Surgical crossectomy and saphenic trunk sclerotherapy. Preliminary results of a combined approach to the treatment of saphenous vein varices.

AIM: Here our proposal of a new approach to the incontinent saphenous-femoral junction (SFJ) based on the combination of surgery and sclerotherapy for treatment of incontinent varices. It is a two-step procedure with a surgical ligation and transection of SFJ followed by a sclerosis of saphenous trunk and extra-fascial tributaries. MATERIALS AND METHODS: From January to December 2017, 95 patients (63 females and 32 males) with a mean age of 56.43 ± 6.07 years for a total of 121 limbs were treated with the SHSC approach. Under local anesthesia, after surgical selective hemodynamic crossectomy and a retrograde cannulation of the saphenous trunk by means of 8-10 ch nelaton-like catheter, 0.5-1% polydocanol foam, obtained with Tessari's technique, is injected into the vein. During injection, the catheter must be progressively withdrawn, so that the entire vein comes in contact with the foam. RESULTS: 121 limbs have been treated with the above technique. A complete obliteration of the saphenous trunk was observed after 116 (95.86%) treatments in the immediate postoperative time. With regard to collateral veins sclerosis, 99 (81.81%) complete obliterations were observed. 28 (23.14%) collateral varices had to be refined by sclerotherapy. DISCUSSION: SHSC associates the execution of a selective hemodynamic crossectomy with an intraoperative foam sclerotherapy for the treatment of the saphenous trunk and collateral varicose veins. SHSC, compared to classical US-guided foam sclerotherapy seems to be safer, with fewer risks of pulmonary and / or cerebral embolic complications. SHSC prevents blood wash out which could destabilize the consolidation of the saphenous trunk sclerosis. CONCLUSIONS: SHSC can be considered an effective treatment of varicose veins, simple to perform, minimally invasive and well tolerated KEY WORDS: Crossectomy, Saphenous vein, Sclerotherapy, SFJ.

[Linee guida flebo-linfologiche SIF-SICVE 2016 della Società Italiana di Flebologia e della Società Italiana di Chirurgia Vascolare ed Endovascolare].

Phlebology is not a specialty for its own in Italy. Phlebological patients are treated by vascular and general surgeons, dermatologists, phlebologists, angiologists, internists and even general practitioners. Even tough guidelines present a series of recommendations based on evidence-based medicine, guidelines may also be a tool to unify the diagnostic and therapeutic approach in a vast medical field like phlebology. Since vascular surgeons and phlebologists are particularly involved in phlebology-related pathologies the scientific societies of the Italian Society of Phlebology (SIF) and the Italian Society for Vascular and Endovascular Surgery (SICVE) decided to cooperate for the preparation of phlebo-lymphological guidelines. These guidelines comprehend also an important chapter dealing with the lymphology of the lower extremities; phlebological active physicians are often faced with lymphatic pathologies and a good differential diagnosis can be sometimes very helpful. Sclerotherapy and Surgery as the major therapeutical alternatives are extensively analyzed, but also the compression therapy, the medical and physical therapy are presented under the critical view of evidence based analyses. Separate chapters deal with the treatment alternatives for superficial and deep venous thromboses and the recommendations for the treatment of venous ulcers. The current scientific evidences were confronted with the experiences of Italian specialists and the particular practice and reality in Italy. They represent therefore the actual valid positions and recommendations in Italy which shall be updated regularly.

Role of the haemodynamic mapping in varicose vein surgery of lower limbs.

AIM: To demonstrate the importance of preoperative ultrasound haemodynamic mapping of venous system in surgery of varicose veins. MATERIALS AND METHODS: Doppler ultrasound evaluation of haemodynamic features of lower limb venous system according to Franceschi's subdivision. DISCUSSION: The importance of Doppler mapping in varicose veins surgery shows a similarity with the Plebographic classification of venous system developed by W. Hach. The study also reassesses the role of varicectomy in the surgery of varicose veins. CONCLUSIONS: Preoperative Doppler ultrasound mapping is essential to avoid accident and prevent recurrence of varicose veins. KEY WORDS: Doppler US, Surgery, Great Saphenous Vein, Varicose Veins, Stripping.

The use of transillumination as a rational approach to sclerotherapy and endovascular laser ablation of varices. Results in the use of an original instrument.

