeutico, le significative perdite in ore lavorative e le ripercussioni sulla qualità di vita.
La prevalenza attuale della patologia venosa superficiale a carico degli arti inferiori si stima tra il 10-50% nella popolazione adulta maschile e tra
il 50-55% in quella femminile. La malattia varicosa è presente, clinicamente manifesta, nel 10-33% delle donne e nel 10-20% dei maschi adulti.
L importanza del trattamento chirurgico delle varici si desume nel nostro sistema sanitario dalla frequenza della domanda:in Italia circa 100.000
interventi/anno (Linee Guida SICVE).
Questa preponderanza della malattia venosa superficiale ha portato negli anni ad una lunga e controversa diatriba riguardante il trattamento elettivo
dell’ Insufficienza Safenica.
Scopo di questo studio non è quello di prendere parte a tale annoso dibattito nel tentativo di dimostrare quale delle metodiche sia la migliore, ma
quello di effettuare un approccio terapeutico mini invasivo, rapido e a basso costo della patologia venosa dei punti di fuga soprafasciali (R3) incontinenti, un tempo trattati mediante flebectomia secondo Muller, utilizzando la metodica scleroterapica con schiuma fornendo cosi al paziente un
trattamento indolore e scevro da complicanze maggiori e garantendo altresì una riduzione dei costi in termini di materiali utilizzati e tempo impiegato.
Principale intento è quello di standardizzare la metodica in modo che essa possa essere universalmente riproducibile garantendo lo stesso risultato
(obliterazione definitiva del punto di fuga R3) con singolo trattamento.
MATERIALI E METODI
Sono stati reclutati per lo studio 37 pazienti (30 e 7 ) con Età compresa tra i 30 e i 75 anni e Ceap :C2-C4. EP.AS5.PR.
Il calibro delle R3 incontinenti trattate misurate con ecocolordoppler è compreso tra 6 e 8 mm di diametro.
La schiuma sclerosante utilizzata è prodotta con metodo Tessari utilizzando Idrossi-polietossi-Dodecano allo 0,5 % 1ml e aria 4 ml in due applicazioni nello stessa seduta per un totale massimo di 10 cc di schiuma in singolo trattamento.
L’ iniezione è stata eseguita sotto controllo Ecodoppler in corrispondenza del punto di fuga dell’R3 con Tecnica iniettiva dall’ Alto in Basso con ago
28 G.
Al termine del trattamento ai pazienti è stata applicata una compressione eccentrica nel punto di iniezione per 1 gg ed elastocompressione tramite
calza elastica di II Classe per 10 gg, Terapia orale con Flebotonico e consigliata attività fisica.
Il Follow up mediante Ecodoppler è stato effettuato a 7 giorni,1 mese,tre mesi, sei mesi e un anno.
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Sclerotherapy
RISULTATI
Il Follow Up dei pazienti ad un anno ha mostrato sclerosi completa delle R3 insufficienti nel 100% dei casi dopo singolo trattamento.
Uniche complicanze verificatesi in 10 pazienti (27%) oggetto di studio sono state la comparsa di Emosiderosi transitoria dovuta alla flogosi avventiziale e alla diapedesi delle emazie attraverso la tunica media del vaso e la formazione di Coaguli sanguigni (sintomatici solo nel 2% dei casi).
La attenuazione importante e in molti casi la scomparsa dell’Emosiderosi si è ottenuta tramite applicazione topica di chelanti del ferro e terapia orale
con antiinfiammatori.
I coaguli sanguigni sono stati drenati tutti sia quelli sintomatici che quelli asintomatici dopo sette giorni dalla seduta scleroterapica.
DISCUSSIONE
Scopo della Chirurgia della Varici è da sempre al di là della tecnica adottata quello di ottenere la risoluzione della patologia quando sintomatica e
prevenire o curare le sue complicanze, fermo restando il carattere evolutivo dell’IVC.
Le Collaterali Safeniche sovrafasciali punti di fuga vengono ormai da tempo trattate con metodiche alternative alla Flebectomia che sono mini invasive, meno costose e di comprovata efficacia.
