Prof. Lorenzo Tessari Trieste (Italy)

Transcription

1 Prof. Lorenzo Tessari Trieste (Italy)

2 Prof. Lorenzo Tessari Trieste (Italy)

3 IN THE LAST 50 YEARS

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5 ECO-(COLOR)-DOPPLER E CLAUDE FRANCESCHI

6 DISTRIBUZIONE SEGMENTARIA DEL REFLUSSO NELLA VGS 15 % 30 % 52 % 3 %

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11 European Foam Sclerotherapy Consensus Meeting Tegernsee (GER) April 03 European Foam Sclerotherapy Consensus Meeting Tegernsee (GER) April 06

12 European Consensus Meeting on Foam Sclerotherapy, April, 46, 2003, Tegernsee, Germany. Xaver Breu and Stephan Guggenbichler. Dermatologic Surgery 30:5, (2004) Prospective study on foam sclerotherapy. Breu-F-X, Marshall-M, Guggenbichler-S Vasomed {VASOMED}, 2004, Vol/Iss/Pg. 16/4 (133), ISSN: The History of Sclerosing Foams. Jan-Christoph G. R. Wollmann, MD. Dermatologic Surgery 30:5, (2004) Guidelines for Sclerotherapy of Varicose Veins (ICD 10: I83.0, I83.1, I83.2, and I83.9). E. Rabe, MD F. Pannier-fischer, MD H. Gerlach, MD, F. X. Breu, MD S. Guggenbichler, MD and M. Zabel, MD Dermatologic Surgery 30:5, (2004)

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14 Morrison N, Cavezzi A, Bergan J, Partsch H. Regarding "Stroke after varicose vein foam injection sclerotherapy". J Vasc Surg Jul;44(1):224-5; author reply

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17 FV 3% AIR T. 0 ATOSSISCLEROL AIR 3% T.0 FV 3% GAS O 2 30% CO 2 70% T.0 AT 3% GAS O 2 30% CO 2 70% T.0

18 CO 2 O 2 N

19 1- Left GSV elevated of 30 cm.and immobile limb 4 cc of foam polidocanol 0,5%+ CO2 O2 1-The first bubbles arrive in the right heart after stop of the bubble flow after Mobilisation (foot dorsiflexion) after 8 : reappearance of the bubbles for 2 50 Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy info@tessaristudi.it

20 1st step: administration of Pertechnetate (alone) 1 step: administration of Pertechnetate alone) Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy info@tessaristudi.it

21 Observation 1 In the 4 examinations performed after sclerotherapy the time/activity curves relative to the pulmonary intravascular transit are similar to the time/activity curve of the pertechentate alone Tc99 At 2% air Tc99 At2% CO 2o O Tc99 STS1% CO 2o O Tc99 STS1% air Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy info@tessaristudi.it

22 1. The use of 99m TcO 4- is not a correct procedure for analysing the pathway of the sclerosant foam in the vascular system. 2. Other procedures are needed to point out - a possible cronic polmonary damage, - where the sclerosant drug ends up -The sclerosant drug does not damage the lungs Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy info@tessaristudi.it

23 Effects of Sclerosants on Coagulation and Cell Function In Vitro Studies of Cell Damage Kurosh Parsi, Thomas Exner, David Connor, Joanne Joseph & David Ma *Plasma proteins particularly albumin neutralise sclerosants. *STS is 10 times more effective in saline than in blood. *Pol is 50 times more effective in saline than in blood. Bologna 2008 By kind courtesy of Dr. K Parsi & K. Mayers

24 In Vitro Studies - Postulated Foam is more effective than liquid possibly due to displacement of blood resulting in less exposure to serum albumin Foam sclerotherapy may be more effective if blood is displaced by saline Post-sclerotherapy DVT is possibly uncommon due to neutralisation of sclerosants by albumin in deep vein Bologna 2008 By kind courtesy of Dr. K Parsi & K. Mayers

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26 Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

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28 GRADIENTI RETROGRADI GRADIENTE IPERPRESSIVO VALSALVA GRADIENTE GRAVITAZIONALE TEST STATICO COMPRESSIONE/RILASCIAMENTO TEST DINAMICI PARANA OSCILLAZIONE FLESSIONE DELLE DITA DEL PIEDE SOLLEVAMENTO SULLA PUNTA DEI PIEDI

29 COMPRESSI ONE RILASCIAME NTO TEST DINAMICI Gradiente IPERPRESSIVO VALSALVA MOBILIZZAZIONE DI SANGUE > NELLA RETE SUPERFICIALE MOBILIZZAZIONE DI SANGUE > NELLA RETE PROFONDA

