CC BY
16saddle" syndrome and calcification of basal ganglia in MRI scanning is interesting.
References
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2. Chung J, Ahn KS, Kang CH, Hong SJ, Kim BH. Hoffmann's disease: MR imaging of hypothyroid myopathy. Skeletal Radiol. 2015;44(11):1701-4. doi: 10.1007/s00256-015-2226-1
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THE IMPORTANCE OF SCLEROTHERAPY IN THE TREATMENT OF CHRONIC
VENOUS INSUFFICIENCY
Musayev V.A.
Department of Invasive Radiology of Medical Faculty of the University of Gazi, Ankara, Turkey
ABSTRACT
Chronic venous insufficiency (XVI) and associated varicose veins are the cause of major diseases and are very common among the population. Venous insufficiency covers about 10-35% of the population. On average 25% of women and 15% of men suffer from severe pathological conditions. In addition, the spread of venous system diseases is rising as the average life expectancy of the population increases. In advanced age, varicose veins, telangiectomy and venous insufficiency hyperpigmentation, lipodermatosclerosis, other skin changes, especially acute or trophic ulcers, increase in frequency. Factors such as gender and ethnicity play an important role. The frequency of inheritance in women is twice as high as men. However, traumatic events such as trophic changes in men and edema are more common in women than in women.
Keywords: Chronic venous insufficiency, varicose veins, thrombophlebitis, associated, superficial,perfo-rated venules,
Chronic venous insufficiency (CVi) is a common problem associated with varicose veins, which is usually asymptomatic but can cause pain, itching, edema, color changes and open ulcers [1]. Over 15 years varicose vein formation is observed in 20-25% of women and 10-15% of men [2]. Varicose veins may be asymptomatic or may cause severe symptoms. Standing for a
long time may cause pain, itching, burning, tingling, night cramps, edema, skin changes and venous ulcers in chronic cases. Preventing daily activities of people can cause work and time loss [3]. Thrombophlebitis and associated pulmonary emboli may rarely develop
in varicose veins [4,5]. In fact, deaths related to spontaneous variceal hemorrhage have also been reported in the literature [6,7].
There are many etiological factors for venous insufficiency and varicose veins; genetic predisposition, age, sex, obesity, pregnancy, intraabdominal malignancies, thrombophilebit, leg leg injury and long standing [8-11].
CVi is seen in 95% superficial and perforated venules (PV). Isolated deep venous insufficiency and associated varicose veins are rarely seen, and deep vein thrombosis (DVT) usually occurs due to deterioration of structure and function of the end venous valves [12]. In many studies examining the development of ulcer due to CVS, perfornant venous insufficiency was detected in 56-63% of cases. Most of the patients with CRF end-stage ulcers have at least two (multisystemic) insufficiency of superficial, deep, and perforating veins, and isolated perforating insufficiency is rare [13].
In the treatment of superficial venous insufficiency and varicose veins, the primary treatment method has been surgery for many years. Current surgical methods for the treatment of perforating venules are subfascial endoscopic perforation surgery (SEPS) [3,10,14,15], although waxing and stripping are commonly used in the surgical treatment of safenofemoral insufficiency.
In recent years, methods such as endovenous laser ablation (EVLA), radiofrequency ablation (RFA) and foam sclerotherapy (KS) have begun to be used in the treatment of superficial venous insufficiency. Ultrasonography (US) guided and under local anesthesia, these methods, which have many advantages, are alternatives to surgical methods [10,16,17]. Minimal invasive and complication rates are very low, and thermal injury to the EVLA and RFA venom wall and foam sclerother-apy (KS) cause ablation by chemical damage. These treatments, which are as effective as surgical techniques and have lower mortality and morbidity than surgery, are the most current treatments available today [18-20].
Our aim in this study is to evaluate the efficacy of percutaneous endovenous ablation treatments applied between April 2009 - December 2015 in our center for the treatment of superficial venous insufficiency, which is an important clinical condition which can cause serious symptoms besides cosmetic problems and decrease sick life quality and socioeconomic results.
CVi and varices are a major cause of morbidity and are common [21]. Venous insufficiency affects approximately 10% - 35% of the population, approximately 25% of which is female and 15% is male. In addition, the prevalence of venous system diseases increases as the average life span of the community increases [22]. With advanced age, varicose veins, tel-angiectases and hyperpigmentation due to venous congestion, lipodermatosclerosis and increased active or healed ulcers are observed. Gender and ethnicity are also as important as age. The prevalence of varicose veins in women is twice that of men. However, the rate of appearance of trophic changes and edema in men is 50% higher than in women. The risk of chronic venous
insufficiency is highest for white rickets and lowest for African Americans and Asian populations according to the San Diego Population Study [23]. In the Edinburgh Ven Study, the prevalence of truncal varicose veins was 20% in men 18-24 years and 5.3% in women; 61,4% were reported in men between 55-64 years, and 50,5% in women (30). In the Tecumseh Community Health Study, the prevalence of truncal varicocele was reported to be 25.9% for females and 12.9% for males [24]. The Edinburgh Ven study, which investigated the relationship between life style and venous insufficiency in 2001, it has been concluded that lower extremity venous power may be associated with factors such as ges-tational age in women, low dose oral contraceptive use, obesity and mobile work life, and menstruation in length and stool in addition to a strong and consistent factor [25]. The prevalence of varicose veins in the study performed by Kom§uoglu et al. Was 14,6% in males and 22,1% in females [26].
In the majority of epidemiological studies conducted, varicose veins were reported to be more common in women than in men, but in some studies prevalence was found to be higher in men [27,30].
Other important risk factors other than age, gender and ethnicity are family history, lower extremity injury, prolonged survival, obesity, and hormonal balance in women ([25,26,28,29].
The heartbeat of lower extremity venous blood is a complex mechanism. There are three major components of this mechanism. These; the robustness of the lower extremity calf muscle pump, the non-obstructive venous flow and the adequacy of venous valves. Cap function plays an important role in venous system physiology [10,21,31].
Normal caps are collagen-containing structures in a bicuspid structure that allows only one-way flow. Normally operated valves are defined as incompetent, allowing for competitive, retrograde flow. Primary valve insufficiency usually results from the loss of elasticity of the ven wall. In case of secondary endocardial insufficiency, the etiology is often DVT.
