Phlebological Review 1/2021

Page 1

ISSN 1232-7174

2021; Vol. 29, 1

Official Journal of the Polish Society of Phlebology

9 771232 717110


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Official Journal of the Polish Society of Phlebology



Founded in 1993 by Dr Tomasz Drążkiewicz Official Journal of the Polish Society of Phlebology

EDITORIAL STAFF Editor-in-Chief Honorary Editor-in-Chief Associate Editor

Marian Simka (Poland) Tomasz Drążkiewicz (Poland) Zbigniew Rybak (Poland)

Editorial Office

Phlebological Review Editorial Office ul. Kleeberga 2, 61-615 Poznań phone/fax: +48 61 822 77 81 e-mail: phlebologicalreview@termedia.pl

Deputy Editors

Zbigniew Krasiński (Poland) Tomasz Urbanek (Poland) Tomasz Zubilewicz (Poland)

Section Editors

Biophysics in phlebology Fausto Passariello (Italy)

Endovascular treatment Marzia Lugli (Italy)

Laser & RF treatment Uldis Maurins (Latvia)

Leg ulcers & chronic wounds Zbigniew Rybak (Poland)

Lymphatic disorders Waldemar Olszewski (Poland)

MR imaging E. Mark Haacke (USA)

Thromboembolic disorders Evi Kalodiki (UK)

Ultrasonography Paolo Zamboni (Italy)

Vascular malformations Byung-Boong Lee (USA)

Venous disorders of the central nervous system Stefano Bastianello (Italy)

Venous & lymphatic disorders in tropical countries Surgical treatment of varicose veins Malay Patel (India) Arkadiusz Jawień (Poland) Dermatological disorders & Cosmetic treatment in phlebology Eberhard Rabe (Germany)

Sclerotherapy Alessandro Frullini (Italy) Compression therapy Giovanni Mosti (Italy) Language editor

Timothy Alexander (English)

Statistics editor

Małgorzata Misztal

Editorial Board

R. Adamiec (Poland), A. Cavezzi (Italy), L. Cierpka (Poland), A. Dorobisz (Poland), M. Drążkiewicz (Poland), Ł. Dzieciuchowicz (Poland), B. Eklöf (USA), M. Gabriel (Poland), S. Głowiński (Poland), P. Gutowski (Poland), T. Jargiełło (Poland), J. Kłoczko (Poland), W. Kostewicz (Poland), M. Kucharzewski (Poland), W. Kuczmik (Poland), Z. Mackiewicz (Poland), G. Madycki (Poland), W. Majewski (Poland), M. Maruszyński (Poland), S. Molski (Poland), M. Motyka (Poland), G. Oszkinis (Poland), R. Niżankowski (Poland), M. Pardela (Poland), F. Pukacki (Poland), J. Sadowski (Poland), S. Sajdak (Poland), A. Sieroń (Poland), M. Skórski (Poland), R. Staniszewski (Poland), W. Staszkiewicz (Poland), P. Szopiński (Poland), M. Szostek (Poland), P. Szyber (Poland), W. Tomkowski (Poland), A. Undas (Poland), Z. Várady (Germany), J. Windyga (Poland), W. Witkiewicz (Poland), M. Zaniewski (Poland), K. Ziaja (Poland)

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CONTENTS 1/2021 PRO MEMORIAM

Professor Waldemar Lech Olszewski

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Doctor Krystyna Twardowska-Saucha

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Andrzej Szuba

Tomasz Drążkiewicz

EDITORIAL PAPERS

30 Years of the polish society of phlebology – how it all happened Tomasz Drążkiewicz

Sclerotherapy contraindications, sequelaes, and complications – informing patients properly and objectively is required Tomasz Urbanek, Maciej Piotr Rzepka, Agnieszka Jolanta Roj, Patrycja Alicja Rozwadowska

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ORIGINAL PAPERS

The awareness of airline passengers about the risk of deep venous thrombosis during an aeroplane flight

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Single-centre experience with mechanochemical ablation of insufficient veins with the Flebogrif® catheter in a 36-month follow-up

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Marcin Kucharzewski, Katarzyna Duda, Adrianna Doman, Marek Olesz, Wacław Kuczmik, Tomasz Urbanek

Marek Iłżecki, Piotr Terlecki, Stanisław Przywara, Tomasz Zubilewicz REVIEW PAPER

Sclerotherapy – from historical research to the modern and efficient method of phlebological treatment Joanna Borecka-Sobczak

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CASE REPORTS

Challenges in the reflux ablation in a patient with chronic venous leg ulcer – case report

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Iliocaval stenting – case report

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Abstracts of the oryginal papers – International Congress of Polish Society of Phlebology 10–12 June 2021

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Maciej Jusko, Tomasz Urbanek

Jan Jakub Kęsik, Tomasz Zubilewicz



In this issue… Dear Colleagues and Friends, This 2021-year issue of the Phlebological Review will be released just before the International Congress of the Polish Society of Phlebology. This event will be unique. Since we are still amidst the COVID-19 pandemics, we are forced to meet online – as we have already used to do for over a year regarding other scientific and educational activities. Nonetheless, I do hope that all of you will enjoy the congress, as well as the articles published in this issue. Firstly, there is the paper written by the first President of our Society, Dr. Tomasz Drążkiewicz, presenting history of the Polish Society of Phlebology. In this issue you can also find another educational paper – on the history of sclerotherapy. I invite you to read this interesting article describing how this most commonly used method for the treatment of varicose veins has evolved. Then there is the paper dealing with information provided to the patients before sclerotherapy, and how such information is given in different phlebological centres in Poland. Another paper discusses the problem of awareness of airline passengers of the risk of thromboembolism associated with the flights. Next original contribution presents the late results of mechanochemical ablation of incompetent veins with the use of the Flebogrif device. Finally, there are two case reports: describing a successful treatment of a recalcitrant venous leg ulcer year with laser ablation of incompetent saphenous vein and describing a successful endovascular revascularisation of thrombosed inferior vena cava. I hope you enjoy your read. Sincerely, Marian Simka, MD PhD Editor-in-Chief



Katowice, Poland

June 4, 2021

Ladies and Gentlemen, This year’s International Congress of the Polish Society of Phlebology coincides with a special occasion: the thirtieth anniversary of the foundation of the Phlebology Society in Poland. Founded back in 1991 in the city of Katowice as the Phlebological Society, it was rechristened the Polish Society of Phlebology the following year. For a summary of our Society’s history, I recommend reading a very interesting article penned by our own Dr. Tomasz Drążkiewicz, one of its founders, which can be found in this issue of the Phlebological Review. The road was long, but the thirty years we spent building and developing the field of phlebology in Poland were not in vain: since the 1990s, we have made tremendous progress in both the diagnosis and treatment of venous and lymphatic diseases. As it stands, Polish phlebology in 2021 offers modern diagnostics and treatment protocols based on the latest scientific and technological developments. This staggering progress, clearly evident in our everyday clinical practice, would be not possible without the didactic, organizational, and scholarly efforts of the Polish Society of Phlebology and its esteemed Members. We have come a long way since the Society’s foundation. Today, phlebology is recognized as a separate, distinct discipline of vascular medicine, focused on a variety of clinical problems, including chronic and acute venous diseases as well as lymphatic system disorders. Through the efforts of many Polish phlebologists, modern treatments are now available to venous disease patients nationwide. The thirtieth anniversary of our Society seems like the right time to extend our most heartfelt thanks to all of its Members, Presidents, and Executive Committies, as well as to everyone who worked with the Polish Phlebological Society and contributed to development of Polish phlebology, both at home and abroad. The success of Polish phlebology is a success for all of us – once again, thank you all very much. I would also like to give special thanks to our industry Partners for their help and cooperation. And, last but not least, a very special round of thanks to all of our colleagues, who have spent precious time organizing phlebological and lymphological events and publishing their research articles. With best wishes, Prof. Tomasz Urbanek President of the Polish Society of Phlebology



Pro Memoriam

PROFESSOR WALDEMAR LECH OLSZEWSKI 1941–2020 Professor Waldemar Lech Olszewski, Honorary Member of Polish Society of Phlebology passed away on November 8th. He was born on September 3, 1931 in Poland. Graduated in 1954, he passed Board in Surgery exams in 1962, received degrees of Doctor of Philosophy in 1962 and Doctor of Science in 1968. Since 1970 Olszewski has been an associate professor at the Department of Surgery of the Warsaw Medical Academy, and the Medical Research Center at Polish Academy of Sciences in Warsaw. In 1978 he received a full professor degree at the same centers, and became chairman of the Clinical Department of Surgery, Ministry of Internal Affaires/Polish Academy of Science Hospital, Warsaw. Professor Olszewski received postgraduate training at the Hammersmith Hospital in London from 1962 to 1963, then at Harvard Medical School in Boston, from 1968 to 1970. He worked at City Hospital, Warsaw, and then Dept. of Surgery, Medical Academy, and Medical Research Center, Warsaw as head of Department of Surgical Research & Transplantation and since 1997 as Chief of Clinical Department of Surgery, Ministry of Internal Affaires/Polish Academy of Sciences Hospital, Warsaw. Other professional positions include Visiting Professor at Radiumhospitalet, Oslo (since 1976), St. Bartholomew’s Medical School, London (since 1994), Research Officer World Health Organization, Madras-Pondicherry-Benares, India (since 1992). For over 50 years professor Olszewski carried out research on lymphatic system. He has made many important discoveries related to lymphatic system functioning. However professor Olszewski’s clinical and research activities were not limited to lymphatic system and included vascular surgery, transplantation, physiology and surgery of the lymphatic system and immunology. His most important scientific contributions include designing and introducing into clinical practice the surgical lympho-venous shunts (1966), discovery of spontaneous rhythmic lymphatic contractility in humans (1980), proving that bacterial factor is responsible for development of human limb lymphedema (1994), introducing low-dose, long-term penicillin administration for prevention of chronic dermatitis and lymphangitis in Asian countries (1996), detecting the phenomenon of non-specific elimination of cell grafts (1990), preservation of tissues for transplantation in dehydrating sodium chloride (2003). In his last years devoted a lot of work to the fluid hydromechanics in tissue edema. Recently, he has developed a new method for treating lymphedema with the help of subcutaneously implanted silicone drains. He authored and co-authored five scientific books and over 600 research papers. Professor Olszewski was a member of many national and international scientific societies and served as President of European Society for Surgical Research (1977–1978), International Society of Lymphology (1989–1991), Polish Society of Immunology (1995–1998). He has received multiple awards and honors including: Doctor Honoris Causa-Universita di Genova (2005), Lymphatic Research Leadership Award (2006), Best Career Investigator Award from two American medical organizations – the National Lymphedema Network and the Lymphology Association of North America (2006), and Deutsche Gesellschaft für Phlebologie Ratschow Medal (2012). He conducted his research on lymphedema and lymphatic system with scientists from many countries worldwide including India, China, Egypt as well as Italy, Norway and the USA. His international scientific activities were validated with the Bene Merito Medal – by Polish Foreign Ministry for Contribution to World Medicine (2013). We regret to say goodbye to Professor Olszewski, our teacher and mentor, and join in pain with his family. Andrzej Szuba President, International Society of Lymphology President of the Section of Lymphology of the Polish Society of Phlebology and Polish Society of Phlebology

Phlebological Review 2021

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Pro Memoriam

DOCTOR KRYSTYNA TWARDOWSKA-SAUCHA 1941–2020 With deep regret we announce that on December 21, 2020, having lived 79 years, passed away Krystyna Twardowska-Saucha MD, PhD, internist and specialist in industrial medicine. She graduated 1967 from Faculty of Medicine at the Silesian Medical Academy, now Medical University of Silesia, Katowice, Upper Silesia, Poland. She defended her PhD in medical sciences (PhD) at the University in 1977. In 1981 she obtained a specialization in the field of internal medicine. In 1984 she became a specialist in the field of industrial medicine. On a daily basis, she dealt with diagnostics and treatment – among others, diseases of the digestive, circulatory and nervous systems, she also issued opinions in the field of occupational medicine. She was a physician, university teacher, educator of many generations of doctors, a long-time employee of the Department and Clinic of Internal Medicine, Diabetology and Nephrology in Zabrze (Upper Silesia, Poland). Together with her husband (a lawyer), in 1985, she founded one of the first Polish private modern vein treatment centers in Zabrze. She was one of the pioneers of modern sclerotherapy of varicose veins. She worked there almost until the last days. She was a Co-Founder Member of the Silesian Medical Chamber in Katowice, which was reactivated in 1989. She was also the Co-Founder Member of the Polish Society of Phlebology (PTF/1991) and a long-term member of the Board of the PTF (1991–2003), serving for two terms as Vice President (1991–1994 and 1994–1997) and General Secretary (1997–2000 and 2000–2003). Together with M. Maruszyński and T. Drążkiewicz, Dr. Krystyna Twardowska-Saucha participated in the preparation and submission of documents allowing the PTF to join the IUP/UIP (Sydney, Australia 1998). She was able to establish valuable contacts with outstanding specialists who, thanks to her, often and willingly have visited Poland and invited Polish phlebologists to learn in their centers around the world. Together with her husband, she was proud of their son, who works as an experienced and respected specialist in the field of anesthesiology and intensive care in one of Europe’s largest centers of CardioVascular Surgery and Transplatology in Zabrze. The departure of this kind, modest and hardworking person makes us realize that time does not stand still. May the memory of her stay forever among those who knew and valued her. To her husband – Bogusław Saucha and the son – Wojciech Saucha and their whole Family we make a declaration of support in difficult times. It can be said without exaggeration that She sacrificed her health and life for medicine and Her patients. Let us pay tribute to Her.

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Dr. Tomasz Drążkiewicz and Polish Society of Phlebology

Phlebological Review 2021


30 YEARS OF THE POLISH SOCIETY OF PHLEBOLOGY – HOW IT ALL HAPPENED Tomasz Drążkiewicz

EDITORIAL PAPER

Department of Vascular Surgery and Endovascular Procedures, the John Paul II Hospital, Kraków, Poland

Phlebological Review 2021; 29, 1: 3–18 DOI: https://doi.org/10.5114/pr.2021.106836

My motto If you do something important and it survives, you should always be respected, happy and calm.

THE FIRST MENTION OF VEINS IN THE HISTORY OF MEDICINE Ancient history 4th/3rd century B.C. Hippocrates (c. 460–c. 377 BC), Greek physician, one of the precursors of modern medicine (author of Corpus Hippocraticum), known as the father of medicine.

2nd century A.D. Galen – Claudius Galenus (129–200 A.D.), Roman doctor of Greek origin, anatomist, philosopher, talented researcher, and writer, one of the most outstanding ancient doctors. He described, among other things, the heart valves and the differences between the arteries and veins. He established that blood flowed through the arteries and veins, not air, as previously thought.

Modernity/renaissance 1507 Leonardo da Vinci (1452–1519), Italian Renaissance painter, sculptor, architect, engineer, explorer, mathematician, anatomist, inventor, geologist, philosopher, musician, writer. He deduced that all veins and arteries derive from the heart.

1628 William Harvey (1578–1657), English biologist. He made a breakthrough in biology by describing the blood-

Phlebological Review 2021

Submitted: 30.04.2021 Accepted: 18.05.2021 ADDRESS FOR CORRESPONDENCE Tomasz Drążkiewicz Department of Vascular Surgery and Endovascular Procedures The John Paul II Hospital 80 Pradnicka St. 31-202 Kraków, Poland e-mail: t.drazkiewicz@szpitaljp2.krakow.pl

stream. For the first time ever, he discovered that the heart acts as a suction pump and causes constant blood circulation in the vessels with which it forms a closed system.

SELECTED ESSENTIAL INFORMATION ABOUT PHLEBOLOGY IN THE WORLD The history of varicose veins treatment goes back to ancient times. However, for many centuries no diagnostic methods were known, and the methods of treatment were very primitive and limited. Contemporary phlebology was beginning to develop starting in the mid-18th (compression therapy) and early 20th century. Some of the most famous pioneers of invasive phlebology treatment were W.W. Babcock1 (1907, Philadelphia, USA) and both J. Sicard (Paris, F) and P. Linser (Tübingen, D), who in 1904 simultaneously and accidentally discovered the possibility of sclerotherapy of varicose veins. In the 20th century, classic surgery and classic sclerotherapy were the main methods used in the invasive treatment of varicose veins of the lower extremities. Over the last decade of the 20th century and the two decades of the 21st century the diagnostics, prophylaxis and treatment of varicose veins have changed radically thanks to the use of constantly improved medical equipment including duplex Doppler ultrasound (DUS/USG) and radiological equipment with the use of innovative treatment techniques. Thanks to the improved classic surgery of varicose veins (limited stripping, phlebectomy) and dynamic development of minimally invasive endovascular/endovenous 1

Babcock WW. A new operation of varicose veins of the leg. New York Medical J 1907; 86: 153-156.

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Tomasz Drążkiewicz

methods using inter alia radio, laser, steam ablation or chemical obliteration (adhesives, foam sclerotherapy), there is tremendous progress in terms of both safety and effectiveness.

1947 It was not until 1947 that Raymond Tournay (1893– 1984) coined the term phlébologie, and he introduced this term into the world’s medical vocabulary and terminology. The oldest scientific and didactic association in the field of phlebology is the French Society of Phlebology (Société Française de Phlébologie – SFP), founded in 1947 in Paris by R. Tournay, J. Sicard and J. Marmasse. R. Tournay was its general secretary for many years.

1953 The second national association was the Phlebological Association of Italy (l’Associazione Flebologica d’Italia) – now the Italian Society of Phlebology/Società Italiana di Flebologia (SIF). Their founder was G. Bassi. Currently, five separate associations with a phlebological profile originate from here.

1957 The third national association was the German Society of Phlebology (Deutsche Gesellschaft für Phlebologie – DGP), founded March 24, 1957 in Frankfurt/M initially as the Deutsche Arbeitsgemeinschaft für Phlebologie. Indeed there was an Association of Specialists for Leg Diseases in Germany between 1909 and 1934, even temporarily publishing its own journal, but with regard to current standards, this organization was more a professional association than a scientific society. Therefore, the majority of authors agree that the Société Française de Phlébologie (SFP) was the world’s first scientific phlebological association. Here is a classic example of the importance of historical details in the competition for the palm of priority. In the same year, on November 16, 1957, the fourth association, the Benelux Society of Phlebology (Benelux Vereniging voor Flebologie/Société Bénéluxienne de Phlébologie) was founded in Eindhoven under the aegis of H.R. van der Molen.

1959 On March 24, 1959 in Paris, Union Internationale de Phlébologie (UIP2)/International Union of Phlebology (IUP) was established by these four previously existing associations. The first UIP World Congress was held in Chambéry in 1960. Directors: J. Marmasse and Suzanne 2

www.uip-phlebology.org/history.

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Bourgeois. The last one (18th) UIP World Congress took place in February 3–8, 2018 in Melbourne (Australia). The next (19th) UIP Congress should be in Istanbul, Turkey in September 12–16, 2022. Today UIP is composed of 74 member societies from 71 countries. The current UIP president is K. Parsi (Australia, 2019–2023). Former UIP president: N. Morrison (USA, 2015–2019).

1960 The Swiss Society of Phlebology (SSP) was constituted by A. Bolliger, H.J. Leu and K. Sigg.

1963 The Scandinavian Society for Phlebology/Societas Phlebologica Scandinavica (SPS) (Denmark, Finland, Norway and Sweden) was founded by G. Bauer and K. Hæger.

1968 The first Latin-American purely phlebologically orientated association, the Sociedad Argentina de Flebologia y Linfologia (SAFL), was brought to life and was acknowledged by the bodies of the UIP.

1973 The Canadian Society of Phlebology (Société Canadienne de Phlébologie – SCP) was founded by G. Cloutier.

1974 The Australasian College of Phlebology (ACP): In 1999 the name was officially changed to the present one when connection was made from originally the Australian and New Zealand Society of Phlebology, founded by P. Conrad and W. Campbell (1974) and the Sclerotherapy Society of Australia, founded by P. Thibault (1993). ACP is currently the most advanced in the world in phlebology education. There are a number of different membership (fellowship) classes to incorporate a variety of professionals working in areas related to phlebology. Currently, there is no formal recognition for phlebology as a medical specialty in the world. In Australia, ultimately, the long term goal of ACP is achieving Australian Medical Council (AMC) recognition of phlebology as a distinct medical specialty. The recognition process is a long one and needs a lot of resources. The ACP is committed to achieving this aim.

1985 Especially interesting is the history of the establishment of the phlebology society in the USA. It all started with A. Butie (originally from Switzerland), who found-

Phlebological Review 2021


30 years of the Polish Society of Phlebology – how it all happened

ed the North American Society of Phlebology (NASP) in August 4, 1985, incorporated the society in June of 1986, and held the first annual meeting in February of 1988. At that time in the United States the use of Doppler ultrasound (DUS/USG) was not widely known and not used for evaluation of varicose veins. Doctor Butie’s vision was to share his knowledge to improve patient care in the USA. There was a group in New York that already had some sort of a society founded, but he was not impressed with the level of scientific knowledge in that group, so he decided to start own group together with 14 co-founder members. Based on the NASP, different branches were formed and are now functioning, working together with different associations. The most famous of these are: the American Venous Forum (AVF) founded in 1987, and the American College of Phlebology (ACP), which today is called the American Vein and Lymphatic Society (AVLS) – the name was changed on November 19, 2018 during the 32nd ACP Annual Congress in Nashville, Tennessee, USA. Regardless of their goals and form and mode of action, all these organizations identify Dr Butie as the founder of American phlebology.

1991 The Polish Society of Phlebology (PTF), initially as the Society of Phlebology in Katowice, was founded on September 23, 1991 on the initiative of T. Drążkiewicz on June 23, 1991. The PTF is the first medical association founded in Central and Eastern Europe after 19893. A year later, the second such society was established in the Czech Republic.

1992 Czech Society of Phlebology/Česka Flebologicka Společnost (CFS). The founder (1992) of the CFS, Maruška Horáková (1925–2003), was one of the most famous, outstanding phlebologists, sitting in the authorities of the UIP and honoured with honorary membership of several phlebology societies. Earlier (1973) the Phlebology Section of the Czech Society of Dermatology and Venereology was established.

2000 The European Venous Forum (EVF) was established in 2000 in Lyon, France as an idea of A. Nicolaides under the leadership of M. Perrin. The EVF works under the auspices of the Union Internationale de Phlébologie (UIP) and the International Union of Angiology (IUA). The objective is to develop education, scientific knowledge, research and clinical expertise of the highest quality and establish 3

J une 4, 1989 – the first free elections and the end of real socialism in Poland.

Phlebological Review 2021

standards in the field of venous disease. Membership is wide and open to anyone who has an interest in the field irrespective of medical discipline. The EVF was founded to follow the example of the American Venous Forum (AVF, founded 1987), according to Bo Eklöf, a former president of the AVF. M. Perrin confirmed this, stating: “the AVF was the stimulus for the creation of the EVF.” Perrin added – laughing, as he looked back at that first Lyon Congress – “I did not care about an article published in a French vascular journal some months later, which stated that ‘Michel Perrin is a traitor, because he organised an English-speaking convention in Lyon, the Gaul capital’.” This is just one example in this foreign place of how difficult it is to convince some of a new idea (author’s – T.D., footnote).

2010 The first European Venous Forum Hands-on Workshop on Venous Disease (EVF HOW) was organized in 2010 in Larnaca, Cyprus. Chairmen: B. Eklöf and P. Neglén.

2013 European College of Phlebology (ECoP). Why was the ECoP founded? E. Rabe, ECoP founder: “Venous disease is common in Europe. The development of phlebology in the last decade has changed the medical profession substantially. Nevertheless, phlebology is not well recognized in the European medical system. In addition, phlebology is an interdisciplinary specialisation involving vascular surgeons, internists, dermatologists, radiologists, haematologists, general practitioners and practitioners of other disciplines who also play an important role in patient care. To endorse the European cooperation in phlebology, including education and certification, we founded the European College of Phlebology in April 2013”. The founding executive board of the ECoP, E. Rabe, M. Neumann, A. Davies and C. Wittens, would like to invite you to the first ECoP Course to be held 26–28 of November 2021 in Amsterdam. This course is organized with educational lectures and hands-on practical training especially for the professionals dedicated to venous disease. All professionals – nurses, vascular technicians, doctors, medical specialists, trainees and all others involved in venous pathology – are invited to join in. The European College of Phlebology supports Phlebology in Europe.

2015 The EVF HOW Plus – new improved practical courses. Started in an improved form in 2015 by O. Maleti and Marzia Lugli. Originator: Bo Eklöf.

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Fig. 1. Fathers of the idea of establishing a phlebological association in Poland, from left to right: B. Eklöf (S), T. Drążkiewicz (PL), W. Hach (D)

THE POLISH SOCIETY OF PHLEBOLOGY (POLSKIE TOWARZYSTWO FLEBOLOGICZNE – PTF) The history of the society is based on my memory, but also on the memory of the witnesses of those events, as well as the preserved archival evidence-based documents. Special thanks go to Mrs. Ewa Skwarek, who for 10 years – from 1992 to 2002 – was leading the PTF Authorities Office and the Editorial Office of the Phlebological Review. I have been asked many times about how the PTF was established. Let everything be clear: from the autumn of 1990, my intention was to establish a nationwide association of phlebology in Poland. My idea of establishing the society was surprising. Here we must go back to the end of the 1980s and the beginning of the 1990s. Back then, I could not have foreseen how my two casual contacts with B. Eklöf4 and W. Hach5 would have such a significant impact on my personal and professional future, and not only mine (Fig. 1).

The beginnings of modern phlebology in Poland In Poland, the medical community has been interested in and dealt with venous issues for many generations. At this point, it is impossible to mention even the most important 4

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rofessor Bo Eklöf (b. 1935), MD, PhD – Swedish general P and vascular surgeon, phlebologist. President of the American Venous Forum (2003–2005) and the American Venous Forum Foundation (2007–2008). rofessor Wolfgang Hach (b. 1930), MD, PhD – German generP al and vascular surgeon, internist, radiologist, phlebologist. First Honorary Member of the Polish Society of Phlebology (1994).

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ones in this topic. At the beginning of the twentieth century, as soon as W.W. Babcock developed (1905) and published (1907) the original method of varicose vein surgery, such operations began to be performed around the world, including in Poland in all hospitals with surgery departments within their structures. As I mentioned above, in 1947 in France, R. Tournay introduced the term phlebology to the medical vocabulary, which was slowly spreading in other countries. Until 1990, there were many famous doctors in Poland, mainly surgeons treating venous diseases, but no one used the term phlebology. It should be noted here that at the end of the 1980s, in the so-called Eastern European Countries, including Poland, mostly matters in medicine were determined not only by professional but also political considerations. At that time in Poland, it was not customary to use Western neologisms in medicine. I came across this term for the first time in 1988, when – while working as a surgeon in Kuwait, I met Professor Bo Eklöf from Sweden, who said that he was working in Kuwait as a vascular surgeon, phlebologist, and the head of the University Department of Vascular Surgery. He added that perhaps we would be able to establish cooperation when I completed the Polish contract as general surgeon. I did not ask what exactly he meant then, but I really liked the topic of phlebology very much. However, cooperation did not take place, because immediately after this meeting, I found out that in October 1988, Professor Roman Adamczyk6 – the head of the 6

rofessor Roman Adamczyk (1925–1988), MD, PhD – one of P the pioneers of general, vascular, cardiac surgery and phlebology in Poland – head of the Department of General and Vascular Surgery (1977–1988), University of Silesia, Katowice, Poland.

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30 years of the Polish Society of Phlebology – how it all happened

department where I worked in Katowice since 1977 – died suddenly. So I decided to return to Poland to continue my work in the department and further research and teaching activities. Several years later, the very friendly cooperation of our society with B. Eklöf began, and it continues to this day. One and a half years later in August 1990, during a holiday trip to the south of Europe, I stopped for a week in the health resort of Bad Nauheim, near Frankfurt am Main. I fortuitously found out that there is a hospital where, among other things, varicose veins are treated. I decided to go there. It turned out to be William Harvey Klinik, which still operates, among others, the Vascular Surgery Department. It was then that I got to know the medical director and the head of the department. He was Professor Wolfgang Hach, widely known in Europe and around the world. When he found out where I was from and what I was doing, he invited me to the hospital for a few days as a visiting vascular surgeon. On the very first day, I heard again the word ‘phlebology’. I learned that Professor Hach was an active long-term member and current president (1988–1991) of the German Society of Phlebology (DGP), which had been in existence for 33 years at the time. During that meeting the question was – among other things – whether there was any phlebological association in Poland. If so, the DGP would be open to cooperation with Polish phlebologists. I replied that I did not know because I had been working abroad for almost two years, but after returning from vacation I would check and let him know. At the end of this meeting, I also learned that in the autumn of 1991 another 34th Congress of this Society (DGP) would be held in Frankfurt am Main, to which I was initially invited. I left there convinced that probably such an association or at least some phlebology section existed in Poland. After returning to Poland in September 1990, I paid a visit to the Provincial Court in Katowice. After a few days, it turned out that no medical association with such a profile was registered in Poland! The second piece of good news was that thanks to the first free elections held in Poland 15 months earlier – on June 4, 1989 – and the end of real socialism in Poland, many regulations had been changed, among others, those related to the registration of associations. Before that, registration with the Supreme Court was required. Now such registration could take place in the Provincial Court, in accordance with the place of the planned seat of the association! I received instructions with a list of the necessary documents to be submitted. These were: application for the registration of the association, a list with the signatures of at least 15 co-founder members, and the statute. I let Professor Hach know, and soon he sent me not only the current DGP statute, but also the statutes of several other phlebological societies to which he had access. When, after a few months, I had developed the draft statute, I met two people who had been treating vein diseases in their private centre in Zabrze since 1985. They were Dr Krystyna Twardowska-Saucha and her husband, a law-

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yer, Bogusław Saucha. This cooperation was very beneficial for many years to come. In the spring of 1991, thanks to the very significant help of B. Saucha, as an outstanding lawyer, we jointly proceeded to refine the final version of the statute. The task turned out to be much more difficult and complex than it seemed at the beginning. At that time, I did not realize how much work and effort I had to do. The question arose: Why are 15 people required to register? It turned out that this was the number necessary to conduct the founding meeting and appoint the so-called officials to the authorities, and then to register the association.

Beginnings of the Polish Society of Phlebology 1991.06.23, Katowice (Poland) – initial meeting with the participation of T. Drążkiewicz, originator and initiator of the establishment of the Polish Society of Phlebology, author of the draft statute and B. Saucha, co-author of the draft version of the statute. The main purpose of this meeting was to prepare the documents necessary to convene the founding assembly. Here I would like to announce that after this meeting I sent invitations to 52 heads of clinics and departments of the Silesian Medical Academy in Katowice7, to participate in the founding meeting. After three months, only three had replied. 1991.09.23, Katowice (Poland) – the founding meeting. A broader explanation should be given at this point. Well, from the very beginning, my intention was to establish a nationwide association called the Polish Society of Phlebology. What, then, was the real reason for the original name: Society of Phlebology (without the word ‘Polish’)? According to the archival protocol from the founding meeting (September 23, 1991), in the draft statute submitted at that time, together with Mr. Saucha, we entered the name PTF. Unfortunately, three candidates for the future Scientific Committee, who were present at the founding assembly – raised a reservation, questioning this name. They proposed the name ‘Society of Phlebology in Katowice’. They argued that the name of the PTF proposed by both of us could cause an unpredictable reaction from the medical community in Poland, especially among vascular surgeons. In this situation, we both (Mr. Saucha and I) submitted a motion to put this topic to a vote. Unfortunately, the vote did not take place in the end. I think that at this meeting no one, except the two of us, fully believed in the success of the entire project. So, the name of the Society of Phlebology in Katowice remained, but I managed to push through the entry in § 1 of the statute: “The area of ​​the Society’s activity is the territory of the Republic of Poland.” Opponents sceptical about the name PTF were partially right. When the news of the new movement spread throughout Poland, there was an embarrassing silence on the side of vascular surgeons that lasted almost a year, which meant that this information was not accepted. The situation improved 7

Now the Medical University of Silesia in Katowice, Poland.

