Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3823_Библиотеки_им_академика_М_И_Перельмана
.pdf
one to three days to reduce postprocedure bruising and
tenderness.
Follow‐Up
Patients are encouraged to walk after the procedure.
Follow‐up protocols vary by institution [11]. In general,
patients are encouraged to undergo a repeat venous
ultrasound to ensure successful occlusion of the treated
vein and confirm the absence of deep venous injury, one
to three days postprocedure. The patient is also provided
a repeat clinical evaluation in one to three weeks. Long‐
term therapy comprises encouraging the use of 20–30
compression stockings regularly [12]. The duration of
compression stocking therapy is guided by clinical
judgment.
Endovenous Laser Ablation (EVLA)
Step 1. Access to the refluxing superficial vein is first
obtained at its lowest point of incompetence under
ultrasound guidance (long‐axis views preferred) with a
21G introducer needle and 0.018 in. wire under local
anesthesia (1% lidocaine). Utilizing a modified Seldinger
technique, a 4 Fr micropuncture sheath is advanced into
the vein over the 0.018‐in. wire.
Step 2. Once access is secured, the 0.018‐in. wire is
exchanged for a 0.035‐in. guidewire. Then the 4 Fr
micropuncture sheath is exchanged for the long
endovenous laser sheath, which is slowly advanced into
saphenous vein under ultrasound guidance to the
saphenofemoral junction. Intraluminal position of the
sheath is confirmed by aspirating nonpulsatile venous
blood from the sheath and visualization under
ultrasound.
Step 3. Once the sheath is secured in place, a 600 μm
laser fiber (Angiodynamics VenaCure EVLT system™,
Latham, NY, USA) is advanced through the sheath, to the
saphenofemoral junction. While holding the laser fiber in
place, the sheath is withdrawn 3 cm to expose the distal
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
bare‐tipped laser fiber near the saphenofemoral
junction.
Step 4. The sheath and fiber are then pulled back
together, so that the tip of the laser fiber is positioned at
least 2.5 cm from the saphenofemoral junction. Laser‐
fiber tip positioning is confirmed under ultrasound
guidance and with direct visualization of the red beam of
the laser fiber through the skin (Figure 17.3).
skin with red beam.
Step 5. Once the catheter is in place, local tumescent
anesthetic solution (450 ml 0.9% normal saline, 35 ml
0.1% lidocaine, and 15 ml 0.8% sodium bicarbonate) is
injected under ultrasound guidance in the perivenous
space of the saphenous vein.
Step 6. Laser generator is then activated, delivering 12
W of energy to the 810‐nm diode laser fiber. While
activated, the fiber is slowly withdrawn at an average
rate of seven seconds per centimeter to ensure adequate
treatment of the venous segments during the slow
continuous pull‐back.
Step 7. At the end of the procedure, the catheter and
sheath are removed. Hemostasis is achieved by manual
compression at the site of venous access. Compression
bandages and stockings are applied on the treated leg for
one to three days to reduce postprocedure bruising and
tenderness.
Nonthermal Techniques
Newer nonthermal techniques have emerged in recent
years that do not require tumescent anesthesia (reduces
number of needle pricks) or exposure to a heating
element (reduces potential for pain and nerve injury)
[13]. Collectively, they are less traumatic and are
associated with fewer local complications with increased
patient satisfaction. Cyanoacrylate glue (CAG) ablation
and foam sclerotherapy are two forms of noncatheter
based, nontumescent, and nonthermal modalities. Here,
we will focus on the catheter‐based hybrid model,
MOCA. It utilizes a special rotating catheter that not only
mechanically damages the endothelium inside the vein
but also allows for simultaneously infusion a sclerosant
solution through the catheter to further injure the vein
wall [14]. Free of tumescent and thermal effects, MOCA
has emerged as a valid alternative to RF ablation and
EVLA catheter‐based therapies.
Mechanico‐Chemical Ablation
(MOCA)
Step 1. Access to the refluxing superficial vein is first
obtained at its lowest point of incompetence under
ultrasound guidance (long‐axis view preferred [15]) with
a 21G introducer needle and 0.018 in. wire under local
anesthesia (1% lidocaine). Utilizing a modified Seldinger
technique, a 4 Fr micropuncture sheath is advanced into
the vein over the 0.018‐in. wire.
Step 2. Intraluminal positioning of the 4 Fr sheath is
confirmed by aspirating nonpulsatile venous blood from
the sheath and visualization under ultrasound. Once
confirmed the 0.018‐in. wire is removed and the catheter
(Endovenous ClariVein™, South Jordan, UT, USA) is
advanced into the 4 Fr sheath where it is advanced under
ultrasound guidance 2.5 cm from saphenofemoral
junction. The catheter tip has an angled shape to
facilitate directionality during advancement.
