Endovenous laser therapy with echosclerotherapy as a hybrid method for chronic venous insufficiency: experience in 200 patients and literature review.

OBJECTIVE: Surgical treatment of chronic venous insufficiency (CVI) includes sclerotherapy, cryosurgery, CHIVA method (from the French for ambulatory conservative hemodynamic treatment venous insufficiency), chemical and mechanical obliteration, or phlebectomy. A hybrid treatment that combines sclerotherapy with endovenous laser ablation (EVLA) at 980 nm or 1470 nm or Nd:YAG laser at 1064 nm is also increasingly used. This paper synthesizes the current knowledge of CVI of the lower limbs and demonstrates promising clinical practice experiences using a hybrid method that combines EVLA with intraoperative or postoperative ultrasound-guided foam sclerotherapy (UGFS), also known as echosclerotherapy. PATIENTS AND METHODS: A group of 200 patients was enrolled in the study. All patients underwent a hybrid method of treatment combining EVLA and UGFS. Under tumescent anesthesia, venipuncture of the great saphenous vein (GSV) trunk was performed, followed by 1470 nm laser therapy (80-100J/10W). During the procedure, 2% polidocanol foam was injected into the insufficient collateral veins extending from the main trunk of the GSV. After surgery, compression therapy in the form of grade II compression stockings was used. All patients underwent a follow-up duplex Doppler ultrasound four weeks after the procedure. RESULTS: It was observed that 196 patients had complete obstruction of the femoral segment of the GSV, while four patients showed signs of minor recanalization of the femoral segment. After 12 months, 198 patients showed complete fibrosis, partial or complete absorption of the saphenous vein, and varicose lesions. Two patients underwent UGFS again after 12 months because of recurrent varicose lesions. At four weeks after UGFS, local pain of thrombosed varicose lesions was observed in 20% of patients. Hemosiderin staining was observed in 15% of patients, but this completely resolved within 6-12 months. In 1% of cases, symptoms of dyspnea and cough were reported, which resolved a few minutes after the procedure - approximately 1% of patients presented with symptoms of matting. There were no severe complications during the 12-month follow-up period. CONCLUSIONS: A high efficiency of 98% was observed (196/200 patients) at the 12-month follow-up after hybrid EVLA with UGFS treatment. Follow-up UGFS at four weeks after laser ablation showed 99% efficacy at the 12-month postoperative follow-up. Major complications after the hybrid method treatment combining EVLA with UGFS were not observed. Hybrid methods are more effective (98-99%) and give a lower chance of relapse.

The effects of aneurysm repair using an aortic prosthesis on the electrical parameters of the muscular layer of the abdominal aorta.

The study was carried out on 10 swine of 20-30 kg body weight. Five animals were assigned to each of 2 groups. An aneurysm of the abdominal aorta was created experimentally in animals from the first and second study group. After 4 weeks, animals from the second group were subject to aneurysm repair using an aortic prosthesis. During the experiment, we measured the myoelectric activity of the muscular layer of the abdominal aorta and aneurysmal lesion with the ultrasonographic technique. Measurements of the aorta and aneurysmal lesion and histopathological analyses were carried out post-mortem. We found a statistically significant decrease in the myoelectric activity of the aorta on the aorta-straight prosthesis interface and a significant decrease in the thickness of the muscular layer of the aorta on the aorta-prosthesis interface. No similar changes were found for experimentally induced aneurysms of the abdominal aorta. A straight prosthesis graft may not be the perfect option in the treatment of abdominal aortic aneurysm, as it contributes to the remodelling of the tissue on the prosthesis-aorta interface. This may result in the relapse of an aneurysm and post-operative complications.

Experimental methods of abdominal aortic aneurysm creation in swine as a large animal model.

Animal models of abdominal aortic aneurysms (AAA) enable preclinical studies on new therapeutic approaches and help to understand pathophysiology of the disease. The aim of this study was to demonstrate the effectiveness of selected methods of experimental induction of abdominal aortic aneurysm in swine and to adapt the EMG examination (electromyography) to record the vessel wall changes. The animals were divided into 3 groups comprising 4 individuals in whom AAA was surgically induced. In the first group the AAA was induced by mechanical stretching of the aortic wall and injection of 500 IU elastase under pressure. The second group received elastase and 6000 IU of collagenase. In the third group 0.5 M CaCl2 solution was introduced additionally. Enlargement of abdominal aorta was monitored for 4 weeks. The first group did not show any aorta dilatation. In the second group the aortic lumen was dilated on average by 71±3.5% (P≤0.001) as shown at autopsy and by 76.6±9.3% as measured by the ultrasound method. In the third group aorta was dilatated by 104.2±11.3% as obtained by ultrasound and 72±3% at post-mortem examination. Myoelectric activity of VSMC (vascular smooth muscle cell) was demonstrated and it was characterized by the presence of three types of waves closely related to the pressure changes in the vessel lumen. We conclude that collagen fibers damage plays a significant role in the AAA development in swine. The inflammatory process in the vessel's wall also contributes to AAA development. However, myoelectrical activity of VSMC does not significantly change despite histologically confirmed loss of muscular layer.

In vitro study on the effects of some selected agonists and antagonists of alpha(1)-adrenergic receptors on the contractility of the aneurysmally-changed aortic smooth muscle in humans.

The study included 18 sections of the aneurysmally-changed abdominal aortas, obtained from patients of the Provincial Specialist Hospital in Wroclaw and 18 sections of normal abdominal aortas obtained from swine. The collected samples were placed horizontally in the incubation chamber. Changes in their transverse section area were registered. They were stretched to a tension of 5 mN. Krebs-Henseleit buffer was used as the incubatory environment. Incubation of the sections was performed at a temperature of 37°C, in the gaseous mixture of oxygen and carbon dioxide used in the following proportion: 95% of O(2) and 5% of CO(2). Contractions of the aorta were registered with isotonic transducers (Letica Scientific Instruments). In the studies, we examined the influence of α(1)-adrenergic receptors (and their subtypes α(1A), α(1B), α(1D)) on the contractility of the aortic muscle in humans and swine by their stimulation or inhibition with some selected agonists or antagonists. This time, it was shown that the stimulation of α(1)-adrenergic receptors leads to contractions of the human and swine aortic muscle; the observed increase in the muscle tone may follow from the stimulation of all subtypes of alpha-1 receptor (α(1A), α(1B), α(1D)). All three subtypes of 1-adrenergic receptor are engaged in vasoconstriction, especially of α(1A) and α(1D) subtypes; the α(1B) subtype is less significant for aortic contractility. The contractile response of the aneurysmally-changed abdominal aorta in humans to agonists of α-adrenergic receptors was significantly less intense than that of the normal porcine aorta. It can be concluded that aneurysms influence the contractile response of the aorta.