Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_3897_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

10.10.2026

Размер:

9 Мб

Скачать

☆

<<< < Предыдущая 1 2 3 4 5 67 / 197 8 9 10 11 12 13 14 15 16 17 18 19 > Следующая >>>

N. Morrison and N.M. Khilnani

generation RF ClosureFast™ are emerging and

seem to show even better results [ 57, 58 ] .

Five-year data published in 2005 from the

VNUS registry suggest that the early generation

Closure™ procedure was effective in occluding

target veins and abolishing re ﬂ ux [ 59 ] , with 87.2%

GSV occlusion at 5 years. A major de ﬁ ciency of

this report is the lack of life-table analysis effec-

tively ignoring all patients lost to follow up, with

higher success rates that could be misinterpreted.

Rasmussen [ 60 ] and Christenson [ 61 ] have

reported comparison studies of laser versus con-

ventional stripping with similar patient reported

outcomes.

Case series from Min [ 62 ] , Sadick [ 63 ] , Myers

[

64 ] , Theivacumar [ 65 ] , and Disselhoff [ 66 ] ,

among many others, report from 76% to 100%

occlusion, with the variability most likely related

to length of follow up and duplex evaluation

(Table

7.2 ). It should be noted that there exist few,

if any long term outcome reports beyond 5 years.

Complications

Complications may be divided into intra-opera-

tive and postoperative adverse events.

Intra-operative adverse events can be subdivided

into technical challenges and adverse patient events

(Table 7.3 ). The technical challenges one may

encounter are: dif ﬁ cult access (venospasm, access

location); and problems threading the catheter/ ﬁ ber

(vein tortuosity, aneurysmal segments, or sclerosis

from previous sclerotherapy). Adverse patient

events may include dysrhythmia or vagal reaction

(often because of anxiety) or saphenous nerve pain

or transient heat (inadequate anesthetic in ﬁ ltration).

Postoperative adverse events (or expected

sequelae) include bruising, paresthesia, infection,

intramural hematoma, skin burn, super ﬁ cial

thrombophlebitis, lymphedema, and deep vein

thrombosis (Table

7.4 ). Bruising is nearly always

minimal, and of less than 2 weeks duration. Unlike

following groin-to-ankle stripping, paresthesia

following endovenous ablation is usually mild,

short-lived, and limited to the distal thigh. It is

Table 7.2 Published observational series of laser for truncal re ﬂ ux

Study and reference # Limbs Vein Anatomical success (%) DUS f/u (mos)

Min et al. (2003) [

67 ] 499 GSV 98 17

Proebstle et al. (2003) [

58 ] 104 GSV 90 12

Sadick and Wasser (2004) [

68 ] 31 GSV 97 24

Goldman et al. (2004) [

69 ] 24 GSV 100 6

Timperman (2005) [

70 ] 100 GSV 91 9

Puggioni et al. (2005) [

71 ] 77 GSV/SSV 94 1

Kabnick (2006) [

72 ] 60 GSV 92 12

Sadick and Wasser (2007) [

63 ] 94 GSV 96 48

Theivacumar et al. (2007) [

65 ] 81 GSV 98 12

Gibson et al. (2007) [

36 ] 210 SSV 100 1.5

Desmyttere et al. (2007) [

73 ] 511 GSV 97 48

Hamel-Desnos et al. (2009) [

74 ] 1,703 GSV/SSV 97 6

Pannier et al. (2009) [

52 ] 143 GSV/SSV 100 6

Myers and Jolley (2009) [

75 ] 509 GSV/SSV 76 48

Van den Bremmer et al. (2009) [

76 ] 403 GSV 94 1.5

Disselhoff et al. (2011) [

66 ] 86 GSV 65–79 60

Table 7.3 Intraoperative adverse events

Technical challenges Adverse patient events

Dif ﬁ cult access Painful insertion

Dysrhythmia

Trouble threading introducer

wire/ catheter

Vagal reaction

Treatment interruption (with

ClosurePLUS)

Transient heat

Unable to reinsert catheter Saphenous nerve pain

GSV tortuosity

Aneurysmal segments

https://t.me/med1917

537 Elimination of Truncal Vein Re ﬂ ux: Surgery, Thermal Ablation, and Chemical Ablation

seen in 2–23% of patients [ 77, 78 ] , and its rate of

occurrence is directly related to the care taken to

identify paresthesia and inversely related to the

experience of the practitioner with ultrasound

guided techniques. Infection and skin burns are

rare, occurring in less than 1% of patients. These

are avoided with good sterile technique, and accu-

rately-placed and adequate ultrasound guided

anesthetic to protect the structures in close prox-

imity to the vein, and to separate the skin from the

underlying vein. Super ﬁ cial thrombophlebitis is

seen in less than 5% of cases [ 59, 61, 71 ] , and

responds to the usual clinical measures of anti-

in ﬂ ammatory medication, compression, and

ambulation. Lymphedema has not been reported,

but we have seen it in our own center, and is

believed to be related to unrecognized impaired

lymphatic drainage usually present prior to any

procedures. Treatment of this complication (or

more likely sequela) may include therapeutic

lymphatic massage, compression devices includ-

ing multilayered low-stretch bandages and lym-

phatic pumps, compression hose, and exercise.

