Transcript Solum certum nihil esse certi”

TRATTAMENTO
ENDOVASCOLARE DELL’IVC
DAL DOGMA ALL’INNOVAZIONE
G.B. AGUS
Direttore dell’Istituto di Chirurgia Vascolare
Università di Milano
Chirurgo Vascolare Ospedaliero 1970-1988
PATTERNS EMODINAMICI DELLA
MALATTIA VARICOSA
• Trattare la crosse della VGS non è
sempre necessario.
• La giunzione safeno-femorale risulta
competente in circa il 30-55% dei casi
e non sono presenti alterazioni proprie
del territorio safenico interno nel 1520%
[Goren G and Yellin AE, 1990;
Camilli S, 1992; Abu.Own A, 1994;
Guex JJ et Al, 1995; Myers KA, 1995;
Singh S et Al, 1997; Jutley RS et Al,
2001; Cappelli M et Al, 2004]
Gradiente IPERPRESSIVO
VALSALVA
COMPRESSIONE
RILASCIAMENTO
TEST DINAMICI
MOBILIZZAZIONE DI
SANGUE
>
NELLA RETE
SUPERFICIALE
MOBILIZZAZIONE DI
SANGUE
>
NELLA RETE
PROFONDA
“OLD” STRIPPING TECHNIQUE
• New techniques eliminate the psychologic
barrier to treatment caused by the term
“stripping” and allow the objectives of surgery to
be achieved with minimal invasion and quick
recovery.
[Bergan J.J., 2002]
REVIEW. NERVE INJURIES AND
VARICOSE VEIN SURGERY
Incidence of saphenous nerve injury :
partial vs complete LSV stripping
7% vs 39%
[Sam RC, Silverman SH , Bradbury AW
Eur J Vasc Endovasc Surg 2004; 27: 113-20]
STRIPPING IN 2000
Stripping of the greater saphenous vein to
the below-knee level has proven to be a
more successful method of treating greater
saphenous vein reflux and has been shown
to reduce the risk of reoperation for
recurrent varicosities.
[Neglen P et Al., 1993; Rutgers PH et Al. 1994;
Sarin S et Al., 1994; Bergan JJ, 1996;
Dwerryhouse S et Al., 1999; Winterborn RJ et Al,
2004]
Saphenofemoral ligation with
ligation and division of the
tributaries
[Moore and Thelwall Thomas, 1896; Homans,1916]
What is neovascularization
and why is it prevalent after
high ligation ?
[Bergan J.J., 2005]
Today it appears that avoidance of a groin incision prevents
neovascularizations in varicose vein surgery
[Bergan JJ, 2005]
INNOVAZIONE
“I benefici, i rischi, i costi e l’efficacia di
ogni nuovo metodo devono essere
confrontati con quelli del miglior
trattamento profilattico, diagnostico e
terapeutico disponibile al momento”
[Dichiarazione di Helsinki, 2000, Sez. C, Clausola 29]
E.V.L.T. – Endo Venous Laser Treatment
• I vantaggi:
 obliterazione della vena
safena interna per effetto
termico (90°) indotto dal
thermal injury panmurale
dato dall’interazione tra luce
polarizzata e cromoforo
(acqua, emoglobina), non a
contatto della parete
 Mini-invasività, eseguibile in
anestesia locale e in day
surgery. Pronto recupero
funzionale
 Metodica eseguibile anche in
presenza di tortuosità
safeniche
 Nessun limite di utilizzo in
relazione al calibro del vaso
 Costi dei materiali accettabili
in relazione ai DRG ottenibili
A LITERATURE ANALYSIS AT MARCH 1st 2004
Lower limb varicose veins endoluminal treatment by
endovenous laser and radiofrequency.
• 50 articles published in English (36) and French language
(14), to compare the two procedures between them and
with the classical surgery.
• The endovenous surgery methods were proven to be less
aggressive and effective at mid-term.
[ Perrin M., Phlebologie 2004; 57,N. 2: 125-33]
UNIQUE PROCEDURE PROTOCOL OF PRACTICE
While EVLT-ELVeS, which is FDA approved, uses
only one type of device manufactured and is
distributed by a single company, there are also other
techniques using different types of Laser equipment
and devices with multiple variants but without the
benefit of a single well-defined protocol for their use.
I.E.W.G.
The Italian Endovenous-Laser Working Group
(IEWG) is a homogeneous group of surgeons
and phlebologists who use the same kit-device
for these reasons.
L’ IEWG METTE IN GUARDIA
DALL’ ESTRO ITALIANO
•
•
•
•
•
•
Generatore Laser in regalo
Indicazioni cliniche personali
La babele delle procedure
Erogazione a luci rosse
Kamasutra energetico per J – W – T
Il dogma della crossectomia associata
Clinical data
Follow up
Procedures
Months
Vein
occlusion
MI
SI
AR
PD-VR
PD
38
20
100%
47
12
98%
484
48
98%
76
17
98%
63
14
98%
100
99
98
97
96
95
S
P
V
M
A
12
14
17
20
48
94
93
92
months
Clinical data
Complications
38%
Ecchymosis
281
12
Ipo / Iperpigmentation
1
Skin Burns
5
Paresthesia
5
Hematoma
6
S.V.T
15
Pain
0
D.V.T.
0
50
100
150
200
250
300
Results
Patient compliance
800
629
600
400
85%
200
0
10
97
13%
0
None
Low
Good
Excellent
CLINICAL REMARKS
• Present evidence suggests that less saphenous
veins should be treated.
• With proper indications to the treatment of
saphenous reflux minimally invasive techniques
should be used.
• Results 3-5 years of endovenous laser indicate
a very effective and safe treatment of GSV.
• Endovenous laser is a cost-benefit procedure.
METHODOLOGICAL REMARKS
• It remains to be established whether the treatment
without SFJ ligation is a risk for recurrence.
• As technology for the treatment of varicose veins
expands, we must remain vigilant.
• Critical scientific outcomes assessment before
widespread application of new techniques is
essential.