“To whom to offer isolated EVLK, and to whom ASVAL?” online colloquium with interactive discussion 22.04.2020/XNUMX/XNUMX

On April 22, 2020, a scientific and practical conference was held in the online meeting mode: "To whom should I offer isolated EVLK, and to whom ASVAL?" The event was led by Professor Konstantin Vitalievich Mazayshvili (Surgut, Russia). Presentations were made by: phlebologist, professor Igor Anatolievich Zolotukhin (Moscow, Russia), vascular surgeon, phlebologist, Juris Rits (Riga, Latvia), phlebologist, candidate of medical sciences, Sergei Mikhailovich Markin (St. Petersburg, Russia).

Speakers of the conference “To whom should I offer an isolated EVLK, but to whom ASVAL?”

Speakers of the conference “To whom should I offer an isolated EVLK, but to whom ASVAL?”

Sergei Mikhailovich Markin, phlebologist, candidate of medical sciences, (St. Petersburg), presented the message: “What to choose: isolated removal of the trunk or tributaries? Survey results prof. Communities. ” Sergei Mikhailovich shared an analysis of an online survey conducted among 115 leading phlebologists in Russia. The results of this survey were not a revelation. Isolated thermobliteration of stem veins is a fairly popular technique among members of the Russian phlebological community. Someone performs this manipulation more often, someone less. Isolated thermobliteration, as the first stage of treatment of a patient or as a full-fledged self-sufficient procedure for the treatment of varicose veins, it all depends on the clinical situation and the preferences of a specialist. In any case, the method of isolated thermobliteration is the method of choice for Russian phlebologists.

Survey of conference participants

Survey of conference participants

Things are somewhat more complicated with venous preservation technologies, ASVAL and CHIVA. Up to 60% of respondents use these methods with the phrase “occasionally and rarely”. The preference is clearly dominated by ASVAL technology. Nevertheless, there is a lack of understanding of clear criteria for selecting patients for this operation in most cases. Isolated miniflebectomy in the nonmaginal form of varicose veins is still not = ASVAL.

Juris Rits, vascular surgeon, phlebologist, leading specialist of the clinic Dr. Maurins, (Riga, Latvia), presented the message: “Isolated EVLK. To whom, how and when I do it in my practice. ”

Phlebologist Juris Rits (Riga, Latvia) reports

Phlebologist Juris Rits (Riga, Latvia) reports

In the clinic of Dr. Maurins, a combined operation, including stem thermobliteration and miniflebectomy, is performed on only a third of patients, the rest only undergoes a laser. In the future, the second group of patients the next stage can be performed miniflebectomy or sclerotherapy of varicose veins. The principle of patient selection, treatment strategy and clinic statistics, in the context of isolated thermobliteration, was voiced by Dr. Rits.

Operates Dr. Juris Rits (Riga, Latvia)

Operates Dr. Juris Rits (Riga, Latvia)

Frankly, far from everything, the opinion of the Latvian phlebologist can be agreed. The overwhelming majority of domestic experts would argue with so many points made in the lecture. Both patient selection and primary treatment tactics are highly dependent on the logistics of the clinic. Patients with severe varicose veins, the presence of a large number of varicose nodes, require a significant amount of time for a single treatment. This is not a secret for a practitioner. Therefore, the second stage in the Riga Clinic is a miniflebectomy or sclerotherapy of the remaining varicose veins in a period of 3 months. This approach apparently suits the Baltic patients, known for their Nordic calm. In local, Russian realities, from the vast majority of patients you can hear a clear request what needs to be done for the procedure, if not all, then as much as possible. On the issue of treatment, especially surgical, our people do not like to return.

Igor Anatolievich Zolotukhin (Moscow, Russia), opened the topic: “ASVAL. To whom, how and when I do it in my practice. ”

Professor Zolotukhin today is a leading specialist in Russia practicing venous preservation technology ASVAL, so it was very interesting to hear his vision of this technique after several years of practice. Igor Anatolyevich began the lecture with the history of phlebectomy, dating back to antiquity and Plutarch.