Deep vein thrombosis (DVT) is the most

signi ﬁ cant complication in most reports, and is

generally reported to occur in 3% or less of the

patients (depending on the duplex scanning inter-

val and the quality of the examination) [ 75 ] . The

incidence of DVT following thermal ablation is

very similar to van Rij’s reported incidence fol-

lowing surgical ablation [ 79 ] . Most reported cases

are calf vein thrombosis, and if stability is dem-

onstrated by serial duplex examinations, these

are of limited clinical signi ﬁ cance. More proxi-

mal thromboses do occur, however, and should

be aggressively searched for and treated [ 80 ] .

Therapy is usually as an outpatient, with com-

pression, ambulation, anti-in ﬂ ammatory medi-

cation or anticoagulation (short term with low

molecular-weight heparin, or longer term with

oral agents), and even percutaneous pharmacom-

echanical therapy for more proximal thromboses.

DVT can occur as an extension of thrombus

from the treated truncal vein across the junctional

connection into the deep vein or in the calf or

femoral/popliteal veins [ 80– 82 ] . The reported

rate of junctional thrombosis following GSV

endovenous thermal ablation varies widely. This

variability may relate to the timing of the follow-

up exam and the methods used. This type of DVT

is almost universally asymptomatic and seems to

be different than that of spontaneous unprovoked

GSV thrombosis with extension or when com-

pared with typical femoral vein thrombosis [ 83 ] .

Neovascularization, appearing on ultrasound

examination as grape-like clusters of veins in the

groin (Fig. 7.6 ) and commonly seen in recurrence

following traditional stripping procedures, is rarely

seen following endovenous thermal ablation.

Table 7.4 Postoperative adverse events (or expected sequelae)

Bruising Paresthesia

Skin burn Super ﬁ cial

thrombophlebitis

Lymphedema Deep vein thombosis

Infection

Fig. 7.6 Groin recurrence

(neovascularization – NEO)

near former saphenofemoral

junction

https://t.me/med1917

N. Morrison and N.M. Khilnani

Discussion

Considerable confusion in the literature has

emerged regarding the de ﬁ nition of successful

treatment, the means used to detect treatment fail-

ures, and the reporting of results. Technology

assessment studies testing surrogate outcome

markers dominated the early literature, and exten-

sive advancements in the technology of ultrasound

over the past 10 years have allowed far more criti-

cal evaluation of technological results than were

possible in the past. As a result of these advance-

ments, it is now possible to more readily identify

incompletely ablated veins. Recurrent patency

can occur anywhere in the thermally-ablated por-

tion of the vein, either along its length or segmen-

tally. Segmental recurrent patency is usually seen

at the site of an incompetent perforator or a

re ﬂ uxing tributary. Many patients with incomplete

ablation by ultrasound will experience temporary

resolution of symptoms following an ablation

procedure, only to have those symptoms return

when re ﬂ ux becomes clinically signi ﬁ cant.

Identi ﬁ cation of recurrent patency, incomplete

ablation, or treatment failures is dependent on the

sensitivity of the ultrasound equipment used for

postoperative examination, the expertise of the

sonographer, and the vigor with which the exami-

nation is conducted. All of these factors are of

paramount importance in critical reporting of

results.

Duplex examination for successful ablation of

a vein should include gray scale, compression,

and color ﬂ ow Doppler to rule out minimally pat-

ent segments since patients complaining of local-

ized pain in the area of a previously ablated vein

deserve very careful examination for an incom-

pletely ablated segment.

It has been reported that most incompletely

ablated or recanalized veins will be seen in the

ﬁ rst few months following treatment, since fail-

ure rates do not steadily increase over time [

59 ] .

However, we have identi ﬁ ed patients more than

6 years following apparently successful abla-

tion, with recurrent symptoms and partially pat-

ent segments. Thus, it is necessary to perform

thorough follow up of these patients for 1 year,

and then either yearly or certainly when recurrent

symptoms occur. Theivacumar and colleagues

have followed patients with recanalization and

found that these veins do not eventually close,

but rather remain partially patent [ 84 ] . They

point out that patients with partial recanalization

remain asymptomatic, but it has been our experi-

ence that these veins will often lead to recurrent

varices or symptoms.

More prospective randomized controlled trials

comparing several ablation methods are being

reported, with general agreement that long-term

clinical outcome studies must continue to test the

success of thermal ablation procedures, docu-

menting patient outcomes such as relief of symp-

toms, ulcer healing and time to recurrence,

prevention of progression of chronic venous

insuf ﬁ ciency, improvement in quality of life, and

cosmetic appearance [ 34, 40, 48, 53, 60, 61, 66,

85– 89 ] .

Patients with a high body mass index have

been shown to have a higher rate of failure with

laser and RFA [ 59, 70 ] .

Comparison studies of RF vs laser thermal

ablation in general have demonstrated no major

differences in technical success [ 8, 60 ] .

However, the incidence of bruising (ecchymo-

sis) and postoperative pain has generally been

shown to be lower with RF or higher wave-

length lasers than with lower wavelength laser

ablation [ 72, 88, 90 ] .

Several randomized controlled trials have been

published comparing laser ablation with conven-

tional vein stripping, most of which include quality

of life (QoL) measurements. In general, laser abla-

tion is found to be equal to or better than stripping

with respect to QoL outcomes [ 33, 60, 61, 86, 89 ] .

Anecdotal reports of laser ﬁ ber fracture have

been made to the device manufacturers. It appears

that most of these occur with ﬁ bers that are re-used,

and risk of this complication can be minimized by

gently ﬁ ber handling and careful inspection with an

activated aiming beam prior to insertion.

