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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3786_Библиотеки_им_академика_М_И_Перельмана
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Phlebology, Vein
Surgery and
Ultrasonography
Diagnosis and Management
of Venous Disease
Eric Mowatt-Larssen
Sapan S. Desai
Anahita Dua
Cynthia E. K. Shortell
Editors
123

Phlebology, Vein Surgery
and Ultrasonography


Eric Mowatt-Larssen • Sapan S. Desai
Anahita Dua • Cynthia E.K. Shortell
Editors
Phlebology,
Vein Surgery
and Ultrasonography
Diagnosis and Management
of Venous Disease

Editors
https://t.me/med1917
Eric Mowatt-Larssen
Vein Specialists of Monterey
Monterey, CA
USA
Sapan S. Desai
Department of Surgery
Duke University Medical Center
Durham, NC
USA
Department of Cardiothoracic and
Vascular Surgery
University of Texas at Houston
Medical School
Houston, TX
USA
Anahita Dua
MSB 5.030
University of Texas-Houston
Houston, TX
USA
Cynthia E.K. Shortell
Department of Vascular Surgery
Duke University Medical Center
Durham, NC
USA
ISBN 978-3-319-01811-9 ISBN 978-3-319-01812-6 (eBook)
DOI 10.1007/978-3-319-01812-6
Springer Cham Heidelberg New York Dordrecht London
Library of Congress Control Number: 2013956742
© Springer International Publishing Switzerland 2014
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of
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or by similar or dissimilar methodology now known or hereafter developed. Exempted from this
legal reservation are brief excerpts in connection with reviews or scholarly analysis or material
supplied specifi cally for the purpose of being entered and executed on a computer system, for
exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is
permitted only under the provisions of the Copyright Law of the Publisher's location, in its
current version, and permission for use must always be obtained from Springer. Permissions for
use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable
to prosecution under the respective Copyright Law.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specifi c statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
While the advice and information in this book are believed to be true and accurate at the date of
publication, neither the authors nor the editors nor the publisher can accept any legal responsibility
for any errors or omissions that may be made. The publisher makes no warranty, express or
implied, with respect to the material contained herein.
Printed on acid-free paper
Springer is part of Springer Science+Business Media (
www.springer.com)

F o r e w o r d
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The latter half of the twentieth century saw very little advancement or
innovation in the diagnosis and treatment modalities of venous disease.
The standard diagnostic testing for deep venous disease, whether for acute or
chronic thrombosis or for insuffi ciency, consisted primarily of venography,
with treatment options limited to compression, leg elevation, anticoagulation,
and occasionally open surgical intervention. For superfi cial venous disease,
diagnostic testing at that time was limited even more to physical examination,
with treatment being standard surgical high ligation and stripping with
avulsion phlebectomy and perforator ligation.
Venous disease diagnostics were dramatically improved late in the
twentieth century by advances in imaging modalities. The fi rst and most
important among these was duplex ultrasound, followed by computerized
tomography (CT) and magnetic resonance imaging (MRI). More recently,
diagnostic vascular enhancement techniques have made CT and MRI even
more useful. We have also been reaping further diagnostic benefi ts from
advancements in ultrasound testing, using intravascular ultrasound (IVUS),
for example, to diagnose deep venous disease. While not perfect, duplex
ultrasound has become the gold standard for at least the initial diagnostic
maneuver for most venous disorders, even including those related to lymphedema and vascular malformations.
These diagnostic advancements have allowed scientifi c investigators
worldwide to gain a clearer understanding of venous disorders and have
resulted in truly dramatic changes in the therapeutic realm. We are moving
rapidly toward evermore minimally invasive treatments for both deep and
superfi cial venous disorders. An international explosion of interest in venous
disease is bringing a wide spectrum of expertise to bear upon our understanding of venous pathophysiology. This has allowed the fi eld to move from one
mostly dominated by art and anecdotal science to one based on rigorous
investigation and scientifi c principles. Hugo Partsch describes this as a transition from “eminence-based medicine” to “evidence-based medicine.” Such
advancements must be very gratifying to the venous practitioners working in
the fi eld for the past half century. They certainly are stimulating to those
entering the fi eld from other disciplines.
Phlebology, Vein Surgery and Ultrasonography is an excellent description
of current thinking regarding venous disorders, but I think of this text as simply a progress report on the journey to greater understanding of venous disorders. By reading this book, you will, I hope, be stimulated to add to this fund
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of knowledge with scientifi c investigations of your own or in support of others, with the goal of producing high-quality reports to help us care for the vast
number of patients with venous disorders.
Nick Morrison
Foreword

