International Conference "2-th North-European Endovenous Forum 2019", Riga, Latvia, 16-18 August 2019
From 16 to 18 on August 2019, the 2 North European Endovenous Forum was held in Riga. The event was actively attended by an employee of the Medical Innovation Phlebological Center, Ph.D., leading surgeon and phlebologist Dmitry Anatolyevich Fedorov.
Surgeon-phlebologist "MIFTS" Fedorov D.A. at a conference in Riga
The forum program included a large number of interesting posts on the topic of endovenous surgery.
Karl Henrik Schell, phlebologist, (Malmö, Sweden), presented the message: "What are the modern methods of endovenous obliteration and when to use them in the treatment of varicose veins."
Phlebologist Carl Henrik Shell (Malmö, Sweden) reports
Nowadays, the dominance of endovenous surgery is dominant, in the context of the new non-thermal non-tumorscent methods that have appeared, the logical question is: what technique is better to use in each case? Dr. Henrik Shell presented an algorithm for choosing a method for treating varicose veins. The most important selection options, from the point of view of the Swedish doctor:
- The size of the vein.
- Anatomical location.
- Stage of chronic venous insufficiency.
Both the content of the report and its conclusions are a reason for expert discussions. The advantages of non-thermal methods are lost upon closer examination and analysis of the results, significantly losing thermal ablation in universality.
Dr. Ulf Thorsen Zirau, phlebologist, Berlin, Germany, presented the message: "Sequential studies performed on over 2250 saphenous veins in 1250 clinical cases."
Reported by Ulf Thorsen Zirau (Berlin, Germany)
In his report, Dr. Zirau spoke about the advantages of the VenaSeal adhesive obliteration technique based on its application in his clinic for 7 years. Dr. Zirau devoted his next message to the topic: "3-year experience of using foam sclerobliteration of varicose veins." The German doctor spoke about the advantages of the technique and its successful personal application, including for the obliteration of varicose veins. Unfortunately, not all specialists will share his positive attitude. It is not for nothing that in the entire progressive world, in Europe, the USA, Russia, stem sclerotherapy has given way to thermobliteration. And this did not even happen yesterday, but many many years ago.
Dr. Ins Udris, surgeon-phlebologist, leading specialist of the Baltic Vein Clinic (Riga, Latvia), presented an interesting message: “4 years of experience with 1940 Nm diode laser and total endovenous obliteration”.
Reported by Dr. Ince Udris (Riga, Latvia)
Dr. Udris is one of the pioneers of the 1940 Nm laser in the Baltics and has perhaps the most experience in the world with this technology. Recent years can be called a kind of phlebology boom all over the world. The latest techniques have appeared that practically do not require anesthesia. Many serious specialists have switched their attention, and not only, to non-tumescent techniques (MOCA, Flebogrif, VenaSeal). Mechanochemistry is an excellent technique. But, as it turned out, it has significant limitations in its application. Glutinous obliteration, even despite active commercial promotion, raises more and more questions. And the good old laser continues to be the "gold standard" in the treatment of varicose veins. The advantages of using a new generation laser are obvious to everyone who has personally used thermobliteration of veins with a wavelength of both 1940 Nm and 1470 Nm. Initially, the appearance of a laser with a new length caused a wave of skepticism and even some negativity. Especially among the proponents of non-tumescent anesthesia techniques. And many doctors are accustomed to working on a wave of 1470 Nm and everything suited them. "The best is the enemy of the good, and why remake what works great anyway," they said. However, the one-micron laser, which was popular at the time, gave way to the one-and-a-half micron (1470 Nm) laser, and, under the friendly applause of the public, fell into the dustbin of history. Today, hardly anyone will defend the advantages of a 1940-micron laser. A doctor from Riga presented the undeniable advantages of the latest 1470 Nm lasers in the form of a comparative histology of venous walls treated with lasers of 1940 and 50 Nm at the same energy (LEED). LEED 1940 J / cm was used. This energy is clearly not enough for adequate treatment of the vein with a 1940-micron laser, but XNUMX Nm perfectly coped with the task of vein obliteration with the same parameters. This study, combined with the obvious advantages of the physics of the process, allows us to say that XNUMX Nm is the third generation of endovenous lasers. And the new wavelength has undeniable advantages. What is this for the doctor and the patient?
- High efficiency with significantly reduced energy.
- Fewer postoperative side effects (paresthesia, ecchymosis) due to weaker radiation penetration into the tissues surrounding the vein.
- The ability to safely work with a laser in the supra-fascial vein segment.
These, at first glance, inconspicuous details and form, the separation of the third generation from the second. Which, by the way, is no less than the advantage of the latter over single-microns (810 and 970 Nm).
Dr. Udris devoted his next message to the topic: “6-year experience of one center (Baltic Vein Clinic) in the treatment of stem varicose veins with adhesive obliteration”. In general, the Latvian doctor over the years of use assessed the technique of adhesive obliteration positively. He also mentioned the specific nuances of the procedure:
- Aseptic inflammatory reaction encountered in 5% of cases.
- Unacceptable result when working with suprafascial segments of the veins (the formation of a permanent cord with an inflammatory reaction).
