АССОЦИАЦИЯ ФЛЕБОЛОГОВ РОССИИ

Коллеги, в данном разделе предлагаю публиковать тезисы, посвященные ЭВЛК вен.
Размещаю тезисы опубликованные раннее Виктором Княжевым


Vascular News
Laser vein closure nearly pain free
Fri 20-Feb-2009 11:11
Using a radial-firing 1470nm laser could result in more specific targeting of the vein wall and has several beneficial outcomes, including the possibility of avoiding use of anaesthetics, according to research presented data at the American Venous Forum in Arizona this month.
Jose Almeida and his team found that it was possible to reduce delivered energy to the vein wall from 60-80J/cm to 30 J/cm by more specific targeting. The decreased energy delivery meant that significant volumes of perivenous tumescent anaesthesia to compress and reduce the vein diameter, and creation of a heat sink, were not required. However, small quantities of local anaesthesia were applied.
The study aimed to evaluate whether a water-specific laser wavelength would close incompetent saphenous veins without perivenous tumescent anaesthesia using minimal energy dosing. The researchers say that the first 24 hours were virtually painless for patients, and eccymoses was absent. Also, they state that the primary closure rate (90.3%) is comparable to current thermal ablation benchmarks.
"Our hypothesis," said Almeida, "was that because of the high affinity of water to 1470nm wavelength, vein closure could be achieved with less energy, less heat production, less perforation, less pain and bruising, and perhaps, closure could be achieved without anaesthesia."

Endovenous Laser Ablation (EVLA) of the Anterior Accessory Great Saphenous Vein (AAGSV): Abolition of Sapheno-Femoral Reflux with Preservation of the Great Saphenous Vein

N.S. Theivacumar, R.J. Darwood and M.J. Gough
Abstract
Aim
During surgery for sapheno-femoral junction (SFJ) and anterior accessory great saphenous vein (AAGSV) reflux, many
surgeons also strip the great saphenous vein (GSV). This study assesses the short-term efficacy (abolition of reflux on Duplex ultrasound) of endovenous laser ablation (EVLA) of the AAGSV with preservation of a competent GSV in the treatment of varicose veins occurring due to isolated AAGSV incompetence.
Method
Thirty-three patients (21 women and 12 men) undergoing AAGSV EVLA alone (group A) and 33 age/sex-matched controls undergoing GSV EVLA (Group B) were studied. Comparisons included ultrasound assessment of SFJ competence, successful axial vein ablation, Aberdeen Varicose Vein Symptom Severity Scores (AVVSS) and a visual analogue patient-satisfaction scale.
Results
At the 1-year follow-up, EVLA had successfully abolished the target vein reflux (AAGSV: median length 19 cm (inter-quartile range, IQR: 14–24 cm) vs. GSV: 32 cm (IQR 24–42 cm)) and had restored SFJ competence in all patients. Twenty of the 33 patients (61%) in group A and 14 of the 33 (42%) in group B (p = 0.218) required post-ablation sclerotherapy at 6 weeks post-procedure for residual varicosities. The AVVSS at 12 months follow-up had improved from the pre-treatment scores in both the groups (group A: median score 4.1 (IQR 2.1–5.2) vs. 11.6
(IQR: 6.9–15.1) p < 0.001; group B: median score 3.3 (IQR 1.1–4.5) vs. 14.5 (IQR 7.6–20.2), p < 0.001), with no significant difference between the groups. Patient-satisfaction scores were similar (group A: 84% and group B: 90%). Previous intervention in group A included GSV EVLA (n = 3) or stripping (n = 9). Thus, the GSV was preserved in 21 patients. The AVVSS also improved in this subgroup (4.4 (2.0–5.4) vs. 11.4 (6.0–14.1), p < 0.001) and SFJ/GSV competence was found to be restored at the 1-year follow-up.
Conclusions
AAGSV EVLA abolishes SFJ reflux, improves symptom scores and is, therefore, suitable for treating varicose veins associated with AAGSV reflux.
European Journal of Vascular and Endovascular Surgery, Volume 37, Issue 4, April 2009, Pages 477-481

Randomized Clinical Trial Comparing Endovenous Laser Ablation of the Great Saphenous Vein with and without Ligation of the Sapheno-femoral Junction: 2-year Results