Dysfunctions in the lower extremity venules in the CVi are due to congenital or acquired factors in the valves that prevent the backward escape of the blood due to gravity. Disturbances in valve functions cause the existing hydrostatic pressure to directly reflect on the venous segments and cause backward escape. Due to the increase in venous pressure, the veins extend away from each other. As a result, valve regurgitation and reflux become more prominent, and proximal valve regurgitation can progress to distraction and retain long segments. Venous hypertension can cause protein-rich fluid and blood cells to migrate from the capillary walls into the intercellular space. The earliest result is soft tissue edema. Long-term skin thickening, hyperpigmenta-tion and deep ulceration develop. [10,14,21,31,33].
Ven wall consists of intimal, medial and adventi-tial strata. The intimal layer is on the basal membrane and releases prostaglandin I2, antithrombin cofactors, thrombomodulin and tissue plasminogen activator. The medial layer consists of three smooth muscle layers with elastin and collagen. Compared to the arteries, this
muscle layer is weaker. The Adventisial layer is the thickest layer and contains more collagen [34].
Superficially, deep, and most of the perforated vending machines have bicisteal caps made up of endo-thelial catheps supported by a thin connective tissue layer. The number of the caps at the distal part of the leg is quite large, and the numbers toward the hip gradually decrease. In the lower limb, the function of the valves is to divide the hydrostatic pressure into segments, so that the blood flow is from the superficial system to the depth, from the top to the bottom |34|.
The lower extremity venules are classified according to their location in the deep or superficial compartment and the muscles are related to the relationship with the fascia (Figure 1). Accordingly, there are three groups, superficial, deep and perforated. Deep venoms, muskuler extends under the fascia and drains the lower extremity muscles. Superficial venules extend in subcutaneous fat tissue on deep fascia and provide cutaneous microcirculation. Perforan venler muscles connect the deep and superficial venules by piercing the fascia [341.
Fig. 1. Relationship between lower extremity and facial planes [35].
Anterior tibial, posterior tibial, and peroneal ven-ules provide calf drainage. These veins as a pair are accompanied by the same named arteries. Proximal two posterior tibial venes join together to form a short posterior tibial root and the peroneal double becomes a short root in the same way. These two roots m. At the lower edge of the popliteus, it joins to form popliteal vein. Duplicated anterior tibial venules form a short root and popliteal veneers are involved. The most important muscular venules that guide calf muscles are gastrocnemius and soleal venules. The gastrocnemius venules can be seen at the medial head of the gas-trocnemius and become either popliteal ven or posterior tibial vendedin one. Soleal venules are located centrally in the soleal muscle in the posterior aspect of the tibia. These venules, which can be as large as one centimeter, become a drain on the posterior tibial or peroneal system. The popliteal vein extends longitudinally along the popliteal fossa posterior to the popliteal artery and then is medially directed to enter the adductor duct. Popliteal ven is duplicated at 5% [36].
The popliteal vein is called the superficial femoral vein at the proximal end of the adductor duct. Superficial femoral and superficial femoral arteries extend deep into the thigh anteromedial. Proximal to the thigh, the deep femoral vein superficial femoral vene is inserted 4-12 cm below the ligamentum inguinalum to form the main femoral vein. After passing the inguinal ligament, the main femoral vein becomes the external iliac vein. Approximately at the sacroiliac joint level, the external iliac vein is formed by the involvement of the internal iliac vein. At about L5, the opposite side joins the main iliac vein and forms a vena cava inferior (37).
The ultrasonic probe has two transducers mounted back-to-back that generate continuous sound waves and detect rotating echoes. Here, the sound wave is continuous and there is no axial resolution in this method, it can not determine where the sound comes from. All the currents are detected on the way that sound progresses. Since this US method uses a narrow frequency band, the accuracy is high[52].
Here, the doppler signal generated by the doppler device is generated from the phase changes of the echo signals of the consecutive pulse echo sequences. Ultrasonic probe is warned in short bursts. Both reflected and scattered echo signals are detected by the same probe, amplified in the receiver, and modulated by demodulation. In the next step, a part of the signal at the sampling interval (gate) selected by the user is integrated. This signal, received and limited during the duration of a particular pulse echo signal, causes the Dop-pler signal to propagate.
It is used in combination with B-mode imaging and the duplex Doppler method takes the name. There are several transducer elements and long pulses are produced that will make the doppler information more sensitive.
Blood flow Doppler examination is preceded by a sampling area (gate) on the B-mode image. Then the appropriate sound beam angle is determined for this area. The frequency difference of the rotating equipments is printed on the monitor in frequency (kHz) / time graph alongside the B-mode view. The frequency values are automatically converted to a speed according to the sound beam angle, and the spectrum is generally a speed / time (cm / sec) curve. In the dopler graph, the
time is on the x axis in seconds, and the speed or frequency is on the y axis in kHz or cm / sec. Those who approach the sound beam from the currents are printed on the line, while those who are away are printed on the line.
In this US method, the doppler information sent to the tissue is obtained by taking a plurality of sampling areas along a pulse line. Multigate sampling is done in Color Doppler US. After the information from these sections is colored according to the speed and direction, the color Doppler images are obtained if they are placed in the vein image.
The direction of the current is detected by color shift (blue or red), phase shift. Here, information related to the current shape and speed is indicated by color tones (color saturation coding) or with different colors (different color coding) [52].
The characteristics of normal venules can be summarized as follows [53]:
1. The normal venous wall gray scale is not echo-genic in the ultrasound, the inner surface is flat. The wall is very incised and thickening suggests pathology.
2. If the image quality is perfect, the covers can be seen. The flaps forming the caps are thin and delicate. The free edges of the flaps are symmetrical and move freely with current motion. When it is closed, the valve flaps come in the core of the vein and when folded it folds so that it will be parallel to the vein wall.
The third lumen can be obliterated with a slight pressure from the outside. This simple observation is of great importance to the case. Because, if there is a lumen thrombus, there is no ven compress when the compression of the neighboring artery is changed.
4. Lower extremity major venules are usually wider than the accompanying artery. Thrombosis should be suspected if the venous artery is large in size and large in size and does not change in size with respiration.
5. The blood flow in the middle and large venules on the extremity is spontaneous when the person is at rest. Loss of spontaneous flow may be due to obstruction or proximal or distal obstruction of this region.
6. Normal venous flow is respirofacial. In the obstruction, the blood passes through very small quantities of small cholesterol or recanalization regions and the phasic changes disappear.
7. Valsalva maneuver after deep inspiration causes sudden interruption of current in large and medium sized venles. This important finding indicates the extent of the venous system from the examination field to the right heart.
8. Manual compression performed distal to the region under examination increases venous flow. The loss of this response indicates a severe obstruction distal to the region under investigation.