Rare serious complications have been reported

including arteriovenous ﬁ stula, (the mechanism of

which is not identi ﬁ ed) [ 91, 92 ] , stroke [ 93 ] and

death (Morrison N, personal communication 2008).

Adjunctive treatment in order to remove all

sources of insuf ﬁ ciency from the venous

https://t.me/med1917

557 Elimination of Truncal Vein Re ﬂ ux: Surgery, Thermal Ablation, and Chemical Ablation

circulation is considered by most to be mandatory.

Adjunctive treatment may include endovenous

ablation (repeat thermal or chemical); ambulatory

phlebectomy; and visual sclerotherapy. These

techniques will help to achieve the greatest reso-

lution of the patient’s varicosities and symptoms.

The total cost of performing endovenous ther-

mal ablation in the of ﬁ ce setting under local

anesthesia, exclusive of the provider’s time, is

$400-1,100US depending on the particular equip-

ment and system used.

Conclusions

Endovenous thermal ablation is generally safe.

Technical challenges, intraoperative and post-

operative adverse events and sequelae are

infrequent and generally are seen less fre-

quently than with more traditional surgical

procedures.

Differences in methods of follow-up examina-

tion and in de ﬁ nitions of successful treatment

may help explain differences in results between

published reports and in those seen in the pro-

viders own clinical setting. Only long-term

follow-up will show where these minimally

invasive methods belong in the therapeutic

armamentarium of the treatment of chronic

venous insuf ﬁ ciency of the lower extrem-

ity. While some surgeons have expressed the

view that none of these techniques have yet

been shown to better conventional surgery in

the mid to long term [ 60, 61, 85, 94, 95 ] , the

patient’s perception has uniformly been that

minimal invasion is better.

Results

Pearls and Pitfalls

Faster recovery following thermal ablation than

traditional surgery

RF and laser equally effective

Ultrasound guided techniques most important

impediment to technical success

Primary perforator vein thermal ablation

inappropriate

DVT uncommon but can occur

Keys to Success

Adjunctive treatment of all re ﬂ ux sources (phlebec-

tomy, sclerotherapy) following thermal ablation

Long term duplex follow up

Endovenous Chemical Ablation

(Foam Sclerotherapy)

Most of the pertinent information regarding foam

sclerotherapy is covered in the chapter on Foam

Sclerotherapy. Numerous comparative trials have

been conducted recently showing ef ﬁ cacy and

safety pro ﬁ les better with foam than with liquid

sclerotherapy [ 96– 99 ] . and similar to those for

surgical and thermal ablation, especially if

patients are followed closely and repeated injec-

tion sessions are performed in the event of incom-

plete ablation of the target vein or incomplete

treatment of the patient’s symptoms [ 5, 85 ] . The

overwhelming body of published clinical evi-

dence supports foam sclerotherapy as a reason-

ably safe method of super ﬁ cial venous ablation.

References

1. Bergan JJ. Management of external hemorrhage from

varicose veins. Vasc Surg. 1997;31:413–8.

2. Hamahata A, Yamaki T. Foam sclerotherapy for

spouting haemorrhage in patients with varicose veins.

Eur J Vasc Endovasc Surg. 2011;41(6):856–8.

3. Marston W. Super ﬁ cial surgery and perforator inter-

ruption in the treatment of venous leg ulcers. In:

Bergan JJ, editor. Foam sclerotherapy. London: Royal

Society of Medicine Press; 2008.

4. Knipp B, Wake ﬁ eld T, et al. Endovenous laser abla-

tion: venous outcomes and thrombotic complications

are independent of the presence of deep venous

insuf ﬁ ciency. J Vasc Surg. 2008;48:1538–45.

5. Marston W, et al. The importance of deep venous

re ﬂ ux velocity as a determinant of outcome in patients

with combined super ﬁ cial and deep venous re ﬂ ux

treated with endovenous saphenous ablation. J Vasc

Surg. 2008;48(2):400–5; discussion 405-6.

6. Kurz X, Kahn SR, Abenhein L. Chronic venous disorders

of the leg: epidemiology, outcomes, diagnosis and man-

agement. Summary of an evidence-based report of the

VEINES task force. (Venous Insuf ﬁ ciency Epidemiologic

and Economic Studies). Int Angiol. 1999;18:83–102.

https://t.me/med1917

N. Morrison and N.M. Khilnani

7. Ahmad I, Ahmad W, Dingui M. Prevention or reversal of

deep venous insuf ﬁ ciency by aggressive treatment of

super ﬁ cial venous disease. Am J Surg. 2006;191(1):33–8.

8. Puggioni A, et al. The safety of radiofrequency ablation

of the great saphenous vein in patients with previous

venous thrombosis. J Vasc Surg. 2009;49:1248–55.

9. Tong Y, Royle J. Recurrent varicose veins following

high ligation of the long saphenous vein: a duplex

ultrasound study. Cardiovasc Surg. 1999;3:485–7.

10. Rutgers PH, Kitslaar PJEHM. Randomized trial of

stripping versus high ligation combined with sclero-

therapy in the treatment of the incompetent greater

saphenous vein. Am J Surg. 1994;168:311–5.

11. Jones L, Braithwaite BD, Selwyn D, Cooke S,

Earnshaw JJ. Neovascularization is the principal cause

of varicose vein recurrence: results of a randomized

trial of stripping the long saphenous vein. Eur J Vasc

Endovasc Surg. 1996;12:442–5.

