Haemodynamic strategy for treatment of diastolic anterograde giacomini varicose veins.

OBJECTIVES: To assess the diagnosis and outcome of a haemodynamic strategy for the treatment of primary varicose veins associated with anterograde diastolic flow (ADF) in the Giacomini vein (GV). METHODS: ADF in the GV, with the escape point located at the saphenopopliteal junction, was demonstrated in 15 patients (15 limbs) by duplex ultrasound. No other escape points were seen in this group. ADF was defined as the flow present in the relaxing phase after isometric contraction of the lower limb, measured in the standing position. Duplex and clinical follow-up was performed prospectively at 1 week, at 1, 3, 6, and 12 months and once per year thereafter, between 1998 and 2001. Surgery consisted of flush division of the GV from the small saphenous vein (SSV) and division of the incompetent collateral veins from the GV. RESULTS: GV diameter showed an average reduction from 6 to 4 mm 33 months after surgery. Fourteen patients (93%) showed no symptoms or varicose veins. GV reconnection and recurrent ADF was demonstrated in two patients (13%). CONCLUSIONS: ADF is a rare condition associated with primary varicose veins. ADF occurs when there is a closed venovenous shunt with recirculation in the muscular diastole. This implies that, although a part of the circuit is ascendant, the re-entry point must be located downstream to the escape point. Accurate duplex assessment is required to distinguish this atypical haemodynamic condition from an abnormal systolic circuit bypassing a deep vein obstruction. Interruption of the GV above its junction with the SSV abolished ADF with an acceptable rate of recurrences.

Cirugía hemodinámica venosaen el tratamiento del síndrome varicoso / Venous haemodynamic surgery in the treatment of varicose syndrome

Objetivo. El presente trabajo de revisión pretende poner al día los diferentes aspectos del tema: justificación del método, terminología anatomicofuncional utilizada, principios estratégicos y modalidades de su aplicación. Finalmente, se analizan los resultados comunicados de las diferentes series disponibles. Desarrollo. La cura CHIVA (cura conservadora hemodinámica de la insuficiencia venosa ambulatoria) fue descrita por Franceschi en 1988. Tras una expansión inicial del procedimiento, su utilización disminuyó a causa de difundirse sin haberse testado adecuadamente. La estandarización posterior del método ha motivado que diferentes grupos adopten dicha estrategia con resultados satisfactorios. La terminología propuesta por la Asociación Europea de CHIVA en el año 2002 permite aplicar con precisión los distintos tipos de estrategias de este tratamiento. Se remarca que en el registro de actividad de la Sociedad Española de Angiología y Cirugía Vascular correspondiente al año 2002, una tercera parte de las varices intervenidas en unidades o servicios de Angiología y Cirugía Vascular en España se realizaron mediante cirugía hemodinámica venosa. Conclusiones. No existe una evidencia definitiva (se están desarrollando ensayos clínicos prospectivos aleatorizados) en favor de la cura CHIVA; sin embargo, los datos disponibles apoyan la alternativa de dicho procedimiento frente a la flebectomía en el tratamiento de las varices (AU)

Durability of reflux-elimination by a minimal invasive CHIVA procedure on patients with varicose veins. A 3-year prospective case study.

OBJECTIVES: to assess the outcome of a conservative and haemodynamic method for insufficient veins on an ambulatory basis (French acronym, "CHIVA") with preservation of the greater saphenous vein (GSV) for treatment of primary varicose veins. METHODS: duplex incompetence of the sapheno-femoral junction (SFJ) and the GSV trunk, with the re-entry perforating point located on a GSV tributary was demonstrated in 58 patients with varices (58 limbs). The re-entry point was defined as the perforator, whose compression of the superficial vein above its opening eliminates reflux in the GSV. Duplex scanning was performed preoperatively and at 7 days, and patients were followed prospectively at 1, 3, 6, 12, 24, and 36 months after CHIVA. Operation consisted in flush ligation and division from the GSV of the tributary containing the re-entry perforating vein (no additional high ligation is included). If reflux returned, SFJ interruption was performed in a second surgical procedure. RESULTS: the GSV diameter showed an average reduction from 6.6 to 3.9 mm 36 months after surgery. Reflux in the GSV system was demonstrated in all but five (8%) patients. Of the 53 patients with recurrent reflux, 46 underwent SFJ interruption. CONCLUSIONS: elimination of reflux in the GSV after the interruption of insufficient collaterals is only temporary.

