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3 rd Panhellenic Congress of Phlebology and 2 nd Annual Meeting

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CMYK
Περιεχόµενα • Contents
Σελ. / Page
Θέµατα / Τοpics ........................................................................................................................2
Χαιρετισµός Προέδρων / Welcome letter ...............................................................................3
Προσκεκληµένοι Οµιλητές – Συντονιστές / Faculty List .......................................................5-8
Πρόγραµµα µε µια Ματιά / Program at a Glance ...................................................................9
Επιστηµονικό Πρόγραµµα / Scientific Program ...............................................................11-25
Π Ε Ρ Ι Ε Χ Ο Μ Ε Ν Α
Επιτροπές / Committees ..........................................................................................................4
Παρουσιάσεις Οµιλητών / Speakers’ Abstracts ...............................................................27-66
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Γενικές Πληροφορίες / General Information....................................................................86-89
Ευχαριστίες / Acknowledgements .........................................................................................90
Ευρετήριο Συγγραφέων / Authors’ Index ........................................................................91-94
1
C O N T E N T S
Προφορικές Ανακοινώσεις / Oral Presentations..............................................................67-85
CMYK
•
ΧΡΟΝΙΑ ΦΛΕΒΙΚΗ ΝΟΣΟΣ
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ΦΛΕΒΙΚΗ ΘΡΟΜΒΟ ΕΜΒΟΛΗ
•
ΕΝ∆ΟΑΓΓΕΙΑΚΗ ΘΕΡΑΠΕΙΑ ΦΛΕΒΙΚΩΝ ΝΟΣΩΝ
•
ΤΡΑΥΜΑΤΙΚΕΣ ΚΑΚΩΣΕΙΣ ΦΛΕΒΩΝ
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ΤΟ ΟΙ∆ΗΜΑΤΩ∆ΕΣ ΚΑΤΩ ΜΕΛΟΣ
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ΦΛΕΒΙΚΑ ΣΥΝ∆ΡΟΜΑ & ∆ΥΣΠΛΑΣΙΕΣ
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ΑΠΕΙΚΟΝΙΣΤΙΚΗ ∆ΙΕΡΕΥΝΗΣΗ ΦΛΕΒΙΚΩΝ ΠΑΘΗΣΕΩΝ
Σ Υ Ν Ε ∆ Ρ Ι Ο Υ
•
M A I N
T O P I C S
Θέµατα Συνεδρίου
Θ Ε Μ Α Τ Α
Main Topics
2
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CHRONIC VENOUS DISEASE
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VENOUS THROMBOEMBOLISM
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ENDOVENOUS TREATMENT OF VENOUS DISEASES
•
VENOUS TRAUMA
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LOWER LIMB OEDEMA
•
VENOUS SYNDROMES & DYSPLASIAS
•
VENOUS IMAGING
Χαιρετισµός Προέδρων
Welcome Letter
Αγαπητοί Συνάδελφοι,
Dear colleagues,
Η Ελληνική Φλεβολογική Εταιρεία σας καλωσορίζει στο 3ο Πανελλήνιο Συνέδριο Φλεβολογίας, που φέτος πραγµατοποιείται σε συνδυασµό µε το 2nd Annual Meeting oof the
Balkan Venous Forum, στις 21 και 22 Ιανουαρίου 2011 στο Ξενοδοχείο Crowne Plaza, στην
Αθήνα.
It is our great pleasure, on behalf of the Organizing Committee, to welcome you to the
3rd Panhellenic Congress of Phlebology and
the 2nd Annual Meeting of the Balkan Venous Forum, which is being held in Athens on
January 21st – 22nd, 2011, at the Crowne
Plaza Hotel.
Η επιτακτική ανάγκη για υπεύθυνη ενηµέρωση
και σωστή αντιµετώπιση των ασθενών µε φλεβικές παθήσεις αποτέλεσαν τα κίνητρα για την
οργάνωση αυτού του Συνεδρίου.
The aim of the Congress is to cover all aspects
of Venous Diseases giving the opportunity to
health professional to discuss the new developments in prevention, diagnosis and treatment of venous diseases.
Στόχος µας είναι η ενηµέρωση των ιατρών που
ασχολούνται µε τις αγγειακές φλεβικές παθήσεις και για την εξέλιξή στους τοµείς της παθολογίας και της χειρουργικής σε θέµατα που
αφορούν τη διάγνωση και τη θεραπεία των
παθήσεων του φλεβικού συστήµατος αλλά
και γενικότερα κρίσιµα θέµατα όπως η πνευµονική εµβολή και φλεβική θρόµβωση που
αφορούν ειδικότητες πλην της Αγγειοχειρουργικής, όπως Ορθοπεδική, Παθολογία, Γενική
Χειρουργική, ∆ερµατολογία, Νευρολογία,
Πλαστική Χειρουργική, Γενική Ιατρική κλπ.
Σκοπός του Συνεδρίου θα είναι µέσα από συζητήσεις, ανταλλαγές απόψεων και εµπειριών
να δοθούν απαντήσεις σε κρίσιµα ερωτήµατα
που αφορούν άλλες θεραπευτικές µεθόδους
και την εκπαίδευση των νέων ειδικών Αγγειοχειρουργών.
Το Συνέδριο τιµούν µε την παρουσία τους διακεκριµένοι Έλληνες και ξένοι οµιλητές από την
Ευρώπη και την Αµερική, αλλά και αντιπρόσωποι του Balkan Venous Forum, που θα παρουσιάσουν τη δική τους προσωπική και εθνική
εµπειρία στον τοµέα των φλεβικών παθήσεων.
Είναι για εµάς ιδιαίτερη χαρά και τιµή, η συµµετοχή στο Συνέδριο αυτό όχι µόνο των ξένων
προσκεκληµένων, αλλά και των συναδέλφων
ιατρών από όλα τα µέρη της Ελληνικής Επικράτειας, και σας ευχαριστούµε όλους θερµά
για την παρουσία σας.
The Scientific Programme includes round tables, lectures, workshops, satellite lectures,
and oral presentations. Discussion during the
sessions is encouraged. Distinguished scientists in the venous field have been invited in
the faculty ensuring a high quality scientific
programme.
The Hellenic Phlebological Society has the
privilege to organize this meeting jointly with
the Balkan Venous Forum, which had its inaugural meeting in 2009 in Belgrade, Serbia. Our
aim is to bring together all physicians and
healthcare professionals dealing with the venous diseases in the greater Balkan region and
to promote collaboration in areas of common
interest.
Athens, the venue of the joint Meeting, is one
of the most historical capitals in Europe, with
excellent cultural and historical opportunities.
It is the place where Democracy was born,
while Acropolis with its new museum features
one of the historical highlights representing
the wealth of our human civilization.
We expect you to enjoy a high-quality Meeting along with our wholehearted hospitality
hoping that you will have the opportunity to
spend some fruitful time with friends in a relaxing atmosphere.
We would like to thank you all for coming.
Με συναδελφικούς χαιρετισµούς,
With warm regards,
Οι Πρόεδροι,
The Presidents,
Νικόλαος Παγκράτης
Αθανάσιος Γιαννούκας
Nikolaos Pangratis
Athanasios D. Giannoukas
3
CMYK
ΕΛΛΗΝΙΚΗ ΦΛΕΒΟΛΟΓΙΚΗ EΤΑΙΡΕΙΑ
Επίτιµοι Πρόεδροι:
Μπάλας Π.
Παπαδηµητρίου ∆.
Πανούσης Π.
∆ΙΟΙΚΗΤΙΚΟ ΣΥΜΒΟΥΛΙΟ
Πρόεδρος:
Αντιπρόεδρος:
Γεν. Γραµµατέας:
Ειδ. Γραµµατέας:
Ταµίας:
Μέλη:
Αν. Μέλη:
Παγκράτης Ν.
Κατσένης Κ.
Βασδέκης Σ.
Γιαννούκας Α.
Κώτσης Θ.
Γιαννακάκης Σ.
Καλοδίκη Ε.
Φίλης Κ.
Λάζαρης Α.
Σιγάλα Φ.
HELLENIC PHLEBOLOGICAL SOCIETY
Honorary Presidents: Balas P.
Papadimitriou D.
Panousis P.
BOARD MEMBERS
OF THE HELLENIC PHLEBOLOGICAL SOCIETY
President:
Vice President:
General Secretary:
Assis. Secretary:
Treasurer:
Members:
Assoc. Members:
Pangratis Ν.
Κatsenis Κ.
Vasdekis S.
Giannoukas Α.D.
Kotsis Th.
Giannakakis S.
Kalodiki Ε.
Filis Κ.
Lazaris Α.
Sigala F.
ΟΡΓΑΝΩΤΙΚΗ ΕΠΙΤΡΟΠΗ
ORGANIZING COMMITTEE
ΣΥΜΒΟΥΛΕΥΤΙΚΗ
ΕΠΙΣΤΗΜΟΝΙΚΗ ΕΠΙΤΡΟΠΗ
ADVISORY
SCIENTIFIC COMMITTEE
Baktiroglu S. (Τουρκία)
Droc I. (Ρουµανία)
Geroulakos G. (Μ. Βρετανία)
Goranova E. (Βουλγαρία)
Kalodiki E. (Μ. Βρετανία)
Kapedani E. (Αλβανία)
Kurtoglu M. (Τουρκία)
Labropoulos N. (ΗΠΑ)
Maksimovic Z. (Σερβία)
Milic D. (Σερβία)
Radu D. (Ρουµανία)
Xhepa S. (Αλβανία)
Ανδρικόπουλος Β. (Ελλάδα)
Αρβανίτης ∆. (Ελλάδα)
Andrikopoulos V. (Greece)
Arvanitis D. (Greece)
Baktiroglu S. (Τurkey)
Bastounis E. (Greece)
Christopoulos D. (Greece)
Dimakakos P. (Greece)
Droc I. (Romania)
Gerasimidis Th. (Greece)
Geroulakos G. (U.K.)
Goranova E. (Bulgaria)
Kalodiki E. (U.K.)
Kapedani E. (Albania)
Kiskinis D. (Greece)
Kurtoglu M. (Turkey)
Nικολαΐδης Α.
Μπάλας Π.
Raju S.
Σέχας Μ.
Πρόεδροι Συνεδρίου: Γιαννούκας Α.
Παγκράτης Ν.
Αντιπρόεδροι:
Κατσαµούρης Α.
Κατσένης Κ.
Γεν. Γραµµατέας:
Βασδέκης Σ.
Ταµίες:
Κώτσης Θ.
Φίλης Κ.
Μέλη:
Γεωργιάδης Γ.
Γιαννακάκης Σ.
∆ράκου Α.
Ιωάννου Χ.
Κάκκος Σ.
Κούτσιας Σ.
Κτενίδης Κ.
Κώστας Θ.
Λάζαρης Α.
Ρούσας Ν.
Σιγάλα Φ.
Σφυρόερας Γ.
Επίτιµοι Πρόεδροι:
4
Γερασιµίδης Θ. (Ελλάδα)
∆ηµακάκος Π. (Ελλάδα)
Κισκίνης ∆. (Ελλάδα)
Λαζαρίδης Μ. (Ελλάδα)
Λιάπης Χ. (Ελλάδα)
Μαλτέζος Χ. (Ελλάδα)
Ματσάγκας Μ. (Ελλάδα)
Μπαστούνης Ε. (Ελλάδα)
Πανούσης Π. (Ελλάδα)
Παπαγεωργίου Α. (Ελλάδα)
Παπαδηµητρίου ∆. (Ελλάδα)
Τσέτης ∆. (Ελλάδα)
Τσολάκης Ι. (Ελλάδα)
Χριστόπουλος ∆. (Ελλάδα)
Honorary Presidents: Nicolaides A.
Balas P.
Raju S.
Sechas M.
Presidents:
Giannoukas A.D.
Pangratis N.
Vice-Presidents:
Katsamouris A.N.
Katsenis K.
Secretary General:
Vasdekis S.
Treasurers:
Kotsis Th.
Filis K.
Members:
Drakou A.
Georgiadis G.
Giannakakis S.
Ioannou Ch.
Kakkos S.
Kostas Th.
Koutsias S.
Ktenidis K.
Lazaris A.
Roussas N.
Sigala F.
Sfyroeras G.
Labropoulos N. (U.S.A)
Lazaridis M. (Greece)
Liapis Ch. (Greece)
Maksimovic Z. (Serbia)
Maltezos Ch. (Greece)
Matsagas M. (Greece)
Milic D. (Serbia)
Panousis P. (Greece)
Papadimitriou D. (Greece)
Papageorgiou A. (Greece)
Radu D. (Romania)
Tsetis D. (Greece)
Tsolakis I. (Greece)
Xhepa S. (Albania)
Οµιλητές - Συντονιστές
Associate Professor, Istanbul Medical Faculty, Istanbul University,
Turkey
Ass. Professor, Vascular Surgeon, Stony Brooke Medical Center, USA
Professor of Vascular Surgery, Centre Hospital Univairsitaire Tenon,
Paris-France
Ass. Professor of Vascular Surgery, University National Cardiovascular
Hospital, Sofia-Bulgaria
Senior Vascular Research Fellow, Vascular Surgery Department
Ealing Hospital & Imperial College London-UK
Thrombosis & Haemostasis Research Laboratory,
Loyola University Medical Centre, Maywood IL, USA
Profressor of Vascular Surgery, Tirana - Albania
Vascular Surgeon, Italian Institute of Phlebology, Ferrara-Italy
Professor of General and Vascular Surgery, stanbul Medical Faculty
Emergency Surgery Turkey
Professor of Surgery and Radiology, Director of Vascular Laboratory
Dept of Surgery, Stony Brook University Medical Center, New YorkUSA
Vascular and General Surgeon, Chief of Dept for Vascular Surgery
Clinical Centre Nis, President of Balkan Venous Forum, Serbia
Emeritus Professor of Vascular Surgery, Imperial College, London-UK
Vascular and General Surgeon, Surgical Service Dept. of Vascular Surgery, General Hospital Uzice-Serbia
MD, Head of the Dermatovenerological Clinic, University Clinical
Centre Ljubljana, President of Association of Slovenian Dermatovenerologist, Slovenia
Professor of Internal Medicine, Chief of the Thromboembolism Unit,
University of Padua-Italy
Assist. Professor of Vascular Surgery, Timisoara-Romania
Vascular Surgeon, The RANE Center, Flowood, Mississipi-USA
Assistant Professor of Dermatology, Dept of Dermatology and Allergology, University of Szeged-Hungary
Vascular Surgeon, University Hospital Centre "Mother Teresa",
Tirana-Albania
Αγγειοχειρουργός, Aν Καθηγητής Πανεπιστηµίου Αθηνών, Β' Χειρουργική Κλινική, Νοσοκοµείο ΑΡΕΤΑΙΕΙΟ
Χειρουργός
Αν. Καθηγητής Αγγειοχειρουργικής Πανεπιστηµίου Αθηνών, Αγγειοχειρουργική Μονάδα Γ' ΠΧ Πανεπιστηµιακό Γενικό Νοσοκοµείο ΑΤΤΙΚΟΝ
Αγγειοχειρουργός, Επιµ. B' Αγγειοχειρουργικής Κλινικής, Γενικό Νοσοκοµείο ΚΑΤ
Καθηγητής Αγγειοχειρουργικής Πανεπιστηµίου Θεσσαλίας, ∆ιευθυντής Αγγειοχειρουργικής Κλινικής, Πανεπιστηµιακό Νοσ/µείο Λάρισας
Αγγειοχειρουργός, Αγγειοχειρουργική Κλινική Ιατρικό Κέντρο Αθηνών
Αγγειοχειρουργός, Αγγειοχειρουργική Κλινική Ιατρικό Κέντρο Αθηνών
Οµ. Καθηγητής Αγγειοχειρουργικής Πανεπιστηµίου Αθηνών
Επικουρική Eπιµελήτρια Αγγειοχειρουργικής Κλινικής, Πανεπιστηµιακό Γενικό Νοσοκοµείο Λάρισας
Gasparis Α.
Gerotziafas G.
Goranova E.
Kalodiki E.
Kapedani E.
Kontothanassis D.
Kurtoglu M.
Labropoulos N.
Milic D.
Nicolaides A.
Pejic M.
Planinšek-Rucigaj T.
Prandoni P.
Radu D.
Raju S.
Szolnoky G.
Xhepa S.
Αράπογλου Β.
Βαλσάµης Μ.
Βασδέκης Σ.
Γιαννακάκης Σ.
Γιαννούκας Α.
Γουγουλάκης Α.
∆ελής Κ.
∆ηµακάκος Π.
∆ράκου Κ.
5
Σ Υ Ν Τ Ο Ν Ι Σ Τ Ε Σ
Aksoy Μ.
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ΤΙΤΛΟΣ
Ο Μ Ι Λ Η Τ Ε Σ
ΟΝΟΜΑ
CMYK
ΟΝΟΜΑ
Ο Μ Ι Λ Η Τ Ε Σ
-
Σ Υ Ν Τ Ο Ν Ι Σ Τ Ε Σ
Ιωάννου Χ.
ΤΙΤΛΟΣ
Επίκουρος Καθηγητής Αγγειοχειρουργικής, Αγγειοχειρουργική Κλινική, Ιατρική Σχολή Πανεπιστηµίου Κρήτης, Ηράκλειο
Επ. Καθηγητής, Αγγειοχειρουργική Κλινική Τµ. Ιατρικής Πανεπιστηµίου
Κάκκος Σ.
Πατρών
Κατσαµούρης Α.
Καθηγητής Αγγειοχειρουργικής Α.Π.Θ.
Κατσένης Κ.
Αν. Καθηγητής Αγγειοχειρουργικής Πανεπιστηµίου Αθηνών, Β' Χειρουργική Κλινική Νοσοκοµείο ΑΡΕΤΑΙΕΙΟ
Κισκίνης ∆.
Καθηγητής Χειρουργικής- Αγγειοχειρουργικής
∆ιευθυντή Α' Χειρουργικής Κλινικής ΑΠΘ, Γ.Ν.Θ. Παπαγεωργίου
Κούτσιας Σ.
Λέκτορας Αγγειοχειρουργικής, Πανεπιστηµιακό Νοσοκοµείο Λάρισας
Κτενίδης Κ.
Επίκ. Καθηγητής Αγγειοχειρουργικής, Α' Χειρουργική Κλινική Γ.Ν.Θ.
Παπαγεωργίου
Κώστας Θ.
Επιµελητής Αγγειοχειρουργικής, Παν/κό Νοσ/µείο Ηρακλείου Κρήτης
Κώτσης Θ.
Επ. Καθηγητής Αγγειοχειρουργικής Πανεπιστηµίου Αθηνών, Νοσοκοµείο ΑΡΕΤΑΙΕΙΟ
Λάζαρης Α.
Επ. Καθηγητής Αγγειοχειρουργικής Πανεπιστηµίου Αθηνών, Γ' Χειρουργική Κλινική, Αγγειοχειρουργική Μονάδα Πανεπιστηµιακό Γενικό Νοσοκοµείο ΑΤΤΙΚΟΝ
Λαζαρίδης Μ.
Καθηγητής Αγγειοχειρουργικής ∆.Π.Θ, Αλεξανδρούπολη
Λιάπης Χ.
Καθηγητής Αγγειοχειρουργικής Πανεπιστηµίου Αθηνών, ∆/ντής Αγγειοχειρουργικής Κλινικής, Πανεπιστηµιακό Γενικό Νοσοκοµείο ΑΤΤΙΚΟΝ
Μαλτέζος Χ.
Αγγειοχειρουργός, Συντονιστής-∆/ντής Αγγειοχειρουργικής Κλινικής
Γ.Ν.Α. ΚΑΤ
Ματσάγκας Μ.
Αν. Καθηγητής Αγγειοχειρουργικής, Αγγειοχειρουργική Μονάδα Πανεπιστηµιακού Νοσοκοµείου Ιωαννίνων
Μπαστούνης Η.
Οµ. Καθηγητή Χειρουργικής Πανεπιστηµίου Αθηνών
Μπουντούρογλου ∆. MSc, FRCS, DIC, Αγγειοχειρουργός
Παγκράτης Ν.
Αγγειοχειρουργός, Πρόεδρος Ελληνικής Φλεβολογικής Εταιρείας
Πανούσης Π.
Επικ. Καθηγητής Αγγειοχειρουργικής Πανεπιστηµίου Αθηνών
Παπαγεωργίου Α.
Αγγειοχειρουργός, ∆ιευθυντής Αγγειοχειρουργικής Κλινικής Ναυτικού
Νοσοκοµείου Αθηνών, Πρόεδρος Ελληνικής Αγγειολογικής Εταιρείας
Παπαδηµητρίου ∆.
Καθηγητής Χειρουργικής-Αγγειοχειρουργικής, Ιατρικής Σχολής Α.Π.Θ.
Παπαδοπούλου Χ.
Φυσικοθεραπεύτρια, Τµ. Φυσικοθεραπείας, Πανεπιστηµιακό Γενικό
Νοσοκοµείο Λάρισας
Σάλτα Ρ.
Φυσικοθεραπεύτρια, Τµ. Φυσικοθεραπείας, Πανεπιστηµιακό Γενικό
Νοσοκοµείο Λάρισας
Σιγάλα Φ.
Λέκτορας Αγγειοχειρουργικής, Α' Προπαιδευτική Χειρουργική Κλινική Πανεπιστηµίου Αθηνών Γ.Ν.Α. ΙΠΠΟΚΡΑΤΕΙΟ
Σφυρόερας Γ.
Αγγειοχειρουργός, Eπιµελητής Αγγειοχειρουργικής Κλινικής, Πανεπιστηµιακό Γενικό Νοσοκοµείο Λάρισας
Τραυλού Α.
Αιµατολόγος, Αν. Καθηγήτρια Ιατρικής Σχολής Ε.Κ.Π.Α., ∆/ντρια Αιµατολογικού Εργαστηρίου-Μονάδας Αιµοδοσίας Π.Γ.Ν. ΑΤΤΙΚΟΝ
Τριπολίτης Α.
Αγγειοχειρουργός, Τέως Πρόεδρος Αγγειολογικής Εταιρείας
Τσολάκης Ι.
Καθηγητής Αγγειοχειρουργικής, ∆/ντής Αγγειοχειρουργικής Κλινικής
Παν/κού Νοσ/µείου Πατρών
Φίλης Κ.
Επίκ. Καθηγητής Αγγειοχειρουργικής Ε.Κ.Π.Α., Α' Προπαιδευτική Χειρουργική Κλινική Πανεπιστηµίου Αθηνών Γ.Ν.Α. ΙΠΠΟΚΡΑΤΕΙΟ
Χριστόπουλος ∆.
Αν. Καθηγητής Αγγειοχειρουργικής, Νοσοκοµείο Γεννηµατάς Θεσσαλονίκης
6
Faculty List
Aksoy M.
Associate Professor, Istanbul Medical Faculty, Istanbul University,
Turkey
Ass. Professor of Vascular Surgery, University of Athens, Aretaieion
Hospital, Greece
Emeritus Professor of Vascular Surgery, University of Athens-Greece
MSc, FRCS, DIC, Vascular Surgeon, Athens-Greece
Ass. Professor of Vascular Surgery, Gennimatas Hospital, Thessaloniki-Greece
PhD, FRCS, Consultant Vascular/Endovascular Surgeon, Athens Medical Center, Greece
Emeritus Professor of Vascular Surgery, University of Athens-Greece
Registrar in Vascular Surgery, Dept of Vascular Surgery, University
General Hospital of Larissa-Greece
Assist. Professor of Vascular Surgery, 1st Propedeutic Dept of Surgery, Hippokrateion Hospital of Athens-Greece
Ass. Professor, Vascular Surgeon, Stony Brooke Medical Center, USA
Professor of Vascular Surgery, Centre Hospital Univairsitaire Tenon,
Paris-France
MD, PhD, Vascular Surgeon, KAT Hospital, Athens-Greece
Professor of Vascular Surgery, University General Hospital of LarissaGreece
Ass. Professor of Vascular Surgery, University National Cardiovascular
Hospital, Sofia-Bulgaria
Vascular Surgeon, Dept of Vascular Surgery, Athens Medical Center,
Greece
Assist. Professor of Vascular Surgery
University of Crete Medical School, Heraklion, Crete-Greece
Ass. Professor of Vascular Surgery, University of Patras Medical
School, Patras-Greece
Senior Vascular Research Fellow, Vascular Surgery Department
Ealing Hospital & Imperial College London-UK
Thrombosis & Haemostasis Research Laboratory,
Loyola University Medical Centre, Maywood IL, USA
Professor of Vascular Surgery, Tirana - Albania
Professor of Vascular Surgery, Αristoteleian University of Thessaloniki-Greece
Ass. Professor of Vascular Surgery, University of Athens, Aretaieion
Hospital, Greece
Professor of Vascular Surgery, Aristotelian University of ThessalonikiGreece
Vascular Surgeon, Italian Institute of Phlebology, Ferrara-Italy
MD, Consultant in Vascular Surgery, University Hospital of Heraklion,
Crete-Greece
Assistant Professor of Vascular Surgery, University of Athens, Aretaieion Hospital, Greece
Lecturer in Vascular Surgery, University Hospital of Larissa-Greece
Assistant Professor of Vascular Surgery, Aristotelian University of
Thessaloniki-Greece
Professor of General and Vascular Surgery, stanbul Medical Faculty
Emergency Surgery Turkey
Professor of Surgery and Radiology, Director of Vascular Laboratory
Dept of Surgery, Stony Brook University Medical Center, New YorkUSA
Arapoglou V.
Bastounis E.
Bountouroglou D.
Christopoulos D.
Delis K.
Dimakakos P.
Drakou K.
Filis K.
Gasparis A.
Gerotziafas G.
Giannakakis S.
Giannoukas A.
Goranova E.
Gougoulakis A.
Ioannou Ch.
Kakkos S.
Kalodiki E.
Kapedani E.
Katsamouris A.
Katsenis K.
Kiskinis D.
Kontothanassis D.
Kostas Th.
Kotsis Th.
Koutsias S.
Ktenidis K.
Kurtoglu M.
Labropoulos N.
7
L I S T
TITLE
F A C U L T Y
NAME
CMYK
NAME
TITLE
Lazarides M.
Professor in Vascular Surgery, Democritus University, Alexandroupolis-Greece
Assistant Professor of Vascular Surgery, University of Athens, Attikon
General Hospital, Greece
Professor of Vascular Surgery, University of Athens, Attikon General
Hospital, Greece
Vascular Surgeon, Director-Head of Vascular Department General
Hospital of Attica "KAT", Athens-Greece
Assosiate Professor of Vascular Surgery, Dept of Surgery-Vascular
Surgery Unit, Medical School, University of Ioannina-Greece
Vascular and General Surgeon, Chief of Dept for Vascular Surgery
Clinical Centre Nis, President of Balkan Venous Forum, Serbia
Emeritus Professor of Vascular Surgery, Imperial College, London-UK
Vascular Surgeon, President of the Hellenic Phlebological Society, Athens-Greece
Ass. Professor of Vascular Surgery, University of Athens-Greece
Professor of Vascular Surgery, Medical School Aristotelian University
of Thessaloniki-Greece
Physiotherapist, Physiotherapy Dept, University General Hospital of
Larisa
Vascular Surgeon, President of the Hellenic Society of Angiology, Director of Vascular Clinic of Naval and Veterans Hospital of AthensGreece
Vascular and General Surgeon, Surgical Service Dept. of Vascular Surgery, General Hospital Uzice-Serbia
MD, Head of the Dermatovenerological Clinic, University Clinical
Centre Ljubljana, President of Association of Slovenian Dermatovenerologist, Slovenia
Professor of Internal Medicine, Chief of the Thromboembolism Unit,
University of Padua-Italy
Assist. Professor of Vascular Surgery, Timisoara-Romania
Vascular Surgeon, The RANE Center, Flowood, Mississipi-USA
Physiotherapist, Physiotherapy Dept, University General Hospital of
Larisa
Vascular Surgeon, University General Hospital of Larissa-Greece
Lecturer in Vascular Surgery, University of Athens Medical School,
Greece
Assistant Professor of Dermatology, Dept of Dermatology and Allergology, University of Szeged-Hungary
Haematologist, Assoc. Professor, School of Medicine, University of Athens, Head of Haematology Laboratory & Blood Transfusion Unit
"ATTIKON" University General Hospital, Athens-Greece
Vascular Surgeon, Former President of Hellenic Vascular Society, Athens-Greece
Professor of Vascular Surgery, Director of Vascular Surgery Dept , University of Patras-Greece
Surgeon, Athens-Greece
Ass. Professor of Vascular Surgery, University of Athens, Attikon General Hospital, Greece
Vascular Surgeon, University Hospital Centre "Mother Teresa",
Tirana-Albania
Lazaris A.
Liapis Ch.
Maltezos Ch.
Matsagkas M.
Milic D.
Nicolaides A.
Pangratis N.
L I S T
Panousis P.
Papadimitriou D.
Papadopoulou Ch.
Papageorgiou A.
F A C U L T Y
Pejic M.
Planinšek-Rucigaj T.
Prandoni P.
Radu D.
Raju S.
Salta R.
Sfyroeras G.
Sigala F.
Szolnoky G.
Travlou A.
Tripolitis A.
Tsolakis I.
Valsamis M.
Vasdekis S.
Xhepa S.
8
08:00-08:30 Εγγραφές
ΑΙΘΟΥΣΑ «ΣΩΚΡΑΤΗΣ Α»
Friday, January 21st 2011
Registration
HALL «SOCRATES A»
08:30-10:30 Προφορικές Ανακοινώσεις Ι
Oral Presentations Ι
10:30-11:00 ∆ιάλειµµα καφέ-Επίσκεψη στην Έκθεση
Coffee Break-Visit to the Exhibition
11:00-12:30 Στρογγυλό Τραπέζι Ι: Ανάπτυξη και
Εξέλιξη χρόνιας φλεβικής νόσου
Round Table Ι: Development and
progression of Chronic Venous Disease
12:30-14:00 Στρογγυλό Τραπέζι ΙI: Αντιµετώπιση
χρόνιας φλεβικής νόσου
Round Table ΙI: Management of Chronic
Venous Disease
14:00-15:00 Ελαφρύ Γεύµα
Light Lunch
15:00-16:30 Προφορικές Ανακοινώσεις ΙΙ
Oral Presentations ΙΙ
16:30-17:10 Σενάρια φλεβικών περιπτώσεων
Venous Case Scenarios
17:10-17:30 ∆ορυφορική ∆ιάλεξη: Αποτελέσµατα
µελέτης CALISTO για τη θεραπεία της
επιπολής φλεβικής θρόµβωσης
Satellite Lecture: Treatment of superficial
vein thrombosis in the legs, lessons from
the CALISTO trial
17:30-18:00 ∆ιάλειµµα καφέ-Επίσκεψη στην Έκθεση
Coffee Break-Visit to the Exhibition
18:00-18:20 ∆ιάλεξη Ι: Τεχνικές επανασυραγγοποιήσης και ενδοναρθηκών
Invited Lecture I: Recannalization and
stenting techniques
18:20-18:40 ∆ιάλεξη ΙΙ: Σύγκριση των µοντέλων
εκτίµησης του κινδύνου για φλεβική
θροµβοεµβολή
Invited lecture II: Comparative evaluation
of risk assessment models for VTE
19:00-20:00 Τελετή Έναρξης
Opening Ceremony
19:00-19:20 Χαιρετισµοί
Welcome Addresses
19:20-20:00 Εναρκτήρια ∆ιάλεξη:
Σύγχρονη αντιµετώπιση
θροµβοεµβολής
Opening Lecture:
The state-of-the-art management of venous
thromboembolism
20:00
Welcome Reception
∆εξίωση Υποδοχής
Σάββατο, 22 Ιανουαρίου 2011
ΑΙΘΟΥΣΑ «ΣΩΚΡΑΤΗΣ Α»
Saturday, January 22nd 2011
HALL «SOCRATES A»
08:00-10:00 Προφορικές Ανακοινώσεις ΙΙΙ
Oral Presentations ΙΙΙ
10:00-11:30 Στρογγυλό Τραπέζι ΙIΙ: Φλεβική
Θροµβοεµβολή – Τι νεώτερο;
Round Table ΙIΙ: Venous Thromboembolism –
What’s new?
11:30-12:00 ∆ιάλειµµα καφέ-Επίσκεψη στην Έκθεση
Coffee Break-Visit to the Exhibition
11:30-12:00 Συνεδρίαση Προεδρείου
Balkan Venous Forum
Balkan Venous Forum Board Meeting
12:00-12:30 Επίσηµη ∆ιάλεξη Ελληνικής
Φλεβολογικής Εταιρείας: Φλεβικές
Αγγειοδυσπλασίες
Hellenic Phlebological Society Keynote
Lecture: Venous Malformations
12:30-14:15 Στρογγυλό Τραπέζι ΙV: Πως κάνω...
Round Table ΙV: How I do it
14:15-15:15 Ελαφρύ Γεύµα
Light Lunch
14:45-15:30 Γενική Συνέλευση Balkan Venous Forum
Balkan Venous Forum General Assembly
15:30-18:15 Πρακτικό Σεµινάριο: Ενδαγγειακές
Τεχνικές Φλεβικών Παθήσεων
Workshop: Endovenous Treatment of
Venous Diseases
18:15-18:45 ∆ιάλειµµα καφέ-Επίσκεψη στην Έκθεση
Coffee Break-Visit to the Exhibition
18:45-20:15 Στρογγυλό Τραπέζι V: Οίδηµα κάτω
άκρου: ∆ιάγνωση και Θεραπεία
Round Table V: Limb swelling: Diagnosis
and treatment
20:15-20:30 Απονοµή Βραβείων-Λήξη Συνεδρίου
Prize announcement-Closing Remarks
9
Π Ρ Ο Γ ΡΑ Μ Μ Α Μ Ε Μ Ι Α Μ ΑΤ Ι Α • P R O G R A M AT A G L A N C E
Παρασκευή, 21 Ιανουαρίου 2011
CMYK
10
Ε π ι σ τ η µ ο ν ι κ ό Π ρ ό γρ α µ µ α
Scientific Program
11
CMYK
Παρασκευή 21 Ιανουαρίου 2011
Αίθουσα «ΣΩΚΡΑΤΗΣ Α»
08:00 – 08:30 Εγγραφές
Ι α ν ο υ α ρ ί ο υ
2 0 1 1
08:30 – 10:30 Προφορικές Ανακοινώσεις I
Προεδρείο: K. Φίλης (Ελλάδα) – S. Xhepa (Αλβανία)
Ο01
O02
O03
O04
Π α ρ α σ κ ε υ ή
2 1
O05
O06
O07
O08
O09
12
H3 AND H4 RECEPTOR-MEDIATED EFFECTS IN PERIPHERAL BLOOD
VESSELS IN ADJUVANT ARTHRITIS
Kyriakidis K, Zampeli E, Tiligada E
Department of Pharmacology, Medical School, University of Athens,
Athens, Greece
SCLEROTHERAPY OF TELANGIECTASES, RETICULAR AND VARICOSE
VEINS: SYSTEMATIC REVIEW OF SAFETY DATA
Eugenia Ch. Yiannakopoulou
Department of Basic Medical Lessons Faculty of Health and Caring
Professions Technological Educational Institute of Athens
SPLACHNIC VEIN THROMBOSIS AND PREDISPOSING FACTORS:
A RETROSPECTIVE STUDY OF SIXTEEN CASES
Kouvelos George1, Koliou Panagiotis2, Mitsis Michalis3, Kolaitis Nikolaos2,
Vartholomatos George2, Fatouros Michalis3, Matsagkas Miltiadis1
1
Department of Surgery- Vascular Surgery Unit, Medical School, University
of Ioannina
2
Haematology Laboratory, Molecular Biology Unit, University Hospital of
Ioannina
3
Department of Surgery, Medical School, University of Ioannina
REVIEW OF DEEP VEIN THROMBOSES HOSPITALIZED IN OUR CLINIC:
A FIVE YEARS EXPERIENCE
Pyrgakis K, Kasfikis F, Goulas S, Giannakakis S, Siskos D,
Papacharalambous G, Antoniou I, Maltezos Ch.
Vascular Surgery Clinic of KAT Hospital, Athens, Greece
DEEP VEIN THROMBOSIS IN A CASE OF ADAMANTIADIS- BEHCET
DISEASE: A CASE AND A REVIEW
Voulalas G, Giannakakis S, Psyllas A, Papacharalambous G, Goulas S,
Antoniou I, Maltezos Ch.
Vascular Suregry Clinic of KAT Hospital, Athens, Greece
PRIMARY VARICOSE VEINS OF THE UPPER EXTREMITY.
Xanthopoulos D, Loupou A, Papavasiliou V, Kaperonis E, Bazigos G,
Melas M, Karathanos C, Arvanitis D.
Department of vascular surgery, Sismanoglio General Hospital of Athens
CASE REPORT: SPONTANEOUS THROMBOSIS OF THE AXILLARYSUBCLAVIAN VEIN CAUSING SUPERIOR VENA CAVA SYNDROME
Philippakis G.1, Gionis M.1, Mitsikas D.2, Spyrantis M.2, Papadopoulos L.2,
Samiotakis E.3, Zarifis G.3, Moustardas M.1
1
Thoracic and Vascular Surgery Department, Chania General Hospital,
Greece
2
Department of General Surgery, Chania General Hospital, Greece
3
Department of Radiology, Chania General Hospital, Greece
CASE REPORT: ILIOFEMORAL DVT CAUSING CHRONIC PELVIC PAIN
SYNDROME
Spyrantis M.2, Mitsikas D.2, Philippakis G.1, Moustardas M.1
1
Thoracic and Vascular Surgery Department, Chania General Hospital,
Greece
2
Department of General Surgery, Chania General Hospital, Greece
CASE REPORT: GALLBLADDER HYDROPS CAUSING INTERMITTENT
LIMB OEDEMA
Oikonomou K.2, Mitsikas D.2, Korakas P.3, Gionis M.1, Zarifis G.3,
Fragkiadakis G.1, Moustardas M.1
1
Thoracic and Vascular Surgery Department, Chania General Hospital,
Greece
2
Department of General Surgery, Chania General Hospital, Greece
3
Department of Radiology, Chania General Hospital, Greece
O10
O12
11:00 – 12:30 Στρογγυλό Τραπέζι I
ΑΝΑΠΤΥΞΗ ΚΑΙ ΕΞΕΛΙΞΗ ΧΡΟΝΙΑΣ ΦΛΕΒΙΚΗΣ ΝΟΣΟΥ
Συντονιστές: ∆. Χριστόπουλος (Ελλάδα) – T. Planinšek Ručigaj (Σλοβενία)
11:50 – 12:30 Συζήτηση
13
2 0 1 1
11:00 – 11:10 Παθογένεια και φυσική ιστορία πρωτοπαθούς Φλεβικής Νόσου
N. Labropoulos (ΗΠΑ)
11:10 – 11:20 Κατηγοριοποίηση και βαθµονόµηση Χρόνιας Φλεβικής Νόσου
Σ. Κάκκος (Ελλάδα)
11:20 – 11:30 Η σηµασία της ανεπάρκειας του επιπολής φλεβικού δικτύου
στη Χρόνια Φλεβική Νόσο
Σ. Βασδέκης (Ελλάδα)
11:30 – 11:40 Ο ρόλος των διατιτραινουσών στη πρόοδο και βαρύτητα της Χρόνιας
Φλεβικής Νόσου
Κ. ∆ελής (Ελλάδα)
11:40 – 11:50 Πρόοδος της χρόνιας φλεβικής νόσου: υπάρχουν προδιαθετικοί παράγοντες?