12. Conrad P, Gassner P. Invagination stripping of the

long and short saphenous vein using the PIN stripper.

Aust N Z J Surg. 1996;66:394–6.

13. Lees T, Beard J, Ridler B, Szymanska T. A survey of

the current management of varicose veins by mem-

bers of the Vascular Surgical Society. Ann R Coll

Surg Engl. 1999;81:407–17.

14. Oesch A. “Pin-stripping”: a novel method of atrau-

matic stripping. Phlebology. 1993;8:171–3.

15. Neser RA, Caffaro RA. Invagination stripping with

ultrasound-guided perivenous tumescence: an origi-

nal method of great saphenous vein stripping.

Dermatol Surg. 2011;37(3):349–52.

16. Cavezzi A, Carigi V, Collura M. Colour ﬂ ow duplex

scanning as a preoperative guide for mapping and for

local anaesthesia in varicose vein surgery. Phlebology.

2000;15(1):24–9.

17. Spitz GA, Braxton JM, Bergan JJ. Outpatient varicose

vein surgery with transilluminated powered phlebec-

tomy. Vasc Surg. 2000;34:547–55.

18. Gloviczki P, Bergan JJ, Rhodes JM, Canton LG,

Harmsen S, Listup DM, the North American Study

Group. Mid-term results of endoscopic perforator

vein interruption for chronic venous insuf ﬁ ciency:

lessons learned from the North American Subfascial

Endoscopic Perforator Surgery (NA-SEPS) Registry.

J Vasc Surg. 1999;29:489–502.

19. Bergan J. Advances in venous surgery: SEPS and phle-

bectomy for chronic venous insuf ﬁ ciency. Dermatol

Surg. 2002;28:26–8.

20. Scavee V. Transilluminated powered phlebectomy:

not enough advantages? Review of the literature. Eur

J Vasc Endovasc Surg. 2006;31:316–9.

21. Winterborn R, Earnshaw J. Crossectomy and great saphen-

ous vein stripping. J Cardiovasc Surg. 2006;47:19–33.

22. Egan B, Donnelly M, Bresnihan M, Tierney S, Feeley

M. Neovascularization: an “innocent bystander” in

varicose veins. J Vasc Surg. 2006;44:1279–84.

23. van Riij A, Jiang P, Solomon C, Ross A, Hill G.

Recurrence after varicose vein surgery: a prospective

long-term clinical study with duplex ultrasound scanning

and air plethysmography. J Vasc Surg. 2003;38:935–43.

24. Franceschi C. Theory and practice of the conservative

haemodynamic cure of incompetent and varicose

veins in ambulatory patients. France: Editions de

l’Armancon; 1993.

25. Zamboni P, Cisno C, Marchetti F, Quaglio D, Mazza P,

Liboni A. Re ﬂ ux elimination without any ablation or discon-

nection of the saphenous vein. A haemodynamic model for

venous surgery. Eur J Vasc Endovasc Surg. 2001;21:361–9.

26. Cappelli M, Molino Lova R, Ermini S, Zamboni P.

Hemodynamics of the sapheno-femoral junction.

Patterns of re ﬂ ux and their clinical implications. Int

Angiol. 2004;23:25–8.

27. Escribano JM, Juan J, Bo ﬁ ll R, Maeso J, Rodr’iguez-

Mori A, Matas M. Durability of re ﬂ ux-elimination by

minimally invasive CHIVA procedure on patients

with varicose veins. A 3-year prospective case study.

Eur J Vasc Endovasc Surg. 2003;25:159–63.

28. Carandino S, Mari C, De Palma M, Marcellino MG, Cisno C,

Legnaro A, Zamboni P, et al. Varicose vein stripping vs

haemodynamic correction (CHIVA): a long term random-

ized trial. Eur J Vasc Endovasc Surg. 2008;35:230–7.

29. Pares JO, et al. Varicose vein surgery: stripping versus

the CHIVA method: a randomized controlled trial.

Ann Surg. 2010;251(4):624–31.

30. Pittaluga P, Chastanet S, Guex JJ. Great saphenous

vein stripping with preservation of sapheno-femoral

con ﬂ uence: hemodynamic and clinical results. J Vasc

Surg. 2008;47:1300–4.

31. Pittuluga P, Chastanet S, et al. Midterm results of the

surgical treatment of varices by phlebectomy with

conservation of a re ﬂ uxing saphenous vein. J Vasc

Surg. 2009;50:107–18.

32. Pittaluga P, Chastanet S, et al. The effect of isolated

phlebectomy on re ﬂ ux and diameter of the great

saphenous vein: a prospective study. Eur J Vasc

Endovasc Surg. 2010;40(1):112–8.

33. Mekako AI, Hat ﬁ eld J, Bryce J, et al. A nonrandom-

ized controlled trial of endovenous laser therapy and

surgery in the treatment of varicose veins. Ann Vasc

Surg. 2006;20:451–7.

34. Lurie F, Creton D, Eklof B, Kabnick LS, Kistner RL,

Pichot O, Sessa C, Schuller-Petrovic S. Prospective

randomised study of endovenous radiofrequency

obliteration (closure) versus ligation and vein strip-

ping (EVOLVeS): two-year follow-up. Eur J Vasc

Endovasc Surg. 2005;29:67–73.

35. Van den Bos R, et al. Treatment of incompetent perfo-

rating veins using the radiofrequency ablation stylet: a

pilot study. Phlebology. 2009;24:208–12.