Placa móvil carotídea / Mobile carotid plaque

Introducción. La literatura sólo observa la publicación de siete casos de placa móvil sobre carótida cuya descripción imprecisa dificulta que se diferencie de las lesiones móviles de tipo trombo. Por otra parte, la historia natural de este tipo de lesiones no es conocida y su tratamiento resulta controvertido por cuanto existe la tendencia de elegir el tipo de tratamiento a seguir de acuerdo con el `potencial embolígeno' de la afección. Casos clínicos. Se describen dos casos de placa móvil sobre carótida. El diagnóstico se ha practicado en ambos casos mediante ecografía Doppler. El primer caso es un paciente neurológicamente sintomático, cuya placa móvil está asociada a una estenosis superior al 70 por ciento. Se le se indica tratamiento quirúrgico. El segundo caso es neurológicamente asintomático. En el estudio mediante ecografía Doppler se observa el fragmento de placa móvil sobre la carótida común, en la zona del seno carotídeo, sobre una estenosis del 30-50 por ciento. En la zona distal de la misma, sobre el bulbo de la carótida interna, se encuentra una estenosis >70 por ciento. En este caso se indica tratamiento médico debido al deteriorado estado general del paciente. Ambos pacientes han evolucionado favorablemente. Conclusiones. Sumados al segundo caso aquí descrito, son tres los pacientes con placa móvil carotídea (neurológicamente asintomáticos) que han evolucionado favorablemente con tratamiento médico. Mientras no se disponga de más datos acerca de la historia natural de estas lesiones no deberían considerarse, por sí mismas, motivo suficiente para indicar la endarterectomía carotídea. La posible indicación de tratamiento quirúrgico estará en función del grado de estenosis carotídea (AU)

[Mobile carotid plaque]. / Placa móvil carotídea.

INTRODUCTION: In the literature only seven cases have been published describing a mobile carotid plaque, and lack of precise description makes it difficult to differentiate these lesions from mobile thrombotic lesions. The natural history of these lesions is not known and their treatment is controversial, although there is a tendency to choose the type of treatment to be given according to the embologenic potential of the lesion. CLINICAL CASES: We report two cases with mobile carotid plaques. In both cases diagnosis was made on ultrasound Doppler. The first patient had neurological symptoms and a mobile plaque associated with stenosis of over 70%. Surgical treatment was indicated. The second patient had no neurological symptoms. On ultrasound Doppler studies there was a fragment of mobile plaque in the common carotid artery, in the region of the carotid sinus with stenosis of 30 50%. Distal to this zone, in the bulb of the internal carotid artery there was stenosis of >70%. In this case medical treatment was given in view of deterioration in the patient s general state. Both patients improved. CONCLUSIONS: Including our second case, three patients with mobile carotid plaques (neurologically asymptomatic) have now been reported to have made good progress with medical treatment. Until there is more data regarding the natural history of these lesions, they should not be considered to be in themselves sufficient reason for carrying out carotid endarterectomy. The possibility of indicating surgical treatment depends on the degree of carotid stenosis.

Surgery of the innominate artery.

The authors describe their experience with the surgical treatment of 28 patients with obliteration or stenosis of the innominate artery. In 18 (64.3%) patients an intrathoracic operation was done and in three of these a multiple bypass from the aorta to the affected trunks was carried out. In the remaining 10 patients (35.7%) extrathoracic operations were carried out. Immediate results were good in 24 (85.7%) of cases. Thrombosis occurred in 3 during the first 30 days after operation. One patient suffered thrombosis of the bypass and following removal of this became comatose and subsequently died. Long term results were good inasmuch as at 5 years 94.8% of patients survived with a patent reconstruction. The clinical procedures reviewed as is the topography of associated lesions of the other supra-aortic trunks together with the different techniques employed and their indications. The authors express their preference for the technique of an end to side graft in the aorta and end to end in the innominate artery, when the distal portion of this artery is patent and the age and general state of the patient permits a thoracic approach. This technique assures revascularization of the right carotid and vertebral areas, apart from complying with optimal hemodynamic conditions.