T. Κώστας (Ελλάδα)
Ι α ν ο υ α ρ ί ο υ
10:30 – 11:00 ∆ιάλειµµα Καφέ – Επίσκεψη στον χώρο της Έκθεσης
2 1
O13
Π α ρ α σ κ ε υ ή
O11
CASE REPORT: AMPUTATIVE INJURY OF THE UPPER EXTREMITY AFTER
GUNSHOT-NECESSITY OF VEIN REPAIR
Gionis M.1, Manimanaki A,2. Poulios G.1, Philippakis G.1, Kaimasidis G.1,
Mitsikas D.3, Tsantrizos P.3, Kontoudaki E.4, Fratzeskaki S.5, Mantakas E.6,
Moustardas M.1
1
Thoracic and Vascular Surgery Department, Chania General Hospital,
Greece
2
Department of Orthopedic Surgery, Chania General Hospital, Greece
3
Department of General Surgery, Chania General Hospital, Greece
4
Intensive Care Unit, Chania General Hospital, Greece
5
Department of Anesthesiology, Chania General Hospital, Greece
6
Department of Radiology, Chania General Hospital, Greece
CASE REPORT: ALMOST FATAL ILIOFEMORAL VEIN’S BLEEDING BECAUSE
OF A DOUBLE GUNSHOT
Antoniou Ch.2, Tsiminikakis N.2, Lampousakis E.2, Mitsikas D.2, Spyrantis M.2,
Philippakis G.1, Moustardas M.1
1
Thoracic and Vascular Surgery Department, Chania General Hospital, Greece
2
Department of General Surgery, Chania General Hospital, Greece
PLASMINOGEN ACTIVATOR INHIBITOR-1 AND D-DIMMERS AFTER
LAPAROSCOPIC VERSUS OPEN SURGERY FOR COLON CANCER RESECTION
F. Sigala1, A. Travlou2, E. Merkouri2, D. Tsamis1, D. Linardoutsos1, K. Lilis1,
T. Hristophidis1, G. Theodoropoulos1, E. Leandros1, G. Zografos1, K. Filis1
1
First Department of Propaedeutic Surgery, Hippokrateion Hospital, University of Athens Medical School, Greece
2
Laboratory of Haematology-Blood Tranfusion Unit, Attikon Hospital, University of Athens Medical School, Greece
VARICOSE VEINS DISEASE COMPLICATED BY SUPERFICIAL VEIN
THROMBOSIS: EVALUATION OF VEIN WALL APOPTOSIS AS A
PREDISPOSING FACTOR.
K. Filis1, N. Kavantzas2, D. Hrisikos1, T. Isopoulos1, D. Linardoutsos1,
P. Antonakis1, E. Lagoudianakis1, E. Gomatos1, G. Zografos 1, F. Sigala1
1
Division of Vascular Surgery, First Department of Propaedeutic Surgery,
University of Athens Medical School, Athens, Greece
2
First Department of Pathology, University of Athens Medical School, Athens, Greece
CMYK
12:30 – 14:00 Στρογγυλό Τραπέζι II
Π α ρ α σ κ ε υ ή
2 1
Ι α ν ο υ α ρ ί ο υ
2 0 1 1
ΑΝΤΙΜΕΤΩΠΙΣΗ ΧΡΟΝΙΑΣ ΦΛΕΒΙΚΗΣ ΝΟΣΟΥ
Συντονιστές: A. Κατσαµούρης (Ελλάδα) – M. Kurtoglu (Τουρκία)
12:30 – 12:40 Έχει σηµασία το µήκος εκρίζωσης της µείζονος σαφηνούς;
T. Κώστας (Ελλάδα)
12:40 – 12:50 Θεραπεία µε laser της µείζονος και ελάσσονος σαφηνούς φλέβας:
πρώιµα και απώτερα αποτελέσµατα
D. Kontothanassis (Ιταλία)
12:50 – 13:00 Θεραπεία µε ραδιοσυχνότητες: πρώιµα και απώτερα αποτελέσµατα
A. Gasparis (ΗΠΑ)
13:00 – 13:10 Είναι ασφαλής η σκληροθεραπεία των φλεβικών κιρσών µε αφρό;
∆. Μπουντούρογλου (Ελλάδα)
13:10 – 13:20 Ενδείξεις και τεχνικές φλεβικής αγγειοδιαστολής
S. Raju (ΗΠΑ)
13:20 – 13:30 Θεραπεία φλεβικών ελκών
D. Milic (Σερβία)
13:30 – 14:00 Συζήτηση
14:00 – 15:00 Ελαφρύ Γεύµα
15:00 – 16:30 Προφορικές Ανακοινώσεις II
Προεδρείο: A. Λάζαρης (Ελλάδα) - E. Goranova (Βουλγαρία)
O14
O15
O16
O17
O18
O19
O20
O21
14
PERCUTANEOUS PROSTHETIC VENOUS VALVE AS ENDOVASCULAR
TREATMENT OF LOWER LIMB REFLUX
Constantinos Zervides
Cardiovascular Implants & Medical Devices Research Group
Intercollege Larnaca, Larnaca
MULTI-LAYER BANDAGING SYSTEM WITH TUBULCUS® IN THE
TREATMENT OF VENOUS LEG ULCERS
Vladimir Zivkovic, MD; Robert Stefanovic, MD; Zoran Damnjanovic, MD;
Vladimir Stojiljkovic, MD; Sasa Zivic, MD; Dragan Milic, MD, PhD
Clinic for Vascular Surgery, Clinical Centre Nis, Serbia
POSTTHROMBOPHLEBITIS SYNDROME- DIAGNOSTIC AND PHYSICAL
THERAPY
Dragica Rondovic, Rade Kostic, Zaklina Damnjanovic
Special centre for rehabilitation “Gamzigrad” Gamzigradska banja” Serbia
INHERITANCE IS AN IMPORTANT RISK FACTOR FOR CHRONIC VENOUS
INSUFFICIENCY
Matić Milan1, Duran Verica1, Gajinov Zorica1, Rajić Novak1,
Matić Aleksandra2, Ivkov Smić Milana1, Roš Tatjana1
1
Clinical center of Vojvodina, Dermatovenereological Clinic, Novi Sad, Serbia
2
Institute for Child and Youth health care of Vojvodina, Novi Sad, Serbia
OBESITY AND AGING AS RISK FACTORS OF SUPERFICIAL
THROMBOPHLEBITIS IN PATIENTS WITH PRIMARY VARICOSE VEINS
Karathanos Ch., Saleptsis V., Roussas N., Antoniou G., Sfyroeras G.,
Koutsias S., Giannoukas AD.
Department of Vascular Surgery, University Hospital of Larissa, Larissa, Greece
CLINIC PRESENTATION OF VENOUS CONGENITAL MALFORMATIONS
Javorka Delic
THE IMPORTANCE OF PREOPERATIVE ULTRASONOGRAPHY CHECKUP
OF LOWER LIMB DEEP VEINS IN THE PATIENTS WITH HIP AND KNEE SURGERY
Zivanic D, Nikolic- Pucar J, Gajic D, Lolic S.
Institute for Physical Medicine and Rehabilitation “ Dr Miroslav Zotovic”
B. Luka, RS, BiH
COMBINED MANAGEMENT OF THE GIGANTIC AND SQUALID
VENOUS ULCERS
MA Pejić, NP Lučić, RM Koprivica, JS Stanković, B. Nikitović
Surgical service-dept. of vascular surgery, General hospital Užice, Serbia
O22
DEEP VEIN THROMBOSIS AND PULMONARY THROMBOEMBOLISM
DURING PREGNANCY – RECCOMENDATION FOR SAFE BIRTH DELIVERY
Miljko A. Pejic, NP Lucic, RM Koprivica, JS Stankovic
General hospital Uzice – vascular surgery dept., Uzice, Serbia
16:30 – 17:00 Σενάρια φλεβικών περιπτώσεων
Συντονιστής: N. Labropoulos (ΗΠΑ)
Π α ρ α σ κ ε υ ή
17:10 – 17:30 ∆ορυφορική ∆ιάλεξη
Προεδρείο: ∆. Παπαδηµητρίου (Ελλάδα) – D. Radu (Ρουµανία)
Αποτελέσµατα µελέτης CALISTO για τη θεραπεία της επιπολής
φλεβικής θρόµβωσης
P. Prandoni (Iταλία)
17:30 – 18:00 ∆ιάλειµµα – Επίσκεψη στον χώρο της Έκθεσης
18:00 – 18:20 ∆ιάλεξη Ι
Προεδρείο: Η. Μπαστούνης (Ελλάδα) – G. Szolnoky (Ουγγαρία)
Τεχνικές επανασηραγγοποιήσης και ενδοναρθηκών
S. Raju (ΗΠΑ)
18:20 – 18:40 ∆ιάλεξη ΙΙ
Προεδρείο: Σ. Βασδέκης (Ελλάδα) – E. Kapedani (Αλβανία)
2 1
Σύγκριση των µοντέλων εκτίµησης του κινδύνου για φλεβική
θροµβοεµβολή
G. Gerotziafas (Γαλλία)
Ι α ν ο υ α ρ ί ο υ
19:00 – 20:00 Τελετή Έναρξης
19:00 – 19:20 Xαιρετισµοί
Προεδρείο: N. Παγκράτης (Ελλάδα) – Α. Γιαννούκας (Ελλάδα)
19:20 – 20:00 Εναρκτήρια ∆ιάλεξη
Προεδρείο: X. Λιάπης (Ελλάδα) – Π. Μπάλας (Ελλάδα)
Σύγχρονη αντιµετώπιση θροµβοεµβολής
A. Nicolaides (Κύπρος)
20:00
∆εξίωση Υποδοχής
2 0 1 1
15
CMYK
Σάββατο 22 Ιανουαρίου 2011
Αίθουσα «ΣΩΚΡΑΤΗΣ Α»
08:00 – 10:00 Προφορικές Ανακοινώσεις III
Προεδρείο: Θ. Κώτσης (Ελλάδα) – M. Pejic (Σερβία)
Ι α ν ο υ α ρ ί ο υ
2 0 1 1
O23
O24
O25
O26
O27
Σ ά β β α τ ο
2 2
O28
O29
O30
O31
O32
16
3D MODELLING OF A VENOUS VALVE: HOW EFFECTIVE ARE POSTURAL
CHANGES UNDER GRAVITY, IN “WASHOUT” RECIRCULATORY
REGIONS IN THE LEE OF VENOUS VALVES?
Dr. Constantinos Zervides
Cardiovascular Implants & Medical Devices Research Group Intercollege
Larnaca, Larnaca
A RANDOMIZED TRIAL OF CLASS 2 AND CLASS 3 ELASTIC COMPRESSION
IN THE PREVENTION OF RECURRENCE OF VENOUS ULCERATION
Robert Stefanovic, MD; Vladimir Zivkovic, MD; Zoran Damnjanovic, MD;
Vladimir Stojiljkovic, MD; Sasa S. Zivic, MD; Dragan J. Milic, MD, PhD
Clinic for Vascular Surgery, Clinical Centre Nis, Serbia
THE ROLE OF COLOR DUPLEX SONOGRAPHY IN RECCURENT
VARICOSE VEIN SURGERY
Kostov I.1, Mladenovic D.1, Kostova N.2, Uzunova T.1
1
Surgery Clinic- “ St. Naum Ohridski” Skopje, F.Y.R.O.M.
2
Clinic of Cardiology– Skopje, F.Y.R.O.M.
SURGICAL CORRECTION OF ISOLATED SUPERFICIAL REFLUX IN
CHRONIC VENOUS LEG ULCERATION OFFERS FAVOURABLE ULCER
HEALING RATE WITH MINIMAL LONG-TERM RECURRENCES
Terzoudi S, Georgakarakos E, Karpouzis A, Georgiadis G, Lazarides M.
Department of Vascular Surgery, Alexandroupolis Univercity Hospital,
Dimokritos Univercity
QUALITY OF LIFE IMPROVEMENTS AFTER ENDOVENOUS TREATMENTS
CORRELATE WITH BASELINE VALUES RATHER THAN SEVERITY
SCORES OR TYPE OF INTERVENTION
Lattimer C1,2, Kalodiki E1,2, Azzam M1, Shawish E1, Makris G1,2, Geroulakos G1,2
1
Ealing Hospital, Middlesex, UK
2
Imperial College, London, SW7 2AZ
CLINICAL AND ANATOMIC CHARACTERISTICS OF PATIENTS REQUIRING
SECONDARY PROCEDURES AFTER GREAT SAPHENOUS ENDOVENOUS
ABLATION
Angela A. Kokkosis, M.D. and Harry Schanzer, M.D.
Division of Vascular Surgery, The Mount Sinai Medical Center, NY
HEALING OF ACUTE AND CHRONIC WOUNDS: DON’T FORGET LYMPHATICS!
Szolnoky G1, Erős G2, Szentner K2, Szabad G1, Dósa-Rácz É1, Kemény L1,3
1
Department of Dermatology and Allergology, University of Szeged, Hungary
2
Institute of Surgical Research, University of Szeged, Hungary
3
Dermatological Research Group of the Hungarian Academy of Sciences,
Szeged, Hungary
QUALITY OF LIFE IN PATIENTS WITH LYMPHOEDEMA: INITIAL RESULTS
OF THE ONLY GREEK LYMPHOEDEMA CENTRE IN THE PUBLIC SECTOR
Papadopoulou Ch., Roussas N., Salta R., Tsioli S., Tsiouri I., Nakos Ch.,
Roussaki Schulze A-V., Giannoukas A.D.
Lymphoedema Centre and Departments of Vascular Surgery and
Dermatology, University Hospital of Larissa, Larissa, Greece
CLINIC INDICATORS OF HARD–TO-HEAL VENOUS ULCERATIONS
Javorka Delic
ENDOVENOUS LASER ABLATION TREATMENT IN THE TREATMENT
OF VARICOSE VEIN DISEASE
Dr. Stylianos Papas M.D, Vascular Surgeon
Dr. Eleftherios Koulouteris M.D, F.MAS, D.MAS, General Surgeon
O33
O34
10:00 – 11:30 Στρογγυλό Τραπέζι III
ΦΛΕΒΙΚΗ ΘΡΟΜΒΟΕΜΒΟΛΗ – ΤΙ ΝΕΩΤΕΡΟ;
Συντονιστές: ∆. Κισκίνης (Ελλάδα) – Κ. Κατσένης (Ελλάδα)
2 2
10:00 – 10:10 Ποιός πρέπει να ελέγχεται για θροµβοφιλία
A. Nicolaides (Κύπρος)
10:10 – 10:20 Περιπατητική θεραπεία ΕΒΦΘ
M. Kurtoglu (Τουρκία)
10:20 – 10:40 Φαρµακοµηχανική θροµβόλυση για εγγύς ΕΒΦΘ
A. Gasparis (ΗΠΑ)
10:40 – 10:50 Ενδείξεις χρήσης φίλτρων κάτω κοίλης φλέβας
M. Aksoy (Τουρκία)
10:50 – 11:00 Νέες µορφές αντιπηκτικών
A. Τραυλού (Ελλάδα)
Σ ά β β α τ ο
O35
H ΧΡΗΣΗ ΕΠΙΘΕΜΑΤΩΝ ΜΕ ΑΡΓΥΡΟ ΣΤΗΝ ΘΕΡΑΠΕΙΑ ΕΠΟΥΛΩΣΗΣ
ΤΩΝ ΦΛΕΒΙΚΩΝ ΕΛΚΩΝ
∆ηµακάκος Ε., Καλκανδής Χρ., ∆αφνής ∆., Βασιλόπουλος Ι., Καλλίνης Α.,
Λοίζος Α., Κατσένη Κ., Κατσένης Κ.
Αγγειοχειρουργική Μονάδα Β΄ Χειρουργικής Κλινικής Πανεπιστηµίου
Αθηνών Αρεταίειο Νοσοκοµείο
ΟΙ ΘΕΡΜΟΡΥΘΜΙΣΤΙΚΕΣ ΜΕΤΑΒΟΛΕΣ ΤΟΥ ∆ΕΡΜΑΤΟΣ ΣΤΗ ΧΡΟΝΙΑ
ΦΛΕΒΙΚΗ ΝΟΣΟ
∆ηµακάκος Ε., Κατσένης Κ., Αράπογλου Β., Καλκανδής Χ., ∆αφνής ∆.,
Βασιλόπουλος Ι., Καλλίνης Α., Λοίζος Α., Κατσένη Κ.
Αγγειοχειρουργική Μονάδα Β΄ Χειρουργικής Κλινικής Αρεταιείου
Πανεπιστηµιακού Νοσοκοµείου Αθηνών
OVARIAN VEIN REFLUX AND RECURRENT VARICOSE VEINS.
REPORT OF TWO CASES
Vasdekis S., Athanasiadis D., Broutzos E., Lazaris A.
Vascular Unit, 3RD Surgical Department, University Hospital Attikon, Athens, Greece
Ι α ν ο υ α ρ ί ο υ
11:10 – 11:30 Συζήτηση
11:30 – 12:00 ∆ιάλειµµα – Επίσκεψη στον χώρο της Έκθεσης
11:30 – 12:00 Συνάντηση Προεδρείου Balkan Venous Forum
12:00 – 12:30 Επίσηµη ∆ιάλεξη Ελληνικής Φλεβολογικής Εταιρείας
Προεδρείο: I. Τσολάκης (Ελλάδα) – Α. Τριπολίτης (Ελλάδα)
Φλεβικές αγγειοδυσπλασίες
Π. ∆ηµακάκος (Ελλάδα)
2 0 1 1
12:30 – 14:15 Στρογγυλό Τραπέζι IV
ΠΩΣ ΚΑΝΩ...
Συντονιστές: Α. Γουγουλάκης (Ελλάδα) – Χ. Μαλτέζος (Ελλάδα)
12:30 – 12:40 Πως εξετάζω µε υπερήχους
Β. Αράπογλου (Ελλάδα)
12:40 – 12:50 Πως κάνω εκρίζωση
∆. Χριστόπουλος (Ελλάδα)
12:50 – 13:00 Πως κάνω τοπικές εκτοµές
Α. Παπαγεωργίου (Ελλάδα)
13:00 – 13:10 Πως κάνω σκληροθεραπεία σαφηνούς
M. Βαλσάµης (Ελλάδα)
13:10 – 13:20 Πως κάνω σκληροθεραπεία σε ευρυαγγείες
Σ. Γιαννακάκης (Ελλάδα)
13:20 – 13:30 Πως κάνω κατάλυση µε laser
Γ. Σφυρόερας (Ελλάδα)
17
CMYK
13:30 – 13:40 Πως κάνω κατάλυση RF
Χ. Ιωάννου (Ελλάδα)
13:40 – 13:50 Πως κάνω βαλβιδοπλαστική
K. Κτενίδης (Ελλάδα)
13:50 – 14:15 Συζήτηση
14:15 – 15:15 Ελαφρύ Γεύµα
2 0 1 1
15:30 – 18.15 Πρακτικό Σεµινάριο
ΕΝ∆ΑΓΓΕΙΑΚΕΣ ΤΕΧΝΙΚΕΣ ΦΛΕΒΙΚΩΝ ΠΑΘΗΣΕΩΝ
Συντονιστές: Α. Γιαννούκας (Ελλάδα) – N. Labropoulos (ΗΠΑ) –
Μ. Ματσάγκας (Ελλάδα)
Ι α ν ο υ α ρ ί ο υ
14:45 – 15:30 Γενική Συνέλευση Balkan Venous Forum
15:30 – 15:40 Τι απεικόνιση χρειάζεται για τις τεχνικές φλεβικής κατάλυσης
N. Labropoulos (ΗΠΑ)
15:40 – 16:00 Τεχνικές κατάλυσης µε ραδιοσυνχότητες και laser
Σ. Κούτσιας (Ελλάδα)
16:00 – 16:10 Tips και tricks στις τεχνικές θερµικής κατάλυσης σαφηνούς
A. Gasparis (ΗΠΑ)
16:10 – 16:20 Tips και tricks στη σκληροθεραπεία αφρού
D. Kontothanassis (Ιταλία)
16:20 – 16:40 Τεχνικές φλεβικών ενδοναρθήκων
A. Gasparis (ΗΠΑ)
Εκπαιδευτές: Ν. Λιάσης (Ελλάδα)
D. Kontothanassis (Ιταλία)
A. Gasparis (ΗΠΑ)
N. Labropoulos (ΗΠΑ)
16:40 – 17:00 Συζήτηση
Σ ά β β α τ ο
2 2
17:00 – 18:15 Πρακτική εξάσκηση σε µοντέλα
18:15 – 18:45 ∆ιάλειµµα Καφέ – Επίσκεψη στον χώρο της Έκθεσης
18:45 – 20:00 Στρογγυλό Τραπέζι V
ΟΙ∆ΗΜΑ ΚΑΤΩ ΑΚΡΟΥ: ∆ΙΑΓΝΩΣΗ ΚΑΙ ΘΕΡΑΠΕΙΑ
Συντονιστές: Π. Πανούσης (Ελλάδα) – Μ. Λαζαρίδης (Ελλάδα) –
E. Καλοδίκη (Μ. Βρετανία)
18:45 – 18:55 Έλεγχος σε οίδηµα κάτω άκρου
K. ∆ράκου (Ελλάδα)
18:55 – 19:05 Φαρµακευτική θεραπεία
Θ. Κώτσης (Ελλάδα)
19:05 – 19:15 Ελαστικές Κάλτσες
E. Καλοδίκη (Μ. Βρετανία)
19:15 – 19:25 Ελαστικοί επίδεσµοι
Φ. Σιγάλα (Ελλάδα)
19:25 – 19:35 Μηχανήµατα συµπίεσης
Α. Λάζαρης (Ελλάδα)
19:35 – 19:45 Αντιµετώπιση λεµφοιδήµατος σε εξωτερικούς ασθενείς
Χ. Παπαδοπούλου, Ρ. Σάλτα (Ελλάδα)
19:45 – 19:55 Η θεραπεία του λεµφοιδήµατος στη Σλοβενία
Tanja Planinšek Ručigaj (Σλοβενία)
19:55 – 20:15 Συζήτηση
20:15 – 20:30 Ανακοίνωση Βραβείων – Λήξη Συνεδρίου
18
Friday January 21st 2011
Hall «SOCRATES Α»
08:00 – 08:30 Registration
08:30 – 10:30 Oral presentations I
Chairmen: K. Filis (Greece) – S. Xhepa (Albania)
Ο01
O03
O05
O09
19
2 0 1 1
O08
s t
O07
2 1
O06
J a n u a r y
O04
F r i d a y
O02
H3 AND H4 RECEPTOR-MEDIATED EFFECTS IN PERIPHERAL BLOOD
VESSELS IN ADJUVANT ARTHRITIS
Kyriakidis K, Zampeli E, Tiligada E
Department of Pharmacology, Medical School, University of Athens,
Athens, Greece
SCLEROTHERAPY OF TELANGIECTASES, RETICULAR AND VARICOSE
VEINS: SYSTEMATIC REVIEW OF SAFETY DATA
Eugenia Ch Yiannakopoulou
Department of Basic Medical Lessons Faculty of Health and Caring
Professions Technological Educational Institute of Athens
SPLACHNIC VEIN THROMBOSIS AND PREDISPOSING FACTORS: A
RETROSPECTIVE STUDY OF SIXTEEN CASES
Kouvelos George1, Koliou Panagiotis2, Mitsis Michalis3, Kolaitis Nikolaos2,
Vartholomatos George2, Fatouros Michalis3, Matsagkas Miltiadis1
1
Department of Surgery- Vascular Surgery Unit, Medical School, University
of Ioannina
2
Haematology Laboratory, Molecular Biology Unit, University Hospital of
Ioannina
3
Department of Surgery, Medical School, University of Ioannina
REVIEW OF DEEP VEIN THROMBOSES HOSPITALIZED IN OUR CLINIC:
A FIVE YEARS EXPERIENCE
Pyrgakis K, Kasfikis F, Goulas S, Giannakakis S, Siskos D,
Papacharalambous G, Antoniou I, Maltezos Ch.
Vascular Surgery Clinic of KAT Hospital, Athens, Greece
DEEP VEIN THROMBOSIS IN A CASE OF ADAMANTIADIS- BEHCET
DISEASE: A CASE AND A REVIEW
Voulalas G, Giannakakis S, Psyllas A, Papacharalambous G, Goulas S,
Antoniou I, Maltezos Ch.
Vascular Suregry Clinic of KAT Hospital, Athens, Greece
PRIMARY VARICOSE VEINS OF THE UPPER EXTREMITY.
Xanthopoulos D, Loupou A, Papavasiliou V, Kaperonis E, Bazigos G,
Melas M, Karathanos C, Arvanitis D.
Department of vascular surgery, Sismanoglio General Hospital of Athens
CASE REPORT: SPONTANEOUS THROMBOSIS OF THE AXILLARYSUBCLAVIAN VEIN CAUSING SUPERIOR VENA CAVA SYNDROME
Philippakis G.1, Gionis M.1, Mitsikas D.2, Spyrantis M.2, Papadopoulos L.2,
Samiotakis E.3, Zarifis G.3, Moustardas M.1
1
Thoracic and Vascular Surgery Department, Chania General Hospital, Greece
2
Department of General Surgery, Chania General Hospital, Greece
3
Department of Radiology, Chania General Hospital, Greece
CASE REPORT: ILIOFEMORAL DVT CAUSING CHRONIC PELVIC PAIN
SYNDROME
Spyrantis M.2, Mitsikas D.2, Philippakis G.1, Moustardas M.1
1
Thoracic and Vascular Surgery Department, Chania General Hospital, Greece
2
Department of General Surgery, Chania General Hospital, Greece
CASE REPORT: GALLBLADDER HYDROPS CAUSING INTERMITTENT
LIMB OEDEMA
Oikonomou K.2, Mitsikas D.2, Korakas P.3, Gionis M.1, Zarifis G.3,
Fragkiadakis G.1, Moustardas M.1
1
Thoracic and Vascular Surgery Department, Chania General Hospital, Greece
2
Department of General Surgery, Chania General Hospital, Greece
3
Department of Radiology, Chania General Hospital, Greece
CMYK
O10
O12
F r i d a y
J a n u a r y
2 1
s t
2 0 1 1
O11
O13
CASE REPORT: AMPUTATIVE INJURY OF THE UPPER EXTREMITY AFTER
GUNSHOT-NECESSITY OF VEIN REPAIR
Gionis M.1, Manimanaki A,2. Poulios G.1, Philippakis G.1, Kaimasidis G.1,
Mitsikas D.3, Tsantrizos P.3, Kontoudaki E.4, Fratzeskaki S.5, Mantakas E.6,
Moustardas M.1
1
Thoracic and Vascular Surgery Department, Chania General Hospital, Greece
2
Department of Orthopedic Surgery, Chania General Hospital, Greece
3
Department of General Surgery, Chania General Hospital, Greece
4
Intensive Care Unit, Chania General Hospital, Greece
5
Department of Anesthesiology, Chania General Hospital, Greece
6
Department of Radiology, Chania General Hospital, Greece
CASE REPORT: ALMOST FATAL ILIOFEMORAL VEIN’S BLEEDING
BECAUSE OF A DOUBLE GUNSHOT
Antoniou Ch.2, Tsiminikakis N.2, Lampousakis E.2, Mitsikas D.2,
Spyrantis M.2, Philippakis G.1, Moustardas M.1
1
Thoracic and Vascular Surgery Department, Chania General Hospital, Greece
2
Department of General Surgery, Chania General Hospital, Greece
PLASMINOGEN ACTIVATOR INHIBITOR-1 AND D-DIMMERS AFTER
LAPAROSCOPIC VERSUS OPEN SURGERY FOR COLON CANCER RESECTION
F. Sigala1, A. Travlou2, E. Merkouri2, D. Tsamis1, D. Linardoutsos1, K. Lilis1,
T. Hristophidis1, G. Theodoropoulos1, E. Leandros1, G. Zografos1, K. Filis1
1
First Department of Propaedeutic Surgery, Hippokrateion Hospital, University of Athens Medical School, Greece.
2
Laboratory of Haematology-Blood Tranfusion Unit, Attikon Hospital, University of Athens Medical School, Greece.
VARICOSE VEINS DISEASE COMPLICATED BY SUPERFICIAL VEIN
THROMBOSIS: EVALUATION OF VEIN WALL APOPTOSIS AS A
PREDISPOSING FACTOR
K. Filis1, N. Kavantzas2, D. Hrisikos1, T. Isopoulos1, D. Linardoutsos1,
P. Antonakis1, E. Lagoudianakis1, E. Gomatos1, G. Zografos 1, F. Sigala1
1
Division of Vascular Surgery, First Department of Propaedeutic Surgery,
University of Athens Medical School, Athens, Greece
2
First Department of Pathology, University of Athens Medical School, Athens, Greece
10:30 – 11:00 Coffee Break – Visit to the exhibition area
11:00 – 12:30 Round Table I
Development and progression of Chronic Venous Disease
Moderators: D. Christopoulos (Greece) – Tanja Planinšek Ručigaj (Slovenia)
11:00 – 11:10 Pathogenesis and natural history of primary chronic venous disease
N. Labropoulos (USA)
11:10 – 11:20 Classification and scoring of chronic venous disease
S. Kakkos (Greece)
11:20 – 11:30 The impact of superficial reflux on Chronic Venous Disease
S. Vasdekis (Greece)
11:30 – 11:40 The role of perforating veins in the progression and severity of
chronic venous disease
K. Delis (Greece)
11:40 – 11:50 Progression of chronic venous disease: Are there any predisposing factors?
T. Kostas (Greece)
11:50 – 12:30 Discussion
12:30 – 14:00 Round Table II
Management of Chronic Venous Disease
Moderators: A. Katsamouris (Greece) – M. Kurtoglu (Turkey)
12:30 – 12:40 Does the length of great Saphenous Vein stripping matter?
T. Kostas (Greece)
20
12:40 – 12:50 Laser ablation of great and small Saphenous Vein: Early and late results
D. Kontothanassis (Italy)
12:50 – 13:00 Radiofrequency ablation: Early and late Results
A. Gasparis (USA)
13:00 – 13:10 Is foam sclerotherapy for varicose veins safe and effective?
D. Bountouroglou (Greece)
13:10 – 13:20 Indications and technique on venous stenting
S. Raju (USA)
13:20 – 13:30 Treatment of venous ulcers
D. Milic (Serbia)
13:40 – 14:00 Discussion
15:00 – 16:30 Oral presentations II
Chairpersons: A. Lazaris (Greece) - E. Goranova (Bulgaria)
O14
O16
O17
O21
O22
16:30 – 17:10 Venous Case Scenarios
Moderator: N. Labropoulos (USA)
21
2 0 1 1
O20
s t
O19
2 1
O18
J a n u a r y
O15
PERCUTANEOUS PROSTHETIC VENOUS VALVE AS ENDOVASCULAR
TREATMENT OF LOWER LIMB REFLUX
Constantinos Zervides
Cardiovascular Implants & Medical Devices Research Group
Intercollege Larnaca, Larnaca
MULTI-LAYER BANDAGING SYSTEM WITH TUBULCUS® IN THE
TREATMENT OF VENOUS LEG ULCERS
Vladimir Zivkovic, MD; Robert Stefanovic, MD; Zoran Damnjanovic, MD;
Vladimir Stojiljkovic, MD; Sasa Zivic, MD; Dragan Milic, MD, PhD
Clinic for Vascular Surgery, Clinical Centre Nis, Serbia
POSTTHROMBOPHLEBITIS SYNDROME-DIAGNOSTIC AND PHYSICAL THERAPY
Dragica Rondovic, Rade Kostic, Zaklina Damnjanovic
Special centre for rehabilitation “Gamzigrad” Gamzigradska banja” Serbia
INHERITANCE IS AN IMPORTANT RISK FACTOR FOR CHRONIC VENOUS
INSUFFICIENCY
Matić Milan1, Duran Verica1, Gajinov Zorica1, Rajić Novak1,
Matić Aleksandra2, Ivkov Smić Milana1, Roš Tatjana1
1
Clinical center of Vojvodina, Dermatovenereological Clinic, Novi Sad, Serbia
2
Institute for Child and Youth health care of Vojvodina, Novi Sad, Serbia
OBESITY AND AGING AS RISK FACTORS OF SUPERFICIAL
THROMBOPHLEBITIS IN PATIENTS WITH PRIMARY VARICOSE VEINS
Karathanos Ch., Saleptsis V., Roussas N., Antoniou G., Sfyroeras G.,
Koutsias S., Giannoukas AD.
Department of Vascular Surgery, University Hospital of Larissa, Larissa, Greece
CLINIC PRESENTATION OF VENOUS CONGENITAL MALFORMATIONS
Javorka Delic
THE IMPORTANCE OF PREOPERATIVE ULTRASONOGRAPHY CHECKUP
OF LOWER LIMB DEEP VEINS IN THE PATIENTS WITH HIP AND KNEE SURGERY
Zivanic D, Nikolic- Pucar J, Gajic D, Lolic S.
Institute for Physical Medicine and Rehabilitation “ Dr Miroslav Zotovic”
B. Luka, RS, BiH
COMBINED MANAGEMENT OF THE GIGANTIC AND SQUALID VENOUS ULCERS
MA Pejić, NP Lučić, RM Koprivica, JS Stanković, B. Nikitović
Surgical service-dept. of vascular surgery, General hospital Užice, Serbia
DEEP VEIN THROMBOSIS AND PULMONARY THROMBOEMBOLISM
DURING PREGNANCY – RECCOMENDATION FOR SAFE BIRTH DELIVERY
Miljko A. Pejic, NP Lucic, RM Koprivica, JS Stankovic
General hospital Uzice – vascular surgery dept., Uzice, Serbia
F r i d a y
14:00 – 15:00 Light lunch
CMYK
17:10 – 17:30 Satellite Lecture
Chairpersons: D. Papadimitriou (Greece) – D. Radu (Romania)
Treatment of superficial vein thrombosis in the legs, lessons from
the CALISTO trial
P. Prandoni (Italy)
17:30 – 18:00 Coffee break – Visit to the exhibition area
Recannalization and stenting techniques
S. Raju (USA)
18:20 – 18:40 Ιnvited Lecture ΙΙ
Chairpersons: S. Vasdekis (Greece) – E. Kapedani (Albania)
Comparative evaluation of risk assesement models for VTE
G. Gerotziafas (France)
19:00 – 20:00 Opening ceremony
19:00 – 19:20 Welcome Addresses
Chairpersons: N. Pangratis (Greece) – A. Giannoukas (Greece)
19:20 – 20:00 Opening Lecture
Chairpersons: Ch. Liapis (Greece) – P. Balas (Greece)
The state-of-the art management of venous thromboembolism
A. Nicolaides (Cyprus)
20:00
F r i d a y
J a n u a r y
2 1
s t
2 0 1 1
18:00 – 18:20 Invited lecture Ι
Chairpersons: E. Bastounis (Greece) – G. Szolnoky (Hungary)
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Welcome Reception
Saturday January 22nd 2011
Hall «SOCRATES Α»
08:00 – 10:00 Oral presentations III
Chairmen: Th. Kotsis (Greece) – M. Pejic (Serbia)
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2 0 1 1
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2 2
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J a n u a r y
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S a t u r d a y
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3D MODELLING OF A VENOUS VALVE: HOW EFFECTIVE ARE POSTURAL
CHANGES UNDER GRAVITY, IN “WASHOUT” RECIRCULATORY
REGIONS IN THE LEE OF VENOUS VALVES?
Dr. Constantinos Zervides
Cardiovascular Implants & Medical Devices Research Group Intercollege
Larnaca, Larnaca
A RANDOMIZED TRIAL OF CLASS 2 AND CLASS 3 ELASTIC COMPRESSION
IN THE PREVENTION OF RECURRENCE OF VENOUS ULCERATION
Robert Stefanovic, MD; Vladimir Zivkovic, MD; Zoran Damnjanovic, MD;
Vladimir Stojiljkovic, MD; Sasa S. Zivic, MD; Dragan J. Milic, MD, PhD
Clinic for Vascular Surgery, Clinical Centre Nis, Serbia
THE ROLE OF COLOR DUPLEX SONOGRAPHY IN RECCURENT
VARICOSE VEIN SURGERY
Kostov I.1, Mladenovic D.1, Kostova N.2, Uzunova T.1
1
Surgery Clinic- “ St. Naum Ohridski” Skopje, F.Y.R.O.M.
2
Clinic of Cardiology– Skopje, F.Y.R.O.M.
SURGICAL CORRECTION OF ISOLATED SUPERFICIAL REFLUX IN
CHRONIC VENOUS LEG ULCERATION OFFERS FAVOURABLE ULCER
HEALING RATE WITH MINIMAL LONG-TERM RECURRENCES
Terzoudi S, Georgakarakos E, Karpouzis A, Georgiadis G, Lazarides M.
Department of Vascular Surgery, Alexandroupolis Univercity Hospital,
Dimokritos Univercity
QUALITY OF LIFE IMPROVEMENTS AFTER ENDOVENOUS TREATMENTS
CORRELATE WITH BASELINE VALUES RATHER THAN SEVERITY
SCORES OR TYPE OF INTERVENTION
Lattimer C1,2, Kalodiki E1,2, Azzam M1, Shawish E1, Makris G1,2, Geroulakos G1,2
1
Ealing Hospital, Middlesex, UK
2
Imperial College, London, SW7 2AZ
CLINICAL AND ANATOMIC CHARACTERISTICS OF PATIENTS REQUIRING
SECONDARY PROCEDURES AFTER GREAT SAPHENOUS ENDOVENOUS
ABLATION
Angela A. Kokkosis, M.D. and Harry Schanzer, M.D.
Division of Vascular Surgery, The Mount Sinai Medical Center, NY
HEALING OF ACUTE AND CHRONIC WOUNDS: DON’T FORGET LYMPHATICS!
Szolnoky G1, Erős G2, Szentner K2, Szabad G1, Dósa-Rácz É1, Kemény L1,3
1
Department of Dermatology and Allergology, University of Szeged, Hungary
2
Institute of Surgical Research, University of Szeged, Hungary
3
Dermatological Research Group of the Hungarian Academy of Sciences,
Szeged, Hungary
QUALITY OF LIFE IN PATIENTS WITH LYMPHOEDEMA: INITIAL RESULTS
OF THE ONLY GREEK LYMPHOEDEMA CENTRE IN THE PUBLIC SECTOR
Papadopoulou Ch., Roussas N., Salta R., Tsioli S., Tsiouri I., Nakos Ch.,
Roussaki Schulze A-V., Giannoukas A.D.
Lymphoedema Centre and Departments of Vascular Surgery and
Dermatology, University Hospital of Larissa, Larissa, Greece
CLINIC INDICATORS OF HARD–TO-HEAL VENOUS ULCERATIONS
Javorka Delic
ENDOVENOUS LASER ABLATION TREATMENT IN THE TREATMENT
OF VARICOSE VEIN DISEASE
Dr. Stylianos Papas M.D, Vascular Surgeon
Dr. Eleftherios Koulouteris M.D, F.MAS, D.MAS, General Surgeon
CMYK
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10:00 – 11:30 Round Table III
J a n u a r y
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H ΧΡΗΣΗ ΕΠΙΘΕΜΑΤΩΝ ΜΕ ΑΡΓΥΡΟ ΣΤΗΝ ΘΕΡΑΠΕΙΑ ΕΠΟΥΛΩΣΗΣ
ΤΩΝ ΦΛΕΒΙΚΩΝ ΕΛΚΩΝ
∆ηµακάκος Ε., Καλκανδής Χρ., ∆αφνής ∆., Βασιλόπουλος Ι., Καλλίνης Α.,
Λοίζος Α., Κατσένη Κ., Κατσένης Κ.