9. In the normal venous system, the flow flows only in one direction, only in the heart.
The Doppler US examination performed in patients with suspected varicose veins and / or venous insufficiency is a modality that can be used for treatment and follow-up as well as diagnosis of failure.
With a good Doppler US examination, large and small stage vender reflux and dilation presence, source
or sources of reflux if present, existence and location of varicose veins not observed by physical examination, reflux in varicose veins, reflux in deep venous system, presence of obstruction in the deep venous, which level is present, and whether there is arterial insufficiency in the leg [39, 54].
The examination should definitely be done while the patient is standing. Pseudo-negativity and sometimes pseudo-positivity can often be seen in examinations performed in a lying position [33]. 7.5-10 MHz linear transducers are used in the review. RDUS can make it easier to review, but power Doppler is more reliable. The purpose of the Doppler US is to identify all varicose veins that are failing and to know if they are responsible for the patient's clinic.
Lower extremity venous system Doppler US examination has a standard initial position on the supine position. The evaluation can be started with a convex probe and the vena cava can be initiated with inferior and iliac veins, or this region can be left at the end of the examination. However, these venues must be evaluated. AFV is evaluated for thrombosis and reflux. Failure assessment should be performed while the patient is standing in accordance with the pathophysiol-ogy. At this time, the patient should be higher in order to make the examination more comfortable [39, 54, 55].
BSV is examined from SFB to distant in terms of possible association with varicose veins. The BSV diameter is then measured. The diameter, normally 4 mm or less, is often greater than 7 mm in reflux. The BSV diameter, which is insufficient in the branches, gradually decreases towards distraction. BSV diameter increases at clinically significant perfornane venous insufficiency levels. Care should be taken in terms of possible PVY at levels where BSV diameter increases. The B-mode is assessed with a diameter increase in the examination or with the RDUS, which is associated with varicose veins and the reflux is suspicious. Valsalva maneuver or distal augmentation is performed to evaluate possible retrograde flow in BSV. The short-time retrograde flow until the valves are closed is physiological. As a criterion of failure, 0.5 second and reflux current is taken into consideration, reflux current which is usually several seconds passes in insufficient venues is observed.
The patient is then told to return to the back of the practitioner and evaluation is made in terms of possible reflux or thrombus in the popliteal vendor. Assessment of KSV is similar to that of BSV. KSV lesions are examined in relation to diameter and varicose veins. The relationship between CSV and plasticine venous is evaluated [39, 54]. Variations in the outcome of CSV should be kept in mind [56]. Despite varicose veins in some patients, there is no failure in the saphenous veins. Generally, this type of varicose veins seen in multipa-rous women is a source of pudental and gluteal venous insufficiency. Another cause of varicose veins on the popliteal fossa in the lateral and medial thighs, which is not associated with saphenous veins, is perforating venous insufficiency diagnosed by RDUS [39, 54].
Venography is useful for anatomic and hemodynamic evaluation of the venous system. For the diagnosis of DVT, "assendan venography" is of value as a gold
standard. "Desendan venography" is used to assess valvular insufficiency [57,58].
The ascending venography is performed by applying a tourniquet at the ankle level and the superficial venous is occluded and injection of a contrast material into the back of the foot is performed. Thus, it reveals the openness of the venous system and the venous anatomy.
Desendan is used to determine venography, reflux and degree. Contrast material is injected into the inguinal area by entering the femoral vene. Valsalva is maneuvered. Deep femoral venous, superficial femoral vein and incompetent valves are seen in SFB. Primer provides prolongation of the shortened, retracted caps due to post-thrombotic syndrome with prolonged, flap caps.
Desendan reflex classification of venography
(58);
Grade 0: The cover is solid. No significant contrast media reflux
Grade 1: minimal inability at the valve. Reflux due to proximal thigh
Grade 2: Moderate inability to cover. Reflux limited by femoral distal
Grade 3: Moderate inability to cover. Reflux up to knee level or below index
Grade 4: Severe disability on the cover. Reflux into the calf's veins to the level of the ankle.
There is a risk of radiation on CT venography and iodinated contrast is used. In MR venography, radiof-requency waves are used and are sensitive to movement. The accuracy of these methods in the femoropop-liteal region is close to the RDUS and venography [59]. Everything that is too expensive to compare with the RDUS
Lifestyle change and patient education are important in treatment. Treatment options include compression, medical treatment, or interventional procedures. The type of treatment to be treated depends on the individual characteristics, the patient's expectations and the CEAP classification.
Frequent exercise can significantly reduce the complaints of varicose veins, and lifestyle changes have great precaution in preventing varicose veins. Avoid standing or sitting for a long time to prevent blood from being ponded. If an individual's occupation or daily life requires a long period of standing or permanent sitting, he should move his legs and legs regularly. Since sudden temperature increases and temperature widens the veins, it should be avoided for long periods in hot bath, sauna, sunshine. To prevent blood circulation; very tight trousers, corsets, tight pantyhose, narrow throat socks should not be worn. To remove the factors that damage the veins; excess weight, chronic constipation, hormones (some birth control pills) at extremely high doses should be avoided. Dietary habits with low fat and high fiber ratio should be recommended. To facilitate the return of the blood, the legs should be slightly raised and the legs should be showered with cold water. Muscle exercises should be done 2-3 times a day several times a day. Sports such as walking or swimming, which activate leg muscles that
help move the heart towards the blood gravity, should be done regularly.
Elastic compression stockings have an essential role in the treatment of CVE. Elastic compression shoe is recommended for patients who have fewer complaints or are at increased risk for surgery. Appropriate elastic compression restores the symptoms of patients with varicose veins, increases venous hemodynamics, reduces edema and provides relief [61,62].
Compression socks are located in different pressure ranges and are used in the pressure ranges required by the patient's complaints and the degree of disease. Compression socks are divided into 5 classes according to their pressure [61];
Class A: 10-14 mmHg (very low pressure)
Class 1: 15-21 mmHg (light pressure)
Class 2: 25-32 mmHg (medium pressure)
Class 3: 34-46 mmHg (strong pressure)
Class 4:> 49 mmHg (very strong pressure)
The most important point in this treatment is the application of compression stockings on the right scale and in the form of effective pressure.
The beneficial effects of compression stockings depend on the following mechanisms: Providing support for connective tissue;. Upgrading tissue pressure;. Reduce the amount of filtration ; Reduction and prevention of diabetes; Suppression of venous hypertension; Preventing cap failure; Increase knee lower muscle power;. Increase blood flow velocity in the veins; Supporting lymph circulation; Thrombosis and embolism protection.