- Sequestration, glue with its spontaneous removal through ulceration of the skin.
Mike Whiteley, professor, (London, UK), presented: "New techniques for thermal obliteration of superficial veins with reflux: endovenous microwave ablation and high-intensity, focused ultrasound."
Reported by Professor Mike Whiteley (London, UK)
In the first part of the message, Dr. Whiteley talked about the specifics of the action, which, in order, has bothered everyone, but no less effective radio-frequency ablation. The second part of the message was devoted to a fundamentally new method of treatment of varicose veins. High-intensity focused ultrasound is a fundamentally new technique for venous obliteration. Anesthesia is not required, invasiveness is completely absent (there are not only incisions, but also punctures). What remains to competing methods is to quietly live out your century in a more budgetary segment. But, a number of questions remain. How effective is the effect of a focused ultrasonic wave on a varicose vein? After all, a vessel is not a muscle cord, but a thin-walled tube filled with blood. No substantiated evidence of the presence of a significant clinical effect in the technique (clinical observations, histology results) was presented by the author.
Evgeny Vladimirovich Shaidakov, professor, (St. Petersburg, Russia), presented the message: "Morphological changes in the venous wall after radiofrequency ablation." Dr. Shaydakov, on the basis of a study supported by histological data, spoke about the optimal modes of radio-frequency obliteration.
Patricia Ivanova, vascular surgeon, (Riga, Latvia), presented the message: "Endovasal treatment of acute venous thrombosis, current trends."
Reported by Patricia Ivanova (Riga, Latvia)
The lecture is devoted, for the most part, to the organization of care for patients with acute venous thrombosis in Latvia, and specifically in Riga. However, the issue raised by Dr. Ivanova is relevant for other countries. Which is better, standard anticoagulant therapy or local thrombolysis. The answer is obvious. But the expansion of indications for more active tactics, thrombolysis, lies in the economic plane and significantly depends on the financial component. Both catheter and significantly more expensive methods of pharmaco-mechanical thrombolysis remain inaccessible for routine use. And the answer is banal: the price of the question.
Alexey Sergeevich Pankov, X-ray endovascular surgeon, Ph.D. (Moscow, Russia) presented the message: “Do we really need intravascular ultrasound (IVUS) for stenting in patients with post-thrombotic disease? 2 clinical cases ". Using the example of specific clinical situations, Aleksey Sergeevich demonstrated the advantages of using (IVUS) both for determining the indications for venous stenting and for assessing the degree of stent expansion.
Alexandra Kushpelo, surgeon, specialist in the treatment of trophic ulcers of the lower extremities, long-term healing wounds and pressure ulcers at the Baltic Vein Clinic, (Riga, Latvia), presented the message: "Our experience and the latest technologies in the treatment of trophic ulcers."
Reported by Alexander Kushpelo (Riga, Latvia)
Dr. Kushpelo shared the algorithms for the treatment of venous trophic wounds, used in their own practice.
Martin Malina, Professor, (London, UK), presented the report: “Aspects of endovascular treatment of the great veins”. Dr. Malina revealed the features of endovascular treatment in the most difficult category of patients with chronic vena cava occlusion.
Thomas Proestble, Professor, (Mainz, Germany), presented the message: "Laser fiber type or emission wavelength - what is more important for laser ablation?"
Reported by Professor Thomas Proestbl (Mainz, Germany)
The retrospective study demonstrated by Dr. Proestble came to the quite expected conclusions that the efficiency and safety of the laser procedure significantly increase:
- Radial fiber type.
- Higher wavelength.
David Beckett, Clinical Radiologist, London, UK, presented the message: "Treatment of Pelvic Congestion Syndrome - How I Do It." The British doctor shared his successful experience in the treatment of pelvic varicose veins.
Priit Poder, Vascular Surgeon, (Tallinn, Estonia), presented the report: "Phlebitic reaction after closure of the saphenous vein major or minor with cyanoacrylate - what do we know about it."
Report by Priit Poder (Tallinn, Estonia)
According to the literature that Dr. Podder cited after glue obliteration, symptoms such as redness of the skin, itching, swelling, soreness are found in 20-25% of patients. Typically, this is 7-10 day after the procedure. In some cases, the inflammatory reaction leads to necrosis and ulceration with a fairly severe course. Algorithms for the treatment of phlebitis after cyanocrylate are not fully defined. Dr. Podder urged all phlebologists using glue obliteration to pay attention to the following:
- Patients should be aware that cyanocrylate adhesive is an implant.
- Specialists should think about how to treat a phlebitis reaction.
- Especially should be taken into account the fact that the adhesive in the vein will dissolve for a long time.
Ahmet Baris Durukan, professor, (Isak, Turkey), in the message: "A story about the VariClose technology for the treatment of chronic venous insufficiency" told about the use of adhesive obliteration in Turkey.