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Tomasz Drążkiewicz

when I started explaining to sceptics that our society was multidisciplinary, and hence our members included both doctors of various specialties and people representing other professions (e.g., nursing, rehabilitation, physiotherapy, and many others, even law), which meant that our activities, from the very beginning, would not interfere with the activities of other associations. In mid 1992, there was a breakthrough change of attitude – among others, on the part of the most influential vascular surgeons at the time, who had just established the Polish French Angiological Society (P-FTA) on the initiative of Z. Mackiewicz (Poland) and M. Perrin (France). During the 1st P-FTA Congress, which was then held in Pułtusk (Poland), it was finally acknowledged and confirmed that we had a nationwide phlebological society, which was established as the first medical association in Poland and in our part of Europe after 1989. From that moment on, other medical associations of various profiles began to emerge, including the Polish Angiological Society (PTA) (B. Kowal-Gierczak, Wrocław, 1992). I think that the above statements comprehensively answer important questions about the origins of our society. The participants were the following persons (in alphabetical order), who were specified in the protocol as co-founder members: Marek Błaszczyński (Katowice), Marek Drążkiewicz (Bielsko-Biała), Tomasz Drążkiewicz (Katowice), Urszula Drążkiewicz (Katowice), Zygmunt Fiutek (Zabrze), Jacek Gawrychowski (Zabrze), Teresa Kozik (Bielsko-Biała), Tomasz Kozik (Bielsko-Biała), Hanna Matuszewska-Zbrońska (Zabrze), Marian Pardela (Zabrze), Tadeusz Petelenz (Katowice), Bogusław Saucha (Zabrze), Krystyna Twardowska-Saucha (Zabrze), Ryszard Zbroński (Zabrze), Krzysztof Ziaja (Katowice). At this point it is worth adding that in June 1991, upon the news that I was going to organize a founding meeting in September with the participation of 15 people, I was informed by W. Hach that the Board of the German Society of Phlebology (DGP) had decided on his request to invite all 15 co-founder members of our society to participate in the 34th DGP Congress, which was to take place in early October. We had very little time, but we made it. Two weeks after our meeting, we travelled with a group of 14 out of 15 co-founder members to Frankfurt am Main. Those were four unforgettable days. We all received free congress participation and a free 4-day stay in top-class hotels and a staggering amount of DM 500 per person for our own needs! It should be remembered that at that time the monthly salary of a doctor in Poland was the equivalent of no more than 50 DM (!). Since then, there has been very close and successful cooperation with DGP. Thanks to this, many Polish phlebologists have trained in local centres, as well as in other countries. For many years now prominent phlebologists from all over the world have accepted invitations to international meetings organized by us and often we hear from them that the level of phlebology in Poland is currently very similar to the global one. This is evidenced, for example, by the European Chapter Meeting of the International Union of Phlebology (UIP), organized in Kraków 8

by the current president of the PTF (see below, under the date 2019.08.25–27). 1991.11.19, Katowice (Poland) – incorporation in the Court. 1991.11.27, Katowice (Poland) – 1st General Assembly of Members. Election of the authorities for the 1st term of office 1991–1994. President – T. Drążkiewicz (Katowice), Vice President – K. Twardowska-Saucha, General Secretary – B. Saucha, Treasurer – M. Błaszczyński, President Elect at the 1st Congress of the Society (1994, Bielsko-Biała) – M. Drążkiewicz. Scientific Committee: M. Pardela, T. Petelenz, K. Ziaja. 1991.12.19, Katowice (Poland) – Acquisition of personality in law. This meant that our society could formally start operating in Poland and internationally. 1992.03.12, Warszawa (Poland) – Scientific Symposium (the first fully phlebological meeting in Poland). Post-thrombotic syndrome. Leg ulcers. Chairman: M. Szostek. 1992.05.18, Katowice (Poland) – 1st Inaugural International Scientific and Training Conference of the Society (PTF). Phlebology Yesterday and Today. Chairman: T. Drążkiewicz. Special guest U. Schultz-Ehrenburg (D). Number of participants: 40. 1992.06.24, Katowice (Poland) – 1 st PTF Training Course. Sclerotherapy. Chairman: T. Drążkiewicz, M. Nowakowski. 1992.11.25, Katowice (Poland) – 2nd Extraordinary General Assembly of Members. Change in the statute: change of the name from the Society of Phlebology to the Polish Society of Phlebology. The written application was submitted by Dr A. Witek, gynaecologist and obstetrician from Katowice, who later (1993) also became one of the editorial secretaries of the Phlebological Review. A similar oral proposal was made by colleagues from Wrocław: P. Szyber and Z. Rybak, very active organizers of many PTF meetings (see further information) (Fig. 2). The Provincial Court in Katowice made an entry in the register of associations: Based on the documents provided (including the Protocol from the Extraordinary General Meeting of Members of November 25, 1992), the name was changed in the register of the nationwide association existing since September 23, 1991, from the Phlebological Society in Katowice, to the Polish Society of Phlebology. Thus, from a formal point of view, September 23, 1991 was recognized in law as the date of establishment of the Polish Society of Phlebology. 1992.11.25, Katowice (Poland) – 2nd PTF Training Course. Phlebotropic drugs. 1993.04.23, Katowice (Poland) – 3rd PTF Training Course. Practical Aspects of Compression Therapy and Sclerotherapy. 1993.05.21, Katowice (Poland) – meeting of the PTF Main Board. An official journal of the PTF was established, as well as the bilingual Polish-English journal Phlebological Review. At that time, it was – after the British Phlebology – the world’s second English-language journal of phleboPhlebological Review 2021


30 years of the Polish Society of Phlebology – how it all happened

Fig. 2. Polish Society of Phlebology, 25.11.1992, Katowice (PL). Management: Board and Scientific Committee (1991–1994) logy. Being the initiator and founder of this journal, I was elected Editor-in-Chief by the PTF Board (1993–2001, volume 1–9). The subsequent Editors-in-Chief were: M. Skórski (2002, volume 10) and Z. Rybak (2003–2013, volume 11–21). Currently (from 2014, volume 22) the Editor-inChief is M. Simka. Currently, the journal is published in English under the name Phlebological Review. In 2022, we will celebrate the 30th year (volume 30) of publishing our journal. So, there will be an opportunity to summarize and present the next chapter in the history of Polish phlebology. 1993.06.05, Katowice (Poland) – 2nd PTF International Scientific and Training Conference. Practical Aspects of Compression Therapy and Sclerotherapy. Chairmen: T. Drążkiewicz, M. Nowakowski. Number of participants: 110. 1993.09.06–10, Budapest (Hungary) – 1st European Congress of the Union Internationale de Phlébologie/ International Union of Phlebology with around 1000 participants from all over the world, including a large group of Polish phlebologists. At the congress, which took place simultaneously with the 56th Congress of the Society of Polish Surgeons (see below), about 1000 participants attended. 1993.09.06–10, Lublin (Poland) – 56th Congress of the Society of Polish Surgeons (Towarzystwo Chirurgów

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Polskich – TChP). The chairman, P. Misiuna8, wanting to honour the establishment of the Polish Society of Phlebology (1991), planned the first Phlebology Session in Poland during the TChP Congress, inviting me to conduct it. Unfortunately, this session was cancelled because the leader of the previous session, Prof. Andrzej Cencora9, suddenly fainted – he happily recovered soon, and this event went down in history both in Polish surgery and phlebology. 1993.12.07, Katowice (Poland) – Inaugural edition of the bilingual (Polish and English) official indexed journal 8

n January 8, 2021, the sad news reached us – Professor O Paweł Misiuna (1928–2021) died at the age of 93. He was MD, PhD, an outstanding general surgeon, vascular surgeon, oncologist and phlebologist, founder, and head of the Vascular and then General Surgery Departments in Lublin, Provincial (Lublin) and regional consultant, academic teacher, and tutor of several generations of doctors. We honor his memory.

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rofessor Andrzej Cencora (1938–2008) – general and vasP cular surgeon, angiologist, phlebologist. Provincial (Kraków) and Regional Consultant for vascular surgery. Head of the Department of Vascular Surgery and Angiology (1982–2006). University teacher. Polish representative in the European Society of Vascular Surgery.

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Tomasz Drążkiewicz

Fig. 3. 1st Congress of the Polish Society of Phlebology, 1994, Bielsko-Biała (PL) – information of the Polish Society of Phlebology, Phlebological Review 1993; 1: 1-87. 1994.04.29–30, Bielsko-Biała (Poland) – 1st Inaugural International Congress of the Polish Society of Phlebology. President of the Congress: M. Drążkiewicz. (Fig. 3). Number of participants: 375. Special Lecturers: W. Hach (D), G. Fegan (UK), U. Hepp (D), M. Moniuszko (CA), W. Noszczyk (PL), Z. Várady (D), J. Grotewohl (D), A. Cavezzi (I). During the congress, 6 phlebologists received a diploma of Honorary Member of the Polish Society of Phlebology: W. Hach, G. Fegan, M. Moniuszko, J. Nielubowicz, W. Noszczyk, Z. Várady. 1994.06.30 – 3rd General Assembly of PTF Members. Election of the authorities for the 2nd term of office 1994– 1997. President – T. Drążkiewicz (Katowice), Vice President – K. Twardowska-Saucha, General Secretary – B. Saucha, Treasurer – M. Błaszczyński. President-Elect at the 2nd Congress of the Society (1997, Wrocław) – P. Szyber. Scientific Committee: M. Pardela, T. Petelenz, K. Ziaja. 1994.05.10, Zabrze (Poland) – 1st PTF International Sclerotherapy Training Course. Training Course Manager: G. Fegan, Chairmen: Krystyna Twardowska-Saucha, T. Drążkiewicz. (Fig. 4). 1995.09.03–08, London (United Kingdom) – 12th World Congress of the International Union of Phlebology (UIP/IUP). Primary handing over of the application for

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the admission of PTF to UIP: T. Drążkiewicz (PTF president) to G. Jantet (UIP president). 1995.04.26, Katowice (Poland) – 3rd PTF International Scientific and Training Conference. Ulcus Cruris. 1996.04.24–25, Katowice (Poland), Silesian Opera – 4th PTF International Scientific and Training Conference. 5th Anniversary of the PTF. Compression Therapy – the first international trilingual meeting in Poland with simultaneous translation (Polish, English, German). Chairmen: T. Drążkiewicz, K. Ziaja. Number of participants: 350. 1997.04.27–29, Wrocław (Poland) – 2nd International Congress of the Polish Society of Phlebology. President of the Congress: P. Szyber. Special Lecturers (inter alia): W. Hach (D), A. Cavezzi (I), M. Perrin (F). 1997.04.29. – General Assembly of Members. Election of the authorities for the 3rd term of office PTF 1997–2000. President – M. Maruszyński (Warszawa), Vice President – Z. Rybak, General Secretary – Krystyna Twardowska-Saucha, Treasurer – M. Błaszczyński. Members of the Board: T. Drążkiewicz, M. Kucharzewski, S. Molski, A. Ruciński, A. Żychliński. 1997.09.12–13, Kołobrzeg (Poland) – 5 th PTF Jubilee International Scientific and Training Conference. Practical Course of Sclerotherapy (with live video recording). Chairmen: A. Żychliński, T. Drążkiewicz, M. Nowakowski.

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30 years of the Polish Society of Phlebology – how it all happened

Fig. 4. 1st Polish Society of Phlebology International Workshop for Sclerotherapy, 1994, Zabrze (PL). From left to right: G. Fegan (UK), Krystyna Twardowska-Saucha (PL), T. Drążkiewicz (PL), M. Błaszczyński (PL) 1998.03.12–14, Szklarska Poręba (Poland) – 6th PTF International Scientific and Training Conference. Diagnostics of Vein Diseases (with live video recording). Chairmen: P. Szyber, Z. Rybak. 1998.06.17. – Affiliation of the PTF at the Polish Ministry of Health and Social Care. 1998.09.09–13, Sydney (Australia) – 13th World Congress of the International Union of Phlebology (UIP). Important Event (1998.09.10): UIP Membership for the Polish Society of Phlebology – thanks to the Board of the UIP, especially: A. Davy (president of UIP 1989–1995), G. Jantett (president of UIP 1995–1999) and A. Nicolaides (former president of IUA). Documents for the access to UIP were prepared by: M. Maruszyński (president PTF, 1997–2000), T. Drążkiewicz (president founder of PTF, 1991) and Krystyna Twardowska-Saucha (general secretary of PTF, 1997–2000). 1999.03.11–14, Szklarska Poręba (Poland) – 7th PTF International Scientific and Training Conference. Compression Therapy. 1999.05, Bydgoszcz (Poland) – 1st Polish-Italian Phlebology Meeting. 1999.06.10–12, Berlin (Germany) – 1st German-Polish Symposium of Phlebology.

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2000.03.02–05, Szklarska Poręba (Poland) – 8th PTF International Scientific and Training Conference. Venous Insufficiency and its Complications in Pregnant Women. 2000.05.23–25, Warszawa (Poland) – 3rd International Congress of the Polish Society of Phlebology. President of the Congress: M. Maruszyński. Granting the title of honorary member of the PTF to special lecturer G. Jantett (F). 2000.05.25. General Assembly of PTF Members. Election of the authorities for the 4th term of office 2000–2003. President – Z. Rybak (Wrocław), Vice President – M. Skórski, General Secretary – K. Twardowska-Saucha, Treasurer – A. Żychliński. 2001.03.01–04, Szklarska Poręba (Poland) – 9th PTF International Scientific and Training Conference. 10th An­niversary of the PTF. Laboratory Diagnostics Methods Used in CVI. Chairmen: Z. Rybak, P. Szyber. 2001.05.05, Bydgoszcz (Poland) – 10th PTF International Scientific and Training Conference/2nd Polish-Italian Phlebology Meeting. Under the patronage of PTF (PL) and SIF (I). 2001.05.18–20, Kołobrzeg (Poland) – 11th PTF International Scientific and Training Conference. Application of Freezing and Obliteration Techniques in the Treatment of Varicose Veins. 10th Anniv. of the PTF.

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Tomasz Drążkiewicz

2002.03.01–03, Szklarska Poręba (Poland) –12th PTF International Scientific and Training Conference. PostThrombotic Syndrome (PTS). 2002.09.17–18, Sopot (Poland) – 13th PTF International Scientific and Training Conference. Advances in Phlebology. 2003.02.27.–03.02, Krynica (Poland) – 14 th PTF International Scientific and Training Conference. Ulcus Cruris Venosum. 2003.05, Bydgoszcz (Poland) – 15th PTF International Scientific and Training Conference. 3rd Polish-Italian Phlebology Meeting. Under the patronage of PTF (PL) and SIF (I). 2003.06.20–23, Wrocław (Poland) – 4th International Congress of the Polish Society of Phlebology. President of the Congress: Z. Rybak. Special Lecturers (inter alia): M. Perrin, A. Cavezzi (I). 2003.06.23. – General Assembly of PTF Members. Election of the authorities for the 5th term of office 2003– 2006. President – A. Jawień (Bydgoszcz), Vice President – A. Cencora, General Secretary – M. Ciecierski. Treasurer – A. Żychliński. 2004.03.04–07, Szklarska Poręba (Poland) – 16th PTF International Scientific and Training Conference. Compression Therapy. Treatment of Chronic Wounds.

2004.06.25–27, Warszawa (Poland) – 5th Jubilee Congress of the European Venous Forum (EVF). President of the Congress: A. Jawień. Number of participants: 350. 2005.03.03–06, Krynica (Poland) – 17th PTF International Scientific and Training Conference. Contemporary Trends in Phlebology. 2005.06.10–11, Bydgoszcz (Poland) – 4th Polish-Italian Phlebology Meeting. Under the patronage of PTF (PL) and SIF (I). 2006.03.09–12, Szklarska Poręba (Poland) – 18th PTF International Scientific and Training Conference. Venous and Lymphatic Insufficiency and VTE in Pregnant Women. 2006.04.27, Kraków (Poland) – 1st Kraków International Workshops of Phlebology (KIWP). Advances in Phlebology 2006. Chairmen: T. Drążkiewicz, J. Sadowski. 2006.06.01–03, Bydgoszcz (Poland) – 5 th Jubilee International Congress and 15th Anniversary of the Polish Society of Phlebology. President of the Congress: A. Jawień. (Fig. 5). The Ceremonial Lectures were given by special guests from abroad: BB. Lee (USA), N. J. Caprini (USA), N. Labropoulos (USA), N. Morrison (USA), H. Partsch (Australia), M. Perrin (France), A. Cavezzi (Italy). 2006.06.03 – General Assembly of Members. Election of the authorities for the 6th term of office PTF, 2006–2009.

Fig. 5. 5th Jubilee Congress and 15th Anniversary of the Polish Society of Phlebology, 2006, Bydgoszcz (PL). Chairman: A. Jawień

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30 years of the Polish Society of Phlebology – how it all happened

President – W. Staszkiewicz, Vice President – A. Cencora, General Secretary – G. Madycki. Treasurer – W. Hendiger. 2007.03.01–03, Szczyrk (Poland) – 19th PTF International Scientific and Training Conference. Phlebology of the 21st Century. 2007.04.19, Kraków (Poland) – 2nd Kraków International Workshops of Phlebology (KIWP). Advances in Phlebology 2007 (more info, see: web). 2007.05, Bydgoszcz (Poland) – 5th Jubilee Polish-Italian Phlebology Meeting. 2007.09.27, Mainz (Germany) – International Symposium of Phlebology: Hungary, Mexico and Poland. Phlebology Update. Chairman: Z. Várady. 2008.03.06–09, Szklarska Poręba (Poland) – 20th PTF Jubilee International Scientific and Training Conference. Hemorrhoidal Disease and Aesthetic Phlebology. Chairmen: Z. Rybak, P. Szyber. 2008.05.08–09, Kraków (Poland) – 3rd Kraków International Workshops of Phlebology (KIWP). Advances in Phlebology 2008. 2009.05.28–30, Warszawa (Poland) – 6th International Congress of the Polish Society of Phlebology. President of the Congress: W. Staszkiewicz. During the congress, in recognition of active organizational, scientific, and training activities, four persons were awarded honorary member of PTF diplomas. They were four presidents of previous PTF terms of office: T. Drążkiewicz, M. Maruszyński, Z. Rybak and A. Jawień. Diplomas were presented by W. Staszkiewicz, president of PTF (2006–2009). 2009.05.30. General Assembly of PTF Members. Election of the authorities for the 7th term of office 2009–2012. President – W. Staszkiewicz (Warszawa), Vice President – vacant, General Secretary – G. Madycki, Treasurer – W. Hendiger. Members of the Board: M. Gabriel, A. Jawień, G. Madycki, Z. Krasiński, P. Terlecki, Z. Rybak. 2010.03.11–14, Szklarska Poręba (Poland) – 21st PTF International Scientific and Training Conference. Endovascular Treatment of Venous Diseases. 2010.06.10–11, Kraków (Poland) – 22 nd PTF In-­ ternational Scientific and Training Conference and 4th Kraków International Workshops of Phlebology and Related Disciplines. Progress in Phlebology and Related Disciplines 2010. Advances in Phlebology, Angiology and Lymphology, CVI, Pulmonary Embolism, Leg Ulcers, Leg Lymphedema, Diabetic Foot. Live Op-Transmissions. Chairmen: T. Drążkiewicz, J. Sadowski. A special event was the signing of the bestselling Polish edition of the book Chirurgia Żył (2010, volumes I, II) by the main author, Prof. Wolfgang Hach (original: VenenChirurgie (2nd edition, 2007/D). Scientific consultation for the Polish edition of Prof. M. Szostek. During the conference, the Board and the Scientific Committee of the PTF established a council which appointed the title (fellowship): Fellow of the Polish Soci-

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ety of Phlebology (FPSPh). This title was awarded to several distinguished Polish and foreign phlebologists10. 2011.03.10–13, Szklarska Poręba (Poland) – 23rd PTF International Scientific and Training Conference. 20th Anniversary of the PTF. Chairmen: Z. Rybak, P. Szyber. 2012.02.23, Kraków (Poland) – 24th PTF Conference/1st Inaugural International Symposium on Venous Interventions. Acute and Chronic Deep vein Obstruction – Endovascular Treatment of Deep Vein Thrombosis and Chronic Obstruction of the Venous System. Initiator and chairman: T. Urbanek11. 2012.3.01–03, Zakopane (Poland) – 7th International Congress of the Polish Society of Phlebology. President of the Congress: W. Staszkiewicz. 2012.03.01–03 – General Assembly of PTF Members. Election of the authorities for the 8th term of office 2012–2015. President – T. Urbanek (Katowice), Vice President – W. Staszkiewicz, General Secretary – M. Kucharzewski, Treasurer – W. Hendiger. 2013.03.14–17, Szklarska Poręba (Poland) – 25th PTF Jubilee International Scientific and Training Conference. Chairman: Z. Rybak. 2013.03.13–14, Kraków (Poland) – 26th Conference PTF/2nd International Symposium on Venous Interventions. Focus on Compression. 2013.09.08–13, Boston (USA) – 17th World Meeting of the International Union of Phlebology (UIP/IUP). During this congress a Special Polish Session was held. Society Session: Polish Society of Phlebology, September 11, 2013, 900–1030 am. Chairman: T. Urbanek (details12). 2014.03.06–09, Karpacz (Poland) – 27th International Scientific and Training Conference of PTF. 2014.09.12–14, Zakopane (Poland) – 28th PTF Conference. Phlebology on the Kalatówki Glade13/v.1.0. Chairman: T. Urbanek. 2014.11.29, Poznań (Poland) – 29 th PTF Conference/1st Aesthetic Phlebology. 2014.12.05–06, Kraków (Poland) – 30th Conference PTF/3rd International Symposium on Venous Interventions. Focus on Acute and Chronic Deep Vein Obstruction (part II). 2015.06.11–13, Kraków (Poland) – 8th International Congress of the Polish Society of Phlebology. President of the Congress: T. Urbanek. 10

similar title (fellowship) is given to some phlebologists in A Australia and the USA: Fellow of Australian/American College of Phlebology (FACPh).

11

rofessor Tomasz Urbanek is the Chairman of the entire series P of the International Symposium on Venous Interventions.

12

www.uip-phlebology.org/uip2013Boston.

13

alatówki is an ecological glade located in the Bystra Valley K in the Western Tatras in the vicinity of the city of Zakopane. In Kalatówki there was the first Polish ski resort and the first ski competitions in Poland took place there in 1910.

13


Tomasz Drążkiewicz

Fig. 6. 37th PTF Conference/5th Jubilee International Symposium on Venous Interventions, 09–10.12.2016, Kraków (PL), organized by Polish Society of Phlebology in cooperation with American Venous Forum 2015.06.13 – General Assembly of PTF Members: Establishment of the Lymphology Section of the PTF. President of the Section: A. Szuba (Wrocław). Election of the authorities for the 9th term of office 2015–2018. President – T. Zubilewicz (Lublin), Vice President – W. Staszkiewicz, General Secretary – M. Kucharzewski, Treasurer – W. Hendiger, Board Members: M. Gabriel, A. Jawień, G. Madycki, Z. Krasiński, P. Terlecki, Z. Rybak. One of the invited speakers was professor B.B. Lee14 (USA), the world’s leading specialist in congenital vascular malformations and lymphedema, and a great friend of Polish phlebologists and vascular surgeons. He has been a frequent guest at our scientific meetings for many years. He has visited the John Paul II Hospital in Kraków twice: in 2007 and 2015. Recently, when watching an operating theatre with a new hybrid room he said, smiling broadly, “I have seen so many vascular centres in the world. I can say that yours is one of the most modern”. 2015.09.19, Warszawa (Poland) – 31st PTF Conference/2nd Aesthetic Phlebology. 2015.10.22–24, Kraków (Poland) – 6th EVF HOW PLUS Hands-on Workshop on Venous Disease. Directors: B. Eklöf (S/USA), P. Neglén (S/CY), A. Nicolaides (CY/UK). Chairman: T. Urbanek (details15). 14

yung-Boong Lee MD, PhD, FACS – a clinical professor at B the George Washington University School of Medicine and Health Sciences, Washington, D.C., director of the Center for Lymphedema and Vascular Malformation.

15

hlebological Review 2015; 23, 4: 110-113. https://www. P termedia.pl/Journal/Phlebological_Review-76 .

14

2015.12.11–12, Kraków (Poland) – 32nd PTF Conference/4th International Symposium on Venous Interventions (ISVI). Focus on Ulcus Cruris. 2016.03.17–20, Karpacz (Poland) – 33rd PTF Conference. Advances and Innovations in Phlebology. 25th Anniversary of the PTF. Chairman: T. Urbanek, Z. Rybak. 2016.04.23–24, Wrocław (Poland) – 34. PTF Conference/1st PTF Conference of the Lymphology Section. Lymphoedema – Pathophysiology, Diagnostics, Treatment. Chairman: A. Szuba. 2016.06.11, Warszawa (Poland) – 35th PTF Conference/3rd Aesthetic Phlebology. 2016.09.09–11, Zakopane (Poland) – 36th PTF Conference/Phlebology on the Kalatówki Glade v.2.0. 2016.12.09–10, Kraków (Poland) – 37th PTF Conference/5th Jubilee International Symposium on Venous Interventions (ISVI), organized by PTF in cooperation with the American Venous Forum (AVF) Focus on Modern Phlebology. Chairmen: T. Urbanek (PL) and L.S. Kabnick (USA). Special Lecturer J.A. Caprini (USA)16 (Fig. 6). 2017.03.17–19, Krynica Górska (Poland) – 38th International Scientific and Training Conference of PTF. Phlebology Today and Tomorrow. 2017.09.23, Warszawa (Poland) – 39th PTF Conference/4th Aesthetic Phlebology. 2017.10.26–28, Kraków (Poland) – 8th EVF HOW Plus – Hands-on Workshop on Venous Disease. Chairmen: Marianne De Maeseneer (B), T. Urbanek (Poland), S. Black (UK). 16

www.venousinterventions.com.pl/5th-venous/.

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30 years of the Polish Society of Phlebology – how it all happened

2017.12.08–09, Kraków (Poland) – 40th PTF Conference/6th International Symposium on Venous Interventions (ISVI). Focus on Pelvic Congestion Syndrome and Varicose Vein of Pelvic Origin. 2018.02.04–08, Melbourne (Australia) – 18th World Meeting of the International Union of Phlebology. This again under the auspices of the UIP Congress gathered as usual participants from all over the world including a large group from Poland, who often share with us the knowledge they have acquired. Both the present president of the PTF, T. Urbanek, and his predecessors are already very well recognized in the world and thanks to their experience and commitment they occupy important functions in the international vascular forums, including phlebology. Thanks to this, the rank of our society is constantly growing. 2018.03.16–17, Wrocław (Poland) – 41st PTF Conference. 2nd Conference of the Lymphology Section of the PTF. Lymphoedema in Oncology. 2018.06.21–23, Lublin (Poland) – 9th International Congress of the Polish Society of Phlebology. President of the Congress: T. Zubilewicz. 2018.06.23 – General Assembly of PTF Members. Election of the authorities for the 10 th term of office 2018–2021. President – T. Urbanek (Katowice), Vice President – M. Gabriel, General Secretary – M. Kucharzewski, Treasurer – W. Hendiger. Board Members: Past-President – T. Zubilewicz, President-Elect for the 11th term of office (2021–2024) – Z. Krasiński, A. Jawień, Z. Rybak, M. Iłżecki, P. Terlecki, A. Jaworucka-Kaczorowska, A. Zieliński. As a result of close long-term cooperation of Prof. Gloviczki (USA) with Polish phlebologists and vascular surgeons, an interesting idea arose during the congress. Due to the significant advances in phlebology over the past 10 years it has been confirmed to publish in Polish the latest American Handbook of Venous and Lymphatic Disorders – the fourth edition from 2019 edited by Prof. P. Gloviczki (first published in 1996). The scientific editors of the Polish edition (2020), titled Choroby żył i naczyń limfatycznych, are Prof. P. Andziak (Warsaw) and Prof. T. Zubilewicz (Lublin). 2018.09.07–09, Zakopane (Poland) – 42 nd PTF Conference/Phlebology on the Kalatówki Glade/v.3.0. Exchange of Experience and Ongoing Discussions of Clinical Phlebological Cases (Fig. 10). 2018.10.06, Warszawa (Poland) – 43rd PTF Conference/5th Jubilee Conference – Aesthetic Phlebology. 2018.11.30–12.01, Kraków (Poland) – 44th PTF Conference/7th International Symposium on Venous Interventions. Focus on Post-Thrombotic Syndrome. 2019.08.25–27, Kraków (Poland) – International Union of Phlebology. UIP Chapter Meeting. Head of Local Organising Committee: T. Urbanek (Poland). The

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sunny city of Kraków, Poland was an ideal venue for the UIP chapter meeting for 2019. More than 1300 delegates from 71 countries (5 continents) attended the meeting over 3 days. Over the course of the 3 days, the scientific programme comprised 4 parallel streams, 36 scientific sessions, 7 poster session and 19 workshops. Delegates from all over the world participated in this event, enjoying the beauty of Kraków and the latest advances in the industry. The opening ceremony was a visual delight for all those who attended and the gala dinner in the spectacular Gardens of the Archaeological Museum of Kraków. It was the largest meeting of this type in our part of Europe, highly rated, one of the last international and national direct scientific meetings before the current pandemic17. A nice, pro-ecological event took place during the congress. A symbolic tree was planted to celebrate this event – it was named the UIP 2019 Tree (Fig. 7).

Fig. 7. Union Internationale de Phlébologie Chapter Meeting – UIP 2019 Tree (Swedish Whitebeam/Sorbus intermedia), 2019, Kraków (PL) 2019.11.17–18, Warszawa (Poland) – 45th PTF Conference/6th Conference – Aesthetic Phlebology. Aesthetic and minimally invasive treatment in phlebology. Lipoedema – how to proceed? The last direct phlebological meeting in Poland before the pandemic. 2020.11.07–08, Katowice (Poland) – 46th PTF Conference. PTF General Assembly of Members (online). 7th Conference – Aesthetic Phlebology. Phlebology in Poland A.D. 2020. 17

ast World Congress of the Union Internationale de P Phlébologie (uip-phlebology.org).