36. Gibson KD, Ferris BL, Polissar N, Neradilek B,

Pepper D. Endovenous laser treatment of the short

saphenous vein: ef ﬁ cacy and complications. J Vasc

Surg. 2007;45(4):795–801; discussion 801–3.

37. Tellings S, Ceulen R, Sommer A. Surgery and

endovenous techniques for the treatment of small

saphenousvaricose veins: a review of the literature.

Phlebology. 2011;26(5):179–84.

38. Proebstle T, Herdemann S. Early results and feasibility

of incompetent perforator vein ablation by endovenous

laser treatment. Dermatol Surg. 2007;33:162–8.

https://t.me/med1917

577 Elimination of Truncal Vein Re ﬂ ux: Surgery, Thermal Ablation, and Chemical Ablation

39. Hingorani A, Ascher E, et al. Predictive factors of

success following radio-frequency stylet (RFS) abla-

tion of incompetent perforating veins (IPV). J Vasc

Surg. 2009;50:844–8.

40. Theivacumar N, Darwood R, Gough M. Endovenous

laser ablation (EVLA) of the anterior accessory great

saphenous vein (AAGSV): abolition of sapheno-fem-

oral re ﬂ ux with preservation of the great saphenous

vein. Eur J Vasc Endovasc Surg. 2009;37(4):477–81.

41. Stuart W, et al. Saphenous surgery does not correct

perforator incompetence in the presence of deep

venous re ﬂ ux. J Vasc Surg. 1998;28:834–8.

42. O’Donnell T. The present state of surgery of the

super ﬁ cial venous system in the management of

venous ulcer and the evidence for the role of perfora-

tor interruption. J Vasc Surg. 2008;48:1044–52.

43. van den Bos R, Milleret R, et al. Proof-of-principle

study of steam ablation as novel thermal therapy for

saphenous varicose veins. J Vasc Surg. 2011;53:181–6.

44. Theivacumar NS, et al. The clinical signi ﬁ cance of

below-knee great saphenous vein re ﬂ ux following

endovenous laser ablation of above-knee great saphen-

ous vein. Phlebology. 2009;24(1):17–20.

45. Lumdsen A, Peden E. Clinical use of the new VNUS

ClosureFAST radiofrequency catheter. Endovasc

Today (Suppl) 2007:7–10.

46. Doganci S, Demirkilic U. Comparison of 980 nm

laser and bare-tip ﬁ bre with 1470 nm laser and radial

ﬁ bre in the treatment of great saphenous vein varicosi-

ties: a prospective randomised clinical trial. Eur J

Vasc Endovasc Surg. 2010;40:254–9.

47. Schwarz T, et al. Endovenous laser ablation of vari-

cose veins with the 1470-nm diode laser. J Vasc Surg.

2010;51:1474–8.

48. Pannier F, Rabe E, Maurins U, et al. Endovenous laser

ablation of great saphenous veins using a 1470 nm

diode laser and the radial ﬁ bre – follow-up after six

months. Phlebology. 2011;26:35–9.

49. Vuylstede M, et al. Intraluminal ﬁ bre-tip centring can

improve endovenous laser ablation: a histological

study. Eur J Vasc Endovasc Surg. 2010;40(1):110–6.

50. Chong PFS, Kumar R, Kushwaha R, Sweeney A,

Chaloner EJ. Technical tip: cold saline in ﬁ ltration

instead of local anaesthetic in endovenous laser treat-

ment. Phlebology. 2006;21:88–9.

51. Proebstle TM, Gul D, Lehr HA, et al. Infrequent early

recanalization of greater saphenous vein after endovenous

laser treatment. J Vasc Surg. 2003;38:511–6.

52. Pannier F, Rabe E, Maurins U. First results with a new

1470-nm diode laser for endovenous ablation of incom-

petent saphenous veins. Phlebology. 2009;24(1):26–30.

53. Khilnai N, et al. Multi-society consensus quality improve-

ment guidelines for the treatment of lower extremity

super ﬁ cial venous insuf ﬁ ciency with endovenous thermal

ablation from the Society of Interventional Radiology,

Cardiovascular Interventional Radiological Society of

Europe, American College of Phlebology, and Canadian

Interventional Radiology Association. J Vasc Interv Radiol.

2010;21:14–31.

54. Kundu S, et al. Recommended reporting standards for

endovenous ablation for the treatment of venous

insuf ﬁ ciency: Joint Statement of the American Venus

Forum and the Society of Interventional Radiology. J

Vasc Surg. 2007;46:582–9.

55. Stotter L, Schaff I, Bockelbrink A. Comparative out-

comes of radiofrequency endoluminal ablation, invagi-

nation stripping and cryostripping in the treatment of

great saphenous vein insuf ﬁ ciency. Phlebology.

2006;21(2):60–4.

56. Rautio T, Ohinmaa A, Perala J, Ohtonen P, Heikkinen T,

Wiik H, et al. Endovenous obliteration versus conven-

tional stripping operation in the treatment of primary

varicose veins: a randomized controlled trial with

comparison of the costs. J Vasc Surg. 2002;35:

958–65.

57. Subramonia S, Lees T. Radiofrequency ablation vs

conventional surgery for varicose veins: a comparison

of treatment costs in a randomised trial. Eur J Vasc

Endovasc Surg. 2010;39(1):104–11.

