[Connection of perforating and intramuscular veins of the crus in varicosity]. / Sviaz' perforantnykh i vnutrimyshechnykh ven goleni pri varikoznoi bolezni.

AIM: This study was undertaken to investigate the clinical anatomy of indirect perforating veins and their connection to the intramuscular venous collector of the crus by means of MSCT phlebography. PATIENTS AND METHODS: From 2015 till now, MSCT phlebography was used to examine a total of 400 patients with chronic diseases of lower limb veins. According to the CEAP classification, clinical class C0-C1 was present in 108 (27%) subjects, C2-C3 - in 173 (43.3%) patients, and C4-C6 - in 119 (29.7%) patients. All examinations were performed using a 128-slice multispiral CT scanner Philips Ingenuity, followed by 3D reconstruction with the help of the IntelliSpace Portal Image Editing Software package. RESULTS: In the 400 extremities examined, we identified a total of 11 655 indirect perforating veins of the calf. Studying the anatomical localization of perforating veins demonstrated that 3248 veins belonged to the posterior tibial group, 1830 veins - to the lateral group, 873 veins - to the paraachillary group, 276 veins - to the intergemellary group, 4451 veins - to the medial group, and 997 perforating veins - to the lateral group. 3D imaging made it possible to trace the entire course of the perforating veins originating from the posterior arched, intersaphenous, oblique veins or other communicating branches to the subfascial and intramuscular portions to the connection with the gastrocnemius and soleus veins which as the disease progresses undergo ectasia with the formation therein of pathological segmental hypervolemia. CONCLUSION: Studying the ratio of the revealed indirect perforating veins of the determined groups and the presence of gradually developing ectasia of the intramuscular venous collectors in patients of various clinical classes from C0-C1 to C4-C6 made it possible to draw a conclusion on the involvement of perforating veins and intramuscular veins of the crus into the common pathohaemodynamic circle of the development and progression of chronic venous insufficiency in patients with varicose veins.

[Efficacy of combination of needle extract, hesperidin and vitamin C in treatment of chronic venous diseases]. / Éffektivnost' kombinatsii ékstrakta iglitsy, gesperidina i vitamina S v lechenii khronicheskikh zabolevanii ven.

BACKGROUND: In Russia, physicians are virtually unaware of drugs based on needle extract. However, abroad, saponins and, in particular, a combined preparation containing needle extract, hesperidin and vitamin C is one of drugs of choice, if not the leading medication in treatment of venous oedemas and other venous symptoms. AIM: The authors conducted a systematic review of the Russian-and English-language literature using the following search terms: saponins, hesperidin, needle, ruscus, ruscogenin (and their Russian equivalents), each of which was entered in a combination with the word 'venous' or its Russian equivalent, respectively. RESULTS: Ruscogenin and neoruscogenin from the root of needle possess anti-inflammatory properties and induce venous wall contraction, thus making it possible to use needle extract in treatment of chronic venous insufficiency. It was experimentally determined that needle extract stimulates vein contractility, decreasing permeability of the venous wall, influencing extracellular matrix proteins, inhibiting leukocyte migration through regulation of both proteins and matrix ribonucleic acid. Analysed herein are the results of original studies of a combination of needle extract, flavonoid hesperidin methyl chalcone and ascorbic acid, also examining in detail the mechanism of action conditioned by synergism of pharmacological effects of these components. This is followed by discussing the place of saponins in the classification of phlebotropic drugs and comparing efficacy of needle root extract with that of other phlebotonics. CONCLUSION: It was experimentally determined that a combination of needle extract, hesperidin and vitamin C possesses multiple additive phlebotropic effects. According to clinical trials, it leads to relief of most symptoms and a decrease in the ankle volume (high level of evidence 1A), being not inferior by clinical efficiency and duration of action to the best-known flavonoids, whereas by the venotonizing effect, decreased permeability of the vascular wall, and inhibition of leukocytic aggression even superior thereto. Further experimental and clinical studies of efficacy of this combination for various forms of chronic venous diseases and venous thromboses are warranted.

[A device for endoluminal thermal obliteration of varicose veins]. / Ustroistvo dlia provedeniia éndoliuminal'noi termicheskoi obliteratsii varikoznykh ven.