AIM: To explain the mode of using and the obtained results during EVLA procedures and sclerotherapies with support of Visioven®, a laser transillumination instrument. MATERIALS AND METHODS: 205 patients suffering from Chronic Venous Insufficiency - CEAP-C stage 1-2 enrolled (103 females and 102 males) and divided into two groups. A Group: patients candidate for sclerotherapy; B Group: patients to be subjected to endovascular laser ablation (EVLA). In both groups patients were divided into two sub-groups on the basis of the use of Visioven® or not during the procedure. The analyzed outcome variables were the total number of cannulations necessary to treat a whole limb, and the total procedure time. RESULTS: There is a statistically significant difference between the sub-groups in which Visioven® was used and the ones in which the procedure has been performed without using of any tools. Both in the sclerotherapy group than in the EVLA one, there is not a statistically significant difference for the time required to complete the procedures carried out with Visioven® compared with the ones performed without the use of any transillumination. DISCUSSION: Complete closure of the vein was highlighted. Total number of cannulations in sclerotherapy and EVLA procedures was reduced, as a consequence of a "smart" and "targeted" treatment achieved with Visioven® CONCLUSION: The VISIOVEN® system leads to have a more rational approach to sclerotherapy or Laser Ablation of teleangectasias and reticular veins as we can immediately verify the effectiveness of the treatment and adapting it to the desired effects. KEY WORDS: Chronic Vein Insufficiency, EVLA, EVLT, Laser, Varicose vein.

Comparison of traditional surgery and laser treatment of incontinent great saphenous vein. Results of a meta-Analysis.

AIM: This paper aims to compare EVLA to traditional surgery, by evaluating the incidence of recurrences. MATERIAL OF STUDY: We performed a meta-analysis to challenge both surgical and LASER treatment, using, as clinical outcome, the presence or the absence of reflux. A systematic review of literature about the treatment of varicose veins was performed, searching in the following databases: PUBMED-MEDLINE, Cochrane Library. Search terms considered were: stripping, HL/S, surgery, LASER, EVL*, varicose vein, GSV, saphenous vein. Only RCTs based at least on sixmonths follow-up were considered eligible in the study. Methodological quality of the included studies was evaluated using Cochrane Collaboration Bias Risk Assessment Tool. Effects of the dichotomous variables taken in consideration were evaluated using pooled risk-ratios with 95% C.I. Articles were evaluated initially from abstracts; eligible papers were fulltext examined. RESULTS: We have considered 2 groups, A and B. A Group: 756 legs treated with conventional surgical procedure; B Group: 755 legs treated with EVLA technique. A Group showed 175 post-procedure recurrences, while B showed 97 recurrences. The average O.R. was 1.72; minimum O.R. was of .497 while the maximum was of 8.064. DISCUSSION: The obtained OR average value is 1.72 with a 95% C.I. of 0.94-3.12, which includes the value 1, contrary to the criteria for rejection of the null hypothesis. For this reason there is not a statistically significant difference between the results obtained by the two techniques. CONCLUSIONS: The endovascular laser ablation (EVLA) does not prove to be superior in terms of recurrence, to the surgical technique. However, it remains a viable treatment option in patients with impaired great saphenous vein, reducing postoperative pain and hospital stay. KEY WORDS: Laser therapy, Meta-analysis, Saphenous vein, Surgery, Venous insufficiency.

Prophylactic GSV surgery in elderly candidates for hip or knee arthroplasty.

Aging is one of the major risk factors for varicose veins. The same is for Knee and Hip Osteoarthritis. Most of the patients undergoing to Hip (THA) or Knee (TKA) arthroplasty are over sixteen. Varicose veins, excluding thrombophilia, are the most significant risk factors for VTE after THA and TKA. This study investigates on the usefulness of prophylactic treatment of GSV insufficiency in elderly patients undergoing to orthopedic surgery. A retrospective study enrolling 44 over-sixty five patients, undergoing to TKA or THA. 24 patients underwent to traditional surgery and 20 to EVLA. The presence of evident varicosities and/or a saphenic reflux lasting > 500 ms has been considered as operability criterion. Both in surgery and EVLA group has been performed the ablation of visible varicosities and only saphenic refluxing traits. RESULTS: 1 case of symptomatic DVT was recorded after arthroplasty. A statistically significant difference (p = 0.006) of recovery time between surgery and EVLA groups has been detected. There is not a statistically significant difference in long-term recurrence rate between surgery and EVLA. CONCLUSIONS: It is useful to program GSV surgery, before treat hip or knee. This study showed a 50% decrease in the incidence of postoperative DVT.