Pref ace
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Phlebology is in the midst of a revolution brought on by technological
advancements. Duplex ultrasound is used before treatments to map refl ux and
see clots and obstructions in diagnosis, during many procedures to ensure
accurate treatments, and used afterward to check technical success and
avoidance of complications. Furthermore, because it allows noninvasive
monitoring of venous pathology, it has acted much like the invention of the
telescope and allowed paradigm-challenging observations about the natural
history of refl ux. It turns out the understandings of Rima and Trendelenburg
from the nineteenth century are incorrect, and refl ux often spreads proximally
up the great saphenous vein over time. We have not fi gured out the implications of these fi ndings.
Meanwhile, endovascular techniques have become dominant, even as
surgical techniques have continued to improve and advance. Laser ablation,
radiofrequency ablation, and chemical ablation (sclerotherapy) compete with
high ligation with or without stripping, ambulatory phlebectomy, powered
phlebectomy, and subfascial endoscopic perforator surgery. Threedimensional venography and intravascular ultrasound allow us to diagnose
and treat proximal venous problems at ilio-caval and pelvic veins few
physicians even considered only 10 years ago.
All this intellectual fervor has led to two new certifi cations. Physicians
who are diplomates of the American Board of Phlebology specialize in
venous disease management. Physicians and ultrasonographers can attain
certifi cation as a registered phlebology sonographer.
I hope the reader will sense some of the excitement of the birth of this new
specialty in this book. The authors come from a wide range of specialties,
consistent with the history of phlebology, which has always smartly embraced
the diverse perspectives of multiple different medical fi elds. The faculty is
also international, an overt acknowledgement that the work of our international colleagues has been instrumental in moving our understanding of
venous disease forward. Finally, ultrasound is integrated into this text,
because it is my belief that good ultrasound is essential in providing excellent
care for our patients.
Although phlebology is young, venous diseases are common, and the
shoulders we stand on are ancient. The high risk of refl ux in our species may
well be primarily the result of bipedalism, which magnifi es the impact of
gravity when venous valves fail. Compression is seen in cave paintings from
our hunter-gatherer origins from over 5000 years ago. All the ancient cultures
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who left written records described vein symptoms and treatments. Recent
rapid developments in our understanding were only possible through the
work of several organizations, such as the International Union of Phlebology,
American College of Phlebology, and American and European Venous
Forums. Important textbooks were written and edited by giants in the fi eld,
such as Craig Feied, Robert Weiss, Helane Fronek, Mitchell Goldman, John
Bergan, JJ Guex, and Peter Gloviczki.
This volume would have been impossible without the amazing technical
skills of Dr. Sapan Desai. He has already impacted the arena of medical education in profound ways and you will see the fruits of his abilities in the pages
which follow. I owe many thanks also to Dr. Cynthia Shortell. Besides her
contributions to the editing for this book, she has taught me a tremendous
amount over our years of collaboration.
To the reader: please read, challenge, enjoy, and savor!
Monterey, CA, USA Eric Mowatt-Larssen
Preface

Contents
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Part I Basic Sciences
1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Brian S. Knipp and David L. Gillespie
2 Pathophysiology of Refl ux. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Sergio Gianesini and Paolo Zamboni
3 Presentation of Chronic Venous Disease . . . . . . . . . . . . . . . . . . 33
Michael A. Vasquez and Cary Munschauer
4 Refl ux Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Daniel F. Geersen and Eric Mowatt-Larssen
Part II Vein Testing
5 Ultrasound Physics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Frank R. Miele
6 Ultrasound for Refl ux . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Joseph A. Zygmunt Jr.
7 Ultrasound for Phlebology Procedures . . . . . . . . . . . . . . . . . . . 95
Diana L. Neuhardt
8 Physiologic Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Julianne Stoughton
9 Conventional and Cross-Sectional Venography . . . . . . . . . . . . 115
Charles Y. Kim and Carlos J. Guevara
Part III Superfi cial Vein Therapy
10 Endovenous Thermal Ablation. . . . . . . . . . . . . . . . . . . . . . . . . . 135
Mark N. Isaacs
11 Chemical Superfi cial Vein Ablation . . . . . . . . . . . . . . . . . . . . . . 147
Nick Morrison
12 Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Marc A. Passman
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