B.C.V.M. Disselhoffa, , , D.J. der Kinderenb, J.C. Kelderc and F.L. Molld

Abstract
Objective
To evaluate whether ligation of the sapheno-femoral junction (SFJ) improves the 2-year results of endovenous laser ablation (EVA).
Methods
Forty-three symptomatic patients with bilateral varicose veins were studied in which one limb was randomly assigned to receive EVA without SFJ ligation, and the other limb received EVA with SFJ ligation. Recurrence of varicose veins and abolition of great saphenous vein (GSV) reflux on duplex ultrasound imaging, and venous clinical severity score (VCSS) were investigated at 6, 12, and 24 months after treatment.
Results
Two-year life table analysis showed freedom from groin varicose vein recurrence in 83% of 43 limbs (95% CI; 67–95%) in the EVA without ligation group and in 87% of 43 limbs (95%; CI 73–97) of limbs in the EVA with ligation group (P = 0.47). Thirty-eight (88%) treated GSV segments were ablated completely in the EVA without ligation group and 42 (98%) in the EVA with ligation group (N.S.). Groin recurrence was due to an incompetent SFJ/GSV (9%) and to incompetent tributaries (7%) in the EVA without ligation group and due to neovascularisation (12%) in the EVA with ligation group. The VCSS improved significantly and was comparable in both groups.
Conclusion
The addition of SFJ ligation to EVA makes no difference to the short-term outcome of varicose veins treatment. Establishing whether SFJ ligation results in a poorer long-term outcome because of neovascularisation needs to be studied in larger populations with longer follow-up. Registration number: ISRCTN60300873
(http://www.controlled-trials.com).
European Journal of Vascular and Endovascular Surgery
Volume 36, Issue 6, December 2008, Pages 713-718


Endovenous Laser Ablation of the Incompetent Small Saphenous Vein with a 980-nm Diode Laser: Our Experience with 3

Years Follow-up

S.W. Park, J.J. Hwang, I.J. Yun, S.A. Lee, J.S. Kim, S.H. Chang, H.K. Chee, S.J. Hong, I.H. Cha and H.C. Kim

Abstract
Purpose
To demonstrate the long-term treatment outcomes of endovenous laser ablation (EVA) of incompetent small saphenous veins (SSV) with a 980-nm diode laser.
Materials and methods
Eighty-four patients (96 limbs), with varicose veins and reflux in the SSV on duplex ultrasound examination, were treated with a 980-nm diode laser under ultrasound- or fluoroscopy-guidance. Patients were evaluated at 1 week and 1, 3, 6 months, 1 year and yearly thereafter.
Results
In the 96 limbs, the technical success rate was 100%. The SSV remained closed in 89 of 93 limbs (96%) after 1 month, all of 82 limbs after 6 months, 77 limbs after 1 year, 71 limbs after 2 years and 55 limbs after 3 years. In four limbs where recanalisation was observed, repeat EVA was done resulting in successful obliteration of the SSV. No major complication occurred however bruising (27%), tightness or pain (13%) and paraesthesia (4.2%) were observed.
Conclusion
Endovenous laser ablation with a 980-nm laser wavelength is an easy and safe procedure in incompetent SSVs. After successful treatment, there is a very low rate of recanalisation of the SSV, which suggests that the procedure will provide lasting results.
European Journal of Vascular and Endovascular Surgery, Volume 36, Issue 6, December 2008, Pages 738-742

Endovenous laser ablation: venous outcomes and thrombotic complications are independent of the presence of deep venous insufficiency.
Knipp BS, Blackburn SA, Bloom JR, Fellows E, Laforge W, Pfeifer JR, Williams DM, Wakefield TW; Michigan Venous Study