Amongst the techniques of endoluminal thermal obliteration of varicose veins, the most commonly employed treatment modalities are endovasal radiofrequency ablation and endovasal laser obliteration, both using a generating source and a special device for carrying out thermal obliteration. It has been noted that each of the methods of thermal obliteration has a number of disadvantages, irrespective of using the energy of magnetic oscillations in a radiofrequency range or laser radiation, including high cost of expendable materials and equipment. The device we worked out for endoluminal thermal obliteration of varicose veins was based on the principle of high efficacy and safety, with a significant decrease in the cost of carrying out the manipulation. This was achieved by means of developing a new device wherein a thermal effect is exerted not via the direct impact of laser radiation on the venous wall but at the expense of using laser energy exceptionally for heating a metal tip located at the distal end of high-strength metallized fibre coated with a heat-resistant polymer. Analysing the initial short-term results of using the new technique of thermal obliteration in treating a total of 50 patients presenting with varicose veins made it possible to draw a conclusion on high efficacy of the method and its safety. The proposed device may repeatedly be used with any and simplest-in-design source of laser radiation regardless of the wavelength and power of radiation. Implementation of this technique into clinical practice will make it possible to decrease manifold the cost of the procedure of thermal obliteration of varicose veins, currently carried out with the use of the classic techniques - endovasal laser obliteration and endovasal radiofrequency ablation.

[Saint Petersburg Venous Forum 'Christmas Meetings' - 10th anniversary]. / Sankt-Peterburgskomu Venoznomu Forumu «Rozhdestvenskie vstrechi¼ - 10 let.

The article is a review of the reports delivered at the annual Saint Petersburg Venous Forum 'Christmas Meetings'. In 2017 it was held for the 10th time. Widely covered at the Forum were problems concerning non-tumescent methods of treatment of varicose veins, methods of diagnosis and treatment of deep-vein diseases, problems of pathogenesis of post-thrombotic disease, terminology in problems of phlebology.

[Experience with using cyanoacrylate glue in endovascular treatment of varicose veins]. / Opyt primeneniia tsianoakrilatnogo kleia pri éndovaskuliarnom lechenii varikoznoi bolezni.

The method of cyanoacrylate-mediated obliteration of subcutaneous veins is known to be an alternative to thermal endovascular obliteration and eliminates the need for tumescent anaesthesia. This technique is based on glue-induced damage to the venous intima, followed by immune response according to the delayed-type hypersensitivity principle. The authors report herein their first experience with using cyanoacrylate-mediated embolization in treatment of patients presenting with varicose veins. The operation was carried out using the VenaSeal closure system (Medtronic). Under ultrasonographic guidance, we performed cyanoacrylate-mediated obliteration of the trunk of the great saphenous vein, without tumescence. The procedure turned out to be well tolerated, with no pain in the zone of cyanoacrylate obliteration reported by the patients in the postoperative period. By means of ultrasonographic control carried out within 1-month of follow up we assessed obliteration of the vein, with the diameter of the obliterated portion amounting to 0.3-0.4 cm. No phlebitis, allergic reactions, nor evidence of deep vein thrombosis were observed. We also performed a morphological study of the removed suprafascial segment of the vein, containing the cyanoacrylate adhesive. The obtained findings demonstrated detachment and destruction of the intima, swelling and loosening of the media, as well active degranulation of mast cells, thus making it possible to suppose the presence of toxic damage to the venous wall induced by cyanoacrylate glue. Hence, the experience thus gained appears to be unequivocally suggestive of remarkable simplicity of performing cyanoacrylate-mediated embolization whose indisputable advantages include the painless nature of the procedure and no need for tumescent anaesthesia. In order to assess efficacy and safety of this technique, further studies are required.

[Endovascular treatment of a patient with post-thrombotic disease and obstruction of a cava filter]. / Éndovaskuliarnoe lechenie bol'nogo s posttromboticheskoi bolezn'iu i obstruktsiei kava-fil'tra.