In order for the compression sack to have optimal effect, it is necessary to wear it after the morning and travel through the compression sock during the day .
The venoactive drugs used in the medical treatment of CVD are composed of several drug groups. They may be of vegetable origin or synthetic . Venoac-tive drugs exert their antioxidant mechanism to treat edema and symptoms of CVS. These drugs provide symptomatic relief when they do not correct the existing disease. It reduces symptoms such as edema, pain, tiredness and muscle cramps.
Venoactive drugs are generally recommended for 3 months. However, the duration of treatment may be extended in patients with symptoms that persist despite treatment. No venoactive drugs should be used in suckling women.
Surgical techniques are classified in two groups.
1- Ablative Surgery
2- Conservative Surgery
Ablative surgical methods; safen stripping, simple crossectomy and phlebectomy.
Stripping from ablative surgical techniques is the standard surgical method. Technically it can be removed from the SFB to the medial malleolea (long), from the SFB to the middle of the leg (middle), from the SFB to the stomach (short) or from the SFB to the middle of the thigh (very short). Since the saphenine nerve can cause damage during the procedure, removal of saphenin is not preferred in recent years. SFB is explored by incision at the groin level in the process and the branches are connected and cut. After that, cuts are made at what level to be caudally stripped. The caudal
section of the stem is connected, the cranial segment is cut, the stripper is placed in the stern vein, advanced to the flap and drawn with a stripper [61].
In the crossectomy method, all the collelets and safen ven are ligated and separated from SFB. The aim of this procedure is to protect the reflexes from splenic vein tying and to use them as grafts in arterial bypass [61]. The recurrence of varices is more frequent in scleral grafting than in grafting [63].
Phlebectomy is the process of microinjection of varicose veins. Flebectomy is often used with stripping and fixation methods [3,61].
In conservative surgery, it is aimed to maintain drainage of safen ven, but to prevent reflux. Safenofem-oral external valvuloplasty or CHIVA (Conservatice Hemodynamique de Insuffisance Venieuse en Ambula-torie) method is applied [61,64].
In recent years endovenous obliteration of venous venous reflux has emerged as an alternative to surgical methods in order to reduce morbidity and healing time in the treatment of varicose veins. Disadvantages of surgical treatments are usually under general anesthesia, incision at the groin level for SFB attachment, pain and caries due to scraping on the thigh, nerve damage, leaving the wound beneath the knee or ankle, and staying in the hospital. Endovenous obliteration methods are frequently used today to remove these disadvantages. Chemical and physiological methods are used to obliterate the saphenin vein. Methods such as endovenous laser ablation (EVLA), radiofrequency ablation (RFA) and foam sclerotherapy have revolutionized the treatment of superficial venous insufficiency [9]. These methods, performed under US guidance and under local anesthesia, have included surgical procedures [65]. These are the most current treatments that are applied today with minimal invasive and low complication rates.
Sclerotherapy and varicose veins have been used in the world for many years. The basic principle in this method is to provide a fibrotic healing that will cause continuous venous occlusion by injecting a substance that causes endothelial damage into the desired vene. The early times are often used because they are cheap, and they are no longer used alone due to high failure rates [66]. Local sclerosing agents are used here. The most common sclerosing agents used worldwide are polydocanol (Aethoxysclerol) and sodium tetradecyl sulphate (Sotradecol) [67]. Liquid sclerotherapy for reticular, spider veins and varicose veins below 3 mm, foam sclerotherapy for larger varicose veins. If the patient has proximal venous reflux and venous hypertension at the same time, these problems should be corrected first. Otherwise, the recurrence rates will be too high. Liquid and foam sclerotherapy are used in conjunction with endovenous obliteration techniques to obliterate residual varices [68].
The Tessari method is commonly used to form foam [69]. In this method, two 10 ml injectors are connected via a 3-way tap. 1-2 ml of sclerosing agent is injected into one of the injectors, 4-8 ml of air is drawn into the other and mixed with each other until a thick foamy state is obtained 15 to 30 times. This mixture, which is formed by this method, is given directly to the
visible heirs while the others are given in the US guide-with the appropriate needle according to the variceal diameter.
Foam sclerotherapy is superior to liquid sclero-therapy [87,99,100]
- The foam can be directed as it can be seen in the inspection.
- Allergy is lower.
- There is less input.
- It affects a smaller amount and a wider region in concentration.
- Perivascular damage is low.
- When it mixes with blood, it pushes blood and increases intima damage.
We can list the most ideal indications for sclero-therapy in the following way; telengectasia, reticular venules, isolated varicose veins, recurrent varicosities, perforating venous associated varicosities. In addition, we can list the suspicious indications for sclerotherapy as follows; large varicosities, SFB and KSV reflux, SFB and BSV reflux.
The polydokanol used leads to a strong vasoconstriction of the endothelial cells in the foam vesicles. Foam treatment, after the process is covered with a bandage bandage is tightly wrapped blood injection is prevented again. After the gas contained in the foam is absorbed, the vasoconstriction of the bacterium and vasodilation in the veins come into play. If the leg is not wrapped around the bandage, it can fill up the blood vessel again and lead to the formation of thrombus and phlebitis.
1. Over 70 years of age and sedentary life;
2. Pregnancy (ulcer, danger of rupture, vulvar varis);
3. Advanced level of rheumatic disease that will prevent mobility of the patient
4. Systemic disease;
5. People with allergic disease;
6. Lower extremity arterial diseases;
7. Fever diseases;
8. The use of anticoagulants;
9. Acute superficial or deep venous thrombosis;
10. Obesity to prevent mobility and compression.
Sclerotherapy Complications: Octosis (10-20%);
Pain (5-10%); Temporary edema and swelling; Pigmentation (10%) disappears within 6-12 months; Thrombophlebitis (1-2%); Necrosis; Deep vein thrombosis and pulmonary embolism; Anaphylaxis; innefec-tive injection
Sclerotherapy should be performed when the patient is in a lying position. Processing should start from the worst area first. An optimal sclerotherapy procedure should be intravenous and should not involve extravasation. In case of extravasation, massage and compression should be applied immediately.
RFA, a minimally invasive procedure, can be performed under local or regional anesthesia. The energy generated by radio waves is utilized. Energy can be delivered either continuously or sinusoidally. The mechanism of action of radio waves is in the form of contact with the electrode, touching with the effect of heat.