Questo studio tende a dimostrare come a concentrazione e dosaggio prestabiliti di schiuma, si possa ottenere l’obliterazione mediante singola
seduta nel 99% dei casi in vasi R3 sede di reflusso con diametri compresi in un range di 6-8mm.
Risultato che rimane stabile anche dopo un anno di follow up.
Seppur esso sia un tempo troppo breve per considerare i risultati ottenuti come irreversibili e definitivi, gli obiettivi raggiunti permettono altresì di
poter considerare la tecnica scleroterapica con schiuma una valida alternativa alla flebectomia.
Infatti la scleroterapia con schiuma consente di ottenere risultati simili a quelli ottenuti con le flebectomie di Muller con il vantaggio di presentare costi
inferiori (la scleroterapia essendo assolutamente indolore non prevede l’ uso dell’ anestesia locale o di sterilizzatrice per ferri chirugici).
L’ insufficienza delle R3 origina dall’ incontinenza valvolare conseguente a poussè ipertensive determinate dall’aumentato afflusso ematico proveniente da vene sottoaponeurotiche.
Pertanto il trattamento del punto di fuga garantisce la risoluzione della patologia nel rispetto dell’emodinamica,considerando lo scarso effetto che
lo scleroterapico in tali quantità e a tale concentrazioni ha a livello del distretto safenico e venoso profondo.
La schiuma sclerosante segue infatti principi fisici precisi e ben noti, ovvero si sposta sempre secondo un gradente pressorio favorevole ( da una
zona ad alta pressione verso una zona a minor pressione) e garantisce un maggior contatto con l’ endotelio nei vasi di maggior calibro rispetto a
quelli più piccoli ciò grazie al flusso turbolento che assume durante l’ iniezione, garantendo così una efficacia sclerosante maggiore nei primi (ciò è
ampliamente dimostrato in letteratura per diametri fino a 8 mm).
CONCLUSIONI
Il trattamento Scleroterapico con schiuma dei punti di fuga R3 è valida alternativa alle flebectomie e alle altre metodiche di trattamento conservative
non chirurgiche.
Il suo basso costo e la sua semplicità di esecuzione la annovera tra le tecniche gold standard per il trattamento delle R3 ectasiche.
La compliance alla Scleroterapia con schiuma è massima per il paziente che deve rispettare poche norme post trattamento garantendo peraltro
un risultato ottimale con singola seduta. Controlli Ecodoppler annuali sono effettuati sia per avere una prosecutio temporis nel follow up, sia per
garantire l’immediato riconoscimento e trattamento di malattia residua o di nuova insorgenza.
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Sclerotherapy
ENDOVENOUS LASER TREATMENT OF GREAT SAPHENOUS VEINS WITH A 1540 NM DIODE LASER USING TUMESCENT
COLD SALINE SOLUTION WITHOUT LOCAL ANESTHESIA
Alvise C.*[1]
[1]Padova
Objectives: conventional treatment for great saphenous system varicose veins is the ligation over the saphenofemoral junction (SFJ) and stripping of
the great saphenous vein (GSV). Saphenectomy generally entails general or spinal anesthesia and in many centers patients undergoing this operation are hospitalized for at least one day. Endovenous laser treatment (EVLT) is an office-based procedure that can be performed under tumescent
local anesthesia (TLA) with similar early and midterm results but with less discomfort to the patient, improved early QOL, and earlier return to work.
Unfortunately during TLA, significantly higher plasma concentrations of lidocaine have been observed 0.5 to 4 h after its infusion. This indicates the
need for carefully conducted patient observations immediately after infiltration into the aforementioned areas. Our hypothesis is that the positive
effects of a cold saline tumescent solution (CSTS) can be retained even without the addition of local anesthetics drugs. This also may occur when
EVLT with TLA is performed, especially in bilateral treatments, because significant amounts of local anesthetic drug can be released. It should be
noted therefore something of a contradiction, since the EVLT is a minimally invasive procedure that allows the patient to leave the clinic very quickly.
