[VCT classification (valve, cusp, tributary) and venous endoscopy]. / Classification VCT (Valve, Cusp, Tributary) et endoscopie veineuse.

The V.C.T. classification (valve, cusp, tributary) results from a visual interpretation of endoscopic images of acquired valvular lesions in the deep and superficial veins. In 1991, we published a classification of saphenous back flow based in endoscopic views, but the rich French language used is difficult for our foreign colleagues to use. In 1992, S. Hoshino published highly simplified endoscopic results which only distinguish three types of valves, but which have the advantage of allowing quite useful illustrations. We thus propose in 1997 an illustrated and schematic classification. This V.C.T. classification in English is based on our results in 1990, the three types proposed in 1992 by Hoshino, and new images obtained since our former publication. We distinguished five types of valves scored 0 to 4 (type 0 being a normal valve) and four types of cusp scored 0 to 3. In addition, we found it was quite useful to note the number and position of border or wallside supravascular tributary veins. This classification is indispensable for standardized assessment of valve damage and to compare results after valve repair or transposition.

[Simultaneous echographic and endoscopic examination of morphologic anomalies of the valves of the internal saphenous vein]. / Examen simultané échographique et endoscopique des anomalies morphologiques des valvules de la saphène interne.

We attempted to determine whether the duplex-scan of valves is sufficiently specific and sensitive. We also studied morphological anomalies identified endoscopically leading to the pretherapeutic classification (VCT) to determine whether they are recognized by sonography. Finally, we studied valve kinetics to search for a correlation between morphological anomalies and changes in valve kinetics. We performed an endoscopy of the long saphenous vein during 3S procedures (saphenous vein-section-sclerosis) and a simultaneous duplex scan. The probe was positioned ahead of the endoscope which could visualize its tip. B mode and TM mode were used to evaluate valve kinetics. There was a satisfactory correlation between the ultrasonic findings and the endoluminal aspect. Certain abnormalities, visualized sonographically but of imprecise etiology, were identified endoscopically. The results of the two endoscopic and sonographic examinations were compared with clinical experience with valve diseases.

[Does the inferior vena cava have 2 surfaces and 2 borders also?]. / La veine cave inférieure a-t-elle aussi deux faces et deux bords?

The vena cava that has a preferential flattening axis, has also 2 wall sides and 2 borders. The back wall fits closely round on the back vertebral plane and the main colaterals terminate on the borders of the vein. TM echography perfectly analyses the movements of the walls of the vein, as well as the respiratory and auricular movements. In a lying patient, echo-doppler colour shows the expiratory acceleration of the vena cava flow in subrenal area associated with an inspiratory slowing down (as well as for the femoral veins) and the inspiratory acceleration of the flow in suprarenal area associated with an expiratory slowing down. In a standing patient, the vena is cylindrical. When he/she walks on a treadmill, the diameter of the cava seems to be constant, i.e. quasi identical to the aorta's, as fluxes vary in the aorta according to the ventricular contractions and in the LVC according to the patient's gait.

A vein has a preferential axis of flattening.

BACKGROUND: A vein is a collapsible tube. As such, has it one or several axes of flattening? OBJECTIVE: The objective is to demonstrate that several venous parts, like valves or orifices of tributary veins, are directed towards one axis. METHODS: With dynamic endoscopies for superficial veins and with anatomical injections of latex for deep veins. RESULTS: All the valvular free borders of the superficial veins are parallel to the skin's surface, all the terminal orifices of the perforator are really situated on the commissure linear (linear joining two superposed valvular commissures) of the deep veins. CONCLUSION: A vein has a preferential axis of flattening, and its cross-section configuration can be defined as: two wallsides and two borders. The bicuspid valve's cornua are situated on the borders of the vein. The terminal orifices of the perforators are situated on the borders of the deep veins. The models of the musculovenous pump of the calf have to be altered.

[A dynamic model of the muscular pump of the calf in deep venous insufficiency]. / Modèle dynamique de la pompe musculaire du mollet dans l'insuffisance veineuse profonde.

The dynamic model described in 1989 is characterised by the emptying of blood from perforators into the deep venous column (DVC) during a muscle contraction. Muscular squeezing and convective acceleration favor such emptying. In 1990, using dynamic venous endoscopy, it was possible to define the following for a saphenous vein: an outer (or deep) surface, an inner (or superficial) surface and two edges. In 1992, it can be said that the deep veins also have two surfaces and two edges. Anatomically, valve commissures are on the edges of the veins which are also known as commissural lines. Physiologically, this zone (edge of the vein) is potentially less collapsible. Diagrams of models of muscle pumps require modification: valve commissures and orifices of perforators must be aligned. Fluid flow (flux and reflux) is more durable along the edges of the vein.