Step 3. Tumescent anesthesia is not required for this
procedure. Rather, a liquid sclerosant is prepared
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
containing of liquid 1.5% sodium tetradecyl sulfate (2.5
ml of 3% STS and 2.5 ml of 0.9% NS). An alternative to
the liquid 1.5% STS, the sclerosant can also be prepared
in a foam consistency.
Step 4. Sclerosant foam is prepared by the Tessari
method, where a 5 cc syringe containing 1 ml of 1.5% STS
and 4 ml of room air is connected to second 5 cc syringe
by way of three‐way stop cock valve. The syringes are
tilted 45° from a flat position and mixed vigorously back
and forth 20 times to produce the smallest foam bubbles
(Figure 17.4a–c).
Step 5. Once liquid or foam sclerosant is prepared, the
catheter is turned on to initiate mechanical damaged to
the endothelium, where it rotates 360° at 3500 rpm
(high setting). The catheter is then slowly withdrawn at a
rate of 2–3 mm/s while simultaneously injecting 0.5 ml
of sclerosant (liquid or foam).
Step 6. Once the desired segment is treated, the catheter
and 4 Fr micropuncture sheath are withdrawn and
hemostasis achieved with manual compression of the
venous access site. Compression bandages and stockings
are applied on the treated leg for one to three days to
reduce postprocedure bruising and tenderness.
Figure 17.4 The ClariVein device consists of a 9 V
battery‐motorized handle (a) with infusion catheter that
has an angled tip (b). Angled tip allows for steering and
directionality (c). Tessari method for sclerosant foam
preparation.
Limitations
Despite advances in minimally invasive techniques for
saphenous vein ablation, we have observed several
aspects of disease location and anatomy that need special
consideration when selecting treatment modalities.
Thermal techniques involving heat elements typically
require 10 cm of subcutaneous tissue above the target
vein to prevent skin burns or nerve damage. This is most
particularly important when performing below the knee
interventions, where nonthermal modalities are often
preferred. If a thermal modality is considered,
decreasing the voltage and ensuring adequate tumescent
anesthesia become critical. Similarly, when encountering
aneurysmal vein segments (>10 cm diameter), we have
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
observed better long‐term occlusion rates with EVLT
versus ClariVein. Firm external compression over the
vein segments while delivering treatment cycles is a key
for successful outcomes.
Summary
Since the introduction of minimal invasive modalities for
the treatment of saphenous vein incompetence, many
new techniques have emerged. While most techniques
report favorable anatomic success rates, more emphasis
is now being placed on the secondary treatment
outcomes, such as postprocedural pain, hematoma,
quality of life, and return to normal activities.
Development of the nontumescent, nonthermal
techniques promises to offer many of these advantages.
Although proficiency in the “gold standard” techniques
of RFA and EVLA is vital, learning these newer
techniques such as MOCA can prove effective in
achieving excellent results with greater patient
satisfaction.
References
1 Davies, A.H. (2019). The seriousness of chronic venous
disease: a review of real‐world evidence. Adv. Ther. 36
(Suppl 1): 5–12. https://doi.org/10.1007/s12325‐019‐
0881‐7. Epub 2019 Feb 13. PMID: 30758738.
2 Rabe, E., Guex, J.J., Puskas, A. et al. (2012).
Epidemiology of chronic venous disorders in
geographically diverse populations: results from the
Vein Consult Program. Int. Angiol. 31 (2): 105–115.
3 Rice, J.B., Desai, U., Cummings, A.K. et al. (2014).
Burden of venous leg ulcers in the United States. J.
Med. Econ. 17 (5): 347–356.
https://doi.org/10.3111/13696998.2014.903258.
4 Labropoulos, N. (2019). How does chronic venous
disease progress from the first symptoms to the
advanced stages? A review. Adv Ther. 36 (Suppl 1):
13–19. https://doi.org/10.1007/s12325‐019‐0885‐3.
Epub 2019 Feb 13.PMID: 30758741.
5 Niedzwiecki, G. (2005). Endovenous thermal ablation
of the saphenous vein. Semin. Intervent. Radiol. 22
(3): 204–208. PMCID: PMC3036276, PMID:
21326694.
6 Bootun, T., Lane, R.A., and Davies, A.H. (2016). A
comparison of thermal and non‐thermal ablation.
Rev. Vasc. Med. 4–5: 1–8.