History of miniflebectomy technique

Miniflebectomy founder Dr. Robert Muller

The pioneer of minimally invasive removal of veins in the modern version, practically the same as we know miniflebectomy now, is Swiss dermatologist Robert Muller. But miniflebectomy, this is only the technical component of the ASVAL technique. It is impossible to get a good result only by performing this procedure to the patient. The ASVAL method is based on a deep understanding of the processes of venous hemodynamics.

Pathogenetic substantiation of ASVAL technique

Pathogenetic substantiation of ASVAL technique

In this context, venous preservation technology is much more complicated than any other modern method of treatment of varicose veins. The main objective of the ASVAL method is the restoration of physiological blood flow through the trunk of a large saphenous vein using a miniflebectomy of varicose dilated inflows. The key to success lies in the competent selection of patients through a good analysis of clinical and ultrasound data. Only such an approach can guarantee the main thing in modern medical practice, to obtain a patient who is satisfied with the treatment. Dr. Zolotukhin proposed the following selection criteria:

  • An ascending type of varicose veins (the inflows are first affected, then the stem vein is involved in the process).
  • A small length of the vein with reflux along the trunk.
  • The diameter of the varicose dilated main vein (usually up to 10 mm).
  • Anterior saphenous vein
  • Young age of the patient
  • Patience of the patient when informing him about the nature and extent of surgical intervention.

If these criteria are met and the subtle aspects of venous hemodynamics are understood, there is a real opportunity to achieve a very good clinical result and, as a result, to receive a grateful patient.

In general, the following aspects hinder the more widespread implementation of ASVAL venous preservation technology:

  • The difficulty of understanding venous hemodynamics for the practical implementation of the method in clinical practice.
  • Fear of receiving an unsatisfactory treatment outcome.
  • The complexity of developing pricing and marketing component of ASVAL.

The last point is no less important than the previous ones, since it is the financial aspect that is more important than ever for promoting any technology in modern realities.

Professor reports, MD Zolotukhin I.A.

Professor reports, MD Zolotukhin I.A.

Summarizing the above. This online conference left me with a double impression. It seems to be an interesting topic! Isolated EVLK versus ASVAL (isolated miniflebectomy). Speakers cited their arguments in favor of a particular method. Yes, to a greater extent, the arguments of Igor Anatolyevich were more weighty. In defense of the ASVAL technique, a remarkable theory of upward reflux, which has a right to exist, was given. An opponent from the Baltic states was not ready for a serious justification of an isolated EVLK. His arguments were neither convincing nor scientific. To the participants' question: what evidence can you give to conduct an isolated EVLK, only one argument convincingly sounded - financial. If the patient wants to reduce the cost of intervention, then he is offered isolated EVLK. And after 3 months, if necessary, there will be additional intervention: miniflebectomy (rarely) or sclerotherapy (often). From all this, it follows that this is not an isolated intervention in its pure form, but the first stage of the treatment of varicose veins in a particular patient. What, of course, the patient is warned about at the first consultation. Other arguments in favor of EVLK were: the general condition of the patient, age, the presence of severe concomitant pathology and an increase in the time of intervention for more than one hour (due to miniflebectomy). At the same time, Juris emphasized that he performs laser intervention on BPV for 12-15 minutes, and for MPV for 8-10 minutes. The question arises: what can be done the remaining 45-50 minutes? Miniflebectomy, no matter how large in volume it is, is never performed for more than 45 minutes. During this time, you can remove not only all varicose veins, but also all healthy ones (if desired). Summarizing all of the above, it becomes clear that there is no question of any isolated EVLK. This is not a pure technique, but, as I said, the first stage of treatment for varicose veins.

With the ASVAL technique, not everything is clear either. It turns out that, performing ASVAL, we deliberately subject the patient to ongoing examinations in order to observe the extended trunk. The diameter will decrease, good! No, then we’ll do RFA or stripping! Why this is needed is not entirely clear! To confirm the theory of upward reflux? Yes, performing MMI interventions for patients - for free, you can experiment, but in private clinics, when patients spend considerable amounts on the result, such experiments will not lead to anything good. In my opinion, we are not yet ready to accept this theory.

It is a pity that at the very end of the conference it was interrupted by technical problems and it was not possible to talk longer and express their opinion on these treatment methods. However, this was a memorable event in which there were interesting reports and equally interesting answers to questions of interest to phlebologists.