RFA is based on the principle that a pair of bipolar electrodes is applied to the venous wall and an alternating electrical current is passed through the radiofre-quency electrodes. Each catheter has a temperature sensor at the end of one of the electrode blades. Thus, the heat generated in the ven wall is fed back. With this method, it became possible to heat the ven wall to the target temperature and to heat it without overheating. Despite this negative feedback, it is important to note that the total energy delivered to the wall is a result of the heat generated and the rate of catheter withdrawal. If the catheter is pulled too fast, only the thin layers of venules can be treated. When pulled very slowly, neighboring tissues may be damaged. The degree of heat is carefully controlled to control contraction of the collagen and the activation of the ven wall by thermoregulation. Today, two different catheters have been developed, 6F for small venules and 8F for large ven-ules. The technique used to close the BSV is applied to the BSV under the knee under the knee. A 14G cannula is inserted into the BSV, the wire is inserted into the BSV, and then the 6F or 8F catheter short sleeve is inserted using the Seldinger technique. Once the wire and intraduser are withdrawn, the catheter vende can be advanced to SFB. Under US control, the electrodes are opened in the inferior epigastric vein junction and the radiofrequency current is initiated. After the heat reaches the treatment level, the catheter is withdrawn at a predetermined rate [70].
It is recommended to heat the ven wall to 85 degrees when using RFA. At this temperature, collagen contraction and denaturation occur in the venous wall. The heat effect also results in endothelial damage, de-naturation of blood proteins, and therefore inflammatory reaction. Following the fibrotic healing process, the vendor causes complete and permanent occlusion [71]. Dunn et al. [72] reported that by heating the venous wall to 90 degrees, they increased catheter withdrawal speed, shortened the duration of the procedure and obtained similar results with studies performed by heating ven wall to 85 degrees for occlusion and complication rates on 6 month follow-ups.
The presence of blood in the treated venous lumen causes a thrombus that adheres to the electrodes and prevents effective treatment. In this case the catheter must be retracted and the electrodes cleaned. The catheter should then be reinserted and the venous catheter should be treated to provide appropriate treatment. If this is not done, the thrombus may remain in place and the venous wall may not be adequately treated. This may lead to recanalization in the mid-long term [70].
Studies have shown that RFA is superior to surgery in terms of postoperative pain, return to daily activities, and patient satisfaction [73]. Although RFA therapy is costly compared with surgical treatment, this rate is balanced by early return to work in the RFA treatment [74].
Endovascular Laser Ablation (EVLA) Therapy is the procedure of creating severe thermal ablation in the venous wall by laser beam under local anesthesia in patients with chronic venous insufficiency with the help of Doppler US. In venous insufficiency, surgery was first applied as an alternative in 2001 by Navarro et al.
810 nm diode laser in BSV failure [75]. Initially used in the treatment of BSV insufficiency, several studies have shown that it has been successfully used in the treatment of KSV [76,77] and AASV [78]. Very few cases reported EVLA therapy for isolated perforating venous insufficiency [79, 80]. The most important advantages of the method are; absence of scar-incision, local anesthesia, painlessness and the patient's ability to get up and walk after the procedure. Because of these advantages, the EVLA method is the first choice treatment for venous insufficiency worldwide [81,82].
In this method, the purpose is to remove the reflux, ven lumen present in the SFB and vein lumen by occlusion. In EVL treatment 810, 940 and 980 nanometer wave length diode laser devices are used. Recently, laser devices with wavelengths of 1470 nm have also become widespread. The high energy applied causes contraction in the collagen fibers in the venous wall and leads to narrowing of the venous lumen. The endove-nous coagulum formed during the treatment is important in obstruction of the venous lumen. Thrombotic occlusion provides a venous fibrotic band after EVLA therapy.
During EVL treatment, it is necessary to first give the patient a suitable position. For the procedure for BSV, the pron position should be preferred for supine, vena safena parva. The entry point according to the venous insufficiency map prepared in the pre-procedure RDUS guideline is determined to completely cover the venous segment in which the insufficiency is detected. The entrance site for BSV insufficiency is the point at which the BSV first expands at the level of the knee joint or inferior cut of the joint. In some publications, it is argued that the entry point should be at the lowest ven-level level at which the segment with primer failure can be entered [66]. The entry point from the distal calf level is determined for the VSP. According to localizations, perforation venues have the safest and shortest entrance point.
In the saphenous venules, EVLA therapy is performed in the presence of the tumor anesthesia (TA). Tumor anesthesia consists of a mixture of saline, local anesthetic and vasoconstrictor. Some authors suggest that the TA solution should be neutralized with bicarbonate as it reduces the burning sensation [83, 84].
The benefits of Tumor Anesthesia can be summarized as follows:
- The patient does not feel pain during the EVL treatment. Patients feel pain within 5-8 days following the procedure is due to inflammation after a successful EVL treatment.
- Blood in large diameter vessels is discharged with compression, thus increasing the efficiency of the ablation procedure.
- The surrounding tissue acts as a thermal buffer against heat damage and prevents the surrounding tissues from being damaged by laser heat. During a successful ovarian anesthesia, the patient does not feel any pain during the EVLA procedure and there are no complications such as skin burns and paresthesia due to heat trauma in the surrounding tissues [1]. It may be difficult to enter the vein depending on the patient and technique during the procedure. This problem can be especially
prevalent in obese patients. Venospasm can sometimes make it difficult to enter the vasculature. Providing the patient with the reverse trendelenburg position during the operation may facilitate entry of the valve. There may be difficulties in advancing the catheter due to tor-tious venules, aneurysmatic segments, and sclerotic venules.
The vagal reaction may be dysrhythmia, pain from the saphenous nerve, or pain due to insufficient local anesthesia.
The most rare complication is DVT. The most visible area is the calf region and the clinic is in the form of a limited table. Anti-inflammatory agents, compression, anticoagulant agents (low-molecular-weight hep-arin or long-term oral anticoagulant agents) are used in treatment. The thrombus protrusion shows retraction within 3 weeks under anticoagulation [98].
SFB should be terminated in the case of the BSV failure of the laser fiber, and a few cm below the SPB in the case of KSV failure. In the treatment of BSV failure, the fiber tip must also be below the epigastric venous. In the treatment of perforating ven failure, the fiber tip is brought to the facial or subfacial level in the presence of the US [85].
Parameters: Some parameters have been determined for a successful and safe EVLA treatment [86]. These parameters are the laser dose, the wavelength and the degree of fiber attraction.
Wavelength: Several wavelengths have been proposed for EVLA therapy so far: 810, 940, 980, 1064, 1320, 1470. In vitro studies comparing heparinized caloric thermal damage to three different wavelengths (810, 940, 980 nm) equal results were obtained in one study [86].