7 Bootun, R., Lane, T.R., and Davies, A.H. (2016). The
advent of non‐thermal, non‐tumescent techniques for
treatment of varicose veins. Phlebology 31 (1): 5–14.
https://doi.org/10.1177/0268355515593186. Epub
2015 Jun 30. PMID: 26130051.
8 Bootun, R., Lane, T.R., Dharmarajah, B. et al. (2016).
Intra‐procedural pain score in a randomised
controlled trial comparing mechanochemical ablation
to radiofrequency ablation: the Multicentre Venefit™
versus ClariVein® for varicose veins trial. Phlebology
31 (1): 61–65.
https://doi.org/10.1177/0268355514551085. Epub
2014 Sep 5. PMID: 25193822.
9 Lane, T., Bootun, R., Dharmarajah, B. et al. (2017). A
multi‐Centre randomised controlled trial comparing
radiofrequency and mechanical occlusion chemically
assisted ablation of varicose veins ‐ final results of the
Venefit versus Clarivein for varicose veins trial.
Phlebology 32 (2): 89–98.
https://doi.org/10.1177/0268355516651026. Epub
2016 Jul 9. PMID: 27221810.
10 Wallace, T., Leung, C., Nandhra, S. et al. (2017).
Defining the optimum tumescent anaesthesia solution
in endovenous laser ablation. Phlebology 32 (5): 322–
333. https://doi.org/10.1177/0268355516653905.
Epub 2016 Jun 15. PMID: 27306991.
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
11 Carroll, C., Hummel, S., Leaviss, J. et al. (2013).
Clinical effectiveness and cost‐effectiveness of
minimally invasive techniques to manage varicose
veins: a systematic review and economic evaluation.
Health Technol. Assess. 17 (48): i–xvi, 1–141.
https://doi.org/10.3310/hta17480. PMID: 24176098;
PMCID: PMC4780990.
12 Gloviczki, P., Comerota, A.J., Dalsing, M.C. et al.
(2011). The care of patients with varicose veins and
associated chronic venous diseases: clinical practice
guidelines of the Society for Vascular Surgery and the
American Venous Forum. J. Vasc. Surg. 53 (Suppl):
2S–48S.
13 Tekin, A.İ., Tuncer, O.N., Memetoğlu, M.E. et al.
(2016). Nonthermal, nontumescent endovenous
treatment of varicose veins. Ann. Vasc. Surg. 36: 231–
235. https://doi.org/10.1016/j.avsg.2016.03.005.
Epub 2016 Jul 13. PMID: 27421205.
14 Witte, M.E., Zeebregts, C.J., de Borst, G.J. et al.
(2017). Mechanochemical endovenous ablation of
saphenous veins using the ClariVein: a systematic
review. Phlebology 32 (10): 649–657.
https://doi.org/10.1177/0268355517702068. Epub
2017 Apr 12. PMID: 28403687.
15 Stone, M.B., Moon, C., Sutijono, D., and Blaivas, M.
(2010). Needle tip visualization during ultrasound‐
guided vascular access: short‐axis vs long‐axis
approach. Am. J. Emerg. Med. 28 (3): 343–347.
[PMID: 20223394].
Index
a
Abdominal aortic aneurysm (AAA) 30, 50. See also
Endovascular abdominal aortic aneurysm repair (EVAR)
Access site bleeding 176–179. See also Retroperitoneal
hematoma (RPH)
Access site complications 175–191
Acute deep venous thrombosis (DVT) 196–203
Acute limb ischemia (ALI) 151–160
defined 151
endovascular techniques 151
Angiojet® thrombectomy device 159
aspiration thrombectomy 155, 159
diagnostic angiography 151–152
EKOS™ catheter 153, 155, 159–160
embolic protection devices 153, 158
excimer laser thrombectomy 160
lesion crossing technique 152–153
mechanical adjunct therapies 153, 157
Penumbra Indigo® 159
thrombolytic agents 153, 154
tPA contraindications 153, 157
treating underlying lesion 160
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Acute mesenteric ischemia (AMI) 85–91
arterial thrombosis 85
diagnosis
contrast‐enhanced CT 86–87
history and physical exam 86
laboratory studies 86
etiologies 85
NOMI 85, 86
surgical intervention
angiogram 89, 90
aspiration embolectomy 88–89
endovascular therapy 91
follow‐up 91
infusion 91
SMA selection 87–88
thrombolysis 89–91
vascular access and sheath selection 87
AFX™ graft 60
ALI. See Acute limb ischemia (ALI)
Alteplase 153, 154
Alto™ system 52
AMI. See Acute mesenteric ischemia (AMI)
Angiojet® thrombectomy device 159
Angiosomes 140, 141
Соседние файлы в папке Библиотека им академика М.И. Перельмана