58. Proebstle T, et al. Three-year European follow-up of

endovenous radiofrequency-powered segmental ther-

mal ablation of the great saphenous vein with or without

treatment of calf varicosities. J Vasc Surg. 2011;54:

146–52.

59. Merchant RF, Pichot O. Long-term outcomes of

endovenous radiofrequency obliteration of saphenous

re ﬂ ux as a treatment for super ﬁ cial venous insuf ﬁ ciency.

J Vasc Surg. 2005;42:502–9.

60. Rasmussen LH, Eklof B, et al. Randomised clinical

trial comparing endovenous laser ablation with strip-

ping of the great saphenous vein: clinical outcome

and recurrence after 2 years. Eur J Vasc Endovasc

Surg. 2010;39:630–5.

61. Christenson J, et al. Prospective randomized trial com-

paring endovenous laser ablation and surgery for treat-

ment of primary great saphenous varicose veins with a

2-year follow-up. J Vasc Surg. 2010;52:1234–41.

62. Min RJ, Zimmet SE, Isaacs MN, Forrestal MD.

Endovenous treatment of the incompetent greater

saphenous vein. J Vasc Interv Radiol. 2001;12:

1167–71.

63. Sadick NS, Wasser S. Combined endovascular laser

plus ambulatory phlebectomy for the treatment of

super ﬁ cial venous incompetence: a 4-year perspec-

tive. J Cosmet Laser Ther. 2007;9(1):9–13.

64. Myers K, Fris R, Jolley D. Treatment of varicose veins by

endovenous laser therapy: assessment of results by ultra-

sound surveillance. Med J Australas. 2006;185:

199–202.

65. Theivacumar NS, Beale RJ, Mavor AI, Gough MJ.

Initial experience in endovenous laser ablation (EVLA)

of varicose veins due to small saphenous vein re ﬂ ux.

Eur J Vasc Endovasc Surg. 2007;33(5):614–8.

66. Disselhoff B, et al. Five-year results of a randomised

clinical trial of endovenous laser ablation of the great

saphenous vein with and without ligation of the

saphenofemoral junction. Eur J Vasc Endovasc Surg.

2011;41:685–90.

https://t.me/med1917

N. Morrison and N.M. Khilnani

67. Min RJ, Khilnani N, Zimmet SE. Endovenous laser

treatment of saphenous vein re ﬂ ux: long-term results.

J Vasc Interv Radiol. 2003;14:991–6.

68. Sadick NS, Wasser S. Combined endovascular laser

with ambulatory phlebectomy for treatment of

super ﬁ cial venous incompetence-a two-year perspec-

tive. J Cosmet Laser Ther. 2004;6:44–9.

69. Goldman MP, Mauricio M, Rao J. Intravascular 1320-

nm laser closure of the great saphenous vein: a 6 to

12-month follow-up study. Dermatol Surg. 2004;30:

1380–5.

70. Timperman PE. Prospective evaluation of higher

energy great saphenous vein endovenous laser treat-

ment. J Vasc Interv Radiol. 2005;16:791–4.

71. Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki

P. Endovenous laser therapy and radiofrequency abla-

tion of the great saphenous vein: analysis of early

ef ﬁ cacy and complications. J Vasc Surg. 2005;42:

488–93.

72. Kabnick LS. Outcome of different endovenous laser

wavelengths for great saphenous vein ablation. J Vasc

Surg. 2006;43(1):88–93.

73. Desmyttere J, Grard C, Wassmer B, Mordon S.

Endovenous 980-nm laser treatment of saphenous veins in

a series of 500 patients. J Vasc Surg. 2007;46:1242–7.

74. Hamel-Desnos C, Ge’rard J-L, Desnos P. Endovenous

laser procedure in a clinic room: feasibility and side

effects study of 1700 cases. Phlebology.

2009;24:125–30.

75. Myers K, Jolley D. Outcome of endovenous laser

therapy for saphenous re ﬂ ux and varicose veins:

medium-term results assessed by ultrasound surveil-

lance. Eur J Vasc Endovasc Surg. 2009;37:239–45.

76. den Bremer V, et al. Implementation of endovenous

laser ablation for varicose veins in a large community

hospital: the ﬁ rst 400 procedures. Eur J Vasc Endovasc

Surg. 2009;37:239–45.

77. Rautio T, Perala J, Wiik H, Juvonen T, Haukupuro K.

Endovenous obliteration with radiofrequency resistive

heating for greater saphenous vein insuf ﬁ ciency: a fea-

sibility study. J Vasc Interv Radiol. 2002;13:569–75.

78. Weiss R, Weiss M. Controlled radiofrequency

endovenous occlusion using a unique radiofrequency

catheter under duplex guidance to eliminate saphen-

ous varicose vein re ﬂ ux: a 2-year follow-up. Dermatol

Surg. 2002;28:38–42.

79. van Rij A, et al. Incidence of deep vein thrombosis after

varicose vein surgery. Br J Surg. 2004;91:1582–5.

80. Mozes G, Kalra M, Carmo M, Swenson L,

Gloviczki P. Extension of saphenous thrombus into

the femoral vein: a potential complication of new

endovenous ablation techniques. J Vasc Surg.

2005;41:130–5.

81. Merchant RF, Kistner RL, Kabnick LS. Regarding, “is

there an increased risk for DVT after the closure pro-

cedure?”. J Vasc Surg. 2003;38:628.