Αγγειοχειρουργική Μονάδα Β΄ Χειρουργικής Κλινικής Πανεπιστηµίου
Αθηνών Αρεταίειο Νοσοκοµείο
ΟΙ ΘΕΡΜΟΡΥΘΜΙΣΤΙΚΕΣ ΜΕΤΑΒΟΛΕΣ ΤΟΥ ∆ΕΡΜΑΤΟΣ ΣΤΗ ΧΡΟΝΙΑ
ΦΛΕΒΙΚΗ ΝΟΣΟ
∆ηµακάκος Ε., Κατσένης Κ., Αράπογλου Β., Καλκανδής Χ., ∆αφνής ∆.,
Βασιλόπουλος Ι., Καλλίνης Α., Λοίζος Α., Κατσένη Κ.
Αγγειοχειρουργική Μονάδα Β΄ Χειρουργικής Κλινικής Αρεταιείου
Πανεπιστηµιακού Νοσοκοµείου Αθηνών
OVARIAN VEIN REFLUX AND RECURRENT VARICOSE VEINS.
REPORT OF TWO CASES
Vasdekis S., Athanasiadis D., Broutzos E., Lazaris A.
Vascular Unit, 3RD Surgical Department, University Hospital Attikon, Athens, Greece
Venous Thromboembolism – What’s new?
Moderators: D. Kiskinis (Greece) – K. Katsenis (Greece)
10:00 – 10:10 Who should be screened for thrombophilia
A. Nicolaides (Cyprus)
10:10 – 10:20 Ambulatory DVT treatment
M. Kurtoglu (Turkey)
10:20 – 10:30 Pharmacomechanical thrombolysis for proximal DVT
A. Gasparis (USA)
10:30 – 10:40 Current indications in the use of caval filters
M. Aksoy (Turkey)
10:40 – 10:50 New forms of anticoagulants
A. Travlou (Greece)
11:00 – 11:30 Discussion
11:30 – 12:00 Coffee break - Visit to the exhibition area
S a t u r d a y
11:30 – 12:00 Balkan Venous Forum Board Meeting
12:00 – 12:30 Hellenic Phlebological Society Keynote lecture
Chairpersons: I. Tsolakis (Greece) – A. Tripolitis (Greece)
Venous malformations
P. Dimakakos (Greece)
12:30 – 14:15 Round Table IV
How I do it
Moderators: A. Gougoulakis (Greece) – Ch. Maltezos (Greece)
12:30 – 12:40 How I examine the veins with ultrasound
V. Arapoglou (Greece)
12:40 – 12:50 How I do saphenous stripping
D. Christopoulos (Greece)
12:50 – 13:00 How I do phlebectomies
A. Papageorgiou (Greece)
13:00 – 13:10 How I do saphenous u/s guided sclerotherapy
M.Valsamis (Greece)
13:10 – 13:20 How I do sclerotherapy in the reticular veins
S. Giannakakis (Greece)
13:20 – 13:30 How I do saphenous Laser ablation
G. Sfyroeras (Greece)
24
13:30 – 13:40 How I do saphenous RF ablation
Ch. Ioannou (Greece)
13:40 – 13:50 How I do deep vein valvuloplasty
K. Ktenidis (Greece)
13:50 – 14:15 Discussion
14:15 – 15:15 Light lunch
14:45 – 15:30 Balkan Venous Forum General Assembly
S a t u r d a y
15:30 – 18:15 Workshop: Endovenous Treatment of Venous Diseases
Co-ordinators: A. Giannoukas (Greece) - N. Labropoulos (USA) M. Matsagkas (Greece)
Instructors: N. Liasis (Greece)
D. Kontothanassis (Italy)
A. Gasparis (USA)
N. Labropoulos (USA)
J a n u a r y
15:30 – 15:40 What imaging is needed for the VVs ablation procedures
N. Labropoulos (USA)
15:40 – 16:00 Techniques for RF and laser ablations
S. Koutsias (Greece)
16:00 – 16:10 Tips and tricks on thermal saphenous ablation techniques
A. Gasparis (USA)
16:10 – 16:20 Tips and tricks in foam sclerotherapy
D. Kontothanassis (Italy)
16:20 – 16:40 Venous stenting techniques
A. Gasparis (USA)
16:40 – 17:00 Discussion
17:00 – 18:15 Hands-on practice on models
18:15 – 18:45 Coffee break – Visit to the exhibition area
18:45 – 20:00 Round Table V
2 2
Limb swelling: Diagnosis and treatment
Moderators: P. Panoussis (Greece) – M. Lazarides (Greece) - E. Kalodiki (UK)
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18:45 – 18:55 Investigations for limb swelling
K. Drakou (Greece)
18:55 – 19:05 Medical Treatment
Th. Kotsis (Greece)
19:05 – 19:15 Elastic stockings
E. Kalodiki (UK)
19:15 – 19:25 Elastic bandages and garments
F. Sigala (Greece)
19:25 – 19:35 Pneumatic compression devices
A. Lazaris (Greece)
19:35 – 19:45 Outpatient treatment of Lymphoedema
Ch. Papadopoulou, R. Salta (Greece)
19:45 – 19:55 Lymphoedema treatment in Slovenia
Tanja Planinšek Ručigaj (Slovenia)
19:55 – 20:15 Discussion
20:15 – 20:30 Prize announcement and Closing Remarks
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CMYK
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Παρουσιάσεις Οµιλητών
Speakers’ Abstracts
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Παρασκευή 21 Ιανουαρίου 2011 • Friday January 21st 2011
Στρογγυλό Τραπέζι I • Round Table I
Σ τ ρ ο γ γ υ λ ό
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ΑΝΑΠΤΥΞΗ ΚΑΙ ΕΞΕΛΙΞΗ ΧΡΟΝΙΑΣ ΦΛΕΒΙΚΗΣ ΝΟΣΟΥ
DEVELOPMENT AND PROGRESSION OF CHRONIC VENOUS DISEASE
PATHOGENESIS AND NATURAL HISTORY OF PRIMARY CHRONIC VENOUS DISEASE
Dr. Nicos Labropoulos
Professor of Surgery and Radiology, Director, Vascular Laboratory Department of Surgery
Primary venous disease affects two-third of the limbs with chronic venous disease (CVD). Family
history has the strongest association with the development of CVD indicating the importance of
genetic predisposition. Cornu-Thenard et al found 90% of individuals in which both parents suffered from varicose veins also had such disease. In those with only one parent affected, varicose
veins were found in 25% of males versus 62% of females. The predominant theory for the development of CVD is the “weakening” of the venous wall. According to this theory the venous
wall dilates and the affected vein segment becomes incompetent. This may be induced by the increased venous hydrostatic pressure which is transmitted to the vein wall causing smooth muscle relaxation, endothelial damage, and extracellular matrix degradation with subsequent vein
wall weakening and dilatation. There has also been suggested that valve damage may occur due
to local inflammation. Leukocyte migration, plasma-granulocyte activation, and increase activity
of metalloproteinases causing degradation of the valve leaflets support that theory.
Currently, it is unknown what initiates the changes in the venous wall. Because the effect of venous
reflux in the lower limbs is more apparent for gravitational and hydrostatic reasons in the upright posture, it has been traditionally thought that this hemodynamic abnormality develops in a retrograde
fashion. In primary CVD, where the valves are intact, it could be assumed that incompetence or absence of the iliac and common femoral valves are the initiating factors for a retrograde development
of reflux. Although, such a pathophysiology is possible, the vast majority of literature counteracts this
hypothesis. Several functional, morphological and biochemical studies have shown that venous wall
changes can occur in any vein segment irrespective of the site and function of the valves. It has been
shown that venous disease can start in any vein in the lower limb but is most common in the superficial veins and particularly in the saphenous veins and their tributaries. It may have an ascending, descending or multicentric process. It is also shown that reflux progresses in the same manner. All veins
are affected but the superficial veins are most often involved in the progression of primary CVD. Reflux is most common in the superficial veins in the whole spectrum of CVD. Superficial vein reflux affects the perforator veins in an ascending manner as progression of vein wall disease, in a descending manner at reentry point via the high flow rate which may dilate the perforator veins or in both
directions. In the descending path wall disease may also be important together with or separate to
increased flow. The perforator veins in turn affect the deep that are communicating with and with
time render those incompetent as well. In a similar manner the great saphenous vein can induce reflux in the common femoral vein and the small saphenous and gastrocnemial veins can make the
popliteal vein incompetent.
References
Bergan JJ, Pascarella L, Schmid-Schonbein GW. Pathogenesis of primary chronic venous disease:
Insights from animal models of venous hypertension. J Vasc Surg 2008;47: 183-192.
Cornu-Thenard A, Boivin P, Baud JM, De Vincenzi I, Carpenter P. Importance of familial factor in
varicose disease. J Dermatol Surg Oncol 1994;20:318-26.
Labropoulos N, Giannoukas AD, Delis K, et al. Where does venous reflux start? J Vasc Surg
1997;26:736-42.
Labropoulos N, Leon L, Kwon S, Tassiopoulos AK, Fajardo JA, Kang SS, Mansour MA, Littooy FN.
Study of the venous reflux progression. J Vasc Surg 2005;41:291-5.
Labropoulos N, Tassiopoulos AK, Bhatti A, Leon L. Development of reflux in the perforator veins
in primary venous disease. J Vasc Surg 2006;43:558-62.
Raffetto JD, Khalil RA. Mechanisms of varicose vein formation: valve dysfunction and wall dilation. Phlebology 2008;23:85-98.
28
Παρασκευή 21 Ιανουαρίου 2011 • Friday January 21st 2011
Στρογγυλό Τραπέζι I • Round Table I
CLASSIFICATION AND SCORING OF CHRONIC VENOUS DISORDERS
Stavros K. Kakkos, MD, MSc, PhD, Ioannis A. Tsolakis, MD, PhD
Department of Vascular Surgery University of Patras Medical School, Patras, Greece
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Τ ρ α π έ ζ ι
The necessity for clear communication between venous specialists and the development of a
common language (terminology and assessment tools) in the era of health care globalization has
been a continuous saga for over three decades. In 1988, a subcommittee on Reporting Standards
in Venous Disease, part of the Ad Hoc Committee on Reporting Standards, of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular
Surgery compiled and published the legendary “Reporting standards in venous disease”.1 Chronic venous insufficiency (CVI), as chronic venous disease was called at that time was defined and
classified by anatomical region, origin and clinical severity. Asymptomatic CVI was defined as
class 0, while symptomatic CVI was classified into three groups of progressive severity, class 1 for
patients with mild symptoms, class 2 for patients with moderate symptoms and class 3 to describe the most severe symptoms, including chronic distal leg pain associated with ulcerative or
preulcerative skin changes, eczematoid changes, and/or severe edema. It was stated that Class 3
was usually (but not always) due to extensive involvement of the deep venous system. Findings
on physical examination were also defined, as well as methods and modalities used to investigate and treat CVI, respectively. The committee purposely provided numeric grading schemes for
disease severity, realizing that although some of the recommendations were arbitrary, they were
the most generally acceptable by members of the committee. These recommendations were offered as guidelines to serve the clarity and precision of communication.
A few years later, in 1994 an international consensus conference on chronic venous disease held
under the auspices of the American Venous Forum and chaired by Andrew N. Nicolaides, updated the reporting standards,2 and used the term “Chronic Venous Disease”. The latter was described in a more systemic way by the new classification; the updated reporting standards are
widely known with the acronym CEAP, because they suggested that limbs with chronic venous
disease should be classified according to clinical signs (C), cause - etiology (E), anatomic distribution (A), and pathophysiologic condition (P). The new classification system replaced the clinical
classes 0 to 3, previously in use and chronic venous disease is now classified into 7 clinical classes: Class 0, no visible or palpable signs of venous disease, Class 1, telangiectases, reticular veins,
malleolar flare, Class 2, varicose veins, Class 3, edema without skin changes, Class 4, skin changes
ascribed to venous disease (e.g., pigmentation, venous eczema, lipodermatosclerosis), Class 5
skin changes as defined above with healed ulceration and Class 6, skin changes as defined above
with active ulceration. Etiological classification was not changed, anatomical classification was
expanded, while pathophysiological classification was introduced for the first time (reflux, obstruction or both), most likely being the result of the wide dissemination of duplex ultrasonography by the mid 1990’s. The same committee introduced also a scoring system for chronic venous disease,3 which has been subsequently expanded and improved and is known as venous
severity scoring (VSS).4 Because many of the components of the CEAP classification are relatively static and others use detailed alphabetical designations, i.e. it is not fully quantifiable, CEAP is
not suitable to gauze venous severity and trace changes in response to treatment. Three scores
were introduced as part of VSS: 1. Venous Clinical Severity Score (VCSS), based on nine clinical
characteristics graded from 0 to 3 and additionally use of conservative therapy (compression and
elevation), using the same points, to produce a 30 point-maximum flat scale. 2. Venous Segmental Disease Score, which combines the anatomic and pathophysiologic components of CEAP.
3. Venous disability score (VDS). Validation of these scoring systems has been reported in the
past.5 More recently, a revised version of the CEAP classification of chronic venous disorders
(CVD), as chronic venous disease should nowadays be referred to, was published.6 The revised
classification scheme, among others, refined several definitions and the C classes of CEAP, and
introduced a basic CEAP version as a simpler alternative to the full (advanced) CEAP classification. Class C4 (skin and subcutaneous tissue changes) particularly was divided into 2 subclasses:
C4a defined as pigmentation or eczema and C4b defined as lipodermatosclerosis or atrophie
blanche, in order to better define the differing severity and prognostic value of these findings. It
also supported the widely accepted notion that CEAP is a descriptive classification, whereas ve-
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DEVELOPMENT AND PROGRESSION OF CHRONIC VENOUS DISEASE
Παρασκευή 21 Ιανουαρίου 2011 • Friday January 21st 2011
Στρογγυλό Τραπέζι I • Round Table I
nous severity scoring and quality of life scores are instruments for longitudinal research to assess
outcomes.In conclusion, CVD can nowadays be graded and classified into clearly defined categories. Clinical presentation, etiology, anatomical pattern and pathophysiology of venous disease
are all clearly defined. Some methodology, like VCSS is complex and most likely restricted to research reports. Others, like basic CEAP, are fairly simple and can be used in everyday practice.
Their routine use is intended to facilitate H & P completion and communication between specialists.
References
1. Subcommittee on Reporting Standards in Venous Disease and Ad Hoc Committee on Reporting Standards., Society for Vascular Surgery., North American Chapter of the International Society for Cardiovascular Surgery. Reporting standards in venous disease. J Vasc Surg
1988; 8(2):172-81.
2. Porter JM, Moneta GL, and an International Consensus Committee on Chronic Venous Disease. Reporting standards in venous disease: an update. J Vasc Surg 1995; 21(4):635-45.
3. Kistner RL, Eklof B, Masuda EM. Diagnosis of chronic venous disease of the lower extremities:
the “CEAP” classification. Mayo Clin Proc 1996; 71(4):338-45.
4. Rutherford RB, Padberg FT, Jr., Comerota AJ, et al. Venous severity scoring: An adjunct to venous outcome assessment. J Vasc Surg 2000; 31(6):1307-12.
5. Kakkos SK, Rivera MA, Matsagas MI, et al. Validation of the new venous severity scoring system in varicose vein surgery. J Vasc Surg 2003; 38(2):224-8.
6. Eklof B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification for chronic venous
disorders: consensus statement. J Vasc Surg 2004; 40(6):1248-52.
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DEVELOPMENT AND PROGRESSION OF CHRONIC VENOUS DISEASE
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Παρασκευή 21 Ιανουαρίου 2011 • Friday January 21st 2011
Στρογγυλό Τραπέζι I • Round Table I
THE IMPACT OF SUPERFICIAL REFLUX ON CHRONIC VENOUS DISEASE
Spyros Vasdekis, MD, PhD
Vascular Unit 3rd Surgical Department, University Hospital ‘Attikon’, Athens, Greece
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1. Tassiopoulos AK, Golts E, Oh DS, Labropoulos N. Current concepts in chronic venous ulceration. Eur J Vasc Endovasc Surg 2000;20:227-32
2. Porter JM, Moneta GL: Reporting standards in venous disease: An update. International Consensus Committee on Chronic Venous Disease .J Vasc Surg 21:635-645, 1995
3. Labropoulos N, Delis K, Nicolaides AN, et al: The role of the distribution and anatomic extent
of reflux in the development of signs and symptoms in chronic venous insufficiency. J Vasc
Surg 23:504-510,1996
Τ ρ α π έ ζ ι
Chronic venous disease (CVD) encompasses the full spectrum of signs and symptoms associated
with classes C0 to C6 of the CEAP classification system .Despite the diversity of signs and symptoms associated with CVD, it seems likely that all are related to venous hypertension. In most
cases, venous hypertension is caused by reflux through incompetent valves, but other causes include venous outflow obstruction or calf muscle pump failure owing to obesity or leg immobility. Reflux may occur in the superficial or deep venous system or in both. Detection and quantification of reflux by duplex ultrasound has been used in many studies with the aim to find its relation to the development of symptoms.
Isolated superficial reflux can be the cause of venous liposclerosis and /or ulceration. In a recent
review of 1153 cases of venous ulceration the distribution of reflux in the superficial veins alone
was 45 percent, in the deep veins alone 12 percent and in both systems 43 percent (1). Reflux that
is limited to the superficial veins is responsible for 17% to 54% of the highest CEAP Classes (2).
This is important because superficial reflux is easily treated by minimally invasive techniques.
It is now evident that is not only the presence of superficial reflux but also its distribution that
plays an important role to the development of symptoms and signs. Reflux advances from the
tributaries and accessory saphenous saphenous veins to the saphenous trunks or develops in
new locations. The frequency of sub-ostial or more distal trunk reflux was evaluated at around
50% (3).. Patients with skin damage have a higher prevalence of junctional involvement. Junctional reflux which is in continuity with the saphenous trunks is associated with a greater
amount of refluxing blood and higher venous hypertension. The saphenous diameter, the presence and extension of local varicosities as well as the severity of reflux are factors that may play
important role to the severity of symptoms.
Unfortunately there is not, so far, a reliable method of venous reflux quantification for individual veins. Airplethysmography provides information about the whole calf and is mainly used for
hemodynamic studies. Duplex scanning has become the method of choice in the evaluation of
varicose vein disease, providing direct anatomical and functional information of the entire venous system relevant to the surgical approach. Superficial reflux can be treated with stripping,
isolated phlebectomies, thermal ablation or foam sclerotherapy. The selection of the proper technique depends greatly upon the accuracy of duplex examination and the hemodynamics of the
reflux distribution. It is therefore necessary for the vascular surgeon to perform himself the preoperative duplex evaluation of the superficial veins in order to select the best treatment modality for the individual patient.
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DEVELOPMENT AND PROGRESSION OF CHRONIC VENOUS DISEASE
I
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Παρασκευή 21 Ιανουαρίου 2011 • Friday January 21st 2011
Στρογγυλό Τραπέζι I • Round Table I
Σ τ ρ ο γ γ υ λ ό
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ΑΝΑΠΤΥΞΗ ΚΑΙ ΕΞΕΛΙΞΗ ΧΡΟΝΙΑΣ ΦΛΕΒΙΚΗΣ ΝΟΣΟΥ
DEVELOPMENT AND PROGRESSION OF CHRONIC VENOUS DISEASE
PROGRESSION OF CHRONIC VENOUS DISEASE: ARE THERE ANY PREDISPOSING FACTORS?
Theodoros I. Kostas
MD, Consultant in Vascular Surgery, University Hospital of Heraklion, Crete Greece
Introduction/Objective: Chronic venous disease (CVD) is one of the commonest vascular disorders.1 However, only a few longitudinal studies have been reported on the natural history of primary CVD. Most of the available information arises from cross-sectional studies showing that the
severity of CVD is often thought to be related to the magnitude and distribution of reflux as well
as the length of time it has been present.2,3 Unfortunately, the rate of progression from asymptomatic evidence of reflux to onset of symptoms that lead to severe clinical manifestations of
CVD, such as skin changes and ulceration, still remains very poorly defined.4
Several risk factors have been associated with the development of CVD, including older age,5 female gender,5,6 family history,5,7 standing occupation,8-12 obesity,6,10-12 and multiparity.7,10,12,13 However, other potential factors that may be involved in CVD progression have not been well studied, such as estrogen treatment (ET),10,11,14 and warrant further investigation. On the other hand,
although many studies have shown that elastic compression stockings are the keystone of CVD
treatment in the context of symptom relief,15 ulcer healing,16 and antithrombotic prophylaxis,17
limited evidence is present on supportive role of elastic stocking use (ESU) in the inhibition of
CVD progression that is limited mainly to patients with post-thrombotic etiology.18
Although the advents of color duplex ultrasound (CDU) imaging and improvements in the classification of CVD19 have significantly enhanced our current understanding of the underlying
pathophysiology, studies on the natural history and progression of CVD are still scarce. The presenting study, which has been recently published in the Journal of Vascular Surgery,19 was
prospectively conducted to determine the progression of CVD in contralateral untreated limbs of
patients who underwent unilateral varicose vein surgery. More specifically, we wished to identify changes in the distribution and extent of reflux as well as changes in clinical manifestations
during a 5-year period. We also aimed to evaluate any correlation between CVD progression and
the modification of specific potential risk factors during the same 5-year period, such as orthostatism, obesity, ET, multiparity, and the ESU.
Methods: The contralateral limb of 73 patients (95% women; mean age, 48 ± 12 years) undergoing
varicose vein surgery was prospectively evaluated using physical and color duplex examination and
classified by CEAP. After 5 years of follow-up, development of new sites of reflux among the contralateral, preoperatively asymptomatic limbs and modification of predisposing factors, including prolonged orthostatism, obesity, estrogen therapy (ET), multiparity, and elastic stockings use (ESU), were
assessed. Data were analyzed with Pearson χ2, t test, binary logistic regression, and Spearman ρ.
Results: Forty-eight new sites of reflux (superficial system, 37; perforators, 5; deep veins, 6) were
revealed in 38 limbs (52%). CEAP scores significantly deteriorated: clinical, 2.2 ± 0.5 from 0.1 ±
0.03 (P < .01); anatomic, 3.8 ± 1.2 from 2.6 ± 2.5 (P < .05); disability, 1.9 ± 0.7 from 0 (P < .01);
and severity, 7.9 ± 2.4 from 2.7 ± 2.2 (P < .01). Patient compliance to predisposing factor modification was low; no change was observed during follow-up (orthostatism, P ± .9; obesity, P ±
0.7; ET, P ± .9; multiparity, P±.4; ESU, P ±.3). CVD progression was significantly lower in patients
who controlled orthostatism versus those who maintained orthostatism or initiated it (P < .001)
and in patients who controlled preoperative obesity versus those who became obese or maintained obesity (P < .001). Non-ESU patients had a significantly higher incidence of CVD progression vs those who started ESU or continued during the study (P < .001). By binary logistic regression analysis, orthostatism (P ± .002; B coefficient value [BCV] ± 1.745), obesity (P ± .009;
BCV ± 1.602), and ESU (P ± .037; BCV ± 0.947) were independent predictive factors for CVD progression, whereas multiparity (P ± .174) and ET (P ± .429) were not.
Conclusions: In about half of patients with unilateral varicosities, CVD developed in the contralateral initially asymptomatic limb in 5 years. CVD progression consisted of reflux development
and clinical deterioration of the affected limbs. Obesity, orthostatism, and noncompliance with
ESU were independent risk factors for CVD progression, but ET and multiparity were not. Maintenance of a normal body weight, limitation of prolonged orthostatism, and systematic ESU may
be recommended in patients with CVD to limit future disease progression.
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References
1. Criqui MH, Jamosmos M, Fronek A, Denenberg JO, Langer RD, Bergan J, et al. Chronic venous
disease in an ethnically diverse population: the San Diego Population Study. Am J Epidemiol
2003;158:448-56.
2. Labropoulos N, Delis K, Nicolaides AN, Leon M, Ramaswami G. The role of the distribution
and anatomic extent of reflux in the development of signs and symptoms in chronic venous
insufficiency. J Vasc Surg 1996;23:504-10.
3. Labropoulos N, Giannoukas AD, Delis K, Mansour MA, Kang SS, Nicolaides AN, et al. Where
does venous reflux start? J Vasc Surg 1997;26:736-42.
4. Tran NT, Meissner MH. The epidemiology, pathophysiology, and natural history of chronic venous disease. Semin Vasc Surg 2002;15: 5-12.
5. Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic venous
insufficiency and varicose veins. Ann Epidemiol 2005;15:175-84.
6. Seidell JC, Bakx KC, Deurenberg P, van den Hoogen HJ, Hautvast JG, Stijnen T. Overweight
and chronic illness—a retrospective cohort study, with a follow-up of 6-17 years, in men and
women of initially 20-50 years of age. J Chronic Dis 1986;39:585-93.
7. Laurikka JO, Sisto T, Tarkka MR, Auvinen O, Hakama M. Risk indicators for varicose veins in
forty- to sixty-year-olds in the Tampere varicose vein study. World J Surg 2002;26:648-51.
8. Gourgou S, Dedieu F, Sancho-Garnier H. Lower limb venous insufficiency and tobacco smoking: a case-control study. Am J Epidemiol 2002;155:1007-15.
9. Brand FN, Dannenberg AL, Abbott RD, Kannel WB. The epidemiology of varicose veins: the
Framingham Study. Am J Prev Med 1988;4:96-101.
10. Fowkes FG, Lee AJ, Evans CJ, Allan PL, Bradbury AW, Ruckley CV. Lifestyle risk factors for lower limb venous reflux in the general population: Edinburgh Vein Study. Int J Epidemiol
2000;30:846-52.
11. Sisto T, Reunanen A, Laurikka J, Impivaara O, Heliövaara M, Knekt P, et al. Prevalence and risk
factors of varicose veins in lower extremities: mini-Finland health survey. Eur J Surg
1995;161:405-14.
12. Jawien A. The influence of environmental factors in chronic venous insufficiency. Angiology
2003;54(suppl 1):S19-31.
13. Dindelli M, Parazzini F, Basellini A, Rabaiotti E, Corsi G, Ferrari A. Overweight and chronic illness—a retrospective cohort study, with a follow-up of 6-17 years, in men and women of initially 20-50 years of age. J Chronic Dis 1986;39:585-93.
14. Vin F, Allaert FA, Levardon M. Influence of estrogens and progesterone on the venous system
of the lower limbs in women. J Dermatol Surg Oncol 1992;8:888-92.
15. Benigni JP, Sadoun S, Allaert FA, Vin F. Efficacy of class 1 elastic compression stockings in the
early stages of chronic venous disease. A comparative study. Int Angiol 2003;22:383-92.
16. Sieggreen MY, Kline RA. Recognizing and managing venous leg ulcers. Adv Skin Wound Care
2004;17:302-11.
17. MacLellan DG, Fletcher JP. Mechanical compression in the prophylaxis of venous thromboembolism. ANZ J Surg 2007;77:418-23.
18. Aschwanden M, Jeanneret C, Koller MT, Thalhammer C, Bucher HC, Jaeger KA. Effect of prolonged treatment with compression stockings to prevent post-thrombotic sequelae: a randomized controlled trial. J Vasc Surg 2008;47:1015-21.
19. Kostas T, Ioannou CV, Drygianakis I, Georgakarakos E Chronic venous disease progression and
modification of predisposing factors. J Vasc Surg 2010; 51:900-7.
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DEVELOPMENT AND PROGRESSION OF CHRONIC VENOUS DISEASE
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ΑΝΤΙΜΕΤΩΠΙΣΗ ΧΡΟΝΙΑΣ ΦΛΕΒΙΚΗΣ ΝΟΣΟΥ
MANAGEMENT OF CHRONIC VENOUS DISEASE
DOES THE LENGTH OF GREAT SAFENOUS VEIN STRIPPING MATTER?
Theodoros I. Kostas
MD, Consultant in Vascular Surgery, University Hospital of Heraklion, Crete Greece
Introduction/Objective: Stripping of the great saphenous vein (GSV) to a level just below the knee
has been suggested by many authors as the optimum balance between the risk of saphenous nerve injury (SNI) and recurrence after varicose vein surgery.1-3 However, a significant number of
patients with varicose vein disease show significant reflux in the below knee GSV along with its
major tributaries, even though they do not present varicose enlargement of these affected
veins.4 In addition, there is reported evidence that limbs, which had undergone stripping of GSV
restricted to the knee level, may develop incompetence in the residual GSV segment postoperatively.5
Even though limited knee level stripping has been widely accepted as the gold standard operation for GSV varicosities, there is inadequate data concerning the impact of the GSV tibial remnant in recurrence after varicose vein surgery, which may be incompetent preoperatively or may
develop reflux postoperatively. Nevertheless, stripping of the GSV to the knee level significantly
reduces the risk of SNI, however, it does not eliminate it, as there is evidence that this could occur in a rate ranging from 5% to 27%.1,6 Furthermore, recent studies have shown that the risk
for trauma to this nerve should not be considered as a major deterrent to avoid a whole length
GSV stripping as its adverse symptoms are gradually regressed postoperatively.6,7
Motivated by the above contradicting opinions, we performed a prospective study in order to investigate the effect of stripping the below knee GSV segment on varicose vein recurrence and
any disability induced after SNI during a 5-year period. This study was based on current guidelines for evaluating the treatment of chronic venous disease (CVD)8,9 and was published in the
Journal of Vascular Surgery,10 offering a different approach to this controversial issue.
Methods: One hundred and six limbs (86 patients, 64 female, mean age 46 years), that underwent GSV stripping, to the knee or ankle level, were prospectively followed up at 1 month and
5 years postoperatively with clinical examination and color duplex imaging (CDI), in order to evaluate SNI and the development of recurrence. The extent of GSV stripping complied with preoperative CDI in 84 limbs (79%) that were subjected to GSV stripping to the ankle and full abolishment of duplex-confirmed reflux. Furthermore, 19 limbs (18%) underwent stripping restricted
to the below knee level since the distal GSV was competent. On the contrary, in three limbs (3%),
the extent of stripping did not comply with preoperative CDI due to the absence of varicosities
in the tibia, and stripping was restricted to the knee level, although they had reflux along the whole GSV length.
Results: Overall recurrence was found in 24 out of 106 operated limbs (23%) after 5 years. Recurrence was found to be 20% (17/84) in the limbs with total GSV stripping and 32% (7/22) in
the limbs with restricted GSV stripping (P > .05). However, the recurrence rate in the tibial area
was significantly lower in limbs subjected to GSV stripping, which was in compliance with the
preoperative CDI (9/103, 9%) compared with those that had undergone GSV stripping that was
not in agreement with the preoperative CDI (3/3, 100%; P < .005). Neurological examination at
1 month postoperatively, revealed SNI in 17 limbs (16%). However, at the 5-year neurological reassessment, we found that seven out of these limbs (40%) were alleviated from SNI adverse
symptoms presenting only deficits in sensation. In addition, no significance was found concerning SNI between limbs subjected to total and restricted GSV stripping (16/84 vs 1/22; P > .05).
Conclusions: Although SNI may occur after both restricted and total GSV stripping, this does not
influence limb disability since symptoms seem to regress in almost half of the limbs 5 years postoperatively. Therefore, we believe that the extent of GSV stripping should not be lead by the intent of avoiding SNI. In addition, we revealed that the extent of GSV reflux has no impact on the
overall likelihood of developing recurrence due to unavoidable causes of recurrence such as neovascularization and CVD progression. However, if we consider the significant increase of recurrence in the tibia, when we preserve an insufficient tibial part of the GSV, we could suggest that
recurrence, following GSV varicose veins surgery, could be reduced if the level of GSV stripping
is based on preoperative duplex-confirmed venous reflux mapping.
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References
1. Koyano K, Sakaguchi S. Selective stripping operation based on Doppler ultrasonic findings for
primary varicose veins of the lower extremities.Surgery 1988;103:615-9.
2. Holme JB, Skajaa K, Holme K. Incidence of lesions of the saphenous nerve after partial or
complete stripping of the long saphenous vein.Acta Chir Scand 1990;156:145-8.
3. Lees TA, Beard JD, Ridler BMF, Szymansksa T. A survey of the current management of varicose
veins by members of the Vascular Surgical Society. Ann R Surg Engl 1999;81:407-17.
4. Labropoulos N, Belcaro G, Giannoukas AD, Delis K, Mansour AM, Kang S, et al. Can the main
trunk of greater saphenous vein be spared in patients with varicose veins? Vasc Surg
1997;31:531-4.
5. Dwerryhouse S, Davies B, Harradine K, Earnshaw JJ. Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a randomized
trial. J Vasc Surg 1999;29:589-92.
6. Wood JJ, Chant H, Laugharne M, Chant T, Mitchell DC. A prospective study of cutaneous nerve injury following long saphenous vein surgery. Eur J Vasc Endovasc Surg 2005;30:654-8.
7. Morrison C, Dasling MC. Sings and symptoms of saphenous nerve injury after greater saphenous vein stripping: prevalence, severity, and relevance for modern practice. J Vasc Surg
2003;38:886-90.
8. Perrin M, Guex JJ, Ruc_ley CV, DE Palma RG. The REVAS Group. Recurrent varices after surgery (REVAS), a consensus document. Cardiovasc Surg 2000;8:233-45.
9. Perrin M, Lambropoulos N, Leon LR, Jr. Presentation of the patient with recurrent varices after surgery (REVAS). J Vasc Surg 2006;43:327-34.
10. Kostas T, Ioannou CV, Veligradakis M, Pagonidis K, Katsamouris A, The appropriate length of
great saphenous vein stripping should be based on the extent of reflux and not on the intent
to avoid saphenous nerve injury. J Vasc Surg 2007;46:1234-41.)
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Παρασκευή 21 Ιανουαρίου 2011 • Friday January 21st 2011
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ΑΝΤΙΜΕΤΩΠΙΣΗ ΧΡΟΝΙΑΣ ΦΛΕΒΙΚΗΣ ΝΟΣΟΥ
MANAGEMENT OF CHRONIC VENOUS DISEASE
RADIOFREQUENCY ABLATION: EARLY AND LATE RESULTS
A. Gasparis
Ass. Professor, Vascular Surgeon, Stony Brooke Medical Center, USA
Endovenous ablation, using radiofrequency energy, to treat incompetent saphenous vein has been shown
to be a less invasive treatment option compared to high ligation and stripping. Early and long-term results suggest that radiofrequency ablation techniques are at least as effective and durable as traditional
saphenous vein surgery.1,2,3 The two currently available methods to achieve ablation of incompetent veins
using radiofrequency energy are radiofrequency ablation (RFA) with VNUS Closure Plus catheter and radiofrequency powered segmental ablation (RPSA) using the VNUS ClosureFAST catheter. Both treatment
modalities expose vascular endothelium to high-frequency alternating current. This results in contraction
of venous wall collagen with subsequent fibrotic endoluminal obliteration.
Radiofrequency ablation of saphenous veins has proven efficacy with an excellent side effect profile. Merchant et al. looked at 5 year results in patients treated with RFA and showed occlusion
rate of 87.2% and reflux-free rate of 83.8%. Patients with good anatomic success experienced a
94% clinical improvement. 1 Despite the excellent results, when compared with endovenous laser
treatment RFA has the disadvantage of being a lengthy pullback procedure. This drawback lead
to the development of a second generation catheter, the ClosureFAST.
Radiofrequency powered segmental ablation has become available relatively recently, but increasing
amount of clinical data and patient’s satisfaction support this technique as a reasonable therapy for superficial reflux disease. Initial experience and mid-term results with Closure Fast catheter have documented substantially decreased average procedural time, little postoperative discomfort and mid-term occlusion rates that approximated 100%. In the RECOVERY study4 comparing ClosureFAST to 980-nm EVL, results showed patients treated with the ClosureFAST catheter experienced significantly less post-procedure
pain, bruising and tenderness when compared to laser ablation. There were statistically fewer complications in limbs treated with the ClosureFAST compared to laser ablation (P=0.021). Proebstle et al treated
194 patients with ClosureFAST the average total endovenous procedure time was 16.4 +/- 8.2 minutes,
and the average total energy delivery time was 2.2 +/- 0.6 minutes. Occlusion rates were 99.6% at 6
months according to life-table analysis. The average Venous Clinical Severity Score was 3.4 +/- 1.2 at 3
days, 0.9 +/- 1.6 at 3 months, and 1.5 +/- 1.8 at 6 months compared with 3.9 +/- 2.0 at baseline.5 Occlusion rates and clinical results have been maintained at 1 year, confirming efficacy of RPSA.6
Radiofrequency ablation has been shown to have excellent clinical results with approximately
90% occlusion rates at 5 years. Second generation technology has maintained clinical results
with minimal postoperative pain, high occlusion rates and improved quality of life while overcoming its main disadvantage compared to laser ablation – lower treatment time.
References
1. Merchant RF, Pichot O; the Closure Study Group. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg 2005;42:502-9.
2. Lurie F, Creton D, Eklof B, Kabnick LS, Kistner RL, Pichot O, et al. Prospective randomised trial of endovenous radiofrequency obliteration (closure) versus ligation and stripping (EVOLVeS): two year follow-up. Eur J Vasc Endovasc Surg 2005;29:67-73.
3. Elkaffas KH, Elkashef O, Elbaz W. Great Saphenous Vein Radiofrequency Ablation Versus
Standard Stripping in the Management of Primary Varicose Veins: A Randomized Clinical Trial. Angiology. 2010 Aug 18. Epub ahead of print.
4. Almeida JI, Kaufman J, Göckeritz O, Chopra P, Evans MT, Hoheim DF, Makhoul RG, Richards T,
Wenzel C, Raines JK. Radiofrequency endovenous ClosureFAST versus laser ablation for the
treatment of great saphenous reflux: a multicenter, single-blinded, randomized study (RECOVERY study) J Vasc Interv Radiol. 2009;20(6):752-9.
5. Proebstle TM, Vago B, Alm J, Göckeritz O, Lebard C, Pichot O. Treatment of the incompetent
great saphenous vein by endovenous radiofrequency powered segmental thermal ablation:
first clinical experience. J Vasc Surg. 2008;47(1):151-156.
6. Creton D, Pichot O, Sessa C, Proebstle TM; ClosureFast Europe Group. Radiofrequency-powered segmental thermal obliteration carried out with the ClosureFast procedure: results at 1
year.Ann Vasc Surg. 2010 Apr;24(3):360-6. Epub 2010 Jan 29.
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Παρασκευή 21 Ιανουαρίου 2011 • Friday January 21st 2011
Στρογγυλό Τραπέζι ΙI • Round Table IΙ
IS FOAM SCLEROTHERAPY FOR VARICOSE VEINS SAFE AND EFFECTIVE?
Dimitris Bountouroglou MSc DIC FRCS
Vascular Surgeon
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Traditional varicose vein surgery has recently faced a challenge from the introduction of minimally invasive surgery, including ultrasound guided foam sclerotherapy (USGFS), radiofrequency
(RF) and laser saphenous vein ablation.
Foam sclerotherapy was invented in 1939 (McAusland) to treat spider veins. USGFS started to become popular in the early 2000, as a result of the 2-syringe easy and fast method to produce
foam, and the use of ultrasound to guide its distribution.
Today USGFS is widely accepted as treatment of reticular varicose veins, isolated incompetent saphenous tributaries, primary venous incompetence, and recurrent varicose veins after surgery;
it is also an appropriate method for use in elderly patients unsuitable for surgery, patients on anticoagulants and in patients with venous leg ulcers.
A single session of UGFS can eradicate reflux in the greater saphenous vein in over 95% of patients with symptomatic primary venous incompetence. Recanalisation at 12 months is superior
to that reported after surgery and similar to that observed following other minimally invasive
techniques.