Reported by Professor Ahmet Baris Durukan (Isak, Turkey)
Marcis Gedins, vascular surgeon, (Riga, Latvia), presented the message: "A patient with chronic arterial occlusion and chronic venous insufficiency: is an intervention necessary?" Intervention is definitely needed. Another question is how to perform the procedure not only effectively, but also safely for a patient with arterial pathology. The radial type of emission of the fiber and laser radiation with a wavelength of 1940 Nm help well in this, which makes the procedure as delicate and safe as possible. An excellent treatment result is achieved, and the procedure for endovenous laser obliteration can and should be performed even in patients with arterial insufficiency.
Evgeny Arkadievich Ilyukhin, phlebologist, candidate of medical sciences, member of the European Venous Forum, (St. Petersburg, Russia), presented the message: “Endovenous laser obliteration - evolution and limitations”.
Reported by Evgeny Arkadevich Ilyukhin (St. Petersburg, Russia)
Evgeny Arkadevich once again shared his own view of the state of affairs in modern phlebology. Dr. Ilyukhin brilliantly presented the evolution of laser coagulation. But, like all brilliant personalities, he was a little ahead of his time. Years on 5-10, or even more. Of course, the future lies with non-tumescence techniques. Moreover, it is highly probable that the future of not only phlebology, but also a significant part of modern surgery, will be based on non-invasive technologies. The question is when? What do we have today?
Such a variety, which is given to a modern doctor in choosing a method of treating varicose veins, has never been in history. But if you look closely, the choice of technique for the practitioner is not that great. Mechanochemical obliteration, being the direct heir of stem sclerotherapy, has retained its main drawback, a high percentage of direct recurrence and recanalization. The situation can be changed by the use of tumescent anesthesia, but then the technique will lose its main feature and become tumescent. Sticky obliteration from the very moment of its appearance raises doubts. Yes, the vein is sealed, but is it necessary? Small bleeding defects in the dura mater are one thing when, in fact, there is no alternative. Gluing a vein, the volume of which reaches 100 ml or more, with the help of glue ... For the purpose of the experiment, it would be interesting, but phlebologists would use this technique at home, if they were in the place of patients. High intensity focused ultrasound. No words, perhaps this is the future. But, at the moment, only theory, loud statements and no hard evidence. Good, highly efficient thermobliteration techniques have another significant advantage, such as versatility. It was this quality that was famous only for classical venous surgery, which dominated the treatment of varicose veins for over a hundred years, and deservedly so. And they moved the colossus, even in its best interpretations, precisely by the thermal obliteration technique. Today they dominate and improve, in fact, having no direct competitors. In fact, the main trend today, in our opinion, is the use and modernization of endovenous laser obliteration, and not something else.
Alfred Arvesen, Phlebologist (Oslo, Norway), presented the message: “Steam Ablation, V-Box Technology (Steam and Radio Frequency). Dr. Arvesen talked about the benefits of 2 generation steam ablation devices in treating varicose veins.
Reported by Alfred Arvesen (Oslo, Norway)
Philippe Rochon, phlebologist, (Lille, France), presented the message: “Innovation in EVLK”.
Reported by Dr. Philippe Rochon (Lille, France)
Dr. Rocheon presented modern European developments of phleboextractors for laser coagulation. The French device is very interesting because of the synchronization of the laser apparatus with the extractor, which allows you to set the necessary LEED (energy density) in the automatic coagulation mode.
Laser generator with automatic extractor
This technology somewhat simplifies the EVLK procedure for a phlebologist and will be a good help, especially for beginners.
Orest Shimechko, phlebologist, (Lvov, Ukraine), presented the message: "12 years of experience in laser ablation and a clinical case with EVLK of a deep vein."
Phlebologist Orest Shimechko reports (Lviv, Ukraine)
Dr. Shimechko presented a rather interesting clinical case of treating a patient with a long history of trophic venous ulcers. The patient underwent a series of laser obliteration, echogenic sclerotherapy. Each of the interventions led to a fairly quick healing of the ulcer. But a few years after the intervention, a relapse of the trophic wound was noted. New ulcers localized distally. The latter procedure is most noteworthy, since in addition to the EVLK of perforating veins, laser obliteration of the deep vein and the posterior tibial was performed. Of course, the author’s courage and innovation deserves at least attention. However, one must understand that with such a chronic, recurring course of the disease, it was much easier and safer to choose a good compression jersey. In this situation, golfs would do just fine. The constant use of compression is not the most convenient thing for the patient, but sometimes it’s just nothing else.
Master classes from leading European phlebologists
After the theoretical part, a series of master classes on the use of modern techniques was held. The most interesting were the procedures presented by Turkish and Latvian colleagues. Ahmet Baris Durukan introduced the Turkish version of adhesive obliteration. The device was supplemented with a device that prevents the flow of glue into the deep venous system.
The chief specialist of the Baltic Vein Clinic, vascular surgeon, phlebologist, full member of the Latvian Association of Vascular Surgeons, the Latvian Society of Surgeons, the Latvian Phlebological Society, the President of the Latvian Wound Treatment Association, Ins Udris, demonstrated the technique of “total laser coagulation”. EVLK of varicose veins on the lower leg caused quite conflicting opinions and comments of experts. But, definitely, a number of phlebologists will practice this technique.
Surgeon phlebologist "MIFTS", Ph.D. Fedorov D.A. and Ince Udris after the master class