Ενδοαγγειακή Αντιμετώπιση Φλεβικών Παθήσεων Προ επεμβατική αξιολόγηση, ενδείξεις - αντενδείξεις Νικόλαος Ι. Ρούσας MD, Msc, PhD (Genova-Thessaly) Αγγειοχειρουργός

GSV BeforeTreatment Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

GSV After Treatment Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Is pre-op duplex assessment important for varicose vein surgery? Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

EVLA Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

STRIPPING Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Ultrasonic assessment Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Detection of reflux on Doppler Reflux is present when retrograde flow lasts for at least 1 sec Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Detection of reflux on colour facility Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

TRIPLEX ΦΛΕΒΩΝ ΔΙΑΓΝΩΣΤΙΚΗ ΑΞΙΑ Η αποτυχία να εντοπιστούν όλες τις πηγές της φλεβικής ανεπάρκειας είναι πιθανό να οδηγήσει σε πρώιμη υποτροπή Οι πληροφορίες που παρέχονται έχουν σημαντικές επιπτώσεις στην επιλογή της κατάλληλης θεραπείας Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

ΑΝΑΤΟΜΙΑ ΕΠΙ ΠΟΛΛΗΣ ΦΛΕΒΙΚΟΥ ΣΥΣΤΗΜΑΤΟΣ ΚΑΤΩ ΑΚΡΩΝ Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

ΑΝΑΤΟΜΙΑ ΕΠΙ ΠΟΛΛΗΣ ΦΛΕΒΙΚΟΥ ΣΥΣΤΗΜΑΤΟΣ ΚΑΤΩ ΑΚΡΩΝ SCI: Λαγόνιος Περισπωμένη SE: Επιπολής Επιγαστρική SEP: Αιδοιική AASV: Πρόσθια Επικουρική Σαφηνής PASV: Οπίσθια Επικουρική Σαφηνής Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

ΑΝΑΤΟΜΙΚΕΣ ΠΑΡΑΛΑΓΕΣ Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

ΑΝΑΤΟΜΙΑ ΕΠΙ ΠΟΛΛΗΣ ΦΛΕΒΙΚΟΥ ΣΥΣΤΗΜΑΤΟΣ ΚΑΤΩ ΑΚΡΩΝ Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Διατιτραίνουσα του DODD Διατιτραίνουσα του BOYD Διατιτραίνουσα του COCKETT Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Bound anteriorly by superficial fascia & posteriorly by deep fascia GVS “eye” Bound anteriorly by superficial fascia & posteriorly by deep fascia Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Small Saphenous Vein (SSV) Courses from lateral ankle up posterior calf Terminates in popliteal fossa at Saphenopopliteal Junction (SPJ) Variable confluence with Popliteal Vein (PV) Proximal portion lies between superficial & deep fascial layers Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

SSV Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Perforator Vein Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Indication Clinical Medical Indications for EVTA Quality of life affecting symptoms of venous insufficiency Skin changes associated with chronic venous hypertension Corona phlebectasia Lipodermatosclerosis Atrophie blanche pigmentation in the gaiter region of the lower leg Healed or active ulceration Edema Superficial thrombobophlebitis Multi-society Consensus Quality Improvement Guidelines for the Treatment of Lowerextremity Superficial Venous Insufficiency with Endovenous Thermal Ablation from the Society of Interventional Radiology, Cardiovascular Interventional Radiological Society of Europe, American College of Phlebology, and Canadian Interventional Radiology Association J Vasc Interv Radiol 2010; 21:14–31 Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

INDICATION Medical Indications for EVTA Anatomic Significant duplex US–documented reflux More than 0.5 seconds following a provocative maneuver Straight vein segment Diametre of central GSV > 15 mm may be associated with thrombus extension to CFV Presence of tortuous or aneurysmal segments Vein depth and maximum diameter Intra- or epifascial vein segment meeting other anatomic criteria Duplicate systems Large side branches Incompetent perforators or tributaries Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

CONTRAINDICATION Pregnancy or nursing* Relative Contraindications for EVTA Pregnancy or nursing* Obstructed deep venous system inadequate to support venous return after EVTA Liver dysfunction or local anesthetic allergy limiting local anesthetic agent use Severe uncorrectable coagulopathy, intrinsic or iatrogenic Severe hypercoagulability syndromes Inability to wear compression stockings secondary to inadequate arterial circulation, hypersensitivity to the compressive materials, or musculoskeletal or neurologic limitations to donning the stocking itself Inability to adequately ambulate after the procedure Sciatic vein reflux Nerve stimulator * Secondary to concerns related to anesthetic drug use and related to vein or heated blood effluent which may pass through the placenta to the fetus. Multi-society Consensus Quality Improvement Guidelines for the Treatment of Lowerextremity Superficial Venous Insufficiency with Endovenous Thermal Ablation from the Society of Interventional Radiology, Cardiovascular Interventional Radiological Society of Europe, American College of Phlebology, and Canadian Interventional Radiology Association J Vasc Interv Radiol 2010; 21:14–31

Aneurysmal or Tortuosity Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR) Images courtesy of Olivier Pichot, MD Images courtesy of Olivier Pichot, MD Aneurysmal or Tortuosity Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Thrombosis Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Position of the patient Greater saphenous Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Position of the patient Lesser saphenous Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Pre-op Ultrasound Assessment Map and mark Maximum diameter Tortuous segments Aneurysmal segments Areas where vein is very close to skin Large branches or perforators Potential access sites Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Vein depth from the skin: Why is so important? The aim of ablation procedures is to damage the inner vein wall without causing a full-thickness burn, which could lead to perforation of the vein resulting in bruising or haematoma formation If vein lies superficially, close to skin the ablation may cause burn Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

ILIOFEMORAL THROMBOSIS CT venography Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Rationale Endovascular thrombolytic therapy is reasonable to perform for selected patients with DVT causing acute limb-threatening circulatory compromise, acute inferior vena cava occlusion, acute ilio-femoral DVT for the purposes of limb salvage and relief of presenting DVT symptoms, and appears likely to prevent post-thrombotic syndrome (PTS) in patients with proximal DVT. Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

PHARMACO MECHANICAL THROMBOLYSIS Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

TRELLIS Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

EKOS Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

PHARMACO MECHANICAL THROMBOLYSIS Criteria to perform: Patent POP V Thrombus between CIV and mid-thigh CT PA (-)/ no RV dilatation/ no IVC thrombus No need for IVC filter Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

PHARMACO MECHANICAL THROMBOLYSIS How to perform Popliteal vein puncture U/S guided - 11 Fr sheath 5Fr pigtail to insert to the top of thrombus Withdrawal of pigtail while injecting 10ml rtPA Trelis or Angiojet Time from puncture to Trelis / Angiojet < 10 min Repeat venogram: if thrombus is cleared Stent in the iliac extending into IVC: Wallstent or Cook Zilver Vena (18mm – 14mm) Follow-up: 1d: U/S 6wks: CTV 6mths: U/S 12 mths: CTV Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

IVC filter placement Indications DVT and covtraindication for anticoagulation Reccurent PE being on adequate anticoagulation Pre-procedural evaluation MR or CT venography is required for IVC and iliac vein patency and IVC diametre measurement Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)

Thank you Νικόλαος Ι. Ρούσας MD, Msc, PhD (IT-GR)