Balloon angioplasty and stenting have increasingly been gaining widespread application for treatment of post-thrombotic alterations in the system of the vena cava. Endovascular ultrasonographic examination makes it possible with the utmost degree of reliability to determine both the extension and degree of the narrowing of venous segments, thus proving a possibility of choosing a venous stent of an appropriate diameter. Restoration of an adequate venous lumen leads to normalization of blood flow and elimination of venous hypertension. However, unsolved as yet remains the problem concerning proper management of post-thrombotic obstructions of the inferior vena cava at the level of a cava filter. Owing to a wide variety of configurations of cava filters to deploy, there are no common approaches to elimination of such obstruction. Presented herein is a clinical case report regarding successful endovascular treatment of a patient diagnosed with post-thrombotic disease secondary to endured thrombosis. The findings of both phlebography and endovascular ultrasonographic examination made it possible to diagnose obstruction of the left common iliac vein, external iliac vein, and inferior vena cava to the level of the cava filter previously deployed. In the segment of the inferior vena cava at the level of the cava filter also revealed was a pronounced luminal narrowing exceeding 90% of its diameter. We carried out stenting of the common and external iliac veins, inferior vena cava, and the cava filter. Swelling of the left leg subsided spontaneously within 2 weeks and the first postoperative month was accompanied by gradual disappearance of the previously existing feeling of heaviness in the lower limbs and a dramatic decrease in fatigue by the end of the working day.

[First experience with intravascular ultrasonographic examination in diagnosis of post-traumatic obstruction of deep veins]. / Pervyi opyt vnutrisosudistogo ul'trazvukovogo issledovaniia v diagnostike posttromboticheskoi obstruktsii glubokikh ven.

Intravascular ultrasonography (IVUS) is a highly effective method of diagnosis of post-thrombotic obstructions. Its possibilities by determining the degree and extension of obstructions of deep veins are superior to those of not only non-invasive methods of examination (ultrasonography, CT and MRI) but of phlebography whose results until recently were considered fundamental in diagnosis of the disease concerned. Limited possibilities of phlebography often lead to diagnostic errors when determining the degree and extension of post-thrombotic obstructions. Intravascular ultrasonography makes it possible to obtain a maximally objective picture of the degree of intravascular alterations in post-thrombotic diseases, as well as to determine the indications for performing balloon dilatation and stenting of deep veins. First experience in using intravascular ultrasonography in the Clinic of the Institute of Experimental Medicine confirmed these provisions. A total of 15 patients diagnosed with post-thrombotic disease while examination were subjected to antegrade transfemoral phlebography in the direct and lateral projections and IVUS. Significant post-thrombotic obstruction was revealed by phlebography in 3 (20%) of the 15 patients and confirmed by the findings of IVUS. In 12 (80%) patients only carrying out IVUS made it possible to detect pronounced obstruction of veins (more than 50% of its diameter) remaining undiagnosed by phlebography. Unnoticed in phlebography turned out to be May-Thurner syndrome in a female patient. Compression of the left common iliac vein by the right common iliac artery exceeding during systole 70% of the initial diameter of the vein was also revealed while performing IVUS. At the same time phlebography remains an indispensable method of examination while assessing collateral blood flow, thus making it possible to recommend its performing in combination with IVUS for obtaining the most complete notion on post-thrombotic alterations in deep veins of the inferior vena cava system.

Peculiarities of Blood Flow Changes in Venae Cavae during Experimental Pulmonary Embolism.

The model of acute pulmonary embolism in rabbits demonstrated reduced pulmonary blood flow, cardiac output, left atrial pressure, and blood flow in venae cavae against the background of elevated left pulmonary artery pressure and increased pulmonary vascular resistance. Simultaneously, the blood flow in the superior vena cava decreased to a lesser extent than that in the inferior vena cava, which was a characteristic feature of the model of pulmonary pathology. In contrast, when histamine was infused into the left jugular vein to equally elevate pressure in pulmonary artery as in the above model, the blood flow in the superior vena cava decreased to a greater extent than that in inferior vena cava. During stenosis of inferior vena cava that decreased the cardiac output to the level observed during modeled pulmonary embolism, the blood flows in both venae cavae dropped equally.

[Antegrade diastolic blood flow and classic reflux in varicose dilatation of the intersaphenous vein].