Group.
Section of Vascular Surgery, University of Michigan, Ann Arbor, Michigan, USA. bknipp@med.umich.edu
OBJECTIVE: We hypothesize that endovenous laser ablation (EVA) therapy is equally successful in improving venous insufficiency symptoms in patients with or without deep venous insufficiency (DVI). METHODS: From January 2005 through August 2007, EVA of the great saphenous vein (GSV) was attempted in 364 patients (460 limbs) with symptomatic GSV reflux. The GSV was successfully cannulated and obliterated in all but 17 limbs. EVA was performed alone in 308 limbs (69.5%) and with phlebectomy or perforator ligation (EVAP) in 135 limbs (30.5%). Venous clinical severity scores (VCSS) were recorded preoperatively and at 30, 90, 180, and 360 days postoperatively. Patients were classified as those with or without DVI based on duplex imaging valve closure times at the common femoral vein (CFV) and popliteal vein (PV). In a subset of 181 patients undergoing EVA therapy in the operating room, perioperative
thrombosis prophylaxis was administered based on a risk-stratification protocol. Patients were assessed with direct end points (VCSS) and indirect end points (vein occlusion rates). RESULTS: Successful performance of EVA led to complete saphenous vein ablation in 99.8% at 1 month and 95.9% at 1 year. Median VCSS preoperatively was 6 (interquartile range, 5-Cool, generally decreasing over all time points to 4 (interquartile range, 2-5) beyond 360
days (P < .001). Male gender was independently associated with greater improvement in scores with time (P = .019).
Changes in VCSS and duration of vessel occlusion were equivalent regardless of DVI for both isolated EVA and EVAP.
For EVAP, the true deep venous thrombosis (DVT) rate was 2.2%, whereas for isolated EVA, the rate was 0% (P = .028);
the rate of saphenofemoral thrombus extension was 5.9% for EVAP vs 7.8% for isolated EVA (P = .554). The use of risk-adjusted heparin prophylaxis in patients undergoing EVAP did not have a significant effect on thrombotic complications. There were no differences in true DVT, thrombus extension, or superficial thrombophlebitis between patients with or without DVI. Performance of concomitant phlebectomy, DVI, gender, and age had no effect on the duration of vessel occlusion. CONCLUSION: EVA produces successful ablation and is associated with sustained
improvement in VCSS. These outcomes are independent of the presence of DVI. Finally, the use of a risk-adjusted thrombosis prevention protocol had no effect on the rate of superficial thrombus extension from EVA or EVAP in patients undergoing general anesthesia.
J Vasc Surg. 2008 Dec;48(6):1538-45. Epub 2008 Oct 1.

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Endovenous laser ablation of varicose veins: review of current technologies and clinical outcome.
Johnson CM, McLafferty RB.
Division of Vascular Surgery, Southern Illinois University, Springfield 62794-9638, USA. cjohnson@siumed.edu
Symptomatic lower extremity varicose veins represent one of the most common vascular conditions in the adult population. Associated symptoms ranged from mild conditions such as fatigue, heaviness, and itching to more serious conditions such as skin discoloration and leg ulceration. The predominant causative factor of this condition is reflux of the great saphenous vein (GSV), which is traditionally treated with surgical saphenofemoral ligation and stripping of the incompetent saphenous vein. In recent years, there have been significant advances in saphenous vein ablation using percutaneous techniques, including the endovenous laser therapy (EVLT). In this article, the authors discuss the therapeutic evolution of this technology, theoretical basis of laser energy in GSV ablation, and procedural techniques of EVLT using duplex ultrasonography. Additional discussion of procedural-related complications, such as deep vein thrombosis, skin burn, saphenous nerve injury, and phletibis, and ecchymosis, are provided. Lastly, clinical results of EVLT in GSV ablation are discussed. Current literatures support EVLT as a safe and effective treatment option for varicosities caused by GSV incompetence.
Vascular. 2007 Sep-Oct;15(5):250-4.

Хотя публикация не самая свежая- декабрь 2007 - тема статьи очень любопытна - авторы позиционируют ее как первую работу по ЭВЛК "нежеланных" вен рук с косметической целью.

Plast Reconstr Surg. 2007 Dec;120(7):2017-24.
Laser ablation of unwanted hand veins.
Shamma AR, Guy RJ.
Brevard Plastic Surgery and Skin Treatment Center, Melbourne, Fla. 32901, USA.



PMID: 18090768 [PubMed - indexed for MEDLINE]

Randomised comparison of costs and cost-effectiveness of cryostripping and endovenous laser ablation for varicose veins: 2-year results.