Healing rates following UGFS for chronic venous ulcerations are comparable to those reported
after surgery but recurrence may be lower. UGFS is a safe, clinically effective and, thus, highly attractive minimally invasive alternative to surgery in patients with C5 and C6 disease.
Ultrasound-guided foam sclerotherapy for great and small saphenous varicose veins leads to significant improvements in generic and disease-specific HRQOL for at least 12 months after treatment.
The most frequently encountered complications following UGFS were skin staining (28%), superficial thrombophlebitis (18%) and pain (14%).
UGFS for CEAP 2-6 venous incompetence is associated with a low complication and retreatment
rate. However, as patients are at risk of developing recurrent and new superficial venous reflux
they should be kept under review. Further UGFS for new or recurrent disease is simple, safe, and
effective.
UGFS is a safe and effective method of treating varicose veins. The relative advantages or disadvantages of this treatment in the longer term have yet to be published.
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Παρασκευή 21 Ιανουαρίου 2011 • Friday January 21st 2011
ΑΝΤΙΜΕΤΩΠΙΣΗ ΧΡΟΝΙΑΣ ΦΛΕΒΙΚΗΣ ΝΟΣΟΥ
MANAGEMENT OF CHRONIC VENOUS DISEASE
INDICATIONS AND TECHNIQUES IN VENOUS STENTING
Seshadri Raju MDFACS
The Rane Center, Flowood. MS. USA
The advent of intravascular ultrasound (IVUS) and the emergence of venous stent technology is
changing traditional treatment paradigms in advanced chronic venous disease. While the frequent presence of obstruction in post thrombotic patients has been recognized, primary chronic
venous disease (CVD) has been considered as overwhelmingly due to reflux. IVUS use however
shows that iliac vein obstruction is present in >90% of patients whether ‘primary’ or postthrombotic in etiology. Stent correction of the lesion has proven to be minimally invasive, safe
and effective in a wide spectrum of CVD patients. Because of its relative simplicity and safety, stent treatment has ben extended to even subsets that would be precluded from open surgery.
Most surprisingly, stent correction of iliac vein obstruction alone is effective even when associated severe reflux is left uncorrected.e Patients with advanced manifestations of chronic venous
disease are potential candidates for iliac vein stenting. They should be investigated by IVUS as
venography and other pressure based techniques have poor sensitivity. Venous stenting differs
in important respects from arterial stenting. Specific details are described in the abstract covering the second presentation by the author on this topic.
A paradigm shift in the treatment of advanced CVD patients is in evolution. From a larger perspective, fundamental questions regarding the relative importance of obstruction and reflux arise.
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Παρασκευή 21 Ιανουαρίου 2011 • Friday January 21st 2011
Στρογγυλό Τραπέζι ΙI • Round Table IΙ
TREATMENT OF VENOUS ULCERS
Dragan J Milic, MD, PhD
Vascular and General Surgeon, Serbia
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Venous leg ulcers are a major health problem because of their high prevalence and associated
high cost of care, slow healing and high recurrence rate. They affect at least 0.2 percent of the
population in the developed countries, and their prevalence increases considerably with age, affecting about 2% of the population over the age of eighty. Venous ulcers can be defined as
wounds with a “full-thickness depth” and a “slow healing tendency.” In most cases venous ulcers represent the final outcome of lower extremity chronic venous insufficiency. More than 6
million persons in the United States have chronic venous insufficiency, leading to treatment costs
of up to $2.5 billion and 2 million lost workdays annually. There is a probable underestimation of
the true extent of this condition due to under-reporting and inadequate assessment.
Venous ulcers are the result of a complex chain of events resulting from venous valvular incompetence and subsequent superficial venous hypertension. It is unclear how venous hypertension
results in ulceration. Recently proposed theories, such as leukocyte plugging in the vessels of the
lower extremities, abnormalities of the fibrinolytic system, pericapillary fibrin cuff deposition and
trapping of growth factors by macromolecules in the dermis, are some of the consequences of
venous hypertension thought to be responsible for the development of venous leg ulcers.
Treatment of venous ulcers should be pathophysiology based and there are many treatment
modalities available. In order to achieve best possible healing results with low recurrence rate,
treatment algorithm may comprise several steps:
I. Correcting Hemodynamic Abnormalities (Correcting underlying venous lesion - reflux or obstruction)
II. Lower limb compression/ambulation
III. Cellular/enzymatic (Pharmacologic) Therapy
IV. Skin grafting or tissue bioengineering
Correcting the underlying venous lesion and the use of compression are two
most important treatment modalities for venous leg ulcers.
For correcting underlying venous lesion there are many available treatment options:
- Ablative surgery
Traditional open surgical and Endovenous procedures
Foam Sclerotherapy
- Reconstructive Surgery
- PTA and Stenting
ESCHAR study clearly demonstrated that correction of an underlying venous lesion reduces recurrence rate for venous ulcers.
However, compression therapy remains the most widely used treatment for venous leg ulcers.
The mode of action is not clearly understood but it is postulated that the application of external
pressure to the calf muscle raises the interstitial pressure, decreases the superficial venous pressure and improves venous return–leading to a reduction in the superficial venous hypertension.
The goals of compression treatment in patients with venous ulceration are reduction of edema,
pain and lipodermatosclerosis, ulcer healing, and prevention of recurrence. A recent meta-analysis concerning the treatment of venous ulcers with compression concluded that: 1) compression
is better than no compression, 2) high compression is more effective than low compression (5060 mm Hg) and 3) multi-layered systems are more effective than single-layered systems.
However, further studies are needed in order to determine the best treatment modalities for venous ulcers.
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MANAGEMENT OF CHRONIC VENOUS DISEASE
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Παρασκευή 21 Ιανουαρίου 2011 • Friday January 21st 2011
∆ορυφορική ∆ιάλεξη • Satellite Lecture
ΑΠΟΤΕΛΕΣΜΑΤΑ ΜΕΛΕΤΗΣ CALISTO ΓΙΑ ΤΗ ΘΕΡΑΠΕΙΑ ΤΗΣ ΕΠΙΠΟΛΗΣ
ΦΛΕΒΙΚΗΣ ΘΡΟΜΒΩΣΗΣ
TREATMENT OF SUPERFICIAL VEIN THROMBOSIS IN THE LEGS LESSONS FROM
THE CALISTO TRIAL
Paolo Prandoni, MD, PhD
Thromboembolism Unit, University of Padua (Italy)
Superficial-vein thrombosis (SVT) of the legs is frequent, with an estimated incidence that may exceed
that of deep-vein thrombosis (1). Patients with isolated SVT are at risk of subsequent symptomatic venous thromboembolic (VTE) complications. In a large, prospective, observational study, the three-month
risk of such complications was 8.3%, including a 3.3% risk of deep-vein thrombosis (DVT) or pulmonary
embolism (PE) (2). The treatment of this disease has not been adequately addressed by randomized trials. Accordingly, the recommendations in various guidelines are weak, and in practice, therapeutic strategies are heterogeneous, including no treatment, surgery, anti-inflammatory agents and anticoagulants (3). The few randomized studies reported did not clarify the need for surgery, or the value, dose
and duration of anticoagulants or anti-inflammatory agents. The two largest studies, evaluating lowmolecular-weight heparin, suggest that therapeutic or intermediate dose regimens do not provide substantial benefits over low-dose (prophylactic) regimens, and that both 12 and 30 days of treatment are
too short, most symptomatic VTE complications occurring after the treatment period (4,5).
Recently, the results of a placebo-controlled, multicenter study (the Calisto study) aimed at to evaluating the efficacy and safety of fondaparinux, a specific inhibitor of factor Xa, in reducing symptomatic
VTE complications and/or death from any cause in patients with acute isolated SVT have been published (6). 3002 patients with SVT as shown by ultrasonography (at least 5 cm length) were assigned
to receive either subcutaneous once-daily fondaparinux 2.5 mg or placebo for 45 days, provided that
the thrombotic disorder had not yet involved the sapheno-femoral junction and patients were free
from cancer and history of previous VTE. The primary efficacy outcome was the composite of symptomatic events at Day 47: death from any cause, PE, DVT, and extension or recurrence of SVT. The main
safety outcome was major bleeding. Follow-up lasted up to Day 77. The primary efficacy outcome occurred in 13 of 1502 patients (0.9%) in the fondaparinux group and 88 of 1500 patients (5.9%) in the
placebo group (relative risk reduction: 85%; 95% confidence interval, 74 to 92; P<0.001). The incidence
of each component of the primary efficacy outcome was significantly reduced in the fondaparinux
group. Importantly, fondaparinux reduced by 85% the risk of PE or DVT, from 1.3% to 0.2% (95% confidence interval, 50 to 95; P<0.001). The number needed to treat to prevent one VTE episode was 88.
Similar risk reductions were observed at Day 77. Major bleeding occurred in one patient in each group.
The incidence of serious adverse events was 0.7% with fondaparinux and 1.1% with placebo.
The results of the Calisto study open a new era in the treatment of SVT of the legs. They suggest that
this clinical condition is not as benign as regarded in the past. The use of preventive doses of fondaparinux for six weeks is effective and well tolerated in the treatment of patients with this thrombotic disorder. The benefit of such therapeutic approach persists beyond the duration of treatment.
References
1. Di Minno G, Mannucci PM, Tufano A, et al, on behalf of the FAST Study Group. The first ambulatory screening on thromboembolism: a multicentre, cross-sectional, observational study
on risk factors for venous thromboembolism. J Thromb Haemost 2005;3:1459-66.
2. Decousus H, Quere I, Presle E, et al for the POST Study Group. Superficial vein thrombosis and
venous thromboembolism: a large prospective epidemiological study. Ann Intern Med
2010;152:218-224.
3. Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based
Clinical Practice Guidelines (8th Edition). Chest 2008;133 (6 Suppl):454S-545S.
4. The STENOX Study Group. A randomized double-blind comparison of low-molecular-weight
heparin, a non-steroidal anti-inflammatory agent, and placebo in the treatment of superficial-vein thrombosis. Arch Intern Med 2003;163:1657-63.
5. The VESALIO Investigators Group. High vs. low doses of low-molecular-weight heparin for
the treatment of superficial vein thrombosis of the legs: a double-blind, randomized trial. J
Thromb Haemost 2005;3:1152-57.
6. Decousus H, Prandoni P, Mismetti P, et al. Fondaparinux for the treatment of superficial-vein
thrombosis in the legs. N Engl J Med 2010; 363: 1222-12
40
Παρασκευή 21 Ιανουαρίου 2011 • Friday January 21st 2011
∆ιάλεξη I • Invited Lecture I
ΤΕΧΝΙΚΕΣ ΕΠΑΝΑΣΥΡΑΓΓΟΠΟΙΗΣΗΣ ΚΑΙ ΕΝ∆ΟΝΑΡΘΗΚΩΝ
RECANNALIZATION AND STENTING TECHNIQUES
I n v i t e d
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41
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References
1. Raju S, Darcey R, Neglen P. Unexpected major role for venous stenting in deep reflux disease.
J Vasc Surg. 2010;51:401-8; discussion 8.
2. Raju S, Neglen P. High prevalence of nonthrombotic iliac vein lesions in chronic venous disease: a permissive role in pathogenicity. J Vasc Surg. 2006;44:136-43; discussion 44.
3. Raju S, Hollis K, Neglen P. Obstructive lesions of the inferior vena cava: clinical features and
endovenous treatment. J Vasc Surg. 2006;44:820-7.
4. Neglen P, Raju S. Intravascular ultrasound scan evaluation of the obstructed vein. J Vasc Surg.
2002;35:694-700.
5. Raju S, Neglen P. Percutaneous recanalization of total occlusions of the iliac vein. J Vasc Surg.
2009;50:360-8.
6. Neglen P, Tackett TP, Jr., Raju S. Venous stenting across the inguinal ligament. J Vasc Surg.
2008;48:1255-61.
Ι
Unlike in the arterial system, the femoral vein can be accessed with ultrasound guidance at any
site in the adductor canal. Because of the low pressure, access site bleeding is rare with use of a
sealing device (VasosealTM). A mid-thigh approach works well with the patient in supine position
(an advantage over popliteal approach particularly in obese patients). A size 10 or 11 sheath is
used unlike smaller sized sheaths in the arterial system. A 32 or 36 hundredth GlidewireTM is used
for most purposes. An initial venogram defines the anatomy. The lesions are identified with IVUS
(6Fr. catheter system 15 Mhz; VolcanoTM or Boston Scientific). The lesions should be dilated to
normal anatomical caliber (22, 16, 14 and 12 mm for IVC, CIV, EIV and CFV respectively in most
normal sized adults). Large caliber balloons are available from several manufacturers. The AtlasTM
balloon manufactured by the BardTM company can provide dilatation upto 16-18 ATM which is
particularly useful in treating tough postthrombotic stenosis and instent restenosis. Bleeding
complications from such dilatation is extremely rare7 presumably due to the low prevailing pressure and containment by perivenous structures. Failure to gain proper dilatation and placement
of undersized stents may result in poor limb venous decompression (poor symptom relief) or stent occlusion. Large stents of corresponding size (Boston ScientificTM) preferably oversized by at
least 2 mm should be placed to facilitate later overdilatation in case of restenosis. Proper stent
placement is facilitated by frequent use of IVUS during the procedure. The stent should be extended for 3-5 cm into the inferior vena cava to prevent distal migration that frequently occurs
if the stent is not projected into the vena cava. All lesions in the iliac venous system should be
covered in continuity with stents using generous stent overlaps. Failure to cover all lesions initially may result in the need for later reinterventions. The stent stack can be extended below the
inguinal ligament into the common femoral vein for this purpose. Stent occlusions, erosions and
fractures do not occur in infrainguinal extensions of braided stents in the venous system. Aspirin
is adequate for stent maintainance except in cases of thrombophilia or sever or recurrent thromboses.
This basic technique with modifications can be used to stent the inferior vena cava and in recannalization procedures in correcting CTO lesions.
Periodic stent monitoring by duplex and timely correction of stent malfunction can improve outcomes.
In an analysis of 982 iliac vein stent placements for CVD, there was no mortality and morbidity minor.
Early (<30 day) DVT occurred in 1.5% and later (>30 days) in 1%. 23 (3%) stents occluded during the
observation period. Stent thrombosis was exclusive to postthrombotic obstruction, none occluded in
limbs stented for NIVL. Cumulative long term stent patency was 100% in primary limbs and 86% in
postthrombotic limbs at 6 years. In a subset analysis of 528 stented limbs, with combined obstruction/reflux, axial reflux was present in 42% and the reflux segment score was >3 in 59%. Significant
improvement (cumulative) in pain occurred in 78% with complete relief in 67% when followed upto 5
years; cumulative improvement in swelling occurred in 55% with complete relief in a third of the patients; cumulative healing of ulcers and dermatitis was 54% and 81% respectively. Quality of life measures improved significantly.
∆ ι ά λ ε ξ η
Seshadri Raju MDFACS
The Rane Center, Flowood. MS. USA
Παρασκευή 21 Ιανουαρίου 2011 • Friday January 21st 2011
∆ιάλεξη I • Invited Lecture I
7. Neglen P, Hollis KC, Olivier J, Raju S. Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical, and hemodynamic result. J Vasc Surg.
2007;46:979-90.
8. Raju S, Tackett P, Jr., Neglen P. Reinterventions for nonocclusive iliofemoral venous stent malfunctions. J Vasc Surg. 2009;49:511-8.
9. Kolbel T, Lindh M, Akesson M, Wasselius J, Gottsater A, Ivancev K. Chronic iliac vein occlusion: midterm results of endovascular recanalization. J Endovasc Ther. 2009;16:483-91.
10. Hartung O, Loundou AD, Barthelemy P, Arnoux D, Boufi M, Alimi YS. Endovascular management of chronic disabling ilio-caval obstructive lesions: long-term results. Eur J Vasc Endovasc
Surg. 2009;38:118-24.
11. Knipp BS, Ferguson E, Williams DM, Dasika NJ, Cwikiel W, Henke PK, et al. Factors associated with outcome after interventional treatment of symptomatic iliac vein compression syndrome. J Vasc Surg. 2007;46:743-9.
12. Raju S, RL. D, P. N. Iliac vein stenting in the obese. J Vasc Surg. In press.
13. Raju S OM, Neglén P. Iliac vein stenting in post menopausal leg swelling. J Vasc Surg. In press.
∆ ι ά λ ε ξ η
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ΤΕΧΝΙΚΕΣ ΕΠΑΝΑΣΥΡΑΓΓΟΠΟΙΗΣΗΣ ΚΑΙ ΕΝ∆ΟΝΑΡΘΗΚΩΝ
RECANNALIZATION AND STENTING TECHNIQUES
42
Παρασκευή 21 Ιανουαρίου 2011 • Friday January 21st 2011
THE STATE-OF-THE ART MANAGEMENT OF VENOUS THROMBOEMBOLISM
ΣΥΓΧΡΟΝΗ ΑΝΤΙΜΕΤΩΠΙΣΗ ΘΡΟΜΒΟΕΜΒΟΛΗΣ
A. Nicolaides
Professor Emeritus, Vascular Surgeon
International Consensus Statement (Guidelines according to scientific evidence) Under the auspices of the Cardiovascular Disease Educational and Research Trust,
Cyprus Cardiovascular Disease Educational and Research Trust,European Venous Forum,International Surgical Thrombosis Forum,International Union of Angiology and Union Internationale du
Phlebologie. Edition 2006
Original Publication: Nicolaides AN, Fareed J, Kakkar AK, Breddin HK, Goldhaber SZ, Hull R,
Kakkar VV, Michiels JJ, Myers K, Samama M, Sasahara A, Kalodiki E. Prevention and treatment of
venous thromboembolism. International Consensus Statement (Guidelines according to scientific evidence). Int Angiol 2006;25:101-161
EVIDENCE AND GRADES OF RECOMMENDATION
Grade A recommendations are based on level 1 evidence from randomized controlled trials with consistent results (e.g., in systematic reviews), which are directly applicable to the target population. Single randomised controlled trials have not been accepted as level 1 even when they were of a high
quality and methodologically sound, and have been classified as grade B.
Grade B recommendations are based on level 1 evidence from randomized controlled trials with
less consistent results, limited power, or other methodological problems, which are directly applicable to the target population. Grade B recommendations are also based on level 1 evidence
from randomised controlled trials extrapolated from a different group of patients to the target
population.
Grade C recommendations are based on level 2 evidence from well-conducted observational studies with consistent results, directly applicable to the target population.
Only fully published, peer-reviewed papers of directly randomised comparisons for each prophylactic method have been used to determine risk reduction (Tables X-XXI) Non-randomised comparisons of outcome in different trials have not been included as they are potentially biased. Abstracts have not been included as evidence.
The relationship between the incidence of asymptomatic and the incidence of symptomatic VTE
including PE has been known for some time. Reduction in the incidence of asymptomatic DVT
has recently been shown to be accompanied by a corresponding reduction for symptomatic DVT.
Demonstration that asymptomatic below knee DVT is associated with subsequent development
of the post-thrombotic syndrome also validates adoption of surrogate endpoints for efficacy evaluation. Thus, evidence is presented for surrogate outcomes such as the incidence of asymptomatic DVT at screening as well as clinical outcomes (symptomatic DVT or PE) depending on
availability of data.
This document presents the evidence in a concise format and attempts to indicate not only the
magnitute of the effect of different prophylactic regimens but also the quality of the studies. Information on safety (clinically relevant bleeding and other adverse effects) is also provided. When
randomised controlled studies are not available, the lack of data is stated and recommendations
for the design of appropriate studies are made.
Regulatory bodies in Europe and North America now consider the various LMWHs to be distinct
drug products. They require clinical validation for specific indications for each drug and that each
LMWH must be dosed according to the manufacturer’s label and recommendations. Therapeutic
interchange among these products is not appropriate. The choice of LMWH should reflect the
level of clinical evidence and the approval of the regulatory authorities for each indication. This
is emphasized throughout the document.
Finally, evidence has been provided for and reference has been made to methods of prevention
that are rarely or no longer used or the drug has been withdrawn (dextran, antiplatelet therapy,
dihydroergotamine, melagatran/ximelagatran) in order to provide a complete picture to the clinicians and researchers who are new in the field. The reasons for no longer recommending these
drugs have been stated.
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Επίσηµη ∆ιάλεξη Balkan Venous Forum • Balkan Venous Forum Keynote lecture
Επίσηµη ∆ιάλεξη Balkan Venous Forum • Balkan Venous Forum Keynote Lecture
Σ τ ρ ο γ γ υ λ ό
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Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
Στρογγυλό Τραπέζι III • Round Table III
ΦΛΕΒΙΚΗ ΘΡΟΜΒΟΕΜΒΟΛΗ – ΤΙ ΝΕΩΤΕΡΟ;
VENOUS THROMBOEMBOLISM – WHAT’S NEW?
THROMBOPHILIA SCREENING
Andrew Nicolaides
Three main statements have been put forward for the clinical usefulness of screening patients
with DVT for the presence of thrombophilia.
The first statement is that the presence of thrombophilia in patients with DVT will indicate an increased risk for recurrence. If this is true we must then find out by how much is the risk increased. The second statement is that knowledge of the increased risk indicated by thrombophilia testing can result in better clinical decisions on the duration of anticoagulation therapy
because, according to the third statement prolongation of anticoagulation therapy in patients
with thrombophilia decreases the risk of recurrence. The next questions to be asked are what is
the evidence for this last statement and if this is true does the decrease in recurrence outweigh
the risk of major hemorrhage.
Answering the above questions will provide an indication not only of the rationale for screening
and prolongation of anticoagulation therapy but also an indication of the benefit versus adverse
effects.
The evidence that the prevalence of thrombophilia risk factors are increased in patients with DVT is strong. The odds ratio (OR) varies from 2.8 (95% CI 1.4 to 5.6) for Prothrombin 20210A mutation to 7.9 (95% CI 4.4 to 14) for Factor V Leiden mutation. Others occupy an intermediate
position: Protein C 3.8 (95% CI 1.7 to 7.0), Protein S 0.8 (95% CI 0.2 to 3.0), Antithrombin 5.0
(95% CI 0.7 to 34), APC resistance for wild type Factor V 4.4 (95% CI 2.9 to 6.6) (1) and homocysteine 2.5 (95% CI 1.2 to 5.2).
What is the increased risk for DVT recurrence?
A series of 1626 consecutive patients who had discontinued anticoagulation after a first episode
of clinical symptomatic proximal DVT and PE were followed up for 10 years. The adjusted hazard ratio for recurrent VTE was 2.3 (95% CI 1.82 to 2.90) in patients whose first VTE was unprovoked, 2.02 (95% CI 1.52 to 2.69) in those with thrombophilia, 1.44 (95% CI 1.03 to 2.03) in
those presenting with primary DVT, 1.39 (95% CI 1.08 to 1.80) for patients who received a shorter than 6 months duration of anticoagulation therapy and 1.14 (95% CI 1.06 to 1.12) for every
10 year increase in age. The latter finding means that comparing a 70 year old to a 30 year old
with DVT the hazard ratio would be 1.56. In other words age and recurrent VTE were associated with a higher recurrence rate that thrombophilia. For individual inherited thrombophilia deficiencies of Antithrombin, Protein C and Protein S after adjustment for gender, age and circumstances of the first event Antithrombin deficiency was an independent risk factor for recurrence
(HR 1.9; 95% CI 1.0 to 3.9). Protein C and Protein S had a marginal increase in risk (HR 1.4; 95%
CI 0.9 to 22).
In pooled results from 10 studies involving 3104 patients with first ever VTE, Factor V Leiden was
associated with an increased odds of recurrence of 1.41 (95% CI 1.14 to 1.17). Pooled results
from 9 studies involving 2903 patients with first ever VTE revealed that Prothrombin G20210A
mutation was associated with an elevated odds of recurrent VTE of 1.72 (95% CI 1.27 to 2.31).
Although the increased odds of recurrence is modest, the absolute risk is more. The estimated
population attributable risk of recurrence for Factor V Leiden was 9% (95% CI 4.5 to 13.2%) and
for Prothrombin G20210A was 6.7% (95% CI 3.4 to 9.9%) (the attributable risk is the proportion
of all thrombotic events that would have been prevented by removing the risk factor). It was
concluded that the increase in risk is modest and unlikely to merit extended duration of anticoagulation.
In contrast to the above combination of defects, homozygous Factor V Leiden and patients with
antiphospholipid syndrome are associated with a substantial increase in recurrence of DVT. The
conclusion is that apart from antiphospholipid syndrome combined or homozygous defects and
possibly Antithrombin deficiency, the impact of thrombophilia on the optimal duration of therapy to prevent recurrent thrombosis is small.
Can we make better clinical decisions if we know the results of thrombophilia screening in
all patients with DVT?
In the ACCP guidelines the following statement has been made: “The presence of hereditary
thrombophilia has not been used as a major factor to guide duration of anticoagulation therapy
44
Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
ΦΛΕΒΙΚΗ ΘΡΟΜΒΟΕΜΒΟΛΗ – ΤΙ ΝΕΩΤΕΡΟ;
VENOUS THROMBOEMBOLISM – WHAT’S NEW?
Τ ρ α π έ ζ ι
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for VTE because evidence from prospective studies suggests that these factors are not major determinants of risk recurrence.” In contrast, in the same guidelines, factors quoted to be associated with increased risk of recurrence are:
Provoked vs unprovoked DVT
RR 2-3
Proximal vs isolated calf DVT
RR 2.0
One or more previous episodes of DVT
RR 1.5
Positive D Dimer one month after stopping anticoagulants
RR 1.5
Male vs female
RR 1.6
Presence of cancer
RR 3.0
Residual thrombosis in proximal veins
RR 1.5
It is on the basis of clinical risk factors that patients with DVT and cancer should be considered
with indefinite anticoagulation therapy and patients with proximal DVT with additional clinical
risk factors listed above and age greater than 50 should be considered for prolonged anticoagulation therapy rather than the presence of thrombophilia.
Is there any evidence that prolonged or indefinite anticoagulation in the presence of thrombophilia reduces the rate of VTE recurrence? There are currently no randomized control trials or
control clinical trials that have assessed the benefit(s) of testing for thrombophilia on the risk of
recurrent VTE.
Does the benefit of prolonged anticoagulant therapy outweigh the risks in patients with
heterozygous FV Leiden mutation?
A decision analysis Markov model (with data extracted from the literature) representing the risks
of developing symptomatic VTE and the risks of major bleeding if oral anticoagulant treatment
is extended beyond 3 months after a first episode of DVT in patients who carry Factor V Leiden
mutation. They concluded that the number of hemorrhages induced would significantly exceed
the number of PE events prevented over the entire 5 year period (10). They concluded that the
decision to promote widespread thrombophilia screening after a first episode of VTE was not justified and the decision to extend oral anticoagulation therapy in such individuals did not lead to
any improved clinical outcome.
Which patients with DVT should be tested?
1. First episode of idiopathic DVT at the age of 50 or younger.
2. History of two or more episodes of recurrent thrombosis especially if the events were unprovoked.
3. Positive family history with two or more first degree relatives with documented venous
thrombosis.
4. Women who develop thrombosis during pregnancy or in the setting of a hormonal agent.
Σ τ ρ ο γ γ υ λ ό
Στρογγυλό Τραπέζι III • Round Table III
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Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
Στρογγυλό Τραπέζι III • Round Table III
ΦΛΕΒΙΚΗ ΘΡΟΜΒΟΕΜΒΟΛΗ – ΤΙ ΝΕΩΤΕΡΟ;
VENOUS THROMBOEMBOLISM – WHAT’S NEW?
PHARMACOMECHANICAL THROMBOLYSIS FOR PROXIMAL DVT
A. Gasparis
Ass. Professor, Vascular Surgeon, Stony Brooke Medical Center, USA
Despite the reduction in major bleeding complications with catheter directed thrombolysis (CDT)
and the improved results with thrombus lysis, there is a persistent hesitation in adopting thrombolysis as a potential treatment option for deep vein thrombosis (DVT). The early reported incidence of major bleeding complications in 10% of patients, the significant time required for treatment with the need for intensive care unit stay and the significant cost associated has been the
major reasons for hesitation of acceptance of thrombolysis. Several percutaneous mechanical
thrombectomy devises are now used in combination with pharmacologic thrombolysis to obtain
similar results with CDT but with decreased treatment time, decreased thrombolytic dose and decreased cost. In comparing pharmacomechanical thrombolysis (PMT) to CDT in 93 patients, Lin
et al.1 found similar treatment success in complete clot lysis between the two groups (CDT 70%,
PMT 75%) with the mean thrombolytic infusion time in the CDT group of 18 ± 8 hours compared
to 76 ± 34 minutes with PMT. There was a decreased blood transfusion requirement in the PMT
group compared to the CDT patients (0.2 packed red blood cell units vs. 1.2 units, p< 0.05) and
decrease ICU stay (0.6 days vs. 2.4 days, p<0.04). Hospital cost analysis showed significant cost
reduction in the PMT group compared to the CDT group. Kim et al.2 in a retrospective study of
40 limbs with DVT compared PMT with CDT to CDT alone. He also reported a significant difference in mean lytic treatment time (26.3 hr vs. 48 hr, p= 0.0004).
Percutaneous Mechanical Thrombectomy Devices
AngioJet Rheolytic Thrombectomy System - The AngioJet rheolytic thrombectomy system produces an area of low pressure at the catheter tip by high-velocity saline jets. Via this mechanism,
thrombus is macerated and evacuated via an effluent lumen into a collection chamber. This device may be used in combination with adjunctive thrombolytic agents (power-pulse technique)
for more complete and rapid thrombus removal.3 Typically, 5-10 mg of tissue plasminogen activator is placed in a 50-mL normal saline bag; with the outflow lumen occluded, the lytics are
“power-pulsed” into the clot and allowed to work for 15 to 30 minutes. Once this is complete,
the catheter is then used in the standard fashion with the outflow lumen opened to remove the
thrombus.
Trellis-8 Peripheral Infusion System - The Trellis-8 Peripheral Infusion System is an isolated
thrombolysis catheter with proximal and distal occluding balloons. Drug infusion holes between
the balloons allow delivery of thrombolytics into the isolated segment and thus avoiding systemic delivery. The segment between the balloons contours into a helical shape which provides
mechanical maceration of the thrombus. This pharmacomechanical combination enables focused
treatment of thrombus within a targeted vessel (Figure 2). O’Sullivan et. al.4 evaluated the performance of the Trellis-8 isolated thrombolysis catheter during single-session PMT combined with
low-dose thrombolysis with tissue plasminogen activator in 19 patients with DVT. Restoration of
venous flow was achieved in all cases; thrombus removal was less than 50% in one case (4%),
50%-95% in 18 cases (82%), and at least 95% in three cases (14%). The median administered
dose of t-PA was 13.4 mg per patient. The mean treatment time was 91 minutes per limb (range,
61-129 min). There were no major complications. Primary assisted patency rate was 100% at 30
days.
Ekos Peripheral Infusion System - Another device that is being used in the treatment of DVT is
the Ekos Peripheral Infusion System, which has been demonstrated to improve the effectiveness
of thrombolytic delivery, over traditional catheters in patients with DVT. The system consists of
a multi-side-port drug-infusion catheter with treatment zones up to 50 cm and an ultrasound
core wire with tiny ultrasound transducers placed evenly along the length of the catheter. Highfrequency, low-power ultrasound is delivered into the thrombus to loosen and separate fibrin
and thus increasing the surface area for thrombolytics to function. Recently, registry data on the
46
Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
ΦΛΕΒΙΚΗ ΘΡΟΜΒΟΕΜΒΟΛΗ – ΤΙ ΝΕΩΤΕΡΟ;
VENOUS THROMBOEMBOLISM – WHAT’S NEW?
use of Ekos on DVT out of 8 centers were presented at the International Symposium on Endovascular Therapy (ISET). It included 53 DVT in 47 patients. Average infusion time was 24 h,
and complete lysis was obtained in 70%. The incidence of bleeding complications was only
3.8%.5
Τ ρ α π έ ζ ι
References
1. Lin PH, Zhou W, Dardik A, Mussa F, Kougias P, Hedayati N, Naoum JJ, El Sayed H, Peden EK,
Huynh TT. Catheter-direct thrombolysis versus pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis. Am J Surg. 2006;192:782-8
2. Kim HS, Patra A, Paxton BE, Khan J, Streiff MB. Catheter-directed thrombolysis with percutaneous rheolytic thrombectomy versus thrombolysis alone in upper and lower extremity deep
vein thrombosis. Cardiovasc Intervent Radiol. 2006;29:1003-7.
3. Cynamon J, Stein EG, Dym RJ, Jagust MB, Binkert CA, Baum RA. A new method of aggressive
management of deep vein thrombosis: retrospective study of the power pulse technique. J
Vasc Interv Radiol 2006;17:1043-9
4. O’Sullivan GJ, Lohan DG, Gough N, Cronin CG, Kee ST. Pharmacomechanical thrombectomy
of acute deep vein thrombosis with the Trellis-8 isolated thrombolysis catheter. J Vasc Interv
Radiol. 2007 Jun;18(6):715
5. McNamara T. Combining Ultrasound with Lytic Infusion Accelerates Lysis with Less Bleeding.
Presented at 19th ISET meeting, Hollywood, Florida 2007.
Σ τ ρ ο γ γ υ λ ό
Στρογγυλό Τραπέζι III • Round Table III
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Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
Στρογγυλό Τραπέζι III • Round Table III
ΦΛΕΒΙΚΗ ΘΡΟΜΒΟΕΜΒΟΛΗ – ΤΙ ΝΕΩΤΕΡΟ;
VENOUS THROMBOEMBOLISM – WHAT’S NEW?
CURRENT INDICATIONS OF IN THE USE OF CAVAL FILTERS
Murat Aksoy
Peripheral Vascular Surgery Unit, Department of General Surgery, Istanbul Medical Faculty, Istanbul University, Turkey
Venous Thromboembolism (VTE) is one of the commonest causes of death today. The standard treatment for VTE is anticoagulation. Nevertheless, a certain rate of patients suffers from pulmonary emboli (PE). The first attempt to prevent death from pulmonary emboli by interrupting the vein was carried out by John Hunter in 1874. In this case, Hunter ligated the femoral vein at the level of venous
thrombus. Many authors followed the idea with ligation or clipping of the inferior vena cava. However, these interventions were associated with a mortality ranging from 12 to 20%. The prototype of
inferior vena cava filter was designed by Mobin-Uddin in 1967. However, it was not before 1973 that
the first modern vena cava filter (VCF) was introduced by Greenfield (1).
In modern day’s practice, the indications for VCF include contraindications to anticoagulation in
VTE such as co-existence of intracranial bleeding or active bleeding, hemorrhagic stroke etc (2).
The use of a VCF is also justified in emergence of complications of anticoagulation such as heparin-induced-thrombocytopenia, and bleeding. Vena cava filters are also introduced in patients,
who fail to achieve therapeutic dose of anticoagulation or recurrent PE despite a proper anticoagulation. There are certain situations where a relative indication for a VCF may exist. These include chronic thromboembolic disease, critical right-heart failure, need of a surgical intervention
in patients with venous thromboembolism, and renal cell carcinoma complicated with renal vein
or vena cava thrombosis. Thrombolytic therapy and free-floating ilio-caval thrombus are no
longer indications for a VCF implantation. The risk of VTE is high in trauma patients. The incidence of VTE in head trauma associated with lower limb trauma exposes the patient at a risk of
79% (3). Therefore, every measure has to be taken in this group of patients. Prophylactic use of
VCF is frequently performed in United States in this setting, although it is less preferred in Europe. However, the late outcome of VCF is associated with complications such as bilateral lower
limb thrombosis, filter migration, inferior vena cava thrombosis, and penetration. Therefore, we
believe that VCF implantation may be replaced by other measures, if available in this relatively young patient group. The contraindications for VCF include chronic vena cava thrombosis, inaccessible vena cava and young age relatively.
Although most of the cava filters are placed infrarenal, they can be placed suprarenal in patients
with renal vein thrombosis, recurrent pulmonary embolism in case of a previously placed infrarenal filter, and recurrent pulmonary emboli following an ovarian vein thrombosis. Filters can
be temporary or permanent. Some types of cava filters are optional, which may be placed for
temporary reasons and may become permanent in the long-term. Although vast majority of filters that are implanted worldwide are permanent, temporary filters should be preferred as a first
choice unless a permanent indication such as paraplegia exists.
Since the complication rates are high following an implantation of VCF, patients should be observed regularly. In addition to follow-up measures, anticoagulation should be continued as long
as the filter is in place.
An ideal filter should be non-thrombogenic, cheap, magnetic-resonance-compatible, should have
a high filtration capability, and keep the venous system patent for life. Nevertheless, we do not
have an ideal filter currently and it is still awaited.
References
1. Greenfield LJ, Proctor MC. Indications and techniques of inferior vena cava interruption. in
Handbook of Venous Disorders 2nd Edition, ed.Gloviczki P, Yao JST. Pp 235-244, Arnold Publishers 2001, New York
2. British Committee for Standards in Haematology Writing Group, Baglin TP, Brush J, Streiff M.
Guidelines on use of vena cava filters. Br J Haematol. 2006 Sep;134(6):590-5.
3. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S.
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Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
ΦΛΕΒΙΚΕΣ ΑΓΓΕΙΟ∆ΥΣΠΛΑΣΙΕΣ
∆ηµακάκος Π.
Οµ. Καθηγητής Χειρουργικής Πανεπιστηµίου Αθηνών
Συγγενείς αγγειακές ανωµαλίες αποτελούν µια σπάνια ετερογενή οµάδα µη εκφυλιστικού και
φλεγµονώδους χαρακτήρα, αγνώστου αιτιολογίας που εµφανίζεται κατά την εµβρυική ηλικία.
Η ποικιλοµορφία που τις διακρίνει, η ταυτόχρονη προσβολή περισσοτέρων αγγειακών συστηµάτων, ο εξατοµικευµένος χαρακτήρας και η σποραδικότητα µε την οποία απαντώνται προκαλούν
διαγνωστικό και θεραπευτικό προβληµατισµό στην καθηµερινότητα του κλινικού γιατρού.
Η ορολογία τους µέχρι και το πρόσφατο παρελθόν κυριαρχείτο διεθνώς από λανθασµένες ιδέες,
σύγχυση παραστάσεων και λαογραφικές παραδόσεις όπου η µητέρα ενοχοποιείτο (φόβοι, συναισθηµατισµοί, επιθυµίες κ.α.) για το «σηµάδι» του παιδιού.
Μόνο κατά τις τελευταίες δύο δεκαετίες η επιστηµονική και τεχνολογική πρόοδος µας κατέστησε
κοινωνούς της ανατοµίας, κυρίως όµως της παθοφυσιολογίας και κατ’ επέκταση της ορολογίας και
ταξινόµησης των σπάνιων αυτών συνδρόµων. Η ταξινόµηση του Αµβούργου (1988) συµπληρούµενη από εκείνης του Denver (1992) και της Σεούλ (1996), καθιστούν σήµερα πλέον κατανοητή την
επικοινωνία των ερευνητών στον τοµέα αυτό στη διεθνή βιβλιογραφία.
Μεταξύ αυτών, οι φλεβικές αγγειοδυσπλασίες αποτελούν τις συχνότερες 1-4% του πληθυσµού,
χωρίς διαφορά συχνότητας φύλου, µε παρουσία σε πολλαπλή ή µεµονωµένη µορφή κατά την
γέννηση, µε εντόπιση στο δέρµα, βλεννογόνο ή οποιοδήποτε άλλο οργανικό σύστηµα (Ήπαρ,
µύες, οστά, σπλάχνα, εγκέφαλο, κ.α.).