15


Tomasz Drążkiewicz

Fig. 8. Congresses of the Polish Society of Phlebology from the 1st (1994) to the 10th (2021) 2020.12.12–13, Katowice (Poland) – 47th PTF Conference/8th International Symposium on Venous Interventions. Focus on chronic venous insufficiency (online). 2021.01.28, Katowice (Poland) – 48th PTF Conference. Practical Phlebology, 1st webinar18. Treatment of Recurrent Varicose Veins (online). 2021.02.18, Katowice (Poland) – 49th PTF Conference. Practical Phlebology, 2nd webinar. Complications in Phlebology (online). 2021.03.17–20, San Antonio (USA) – 33rd Annual Meeting of the American Venous Forum (AVF), inter alia with active participation (online meeting of the PTF representatives). 2021.03.18, Katowice (Poland) – 50th PTF Conference. Practical Phlebology, 3rd webinar. Treatment of Venous Spider Veins and Pathologies of Reticular Veins in Patients with Chronic Venous Disease – Methods, Difficulties, Results (online). 2021.04.08, Katowice (Poland) – 51st PTF Conference. Practical Phlebology, 4th webinar. Difficulties in surgical treatment of superficial vein insufficiency (online). 2021.04.16–17, Wrocław (Poland) – 52nd International PTF Conference/I3rd International Conference of the 18

hairman of the webinar conferences (1–4), Prof. T. Urbanek C (Katowice) MD, PhD, FPSPh.

16

Lymphology Section of the PTF. LYMPHOEDEMA 2021. Diagnostics, Prevention and Treatment of Lymphatic System Diseases (online). Chairman: A. Szuba. 2021.06.10–12, Katowice (Poland) –10 th Jubilee International Congress and 30th Anniversary of the Polish Society of Phlebology (online) 19. President of the Congress: T. Urbanek. The current president of the PTF 2018–2021, Prof. Tomasz Urbanek MD, PhD, FPSPh, is now for the second time in this position. He has been very well recognized in the world for many years. Thanks to his experience and commitment, he occupies important functions in the international phlebology forum, and the current level of phlebology in Poland does not deviate from the highest European and world standards. Thanks to him and his predecessors and successor, the rank of our society is constantly growing (Fig. 8, 9). On 9 th of June a General Assembly of Members (online) will be held. Elections will select (online) new PTF authorities for the next 11th term of the PTF Management Board 2021–2024. According to the statute, the position of the president for 2021–2024 should be taken by Prof. Zbigniew Krasiński from Poznań, elected in 19

or obvious safety reasons, the organization of the congress F was adopted only in the form of a virtual meeting (online).

Phlebological Review 2021


30 years of the Polish Society of Phlebology – how it all happened

Fig. 9. Presidents of the Polish Society of Phlebology from the 1st (1991–1997) to the 11th (2021–2024)

Fig. 10. Polish Society of Phlebology – three presidents at the conference in the Tatra Mountains. In the middle T. Drążkiewicz – the first-founder, on the right T. Urbanek – the present, on the left Z. Krasiński – the next one Lublin (2018). This congress is another milestone opening a new chapter in Polish phlebology (Fig. 10). Let’s hope that the strength of our society will finally mobilize the Polish government authorities, the Ministry of

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Health and Social Welfare (MZiOS) and the National Health Fund (NFZ) to treat patients with chronic venous diseases more seriously, to provide them with reimbursed treatment, which, unfortunately, they often do not have today.

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Tomasz Drążkiewicz

APPENDIX The turn of the 2nd and 3rd decades of the 21st century surprised the whole world with one of the most dangerous phenomena in the history of mankind – a pandemic with unpredictable consequences. Despite this, we phlebologists every day make every effort to work even more intensively in these difficult, dangerous living and working conditions, without sparing our strength. Over the years I have met hundreds of fascinating people, professional phlebologists. And it continues today. Unfortunately, we have no influence on one thing. Time flies inexorably fast. On the other hand, fortunately, if someone does something useful and leaves a lasting trace for posterity, then that person should be satisfied and happy. I can assure you that I am. Now – 30 years after the establishment of the Polish Society of Phlebology – the first completely Polish, comprehensive, and ground-breaking work of outstanding Polish phlebologists, Textbook of Phlebology, is published. A modern handbook, devoted to the multidisciplinary field of medicine that is phlebology, has appeared just in time. I am convinced that in such a difficult and special time it will help to fight more effectively for the health and life of our community. At this point, I express my special appreciation to all the people who made this handbook possible. I would like to provide readers with a lot more information about the history of phlebology. Therefore, I encourage all people with phlebological experience to collect their own interesting memories and find documents or photos that could be used in the future to enrich the history of Polish phlebology and publish it in the form of an extended monograph. I know that my article does not exhaust the topic of the title. I have known and still know many wonderful people from medical circles, both in Poland and worldwide, who we can call phlebologists. Many have put a lot of time and effort into the development of this multidisciplinary field of medicine. It is impossible to list them all, so I have mentioned only some of them. However, I hope that the current and future authorities will set new milestones in the history of phlebology, which we do not know, because it is still ahead of us. And it should not be anything like science fiction, Back to the Future.

Tomasz Drążkiewicz First, second and last names: Tomasz Melchior Drążkiewicz (born October 16, 1949 in Sosnowiec, Poland). He graduated from medical studies at the Medical University of Silesia in Katowice, Poland (formerly the Silesian Medical Academy) 1974. Retired (2015), still an active doctor, general and vascular surgeon, angiologist, phlebologist. MD, PhD, FPSPh/inter alia: Founder (1991), President (1991–1994 and 1994–1997) and President of Honor (2009) of the Polish Society for Phlebology (Polskie Towarzystwo Flebologiczne – PTF), Founder (1993), Editor-in-Chief (1993–2001) and Editor-in-Chief of Honour (2001) of the Phlebological Review (est. 1993). Honorary Member (1993) of the International Forum for Minisurgery of Varicose Veins (IFMVV). Corresponding Member of the German Society of Phlebology (DGP) and Corresponding Member of the French Society of Phlebology (SFP). Member of the Scientific Advisory Committee of the IUP/UIP (1994–2001). Tomasz Drążkiewicz recently asked himself how he was doing. Without thinking, he answered, also to himself: I feel fantastic, because professionally and privately I feel fulfilled. Professionally, because: the Polish Society of Phlebology has been alive for 30 years and is doing well, the history of the society is written, so I consider it all as my life’s work. And privately? I have a successful family life, an understanding and caring wife, two wonderful and wise daughters, and now I am the happiest because on April 7, 2021 I became for the first time the grandfather of little Maja. That is why I believe that, apart from health and happiness, I do not need anything more. Well, unless I become a grandfather once again. And what about a hobby? My hobby? I have the least time for that. But when I have the time, I play and compose (keyboard and guitar) and I take photos everywhere.

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SCLEROTHERAPY CONTRAINDICATIONS, SEQUELAES, AND COMPLICATIONS – INFORMING PATIENTS PROPERLY AND OBJECTIVELY IS REQUIRED ORIGINAL PAPER

Tomasz Urbanek1, Maciej Piotr Rzepka2, Agnieszka Jolanta Roj2, Patrycja Alicja Rozwadowska2 Department of General Surgery, Vascular Surgery, Angiology, and Phlebology, Medical University of Silesia, Katowice, Poland 2 Student’s Scientific Association of Department of General Surgery, Vascular Surgery, Angiology, and Phlebology, Medical University of Silesia, Katowice, Poland 1

ABSTRACT

Introduction: The objective of the article is the analysis of the information provided to patients by medical centres that offer sclerotherapy in Poland, as well as its possible impact on patients’ decisions about the procedure and the choice of a clinic. Material and methods: An analysis of the data obtained from web page information available from 212 medical centres in Poland proposing sclerotherapy treatment. The medical centres were divided into 5 categories: aesthetic clinics, medical centres offering varicose vein treatment, medical and aesthetic centres, private specialist practices, and hospitals. The data provided by medical centres were divided into 5 main categories: main information about the procedure, indication description, information about the contraindications, post-procedure care, and possible complications. Results: In the analysed material, only 34% of medical centres informed potential patients about contraindications and only 37% about possible procedure complications, in their web pages. The most commonly presented complications were haematoma and temporary discoloration of skin, and the possibility of venous thromboembolism occurrence was mentioned only by 10%. Information about the treatment not always being effective was provided by 16% of websites, and only 42.5% informed patients about the possible need of repeated procedures. Conclusions: The results show that in many centres sclerotherapy is considered to be an aesthetic rather than medical procedure. To attract patients, several medical centres inform them only about the indications rather than contraindications but do not provide proper information about the complications and post-treatment precautions.

Phlebological Review 2021; 29, 1: 19–25 DOI: https://doi.org/10.5114/pr.2021.106805 Submitted: 7.05.2021 Accepted: 18.05.2021

ADDRESS FOR CORRESPONDENCE Prof. Tomasz Urbanek Department of General Surgery, Vascular Surgery, Angiology, and Phlebology Medical University of Silesia 45/47 Ziołowa St.

40-635 Katowice, Poland e-mail: urbanek.tom@interia.pl

Key words: varicose veins, chronic venous disease, sclerotherapy, complications.

INTRODUCTION Sclerotherapy is a procedure used in the treatment of telangiectasias, reticular veins, varicose veins, and some other pathologies related to chronic venous disease development and progression [1]. Various techniques of sclerotherapy as well as various agents used for vein obliteration have been proposed [2]. Despite the technical progress and availability of many other minimally invasive methods, sclerotherapy remains one of the most frequently used phlebological treatments and can be based on medical and cosmetic indications. In comparison with venous surgery, sclerotherapy is often classified as a minimally invasive and relatively safe treatment measure, but, as in the case of every medical procedure, complications are possible as well. Rarely, we

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have to deal with neurological or visual complications, skin necrosis, deep vein thrombosis, or pulmonary embolism [1, 2]. Among the most commonly seen complications, skin hyperpigmentation and matting should be mentioned [3]. Proper information about the procedure performance, contraindications, as well as complications is one of the most important steps before the procedure and should be clearly presented to the patients. As in other cases of invasive phlebological treatment, the patient’s informed consent should always be obtained. In Poland, similarly to many other countries, due to the lack of the procedure reimbursement, sclerotherapy is often performed in private medical centres and the cost of the procedure is covered by the patient. Looking for treatment options and possibilities, one of the main sources of patient knowledge concerning performance of a particular

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Tomasz Urbanek, Maciej Piotr Rzepka, Agnieszka Jolanta Roj, Patrycja Alicja Rozwadowska

procedure and its possible complications are the websites of centres specializing in sclerotherapy. Unfortunately, the quality of this information remains questionable regarding objective and precise information concerning indications, contraindications and sequalae of the sclerotherapy procedure. Because a lack of patient awareness regarding possible sclerotherapy complications potentially influences the patient’s decision, also on acceptance of the sclerotherapy results, the proper quality of information should be provided. The study focuses on investigating how Polish medical centres inform their patients about the potential hazards of sclerotherapy treatment.

MATERIAL AND METHODS

100 90 80 70 60 50 40 30 20 10 0

ve ins Te lea n g en iec ou ta sm sia alf or ma tio Ve ns no us leg ulc ers

ein s

Sm all v

tic ula r

Re

os va ric

nt rre cu Re

ev

ein s ev os

ten

Va ric

om pe inc GS V

Fig. 1. Indications for sclerotherapy mentioned in the web page information (summarized as the percentage of centres specifying a particular indication)

20

RESULTS General information about sclerotherapy procedure Eighty-two per cent of the examined centres explained what sclerotherapy is, and 72% of them gave details of the procedure. Seventy-seven per cent of the clinics did not inform patients about any special necessary preparations before the treatment, and 53% did not include any information about the need of performing additional tests such as ultrasonography. As many as 84% of the centres did not present any information about the possibility of a recovery guarantee, and 58% of facilities did not inform the patients about possibility of the necessity of re-do procedures or other treatment modalities. This information would be of high potential value for the patient because the lack of a recovery guarantee can prolong the time and increase the costs of treatment.

Indications for sclerotherapy treatment Information about indications for sclerotherapy treatment was provided by 74% of the medical facility websites; however, the least information about indications was placed on private specialist practice web pages – only 45% of them included any. The most information was presented on the websites of aesthetic and medical clinics. Indications for the treatment were mentioned on 79% of them. It is worth noting that some medical facilities do not provide any details of indications at all. In the study we focused on the indications shown in Figure 1, and we chose 7 conditions for which sclerotherapy is one of the recommended treatments. The most common indications provided on websites were varicose veins and telangiectasias.

Contraindications ce

Percentage

The website materials of 212 Polish medical centres treating the phlebological patients by the means of sclerotherapy were reviewed and evaluated. The research was carried out by using a specially constructed form in which the data officially provided by medical centres on their websites were compared. The following 5 categories of medical centres were selected: aesthetic clinics (73 facilities –34.5% of total), medical centres offering varicose vein treatment (70 facilities – 33%), medical and aesthetic centres (37 facilities –17.5% of total), private specialist practices (20 facilities – 9.5%), and hospitals (12 facilities – 5.5%). The data provided by medical centres were divided into 5 main categories: • main information about the procedure, • indication description, • information about the contraindications, • post-procedure care, • possible complications. The analysed data were collected from clinics’ website offers addressed to potential patients interested in sclero-

therapy. The main parameter to choose the medical centres was the web page offering sclerotherapy and its high rate in a Google Internet search. This method enabled us to imitate the way in which potential patients search for offers and information about this treatment. We chose the most popular web pages. Medical centres were selected from all voivodeships in Poland. As far as big cities are concerned, the greatest number of centres were found in Warsaw, which is connected to a large population in the capital city.

Overall, only 34% of medical centres chosen for the evaluation informed the patients and web page visitors about the potential contraindications to the procedure. According to the data presented in Figure 2, in this category the most highly valued are aesthetic clinics, which informed patients about contraindications most frequently, while the information about any contraindications was presented only by 17% of hospitals.

Phlebological Review 2021


Ho sp ita ls

eti c

cli

nic

s Me dic al din ics Ae s me the dic tic ine and cli nic Do s cto r’s pr ac tic es

100 90 80 70 60 50 40 30 20 10 0

Ae sth

The number and kind of the described contraindication differed between the selected groups of centres (Fig. 3) as well as between the individual centres. In this ranking, hospitals compare unfavourably. Among the most commonly mentioned contraindications, the following conditions were identified: pregnancy and lactation, allergy to the drug used for sclerotherapy, as well as deep vein thrombosis. Benign tumours, cancers, and advanced age were more frequently quoted by aesthetic clinics rather than others, and infections with advanced atherosclerosis were provided more often by medical clinics. The type of contraindication as well as the prevalence of this information on the web page of the medical centres is presented in Figure 4.

Percentage

SCLEROTHERAPY CONTRAINDICATIONS, SEQUELAES, AND COMPLICATIONS – INFORMING PATIENTS PROPERLY AND OBJECTIVELY IS REQUIRED

Fig. 2. Facilities providing information about sclerotherapy contraindications (in %)

2.0 1.5 1.0 0.5

ita ls sp Ho

cs s me thet dic ic a ine nd cli nic Do s cto r’s pra cti ces

ini

Ae

al d dic Me

lin ics

0

cc

The information about possible sclerotherapy complications could be found on 37% of analysed websites only. The facilities that informed about the possibility of complications most often were aesthetic medicine centres (40%), and the least common were the hospital-based centres (Fig. 6).

2.5

eti

Procedure complications

3.0

sth

Information about post-treatment care was present on 68% of the analysed web sites. The most commonly identified recommendation was the necessity of post-procedure compression stocking application. The majority of facilities, as many as 82%, did not provide any information about avoiding sunbathing and sunscreens, which are among of the most important recommendations after sclerotherapy treatment (Fig. 5).

Ae

Post-treatment care

Kind of medical facility

Fig. 3. Average ratio of contraindications provided on a single internet page in the specified centre categories

35 30

Percentage

25 20 15 10 5

tio ns c dis in ea th ep s lac Dia e e o bet f in es jec ti Fre on C s ht At ard he a i ro ova Pa n scl scu ra ero la lys sis r di is s o De f lo ease ep we s ve r li m in tro bs mb Ad o va sis ce Os d a teo ge art h Re ritis u m Co ne Lym atis cti ve phe m tis de su ma Sc ed ler ot ise he rap Ne ase Pr eg y ag opla na s nc ent m y a all e nd r lac gy ta tio n

ste

mi

ec

Inf

De

rm

at

itis

Sy

Tro

mb o

ph

ilia

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Fig. 4. Contraindications specified in the web page information (% of the centres evaluated in the study)

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70

45

60

40

50

35 Percentage

20

25 20 15 10

0

5 0

nic cli eti c

Av oid ing

su an nba d s th i un ng scr ee Av ns oid im mo bil Av isa oid tio ing n hig ht em pe rat ex ure po su Ne re ss co esity mp o res f w sio ear n s ing to ck ing

10

Ho sp ita ls

30

30

s Me dic al din ics Ae s me the dic tic ine and cli nic Do s cto r’s pr ac tic es

40

Ae sth

Percentage

Tomasz Urbanek, Maciej Piotr Rzepka, Agnieszka Jolanta Roj, Patrycja Alicja Rozwadowska

Fig. 5. Post-treatment care information (% of the centres evaluated in the study)

Fig. 6. Percentage of facilities that informed patients about the possibility of complication occurrence

It is significant that as far as the number of complications mentioned on a single website is concerned, medical clinics compare favourably with aesthetic ones (Fig. 7). On the other hand, as presented in Figure 6, the aesthetic clinics most frequently inform patients about possible complications. The most commonly mentioned complications were haematomas and temporary discoloration of skin, which are among the least harmful sequelae. Information about the dangers of pulmonary embolism, which was presented by only 10% of analysed facilities and as many as 80% of medical centres, did not inform patients about possible post-treatment pain. Possible skin loss was scarcely mentioned on the websites; only a few facilities provided information about it (Fig. 8).

[1–3]. The fact that this procedure has medical and aesthetic advantages is beyond any doubt [4]. Because the sclerotherapy costs are not covered by the national insurance system in Poland, most of the sclerotherapy procedures are performed in private centres and hospitals and are fully paid for by the treated patients. The introduction of foam sclerotherapy as well as ultrasound-guided sclerotherapy significantly expanded the possibilities of minimally invasive treatment of venous disease by the means of this therapeutic measure. The efficacy of sclerotherapy in superficial vein incompetence treatment has been confirmed in several prospective observations [5–12]. The minimal invasive procedure character, the possibility to treat a wide spectrum of venous pathologies, as well as the relatively low cost of the treatment, position sclerotherapy among the most commonly used therapeutic tools in the contemporary phlebology. Despite the growing experience as well as the growing number of the sclerotherapy procedures worldwide, sclerotherapy is not always completely successful, and at least in some of the patients treatment failure can be expected [5, 8, 10]. The lack of clinical success of the sclerotherapy procedure can be related to improper patient qualification, improper procedure performance, and to vein recanalization or venous disease progression [13–16]. In the Rasmussen et al. study, 1 year after ultrasound-guided foam sclerotherapy, 16.3% of the saphenous veins remained patent and refluxing [15]. Shadid documented saphenous vein reopening 2 years after ultrasound-guided sclerotherapy in 11.3% of cases. The fact that sclerotherapy is not always the final treatment, and in future we can expect residual varicose veins or disease recurrence, is worth mentioning because in some cases the need for repeated treatment occurs. Fifty-eight per cent of the centres evaluated in our study did not inform patients on their web pages about the potential necessity of re-do procedures or other treatment modalities. Despite the fact that this situation can

DISCUSSION Sclerotherapy is a procedure in which varicose veins are obliterated by liquid or foam solutions injected into abnormally expanded or cosmetically unacceptable veins 2.5 2.0 1.5 1.0 0.5

ita ls Ho sp

cs s me thet dic ic a ine nd cli nic Do s cto r’s pra cti ces

ini

Ae

dic al d Me

Ae

sth

eti cc

lin ics

0

Kind of medical facility

Fig. 7. Number of potential complications per single facility-ratio

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SCLEROTHERAPY CONTRAINDICATIONS, SEQUELAES, AND COMPLICATIONS – INFORMING PATIENTS PROPERLY AND OBJECTIVELY IS REQUIRED

40 35

Percentage

30 25 20 15 10 5

h Itc

ary

Pu lm

on

Sk in

ne cro

sis e mb An Su oli ap sm pe hy rfi lac cia t i cs lt hr ho om ck b De op ep hle ve bit in is th ro mb os Lo is Lo c al ca sw l in ell tra ing ve no us blo Al od ler gy rea cti on Sk i Te n P os de mp t-t fec or rea ary t t m dis en co ts lor kin at ion of sk in He ma to ma s

0

Fig. 8. Complications specified in the web page information (% of the centres evaluated in the study) prolong the treatment duration and potentially increase both the treatment costs and the need for the additional procedure performance, this information is commonly skipped in the available webpage materials. Information about medical indications is a very important part of every offer, and it allows the patient to decide about the need for this treatment [3, 17, 18]. According to the European Sclerotherapy Guidelines (2012), several indications for sclerotherapy performance can be mentioned, including saphenous vein incompetence (grade 1A recommendation), tributary incompetence (1B), residual or recurrent varicose veins (1B), reticular veins and or telangiectasias (1A), perforating veins (1B), incompetent veins in venous leg ulcer patients (1B), as well as venous malformations (1B) [3]. In the performed study, information about the potential indication for the sclerotherapy performance was present, on average, on 74% of the medical facility websites. However, more than half of the available patient materials presented on private specialist practice web pages did not include any indications. The most common indications provided on the evaluated websites were varicose veins and telangiectasias, with significant differences between the medical and aesthetic centres regarding the number of the indications. Only 34% of the medical centres chosen for the evaluation informed the web page visitors about the possible contraindications to the procedure. The results show that most information about contraindications come from facilities belonging to the category of aesthetic clinics, but information about them is very rarely provided by hospitals. Unfortunately, a small percentage of facilities mentioned individual contraindications, although here also aesthetic clinics are better than others. Among the

Phlebological Review 2021

most commonly mentioned, pregnancy, lactation, deep vein thrombosis, and allergy to the sclerosing agent were specified. In the vast majority of the centres, other important contraindications such as acute infection, lack of the possibility of medical compression application, as well as patent foramen ovale with right to left shunt were not mentioned [3, 18]. Information about the recommended post-procedure action was provided by more than half of the analysed facilities. The majority of medical centres recommended wearing medical compression tight length stocking. We rarely found information about avoiding high temperatures and avoiding immobilization, and the even less often, information about avoiding self-tanning creams and sunbathing. These actions require self-discipline and very often make patients completely change their habits, which can affect their decision about undergoing sclerotherapy treatment. Sclerotherapy, like every procedure, includes the risk of many side effects [8, 9]. Because sclerotherapy is divided into 2 major kinds – liquid and foam – there are different risks of side effects [3, 18, 19–22]. Foam sclerotherapy has a relatively high percentage of complications, but it can achieve higher stability of clinical effectiveness in treating varicose veins of lower limbs than liquid sclerotherapy [3, 11, 19, 20]. Several sclerotherapy adverse effects have been reported, and the procedure complications can be divided into common, uncommon, or rare (Table 1, 2). Unfortunately, only a few centres (37%) in our study discussed the subject of the complications on their web pages. The research results show us a divergence, because in this category the best were aesthetic clinics. However, if we analyse the number of side effects provided on a single web page, the medical clinics were the most informative.

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Tomasz Urbanek, Maciej Piotr Rzepka, Agnieszka Jolanta Roj, Patrycja Alicja Rozwadowska

Table 1. Possibility of side effects after sclerotherapy [2, 3] Designation

Incidence

Very common

≥ 10%

Common

≥ 1% – < 10%

Uncommon Rare

≥ 0.1% – < 1% ≥ 0.01% – < 0.1%

Very rare and isolated case

< 0.01%

Table 2. Possibility of side effects after sclerotherapy Type of complication

Frequency with liquid

Frequency with foam

Anaphylaxis

Isolated cases

Isolated cases

Large tissue necrosis

Isolated cases

Isolated cases

Very rare

Very rare

Isolated cases

Isolated cases

Very rare

Uncommon

Severe complications

Proximal deep vein thrombosis Pulmonary embolism Benign complications Headaches and migraines Skin reaction (local allergy)

Very rare

Very rare

Matting

Common

Common

Residual pigmentation

Common

Common

Rare

Very rare

Skin necrosis

We can assume that evaluated aesthetic clinics did not provide very specific information about side effects but they only focused on the fact that they exist. Considering the frequency of complications, we can notice that offers provide only information about the most common and least dangerous ones and occasionally mention rare and very dangerous side effects such as pulmonary embolism, which can be lethal. Some limitations of our study should also be mentioned. The study was based on the webpage information available for potential sclerotherapy customers, but it did not include the content of the information for the patient or the information contained in the patient informed consent form signed by the patients before the procedure. Because we did not have access to these documents from the individual centres, we approached their web materials as patients in the initial phase of their decision making do. Of course, we can expect that the information provided during the medical qualification visit is more precise and differs from the web page information. Another important limitation of our research is the fact that many of the sclerotherapy specialists in our country still do not have a dedicated web page that could be a source of information for potential patients, and these centres were not available for the potential information analysis.

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CONCLUSIONS To attract patients, several medical centres inform them only about the indications rather than contraindications, and they do not provide proper information about the complications and post-treatment precautions. The way in which information about every aspect of sclerotherapy is provided constitutes evidence that this intervention is disregarded, treated rather like a beauty treatment and available for everyone. Unfortunately, this intervention is usually covered financially by patients, which is strongly connected with the interest of profit-driven clinics offering sclerotherapy. Most of their offers look like advertisements or commercial spots, and only few of them focus on crucial medical facts. The authors declare no conflict of interest.

References 1. Weiss MA, Hsu JT, Neuhaus I, Sadick NS, Duffy DM. Consensus for sclerotherapy. Dermatol Surg. 2014; 40: 1309-1318. 2. Guex JJ. Complications of sclerotherapy: an update. Dermatol Surg. 2010; 36: 1056-1063. 3. Rabe E, Breu F, Cavezzi A, et al. European guidelines for sclerotherapy in chronic venous disorders. Phlebology 2014; 29: 338-354. 4. Khunger N, Sacchidanand S. Standard guidelines for care: sclerotherapy in dermatology. Indian J Dermatol Venereol Leprol 2011; 77: 222-231. 5. Rabe E, Schliephake D, Otto J, Breu FX, Pannier F. Sclerotherapy of telangiectasias and reticular veins: a double-blind, randomized, comparative clinical trial of polidocanol, sodium tetradecyl sulphate and isotonic saline (EASI study). Phlebology 2010; 25: 124-131. 6. Kahle B, Leng K. Efficacy of sclerotherapy in varicose veins – a prospective, blinded placebo controlled study. Dermatol Surg 2004; 30: 723-728. 7. Ouvry P, Allaert FA, Desnos P, Hamel-Desnos C. Efficacy of polidocanol foam versus liquid in sclerotherapy of the great saphenous vein: a multicenter randomised controlled trial with a 2-year follow-up. Eur J Vasc Surg 2008; 36: 366-370. 8. Kakkos SK, Bountouroglou DG, Azzam M, Kalodiki E, Daskalopoulos M, Geroulakos G. Effectiveness and safety of ultrasound-guided foam sclerotherapy for recurrent varicose veins: immediate results. J Endovasc Ther 2006; 13: 357-364. 9. Coleridge Smith P. Chronic venous disease treated by ultrasound guided foam sclerotherapy. Eur J Vasc Endovasc Surg 2006; 32: 577-583. 10. Paraskevas P. Successful ultrasound-guided foam sclerotherapy for vulval and leg varicosities secondary to ovarian vein reflux: a case study. Phlebology 2011; 26: 29-33. 11. Cavezzi A, Frullini A, Ricci S, Tessari L. Treatment of varicose veins by foam sclerotherapy: two clinical series. Phlebology 2002; 17: 13-18. 12. Pang KH, Bate GR, Darvall KAL, Adam DJ, Bradbury AW. Healing and recurrence rates following ultrasound guided foam sclerotherapy of superficial venous reflux in patients with chronic venous ulceration. Eur J Vasc Endovasc Surg 2010; 40: 790-795.

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13. Chen CH, Chiu CS, Yang CH. Ultrasound-guided foam sclerotherapy for treating incompetent great saphenous veins – results of 5 years of analysis and morphologic evolvement study. Dermatol Surg 2012; 38: 851-857. 14. Rabe E, Otto J, Schliephake D, Pannier F. Efficacy and safety of great saphenous vein sclerotherapy using standardised polidocanol foam (ESAF): a randomised controlled multicentre clinical trial. Eur J Endovasc Vasc Surg 2008; 35: 238-245. 15. Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation,radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg 2011; 98: 1079-1087. 16. Shadid N, Ceulen R, Nelemans P, et al. Randomized clinical trial of ultrasound-guided foam sclerotherapy versus surgery for the incompetent great saphenous vein. Br J Surg 2012; 99: 1062-1070. 17. Rabe E, Partsch H, Hafner J, et al. Indications for medical compression stockings in venous and lymphatic disorders: an evidence-based consensus statement. Phlebology 2018; 33: 163-184. 18. Rabe E, Pannier F. Sclerotherapy of varicose veins with polidocanol based on the guidelines of the German Society of Phlebology. Dermatol Surg 2010; 36: 968-975. 19. Gibson K, Gunderson K. Liquid and foam sclerotherapy for spider and varicose veins. Surg Clin North Am 2018; 98: 415-429. 20. Bi M, Li D, Chen Z, et al. Foam sclerotherapy compared with liquid sclerotherapy for the treatment of lower extremity varicose veins: a protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99: e203327. 21. Yiannakopoulou E. Safety concerns for sclerotherapy of telangiectases, reticular and varicose veins. Pharmacology 2016; 98: 62-69. 22. Subbarao NT, Aradhya SS, Veerabhadrappa NH. Sclerotherapy in the management of varicose veins and its dermatological complications. Ind J Dermatol Venereol Leprol 2013; 79: 383-388.

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THE AWARENESS OF AIRLINE PASSENGERS ABOUT THE RISK OF DEEP VENOUS THROMBOSIS DURING AN AEROPLANE FLIGHT Marcin Kucharzewski1, Katarzyna Duda2, Adrianna Doman2, Marek Olesz2, Wacław Kuczmik3, Tomasz Urbanek3

European Centre of Phlebology, Katowice, Poland Student’s Society of Science, Department of General Surgery, Vascular Surgery, Angiology, and Phlebology, Medical University of Silesia, Katowice, Poland 3 Department of the General Surgery, Vascular Surgery, Angiology, and Phlebology, Medical University of Silesia, Katowice, Poland

ORIGINAL PAPER

ABSTRACT

ADDRESS FOR CORRESPONDENCE Dr Marcin Kucharzewski European Centre of Phlebology Katowice, Poland e-mail: mkucharzewski@onet.eu

1 2

Introduction: Venous thrombosis associated with immobilization during travel is also called economy-class syndrome or traveller`s thrombosis. The risk of deep venous thrombosis (DVT) during a long flight is about 0.02 to 2.7% and increases with the duration of the flight. Material and methods: The aim of the study was to determine the level of knowledge of airline passengers regarding the relation between the flight and the occurrence of venous thrombosis. Four hundred airline passengers took part in the study. An anonymous questionnaire was conducted. Results: Fifty-two per cent confirmed the potential influence of long air travel on the increased risk of thrombosis, including the following: prolonged sitting, flight duration which increases the risk, and variation of pressures and conditions in the aircraft compared to those prevailing at sea level. The question about the possibility of taking preventive actions during a long flight by plane was answered by 51% of the respondents. Sixty per cent of the respondents indicated exercises, 45% indicated drugs, and compression products were mentioned by 23%. The terms “economy-class syndrome” or “traveller’s thrombosis” were unknown to most of the respondents. Conclusions: Despite easy access to the Internet and magazines, knowledge among travellers remains low when it comes to the connection between deep vein thrombosis morbidity and travelling by plane, and similarly in terms of prevention and risk factors. It is essential to take up large-scale and systemic actions that could enhance the awareness of minimising the risk of DVT.