Numerous clinical trials have shown no difference in venous occlusion rates between the three wavelengths (810, 940, 980 nm), suggesting that efficacy and safety are equal [87,88, 89]. In a study comparing 810 nm and 980 nm versus equal ven occlusion rates, it was shown that pain, ecchymosis and phlebitis were lower in the 980 nm group. This is attributed to the fact that 980 nm is specific for water and hemoglobin (Hgb), 810 nm for HB by the authors, and thus the smaller wave lengths are absorbed more by the blood [90]. Several theories about therapeutic effect have been put forward. One theory in this regard is that the air bubbles leaving the laser fiber tip cause thermal damage to the ven wall. Depending on the wavelength of the laser, hb or hb act as hb chromophore without absorbing water, and the energy turns into heat energy. Here the heat starts to cause blood to boil and air bubbles appear in the lumen in the US. In vitro studies using 810, 940, 980 nm lasers have shown that the volume of air bubbles depends on the laser energy, which is not dependent on the wavelength [86]. Endothelial and sub-endothelial damage occurs when air bubbles transfer heat to the venous wall. Intimal destruction due to thermal damage to the venous wall, denial of collagen in the medulla, and subsequent panmural damage due to intraluminal minimal thrombosis. The thrombus there is more stable than the spontaneous thrombophlebitis. The decrease in vessel diameter after the procedure may be due to collagen denaturation in the media.
Laser Dose: Because of the fact that laser wave lengths are not so effective on EVLA treatment results, energy production methods and energy dose standardization have been carried out in recent years. Endolumi-nal laser energy production was first reported by Bone in 1999 [91].
The dose unit of laser energy is usually measured in J / cm 2 depending on the length of the treated vein, but is also used in J / cm 2 in terms of the linear endo-venous energy density (LEED). The current calculation is based on measuring the cross-sectional area of the venous and may result in different results depending on the measuring point. The ven diameter may also change due to catheterization spasm and tumescent anesthesia [92]. In recent years it has been suggested that there is a relationship between venous occlusion and energy elevation per cm cm [88, 89, 93]. The average energy range for effective ablation therapy was accepted as 60100 J / cm in the literature. There is only one article in the literature that uses pulse energy as high as 100-150 J, and this study reported high nerve and skin damage. It is understandable that although high energy increases clinical success (93,94), it also increases unwanted complications associated with the procedure.
It has also been reported in the literature that the risk of DVT is increased when the specified energy ranges are exceeded [66].
In EVL therapy, laser energy can be given continuously or in pulses. Constant energy is dissipated in the EVLA treatment using continuous wave. It is produced by opening and closing the laser energy with short pulses. The rate of fiber pull is in the range of 1-3 mm in continuous form. A stronger different laser type is used in Pulse EVL treatment. Pulse EVLA treatment usually 1 sec. Intervally, 1 sec. the laser fiber is pulled 2-3 mm and the dam is energized for pulses of 1 second [96, 97].
Min and his colleagues compared sustained and pulsar laser application, resulting in less side effects in continuous fiber extraction [95, 97].
It may be difficult to enter the vein depending on the patient and technique during the procedure. This problem can be especially prevalent in obese patients. Venospasm can sometimes make it difficult to enter the vasculature. Providing the patient with the reverse trendelenburg position during the operation may facilitate entry of the valve. Catheter advancement due to tortious venules, aneurysmatic segment, and sclerotic venules
The superficial veins of the lower extremity consist of large saphenous veins, small saphen veins and their branches and reticular veins. Reticular venules are networked venous structures that run parallel to the skin surface between the superficial fascia and the dermis. They train the skin and subcutaneous tissues on the lower extremity. These venules are associated with the deep venous system via either saphenous tympanic venules or perforating venules. It has been shown that 60% of patients with uterine telangiectases in the UK have a direct relationship between the deep system and retinal venous insufficiency via perforation venules [38].
The large saphenous vein (BSV) begins as the continuation of the arcus venosus dorsalis pedis in the medial to the foot ridge of our body, through the medial malleolus in the ankle, with saphenus. The main femoral vene is opened by penetrating the posteromedial of the knee joint and piercing the deep fascia on the inner surface of the thigh [34].
BSV is in the superincompartment, in the safenous compartment between the saphenous fascia on the surface and the muscular fascia in the deep. In the ultraso-nography (US) examination of the thigh, the transverse view of this compartment was defined as the Egyptian eye image (fig. 2). In the saphenous compartment, the nerve and arteries coexist with the saphen vein, and the
reticular venules and the tributaneous venules are out of the saphenous compartment [38-40].
The region where the main femoral vein is placed about 3 cm below the inguinal ligament of the BSV is called the safenofemoral junction (SFB). In BSV, 94100% of the cases have a terminal lid 1-2 mm distal from the SFB. In addition, there is often a separate fixed lid 2 cm distal from the terminal lid. Some major tympanic venules (superficial circumflex iliac vein, superficial epigastric vein, superficial external pudental ven) join BSV to these two lids. These venules are responsible for venous drainage of the pudendal space and lower abdominal wall.
Fig. 2. LSV's view of Egyptian eyes in transverse US
The BSV is always in the safenous compartment in the lower leg and upper thigh sections. Nevertheless, reduction in calibration or in some segments may not be followed in any of the saphenous compartment, which is called segmental hypoplasia of BSV. The mo st common form of segmental hypoplasia is the BSV penetrating the saphenous fascia into the subcutaneous tributary branch and continuing as the BSV in the sa-phenous compartment by penetrating the fascia again in the middle thigh segment [41, 42].
Some varicose veins or accessory saphenous veins parallel to BSV cause confusion in the identification of BSV duplications. For true BSV duplication, two separate branches parallel to each other in the saphenous compartment are required. However, the tributary ven-ules are in the saphenous compartment and the accessory saphenous veins are not in the same compartment as the BSV. In recent studies, actual BSV duplication was observed at 1% in the population [43].
Tributary venules are venules that are associated with the saphenous vein, either parallel or oblique, outside the saphenous compartment, and reattach the sa-phenous fascia to the saphenous compartment. These venoms may sometimes be miscible with accessory safenose venue, duplication or BSV itself. Thigh anterior and posterior circumflex femoral veins, leg anterior branch and posterior arch vein (Leonardo's vein) are some of the major tributary venules. Anterior branches
and posterior arches begin directly after the medial malleolus and become BSV drained distal to the knee. The anterior circumflex femoral vein joins the BSV about 2-3 cm inferior in SFB and trains the anterolateral subcutaneous tissues of the thigh. This is why it is called anterolateral ven. The posterior circumflex administers posteromedial subcutaneous tissue of the thigh-vein thigh. Occasionally, small saphenous veins can also be seen in the thigh. This extension of the small safen venue is called Giacomini Venus. There is also a tributary venous called the lateral venous system, which drains the lateral subcutaneous tissues of the thigh [44].
