АССОЦИАЦИЯ ФЛЕБОЛОГОВ РОССИИ

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Вот еще подобная публикация
Endovenous laser treatment combined with a surgical strategy for treatment of venous insufficiency in lower extremity: a report of 208 cases.
Huang Y, Jiang M, Li W, Lu X, Huang X, Lu M.
Source
Department of Vascular Surgery, Ninth People's Hospital, affiliated to Shanghai Second Medical University, China. yvhuang772@yahoo.com
Abstract
BACKGROUND:
We assessed the safety and efficacy of endovenous laser treatment (EVLT) of the saphenous vein combined with a surgical strategy for treatment of deep venous insufficiency in the lower extremity.
METHODS:
Two hundred thirty venous insufficiencies of the lower limbs in 208 consecutive patients (93 men and 115 women; mean age, 54.15 years) were treated with EVLT combined with surgical strategies. All patients were symptomatic. There were 84 limbs (36.5%) in C(2), 25 (10.9%) in C(3), 109 (47.7%) in C(4), 1 (0.4%) in C(5), and 9 (3.9%) in C(6) (CEAP), and Klippel-Trenaunay syndrome was present in 2 limbs. A total of 119 (51.7%) had perforator vein incompetence. Four therapeutic methods were included in this series according to symptoms, CEAP classification, and venous reflux. Simple EVLT was performed for 15 patients with only great saphenous vein (GSV) incompetence or Klippel-Trenaunay syndrome in 19 lower limbs. EVLT combined with high ligation of the GSV and open ligation of perforators was performed for 5 patients with GSV and perforator incompetence in 5 lower limbs. EVLT was combined with high ligation of the GSV for 76 patients with GSV incompetence in 94 lower limbs. EVLT was combined with external banding of the first femoral venous valve and high ligation of the GSV for 112 patients with primary deep venous insufficiency in 112 lower limbs. All patients were followed up on an outpatient basis for physical examinations and postoperative complaints, and duplex ultrasonography was performed 2 weeks, 6 months, and 1 year after operation.
RESULTS:
All patients tolerated the procedure well and returned to normal daily activities immediately, achieving a 100% immediate clinical success rate. Spot skin burn injuries occurred in 2 patients (1.0%). Paresthesia in the gaiter area was noted in 15 patients (7.2%). No postprocedural symptomatic deep venous thrombosis or pulmonary embolism occurred. Three patients had local recurrent varicose veins in the calf (1.4%) during a 2- to 27-month follow-up (mean, 6.12 months). Postoperative clinical classes were significantly improved between 2 weeks and 24 months (P = .0001 at 2 weeks and 3 to 18 months; P = .0055 at 24 months compared with before operation), especially in preoperative C(2) to C(3) stage patients, who achieved complete amelioration.
CONCLUSIONS:
EVLT is a novel minimally invasive treatment with advantages of safety, effectiveness, and simplicity, and it leaves no scars. Its indications can be expanded by combining EVLT with surgical strategies.
J Vasc Surg. 2005 Sep;42(3):494-501; discussion 501
PMID:
16171594
[PubMed - indexed for MEDLINE]

Arteriovenous fistula after endovenous laser treatment of the short saphenous vein.
Timperman PE.
Source
Arnett Clinic, 2600 Greenbush Avenue, Lafayette, Indiana 47904, USA. paultimperman@verizon.net
Abstract
Reports of major complications from endovenous laser treatment of saphenous veins with use of perivenous tumescent anesthesia are very rare. The author reports a major complication of endovenous laser treatment, the creation of an arteriovenous (AV) fistula. The fistula was created between the short saphenous vein (SSV) and the superficial sural artery in the popliteal fossa during endovenous laser treatment of the SSV. The proximity of the superficial sural artery and the SSV in the popliteal fossa increases the risk of fistula formation. Color-flow Doppler ultrasonography can demonstrate potentially dangerous anatomic relationships between the vein segment intended for treatment and adjacent arteries. Recognition of these relationships should increase the operator's ability to minimize the risk of AV fistula formation.
J Vasc Interv Radiol. 2004 Jun;15(6):625-7.