Αναπτύσσονται ταυτόχρονα και κατ’ αναλογία προς την ανάπτυξη του παιδιού, δεν υποστρέφονται, ενώ τραύµα, εφηβεία, εγκυµοσύνη, αντισυλληπτικά, θρόµβωση ή αιµορραγία αυξάνουν αιφνίδια το µέγεθος τους.
Το τοίχωµα είναι λεπτό, ελλείψει λείων µυϊκών κυττάρων, ενώ σε σπάνιες οικογένειες µε πολλαπλές τέτοιες ανωµαλίες συνυπάρχει γονιδιακή µετάλλαξη, υπεύθυνη για την αλλοίωση αυτή και
την άµεση σχέση ενδοθηλιακών και µυϊκών κυττάρων. Τέτοια σύνδροµα είναι τα πολλαπλά γλοµαγγειώµατα, και η οικογενής δερµατοβλενογόνος και ενδοκρανιακή σηραγγώδης φλεβική δυσπλασία.
Η διάγνωση είναι κλινική και η επιβεβαίωση ακτινολογική (Υπερηχογράφηµα, µαγνητική αγγειογραφία και αξονική τοµογραφία), η δε θεραπεία ανάλογα προς την ποιότητα (απλή ή σύνθετη),
τα συµπτώµατα, την εντόπιση και την έκταση συντηρητική (Laser, σκληροθεραπεία) ή χειρουργική
εξαίρεση. Σύνθετες εκτεταµένες εν τω βάθει φλεβικές δυσπλασίες, εµπλεκόµενες µε άλλες ανατοµικές κυρίως αγγειονευρικές δοµές απαιτούν υπεύθυνη αξιολόγηση ως προς τα οφέλη της εµφάνισης ή της λειτουργικότητας µετά από µια τέτοια επέµβαση.
Σύνθετες µορφές αγγειοδυσπλασιών µε συµµετοχή περισσότερων συστηµάτων και σε ποικίλη συχνά µορφή, συνοδεύονται από υψηλές διαγνωστικές και θεραπευτικές απαιτήσεις. Τέτοια είναι µικτά σύνδροµα όπως το Σ. Klippel-Trenaunay 1990 (Αιµαγγείωµα, άτυποι κιρσοί, εν τω βάθει φλεβική απλασία, λεµφαγγειεκτασία, υπερτροφία µαλακών ή και οστικών µορίων, καρδιακές και άλλες αγγειακές βλάβες) το Σ. Parker-Weber 1918 (διάχυτες αρτηριοφλεβώδεις ανωµαλίες, δυσπλασίες αιµοφόρων (τριχοειδών) και λεµφικών αγγείων) ή αρτηριοφλεβώδεις επικοινωνίες που απαντώνται σε κάθε ανατοµική περιοχή και οργανικό σύστηµα.
Ιδιαίτερα στις τελευταίες, το φλεβικό σύστηµα ως υποδοχέα του όγκου µιας αρτηριοφλεβώδους
δυσπλασίας καθίσταται από «οικοδεσπότης» «µετανάστης» στο χώρο του, αφού οι νέες αιµοδυναµικές συνθήκες δηµιουργούν ακραίες για τη φύση παθοφυσιολογικές συνθήκες ( µη αναστρέψιµες µυοκαρδιακές βλάβες, ανευρύσµατα, ενδοκαρδίτιδα, σηψαιµία, τοπική διόγκωση και ισχαιµία κ.α.) και απαιτούν έγκαιρη µορφολογική και αιµοδυναµική ανάλυση µε άµεση ανατοµική και
τουλάχιστον λειτουργική βελτίωση της βλάβης και κατ’ επέκταση της πρόγνωσης του αρρώστου.
Έλεγχος µιας 20-ετούς περιόδου 25.000 αγγειακών εξετάσεων στο Αγγειοχειρουργικό Τµήµα του
Αρεταίειου Νοσοκοµείου διαπίστωσε 265 συγγενείς αγγειακές ανωµαλίες εκ των οποίων 77,3%
(205/265) ήσαν περιφερικού (extratruncular) φλεβικές δυσπλασίες και 22,7% (60/265) κεντρικού
(truncular) µε προσβολή κεντρικών αγγειακών στελεχών διάχυτης ή εντοπισµένης µορφολογίας.
Από την τελευταία οµάδα 22 (36,6%) ήταν αρτηριοφλεβώδεις δυσπλασίες, εχειρουργήθησαν οι
20 (90%) και υποτροπίασαν το 35% (7/20).
Τριάντα (50%) ήταν αµιγείς φλεβικές ανωµαλίες, εχειρουργήθησαν 9 (30%) και υποτροπίασαν
44,5% (4/9). Οι τελευταίοι οκτώ αφορούσαν λεµφαγγειακές ανωµαλίες µε συντηρητική αντιµετώπιση.
49
Επίσηµη ∆ιάλεξη Ελληνικής Φλεβολογικής Εταιρείας • Hellenic Phlebological Society Keynote Lecture
Επίσηµη ∆ιάλεξη Ελληνικής Φλεβολογικής Εταιρείας • Hellenic Phlebological Society Keynote Lecture
Επίσηµη ∆ιάλεξη Ελληνικής Φλεβολογικής Εταιρείας • Hellenic Phlebological Society Keynote Lecture
Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
Επίσηµη ∆ιάλεξη Ελληνικής Φλεβολογικής Εταιρείας • Hellenic Phlebological Society Keynote Lecture
ΦΛΕΒΙΚΕΣ ΑΓΓΕΙΟ∆ΥΣΠΛΑΣΙΕΣ
Συνολικά εχειρουργήθει το 48,33% (29/60) και υποτροπίασε το 38% (11/29) µετά 8 έτη.
Αυτά επιβεβαιώνουν ότι η ταυτόχρονη προσβολή περισσότερων αγγειακών συστηµάτων, η µορφολογική πολυµορφία, και η σπανιότητα αυτή της νοσολογικής οντότητας απαιτεί λεπτοµερή ανατοµική και παθοφυσιολογική διαγνωστική ανάλυση ακολουθούµενη από µια εξ’ ίσου εξατοµικευµένη συχνά απαραίτητη θεραπευτική σύνθεση. Ο δρόµος για την Ιθάκη προβάλει µακρινός,
όπως και οι προβληµατικές µε τις εκ γενετείς νοσολογικές οντότητες.
Συγγενείς παθήσεις σε αντίθεση από τις επίκτητες, δηµιούργηµα αυτής της ίδιας της φύσεως µε
τους δικούς της όρους, επιφυλάσσουν µεγαλύτερες δυσκολίες στην αντιµετώπισή τους, γι’ αυτό
και ειδικά κέντρα µε εξειδικευµένους γιατρούς σε πλαίσια αρµονικής οµαδικής συνεργασίας υπόσχονται καλύτερα αποτελέσµατα.
50
Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
ΠΩΣ ΚΑΝΩ...
HOW I DO IT
ΠΩΣ ΚΑΝΩ ΕΚΡΙΖΩΣΗ
∆. Χριστόπουλος
Καθηγητής Αγγειοχειρουργικής Πανεπιστηµίου Θεσσαλονίκης
Τ ρ α π έ ζ ι
Ι V
•
Προεγχειρητικά κάνω πάντοτε ένα τρίπλεξ φλεβών και στα δύο κ. άκρα, ώστε να εντοπίσω τις
ανεπαρκείς επικοινωνίες των επιπολής φλεβών µε το εν τω βάθει σύστηµα. Αναλυτικότερα, ελέγχω την σαφηνοµηριαία και σαφηνοιγνυακή συµβολή, και προσδιορίζω το ύψος της τελευταίας σε
σχέση µε τη δερµατική πτυχή του γόνατος. Επίσης εντοπίζω τις ανεπαρκείς διατιτρώσες. Σηµαδεύω
τις ανεπαρκείς φλέβες.
Σαφηνοµηριαία ανεπάρκεια
Με επισκληρίδιο ή γενική αναισθησία κάνω µια τοµή 2-3 εκ. στη βουβωνική δερµατική πτυχή επί
τα εντός του ψηλαφούµενου σφυγµού της µηριαίας αρτηρίας και παρασκευάζω την µείζονα σαφηνή φλέβα και όλους τους κλάδους της προ της συµβολής της µε την µηριαία φλέβα. Οι κλάδοι
κινητοποιούνται τουλάχιστον για 1-2 εκ. διατέµνονται και απολινώνονται ένας-ένας. Αυτό είναι
απαραίτητο για να αποφευχθούν οι υποτροπές. Η µ.σαφηνής διατέµνεται, η σαφηνοµηριαία συµβολή απολινώνεται µε περαστή ραφή και συγκλείεται το ωοειδές τρήµα.
Η περιφερική µ.σαφηνής κινητοποιείται όσο επιτρέπει η τοµή και διατέµνονται τυχόν κλάδοι της.
∆ιεκβάλεται το striper προς τα κάτω και προωθείται µέχρι κάτω από το γόνατο, αλλά όχι περισσότερο από τα 2/3 της κνήµης. Με τοµή 3-4 χιλ παρασκευάζεται η φλέβα στο σηµείο όπου έχει
φτάσει το striper. Η εκρίζωση της σαφηνούς γίνεται µε τον ασθενή σε ανάροπο θέση και µε εγκολεασµό της σαφηνούς, χωρίς τη χρήση της ελαίας, ώστε να µην τραυµατιστεί το σαφηνές νεύρο.
Ακολουθούν µικροφλεβεκτοµές και επίδεση του σκέλους.
Σαφηνοιγνυακή ανεπάρκεια
Με τον ασθενή σε πρηνή θέση γίνεται µια τοµή 2-3 εκ , 1 εκ. περιφεριοκότερα του σηµείου όπου
εντοπίστηκε µε το Τρίπλεξ η σαφηνοιγνυακή συµβολή. Παρασκευάζεται η ελ. σαφηνής και απολινώνονται οι κλάδοι της . Ακολουθεί διατοµή της φλέβας και απολίνωση της σαφηνοιγνυακής
συµβολής µε περαστή ραφή. Ενταφιάζεται το κολόβωµα. Κινητοποιείται το περιφερικό τµήµα της
ελ σαφηνούς όσο επιτρέπει η τοµή και αφαιρούνται περί τα 5 εκ. της φλέβας. Πλήρη εκρίζωση
κάνω πολύ σπάνια και πάντα µε εγκολεασµό της φλέβας, λόγω σηµαντικού κινδύνου τραυµατισµού του ελάσσονος σαφηνούς νεύρου.
Σ τ ρ ο γ γ υ λ ό
Στρογγυλό Τραπέζι IV • Round Table IV
R o u n d
T a b l e
I V
51
Σ τ ρ ο γ γ υ λ ό
Τ ρ α π έ ζ ι
Ι V
•
R o u n d
T a b l e
I V
Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
Στρογγυλό Τραπέζι IV • Round Table IV
ΠΩΣ ΚΑΝΩ...
HOW I DO IT
ΠΩΣ ΚΑΝΩ ΤΙΣ ΤΟΠΙΚΕΣ ΕΚΤΟΜΕΣ
Αντώνης.Ν. Παπαγεωργίου
Πρόεδρος Ελληνικής Αγγειολογικής Εταιρείας, Αγγειοχειρουργός, ∆ιευθυντής
Αγγειοχειρουργικής Κλινικής, Ναυτικό Νοσοκοµείο Αθηνών
Η χειρουργική τακτική για την εκρίζωση των κιρσών µέχρι πρότινος συνίστατο σε µεγάλες τοµές
στο δέρµα, µε σκοπό την καλύτερη αφαίρεση των επιφανειακών ( επιπολής ) φλεβικών στελεχών.
Η µέθοδος αυτή ήταν και είναι αποτελεσµατική για την πληρέστερη εκτοµή όλων των κιρσών ως
και για την πρόληψη των υποτροπών, όµως στις περισσότερες περιπτώσεις η επούλωση των τοµών δεν είχε το επιθυµητό αισθητικό αποτέλεσµα αφήνοντας δύσµορφες ουλές. Αυτό συνετέλεσε ώστε αρκετοί χειρουργοί να εφαρµόσουν και να αναπτύξουν µια διαφορετική τεχνική µε την
οποία οι επιφανειακοί φλεβικοί κλάδοι αποκαλύπτονται και καταστρέφονται ή απολινώνονται δια
µέσου πολλαπλών µικρών τοµών (2-3mm).
Η τεχνική αυτή εφαρµόζεται σε φλεβικά στελέχη που ανεπαρκούν και βρίσκονται κάτω από την
σαφηνοµηριαία και σαφηνοιγνυακή συµβολή. Οι τοµές του δέρµατος είναι µικρές περίπου 1-2 mm
και οι φλέβες εκτέµνονται µε ειδικό άγκιστρο. Η επέµβαση γίνεται µε τοπική αναισθησία και έχει
συνήθως πολύ καλά τόσο άµεσα όσο και απώτερα αισθητικά αποτελέσµατα. Σε σχέση µε την
σκληροθεραπεία ,που µπορεί να εφαρµοσθεί σε αυτά τα φλεβικά στελέχη, αποφεύγεται ο κίνδυνος ενδαρτηριακής έγχυσης του φαρµάκου, δερµατικής νέκρωσης και υπέρχρωσης του δέρµατος.Το µικρό µήκος της τοµής έχει σαν αποτέλεσµα να µην αφήνει δύσµορφη ουλή και παρατηρείται ικανοποιητικό αισθητικό αποτέλεσµα. Εξάλλου το γεγονός ότι η επέµβαση γίνεται µε τοπική
αναισθησία µειώνει τους πιθανούς κινδύνους που µπορεί να παρατηρηθούν από την περιοχική ή
γενική ενδοτραχειακή αναισθησία που απαιτείται για την κλασσική σαφηνεκτοµή.
Πρέπει να προηγηθεί λεπτοµερής κλινική και υπερηχογραφική εξέταση του φλεβικού συστήµατος τόσο του επιφανειακού όσο και του εν τω βάθει φλεβικού συστήµατος, για την ύπαρξη ή όχι
παλινδρόµησης, αλλά και για την χαρτογράφηση των φλεβικών στελεχών που πρόκειται να γίνει
παρέµβαση.Άν διαπιστωθεί σηµαντική παλινδρόµηση στην σαφηνοµηριαία ή σαφηνοιγνυακή
συµβολή θα πρέπει να διορθωθεί πριν από οποιαδήποτε προσπάθεια τοπικής εκτοµής.
Αν και οποιοδήποτε φλεβικό τµήµα µπορεί να εκταµεί µε τα ειδικά άγκιστρα, εν τούτοις θα πρέπει να αποφεύγονται τα τµήµατα των φλεβών που βρίσκονται στην ραχιαία επιφάνεια του άκρου
ποδόςως και στην ιγνυακή πτυχή.Οι φλέβες που κυρίως αντιµετωπίζονται µε τοπικές εκτοµές είναι
διατεταµένα ελικοειδή φλεβικά τµήµατα, κλάδοι της Μείζονος και της Ελάσσονος Σαφηνούς, οι αιδοιικές φλέβες και φλέβες στην έξω επιφάνεια του µηρού. Η µόνη αντένδειξη για τοπική εκτοµή
είναι η παλινδρόµηση της σαφηνοµηριαίας και σαφηνοιγνυακής συµβολής.
Η τοπική εκτοµή απαιτεί µικρό αριθµό χειρουργικών εργαλείων: ένα µαχαιρίδιο No 11για τις τοµές, πολλές λαβίδες mosquito για την σύλληψη και εκτοµή των φλεβικών τµηµάτων, ως και διάφορα είδη αγκίστρων όπως το άγκιστρο Muller, το άγκιστρο Oesch ή το άγκιστρο Ramelet.
Οι τεγχειρητικές τοµές δεν απαιτούν συρραφή , ή µένουν ως έχουν ή συµπλησιάζονται µε sterile
strips. Η επίδεση του σκέλους είναι υποχρεωτική και καλύπτει όλες τις τοµές.Ο ασθενής είναι περιπατητικός και πλήρως δραστηριοποιηµένος.Η επιστροφή στις καθηµερινές δραστηριότητες του
είναι άµεση.Η επίδεση αφαιρείται µετά από 48 ώρες και συστήνεται στον ασθενή να φέρει ελαστικές κάλτσες.΄Αν απαιτηθεί γίνεται συµπληρωµατική σκληροθεραπεία αφού έχει επιτευχθεί ικανοποιητική επούλωση στις τοµές.
Υποτροπή των κιρσών παρατηρείται αν δεν έχει προηγουµένως αρθεί η παλινδρόµηση .Άλλες
επιπλοκές είναι το οίδηµα, η αιµορραγία ,η δηµιουργία αιµατώµατος, οι τηλαγγειεκτασίες που δηµιουργούνται στα σηµεία των τοµών ως και ερεθισµός του δέρµατος από τα επιθέµατα στις τοµές,
επιπλοκές που όµως δεν είναι συχνές.
52
Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
ΠΩΣ ΚΑΝΩ...
HOW I DO IT
ΠΩΣ ΚΑΝΩ ΣΚΛΗΡΟΘΕΡΑΠΕΙΑ ΣΑΦΗΝΟΥΣ
Μάριος Βαλσάµης
Χειρουργός
Τ ρ α π έ ζ ι
Η σκληροθεραπεία των αξόνων των σαφηνών φλεβών (Μείζονος και Ελάσσονος σαφηνούς) κοντά στα σηµεία εκβολής τους στο εν τω βάθη σύστηµα, είναι µια τεχνική περιπατητικής θεραπείας
κιρσών των κάτω άκρων, που ξεκίνησε το 1950 στη Γαλλία. Σκοπός ήταν, να κλείσουν οι συγκεκριµένες φλέβες όσο πιο ψηλά γίνεται και έτσι να ελαττωθεί η παλίνδροµη ροή του φλεβικού αίµατος στα κατώτερα σηµεία του ποδιού, όπου συνήθως εµφανίζονται οι κιρσοί. Η τεχνική δεν αντιµετώπιζε συνολικά το πρόβληµα των κιρσών, αποτελούσε όµως το πρώτο και εξαιρετικά σηµαντικό βήµα στην αντιµετώπιση των κιρσών των κάτω άκρων µε σκληρυντικές ενέσεις. Η τεχνική
παρουσίαζε εντυπωσιακά αποτελέσµατα, απαιτούσε όµως αρκετή επιδεξιότητα. Με την εφαρµογή
των υπερήχων στη σκληροθεραπεία, το 1988, η «υπερηχογραφικά κατευθυνόµενη σκληροθεραπεία» συστηµατοποιήθηκε καλύτερα και η τεχνική έγινε πιο εύκολη, µε ελαχιστοποίηση των επιπλοκών. Η εφαρµογή του «αφρού» στη σκληροθεραπεία των σαφηνών, στις αρχές τις δεκαετίας
µας, απλούστευσε περισσότερο την τεχνική και έδωσε ακόµα µεγαλύτερη ώθηση στη περιπατιτική θεραπεία των φλεβικών προβληµάτων των κάτω άκρων.
Στην παρουσίασή µας αναφερόµαστε συνολικά στις τεχνικές λεπτοµέρειες της υπερηχογραφικά
καθοδηγούµενης σκληροθεραπείας των αξόνων της Μείζονος και Ελάσσονος σαφηνούς φλέβας,
µε χρήση αφρού. Παρουσιάζονται µε πρακτικό τρόπο τα εξής: Έλεγχος φλεβικού δικτύου αµέσως
πριν τη θεραπεία. Σχεδιασµός στρατηγικής. Επιλογή Φαρµάκου. Θέση Ασθενούς. Παρασκευή
αφρού. Τεχνική καθετηριασµού και έγχυσης. Έλεγχος αµέσως µετά την έγχυση. Έλεγχος στην επόµενη συνεδρία. Follow-up ασθενούς.
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Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
Στρογγυλό Τραπέζι IV • Round Table IV
ΠΩΣ ΚΑΝΩ...
HOW I DO IT
ΣΚΛΗΡΟΘΕΡΑΠΕΙΑ ΕΥΡΥΑΓΓΕΙΩΝ
Σωτήρης Γ. Γιαννακάκης
Αγγειοχειρουργός, Επιµελητής Γ.Ν.Α. ΚΑΤ
Ο ορισµός των ευρυαγγειών (ή τηλεαγγειαεκτασιών) καθορίσθηκε το 1807 από τον von Graf, ο
οποίος τις περιγράφει ως επιφανειακά αγγεία του δέρµατος ορατά δια του γυµνού οφθαλµού. Με
µεγαλύτερη σαφήνεια θα µπορούσαµε να τις περιγράψουµε ως αγγεία διαµέτρου 0,1 – 1mm που
συνήθως πρόκειται για φλεβίδια, αρτηρίδια ή τριχοειδή µε συνηθέστερη εντόπιση τα κάτω άκρα
και σαφή προτίµηση στο γυναικείο φύλο.
Σκληροθεραπεία είναι η διαδικασία κατά την οποία µία φαρµακευτική ουσία εγχέεται ενδοαυλικά
στην ευρυαγγεία που αρχικά προκαλεί θρόµβωση και ακολούθως ίνωση και σταδιακή εξαφάνισή
της. Η θρόµβωση προκαλείται µε τη διαδικασία της χηµικής καταστροφής του ενδοθηλίου που ως
γνωστόν είναι ο ένας παράγοντας από τη γνωστή τριάδα του Virchow. Aρκετοί σκληρυντικοί παράγοντες βρίσκονται στη διάθεσή µας σήµερα.
Οι πιο γνωστοί και ευρύτερα χρησιµοποιούµενοι (µε αναφορά στη χώρα προέλευσης) είναι:
1. Sodium tetradecyl sulfate (STD) – Mεγ. Βρετανία
2. Polidocanol (Aethoxysklerol) – Γερµανία, Αυστρία, Ελβετία
3. Παράγωγα γλυκερίνης (Scleremo) – Γαλλία.
Τεχνικά στοιχεία σκληροθεραπείας
Πάντα προηγείται προσεκτική κλινική εξέταση του ασθενούς προς αποκλεισµό σταδίου φλεβικής
ανεπάρκειας ≥ ΙΙ κατά CEAP, δηλαδή συνύπαρξης κιρσών και επιπλοκών αυτών όπως οίδηµα, λιποδερµατοσκλήρυνση ή και φλεβικό έλκος. Ο λόγος είναι ότι η θεραπεία αυτών των παθολογικών καταστάσεων θα πρέπει να προηγείται γιατί αλλιώς η σκληροθεραπεία των ευρυαγγειών δεν
θα έχει τα προσδοκώµενα αποτελέσµατα. Επίσης, µία λεπτοµερής ενηµέρωση όσον αφορά τον
τρόπο εφαρµογής της θεραπείας, τον κατά προσέγιση αριθµό των απαιτούµενων συνεδρειών, το
αναµενόµενο τελικό αποτέλεσµα και τέλος την ελαστική συµπίεση µε επιδέσµους ή κάλτσες είναι
απαραίτητο να προηγείται της θεραπείας. Στο σηµείο αυτό συνιστάται ένα ενηµερωτικό σηµείωµα
µε όλες τις απαραίτητες πληροφορίες. Η θεραπεία θα πρέπει να ξεκινά
από περιοχές του κεντρικού µηρού και να επεκτείνεται προς την περιφέρεια σταδιακά. Καλό είναι
τα κάτω άκρα να χωρίζονται τοπογραφικά σε ενότητες (π.χ. δεξιός µηρός, δεξιά κνήµη κ.ό.κ.) και
να τελειώνει η θεραπεία του ενός άκρου
πριν ξεκινήσει αυτή του ετερόπλευρου. Η επιλογή της βελόνας θα πρέπει να σχετίζεται µε τη διάµετρο του αντιµετωπιζόµενου αγγείου αλλά συνήθως µία βελόνα 30G επαρκεί για όλες τις πιθανές διαµέτρους. Οσον αφορά την επιλογή σύριγγας µιας χρήσεως, η προτεινόµενη είναι αυτή των
2,5ml λόγω του ότι το µέγεθος της είναι το ευκολότερα χειριζόµενο µε το ένα χέρι ενώ αυτή του 1
ml (ινσουλίνης) λόγω της µεγάλης απόστασης από το άκρο του εµβόλου έως την άκρη της βελόνας της είναι πιο δύσχρηστη σε χειρισµό ακριβείας. Το χρησιµοποιούµενο τοπικό αντισηπτικό είναι
διάλυµα αλκοόλης, το οποίο µάλιστα βοηθά και στη καλύτερη εντόπιση του περιγράµµατος. Ενας
καλός φωτισµός φθορίου επαρκεί χωρίς απαραίτητα τη χρήση φακού µεγέθυνσης. Τέλος πρό της
εγχύσεως το δέρµα θα πρέπει να ακινητοποιείται στο σηµείο εισόδου της βελόνας και αυτό επιτυγχάνεται µε απλή διάταση της περιοχής από τα 3 πρώτα δάκτυλα του άλλου χεριού του γιατρού.
Είναι αυτονόητο ότι η ακριβής ενδοαυλική έγχυση απαιτείται τόσο για την αποτελεσµατικότητα της
θεραπείας όσο και για τη µείωση των πιθανών επιπλοκών. Ωστόσο αυτό στην αρχή της ενασχόλησης του γιατρού µε τη σκληροθεραπεία δεν είναι πάντα εφικτό και ένα από τα συχνότερα λάθη
είναι η έγχυση σε βαθύτερο επίπεδο από το σωστό. Στην πράξη η πλειοψηφία των ευρυαγγειών
είναι πολύ επιφανειακά και για την ακρίβεια ενδοεπιδερµικά. Εαν ο γιατρός παρατηρήσει δηµιουργία ποµφού στο σηµείο της έγχυσης θα πρέπει να τη σταµατά αµέσως.
Η ποσότητα που µπορεί µε ασφάλεια να εγχυθεί εξαρτάται από το σκεύασµα που έχει επιλεχθεί,
την πυκνότητα του και κατά δεύτερο λόγο από τη διάµετρο των αντιµετωπιζόµενων αγγείων. Συνιστάται από την φαρµακευτική εταιρεία της πολιδοκανόλης π.χ. να µην υπερβαίνει ο γιατρός την
ποσότητα των 10 ml. Eµπειρικά και για λόγους ασφαλείας καλό θα είναι να µην υπερβαίνει ο γιατρός την ποσότητα των 3 – 4 ml ανά συνεδρεία. Επίσης, σε κάθε συγκεκριµένο σηµείο έγχυσης
σκληρυντικής ουσίας, η εγχεόµενη ποσότητα δεν πρέπει να υπερβαίνει την ποσότητα των 0,5 ml
ακόµη και αν αυτό απαιτείται από τη διάµετρο του αντίστοιχου αγγείου. Ο λόγος είναι ότι στην πε-
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ρίπτωση αυτή ο κίνδυνος τοπικής επιπλοκής από το δέρµα πολλαπλασιάζεται. Επίσης, θα πρέπει
να αναφερθεί ότι σε φλεβεκτασίες µεγαλύτερης διαµέτρου µπορεί να επιλεχθεί η µέθοδος της
σκληροθεραπείας µε αφρό (µέθοδος Tessari).
Εαν θα πρέπει να επιλεγεί µία και µόνη πυκνότητα ενός σκευάσµατος π.χ. της πολιδοκανόλης, η
πυκνότητα που µπορεί να είναι αποτελεσµατική και κατά το δυνατόν ασφαλής στην πλειοψηφία
των αντιµετοπιζόµενων ευρυαγγειών είναι αυτή του 1%. Στο τέλος της κάθε συνεδρείας τοποθετούνται τοπικά βαµβάκια και η περιοχή περιδένεται µε ελαστικό επίδεσµο. Η συµπίεση διατηρείται
3 – 5 ηµέρες και εφαρµόζεται ακολούθως ελαστική κάλτσα διαβαθµισµένης πιέσης Classe II για
διάστηµα 10 – 14 ηµερών. Οι συνεδρείες επαναλαµβάνονται ανά 5 – 7 ηµέρες και στο διάστηµα
αυτό θα πρέπει η ελαστική συµπίεση να παραµείνει καθώς και περίπου 2 εβδοµάδες από την τελευταία συνεδρεία.
Οι πιο γνωστές επιπλοκές είναι αλλεργικές αντιδράσεις, τοπικές και συστηµατικές (ευτυχώς σπανιότατες), δυσχρωµία, επιπολής και σπανότερα εν τω βάθει θροµβοφλεβίτιδα και τέλος δερµατική
νέκρωση. Οταν τηρηθούν πιστά οι οδηγίες της ασφαλούς εφαρµογής τότε οι επιπλοκές είναι σπανιότατες. Οι συνηθέστερες είναι η τοπική δυσχρωµία (pigmentation) και το <<matting>>, η δηµιουργία δηλαδή τοπικά νέων πολυάριθµων ευρυαγγειών πολύ µικρής διαµέτρου.
Το τελικό αποτέλεσµα είναι στην πλειοψηφία των ασθενών είναι ικανοποιη-τικό µε εξαφάνιση περίπου του 80 – 90% του συνόλου των αρχικών ευρυαγγειών ενώ θα πρέπει να τονίζεται από την
αρχή της θεραπείας στον ασθενή ότι σε ετήσια βάση θα χρειάζεται κάποια επαναληπτική θεραπεία
1-2 συνεδρειών, µιας και το πρόβληµα των ευρυαγγειών είναι γονιδιακό.
Συµπερασµατικά θα πρέπει να αναφερθεί ότι η ενασχόληση µε την εξαφάνιση των ευρυαγγειών
κυρίως έχει κοσµητικό ρόλο αλλά συχνά απαλάσσει τον ασθενή από ορισµένα τοπικά συµπτώµατα όπως καύσος ή πόνος. Ο κατά κύριο λόγο αισθη-τικός χαρακτήρας της σκληροθεραπείας δεν
δικαιολογεί φτωχό αποτέλεσµα σε σχέση µε το προσδοκώµενο αλλά κυρίως δεν δικαιολογεί εύκολα συχνή εµφανίση επιπλο-κών. Για το λόγο αυτό η προσεκτική αρχική ενηµέρωση σε συνδυασµό µε την επαρκή πείρα και τεχνική εγγυώνται ένα καλό αποτέλεσµα.
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ΠΩΣ ΚΑΝΩ...
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ΠΩΣ ΚΑΝΩ ΚΑΤΑΛΥΣΗ ΜΕ ΡΑ∆ΙΟΣΥΧΝΟΤΗΤΕΣ (RF)
Χρήστος Β. Ιωάννου
Επίκουρος Καθηγητής Αγγειοχειρουργικής, Αγγειοχειρουργική Κλινική,
Ιατρική Σχολή Πανεπιστηµίου Κρήτης, Ηράκλειο
Η χρόνια φλεβική ανεπάρκεια (ΧΦΑ) αποτελεί µία από τις συχνότερες αιτίες επίσκεψης των ασθενών στον Αγγειοχειρουργό. Υπάρχουν διάφορες θεραπευτικές µέθοδοι για την αντιµετώπιση της
ΧΦΑ. Η κατάλυση µε ραδιοσυνότητες (RF) είναι µία ελάχιστα παρεµβατική µέθοδος που χρησιµοποιεί υψίσυχνα ραδιοκύµατα για τη θέρµανση και σύγκλειση της σαφηνούς φλέβας, µεγάλων κλάδων και διατιτραινουσών φλεβών σε ασθενείς µε κιρσούς. Ο καθετήρας συνήθως τοποθετείται διαδερµικά και οδηγείται έως 2 cm πριν την σαφηνοµηριαία συµβολή. Ο καθετήρας φέρει µεταλλικό
άκρο µήκος 7 cm και η εκποµπή ραδιοσυνότητες γίνεται σε συνεδρίες των 20 sec. Ενεργοποιείται
η εκποµπή ραδιοκυµάτων και αρχίζει η εφαρµογή θερµοκρασίας που φθάνει τους 120 oC. Μετά
την ολοκλήρωση της κατάλυσης του πρώτου φλεβικού τµήµατος, ο καθετήρας αποσύρεται 6,5 cm
και επαναλαµβάνεται η διαδικασία µέχρι να συγκληθεί όλη η φλέβα στόχος.
Η παρούσα οµιλία θα παρουσίαση την τεχνική της φλεβικής κατάλυσης µε ραδιοσυνότητες (RF) ως
θεραπεία της φλεβικής ανεπάρκειας, θα αναδείξει διάφορες τεχνικές λεπτοµέρειες της µεθόδου και
να παρουσιασθούν διάφορες συµβουλές που θα βοηθήσουν ώστε να επιτευχθεί το καλύτερο δυνατό αποτέλεσµα και να αποφευχθούν τυχόν επιπλοκές. Επίσης, θα συγκριθούν τα βραχυπρόθεσµα και µακροπρόθεσµα αποτελέσµατα της φλεβικής κατάλυσης µε RF σε σύγκριση µε τη χειρουργική εκρίζωση ή την κατάλυση µε laser (EVLT). Ακόµη, θα συζητηθούν οι επιπλοκές της φλεβικής κατάλυσης µε RF.
Έχει φανεί πως οι ασθενείς επιστρέφουν γρηγορότερα στην φυσιολογική καθηµερινή δραστηριότητά και στην εργασία τους µετά από την θεραπεία τους µε RF. Ως εκ τούτου, έχει παρατηρηθεί ότι
όλο και περισσότεροι θεράποντες εκτελούν την µέθοδο αυτή σε ειδικά εξοπλισµένο εξωτερικό ιατρείο, προφέροντας ακόµη περισσότερη ευελιξία στην θεράποντα και µεγαλύτερη άνεση στον
ασθενή µε ακόµη γρηγορότερη επιστροφή στην εργασία του.
Αξίζει να αναφερθεί ότι το American Venous Forum (AVF) προτείνει την κατάλυση µε RF ως µία
ασφαλής και αποτελεσµατική µέθοδο για την θεραπεία κιρσών και τα κλινικά αποτελέσµατα της
µεθόδου είναι συγκρίσιµα µε την κλασσική χειρουργική εκρίζωση της µείζονος σαφηνούς φλέβας.
Επίσης, το AVF προτείνει την κατάλυση µε RF ως θεραπεία εκλογής σε ασθενείς υψηλού κινδύνου,
όπως σε παχύσαρκους, σε ασθενείς που λαµβάνουν αντιπηκτική αγωγή ή έχουν σοβαρές συνοδές
παθήσεις.
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Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
ΠΩΣ ΚΑΝΩ...
HOW I DO IT
ΤΕΧΝΙΚΕΣ ΦΛΕΒΙΚΗΣ ΒΑΛΒΙ∆ΟΠΛΑΣΤΙΚΗΣ ΣΤΑ ΚΑΤΩ ΑΚΡΑ
Κ. Κτενίδης
Νοσοκοµείο Παπαγεωργίου, Α΄ Πανεπιστηµιακή Χειρουργική Κλινική,
Αριστοτέλειο Πανεπιστήµιο Θεσσαλονίκης (∆/ντής: Καθηγητής ∆ηµήτριος Κισκίνης)
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Εισαγωγή
H βαλβιδική ανεπάρκεια των φλεβών στα κάτω άκρα (διεθνής όρος & κωδικός: venous valve incompetency & ICD-9/10: 459.81/I87.2) είναι µία πάθηση, που εµφανίζεται συχνά στο επιπολής και
σπανιότερα στο εν τω βάθει φλεβικό σύστηµα. Στη δεύτερη περίπτωση αναπτύσσεται βαριά χρόνια φλεβική ανεπάρκεια, που χαρακτηρίζεται από µεγάλη δυσκολία στην θεραπευτική αντιµετώπιση. Σε αυτή την οµάδα των ασθενών µπορεί να ενδείκνυνται διορθωτικές επεµβάσεις στις φλεβικές βαλβίδες ή βαλβιδοπλαστικές 2,4,6,7,10,12. Τα αίτια της νόσου είναι συγγενείς γενετικές ανωµαλίες (πρωτογενής µορφή) ή επίκτητα νοσήµατα όπως εν τω βάθη φλεβοθρόµβωση (δευτερογενής
µορφή). Στην πρωτογενή µορφή υπάρχουν γενετικές ανωµαλίες του φλεβικού τοιχώµατος, όπως
αύξηση των ινών του κολλαγόνου και ελάττωση των ελαστικών ινών µε αποτέλεσµα υπερτροφία
και αύξηση της φλεβικής διαµέτρου, αλλά και συγγενείς ανωµαλίες στην κατασκευή των φλεβικών βαλβίδων όπως απλασία, υποπλασία και δυσπλασία. Στη δευτερογενή βαλβιδική ανεπάρκεια
παρατηρείται ανεπανόρθωτη βλάβη των βαλβίδων µετά από εν τω βάθει φλεβοθρόµβωση. Η αποφραγµένη φλέβα επανασηραγγοποιήται µεν έως και στο 80% των περιπτώσεων αλλά οι βλάβες
στις φλεβικές βαλβίδες είναι συχνά σοβαρές και οδηγούν σε φλεβική ανεπάρκεια. Οι γλωχίνες της
βαλβίδας δεν δυσλειτουργούν όπως στην πρωτογενή µορφή, αλλά παρατηρείται πλήρης καταστροφή και απορρόφηση. Η κλινική σηµειολογία ταυτίζεται µε αυτή της χρόνιας φλεβικής ανεπάρκειας του επιπολής φλεβικού συστήµατος µε κύρια συµπτώµατα το έντονο οίδηµα, την δερµατοσκλήρυνση και το φλεβικό έλκος. Η διάγνωση επιτυγχάνεται κυρίως απεικονιστικά ή µε λειτουργικές παρακλινικές εξετάσεις. Οι ασθενείς ελέγχονται µε πληθυσµογραφία, φλεβοµανοµετρία,
Υ/Γ Triplex και φλεβογραφία. Η πληθυσµογραφία και η φλεβοµανοµετρία χρησιµοποιούνται κυρίως για την εκτίµηση της λειτουργικής διαταραχής των φλεβών. Το Υ/Γ Triplex και η φλεβογραφία απεικονίζουν την κατάσταση των βαλβίδων µε ακριβή µέτρηση του χρόνου σύγκλισης τους
κατά τη διαδικασία Valsalva. Σε περιπτώσεις προγραµµατισµού της βαλβιδοπλαστικής απόλυτη
απαραίτητη κρίνεται η µελέτη του φλεβικού συστήµατος µε ανιούσα και προ πάντων κατιούσα
φλεβογραφία. 2,8, 13
Τεχνικές βαλβιδοπλαστικής
Η θεραπεία της χρόνιας βαλβιδικής ανεπάρκειας των εν τω βάθει φλεβών περιλαµβάνει συντηρητικά και χειρουργικά µέτρα. Μεταξύ των συντηρητικών µέτρων ιδιαίτερα σηµαντική είναι η απώλεια βάρους, η τακτική άσκηση και η ελαστική θεραπεία. Για την πρωτοπαθή βαλβιδική ανεπάρκεια των εν τω βάθει φλεβών αναπτύχθηκαν µία σειρά διορθωτικών επεµβάσεων όπως ανοιχτή
διόρθωση των βαλβίδων, ηµίκλειστη αγγειοσκοπικά υποβοηθούµενη βαλβιδοπλαστική και κλειστή βαλβιδοπλαστική µε τη χρήση εξωτερικού κολάρου.2,4,6,10,12 Η πιο αποτελεσµατική µέθοδος είναι η εσωτερική βαλβιδοπλαστική, που περιγράφεται σε διάφορες παραλλαγές. (εικ.1,εικ.2) Η µεταµόσχευση βαλβίδος από φλέβες των κάτω και άνω άκρων αποτελούν την εναλλακτική µέθοδο
στην βαλβιδοπλαστική. Ενώ η µέθοδος δεν παρέχει καλύτερα αποτελέσµατα, µπορεί να εφαρµοσθεί σε αντίθεση µε τις βαλβιδοπλαστικές και σε ασθενείς µε δευτεροπαθή βαλβιδική ανεπάρκεια.