Phlebological Review 2021, 29, 1: 26–31 DOI: https://doi.org/10.5114/pr.2021.106740 Submitted: 14.05.2021 Accepted: 19.05.2021

Key words: economy-class syndrome, traveller`s thrombosis, venous thrombosis after air travel.

INTRODUCTION In series of publications, venous thrombosis associated with immobilization during travel is also called economy-class syndrome. The common name in the past as the economy-class band is now rarely used, inter alia due to the fact that the occurrence of thrombosis is not only related to air travel in less convenient economy-class conditions. The term was first used in 1977 by Semington and Stack [1]. Venous thromboembolism, clinically manifested as deep vein thrombosis and pulmonary embolism, is still the third cause of death among vascular diseases. The annual incidence worldwide is about 1–2 cases per 1000 in the adult population [2]. The link between long-term air travel and the possibility of venous thrombosis was first noticed in 1954 by Homans, who described two cases of flight-related thrombosis [3]. Currently, this topic is the subject of increasing discussions, the search for risk

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factors, and the implementation of prevention. However, it does not necessarily translate into an increase in knowledge among passengers. According to the results of the conducted studies, it is estimated that the risk of postflight thrombosis (most often clinically asymptomatic) is 0.5–2.8% [4]. In 2019, based on statistical data obtained from the Internet (https://zbiam.pl/artykuly/transportlotniczy-na-swiecie-w-2019-r), it was estimated that worldwide, commercial airlines carried just over 9 billion passengers. Compared to 2018, there was an increase of 3.4%. In Poland, based on data obtain from the Civil Aviation Authority (www.ulc.gov.pl/pl/regulacja-rynku/statystyki-i-analizy-rynku-transportu-lotniczego/3724-statystyki-wg-portow-lotniczych), around 49 million people travelled by plane in 2019. Compared to 2018, there was an increase of 7.2%. The course of thrombosis in at least 50% is asymptomatic or only slightly symptomatic, which

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The awareness of airline passengers about the risk of deep venous thrombosis during an aeroplane flight

causes frequent underestimation of the syndromes by patients (in the case of leg vein thrombosis, the percentage of asymptomatic patients seems to be even higher) [5]. The often uncharacteristic course of symptoms related to the development or already present thrombosis may be associated with pain and/or swelling of the limb. However, at this point, it should be emphasized that a number of other diseases can lead to similar problems, including chronic venous disease, which is relatively common in the adult population. A number of factors related to airplane conditions and those directly related to the traveller are potentially responsible for the occurrence of venous thrombosis. Blood stasis, hypercoagulability, and endothelial damage are the 3 components of the Virchow Triad, which play an important role in the formation of blood clots in the vessels. The differences in conditions on board significantly affect the 3 above-mentioned factors. Oxygen hypobaria caused by lower atmospheric pressure leads to a decrease in blood saturation to 90% among healthy people. In the elderly and those with lung and heart diseases, blood saturation may drop even to 80% [6]. Hypoxia reduces the fibrinolytic activity of endothelial cells and damages platelets, which causes hypercoagulability and leads to the release of vascular relaxing factors, which slow down the flow. Air humidity in aircraft cabins is only 10–20% (comparable to desert conditions) and promotes rapid dehydration by evaporation [1, 6]. In addition, long-term immobilization reduces the flow in the lower limbs by up to 2/3, leading to blood stagnation. The risk factors for thrombosis related directly to the health of passengers include the following: female gender, age > 65 years, overweight, height > 185 cm, use of oral contraceptives, history of deep vein thrombosis, surgery during the preceding 4–6 weeks, flight, trauma, cancer, or current thrombophilia [7, 8]. The presence of individual risk factors significantly influences the overall risk of long-term immobilization during travel. The global assessment of the risk of venous thromboembolism in this population allows us to distinguish patients with a low, moderate, or high risk of thrombosis (Table 1) [1, 9–11]. Another important issue is flight duration. The risk of thrombosis among passengers on flights lasting less than 4 hours in relation to non-travellers is about 2 times higher (odds ratio [OR]: 2.20; 95% CI: 1.29–3.73) [12, 13]. tudies have shown that the increased risk of thrombosis persists not only during the flight, but also for at least 4 weeks after the flight [7]. For long flights (more than 12 hours as a single or as multiple flights), the risk of travel-related thrombosis is approximately 3 times higher (OR: 2.75; 95% CI: 1.44–5.28) [14]. Awareness of the problem of travel-related immobilization means that information related to this issue appear in some published guidelines on antithrombotic prevention [4, 15]. On the other hand, the level of awareness of this problem among

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potential air travellers, as well as other forms of travel associated with chronic immobilization, remains limited. It should also be noted that in the era of the Internet, easy flow and access to information, the education of plane passengers is a rare practice, among airlines and GPs. In an attempt to answer the question about the awareness of airline passengers in terms of the risk of deep vein thrombosis, as well as the symptomatology of the disease and the possibilities of its prevention, the study attempted to assess the knowledge of the above-mentioned population in the above-mentioned scope in a survey conducted at an international airport.

MATERIAL AND METHODS Four hundred airline passengers took part in the study. An anonymous questionnaire was conducted with them. The inquiry was carried out at Katowice-Pyrzowice Airport with the consent of the airport authorities, between 15.02.2019 and 17.05.2019. The questionnaire consisted of 29 questions concerning knowledge about the disease, incl. symptoms, risk factors, and principles of prevention. Passengers were also asked about the connection between venous thrombosis and flight, the number of flights per year, the presence of possible symptoms in themselves, or the use of prophylaxis during the flight. There were 27 closed and 2 open-ended questions.

Table 1. Thrombosis risk level depending on risk factors (own modification based on the literature) [9–12] Risk level Low

Risk factors No risk factors or: Age < 40 years from Overweight Minor surgery (up to 3 days ago)

Moderate (more than 1 risk factor)

Postpartum period (up to 2–6 weeks) Lower limb injury (up to 6 weeks ago) Age > 60 years Hormone therapy (including oral contraceptives) Varicose veins of the lower legs Obesity (BMI > 30) Presents circulatory failure Myocardial infarction (up to 6 weeks back) History of idiopathic venous thrombosis, currently untreated History of venous thrombosis after flying

High

Major surgery (up to 4–6 weeks) Extensive trauma (4–6 weeks) Immobilization in a plaster cast Cancer Cancer chemotherapy (up to 6 months) or planned chemotherapy History of idiopathic venous thrombosis, currently untreated History of venous thrombosis after airplane flight Confirmed thrombophilia

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Marcin Kucharzewski, Katarzyna Duda, Adrianna Doman, Marek Olesz, Wacław Kuczmik, Tomasz Urbanek

80

76

75 67

70 60 50

60 53

47

52

48

40 30

57

50 50

47

4340 33

53

31

25

24

RESULTS

69

20 10 0 Calf Calf Entire leg Limb Limg pain oedema oedema warming bruising female – yes men – yes female – no men – no

Fig. 1. Percentage distribution of knowledge of the respondents about potential symptoms in a patient with deep vein thrombosis The open ones were about giving the definition of ECS and traveller’s thrombosis. The respondents were aged 18–76 years, 56% of the respondents were women, and 44% were men. The aim of the study was to determine the level of knowledge and awareness of airline passengers regarding the relation between the flight and the occurrence of venous thrombosis. 90 80

80

70 60 50 40 30 20

11

9

10

0 Don’t know Low comfort flight

High risk of the thrombosis

Fig. 2. Knowledge (understanding of the term) of the respondents about the concept of “economy-class syndrome” (%) 80 70

72

60 50 40 28

30 20 10

0

Don’t know

Higher risk of the thrombosis

Fig. 3. Knowledge – understanding of the term travel thrombosis among the respondents (%)

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Eighty-four per cent of the respondents correctly defined the term venous thrombosis. Women (94%) were more aware of this, while among men the percentage of correct answers was 74%. Only 1.75% of the respondents suffered from venous thrombosis, but 16% of the respondents had the disease in the family. The existence of a relationship between a long air trip and venous thrombosis was noted by 69% of respondents, and 17% could not explain it. Fifty-two per cent of respondents confirmed the influence of the long air travel on the increased risk of thrombosis, including the following: prolonged sitting in one position, which may be conducive to blood clots, flight duration, which increases the risk, and variation of pressures and conditions in the aircraft compared to those prevailing at sea level .The respondents were also asked a question about the symptoms that occur in the event of thrombosis. Among the 5 listed, the most commonly indicated symptoms of venous thrombosis were as follows: pain in the lower leg, swelling, swelling of the entire limb, increased warming of the limb, and discoloration of the limb-bruising. The percentage results among the respondents are presented in Figure 1. Among the results, it is worth paying attention to the disproportion in knowledge between the two sexes. The correct answer to particular questions was provided by an average of 20% more women than men. In the next question, the lower leg problems reported by passengers in connection with air travel were assessed. Among the most common symptoms observed while traveling, the respondents reported lower leg pain (15.25%; 60.7% of which were women and 39.3% men) and swelling of the calf, reported by 13% of respondents (65.4% of whom were women and 34.6% were men). Less frequently reported symptoms were swelling of the entire limb – 5.25%, increased limb warming – 5.75%, and the rarest symptom – change in colour of the limb to bluish, reported by 2.25% of respondents. The next two questions were related to the passenger’s definition of both “economy-class syndrome” and “traveller’s thrombosis”. Economy-class syndrome (ECS) turned out to be a term unknown to almost 89% of respondents. The answers given by the respondents can be divided into 3 categories: • the answer “I do not know” or no answer, • an answer suggesting reduced flight comfort, • a correct answer, • i.e. the association of reduced space with limb immobilization and blood flow abnormalities which increase the chance of developing deep vein thrombosis (Fig. 2). Also, the term “traveller’s thrombosis” turned out to be unknown to the majority of the respondents (Fig. 3). To the question about the possibility of taking preventive actions during a long flight by plane was answered by 51% of the respondents. Most of the respondents, from

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The awareness of airline passengers about the risk of deep venous thrombosis during an aeroplane flight

the group that answered correctly to the question (58%), indicated activities such as walking, moving during the flight, or stretching exercises, while 45% pointed out drugs, 13% mentioned aspirin, and low-molecular-weight heparin was indicated by 28% of the respondents. Compression products were mentioned as a preventive measure by 23% of those who answered this question, and only 5% indicated adequate hydration of the body (Fig. 4). Next question about prophylaxis concerned its use by the travellers themselves. Compression stockings were used by few responders (7.5%). The respondents were also asked if they had ever heard that before a long flight, it is best to take a drug that suppresses clotting, e.g. an aspirin tablet or an anticoagulant injection. Aspirin was indicated by 34% of the respondents and an anticoagulant injection by 27%. The knowledge of prophylactic exercises against venous thrombosis was also asked. Twenty-two per cent showed knowledge in this area. Among the exercises they mentioned were the following: movement on the plane, stretching the legs, frequent change of sitting position, and contracting the calf muscles. The last part of the survey focused on passengers’ knowledge of potential risk factors for venous thromboembolic events (VTE). Eighty-eight per cent saw a link between thrombosis and obesity. Ninety per cent of people interviewed said that longer flight distance causes thrombosis to occur more often. The distribution of responses to individual time intervals is presented in Figure 5. When asked whether intensive sports practice in the short term before the flight increases the risk of venous thrombosis, 44% of the respondents answered in the affirmative. Seventy-eight per cent of respondents qualified the surgery before the flight as a risk factor. Multiple flights in a short period of time were considered by 64% of respondents to increase the risk of thrombosis. Congenital coagulation disorders and neoplastic disease were consid70 60

60

ered by 76% and 61% of respondents as factors causing thrombotic disease, respectively. Respondents were also asked about drugs that increase the risk of deep venous thrombosis (DVT). Seventy-six per cent of them did not know what drugs contributed to the disease, and of the remaining group 48% reported that they were hormonal drugs, contraceptives, or hormone replacement therapy. The respondents’ knowledge about the influence of meals on the higher incidence of deep vein thrombosis was assessed. Sixty-one per cent answered that foods are a risk factor, with 84% saying that alcohol and/or coffee should be avoided. Only 86% were aware of adequate hydration in the prevention of thrombosis. Seventy-two per cent of respondents replied that the way of dressing reduces the risk of thrombosis, 48% of them indicated that “loose” clothing was the best. The last question was about the effect of growth on DVT; 41% of respondents replied that body height is important in causing the disease.

DISCUSSION In the year 2001, the WHO suggested the probability of a connection between DVT and long-haul flights; however, it was not clearly proven due to a lack of relevant data. As a result, the WRIGHT Project (the WHO Research Into Global Hazards of Travel) was launched, and the outcome of the first phase was published in 2007. It proved that a long journey is a risk factor for DVT occurrence. The project provided results which stated that in the case of healthy people travelling for less than 4 hours, the risk is 1/6000. While with the extension of the time and number of flights, the risk increases to 1/1000. The analysis published so far confirms the existence of this dependence, and thus passengers should be informed about the risk factors and the principles of its prevention [16]. An unquestionable obstacle in the implementation of these recommendations is the lack of high-quality evidence resulting from evidence-based medicine, as well as the lack of special obligation from insurers and airlines to apply appropriate antithrombotic prevention rules while travelling by plane [15, 17]. The awareness among trav-

50 40

40 30 20

27

25

23

35

36 32

30

27

25

10

4

20

5

3

0

ion

g dr

at

at

hin Hy

lot

ics

tab le c

to n

5

5

mf Co

Fig. 4. Methods of venous thrombosis prophylaxis indicated by the respondents (%)

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10

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pa rin He

id ac

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era py

ety Ac

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mp

res

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nt

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ise

15

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2–4 h

4–8 h

Over 8 h

Fig. 5. Knowledge of the respondents about the relationship between flight distance and the risk of venous thrombosis (%)

29


Marcin Kucharzewski, Katarzyna Duda, Adrianna Doman, Marek Olesz, Wacław Kuczmik, Tomasz Urbanek

ellers about the connection between the onset of VTE symptoms and being on a flight is alarmingly low, and the lack of knowledge about risk factors and prevention is disturbing. The analysis of our research results showed that only 52% of passengers discern an association between long-term air travel and the onset of DVT. The knowledge of any preventive methods also oscillates around 50%, of which only 7.5% of passengers have ever used prophylaxis during the flight. These results show that despite the growing number of people travelling by plane, awareness of the risk of DVT remains low. The level of knowledge about the discussed issues among Polish travellers does not differ much from travelling French citizens. This is reflected in a study by the French Society of Phlebologists. Compared to the French citizens, understanding of the factors contributing to the risk of deep vein thrombosis, i.e. drinking, moving around onboard during the flight, and the type of clothing, was higher among our respondents. On the other hand, knowledge about the beneficial effects and the possibility of using compression therapy in the prevention of deep vein thrombosis turned out to be significantly less widespread among the surveyed Polish citizens (7%) compared to the French (77%). One third of the respondents knew the method of taking aspirin before a long flight, which according to the current recommendations is not a recommended practice, but only suggested in the absence of the other methods of pharmacological prophylaxis [18]. In the recommendations of the French Society of Angiology, 15% of the respondents declared the use of aspirin before the flight [18]. According to the document of Aviation, Space, and Environmental Medicine from the year 2001, the main risk factors which contribute to morbidity of VTE are: blood disorders affecting the tendency of clotting, and impaired blood clotting mechanism, such as a clotting factor abnormality, as well as cardiovascular diseases, current or past neoplastic disease, recent major surgery, recent trauma to the lower limbs or abdomen, previous episode of VTE or a positive family history, pregnancy, oestrogen therapy, including oral contraception, age over 40 years, and prolonged immobilisation. As can be seen from the results of the survey conducted at Katowice-Pyrzowice Airport, many of these factors remain unknown to the passengers travelling in our country, for example, the influence of drugs, especially oral contraceptives, or the influence of an active neoplastic disease. Factors related to a higher level of awareness among surveyed passengers turned out to be obesity, dehydration, and excessive alcohol intake. The connection between the occurrence of DVT and long-haul flights was first observed by Homans in 1954, who described 2 passengers with the dependency mentioned previously herein [3]. This topic became a subject of research. In the research project LONFLIT 1 by Belcaro, 355 passengers with low risk and 389 passengers with high risk of deep vein thrombosis were followed. After

30

12 hours of flying within the span of 24 hours a Doppler ultrasound examination was performed. In the lowrisk group, no signs of DVT were observed, whereas in the high-risk group, signs in ultrasound examination occurred among 2.8% of passengers. Those with low risk were not advised to use antithrombotic prophylaxis. This research demonstrate the importance of being familiar with risk factors, so it is possible to find passengers with high risk of occurrence of DVT and use pharmacological prevention among them [19]. According to the British Society of Cardiothoracic Surgery (BTS Guidelines), passengers should be divided into 3 groups in terms of risk of DVT after long-distance flight. DVT prophylaxis depends on the ascribed group – low, medium, and high risk. In the low-risk group recommended methods are stretching exercises, walks, and avoiding alcohol intake. For those in the medium-risk group compression therapy and alternatively low-molecular-weight heparin therapy are advised, and for high-risk patients compression therapy and LMWH [11]. Another research by Belcaro et al., LONFLIT 2, applied compression therapy in travellers. Among 833 passengers, 422 represented the control group, while 411 people used compression therapy up to 48 hours before the departure. Afterwards, within a 24-hour period including a 12-hour long-haul flight, Doppler ultrasound was performed. In the control group DVT signs were observed in 4.5% of patients, while in people using compression therapy only 0.24% presented changes in ultrasound examination suitable with DVT (1 person) [19]. The term economy-class syndrome is not known by the majority of plane travellers. This term is misleading according to the UK House of Lords Select Committee on Science and Technology guidelines; thus, they propose using the term flight-related DVT or traveller’s thrombosis instead [20]. In the year 2003, the American Public Health Association have esteemed awareness of passengers about the Economy-class syndrome. From 1000 people, only 10 (1%) responded to the question, while 5 (0.5%) replied with a valid response. The rest of the responders connected the term with economy-class flight. In comparison with present outcomes, we can observe slight enhancement. Twenty per cent of the surveyed applied to explain the definition, and 3% did it correctly. In the span of 16 years, the number of flights increased significantly, and so higher awareness about health problems in the journey is expected, and the research results should arouse concern. According to the surveys, knowledge about DVT risk factors is continually low. It is worth mentioning that in the aspect of low acknowledgment in travellers, information given by airlines plays crucial role. Among Polish hauliers there is a lack of guidebooks about deep vein thrombosis and its prevention. Contentedly, worldwide, we can observe a trend of campaigns about DVT by airlines, for example in the United Kingdom and France. It should be noticed that such information is provided on

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The awareness of airline passengers about the risk of deep venous thrombosis during an aeroplane flight

the website of the Spanish government (Información Terapéutica Del Sistema Nacional De Salud) [21].

CONCLUSIONS Despite easy access to the Internet and magazines, knowledge among the travellers remains low when it comes to the connection between deep vein thrombosis morbidity and flying, similarly in terms of prevention and risk factors. It is essential to undertake large-scale and systemic actions that could enhance the awareness of minimizing the risk of DVT. The authors declare no conflict of interest.

References 1. Dusse LMS, Ferreira Silva MV, Gonçales Freitas L, Marcolino MS, das Graças Carvalho M. Economy class syndrome: what is it and who are the individuals at risk? Rev Bras Hematol Hemoter 2017; 39: 349-353. 2. Bagshaw M. The Air Transport Medicine Committee, Aerospace Medical Association Traveller’s Thrombosis: a Review of Deep Vein Thrombosis Associated with Travel. Aviat Space Environ Med 2001; 72: 848-851. 3. Homans J. Thrombosis of the leg veins due to prolonged sitting. N Engl J Med 1954; 250: 148-149. 4. Guyatt GH, Crowther M, Gutterman DD, Schuünemann HJ. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141: 7S-47S. 5. Schwarz T, Siegert G, Oettler W, et al. Venous thrombosis after long-haul flights. Arch Intern Med 2003; 163: 2759-2764. 6. Assessing fitness to fly. Guidelines for health professionals from the Aviation Health Unit, UK Civil Aviation Authority, 2012; 5. 7. Kuipers S, Cannegieter SC, Middeldorp S, et al The absolute risk of venous thrombosis after air travel: a cohort of 8,755 employees of international organizations. PLoS Med 2007; 4: 1508-1514. 8. Kahn Sr, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012; 14: e195S-226S. 9. Watson HG, Baglin TP. Guidelines on travel-related venous thrombosis. Br J Haematol 2010; 152: 31-34. 10. Schobersberger W, Toff WD, Eklöf B, et al. Traveller’s thrombosis: international consensus statement. Vasa 2008; 37: 311-317. 11. Ahmedzai S, Balfour-Lynn IM, Bewick T, et al. Managing passengers with stable respiratory disease planning air travel: British Thoracic Society recommendations. Thorax 2011; 66: i1-i30. 12. Scurr JH, Machin SJ, Bailey-King S, Mackie IJ, McDonald S, Smith PDC. Frequency and prevention of symptomless deepvein thrombosis in long-haul flights: a randomised trial. Lancet 2001; 357: 1485-1489 13. MacCallum PK, Enid DA, Hennessy M, et al. Cumulative flying time and risk of venous thromboembolism. Br J Haematol 2011; 155: 613-619.

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14. Perez-Rodriguez E, Jiménez D, Díaz G, et al. Incidence of air travel-related pulmonary embolism the Madrid-Barajas airport. Arch Intern Med 2003; 163: 2766-2770. 15. Zawilska K, Bała M, Błędowski P, et al. Polskie wytyczne profilaktyki i leczenia żylnej choroby zakrzepowo-zatorowej – aktualizacja 2012. Pol Arch Med. Wewn 2012; 122: 3-76. 16. WHO Research Into Global Hazards of Travel (WRI GHT) Project – final report 2007 (https://www.who.int/cardiovascular_diseases/publications/WRIGHT_INFORMATION/en/). 17. Schünemann HJ, Cushman AM, Burnett E, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv 2018; 2: 3198-3225. 18. Cazaubon M, Belcaro G, Anastasie B, et al. Audit de la SFA sur les habitudes des patients lors des vols aériens vis-à-vis de la compression médicale. Angiol 2012; 1: 79-80. 19. Belcaro G, Geroulakos G, Nicolaides ANN, Myers KA, Winford M. Venous thromboembolism from air travel: the LONFLIT study. Angiol 2001; 52: 369-374. 20. Science and Technology – Fifth Report Session1999-2000 Publications on the internet Science and Technology Committee Publications House of Lords British parliament (https://publications.parliament.uk/pa/ld199900/ldselect/ldsctech/121/12101. htm). 21. Ruiz-Giménez Arrieta N, Suárez Fernández C. Tromboembolismo venoso y síndrome de la clase turista: medidas preventivas. Sist Nacional Salud 2007: 431; 118-125.

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SINGLE-CENTRE EXPERIENCE WITH MECHANOCHEMICAL ABLATION OF INSUFFICIENT VEINS WITH THE FLEBOGRIF® CATHETER IN A 36-MONTH FOLLOW-UP Marek Iłżecki, Piotr Terlecki, Stanisław Przywara, Tomasz Zubilewicz

ORIGINAL PAPER

Department of Vascular Surgery and Angiology, Medical University of Lublin, Lublin, Poland

Phlebological Review 2021; 29, 1: 32–37 DOI: https://doi.org/10.5114/pr.2021.106880

ABSTRACT

Submitted: 26.05.2021 Accepted: 31.05.2021

Introduction: Flebogrif® is the youngest representative of the MOCA treatment group. Its minimally invasive nature and high effectiveness contribute to its popularity. In the presented study, its effectiveness was assessed over a 36-month follow-up. Material and methods: Observations were conducted over a 36-month period as a prospective study. Two hundred patients meeting the established inclusion criteria were enrolled in the study, including 170 women aged 18 to 87, mean age 56 years, and 30 men, age 23 to 75, mean age 46 years. The obtained numerical data were statistically analysed using tests for variables with nonparametric distribution: Wilcoxon test and Friedman’s ANOVA. The follow-up visits were scheduled as follows: baseline, 1, and 4 weeks and 3, 6, 12, 24, and 36 months. Numerical data were collected based on the assessment validation of venous clinical severity score (VCSS) and visual analogue scale (VAS). Ultrasound evaluation was performed to assess the anatomical effectiveness of the procedure. The safety of the method was assessed in terms of the severity and number of complications. Results: Based on the VCSS and VAS scale assessment, a statistically significant decrease in the intensity of clinical symptoms was observed both between monitoring visits and in relation to the baseline. One case of deep vein thrombosis (0.5%), 1 prolongated pain, 35 thrombophlebitis, and 28 discolourations (32%) were reported. The 12-month success rate dropped to 92% and remained there until 36 months. Conclusions: A high success rate of 92% was achieved, which is comparable with other methods currently used in the ablation of insufficient superficial veins. High safety of the method and low number of complications is expressed. Good cosmetic effect. A quick return to previous physical activity is an additional incentive for its use.

ADDRESS FOR CORRESPONDENCE

Prof. Marek Iłżecki Chair and Department of Vascular Surgery and Angiology Medical University of Lublin Lublin, Poland e-mail: ilzecki.m@gmail.com

Key words: varicose veins, MOCA, Flebogrif®.

INTRODUCTION Recent years have brought a number of solutions for the treatment of venous insufficiency. It seems that thermal techniques such as EVLT, RFA, and STEAM dominate the medical market thanks to the effectiveness and repeatability of the therapeutic effect [1]. The ClariVein method proposed by Michael Toll was a new opening in the field of minimally invasive procedures for the treatment of superficial venous insufficiency [2]. The essence of the procedure was a combination of 2 factors: mechanical damage combined with chemical destruction of the endothelium. The immediate effect of the procedure was the closure of the vein lumen by a formed hemoclot, while the initiated chronic inflammation led to its fibrosis and permanent occlusion [3]. Follow-up over a period of 12 months showed an effectiveness of 88–100% [4]. In 2011, Professor Piotr Ciosek, Head of the First Chair and Clinic of General and Vascular Surgery, II Fac-

32

ulty of Medicine, Medical University of Warsaw, presented an idea for a device whose essence of operation referred to the concept of mechanical-chemical ablation [5]. An innovative solution was to replace the rotating core with a ball, as is the case with the ClariVein® catheter (which causes several unexpected, unpleasant complications), with 5 cutting elements damaging the endothelial surface (Fig. 1) [6]. The currently used catheter is the result of a number of technological and functional improvements patented by Balton Sp. z o. o., increasing its effectiveness and, above all, safety. The many advantages of the new Flebogrif® catheter include its simplicity, intuitive operation, and durability. A unique feature is its ability to adapt the radial force of the cutting elements to the diameter of the vein, which increases the effect of the mechanical MOCA phase with the use of a Flebogrif. aAnalysis of histological images confirmed the effectiveness of the working part (cutting elements) of the catheter. Dam-

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Single-centre experience with mechanochemical ablation of insufficient veins with the flebogrif® catheter in a 36-month follow-up

age to the endothelial surface caused by the action of the hooks penetrated the muscular layer of the vessel wall.

MATERIAL AND METHODS The effectiveness of the method using the Flebogrif® catheter was analysed in relation to other treatments. In our own material, 200 patients were subjected to ablation of the insufficient vein of the great saphenous vein/small saphenous vein system. The authors obtained approval for the study based on the decision of the Bioethics Committee (KF-0254/226/2015). Patients presented features of venous insufficiency classified according to the CEAP scale between C₂ and C₆. Table 1 presents the demographic data and clinical cardiovascular disease advancement of the study group. In the adopted study plan, follow-up visits were arranged in the following order: baseline, 1, and 4 weeks and 1, 3, 6, 12, 24, and 36 months. The intensity of clinical symptoms of the disease was classified using the venous clinical severity score (VCSS) scale, ranging between 7 and 21 points. During the established observation period, a slow decline in the study participants was noted, which to some extent explains the radical improvement after the surgery. A quick return to full physical activity and a significant reduction in the symptoms associated with the underlying disease contributed to the resignation of a certain

Fig. 1. Flebogrif® catheter

Table 1. Demographic data of the observed group (age, gender), numerical distribution of the study group according to the CEAP scale, and the age range of the operated patients Scale

Age

p

≤ 56.5

> 56.5

n

M

SD

n

M

SD

VCSS-b

100

9.40

3.76

100

12.03

3.74

< 0.001

VCSS-1

87

6.99

3.86

95

9.08

3.65

< 0.001

VCSS-3

85

4.93

3.43

94

6.57

3.44

< 0.001

VCSS-6

83

3.83

3.15

91

5.58

2.88

< 0.001

VCSS-12

77

3.64

2.98

91

5.05

2.75

< 0.001

VCSS-24

67

4.18

2.92

91

5.04

2.56

0.0930

VCSS-36

65

4.90

2.77

89

5.17

2.22

0.8899

VAS-b

100

2.68

1.61

100

3.77

1.72

< 0.001

VAS-1

87

1.54

1.34

95

2.20

1.44

< 0.001

VAS-3

85

0.62

0.98

94

1.19

1.36

< 0.01

VAS-6

83

0.45

0.83

91

0.98

1.18

< 0.001

VAS-12

77

0.38

0.67

91

0.78

0.96

< 0.01

VAS-24

67

0.29

0.51

91

0.88

1.01

< 0.01

VAS-36

65

0.45

0.63

89

0.81

0.89

0.0772

VCSS – venous clinical severity score, VAS – visual analogue scale

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Marek Iłżecki, Piotr Terlecki, Stanisław Przywara, Tomasz Zubilewicz

The results of our own research were analysed in 4 categories: • clinical success, defined as an objective improvement in the clinical condition, based on the assessment according to the VCSS scale and the visual analogue scale (VAS), • effectiveness of the method, expressed as a percentage of closed veins, based on the ultrasound assessment, • method safety, expressed in terms of observed complications, • advantages of the catheter/Flebogrif method® including technical.

182

179

174

168

156

158

152

148

150

170

170

198

157

200

158

200

154 98

100 50

30

28

24

22

18

16

14

14

hs nt

hs

mo

STATISTICAL ANALYSIS METHODS

36

mo

nt 24

mo

nt

hs

s

Male

12

on

th

s th

6m

on

th

3m

on

1m

1w ee k

Ba se lin e

0

Female

The numerical data obtained during the observation, obtained on the basis of the assessment of clinical symptoms related to the underlying disease using the VCSS (Venous clinical severity score) scale, and the VAS, were statistically analysed using the Wilcoxon tests (for paired samples) and Friedman’s ANOVA for the independent variables with nonparametric distribution. In the performed statistical analysis, the behaviour of the observed variable between the established time points (follow-up visits) as well as in relation to the baseline day was assessed. The obtained results showed a statistically significant difference in the intensity of the examined feature as assessed by the VCSS scale between individual visits, and also in relation to day zero (baseline).

Fig. 2. Number of patients participating in visits during the 36-month follow-up number of patients from participation in monitoring visits. The interchangeability of the number of patients participating in monitoring visits is presented in Figure 2. The observed natural decrease in the number of participants in the Flebogrif® trial is essential for the full evaluation of the method’s effectiveness and is probably the weak point of each clinical trial. The ablated saphenous vein was punctured at different levels depending on the length of the inefficient segment; in the case of the small saphenous vein it was always punctured at the lowest point of the axial reflux. The numerical distribution of the puncture level is presented in Table 2. In 172 cases, the saphenous vein was ablated, which accounted for 86% of the study group, and the small saphenous vein was closed in 28 cases, which accounted for 14% of the studied group of patients. The range of diameters of the veins treated with the Flebogrif® catheter, depending on the side of the operated limb and sex, are presented in Table 3.