82. Wright D, et al. Post ablation super ﬁ cial thrombus

extension (PASTE) into the common femoral vein as

a consequence of endovenous ablation of the great

saphenous vein. Acta Phlebol. 2010;11:59–64.

83. Neuhardt D. Incidence of deep vein thrombosis in a

duplicated femoral vein following Foam USG of the

GSV. First days of phlebology, Parma; 2006.

84. Theivacumar N, et al. Fate of the great saphenous vein

following endovenous laser ablation: does re-canali-

sation mean recurrence? Eur J Vasc Endovasc Surg.

2008;36:211–5.

85. Rasmussen LH, Eklof B, et al. Randomized clinical trial

comparing endovenous laser ablation, radiofrequency

ablation, foam sclerotherapy and surgical stripping for

great saphenous varicose veins. Br J Surg. 2011;98:

1079–87.

86. Goode SD, Braithwaite BD, et al. Laser and radiofre-

quency ablation study (LARA study): a randomised

study comparing radiofrequency ablation and endovenous

laser ablation (810 nm). Eur J Vasc Endovasc Surg.

2010;40(2):246–53.

87. Shepard AC, Gohel MS, Brown LC, Metcalfe MJ,

Hamish M, Davies AH. Randomized clinical trial of

VNUS ClosureFAST radiofrequency ablation versus

laser for varicose veins. Br J Surg. 2010;97:810–8.

88. Gale S, et al. A randomized, controlled trial of

endovenous thermal ablation using the 810-nm wave-

length laser and the ClosurePLUS radiofrequency

ablation methods for super ﬁ cial venous insuf ﬁ ciency

of the great saphenous vein. J Vasc Surg.

2010;52:645–50.

89. Disselhoff BC, et al. Randomized clinical trial com-

paring endovenous laser ablation of the great saphen-

ous vein with and without ligation of the

sapheno-femoral junction: 2 year results. Eur J Vasc

Endovasc Surg. 2008;36:713–8.

90. Proebstle TM, Moehler T, Gul D, Herdemann S.

Endovenous treatment of the great saphenous vein

using a 1,320 nm Nd: YAG laser causes fewer side

effects than using a 940 nm diode laser. Dermatol

Surg. 2005;31(12):1678–83.

91. Timperman P. Arteriovenous ﬁ stula after endovascu-

lar laser treatment of the short saphenous vein. J Vasc

Interv Radiol. 2004;15:625–7.

92. Zimporin S, et al. A case of external iliac arterio-

venous ﬁ stula and high-output cardiac failure after

endovenous laser treatment of great saphenous vein.

J Vasc Surg. 2010;51:715–9.

93. Caggiati A, Franceschini M. Stroke following

endovenous laser treatment of varicose veins. J Vasc

Surg. 2010;51:218–20.

94. Campbell B. New treatments for varicose veins. BMJ.

2002;324:688–9.

95. Soumian S, Davies AH. Endovenous management of

varicose veins. Phlebology. 2004;19(4):163–9.

96. Ceulen R, et al. Outcomes and side effects of

duplex-guided sclerotherapy in the treatment of

great saphenous veins with 1% versus 3% polido-

canol foam: results of a randomized controlled trial

with 1-year follow-up. Dermatol Surg. 2007;33:

276–81.

97. Hamel-Desnos C, Desnos P, Wollmann JC, Ouvry P,

Mako S, Allaert FA. Evaluation of the ef ﬁ cacy of

polidocanol in the form of foam compared with liq-

https://t.me/med1917

597 Elimination of Truncal Vein Re ﬂ ux: Surgery, Thermal Ablation, and Chemical Ablation

uid form in sclerotherapy of the greater saphenous

vein: Initial results. Dermatol Surg. 2003;19:

1170–5.

98. Hamel-Desnos C, Allaert F-A. Liquid versus foam

sclerotherapy. Phlebology. 2009;24:240–6.

99. Yamaki T, Nozaki M, Iwasaka S. Comparative study

of duplex-guided foam sclerotherapy and duplex-

guided liquid sclerotherapy for the treatment of

super ﬁ cial venous insuf ﬁ ciency. Dermatol Surg.

2004;30:718–22.

https://t.me/med1917

N.S. Sadick et al. (eds.), Practical Approach to the Management and Treatment of Venous Disorders,

Introduction

Varicose veins are super ﬁ cial dilated veins that

may be troublesome for cosmetic reasons or

because they are symptomatic. However, in all

settings, they are always the result of increased

venous pressure and possibly an underlying

source of re ﬂ ux. The traditional approach to treat-

ing large varicose veins and complicated venous

pathology has been surgical. However improve-

ment in sclerotherapy methods as well as other

minimally invasive techniques has allowed for

non-surgical treatment of large diameter vessels.

The sources of the high-pressure re ﬂ ux that

lead to the development of varicosities must be

addressed before treatment of associated feeding

varicosities can begin. This can be achieved through

surgical or endovascular techniques described in

the preceding chapters. It is only after the source

of re ﬂ ux has been identi ﬁ ed and truncal veins have

been addressed that the clinician can approach

tributaries. In general, in order to reduce recur-

rence and improve clinical outcomes tributaries are

treated in order of decreasing vessel diameter, with

varicosities being ﬁ rst, and telangiectasias last. It

is with these thoughts in mind that this chapter on

the treatment tributaries: varicose veins, reticular

veins or telangiectasias and venulectasias has been

written. Table 8.1 emphasizes this fact and portrays

a rational approach to the management of venous

pathology.

