Clinical manifestations of chronic superficial venous insufficiency are described, followed by recommendations for diagnostic evaluation and various treatment possibilities.
Clinical manifestations of chronic superficial venous insufficiency are described, followed by recommendations for diagnostic evaluation and various treatment possibilities.
Clinical manifestations of chronic superficial venous insufficiency are described, followed by recommendations for diagnostic evaluation and various treatment possibilities.
Background. Minimally invasive treatment of varicose veins is becoming more and more important as it represents less burden to the patient and health system. The success of the different methods ...depends on their capability to eliminate the reflux at the sapheno-femoral junction (SFJ) and the incompetent greater saphenous vein (GSV). In achieving these only three methods are successful: ultrasound (US) guided catheter sclerosation, radiofrequency or laser endovenous obliteration of GSV.Aims. To demonstrate a novel way to use a laser energy through an endoluminal laser fiber for the minimally invasive treatment of truncal varicosities and the elimination of SFJ reflux.Methods. The patients with US detected reflux in the SFJ and GSV were treated on the outpatient basis under local anaesthesia with laser mediated heat energy in the GSV 2–3 cm from SFJ with the laser of wave length of 980 nm with the power 15 W and the impulse duration of 1 sek. We used 20–40 impulses along the treated segment of GSV. The exact position of the laser fiber was determined by the US. The smaller branch varices were removed by mini phlebectomies. Patients tolerated well the procedure and they were dismissed from the hospital with applied compression stockings (CCL II) immediately after the completion of the procedure. The control US was done one week, four weeks and three months later. At one week one out of 16 patients presented with no occlusion of the GSV. At four weeks another patient had recanalisation of GSV but without the reflux. All other patients had the short GSV stump in which the patent epigastric vein was draining while the remaning part of the GSV was obliterated by the thrombus. Except for some skin ecchymosis and mild induration in the but patients did not have any other problems. The unsuccessful treatment in two patients is probably due to insufficient applied energy.Conclusions. Endovenous laser obliteration of GSV is an effective method that can be performed on the outpatient basis under local anaesthesia. Patients tolerate well the intervention. The preliminary results promise that the method, after additional experiences, could become in some patients an adequate alternative to classical surgical treatment of the varicosities of GSV, which remains the »the gold standard«.
Background. Endarterectomy of the internal carotid artery, supported by medicamental treatment, is the best method used to prevent stroke with symptomatic patients with an over 70-percent narrowing ...of the ipsilateral carotid artery. With patients who have successfully passed the operation the occurrence of the stroke is less often than with non-operated patients (1% vs. 6–10% per year). Therefore, it is important that the operation is carried out as safely as possible. Currently, the average acceptable rate of death and/ or severe stroke risk stands at between 2–4%. Greatest problems faced during carotid artery surgery are embolism of the affected artery during preparation, brain ischaemia during the blockade of the carotid artery, and embolism and intimal tearing due to injury of the internal carotid artery by the temporary internal shunt. Due to the risk of causing an embolism and intimal tearing, the use of the internal shunt can be dangerous. Therefore, selective usage of the shunt is recommended when necessary due to brain ischaemia.Methods. Under block/conduction anaesthesia (deep and superficial cervical block) we have performed surgery on 23 patients (16 males, 7 females) because of severe stenosis of the internal carotid artery (over 70%). A mixture of Xylocain 1% and Marcain 1.5% was used for the cervical block. Cerebral blood circulation was monitored by neurological testing of the patient awake during the procedure. During the procedure, we performed standard monitoring of the vital functions including the blood pressure. Additionally, the transcranial Doppler monitoring of the blood flow through the middle cerebral artery was used with 20 of the patients.Results. Even after placing the artery clamp and cutting off the blood flow through the internal carotid artery no neurological deficits were observed with 18 patients, neither did we use temporary internal shunt with them. Five patients suffered problems with loss of consciousness, therefore we used the internal shunt. With all but one patient we performed a typical longitudinal endarterectomy and used the Dacron patch to close the carotid artery. Those patients underwent operation and post-operation treatment without complications and were dismissed from hospital five to seven days after the operation. Meanwhile, one patient’s condition worsened severely during preparation of the carotid artery even before the placement of the artery clamp, which resulted in paralysis on the contralateral side and loss of consciousness. The operation was suspended, the patient was treated conservatively.Conclusions. The patients handled the procedure under block/ conduction anaesthesia well. Neurological testing of the patient awake during the procedure was a reliable method to ascertain cerebral blood circulation. Temporary internal shunt was used with patients who suffered a neurological deficit during the blockade of the carotid artery. As a result, the neurological deficit improved.