RESULTS On the basis of the performed statistical analysis, a statistically significant decrease in the intensity of clinical symptoms measured with the VCSS scale and the intensity of pain was found. Among the analysed factors, the age of the patients was most influenced by the differences in the numerical values ​​obtained on the basis of the patient’s clinical assessment according to the VCSS scale

Table 2. Numerical distribution of puncture sites of the saphenous vein in females and males Gender

Puncture site

Below the knee

Above the knee

Knee level

GSV

SSV

Female

37

36

72

25

Male

7

6

15

3

GSV – great saphenous vein, SSV – small saphenous vein

Table 3. The range of the vein diameter depends on the puncture level, the side of the operated vein, and gender Diameter of the vein (from — to/ average) Below SFJ

4.2–22.1/8.1

34

Mid-thigh

3.8–17.1/6.2

Operated limb

Knee level

3.8–11.9/6.6

Females

Males

Right

Left

Right

Left

68

102

13

17

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Single-centre experience with mechanochemical ablation of insufficient veins with the flebogrif® catheter in a 36-month follow-up

Table 4. Influence of patients’ age on the shaping of differences in numerical values obtained from the venous clinical severity score and visual analogue scale Recanalization

Female

16 14 12

Male

GSV

SSV

GSV

SSV

10

Full rec.

5

3

2

8

Partial r.

4

1

GSV – great saphenous vein, SSV – small saphenous vein

and the subjective feeling of pain measured with the VAS scale (Table 4). The largest statistically significant difference was observed between the baseline value and the 12-month follow-up, while the decrease in the intensity of the examined feature between months 12–24 and 24–36 was not statistically significant. Figure 3 shows the graphical form of statistical significance as assessed by VCSS and VAS. During the 36-month observation, 15 cases of recanalization were recorded, which constituted 8% of the studied group. Based on the European Consensus for Sclerotherapy the following recanalization classification criteria were adopted: success – no flow of the vein completely closed by fibrous changes, partial recanalization – reflux < 0.5 s, reduction of the vein diameter, failure – reflux > 0.5 s, full vein patency [7, 8]. Among the 10 identified cases of complete recanalization (according to the adopted criteria), 8 were related to the saphenous vein and 2 to the small saphenous vein. In the partial recanalization group, 4 cases concerned the saphenous vein, and 1 case concerned the small saphenous vein. Table 5 presents the numerical distribution of recanalization in the observed group of patients, taking gender into account. Safety analysis of the MOCA method using the Flebogrif ®catheter during the 36-month follow-up, it showed one case of deep vein thrombosis (DVT) among serious complications. In the course of further diagnostics, the patient was diagnosed with factor V Leiden mutation. The patient underwent anticoagulant therapy with NOAC drugs. Among minor complications, there was 1 case of prolonged pain, 35 cases of superficial vein thrombosis, and 28 cases of hyperpigmentation. No adverse effects related to the type of sclerosing agent used were observed. After the procedure, patients were

6 4 2 0 VCSS B VCSS 3 VCSS 12 VCSS 36 VCSS 1 VCSS 6 VCSS 24 Mean Mean ± SD

Fig. 3. Variation in the numerical value of VCSS at subsequent follow-up visits over the period of 36 months discharged home within an hour. The only trace of the procedure was the puncture site.

DISCUSSION A method of mechanical-chemical ablation of inefficient veins of the superficial system using the Flebogrif catheter® is a valuable supplement to the group of minimally invasive treatments covered by the common name MOCA. The combination of 2 factors of the mechanical destruction of the endothelium and the chemical action of sclerosant significantly increased the effectiveness of the method [9]. Sclerotherapy as an independent procedure used in obliteration of inefficient superficial veins is effective although, according to the literature, it is slightly lower than the currently most commonly used thermal methods, such as EVLT or RFA [10]. It should be emphasized, however, that the relatively low price increases the availability of the procedure, which encourages a certain group of doctors and patients to use it. The undoubted advantage of the Flebogrif, like other treatments (ClariVein), is the elimination of the thermal factor, which significantly widens the possibilities of using the method in areas with a high risk of neurological damage, sometimes accompanying EVLT, RFA, or STEAM [11, 12].

Table 5. Numerical distribution of recanalization/failure by sex and ablated great saphenous vein/small saphenous vein C2

92 (46%)

C3

32 (16%)

C4

46 (23%)

C5

26 (13%)

C6

4 (2%)

Phlebological Review 2021

Sex

Number of patients

Age

Total

Max

Average

Min

Females

170

87

56

18

Males

30

75

46

23

200

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Marek Iłżecki, Piotr Terlecki, Stanisław Przywara, Tomasz Zubilewicz

Unlike Clarivein, in the Flebogrif method® only a foamed sclerosant is used according to the Tessari method in the proportion of 4 volumes of air to 1 volume of Polidocanol [12, 13]. The obtained results indicate the high efficiency of the method, reaching 92% of closed veins in a 36-month follow-up. The vast majority of failures were observed in the first 6 months (8 at the 3-month visit and 6 cases at the 6-month visit, respectively), which to some extent should be explained by the learning curve. In the remaining months, isolated cases of recanalization were observed. Another important advantage of the Flebogrif catheter® is that there is no need to use tumescence, which is sometimes the cause of haematomas, arterial damage, and trunks of nerves accompanying the vein, which are important complications associated with thermal ablation [14]. A distinguishing feature of the method is the possibility of repeating the mechanical damage to the vessel wall through the cutting part of the Flebogrif® catheter, while maintaining the original position of the guide. The undoubted advantage of the Flebogrif catheter, as well as other MOCA methods, is the lack of the need for anaesthesia (general, epidural). An additional advantage of the method is the short duration of the procedure (10–15 minutes). The complete set delivered at the factory allows the procedure to be performed without the need to invest in additional equipment. The very good visibility of the elements of the working part of the catheter in the ultrasound image allows for precise positioning in a dedicated place, i.e. 2–2.5 cm from the mouth of the saphenous vein to the femoral vein. Another important feature of the catheter/Flebogrif method® is a rapid return of the patient to previous physical activity, which is essential for the younger group of patients. The disadvantage of the method using the Flebogrif® catheter is the inability to ablate insufficient perforators, which is determined by the specificity of its construction. The simplicity of its construction and, consequently, its simple and intuitive operation are another positive of the discussed method of mechanical and chemical ablation of veins. During the entire observation period, no mechanical defects were found that could, on the one hand, affect the safety of the procedure, and on the other hand, its effectiveness. Lene and Moore described an interesting complication related to the unintentional wrapping of a vein around the rotating tip of the ClariVein® working part, which radically changed the original nature of the procedure from minimally invasive to the classic painful saphenectomy [6]. However, these kinds of complications constitute a fraction of a percent. Contraindications to MOCA using the Flebogrif catheter®, as with other endovascular procedures, are as follows: the current DVT and its occlusion/obstruction, pregnancy, acute infectious disease, lower limb ischaemia, severe lymphoedema, bleeding diathesis, allergic reaction to the sclerosant, or local skin infection.

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Summing up, it should be stated that the obtained high effectiveness rate of the method using the Flebogrif® catheter is a promise of therapeutic repeatability, which seems to be the main argument for further use. It should also be remembered that the apparently natural decrease in the number of patients participating in monitoring visits (typical for most studies) may to some extent affect the actual success/failure rate due to the lack of information on the outcome of surgery in those patients with potential recanalization.

CONCLUSIONS A high success rate of up to 92% was achieved, which is comparable with the results of other methods currently used in the ablation of insufficient superficial veins. The high safety of the method and low number of complications were expressed, as well as good cosmetic effect and a quick return to previous physical activity is an additional incentive to use it. The authors declare no conflict of interest.

References 1. Elrasheid A, Kheirelseid H, Gillian C, et al. Systematic review and meta-analysis of randomized controlled trials evaluating long-term outcomes of endovenous management of lower extremity varicose veins. J Vasc Surg Venous Lymphat Disord 2018; 6: 256-270. 2. Elias S, Raines JK. Mechanochemical tumescentless endovenous ablation: final results of a preliminary clinical study. Phlebology 2012; 27: 67-72. 3. Mueller RL, Raines JK. ClariVein mechanochemical ablation: background and procedural details. Vasc Endovascular Surg 2013; 47: 195-206. 4. Witte ME, Zeebregts CJ, de Borst GJ, Reijnen MMPJ, Boersma D. Mechanochemical endovenous ablation of saphenous veins using the ClariVein: a systematic review. Phlebology 2017; 32: 649-657. 5. Ciostek P, Kowalski M, Woźniak W, et al. Phlebogriffe – a new device for mechanical-chemical ablation of insufficient saphenous veins: a pilot study. Phlebological Rev 2015; 23: 72-77. 6. Lane TR, Moore HM, Franklin IJ, Davies AH. Retrograde inversion stripping as a complication of the ClariVein mechanochemical venous ablation procedure. Ann R Coll Surg Engl 2015; 97: e18-20. 7. Breu FX, Guggenbischler S, Wollmann JC. Europäische Konsensuskonferentz zur Schaumaklerotherapie der Varikose. Gefässchir 2011;16: 236-241. 8. Rabe E, Brief FX, Cavezzi A, et al. Guideline group. European guidelines for sclerotherapy in chronic venous disorders. Phlebology 2014; 29: 338-354. 9. Mueller RL, Raines JK. ClariVein mechanochemical ablation: background and procedural details. Vasc Endovascular Surg 2013; 47: 195-206. 10. Van Eekeren RR, Boersma D, de Vries JP, Zeebregts CJ, Reijnen MM. Endovenous treatment of insufficient saphenous vein

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Single-centre experience with mechanochemical ablation of insufficient veins with the flebogrif® catheter in a 36-month follow-up

diseases – literature review update. Semin Vasc Surg June 2014; 27: 118-136. 11. Nemoto H, Mo M, Ito T, et al. Japanese Endovenous Ablation Committee for Varicose Veins. Venous thromboembolism complications after endovenous laser ablation for varicose veins and role of duplex ultrasound scan. J Vasc Surg Venous Lymphat Disord 2019; 7: 817-823. 12. Woźniak W, Mlosek RK, Ciostek P. Complications and failure of endovenous laser ablation and radiofrequency ablation procedures in patients with lower extremity varicose veins in a 5-year follow-up. Vasc Endovascular Surg 2016; 50: 475-483. 13. Costantino DC, Antonino S, Fiorillo A, Matula ThJ. Size of sclerosing foams prepared by ultrasound, mechanical agitation, and the handmade tessari method for treatment of varicose veins. J Ultrasound Med 2017; 36: 649-658. 14. Bunke N, Brown K, Bergan J. Foam sclerotherapy: techniques and uses. Perspect Vasc Surg Endovasc Ther 2009; 21: 91-93.

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SCLEROTHERAPY – FROM HISTORICAL RESEARCH T0 THE MODERN AND EFFICIENT METHOD OF PHLEBOLOGICAL TREATMENT REVIEW PAPER

Joanna Borecka-Sobczak

Phlebological Review 2021; 29, 1: 38–43 DOI: https://doi.org/10.5114/pr.2021.106557

Phlebological Clinic, Gdańsk, Poland ABSTRACT

Venous insufficiency most likely accompanied humanity from the moment that man adopted an upright posture. The beginnings of sclerotherapy go back many years – it was in the Classical Era that Hippocrates recommended puncturing varicose veins. In fact, minimally invasive treatment became available only in the mid-nineteenth century, when Francis Rynd invented the hypodermic needle, and Charles-Gabriel Pravaz in 1851 introduced a hypodermic syringe. It was already more than 100 years ago that chemicals were injected into veins to get rid of varicose veins. The pioneer of phlebology is considered to be Professor Paul Linser. In the 1920s, he used 1–2% mercury perchloride injection in over 6000 patients. In the 1960s, George Fegan presented modern compression sclerotherapy in the journal The Lancet, which again popularized this method. In 1963 Doctor Peter Lunkenheimer used polidocanol for the first time in his patient. The era of foam sclerotherapy began when, in 1939, Stuart McAusland performed and described obliteration with foam. The introduction of ultrasound to sclerotherapy was a milestone along with the discovery that foam is visible on ultrasound. The precision of the method has reached an unprecedented level. Contemporary guidelines for sclerotherapy were presented in a document during a Guideline Conference held by the German Society of Phlebology in 2012. In the 21st century, along with the development of minimally invasive medicine, sclerotherapy has once again gained an important position in the treatment of veins.

Submitted: 10.05.2021 Accepted: 19.05.2021 ADDRESS FOR CORRESPONDENCE Joanna Borecka-Sobczak Phlebological Clinic 27 Partyzantów St. 80-254 Gdańsk, Poland e-mail: jbs.poradnia@gmail.com

Key words: sclerotherapy, varicose veins, history of vein treatment, venous insufficiency.

INTRODUCTION Venous insufficiency of the lower extremities most likely accompanied humanity from the moment man adopted an upright posture. From then on, the veins had to do a lot more work to bring the blood to the heart [1]. The first illustration of a varicose vein, discovered at the foot of Acropolis in Athens and dating back to the 4th century BC, was dedicated to Dr Amynos, perhaps one of the first phlebologists [2]. The beginnings of sclerotherapy go back many years – it was in the Classical Era that Hippocrates recommended puncturing varicose veins and described incidental obliteration, which occurred after the inflammation resulting from such a puncture of the varicose veins [1, 3]. And it all happened even before William Harvey (1578–1657) discovered blood circulation.

THE BEGINNINGS OF SCLEROTHERAPY For years, there has been a search for the treatment of varicose veins, in which the major focus has been on

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surgical treatment, although not all doctors have recommended such an approach. In the 17th century such methods were not very popular [2], and bandages were recommended for the treatment of varicose veins and ulcers. It was in that period that a royal physician, Richard Wiseman, invented a stocking made of delicate skin (preferably dog skin) and proposed it for the treatment of venous shin ulcers [4–6]. Until the end of the 19th century, surgical treatment was very traumatic because there were no antiseptics and no anaesthesia; Richard Wiseman claimed that such treatment was painful, caused large “bumps”, wounds, and bleeding [4]. Simultaneously with surgical methods, alternative forms of therapy were sought. It was noticed that in the wake of inflammation of varicose veins their reduction and/or obliteration could be observed. Initially, an agent was injected perivascularly, which caused irritation of the surrounding tissues, and inflammation of the vessel and its obliteration.

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Sclerotherapy – from historical research t0 the modern and efficient method of phlebological treatment

The first attempts to apply this method were made in the 17th century by Eisholz, and in Switzerland by Zollikofer. At that time, alcohol and acid were injected into the veins, and it is not known whether the patients survived [1, 7]. Minimally invasive treatment became available only in the mid-nineteenth century, when the Irish physician Francis Rynd invented the hypodermic needle (in 1845), and the French Charles-Gabriel Pravaz in 1851 designed and introduced a hypodermic syringe, with which he originally treated aneurysms [3, 7]. Thanks to the new syringe, the injection therapy could develop more dynamically. In 1853 in Vienna, Charles-Gabriel Pravaz and Eduard Chassaignac applied iron perchloride for the purpose of vein obliteration in 32 patients [2, 3]. Also, in Lyon, professor of surgery Joseph Pierre Pétrequin together with professor of pharmacy Prof. Soquet concluded that an iodine-tannin solution could give better results than iron perchloride, and at the Congress in Paris in 1853 they presented the preliminary results of injections with this agent made in 16 patients. Next, in 1875, they presented the results of treating 200 patients with such a solution with good results and without severe complications [7]. Hence, it was already more than 100 years ago that chemicals were injected into veins to cure varicose veins. Various substances were then used to heal varicose veins, such as: 5% phenol, perchlorate and iron perchloride, 20% NaCl, 60% glucose, sodium morrhuate, iodine solutions, alcohol solutions, sodium salicylate, and chromic alum of glycerol. Unfortunately, it was not yet understood what caused the sepsis or what the effects of the use of a caustic solution were. Most of the agents used were toxic, so there were complications in the form of infections, inflammations, severe pain and swelling, as well as focal skin necrosis, which discouraged further attempts. The resultant inflammatory reaction was so strong that sclerotherapy continued to be overshadowed by surgical treatment. In 1894, the Surgical Congress in Lyon went as far as to condemn the method due to its complications and the lack of satisfactory results [3, 7].

THE DEVELOPMENT OF SCLEROTHERAPHY IN THE 20TH CENTURY The pioneer of phlebology is considered to be Professor Paul Linser (1871–1963), a German physician, the first head of the Department of Dermatology and Venereology at the University of Tübingen. In the early 1900s, he noticed that the mercurial preparation used to treat syphilis caused sclerosis of the veins in his arm, so he began to apply it in varicose vein treatment. In the 1920s, Paul Linser started to use a 1–2% mercury perchloride injection, which he gave to over 6000 patients. Later, his assistant, Karl Linser (1895–1976), who also became a professor, used 22% sodium chloride when iron

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was found to be nephrotoxic [1, 3, 7]. Therefore, the search for a substance that would be effective and at the same time had fewer side effects continued. More or less at the same time, a flexible internal saphenous stripper was developed by Babcock and vein surgery was becoming increasingly precise, and in 1911 Ehrlich proved the safety of chemically induced thrombosis. It was then that sclerotherapy became more popular; however, the fear of fatal pulmonary embolism discouraged some medics from applying this method of treatment. Nevertheless, in subsequent decades, numerous doctors used sclerotherapy, improving the method [2]. Professor Sicard, a neurologist, and his colleagues found that luargol, which was used to treat syphilis, caused thrombosis, and that this was due to the presence of sodium bicarbonate in the solution. They used the solution to treat varicose veins in several thousand patients [7]. In the 1940s sclerotherapy was not popular. However, a publication by Egmont James Orbach in 1944 introduced the air-block technique, which involved injecting first a small amount of air into a vein (1 cm3) and then the medicine in the form of a solution. Currently, this technique is not used, but some phlebologists use its modification, i.e. the foam-block techniques, invented by the Swiss doctor Karl Sigg in 1949, where instead of air an large-bubble foam is introduced into the vein [8, 9]. In his publication Orbach listed the types of sclerosing agents used in sclerotherapy and mentioned a new synthetic surface active substance – sodium tetradecyl sulphate (STS) [9]. A breakthrough in the treatment with this method was the development of STS in 1946 and its use by the German surgeon Leopold Reiner. This medicine proved much more effective and at the same time caused fewer complications [7]. In the 1960s, the Irishman George Fegan presented modern compression sclerotherapy in The Lancet (1963), which again popularized this method. In the article, entitled “Continuous compression technique of injecting varicose veins”, he described a study involving over 13,000 patients. He treated varicose veins with 3% STS injections, administering 0.5 mL into one area, giving 10–20 shots in a single session. During treatment, finger pressure was applied on each side of the place of injection, and immediately afterwards a bandage was wound there. Next, an elastic stocking was put on, which the patient would wear continuously day and night until the next visit. Pregnancy or a history of deep vein thrombosis were not contraindications [10]. At around the same time, German pharmaceutical company BASF, which produced polidocanol, abandoned its use as an anaesthetic because it was found to induce venous thrombosis. And so, by chance, it turned out that the substance could be a good sclerosant. Otto Henschel, the then scientific director of Kreussler Pharma in Germany, became interested in this substance, and in 1963.

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Dr Peter Lunkenheimer used polidocanol for the first time in his patient [3, 7]. In the 1960s, sclerotherapy became more popular than surgery, but in the 1970s, surgery took the lead again due to better outcomes in long-term studies. In the article entitled “Quick treatment – a modified method of sclerotherapy of varicose veins” published in the Vasa journal in 1975, Sigg and Zelikovski described 58,000 cases of sclerotherapy treatment [2, 11]. In the following years, two methods of sclerotherapy were applied: the Tournay method and the Sigg method. The first one involves injection and introduction of a sclerosant being made to a patient in a horizontal position. The Sigg method, which is more complicated, recommends puncturing the vein in an upright position, then the patient lies down, which causes the vein to empty, and the sclerosant is injected, possibly with preceding injection of air into the vein (air-block) [1].

FOAM SCLEROTHERAPY Initially, sclerotherapy treatment involved the use substances in the form of a liquid; however, it was later noticed that by foaming some solutions better treatment results could be obtained with smaller amounts of medicine. The era of foam sclerotherapy began when, in 1939, Stuart McAusland performed and described obliteration with foam (obtained by shaking sodium morrhuate) injected into telangiectasia. He popularized this technique in the United States. The technique has since been improved in various ways (double-syringe system, lowand high-pressure techniques) [2, 3, 7, 12]. The agents that can be foamed are those that damage endothelial cells by reacting with lipids (STS and polidocanol). The method has been in use to this day. Alcohol, which was one of the first sclerosants, is still used to close and to eliminate vascular malformations. Unfortunately, the continuing problem was the lack of foam standardization (gas proportions, sclerosant concentration, bubble size) [2]. In 1995, Cabrera Garido was the first to use a modification of the method, which involved addition of CO2, being a safer gas. However, the resultant foam had bubbles that disintegrated quickly. In 2000, Tessari introduced a method with two syringes connected by a three-way stopcock, in which one syringe contains the medicine, the other contains air in proportions of 1 to 4, and the pistons that move alternately generate microfoam [7, 8].

ULTRASOUND-GUIDED SCLEROTHERAPY The next milestone in the treatment of varicose veins was the use of Doppler ultrasound for the purposes of vascular diagnostics. Initially, the use of “blind” Doppler (Continuous Wave Doppler) enabled localization of the

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vessel. Next, with the development of imaging diagnostics – colour and pulsed Doppler, thanks to which an accurate image of the vessel could be obtained – it became possible to inject the sclerosing agents precisely into the centre of the vessel. The first ultrasound-guided sclerotherapy procedure was performed by Schadeck in Paris in 1984 [7]. Echosclerotherapy is a sclerotherapy of the main superficial venous trunks – great saphenous vein and small saphenous vein – where the obliterating agent is injected under direct ultrasound guidance. Ultrasound makes it possible to observe how the injected foam travels. The course of even small veins can be traced using ultrasound, as a result of which the procedure is more precise [8, 13]. Many details began to be considered, for example whether the type of material the syringe used for treatment is made of affects the stability of foam, and what type of needle does not destabilize the foam. The method has been getting more and more precise [13, 14]. Currently, high frequency linear probes are available. Before and after the procedures, ultrasound checks are performed. Today, practically every sclerotherapy is performed under ultrasound guidance [15].

SCLEROTHERAPY MODIFICATIONS IN THE 21ST CENTURY In the 21st century, along with the development of minimally invasive medicine, sclerotherapy has once again gained an important position in the treatment of veins. In Poland, sclerotherapy began to be used more widely around 2000. It is still developing, and an increasing number of phlebology centres are being established. The sclerotherapy agents that are used nowadays come in the form of a liquid or a foam that is usually created following the Tessari method with the use of air. It is not uncommon to combine liquid and foam, whose concentrations depend on the vein diameter [13]. Contemporary guidelines for sclerotherapy were presented in a document drafted on behalf of 23 different European Phlebology Societies during a Guideline Conference held by the German Society of Phlebology in Mainz between 7 and 10 May 2012. Sclerotherapy is recommended for all types of veins, in particular: • incompetent saphenous veins (grade 1A), • incompetent tributaries of saphenous veins (grade 1B), • incompetent perforating veins (grade 1B), • reticular varicose veins (grade 1A), • telangiectasias (grade 1A), • residual and recurrent varicose veins after previous interventions (grade 1B), • varicose veins of pelvic origin (grade 1B), • varicose veins (refluxing veins) in proximity of leg ulcers (grade 1B), • venous malformations (grade 1B) [16].

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Sclerotherapy – from historical research t0 the modern and efficient method of phlebological treatment

Over the past 10 years, since in-office ultrasound has become a standard, there have been many modifications to this method, such as sclerotherapy with a catheter, with the use of cannulas, the ScleroSafe system, as well as mechanical-chemical methods such as the Flebogrif and ClariVein systems [17–19]. Moreover, sclerotherapy often applies tumescent anaesthesia so as to shrink the vein as much as possible, which increases the likelihood of its closure with the use of less of the medicine.

One of the methods often used in hybrid or combined treatment is obliteration. For example, laser thermal ablation of the great saphenous vein or the small saphenous vein and sclerotherapy of varicose veins are performed simultaneously [19]. Some phlebologists use various assisting devices, such as vein illuminators, which also adds to the accuracy of the procedure. Examples of the current use of sclerotherapy are presented in the figures below.

Fig. 1. Echosclerotherapy of the great saphenous vein – ultrasound-guided vein puncture

Fig. 2. Incompetent great saphenous vein and inflows-varicose veins – before sclerotherapy

Fig. 3. Incompetent great saphenous vein and inflows-varicose veins – after sclerotherapy

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Fig. 4. Intravenous treatment – ScleroSafe system

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Fig. 7. Reticular varicose veins and telangiectasias before sclerotherapy

Fig. 5. Incompetent anterior accessory saphenous vein before sclerotherapy

Fig. 6. Incompetent anterior accessory saphenous vein three weeks after sclerotherapy

Fig. 8. Reticular varicose veins and telangiectasias three weeks after sclerotherapy

Fig. 9. Telangiectasias before sclerotherapy

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Fig. 10. Telangiectasias three weeks after sclerotherapy

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Sclerotherapy – from historical research t0 the modern and efficient method of phlebological treatment

Fig. 11. Incompetent popliteal perforating vein before sclerotherapy

Fig. 12. Incompetent popliteal perforating vein three weeks after sclerotherapy

CONCLUSIONS

7. Myers K. A history of injection treatments – II sclerotherapy. Phlebology 2019; 34: 303-310. 8. Wollmann J-CGR. The history of sclerosing foams. Derm Surg 2004; 30: 694-703. 9. Orbach EJ. Sclerotherapy of varicose veins-utilization of an intravenous air block. Am J Surg 1944; 66: 362-366. 10. Fegan WG. Continuous compression technique of injecting varicose veins. Lancet 1963; 2: 109-112. 11. Tolins SH. Treatment of varicose veins. An update. Am J Surg 1983; 145: 248-252. 12. Geroulakos G. Foam sclerotherapy for the management of varicose veins: a critical reappraisal. Phlebolymphol 2006; 13: 202-206. 13. Cavezzi A, Tessari L. Foam sclerotherapy techniques: different gases and methods of preparation, catheter versus direct injection. Phlebology 2009; 24: 247-251. 14. Lai SW, Goldman MP. Does the relative silicone content of different syringes affect the stability of foam sclerotherapy? J Drugs Dermatol 2008; 7: 399-400. 15. Hawro P, Gabriel M, Madycki G, et al. Zalecenia dotyczące wykonywania ultrasonograficznego badania dopplerowskiego żył kończyn dolnych Polskiego Towarzystwa Chirurgii Naczyniowej i Polskiego Towarzystwa Flebologicznego. Acta Angiologica 2013; 19: 99-117. 16. Rabe E, Breu FX, Cavezzi A, et al. European guidelines for sclerotherapy in chronic venous disorders. Phlebology 2014; 29: 338-354. 17. Iłżecki M, Terlecki P, Przywara S, et al. The novel minimally invasive mechano-chemical technique of the saphenous vein ablation. Our center experience: results of 24 months follow-up. Acta Angiologica 2019; 25: 127-132. 18. Witte ME, Zeebregts CJ, de Borst GJ, et al. Mechanochemical endovenous ablation of saphenous veins using the ClariVein: a systematic review. Phlebology 2017; 32: 649-657. 19. ESVS, European Society for Vascular Surgery. Przewlekła choroba żylna. Wytyczne postępowania klinicznego Europejskiego Towarzystwa Chirurgii Naczyniowej. Eur J Vasc Endovas Surg 2015; 49: 678-737.

Medicine has always aimed to help with suffering. Since ancient times, when surgery was not a safe method, injections into varicose veins were already performed. Unfortunately, the injected substances were often toxic and caused numerous painful complications. The first revolution came with a syringe for injection devised by Pravaz. The next step leading us to today’s sclerotherapy was the discovery of foam by McAusland. Finally, effective and safe substances were developed – STS and polidocanol – which are used to this day. A milestone was the introduction of ultrasound to sclerotherapy and the discovery that foam is visible on ultrasound. The precision of the method has reached an unprecedented level. And although there is still nothing to replace the experience of a doctor, never before has such minimally invasive treatment been possible as is nowadays. The author declares no conflict of interest.

REFERENCES 1. Milik K, Gembal P, Kęsik J, Zubilewicz T. Leczenie operacyjne chorób żylnych i urazów żył kończyn dolnych na przestrzeni dziejów. Chir Pol 2006; 8: 269-273. 2. Van den Bremer J, Moll FL. Historical overview of varicose vein surgery. Ann Vasc Surg 2010; 24: 426-432. 3. Kózka M, Snarska A, Drygalski T, Dolecki M. Zabiegowe leczenie żylaków na przestrzeni wieków. Przegl Lek 2007; 64: 7-8. 4. Royle J, Somjen GM. Varicose veins: Hippocrates to Jerry Moore. ANZ J Surg 2007; 77: 1120-1127. 5. Janbon C, Laborde JC, Quere I. History of the treatment of varices. J Mal Vasc 1994; 19: 210-215. 6. Sumner DS. Presidential address: entering the third millennium. J Vasc Surg 2000; 32: 833-839.

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CHALLENGES IN THE REFLUX ABLATION IN A PATIENT WITH CHRONIC VENOUS LEG ULCER – CASE REPORT Maciej Jusko1,2, Tomasz Urbanek1,2

CASE REPORT

epartment of General Surgery, Vascular Surgery, Angiology and Phlebology, D Medical University of Silesia, Katowice, Poland 2 European Center of Phlebology, Katowice, Poland

Phlebological Review 2021; 29, 1: 44–49 DOI: https://doi.org/10.5114/pr.2021.106881

1

Submitted: 17.05.2021 Accepted: 21.05.2021

ABSTRACT

Introduction: Venous leg ulcer is a severe health problem for patients with a long history of venous hypertension. The treatment includes invasive procedures including both surgical removal of insufficient veins and their intravenous ablation. The latter technique, although often used especially in patients with refractory or recurrent ulceration, sometimes encounters difficulties that reduce the chances of its success. Material and methods: In a patient with a 30-year history of venous ulceration due to insufficient saphenous vein, intravenous laser ablation was performed due to the inability to heal the ulcer for a long time with various forms of conservative treatment. Results: Within a few weeks of the surgery, the venous ulcer was effectively healed. After 8 months, recanalization of the proximal section of the great saphenous vein, connecting with the varicose veins of the thigh, leg and venous plexuses in the area of the ulcer, was found, but without the accompanying opening of the wound. Despite the constant use of compression therapy by the patient, about a year after the procedure, the ulcer reopened. Next, sclerotherapy of the insufficient great saphenous vein trunk as well as varicose veins was performed, resulting in the wound healing again. Conclusions: The procedure of intravenous ablation of insufficient venous trunks is an effective form of venous ulcer treatment. However, in order to maintain a long-term positive effect of treatment, it is advisable to eliminate all sources of venous insufficiency as early as possible and carefully monitor the patient at all stages of therapy.

ADDRESS FOR CORRESPONDENCE Maciej Jusko MD European Center of Phlebology 13D Fabryczna St. 40-611 Katowice, Poland e-mail: juskomaciej@gmail.com

Key words: venous insufficiency, sclerotherapy, venous ulcer, endovenous laser ablation.