PMID:15178724 [PubMed - indexed for MEDLINE]


Eur J Vasc Endovasc Surg. 2009 Aug;38(2):234-6. Epub 2009 Jun 12.
Arterio-venous fistula following endovenous laser ablation for varicose veins.
Theivacumar NS, Gough MJ.
Source
Leeds Vascular Institute, The General Infirmary at Leeds, Leeds LS1 3EX, UK.
Abstract
Endovenous laser ablation (EVLA) obliterates incompetent truncal veins as an alternative to varicose veins surgery. We describe 3 patients who developed an arterio-venous fistula (AVF) following great (GSV: 1) or small (SSV: 2) saphenous vein EVLA. Two fistulae closed spontaneously with conservative management. Concomitant venous and arterial wall thermal injury or needle trauma during administration of tumescent anaesthesia may cause this rare complication. Haemodynamic effects appear minimal and spontaneous closure is likely, supporting a non-interventional policy.
PMID:
19524461
[PubMed - indexed for MEDLINE]
Ann Vasc Surg. 2009 May-Jun;23(3):412.e15-7. Epub 2008 Oct 29.
Iatrogenic arteriovenous fistula following endovenous laser therapy of the short saphenous vein.
Vaz C, Matos A, Oliveira J, Nogueira C, Almeida R, Mendonça M.
Source
Vascular Surgery Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal. carolina_vaz@aeiou.pt
Abstract
Short saphenous vein incompetence is present in up to 20% of patients with varicose veins. Studies looking at the success and complication rates associated with endovenous laser ablation of the short saphenous vein included only a small number of patients. The authors report the case of a 51-year-old woman presenting with a painful right leg edema. She had a history of previous endovenous laser ablation of the right and left great saphenous veins and right short saphenous vein. Duplex scan was performed and showed an arteriovenous fistula between branches of the popliteal artery and vein. Surgical ligation of the fistula was performed. At 8-month follow-up, the patient remains asymptomatic.
PMID:
18973984
[PubMed - indexed for MEDLINE]
J Vasc Surg. 2010 Mar;51(3):715-9. Epub 2010 Jan 25.
A case of external iliac arteriovenous fistula and high-output cardiac failure after endovenous laser treatment of great saphenous vein.
Ziporin SJ, Ifune CK, MacConmara MP, Geraghty PJ, Choi ET.
Source
Department of Surgery, Washington University School of Medicine, St Louis, MO 63110, USA.
Abstract
Valvular incompetence in the great saphenous vein (GSV) is the most common cause of superficial venous insufficiency and symptomatic varicose vein development. Recently, less invasive modalities such as foam sclerotherapy, radiofrequency ablation (RFA), and endovenous laser treatment (EVLT) have gained popularity in the treatment of saphenofemoral junction and saphenous truncal incompetence over the traditional approach of surgical ligation and stripping. Here, we present the case of a 32-year-old woman who underwent EVLT and was diagnosed subsequently with ipsilateral external iliac arteriovenous (AV) fistula and high-output cardiac failure. She was stabilized medically and treated surgically with a covered stent placed in the external iliac artery with complete resolution of the fistula and cardiac failure. We reviewed the literature and discuss the complications of AV fistulae after EVLT.
PMID:
20100645
[PubMed - indexed for MEDLINE]
Cardiovasc Intervent Radiol. 2009 Jan;32(1):166-8. Epub 2008 May 28.
Treatment of an unusual complication of endovenous laser therapy: multiple small arteriovenous fistulas causing complete recanalization.
Yildirim E, Saba T, Ozulku M, Harman A, Aytekin C, Boyvat F.
Source
Department of Radiology, Baskent University Medical School, Selcuklu, Konya, Turkey. drerkany@yahoo.com
Abstract
A 67-year-old woman was admitted to our institution with pain, night cramping, and visible varicose veins on her left leg. Doppler ultrasonography revealed continuous reflux in the great saphenous vein when the patient did the Valsalva maneuver. Endovenous laser therapy was applied to the great saphenous vein. Doppler ultrasonography 7 days later showed recanalization of, and arterialized flow in, the great saphenous vein. There also were small arterial vessels adjunct to the recanalized side. A left femoral angiography via a right femoral approach showed multiple small arteriovenous fistulas between superficial femoral artery muscle branches and the great saphenous vein. A second endovenous laser treatment was done at 80 J/cm, but the recanalization persisted. We offered to treat this endovascularly, but the patient preferred a surgical option. To the best of our knowledge, this is the first report of the demonstration of such a complication with endovenous laser therapy.
Comment in
• Cardiovasc Intervent Radiol. 2010 Feb;33(1):227-8.
PMID:
18506521
[PubMed - indexed for MEDLINE]