Our hypothesis is that the positive effects of the TLA can be retained even without the addition of local anesthetics drugs, using only a cold saline
tumescent solution (CSTS); local anesthesia is not essential for the peri-operative comfort of the patient if a mild sedation is made; tumescent application can be quite uncomfortable for some patients because the multiple needle steaks are noxious stimuli, even when using a motor pump for
infusion (reducing operating time); a slight sedation instead greatly reduces this discomfort, making unnecessary the application of local anesthetic
drug at the same time. The local cooling effect on tunica adventitia might (and should) instead be maintained by the infusion of CSTS alone. Method:
49 incompetent GSVs in 41 patients (28 females) were treated by EVLA with CSTS without local anesthetic drugs. EVLA was performed with a
1540 nm diode laser and a 600 µc ball-tipped fiber. Intraoperative US was then used to guide delivery of CSTS (cold saline solution 0.9% at 5 °C),
by a motor pump under intravenous sedation (midazolam + fentanil + propofol). The gravity of chronic venous disease was determined according
to the CEAP classification. Patients rated surgery global pain according to four types: ‘extremely,’ ‘rather,’ ‘slightly’ and ‘not at all’ painful. Results:
mean age was 54.2 years (min: 36; max: 83; SD: 13.0) and the mean BMI was 25.7 (min: 19, max: 43; SD: 5.3). 25 cases (51%) were classified
as C3, 20 (41%) as C2, 6 (13%) as C4 and 1 (2%) as C6 according to CEAP classification. Terminal valve was incompetent in 40 cases (82%). 30
(73%) Patients have had symptom; The average diameter of treated GSVs, measured at 3-5 cm distal to the SFJ, with patient in orthostatic position, was 7.6 mm (min: 5 mm; max: 11 mm; SD: 1.8); the presence of one or two segmental vein dilatation (17 cases; mean diameter: 12.9 mm;
min: 8 mm; max: 20 mm) was not an exclusion criteria from EVLT. Midazolam 2.5 mg + a mean of 0.16 mg of fentanil (min: 0.10 ; max: 0,20; SD:
0.4); + a mean of 178,21 mg of propofol (min: 100; max: 300; SD: 47.1) were administrated as intravenous sedation. The average length of treated
47
Sclerotherapy
saphenous veins was 29.6 cm (min: 7 cm, max: 55 cm; SD: 12.0) with a mean operative time of 32.8 minutes (min: 20; max: 60; SD: 8.5). The
total average LEED was 57.7 J/cm (min: 44.0 J/cm; max: 81.1 J/cm; SD: 8.0). The first 10 cm of the vein have been treated with 10 W power, with
an average LEED of 71.0 J/cm (min: 47.2 J/cm; max: 139.2 J/cm; SD: 19.4). The residual GSVs have been treated instead with less power, that
resulted in an average LEED of 51.5 J/cm (min: 29.0 J/cm; max: 81.1 J/cm; SD: 11.0). Approximately 250 mL (min: 100; max: 780; SD: 110.5)
of CSTS was administered, thus creating a 10-mm gap between the skin and the vein as well as more than 10-mm diameter around the vein (as
verified by US examination). Most patients (94%), after infiltration of a small amount of lidocain, were subjected to flebectomies (78%) or sclerofoam
(8%) or both additional procedures (8%) of the varicose tributaries during the same session. In 8 cases (28%) a bilateral EVLT was performed in
the same session. The mean operative time in these cases was slightly higher than unilateral ones: 54 min (min: 40, max: 80; SD: 14.7) vs 40 min
(min: 20, max: 60; SD: 10.9). In all cases the answer to the question: have you had pain during the procedure? It was “not at all”. All patients were
discharged 2-3 hours after surgery. No cases of pain were recorded during the first post-operative day. CONCLUSION: our research shows that
it is possible to make EVLT under intravenous sedation without the use of local anesthetic drugs; sedation is very useful because it eliminates the
patient’s discomfort without compromising a rapid discharge after EVLT; furthermore it allows the surgeon to work quickly and quietly, especially
when the procedure is bilateral and there may be the risk of injecting an high dose of local anesthetics. If tumescence is not necessary to reduce the
perioperative discomfort, CSTS remains a crucial point of EVLT; if this is not performed in fact, even if the EVLT is conducted with recent WSLWs,
there is a high risk of not obtaining GSV obliteration, especially in case of very dilated vein. CSTS mechanically reduces the luminal diameter of the
vein wall to better contact the laser fiber. It’s also very important to reduce the temperature. The method of action of EVLT is based on heat and
heat-induced complications may occur with inadequate application of tumescent technique. CSTS obviates the transfer of thermal energy to nontarget tissues by creating a heat sink. Probably the new WSLWs, thanks to LEED reducing, contribute to the reduction of perioperative pain; even
the new optical fibers make a contribution, thanks to the more homogeneous energy distribution, reducing the risk of the vein wall perforations.
