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II. ХИРУРГИЯ
THE ROLE AND EFFICACY OF LASER ABLATION IN THE CONDUCT OF PHLEBECTOMY OF INCOMPETENT PERFORATING VEINS
Aliyev M. S.
Azerbaijan State Institute of Medical Improvement named after A. Aliyeva, Baku, Azerbaijan Abstract
The aim of the study was to determine and evaluate the effectiveness of endovenous laser ablation (EVLA) during phlebectomy of perforant veins (PV).
Materials and methods. 53 patients(men - 9, women - 44) with vari-cose veins of the lower extremities were hospitalized on the basis of Kaspar clinic and private UNI clinic .The duration of varicose disease ranged from 1 to 47 years and averaged 21.2± 10.9 years. Clinical examination was carried out according to the generally accepted method for these patients. The study included the results of examination and treatment of 53 patients in the period from 20162019 with varicose veins of the lower extremities. The patients were divided into 2 groups. The main group included 31 patients who underwent endovasal laser ablation of the main saphenous veins. The control group consisted of 22 cases of varicose disease in which traditional phlebectomy was used.
Results. Successful transcutaneous access to the PV and placement of a laser light guide in it was carried out in 30 patients. One patient was recorded extravasation with the formation of hematoma during the puncture, in connection with which there was no repeated puncture of PV in the framework of this procedure. It should be noted that the failure in the implementation of EVLA was on the 3rd patient, which we cause with the initial stage of mastering the EVLA PV technique and the relatively small diameter and length of the PV. The procedure was well tolerated by all patients. The average diameter of the treated PV was 3.7 mm (3 to 4.8 mm), and the length was 3.6 cm (2.4 to 6.8 cm). Qualitative ablation of PV was observed in 41 patients, which was confirmed by duplex sonography. Repeated intervention was required in 1 patient after an unsuccessful attempt to puncture the PV.
Conclusions. EVLA is a safe, effective and less traumatic method of eliminating failed PV, performed on an outpatient basis.
МРНТИ 76.29.30
ABOUT THEАUTHORS
Aliyev M.S. - assistant professor of the Azerbaijan State Institute of Medical Improvement named after A. Aliyev
Keywords
Laser ablation, varicosity, phlebectomy
Перфорантты кектамырлар алып тастаудагы аблацияньщ ролi мен ттмдшт
Алиев М.С.
Азербайджанский Государственный Институт Усовершенствования Врачей им. А. Алиева, Баку, Азербайджан
АВТОРЛАР ТУРАЛЫ
Алиев М.С. - А. Алиев arbiHMaFbi дзрбайжан мемлекетк дэр1герлерд1ц бш!м1н жетлдру институтыныц доцентi
Ацдатпа
Зертrеудiц максаты: Перфорантты кектамырлардын (ПК) флебэктомиясы кез1ндеп эндовеноздык лазерлi абляцияньц (ЭВЛА) тиiмдiлiгiн багалаужэне аныктау.
Материалдар жэне ад/стер: Kaspar клиникасына жэне UNIжеке-меншiк клиникасына аяк кектамырларынын варикозды кенеюi бар 53 наукас (9 - ер адам, 44 - эйел) жаткызылды. Варикозды аурулардын узактыты 1 жылдан 47 жыл€а дейiн созылды жэне орташа есеппен 21,2±10,9 жылды курайды. Бул наукастарды клиникалык тексеру жалпы^а ортак эдстеме бойынша щрпзшщ. Зерттеуде 2016-2019 жылдар аралы€ында€ы аяк кектамырларынын варикозды кенеюi бар 53 наукастын тексерлу жэне емдеу нэтижелерi коса усынылды. Наукастар 2 топка белШд'г Непздi топты непзп терiасты кектамырларына эндовазальдык лазерлi абляция жасалеан 31 наукас курады. Бакылау тобын дэстyрлi флебэктомия колданылган варикозды аурулары бар 22 жагдаят курады.
