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TRATTAMENTOENDOVASCOLARE DELL’IVC
DAL DOGMA ALL’INNOVAZIONE
G.B. AGUS
Direttore dell’Istituto di Chirurgia Vascolare
Università di Milano
Chirurgo Vascolare Ospedaliero 1970-1988
PATTERNS EMODINAMICI DELLA MALATTIA VARICOSA
• Trattare la crosse della VGS non è sempre necessario.
• La giunzione safeno-femorale risulta competente in circa il 30-55% dei casi e non sono presenti alterazioni proprie del territorio safenico interno nel 15-20%
[Goren G and Yellin AE, 1990; Camilli S, 1992; Abu.Own A, 1994; Guex JJ et Al, 1995; Myers KA, 1995; Singh S et Al, 1997; Jutley RS et Al, 2001; Cappelli M et Al, 2004]
Gradiente IPERPRESSIVO
VALSALVA
COMPRESSIONE RILASCIAMENTO TEST DINAMICI
MOBILIZZAZIONE DI SANGUE
> NELLA RETE
SUPERFICIALE
MOBILIZZAZIONE DI SANGUE
> NELLA RETE PROFONDA
“OLD” STRIPPING TECHNIQUE
• New techniques eliminate the psychologic barrier to treatment caused by the term “stripping” and allow the objectives of surgery to be achieved with minimal invasion and quick recovery.
[Bergan J.J., 2002]
Incidence of saphenous nerve injury :partial vs complete LSV stripping
7% vs 39%
[Sam RC, Silverman SH , Bradbury AWEur J Vasc Endovasc Surg 2004; 27: 113-20]
REVIEW. NERVE INJURIES AND VARICOSE VEIN SURGERY
STRIPPING IN 2000
Stripping of the greater saphenous vein to the below-knee level has proven to be a more successful method of treating greater saphenous vein reflux and has been shown to reduce the risk of reoperation for recurrent varicosities.
[Neglen P et Al., 1993; Rutgers PH et Al. 1994; Sarin S et Al., 1994; Bergan JJ, 1996; Dwerryhouse S et Al., 1999; Winterborn RJ et Al, 2004]
Saphenofemoral ligation with ligation and division of the tributaries
[Moore and Thelwall Thomas, 1896; Homans,1916]
What is neovascularization and why is it prevalent
after high ligation ? [Bergan J.J., 2005]
Today it appears that avoidance of a groin incision prevents neovascularizations in varicose vein surgery
[Bergan JJ, 2005]
INNOVAZIONE
“I benefici, i rischi, i costi e l’efficacia di ogni nuovo metodo devono essere
confrontati con quelli del miglior trattamento profilattico, diagnostico e terapeutico disponibile al momento”
[Dichiarazione di Helsinki, 2000, Sez. C, Clausola 29]
E.V.L.T. – Endo Venous Laser Treatment
• I vantaggi: obliterazione della vena
safena interna per effetto termico (90°) indotto dal thermal injury panmurale dato dall’interazione tra luce polarizzata e cromoforo (acqua, emoglobina), non a contatto della parete
Mini-invasività, eseguibile in anestesia locale e in day surgery. Pronto recupero funzionale
Metodica eseguibile anche in presenza di tortuosità safeniche
Nessun limite di utilizzo in relazione al calibro del vaso
Costi dei materiali accettabili in relazione ai DRG ottenibili
A LITERATURE ANALYSIS AT MARCH 1st 2004
Lower limb varicose veins endoluminal treatment by endovenous laser and radiofrequency.
• 50 articles published in English (36) and French language (14), to compare the two procedures between them and with the classical surgery.
• The endovenous surgery methods were proven to be less aggressive and effective at mid-term.
[ Perrin M., Phlebologie 2004; 57,N. 2: 125-33]
UNIQUE PROCEDURE PROTOCOL OF PRACTICE
While EVLT-ELVeS, which is FDA approved, uses only one type of device manufactured and is distributed by a single company, there are also other techniques using different types of Laser equipment and devices with multiple variants but without the benefit of a single well-defined protocol for their use.
I.E.W.G.
The Italian Endovenous-Laser Working Group (IEWG) is a homogeneous group of surgeons and phlebologists who use the same kit-device for these reasons.
L’ IEWG METTE IN GUARDIA
DALL’ ESTRO ITALIANO
• Generatore Laser in regalo• Indicazioni cliniche personali• La babele delle procedure • Erogazione a luci rosse • Kamasutra energetico per J – W – T • Il dogma della crossectomia associata
Clinical data Follow up
MI SI AR PD-VR PD
Procedures
Months
Vein occlusion
38
20
100%
47
12
98%
484
48
98%
76
17
98%
63
14
98%
92
93
94
95
96
97
98
99
100
12 14 17 20 48
S VP
months
AM
Clinical dataComplications
0
15
6
5
5
1
12
281
0 50 100 150 200 250 300
D.V.T.
Pain
S.V.T
Hematoma
Paresthesia
Skin Burns
Ipo / Iperpigmentation
Ecchymosis 38%
ResultsPatient compliance
0 1097
629
0
200
400
600
800
None Low Good Excellent
85%
13%
CLINICAL REMARKS
• Present evidence suggests that less saphenous veins should be treated.
• With proper indications to the treatment of saphenous reflux minimally invasive techniques should be used.
• Results 3-5 years of endovenous laser indicate a very effective and safe treatment of GSV.
• Endovenous laser is a cost-benefit procedure.
METHODOLOGICAL REMARKS
• It remains to be established whether the treatment without SFJ ligation is a risk for recurrence.
• As technology for the treatment of varicose veins
expands, we must remain vigilant.
• Critical scientific outcomes assessment before
widespread application of new techniques is
essential.