INTRODUCTION: In the intersaphenous vein (ISV) there may take place the so-called "antegrade" or "paradoxical" reflux. This type of blood flow is revealed in a series of patients during muscular diastole and is a link of the pathogenesis of varicose disease, but has, as distinct from the "classical" reflux, an antegrade direction. An incompetent saphenopopliteal junction (SPJ) is a source of the antegrade diastolic blood flow (ADBF) through the ISV. Descriptions of possible variants of impaired blood flow through the ISV are fragmentary and their interpretations are controversial. Prevalence and pathogenesis of these disorders impairments have not yet been studied. MATERIAL AND METHODS: A cross-sectional study: over 4 years three centres examined a total of 1,413 patients diagnosed with class C2-C6 varicose veins according the CEAP classification. All patients underwent ultrasound duplex scanning of lower limb veins. The ADBF was determined as a unidirectional antegrade blood flow with the duration of not more than 0.5 second, observed after the crus was relived of compression (in the diastole). Of the patients included into the study who had no varicose veins on the contralateral extremity with the ISV being spotted we sequentially selected 40 subjects including them into the Study Group for the analysis of blood flow and the diameter of the ISV in health. RESULTS: Impairments of blood flow in the ISV were revealed in 61 (4.8%) of 1,265 extremities included into the study: the "classical" reflux in 9 (14.8%) limbs, ADBF was revealed in 37 (60.7%) limbs, a combination of the "classical" blood flow and ADBF - in 15 (24.6%) limbs. Hence, the patients were subdivided into three groups. Studying the nature of blood flow through the ISV in the control group on 40 lower limbs revealed no blood flow disorders. The mean ISV diameter amounted to 1.68 mm (ME=1 mm). The ISV diameter was considerably higher in all studied groups as compared with the control one (p<0.0001). The diameter of the ISV in its proximal portion averagely amounted to 4.48 mm (SD 1.337 mm, SE 0.171 mm). The diameter in the distal portion amounted to 5.39 mm (SD 1.725 mm, SE 0.221 mm).

[Role of the endothelium in pathogenesis of chronic postembolic pulmonary hypertension].

The review contains the data concerning the role of the endothelium in the development of chronic postembolic pulmonary hypertension. It is noted that this pathology is associated with changes in the balance of vasoconstrictors and vasodilators, as well as haemostasis factors synthesized by the endothelium, thus leading to remodelling of not only pulmonary arterioles but venous pulmonary vessels. Along with it, the mechanisms of the endothelial function and biochemical markers of this process in patients with chronic postembolic pulmonary hypertension remain insufficiently studied. Such markers may be an increase in blood plasma concentrations of fibrinopeptide A, factor VIII, von Willebrand factor, endothelin I and vascular endothelial growth factor along with a decrease in the level of thrombomodulin.

[THE PULMONARY HEMODYNAMICS FOLLOWING EXPERIMENTAL PULMONARY THROMBOEMBOLISM AND AFTER BLOCKADE OF THE ALPHA-ADRENOCEPTORS].

In acute experiments on the anesthetized rabbits the pulmonary hemodynamics changes following pulmonary thromboembolism were studied in animals with intact circulation and isolated lungs perfusion in the control series and after the blockade of the alpha-adrenoceptors. Following pulmonary embolism in animals with intact circulation in the control group and after the blockade of alpha-adrenoceptors the pulmonary artery pressure and pulmonary vascular resistance increased, but the pulmonary artery flow decreased to the same extent. However, in control animals, the cardiac output decreased more, than the pulmonary flow; the superior vena cava flow was decreased less, than inferior vena cava flow. After the blockade of the alpha-adrenoceptors there were no any imbalance between the decreasing of the cardiac output and pulmonary flow as well as between the decreasing of superior and inferior venae cavae flows. In animals with perfused lungs after the blockade of the alpha-adrenoceptors the pulmonary artery pressure following pulmonary embolism increased to the same level as in animals with intact circulation, however, in the first case the pulmonary vascular resistance increased four times less than in the last one. Thus, we concluded, that following pulmonary thromboembolism the activation of the alpha adrenergic mechanisms could not only promote to increase the resistance of the pulmonary vessels, but these mechanisms are also involved in the changes of the capacitive function of the pulmonary vessels.

[Endogenous venous thrombolysis].

