АССОЦИАЦИЯ ФЛЕБОЛОГОВ РОССИИ

REVERSE FOAM SCLEROTHERAPY OF THE GREAT SAPHENOUS VEIN WITH SAPHENO-FEMORAL LIGATION COMPARED TO STANDARD AND INVAGINATION STRIPPING: A PROSPECTIVE CLINICAL SERIES
Abela R, Liamis A, Prionidis I, et al.
Eur J Endovasc Surg. 2008;36:485-490.
ABSTRACT AND COMMENTARY BY Andreas Oesch, Bern, Switzerland ABSTRACT Ninety limbs with incompetence of the great saphenous vein were prospectively randomized into three groups of 30. All patients were treated by flush ligation of the saphenofemoral junction. The saphenous vein was inactivated by invagination stripping or conventional stripping or ‘reverse foam obliteration’. The latter technique consisted of canulation of the great saphenous vein (GSV) from approximately 10 cm below the knee up to the groin and injection of 6 ml of foam whilst withdrawing the catheter. Foam was produced with a mixture of 3 mL of 1% STS and 3 mL of air. Surgery was done under general anesthesia combined with additional tumescent infiltration along the GSV. A suction drain was placed in the groin wound along the proximal GSV track and the drained volumes were registered after one day. Legs were dressed postoperatively with elastic adhesive bandages, which were replaced after one day by continuously worn Class II stockings. Patients completed questionnaires about analgesic consumption, bruising, and discomfort. At a 15-day clinic visit the extent of bruising was measured by medical staff and the legs treated by foam sclerosis were scanned by duplex ultrasonography. Blood loss was 15 mL for the foam group and 25 mL for the stripping groups. Patients of the stripping groups showed objectively and subjectively more bruising and used more analgesia than those treated by foam. Technical failures included 3 patients where the stripper and 3 patients where the catheter could not be introduced to the desired point. In 3 patients invagination stripping was incomplete due to rupture of the vein. One of the remaining 27 patients treated by foam showed a patent segment after 15 days. COMMENTS The combination of flush ligation and intraoperativsclerotherapy of the saphenous vein goes back to Moscovicz in 1927. The method was abandoned very soon following several lethal pulmonary embolisms, which were probably partially due to the large volumes (30 – 60 mL) of injected sclerosant.However, the method is not as safe as it seems at first glance. The occlusion of the junction does not prevent the sclerosing agent from entering the deep veins through other channels, especially in immobile patients. This risk is certainly very low when using a volume of just 6 mL. It is claimed that surgery of the junction induces neovascularization and recurrence, which can be avoided by using endovascular techniques. This theory suggests that the combination of surgery and foam sclerotherapy would yield worse results than foam alone, but this has to be proven by a comparative long-term study. This investigation shows that stripping results in a higher blood loss, bruising, and pain than flush ligation and sclerotherapy. In myopinion, this difference is not overwhelming (eg, additional drained blood: + 10 mL). The foam treatment including intra-operative duplex, tumescent anesthesia, and the necessity of a post-operative duplex check seems far more complicated than surgery alone. Having developed the technique of pin stripping, I cannotdissimulate a special interest when conventional and pin stripping are compared. This study shows almost no difference, which is not unexpected. The main parameters—bruising and blood loss—are hardly influenced by the shape of the stripping device, but by the number and size of GSV tributaries. The real advantages of the technically more demanding pin stripping lie in the prevention of lesions of sensory nerves below the knee and in the selective removal of incompetent vein segments without large incisions.

Ну, в общем, очень верный комментарий - статья не дает никакой обоснованной информации. Больше вопросов, чем ответов... Публикация ради публикации