BACKGROUND: Although endovenous laser ablation for varicose veins is replacing surgical stripping, proper economic evaluation with adequate follow-up in a randomised clinical trial is important for considered policy decisions regarding the implementation of new techniques. METHODS: Data from a randomised controlled trial comparing cryostripping and endovenous laser ablation in 120 patients were combined to study Short Form (SF) 6D outcome, costs and cost-effectiveness 2 years after treatment. Incremental cost per quality-adjusted life year (QALY) gained 2 years after treatment was calculated using different strategies, and uncertainty was assessed with bootstrapping. RESULTS: Over the total study period, mean SF-6D scores improved slightly from 0.78 at baseline to 0.80 at 2 years for patients who underwent cryostripping and from 0.77 to 0.79 for patients who underwent endovenous laser. QALY (SF-6D) was 1.59 in patients who underwent cryostripping and 1.60 in patients who underwent endovenous laser 2 years after treatment. The costs of cryostripping and endovenous laser per patient were euro 2651 and euro 2783, respectively. Bootstrapping indicated that cryostripping was associated with an incremental cost-effectiveness ratio of euro 32 per QALY gained. With regard to different strategies, outpatient cryostripping was less costly and more effective 2 years after treatment. CONCLUSION: In this study, in terms of costs per QALY gained, outpatient cryostripping appeared to be the dominant strategy, but endovenous laser yielded comparable outcomes for a relatively little additional cost.

PMID: 19111485

Крио рулит

Randomized clinical trial comparing endovenous laser with cryostripping for great saphenous varicose veins.

Disselhoff BC, der Kinderen DJ, Kelder JC, Moll FL.

Department of Surgery, Mesos Medical Centre, Utrecht, The Netherlands.

BACKGROUND: The aim of this randomized single-centre trial was to compare the 2-year results of endovenous laser ablation (EVLA) and cryostripping for varicose veins. METHODS: A total of 120 patients with uncomplicated great saphenous varicose veins were randomized equally to one of the two treatments. Principal outcomes measures were: freedom from recurrent varicose veins on duplex imaging, and improvement in Venous Clinical Severity Score (VCSS) and Aberdeen Varicose Vein Severity Score (AVVSS) 6, 12 and 24 months after treatment. RESULTS: Life-table analysis showed overall freedom from recurrent incompetence at 2 years in 77 (95 per cent confidence interval (c.i.) 72 to 78) per cent of patients after EVLA and in 66 (95 per cent c.i. 60 to 67) per cent after cryostripping (P = 0.253). VCSS and AVVSS values improved significantly after treatment, but the differences between the treatments were not significant. EVLA provided significantly more favourable results than cryostripping with respect to duration of operation, postprocedural pain, induration and resumption of normal activity. CONCLUSION: EVLA and cryostripping were similarly effective in patients with varicose veins, but patients favoured EVLA because of less pain and postoperative morbidity, and quicker return to normal activity. Registration number: ISRCTN33832691 (http://www.controlled-trials.com).

PMID: 18763255

крио:лазер = 1:1

Endovenous lasering versus ambulatory phlebectomy of varicose tributaries in conjunction with endovenous laser treatment of the great or small saphenous vein.
Kim HK, Kim HJ, Shim JH, Baek MJ, Sohn YS, Choi YH.

Department of Thoracic and Cardiovascular Surgery, Guro Hospital, Korea University Medical Center, Seoul, South Korea.