[Endoscopic study of reflux of the saphenous valve]. / Etude endoscopique des reflux valvulaires saphéniens.

Saphenous venous endoscopy, invasive and non-physiological, enables the in vivo and in situ observation of the valve system. A saphenous vein has a preferential flattening axis parallel to the outside of the skin with two walls, internal and external, and two borders. A valve is inserted on one vein wall, with the valve horns being on the borders. The free borders of a bivalve are parallel with the surface of the skin. The valve system has an antireflux function. There are three main causes of reflux in the saphenous veins: 1. Transitory functional incompetence affecting valves of normal appearance. This incompetence results from valve inertia, flattening of the valve against the sinus wall and loss of co-adaptation. Do active factors producing closure of the valve cup exist against such transitory incompetence? 2. Incongruity between the vein wall and valves. The intercorneal or commissural space allows reflux on the border of the vein. This is the commonest cause of reflux in varicose disease of the vein wall. 3. Actual valve lesions. A distinction is drawn between lesions due to thinning, elongation, stretching, splitting or tearing and those due to thickening, retraction or adhesion. Endoscopy has enabled us to discover cases of varicose disease with predominantly valvular lesions in young individuales in whom early lesions of the valve cup cannot be explained by venous wall disease and has led us to complete the classification of varicose disorders.

[Venous endoscopy]. / Endoscopie veineuse.

The miniaturization of endoscopic equipment now allows exploring the superficial venous system and visualizing the endovein in situ and in vivo. This type of venous endoscopy is an ambulatory procedure, performed during a simple outpatient consultation of angiology, after which the patient is immediately discharged. Although this examination is invasive, non-physiological and expensive, it allows the video recording of the morphology, dynamics and kinetics of the values, of the endovein and of the liquid flows (blood, washing fluid and sclerosing products). The new examination has already enabled us to propose an functional classification of the parietal valves of the great saphenous vein. It makes an intraoperative three-dimensional mapping of the vessels possible, which is sometimes difficult in such particular anatomical regions as the popliteal fossa. It allows performing sclerosis with a visual control and following up the evolution of the immediate endoparietal lesions in situ.

[Sclerotherapy of the external saphenous vein under endoscopic control]. / Sclérose de la saphène externe sous controle endoscopique.

The contribution of investigative venous endoscopy is essential. This out-patient endoscopic technique visualises the venous endothelium, valve systems and collaterals. For example, this technique enabled J.F. Van Cleef and C. Ribreau to draw up an anatomo-physiological classification of the parietal valves of the long saphenous vein on the basis of video films. From a therapeutic standpoint, venous endoscopy has yet to show its value. We chose the short saphenous since treatment of incontinence of this vessel is difficult and controversial: difficult because of anatomical variations, notably its ending and because of its course in the popliteal fossa; controversial because of its relations with the gemellary veins. Treatment of the short saphenous, whether medical or surgical, is not always entirely satisfactory. In case of surgical treatment, together with J.P. Hugentobler, we had already noted the value of three-dimensional localisation by transcutaneous illumination of the precise course of a vein using the cold light of the distal tip of the endoscope. "Venous ligatures" which can be placed intravenously are not currently available. In case of medical treatment by sclerosing injections of the short saphenous junction under endoscopic control, the product used can be injected with great topographical precision and strictly intravenously. Large amounts of product can easily be injected. However, this technique has at least three disadvantages: it is expensive; there is no parallel between endovenous lesions immediately visible by endoscopy and the mid-term results of sclerosing injections; the relations between the gemellary veins and the short saphenous can be identified precisely only by prior ultrasonography. As a result, sclerosing injections under endoscopic control remain within the domain of research.

[Is phlebosuction possible?]. / La phlébosuccion est-elle possible?

Phlebosuction is possible. It permits to increase the congruence between the venous wall and some surgical instruments. Phlebosuction cannulas currently allow "excision-thrombectomy" of a thrombosed varicose cord and some vein removals.

[The "new electrocoagulation" in phlebology]. / La "nouvelle électrocoagulation" en phlébologie.

Today, electrocoagulation benefits from technical improvements, at the level of high frequency electronic generators as well as the composite needles of monopolar electrocoagulation. Thereby, in phlebology, electrocoagulation could again have some indication.