Volume 23, Issue 3, Pages 412.e15-412.e17 (May 2009)




Iatrogenic Arteriovenous Fistula Following Endovenous Laser Therapy of the Short Saphenous Vein
Carolina Vaz , Arlindo Matos, João Oliveira, Clara Nogueira, Rui Almeida, Mergulhão Mendonça
published online 29 October 2008.
Short saphenous vein incompetence is present in up to 20% of patients with varicose veins. Studies looking at the success and complication rates associated with endovenous laser ablation of the short saphenous vein included only a small number of patients. The authors report the case of a 51-year-old woman presenting with a painful right leg edema. She had a history of previous endovenous laser ablation of the right and left great saphenous veins and right short saphenous vein. Duplex scan was performed and showed an arteriovenous fistula between branches of the popliteal artery and vein. Surgical ligation of the fistula was performed. At 8-month follow-up, the patient remains asymptomatic.
Vascular Surgery Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal
Correspondence to Dr. Carolina S. Vaz, Centro Hospitalar do Porto, Cirurgia Vascular, Largo Professor Abel Salazar, Oporto, Portugal
PII: S0890-5096(08)00311-7
doi:10.1016/j.avsg.2008.08.010

Пара обзоров из Канады (Онтарио)

http://www.health.gov.on.ca/english/pro ... 100422.pdf
http://www.health.gov.on.ca/english/pro ... 100921.pdf

Чего говорят-то, Алексей? Читать то стоит?

Женя, в статьях обзор РКИ по эффективности ЭВЛК, РЧО, стриппинга.
Обобщенно в таблицах

После вот этого метаанализа http://forums.rusmedserv.com/showthread.php?t=115115 я к обзорам отношусь очень осторожно. Нужно все перепроверять по включенным РКИ.

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И еще по этому же поводу:
High ligation combined with stripping and endovenous laser ablation of the great saphenous vein: early results of a randomized controlled study.
[b]Kalteis M, Berger I, Messie-Werndl S, Pistrich R, Schimetta W, Pölz W, Hieller F.Source
Department of Surgery, St Franziskus Hospital, Grieskirchen, Austria. manfred.kalteis@aon.at
Abstract
OBJECTIVE:
This study compared postoperative patient comfort and the surgical outcome of endovenous laser ablation (EVLA) or stripping of the great saphenous vein, both performed in conjunction with high ligation.
METHODS:
The study randomized 100 patients with primary trunk varicosities of the great saphenous vein (CEAP clinical class II to IV) to EVLA or stripping. The success of surgery was followed-up by duplex ultrasound imaging at 1, 4, and 16 weeks. Primary end points were the size of the hematoma 1 week after the operation and the preoperative disease-specific Chronic Venous Insufficiency Questionnaire (CIVIQ) quality of life score compared with 4 weeks postoperatively. Secondary end points were postoperative symptoms (pain, use of analgesics, paresthesia at the ankle, residual hematoma), complications, time taken to resume work, the patient's satisfaction with the cosmetic outcome, and the CIVIQ quality of life score at 16 weeks.
RESULTS:
The groups were well matched at baseline. In all, 95 patients could be followed up in accordance with the protocol. The treatment was successful in all patients. Endovenous laser ablation was associated with an occlusion rate of 100%. Hematomas were significantly smaller after EVLA (median [quartiles]) at 125 (55-180) cm(2) vs stripping 200 (123-269) cm(2) (P = .001). No difference was registered between groups for the CIVIQ quality of life score, with EVLA at -1.25 (-7.5-11.25) vs stripping at 4.38 (-5.94-14.38; P = .34). Several postoperative symptoms favored EVLA, but the only significant differences were seen in the minor side effects of surgery at 1 and 4 weeks and discomfort due to paresthesia at the ankle in the first postoperative week. EVLA was associated with a longer period of time until return to work (median [quartiles]) of 20 (14-25.5) days vs 14 (12.8-25) days (P = .054).
CONCLUSION:
Endovenous laser ablation combined with high ligation is safe and effective. Postoperative hematomas are significantly smaller than those after stripping. Short-term quality of life is at least as good as that after stripping. The long-term results warrant further investigation.
PMID:
18295441
[PubMed - indexed for MEDLINE]
J Vasc Surg. 2008 Apr;47(4):822-9; discussion 829. Epub 2008 Mar 4.