Endovenous laser treatment (EVLT) is a widely used minimally invasive alternative to stripping of varicose veins involving the great and small saphenous veins. We expanded the applications to tributary varicosities and compared EVLT alone with combined EVLT and ambulatory phlebectomy. The study included 132 patients (76 males, 56 females) who were treated with EVLT and ambulatory phlebectomy. In addition, 133 patients (67 males, 66 females) were treated only with EVLT. Perforating vein reflux was identified in 65 patients in the combination group (49.2%) and in 121 patients (91.0%) in the EVLT only group (p=0.000). Postoperative complications and reoperation rates were compared between the two groups and the risk factors for reoperation analyzed. Ecchymosis (about 85%) and pain (>20%) were the major postoperative complications for both groups. There were no significant differences in the complications noted between the combination and EVLT only groups. During the follow-up period (25.6+/-12.8 months, range 15.5-37.3, in combination group; 11.8+/-8.2 months, range 1.3-18.5, in EVLT only group), residual tributary varicosities were noted in 12 patients (9.1%) in the combination group and in 11 (8.3%) in the EVLT only group (p=0.813). For patients who had reflux in the perforating veins, the reoperation rate was significantly higher compared to the patients without reflux in the perforating veins in each group (p=0.015 in combination group, p=0.006 in EVLT only group). The presence of perforating reflux was a significant risk factor (odds ratio=3.938, 95% confidence interval 1.05-14.78, p=0.042). EVLT as the sole therapy for the management of combined saphenous and tributary varicose veins was found to be safe and effective. However, longer follow-up is needed for confirmation of these findings.
Ann Vasc Surg. 2009 Mar;23(2):207-11. Epub 2008 Aug 5. PMID: 18684588 [PubMed - indexed for MEDLINE]


Combined endovenous laser treatment and ambulatory phlebectomy for the treatment of saphenous vein incompetence.
Jung IM, Min SI, Heo SC, Ahn YJ, Hwang KT, Chung JK.

Department of Surgery, Seoul National University Boramae Hospital, Seoul, Korea. sb5240@paran.com

OBJECTIVES: The aim of this retrospective study is to assess the safety and effectiveness of endovenous laser treatment (EVLT) combined with ambulatory phlebectomy (AP) as a single procedure for treating saphenous vein incompetence. METHODS: The study enrolled 148 patients with saphenofemoral or saphenopopliteal junction reflux associated with saphenous vein incompetence and enlarged branch veins. Patients were treated with EVLT (135 great saphenous veins, 41 small saphenous veins) concomitantly with AP as a single procedure. All patients were followed up by clinical assessment and duplex ultrasound at one week and 12 weeks after the procedure. RESULTS: No postprocedural deep vein thrombosis and pulmonary embolism occurred. Saphenous vein recanalization rate at three months was 5.7%. Residual varicosities were found in 11.4% of the patients at three months after procedure, but only 2.3% of those required subsequent interventions. CONCLUSION: Combined EVLT and AP could be a safe and effective treatment modality for the saphenous vein incompetence.
Phlebology. 2008;23(4):172-7. PMID: 18663116 [PubMed - indexed for MEDLINE]

Cтатьи корейских авторов являются примером смещенного исследования, а следовательно и заключение смещенное - в одну сторону

В первой статье имеется различие между группами по несостоятельности перфоратных вен с сторону основной группы (только ЭВЛК). С чем это связано, не указано
Далее, длительность наблюдения - она короче в группе только ЭВЛК почти в 2 раза. Почему? Неизвестно
Ну, а про то, что уже давно все болезни вен классифицируют по CEAP корейцы видимо не в курсе
В связи с такими важными отклонениями в исследовании, доверять заключению не следует.

Второе исследование так же смещенное и вызывает вопросы. Почему в ретроспективном исследовании такой разброс сроков наблюдения от недели до 12? Цель этого исследования для меня оказалась непонятной. Что с чем сравнивают?

Вывод: любое исследование должно быть правильно сформированным, чтобы ему можно было доверять.

А почему нет? Через 1 неделю установили окклюзию, через 12 недель оценили результат и поймали реканализацию...

Окклюзия через неделю - это результат технический - промежуточный. О чем это говорит? Правильно или неправильно методологически выполнено вмешательство, буржуи - еще пишут в этой ситуации о суррогатных точках. В данном случае авторы (хотя цель исследования неясна) пытаются доказать эффективность методики, а когда она оценивается? 5 -10 лет.

Думаю, что 3-6 месяцев (хотя у авторов 12 недель) достаточный период, чтобы оценить риск реканализации. Как говорится, если за 12 недель или за 24 недели ствол фиброзировался, маловероятна его реканализация в будущем.

Интересная дискуссия на страницах European Journal of Vascular & Endovascular Surgery - настоящий живой журнал то, чего не хватает отечественным аналогам

Абстракт самой статьи:

Outcome of endovenous laser therapy for saphenous reflux and varicose veins: medium-term results assessed by ultrasound surveillance.