Νέα εξέλιξη αποτελεί η κατασκευή υποκατάστατων φλεβικής βαλβίδος για διαδερµική ενδοαγγειακή εµφύτευση (εικ.3), που µπορούν να χρησιµοποιηθούν τόσο σε πρωτοπαθή όσο και δευτεροπαθή βαλβιδική ανεπάρκεια. Η µέθοδος βρίσκεται στη φάση της κλινικής εκτίµησης. Άλλες τεχνικές, που µπορούν να εφαρµοστούν τόσο σε πρωτοπαθή όσο και σε δευτεροπαθή βαλβιδική ανεπάρκεια είναι οι φλεβικές µεταθέσεις όπως αυτή της εν τω βάθει µηριαίας στην επιπολή µηριαία
φλέβα. Η επέµβαση κατά Palma είναι η κλασική επέµβαση µετάθεσης, όπου η υγιής µείζον σαφηνής φλέβα µετατίθεται στην ετερόπλευρη µηριαία φλέβα για την καλύτερη φλεβική παροχέτευση
του πάσχοντος άκρου4,5,6,8,10,11,12. Οι συνήθεις επιπλοκές της επανορθωτικής χειρουργικής των φλεβών είναι αιµορραγία, επιµόλυνση τραυµάτων, θρόµβωση, πνευµονική εµβολή. Απώτερες επιπλοκές αποτελούν µεταθροµβωτικά σύνδροµα, δυσαπορρόφηση των χειρουργηθέντων βαλβίδων και υποτροπή των αρχικών συµπτωµάτων. Η περιεγχειρητική χρήση αντιπηκτικών φαρµάκων είναι σηµαντική για την ελάττωση του ποσοστού των επιπλοκών. Στους ασθενείς συνιστάται
περιεγχειρητικά η χορήγηση ηπαρίνης και συνέχιση για 3-6 µήνες µετεγχειρητικά µε από του στό-
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Στρογγυλό Τραπέζι IV • Round Table IV
ΠΩΣ ΚΑΝΩ...
HOW I DO IT
µατος αντιπηκτικά. Μακροπρόθεσµα χορηγούνται αντιαιµοπεταλιακά. Σε συνδυασµό µε τα ανωτέρω συνιστάται η ελαστική συµπίεση και η σωµατική άσκηση.2,3,8,12
Συζήτηση
Η βαλβιδοπλαστική είναι η αποτελεσµατικότερη µέθοδος θεραπείας της πρωτοπαθούς βαλβιδικής
ανεπάρκειας των εν τω βάθει φλεβών. Η ανοιχτή βαλβιδοπλαστική επιφέρει επούλωση φλεβικού
έλκους σε ποσοστό 60-90 % των περιπτώσεων σε ασθενείς ανθεκτικά φλεβικά έλκη έναντι άλλης
θεραπείας. Τα περισσότερα κέντρα αναφέρουν 5-ετή ποσοστά υποτροπής περίπου στο 20% των
περιπτώσεων. Παραταύτα µε βάση µία ανασκοπική µελέτη τύπου Cochrane δεν υπάρχουν επιστηµονικά υψηλού επιπέδου µελέτες που υποστηρίζουν την αποτελεσµατικότητα της µεθόδου.
1,2,3,8,12
ΒΙΒΛΙΟΓΡΑΦΊΑ
1. Hardy SC, Riding G, Abidia A. Surgery for deep venous valve incompetence. Cochrane
Database of Systematic Reviews 2004, Issue 3. Art. No.: CD001097.
2. Iafrati MD, O’Donneli TF Jr: Surgical management of chronic venous insufficiency, page
571, In: Mastery of Vascular and Endovascular Surgery GB Zehlennock, TS Huber, LM Messina,AB Lumsden, GL Moneta (Eds) Lippincott Williams & Wilkins Philadelphia 2006
3. Johnson ND, Queral LA, Flinn WR, et al: Late objective assessment of venous valve surgery.
Arch Surg 116:1461–1466, 1981.
4. Kistner RL: Surgical repair of the incompetent femoral vein valve. Arch Surg 110:1336–
1342, 1975.
5. Neglen P, Raju S: Venous reflux repair with cryopreserved vein valves. J Vasc Surg 37:552–
557, 2003.
6. Raju S, Hardy JD: Technical options in venous valve reconstruction. Am J Surg 173:301–
307,1997
7. Psathakis ND, Psathakis DN: Surgical treatment of deep venous insufficiency of the lower
limb. Surg Gynecol Obstet 166:131–141, 1988.
8. Perrin M: Reconstructive surgery for deep venous reflux: A report on 144 cases. Cardiovasc Surg 8:246–255, 2000.
9. Sottiurai VS: Technique in direct venous valvuloplasty. J Vasc Surg 8:646–648, 1988
10. Taheri SA, Lazar L, Elias S, et al: Surgical treatment of postphlebitic syndrome with vein
valve transplant. Am J Surg 144:221–224, 1982.
11. Tripathi R, Ktenidis KD: Trapdoor internal valvuloplasty: A new technique for primary deep
vein valvular incompetence. Eur J Vasc Endovasc Surg 22:86–89, 2001.
12. Sheridan KM, Dalsing MC. The Surgical Treatment of Deep Venous Valvular Incompetence,
page 2287, In: In: Vascular Surgery. Rutherford RB (Editor), 5th edition. Philadelphia, WB
Saunders, 2005
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Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
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Εικ. 1:
Εικ. 2:
Ανοιχτή βαλβιδοπλαστική
Α = φλεβοτοµή
Β = συρραφή γλωχινών
Γ = επιτυχής βαλβιδοπλαστική
I V
Φλεβικές βαλβιδοπλαστικές
Α = τεχνική Kistner
Β = τεχνική Sotiurai
Γ = τεχνική Raju
∆ = τεχνική Trapdoor
Ε = εξωτερική βαλβιδοπλαστική
ΣΤ = τεχνική εξωτερικού κολάρου
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Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
Στρογγυλό Τραπέζι V • Round Table V
EΛΕΓΧΟΣ ΣΕ ΟΙ∆ΗΜΑ ΚΑΤΩ ΑΚΡΟΥ
∆ράκου Αικατερίνη
Επικουρική Επιµελήτρια Αγγειοχειρουργικής, Αγγειοχειρουργική Κλινική,
Παν/κό Γενικό Νοσ/µείο Λάρισας
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Το οίδηµα του κάτω άκρου αποτελεί κοινό σύµπτωµα πολλών και διαφορετικών παθήσεων
γεγονός που µπορεί να καταστήσει δύσκολη τη διαφορική διάγνωση. Η λήψη του ιστορικού του
ασθενούς, η κλινική εξέταση, ο εργαστηριακός και ο απεικονιστικός έλεγχος αποτελούν το κλειδί
της διερεύνησης και της διάγνωσης.
Α. Ιστορικό:
1. ∆ιάρκεια οιδήµατος: ∆ιάκριση µεταξύ οξέος ή χρόνιου (< ή > από 72 ώρες). Η εν τω βάθει
φλεβική θρόµβωση αποτελεί την κυριότερη αιτία εµφάνισης οξέος οιδήµατος και η φλεβική
ανεπάρκεια την συνηθέστερη αιτία χρόνιου οιδήµατος.
2. Παρουσία άλγους: Το λεµφοίδηµα είναι συνήθως ανώδυνο, η χρόνια φλεβική ανεπάρκεια
µπορεί να προκαλεί κράµπες ενώ το έντονο άλγος µπορεί να οφείλεται σε αντιδραστική
συµπαθητική δυστροφία ή κρίσιµη ισχαιµία.
3. Λήψη φαρµάκων: Οι αποκλειστές των διαύλων ασβεστίου και τα αντιφλεγµονώδη φάρµακα
ευθύνονται για την εµφάνιση οιδήµατος
4. Συστηµατικές νόσοι: Η καρδιακή, νεφρική, ηπατική ανεπάρκεια, η πνευµονική υπέρταση συχνά
προκαλούν οίδηµα των κάτω άκρων
5. Νεοπλασία, χειρουργική επέµβαση, ακτινοθεραπεία: Προκαλούν οίδηµα λόγω πιεστικών
φαινοµένων ή καταστροφή του λεµφικού δικτύου.
6. Βελτιώνεται µε την κατάκλιση: Το λεµφοίδηµα συνήθως δεν µεταβάλλεται.
7. Αλλεργία, δήγµατα εντόµων
Β. Κλινική Εξέταση
1. Τοπογραφία οιδήµατος: Το µονόπλευρο οίδηµα συνήθως συνδέεται µε τοπικές αιτίες όπως εν τω βάθει
φλεβική θρόµβωση, ενώ το ετερόπλευρο µε συστηµατική νόσο όπως η καρδιακή ανεπάρκεια. Η ραχιαία
επιφάνεια του ποδός και τα δάχτυλα προσβάλλονται από το λεµφοίδηµα.
2. Εντύπωµα: Η εν τω βάθει φλεβική θρόµβωση και το λεµφοίδηµα σε αρχική φάση αφήνουν
εντύπωµα ενώ το χρόνιο λεµφοίδηµα όχι.
3. Παρουσία κιρσών: Αποτελούν ένδειξη παρουσίας χρόνιας φλεβικής ανεπάρκειας.
4. ∆ερµατικές αλλοιώσεις: Υπερκεράτωση, υπέρχρωση, κυτταρίτιδα, λεµφαγγειίτιδα,
θηλωµατώδεις προσεκβολές, έλκος και σπανιότερα λεµφαγγειοσάρκωµα.
5. Εµπύρετο: Πιθανή παρουσία λοίµωξης όπως ερυσίπελας,
6. Σηµεία συστηµατικής νόσου: ∆ύσπνοια, ορθόπνοια, ίκτερος, ασκίτης.
Γ. Εργαστηριακός Έλεγχος
Στα πλαίσια της διερεύνησης του οιδήµατος ο ασθενής χρειάζεται να υποβληθεί σε εξετάσεις προς
αποκλεισµό συστηµατικών παθήσεων. Η γενική αίµατος και ούρων, ο έλεγχος γλυκόζης,
ηλεκτρολυτών και κρεατινίνης, αλβουµίνης, D-Dimers, θυροειδικών ορµονών και ο ηπατικός
έλεγχος µπορούν να δώσουν πολύτιµες ενδείξεις.
∆. Απεικονιστικός Έλεγχος
1. Έγχρωµο Doppler Υπερηχογράφηµα: Χρήσιµο στη διερεύνηση πιθανής εν τω βάθει φλεβικής
θρόµβωσης, µπορεί να αναδείξει χωροκατακτητικές µάζες που ασκούν πιεστικά φαινόµενα.
2. Ηλεκτροκαρδιογράφηµα, ακτινογραφία θώρακος, υπερηχογράφηµα καρδίας: Χρήσιµα στη
διερεύνηση καρδιακής ανεπάρκειας και πνευµονικής υπέρτασης
3. Αξονική τοµογραφία κοιλίας: Η νεοπλασµατική νόσος ευθύνεται για πιεστικά φαινόµενα και
παρανεοπλαστικά σύνδροµα υπερπηκτικότητας που µπορούν να εκδηλωθούν µε την εµφάνιση
οιδήµατος στα κάτω άκρα.
4. Λεµφοσπινθηρογράφηµα: Μπορεί να επιβεβαιώσει την διάγνωση του λεµφοιδήµατος, να
διακρίνει µεταξύ πρωτογενούς και δευτερογενούς καθώς και να καθορίσει τις αιτίες.
Παρά την εξέλιξη των διαγνωστικών µέσων σε ορισµένους ασθενείς δε εντοπίζεται η αιτία του
οιδήµατος. Στην περίπτωση αυτή αναφερόµαστε στο ιδιοπαθές οίδηµα.
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LIMB SWELLING: DIAGNOSIS AND TREATMENT
Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
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Στρογγυλό Τραπέζι V • Round Table V
ΟΙ∆ΗΜΑ ΚΑΤΩ ΑΚΡΟΥ: ∆ΙΑΓΝΩΣΗ ΚΑΙ ΘΕΡΑΠΕΙΑ
LIMB SWELLING: DIAGNOSIS AND TREATMENT
ELASTIC STOCKINGS
Evi Kalodiki
MD BA DIC PhD FRCS
Aim: The purpose of the Graduated Elastic Compression (GEC) stocking in leg oedema is to improve the efficiency of the calf muscle pump. As a result it will prevent or reduce oedema and/or
the post-thrombotic syndrome. These stockings are prescribed for both superficial C2-6 and deep
venous disease, pregnancy, travel, post-traumatic conditions and lymphatic oedema.
Standardization: The Comité Européen de Normalisation (CEN) or European Committee for Standardization has standardized the pressure exerted at the ankle by the GECs and indicated their
use as follow: Class I slight compression 20 mmHg for heaviness and fatigue at the legs, with little varicosities and no edema and incipient pregnancy Varicose Veins (VV); Class II moderate compression 30 mmHg for pronounced VV, post traumatic oedema, mild C3-5, following superficial
thrombophlebitis, sclerotherapy, venous surgery and more severe pregnancy VV; Class III strong
compression 40 mmHg for all follow-up conditions, severe C3-5, post-thrombotic venous insufficiency and Class IV extra strong compression >60 mmHg for lymphoedema and elephantiasis. Hirai demonstrated that the pressure exerted by GEC varies with the posture, exercise and at the
different sites of the lower limb.1
Prophylaxis: The GEC stockings can be used also prophylactically. Partsch et al. have shown that
GEC Class I or II reduces or prevents edema on people with professions with long periods of sitting or standing.2 Similar results were found by Kraemer et al.3
The relief of symptoms in C2 patients by light weight 7-14 mmHg CEG has been explained with
air-plethysmography by increase of the ejection fraction and decrease of the venous filling index,
residual volume fraction and by inference ambulatory venous pressure.4 The beneficial effected
of GEC on the femoral blood flow velocity during late pregnancy has been studied by Norgren
and his co-workers.5, 6
Partsch and Mosti have shown with MRI scan that with a standing patient a pressure of 22 mmHg external compression results in a 71% reduction of the soleal venous volume but only a 7% reduction
in variceal volume.7 This work has been presented at the Paris Eurochap 2010 meeting by Uhl.8 It confirms that the VV are under higher pressure than a competent deep venous system.
Application: The way we recommend to apply GEC stockings can be found on:
http://bmj.com/cgi/eletters/322/7280/188#20424 Special aids designed to wear the stockings like
the Medi stocking valet, venotrain glider etc should be used following the above recommendations and not the manufacturers’ instructions. Patient compliance is of paramount importance.
Patients with ankylosis in the area of the legs or fingers, awaiting for total hip replacement or
obese, whose mobility is highly restricted, will not be able to apply GEC class II-IV. In this case two class I GEC can be worn one on top of the other achieving the effect of a class II stocking.
References
1. Hirai M. The effect of posture and exercise on elastic stocking compression at different sites
of the leg. Vasa. Aug 1999;28(3):190-194.
2. Partsch H, Winiger J, Lun B. Compression stockings reduce occupational leg swelling. Dermatol Surg. May 2004;30(5):737-743; discussion 743.
3. Kraemer WJ, Volek JS, Bush JA, et al. Influence of compression hosiery on physiological responses to standing fatigue in women. Med Sci Sports Exerc. Nov 2000;32(11):1849-1858.
4. Ibegbuna V, Delis K, Nicolaides AN. Effect of lightweight compression stockings on venous
haemodynamics. Int Angiol. Sep 1997;16(3):185-188.
5. Nilsson L, Austrell C, Norgren L. Venous function during late pregnancy, the effect of elastic
compression hosiery. Vasa. 1992;21(2):203-205.
6. Norgren L, Austrell C, Nilsson L. The effect of graduated elastic compression stockings on
femoral blood flow velocity during late pregnancy. Vasa. 1995;24(3):282-285.
7. Partsch H, Mosti G, Mosti F. Narrowing of leg veins under compression demonstrated by magnetic resonance imaging (MRI). Int Angiol. Oct 2010;29(5):408-410.
8. Uhl JF. The effects of medical compression stockings on venous anatomy. Paper presented at:
19th Eurochap, 2010; Paris.
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Στρογγυλό Τραπέζι V • Round Table V
ΕΛΑΣΤΙΚΟΙ ΕΠΙ∆ΕΣΜΟΙ
Φραγκίσκα Σιγάλα
Λέκτορας Αγγειοχειρουργικής
Α΄ Προπαιδευτική Χειρουργική Κλινική, ΓΝΑ «Ιπποκράτειο», Ιατρική Σχολή Πανεπιστηµίου Αθηνών
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Βιβλιογραφία
1. O’Meara et al:Cochrane Database of Systematic Reviews, Issue 4, 2009
2. Blair SD et al: BJM 1988;297:1159-1161
3. O’Meara et al:BJM 2009;338:1344-1353
4. Blecken SR et al:J Vasc Surg 2005;42:1150-5
Τ ρ α π έ ζ ι
Η αιτιοπαθογένεια του οιδήµατος κάτω άκρων είναι πολλαπλή, για τον λόγο αυτό η σωστή
δίαγνωση είναι απαραίτητη για την θεραπευτική αντιµετώπιση του. Σε οιδήµατα καρδιακής,
νεφρικής, ηπατικής ανεπάρκειας, ή ενδοκρινολογικής, ρευµατολογικής, φαρµακευτικής και
φλεγµονώδης αιτιολογίας θα πρέπει να αντιµετωπίζεται η πρωτοπαθής πάθηση.
Στην αντιµετώπιση οιδηµάτων κάτω άκρων φλεβικής ή λεµφικής αιτιολογίας, η χρήση ελαστικών
επιδέσµων συµβάλλει σηµαντικά στην κλινική βελτίωση τους .Ο µηχανισµός δράσεως της
συµπιέσεως µε ελαστικό επίδεσµο αφορά την αύξηση της ιστικής πιέσεως και την µείωση της
εγκάρσιας διαµέτρων των φλεβικών στελεχών των κάτω άκρων µε αποτέλεσµα, την µείωση της
φλεβικής παλινδρόµησης, την αύξηση της αιµατικής ροής στο εν το βάθει φλεβικό δίκτυο,την
βελτίωση των φλεβικών πιέσεων κατά τη βάδιση, την βελτίωση της υποδόριας κυκλοφορίας και
την αύξηση της ινωδόλυσης. Πριν την εφαρµογή της συµπιεστικής επίδεσης θα πρέπει να
ελέγχονται οι περιφερικές σφύξεις των κάτω άκρων καθώς και ο κνήµο/βραχιόνιος δείκτης. Eάν
ο δείκτης είναι µικρότερος του 0.8, η συµπιεστική επίδεση δεν πρέπει να εφαρµόζεται. Επίσης
αντένδειξη της εφαρµογής της αποτελούν τα έλκη από διαβήτη ή ρευµατοειδή αρθρίτιδα. H
ιδανική πίεση, που ασκείται από την επίδεση, θα πρέπει να είναι ικανή να αποτρέπει το οίδηµα από
την αυξηµένη διαπερατότητα των τριχοειδών. Eίναι γενικά παραδεκτό πως τα επίπεδα πίεσης
πρέπει να κυµαίνονται µεταξύ 30-40mmHg στον αστράγαλο και 15-20mmHg στη γαστροκνηµία.
Aπό τις διάφορες µεθόδους συµπιεστικής επίδεσης που δοκιµάστηκαν, η µέθοδος τετραπλής
επίδεσης Charring Cross (Charring Cross Four-Layer Bandage System) είναι αυτή που έχει τύχει
ευρύτερης αποδοχής και παρουσιάζει τα καλύτερα αποτελέσµατα.. Mε τη µέθοδο τετραπλής
επίδεσης χρησιµοποιούνται επίδεσµοι µε διαφορετικές ιδιότητες και έτσι επιτυγχάνεται συνεχής
άσκηση πίεσης 40mmHg στον αστράγαλο και 17mmHg στη γαστροκνηµία. Tο σύστηµα αυτό
περιλαµβάνει επιδέσµους για να απορροφούν το εξίδρωµα και άλλους για την άσκηση πίεσης. Mε
την εφαρµογή αυτής της µεθόδου επιτυγχάνεται σηµαντική µείωση του οιδήµατος κάτω άκρων και
επούλωση των φλεβικών ελκών σε ποσοστό 74% σε διάστηµα 12 εβδοµάδων. Επιπροσθέτως,
σε µία πρόσφατη µετα-ανάλυση βρέθηκε πως η επίδεση 4 στρωµάτων οδήγησε σε ταχύτερη
επούλωση των φλεβικών ελκών σε σχέση µε την απλή ελαστική επίδεση.
Στην θεραπεία του οιδήµατος και των φλεβικών ελκών σηµαντικό ρόλο παίζουν οι ανελαστικές
επιδέσεις όπως η UnnaBoot, η UnnaFlex, Comprilan (λιγότερο άκαµπτη) και η CircAid ανελαστική
επίδεση όρθωσης. Η ανελαστική επίδεση Unna boot περιέχει οξείδιο του ψευδαργύρου (zinc oxide paste), το οποίο µειώνει το έκζεµα και ταυτόχρονα µειώνει το οίδηµα. Η πίεση που ασκούν στο
σφυρό είναι 30mmHg, η οποία µειώνεται σε 10 mmHg στο 24ωρο µετά την εφαρµογή της.Για τον
λόγο αυτό χρησιµοποιείται η τροποιηµένη Unna boot µε ελαστική εξωτερική ενίσχυση (Convactec’s Unna Flex Elastic Unna Boot) ώστε να επιτυγχάνεται συνεχής άσκηση πίεσης. Σε
ηλικιωµένους ασθενείς µε αρθρίτιδα ή µε µεγάλα φλεβικά έλκη, που απαιτούν επικάλυψη
µεγάλου πάχους συνιστάται η χρήση της CircAid ανελαστικής επίδεσης όρθωσης. Η τελευταία
τοποθετείται ευχερώς στον αστράγαλο όπου και γίνεται επίδεση µε ανελαστικούς velcro
επιδέσµους µε αποτέλεσµα την µείωση του οιδήµατος. Μελέτη σε φλεβικά έλκη παρατηρήθηκε
σηµαντικά ταχύτερη επούλωση τους µε CircAid ανελαστική επίδεση όρθωσης σε σύγκριση µε την
τετραπλή ελαστική επίδεση συµπίεσης.
Συµπερασµατικά, η µηχανική θεραπεία µε τη χρήση επιδέσεων συµπίεσης επιδρά στην µάκρο και
µίκροκυκλοφορία µειώνοντας σηµαντικά το οίδηµα των κάτω άκρων και επιτυγχάνει ταχύτερη
επούλωση των ελκών.
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ΟΙ∆ΗΜΑ ΚΑΤΩ ΑΚΡΟΥ: ∆ΙΑΓΝΩΣΗ ΚΑΙ ΘΕΡΑΠΕΙΑ
LIMB SWELLING: DIAGNOSIS AND TREATMENT
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Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
Σ τ ρ ο γ γ υ λ ό
Τ ρ α π έ ζ ι
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•
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Στρογγυλό Τραπέζι V • Round Table V
ΟΙ∆ΗΜΑ ΚΑΤΩ ΑΚΡΟΥ: ∆ΙΑΓΝΩΣΗ ΚΑΙ ΘΕΡΑΠΕΙΑ
LIMB SWELLING: DIAGNOSIS AND TREATMENT
LOWER LIMB EDEMA: DIAGNOSIS AND TREATMENT
COMPRESSION DEVICES
Andreas M. Lazaris, MD, FEBVS
Assistant Professor of Vascular Surgery
Vascular Unit, 3rd Surgical Department, University of Athens, Attikon Teaching Hospital,
Athens, Greece
Leg edema can exist due to various pathologies. Venous insufficiency, lymphatic disfunction,
deep venous thrombosis, heart failure, pulmonary hypertension, obesity, pregnancy and various
drugs can be some causes of leg edema. Additionally, lipidema, and idiopathic edema in menstruating women, can exist. Compression stockings are usually used for the treatment of leg edema of various reasons. Patients who are refractory to compression stockings may improve with
intermittent pneumatic compression (IPC) devices.
IPC devices compress the leg and/or foot and ankle and act as a pump to improve circulation in
the lower extremities. They consist of an inflatable garment for the leg and an electrical pneumatic pump that fills the garment with compressed air. The garment is intermittently inflated
and deflated with cycle times and pressures that vary between devices. The A-V Impulse System
Foot Pump and the KCI Plexipulse are brands of intermittent pneumatic compression boots on
the market; others include those manufactured by Jobst, Chattanooga, Kendal, and Nutech.
Data from the investigation of the microcirculation where IPC was applied, indicate that IPC increase
the the capillary perfusion, thus the tissue oxygenation. This is in accordance with the observation
of an increased release of nitric oxide, with an up regulation of the fibrinolytic potential of the endothelial cells, and with a suppression of procoagulant activation. Experimental data concerning the
effect of IPC on lymphedema are sparse indicating that IPC is able to reduce the water content of a
lymphedematous extremity, but without improving the lymphatic drainage.
Clinical data indicate the use of IPC as a measure of treatment in various venous or lymphatic
pathologies. IPC boots are generally accepted as a method for preventing deep venous thromboses (DVT) and complications of venous stasis in persons after trauma, orthopedic surgery, neurosurgery, or who for other reasons are unable to walk. The Canadian Coordinating Office of
Health Technology Assessment concluded that “external pneumatic compression reduces the risk
of DVT for patients who cannot walk due to trauma, joint surgery or neurosurgery. There is still
limited evidence, however, supporting the effect of IPC on the healing of venous ulcers and other disorders resulting from chronic venous insufficiency”. Use of the IPC device has expanded to
ambulatory persons as well, who suffer from chronic venous insufficiency of the legs and consequent edema, stasis dermatitis, ulcerations, and cellulitis.
The effect of IPC in venous leg ulcers is unclear. A systemic review of the literature concluded that the effectiveness of the addition of IPC in treatment of venous leg ulcers is unknown. The systemic review identified three small, randomized controlled trials of IPC; all of these trials were different in design. Upon pooling of the results, using a random effects model, the reviewers found no difference in healing rates.
There is no evidence that IPC devices are superior to gradient compression stockings in preventing complications of chronic venous disease. Compliance with gradient compression stockings
has been shown to be essential to their effectiveness; the stockings do not work unless they are
worn. There are no studies, however, that have demonstrated that compliance with IPC devices
is significantly greater than compliance with gradient compression stockings.
IPC has been used as well for the treatment of restless less syndrome (RLS). In a prospective, randomized controlled trial, Lettieri and Eliasson evaluated the effectiveness of pneumatic compression devices as a non-pharmacologic treatment for RLS. Subjects wore a therapeutic or sham
device prior to the usual onset of symptoms for a minimum of 1 hour daily. The authors concluded that pneumatic compression devices resulted in clinically significant improvements in
symptoms of RLS in comparison to the use of sham devices and may used either as an effective
adjunctive or alternative therapy.
It is clear that IPC has a role for the treatment of various leg pathologies. However, further experimental and clinical investigation is needed in order to clarify open questions or endorse sparse existing observations.
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Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
Στρογγυλό Τραπέζι V • Round Table V
ΑΝΤΙΜΕΤΩΠΙΣΗ ΕΞΩΤΕΡΙΚΩΝ ΑΣΘΕΝΩΝ ΜΕ ΛΕΜΦΟΙ∆ΗΜΑ
Παπαδοπούλου Μ.Χ., Στάνκοβα-Σάλτα Ρ.
Τµήµα Φυσικοθεραπείας Πανεπιστηµιακό Γενικό Νοσοκοµείο Λάρισας
Τ ρ α π έ ζ ι
V
Το πολυπαραγοντικό πρόγραµµα αντιµετώπισης λεµφοιδήµατος στο Π.Γ.Ν.Λάρισας µετά την
αρχική αξιολόγηση και διάγνωση στην Πανεπιστηµιακή Αγγειοχειρουργική Κλινική
συµπεριλαµβάνει αξιολόγηση και αντιµετώπιση προβληµάτων στο εξωτερικό ιατρείο της
Πανεπιστηµιακής ∆ερµατολογικής Κλινικής, ψυχολογική αξιολόγηση και υποστήριξη στην
Ψυχολογική Υπηρεσία, διατροφική αξιολόγηση και τροποποίηση στο Τµήµα ∆ιατροφής και 3-4
εβδοµάδες καθηµερινής αποιδηµατικής θεραπείας CDT µε περίδεση, µάλαξη, αντλία, άσκηση και
εκπαίδευση στην αυτοδιαχείριση στο Τµήµα Φυσικοθεραπείας. Το κόστος των επιδεσµικών υλικών
επιβαρύνει τον ασθενή και συνήθως δεν καλύπτεται, αλλά το κόστος θεραπείας καλύπτεται από τα
ταµεία. Οι ασθενείς είναι εξωτερικοί, αλλά υπάρχει δυνατότητα φιλοξενίας στον ξενώνα του ∆ήµου
Λαρισαίων. Την επικοινωνία του προγράµµατος, την ενηµέρωση του κοινού µέσω έντυπου τύπου
και ιστιότοπου έχει αναλάβει κοινωνικός λειτουργός της οµάδας.
Στα 2 χρόνια λειτουργίας του προγράµµατος αντιµετωπίστηκαν ασθενείς µε δευτεροπαθές
λεµφοίδηµα (43%), πρωτοπαθές (24%), φλέβο-λέµφο στατικό οίδηµα (28%) και µε καθαρό
λιποίδηµα (5%). Οι ασθενείς στην πλειοψηφία τους παρουσίασαν ικανοποιητική µείωση της
περιφέρειας του µέλους. Η µείωση αυτή διατηρήθηκε µε απλή κάλτσα σε ορισµένους ασθενείς,
ενώ άλλοι αναγκάστηκαν να καταφύγουν στη λύση της κάλτσας κατά παραγγελία. Περιπτώσεις
αποτυχίας αποδόθηκαν στην ελλιπή συµµετοχή του ασθενή και στη µη χρήση της κάλτσας.
Από τους ασθενείς που κρίθηκαν ικανοί να συµµετέχουν στο πρόγραµµα, το 41% αρνήθηκε λόγω
απόστασης και καθηµερινής προσέλευσης στο νοσοκοµείο, απαιτούµενου χρόνου, οικονοµικού
κόστους του επιδεσµικού υλικού, της κάλτσας και της θεραπείας, αλλά και άρνησης να
χρησιµοποιήσουν γάντι ή κάλτσα. Στους µελλοντικούς στόχους της πολυπαραγοντικής οµάδας
είναι η διευκόλυνση των ασθενών στα παραπάνω προβλήµατα, αλλά και η εξυπηρέτηση
περισσοτέρων ασθενών ανά µήνα, ώστε να µην είναι µεγάλη η περίοδος αναµονής.
Σ τ ρ ο γ γ υ λ ό
ΟΙ∆ΗΜΑ ΚΑΤΩ ΑΚΡΟΥ: ∆ΙΑΓΝΩΣΗ ΚΑΙ ΘΕΡΑΠΕΙΑ
LIMB SWELLING: DIAGNOSIS AND TREATMENT
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Σάββατο 22 Ιανουαρίου 2011 • Saturday January 22nd 2011
ΟΙ∆ΗΜΑ ΚΑΤΩ ΑΚΡΟΥ: ∆ΙΑΓΝΩΣΗ ΚΑΙ ΘΕΡΑΠΕΙΑ
LIMB SWELLING: DIAGNOSIS AND TREATMENT
LYMPHOEDEMA TREATMENT WITH UNDER-PADDING MATERIALS AND
SHORT-STRECH BANDAGES
Aim: To comparing effects of short-stretch bandages alone compare to short-stretch bandages
with under-padding materials on reduction of swelling limb at patients with secondary lymphoedema.
Methods: 40 limbs with lymphoedema we randomize divided into two groups. Group 1: 20 secondary lymphoedema which we treated with short-stretch bandages*. Group 2: 20 secondary
lymphoedema which we treated with short-stretch bandages with under-padding materials*.
We’ve made measurements of the consistencies of oedema with Tissue Tonometer and circumferences of the limbs in centimeters before study and always after we changed the bandages,
which was once of the week.
Results: 1. At all patients in both groups the circumferences of the limb were smaller at the end
of the study. 2. The oedemas were softer and smaller at patients where we used under-padding
materials under short-stretch bandages.
Discussion: Under-padding materials with micromassages speed the effects of short-stretch
bandages at patients with lymphoedema.
* Porelast, Panelast; Lohmann-Rauscher
** Mobiderm; Thuasne
Σ τ ρ ο γ γ υ λ ό
Τ ρ α π έ ζ ι
R o u n d
•
Tanja Planinšek Ručigaj
Dermatovenrologycal clinic, University Clinical Centre, Ljubljana Slovenia
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Στρογγυλό Τραπέζι V • Round Table V
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Προφορικές Ανακοινώσεις
Oral Presentations
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Παρασκευή • Friday 21/01/2011 - 08:30 - 10:30
Προφορικές Ανακοινώσεις Ι • Oral Presentations I
Προφορικές Ανακοινώσεις Ι • Oral Presentations I
O01.
H3 AND H4 RECEPTOR-MEDIATED EFFECTS IN PERIPHERAL BLOOD VESSELS IN ADJUVANT
ARTHRITIS
Kyriakidis K, Zampeli E, Tiligada E
Department of Pharmacology, Medical School, University of Athens, Athens, Greece
Aim: This study aimed to investigate the effects of the histamine H3 and H4 receptor inverse agonists/antagonists GSK334429 and JNJ7777120, respectively, on the histamine content of large
arteries and veins in a rat model of adjuvant arthritis.
Materials and methods: Male Wistar rats (250-300g bw) were maintained under controlled conditions and received complete Freund’s adjuvant i.d. (CFA, Sigma, USA) and/or 1 & 3 mg/kg i.p.
GSK334429 (AD Medhurst, GSK, Essex, UK) or 10 & 30 mg/kg i.p. JNJ7777120 (RL Thurmond, JNJ,
CA, USA). Following sacrifice at day 20, abdominal aorta (AA) and inferior vena cava (IVC) were
dissected out. Tissue histamine was quantified fluorophotometrically. Differences between treatments were located by appropriate statistical analyses.
Results: CFA administration resulted in the development of arthritic signs in the animal paws.
Statistically significant reductions in histamine levels in both AA and IVC were observed following JNJ7777120 administration, while GSK334429 tented to decrease histamine levels in the IVC
of animals with adjuvant arthritis.
Conclusions: The results provided evidence towards H3 and H4 receptor functionality in peripheral blood vessels, implying an automodulatory action of histamine upon binding to these receptors. The (patho)physiological significance of the observed effects in peripheral vessels is currently under investigation.
This study is part of the EU FP7 COST Action BM0806
O02.
SCLEROTHERAPY OF TELANGIECTASES, RETICULAR AND VARICOSE VEINS: SYSTEMATIC
REVIEW OF SAFETY DATA
Eugenia Ch Yiannakopoulou
Department of Basic Medical Lessons Faculty of Health and Caring Professions Technological
Educational Institute of Athens
Aim: Sclerotherapy has been extensively used in the treatment of valvular insufficiency of superficial veins. Although it seems safe, reports of serious adverse events have been published.
The aim of the present study is to critically review safety data of sclerotherapy in the treatment
of varicose veins.
Materials and Methods: Pubmed, Scopus, Google Scholar were searched with the appropriate
search terms up to and including November 2010. Eligible trials were full publications that provided numerical data on the safety of sclerotherapy, as well as clinical or experimental trials, that
provided evidence on the mechanism of adverse events associated with sclerotherapy. Clinical
trials, observational studies, case reports or case series, systematic reviews were included. Extracted data included among others, type of sclerotherapy, sclerosant agent and dosing regimen,
type of treated vessel, number of patients that reported adverse events.
Results: Quantitative synthesis of the data was not attempted, due to the clinical heterogeneity
of the trials. Adverse events were local and systemic. Local adverse events included pigmentation, pain, ulcer formation, new vessel formation, skin necrosis, pyoderma gangrenosum. Systemic adverse events included visual disturbances, chest tightness, deep venous thrombosis, pulmonary embolism, transient ischemic attack, ischemic stroke, septicemia, allergic reaction, cardiac toxicity, amputation following intra-arterial injection, death.
Conclusion: Local adverse events of sclerotherapy are common. In addition, sclerotherapy can
cause rare but serious adverse events and even death. Physicians should be aware of these possible adverse events, inform patients accordingly and be prepared for the appropriate management of serious adverse events.
Bl,aise et al., Uncu et al.
Hamel Desnos 2009
Rabe et al.
Gillet et al. 2009
Hamel-Desnos
Ouvry et al
Rabe et al 2008
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Προφορικές Ανακοινώσεις Ι • Oral Presentations I
SPLACHNIC VEIN THROMBOSIS AND PREDISPOSING FACTORS: A RETROSPECTIVE STUDY
OF SIXTEEN CASES
Kouvelos George1, Koliou Panagiotis2, Mitsis Michalis3, Kolaitis Nikolaos2, Vartholomatos
George2, Fatouros Michalis3, Matsagkas Miltiadis1
1 Department of Surgery- Vascular Surgery Unit, Medical School, University of Ioannina
2 Haematology Laboratory, Molecular Biology Unit, University Hospital of Ioannina
3 Department of Surgery, Medical School, University of Ioannina
Aim: Predisposing factors to abdominal vein thrombosis are divided into two main categories:
congenital and acquired. The aim of our study was to estimate the prevalence of inherited and
acquired thrombophilic predisposing factors in patients with abdominal venous thrombosis and
to compare the etiological thrombosis profiles between Budd-Chiari syndromes (BCS) and splanchnic vein thrombosis (SVT) in non-cirrhotic patients.
Methods: Sixteen patients with abdominal venous thrombosis were retrospectively evaluated.
Patients with cirrhosis were not included. The patients were divided into two groups, the BuddChiari group (hepatic vein, inferior vena cava thrombosis) and the splanchnic venous thrombosis
group (portal, splenic, superior mesenteric veins) according to venous site involved. Risk factor evaluation included measurements for protein C-S, ATIII, several coagulation factors and the presence of mutations. When these tests were negative, thalassemia and sickle cell disease were also estimated.
Results: Nine patients had SVT, 6 had BCS, while one had mixed venous thrombosis. The acquired
risk factors were significantly more common in the SVT group (SVT vs BCS: 56% vs 17%, p<0.05)
while the hereditary factors had no significant differences (SVT vs BCS: 11% vs 33%). No thrombophilic predisposing factors were identified in 50% of patients with BCS and in 33% with SVT.
In 3 out of 6 patients that no causal factors were identified haemoglobin electrophoresis revealed double compound heterozygosity for HbS/b-thalassemia.
Conclusion: Hereditary and acquired risk factors play an important role in the pathogenesis of
abdominal venous thrombosis. Apart from the already known factors, sickle cell disease is a welldocumented factor for thrombosis at various vasculature sites. Our study underlines the possibility that a double compound heterozygosity of factors that predispose thrombosis in the homozygous state would cause abdominal thrombosis under specific circumstances. Further investigation is needed in order to find other factors causing thrombosis, in cases where the already
known predisposing factors cannot help to establish a diagnosis, especially in regions where thalassemia and sickle cell disease are prevalent.
O04.
REVIEW OF DEEP VEIN THROMBOSES HOSPITALIZED IN OUR CLINIC: A FIVE YEARS
EXPERIENCE
Pyrgakis K, Kasfikis F, Goulas S, Giannakakis S, Siskos D, Papacharalambous G, Antoniou I,
Maltezos Ch.
