abordarea holistica in patologia venoasa
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The need for a holistic The need for a holistic aproach to patient care aproach to patient care
in in Chronic Venous DiseaseChronic Venous Disease
Alexandru ANDRITOIU, MD, Alexandru ANDRITOIU, MD, MPhMPh
Emergency Military Hospital Emergency Military Hospital Craiova Craiova
CVD definitionCVD definition• Morphological and functional abnormalities of the
venous system of long duration manifested either by symptoms and/or signs indicating the need for investigation and/or care.
• It is caused by venous valvular incompetence with or without associated venous outflow
obstruction, which may affect the superficial venous system, the deep venous system, or both.
• Venous dysfunction may result from either a congenital or an acquired disorder.
• CVD is the consequence of venous hypertension.
Eklof B, Perrin M, Delis KT, et al. Updated terminology of chronic venous disorders:the Vein Term Transatlantic interdisciplinary Consensus Document. J Vasc Surg. 2009;49:498-501.
Venous anatomic segment classification
Superficial and perforating Superficial and perforating veinsveins
Anatomical distribution of venous Anatomical distribution of venous systemsystem
1. Tegument2. Fascia superficiala3. Fascia musculara4. Compartimentul profund5. Compartimentul v. safene (interfascial)6. Compartimentul subcutanat (vv colaterale sau tributare)
Venous haemodynamicsVenous haemodynamics
• About 75% of circulating blood in the body is moving through the venous system.
• Understanding the mechanisms by which venous return to the heart is crucial to understanding the physiology of the vascular system.
Physiology of venous blood Physiology of venous blood flowflow
Venous retourn from legs is governed by
• Arterial pressure• Calf musculovenous pump• Gravity• Thoracic pump• Valves in veins
Pathophysiology of CVIPathophysiology of CVI
• Muscle pump failure (primary)• Venous obstruction• Venous valvular incompetence1. perforator incompetence2. superf veins incompetence3. deep vein incompetence
Phlebology 2008;23:85–98
John BERGAN, MDThe Vein Institute of La JollaDepartment of SurgeryUCSD School of Medicine La Jolla, CA, USA
MEDICOGRAPHIA, VOL 30, No. 2, 2008
Types of valvesTypes of valves
A). unicuspid B) bicuspid C) tricuspid D) quaricuspid
Classification of valvular lesions• Functional valve lesions (type I)• Traumatic organic valve lesions (type II)• Inflammatory organic lesions (type III)• Valvular vestiges (type IV)
Venous valvesVenous valves
Normal vein Varicose vein
VVenoenouuss Reflux Reflux
Valvular incompetence- Valsalva maneuver- Calf compression
Competent VeinCompetent Vein
Start Valsalva End Valsalva
Competent vein
Symptomatic varicose Symptomatic varicose veinsveins
• pain• aching• discomfort • swelling• heaviness• itching that are thought to be due to the effects of
superficial venous reflux and for which no other more likely cause is apparent.
MEDICOGRAPHIA, Vol 33, No. 3, 2011
Guidelines Guidelines
The ,,common language,,The ,,common language,,1994). The American Venous Forum (AVF) has created
the CEAP (Clinical-Etiological-Anatomical-Pathophysiological) classification.
1998). REVAS (REcurrence after VAricose vein Surgery) 2000). The Venous Clinical Severity Score (VCSS)2004). Several consensus documents from the Union
Internationale de Phlébologie (UIP) led to the revision of the CEAP classification system.
2009). The latest update of terminology for CVD-VEINTERM consensus document.
All these efforts have led to the creation of a common language in CVD, which is essential for the
establishment of clinical practice guidelines.
Medicographia. 2011;33:245-252
VEIN-TERMVEIN-TERMChronic venous disordersChronic venous diseaseChronic venous insufficiency (C3*-C6):Venous symptomsVenous aneurysm
Venous valvular incompetenceVenous reflux (primary, secondary)Axial reflux (superficial, deep, combined)Segmental reflux
Eklöf B, Perrin M, Delis KT, Rutherford RB, Gloviczki P. Updated terminology of chronic venous disorders: The VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg. 2009:49:498-501
VEIN TERM (contin…)VEIN TERM (contin…)• Perforator incompetence• Venous occlusion, obstruction• Venous compression• Recanalization
Eklöf B, Perrin M, Delis KT, Rutherford RB, Gloviczki P. Updated terminology of chronic venous disorders: The VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg. 2009:49:498-501
VEIN TERM (surgery)VEIN TERM (surgery)• High ligation and division• Stripping• Venous ablation• Perforating vein interruption-ligation-
ablation• Miniphlebectomy• Sclerotherapy• Endophlebectomy
Eklöf B, Perrin M, Delis KT, Rutherford RB, Gloviczki P. Updated terminology of chronic venous disorders: The VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg. 2009:49:498-501
CEAPCEAP
Telangiectasias (C1)Telangiectasias (C1)
• Confluence of dilated intradermal venules less than 1 mm in caliber.