J Vasc Surg. 2007 Aug;46(2):308-15. Epub 2007 Jun 27.
Randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patients with varicose veins: short-term results.
Rasmussen LH, Bjoern L, Lawaetz M, Blemings A, Lawaetz B, Eklof B.Source
Danish Vein Centre, Naestved, Denmark. larshrasmussen@yahoo.com
Abstract
BACKGROUND:
Endovenous laser (EVL) ablation of the great saphenous vein (GSV) is thought to minimize postoperative morbidity and reduce work loss compared with high ligation and stripping (HL/S). However, the procedures have not previously been compared in a randomized trial with parallel groups where both treatments were performed in tumescent anesthesia on an out-patient basis.
METHODS:
Patients with varicose veins due to GSV insufficiency were randomized to either EVL (980 nm) or HL/S in tumescent anesthesia. Miniphlebectomies were also performed. Patients were examined preoperatively and at 12 days, and 1, 3, and 6 months postoperatively. Sick leave, time to normal physical activity, pain score, use of analgesics, Aberdeen score, Medical Outcomes Study Short Form-36 quality-of-life score, Venous Clinical Severity Score (VCSS), and complication rates were investigated. The total cost of the procedures, including lost wages and equipment, was calculated. Cost calculations were based on the standard fee for HL/S with the addition of laser equipment and the standard salary and productivity level in Denmark.
RESULTS:
A follow-up of 6 months was achieved in 121 patients (137 legs). The groups were well matched for patient and GSV characteristics. Two HL/S procedures failed, and three GSVs recanalized in the EVL group. The groups experienced similar improvement in quality-of-life scores and VCSS score at 3 months. Only one patient in the HL/S group had a major complication, a wound infection that was treated successfully with antibiotics. The HL/S and EVL groups did not differ in mean time to resume normal physical activity (7.7 vs 6.9 calendar days) and work (7.6 vs 7.0 calendar days). Postoperative pain and bruising was higher in the HL/S group, but no difference in the use of analgesics was recorded. The total cost of the procedures, including lost wages, was euro 3084 ($3948 US) in the HL/S and euro 3396 ($4347 US) in the EVL group.
CONCLUSIONS:
This study suggests that the short-term efficacy and safety of EVL and HL/S are similar. Except for slightly increased postoperative pain and bruising in the HL/S group, no differences were found between the two treatment modalities. The treatments were equally safe and efficient in eliminating GSV reflux, alleviating symptoms and signs of GSV varicosities, and improving quality of life. Long-term outcomes, particularly with respect to recurrence rates, shall be investigated in future studies, including the continuation of the present.
Republished in
• Ugeskr Laeger. 2007 Dec 17;169(51):4442-4.
PMID:
17600655
[PubMed - indexed for MEDLINE] [/b]

Хочу поделиться своими впечатлениями от приведенных Виктором абстрактов.

1. Китайские коллеги.

Посмотрите на количество пациентов и разнообразие проведенных вмешательств. Конечные точки вообще не обозначены, и чем измерялась эффективность вмешательств - непонятно. Как можно называть ЭВЛО малоинвазивным вмешательством, если делается кроссэктомия, экстравазальная коррекция клапана бедренной вены и лигирование перфорант? В общем, куча мала, ноль информации и по безопасности, и по эффективности чего бы то ни было.

2. Австрийские специалисты.

Пример хорошо проведенного исследования и вполне реальные и достижимые цели - сравнить ранний послеоперационный период. Ведь отличия в нем - одни из ключевых в классическом хирургическом лечении и эндовазальном. Но! Каков режим лазера? По абстракту судить об этом невозможно. Наверняка эта информация есть в полном тексте и это исследование заслуживает внимания. Сроки восстановления работоспособности несколько неожиданны, что заставляет еще раз подумать о целесообразности комбинации ЭВЛО и кроссэктомии.