Widely incorporated into vascular surgery pharmacological thrombolysis in treatment for deep vain thrombosis is fraught with a series of unsolved problems requiring further consideration. In spite of aggressive nature of treatment in a series of cases pharmacological thrombolysis sometimes turns out ineffective. Along with it, the results of experimental studies suggest a possibility of accelerating resorption of thrombotic masses and inhibiting remodelling of the venous wall by means of influencing effector cells of endogenous thrombolysis. A detailed study of the mechanisms of thrombolysis would make it possible to formulate strict criteria for carrying out pharmacological thrombolysis and to increase its efficacy.

[Carbonization in endovasal laser obliteration by radial light guide with wavelength of 1470 and 970 nm].

The authors assessed the effect of carbonization and its influence on the parameters of endovasal laser obliteration (EVLO) depending on wavelength of laser radiation (970 and 1470 nm) using a light guide with radial emission. They also analysed the value of drop of radiation power of the light guide after performing EVLO and visually assessed the degree of damage of the glass tip of the radial fibre by means of ultra-close-up photography. The study comprised a total of 20 patients with varicose disease. A total of ten procedures of EVLO were performed in two modes: mode one - W-laser 1470 nm, mode two - H-laser 970 nm, using fibre with radial emission, an automatic retractor of the light guide. It was determined that the median of power loss after EVLO with W-laser amounted to 0.6 W, and that for H-laser - 3.15 W (p=0.002). Ultra-close-up photography showed pronounced damage of the glass tip of the radial light guide while using H-laser and no damages while using the W-laser. It was proved that using laser radiation with wavelength of 970 nm using the light guide with radial emission leads to pronounced carbonization on the surface of the glass tip of the light guide, its damage, a decrease in radiation power and risk of mechanical destruction of the flask. Using the laser with wavelength of 1470 nm with the use of radial light guide did not result in the development of such negative effects, which increases the service life of laser fibre and makes it possible to use it for obliteration of several segments in one patient.

[Fifth EVF HOW: Hands-on Workshop on Venous Disease (Limassol, Cyprus) 30 October - 1 November 2014].

The fifth Hands-on Workshop on Venous Diseases of the European Venous Forum was held from October 30 to November 1, 2014 in Limassol, Cyprus. Leading specialists from European countries for three days delivered reports concerning modern trends in diagnosis and treatment of venous diseases. The participants of the hands-on workshop had a unique possibility to learn first-hand the latest recommendations concerning diagnosis and treatment of varicose disease, acute venous thromboses, post-thrombotic disease, to know about advanced technologies being just introduced into clinical practice.

[MECHANISMS OF THE PULMONARY CIRCULATORY CHANGES FOLLOWING EXPERIMENTAL PULMONARY THROMBOEMBOLISM].

In acute experiments the pulmonary hemodynamics changes following pulmonary embolism were studied in rabbits with intact circulation and isolated lungs perfusion. In both cases the pulmonary vascular resistance increased to the same extent. The pulmonary artery pressure following pulmonary embolism in intact animals increased less, than in the case of isolated lungs perfusion, because the pulmonary artery flow decreased. The experiments with the restriction of the inferior vena cava flow have revealed that pulmonary artery pressure and flow decreased, where the pulmonary artery flow was reduced in the same level as following pulmonary embolism. At the same time the pulmonary vascular resistance was increased in two times less, than following pulmonary thrombosis. Thus we concluded, that following pulmonary embolism the pulmonary artery pressure is dependent on the pulmonary artery flow and pulmonary vascular resistance. The pulmonary artery flow changes are caused by the venous return and right ventricular contractility changes and not correlated with the pulmonary vascular resistance alterations.

[European venous forum (Saint-Petersburg, July 2-4, 2015)].

At the beginning of July 2015 Saint-Petersburg/or several days turned out to be in the centre of events of the European Ph lebo logical Community. It became the venue for more than 800 participants of the European Venous Forum (EVF) from 60 countries of the world and 67 regions of Russia. It was for the .first time over 16 years of the existence of this European-largest phlebological organization that Russia was afforded the honour for holding the conference. The article deals with a review of the main materials presented at the Forum, as well as the most interesting trends of the development of modern phlebology.

[Efficacy of Venarus in treatment of patients with post-thrombotic disease of lower limbs].