Eur J Vasc Endovasc Surg. 2009 Feb;37(2):239-45. Epub 2008 Nov 6.

Myers KA, Jolley D.

Epworth Hospital, 32 Erin Street, Richmond, Melbourne, Victoria 3121, Australia. kamyers@bigpond.net.au

OBJECTIVE: To assess the efficacy of endovenous laser therapy (EVLT) for treating saphenous reflux associated with varicose veins. DESIGN: Out-patient treatment by EVLT with an 810nm laser wavelength with results assessed by ultrasound surveillance. PATIENTS: 361 patients who received EVLT for 509 incompetent saphenous veins over a five-year period. METHODS: EVLT was used for proximal saphenous veins and ultrasound-guided sclerotherapy (UGS) for distal saphenous veins and tributaries. Control of reflux and occlusion or obliteration of the saphenous veins was assessed by serial ultrasound studies. Univariate Kaplan-Meier life table analysis showed cumulative primary and secondary success rates, and multivariate Cox regression analysis assessed covariates that could be associated with increased risk of ultrasound failure. RESULTS: Life table analysis showed primary success at four years in 76% (95% CI 56-87%) and secondary success at four years after further treatment of recurrence by UGS in 97% (95% CI 93-99%). Cox regression analysis showed a non-significant trend towards worse primary success in male patients and worse results for older patients and limbs with clinical CEAP categories C4-6. Cox regression showed significantly worse secondary success for limbs with clinical CEAP C4-6. CONCLUSIONS: EVLT effectively controls saphenous reflux particularly with ultrasound surveillance to detect early recurrence that can be treated by UGS. Modifications in technique may be required to improve the late primary success rate.
PMID: 18993093

И дискуссия:


Regarding "Outcome of endovenous laser therapy for saphenous reflux and varicose veins: medium-term results assessed by ultrasound surveillance".

Eur J Vasc Endovasc Surg. 2009 Apr;37(4):499. Epub 2009 Feb 20.

Ghosh J, Baguneid MS.

To the editor,

We read with interest the medium-term outcomes for patients undergoing the endovenous laser ablation (EVLA) procedure reported by Myers and Jolley.1

A principal determinant of the success of EVLA is the quality of energy delivered per centimetre (Jcm−1) of treated vein, which acts as an indicator for fluence (Jcm−2). A mathematical model by Mordon et al.2 demonstrated that for 3-mm and 5-mm diameter veins, 65Jcm−1 and 100Jcm−1, respectively, are required to obtain permanent vessel wall damage in the continuous mode. This model harmonises with the observational study by Theivacumar et al.,3 which found optimal long saphenous vein ablation with ≥60Jcm−1. Interestingly, phlebitis and complication profile do not appear to be increased in comparison to lower energy densities.

In the Myers and Jolley series, the median energy delivery was 44Jcm−1 (range: 16–128) and the primary success of EVLA at 4 years was 76%. One may postulate that primary success rates may be further improved by achieving a median energy delivery of ≥60Jcm−1. EVLA is still a novel technology in many centres and the technique continues to undergo refinement. Practitioners of EVLA should thus be encouraged to prospectively monitor their outcomes so that the optimal technique may be elucidated.


Response to letter to the editor re: Outcome of endovenous laser therapy for saphenous reflux and varicose veins: medium-term results assessed by ultrasound.

Eur J Vasc Endovasc Surg. 2009 Jun;37(6):742. Epub 2009 Feb 20.

Myers KA, Jolley D.

Drs. Ghosh and Baguneid agree with our conclusion that “It may well be that success rates will improve with increasing power …”, although multivariate analysis showed no relation between power and outcome. However, the references quoted provide little assistance. Mordon et al.1 studied a mechanical model and reported that “for a 3mm vein diameter… for 10W and 2mm/s pullback speed… a minimum of 100J/cm…,” and that “for a 5mm vein diameter… for 15W and 2mm/s pullback speed… a minimum of 150J/cm…” is required to damage the vessel wall. Theivacumar et al.2 reported median energy density of 48Jcm−1 in limbs with complete occlusion and 37Jcm−1 in those with partial occlusion; it is unlikely that these would differ significantly from the median 44Jcm−1 reported in our study. The techniques in both references differed from ours and, therefore, comparisons cannot be made.