Povzetek Izhodisca. Endarterektomija notranje arterije karotis v kombinaciji z medikamentnim zdravljenjem je najboljsa metoda za preprecevanje mozganske kapi pri simptomatskih bolnikih z vec kot ...70-odstotno zozitvijo istostranske karotide. Pri uspesno operiranih bolnikih je pogostnost mozganske kapi manjsa v primerjavi z neoperiranimi (1% proti 6-10% na leto). Zato je pomembno, da je operacija cim bolj varna. Sedaj je povprecna in sprejemljiva nevarnost za smrt in/ali hujso mozgansko kap 2-4%. Najvecji problemi med operacijo na karotidah so: embolizacija iz obolele arterije med preparacijo, ishemija mozganov med zaporo karotide in embolizacija ter intimalno zatrganje zaradi poskodbe notranje karotide z zacasnim notranjim obtokom (shunt). Uporaba notranjega obtoka je zaradi moznosti povzrocitev embolizacije in intimalnega zatrganja nevarna. Zato predlagajo selektivno uporabo obtoka, ko je to potrebno zaradi ishemije mozganov. Metode. V prevodni anesteziji (globoki in povrhnji cervikalni blok) smo operirali 23 bolnikov (16 moskih in 7 zensk) zaradi hude stenoze (> 70%) notranje karotide. Za cervikalni blok smo uporabili mesanico 1-odstotnega Xylocaina in 0,5-odstotnega Marcaina. Stanje prekrvljenosti mozganov smo ugotavljali z nevroloskim testiranjem budnega bolnika med posegom. Med posegom smo uporabili standardni nadzor vitalnih funkcij, vkljucno s krvavim nadzorom krvnega tlaka. Pri 20 bolnikih smo hkrati tudi uporabili transkranialni doplerski nadzor pretoka skozi srednjo mozgansko arterijo. Rezultati. Pri 18 bolnikih tudi po namestitvi zilne stiskalke in prekinitvi pretoka skozi notranjo karotido nismo opazili nevroloske izgube. Pri njih nismo uporabili zacasnega notranjega obtoka. Pri petih bolnikih je prislo do motenj zavesti, zato smo uporabili notranji obtok. Pri vseh bolnikih razen pri enem smo napravili znacilno vzdolzno endarterektomijo in arterijo karotis zasili z uporabo Dacronske krpice. Ti bolniki so operacijo in pooperativni potek prestali brez zapletov in so bili odpusceni peti do sedmi dan po operaciji. Pri enem bolniku je med prepariranjem karotide, se preden smo namestili zilno stiskalko, prislo do nenadnega poslabsanja s paralizo po kontralateralni strani in motnjo zavesti. Operacijo smo prekinili in bolnika zdravili konzervativno. Zakljucki. Bolniki so poseg v prevodni anesteziji dobro prenasali. Nevrolosko testiranje budnega bolnika med posegom je bila zanesljiva metoda za ugotavljanje prekrvljenosti mozganov. Pri bolnikih, pri katerih je med zaporo karotide prislo do nevroloskih izpadov, smo uporabili zacasni notranji obtok (shunt) in nevroloski izpad se je popravil.
Povzetek Izhodisca. Minimalno invazivno zdravljenje krcnih zil pridobiva na pomenu zaradi manjse obremenitve za bolnika in zdravstveni sistem. Uspesnost razlicnih metod je odvisna od zmoznosti ...metode, da odpravi obratni tok v podrocju safeno-femoralnega ustja (SFU) in odstrani iz obtoka oboleli del velike vene safene (VSM). Pri tem so uspesne le tri metode: ultrazvocno (UZ) vodena kateterska sklerozacija, radiofrekvencna ali laserska endovenska obliteracija VSM. Cilj. Prikazati nov nacin uporabe laserske energije preko endovenoznega laserskega vlakna za minimalno invazivno zdravljenje debelnih varic in odstranitve obratnega toka v SFU. Metode. Bolnike z UZ ugotovljenim obratnim tokom krvi v SFU in VSM smo zdravili ambulantno v lokalni anesteziji z dovajanjem toplotne energije v VSM 2-3 cm pod SFU s pomocjo laserja valovne dolzine 980 nm in jakosti 15 W in trajanjem impulza 1 sek. Uporabili smo 20-40 impulzov vzdolz zdravljenega dela VSM. Natancno namestitev vlakna smo dolocili z UZ. Pri vseh smo opravili se mini flebektomijo manjsih varic. Bolniki so poseg dobro prenasali in so neposredno po posegu z namesceno kompresijsko nogavico (Ccl II) zapustili bolnisnico. Kontrolni UZ smo opravili teden dni, stiri tedne in tri mesece po posegu. Pri enem od 16 bolnikov smo ze ob prvi kontroli ugotovili, da nismo dosegli trombotske zapore VSM. Po stirih tednih se je ponovno vzpostavil pretok v VSM, vendar brez obratnega toka se pri enem bolniku. Vsi ostali bolniki so imeli ob kontrolah kratek krn VSM, v katerega se je izlivala kri iz epigastricne vene, preostanek VSM je imel trombotsko zaporo. Bolniki po posegu razen nekaj podkoznih izlivov krvi in manjsega obcutka bolece zatrdline na stegnu drugih tezav niso imeli. Neuspeh pri dveh bolnikih pripisujemo prenizki uporabljeni energiji. Zakljucki. Endovenska laserska obliteracija VSM je uspesna metoda, ki jo lahko izvajamo ambulantno in v lokalni anesteziji. Bolniki poseg dobro prenasajo. Predhodni rezultati obetajo, da bo metoda, ko bomo pridobili se dodatne izkusnje, lahko pri nekaterih bolnikih uspesno nadomestila klasicno operativno zdravljenje krcnih zil VSM, ki ostaja »zlati standard«.
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