DUPLEX ULTRASOUND CHANGES IN THE GREAT SAPHENOUS VEIN AFTER ENDOSAPHENOUS LASER OCCLUSION WITH 808-NM WAVELENGTH
Corcos L, Dini S, Peruzzi G, et al.
ABSTRACT AND COMMENTARY BY Mitchel P. Goldman, La Jolla, CA, USA ABSTRACT The lead author with decades of experience in vascular surgery and the use of lasers to treat aberrant veins with intravascular ablation has carefully evaluated the histologic effects in 8 patients. Forty four of 182 affected limbs with CEAP C2 to C6 were selected for intravenous laser ablation of the great saphenous vein (GSV). After ligation of the saphenofemoral junction (SFJ), an 808-nm diode laser was inserted into the distal GSV and pulled back and forth through the vein at 12 – 15 W so that an average of 30-40J/cm of energy was given. Vein fragments were histologically evaluated after 5 minutes and 1 and 2 months. Duplex evaluation of 44 limbs was performed at 1 week and 1,2,6 and 12 months. Organized thrombosis with and without recannalization was seen. 18.7% of veins were not occluded. 22.7% of veins had recanalizations of short segments. 4.5% of veins totally recannalized and post-operative phlebitis occurred in 13.6%. COMMENTARY What is most revealing in this study is the honesty of the scientific evaluation of patients by this surgical group. Why 41.4% of treated GSV recanalized in full or in part is unknown and far in excess of any other report with using any intravascular laser or radiofrequency device. This is particularly concerning since the SFJ was ligated in all patients prior to laser treatment. The authors propose that SFJ ligation results in a decrease in venous diameter but then note that post-operative painful phlebitis occurred in veins >10 mm in diameter. If the authors hypothesis is that SFJ ligation should decrease neovascularization and recanalization of the GSV, why did they demonstrate a rate of recanalization 4-6 times higher than all other published reports? Clearly there are other factors at play. I believe that despite excellent surgical technique, the use of an 808-nm intravascular laser produces suboptimal damage to the vascular wall.1-3 The failure to use tumescent anesthesia most-likely resulted in the GSV being filled with blood since tumescence producing a marked narrowing of the vessel diameter.4 This proves theexperience of the surgeon’s ability to prevent thermal cutaneous and perivascular damage but may not apply to other less-experienced surgeons. It would be interesting to know how the patients treated withsubarachnoid anesthesia and pharmacologic prophylaxis withheparin before surgery and at 12 hours did relative to patients treated with local anesthesia alone. Patients treated without local anesthesia are clearing not ambulatory for a few hours after the surgicalprocedure. Were all other patients immediately ambulatory? Were post-operative compression stockings worn continuously for 5 days or only while ambulatory? Did the class I stocking provide sufficient compression? It is this reviewers conclusion that this excellent paper provides evidence that the use of an 808-nm intravascular laser produces thrombosis through coagulation and NOT from a direct thermal effect on the vascular wall. The resulting excessive recannalization is identical to other techniques for treating the incompetent GSV such as sub-optimal sclerotherapy without compression.5 REFERENCES 1. Nootheti PK, Cadag KM, Goldman MP. Review of intravascular approaches to the treatment of varicose veins. Dermatol Surg. 2007;33:1149-1157. 2. Goldman MP, Mauricio M, Rao J. Intravascular 1320nm Laser Closure of the Great Saphenous Vein: A 6-12 Month Follow-up Study. Dermatol Surg. 2004;30:1380-1385. 3. Goldman MP, Detwiler SP. Endovenous 1064-nm and 1320-nm Nd:YAG Laser Treatment of the Porcine GreaterSaphenous Vein. Cosmetic Dermatol. 2003;16:25-28.4.Smith SR, Goldman MP. Tumescent Anesthesia in Ambulatory Phlebectomy. Derm Surg. 1998;24:453-456. 5. Goldman MP, Bergan JJ, Guex JJ. Sclerotherapy treatment of varicoseand telangiectatic leg veins: fourth edition. Mosby/Elsevier,London 2007.
J Vasc Surg. 2008;48:1262-1271.

Голдман, как мне кажется, законно разбил статью в пух и прах. Токо я бы сделал вывод о том, что в представленной методике формирование легко реканализируемого тромба в просвете вены после ЭВЛК может быть связано как с выбранной длиной волны, так и с недостаточной мощностью воздействия.

P.S. Виктор, мы ведь сделали отдельную ветку для тезисов по эндоваскулярным методам лечения ХЗВ.

Интересное голландское РКИ о "пользе" длительного ношения трикотажа после операции...

To wear or not to wear compression stockings after varicose vein stripping: a randomised controlled trial.


Houtermans-Auckel JP, van Rossum E, Teijink JA, Dahlmans AA, Eussen EF, Nicolaï SP, Welten RJ.
Department of Surgery, Atrium Medical Centre Parkstad, Heerlen, PO Box 4446, 6401 CX Heerlen, the Netherlands.
Eur J Vasc Endovasc Surg. 2009 Sep;38(3):387-91. Epub 2009 Jul 15.