However if no TLA or intravenous sedation are made, patients may feel pain even when using low energy with WSLWs and new fibers. In conclusion, our results show that EVLT with a 1540 nm diode laser and ball-tipped fiber using CSTS under sedation without diluted anesthetic drugs is a
suitable technique, very popular with patients.
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Sclerotherapy
PROTECTIVE EFFECT OF 2-HYDROXY-3-METHYL-1,4-NAPHTOHYDROCHINON-2-P-AMINOBENZOATE (AMINAPHTONE)
ON VASCULAR PERMEABILITY AND CAPILLARY – LIKE FRAGILITY
Di Stefano R.*[1], Felice F.[1], Feriani R.[1], Belardinelli E.[1], Frullini A.[2]
[1]Cardiovascular Research Laboratory, Department of Surgical, Medical and Molecular Pathology and Critic Area, University of Pisa, Pisa, Italy, [2]Studio Medico
Flebologico
Background. In vitro and in vivo studies suggest that Aminaphtone (AMNA), a naphtohydrochinone used in the treatment of capillary disorders, may
affect edema in chronic venous insufficiency (CVI).
Aim. The purpose of this study is to investigate the effect of the drug on the vascular endothelial permeability and to test the capability of AMNA to
stabilize three-dimensional capillary-like structures formed by Human Umbilical Vein Endothelial Cells (HUVECs).
Methods. HUVECs were isolated from umbilical vein of fresh human umbilical cords. The effect on cell permeability was evaluated pre-treating cells
for 12 h with 50 ng/ml VEGF and then for 8 h with different concentrations of AMNA (0.5-1-5-10-50 µg/ml). Capillary-like structures formation was
assessed by Matrigel assay. Cell-cell contact were evaluated by immunofluorescent localization of VE-cadherin.
Results. Treatment with 10 µg/ml AMNA significantly decrease permeability VEGF-induced (P<0.05), restoring normal condition. Moreover, cells
pre-treated with AMNA show a significant improvement and stabilization at 48 hours of capillary-like structures formation as compared with untreated cells both in number of meshes (P<0.01) and master segment lengths (P<0.01). Finally, 10 µg/ml AMNA treatment induce an increase in
VE-cadherin expression.
Conclusion. Results showed that AMNA significantly protects endothelium to permeability VEGF-induced and stabilize endothelial cells organized
in capillary-like structures on Matrigel. Both these results might be related to a direct effect on VE-cadherin, major member of the Ca2+ dependent
adhesion molecules, that affects cell-cell binding, critical to the maintenance of adherent junctions. These results validate the effect of AMNA on CVI
edema and the protective role on capillary fragility.
Keywords. Aminaphtone, Human Umbilical Vein Endothelial Cells, permeability, angiogenesis
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Sclerotherapy
COMPARISON BETWEEN CHIVA METHOD AND ASVAL TREATMENT
Ermini S.*[1]
[1]Studio Flebologico ~ Firenze ~ Italy
ASVAL treatment is based on the varicose vein ascending theory, while CHIVA only treats the hemodynamic pattern without performing extensive
phlebectomies justified by the reservoir theory. The ascending theory has not been confirmed by any pathological or observational studies, therefore
many pathological observations and a longitudinal observational study confirm the descending theory. The reservoir effect is described by ASVAL
supporters as a volume with a passive aspirative effect, while no flow can exist without energy, as described by the first hemodynamic principle. In
the DUS selection of patients there are differences between CHIVA and ASVAL: ASVAL is only based on the elimination of a centrifugal flow after
finger tributary compression, while the CHIVA strategy also deals with muscle contraction flow events. ASVAL is not a saphenous sparing surgery
procedure, because if a centrifugal flow reappears after a tributary phlebectomy, a saphenous stripping or a laser ablation is performed.