Нэтижелер'/: 30 наукастын ПК-на терiаралык колже^мдшк жэне оган лазерлi сэулежол енпзу сэтт турде жузеге асырылды. Пункция кез1нде бiр наукаста гематома пайда болып, экстравазация аныкталды. Сондыктан осы емшаранын аясында кайталама ПКпункциясыжурпзшгенжок. Ескерте кетелн жайт, ЭВЛА-ны орындау кезтдеп сэтаздк 3-шi наукаста байкалды, бiз муны ПК-нын ЭВЛА техникасын игеруiнiн бастапкы кезе^мен жэне ПК-нын диаметрi мен узынды^ынын кыска болуымен байланыстырамыз. Емшараны барлык наукастар жаксы еткердi. бнделген ПК-нын орташа диаметрi 3,7 мм-ны (3-4,8 мм), ал узынды^ы 3,6 см-ны (2,4-6,8 см) курады. 41 наукастан ПК-нын сапалы абляциясы бакыланды. Бул дуплекслк сонография аркылы дэлелдендi. ПК пункциясынын сэтаз орындалуынан кейiн 1 наукаска кайталама араласу кажет болды.
Цорытынды: ЭВЛА - амбулаториялык жа€дайларда орындалатын каушаз, тиiмдi жэне ПК-ны жоюдaFы жаракаты аз эдс.
Туйш сездер
лазерлк аблация, флебэктомия, варикоз
Роль и эффективность применения лазерной абляции при проведение флебэктомии перфорантных вен
ОБ АВТОРАХ
Алиев М.С. -
Доцент АГИУВ им. А. Алиева
Ключевые слова
лазерная аблация, флебэктомия, варикоз
Алиев М.С.
Азербайджанский Государственный Институт Усовершенствования Врачей им. А. Алиева, Баку, Азербайджан
Аннотация
Целью исследования являлось определение и оценка эффективности эндовенозной лазерной абляции (ЭВЛА) при флебэктомии перфорантных вен (ПВ).
Материалы и методы. 53 пациента (мужчины - 9, женщины - 44) с варикозным расширением вен нижних конечностей были госпитализированы в клинику Kaspar и частную клинику UNI. Длительность варикозной болезни варьировала от 1 года до 47 лет и в среднем составила 21,2± 10,9 года. Клиническое обследование проводилось по общепринятой для этих больных методике. В исследование включены результаты обследования и лечения 53 больных в период с 2016 по 2019 год с варикозным расширением вен нижних конечностей. Пациенты были разделены на 2 группы. Основную группу составили 31 пациент, которому была выполнена эндовазальная лазерная абляция основных подкожных вен. Контрольную группу составили 22 случая варикозной болезни, у которых применялась традиционная флебэктомия.
Результаты. Успешный чрескожный доступ к ПВ и размещение в нем лазерного световода был осуществлен у 30 пациентов. У одного больного была зафиксирована экстравазация с образованием гематомы во время пункции, в связи с чем повторная пункция ПВ в рамках данной процедуры не проводилась. Следует отметить, что неудача в выполнении ЭВЛА была отмечена у 3-го пациента, что мы связываем с начальным этапом освоения техники ЭВЛА ПВ и относительно небольшим диаметром и длиной ПВ. Процедура была хорошо переносима всеми пациентами. Средний диаметр обработанного ПВ составлял 3,7 мм (от 3 до 4,8 мм), а длина-3,6 см (от 2,4 до 6,8 см). Качественная абляция ПВ наблюдалась у 41 пациента, что было подтверждено дуплексной сонографией. Повторное вмешательство потребовалось у 1 пациента после неудачной попытки пункции ПВ.
Выводы. ЭВЛА - это безопасный, эффективный и менее травматичный метод устранения ПВ, выполняемый в амбулаторных условиях.
Relevance of the problem
The Choice of method of treatment of patients with varicose disease of the lower extremities today remains one of the most pressing problems of modern surgery, due primarily to the extreme prevalence of this disease. According to [2,3 11].varicose veins of the lower extremities occur in 26-38% of women and 10-20% of men of working age [4]. According to other data, varicose disease affects from 20 to 50% of the population of industrialized countries [2, 11]. In addition, varicose veins of the lower extremities is the most common pathology of peripheral vessels, there is also a steady tendency to increase the incidence and rejuvenation of the patient population [9, 10]. According to the literature, in recent years there has been an increase in the incidence of persons of the most working age and an increase in the number of complicated forms of the disease, leading to persistent disability [1, 8, 11].
Steadily progressive and long-term course of the disease, the tendency to frequent complications, cosmetic defect significantly reduce the "quality of life" of patients. The relevance of this the problem is also due to the tendency to frequent recurrence of the disease, large financial costs for the treatment of this category of patients [3, 7, 9].