Is the fibrotic parietal thickening a reliable parameter for diagnosing previous asymptomatic deep vein thrombosis?

AIM: Research of a starting point to debate about the possibility of identifying a unique sign of previous DVT. MATERIAL OF STUDY: A retrospective study involving 202 outpatients with venous insufficiency of the lower limbs (CEAP classes C 4/6), classified according to the affected venous district. Patients positive for deep vein thrombosis (DVT) were subjected to Compression Ultra Sound test (CUS test) with measurement of the wall thickness at the point of formation of the thrombus and at fixed points of common femoral and popliteal veins used also in the patients with negative history of DVT RESULTS: Among total group, only 19 patients (9.40%) had an history of DVT. No one of them had a superficial incontinence. The measurement of wall thickness in positive DVT history patients (group A) resulted in an average value of 1.10 mm (s.d=0.06), while the average value obtained in negative DVT history (group B) was 0.55 mm (s.d.= 0.20). However, in 13 patients wall thickness was > 1mm (mean: 1.04 mm). The difference between the averages of group A and B was statistically significant (p <0.05). DISCUSSION: In all positive DVT history patients and in 13 ones with negative history we found an increase in wall thickness, with a value > 1 mm. Can the wall thickening more than 1 mm be considered an indicator of previous DVT? Can it be considered a "marker" for thrombophilia status? CONCLUSIONS: The usefulness of a sign of previous DVT (even if asymptomatic), detected during a routine Doppler ultrasound check of lower limbs, could be a warning bell to investigate thrombophilia status. KEY WORDS: Chronic Venous Insufficiency, Duplex ultrasound, Hypercoagulability, Post-thrombotic Syndrome, Venous Thromboembolism.

Verification of the effectiveness of silver dressings to prevent reinfection of skin ulcers after debridement.

OBJECTIVE: To test the usefulness of silver dressings in patients with skin ulcers in the healing phase after debridement. MATERIALS AND METHODS: After randomly selected a group of 30 patients and divided them into three groups (A, B and C) according to the type and severity of the ulcer, we used respectively for each group antiseptics-free dressings, hydrofiber dressings with a low or a high content of silver. Then we performed samples by aspiration from the bottom of the wound three times (zero time, after two weeks, after a month) to prepare bacterial cultures. RESULTS: In group A, 5 ulcers showed signs of critical colonization after two weeks and 2 of these showed evidence of infection without progression to healing after a month. In groups B and C, no ulcer showed signs of infection with negative cultures. In these two groups, wounds evolved towards healing. CONCLUSIONS: Silver dressings seem to be the best option for the prevention of reinfection of skin ulcers; silver concentration should vary according to the degree of ulcer contamination. Dressings with hydrofibers avoid the accumulation of secretions for bacterial growth which would compromise tissue repair.

Abdominal hypertension and venous insufficiency of lower limbs: is there a relationship?

OBJECTIVE: The purpose of our study is to understand the compression, by subcutaneous fat in obese patients, who present a chronic increase in abdominal pressure, and on the sapheno-femoral cross. Such increase would result in a chronic venous insufficiency (CVI) of lower limbs and, if possible, it will be quantified also according to the posture. MATERIAL AND METHODS: We studied two different groups of patients with CVI: obese and non-obese. The severity of CVI was classified with the CEAP classification or by the standards of recent classifications. Abdominal pressure, by means of Kron's method, and anterior-sagittal diameter were measured in some of the non-obese patients (4 males and 4 females) and in all the obese patients. The diameter of the femoral vein of both groups of patients in supine, sitting and standing positions was also measured. RESULTS: We found a higher incidence of CEAP 5-6 classes in the obese group than in the non-obese one; we also saw a higher incidence of classes 1-2 in the non-obese group than in the obese one. Moreover, Kron's method showed a significant difference in abdominal pressure in relation to the BMI and the increase in the femoral vein diameter appears to be related to the weight and to the position. DISCUSSION: It was clear that the clinical manifestations of CVI are more severe in obese than in non-obese patients. Obesity in our study clearly acts with a continuous compressive action on the veins of the abdomen and thereby on the femoral vein, further contributing to a retrograde flow. So we tried to quantify an entity that until now could only be assumed.