Prince et al. reported no difference for early re-canalisation rates for energy ranging from <60Jcm−1 to >100Jcm−1,3 whereas Vuylsteke et al. reported a significantly higher mean fluence for veins that remained occluded than for those that failed early.4 Proebsle et al. reported that low fluence increased risk for early failure,5 and that patients treated with 30W had better medium-term results than for those treated with 15W.6 These studies also used techniques other than those used in our report.

The effect of laser energy is dependent on wavelength, power, probe-withdrawal rate and whether energy is continuous or pulsed. Commercial systems use wavelengths from 810nm to 1500nm. Planck's formula indicates that energy is proportional to frequency so that higher wavelengths require more exposure time. Published reports use either continuous or pulsed power at various levels to 15W. We agree with Ghosh and Baguneid that determining best protocols to provide highest long-term occlusion rates with least patient discomfort requires randomisation for these variables with long-term surveillance, and we thank them for stimulating discussions.

Нужно ли отменять варфарин на время проведения ЭВЛК?

Очень интересная работа по этому вопросу:

Eur J Vasc Endovasc Surg. 2009 Jul 2.
Influence of Warfarin on the Success of Endovenous Laser Ablation (EVLA) of the Great Saphenous Vein (GSV).
Theivacumar NS, Gough MJ.
Leeds Vascular Institute, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK.

[quote="Евгений Илюхин"]Нужно ли отменять варфарин на время проведения ЭВЛК?

Очень интересная работа по этому вопросу:

Eur J Vasc Endovasc Surg. 2009 Jul 2.
Influence of Warfarin on the Success of Endovenous Laser Ablation (EVLA) of the Great Saphenous Vein (GSV).
Theivacumar NS, Gough MJ.
Leeds Vascular Institute, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK...............................

CONCLUSIONS: EVLA in patients taking warfarin is safe and effective. Since cessation of therapy is unnecessary it should provide a valuable alternative to surgery in these patients.
=========================================

Статья интересна прежде всего тем, что публикаций по поводу того следует или не следует назначать те или иные антикоагулянты при выполнении ЭВЛТ, все же недостаточно и единного мнения по этому вопросу сегодня так и нет.
Не так давно склерозировал варици у одной пожилой дамы из Германии, которая была замужем за болгарским армянином. Последний служил переводчиком, поскольку немецкий я не знаю.
К моему полному недоумению и огорчению первые три сеанса оказались абсолютно безрезультатными. Я снова прошелся по анамнезу больной и тогда-то и оказалось, что перевод ее супруга оказался некачественным- пациентка принимала варфарин в связи с кардиохирурргической операцией в Германии.
Конечно, качество и сам вид лазерного воздействия по своей агрессивности не может сравниваться с химическим склерозированием, но как говорится - и тем не менее.
А на пороге уже стоят и другие вопросы- ЭВЛТ и аспирин и Клопидрогрел и новые прямые антикоагулянты -Прадакса /Ксарелто/ и т.д.
Наверное, при определенных обстоятельствах такие сочетания у какой-то группы больных с сопутствующими заболеваниями, более чем возможны.
Что тогда?
Моя немка, например, испугалась до смерти, что для успеха одного лечения следует временно прекратить другое, да и предлагать такой вариант я не стал. Пускай себе носит эластический трикотаж до конца своей жизни.