Accessory branches of BSV are rarely seen. Anterior accessory saphen vein (AASV) is parallel to the BSV in the thyroidal safenous compartment but it is anterior and posterior. It may be confused with BSV in some cases, but BSV is always located laterally in the AASV when it is located in the medial femoral venous. Accessory safen was seen in 14% of patients with varicose veins [44]. Posterior accessory saphen vein (PASV) is not as common as AASV, although it continues with the saphenous fascia on the thigh [43].
The small saphen vein (KSV) begins at the lateral side of the dorsal pedal and passes posterior to the lateral malleolus, popliteal vesicles are poured in different shapes posterior to the leg. Usually, the ankle postero-medial has tributary branches associated with deep ven-ules and cutaneous tributary branches on the back of the
tail. A number of anastomoses can be found with BSV. The termination of CSV is variable and is defined in 3 different ways [44, 45].
. 1) KSV, popliteal vene is contained at the level of the saphenopopliteal joint.
. 2) KSV is associated with an anastomotic vein with popliteal ven, and the superiority of Giacomini continues as a wing or thigh extension.
. 3) KSV may not be associated with the popliteal ven, and the superiority of Giacomini continues as a span or thigh.
The thigh extension of Giacomini vein or KSV, reflux in BSV, KSV, or vice versa, can lead to BSV as a reflux in the saphenopopliteal junction (SPB) [43].
It has been reported that anatomical studies performed in cadavers have an average of 64 perforans from the crotch to the foot [41]. These veins either directly reach the main axillary venous or indirectly to the vein sinus and to the drain. Usually intramuscular is found in sept. Although there are many numbers and variable levels, the perforating venous can be clinically divided into four groups. These can be grouped as foot perforations, medial and lateral calf perforations, and thigh perforations. While the current is directed towards the superficial system in the leg perforating veins, the flow in the other perfornant veins is straight to the deep system. An average of 4 or 5 paraperoneal perforations in the lateral calf are associated with peroneal venules and CSV. The perforating veins in the medial compartment are the most clinically important group. The posterior tibial venules connect the posterior accessory safen venus with the posterior tibial ven-ules with the paratibial perforating veins BSV. Par-atibial perforating venules are superior and posterior perforating venules are inferior perforated venules. The femoral canal perforating ligaments connect the proximal popliteal or distal femoral veins with BSV [34].
Figure 3. The superficial and perforated veins [35] The small saphen vein (KSV) begins at the lateral side of the dorsal pedal and passes posterior to the lateral malleolus, popliteal vesicles are poured in different shapes posterior to the leg. Usually, the ankle postero-
medial has tributary branches associated with deep ven-ules and cutaneous tributary branches on the back of the tail. A number of anastomoses can be found with BSV. Sural is close to the nerve [43].
The termination of CSV is variable and is defined in 3 different ways [44, 45].
1) KSV, popliteal vene is contained at the level of the saphenopopliteal joint.
2) KSV is associated with an anastomotic vein with popliteal ven, and the superiority of Giacomini continues as a wing or thigh extension.
3) KSV may not be associated with the popliteal ven, and the superiority of Giacomini continues as a span or thigh.
The thigh extension of Giacomini vein or KSV, reflux in BSV, KSV, or vice versa, can lead to BSV as a reflux in the saphenopopliteal junction (SPB) [43].
It has been reported that anatomical studies performed in cadavers have an average of 64 perforans from the crotch to the foot [41]. These veins either directly reach the main axillary venous or indirectly to the vein sinus and to the drain. Usually intramuscular is found in sept. Although there are many numbers and variable levels, the perforating venous can be clinically divided into four groups. These can be grouped as foot perforations, medial and lateral calf perforations, and thigh perforations. While the current is directed towards the superficial system in the leg perforating veins, the flow in the other perfornant veins is straight to the deep system. An average of 4 or 5 paraperoneal perforations in the lateral calf are associated with peroneal venules and CSV. The perforating veins in the medial compartment are the most clinically important group. The posterior tibial venules connect the posterior accessory safen venus with the posterior tibial ven-ules with the paratibial perforating veins BSV. Par-atibial perforating venules are superior and posterior perforating venules are inferior perforated venules. The femoral canal perforating ligaments connect the proximal popliteal or distal femoral veins with BSV [34]. The superficial and perfornant venues of the lower extremity are shown in Fig.3.
Fig. 3. The superficial and perforated veins [35]
There are many symptoms related to venous insufficiency. Most of these pain, weight, bloating, itching, restless legs and cramps are encountered. Symptoms tend to be milder in the morning, while intensifying during the day or longer. One of the common complaints is the ankle and foot swelling, which is typically not observed in the morning and becomes apparent at the end of the day, especially during the day. The described symptoms are relieved by the elbow of the legs [46].
Venous insufficiency can be observed in a range of clinically variable telangiectases ranging from active ulcers to non-healing ulcers.
The lower extremity varicosities are divided into three groups according to their size and distance from the skin: spider (telengectazic), reticular and varicose venules [21,30].
They are intradermal and have no protrusion from the skin. Smaller than 1 mm, red colored vascular structures. Often they can be painful with a cosmetic problem. They can be found with or without truncal or reticulate varicose veins.
They are subdermal deposits. There is protrusion from the skin. Blue-violet, vascular structures 1-4 mm in diameter. They can do pain. These are dilate venules that do not belong to the main saphenous trunks or major branches.
Subdermal placement is vascular structures with diameters ranging from 3-4 mm to several centimeters and showing significant protrusion from the skin. They may cause severe symptoms. These are derived from BSV, KSV and their branches.
Fig 4: Types of varicose veins
The varicose veins, which are curved, enlarged and easily repressible, can be identified by typical images. While varicose veins originating from BSV are usually distributed on the inner surface of the thigh and leg, varicose veins originating from CSV are distributed in the posterior part of the leg.
Variceal complications are chronic complications involving acute complications and skin changes (stasis dermatitis, lipodermatosclerosis and ulceration) involving superficial thrombophlebitis and hemorrhage [46].
