Surgical crossectomy and saphenic trunk sclerotherapy. Preliminary results of a combined approach to the treatment of saphenous vein varices.

AIM: Here our proposal of a new approach to the incontinent saphenous-femoral junction (SFJ) based on the combination of surgery and sclerotherapy for treatment of incontinent varices. It is a two-step procedure with a surgical ligation and transection of SFJ followed by a sclerosis of saphenous trunk and extra-fascial tributaries. MATERIALS AND METHODS: From January to December 2017, 95 patients (63 females and 32 males) with a mean age of 56.43 ± 6.07 years for a total of 121 limbs were treated with the SHSC approach. Under local anesthesia, after surgical selective hemodynamic crossectomy and a retrograde cannulation of the saphenous trunk by means of 8-10 ch nelaton-like catheter, 0.5-1% polydocanol foam, obtained with Tessari's technique, is injected into the vein. During injection, the catheter must be progressively withdrawn, so that the entire vein comes in contact with the foam. RESULTS: 121 limbs have been treated with the above technique. A complete obliteration of the saphenous trunk was observed after 116 (95.86%) treatments in the immediate postoperative time. With regard to collateral veins sclerosis, 99 (81.81%) complete obliterations were observed. 28 (23.14%) collateral varices had to be refined by sclerotherapy. DISCUSSION: SHSC associates the execution of a selective hemodynamic crossectomy with an intraoperative foam sclerotherapy for the treatment of the saphenous trunk and collateral varicose veins. SHSC, compared to classical US-guided foam sclerotherapy seems to be safer, with fewer risks of pulmonary and / or cerebral embolic complications. SHSC prevents blood wash out which could destabilize the consolidation of the saphenous trunk sclerosis. CONCLUSIONS: SHSC can be considered an effective treatment of varicose veins, simple to perform, minimally invasive and well tolerated KEY WORDS: Crossectomy, Saphenous vein, Sclerotherapy, SFJ.

[Linee guida flebo-linfologiche SIF-SICVE 2016 della Società Italiana di Flebologia e della Società Italiana di Chirurgia Vascolare ed Endovascolare].

Phlebology is not a specialty for its own in Italy. Phlebological patients are treated by vascular and general surgeons, dermatologists, phlebologists, angiologists, internists and even general practitioners. Even tough guidelines present a series of recommendations based on evidence-based medicine, guidelines may also be a tool to unify the diagnostic and therapeutic approach in a vast medical field like phlebology. Since vascular surgeons and phlebologists are particularly involved in phlebology-related pathologies the scientific societies of the Italian Society of Phlebology (SIF) and the Italian Society for Vascular and Endovascular Surgery (SICVE) decided to cooperate for the preparation of phlebo-lymphological guidelines. These guidelines comprehend also an important chapter dealing with the lymphology of the lower extremities; phlebological active physicians are often faced with lymphatic pathologies and a good differential diagnosis can be sometimes very helpful. Sclerotherapy and Surgery as the major therapeutical alternatives are extensively analyzed, but also the compression therapy, the medical and physical therapy are presented under the critical view of evidence based analyses. Separate chapters deal with the treatment alternatives for superficial and deep venous thromboses and the recommendations for the treatment of venous ulcers. The current scientific evidences were confronted with the experiences of Italian specialists and the particular practice and reality in Italy. They represent therefore the actual valid positions and recommendations in Italy which shall be updated regularly.

Role of the haemodynamic mapping in varicose vein surgery of lower limbs.

AIM: To demonstrate the importance of preoperative ultrasound haemodynamic mapping of venous system in surgery of varicose veins. MATERIALS AND METHODS: Doppler ultrasound evaluation of haemodynamic features of lower limb venous system according to Franceschi's subdivision. DISCUSSION: The importance of Doppler mapping in varicose veins surgery shows a similarity with the Plebographic classification of venous system developed by W. Hach. The study also reassesses the role of varicectomy in the surgery of varicose veins. CONCLUSIONS: Preoperative Doppler ultrasound mapping is essential to avoid accident and prevent recurrence of varicose veins. KEY WORDS: Doppler US, Surgery, Great Saphenous Vein, Varicose Veins, Stripping.

The use of transillumination as a rational approach to sclerotherapy and endovascular laser ablation of varices. Results in the use of an original instrument.

AIM: To explain the mode of using and the obtained results during EVLA procedures and sclerotherapies with support of Visioven®, a laser transillumination instrument. MATERIALS AND METHODS: 205 patients suffering from Chronic Venous Insufficiency - CEAP-C stage 1-2 enrolled (103 females and 102 males) and divided into two groups. A Group: patients candidate for sclerotherapy; B Group: patients to be subjected to endovascular laser ablation (EVLA). In both groups patients were divided into two sub-groups on the basis of the use of Visioven® or not during the procedure. The analyzed outcome variables were the total number of cannulations necessary to treat a whole limb, and the total procedure time. RESULTS: There is a statistically significant difference between the sub-groups in which Visioven® was used and the ones in which the procedure has been performed without using of any tools. Both in the sclerotherapy group than in the EVLA one, there is not a statistically significant difference for the time required to complete the procedures carried out with Visioven® compared with the ones performed without the use of any transillumination. DISCUSSION: Complete closure of the vein was highlighted. Total number of cannulations in sclerotherapy and EVLA procedures was reduced, as a consequence of a "smart" and "targeted" treatment achieved with Visioven® CONCLUSION: The VISIOVEN® system leads to have a more rational approach to sclerotherapy or Laser Ablation of teleangectasias and reticular veins as we can immediately verify the effectiveness of the treatment and adapting it to the desired effects. KEY WORDS: Chronic Vein Insufficiency, EVLA, EVLT, Laser, Varicose vein.

Prophylactic GSV surgery in elderly candidates for hip or knee arthroplasty.

Aging is one of the major risk factors for varicose veins. The same is for Knee and Hip Osteoarthritis. Most of the patients undergoing to Hip (THA) or Knee (TKA) arthroplasty are over sixteen. Varicose veins, excluding thrombophilia, are the most significant risk factors for VTE after THA and TKA. This study investigates on the usefulness of prophylactic treatment of GSV insufficiency in elderly patients undergoing to orthopedic surgery. A retrospective study enrolling 44 over-sixty five patients, undergoing to TKA or THA. 24 patients underwent to traditional surgery and 20 to EVLA. The presence of evident varicosities and/or a saphenic reflux lasting > 500 ms has been considered as operability criterion. Both in surgery and EVLA group has been performed the ablation of visible varicosities and only saphenic refluxing traits. RESULTS: 1 case of symptomatic DVT was recorded after arthroplasty. A statistically significant difference (p = 0.006) of recovery time between surgery and EVLA groups has been detected. There is not a statistically significant difference in long-term recurrence rate between surgery and EVLA. CONCLUSIONS: It is useful to program GSV surgery, before treat hip or knee. This study showed a 50% decrease in the incidence of postoperative DVT.