INTRODUCTION Venous leg ulcer (VU) is one of the most advanced stages of chronic venous disease (CVD), diagnosed in a significant number of the patients. The treatment of VU is a complex, time-consuming and costly task that requires coordinated and disciplined cooperation between healthcare providers, the patient, and the patient’s family. Although conservative management is the main way of treatment in patients with venous leg ulcer, surgical treatment plays an increasingly important role in the therapeutic approach. According to the results of the ESCHAR study, surgical treatment aimed at reducing venous hypertension in the superficial venous system significantly reduces the risk of recurrence of venous leg ulcers [1]. In this study patients were randomized to a group treated with standard therapy, including compression therapy, or to a group in which surgery in the superficial veins was additionally performed. However, no effect of the surgical treatment on the improvement of ulcer healing results was observed. Technological progress and the development of minimally invasive treatment methods, as well as the recently published results of the EVRA study, have

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significantly changed the approach to CVD surgical treatment [2]. According to the results of the study, early surgical treatment of venous insufficiency using minimally invasive methods of reflux ablation in the superficial vein system, combined with compression treatment, increases the healing rate and speeds up the process. The possibility of using a minimally invasive procedure not only creates a chance to cure the patient, but also potentially reduces the risk of treatment complications. Although the EVRA study proposes surgical treatment early after ulcer diagnosis, surgical ablation of superficial veins with venous hypertension can also be successfully performed much later. This undoubtedly creates a chance to cure patients with a long-lasting VU or with ulceration resistant to the current treatment (recalcitrant ulcer). This paper is a case report of a patient in whom conservative treatment of VU did not bring the desired effect and it became necessary to undergo surgical treatment without full wound healing.

MATERIAL AND METHODS A 70-year-old patient came to our center for the first time in 2019. The patient manifested an extensive scarred

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Challenges in the reflux ablation in a patient with chronic venous leg ulcer – case report

area covering about half of the circumference of the left leg, including the active ulcer area behind the medial ankle (Fig. 1). VU has been present since the first half of the 1990s, and the first symptoms of CVD in the form of varicose veins observed by the patient appeared around the age of 20. From the onset of the disease, the patient had multiple episodes of superficial vein thrombosis of varicose veins in the leg, thigh and left great saphenous vein (GSV). For over 20 years, venous ulcers were treated with exudate-absorbing dressings and compression therapy in the form of 2-degree compression stockings and periodically short-stretch bandages. VU was successfully healed several times, but, despite continued use of compression therapy, VU recurred. The last episode of active VU lasted for 12 months, with a 1 x 3 cm wound during the initial meeting and substantial accompanying effusion. The patient was transferred to our center from another phlebological clinic where he was treated conservatively with short-stretch bandage application, but with no progress in terms of healing of VU for about a half of the year. Additionally, the patient had a long history of hypertension and atrial fibrillation that was treated with rivaroxaban. Obesity was among other aggravating factors. In the past, the patient did not undergo any surgical procedures, such as removal of varicose veins of the lower extremities. During the first visit, the patient presented with active VU behind the medial ankle of the left lower limb with serum effusion. On the medial side of the leg there was a large scar covering most of its medial side, and most of its circumference was affected with lipodermatosclerosis-type trophic changes. The patient had severe swelling of both lower limbs in the proximal area of the ​​ feet, ankles, and legs. In addition, very large varicose veins were visible in the upper part of the leg, the knee area and the lower part of the thigh. The patient did not report pain from the ulcer, although he complained of periodic itching of the skin around it. The patient’s ankle-brachial index (ABI) was measured without any signs of left lower limb ischemia, and a Doppler ultrasound examination of the lower limb venous system was performed.

Fig. 1. Ulceration before treatment

Fig. 2. Great saphenous vein post-thrombotic partition

Fig. 3. Great saphenous vein and varicose veins

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In ultrasound examination, the deep venous system of the left lower limb presented no signs of thrombosis, no post-thrombotic changes and all veins of the deep system were competent. GSV was insufficient from the level of the femoral saphenous junction (FSJ) down the entire length of the thigh to about the middle level of the leg. In the femoral segment, the GSV width was up to a maximum of 15–17 mm (with two segmental widenings up to 23 mm). Inside the vein for most of its length on the thigh and leg, post-thrombotic changes were present, taking the form of thick (up to 4 mm) connective tissue partitions reaching the area of the ​​FSJ (Fig. 2). At many levels, the vein wall thickened. The insufficient branches of the GSV were present in the ​​ lower thigh and the upper part of the leg and most of them were varicose veins. Numerous varicose veins with signs of venous insufficiency were present in t​​ he leg (Fig. 3), reaching the area of VU (Fig. 4). The small saphenous vein was efficient with no post-thrombotic changes and with no connections to insufficient leg varicose veins. The patient was instructed to use foam dressings to absorb effusion, to continue using short-stretch Rosidal K Lohmann & Rauscher bandages applied from the foot up to the groin with two layers of bandages, and was provided with endovenous laser ablation (EVLT). The procedure was carried out on 11.2019. A laser with a wave-

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Maciej Jusko, Tomasz Urbanek

Fig. 5. Wire positioning

Fig. 4. Venous plexus below the ulceration length of 1470 nm and one ring laser wire was used. Due to the intraluminal, post-thrombotic changes, two places for the venous access to GSV had to be used: mid-thigh and mid-calf. The ablation with one ring laser fiber was started 1 cm below the FSJ. Tumescent anesthesia (TA) was performed and GSV ablation with energy of 150 J/cm was carried out (Fig. 5–7). Total energy used was 5750 J. Immediately after the procedure, the patient was instructed to use compression stockings in the 2nd degree of compression and return to the short-stretch bandages afterwards.

RESULTS The first follow-up visit took place 7 days after the procedure and it was noted that the effusion subsided, and the size of the ulcer decreased (Fig. 8). In ultrasound examination the GSV was successfully occluded in the whole femoral section and down to the puncture site. Another follow-up visit took place 30 days after the procedure, when the patient presented a healed area of VU.

Fig. 6. Laser ablation

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Additionally, a slight regression of lipodermatosclerosis and varicose veins was observed. In ultrasound examination the GSV was obstructed, filled with mixed-echogenic interior with dominance of hyperechoic tissues. Due to the healing of the ulcer and the patient’s lack of consent to further surgical treatment at this stage, the surgical treatment of residual varicose veins in the lower limbs was abandoned, and further follow-up visits were recommended. After another 8 months, the local condition of the limb presented as previously, the ulcer was still healed (Fig. 9), but the ultrasound examination revealed partial recanalization of the proximal GSV section at a length of about 20 cm down to the level of the wide venous branch connecting with varicose veins in the ​​ knee and upper part of the leg. The proximal part of the GSV was 8–12 mm wide, with signs of insufficiency, and it contained numerous partitions as well as organized thrombus. Below that section the GSV was still successfully obstructed. The patient was recommended to continue applying compression therapy – 2nd degree compression stockings. Due to the morphology of the changes in the proximal part of the GSV, the patient was not qualified for thermal ablation, as it was highly probable that it would not be possible to pass a guidewire or a probe through it.

Fig. 7. Operation site

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Challenges in the reflux ablation in a patient with chronic venous leg ulcer – case report

Fig. 8. Seven days after endovenous laser ablation

Fig. 9. Eight months after endovenous laser ablation

Moreover, a hard-wall vein is poorly compressible, which would make TA harder to perform. After talking with the patient, sclerotherapy was also abandoned at this stage. Another follow-up was performed one year after the primary surgery due to the reopening of the ulcer behind the medial ankle with active effusion (Fig. 10). Ultrasound examination revealed as previously an insufficient

20 cm proximal section of the GSV with fibrotic partitions and wall attached hyperechogenic thrombi, as well as varicose veins in the thigh and leg, connecting with insufficient venous branches that joined the patent proximal section of the GSV. The lower part of the GSV with sectionally thickened wall presented hyperechoic thrombus. Foam dressings were used for the ulcer locally, and

Fig. 10. One year after endovenous laser ablation

Fig. 11. One and a half years after endovenous laser ablation and 6 months after sclerotherapy

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Maciej Jusko, Tomasz Urbanek

the form of compression was changed, as previously, to short-stretch Rosidal K Lohmann & Rauscher bandages applied from the foot up to the groin with two layers of bandages. The patient was scheduled for further treatment with ultrasound-guided sclerotherapy. Sclerotherapy of varicose veins of the thigh and leg (2% polidocanol, foam) departing from the proximal insufficient section of GSV with closure of the very proximal section (3% polidocanol, foam) was performed. After the procedure, the effusion from the ulcer was reduced. In the next stage, foam sclerotherapy (1% polidocanol) was performed on the venous plexuses present under the ulcer, leading to their closure and complete healing of the ulcer (Fig. 11). A one-month follow-up after sclerotherapy revealed healing of the VU, completely obstructed GSV, obstructed GSV venous branches, and obstructed varicose veins in the thigh and leg. The patient was provided with dedicated UlcerX compression products and continuous follow-up was recommended.

DISCUSSION VU treatment is a complex and usually multi-stage process. As mentioned in the introduction, the key task for achieving therapeutic success is the correct application of various forms of therapy, both conservative and interventional, at the right time [3]. Due to the multitude of possible techniques and the lack of unified guidelines, many patterns of therapeutic approach have developed. Most doctors treating VU agree that the necessary element of any treatment is the use of proper compression therapy and even if it is possible to heal VU without its usage, the effect is short-lived [4]. In the discussed case, compression was used at every stage of treatment, but despite the initial use of short-stretch bandages, it turned out to be insufficient, and the patient had recurrences of VU. Of course, as in any case of VU lasting many years, the question remains as to the correctness of the application of this type of compression, as well as whether the patient is following the recommended therapy during remission of the ulcer. The case discussed in the article confirms the legitimacy of considering surgical treatment in patients with VU due to venous insufficiency, not only in patients with previously diagnosed ulceration (EVRA policy) but also in patients with refractory or recurrent VU. According to clinical observations and research data, patients with VU are characterized not only by a variety of clinical presentations, but also the variety of pathology found in the ultrasound examination. The most common disorder is superficial vein insufficiency (74–93%) with or without concomitant deep vein pathology. According to the literature, isolated superficial vein insufficiency can be found in 17–54% of patients with VU, and isolated lesions limited to the deep vein system in only 10% of these patients [5–10].

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Considering such prevalence of superficial vein insufficiency in the population of patients with VU, it is advisable to look for patients who can potentially benefit from surgical treatment, especially since the currently proposed minimally invasive treatment significantly reduces the potential risk of complications of the operated site. The present case was related to the insufficiency of the post‑thrombotic GSV as well as the development of varicose veins in the thigh and leg. According to the results of the ultrasound examination, the patient was scheduled for EVLT as the first step of treatment. Despite the technical difficulties related to the treatment of the post-thrombotic GSV, its closure allowed the VU to heal, unfortunately, as it turned out later, only temporarily. The further clinical condition of the patient, including the recurrence of VU due to recanalization of the proximal segment of the GSV, suggests the need for careful monitoring of patients undergoing treatment of venous insufficiency, especially in its advanced cases, with the risk of recurrence of VU in mind. The most likely cause of partial (proximal) recanalization of the GSV in the subject was most likely post-thrombotic changes inside the GSV, which reduce the chances of therapeutic success of ablation mainly for two reasons. Firstly, connective tissue partitions and wall clots cause that, regardless of the factor used during ablation, it does not affect equally effectively, or does not affect at all, the vein wall in places where post-thrombotic changes are present. Secondly, post-thrombotic veins are characterized by reduced flexibility, which significantly reduces the effectiveness of TA and its ability to contract the vein on the ablation catheter. For the same reason, the success of surgical methods is also hindered. It is because post-thrombotic veins are more fixed within the subcutaneous tissue, and due to a decrease in their elasticity, their fragility increases, which does not allow long sections of the vein to be removed from access through the usually used small skin incisions. Venous leg ulcer recurrence caused by the recanalization of the GSV proximal segment and the reappearance of reflux within the unremoved network of veins in the thigh and leg also indicates the need for the most radical elimination of reflux in this group of patients already during the primary procedure. After the GSV was closed the VU healed, and as the condition of the limb satisfied our patient, further surgical treatment was discontinued. The clinical course in such cases, however, suggests the validity of treatment aimed at the elimination of all potential sources of reflux leading to the area of VU. The final closure of the ulcer was achieved after the obliteration of the segmental recanalization of the GSV, its insufficient branches as well as the varicose veins of the thigh and leg with a network of veins directly under the VU. It should be emphasized, however, that also in this situation it is justified to conduct further careful observation of the patient.

Phlebological Review 2021


Challenges in the reflux ablation in a patient with chronic venous leg ulcer – case report

CONCLUSIONS Ablation of superficial vein insufficiency increases the possibility of healing of VU. To avoid recurrences, it is necessary to carefully monitor the state of the patient’s venous system as well as to perform treatment aimed at eliminating all sources of reflux that may be a potential cause of VU. The authors declare no conflict of interest.

References 1. Barwell JR, Davies CE, Deacon J, et. al. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet 2004; 363: 1854-1859. 2. Gohel MS, Heatley F, Liu X, et. al. A Randomized trial of early endovenous ablation in venous ulceration. N Engl J Med 2018; 378: 2105-2114. 3. O’Donnell TF, Passman MA, Marston WA, et. al. Management of venous leg ulcers: clinical practice guidelines of the society for vascular surgery (R) and the American venous Forum. J Vasc Surg 2014; 60: 3S-59S. 4. Tan M, Luo R, Onida S, et. al. Venous leg ulcer clinical practice guidelines: what is AGREEd? Eur J Vasc Endovasc Surg 2019; 57: 121-129. 5. Labropouls M, Delis K, Nicolaides AM, et al. The role of the distribution and anatomic extent of reflux in the development of signs and symptoms in chronic venous insufficiency. J Vasc Surg 1996; 23: 504-510. 6. Labropoulos N, Gannoukas AD, Nicolaides AM, et al. The role of venous reflux and calf muscle pump function in non-thrombotic chronic venous insufficiency: correlation with severity of sign and symptoms. Arch Surg 1996; 141:403-406. 7. Labropoulos N, Leon M, Geroulakos G, et al. Venous hemodynamics abnormalities in patients with leg ulceration. Am J Surg 1995; 169: 572-574. 8. Hanrahan LM, Araki CT, Rodriguez AA, et al. Distribution of valvular incompetence in patients with venous stasis ulceration. J Vasc Surg 1991; 3: 805-812. 9. Labropoulos N, Gannoukas AD, Nicolaides AM, et al. New insights into the pathophysiologic condition of venous ulceration with color flow duplex imaging: implications for treatment? J Vasc Surg 1995; 22: 45-50. 10. Yamaki T, Nozaki M, Sasaki K. Color duplex ultrasound in the assessment of primary venous leg ulceration. Dermatol Surg 1998; 24: 1124-1128.

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ILIOCAVAL STENTING – CASE REPORT Jan Jakub Kęsik, Tomasz Zubilewicz

CASE REPORT

Department of Vascular Surgery and Angiology, Medical University of Lublin, Lublin, Poland

Phlebological Review 2021; 29, 1: 50–54 DOI: https://doi.org/10.5114/pr.2021.106892

ABSTRACT

Submitted: 20.05.2021 Accepted: 30.05.2021

In a 45-year-old man, after a traffic accident with multiple trauma complicated with extensive thrombosis involving the inferior vena cava and iliac veins, rapid development of severe post-thrombotic syndrome with leg ulcers prevented final orthopaedic reconstructions and recovery. Three years after the accident endovascular reconstruction with venoplasty and stenting of the inferior vena cava and iliac veins was performed. He was successfully treated with the confluence technique, in which dedicated nitinol venous stents were used. After the procedure, collateral circulation disappeared and the ulcers healed. This allowed the end of orthopaedic treatment and rehabilitation. The patient recovered and did not require additional vascular interventions for 6 years after the procedure.

ADDRESS FOR CORRESPONDENCE Dr. Jan Jakub Kęsik Department of Vascular Surgery and Angiology Medical University of Lublin Lublin, Poland e-mail: jjkesik@gmail.com

Key words: stent, deep venous thrombosis, inferior vena cava, iliac vein, iliocaval confluence.

INTRODUCTION In a patient with inferior vena cava and/or iliac vein chronic total occlusion or severe stenosis, which is associated with skin changes with risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), venous angioplasty and stent recanalization is recommended to aid in venous ulcer healing and to prevent recurrence [1].

CASE PRESENTATION A previously healthy, athletic, 45-year-old man was involved in a traffic accident on 19/09/2012, and he suffered multiple trauma as a result of it. He was transported to hospital in severe general condition, in haemorrhagic shock. Multiple bone fractures including: • transverse processes of L1 and L2 vertebrae on the left side, • left iliac diaphysis, • rear wall of the left ala of ilium, • left femur, • right pubic and ischial bone, • head and subcapital part of the left humerus, • left ulna, • ribs I, V, VI, VII, VIII, and IX on the left side. Internal organ damage: • contusion of the lungs, • rupture of the left diaphragm dome with a displacement of the stomach to the chest. The patient underwent numerous repair operations and a long stay in the intensive-care unit.

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During hospital stay, swelling of the left lower limb was observed, and ultrasound diagnosed a thrombosis of the left iliac veins, which was treated conservatively. Persistent swelling of both lower limbs appeared after leaving the hospital and immobilization. Despite the maintenance of anticoagulant treatment and the use of compression stockings, pain intensified and ulceration of the left shin appeared, disqualifying the patient from final orthopaedic reconstructions. The patient was referred to our centre in 2015. The ultrasound examination revealed obstruction of the inferior vena cava and bilateral iliac veins. The diagnosis was confirmed in angio computed tomography (angioCT): obstruction of the inferior vena cava below the renal veins and obstruction of the common iliac veins (Fig. 1, 2). The decision was made to perform endovascular reconstruction. The procedure was performed under general anaesthesia. Access was through the femoral veins on both sides. Phlebography revealed extensive collateral and confirmed occlusion of the inferior vena caval (IVC) and iliac veins (Fig. 3, 4). The guidewires (Radifocus® Guide Wire M Stiff Type-Terumo) were guided through the obstruction to the upper segment of the IVC. In 2015 our centre did not have intravascular ultrasound (IVUS), so we relied on the angioCT reconstruction and on venography performed in several planes. The predilation was performed with a 16 mm balloon (Atlas™ PTA Dilatation Catheter-Bard) – iliac veins on both sides and the IVC, then with a 22 mm balloon – IVC (Fig. 5). The entry level of renal veins into the IVC was marked by catheterization. The Sinus-XL (Optimed) stent (22 x 80 mm) was implanted to IVC, followed by

Phlebological Review 2021


Iliocaval stenting – case report

Fig. 2. Inferior vena cava

Fig. 1. Inferior vena cava

Fig. 3. Iliac veins. Collaterals (venogram performed through a catheter placed in both femoral veins)

Fig. 4. Level of virtual coronary intervention (venogram performed through a catheter placed in both femoral veins)

post-dilation with the same 22 mm balloon. The upper edge of the stent was placed directly below the level of the renal veins. The left side guidewire (contralateral side) was retracted into the iliac vein and then inserted into the stent (Fig. 6). Two Vici stents (Vici Venous Stent®-Veniti) were implanted at the same time, positioning their upper edges about 2 cm above the lower edge of the stent placed in the inferior vena cava. During post-dilation, the balloons placed in the Vici stents were inflated simultaneously so that one stent did not compress the other

(Fig. 7). Control venography showed normal flow through the stents and loss of collateral circulation (Fig. 8). In the following days, the collateral circulation visible on the skin disappeared and the ulcers healed. The following anticoagulants were used: LMWH, VKA, and currently Dabigatran 2 x 150 mg. At present, 6 years after the reconstruction, the patient does not report oedema. After supplementary orthopaedic treatment and rehabilitation he is able to walk properly, without any complaints. According to the ultrasound

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Fig. 5. Procedural steps: predilatation of Fig. 6. Procedural steps: sStent in Fig. 7. Procedural steps: postdilatation of iliocaval infrarenal virtual coronary intervention virtual coronary intervention confluence assessment, the stents remained patentable and did not require secondary reinterventions.

DISCUSSION

Fig. 8. Procedural steps: final venogram

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At that time, the centre had experience in iliac vein stenting, but the iliocaval confluence had never been reconstructed before. At the beginning of 2015, the following venous stents were available on the market in Poland: Zilver Vena (Cook Medical), Sinus-Venous and Sinous-XL (Optimed), and Vici (Veniti). The Wallstent stent (Boston Scientific) received CE mark approval for venous indication 2 months after our procedure. The selection of the SinusXL stent in the virtual coronary intervention (VCI) segment was simple – it was the only stent of this size available on the market. We have been considering the selection of iliac stents. We chose a closed-cell stent – the Vici stent (Veniti) – because we felt that 2 such stents would work well together as kissing stents. We were concerned that in the case of using 2 open-cell stents, e.g. SinusVenous (Optimed), some elements of one stent could fall into the lumen of the other stent and cross them. We tested such situations

Phlebological Review 2021


Iliocaval stenting – case report

in vitro – holding 2 stents in our hands and press them against each other. We calculated the size of the stents needed in the iliac segment. According to angioCT, we calculated the stent size in 22 mm VCI. At full expansion, the cross-sectional area was about 380 mm2. The cross-sectional areas for smaller stents were: 12 mm = 113 mm2, 14 mm = 154 mm2, and 16 mm = 200 mm2. We decided that the best stent fit and use of the cross-sectional area would be obtained with two 16 mm stents. It is clear that when the 2 stents are inserted as kissing stents inside the stent implanted in the VCI, the shape of surface area of all stents changes to elliptical. The shape of these ellipses depends on the radial forces of the stents used and the forces acting from outside (Fig. 9). Various techniques for endovascular reconstruction of an occluded inferior vena cava have been described in detail by Neglen [2]. He compared 3 techniques and concluded that the best option for the patients with limited caudal involvement of the IVC (< 5 cm) and a normal IVC above is the double-barrel stent configuration. If the changes in the IVC reach higher IVC, he decided that the doubling of the stent in IVC is prohibited and he preferred an inverted Y technique with fenestration. Although he noticed that this technique has the poorest stent-related outcome, with 11% late occlusions and a 37% reintervention rate. The Wallstent (Boston Scientific) was used in all configurations in this group. Similar stent configurations using the Wallstent have been reported by other authors. Some of them additionally used a Gianturco stent (Gianturco, Cook Medical) to provide additional radial force to the distal part of the Wallstent. The Gianturco stent can also be used as an extension beyond the Wallstent in IVC for the reconstruction of iliocaval confluence [3, 4]. Iliocaval confluence stenting using a large diameter stent in IVC and 2 stents inserted in the lower part of this large stent with the double-barrel technique was described by de Graaf (confluence technique) [5]. He used modern nitinol stents also available on the Polish market. Sinus-XL (Optimed) stents were used in the IVC. Bilateral extensions were performed with 16 mm nitinol stents: sinus-XL, sinus Venous and sinus XL-Flex (Optimed), and Zilver Vena (Cook Medical). The authors observed some cases of complete compression of the stent by a second, parallel stent (12-month patency rates were 85%, 85%, and 95% for primary, assisted-primary, and secondary patency, respectively). Thus, they decided to use additional parallel positioned balloon-expandable stents (AndraStent, Andramed) (in that group the primary patency was 100%). In our patient, we decided to use the confluence technique described by de Graaf, with the modification of using closed-cell stents as kissing stents in order to avoid complications related to the strut interactions.

Phlebological Review 2021

Fig. 9. Cross-section of the stents. Computed tomography performed 12 months after the procedure The best tool for determining landing zones is IVUS [6], but in this case the lack of it was replaced by careful CT analysis, multiplanar phlebography, and renal veins catheterization. Additionally, IVUS provides the best visualization of the arrangement of the stents and cross-sectional area in place of their confluence. The authors now believe that such a check should be performed to exclude compression of the stent by a second, parallel stent. Various anticoagulant and antiplatelet treatment regimens have been reported in the literature, but there are still no recommendations for treatment after vein stenting in post-thrombotic syndrome [7]. Analysing experts’ opinions, it seems that in the case of long, complicated stent reconstructions, lifelong anticoagulation should be considered [8].

CONCLUSIONS Endovascular recanalization of the IVC with iliocaval confluence is technically possible, safe, and durable. Successful reconstruction in a truly symptomatic patient can significantly improve the clinical condition. The authors declare no conflict of interest.

References 1. O’Donnell TF Jr, Passman MA, Marston WA, et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. J Vasc Surg 2014; 60: 3S-59S. 2. Neglen P, Darcey R, Olivier J, Raju S. Bilateral stenting at the iliocaval confluence. J Vasc Surg 2010; 51: 1457-1466. 3. Erben Y, Bjarnason H, Oladottir GL, McBane RD, Gloviczki P. Endovascular recanalization for nonmalignant obstruction of the inferior vena cava. J Vasc Surg Venous Lymphat Disord 2018; 6: 173-182. 4. Bjarnason H. Tips and tricks for stenting the inferior vena cava. Semin Vasc Surg 2013; 26: 29-34.

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5. De Graaf R, de Wolf M, Sailer AM, van Laanen J, Wittens C, Jalaie H. Iliocaval confluence stenting for chronic venous obstructions. Cardiovasc Intervent Radiol 2015; 38: 1198-1204. 6. Gagne PJ, Tahara RW, Fastabend CP, et al. Venography versus intravascular ultrasound for diagnosing and treating iliofemoral vein obstruction. Surg Venous Lymphat Disord 2017; 5: 678-687. 7. Attaran RR, Ozdemir D, Lin I-H, Mena-Hurtado C, Lansky A. Evaluation of anticoagulant and antiplatelet therapy after iliocaval stenting: factors associated with stent occlusion. Venous Lymphat Disord 2019; 7: 527-534. 8. Milinis K, Thapar A, Shalhoub J, Davies AH. Antithrombotic therapy following venous stenting: international Delphi consensus. Eur J Vasc Endovasc Surg 2018; 55: 537-544.

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Abstracts of the oryginal papers – International Congress of Polish Society of Phlebology 10–12 June 2021



ORIGINAL PAPER

PRESENTATION ABSTRACTS* *Streszczenia w postaci przesłanej przez autorów

PROFILAKTYKA ŻYLNEJ CHOROBY ZAKRZEPOWO ZATOROWEJ I OCENA RYZYKA WYSTĄPIENIA ZAKRZEPICY ŻYŁ GŁĘBOKICH U PACJENTÓW PODDAWANYCH CHIRURGICZNEMU LECZENIU ŻYLAKÓW KOŃCZYN DOLNYCH – PROSPEKTYWNE BADANIE OBSERWACYJNE Krzysztof Wołkowski1, Maciej Wołkowski2, Tomasz Urbanek3 Oddział Chirurgii o Profilu Chirurgii Ogólnej Urazowo-Ortopedycznym i Urologii Szpitala św. Anny w Miechowie, Polska 2 Szkoła Doktorska Śląskiego Uniwersytetu Medycznego w Katowicach, Katedra Chirurgii Ogólnej, Naczyniowej, Angiologii i Flebologii, Wydział Nauk Medycznych, Katowice, Polska 3 Katedra Chirurgii Ogólnej, Naczyniowej, Angiologii i Flebologii, Śląski Uniwersytet Medyczny w Katowicach, Polska 1

Cel pracy: Inwazyjnemu leczeniu żylaków kończyn dolnych często towarzyszy powikłanie, jakim jest zakrzepica żył głębokich (ZŻG). O jej wystąpieniu decydują, podobnie jak w innych grupach pacjentów leczonych chirurgicznie, nie tylko sposób leczenia, ale także czynniki ryzyka żylnej choroby zakrzepowo-zatorowej (ŻChZZ). Obecne protokoły stosowane w ośrodkach chirurgii żylaków opierają się głównie na indywidualnej ocenie ryzyka, a także na wdrożeniu i ekstrapolacji wytycznych dotyczących profilaktyki ŻChZZ w chirurgii ogólnej. W prezentowanym prospektywnym badaniu oceniano skuteczność rutynowej farmakologicznej profilaktyki ŻChZZ u chorych poddawanych safenectomii. W analizie uwzględniono ocenę czynników ryzyka ŻChZZ oraz wynik w skali Capriniego. Ze względu na ograniczoną liczebność badanej populacji, a także spodziewaną w tym scenariuszu klinicznym ograniczoną częstość występowania zakrzepicy żył głębokich (DVT), nie było możliwe przeprowadzenie walidacji skuteczności skali Capriniego w założonym modelu badawczym. Materiał i metody: Do badania włączono 141 pacjentów poddawanych strippingowi żyły odpiszczelowej i miniflebektomii w znieczuleniu podpajęczynówkowym. Wszystkich chorych zdiagnozowano pod względem występowania czynników ryzyka ŻChZZ (w tym ocenie w skali Capriniego) i zastosowano rutynową profilaktykę przeciwzakrzepową – podawano przez 10 dni 40 mg enoksaparyny. USG doppler żył kończyn dolnych wykonywano przed zabiegiem oraz w 10. i 30. dobie po zabiegu. W badaniu obrazowym potwierdzano objawową lub bezobjawową ZŻG. Punktem końcowym bezpieczeństwa badania było wystąpienie dużego krwawienia podczas zabiegu lub w ciągu 30 dni po operacji. Wyniki: Obecność pooperacyjnej ZŻG rozpoznano w pięciu przypadkach (3,5%). We wszystkich przypadkach potwierdzono jedynie dystalną ZŻG. Pomimo rozległych operacji żylaków obejmujących safenectomię z miniflebektomią wykonywanych w znieczuleniu podpajęczynówkowym, nie rozpoznano takiego epizodu w zakresie proksymalnej części kończyn. Trzy z pięciu przypadków zakrzepicy żył głębokich rozpoznano w 10. dobie pooperacyjnej, a kolejne dwa zostały potwierdzone w badaniu USG wykonanym 30 dni po zabiegu. Nie stwierdzono klinicznie jawnej zatorowości płucnej (PE) ani epizodów krwawienia. Wśród czynników związanych ze statystycznie istotną wyższą częstością ZŻG zidentyfikowano wynik w skali Capriniego z ilorazem szans (OR) = 2,04 (95% CI = [0,998; 4,18]). Kolejnym czynnikiem, który okazał się istotny statystycznie pod względem częstszego występowania ZŻG w okresie pooperacyjnym, był wynik oceny w skali Venous Clinical Severity Score (VCSS) (OR = 1,98; 95% CI [1,19; 3,26]). W analizie wieloczynnikowej regresji logistycznej wiek pacjenta (OR = 0,86; 95% CI [0,75–0,99]), wyniki oceny w skali Capriniego (OR = 4,04; 95% CI [1,26–12,9]) i wynik w skali VCSS (OR = 2,4; 95% CI [1,23–4,7]) miały znaczenie statystyczne jako predyktory wystąpienia pooperacyjnej ZŻG, z wartością p 0,029 dla wieku oraz p = 0,017 i p = 0,009 odpowiednio dla wyników w skali Capriniego i VCSS. Ze względu na ograniczoną liczbę potwierdzonych zdarzeń ZŻG w badanej populacji pacjentów oraz obserwacyjny charakter badania ostateczne kliniczne znaczenie zidentyfikowanych parametrów, w tym wyniku oceny w skali Capriniego i VCSS, należy poddać ocenie w dalszych badaniach klinicznych. Wnioski: Po operacji żylaków kończyn dolnych pacjenci powinni podlegać ocenie ryzyka ŻChZZ na podstawie indywidualnej oceny.