The authors studied efficacy of Venarus in comprehensive treatment of patients presenting with post-thrombotic disease. An open multicenter retrospective study included a total of 110 patients subdivided into two groups. Group One (Study Group) consisted of 51 patients with post-thrombotic syndrome, undergoing comprehensive medical treatment with the use of phlebotonic agent Venarus. Group Two (Control Group) comprised 59 patients with post-thrombotic syndrome undergoing similar conservative treatment but without taking phlebotonics. It was proved that Venarus included into comprehensive treatment of patients with post-thrombotic syndrome led to a statistically significant increase of both psychological and social activity and improved patients' quality of life. During the standard term of administration (2 months) Venarus levelled subjective symptoms and certain objective symptoms (according to the Villalta Scale) of post-thrombotic syndrome. After 2-month use Venarus demonstrated the highest efficacy in treating patients with mild-to-moderate post-thrombotic syndrome. The maximal efficacy was observed after 3 months of administration in standard doses. No side effects were noted during the whole period of the study.

[Analysis of efficacy of radiofrequency obliteration with due regard for the target vein's diameter].

AIM: Data concerning the effect of the target vein's diameter on efficacy of radiofrequency obliteration (RFO) in the current literature are limited. AIM: To assess efficacy of RFO and stripping, peculiarities of the postoperative period course with due regard for the diameter of the target veins, to compare the outcomes of RFO and classical phlebectomy in treatment of varicose disease during 1-year follow up by a composite end point. MATERIAL AND METHODS: A multicenter prospective non-randomized study based on analysing therapeutic outcomes in a total of 218 patients presenting with varicose disease (C2-C3 according to the CEAP). RFO was performed in 108 patients and phlebectomy in 110 subjects. The results were assessed by means of a composite end point including four components: technical outcome at 1-year follow-up, pain, subcutaneous haemorrhage, and paresthesias. The groups of patients who endured RFO and phlebectomy were subdivided into two subgroups according to the target vein's diameter with a border of 14 mm. Statistical analysis. We used the methods of non-parametric statistics (contingency tables, chi squared test), calculating the odds ratio (OR) for a favourable outcome with a 95% confidential interval. Pain dynamics was assessed by means of intellectual data analysis (cluster analysis). RESULTS: «Phelbectomy ≥ 14 mm¼ and «RFO ≥ 14 mm¼. The incidence rate of a good outcome in the subgroups amounted to 20 (30.8%) and 61 (95.3%), respectively. The odds ratio for favourable outcome between the subgroups of RFA and phlebectomy amounted to 45.8; 95% CI (44.5-47.0). "RFA ≥ 14 mm" and "RFA < 14 mm". Favourable outcome rate in the subgroups amounted to 25 (39.1%) and 17 (38.6%), respectively. The differences were not statistically significant, p=0.24. The odds ratio for a good outcome between the RFO subgroups amounted to: OR=0.98; 95% CI (0.18-1.77). Comparative analysis of RFO outcomes between the clinics. Favourable outcome rate in the first clinic was 50 (92.6%), in the second 34 (87.2%), and in the third 13 (86.6%), with the difference being statistically insignificant, p=0.7. The cluster analysis of the pain dynamics after the intervention. The clusters with moderate pain were composed of the patients after phlebectomy. These clusters showed association of pain intensity with increased BMI and greater vein diameter. CONCLUSION: 1) RFA of great-diameter veins by a favourable outcome by the composite end point (CED) turned out to be superior to the classic phlebectomy. 2) For RFA the incidence rate of a favourable outcome by the CED does not depend on the target vein's diameter. 3) A pronounced pain syndrome after phlebectomy was associated with excessive body weight or obesity and greater diameter of the vein.

[Open thrombectomy in treatment of acute thromboses of lower-limb deep veins].

Thrombosis of lower-limb deep veins is one of the most common vascular diseases in the world. For a long time the generally accepted treatment policy was conservative therapy with anticoagulants. The article is a review of the literature containing the results of studies carried out over the past two decades and confirming efficacy of surgical treatment for acute venous thrombosis. Presented are the data showing that thrombectomy performed within the first 10-14 days from the onset of the disease, improving quality of life of patients and preventing invalidization thereof. The gained world experience makes it possible to work out the most effective approaches to treatment of acute venous thromboses.