TRATTAMENTOENDOVASCOLARE 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 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]

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]

Incidence of saphenous nerve injury :partial vs complete LSV stripping

7% vs 39%

[Sam RC, Silverman SH , Bradbury AWEur J Vasc Endovasc Surg 2004; 27: 113-20]

REVIEW. NERVE INJURIES AND VARICOSE VEIN SURGERY

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

MI SI AR PD-VR PD

Procedures

Months

Vein occlusion

38

20

100%

47

12

98%

484

48

98%

76

17

98%

63

14

98%

92

93

94

95

96

97

98

99

100

12 14 17 20 48

S VP

months

AM

Clinical dataComplications

0

15

6

5

5

1

12

281

0 50 100 150 200 250 300

D.V.T.

Pain

S.V.T

Hematoma

Paresthesia

Skin Burns

Ipo / Iperpigmentation

Ecchymosis 38%

ResultsPatient compliance

0 1097

629

0

200

400

600

800

None Low Good Excellent

85%

13%

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.