Superficial thrombophilebit affects BSV, KSV and major branches, causing secondary inflammation in the venous wall with thrombosis. In the acute phase, a painful, sensitive vein and localized redness and temperature increase are seen in this area. Pulmonary embolism due to superficial thrombophilia may develop [4,5]. After the acute phase, pigmentation remains when the fibrous cords are back and the affected vein is close to the skin level [46].
In varicose veins, hemorrhage may be life-threatening as trauma or spontaneously. Death events related to variceal hemorrhage have also been reported in the literature [6,7].
Stasis dermatitis occurs in the skin and subcutaneous tissue due to the effects of inflammatory mediators delivered by venous hypertension. It is characterized by dryness, thickening and rash on the skin. Often night itch is accompanied. Scratching bleeding, infections, draining de-epithelialization areas that can form ulcers
may occur. Lipodermatosclerosis (LDS) is a chronic localization of the skin. It may be with scar and contracture. It is a sign of a serious venous disease. The skin is characterized by chronic inflammation and fibrosis of the subcutaneous and sometimes fascia. In general, venous ulcers arise as a result of trauma in the previous LDS field. Venous ulcers are skin lesions located under and above the internal malleolus, superficial, irregular borders and pink granulation tissue at the base. The prevalence of venous ulcers, the most troublesome complication of venous insufficiency, is 1% in adults [46,47]).
All of these findings have been evaluated together and a CEAP classification has been developed that classifies clinical, etiological, anatomical and pathophysio-logical causes together for a common communication and treatment consensus [48].
Chronic venous insufficiency is one of the diseases that can be diagnosed and diagnosed by listening to patient complaints. It is important to know the exact cause of the problem in order to plan the treatment method to be applied. Diagnostic methods used in the evaluation of the lower extremity venous system can be grouped as providing anatomical and diagnostic information, or providing functional information. US In recent years, the lower extremity is the most important examination method used to diagnose chronic venous insufficiency. This simple and non-invasive diagnostic
method allows anatomical and functional examination with gray scale, duplex and color flow imaging.
In gray scale US, the time between the reflection intensity of the rotating sound (amplitude of the rotating wave) and the reception of sound waves reaching the probe is calculated while the rotating wave is encoded in different gray shades. In addition to this information, the reflected sound wave also includes phase, wavelength and frequency information that is not taken into account when creating the B-mode review image. Using this information, images are produced in Doppler US (50).
Blood is a nonhomogeneous medium of randomly distributed red blood cells, composed of many blood components of various diameters. When the wavelength of the transmitted ultrasound sound wave is too large from the reflective surface (such as erythrocyte), the transmitted ultrasound waves show a scattering called Rayleigh-Tyndall scattering from the surface of erythrocytes in the vascular structures. The amount of scattering is proportional to the fourth order of the frequency of sound .
In fixed textures, the wavelength (X) and frequency (f) of the ultrasonic sound wave are the same as the wave length and frequency of the wave propagating to the probe after reflection. On moving reflective surfaces, there is a frequency difference in the returning sound waves[51].
In 1842, this frequency difference was described by Johann Christian Doppler as 'Doppler Effect' (Doppler Shift). Doppler has found an increase in the frequency of the energy produced by moving energy sources as they move towards the sensing system, and a decrease in frequency when moving away from the sensing system The amount of frequency difference (AF) depends on the blood flow velocity (V0), the frequency of the sound wave from the source to the frequency (Ft), the velocity of the sound in human tissue (c), and the angle of ultrasonic sound wave to the long axis of the vessel (0). All these effects are specified in a single equation (Doppler equation).
Doppler Equation AF= 2Ft.Vo.Cos0/C
The speed of sound waves in human body is assumed to be 1540 m / s on average. Since the other parameters of the Doppler frequency are in the predetermined state, the frequency difference is mainly dependent on the angle. Theoretically, if the Doppler angle is 0 the highest frequency difference is obtained (cos 0 ° = 1). This is not possible in practice and also difficulties arise when the signal is obtained due to reflection of the entire sound waves from the vessel wall at the small opening. When the Doppler angle is 90 the Doppler frequency difference is not detected and the current is not encoded because cos 90 ° is equal to zero. In the sample, when the antegrade and retrograde currents are deteriorated in the approaching angle of 90 false-current information appears in the form of a mirror image in equal amounts above and below the baseline line. In cases where the Doppler angle exceeds 60 °, small changes in the angle give rise to speed values that are well above the true value because of large changes in the cosine value of the angle. For these reasons, it is necessary to make the examinations such that
the angle between the sound waves and the direction of the current is 30-60 ° [58].
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РЕТРОКАВАЛЬНЫЙ МОЧЕТОЧНИК. ОПРЕДЕЛЕНИЕ. ДИАГНОСТИКА. ЛЕЧЕНИЕ.
(ОБЗОР ЛИТЕРАТУРЫ)
Поляков Н.В.
НИИ урологии и интервенционной радиологии им. Н.А. Лопаткина - филиал ФГБУ «НМИЦ радиологии» Минздрава России, Москва, руководитель группы реконструктивной урологии отдела
общей и реконструктивной урологии Кешишев Н.Г.
НИИ урологии и интервенционной радиологии им. Н.А. Лопаткина - филиал ФГБУ «НМИЦ радиологии» Минздрава России, Москва, заведующий инновационным отделом
Григорьева М.В.
НИИ урологии и интервенционной радиологии им. Н.А. Лопаткина - филиал ФГБУ «НМИЦ радиологии» Минздрава России, Москва, младший научный сотрудник инновационного отдела
RETROCAVAL URETER. DEFINITION. DIAGNOSIS. TREATMENT. (A
LITERARURE REVIEW)
Polyakov N. V.
N.A. Lopatkin SRI of urology and interventional radiology - branch of FSBINMRRC of the Ministry of Health of Russia, Moscow, head of the reconstructive urology group in the general and reconstructive urology
department Keshishev N. G.
N.A. Lopatkin SRI of urology and interventional radiology - branch of FSBI NMRRC of the Ministry of
Health of Russia, Moscow, head of the innovative department
Grigoryeva M. V.
N.A. Lopatkin SRI of urology and interventional radiology - branch of FSBI NMRRC of the Ministry of
Health of Russia, Moscow, junior scientific officer in innovative department
АННОТАЦИЯ
Ретрокавальный мочеточник — это редко встречающаяся врожденная аномалия, при которой мочеточник кольцевидно огибает нижнюю полую вену. Компрессия мочеточника нижней полой веной может привести к нарушению пассажа мочи с развитием уретерогидронефроза. В настоящем обзоре представлены данные мировой литературы о диагностике и методах лечения данной патологии.