Thromboembolic tendency (TE) in IBD (Inflammatory bowel disease) patients.

BACKGROUND: The incidence of TE events in IBD patients is higher then in population control. The main reason of it, is the hypercoaugulable state. Our aim was to detect serum markers related to TE, that can assume preventing and prognostic meanings. MATERIALS AND METHODS: We performed a 3 years study on 71 patients with IBD, evaluating hypercoaugulability, and then we compared the results with a 71 patients non IBD group control. We also investigated patients of both groups concerning TE events occurred already. RESULTS: In IBD group we found out that 16 patients (22.5%) had history of TE versus >1% of group control. Nineteen of them, already had knowledge of their previous hypercoaugulating condition. 48 (67%) had increased markers value versus less then 6% detected in group control. In IBD group 43% ,20% and 4.2% had respectively 1, 1-3 or > 3 markers higher levels then normal range. Among the markers investigated, we detected increased levels of plated in 33%, homocysteine in 26.7%, d-dimero 25.3%, c3 in 15.4%, apcr in 5.6%. CONCLUSIONS: From our study we detected highest incidence of TE events, and hypercoaugulating status in IBD group. In our previous investigations, plated, homocysteine, d-dimero, c3, and apcr, seems to be the TE markers with higher sensibility. It seems reasonable, according our experience, to propose a new TE risk score index for IBD patients: low, mild and high risk respectively for patients with 1, 1-3 and >3 markers with higher serum levels then normal range. KEYWORDS: Inflammatory bowel disease, Thromboembolism risk score.

New method for bacterial load measurement during hydro-debridement of cutaneous ulcer.

AIM OF THE STUDY: Based on their experience using Versajet for debridement of chronic wounds, the Authors set up a study protocol to verify whether the hydro-surgical cleansing could offer the possibility of taking tissue specimens suitable for diagnostic microbiological evaluation. The aims of the study were the following: MAIN PURPOSE: To evaluate the efficacy of hydro-surgery in detecting the presence of microorganisms and measuring their load, as an alternative to conventional tissue sampling methods; SECONDARY PURPOSE: To set up an easier and less invasive diagnostic modality than surgical biopsy, even though likewise significant. RESULTS: The results of this study show that tissue specimen collection by hydro-aspiration using Versajet is comparable to biopsy sampling (and in some cases it can be even more reliable); moreover, it is not more time-consuming and is certainly less invasive. Compared to surgical biopsy, with such a method a greater amount of tissue may be collected; moreover, tissue specimens can be taken from a broader surface or, depending on the needs, from a more focused area on the margin or at the bottom of the wound.

[Day care varicose vein surgery in elderly patients. 10 years of experience]. / Il trattamento della malattia varicosa del paziente anziano in regime di Day Surgery. Dieci anni di esperienza.

At present the surgical treatment of lower limb varicose veins is performed mainly as day case surgery. Since 30% of elderly people suffer from this disease, the feasibility of phlebological operations in elderly patients in a day care setting is an emerging problem. All patients (2032 patients) who underwent varicose vein surgery in our Geriatric Surgery Department over a 10-year period from January 1993 to December 2002 were evaluated retrospectively; 312 patients (15.35%) were aged above sixty-five years. In this group of elderly patients, 214 (68.6%) were operated on as inpatients and 98 (31.4%) as day care cases; in the younger group, 60.23% were treated in a day care regimen. All patients were examined and selected depending on general conditions, local conditions and logistics. Among the general conditions the exclusion criteria for elderly patients were concomitant diseases (43.9%) and anxiety (17.8%); as a consequence of local conditions, 31 patients (14.5%) with extensive bilateral varices and 27 patients (12.6%) with complicated recurrent disease were excluded from day care surgery; 24 patients (11.2%) were excluded because of logistics. Almost half (44.9%) of the elderly patients required multiple admissions for diagnostic investigations. The elderly patients underwent fewer saphenous strippings (7.1% vs 15.9%) and below-knee strippings (48.0% vs 56.9%); on the other hand, there were more operations on perforating veins (7.1% vs 1.4%), more varicectomies 10.2% vs 1.7%) and more skin grafts for ulcers (8.2% vs 2.2%). No problems occurred during the interventions and none of the patients had to be re-admitted to hospital for complications. This study provides evidence that varicose veins can be safely managed in a day care unit even in elderly patients, though careful preoperative selection is necessary.