TRATTAMENTO ENDOVASCOLARE DELL’IVC DAL DOGMA ALL’INNOVAZIONE G.B. AGUS Direttore dell’Istituto di Chirurgia Vascolare Università di Milano Chirurgo Vascolare Ospedaliero 1970-1988

PATTERNS EMODINAMICI DELLA MALATTIA VARICOSA • Trattare la crosse della VGS non è sempre necessario. • La giunzione safeno-femorale risulta competente in circa il 30-55% dei casi e non sono presenti alterazioni proprie del territorio safenico interno nel 15-20% [Goren G and Yellin AE, 1990; Camilli S, 1992; Abu.Own A, 1994; Guex JJ et Al, 1995; Myers KA, 1995; Singh S et Al, 1997; Jutley RS et Al, 2001; Cappelli M et Al, 2004]

Gradiente IPERPRESSIVO COMPRESSIONE RILASCIAMENTO TEST DINAMICI MOBILIZZAZIONE DI SANGUE > NELLA RETE SUPERFICIALE NELLA RETE PROFONDA Gradiente IPERPRESSIVO VALSALVA

“OLD” STRIPPING TECHNIQUE New techniques eliminate the psychologic barrier to treatment caused by the term “stripping” and allow the objectives of surgery to be achieved with minimal invasion and quick recovery. [Bergan J.J., 2002]

REVIEW. NERVE INJURIES AND VARICOSE VEIN SURGERY Incidence of saphenous nerve injury : partial vs complete LSV stripping 7% vs 39% [Sam RC, Silverman SH , Bradbury AW Eur J Vasc Endovasc Surg 2004; 27: 113-20]

STRIPPING IN 2000 Stripping of the greater saphenous vein to the below-knee level has proven to be a more successful method of treating greater saphenous vein reflux and has been shown to reduce the risk of reoperation for recurrent varicosities. [Neglen P et Al., 1993; Rutgers PH et Al. 1994; Sarin S et Al., 1994; Bergan JJ, 1996; Dwerryhouse S et Al., 1999; Winterborn RJ et Al, 2004]

Saphenofemoral ligation with ligation and division of the tributaries [Moore and Thelwall Thomas, 1896; Homans,1916] What is neovascularization and why is it prevalent after high ligation ? [Bergan J.J., 2005]

Today it appears that avoidance of a groin incision prevents neovascularizations in varicose vein surgery [Bergan JJ, 2005]

[Dichiarazione di Helsinki, 2000, Sez. C, Clausola 29] INNOVAZIONE “I benefici, i rischi, i costi e l’efficacia di ogni nuovo metodo devono essere confrontati con quelli del miglior trattamento profilattico, diagnostico e terapeutico disponibile al momento” [Dichiarazione di Helsinki, 2000, Sez. C, Clausola 29]

E.V.L.T. – Endo Venous Laser Treatment I vantaggi: obliterazione della vena safena interna per effetto termico (90°) indotto dal thermal injury panmurale dato dall’interazione tra luce polarizzata e cromoforo (acqua, emoglobina), non a contatto della parete Mini-invasività, eseguibile in anestesia locale e in day surgery. Pronto recupero funzionale Metodica eseguibile anche in presenza di tortuosità safeniche Nessun limite di utilizzo in relazione al calibro del vaso Costi dei materiali accettabili in relazione ai DRG ottenibili

A LITERATURE ANALYSIS AT MARCH 1st 2004 Lower limb varicose veins endoluminal treatment by endovenous laser and radiofrequency. • 50 articles published in English (36) and French language (14), to compare the two procedures between them and with the classical surgery. • The endovenous surgery methods were proven to be less aggressive and effective at mid-term. [ Perrin M., Phlebologie 2004; 57,N. 2: 125-33]

UNIQUE PROCEDURE PROTOCOL OF PRACTICE While EVLT-ELVeS, which is FDA approved, uses only one type of device manufactured and is distributed by a single company, there are also other techniques using different types of Laser equipment and devices with multiple variants but without the benefit of a single well-defined protocol for their use.

I.E.W.G. The Italian Endovenous-Laser Working Group (IEWG) is a homogeneous group of surgeons and phlebologists who use the same kit-device for these reasons.

L’ IEWG METTE IN GUARDIA DALL’ ESTRO ITALIANO Generatore Laser in regalo Indicazioni cliniche personali La babele delle procedure Erogazione a luci rosse Kamasutra energetico per J – W – T Il dogma della crossectomia associata

Clinical data Follow up MI SI AR PD-VR PD Procedures Months Vein occlusion 38 20 100% 47 12 98% 484 48 76 17 63 14 S P V M A months

Clinical data Complications 38%

Results Patient compliance 85% 13%

CLINICAL REMARKS Present evidence suggests that less saphenous veins should be treated. With proper indications to the treatment of saphenous reflux minimally invasive techniques should be used. Results 3-5 years of endovenous laser indicate a very effective and safe treatment of GSV. Endovenous laser is a cost-benefit procedure.

METHODOLOGICAL REMARKS • It remains to be established whether the treatment without SFJ ligation is a risk for recurrence. As technology for the treatment of varicose veins expands, we must remain vigilant. Critical scientific outcomes assessment before widespread application of new techniques is essential.