• Synonym-spider veins.
Corona phlebectaticaCorona phlebectatica
Fan-shaped pattern of numerous small intradermal veins on medial or lateral aspects of ankle and foot.
Varicose veins (C2)Varicose veins (C2)
Subcutaneous dilated vein 3 mm in diameter or larger, measured in upright position, may involve saphenous veins, saphenous tributaries, or nonsaphenous superficial leg veins.
Edema (C3)Edema (C3) Perceptible increase in
volume of fluid in skin and subcutaneous tissue, which is characteristically indented with pressure.
Venous edema usually occurs in the ankle region, but may extend to the leg and foot.
PigmentationPigmentation
Brownish darkening of skin, resulting from extravasated blood.
Usually occurs in the ankle region, but may extend to the leg and foot
LipodermatosclerosisLipodermatosclerosis
LDS is a localized chronic inflammation and fibrosis of the skin and subcutaneous tissues of the lower leg, sometimes associated with scarring or contracture of the Achilles tendon.
LDS is a sign of severe CVD
White atrophy (C4b)White atrophy (C4b)
Localized, often circular whitish and atrophic skin areas surrounded by dilated capillaries and sometimes hyperpigmentation.
Sign of severe CVD, and not to be confused with healed ulcer scars.
Venous eczema and Venous eczema and ulcerationulceration
Healed ulcer (C5)Healed ulcer (C5)
Active venous ulcer (C6)Active venous ulcer (C6)
Full-thickness defect of skin, most frequently in the ankle region, that fails to heal spontaneously and is sustained by CVD
Degree of CVIDegree of CVI
Varicosity – Progression to be Varicosity – Progression to be observedobserved
The Team involved in The Team involved in CVDCVD
• GP• Surgery/vascular surgery• Radiologyt (CDUS, venography)• Interventional radiology• Cardiology• Dermatologyy• Angiology-Phlebology
Vascular serviceVascular service
NICE Guideline 2013
Diagnosis of CVDDiagnosis of CVD• Physical exam.Physical exam.• Noninvasive TestingNoninvasive TestingVenous DupplexPhotoplethysmographyAirplethysmographyCT-MRI Venography• Invasive TestingInvasive TestingContrast VenographyIntravascular US Ambulatory venous pressure (AVP)
Circulation 2005;111:2398-2409
VenographyVenography
Functional venous Functional venous diagnosis:diagnosis:
Ambulatory venous Ambulatory venous pressurespressures
Venous Insufficiency, Venous Insufficiency, RefluxReflux
J Vasc Surg 2005;41:645-51
Patterns of SSV refluxPatterns of SSV reflux
Engelhorn C et al. J Vasc Surg 2005;41:645-51
Treatment of CVDTreatment of CVD
•Conservative•Interventional•Surgical
Circulation. 2005;111:2398-2409
Conservative TreatmentConservative Treatment
• compression• wound and skin care• pharmacological (venoactive drugs)• exercise• loss weight
Elastic compression Elastic compression stockingstocking
• Reduces symptoms of aching, fatigue, pain,and swelling
• Increases fibrinolytic activity
• Mainstay of treatment for venous ulcers
Must be graduated
What degree of compression – What degree of compression – When?When?
Classification of theClassification of the main venoactive drugs main venoactive drugs
Nicolaides et al. Int Angiol. 2008;27:1-59.
InterventionalInterventional
• Sclerotherapy (chemical ablation)• Ablative therapy (cold, heat) -RF, laser, steam• Endovascular (stent)
Guided by CDUS
Sclerotherapy of Sclerotherapy of Telangiectasias:Telangiectasias:
TechniqueTechnique
damage to endothelium leads to fibrosis of vein
Ultrasound-guided Ultrasound-guided sclerotherapysclerotherapy
foamed solutions
Foam sclerotherapy
Compression after sclerotherapy improves results (less thrombus formation, fewer inflammatory reactions, less pigmentation)
Washout Foam Washout Foam sclerotherapysclerotherapy
Dr. Khalil Fattah-60,000 sclerotherapy sessions experience
The foam sclerotherapy is associated with risk of DVT, pulmonary embolism, distant side effects such as vision disturbances and vascular headaches, etc. By removing the injected foam, as suggested by Dr. Khalil Fattahi, side effects can be minimized and treatment can be more selective in choosing the exact segment and extent of varicose veins to be treated by foam sclerotherapy (smart Foam Sclerotherapy).