Vascular Surgery Clinic of KAT Hospital, Athens, Greece
Aim: In this study we present the way patients suffering from DVT are diagnosed and treated
in our Clinic. We present also the screening methods of our Clinic for the diagnosis of PE and
malignancies.
Material- Methods: In five years (2005-2009) 327 patients with DVT were referred to our Clinic.
151 (46.1%) were male and 176 female. Some of the patients had medical history of known conditions associated with DVT and in some the etiology was obscure. 169 patients (51.6%) had a
proximal thrombosis, while 111 (33.9%) had a DVT in popliteal veins. The diagnosis was established always by ultrasound. The investigation of the patients contained medical history, blood
tests, chest x-ray and spiral CT scan (chest and abdomen).
Results: In 73 patients (22.3%) a PE was diagnosed. In 77 patients (23.5%) a malignancy was
present. The patients with DVT in the popliteal had a higher percentage of PE (mostly asymp-
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Προφορικές Ανακοινώσεις Ι • Oral Presentations I
O03.
Παρασκευή • Friday 21/01/2011 - 08:30 - 10:30
Προφορικές Ανακοινώσεις Ι • Oral Presentations I
Προφορικές Ανακοινώσεις Ι • Oral Presentations I
tomatic) than those with proximal DVT (33.3% vs 18.3% ). All the patients were treated conservatively for a period of six months at least. The mortality was 0%.
Conclusions: These results showed that this investigation should be made always and that spiral CT scan is cost-effective. The analysis of our data have lead us to many interesting observations as well.
O05.
DEEP VEIN THROMBOSIS IN A CASE OF ADAMANTIADIS- BEHCET DISEASE: A CASE AND
A REVIEW
Voulalas G, Giannakakis S, Psyllas A, Papacharalambous G, Goulas S, Antoniou I, Maltezos Ch.
Vascular Suregry Clinic of KAT Hospital, Athens, Greece
Aim: We present a case of recurrent Deep Vein Thrombosis (DVT) in a patient suffering from
Adamantiadis- Behcet disease. The disease affects mainly males.
Material-Methods: A 30-years-old male was referred to our ER complaining for pain and
swelling of the left leg. The leg was swollen indeed and the Duplex scan showed thrombosis in
the left femoral and great saphenous vein.
The medical history of the patient contained Behcet’s disease which was diagnosed 10 years ago and an old DVT in the same leg 5 years before admission. The laboratory examinations
showed elevated WBC, fibrinogen and sli D-dimers. Initially subcutaneous LMWH was administered and was substituted by oral anticoagulants (Sintrom) later. The patient had fever (39.3oC)
without apparent infection.
Results: The rheumatologic and neurological examination revealed disturbed cutaneous sensitivity and possible inflammation of the femoral nerve in the contralateral leg. Cortisone and aspirin were therefore administered. The patient was released five days later, when he had a normal temperature and therapeutic INR.
Conclusions: DVT is a manifestation of Behcet’s disease in 35% of the patients. The optimal
treatment of thrombosis in such patients is controversial. Aspirin and dipyridamole are often
recommended but their efficacy is doubtful. However Behcet’s disease should be considered a
possible cause of a DVT in young male patients.
O06.
PRIMARY VARICOSE VEINS OF THE UPPER EXTREMITY.
Xanthopoulos D, Loupou A, Papavasiliou V, Kaperonis E, Bazigos G, Melas M, Karathanos C,
Arvanitis D.
Department of vascular surgery, Sismanoglio General Hospital of Athens
Aim: Primary varicose veins of the upper extremity are an extremely rare and interesting pathology. It is believed to have the same cause with those of the lower extremity. We present a case
of a 37 year old man with this unusual condition.
Methods: A healthy 37 year old man reported to our hospital with varicose veins on his left forearm
with occasion association of pain and discomfort. Two years ago, he had been operated for varicosities of his right leg. From his family history, his mother had varicose veins of the lower extremity.
Results: On examination, surrounding skin was normal with no hemangiomas. Bilateral pulses
were normal, no bruit was audible and upper extremities were of equal size.Varicosities dissapeared on raising the arm above the head and in pressuring with tourniquet .Duplex examination revealed varicose veins along cephalic vein distribution, limited on forearm with no evidence
of arteriovenus (AV) fistula. The patient underwent operation by excision of cephalic vein, from
elbow to wrist. Post operative recovery was uneventful. Follow up at sixteen months showed no
residual or reccurent varicosities.
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Παρασκευή • Friday 21/01/2011 - 08:30 - 10:30
Προφορικές Ανακοινώσεις Ι • Oral Presentations I
O07.
CASE REPORT: SPONTANEOUS THROMBOSIS OF THE AXILLARY-SUBCLAVIAN VEIN
CAUSING SUPERIOR VENA CAVA SYNDROME
Philippakis G.1, Gionis M.1, Mitsikas D.2, Spyrantis M.2, Papadopoulos L.2, Samiotakis E.3,
Zarifis G.3, Moustardas M.1
1
Thoracic and Vascular Surgery Department, Chania General Hospital, Greece
2
Department of General Surgery, Chania General Hospital, Greece
3
Department of Radiology, Chania General Hospital, Greece
We report the case of a 70-year-old woman who visited her doctor after developing massive
oedema of her left upper extremity. The patient was found to suffer from spontaneous axillarysubclavian venous thrombosis and superior vena cava syndrome. The thrombus was protruding
into the right atrium through the superior vena cava. We discuss our skepticism concerning medical treatment, the possibility of complications and the probability of cardiac surgery.
O08.
CASE REPORT: ILIOFEMORAL DVT CAUSING CHRONIC PELVIC PAIN SYNDROME
Spyrantis M.2, Mitsikas D.2, Philippakis G.1, Moustardas M.1
1
Thoracic and Vascular Surgery Department, Chania General Hospital, Greece
2
Department of General Surgery, Chania General Hospital, Greece
We report the case of a 57-year-old woman who was admitted to the hospital 32 years ago suffering from deep vein thrombosis of the left lower extremity. The patient had a persistent painful
oedematous limb despite adequate anticoagulation therapy including heparin, coumarinic anticoagulants and anti-embolic socks. The woman refers recurrent severe attacks of abdominal
pain, accompanied by menstrual problems until menopause.
O09.
CASE REPORT: GALLBLADDER HYDROPS CAUSING INTERMITTENT LIMB OEDEMA
Oikonomou K.2, Mitsikas D.2, Korakas P.3, Gionis M.1, Zarifis G.3, Fragkiadakis G.1, Moustardas M.1
1
Thoracic and Vascular Surgery Department, Chania General Hospital, Greece
2
Department of General Surgery, Chania General Hospital, Greece
3
Department of Radiology, Chania General Hospital, Greece
We report the case of an underweight woman with an intermittent limb oedema, who was initially considered to suffer from deep vein thrombosis. The patient was admitted to our clinic for
further evaluation and found accidentally to have a giant gallbladder hydrops which caused the
almost complete obstruction of the inferior vena cava. We discuss the clinical characteristics, radiological features, and outcome of gallbladder hydrops to help understand this rare case.
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Προφορικές Ανακοινώσεις Ι • Oral Presentations I
Conclusions: Primary varicose veins of the upper extremity are an interesting diagnostic challenge.
The differential diagnosis from secondary varicose vein due to AV fistula or deep vein thrombosis is
essential. Duplex examination and plebography are the two main laboratory tests. The treatment includes surgical excision and as an alternative or complementary, sclerotherapy and laser.
Παρασκευή • Friday 21/01/2011 - 08:30 - 10:30
Προφορικές Ανακοινώσεις Ι • Oral Presentations I
Προφορικές Ανακοινώσεις Ι • Oral Presentations I
O10.
CASE REPORT: AMPUTATIVE INJURY OF THE UPPER EXTREMITY AFTER GUNSHOT-NECESSITY
OF VEIN REPAIR
Gionis M.1, Manimanaki A,2. Poulios G.1, Philippakis G.1, Kaimasidis G.1, Mitsikas D.3,
Tsantrizos P.3, Kontoudaki E.4, Fratzeskaki S.5, Mantakas E.6, Moustardas M.1
1
Thoracic and Vascular Surgery Department, Chania General Hospital, Greece
2
Department of Orthopedic Surgery, Chania General Hospital, Greece
3
Department of General Surgery, Chania General Hospital, Greece
4
Intensive Care Unit, Chania General Hospital, Greece
5
Department of Anesthesiology, Chania General Hospital, Greece
6
Department of Radiology, Chania General Hospital, Greece
A young male was brought in the emergency after gunshot during a suicide attempt. We decided to operate on him despite the fact that the amputative injury of the upper extremity after
gunshot is not only a very challenging condition due to the fact that many specialists are involved in limb salvage, but also a life threatening one. It is crucial to decide whether it is better
to amputate at once instead of trying to preserve an almost amputated extremity. Finally we succeeded to preserve his limb. We discuss the necessity of repairing the axillary-brachial vein with
autologous graft after stabilizing the bone and repairing the artery.
O11.
CASE REPORT: ALMOST FATAL ILIOFEMORAL VEIN’S BLEEDING BECAUSE OF A DOUBLE
GUNSHOT
Antoniou Ch.2, Tsiminikakis N.2, Lampousakis E.2, Mitsikas D.2, Spyrantis M.2, Philippakis G.1,
Moustardas M.1
1
Thoracic and Vascular Surgery Department, Chania General Hospital, Greece
2
Department of General Surgery, Chania General Hospital, Greece
We report the case of a 60-year-old man who was brought to the emergency room with massive
iliofemoral bleeding because of a double gunshot. There were two entry points, the first one near the umbilicus and another one over the left inguinal crease. The bleeding was due to iliofemoral vein disruption without involvement of iliofemoral arteries or any other vital organ.
We discuss the surgical management and results with emphasis on possible complications and
how to avoid them.
O12.
PLASMINOGEN ACTIVATOR INHIBITOR-1 AND D-DIMMERS AFTER LAPAROSCOPIC VERSUS
OPEN SURGERY FOR COLON CANCER RESECTION.
F. Sigala1, A. Travlou2, E. Merkouri2, D. Tsamis1, D. Linardoutsos1, K. Lilis1, T. Hristophidis1,
G. Theodoropoulos1, E. Leandros1, G. Zografos1, K. Filis1
1
First Department of Propaedeutic Surgery, Hippokrateion Hospital, University of Athens Medical School, Greece
2
Laboratory of Haematology-Blood Tranfusion Unit, Attikon Hospital, University of Athens
Medical School, Greece
Objectives: Deep vein thrombosis is frequent after surgery for colon cancer. However, possible
difference in risk of thrombosis after laparoscopic versus open colectomy has not been precisely
defined.
Methods: Prospective observational study of 26 colon cancer patients operated by open procedure (OP) and 23 colon cancer patients by laparoscopic surgery (LS). Groups were matched re-
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Παρασκευή • Friday 21/01/2011 - 08:30 - 10:30
Προφορικές Ανακοινώσεις Ι • Oral Presentations I
O13.
VARICOSE VEINS DISEASE COMPLICATED BY SUPERFICIAL VEIN THROMBOSIS:
EVALUATION OF VEIN WALL APOPTOSIS AS A PREDISPOSING FACTOR.
K. Filis1, N. Kavantzas2, D. Hrisikos1, T. Isopoulos1, D. Linardoutsos1, P. Antonakis1,
E. Lagoudianakis1, E. Gomatos1, G. Zografos 1, F. Sigala1
1
Division of Vascular Surgery, First Department of Propaedeutic Surgery, University of Athens
Medical School, Athens, Greece
2
First Department of Pathology, University of Athens Medical School, Athens, Greece
Objectives: The evaluation of a wide range of apoptotic markers in the vein wall of patients with
superficial chronic venous disease (SCVD) and one episode of superficial vein thrombosis (SVT)
compared to SCVD without any episode of SVT.
Methods: Vein specimens were obtained from 19 patients suffering SCVD and 16 patients with
SCVD and history of one episode of superficial vein thrombosis. From each patient, a specimen
of the proximal part of the great saphenous vein (GSV), a specimen of the distal part of the vein
and a specimen of a varicose tributary were used as a means of immunohistochemically localizing the expression of BAX, P53, Caspase 3, BCL-2, BCL-6, BCLxs, BCLxl and Ki-67. Vein specimens
from 10 healthy GSVs were used as controls.
Results: Vein specimens from patients with SCVD and SVT showed increased BCLxs (p=0.029) in
proximal GSV, BAX (<0.01), p53 (p=0.037), Bclxl (p<0.01), Ki-67 (p<0.01) in tributary and caspase3 (p=0.007), BCLxl (p=0.031), BCLxs (p<0.01), Ki-67 (p=0.012) in distal GSV, compared to vein
specimens from patients with SCVD without SVT. In both groups, SCVD with SVT and SCVD without SVT, distal GSV showed increased apoptosis compared to varicose tributaries which subsequently showed increased apoptosis compared to proximal GSV.
Conclusion: Varicose veins after an episode of SVT present increased apoptotic activity, by means
of increased BAX, Caspase 3, BCLxl, BCLxs, Ki-67 compared to varicose veins without any SVT
episode. However, venous hypertension is an independent factor for increased vein wall apoptosis, therefore, the etiologic relationship between increased vein wall apoptosis and SVT in varicose veins disease warrants further studies.
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Προφορικές Ανακοινώσεις Ι • Oral Presentations I
garding gender (p-value=0.57) and age (p-value=0.23). In addition, groups were not significantly different with respect to cancer locality (p-value=0.99), CEA (p-value=0.35), CRP (p-value=0.14)
and type of operation (p-value=0.60). Plasma concentrations of Plasminogen Activator Inhibitor1 (PAI-1) and D-Dimmers (DD) were measured preoperatively, at 24h and 10 days postoperatively.
Results: Overall treatment effect on PAI-1 values was significant (F=6.4 at 1d.f., p-value=0.02).
OP mean values were significantly lower than LS values. The interaction between treatment and
time was not significant (p-value=0.07). This suggests that PA changes in time are not significantly different between groups of patients.
Overall treatment effect on DD values was significant (F=17.2 at 1d.f., p-value<0.001). OP values
were significantly higher than LS values. The interaction between treatment and time was significant (F=11.4 at 2 d.f., p-value=0.001). At 24h, the DD increase for OP patients was significantly higher than the respective DD change to LS patients (F=14.4 at 1d.f., p-value<0.001). At
10 days, the DD decrease for OP patients was significantly different from the DD in LS patients
(F=25.2, p-value<0.001).
Conclusions: Open versus laparoscopic surgery for colon cancer is followed by an increased DD
concentration but not by difference PAI-1 concentration, at the 1st and the 10th postoperative
days.
Παρασκευή • Friday 21/01/2011 - 15:00 - 16:30
Προφορικές Ανακοινώσεις IΙ • Oral Presentations II
Προφορικές Ανακοινώσεις ΙΙ • Oral Presentations IΙ
O14.
PERCUTANEOUS PROSTHETIC VENOUS VALVE AS ENDOVASCULAR TREATMENT OF
LOWER LIMB REFLUX
Dr. Constantinos Zervides
Cardiovascular Implants & Medical Devices Research Group
Intercollege Larnaca, Larnaca
Introduction: Almost 3% of people in the western world will suffer from a venous disease at
some point in their lives but as yet there are very few effective treatments for the venous system. Such diseases are chronic venous insufficiency, venous valve aplasia and deep vein thrombosis all of which affect venous valves and can cause lower limb reflux.Current clinical therapies
are only moderately and there is an urgent need for a better solution. An innovative artificial venous valve is currently in development at Intercollege Larnaca in Cyprus as an endovascular treatment of lower limb reflux.
Aims: Percutaneous implantation is an innovative procedure which will represent an optimal solution
for a large group of patients and will make it possible to quickly perform venous valve replacements in
the clinic thus reducing dramatically the costs to ensure proper treatment to the population.
Methods: Computer models where used for the design and the testing of the venous valve implant based on ISO and FDA protocols.
Results: The implant was designed to minimise the collapsed diameter, to allow direct access to
veins of diameter less than 0.5 mm and to optimise valve securing. It uses synthetic leaflets,
made of a biocompatible and biostable polymeric nanocomposite, used as a scaffold to promote
the colonisation from the host cells thus obtaining progressive remodelling, neovascularisation
and endothelisation of the valve.
Summary: The proposed valve can give a striking contribution to lead the transition from what
it is now a moderate clinical therapy to a sustainable one.
O15.
MULTI-LAYER BANDAGING SYSTEM WITH TUBULCUS® IN THE TREATMENT OF VENOUS
LEG ULCERS
Vladimir Zivkovic, MD; Robert Stefanovic, MD; Zoran Damnjanovic, MD;
Vladimir Stojiljkovic, MD; Sasa Zivic, MD; Dragan Milic, MD, PhD
Clinic for Vascular Surgery, Clinical Centre Nis, Serbia
Background: Venous leg ulcers (VLU) are a major health problem because of their high prevalence and associated high cost of care. The cost of VLU is estimated to be $1 billion per year in
the United States, and the average cost for one patient over a lifetime exceeds $40000 because
the natural history of this disorder is slow healing and high recurrence rate. It is estimated that
0.3% of entire population in Western European countries has an active VLU.
Methods: An open prospective single center study including 438 patients with VLU (ulceration
surface: 3-210 cm2; duration: 3 months-42 years) was performed. During the one year treatment
period patients were treated with multi-layer bandaging system consisted of Tubulcus® (a heelless open-toed elastic class III compression device knitted in tubular form - Laboratoires Innothera, Arcueil, France) and one elastic long stretch bandages (Niva, Novi Sad, Serbia). The exclusion criteria from the study were: heart insufficiency with EF<35, ABPI<0.8 and pregnancy. After ulcer healing, patients in the treatment group wear Tubulcus® (compression stockings class III) in order to avoid recurrence.
Results: The healing rate during the one-year treatment period was 88.58% (388/438) and the
median ulcer healing time was 194 days (21–360 days). The recurrence rate during the one-year
follow up period was 22.16% (86/388).
Conclusions: This study suggests that for VLU, multi–layer compression therapy with Tubulcus®
provides extremely high healing rate. Sustained compression of class III is necessary after ulcer
healing in order to avoid recurrence.
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Παρασκευή • Friday 21/01/2011 - 15:00 - 16:30
Προφορικές Ανακοινώσεις ΙΙ • Oral Presentations IΙ
POSTTHROMBOPHLEBITIS SYNDROME- DIAGNOSTIC AND PHYSICAL THERAPY
Dragica Rondovic, Rade Kostic, Zaklina Damnjanovic
Special centre for rehabilitation “Gamzigrad” Gamzigradska banja” Serbia
Postthrombophlebitic syndrome is the commonest form of the chronic vein insufficiency.
Aim: The importance of physical therapy in vein slowdown curing and in preventing from disease
progression and invalidity.
Method and Subjects: 82 patients suffering from postthrombophlebitic syndrome and showing
clinical gradation of changes according to CEAP classification C2-C3-C4-C5-C6 were treated from
01.01.2009. till 31.12.2009. by physical agents. Diagnostic evaluation of morphological and
chemodynamic occurrences was performed by colour duplex scanning. From pathoanatomic
point of view, the varicose stem of the saphena magna vein with the mouth dilatation, with
thrombotic varicositates of the vein crural segment was detected in 67 patients. Two of them
had a thrombus at the mouth of the saphena magna vein, and 12 of them had postthrombophlebitic sequele on the phemoral segment of the saphena magna vein. 6 patients suffered
from the complete thrombosis of the stem of the saphena vein. Dilated and insufficient perforated veins were reported in 75% of the patients. Balneophysical agents were applied in postthrombophlebitic syndrome:They are thermomineral water of the indifferent temperature in
strictly selected patients,vacusac,vasculator, kinetic, electro and magnetic therapy.
Results: Leg oedema was reduced, dermatophlebosclerotic plates were reduced, trophic changes
were reduced, the appearance of vein ulcers was prevented.These were achieved by the influence of the physical agents on the improving of vein drainage, by reducing of vein hypertension,
by improving of microcirculatiing metabolic processes.
Conclusion: Curing of postthrombophlebotic syndrome posese an overwhelming problem in clinical experience and physical therapy performs a part of complex measures in its curing in improving the quality of living and in preventing from invalidity.
O17.
INHERITANCE IS AN IMPORTANT RISK FACTOR FOR CHRONIC VENOUS INSUFFICIENCY
Matić Milan1, Duran Verica1, Gajinov Zorica1, Rajić Novak1, Matić Aleksandra2,
Ivkov Smić Milana1, Roš Tatjana1
1
Clinical center of Vojvodina, Dermatovenereological Clinic, Novi Sad, Serbia
2
Institute for Child and Youth health care of Vojvodina, Novi Sad, Serbia
Introduction: In most large epidemiological studies inheritance is recognized as a important risk
factor both for varicose veins and CVI. The aim of this research was to check this observation on
our material.
Material and methods: The research was conducted as a prospective study in the Angiology department of the Dermato-venereological Clinic of the Clinical centre of Vojvodina. 162 patients
were included in the research, on the basis of their attendance to the Clinic. All the patients were
divided in to 3 groups; Group 1 with 57 patients with the lighter forms of CVI, Group 2 with 54
patients with the heavier forms of CVI, Group 3 was control group with no symptoms of CVI –
51 examinees.
Results: In 1st group of patients there were 40 (70,18%) patients with varicose veins in family, in
2nd group - 48 (88,89%) and in the control group - 16 (31,37%). When we compared percentages
of patients with varicose veins in family in the groups of patients with CVI and in the control
group we found that this difference was highly statistically significant (p<0,001). In 1st group of
patients there were 8 (14.04%) patients with venous ulcers in family, in 2nd group - 21 (33,89%)
and in the control group - 1 (1.96%). When we compared percentages of patients with venous
ulcers in family in the groups of patients with CVI and in the control group we found that this
difference was also highly statistically significant (p<0,001).
Conclusion: Inheritance is a very important risk factor for chronic venous insufficiency, and this
fact is was also confirmed on our material.
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Προφορικές Ανακοινώσεις IΙ • Oral Presentations II
O16.
Παρασκευή • Friday 21/01/2011 - 15:00 - 16:30
Προφορικές Ανακοινώσεις IΙ • Oral Presentations II
Προφορικές Ανακοινώσεις ΙΙ • Oral Presentations IΙ
O18.
OBESITY AND AGING AS RISK FACTORS OF SUPERFICIAL THROMBOPHLEBITIS IN PATIENTS
WITH PRIMARY VARICOSE VEINS
Karathanos Ch., Saleptsis V., Roussas N., Antoniou G., Sfyroeras G., Koutsias S., Giannoukas AD.
Department of Vascular Surgery, University Hospital of Larissa, Larissa, Greece
Aim: To investigate the role of obesity and aging as risk factors for superficial thrombophlebitis
(STP) in patients with primary varicose veins (VVs).
Material and Methods: Body mass index (BMI) was calculated in 230 sex-matched consecutive
patients with primary VVs. 128 of them (85 women, mean age 56.16, SD 13.76) had a recent
documented episode of STP while the remaining 102 (75 women, mean age 48.67, SD 12.55)
were free of any thrombotic event (control group). None of them reported any other known risk
factor or thrombotic event. All subjects were subjected to blood lipid measurement.
Results: Mean BMI was 27.18kg/m2 (SD 4.7) in the STP group and 25.36kg/m2 (SD 3.6) in control
group. Compared to those with a normal BMI (<25kg/m2), the overweight (25kg/m2>BMI<30kg/m2)
and obese patients (BMI>30kg/m2) had an increased risk of STP by 1.8 - fold (OR 1.85, p=0.038, 95%
CI: 1.03-3.32) and 3.3-fold (OR 3.33, p=0.002, 95% CI: 1.53-7.22), respectively. Dislipidemia was associated with a higher risk of STP (33.6% vs.17.6%) (OR 2.3, 95% CI 1.26-4.42). Also, patients > 60yrs
showed an increased risk of STP development by 3. 5 fold compared to younger patients. In multiple logistic regression analysis the OR of developing STP increases by 2.7% (OR 1.027, p=0.013, 95%
CI 1.006-1.049) for each kilogram increase and by 4.4% for each year of aging (OR 1.044 , p=0.0001,
95% CI 1.023-1.067)
Conclusions: Obesity and aging appear to be associated with an increased risk of STP development in patients with primary VVs.
O19.
CLINIC PRESENTATION OF VENOUS CONGENITAL MALFORMATIONS
Javorka Delic
Congenital Venous Malformation (CVM) were the most common of vascular malformations and
can be truncal, capillar, isolated or combined (by arterial, lymphatic, hearth and sceletal alterations), local and systemic presentation.
Aim of this study was to presente kind and complications of CVM.
CVM were diagnosed at 2 patients, 4 male, 21 female, average age 32 (17-40), in period 20052010, in Angiology Departement. Diagnosis is establisched by clinical presentation, doppler scannning, ultrasound of the soft tissue and lymphoscintigraphy.
The most frequente localisation of CVM were on the lower limb- 50% arms 25%, the corps 14%,
on face 4,5%.
We diagnosed 3 cases of VSM aneurysms, near the ostium, 5 Anaerysms on the arm and foot,
1 The conicity of VSM on entry in deep vein, 1 Duplex VFC on left limb, 1 Lateral position of
VSM, 4 Klippel-Trenonay syndrome, 3 Hypoplasia of VCI (female, Rom population), 1 The inflow
VSP into VFS, 3 Local CVM on extremities, 3 Naevus teleangiectaticus generalisata.
The patients with CVM had the following complications
1. THROMBOSIS OF VFC (one of the duplex), with simultaneity thrombosis VP, VFS
2. THROMBOSIS of aneurysm on the foot.
3. CHRONIC OEDEMA (6 pts.)
4. DERMOPATHIA FIBROSA (3 pts.)
5. VENOUS ULCERATIONS (2 pts.) There were no episode of pulmonal thromboembolism and the
rupture of aneurysm.
Haemodinamisc dusturbance of CVM leads to severe complications in the group young population - veins thrombosis and ulcerations.
Key words: Venous malformations, complications
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Παρασκευή • Friday 21/01/2011 - 15:00 - 16:30
Προφορικές Ανακοινώσεις ΙΙ • Oral Presentations IΙ
THE IMPORTANCE OF PREOPERATIVE ULTRASONOGRAPHY CHECKUP OF LOWER LIMB
DEEP VEINS IN THE PATIENTS WITH HIP AND KNEE SURGERY
Zivanic D, Nikolic- Pucar J, Gajic D, Lolic S.
Institute for Physical Medicine and Rehabilitation “ Dr Miroslav Zotovic” B. Luka, RS, BiH
Aim: The aim of this paper is to show our results in the implementation of preoperative ultrasonography checkup, assessing the risk of deep vein thrombosis in each patient (using a questionnaire), planning and implementation of antithrombotic protection.
Material and methods: 37 randomly selected patients who underwent elective hip and knee implant surgery were examined by duplex ultrasonography 0 - 10 days before the surgery and were
assesed for the presence of risk factors for deep venous thrombosis.
Each patient was performed antithrombotic protection of low molecular weight heparin
(LMWH), lasting 3-6 weeks, elastic bandage to the groin on both legs and early mobilization.
Results: There were 11 men and 26 women in the study, the average age of 66.35 years. 22 patients had degenerative changes, while the state after the fracture of the femur was found in 11
patients, 4 patients were operated on for dislocations previously implanted hip prosthesis. Among the patients 7 of them were with verified state after deep vein thrombosis, 2 had previously verified thrombosis of great saphenous vein and in 2 patients were found acute deep vein
thrombosis. In the postoperative follow-up no patient had acute deep vein thrombosis.
Conclusion: Good preoperative checkup and adequately implemented antithrombotic protection
are important for the prevention of deep vein thrombosis at the most risky operations.
O21.
COMBINED MANAGEMENT OF THE GIGANTIC AND SQUALID VENOUS ULCERS
MA Pejić, NP Lučić, RM Koprivica, JS Stanković, B. Nikitović
Surgical service-dept. of vascular surgery, General hospital Užice, Serbia
Background: Venous ulcers are a major health problem in the western world, because of their
high prevalence and high cost of care. Chronic venous insufficiency (CVI) is the seventh leading
cause of chronic debilitating disease. More than 500,000 people in USA have venous ulcers. In
Serbia many people coming to the vascular surgeon with large and deep ulceration surface.
Methods: Between more than 300 patients with leg ulcers during 4 years, we treated about 70
patients with squalid venous ulceration (ulceration surface more than 100 cm2, duration more
than 12 months) using a combined technic of surgical treatment and multilayer bandaging system with the Tubulcus (elastic compression device knited in stocking form). The patients were
treated with same protocol: surgical debridement of necrosis, antibiotics, compression therapy.
Results: The cumulative healing rate was almost 97 % (82/85), medial healing time was 160 days
(range 60-457). The recurrence rate at 1 year was 12% (10/85). After additional bandaging protocol all recurrent ukcers healed.
Conclusions: Our results approve that multilayer compression management (with Tubulcus) provides an extremly high rate of healing venous ulcers. Compression about 30-40 mm Hg protect
ulcer healing and decreased recurrence.
Key words: venous ulcer, chronic venous insufficiency, Tubulcus
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Προφορικές Ανακοινώσεις IΙ • Oral Presentations II
O20.
Παρασκευή • Friday 21/01/2011 - 15:00 - 16:30
Προφορικές Ανακοινώσεις IΙ • Oral Presentations II
Προφορικές Ανακοινώσεις ΙΙ • Oral Presentations IΙ
O22.
DEEP VEIN THROMBOSIS AND PULMONARY THROMBOEMBOLISM DURING
PREGNANCY – RECCOMENDATION FOR SAFE BIRTH DELIVERY
Miljko A. Pejic, NP Lucic, RM Koprivica, JS Stankovic
General hospital Uzice – vascular surgery dept., Uzice, SERBIA
DVT and PTE in Gynecology and Obstetrics should be considered in a independent way, for the
alterations in the sanguine coagulation and the high risk that it represents. DVT and Pulmonary
Embolism have larger rate than breast carcionoma as cause of death in USA. Venous thromboembolic disease is an important complication in the gravid-puerperal cycle. PE is most incidentaly cause of death at women delivery.
The incidence of deep venous thrombosis is 6 times greater in pregnant women that in non-pregnant women of the same age with new thrombosis every 1000 - 2000 pregnancy.Risk of thrombosis is 6 time frequently in compare with not gravid woman and without oral contraceptives.
Characteristic of DVT in pregnancy:
• More often in the left leg (85%)
• 70 % in Ileofemoral region
• Thrombosis isolated of the iliac vein
• More often post-delivery than before delivery
Thrombosis risk increases in the puerperal period, even 5 times more than in childbearing and
Caesarean increases 10 times the incidence of thrombotic phenomenon and 6 times the risk of
PE!!!
Risk situations of DVT in pregnancy:Advanced maternal age, Multiparity, Obesity, Previous antecedents of DVT, Sepsis, Preeclampsia, Age > 35 years, Caesarean, Weight > 80 kg., Family History of thrombosis, Previous Thrombosis, Thrombophilia.
- HNF, - LMWH, - ORAL ANTICOAGULANTS
HNF: Election medication in the pregnancy. Parenteral administration. Does not cross placentary
barrier – Safe for the fetus. Can favor thrombocitopenia and osteoporosis.
LMWH: Election medication in the pregnancy. Subcutaneous administration. More efficient than
HNF. Does not cross placentary barrier – Safe for the fetus. Smaller risk of trombocitopenia and
osteoporosis.
Anticoagulant therapy: election treatment- follow by oral anticoagulants
It should be used measured prophylaxes to diminish the incidence of DVT and PE. The election of
the prophylaxis measure should spread to obtain bigger effectiveness of prevention with smaller risks of secondary effects, hemorrhages and less cost. The LMWH possesses a better relationship benefit/risk, for that in prevention and treatment is the election rule. The autors describe
the way of management of deep vein thrombosis during pregnancy. More than 50 patients were
successfully treated during 6 years without lactation interrupting and without serious complications. It was very important and necessery for elimination diagnostic tests dangerous for intrauterin fetal life and also, management who eliminated embriopathy and hemorrhagical
diathesis.
Key words: DVT, pregnancy
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Σάββατο • Saturday 22/01/2011 - 08:00 - 10:00
O23.
3D MODELLING OF A VENOUS VALVE: HOW EFFECTIVE ARE POSTURAL CHANGES UNDER
GRAVITY, IN “WASHOUT” RECIRCULATORY REGIONS IN THE LEE OF VENOUS VALVES?
Dr. Constantinos Zervides
Cardiovascular Implants & Medical Devices Research Group Intercollege Larnaca, Larnaca
Introduction: The description of blood pressure and flow in the veins of the human circulation
is of interest to researchers and clinicians throughout the world. A 3D model of a human vein
was constructed and a methodology to examine blood “washout” from the venous valve region
was developed.
Aim: The haemodynamics of opening and closing of venous valves under normal conditions are
poorly understood. This work quantified haemodynamic characteristics of the opening and closure processes.
Methods: The finite element analysis code LS-DYNA was used for the construction and analysis
of the 3-D equivalent of the human vein.
Results: The model allowed a quantitative evaluation of the effect of a valve on the shielding of
the vein from peak transient pressure effects, reported that a valve decreased the dynamic pressures applied to a vein when gravity is applied by a considerable amount and that a 5% removal
of blood particles from location of interest due to gravity, occurs.
Conclusions: Relatively little attention has been paid to the venous system and the valves in the
venous system from a cardiovascular engineering perspective up to now. Given the involvement
of venous valve haemodynamics in the development of deep vein thrombosis this is an area that
needs more detailed investigation. A 3D model of a vein has been developed using a commercial
CFD software package and a methodology was created and adopted to show that the application of gravity helps to remove blood from the locations where flow stasis occurs.
O24.
A RANDOMIZED TRIAL OF CLASS 2 AND CLASS 3 ELASTIC COMPRESSION IN THE
PREVENTION OF RECURRENCE OF VENOUS ULCERATION
Robert Stefanovic, MD; Vladimir Zivkovic, MD; Zoran Damnjanovic, MD;
Vladimir Stojiljkovic, MD; Sasa S. Zivic, MD; Dragan J. Milic, MD, PhD
Clinic for Vascular Surgery, Clinical Centre Nis, Serbia
Background: Venous leg ulcers (VLU) are a major health problem because of their high prevalence and associated high cost of care. Despite the widespread use of compression stockings recurrence rates are high and range between 25–70%.
Methods: An open, prospective, randomized, single-center study, with a 3-year follow-up, was
performed in order to determine the efficacy of two different strengths of compression hosiery
(Class 2 and Class 3) in the prevention of VLU recurrences. Three hundred and thirty eight patients (192 men, 146 women; mean age 58 years) with recently healed venous ulcers were randomized into 2 groups:
Group A) 173 patients who were wearing a heelless open-toed elastic class III compression stockings, and
Group B) 165 patients who were wearing a class 2 elastic stockings.
Results
Eleven patients did not comply with their randomized compression class, 8 (4.6%) in class 3 and
3 (1.8%) in class 2. Overall, 28.4% (93/327) of patients had recurrent leg ulceration by 3 years.
Recurrence occurred in 34 (20.6%) of 165 class 3 elastic compression cases and in 59 (36.4%) of
162 patients of class 2 compression cases. It is interesting that 26 recurrent VLU (28%) developed
not at the primary site of the ulcer but below the medial malleolus, indicating possible insufficient level of compression at that point.
Conclusions
The results obtained in this study suggest that class 3 compression stockings provide statistically significant lower recurrence rate compared to class 2 compression stockings.
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Προφορικές Ανακοινώσεις IIΙ • Oral Presentations III
Προφορικές Ανακοινώσεις ΙΙΙ • Oral Presentations IΙΙ
Προφορικές Ανακοινώσεις IIΙ • Oral Presentations III
Σάββατο • Saturday 22/01/2011 - 08:00 - 10:00
Προφορικές Ανακοινώσεις ΙΙΙ • Oral Presentations IΙΙ
O25.
THE ROLE OF COLOR DUPLEX SONOGRAPHY IN RECCURENT VARICOSE VEIN SURGERY
Kostov I. 1, Mladenovic D.1, Kostova N.2, Uzunova T.1
1
Surgery Clinic- “ St. Naum Ohridski” Skopje, F.Y.R.O.M.
2
Clinic of Cardiology– Skopje, F.Y.R.O.M.
Aim: The aim of this study is to determine the importance of Color Duplex Sonography (CDS) in
recurrent varicose vein after surgery (REVAS).
Methods: We examinee 36 legs in 30 patients with REVAS on lower extremities, operated in last
five years by different surgeons. Mandatory in all patient ligatures and stripping of grate saphenous vein were performed, also stab phlebectomy. We made two planes scanning with CDS
of safenofemoral junction, deep vein and three levels above knee scanning. We also scan popliteofemoral junction and perforate vein for possible pathologic reflux.
Results: In 30 patient we found intact safenofemoral junction with evident safenofemoral reflux
(>5 cm patent grate saphenous vein segment with > 5 sec. reflux). In 27 of them saphenofemoral
tributary insufficiency were present. In 3 patients we found only tributary insufficiency on the
same level. In 1 case we found accessory saphenous vein with firm reflux. In 2 patients we found
under knee perforator insufficiency.
Surgery intervention which included crosectomy and high ligation of grate saphenous vein and
its tributary were performed in 4 patients. We made ambulatory phlebectomy in 6. Others had
no interest for additional surgery intervention.
Summary: Preoperative CDS and proper surgery intervention (included crosectomy with high ligation, stripping of grate saphenous vein and additional stab phlebectomy), greatly prevent incidence of REVAS.
O26.
SURGICAL CORRECTION OF ISOLATED SUPERFICIAL REFLUX IN CHRONIC VENOUS LEG
ULCERATION OFFERS FAVOURABLE ULCER HEALING RATE WITH MINIMAL LONG-TERM
RECURRENCES
Terzoudi S, Georgakarakos E, Karpouzis A, Georgiadis G, Lazarides M.
Department of Vascular Surgery, Alexandroupolis Univercity Hospital, Dimokritos Univercity
Background: The value of superficial venous surgery to venous ulcer healing rates and recurrence
reduction remains controversial. Healing rates of surgical vs compression bandage treatment
were found equally effective in randomized trials and recurrence reduction was attributed to
their combination.
Patients and methods: 29 patients (15 men) with 31 venous ulcers (2 bilateral) entered the study. At presentation the mean(±1 SD, range) age was 49.8 years (±14.1, 31-76), active ulcer diameter 3.89 ± 2.1 cm (1-8), duration(CEAP 6) 10.1 ± 12.3 months (1-48) and Venous Clinical
Severity Score (VCSS) 14.2 (±4.2, 9-22). They all had isolated superficial venous reflux in the preoperative color Duplex and underwent superficial venous stripping with modified mini-Cockett/Linton procedure for perforator’s ablation.
Results: All 29 patients were followed-up prospectively for a mean of 31.8 months (range 4-62)
and 18 of them were long-term evaluated for 64.4 ± 40.5 months. None of them was compliant
with additional compression treatment. All ulcers were healed within 10.82 (± 9.7, 4-48) weeks
(mean± 1 SD, range) and one reported recurrence healed spontaneously.Conclusions: Non delayed surgical management of selected young patients with good ambulatory status, no additional medical history and small ulcer diameter may significantly improve healing time and minimize recurrence even without combined ambulatory compression therapy.
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Σάββατο • Saturday 22/01/2011 - 08:00 - 10:00
O27.
QUALITY OF LIFE IMPROVEMENTS AFTER ENDOVENOUS TREATMENTS CORRELATE
WITH BASELINE VALUES RATHER THAN SEVERITY SCORES OR TYPE OF INTERVENTION
Lattimer C1,2, Kalodiki E1,2, Azzam M1, Shawish E1, Makris G1,2, Geroulakos G1,2
Ealing Hospital, Middlesex, UK
2
Imperial College, London, SW7 2AZ
1
Background: Treatments for chronic venous insufficiency are designed to improve quality of life.