OBJECTIVES: To assess the need to wear compression stockings for 4 weeks after inversion stripping of the great saphenous vein (GSV) from the groin to the level of the knee. DESIGN: Randomised controlled trial. PATIENTS: A total of 104 consecutive patients with primary complete incompetence of the GSV treated by inversion stripping of the GSV. METHODS: Postoperatively treated limbs underwent elastic bandaging for 3 days. Volunteers were randomised to wear a compression stocking for additional 4 weeks (intervention group) or no compression stocking (control group). The primary outcome was limb oedema as assessed by photoelectric leg volume measurement. Secondary outcome measures were pain scores, postoperative complications and return to full work. RESULTS: The control leg volume was 3657ml (standard deviation, SD 687) preoperatively and 3640ml (SD 540) 4 weeks postoperatively (non significant, N.S.). The stocking leg volume was 3629ml (SD 540) preoperatively, falling to 3534ml (SD 543) (P<0.01) 4 weeks postoperatively. The difference in leg volume between both the groups was not statistically significant. Patients in the control group resumed work earlier (control 11 days, stocking 15 days, P=0.02, Mann-Whitney test). No difference was observed in the number and type of complication and in pain scores during the 4-week follow-up period. CONCLUSIONS: Wearing an elastic compression stocking has no additional benefit following elastic bandaging for 3 days in postoperative care after stripping of the great saphenous vein as assessed by control of limb oedema, pain, complications and return to work.

PMID: 19608438

Superficial venous aneurysms of the small saphenous vein.
Chen SI, Clouse WD, Bowser AN, Rasmussen TE.
Division of Vascular and Endovascular Surgery, Wilford Hall USAF Medical Center/San Antonio Military Medical Center, San Antonio, TX 78236, USA.
Historically, superficial venous aneurysms of the lower extremities are considered rare. However, owing to the increased use of duplex ultrasound imaging, these entities are being recognized more frequently. The clinical significance of superficial aneurysms is poorly defined; yet, pulmonary emboli arising from superficial aneurysms have been reported. Symptomatic patients typically complain of the sequelae of reflux, such as edema, pain, mass, and varicosities. Current treatment consists of simple open excision. We report two cases of small saphenous vein aneurysm and provide review of its pathophysiology, presentation, diagnostic evaluation, and therapy.
J Vasc Surg. 2009 Sep;50(3):644-7.
PMID: 19595536 [PubMed - indexed for MEDLINE]
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The difficult venous ulcer: case series of 177 ulcers referred for vascular surgical opinion following failure of conservative management.
Neequaye SK, Douglas AD, Hofman D, Wolz M, Sharma R, Cummings R, Hands L.
Nuffield Department of Surgery, Oxford Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, United Kingdom. s_neequaye@ yahoo.com
Venous leg ulcers are common, chronic, debilitating, and expensive. Evidence supports use of compression bandaging, with superficial venous surgery in selected cases, but these interventions frequently fail to achieve healing. We describe a series of 152 consecutive referrals from a nurse-led specialist dermatology clinic to a vascular surgical service; a group posing particularly challenging problems. This observational study, with median follow-up of 18 months, describes outcomes in a number of important clinically identifiable subgroups. Its findings may assist service planning and discussion of the surgical role within multidisciplinary ulcer management.
Angiology. 2009 Aug-Sep;60(4):492-5. Epub 2009 Apr 26.
PMID: 19398420 [PubMed - indexed for MEDLINE]

