Phlebological conference "A patient with venous pathology at a surgical appointment", Sochi, 04.09.2020/XNUMX/XNUMX.
On September 4, 2020, a scientific and practical conference was held in Sochi: "A patient with venous pathology at a surgical appointment: from varicose veins to post-thrombotic syndrome."
The event was attended by leading specialists in the field of modern treatment of venous pathology, including the head of the Moscow City Center of Phlebology, vascular surgeon, phlebologist, Ph.D. Artyom Yuryevich Semyonov and a leading phlebologist of the Moscow City Center of Phlebology, Ph.D. Dmitry Anatolyevich Fedorov.
Speakers of the phlebological conference in Sochi
Dmitry Aleksandrovich Rosukhovsky, surgeon, phlebologist, chief physician of the clinic "Lastikmed" (St. Petersburg), presented the message: "Eraser is a synergy of two methods."
"Eraser is a synergy of two methods" - reports DA Rosukhovsky. (St. Petersburg)
Dmitry Alexandrovich presented the experience of using the technique of combined removal of telangiectasias and reticular veins. The author's technique was named "Eraser" and is a cryolaser sclerotherapy using additional visualization using a venovisor. Dr. Rosukhovsky shared the applied nuances of the technique.
- Compulsory skin cooling.
- Treatment of all visible vessels.
- If there is no visible reaction to the laser action, additional passes are made.
- The spots should overlap each other with up to 50% overlap.
- All visible vessels are subjected to sclerotherapy.
- It is necessary to inject into all supplying veins.
- The introduction of a viscous sclerosant is performed for a longer time (from several to 30 seconds)
- The injections are often accompanied by a sensation of pain and numbness of the skin, which can last up to several minutes. Cooling is used to neutralize this effect.
- It is necessary to try to achieve the disappearance of blood vessels by the end of the procedure.
Dmitry Aleksandrovich presented the results of a comparative study of the use of the Eraser technology and classical sclerotherapy with a 0,5% solution of ethoxysclerol. The study involved 160 patients (115 in the main and 45 in the control group).
The main results of the study:
- Almost an order of magnitude less coagulum in the Eraser group.
- Severe, long-lasting, hyperpigmentation was noted only in the sclerotherapy group.
- More than fivefold reduction in matting phenomena.
- The eraser was, on average, 30% more painful than sclerotherapy.
The results of the observation of Dr. Rosukhovsky were more than remarkable. Nevertheless, not only the high cost of laser equipment, but also the absence of a hypertonic glucose solution in the official recommendations for sclerotherapy, hinders the widespread introduction into practice of the Eraser technique, as well as the original CLAСS.
Khachatur Mikhailovich Kurginyan, surgeon, phlebologist, deputy chief physician for surgery at the Yauza Clinical Hospital (Moscow) presented two reports. In the first of them, Dr. Kurginyan opened the topic: "The results of the isolated use of a neodymium laser 1064 nm in chronic CVD C1-2."
“Results of isolated application of a neodymium laser 1064 nm for CVC C1-2” - reports Kh.M. Kurginyan. (Moscow)
Dr. Kurginyan shared his experience of using a short-pulse percutaneous laser with a wavelength of 1064 nm. The author noted the convenience, efficiency of the technique and highlighted the following advantages of laser technology for the removal of telangiectasias and reticular veins:
- Suitable for patients with a fear of injections.
- No compression needed.
- It can be used in patients who, for one reason or another, are not suitable for sclerotherapy.
Khachatur Mikhailovich also presented the results of a survey among practicing phlebologists. This study revealed very interesting data:
- More than 60% of the respondents have equipment for percutaneous laser coagulation (PLC).
- Moreover, more than 84% of the same phlebologists choose sclerotherapy to solve aesthetic problems with blood vessels.
The reasons for this choice of phlebologists can be discussed for a very long time. It is obvious that in the near future, percutaneous laser coagulation will not be able to completely replace sclerotherapy. Nevertheless, combined methods, including PLC and sclerotherapy, are becoming more common among leading phlebologists.
Khachatur Mikhailovich dedicated his next message to the topic: "Results of the approbation study: Endovenous mechanochemical ablation with the Phlebogrif device in the treatment of varicose veins of the lower extremities." Khachatur Mikhailovich spoke about the advantages of mechanochemical obliteration technology over thermal methods. Dr. Kurginyan presented his own experience of using the Flebogrif method. The study included 10 venous pools. Good treatment results were obtained in the period up to 2 months inclusive. Summarizing the data obtained, the data of European doctors, as well as the results of observations of other domestic specialists, I would like to know the results of a longer observation. We will wait for results in 6 and 12 months.