30 Quadrilatero Valvolare Safeno-Femorale VALVOLA FEMORALE SOVRA OSTIALE VALVOLA TERMINALE Della giunzione safeno-femorale POINT OF ANALYSIS VALVOLA PRE-TERMINALE VALVOLA FEMORALE SOTTO OSTIALE

31 PATIENTS POPULATION 1294 SFJ investigated on 1030 consecutive patients affected by primary varicose veins Sex: M 22% F 78% Age: ys (55,8 +/- 14,1) GSV diameter at the thigh: 6.5 mm +/ ( 3mm- 15 mm) C.E.A.P.: C 2-6 s Ep As2-4 p17-18 Pr

32 1294 REFLUX DOCUMENTED AT THE SF ARCH OF THE GREAT SAPHENOUS VEIN SQUEEZING TEST + DYNAMIC TESTS + POINT OF ANALYSIS Is this sufficient by itself to diagnose the incompetence of the whole Sapheno- Femoral Junction?

33 THE 1294 SF ARCH WERE EVEN INVESTIGATED UNDER VALSALVA SQUEEZING TEST + DYNAMIC TESTS cases (80%) VALSALVA cases (20%) VALSALVA -

34 1294 G.S.V. With reflux documented at the SF arch under C/R and DYNAMIC TESTS 259 cases (20%) VALSALVA - Back flow from the JUNCTION C/R - VALSALVA - C/R + VALSALVA -

35 1294 ARCH OF THE GREAT SAPHENOUS VEIN SQUEEZING TEST + DYNAMIC TESTS + 1 Question : Where does the reflux sustained by Valsalva manoeuvre come from? 1035 cases (80%) VALSALVA cases (20%) VALSALVA -

36 POINT OF ANALYSIS 1294 G.S.V. With reflux documented at the SF arch under C/R and DYNAMIC TESTS 1035 cases (80%) VALSALVA + VALSALVA + VALSALVA - C/R + VALSALVA + C/R + VALSALVA cases 61% 246 cases 19%

37 246 cases 19% 1 Gruppo : Shunt pelvici 2 Gruppo VALSALVA - SHUNT PELVICO SU COLLATERALE VALSALVA - VALSALVA + VALSALVA casi 10% 116 cases 9% NO SHUNT PELVICO SU COLLATERALE

38 1294 G.S.V. With reflux documented at the SF arch under C/R and DYNAMIC TESTS 1035 cases (80%) VALSALVA + VALSALVA + C/R + VALSALVA cases 2 Question: Is Valsava manoeuvre an expression of a complete incompetence of valves? 61%

39 1294 G.S.V. With reflux documented at the SF arch under C/R and DYNAMIC TESTS 789 cases (61%) VALSALVA + on the femoral side of the terminal valve VALSALVA + VALSALVA + C/R - C/R + C/R + VALSALVA + C/R + VALSALVA + 79 cases 6% 710 cases 55% Only 55% of patients with incompetence of the terminal valve

40 1294 G.S.V. With reflux documented at the SF arch under C/R and DYNAMIC TESTS 789 cases (61%) VALSALVA + on the femoral side of the terminal valve C/R + C/R + VALSALVA cases 55% Only 55% of patients with incompetence of the terminal valve

41 Inguinal ligament FEMORAL VALVE placed above the saphenofemoral junction Above the sapheno-femoral junction Valves are missing in 20 to 24% of cases (Reagan and Folse 1971)

42 Incompetence or absence of the Femoral valve Vals. + C/R + Vals. + C/R +

43 Competence of the Femoral valve Vals. - C/R - Vals. + C/R +

44 PATIENT POPULATION 572 SFJ investigated on 572 consecutive patients affected by primary varicose veins with incompetence of the sapheno-femoral junction Sex: M 22% F 78% Age: yr (55,7 +/- 14,7) GSV diameter at the thigh (15 cm from the groin): 6.7 mm +/ ( 4mm- 15 mm) C.E.A.P.: C 2-6 s Ep As2-4 p17-18 Pr

45 Femoral valve Femoral Valve Observations Percentage Competence % Absence/Incompet ence % Total %

46 1294 G.S.V. With reflux documented at the SF arch under C/R and DYNAMIC TESTS = C/R + C/R + VALSALVA cases 55% Only 55% of patients with incompetence of the terminal valve 41.91% Absence/Incompetence - Femoral valve % ABSENCE /INCOMPETENCE FEMORAL VALVE +TERMINAL VALVE at the saphenous-femoral junction

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48 1 Reflux de la crosse Avec incontinence de Terminal valve Pre-terminal valve Avec continence de Femoral valve 55% de reflux de la crosse Diametre=<7mm

