Leonardo Corcos

Duplex ultrasound changes in the great saphenous vein after endosaphenous laser occlusion with 808-nm wavelength

BACKGROUND Endosaphenous laser ablation is used in the treatment of great saphenous vein insufficiency with various methods, with and without surgical interruption. However, its mode of action and indications are not yet clear. METHODS To verify the mode of action of endosaphenous laser ablation by duplex ultrasound (DUS) follow-up, with the support of histologic observations of eight cases, 44 of 182 affected limbs (CEAP C2 to C6) were selected for intravenous laser ablation of the great saphenous vein. Saphenofemoral junction incompetence was treated by surgical interruption. An 808-nm diode laser (Eufoton, Trieste, Italy) was used (variable pull-back velocity, 1 to 3 mm/s; power, 12 to 15 W; energy, 30 to 40 J/cm). In eight limbs the venous fragments were studied under light microscopy at 5 minutes and after 1 and 2 months. In 44 limbs DUS and clinical examinations were performed from 7 days to 1, 2, 6, and 12 months. RESULTS Variously organized thrombi containing necrotic inclusions and patent areas were observed in the vein lumen. Neither neovascularization nor thrombus extension were detected at the groin by DUS examination. Progressive venous diameter decrease and thrombus fibrotic transformation up to the hypotrophic venous disappearance at 12 months were followed up (P < .00001). Not occluded (18.8%), recanalized short segments (22.7%), two entirely recanalized saphenous veins with varicose recurrence (4.5%), and postoperative phlebitis (13.6%) were observed. Nonocclusions and phlebitis prevailed in the larger veins (P < .05). CONCLUSION The healing process is based on vein thrombosis, fibrosis, and venous atrophy. Saphenofemoral interruption makes venous occlusion easier and prevents potential thrombotic complications and recurrence by recanalization. DUS monitoring makes possible to follow-up the thrombus involution and perform early retreatment. The 808-nm endosaphenous laser should be mainly applied to veins of <10 mm in diameter.

Endovenous 808-nm Diode Laser Occlusion of Perforating Veins and Varicose Collaterals: A Prospective Study of 482 Limbs

BACKGROUND Endovenous laser ablation (EVLA) was performed in the treatment of great and small saphenous veins (GSVs, SSVs), perforating veins (PVs), and varicose collaterals (VCs). OBJECTIVE To verify the outcome in PVs and VCs. MATERIALS AND METHODS Four hundred eighty‐two limbs of 306 patients were studied. EVLA was performed on 167 GSVs, 52 SSVs, and 534 PVs of 303 limbs and on VCs of 467 limbs; 133 GSVs were stripped, 300 of saphenofemoral junctions (SFJs) and 45 saphenopopliteal junctions (SPJs) were interrupted. Limbs were selected using duplex ultrasound examination and photographs; PVs‐VCs diameter (<4 mm) and VC length were measured. EVLA was performed using a 808‐nm diode laser, 0.6‐mm fibers, continuous emission, 4 to 10 W, and 10 to 20 J/cm. Follow‐up on 467 limbs occurred over a mean 27.5 months (range 3 months to 6 years); 98 limbs were followed up for longer than 4 years. RESULTS Operating time range from 10 to 30 minutes per limb. Blood vaporization, thrombosis, fibrosis, and atrophy prevailed in PVs and in the large VCs (>4 mm) and massive coagulation in the smaller (<4 mm). High rate of occlusion was seen, with different rates of patent PV‐VC mainly in diameter >6 mm. Thirty‐nine out of 511 patent PVs (7.6%) and 96 out of 778 VCs (12‐13%) were re‐treated using EVLA or foam sclerotherapy. Minor complications occurred in 88 of the 778 (11%). CONCLUSIONS EVLA of PVs and VCs is effective and faster than surgery in 2‐ to 6‐mm PVs and VCs using an 808‐nm diode laser. This study was supported by Eufoton, Trieste, Italy.

Intra-Operative Phlebography of the Short Saphenous Vein

The short saphenous vein is more and more often held responsible for the onset and development of varicose conditions and post-operative recurrence. In order to perform complete posterior saphenectomy account must be taken of the frequent anatomical variations in the outflow of this vein. A method of intra-operative phlebography of the short saphenous vein has been developed. The results confirm the high rate of the anatomical variations. Intra-operative phlebography facilitates complete posterior saphenectomy without negative effects in terms of surgical trauma and cosmetic results, thanks to the new technical developments.

Preliminary Results of External Sapheno–Femoral Valvuloplasty: A Trial by the Italian Society of Phlebolymphology

A multicentric trial was conducted to compare the various methods, materials and results employed in external valvuloplasty of the sapheno-femoral junction. Dacron, PTFE and absorbable prostheses have been used and have lead to the following conclusions: careful diagnosis and selection of patients is necessary; dilatation of both terminal and sub-terminal saphenous valves should be treated; at present, PTFE seems the best material to use (follow-up for the absorbable material is too short); the operation is effective and can be recommended in selected cases.

Sapheno-femoral valves. Histopathological observations and diagnostic approach before surgery.

background Since the literature indicated that in the early stages of primary venous disease valves are simply dilated, some authors performed external valvuloplasty of deep and superficial venous valves with encouraging results, although some failures were observed without being sufficiently explained. objective To obtain further interpretations of the natural history of venous valve pathology, clarify methods for a correct diagnostic approach, and provide indications for the external valvuloplasty procedure. methods Forty‐two proximal valves of the long saphenous vein removed for varicose veins of the lower limbs were studied with optical microscopy. The relationship between histologic alterations and age of varicose disease was investigated. Five valvuloplastics were explanted for recurrent reflux and submitted to histopathological observation. Preoperative echographic findings and histologic observations were compared. Nineteen limbs were subjected to external valvuloplasty under angioscopic control; preoperative echographic findings and angioscopic observations were compared. results The histologic alterations observed in venous valves were mainly hypotrophy of cusps, which seemed to be the main cause of failure after external valvuloplasty. The frequency of such hypotrophic alterations increases with the age of varicose disease but no statistically significant relationship was found. Preoperative echographic imaging of venous valves does not appear sufficiently predictive when compared with histologic and angioscopic examinations. conclusion Hypotrophic valve damage seems to be prevalent in patients with varicose veins of the lower limbs. Valve cusp hypotrophy may be present in early disease though some normal cusps can be found in advanced disease. When preoperative echographic visualization of cusps is doubtful, intraoperative angioscopy plays the main role in the diagnosis of venous valve disease before and during external valvuloplasty.

Considerations of the Anatomical Variations in the Venous System of the Lower Limbs in Varicose Disease

The Authors experience in the surgical treatment of varicose veins of the lower limbs in the last 15 years, performed on 1500 cases, show that varicose recurrence may be nearly always attributed to unrecognised anatomical variations in the venous system. Methods of preoperative and intraoperative diagnosis are described and the most frequent variants observed are presented and their significance are discussed.

Endovenous laser in the treatment of varicose veins of the lower limbs geriatric patient: results of activity for 6 years

Endovenous laser ablation (ELA) of the incompetent greater (GSV) and short (SSV) saphenous veins have been used with increasing frequency and the mechanism of action was recently clarified by histological, ultrasound and clinical observations. To verify the results obtained in the 535 limbs affected with varicose veins of the lower limbs (VVLL) treated by ELA of the GSV and the SSv, various surgical, sclerosant and ELA, from March 2002 to March 2008.

Structure and Use of the External Phlebo-Extractor

An external phlebo-extractor for removing varicose veins through short incisions is described.