Due to the variety of clinical manifestations of varicose disease and features of the structure of the venous system of the lower extremities, the treatment of this pathology is not standardized. Therefore, the search for new and improvement of exist-
ing methods of treatment of patients with varicose disease continues [2,4,6.] Despite the large number of works devoted to the treatment of patients with varicose disease and the introduction of progressive minimally invasive methods of treatment, there are still many issues that require in-depth research. Of great importance is the study of long-term results of treatment in patients with varicose veins of the lower extremities, who underwent various variants of Stripping, endovasal laser and radiofrequency obliteration, as well as miniflebectomy and sclerotherapy in the tributary form of varicose disease. The question of expediency of endovasal laser and radiofrequency obliteration in patients with the diameter of the main saphenous veins more than 13-14 mm has not been finally resolved. In the domestic and foreign medical literature, there are many scientific papers in which it is reported that the results of these minimally invasive methods of treatment are quite comparable with the results obtained after the application of phlebectomy [6, 7, 8,9] ]. However, there are studies, the authors of which believe that the use of endovasal interventions with a large dimeter of the main saphenous veins is impractical due to the increasing likelihood of complications and recurrence of the disease. [1,3.5. 6 ]. Thus, many problems of treatment of patients with varicose disease of the lower extremities, remain still unsolved. It is necessary to develop and put into practice modern approaches to the treatment of patients with this pathology, which was the basis for this study. The aim of the study was to determine and evalu-
ate the effectiveness of endovenous laser ablation (EVLA) during phlebectomy of perforant veins (PV).
Materials and methods
53 patients( men - 9, women - 44) with varicose veins of the lower extremities were hospitalized on the basis of Kaspar clinic and private UNI clinic .The duration of varicose disease ranged from 1 to 47 years and averaged 21.2 ± 10.9 years. Clinical examination was carried out according to the generally accepted method for these patients. The study included the results of examination and treatment of 53 patients in the period from 20162019 with varicose veins of the lower extremities . The patients were divided into 2 groups. The main group included 31 patients who underwent endo-vasal laser ablation of the main saphenous veins. The control group consisted of 22 cases of varicose disease in which traditional phlebectomy was used.
The age of patients of the main group ranged from 16 to 58 years (on average 35.7 + 8.57 years). The vast majority of them were aged 31-50 years, i.e. belonged to the most socially active part of the population. The time from the onset of the disease to hospital treatment" ranged from 2 to 25 years and averaged 10 + 5 years.In the considered group of patients there were only 2 men" (%). All other patients were women, which once again allows us to emphasize the importance of compliance with cosmetic and aesthetic requirements when performing interventions on the venous system in varicose dis-
ease. Varicose disease of the left lower limb was detected in 37 patients (69.8%), the right - in 14 (26.4%), both - in 2 (3.8%)
All patients underwent endovenous laser ablation (EVLA) with a 1470 nm diode laser, after which they were observed for 12 months (1 day, 1 week, 1,3,6,12 months). Patients with ankle-shoulder index below 0.7, unable to move actively, history of deep vein thrombosis, pregnant women were excluded from the study. All patients were subjected to a thorough physical examination, a duplex examination of the veins of both lower limbs, a detailed questionnaire with the collection of anamnesis. Color duplex ultrasonography (SonoscapeS6 and SonoscapeS8, China) by 8 MHz transmitter was performed in a vertical position in order to identify the source of venous reflux, mark the skin in the PV projection and measure the diameter and length of the epifascial segment. The indication for the elimination of PV was objectively registered with the help of ultrasound pathological venous reflux on them. Even when detecting the failure of PV, the peculiarities of the course of the disease in a particular patient, the localization of the perforant and its characteristics were taken into account. Specific criteria for the feasibility of EVLA perforant considered the following: - the diameter of the perforant is more than 3.5 mm with a reflux duration of more than 0.5 s, regardless of the presence or absence of any trophic changes in the area of its basin (Fig. 1, 2);
Figure 2.
Lower leg PV (reflux more than 0.5 s)
f -.....~
' 1 ^ f___ -д_
Figure 3.
PV Shin (d=3.77 mm) -perforants dimeter less than 3.5 mm with a duration of reflux on them more than 0.5 s, localized in the zone of trophic disorders (classes C4-C6).
The procedure was carried out in a special operating room with precautions when working with lasers. Vein puncture was performed with a venous catheter 18G.a radial laser light guide"slim"(BIOUTEC, Germany) was inserted into the catheter, the distal end of which was installed at the point of transition to the infrafascial part of the PV (Fig. 3).