Phlebological Review 2021

W szacowaniu ryzyka ŻChZZ należy wziąć pod uwagę zarówno stan pacjenta, jak i procedury chirurgiczne opracowane na podstawie czynników uwzględnionych w skali Capriniego oraz związanych z przewlekłą chorobą żylną. Aby zaproponować obiektywny i zwalidowany model oceny ryzyka ŻChZZ, a także zwalidowany protokół profilaktyki przeciwzakrzepowej dla tej konkretnej grupy pacjentów, konieczne są dalsze badania.

VENOUS THROMBOEMBOLISM PROPHYLAXIS AND THROMBOTIC RISK STRATIFICATION IN THE VARICOSE VEINS SURGERY-PROSPECTIVE OBSERVATIONAL STUDY Krzysztof Wołkowski1, Maciej Wołkowski2, Tomasz Urbanek3 Department of Surgery with a Profile of General Trauma and Orthopedic Surgery and Urology, Saint Ann’s Hospital, Miechów, Poland 2 Doctoral School of the Medical University of Silesia in Katowice, Department of General Vascular Surgery, Angiology and Phlebology, Faculty of Medical Sciences, Katowice, Poland 3 Department of General Surgery, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, Katowice, Poland 1

Objectives: An invasive phlebological treatment is still not free from complications such as thrombosis. As in other surgical populations, not only the treatment modality, but also patient condition-related venous thromboembolism (VTE) risk factors matter. The current protocols used in varicose vein surgery centers are based mostly on individual risk assessment as well as on an implementation and extrapolation of general surgery VTE prophylaxis guidelines. In the presented study, the efficacy of routine VTE pharmacological thromboprophylaxis in patients undergoing saphenous varicose vein surgery was prospectively evaluated. In the result assessment, VTE risk factor evaluation and Caprini score results were included; however, due to the limited size of the projected study group, as well as expected limited deep vein thrombosis (DVT) prevalence in this clinical scenario, it was not possible to perform the validation of the Caprini model efficacy in the projected study model. Material and methods: In the study, 141 patients undergoing saphenous vein stripping and miniphlebectomy in spinal anesthesia were included. In all of the patients, VTE risk factors (including Caprini score evaluation) were assessed, and the routine thromboprophylaxis with enoxaparin 40 mg for 10 days was used. The venous ultrasounds were undertaken before the surgery and on the 10th and 30th day after surgery. The study endpoint was the presence of symptomatic or asymptomatic DVT confirmed in the imaging study. The study safety endpoint was major bleeding occurrence intraoperatively or within 30 days after surgery. Results: The presence of a postoperative DVT was diagnosed in five cases (3.5%) In all of these cases, only distal DVT was confirmed. Despite extensive saphenous varicose vein surgery with stripping and miniphlebectomy performed in nontumescent but spinal anesthesia, no proximal lower leg episode was diagnosed. Three out of five DVT cases were diagnosed on day 10 postoperative control, while a further two were confirmed in the ultrasound examination performed 30 days after procedure. No clinically documented pulmonaly embolism (PE) as well as no bleeding episodes were noticed. Among the factors related to the statistically significant higher DVT occurrence, the results of the Caprini score were identified with odds ratio (OR) = 2.04 (95% CI = [0.998; 4.18]). Another factor that became statistically significant in terms of the higher postoperative DVT prevalence was the reported Venous Clinical Severity Score (VCSS) results (OR = 1.98; 95% CI [1.19; 3.26]). In the multiple logistic regression analysis, the patient age (OR = 0.86; 95% CI [0.75–0.99]), Caprini score evaluation results (OR = 4.04; 95% CI [1.26–12.9]) and VCSS results (OR = 2.4; 95% CI [1.23–4.7]) were of statistical significance as predictors for postoperative DVT occurrence, with a p value of 0.029 for age, and p = 0.017 and p = 0.009 for Caprini score results and VCSS results, respectively. Due to the confirmed limited number of the DVT events in our study cohort, as well as the descriptive and explorative nature of the achieved results, the final clin-

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ORIGINAL PAPER PRESENTATION ABSTRACTS

ical potential and significance of the identified parameters, including Caprini score rate and VCSS rate, should be interpreted with caution and studied in the further trials in these clinical settings. Conclusions: All the patients undergoing varicose vein surgery should undergo VTE risk evaluation based on the individual assessment. In VTE risk evaluation, patient and surgical procedure characteristics based on the factors included into the Caprini score but also on specific chronic venous disease-related factors should be taken into consideration. Further studies are needed to propose an objective and validated VTE risk assessment model, as well as a validated antithrombotic prophylaxis protocol in this particular patient group.

PIODERMIA ZGORZELINOWA PO SKLEROTERAPII – STUDIUM PRZYPADKU NOWEJ METODY TERAPEUTYCZNEJ Z ZASTOSOWANIEM ABLACJI LASEREM ND:YAG Łukasz Szczygieł Europejskie Centrum Flebologii, Angelius Provita, Katowice, Polska Cel pracy: Piodermia zgorzelinowa jest rzadkim powikłaniem skleroterapii. Jest to dermatoza neutrofilowa, często związana z chorobami autoimmunologicznymi. Pierwotne objawy skórne zwykle manifestują się jako tkliwe, zapalne grudki, guzki lub krosty z rumieniowym stwardnieniem, które mogą szybko przekształcić się w bolesne owrzodzenia. Leczenie piodermii zgorzelinowej jest długie i trudne. Opcje terapeutyczne obejmują stosowanie miejscowych i ogólnoustrojowych kortykosteroidów, leków immunosupresyjnych i terapii biologicznej. Celem tego studium przypadku jest przedstawienie nowatorskiej terapii zejściowych zmian skórnych po piodermii zgorzelinowej przy użyciu lasera 1064 nm/532 nm Q-Switched Nd:YAG. Materiał i metody: Badana grupa składała się z 8 kobiet w wieku 36–67 lat, u których piodermia zgorzelinowa wystąpiła po skleroterapii piankowej i miała postać od jednego do czterech sinofioletowych przebarwień. W pierwszym etapie leczenia wykorzystwano kortykosteroidy. Kolejny etap terapii składał się z 2–5 sesji ablacji przezskórnej laserem o długości fali 532 nm w trybie Q-Switch, w odstępach sześciotygodniowych, począwszy od 8. miesiąca po wystąpieniu piodermii zgorzelinowej. Na zabieg zgodziło się 7 z 8 pacjentek, ostatnia odmówiła poddania się tej terapii. W celu oceny wydolności układu żylnego wykonano ultrasonograficzne badanie dopplerowskie żył kończyn dolnych. Wyniki: U wszystkich osób poddanych laseroterapii przezskórnej zaobserwowano wybielenie i znaczną poprawę wyglądu zmian skórnych. Pacjentki nie zdecydowały się na kontynuację leczenia, ponieważ uzyskany efekt był zadowalający. U ostatniej pacjentki nie stwierdzono zmiany koloru przebarwienia skóry w ciągu dwuletniej obserwacji. W badanej grupie nie zauważono nieprawidłowości w układzie żył powierzchownych na leczonym obszarze, gdyż wcześniejsza skleroterapia piankowa była prowadzona prawidłowo. Wnioski: Podczas skleroterapii może dojść do rzadkiego powikłania – piodermii zgorzelinowej, które w późniejszej fazie terapii można leczyć laserem 1064 nm/532 nm Q-Switched Nd:YAG.

PYODERMIA GANGRENOSUM AFTER SCLEROTHERAPY: CASE STUDY OF NOVEL LASER TREATMENT Łukasz Szczygieł Europan Centre of Phlebology, Angelius Provita, Katowice, Poland Objectives: Pyoderma gangrenosum is a rare complication of sclerotherapy, as ulcerative, neutrophilic dermatosis, often associated with autoimmune diseases. Primary skin manifestations are usually represented by tender, inflammatory papules, nodules or pustules with erythematous induration, which can quickly evolve into painful ulceration. The treatment of pyoderma gangrenosum is long and challenging – therapeutic options include the application of topical and systemic corticosteroids, immunosuppressive agents and biologic therapy. The aim of this case study is to present a novel therapy of skin residues after pyoderma gangrenosum by using the 1064 nm/532 nm Q-Switched ND:YAG Laser.

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Material and methods: The group consisted of 8 women, age: 36–67. All patients suffered from pyoderma gangrenosum having one to four discolourated cyanosed skin changes after foam sclerotherapy. In the first phase corticosteroids were used. The next step of therapy consisted in 2–5 sessions of repeated laser toning treatment using the 532 nm PTP mode at 6 week intervals, beginning from 8th month after the occurrence of pyoderma gangrenosum. 7 out of 8 patients agreed to the procedure, the last one refused to undergo this therapy. To evaluate actual venous system parameters, the venous Doppler ultrasound of lower limbs was performed. Results: Laser treatment revealed significant improvement in the appearance of skin changes. All patients that underwent laser therapy showed whitening of the cyanosed skin, and decided not to continue treatment as they found the effect satisfactory. In case of the last patient no change was recorded in the skin discolouration during the two-year period of observation. No abnormality in the superficial venous system was observed in the study group in the treated area, as prior foam sclerotherapy was conducted properly. Conclusions: Sclerotherapy is associated with rare complications connected with skin changes caused by pyoderma gangrenosum that can be successfully treated with the 1064 nm/532 nm Q-Switched Nd:YAG Laser.

WPŁYW ŚREDNICY I DŁUGOŚCI IGŁY NA STABILNOŚĆ PIANY SKLEROTYZUJĄCEJ Marcin Skuła, Jacek Hobot, Joanna Czaja, Marian Simka Zakład Anatomii, Uniwersytet Opolski, Opole, Polska Cel pracy: Ocena stabilności piany sklerotyzującej wystrzykniętej przez igły o różnej długości i średnicy w celu zminimalizowania ryzyka powikłań neurologicznych po skleroterapii. Materiał i metody: Pianę uzyskaną metodą Tessariego po zmieszaniu roztworów siarczanu tetradecylu sodu (STS) – stężenia: 0,2%, 0,5%, 1% i 3%, polidokanolu – stężenia: 0,5%, 1%, 2% i 3%, z powietrzem w proporcji 1 : 4 wystrzyknięto przez igły o długości 4 mm, 6 mm i 13 mm oraz średnicy 0,26 mm, 0,3 mm i 0,4 mm. Po wystrzyknięciu piany na szkiełko podstawne mierzono czas jej dezintegracji. Wyniki: Stwierdzono większą stabilność piany uzyskanej z roztworów polidokanolu o większym stężeniu, podczas gdy w przypadku pian uzyskanych z STS zaobserwowano odwrotną zależność. Piany uzyskane z polidokanolu były bardziej stabilne, jeśli były wystrzyknięte przez dłuższe igły. Nie obserwowano znamiennego wpływu długości igły na stabilność piany uzyskanej z STS. Piany wystrzyknięte przez bardzo cienkie igły, o średnicy 0,26 mm, były bardzo niestabilne. W przypadku piany uzyskanej z 0,5% polidokanolu igła 0,3 x 6 mm zapewniała nietypowo dużą stabilność. Wnioski: W czasie skleroterapii piankowej należy brać pod uwagę zarówno średnicę, jak i długość igły stosowanej w czasie zabiegu, gdyż może to mieć wpływ na stabilność aplikowanej piany.

THE EFFECT OF THE CALIBRE AND LENGTH OF NEEDLE ON THE STABILITY OF SCLEROSING FOAM Marcin Skuła, Jacek Hobot, Joanna Czaja, Marian Simka Department of Anatomy, University of Opole, Opole, Poland Objectives: Little is known if a needle through which sclerosing foam is administered, affects the stability of the foam. In order to minimize the risk of neurological adverse events, it is recommended to ad minister maximally stable foam. This study was aimed at assessment of stability of foam ejected through needles of different length and calibre. Material and methods: Sclerosing foam was prepared using the Tessari method. Foams were made of 0.2%, 0.5%, 1% and 3% sodium tetradecyl sulfate and 0.5%, 1%, 2% and 3% polidocanol, which were mixed with room air in the proportion 1 : 4. Foams were ejected through needles 4 mm, 6 mm and 13 mm long and with diameter of 0.26 mm, 0.3mm and 0.4 mm. Time of foam disintegration was measured. Results: There was a higher stability of polidocanol foams made of more concentrated sclerosant, while in the case of sodium tetradecyl

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ORIGINAL PAPER PRESENTATION ABSTRACTS

sulfate foams an opposite relationship has been found. Polidocanol foams were more stable if ejected through longer needles. The length of needdle had no effect on the stability of sodium tetradecyl sulfate foams. Foams ejected through very thin needles (0.26 mm) were very unstable. In the case of 0.5% polidocanol foam the 0.3 x 6 mm needles provided atypically high stability of foam. Conclusions: The calibre and length of Needles should be taken into account During sclerotherapy, since these parameters of needles can affect foam stability.

CYFROWE MODELOWANIE PRZEPŁYWU KRWI W ŻYLE SZYJNEJ WEWNĘTRZNEJ Marian Simka1, Paweł Latacz2 1 2

Zakład Anatomii, Uniwersytet Opolski, Opole, Polska Oddział Neurologiczny, Szpital Uniwersytecki w Krakowie, Polska

Cel pracy: Obecnie uważa się, że patologiczne zastawki żył szyjnych wewnętrznych są głównym źródłem zaburzeń przepływu w tych żyłach. Badania obrazowe – angioTK i angioMR, wskazują jednak, że przyczyną zwężenia na poziomie otworu szyjnego jest nieprawidłowy odpływ żylny z jamy czaszki. Celem naszej pracy było zbadanie zaburzeń przepływu na modelach żył szyjnych wewnętrznych o różnej geometrii za pomocą oprogramowania do cyfrowego modelowania dynamiki przepływu. Materiał i metody: Symulacje komputerowe wykonano za pomocą oprogramowania Flowsquare+ (Nora Scientific, Japan). Zbudowano trójwymiarowe modele żył z różnymi morfologicznie zwężeniami w ich początkowym (dogłowowym) odcinku oraz różnie ukształtowanymi zastawkami w ich dalszym (dosercowym) odcinku. Wyniki: W trójwymiarowych modelach żył bez zwężeń lub ze stopniową zmianą ich średnicy obserwowano prawidłowy przepływ, który był jednokierunkowy, z typowym parabolicznym profilem prędkości i bez separacji strumieni przepływu. W przypadku trójwymiarowych modeli żył ze zwężeniami w ich początkowym odcinku, których morfologia przypominała dyszę, obserwowano nieprawidłowy przepływ: z nasiloną separacją strumieni przepływu i rejonami z wstecznym przepływem. Największe zaburzenia przepływu nie dotyczyły modeli z największymi zwężeniami, ale tych, w których dyszopodobne zwężenie było położone poza główną osią modelu żyły. Nieprawidłowo ukształtowane zastawki w dosercowym odcinku modelowanej żyły zaburzały przepływ, jeśli dyszopodobne zwężenie było położone centralnie, ale nie miały większego znaczenia, jeśli przepływ był już zaburzony przez zwężenie położone asymetrycznie. Wnioski: Modelowanie cyfrowe wskazuje, że podstawowym źródłem nieprawidłowego odpływu krwi z jamy czaszki są prawdopodobnie zwężenia zlokalizowane w górnych odcinkach żył szyjnych wewnętrznych, np. spowodowane przez ucisk przez wydłużony wyrostek poprzeczny kręgu szczytowego lub nieprawidłowy wyrostek rylcowaty kości skroniowej, a nie – jak się uważa obecnie, przez patologiczne zastawki żył szyjnych wewnętrznych.

NUMERICAL MODELING OF THE FLOW IN THE INTERNAL JUGULAR VEIN Marian Simka1, Paweł Latacz2 1 2

Anatomy Department, University of Opole, Opole, Poland Department of Neurology, University Hospital, Krakow, Poland

Objectives: Currently it is thought that pathological jugular valves are the main cause of an impaired venous outflow through the internal jugular veins. However, CT and MR angiographic studies have rather pointed out stenoses at the level of the jugular foramen as the main source of pathological outflow from the cranial cavity. Our study was aimed at assessment of flow characteristics with the use of computational flow modeling software in models of the internal jugular veins exhibiting different geometries. Material and methods: Numerical simulations were performed using the Flowsquare+ (Nora Scientific, Japan) software. We constricted 3-dimensional models of veins, exhibiting stenoses in their cranial portions and differently structured valves in their caudal portions.

Phlebological Review 2021

Results: There was normal, unidirectional flow, with parabolic velocity profile and without flow separation in models without strictures or exhibiting gradual stenoses. On the contrary, in models with nozzle-like strictures in their cranial portions there was an abnormal flow, with an extensive flow separation and regions with reversed flow. The most severe flow abnormalities were not fund in models with the highest degree of stenosis, but in those with nozzle-like strictures localized outside of the long axis of a vessel. Abnormally structured valves also resulted in flow abnormalities, but did not have significant effect in a case of already disturbed flow caused by a stenosis localized upstream. Conclusions: The results of our computational flow modeling suggests that strictures localized in the upper part of the internal jugular vein, e.g. caused by an enlarged transverse process of the atlas or elongated styloid process of the temporal bone, are the main cause of abnormal venous outflow from the cranial cavity, and not pathological jugular valves, as it is currently believed.

ŚWIATŁOWÓD WIELOPIERŚCIENIOWY INFINITE RING W ZABIEGACH EVLA LASEREM NEOV1940 Michał Posmykiewicz Centrum Flebologii, Warszawa, Polska Cel pracy: Ocena skuteczności leczenia oraz bezpieczeństwa zabiegów likwidacji niewydolności żylnej za pomocą lasera diodowego 1940 nm oraz światłowodów wielopierścieniowych INFINITE RING. Materiał i metody: Analizie poddano zabiegi wykonane w Centrum Flebologii od 23 września 2020. Leczeniu poddano pacjentów z niewydolnością żylną głównych pni oraz refluksem w ujściu do żył układu głębokiego. Wyniki: W badanych przypadkach wszystkie żyły zostały całkowicie zamknięte bez poważnych powikłań. Pigmentację zaobserwowano u 3% pacjentów, a wyczuwalne stwardnienia u 9%. Większość pacjentów nie korzystało ze zwolnień lekarskich ani nie zażywało środków przeciwbólowych. Wnioski: Powszechnie stosowana wewnątrzżylna ablacja laserowa (EVLA) jest bardzo skuteczna i mało inwazyjna. Pojawienie się laserów diodowych o długości fali 1940 nm oraz światłowodów wielopierścieniowych pozwala mieć nadzieję na osiąganie dobrych elektów terapii przy znacznie zwiększonym komforcie dla pacjenta oraz minimalizacji działań niepożądanych. Praca przedstawia wyniki krótkoterminowe planowanego opracowania najbardziej optymalnego protokołu leczenia.

INFINITE RING FIBER IN EVLA LASER TREATMENT NEOV1940 Michał Posmykiewicz Centrum Flebologii, Warsaw, Poland Objectives: Assessment of the effectiveness of treatment and the safety of procedures to eliminate venous insufficiency using 1940 nm diode laser and INFINITE RING multi‐ring fibers. Material and methods: The analyzed procedures were performed at the Phlebology Center from September 23, 2020. The treatments refer to patients with venous insufficiency of the main trunks and reflux at the junctions with the deep veins. Results: All veins were completely closed with no serious complications. Pigmentation was observed in 3% of patients, and palpable induration in 9% of patients. Most patients don’t need a break from work and didn’t take any pain relievers drugs. Conclusions: Intravenous laser ablation (EVLA) is widely used, very effective and little invasive. The appearance of diode lasers with a wavelength of 1940 nm and multi‐ring fibers giving a hope for achieving good therapy effects, with increased comfort for the patient and minimum of side effects. The work presents short‐term results. Wider work is planned for the development of the most optimal treatment protocol.

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ODZIEŻ PŁASKODZIANA W LECZENIU OBRZĘKÓW LIMFATYCZNYCH – OGRANICZENIA REFUNDACYJNE Anna Narojczyk, Beata Narojczyk Centrum Flebologii, Warszawa, Polska Cel pracy: Ocena kryteriów refundacji odzieży płaskodzianej. Materiał i metody: Analizie poddano dobór wyrobów dla pacjentów z obrzękiem limfatycznym leczonych w Centrum Flebologii. Od 2004 r. wybrano 4640 produktów: 1541 na kończyny górne, 3099 na kończyny dolne. Od 2013 r. pacjenci korzystają z refundacji. Wyniki: Pacjenci z obrzękiem limfatycznym coraz chętniej akceptują kompresjoterapię, także w formie jeszcze niedawno nieakceptowalnej z powodów estetycznych. Zapisy refundacyjne związane preferencjami technologicznymi ograniczają jednak dostępność wyrobów. Wnioski: Kompresjoterapia za pomocą odzieży jest uznaną i tanią metodą leczenia, mającą szczególne zastosowanie w leczeniu obrzęków limfatycznych. Brak zaopatrzenia pacjentów w produkty niweczy działania terapeutyczne i naraża pacjentów na cierpienie, obniża komfort życia, doprowadza do powikłań i izolacji społecznej oraz zawodowej. Skutkuje to także wzrostem kosztów leczenia i opieki. Dlatego tak ważne wydaje się przeanalizowanie kryteriów przyznawania refundacji.

APPLICATION OF FLAT-KNIT GARMENTS IN TREATING LYMPHEDEMA – RESTRICTIONS ON REIMBURSEMENT Anna Narojczyk, Beata Narojczyk Center of Phlebology, Warsaw, Poland Objectives: Evaluation of reimbursement criteria for flat-knit garments Material and methods: A selection of items of clothing issued by Centrum Flebologii, Warsaw, to lymphedema patients were analyzed. Since 2004, a total of 4,640 products have been sampled: 1,541 for the upper limbs, 3,099 for the lower limbs. Patients have been taking advantage of the reimbursement to which they are entitled since 2013. Results: Patients with lymphedema are becoming increasingly accepting of undergoing compression therapy, also in the form that has, until recently, been unacceptable for aesthetic reasons. However, reimbursement provisions related to technological preferences limit the accessibility of these products, often to the patients who need them most. Conclusions: Compression therapy using special clothing is a recognized and inexpensive treatment method, particularly suitable for treating lymphedema. Failure to supply products to such patients thwarts their therapeutic efforts and exposes them to suffering. It lowers their comfort level and leads to complications as well as social and professional isolation. It also results in increased costs of treatment and care. Therefore, analyzing the criteria for granting reimbursement based on experience gained so far is of great importance.

DOLEGLIWOŚCI BÓLOWE U CHORYCH Z ŻYLNYMI OWRZODZENIAMI KOŃCZYN DOLNYCH – 12-TYGODNIOWE BADANIE PODŁUŻNE Paulina Mościcka1,, Justyna Cwajda-Białasik1, Arkadiusz Jawień2 , Maria T. Szewczyk1 Katedra Pielęgniarstwa Zabiegowego, Zakład Pielęgniarstwa Chirurgicznego i Leczenia Ran Przewlekłych, Collegium Medicum w Bydgoszczy, Uniwersytet Mikołaja Kopernika w Toruniu, Polska 2 Klinika Chirurgii Naczyniowej i Angiologii, Collegium Medicum w Bydgoszczy, Uniwersytet Mikołaja Kopernika w Toruniu, Polska 1

Cel pracy: Analiza dynamiki nasilenia bólu i jego predyktorów w grupie chorych z żylnymi owrzodzeniami kończyn dolnych. Materiał i metody: Do 12-tygodniowej obserwacji włączono 754 pacjentów z owrzodzeniami żylnymi kończyn dolnych. Subiektywne nasilenie bólu mierzono w odstępach tygodniowych za pomocą 11-punktowej wizualnej skali analogowej (VAS). Wyniki: W analizowanym okresie zaobserwowano istotny spadek punktacji VAS. Większe nasilenie bólu obserwowano u pacjentów, u których podczas pierwszej wizyty stwierdzono na powierzchni owrzo-

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dzenia obecność ropy i/lub nieprzyjemnego zapachu, oraz u których rana zlokalizowana była na tylnej części goleni lub miała charakter okrężny. Obecność zaczerwienienia wokół owrzodzenia podczas pierwszej wizyty wiązała się z mniejszym nasileniem bólu. Wnioski: Wdrożenie holistycznego podejścia może przyczynić się do istotnego zmniejszenia występowania i nasilenia bólu u pacjenta z owrzodzeniem żylnym kończyny dolnej. Ocena bólu uzależniona była przede wszystkim od parametrów klinicznych i lokalizacji owrzodzeń.

PAIN COMPLAINTS IN PATIENTS WITH VENOUS LEG ULCERS – A 12-WEEK LONGITUDINAL STUDY Paulina Mościcka1,, Justyna Cwajda-Białasik1, Arkadiusz Jawień2, Maria T. Szewczyk1 Department of Perioperative Nursing, Department of Surgical Nursing and Chronic Wound Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland 2 Department of Vascular Surgery and Angiology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland 1

Objectives: The aim of this study was to analyze the dynamics of pain intensity and its predictors in a group of patients with venous leg ulcers. Material and methods: A total of 754 patients with venous leg ulcers were included in a 12-week observational study. Subjective pain intensity was measured at weekly intervals using an 11-point visual analog scale (VAS). Results: A significant decrease in VAS scores was observed throughout the analysis period. Higher pain intensity was observed among patients in whom pus and/or odor was found in the ulceration during the first visit. Greater pain was reported by patients whose wound was located on the back of the shin or was circular in nature. The presence of redness around the ulceration at the first visit was associated with lower pain intensity. Conclusions: Implementation of a comprehensive holistic approach can significantly reduce the occurrence and severity of pain in a patient with venous leg ulcers. Pain assessment was primarily dependent on clinical parameters and location of venous ulceration.

OCENA SKUTECZNOŚCI I BEZPIECZEŃSTWA LECZENIA METODĄ WEWNĄTRZŻYLNEJ ABLACJI MIKROFALOWEJ Michał Molski, Stanisław Molski Szpital Eskulap – Centrum Leczenia Chorób Serca i Naczyń, Osielsko, Polska Cel pracy: Ocena skuteczności i częstości występowania powikłań po wewnątrzżylnej ablacji mikrofalowej (ang. endovenous microwave ablation – EMWA). Materiał i metody: Od września 2019 r. do kwietnia 2021 r. u 29 pa­cjentów z niewydolnością żylną w znieczuleniu tumescencyjnym i analgosedacji wykonano EMWA (genarator ECO-100D2, antena ECO-100F-2016). Do oceny wydolności i drożności pni żylnych wykorzystano USG GE Versana Premier i sondy 12L 8–12 Mhz. Wyniki: U 29 pacjentów od 27–73 lat, CEAP C3-C6 wykonano ablację 49 pni żylnych, u 15 skleroterapię, u 1 miniflebektomię. Średnica pni żylnych wynosiła od 4 mm do 15 mm, średnia 8,6 mm. Podczas obserwacji trwającej 14–569 dni (średnio 97 dni) w przypadku 3 (6,1%) pni stwiedzono rekanalizacje odcinkowe bez nawrotu refluksu. Nie stwierdzono rekanalizacji całkowitej. Parestezje zgłaszało 4 (13,7%) pacjentów. Nie stwierdzono innych powikłań. Wnioski: W krótkoterminowej obserwacji EMWA jest metodą skuteczną. Poza parestezjami nie stwierdzono innych powikłań.

EVALUATION OF THE EFFECTIVENESS AND SAFETY OF THE ENDOVENOUS MICROWAVE ABLATION – EMWA Michał Molski, Stanisław Molski Eskulap Hospital – Cardiovascular Centre, Osielsko, Poland Objectives: The aim of the study is to evaluate the effectiveness and incidence of complications after EMWA endovenous microwave ablation.

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ORIGINAL PAPER PRESENTATION ABSTRACTS

Material and methods: Between 09.2019 and 04.2021, EMWA (ECO-100D2 genarator, ECO-100F-2016 antenna) in tumescent anesthesia and analgosedation was performed in 29 patients with venous insufficiency. GE Versana Premier ultrasound and 12L 8–12 Mhz probes were used to assess the efficiency and patency of venous trunks. Results: 29 patients aged 27–73 years, CEAP C3-C6 underwent ablation of 49 venous trunks, concomitant sclerotherapy was performed in 15 cases and miniphlebectomy in 1 case. The diameters of the venous trunks were 4 mm to 15 mm, the average was 8.6 mm. In a follow-up of 14–569 days (mean 97 days), 3 (6.1%) trunks showed segmental recanalizations without reflux. There was no complete recanalization. Paresthesia was reported by 4 (13.7%) patients. No other complications were found. Conclusions: In the short term, EMWA intravenous microwave ablation is effective. Apart from paresthesia, no other complications were noticed.

ZASTOSOWANIE SYSTEMU SCLEROSAFE W LECZENIU NIEWYDOLNOŚCI ŻYŁY ODPISZCZELOWEJ DODATKOWEJ PRZEDNIEJ I ŻYŁY GIACOMINI – WYNIKI 6-MIESIĘCZNE Michał-Goran Stanišić Klinika Chirurgii Naczyniowej i Wewnątrznaczyniowej Angiologii i Flebologii, Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu, Polska Angiodiabetica – Klinika Chorób Naczyń i Stopy Cukrzycowej, Poznań, Polska Cel pracy: Ocena skuteczności systemu Scleorsafe z jednoczasowym odessaniem krwi żylnej z leczonego naczynia w skleroterapii dużych pni żylnych oraz zmniejszeniu dolegliwości pozabiegowych. System Sclerosafe rekomendowany jest w leczeniu niewydolności żyły odpiszczelowej dodatkowej przedniej i żyły Giacomini jako alternatywa dla innych termicznych i nietermicznych sposobów ablacji Materiał i metody: Od stycznia do grudnia 2020 r. wykonano 53 zabiegi, wykorzystując system Sclerosafe 150 i 300, w tym 21 interwencji w obrębie żyły odpiszczelowej dodatkowej przedniej (AASV) i 3 interwencje w obrębie żyły Giacomini zakończone obserwacją 6-miesięczną. Grupa pacjentów była niejednorodna pod względem długości i średnicy leczonej żyły oraz płci i wieku. Ocenie poddano skuteczność ablacji (brak rekanalizacji na odcinku > 5 cm) oraz konieczność wykonania minitrombektomii w okresie pozabiegowym. Wyniki: Wszystkie zabiegi zakończyły się sukcesem technicznym. W obserwacji 6-miesięcznej stwierdzono całkowitą obliterację 18 AASV i 3 żył Giacomini. Całkowita rekanalizacja AASV nastąpiła w 2 przypadkach, a częściowa na odcinku > 5 cm w jednym przypadku. Konieczność minitrombektomii wystąpiła u 6 chorych. Wnioski: Wstępne obserwacje wykazują akceptowalność systemu Sclerosafe w ablacji AASV i żyły Giacomini. Wskazane porównanie w badaniach bezpośrednich metodami ablacji farmakomechanicznej i termicznej.