Treatment of recurrent varicose veins of the great saphenous vein by conventional surgery and endovenous laser ablation.
van Groenendael L, van der Vliet JA, Flinkenflögel L, Roovers EA, van Sterkenburg SM, Reijnen MM.
Department of Surgery, Division of Vascular Surgery, Alysis Zorggroep, Location Rijnstate, Arnhem, The Netherlands.
OBJECTIVE: Varicose vein recurrence of the great saphenous vein (GSV) is a common, costly, and complex problem. The aim of the study was to assess feasibility of endovenous laser ablation (EVLA) in recurrent varicose veins of the GSV and to compare this technique with conventional surgical reintervention. METHODS: Case files of all patients treated for GSV varicosities were evaluated and recurrences selected. Demographics, duplex scan findings, CEAP classification, perioperative data, and follow-up examinations were all registered. A questionnaire focusing on patient satisfaction was administered. RESULTS: Sixty-seven limbs were treated with EVLA and 149 were surgically treated. General and regional anesthesia were used more in the surgery group (P < .001). Most complications were minor and self-limiting. Wound infections (8% vs 0%; P < .05) and parasthesia (27% vs 13%; P < .05) were more abundant in the surgery group, whereas the EVLA-treated patients reported more delayed tightness (17% vs 31%; P < .05). Surgically-treated patients suffered less postoperative pain (P < .05) but reported a higher use of analgesics (P < .05). Hospital stay in the surgery group was longer (P < .05) and they reported a longer delay before resuming work (7 vs 2 days; P < .0001). Patient satisfaction was equally high in both groups. At 25 weeks of follow-up, re-recurrences occurred in 29% of the surgically-treated patients and in 19% of the EVLA-treated patients (P = .511). CONCLUSION: EVLA is feasible in patients with recurrent varicose veins of the GSV. Complication rates are lower and socioeconomic outcome is better compared to surgical reintervention.
J Vasc Surg. 2009 Nov;50(5):1106-13.
PMID: 19878788 [PubMed - indexed for MEDLINE]

Iatrogenic vascular injuries in varicose vein surgery: a systematic review.
Rudström H, Björck M, Bergqvist D.
Department of Surgery, Uppsala University Hospital, Uppsala, Sweden. hakan.rudstrom@akademiska.se
World J Surg. 2007 Jan;31(1):228-33.

Abstract
BACKGROUND: Iatrogenic vascular injuries during varicose vein surgery are serious. The aim of this study was to investigate their nature and consequences.
METHOD: A systematic literature research was performed.
RESULTS: The incidence is low (0.0017%-0.3%). We found 81 patients suffering from 87 vascular injuries-44 arterial and 43 deep vein injuries.
CONCLUSION: Vascular injuries during varicose surgery are rare but serious. They are avoidable, and when they occur, early recognition is crucial. Bleeding is a common symptom, especially in deep venous injury. In our study, we reviewed the literature on 81 patients with 87 vascular injuries. Laceration or division of the femoral vein dominated venous injuries (28/43). Partial stripping of the femoral vein was not common (4/43) and occurred when the strip probe passed into the deep veins through a perforator. Arterial stripping predominated in arterial injuries (17/44) and happened when stripping distally during a primary operation, as reported by experienced surgeons, in nonobese women. Major arterial complications resulted in ischemia, often with diagnostic delay and poor reconstruction results. Only 30% (13/44) of arterial injuries were detected peroperatively. The amputation rate was 34% (15/44), but rose to 100% if combined with intra-arterial sclerotherapy (5/5 cases). When stripping an artery below the femoral artery, the amputation rate was high (42%; 5/12) and morbidity severe (85%; 11/12). All fatal injuries (5 cases) were venous. Anatomic knowledge and awareness of the possibility of vascular complications should be preventive. Early detection by routine checking of arterial circulation is important.
PMID: 17180475 [PubMed - indexed for MEDLINE]

Не думай о секундах свысока, у каждого может случится.
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Standard varicose vein surgery.
Perkins JM.
The John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK. Jeremy.perkins@orh.nhs.uk
Abstract
This article examines the practice of standard varicose vein surgery including sapheno-femoral and sapheno-popliteal ligation, perforator surgery and surgery for recurrent varicose veins. The technique of exposure of the sapheno-femoral junction and the sapheno-popliteal junction is outlined and advice given on avoidance of complications for both. The evidence regarding methods of closure over the ligated sapheno-femoral junction is examined as is the requirement for stripping and the use of different types of stripper. The requirement to strip the small saphenous vein and the extent of dissection necessary in the popliteal fossa is also examined. Complications of standard varicose vein surgery are outlined. The frequency of wound infection, nerve injury, vascular injury and venous thromboembolism are listed and strategies to avoid these complications are examined.
Phlebology. 2009;24 Suppl 1:34-41.

PMID: 19307439 [PubMed - indexed for MEDLINE]
Интересно, отчего в этой современной статье ни слова об эндоваскулярных методах лечения , все-таки Оксфорд.