In conclusion CHIVA outcomes are confirmed by four RCTs and a Cochrane review, while ASVAL has no evidence A reference
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Sclerotherapy
LEGATURA/SEZIONE PRE-TERMINALE ECOGUIDATA DELLA GRANDE SAFENA: UNA METODICA AMBULATORIALE
Ricci S.*[1], Moro L.[1]
[1]Roma
Introduzione: I risultati positivi a medio termine dei trattamenti endovascolari sembrano dimostrare che l’interruzione della safena a raso della femorale non sia più un dogma assoluto, come lo è stato nel secolo scorso. Anche la safenectomia senza crossectomia sembra dare risultati stabili.
Inoltre la mancata dissezione della crosse senza interruzione delle tributarie può eliminare uno stimolo alla recidiva inguinale. Su questa base proponiamo una legatura/sezione ecoguidata della safena sub-terminale (a 2 cm dall’ostio) con una metodica semplice e rapida, eseguibile in ambulatorio
chirurgicamente attrezzato.
Materiali e metodi:
Sono stati reclutati 20 pazienti affetti da varici (classe CEAPc: 2) afferenti all’Ambulatorio di Chirurgia Flebologica del Policlinico Campus Bio Medico
di Roma. I criteri di inclusione sono stati la presenza di reflusso safenico da incontinenza della valvola terminale ed un diametro safenico misurato
a 15 cm dalla giunzione superiore a 6 mm (6-10). I criteri di esclusione comprendevano la presenza di obesità (BMI> 28) o pregressi interventi. Le
varicosità sono state trattate mediante flebectomia per micro incisioni in anestesia locale. Durante la fase di studio preoperatoria è stato identificato
(e marcato) il punto in cui la safena diventa più superficiale, passando sopra il muscolo grande adduttore, a circa tre cm dalla piega inguinale, denominato E-Point (Easy Point). Dopo un’anestesia superficiale (per evitare di mascherare il vaso agli ultrasuoni), è stata eseguita un’incisione trasversale di 3mm sul punto marcato sotto guida ecografica. Successivamente con l’ausilio di una mosquito si apre una strada fino alla fascia superficiale
che viene debitamente perforata; utilizzando una sottile pinza passafili ad angolo retto, arrivati nello spazio sotto fasciale fra la safena ed il muscolo
adduttore lungo, viene ancorata la vena Grande Safena, sotto diretta visione ecografica. Dopo ulteriore infiltrazione anestetica, la Grande Safena
veniva estratta dall’incisione, liberata dalle aderenze e sezionata fra due pinze. Il capo distale viene incannulato, iniettato con schiuma sclerosante al
3% e legato. Il capo prossimale viene stirato fino a trovare resistenza e trasfisso con Vycril 3/0 evitando di occludere le tributarie. I margini cutanei
vengono semplicemente approssimati.
Risultati: Trattandosi di uno studio di fattibilità, solo risultati a breve termine sono stati possibili. In nessun caso la procedura è stata interrotta. Il tempo di esecuzione dell’interruzione safenica in media è stato di 10 minuti (8-12). Il controllo post operatorio dei monconi residui a 30 gg ha mostrato
assenza di fenomeni trombotici, lunghezza media del moncone safenico di 1.92 cm, e l’assenza di reflusso al Valsalva. Nessuna complicazione
cutanea è stata registrata.
Conclusioni: L’interruzione ecoassistita della safena è un gesto chirurgico semplice, scevro di rischi, rapido, associabile a tutte le metodiche di
trattamento del reflusso safenico comprese quelle conservative. Il moncone safenico residuo, permettendo il drenaggio delle tributarie della crosse,
è analogo al quello che consegue al trattamento con tecniche endovascolari, ma con un costo molto più basso.