Varicose Veins

The ﬁ rst step in the treatment of varicose veins is

the abolishment of axial re ﬂ ux by endovenous

laser, radiofrequency (RF), chemical or surgical

ablation, or duplex-guided sclerotherapy of the

re ﬂ ux site and the incompetent junction. After

these procedures are undertaken, many varicose

veins may disappear. Remaining varicosities can

be treated with ambulatory phlebectomy (AP) or

with foam and traditional liquid sclerotherapy.

Sclerotherapy and Alternatives

Neil S. Sadick

N. S. Sadick , M.D.

Clinical Professor of Dermatology – Weill Cornell

Medical College , New York, NY , USA

e-mail: nssderm@sadickdermatology.com

Table 8.1 A clinical approach to the treatment of venous

pathology

Axial re ﬂ ux—great and small saphenous veins and

associated junctional incompetence

Endovenous laser ablation (EVLT) Radiofrequency

ablation (surgical ligation/stripping procedures,

duplex-guided sclerotherapy

↓

Truncal varicosities (Foam sclerotherapy, ambulatory

phlebectomy)

↓

Perforating veins (Foam sclerotherapy, ambulatory

phlebectomy, thermal ablation?)

↓

Reticular Veins (Sclerotherapy ± foam, ambulatory

phlebectomy)

↓

Telangiectasia (microsclerotherapy, laser, noncoherent

light-source therapy, IPL ± RF)

https://t.me/med1917

N.S. Sadick

When choosing between AP versus liquid or

foam sclerotherapy for the treatment of varicose

veins several considerations are made. In patients

with multiple varicose veins and highly elevated

varicosities, AP presents increased single-treatment

ef ﬁ cacy, improved clinical outcomes and decreased

hyperpigmentation risk. However AP is a surgical

procedure and in patients who desire a minimally-

invasive approach or in whom surgery is contraindi-

cated, sclerotherapy is preferred (Table 8.2 ).

Diagnostic Approaches

In order to understand the approach to the treat-

ment of large diameter varicosities, one must go

back and review the anatomic variations that may

present as large diameter (usually 2–10 mm) veins.

Lower Extremity varicosities may be divided into

four types. The ﬁ rst type is the most common.

Type I

The patient presents with varicose veins that are

only in the lower leg and receive their re ﬂ ux from

an incompetent saphenofemoral junction in the

groin, which may be demonstrated by Doppler

examination. The great saphenous trunk itself

may also be visibly varicose; often, however, the

great saphenous vein appears normal and serves

as a passive conduit for the re ﬂ ux originating

from the saphenofemoral junction.

Type II

The patient presents with varicose veins localized

to the lower leg. They arise from an incompetent

small saphenous vein (saphenopopliteal incom-

petence) and its associated tributaries.

Type III

Truncal varicose veins present in the thigh or entire

lower limb. This varicose tributary also receives its

re ﬂ ux from an incompetent saphenofemoral junc-

tion. However, the varicose tributary, which is usu-

ally the anterior accessory saphenous vein or

another major tributary, drains immediately at the

junction without a segment of the great saphenous

vein transmitting the re ﬂ ux. Upon clinical and

Doppler examination, the great saphenous vein is

completely normal and there are minimal distal

varicose tributaries.

Type IV

This type represents all cases of varicose veins

that, on duplex examination, have no relationship

with an incompetent saphenofemoral or saphenop-

opliteal junction. These varicosities may present at

any place on the lower limb. This means that they

receive their re ﬂ ux from incompetent perforators,

accessory, great saphenous veins or Treatment

consists of ambulatory phlebectomy or sclerother-

apy only. One attempts to isolate these perforators

by physical examination (fascial gaps), Doppler,

and/or duplex ultrasound evaluation and to treat

these sources ﬁ rst whenever possible. In most

cases sclerotherapy or hook avulsion of the vari-

cose vein as it presents itself will often adequately

treat associated incompetent perforators.

Pretreatment Considerations

Treatment of these larger-diameter veins requires

great and precise attention to detail concerning

anatomic and re ﬂ ux considerations. Being respect-

ful of anatomy will minimize the risk of post-treat-

ment recurrences and complications, which are of

greater concern in dealing with larger-diameter

vessels. Factors of importance in the treatment of

large-diameter varicose veins are as follows:

1 . An understanding of the precise anatomy

of the varicosity under treatment consider-

ation . In this setting duplex ultrasonography

Table 8.2 Varicose vein treatment options

Ambulatory phlebectomy Sclerotherapy

Advantage Disadvantage Advantage Disadvantage

Single treatment ef ﬁ cacy Surgical procedure Non-surgical ↓ Single treatment ef ﬁ cacy

Post-surgical risk Ease of treatment ↑ Hyperpigmentation risk

https://t.me/med1917

<<< < Предыдущая 1 2 3 4 5 67 / 197 8 9 10 11 12 13 14 15 16 17 18 19 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
10.10.20269 Мб0Книга_3891_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20269 Мб0Книга_3892_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20269 Мб0Книга_3893_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20269 Мб0Книга_3895_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20269 Мб0Книга_3896_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20269 Мб0Книга_3897_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20269 Мб0Книга_3899_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202614 Мб0Книга_39_библиотеки_им_акад_М_И_Перельмана.pdf
#
10.10.20269 Мб0Книга_3900_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20269 Мб0Книга_3901_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20269 Мб0Книга_3902_Библиотеки_им_академика_М_И_Перельмана.pdf