Artyom Yuryevich Semyonov, vascular surgeon, phlebologist, candidate of medical sciences, head of the Moscow Innovative Phlebological Center (Moscow), presented the message: "Sclerotherapy of veins in the arms: psychological and legal aspects of treatment, side effects and complications."
"Sclerotherapy of veins in the arms: psychological and legal aspects of treatment, side effects and complications" - reports A.Yu. Semenov. (Moscow)
In the era of modern cosmetics, the age of a woman can be understood far from immediately. One of the noticeable signs of the influence of merciless time on the female body will be the veins in the arms. It is they who, more eloquently than passports, will be able to tell about the age of their mistress. Lipofilling and liposculpture procedures can hide blood vessels in the subcutaneous tissue with enviable efficiency. But this is a temporary effect, several months will pass, and the procedure will need to be repeated. Therefore, contrary to the loud opinion of skeptics, many women strive to get rid of the veins on their hands forever. With the growth of social culture and the well-being of society, it is obvious that the demand for aesthetic removal of arm veins will only grow.
Artyom Yurievich spoke about the key aspects of the sclerotherapy procedure on the hands. The psychological nuances of the patient's personality in this matter are no less important than the tactical and technical side of manipulation.
- First consultation - is it so important for the patient
- Understand the patient's motives (age, athlete, musician, artist)
- Understand the patient's attitude towards treatment
- Explain all the nuances of the procedure (good venous access is eliminated)
- Talk about possible side effects
- Send home to think
- Consultation of a psychologist in case of doctor's doubts.
The main question to be solved at the first, or maybe at the subsequent consultation, is whether the patient will be satisfied with the result. It is very important to suspect early signs of body dysmorphic disorder and other mental disorders.
One of the leading aspects of the procedure is legal. Precision design of medical documentation with fixation of key stages of procedures, intervals between them, photo documentation (before and after) allows you to avoid many unpleasant moments.
Artyom Yurievich spoke in great detail about the applied aspects of arm vein sclerotherapy. Anatomical and physiological features of the venous outflow of the upper extremities make it possible to eliminate superficial veins in the arms without a significant negative effect. Nevertheless, the following undesirable phenomena are inevitable: a decrease in the options for venous access, a deliberate reduction of biological substrates for possible reconstructive interventions.
Key questions of the practical implementation of the procedure for sclerotherapy of veins in the hands:
- Choosing the type of sclerosant
- Choice of concentration
- Foam-form or solution?
- Puncture point selection
- The choice of the volume of sclerosant
For each of these questions, individual experts may not answer in the same way. At the same time, the search for a balance between the risk of complications and effectiveness has already formed certain protocols for the procedure. Dr. Semyonov presented modern approaches to the manipulation of arm veins sclerotherapy. Artyom Yuryevich shared his experience and described in detail the most optimal tactical approaches used in his own medical practice.
Today, arm vein sclerotherapy is a good effective method of aesthetic correction of the upper limbs. Whether to include it in their own practical arsenal, each specialist must decide for himself.
Artem Yuryevich devoted his next message to the topic: "Comparative long-term results of EVLK using laser generators with a wavelength of 1470 nm and 1940 nm."
"Comparative long-term results of EVLK using laser generators with a wavelength of 1470 nm and 1940 nm" - reports A.Yu. Semenov. (Moscow)
Dr. Semyonov presented the results of a comparative study of patients operated on with endovascular lasers with a wavelength of 1470 and 1940 nm. Each of the comparison groups included 500 venous pools in 355 patients in the 1470 nm group and 336 patients in 1940 nm. The following results were obtained:
- In both groups, obliteration of the target veins was 100 percent
- No recanalizations of target veins were noted
- In the second group (1940 nm) LEED and the laser power is significantly less
- There was no difference in the rate of vein resorption
- In the 1940 nm group, coagula was more often observed in the lumen of the vein (3 patients versus 1 in the 1470 nm group, not reliable)
- Pain syndrome is less pronounced in the 1940 nm group (not reliable)
- The incidence of hyperpigmentation is less common in the 1940 group (not reliable).