51
Sclerotherapy
A
ALBERTI A.
ALVISE C.
AYOUB G.
B
BACCAGLINI U.
BARALDI C.
BELARDINELLI E.
BERNARDINI E.
BIHARI I.
FERRARI M.
FERRINI M.
FIGUEIREDO MARCONDES
FIGUEIREDO MATHEUS
FORNASETTI A.
FRULLINI A.
G
GERARDI G.A.
GIRALDI E.
GUGGENBICHLER S.
PICCIOLI A.
PIETRAVALLO A.
PINZETTA C.
R
RADU D.
REIS BASTOS F.
RICCI S.
S
SALVETTI M.
SCEVOLA L.
BIHARI P.
BREU F.
BUSH R.
C
CARELLI M.
CAVALLINI A.
CERATTI S.
CHUNGA PRIETO J.A.
CRISTIANI A.
D
DAL POZZO E.
DEL CORSO A.
DI STEFANO R.
DRAGIC P.
E
ERMINI S.
F
FELICE F.
FERIANI R.
I
IVAN C.D.G.
IVAN V.
K
KASPAR S.
L
LEO M.
LOPARCO O.W.
M
MACEDO OKANO F.
MIRANDA R.
MORALES CONCA G.
MORO L.
N
NERO G.
NOSADINI A.
P
PATEL M.
PAVEI P.
SPINA T.
SPREAFICO G.
U
URBANEK T.
W
WATKINS M.
Z
ZERNOVICZKY F.
52
Sclerotherapy
MAIN Sponsors
Sponsors
ALFA WASSERMANN
ASSITA
B2 PHARMA
BIOLITEC
CIZETA MEDICALI
COVIDIEN ITALIA
EUFOTON
HYPER PHOTONICS
LABORATORI BALDACCI
OMEGA PHARMA
PICCIN NUOVA LIBRARIA
PIZETA PHARMA
RO+TEN
SELTEC MEDICAL
STD
TECHLAMED
aggiornato al 15/03/14
53
Sclerotherapy
Sede Congressuale • Congress Venue • Sede del Congreso
HOTEL SHERATON FIRENZE - Via Giovanni Agnelli, 33, 50126 Firenze
Crediti ECM
7 crediti [è necessaria la presenza alla totalità dell’evento] (for italians only • sólo para los Italianos)
Comitato Scientifico • Scientific Committee • Comité Científico
A. Frullini, A. Pieri, M. Ronconi, P. Pavei, G. Angelino, M. Rendace,
O. W. Loparco, C. Moretti, D. Maurano, M. Forzanini, S. Paradiso
Segreteria Organizzativa • Organizing Secretary • Secretaría Organizativa
VALET - Provider ECM 1328 • Via dei Fornaciai, 29/b - 40129 - Bologna (ITALY)
• Tel. + 39 051 63.88.334 • Fax +39 051 32.68.40 • www.valet.it • congresso@valet.it
54
Sclerotherapy
Comitato Scientifico
Scientific Committee • Comité Científico
A. Frullini, A. Pieri, M. Ronconi, P. Pavei, G. Angelino, M. Rendace,
O.W. Loparco, C. Moretti, D. Maurano, M. Forzanini, S. Paradiso
Segreteria Scientifica
Scientific Secretary • Secretaría Científica
Dr. Alessandro Frullini - AFI - Associazione Flebologica Italiana
Piazza Caduti di Pian d’Albero, 20 - 50063 - Figline Valdarno (Firenze - ITALY)
• Tel. +39 055 91.57.158
• www.associazioneflebologicaitaliana.it
• a.frullini@associazioneflebologicaitaliana.it
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Organizing Secretary • Secretaría Organizativa
CPMA VALET - Provider ECM 1328
Via dei Fornaciai, 29/b - 40129 - Bologna (ITALY)
• Tel. + 39 051 63.88.334
• Fax +39 051 32.68.40
• www.valet.it • congresso@valet.it
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