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По данным нашего материала сроки восстановления работоспособности у больных с ЭВЛО и кроссэктомии + ЭВЛО не отличаются ни на день. Исключение представляют больные из обеих групп,которым по их желанию была произведена общая анестезия / это были наши коллеги женщины, их дочки и несколько очень молодых девушек-причины ясны/
Я привел эти абстракты не для того, чтобы искать в них какие-то неточности и недостатки.
Производит впечатление совсем другое. Ряд специалистов выполняют определенно не столь популярное сочетание кроссэктомии с ЭВЛО и никто не возражает. Нет публикаций, в которых напрямую указывается нецелесообразность подобного сочетания. По-моему все они прочли крылатую фразу Линтона, которую цитировал и я :"Каждый должен идти своей дорогой".

Удивлен высоким процентом клинического рецидива после операции через год

Интересный абстракт от польских коллег по длинам волн для ЭВЛК. Жаль нет англоязычной статьи

Абстракт не очень свежий, но показалось интересным влияние температуры тумесцентного раствора на течение послеоперационного периода.

Vasa. 2010 Aug;39(3):249-55.
1470 nm diode laser for endovenous ablation (EVLA) of incompetent saphenous veins - a prospective randomized pilot study comparing warm and cold tumescence anaesthesia.
Pannier F, Rabe E, Maurins U.
Source

Department of Dermatology, MUMC+ Maastricht, Maastricht, the Netherlands. felizitas.pannier@googlemail.com
Abstract
BACKGROUND:

Major side effects after endovenous laser ablation (EVLA) are pain and bruising. Low temperature of the tumescence fluid might cause additional venous constriction and a cooling effect around the vein. The aim of this study was to show outcome and side effects after EVLA of incompetent great saphenous veins (GSV) with a 1470 nm Diode laser (Ceralas E, biolitec) using cold or warm tumescence fluid for anaesthesia.
PATIENTS AND METHODS:

Between August and November 2007, 85 consecutive patients (85 legs) with an incompetent GSV were treated by EVLA. The patients were randomized in two groups. In 42 patients (Group A) a warm (37 degrees C) and in 43 patients (Group B) a cold (5 degrees C) tumescence fluid (TF) was used for local anaesthesia in the track of GSV. All patients were re-examined after 1, 10 and 30 days clinically and by duplex for complications and occlusion in the treated vein segment. Patient's satisfaction was assessed on a 0 to 4 points scale.
RESULTS:

In each group one patient was lost to follow-up. There was no significant difference concerning gender, age, C of CEAP, BMI or diameter of the treated vein. In Group A a mean of 462 ml TF and in Group B a mean of 428 ml TF were used. In Group A the mean LEED (average linear endovenous energy density) was 114 J / cm and in Group B 115 J / cm. In both groups occlusion of the treated veins was achieved for all patients. The diameter of the GSV at 3 cm below the sapheno-femoral junction shrunk from 1.0 to 0.7 cm in both groups. The modified CEAP clinical score improved in Group A from 2.9 to 0.7 (mean value) and in Group B from 3.0 to 1.1. The mean pain score on a scale from 0 to 4 during day 2 to day 10 was 1.2 in Group A and 1.0 in Group B. At this time patients in Group A took a mean of 3.4 and in Group B 1.7 analgetic tablets. Ecchymoses were rare in both groups (4 in Group A, 7 in Group B).
CONCLUSIONS:

In this prospective randomized comparative study the temperature of the tumescence fluid did not influence the occlusion rate when a high LEED was used. In both groups pain and ecchymoses are less frequent in this study with a 1470 nm diode laser than reported in studies with 810-980 nm systems. Cold tumescence fluid reduced pain slightly and reduced the intake of analgetics significantly.

Серж, это ж известная работа Мауринша, после выхода которой многие, как я понимаю, попробовали охлаждать раствор для тумисценции. Лично я довольно быстро от этого отказался

Так, собственно, и вывод о том, что болевой синдром снижается незначительно

Холодный раствор альтернатива, когда у больного аллергия на лидокаин.