From the observations obtained, the following conclusions can be drawn:
- Postoperative observations show high efficiency and safety of the 1940 nm laser generator.
- Laser power and LEED can be significantly lower than recommended when using 1,5 µm generators.
- A decrease in the amount of energy and a higher absorption of it by the target tissue of the vein wall, reduces the number of side effects after endovenous laser coagulation, and also allows the safe use of laser exposure near the superficial nerves of the leg, lymphatic capillaries and skin during EVLK of varicose tributaries.
- More comfortable and safer work for the operator in difficult areas: perforating veins and epifascial areas.
Thus, the new laser made it possible to reduce the energy parameters of the procedure, but most importantly, it significantly improved the work on the epifascial areas and perforating veins.
Dmitry Anatolyevich Fedorov, Candidate of Medical Sciences, Leading Phlebologist of the Moscow Innovative Phlebological Center, (Moscow, Obninsk), presented the message: “Total EVLO. Results".
“Total EVLO. Results "- reports D.A. Fedorov. (Moscow)
The advent of the 1940 nm endovenous laser has largely changed the approaches not only to the laser stage, but also to the procedure for removing varicose veins as such. Reducing the power during laser ablation has made the routine use of thinner fibers possible. Along with this, it became possible to replace the introducer sheath with a cheaper, more convenient and compact Brown catheter. In addition to the obvious logistical benefits, these changes have contributed to the emergence of a new technique for removing varicose veins - total endovenous laser obliteration. Dmitry Anatolyevich was the first in our country to use this technology in December 2019. Today, the number of patients operated on using this technique is already in the tens, and this number is growing. To demonstrate the advantages of the method, Dr. Fedorov presented to the audience the good results of total EVLO interventions. Dmitry Anatolyevich attributed the following to the advantages of the technology:
- Reduced damage to the skin due to the rejection of miniflebectomy.
- The overall surgical trauma is reduced, since there is no mechanical removal of the veins.
Time will tell how much the new technique will be in demand among doctors and patients, but it certainly deserves attention.
Igor Semyonovich Yavelov, cardiologist, professor, head of the department of fundamental and clinical problems of thrombosis in non-infectious diseases of the Federal State Budgetary Institution "National Medical Research Center of Therapy and Preventive Medicine", (Moscow), presented the message: "Thrombosis of the saphenous veins of the lower extremities: is there an optimal antithrombotic therapy?"
"Thrombosis of the saphenous veins of the lower extremities: is there an optimal antithrombotic therapy?" - reports Yavelov I.S. (Moscow)
Igor Semyonovich shared generalized data on modern therapy of superficial vein thrombosis. Dr. Yavelov commented on the results of the CALISTO and SURPRISE studies. Modern data indicate the advisability of treating deep vein thrombosis not only with drugs of low molecular weight heparins, but also fondaparinux and rivaroxaban. The best evidence base is for fondaparinux. Key takeaways:
- Currently, there is evidence in favor of treating thrombosis of the saphenous veins of the lower extremities using a sufficiently long (at least 45 days) subcutaneous injection of fondaparinux at a dose of 2,5 mg 1 time per day, prophylactic doses of low molecular weight heparin or oral administration of rivaroxaban at a dose of 10 mg Once a day (rivaroxaban is not approved for this indication).
- The question of the advisability of using higher doses of anticoagulants or prolongation of antithrombotic treatment in patients with the highest risk of thrombosis progression, as well as the possibility of refusing anticoagulants in patients with a low risk of thrombotic complications, remains open.
Fondapaprinux is definitely a wonderful drug. But most patients with superficial vein thrombosis are outpatients. These patients prefer pills to injections almost always. Patient compliance is significantly improved with a more convenient dosage form. The use of rivaroxaban in the treatment of superficial vein thrombosis is, in fact, approved in the Russian clinical guidelines for the diagnosis and treatment of chronic venous diseases. Probably, this should be recorded in the relevant recommendations for the diagnosis, treatment and prevention of venous thromboembolic complications (VTEC). This would greatly simplify both the life of both an ordinary phlebologist and his patient in the treatment of superficial vein thrombosis.
The first phlebological conference, which took place after the quarantine, again brought together phlebological colleagues. Again: a lively discussion of reports, questions for speakers, behind-the-scenes discussions - this is what all the participants of this event lacked for so long. Many thanks to the organizers for a great time!
See you in Moscow!