Aim: To determine whether the C score of the CEAP classification, Venous Clinical Severity Score
(VCSS), Venous Filling Index (VFI), or type of intervention, correlate with improvements in the Aberdeen Varicose Vein Questionnaire (AVVQ).
Method: The patients had either laser treatment (n=44) or foam sclerotherapy (n=40). All underwent venous assessments and were followed up at 3 weeks and 3 months.
Results: Seventy patients (83.3%) completed the follow up at 3 months. The median (IQR) of
the AVVQ, VCSS and VFI fell from 21.17 (15.83), 6 (4), 5.1 (4.3) to 8.46 (13.2), 1.5 (4), 1.6 (1.3) respectively, P<0.0005 (Wilcoxon) in all parameters. There was no significant correlation in AVVQ
improvements when compared to improvements in the VCSS (P=0.096, R2=0.047) or the VFI
(P=0.223, R2=0.005) (Spearman). When patients were divided into mild (C2,3) and severe disease
(C4a,4b,5,6) their respective median (IQR) values in AVVQ improvements, 9.7 (9.53) vs 12.1
(13.41) were not significantly different, P=0.267 (Mann-Whitney). Similarly there was no difference between laser and foam treatment, 12.18 (11.0) vs 9.62 (11.2) respectively, P =0.085 (MannWhitney). When the AVVQ improvements at 3 weeks and 3 months were compared to their pretreatment values, R2=0.245 and R2=0.403, significance was achieved, P<0.0005 (Spearman).
Conclusion: Patients with an initial poor quality of life score benefit most from endovenous
treatment. Severity of disease or type of intervention did not play a significant role.
O28.
CLINICAL AND ANATOMIC CHARACTERISTICS OF PATIENTS REQUIRING SECONDARY
PROCEDURES AFTER GREAT SAPHENOUS ENDOVENOUS ABLATION
Angela A. Kokkosis, M.D. and Harry Schanzer, M.D.
Division of Vascular Surgery, The Mount Sinai Medical Center, NY
Background: Endovenous laser therapy (EVLT) of the great saphenous vein(GSV), either with
laser or radio-frequency thermal energy, has almost completely replaced the traditional open surgical stripping procedure used for over 50 years for the treatment of varicose veins secondary to
greater or small saphenous vein reflux. Most practitioners initially perform endovenous ablation
as the first line strategy without specifically addressing the branch varicosities. If the varicosities
persist after this first stage, removal with microphlebectomy or sclerotherapy is required during
a second stage procedure. At this time, there are no clear data on how often these secondary
procedures are needed, and what clinical characteristics make patients more prone to further interventions.
Methods: A retrospective analysis of a prospectively maintained database of patients with varicose veins secondary to reflux of the greater saphenous vein, treated with EVLT between August
2006 and October 2010, was performed. All procedures were carried out by a single surgeon. The
following parameters were considered: age, sex, severity and extent of varicosities, size of the
treated saphenous vein in diameter and length, and amount of energy delivered during the procedure (joules/cm). At one week it was determined if there was extension of the thrombosis
from the great saphenous vein to the deep veins (DVT). At one month it was established whether
or not the patient required a secondary procedure (sclerotherapy or microphlebectomy) to eliminate non-regressing varicose veins.
Results: One-hundred and twenty-two consecutive limbs in 114 patients with varicose veins and
great saphenous (GSV) reflux were treated with EVLT. All patients were categorized with C2 disease, of the CEAP classification, and visible varicose veins were graded clinically on a scale of 15 based on visible size and extent. There were no patients without clinically visible varicosities
81
Προφορικές Ανακοινώσεις IIΙ • Oral Presentations III
Προφορικές Ανακοινώσεις ΙΙΙ • Oral Presentations IΙΙ
Προφορικές Ανακοινώσεις IIΙ • Oral Presentations III
Σάββατο • Saturday 22/01/2011 - 08:00 - 10:00
Προφορικές Ανακοινώσεις ΙΙΙ • Oral Presentations IΙΙ
(grade 10, and at 1 week there were no patients with DVT. The clinical result after EVLT at 1
month was classified as excellent (no varicosities), good (major reduction in size), and poor (no
change). Overall, only 49% (60/122) of the limbs required secondary interventions. The patients
with GSV reflux were then divided into two groups, Group 1: those with grade 2 varicosities,
≤5mm and localized, (45 limbs/ 43 patients); and Group 2: those with grade 3 or higher, >5mm
and localized or extensive, (77 limbs/71 patients). The patients in group 2 were older (53 years
old vs. 46 years old, p=0.03), and had a larger diameter greater saphenous vein proximally
(0.81cm vs. 0.62 cm, p<0.0001). There was no correlation between clinical grade of varicosities
(p=0.7), diameter of the greater saphenous vein proximally (p=0.54, p=0.29), with need for secondary intervention. There was a trend toward more males with higher grade varicosities, but
this was not statistically significant (p=0.13).
Conclusions: Contrary to common practice of combining EVLT with sclerotherapy or microphlebectomy, this study demonstrates that less than half of the affected limbs actually require a secondary procedure. Saphenous trunk diameter and age of the patients correlates with the extent
of visible varicosities; but there is no association between varicosity grade or saphenous diameter, with the need for secondary interventions.
O29.
HEALING OF ACUTE AND CHRONIC WOUNDS: DON’T FORGET LYMPHATICS!
Szolnoky G1, Erős G2, Szentner K2, Szabad G1, Dósa-Rácz É1, Kemény L1,3
1
Department of Dermatology and Allergology, University of Szeged, Hungary
2
Institute of Surgical Research, University of Szeged, Hungary
3
Dermatological Research Group of the Hungarian Academy of Sciences, Szeged, Hungary
Introduction: Wound healing is assumed to be predominantly determined by blood vasculature
development. Clinical observations and histological examinations find that lymph stasis may also be responsible for the maintenance of chronic wounds. The role of lymphatics in acute wound
healing is poorly studied.
Aim: We aimed to examine whether manual lymph drainage (MLD) of decongestive lymphatic
therapy (DLT) improves venous leg ulcer (VLU) healing and to measure acute wound healing in
mice treated with or without anti-blood and/or lymphangiogenesis antibodies.
Methods: 8 patients were treated with a 5-day, while 9 patients with a 10-day-course of DLT.
Control goup consisted of 9 patients receiving compression alone. Wound surfaces were measured on days 5 and 10.
6 SKH-1 hairless mice were included into each treatment group where animals received periwound injections with sterile phosphate buffer saline (PBS) as control or vascular endothelial
growth factor receptor-2 (VEGFR-2) inhibitor DC-101 or the VEGFR-3 neutralizing mF4-31c1 antibodies and wound size measurements were carried out every second day.
Results: There was no statistical difference between 5-day DLT and compression of the same duration regarding ulcer healing (p= 0.125). 10-day-course of DLT significantly increased ulcer healing compared to compression of the same duration (p= 0.039).
Between 8 and 18 days from baseline mean wound surfaces of each group significantly (p<0.05)
differed from each other.
Summary: MLD efficiently supported VLU healing. Wound healing in lymphangiogenesis blocker
mF4-31c1 antibody treated group was significantly inferior to that of control animals.
Conclusion: Lymphatics seem to play non-negligible roles in acute and chronic wound healing.
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Σάββατο • Saturday 22/01/2011 - 08:00 - 10:00
O30.
QUALITY OF LIFE IN PATIENTS WITH LYMPHOEDEMA: INITIAL RESULTS OF THE ONLY
GREEK LYMPHOEDEMA CENTRE IN THE PUBLIC SECTOR.
Papadopoulou Ch., Roussas N., Salta R., Tsioli S., Tsiouri I., Nakos Ch., Roussaki Schulze A-V.,
Giannoukas A.D.
Lymphoedema Centre and Departments of Vascular Surgery and Dermatology,
University Hospital of Larissa, Larissa, Greece
Aim: to access the impact of an out-patient lymphoedema treatment programme on the patients’ Quality of life (QoL).
Patients - Methods: 30 patients participated in a multidisciplinary treatment programme at the
lymphoedema center of the University Hospital of Larissa that includes evaluation from vascular
surgeon and dermatologist, consultation by a dietician and psychologist followed by a 3 to 4week decongestive therapy on of daily basis. We used the Freiburg Life Quality Assessment
(FLQA) at the beginning and at the end of the programme and one, three and six months later.
FLQA in the German version has been found to be valid and reliable for lymphoedema and consists of the following items: Physical status, daily life, social life, emotional well-being, treatment,
satisfaction and profession/ household
Results: We gathered evidence from 28 patients. According to the FLQA, 6 patients had satisfactory improvement, 12 moderate, 7 had no improvement and 3 reported deterioration. All patients had satisfactory reduction of their limb circumference.
Conclusion: The more severe the lymphoedema was at the beginning of the treatment the better decongestive result was achieved. However, with the use of the Greek version of FLQA the
improvement of the QoL did not match the improvement of the limb circumference. Potential
reasons to explain this disparity are the stocking-wearing difficulties and the time-consuming
treatment programme. Validation of the Greek version of FLQA with the addition of new section
including these two parameters may give more reliable results.
O31.
CLINIC INDICATORS OF HARD-TO-HEAL VENOUS ULCERATIONS
Javorka Delic
Hard-to-heal venous ulcerations (H-T-H VU) presented 25% of all chronic venous ulcerations.
H-T-H VU had prolonged time of healing (over one year).
The aim of this prospective and randomise study was to determine incidence and types of local
and systemic qulities of H-T-H venous wounds.
We examined a group H-T-H VU at 65 patients, average age 64,8 (47-88), female 30, male 35. The diagnosis was establisched by Clinic image, Dopler scanning, ultrasoundof the soft tissue, laboratory analysis.
We founded folowing qualities of H-T-H VU
1. OEDEMA with FiBRODERMOPATHIA at 65 pts
2. BIOFILM on the surface of the wound at 50(80%)
3. BACTERIAL RESISTANCE at 38 (65%)
4. CELLULITIS (6), FASIITIS NECROTICANS (1), total 7 infective events (10,8%)
5. CONTACT ALLERGIC DERMAL REACTION at 20 (35%)
6. PHEBOARTHRITIC DISTURBANCE at 21 (36%)
7. PERSISTANTE PAIN at 48 (75%)
8. Paralel PERIFERAL ARTERIAL disease at 5 (7,5%) pts.
The systemic complications were infection at 3 cases, malnutrition 8 (12%), discreasing quality
of life at 65 pts.
The prime clinic pameters of H-T-H VU were oedema with fibrodermopathia and the biofilm. The
findings demonstrates that is need to treat oedema by graduated compressive therapy and to
improve haemodinamic state on microcirculation (nutritive circulation) and usage of proteins, vitamines and other suppleme nts. Also, treats the biofilm by TNT, surgical and others debridman
forms, Polihexamid Sol, but not by antibiotics, because antibiotics weren’t be effective.
Key words: HTH venous ulceration, biofilm, oedema
83
Προφορικές Ανακοινώσεις IIΙ • Oral Presentations III
Προφορικές Ανακοινώσεις ΙΙΙ • Oral Presentations IΙΙ
Προφορικές Ανακοινώσεις IIΙ • Oral Presentations III
Σάββατο • Saturday 22/01/2011 - 08:00 - 10:00
Προφορικές Ανακοινώσεις ΙΙΙ • Oral Presentations IΙΙ
O32.
ENDOVENOUS LASER ABLATION TREATMENT IN THE TREATMENT OF VARICOSE VEIN
DISEASE
Dr. Stylianos Papas M.D, Vascular Surgeon
Dr. Eleftherios Koulouteris M.D, F.MAS, D.MAS, General Surgeon
ELVT ( Endovenous Laser Ablation Treatment) is the method of choice in the treatment of varicose vein disease of the lower extremities. Comparing ELVT to the traditional surgical treatment
for varicose veins it has better results, less hospital stay and minimal complications. In this study
we present our experience and our results concerning ELVT and its superiority over the traditional
one.
Method: During ELVT the surgeon uses the thermal energy of a laser catheter in the venous lumen in order to obliterate the lumen by causing damage to the endothelium. The result of this
thermal injury is thrombosis of the vein. From September 2006 to October 2010, ELVT was used
in 387 patients. The number of veins treated was 485 (353 greater saphenous vein and 122 lesser saphenous vein). All patients were treated for varicose veins first time.
Results: All patients were leaving the clinic on the same day of operation. The pain was minimal
and only few patients needed pain killers after day 3 post-operatively. Infection rate was zero.
Ecchymosis was detected in 12 patients and 3 patients have had hematomas. Both were resolved
spontaneously. On a follow-up period of 3,6,12,18,24 months no major complications( e.g. DVT,
pulmonary embolism) were present. In 3 patients a recanalization of the vein was detected.
Conclusion: Treatment of varicose vein disease using ELVT is a feasible technique, easy to learn
and it is safe without major complications. It is very efficient and it is very well tolerated by the
patients. Patients return to their work earlier than the conventional technique and the long lasting result is perfect.
O33.
H ΧΡΗΣΗ ΕΠΙΘΕΜΑΤΩΝ ΜΕ ΑΡΓΥΡΟ ΣΤΗΝ ΘΕΡΑΠΕΙΑ ΕΠΟΥΛΩΣΗΣ ΤΩΝ ΦΛΕΒΙΚΩΝ ΕΛΚΩΝ
∆ηµακάκος Ε.Καλκανδής Χρ., ∆αφνής ∆. Βασιλόπουλος Ι.,Καλλίνης Α., ΛοίζοςΑ., Κατσένη Κ.,
Κατσένης Κ.
Αγγειοχειρουργική Μονάδα Β΄ Χειρουργικής Κλινικής Πανεπιστηµίου Αθηνών Αρεταίειο
Νοσοκοµείο.
Σκοπός: αυτής τη µελέτης είναι να µελετήσουµε τόσο την ασφάλεια όσο και την
αποτελεσµατικότητα στην επούλωση των φλεβικών ελκών του επιθέµατος µε άργυρο σε 9
εβδοµάδες σε σχέση µε τον κλασικό τρόπο επούλωσης τραυµάτων.
Μέθοδος- Υλικό: Μελετήθηκαν 42 άτοµα από τα οποία τα 29 ήταν γυναίκες και οι 13 ήταν άνδρες.
Οι παραπάνω ασθενείς χωρίστηκαν σε δύο οµάδες: στην οµάδα Α και στην οµάδα Β. Η οµάδα Α
αποτελείτο από 21 ασθενείς (12 γυναίκες και 9 άνδρες),ενώ η οµάδα Β αποτελείτο από 21 ασθενείς
(15 γυναίκες και 6 άνδρες). Και στις δύο οµάδες εγίνετο καθαρισµός των ελκών, πλύσιµο της
βλάβης µε φυσιολογικό όρό και διάλυµα Betadine. Και ακολούθως τοποθετείτο στην οµάδα Α το
επίθεµα µε Ag ενώ στην οµάδα Β γάζα Sodium fusidate. Τέλος η αλλαγή ολοκληρώνετο µε
περίδεση δι ελαστικών επιδέσµων. Η παρακολούθηση των ασθενών διήρκησε για 9 εβδοµάδες.
Αποτελέσµατα: Κατά την διάρκεια των 9 εβδοµάδων της έρευνας, από την οµάδα A
επουλώθηκαν 18 από τους 21 ασθενείς (86%), ενώ από την οµάδα Β επουλώθηκαν 10 από τους
21 ασθενείς (48%) .Η διαπίστωση ότι στήν οµάδα Α η επούλωση είχε καλύτερη πρόοδο από την
οµάδα Β τεκµηριώνεται µε στατιστική διαφορά (p=0,02)
Τέλος κανένας ασθενής δεν παρουσίασε ή δεν παραπονέθηκε για οποιαδήποτε παρενέργεια µετά
την τοποθέτηση του επιθέµατος αργύρου στην οµάδα Α, αλλά και από την γάζα Sodium fusidate
στην οµάδα Β.
Συµπεράσµατα: Σε ασθενείς µε φλεβικά έλκη ανεξαρτήτου µεγέθους και του βαθµού εξιδρώµατος
συστήνεται η χρήση επιθεµάτων µε άργυρο το οποίο έχει µεγάλο αντιµικροβιακό φάσµα και
προάγει τη γρήγορη επούλωση των βλαβών µε αποτέλεσµα την άµεση ανακούφιση του
ασθενούς.
84
Σάββατο • Saturday 22/01/2011 - 08:00 - 10:00
O34.
ΟΙ ΘΕΡΜΟΡΥΘΜΙΣΤΙΚΕΣ ΜΕΤΑΒΟΛΕΣ ΤΟΥ ∆ΕΡΜΑΤΟΣ ΣΤΗ ΧΡΟΝΙΑ ΦΛΕΒΙΚΗ ΝΟΣΟ
∆ηµακάκος Ε., Κατσένης Κ., Αράπογλου Β., Καλκανδής Χ.,∆αφνής ∆., Βασιλόπουλος Ι.,
Καλλίνης Α., Λοίζος Α., Κατσένη Κ.
Αγγειοχειρουργική Μονάδα Β΄ Χειρουργικής Κλινικής Αρεταιείου Πανεπιστηµιακού
Νοσοκοµείου Αθηνών
Εισαγωγή: Είναι γνωστό ότι η βασική λειτουργία του δέρµατος είναι η θερµορύθµιση όπως
γνωστή είναι και η επίδραση της χρόνιας φλεβικής ανεπάρκειας στη µικροκυκλοφορία και κατ’
επέκταση στη δερµατική κυκλοφορία και στις λειτουργίες του δέρµατος.
Μέθοδος-Υλικό: Μελετήθηκαν 35 άτοµα (5 φυσιολογικά άτοµα σαν οµάδα ελέγχου και 30
ασθενείς µε χρόνια φλεβική ανεπάρκεια κάτω άκρων και εχωρίσθησαν σε οµάδες όλων των
σταδίων κατά CEAP). Σε όλα τα άτοµα έγινε µέτρηση θερµοκρασίας δέρµατος στο ύψος των
σφυρών, της κνήµης, του µηρού και στον αντίστοιχο δελτοειδή µυ. Οι µετρήσεις γινόταν τόσο σε
κατακεκλιµένη όσο και σε όρθια θέση.
Αποτελέσµατα: Σε 9 από τους 15 ασθενείς σταδίου 1-3 χρόνιας φλεβικής ανεπάρκειας
διαπιστώθηκε θερµοκρασία ίδια µε τα φυσιολογικά άτοµα, ενώ στα υπόλοιπα 6 άτοµα (2 του
δευτέρου σταδίου και 4 του τρίτου) διαπιστώθηκε µεγαλύτερη θερµοκρασία. Επίσης διαπιστώθηκε
αυξηµένη θερµοκρασία δέρµατος σε όλους τους ασθενείς των σταδίων 4/5/6 κατά CEAP. Τέλος
πρέπει να σηµειωθεί ότι στα 28 από τα 35 άτοµα (85%) η θερµοκρασία ήταν µικρότερη στην
κατακόρυφη θέση σε όλα τα στάδια.
Συµπεράσµατα: Η επίδραση της χρόνιας φλεβικής ανεπαρκείας επηρεάζει την θερµοκρασία του
δέρµατος επιδρώντας στην µικροκυκλοφορία διαφοροποιώντας την βασική λειτουργία του
δέρµατος που είναι η θερµορύθµιση.
O35.
OVARIAN VEIN REFLUX AND RECURRENT VARICOSE VEINS.
REPORT OF TWO CASES
Vasdekis S., Athanasiadis D., Broutzos E., Lazaris A.
Vascular Unit, 3RD Surgical Department, University Hospital Attikon, Athens , Greece
Ovarian vein incompetence is usually associated with the presence of pelvic congestion syndrome
and produces a typical clinical entity. The venous hypertension in the pelvic floor is sometimes
transmitted to the veins of the lower limb resulting in recurrent varicose veins that are difficult
to treat unless the primary cause is cured.
We report of two cases with ovarian vein reflux causing recurrent varicose veins in the left leg.
They were treated by coil embolization and injection of sclerosant in the pelvic veins. The recurrent varicosities were at a second stage treated successfully with sclerotherapy and local
avulsions. One of the patients was submitted to laparotomy two years later by her gynecologist
because he considered the coils as a foreign body.
Ovarian vein reflux remains a vague condition for many gynecologists and vascular surgeons because the venous hemodynamics of the pelvic floor with the lower limb are not fully understood. It should always be investigated when there are recurrent varicosities combined with the
symptomatology of pelvic congestion. Communication of the two specialties about this syndrome is necessary for the benefit of the patient.
85
Προφορικές Ανακοινώσεις IIΙ • Oral Presentations III
Προφορικές Ανακοινώσεις ΙΙΙ • Oral Presentations IΙΙ
Γενικές Πληροφορίες
ΧΡΟΝΟΣ – ΤΟΠΟΣ
Το Συνέδριο θα πραγµατοποιηθεί στις 21 & 22 Ιανουαρίου 2011, στο Ξενοδοχείο Crowne Plaza
(πρώην Holiday Inn), στην Αθήνα. Στον ευρύτερο χώρο του Συνεδρίου θα λειτουργήσουν η
Γραµµατεία του Συνεδρίου και η Έκθεση φαρµακευτικών προϊόντων, ιατρικών οργάνων & µηχανηµάτων.
Π Λ Η Ρ Ο Φ Ο Ρ Ι Ε Σ
ΓΛΩΣΣΑ
• Επίσηµη γλώσσα των παρουσιάσεων στα πλαίσια του 2nd Annual Meeting of the Balkan Venous
Forum (Παρασκευή 21 Ιανουαρίου) θα είναι η Αγγλική.
• Επίσηµη γλώσσα των παρουσιάσεων στα πλαίσια του 3ου Πανελλήνιου Συνεδρίου Φλεβολογίας
(Σάββατο 22 Ιανουαρίου) θα είναι η Ελληνική.
ΕΠΙΣΤΗΜΟΝΙΚΟ ΠΡΟΓΡΑΜΜΑ
Το Επιστηµονικό Πρόγραµµα περιλαµβάνει: Στρογγυλά Τραπέζια, ∆ιαλέξεις, Πρακτικά Σεµινάρια,
και Ελεύθερες Ανακοινώσεις.
ΠΑΡΟΥΣΙΑΣΕΙΣ ΜΕΣΩ Η/Υ
Το Συνέδριο θα διαθέτει ειδική Γραµµατεία παρουσιάσεων, στην οποία θα πρέπει να παραδίδεται
το υλικό σε µορφή CD ή USB stick, µία τουλάχιστον ώρα πριν την παρουσίαση.
ΜΟΡΙΟ∆ΟΤΗΣΗ / CME CREDITS
Στο 3ο Πανελλήνιο Συνέδριο Φλεβολογίας & 2nd Annual Meeting of the Balkan Venous Forum χορηγούνται 12 µόρια Συνεχιζόµενης Ιατρικής Εκπαίδευσης (EACCME-UEMS).
Γ Ε Ν Ι Κ Ε Σ
ΒΡΑΒΕΥΣΕΙΣ
Οι δύο καλύτερες Ανακοινώσεις του Συνεδρίου θα βραβευθούν από τους Προέδρους του Συνεδρίου, κατά την Τελετή Λήξης µε απονοµή ειδικού τιµητικού επαίνου.
∆ΙΚΑΙΩΜΑ ΣΥΜΜΕΤΟΧΗΣ
Μέχρι 10/01/2011
Μετά τις 10/01/2011
Ειδικευµένοι
150 €
170 €
Ειδικευόµενοι
90 €
110 €
Συµµετέχοντες από Βαλκανικές Χώρες
70 €
80 €
Νοσηλευτές/Τεχνολόγοι
70 €
80 €
∆ωρεάν
20 €
Φοιτητές*
Το δικαίωµα συµµετοχής στο Συνέδριο περιλαµβάνει:
Παρακολούθηση Επιστηµονικών Συνεδριάσεων, Πρόσβαση στην Έκθεση, Συνεδριακό Υλικό, ∆ιαλείµµατα Καφέ & Ελαφρού Γεύµατος καθ’ όλη τη διάρκεια του Συνεδρίου, ∆εξίωση Υποδοχής την
Παρασκευή, 21 Ιανουαρίου 2011, Πιστοποιητικό Συµµετοχής.
Το δικαίωµα συµµετοχής για Φοιτητές* στο Συνέδριο περιλαµβάνει:
Παρακολούθηση Επιστηµονικών Συνεδριάσεων, Πρόσβαση στην Έκθεση, Συνεδριακό Υλικό, ∆ιαλείµµατα Καφέ, Ελαφρού Γεύµατος, Πιστοποιητικό Συµµετοχής.
*Απαραίτητη προϋπόθεση εγγραφής των φοιτητών είναι η υποβολή αντιγράφου της φοιτητικής
τους ταυτότητας, µαζί µε την αποστολή του δελτίου συµµετοχής.
86
∆ΙΑΜΟΝΗ
Για την διευκόλυνση των Συνέδρων, έχει γίνει προκράτηση δωµατίων στο Συνεδριακό Ξενοδοχείο.
Για κρατήσεις Ξενοδοχείου παρακαλούµε όπως απευθυνθείτε στη Γραµµατεία του Συνεδρίου ERA
ΕΠΕ, συµπληρώνοντας το ∆ελτίο Εγγραφής & Κρατήσεως δωµατίων.
Ηµερήσιες Τιµές ∆ωµατίων µε πρωινό και φόρους
Ξενοδοχείο
Κατηγορία
Μονόκλινο
∆ίκλινο
CROWNE PLAZA
5* superior
160 €
160 €
ΑΚΥΡΩΣΕΙΣ
ΤΡΟΠΟΙ ΠΛΗΡΩΜΗΣ
Η πληρωµή της Συµµετοχής και της ∆ιαµονής µπορεί να γίνει µε:
• Ταχυδροµική Επιταγή σε διαταγή: ERA ΕΠΕ – Ασκληπιού 17, 106 80 Αθήνα
• Τραπεζικό έµβασµα στην ALPHA Τράπεζα, σε διαταγή: ERA ΕΠΕ, Αρ. Λογαριασµού 101.00.2002044307
• Μέσω πιστωτικής κάρτας
Για την επιβεβαίωση του Ξενοδοχείου είναι απαραίτητη η κατάθεση προκαταβολής µίας (1)
διανυκτέρευσης.
Γ Ε Ν Ι Κ Ε Σ
Το δικαίωµα συµµετοχής στο Συνέδριο δεν επιστρέφεται.
Για ακυρώσεις µέχρι τις 20/12/10 δεν υπάρχουν ακυρωτικά τέλη.
Σε περίπτωση ακύρωσης µετά τις 20/12/10 υπάρχουν 100% ακυρωτικά τέλη επί του συνόλου των
διανυκτερεύσεων.
Π Λ Η Ρ Ο Φ Ο Ρ Ι Ε Σ
ΓΡΑΜΜΑΤΕΙΑ ΣΥΝΕ∆ΡΙΟΥ & ΤΑΞΙ∆ΙΩΤΙΚΟ ΓΡΑΦΕΙΟ
ERA Ε.Π.Ε.
Ασκληπιού 17, 106 80 Αθήνα Τηλ: 210 3634944, Fax: 210 3631690
E-mail: [email protected], Web Site: http.://www.era.gr
Η Γραµµατεία θα λειτουργεί στο Συνεδριακό χώρο καθ’ όλη τη διάρκεια του Συνεδρίου.
ΙΣΤΟΣΕΛΙ∆Α ΣΥΝΕ∆ΡΙΟΥ
Πληροφορίες σχετικά µε το Συνέδριο µπορείτε να βρείτε στην επίσηµη ιστοσελίδα,
www.phlebology2011.gr
87
General Information
VENUE AND DATES
The Congress will take place in Athens January 21st & 22nd 2011, at the Crowne Plaza Hotel,
(50, Michalakopoulou Str., Tel.: +30 210 7278000, Fax: +30 210 7278600).
LANGUAGE
G E N E R A L
I N F O R M A T I O N
• English will be the official language for presentations of the 2nd Annual Meeting of the Balkan
Venous Forum sessions (Friday, January 21st).
• Greek will be the official language for presentations of the 3rd Panhellenic Congress of Phlebology sessions (Saturday, January 22nd).
SCIENTIFIC PROGRAM
The Scientific Program consists of Round Table discussions, Satellite Lectures, Workshops and Oral Presentations.
PC RECEPTION
A presentation reception desk for acceptance and checking presentations on a CD or a USB stick,
will be located near the Congress Hall. Speakers are kindly requested to provide their CDs or USB
sticks at least one hour prior to their respective presentation.
CME CREDITS
The 3rd Panhellenic Congress of Phlebology & 2nd Annual Meeting of the Balkan Venous Forum,
will be accredited by the European Accreditation Council for Continuing Medical Education (EACCME-UEMS) with 12 CME-CPD credits.
BEST PRESENTATION AWARDS
The best 2 presentations will be awarded with a special certificate, during the Congress’s Closing Ceremony.
REGISTRATION FEES
Until January 10th 2011
After January 10th 2011
Regular Doctors
150 €
170 €
Resident Doctors
90 €
110 €
Balkan Countries Participants
70 €
80 €
Non Physicians/Nurses
70 €
80 €
Students
Free
20 €
The registration fees for the participants cover: Access to the Scientific Sessions, Access to the
Exhibition, Congress material, Coffee & Lunch Breaks, Opening Ceremony & Welcome Reception
on Friday January 21st, and Certificate of Attendance.
The registration fees for the students cover: Access to the Scientific Sessions, Access to the Exhibition, Congress material, Coffee & Lunch Breaks, Certificate of Attendance.
88
ACCOMMODATION
To facilitate participants, rooms have been reserved at the Congress venue. For reservations
please contact the Congress Secretariat ERA Ltd. at the e-mail [email protected]
(Daily Hotel room rates including breakfast and taxes)
Hotel
CROWNE PLAZA
Category
Single room
Double room
5* superior
160 €
160€
CANCELLATION POLICY
PAYMENT CONDITIONS
B) By major credit cards
For reservation confirmation one night’s deposit is necessary.
ORGANIZING SECRETARIAT & TRAVEL AGENCY
ERA Ltd
17 Asklipiou Str., 106 80 Athens – Greece
Tel.: +30 210 3634944, 210 Fax: +30 210 3631690
E-mail: [email protected], Web Site: http.://www.era.gr
The Congress Secretariat desk will be located at the Mezzanine Foyer of the Crowne Plaza
Hotel, and will operate during Congress hours.
89
I N F O R M A T I O N
Payment can be effected either:
A) By bank remittance stating the “3rd Panhellenic Congress of Phlebology & 2nd Annual Meeting of the Balkan Venous Forum”, as well as the name of the participant.
To Bank of Cyprus - Athens Branch - 11, Vas. Sofias Ave. & Sekeri Str.,
GR-106 71 - Athens, Greece, to the order of ERA Ltd Account No: 1 1 7 9 0 4 0
(Swift Code: BCYPGRAA), IBAN Code: GR 6907300010000000001179040
Charges to be paid by sender.
Please enclose a copy of transfer receipt with the form.
G E N E R A L
The registration fee is non refundable.
• For written cancellation received until December 20th, 2010, no cancellation fees.
• For written cancellation received after December 20th, 2010, 100% cancellation fees apply.
Ευχαριστίες
A C K N O W L E D G E M E N T S
Η Οργανωτική Επιτροπή του 3ου Πανελλήνιου Συνεδρίου Φλεβολογίας
& 2nd Annual Meeting of the Balkan Venous Forum,
ευχαριστεί θερµά τις ακόλουθες εταιρείες για την ουσιαστική συµβολή τους
στην πραγµατοποίηση του Συνεδρίου.
Acknowledgements
The Organizing Committee of the 3rd Panhellenic Congress of Phlebology
& 2nd Annual Meeting of the Balkan Venous Forum,
gratefully acknowledges the contribution to the organization of the Congress,
of the following Companies.
BAYER HELLAS
BOEHRINGER INGELHEIM HELLAS
COLOPLAST
ELPEN
ENDOTECH MEDICAL TECHNOLOGY
•
GLAXOSMITHKLINE
Ε Υ Χ Α Ρ Ι Σ Τ Ι Ε Σ
GE MEDICAL SYSTEMS
HI-MED SOLUTIONS
LEO PHARMACEUTICALS
NOVARTIS HELLAS
PHARMA SWISS
SANOFI-AVENTIS
SERVIER HELLAS
VIANEX
VICAN – N. ANAGNOSTAKIS
PAPAPOSTOLOU
90
PNOI S.A.
BOOK PAGES
13-20-73
G.
14-21-76
Antoniou
I.
Antoniou
Ch.
13-20-72
Arapoglou
V.
17-24-85
Arvanitis
D.
12-19-70
Athanasiadis
D.
17-24-85
Azzam
M.
16-23-81
Bazigos
G.
12-19-70
Broutzos
E.
17-24-85
Dafnis
D.
17-24-84-85
Damnjanovic
Z.
14-16-21-23-74-79
Damnjanovic
Z.
14-21-75
Delic
J.
14-16-21-23-76-83
Dimakakos
E.
17-24-84-85
Dosa-Racz
E.
16-23-82
Duran
V.
14-21-75
Eros
G.
16-23-82
Fatouros
M.
12-19-69
Filis
K.
13-20-72-73
Fragkiadakis
G.
12-19-71
Fratzeskaki
S.
13-20-72
Gajic
D.
14-21-77
Gajinov
Z.
14-21-75
Georgakarakos
E.
16-23-80
Georgiadis
G,
16-23-80
Geroulakos
G.
16-23-81
Giannakakis
S.
12-19-69-70
Giannoukas
A.D.
14-16-21-23-76-83
Gionis
M.
12-13-19-20-71-72
Gomatos
E.
13-20-73
Goulas
S.
12-19-69-70
Hrisikos
D.
13-20-73
Hristophidis
T.
13-20-72
Isopoulos
T.
13-20-73
Ivkov-Smic
M.
14-21-75
12-19-69-70
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I N D E X
P.
Antoniou
A U T H O R S ’
Antonakis
•
FIRSTNAME
Σ Υ Γ Γ Ρ Α Φ Ε Ω Ν
LASTNAME
Ε Υ Ρ Ε Τ Η Ρ Ι Ο
Ευρετήριο Συγγραφέων • Authors’ Index
I N D E X
A U T H O R S ’
•
Σ Υ Γ Γ Ρ Α Φ Ε Ω Ν
Ε Υ Ρ Ε Τ Η Ρ Ι Ο
LASTNAME
FIRSTNAME
Kaimasidis
G.
Kalkandis
Ch.
17-24-84-85
Kallinis
A.
17-24-84-85
Kalodiki
E.
16-23-81
Kaperonis
E.
12-19-70
Karathanos
Ch.
14-21-76
Karathanos
C.
19-70
Karpouzis
A.
16-23-80
Kasfikis
F.
12-19-69
Katseni
K.
17-24-84-85
Katsenis
K.
17-24-84-85
Kavantzas
N.
13-20-73
Kemeny
L.
16-23-82
Kokkosis
A.
16-23-81
Kolaitis
N.
12-19-69
Koliou
P.
12-19-69
Kontoudaki
E.
Koprivica
RM
Korakas
P.
12-19-71
Kostic
R.
14-21-75
Kostov
I.
16-23-80
Kostova
N.
16-23-80
Kotsis
Th.
17-24-85
Koulouteris
E.
16-23-84
Koutsias
S.
14-21-76
Kouvelos
G.
12-19-69
Kyriakidis
K.
12-19-68
Lagoudianakis
E.
13-20-73
Lampousakis
E.
13-20-72
Lattimer
C,
16-23-81
Lazarides
M.
16-23-80
Lazaris
A.
17-24-85
Leandros
E.
13-20-72
Lilis
K.
13-20-72
Linardoutsos
D.
13-20-72-73
Loizos
A.
17-24-84-85
Lolic
S.
14-21-77
Loupou
A.
12-19-70
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BOOK PAGES
13-20-72
13-20-72
14-21-77-78
BOOK PAGES
Lucic
NP
14-21-77-78
Makris
G.
16-23-81
Maltezos
Ch.
Manimanaki
A.
13-20-72
Mantakas
E.
13-20-72
Matic
M.
14-21-75
Matic
A.
14-21-75
Matsagkas
M.
12-19-69
Melas
M.
12-19-70
Merkouri
E.
13-20-72
Milic
D.
14-16-21-23-74-79
Mitsikas
D.
12-13-19-20-71-72
Mitsis
M.
12-19-69
Mladenovic
D.
16-23-80
Moustardas
M.
12-13-19-20-71-72
Nakos
Ch.
16-23-83
Nicolic-Pucar
J.
14-21-77
Nikitovic
B.
14-21-77
Oikonomou
K.
12-19-71
Papacharalambous G.
12-19-69-70
12-19-69-70
12-19-71
Ch.
16-23-83
Papas
S.
16-23-84
Papavasiliou
V.
12-19-70
Pejic
MA
Philippakis
G.
12-13-19-20-71-72
Poulios
G.
13-20-72
Psyllas
A.
12-19-70
Pyrgakis
K.
12-19-69
Rajic
N.
14-21-75
Rondovic
D.
14-21-75
Ros
T.
14-21-75
Roussaki-Schulze A-V.
14-21-77-78
A U T H O R S ’
L.
Papadopoulou
•
Papadopoulos
Σ Υ Γ Γ Ρ Α Φ Ε Ω Ν
FIRSTNAME
Ε Υ Ρ Ε Τ Η Ρ Ι Ο
LASTNAME
16-23-83
N.
14-16-21-23-76-83
Saleptsis
V.
14-21-76
Salta
R.
16-23-83
Samiotakis
E.
12-19-71
Schanzer
H.
16-23-81
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I N D E X
Roussas
I N D E X
A U T H O R S ’
•
Σ Υ Γ Γ Ρ Α Φ Ε Ω Ν
Ε Υ Ρ Ε Τ Η Ρ Ι Ο
LASTNAME
FIRSTNAME
BOOK PAGES
Sfyroeras
G.
14-21-76
Shawish
E.
16-23-81
Sigala
F.
13-20-72-73
Siskos
D.
12-19-69
Spyrantis
M.
12-13-19-20-71-72
Stankovic
JS
14-15-21-77-78
Stefanovic
R.
14-16-21-23-74-79
Stojiljkovic
V.
14-16-21-23-74-79
Szabad
G.
16-23-82
Szentner
K.
16-23-82
Szolnoky
G.
16-23-82
Terzoudi
S.
16-23-80
Theodoropoulos
G.
13-20-72
Tiligada
E.
12-19-68
Travlou
A.
13-20-72
Tsamis
D.
13-20-72
Tsantrizos
P.
13-20-72
Tsiminikakis
N.
13-20-72
Tsioli
S.
16-23-83
Tsiouri
I.
16-23-83
Uzunova
T.
16-23-80
Vartholomatos
G.
12-19-69
Vasdekis
S.
17-24-85
Vasilopoulos
I.
17-24-84-85
Voulalas
G.
12-19-70
Xanthopoulos
D.
12-19-70
Yiannakopoulou E.
12-19-68
Zampeli
E.
12-19-68
Zarifis
G.
12-19-71
Zervides
C.
14-16-21-23-74-79
Zivanic
D.
14-21-77
Zivic
S.
14-16-21-23-74-79
Zivkovic
V.
14-16-21-23-74-79
Zografos
G.
13-20-72-73
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Σηµειώσεις • Notes
Σ Η Μ Ε Ι Ω Σ Ε Ι Σ
•
N O T E S
95
96
Σ Η Μ Ε Ι Ω Σ Ε Ι Σ
•
N O T E S
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