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TRATTAMENTO ENDOVASCOLARE DELL’IVC DAL DOGMA ALL’INNOVAZIONE

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.

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TRATTAMENTO ENDOVASCOLARE DELL’IVC DAL DOGMA ALL’INNOVAZIONE

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  1. TRATTAMENTOENDOVASCOLARE DELL’IVCDAL DOGMA ALL’INNOVAZIONE G.B. AGUS Direttore dell’Istituto di Chirurgia Vascolare Università di Milano Chirurgo Vascolare Ospedaliero 1970-1988

  2. 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 15-20% [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]

  3. COMPRESSIONE RILASCIAMENTO TEST DINAMICI MOBILIZZAZIONE DI SANGUE > NELLA RETE PROFONDA MOBILIZZAZIONE DI SANGUE > NELLA RETE SUPERFICIALE Gradiente IPERPRESSIVO VALSALVA

  4. “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]

  5. 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]

  6. 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]

  7. 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]

  8. Today it appears that avoidance of a groin incision prevents neovascularizations in varicose vein surgery [Bergan JJ, 2005]

  9. 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]

  10. 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

  11. 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]

  12. 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.

  13. 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.

  14. 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

  15. Clinical dataFollow up M S P V A months

  16. Clinical dataComplications 38%

  17. ResultsPatient compliance 85% 13%

  18. 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.

  19. 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.

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