Vein Specialty Medical Vein Specialty Medical ClinicClinic
Campbell, CACampbell, CA
Dr. Khalil Fattah colection
RF-ablationRF-ablationThe Venefit procedureThe Venefit procedure
Radiofrequency ablationRadiofrequency ablation
Closure FAST™ Catheter. The circular heating element of the catheter measures 7 cm in length which
makes it possible to treat an equivalent length of vein in a few seconds.
GSV Ablation by LaserGSV Ablation by Laser
Pre-Treatment Post-Pre-Treatment Post-TreatmentTreatment
René MILLERETVein Center
Clinique Pasteur3 Rue Pasteur
34120 PézenasFrance
Phlebolymphology. 2011;19(4):174-181
Obliteration of Varicose Veins with Superheated Steam
VenaSeal Sapheon Closure SystemVenaSeal Sapheon Closure System
Cyanoacrylate
SurgicalSurgical• Ligation• Stripping• Miniphlebectomy• Subfascial Endoscopic Perforator
Surgery• Valve Reconstruction
Ligation & stripping Ligation & stripping techniquetechnique
Surgical Treatment of VaricoseSurgical Treatment of VaricoseVeins: PhlebectomyVeins: Phlebectomy
The CHIVA procedureThe CHIVA procedure hemodynamic preservation in venous
insufficiency in ambulatory practice• Is designed to create new hemodynamic
conditions by dividing the pressure column in the varicose veins by disconnecting some venous anastomoses and by redirecting the reflux from the diseased superficial veins into the deep venous system
• The incompetent saphenous trunk is left in place
1988-Franceschi (France)
C ConservatriceH HemodinamiqueI InssufisanceV VeinoseA Ambulatoire
CIVA methodCIVA method
The ASVAL TechniqueThe ASVAL Technique
The ASVAL method recommends preserving the great saphenous vein, unless there is a serious terminal valve insufficiency, and suggests the surgical removal of the superficial varicose reservoir as a primary treatment.
Pittaluga P, Marionneau N, Creton D et al. Traitement chirurgical des varices des membres inferierus: approche moderne. Phlebologie 2004; 57:301–307.
Pittaluga P, Rea B, Barbe R. Methode ASVAL (Ablation Selective des Varices sous Anesthesie Locale): principes et resultats preliminaries. Phlebologie 2005; 2:175–181.
Ablation Selective des Varices sous Anesthesie Locale
A AblationS SelectiveV VaricesA AnestesieL Locale
The endovenous ASVAL method is feasible and has very good technical success rates and clinical results for treating varicose vein disease in patients with segmental GSV reflux and a competent terminal valve.
Subfascial endoscopic perforator Subfascial endoscopic perforator surgerysurgery
The perforating vein The perforating vein after sectioning between the 2 clips
Valvular reconstructionValvular reconstruction• The principle consists in restoring
valvular competence by using different procedures to eliminate reflux through these valves: valvular repair (L. Corcos, Italy 1997), and exo-stent repair of the junction to reduce the diameter of the vein (S. Camilli, Italy 2002, J.R. Lane, Australia 2002).
Venous valvuloplastyVenous valvuloplasty
• Internal valvuloplasy• External valvuloplasty
Internal valvuloplastyInternal valvuloplasty
External valvuloplastyExternal valvuloplasty
the placement of sutures decreases the diameter of the venous wall but keeps the valve cusps from harm’s way. The sutures lie outside the vein lumen in this
approach.
External valvular External valvular stentingstenting
PRP-External PRP-External valvuloplastyvalvuloplasty
PRP in venous ulcerPRP in venous ulcer
(a) a patient of venous ulcer of duration 3 months, (b) after one sitting of platelet rich plasma, (c) ulcer at 4th week and (d) ulcer being healed at 6th week
J Cutan Aesthet Surg. 2013;6(2): 97–99
Echipa Sp. Clinic Militar CraiovaDr Silosi CristianDr Alexandru AndritoiuAblatia prin RF a vv safene
Reporter: Ați afirmat că Angio-Center (Tg. Mures) este un centru unic la nivel național pentru soluțiile aduse bolilor vasculare periferice. Despre ce este vorba?Conf. Dr. Puskás Attila: Este vorba despre o viziune holistică pe domeniul vascular, pentru că această categorie de bolnavi sunt lăsați undeva la periferia actului medical, şi nu numai în țara noastră.
28 oct 2014Medic primar Medicina interna
Masterat Angiologie-Milano
Societatea Română de Angiologie și Chirurgie Vasculară (SRACV), după 25 de ani de la înființarea sa oficială și 10 manifestări știinţifice organizate, continuă să reprezinte o societate științifică de interes general, cu caracter științific și educațional.
The need for Vein Care The need for Vein Care CentersCenters
• Phlebology/Angiology: a distinct medical speciality
• The need for Interventional Phlebology • The role of the Team (holistic aproach)• The need for combination therapies at
the same patient
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