Percutaneous recanalization of total occlusions of the iliac vein.
Raju S, Neglén P.
University of Mississippi Medical Center, Jackson, Miss, USA. rajumd@earthlink.net
BACKGROUND: Venovenous bypass has been the standard in relieving chronic total occlusions of iliac veins. The technical feasibility of percutaneous recanalization was previously reported. Routine applicability of this technique in a wide spectrum of lesions and patients, stent patency, and clinical outcome forms the basis of this presentation. METHODS: During a 9-year period, 167 limbs in 159 unselected patients in a consecutive series with post-thrombotic chronic total occlusions of the iliac and adjacent vein segments underwent percutaneous attempts at recanalization. Patients were not selected based on venographic appearance or extent of the lesion, or excluded because of a preemptive choice of open venovenous bypass surgery. RESULTS: Percutaneous recanalization was successful in 139 of 167 limbs (83%), including patients with bilateral occlusions and 14 patients with inferior vena cava filters incorporated in the treated occlusion. Median age was 53 years (range, 18-84 years). Thrombophilia was identified in 44 patients. Venous dermatitis/ulcer was found in 46% of the treated limbs. Recanalization involved three or more totally occluded vein segments in 42% of the limbs. The cumulative secondary stent patency rate at 4 years was 66%. The cumulative marked relief of pain and swelling at 3 years was 79% and 66%, respectively. Cumulative healing of venous ulcer at 33 months was 56%. Quality of life metrics improved significantly. CONCLUSIONS: Most femoroiliocaval chronic total occlusions lesions can be successfully recanalized percutaneously with very little morbidity, minimal downtime, sustained long-term stent patency, and substantial clinical improvement. The procedure has wide applicability in a broad spectrum of symptomatic patients, including those with extensive lesions, and can be considered for routine use.
J Vasc Surg. 2009 Aug;50(2):360-8. Epub 2009 May 15.
PMID: 19446993 [PubMed - indexed for MEDLINE

Сравнительное исследование радиочастотного и хирургического лечения варикозного расширения вен.
Оценивалась стоимость операции.
Авторы утверждают, что дороговизна вмешательства частично покрывается ранним выходом на работу - несколько некорректное на мой взгляд заключение...

Сам тезис

Eur J Vasc Endovasc Surg. 2009 Oct 28. [Epub ahead of print]
Radiofrequency Ablation vs Conventional Surgery for Varicose Veins - a Comparison of Treatment Costs in a Randomised Trial.
Subramonia S, Lees T.

General Surgery, King's Mill Hospital, Mansfield, UK.
OBJECTIVE: To compare the costs involved (from procedure to recovery) following radiofrequency ablation and conventional surgery for lower limb varicose veins in a selected population. DESIGN: Prospective randomised controlled trial. METHODS: Patients with symptomatic great saphenous varicose veins suitable for radiofrequency ablation were randomised to either RF ablation or surgery (sapheno-femoral ligation and stripping). The hospital, general practice and patient costs incurred until full recovery and the indirect cost to society, due to sickness leave after surgery, were calculated to indicate mean cost per patient under each category. RESULTS: Ninety three patients were randomised. Eighty eight patients (47 - RF ablation, 41 - surgery) underwent the allocated intervention. Ablation took longer to perform than surgery (mean 76.8 vs 47.0min, p<.001). Ablation was more expensive (mean hospital cost per patient pound1275.90 vs pound559.13) but enabled patients to return to work 1week earlier than after surgery (mean 12.2 vs 19.8days, p=0.006). Based on the Annual Survey of Hours and Earnings (Office of National Statistics, UK) for full time employees, the cost per working hour gained after ablation was pound6.94 (95% CI 6.26, 7.62). CONCLUSION: The increased cost of radiofrequency ablation is partly offset by a quicker return to work in the employed group (ISRCTN29015169http://www.controlled-trials.com).

PMID: 19879166 [PubMed - as supplied by publisher]

[quote="Surarcher"]Сравнительное исследование радиочастотного и хирургического лечения варикозного расширения вен.
Оценивалась стоимость операции.
Авторы утверждают, что дороговизна вмешательства частично покрывается ранним выходом на работу - несколько некорректное на мой взгляд заключение...
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Согласен с подобной оценкой. Пример: все больные с лазерной аблацией в нашей клинике категорически отказались от местной анестезии и были оперированы под спинальной, а несколько пациентов даже под общей.
В частном же центре, чтобы не делиться с анестезиологом , почти все больные оперированы под местной туменисцентной анестезией. Все наши пациенты пожелали в обязательном порядке больничный с различной продолжительностью, хотя могли бы выйти на работу с эластическим бинтом уже на следующий день, частник же уверял всех , что никому не давал больничный, а его больные с операционного стола шли на работу ????????
Я даю эти примеры в том плане, что различные платформы и стремления оказывают влияние на выводы, которые предоставляются нашему вниманию и каждый из нас в угоду тому или иному тезису цитирует и обсуждает подобные и далеко не всегда достоверные данные.