Perivenous tumescent anesthesia was performed under sonographic control. The amount of anesthetic solution was 50-100 ml, which was used as a standard Klein solution consisting of saline (1000 ml), 1% lido-caine (100 ml) and 8.4% sodium bicarbonate solution (10 ml). The laser energy was launched in a continuous mode (Biolitec, Germany), traction movements of the light guide were made manually "forward-backward" with gradual extraction of the fiber. The average energy consumption on PV was 310 j (from 150 to 550 j).The effectiveness of treatment was determined by the reduction and / or disappearance of symptoms, as well as a decrease in the diameter of the PV and the absence of hemodynamics in the occluded lumen during duplex examination. A visually analog scale (VAS) and a disease-specific CIVIQ questionnaire (4) were used for complaints and subjective symptoms. When monitoring the dynamics of chronic venous edema, a measuring tape was used. In trophic disorders, the effectiveness of treatment was evidenced by a decrease in inflammatory phenomena and the area of indurative cellulite, as well as signs of venous ulcer epithe-lization.Sonography of obliterated veins after 6 or 12 months revealed complete absorption or a thin fibrous layer without any signs of blood flow. Recanalization of PV, determined by ultrasound preservation of blood flow with no clinical improvement was assessed as a complete lack of treatment result.
Results and discussion
Successful transcutaneous access to the PV and placement of a laser light guide in it was carried out in 30 patients. One patient was recorded extravasation with the formation of hematoma during the puncture, in connection with which there was no repeated puncture of PV in the framework of this procedure. It should be noted that the failure in the implementation of EVLA was on the 3rd patient, which we cause with the initial stage of mastering the EVLA PV technique and the relatively small diameter and length of the PV. The procedure was well tolerated by all patients. The average diameter of the treated PV was 3.7 mm (3 to 4.8 mm), and the length was 3.6 cm (2.4 to 6.8 cm).Qualitative ablation of PV was observed in 41 patients, which was confirmed by duplex sonography (Fig.4). Repeated intervention was required in 1 patient after an unsuccessful attempt to puncture the PV. The average energy consumption per PV was 310 joules.
Pain in the postoperative period was observed in 9 patients (21.43%), of which 5 operated received flurbiprofentiocolchicoside, as an analgesic, 1 tablet 2 times/day orally for 4 days, and the remaining 4-for 1 week. Ecchymosis was observed in 19 patients (45.24%), which disappeared within
1-3 weeks. Induration was observed in 11 patients (26.19%), which also disappeared within
2-3 weeks. 28 patients (66.67%) complained of paresthesia, which did not occur in complaints of operated patients after 3-6 months (average 3.4 months). It should be noted that none of the patients with induration, ecchymosis and paresthe-sia were prescribed any drugs to accelerate the
Table 1.
Frequency of detection of postoperative complications
Complication Major group (n=31) Control Group (n=22)
Hematomas on the hip 2(6.5) 5(22,7)
Paresthesia, numbness 3(9,7) 7(31,8)
Lymphorrhea - 1(4,5)
Infection of p/o wounds - -
Superficial thrombophlebitis* 4(12,9) 8(36.4)
Deep vein thrombosis - -
* within 1 month after operation
elimination of these side effects of EVLA. In the postoperative period there were no such complications as superficial burns, DVT and arteriove-nous fistulas (table. 1).
It should be noted that in contrast to the classical surgical treatment of PV failure, minimally invasive treatments are aimed at reducing the risk and cost of surgery, which is convincingly evidenced by the results of EVLA.
EVLA PV using a diode laser with a wavelength of 1470 nm is clinically safe, acceptable and well tolerated by patients method with excellent cosmetic results and allows the operated almost immediately return to their normal daily activities. Adequate tumescent anesthesia is an important component of EVLA for emptying the vein lumen, as the blood absorbs the energy transferred to the vein wall. As a result, vein occlusion occurs due to thrombosis, the resolution of which in the future leads to recanalization.We used a continuous mode of laser energy supply using a traction technique in the range of 1 cm with extraction at 0.5 cm after supplying a portion of energy in 50-60 j.
Conclusions
EVLA is a safe, effective and less traumatic method of eliminating failed PV, performed on an outpatient basis. The correct calculation of energy and indications on an individual basis allows
Figure 4.
The light guide "slim" is installed in the PV of the Shin.
Figure 5.
PV Shin 1 month after EVLO
us to consider this minimally invasive technique as a successful method of eliminating reflux in PV for the treatment of VB and recurrence of VB and can replace traditional surgical treatment. EVLA is a reliable, safe and effective method of eliminating pathological reflux in the PV of the thigh and lower leg in both WB and RVB.
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