Update of the SFMV (French society of vascular medicine) guidelines on the conditions and safety measures necessary for thermal ablation of the saphenous veins and proposals for unresolved issues.

Venous insufficiency is a very common disease affecting about 25% of the French population (if we combine all stages of its progression). It is a complex disease and its aetiology has not yet been fully elucidated. Some of its causes are well known, such as valvular dysfunction, vein wall defect, and the suctioning effect common to all varicose veins. These factors are generally associated and together lead to dysfunction of one or more of the saphenous veins. Saphenous vein dysfunction is revealed by ultrasound scan, a reflux lasting more than 0.5 seconds indicating venous incompetence. The potential consequences of saphenous vein dysfunction over time include: symptoms (heaviness, swellings, restlessness, cramps, itching of the lower limbs), acute complications (superficial venous thrombosis, varicose bleeding), chronic complications (changes in skin texture and colour, stasis dermatitis, eczema, vein atresia, leg ulcer), and appearance of unaesthetic varicose veins. It is not possible to repair an incompetent saphenous vein. The only therapeutic options at present are ultrasound-guided foam sclerotherapy, physical removal of the vein (saphenous stripping), or its thermal ablation (by laser or radiofrequency treatment), the latter strategy having now become the gold standard as recommended by international guidelines. Recommendations concerning thermal ablation of saphenous veins were published in 2014 by the Société française de médecine vasculaire. Our society has now decided to update these recommendations, taking this opportunity to discuss unresolved issues and issues not addressed in the original guidelines. Thermal ablation of an incompetent saphenous vein consists in destroying this by means of a heating element introduced via ultrasound-guided venous puncture. The heating element comprises either a laser fibre or a radiofrequency catheter. The practitioner must provide the patient with full information about the procedure and obtain his/her consent prior to its implementation. The checklist concerning the interventional procedure issued by the HAS should be validated for each patient (see the appended document).

[Cicatricial uteri. Vaginal delivery under peridural analgesia]. / Utérus cicatriciels. Accouchements par voie basse sous analgésie péridurale.

The results of 108 attempts to deliver women who had previously had caesarean sections vaginally under epidural analgesia are studied. 94 patients (87%) delivered vaginally taking the usual length of time for dilatation and delivery. These confirm that epidural analgesia does not alter the prognosis for this type of delivery. However, one uterus unfortunately ruptured with the rapid death of the baby. This study makes it possible to define certain rules that should be carried out to lessen or even get rid completely of the risk of these accidents. As far as the anaesthetic is concerned, epidural analgesia should be carried out and watched very carefully. Small doses of anesthetics should be used and those in low concentrations. Symmetry analgesia should be good. Medics should be aware of the cumulative effect of adding dose on dose. Finally, morphine or morphine-like substances should either be used carefully or forbidden altogether. These precautions will limit the quantities of epidural analgesics that are delivered and assure that there is symmetry so that it is easier to recognize the signs before rupture of the uterus. As far as the obstetrical side is concerned, although we did not use oxytocics very often (37%) we did not find that there was any risk attached to it. We recommend, however, that internal monitoring should be carried out very often whether oxytocics are used or not. Routinely, instruments should be used for the delivery to lessen the efforts required to expel the baby. Exploring the cavity of the uterus after the delivery does not seem to us to be necessary unless there are the usual obstetric indications for doing this.