49 2 Reflux de la crosse avec incontinence de : Fémorale valve (absente?) Terminale valve Pré-terminale valve 42% de reflux de la crosse Diamètre > 8 mm

50 3 reflux collateral ou Pelvien Avec continence de Terminal valve Avec incontinence de Valve pre-terminal 45% de reflux Diameter < 6 mm

51 Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

52 C/R VALS- C/R + VALSALVA + 45 % 1 TEMPO CHIVA 2 O FOAM DEI REFLUSSI PELVICI

53 42% SAPHENOUS-FEMORAL DECONNECTION Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

54 42% SAPHENOUS-FEMORAL DECONNECTION

55 Saphenous- femoral Deconnection Intervento di Arthur K.C. Li 42% SAPHENOUS-FEMORAL DECONNECTION Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

56 By kind courtesy of Dr. F. ZINI C/R VALS- C/R + VALSALVA + 45 % 1 TEMPO CHIVA 2 O FOAM DEI REFLUSSI PELVICI Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy info@tessaristudi.it

57 C/R VALS- C/R + VALSALVA + FOAM DEI REFLUSSI PELVICI

58 Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

59 Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

60 Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

61 mm A CONTROLLED, COMPARED RANDOMISED TRIAL FOAM + Phlebectomie CLOSURE + Phlebectomie LASER + Phlebectomie 0 PRIMA 1 MESE 3 ANNI R.Milleret (Phlébologie 2004, 57 N 1, ) Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy info@tessaristudi.it

62 Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

63 THE MATCH WILL CONTINUE thank you for your attention Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

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65 Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

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67 PREAMBLE Superficial venous insufficiency of the lower limbs is now considered a multi-focal disease Nowadays any kind of interventions for varicose veins of the lower limbs must be based upon accurate CD maps Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy info@tessaristudi.it

68 Extrasaphenous refluxes It was already clearly demonstrated that at least the 45% of the varicose veins of the greater saphenous vein (GSV) do not originate from sapheno-femoral junction (SFJ) reflux In spite of a complete SFJ and GSV truncular continence, other kinds of refluxes, coming from the groin, from the perineal and/or gluteal regions can appear. Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy info@tessaristudi.it

69 Normal anatomic findings Legend: RK - right kidney LK - left kidney LRV - left renal vein ROV - right ovarian LOV - left ovarian (veins)

70 LOV reflux Normal condition of LOV reflux left-to-right trans-uterine re-entry circuit

71 LOV reflux Early pregnancy condition left-to-right re-entry circuit compression

72 LOV reflux Late pregnancy condition left-to-right re-entry circuit interruption

73 LOV reflux Late pregnancy: external appearance of right groin varicose veins due to the interruption of the left-to-right re-entry circuit Pieri A. et al. Phlébologie 1999; 52 (1): 45-51

74 classification from M. Cappelli- C. Franceschi Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

75 Pelvic shunts classification C. Franceschi modified, from M. Cappelli 1 Point I (groin) round ligament veins 2 Supra-pubic origin (sp. Palma, Santorini) 3 Point P (perineal) - int. pudendal veins 4 Obturatorian vein origin 5 Ischiatic vein / inf. gluteal vein 6 Groin (primary cavernoma)

76 Point P Eje Hipogástrico Perineal superficial (Pudenda interna) 60% Pudenda Externa Perineal superficial Pudenda interna By kind courtesy of Dr. J.Leal Monedero- Dr. S.Zubicoa Ezpeleta

77 Point P reflux: Alcock s channel Internal pudendal vein Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy info@tessaristudi.it

78 Pelvic varicose veins monster varicose veins (the Web)

79 Point P: Perineal Reflux By kind courtesy of Dr. A. Pieri Int. pud. Vein reflux Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

80 Perineal origin of VaricoseVeins By kind courtesy of Dr. A. Pieri Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

81 Claude Franceschi: operation on P Points The operation is performed on both sites, with perineal phlebectomies Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy info@tessaristudi.it

82 Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

83 Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

84 Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

85 Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

86 Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

87 Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

88 Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

89 Colour Duplex still represents the best technical tool to investigate pelvic reflux, both with trans-abdominal and trans-vaginal approach. Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy

90 CONCLUSIONES Todo este sistema venoso funciona por cambios de presión y su alteración genera cambios hemodinámicos en sentido centífugo o centrípeto. El control de esta enfermedad se realizará sobre su etiología así como sobre los puntos de fuga que se hayan desarrollado hacia los sectores inferiores By kind courtesy of Dr. J.Leal Monedero- Prof. LORENZO TESSARI Fond. Gl. Bassi Trieste Italy info@tessaristudi.it