EFFECTIVENESS OF SCLEROSAFE SYSTEM FOR THE TREATMENT OF ANTERIOR ACCESSORY SAPHENOUS VEIN AND GIACOMINI VEIN – SIX-MONTH RESULTS Michal-Goran Stanišić Department of Vascular and Endvascular Surgery of Angiology and Phlebology PUMS, Poznań, Poland Angiodiabetica Clinic of Vascular Diseases and Diabetic Foot, Poznań, Poland Objectives: The Scleorsafe system for sclerotherapy with the simultaneous removal of venous blood from the treated vessel is aimed at improving the effectiveness of sclerotherapy of large venous trunks and reducing adverse events. There are reasonable grounds to use the Sclerosafe system to treat anterior accessory saphenous vein and Giacomini vein as an alternative to other thermal and non-thermal ablation methods Material and methods: From January to December 2020, 53 Sclerosafe (150 and 300) procedures were performed, including 21 interventions in the anterior accessory saphenous vein (AASV) and three interventions within the Giacomini vein with a 6-month observation. The

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patient group was heterogeneous in length and diameter of the treated vein and gender and age. The effectiveness of ablation (no recanalization > 5 cm) and the need for a minithrombectomy during the post-treatment period were assessed. Results: All treatments have been a technical success. In a 6-month follow-up, complete obliteration of 18 AASV and 3 Giacomini veins was confirmed. Total AASV recanalization occurred in two cases and partial > 5 cm in 1 case. The need for a minitrombectomy occurred in 6 patients. Conclusions: Preliminary observations demonstrate the acceptability of the Sclerosafe system in AASV and Giacomini veins ablation. There is a strong need of comparison in direct studies with pharmacomechanical and thermal ablation methods.

PORÓWNANIE WYNIKÓW 36-MIESIĘCZNYCH ABLACJI ŻYŁY ODPISZCZELOWEJ ODSTRZAŁKOWEJ KLEJEM MEDYCZNYM VENASEAL I SYSTEMEM ABLACJI FARMAKOMECHANICZNEJ CLARIVEIN Michał-Goran Stanišić Klinika Chirurgii Naczyniowej i Wewnątrznaczyniowej Angiologii i Flebologii, Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu, Polska Angiodiabetica – Klinika Chorób Naczyń i Stopy Cukrzycowej, Poznań, Polska Cel pracy: Porównanie retrospektywne skuteczności ablacji żyły odpiszczelowej i odstrzałkowej klejem medycznym Venaseal i systemem ablacji farmakomechanicznej Clarivein. Alternatywne wobec ablacji termicznej kleje medyczne i metody farmakomechaniczne cechuje zadowalająca skuteczność i akceptacja pacjentów. Dotychczasowe publikacje porównywały metody ablacji termicznej i nietermicznej. Materiał i metody: Badaniu poddano 196 żył odpiszczelowych i 18 żył odstrzałkowych leczonych systemem Clarivein oraz 148 żył odpiszcelowych i 14 żył odstrzałkowych leczonych klejem Medycznym Venaseal. Oceniano skuteczność ablacji (brak rekanalizacji w odcinku > 5 cm), średnicę i długość leczonych segmentów żył, analizowano działania niepożądane. Wyniki: Mediana długości leczonych segmentów żylnych wynosiła 35 cm, a mediana średnicy żyły odpiszczelowej i odstrzałkowej wynosiła 7 m. Brak rekanalizacji w zakresie żyły odpiszczelowej uzyskano w 96,6% przypadków po 36 miesiącach od zabiegu Venaseal i w 94,3% po zabiegu Clarivein. W zakresie żyły odstrzałkowej po 36 miesiącach uzyskano zamknięcie żyły odstrzałkowej w 100% po Venaseal i w 77,7% po Clarivein. Wyniki wykazują wyższą skuteczność kleju medycznego Venaseal na poziomie istotności p < 0,05. Nie zanotowano różnic w ilości zdarzeń niepożądanych w okresie 36-miesięcznym. Wnioski: Pomimo ograniczeń anatomicznych, klej medyczny Venaseal cechuje większa skuteczność w obserwacji średnio i długoterminowej niż ablacja farmakomechaniczna sposobem Clarivein. Uzyskane wyniki powinny służyć właściwemu wyborowi metody leczenia.

36 MONTH RESULTS OF SMALL AND GREAT SAPHENOUS VEIN ABLATION WITH VENASEAL MEDICAL ADHESIVE AND CLARIVEIN PHARMACOMECHANICAL ABLATION SYSTEM Michał-Goran Stanišić Department of Vascular and Endvascular Surgery of Angiology and Phlebology PUMS, Poznań, Poland Angiodiabetica Clinic of Vascular Diseases and Diabetic Foot, Poznań, Poland Objectives: Retrospective comparison of the effectiveness of small (SSV) and great saphenous vein (GSV) ablation with Venaseal Medical Adhesive and Clarivein Pharmacomechanical Ablation System. Alternative to thermal ablation, medical adhesives and pharmacomechanical methods are characterized by satisfactory effectiveness and a high level of acceptance by patients. Previous publications have compared only thermal and non-thermal ablation methods.

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Material and methods: In the study 196 GSV and 18 SSV veins treated with Clarivein and 148 GSV and 14 SSV treated with Venaseal Medical Adhesive have been included. Long term assessment of the SSV and GSV ablation was performed in regards of recanalization > 5 cm, the diameter and length of the treated vein segments and adverse reactions. Results: The median length of the treated venous segments was 35 cm and the median diameter of the SSV and GSV was 7 mm. Freedom from recanalisation was achieved in 96.6% of cases at 36 months after Venaseal procedure and 94.3% after Clarivein. In terms of SSV after 36 months, the complete occlusion was achieved 100% after Venaseal and in 77.7% after Clarivein. The results show a higher effectiveness of Venaseal medical adhesive at the level of significance p < 0.05. There were no differences in adverse events over a 35-month period. Conclusions: Despite anatomical limitations, Venaseal medical adhesive is more effective at medium and long-term observation than Clarivein pharmacomechanical ablation. The results should be considered in the discussion with patient.

OPATRUNEK URGOSTART CONTACT JAK OPATRUNEK UZUPEŁNIAJĄCY W LECZENIU OWRZODZENIA ŻYLNEGO GOLENI Jakub Majewski1, Jacek Kostecki2, Wacław Kuczmik1 Katedra i Klinika Chirurgii Ogólnej, Chirurgii Naczyń, Angiologii i Flebologii, Śląski Uniwersytet Medyczny w Katowicach, Polska 2 Centrum Medyczne Inmedico, Tychy, Polska 1

Cel pracy: Ocena skuteczności opatrunku Urgostart Contact. Kompresjoterapia oraz opatrunki specjalistyczne są w chwili obecnej podstawą leczenia owrzodzeń żylnych, pamiętać jednak należy, że ucisk na naskórek osób starszych może stanowić problem. Skóra pergaminowa podudzi osób w podeszłym wieku zostaje podczas kompresji bardzo często uszkodzona, co skutkuje pojawieniem się kolejnych trudnych w zaopatrzeniu ran. Pacjenci w takim przypadku często nie chcą stosować bandaży kompresyjnych, a podkolanówki kompresyjne zakłada się bardzo trudno. Circ-aid firmy Medi częściowo rozwiązywało problem, jednak pacjent w dalszym ciągu był zmuszony do zakładania skarpet kompresyjnych, co w wielu przypadkach z powodu słabości w dłoniach było kłopotliwe. Nowy typ opatrunku z matrycą TLC stosowany na skórę podrażnioną szybko poprawia kondycją naskórka oraz umożliwia bezpieczne stosowanie bandaży kompresyjnych bez ryzyka uszkodzeń naskórka. Materiał i metody: Pacjentka lat 76 z dużym obrzękiem podudzia i bardzo obfitym wysiękiem z rany zgłosiła się do poradni w celu leczenia owrzodzenia żylnego podudzia prawego. Zdiagnozowano niewydolność żylną VSM. Zastosowano zgodnie z uzyskanym posiewem antybiotykoterapię. Kompresjoterpia pozwoliła na uzyskanie znacznej poprawy w zakresie obrzęku wydzielania oraz redukcji wielkości owrzodzenia. Wyniki: Rana po około 3 tygodniach została całkowicie zamknięta. Kompresjoterapia oraz długotrwałe wysięki w okolicy tylnej powierzchni podudzia sprawiały, że naskórek podczas zmiany bandaży został uszkodzony, co powodowało częste krwawienia z naskórka oraz skutkowało brakiem możliwości zmiany kompresji na pończochy uciskowe. Bandaże u pacjentki były często luzowane z powodu dolegliwości bólowych naskórka, co w dalszej kolejności sprzyjało zwiększaniu się wysięku. Do terapii włączono opatrunek Urgostart Contact, który skutecznie podleczył uszkodzony naskórek, co umożliwiło szybkie wyleczenie ran oraz zamianę bandaży kompresyjnych na pończochy kompresyjne. Wnioski: Matryca TLC opatrunku Urgostart Contact znacząco przyśpieszyła gojenie rany oraz zabezpieczyła naskórek przed dalszymi uszkodzeniami, co umożliwiło szybsze wdrożenie stosowania pończoch uciskowych.

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URGOSTART CONTACT AS A SUPPLEMENTARY DRESSING IN THE TREATMENT OF VENOUS LEG ULCERS Jakub Majewski1, Jacek Kostecki2, Wacław Kuczmik1 Department of General Surgery, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, Katowice, Poland 2 Medical Centre Inmedico, Tychy, Poland 1

Objectives: Compression therapy and specialist dressings are currently the basis for the treatment of venous ulcers. However, compression and its pressure on the epidermis of the elderly may cause further problems. Parchment skin of elderly people’s legs during compression is very often damaged, which results in the appearance of more difficult wounds to heal. Patients with such a problem often do not want to use compression bandages anymore, and compression stockings are extremely difficult to put on. Medi’s new Circ-aid solution partially solved the problem, but the patient was still forced to put on compression socks, which in many cases was an unsolvable problem due to weakness in the hands. However, the new type of TLC dressing applied to irritated skin quickly improves the condition of the epidermis and enables the safe use of compression bandages without further risk of epidermal damage. Material and methods: A 76-year-old patient came to the clinic for the treatment of venous ulceration of the right leg. A patient with a large swelling of the lower leg and a very abundant exudate from the wound. The patient was diagnosed with venous insufficiency VSM and was administered antibiotic therapy in accordance with the obtained culture. The applied compression therapy allowed for a significant improvement in the area of secretion ​​ edema and reduction of the ulcer size. Results: The wound was completely closed after about 3 weeks, but due to the applied compression and long-lasting exudates in the area of​​ the posterior surface of the shank, the epidermis was very easily damaged during bandage changes, which resulted in frequent epidermal bleeding and resulted in the inability to change compression to compression stockings. The patient’s bandages were often loosened due to pain in the epidermis, which further contributed to the increase in exudate The treatment included the Urgostart contact dressing which effectively healed the damaged epidermis, which allowed for quick healing of wounds and further replacement of compression bandages with compression stockings. Conclusions: The TLC matrix of the Urgostart Contact dressing significantly accelerated the healing of the wound and secured the epidermis against further damage, which enabled faster implementation of compression stockings.

CORONA PHLEBECTATICA – EPIDEMIOLOGIA I PATOGENEZA W POPULACJI LUDZI MŁODYCH Maciej Jusko, Klaudyna Bugla, Piotr Skut, Michał Tworek, Katarzyna Klimek, Tomasz Urbanek Katedra i Klinika Chirurgii Ogólnej, Chirurgii Naczyń, Angiologii i Flebologii, Śląski Uniwersytet Medyczny w Katowicach, Polska Cel pracy: Corona phlebectatica (CP) jest jednym z objawów wskazujących na obecność przewlekłej choroby żylnej (CVD). Pomimo zakwalifikowania CP jako stadium C4c w aktualizacji klasyfikacji CEAP 2020, definiującej zaawansowane postaci choroby, można ją spotkać także w populacji osób młodych. Celem niniejszej pracy jest ocena występowania CP w populacji młodych ludzi i powiązanie jej ze współistniejącymi czynnikami ryzyka, objawami CVD oraz patologiami układu żylnego kończyn dolnych. Materiały i metody: Badana grupa składała się z 518 pacjentów w wieku 20–28 lat. Wszyscy uczestnicy zostali poddani ocenie w Venous Clinical Severity Score (VCSS), Visual Analog Scale (VAS) dotyczącej bólu i kwestionariuszu jakości życia CIVIQ 20 wraz z badaniem czynników ryzyka CVD i stylu życia. Obecność zmian o charakterze CP stwierdzono u 30 badanych (5,7%). W badanej grupie CP oceniano w dwóch stopniach nasilenia: wczesnym – incipiens CP (n = 22), i późnym – definitive CP (n = 8). Następnie w celu oceny układu żylnego wykonano żylne USG Doppler kończyn dolnych.

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ORIGINAL PAPER PRESENTATION ABSTRACTS

Wyniki: Porównanie między grupą badaną a grupą kontrolną ujawniło istotne różnice w zakresie: wzrostu (odpowiednio 177,5 vs 170; p = 0,006), wagi (72,5 vs 63; p = 0,003) i płci (z CP: 60% M, 40% F; bez CP: 33,7% M, 66,3% F; p = 0,005). Istotne różnice uzyskano w skali VAS – ocena bólu (0,8 vs 0,0; p = 0,004) oraz w skali VCSS (1,0 vs 0,0; p = 0,002). Badanie USG wykazało patologiczne zmiany w układzie żył powierzchownych u 43% (n = 13) pacjentów z CP: VSM była niewydolna u 30% badanych (n = 10), żyły przeszywające 13% (n = 4), a VSP u 3% (n = 1). Wnioski: CP jest potencjalnie związana manifestacją objawów CVD również populacji ludzi młodych. Występowanie CP wiąże się z relatywnie częstym występowaniem patologii w układzie żył powierzchownych kończyn dolnych, co moze wskazywać na bardziej prawdopodobny dalszy rozwój tej choroby w przyszłości.

CORONA PHLEBECTATICA – EPIDEMIOLOGY AND PATHOGENESIS IN YOUNG POPULATION Maciej Jusko, Klaudyna Bugla, Piotr Skut, Michał Tworek, Katarzyna Klimek, Tomasz Urbanek Department of General Surgery, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, Katowice, Poland Objectives: Corona phlebectatica (CP) is known as one of the signs indicating the presence of CVD. Despite of CP being classified as C4c in 2020 CEAP classification update, so as the stage of an advanced disease, it can be also found in young population. The aim of this study is to assess the occurrence of CP in the young population and associate it with concomitant risk factors, symptoms of CVD and venous abnormalities of the lower limbs. Material and methods: The group consisted of 518 young volunteers, age: 20–28. All participants received Venous Clinical Severity Score, Visual Analog Scale of pain and CIVIQ 20 quality of life questionnaire, along with a CVD risk factors and lifestyle survey. Corona phlebectatica was identified in 5.7% of the study population. In study group CP was assessed in two severity grades: incipient CP (n = 22) and definite CP (n = 8). Moreover, to evaluate venous system parameters the venous Doppler ultrasound of lower limbs was performed. Results: Comparison between study and control group revealed significant differences in: height (respectively, 177.5 v. 170; p = 0.006), weight (72.5 v. 63; p = 0.003) and gender (with CP: 60% M, 40% F; without CP: 33.7% M, 66.3% F; p = 0.005). Significant differences were obtained in the VAS – pain score (0.8 vs. 0.0; p = 0.004) and the VCSS scale (1.0 v. 0.0; p = 0.002). US examination showed deviations in the superficial vein system among 43% (n = 13) CP subjects: VSM was incompetent in 30% (n = 10), perforator vein in 13% (n = 4), and VSP in 3% (n = 1). Conclusions: CP is associated with the manifestation of CVD symptoms also in the young population. In the CP patients, the presence of pathology in the superficial venous system of the lower limbs can be often identified which can potentially suggest more likely disease development in future.

ŚWIADOMOŚĆ PASAŻERÓW LINII LOTNICZYCH W ZAKRESIE RYZYKA ZAKRZEPICY ŻYLNEJ PODCZAS LOTU SAMOLOTEM Marcin Kucharzewski, Katarzyna Duda, Adrianna Doman, Marek Olesz, Wacław Kuczmik, Tomasz Urbanek Katedra i Klinika Chirurgii Ogólnej, Chirurgii Naczyń, Angiologii i Flebologii, Śląski Uniwersytet Medyczny w Katowicach, Polska Cel pracy: Zakrzepica żylna powstała w wyniku długotrwałego unieruchomienia w czasie podróży zwana jest zespołem klasy ekonomicznej lub zakrzepicą podróżnych. Żylna choroba zakrzepowo-zatorowa (ŻChZZ) klinicznie manifestująca się jako zakrzepica żył głębokich oraz zatorowość płucna wciąż pozostaje trzecią spośród chorób naczyniowych przyczyną śmierci. Roczna zapadalność w skali świata wynosi około 1–2 przypadki na 1000 osób. Ryzyko zakrzepicy żylnej na skutek

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lotu długodystansowego wynosi około 0,02 do 2,7% i wzrasta wraz z ilością czasu. Poziom świadomości tego problemu wśród potencjalnych podróżujących skazanych na długotrwałe unieruchomienie jest ograniczony – celem pracy było jego określenie. Materiał i metody: W badaniu wzięło udział 400 pasażerów linii lotniczych. Przeprowadzono anonimową ankietę. Kwestionariusz składał się z 29 pytań dotyczących ŻChZZ, związku między zakrzepicą żylną a lotem, ewentualnych objawów czy profilaktyki. Wyniki: Badaniu poddano pasażerów w wieku 18–76 lat, 56% stanowiły kobiety, a 44% mężczyźni. Ponad połowa badanych (52%) potwierdziła wpływ długich podróży lotniczych na zwiększone ryzyko zakrzepicy, w tym długotrwałe siedzenie w jednej pozycji, co może sprzyjać powstawaniu zakrzepów, czas lotu zwiększający ryzyko, zmienność ciśnień i warunki panujące w samolocie w porównaniu z warunkami występującymi na poziomie morza. O możliwości podejmowania działań profilaktycznych podczas długiej podróży samolotem słyszało 51% respondentów, 58% badanych, którzy odpowiedzieli na to pytanie jako remedium wskazywało ruch podczas lotu czy ćwiczenia rozciągające, a 40% leki – 13% wspomniało o aspirynie, natomiast heparyna drobnocząsteczkowa została wskazana przez 11% ankietowanych. Wyroby uciskowe jako działanie profilaktyczne zostały wspomniane przez 40% udzielających odpowiedzi na to pytanie, a jedynie 5% wskazało odpowiednie nawodnienie organizmu. Kolejne pytanie odnośnie do stosowania profilaktyki przez podróżnych potwierdziło, że jedynie 7,5% zastosowało podkolanówki uciskowe. Na pytanie o definicję „zespołu klasy ekonomicznej” odpowiedzi nie znało 90,7% respondentów, terminu „zakrzepica podróżnych” nie znało 72,5%. Wnioski: Mimo powszechnego i łatwego dostępu do wiedzy zawartej w poradnikach internetowych i czasopismach, świadomość podróżujących pozostaje niska w zakresie związku między wystąpieniem żylnej choroby zakrzepowo zatorowej a lotem samolotem. Podobne obserwacje dotyczą wiedzy o czynnikach ryzyka i profilaktyce. Konieczne jest podjęcie szeroko zakrojonych systemowych działań zwiększających świadomość społeczną dotyczącą zachowań zmniejszających ryzyko powikłań zakrzepowych

THE AWARENESS OF AIRLINE PASSENGERS ABOUT THE RISK OF VENOUS THROMBOSIS DURING AN AIRPLANE FLIGHT Marcin Kucharzewski, Katarzyna Duda, Adrianna Doman, Marek Olesz, Wacław Kuczmik, Tomasz Urbanek, Department of General Surgery, Vascular Surgery, Angilogy and Phlebology, Medical University of Silesia, Katowice, Poland Objectives: Venous thrombosis associated with immobilization during travel is also called economy-class syndrome or traveller`s thrombosis. Generaly venous thromboembolism (VTE), clinically manifested as deep vein thrombosis and pulmonary embolism is still the third cause of death among vascular diseases. The annual incidence worldwide is about 1–2 cases per 1000 people. The risk of venous thrombosis during long flight is about 0.02 to 2.7% and increases with the duration of the flight. In selected group may reaches even 10% (flight time over 8 hours, passengers age above 50y.) The level of awareness of this problem among potential air travelers, as well as other forms of travel associated with chronic immobilization, remains very limited. The aim of the study was to determine the level of knowledge and awareness of airline passengers regarding the relation between the flight and the occurrence of venous thrombosis Material and methods: 400 airline passengers took part in the study. An anonymous questionnaire was conducted. The questionnaire consisted of 29 questions concerning the knowledge about the disease (VTE), connection between venous thrombosis and flight, the presence of possible symptoms in themselves, or the use of prophylaxis during the flight Results: The respondents were aged 18–76, 56% of the respondents were women and 44% were men. Half of respondents (52%) confirmed influence of the long air travel on the increased risk of thrombosis, including: prolonged sitting in one position which may be conducive to blood clots, flight duration which increases the risk, variation of pressures and conditions in the aircraft compared to those prevailing

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at sea level. To the question about the possibility of taking preventive actions during a long flight by plane answered 51% of the respondents. Most of the respondents, i.e. 58%, indicated activities such as walking, moving during the flight or stretching exercises. 40% indicated drugs as a prophylactic effect, 13% mentioned aspirin, while low molecular weight heparin was indicated by 11% of the respondents. Compression products were mentioned as a preventive measure by 40% of those who answered this question, and only 5% indicated adequate hydration of the body. Next question about prophylaxis (stocking) concerned its use by the travelers themselves. Compression stockings are used by only few responders (7.5%). Two questions were related to the passenger’s definition of “Economy Class Team” or “Travelers Thrombosis”. Economy Class Syndrome (ECS) turned out to be a term unknown to almost 90.7% of respondents and the Travelers Thrombosis” for 72.5%. Conclusions: Despite of easy access to the internet and magazines knowledge of the travellers remains low when it comes to the connection between deep vein thrombosis morbidity and a flight, similarly in terms of prevention and risk factors. It is essential to take up large scale and systemic actions which could possibly enhance the awareness of minimalising the risk of DVT.

KOMPLEKSOWA INTERAKTYWNA DOKUMENTACJA ŻYLNA Piotr Hawro1, Mariusz Kucewicz2, Krzysztof Makarski3 Europejskie Centrum Flebologii, Katowice, Polska SABIOS, Bytom, Polska 3 SHAR-POL, Gliwice, Polska 1 2

Prezentacja przedstawia system informatyczny dla flebologów, zawierający większość aspektów przewlekłej choroby żylnej i wspomagający pracę lekarza. Na podstawie danych z wywiadu lekasrskiego, badania przedmiotowego oraz badania ultrasonograficznego system automatycznie generuje opisy oraz wylicza wskaźniki i skale BMI, VAS, CIVIQ-20, VCSS, CEAP oraz Villalta-Prandoniego. Dedykowana aplikacja zintegrowana z aparatem fotograficznym umożliwia wykonanie zdjęć pacjenta oraz ich archiwizację, porównywanie i możliwość udostępnienia w celu dalszej diagnostyki. Opisywanie badania ultrasonograficznego żył kończyn dolnych wspomagane jest, oprócz automatycznego generowania opisu, graficzną wizualizacją układu żylnego. System poprzez bezprzewodową łączność z aparatem ultrasonograficznym zapewnia możliwość rejestracji w bazie danych filmów USG. Zapewniono możliwość wyboru szablonów raportów oraz edycji tekstu na podglądzie wydruku raportu. Wszystkie dane gromadzone są w bezpiecznym archiwum badań. System jest aktualizowany, uwzględniane są w szczególności zmiany zachodzące w wyniku rozwoju nauki i poglądów na przewlekłą chorobę żylną.

COMPLEX INTERACTIVE VEIN DOCUMENTATION Piotr Hawro1, Mariusz Kucewicz2, Krzysztof Makarski3 European Centre of Phlebology, Katowice, Poland SABIOS, Bytom, Polska 3 SHAR-POL, Gliwice, Polska 1

in a secured archive of the visits. The system is constantly updated, in particular with changes coming from the development of science and views on chronic venous disease.

ZASTOSOWANIE KLEJU CJANOAKRYLOWEGO W LECZENIU NIEWYDOLNOŚCI ŻYŁY ODPISZCZELOWEJ METODĄ WEWNĄTRZNACZYNIOWĄ JEDNOCEWNIKOWĄ – 4-LETNIA OBSERWACJA PACJENTÓW Andrzej Eberhardt1,2, Magdalena Potembska-Eberhardt1, Włodzimierz Hendiger2 Femmed, Prywatna Klinika Medycyny Estetycznej i Flebologii, Warszawa, Polska Oddział Chirurgii Naczyniowej i Ogólnej, Szpital MSWiA, Łódź, Polska

1 2

Cel pracy: Przedstawienie wyników stosowania kleju N-butylo-2-cyjanoakrylowego (systemu VenaBlock i Venex Sealing) do leczenia pacjentów z przewlekłą choroba żylną związaną z niewydolnością żyły odpiszczelowej. Zabieg ablacji wenątrznaczyniowej jednocewnikowej niewydolnej żyły odpiszczelowej klejem cjanoakrylowym (N-butylo-2-cjanoakrylowym) jest uważny za mniej inwazyjny od zabiegów termoablacyjnych. Jako zaletę zabiegów z użyciem klejów tkankowych cjanoakrylowych należy wymienić: natychmiastowe i trwałe zamknięcie żyły, brak objawów ubocznych podczas regresji zamkniętej żyły, do zabiegu nie jest wymagane znieczulenie tumescencyjne. Materiał i metody: Badaniu poddano 153 pacjentów (110 kobiet, 43 mężczyzn, wiek 37–72 lata), średnica żyły odpiszczelowej (VSM) od 5 do 17 mm (średnio 7,8 mm), niewydolność żylna od C2 do C5 (klasyfikacja CEAP), niewydolność VSM określano na podstawie refluksu trwającego dłużej niż 0,5 sek. Używany system do ablacji składał się z pistoletu aplikacyjnego, cewnika aplikacyjnego PTFE i 2 ml kleju cjanoakrylowego N-butylo-2-cjanoakrylowego. U wszystkich pacjentów zastosowano ablację wewnątrzżylną. Każdy chory otrzymywał po zabiegu przez 5 dni heparynę drobnocząsteczkową w dawce profilaktycznej. Po zabiegu nie stosowano kompresjoterapii. Prowadzono 4-letnią obserwację kliniczną z użyciem badania ultrasonograficznego Duplex-Doppler żył w 1., 3., 6., 12., 18., 24., 36. i 48. miesiącu po zabiegu u każdego pacjenta. Wyniki: Zabieg ablacji wykonano w naczyniu na średniej długości 27,3 ±4,2 cm, średnia podana objętość N-butylo-2-cjanoakrylu 1,4 ±0,6 ml, średni czas zabiegu 8,7 ±3,4 min. Współczynnik powodzenia zabiegu 92,1%, całkowite zamknięcie leczonej żyły w 1. miesiącu u 141/153 pacjentów. Całkowity wskaźnik bez nawrotów klinicznych po 4-letniej obserwacji wyniósł 89,28% u pacjentów z VSM o średnicy 5–10 mm i 71,34% u pacjentów z VSM o średnicy 10–17 mm. Wnioski: Klej N-Butylo-2-cyjanoakrylowy podawany pistoletem przez cewnik PTFE w celu wykonania ablacji wewnatrzżylnej wydaje się skuteczną i bezpieczną metodą leczenia niewydolności żyły odpiszczelowej. Należy rozważyć ograniczenia w zastosowaniu metody ablacji klejem niewydolnej żyły odpiszczelowej u pacjentów ze średnicą VSM powyżej 10 mm.

2

The lecture presents an IT system designed for phlebologists. System covers most aspects of chronic venous disease and supports the work of the phlebologist. Based on the data entered by the physician during the interview, physical examination and ultrasound examination, the system automatically generates the descriptions and calculates indicators and scales, such as: BMI, VAS, CIVIQ-20, VCSS, CEAP and Villalts-Prandoni. A dedicated application integrated with the camera, allows taking pictures of the patient and archiving, comparison and sharing them for further diagnostics. In addition to the automatic generation of the description, describing the ultrasound examination of the veins of the lower extremities is supported by graphic visualization of the venous system. The system enables the recording of ultrasound films in the database, through the wireless connection with the ultrasound unit. It is possible to select report templates and edit the texts in the report print preview. All data is stored

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N-BUTYL-2-CYANOACRYLATE GLUE ABLATION FOR THE GREAT SAPHENOUS VEIN INSUFFICIENCY TREATMENT AS A SINGLE-CATHETER PROCEDURE – FOUR -YEARS FOLLOW-UP Andrzej Eberhardt1,2, Magdalena Potembska-Eberhardt1, Włodzimierz Hendiger2 Femmed, Dr Potembska-Eberhardt – Private Clinic of Aesthetic Medicine and Phlebology, Warsaw, Poland 2 Department of Vascular and General Surgery, Clinical Hospital of the Ministry of Internal Affairs, Lodz, Poland 1

Objectives: N-butyl-2-cyanoacrylate glue ablation as a single-catheter procedure for the great saphenous vein (GSV) insufficiency treatment is discussed as being superior to termo-occlusive method in term of its lower invasiveness. The main advantages of this treatment modality are: immediate and permanent immediate and permanent vein clo-

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ORIGINAL PAPER PRESENTATION ABSTRACTS

sure, no side symptoms during the vein regression, no tumescent anesthesia is required for the procedure. Aim of the study: To present the results of the use of N-butyl-2-cyanoacrylate glue [VenaBlock and Venex Sealing system] for the treatment of patients with insufficiency of the Great Saphenous Vein and subsequent varicoses of the lower limbs. Material and methods: The study was performed in the group of 153 patients (110 women, 43 men; 37–72 years old). The diameters of GSV ranged from 5 to 17 mm (mean 7.8 mm). Chronic venous disease advancement ranges from C2 to C5 (CEAP classification). GSV reflux lasting longer than 0.5 s in each patient. Sealing system including delivery gun, PTFE application catheter and 2 ml of N-butyl-2 cyanoacrylate glue – non tumescent endovenous ablation was used in all of the patients. LMWH in prophylaxis doses (subcutaneously) was given for 5 days following the procedure. No external compression device used after the treatment. Two-years clinical follow-up was performed. Duplex-Doppler ultrasound imaging assessments of the veins of the treated limbs were performed in the 1st, 3rd, 6th, 9th, 12th, 18th and 24th month after procedure in every patient. Results: Mean length of the ablation was 27.3 ±4.2 cm and average volume of n-butyl-2 dose delivered was 1.4 ±0.6 ml; mean procedure time was 8.7 ±3.4 min. Procedural success ratio – in 92.1% complete occlusion of the treated vein was achieved during the first month (141/153 pts.). Overall clinical recurrence-free rate after four-years follow-up was 89.28% in patient with GSV diameter 5–10 mm and 71.34% in patient with VSM diameter 10–17 mm. Conclusions: N-butyl-2-cyanoacrylate glue applicate by delivery gun thru PTFE catheter – non tumescent endovenous ablation, appears to be efficient and safe procedure for the treatment of the GSV incompetence. It should be considered to respect restrictions of the diameter of the incompetent GSV treated.

OCENA MIKROBIOLOGICZNA OWRZODZEŃ KOŃCZYN DOLNYCH – JEDNOOŚRODKOWE BADANIE PRZEKROJOWE Justyna Cwajda-Białasik , Paulina Mościcka , Arkadiusz Jawień , Maria T. Szewczyk1,2 1,2

1,2

3

Katedra Pielęgniarstwa Zabiegowego, Collegium Medicum w Bydgoszczy, Uniwersytet Mikołaja Kopernika w Toruniu, Polska 2 Poradnia Leczenia Ran Przewlekłych, Szpital Uniwersytecki nr 1 im. dr. A. Jurasza w Bydgoszczy, Polska 3 Katedra Chirurgii Naczyniowej i Angiologii, Collegium Medicum w Bydgoszczy, Uniwersytet Mikołaja Kopernika w Toruniu, Polska 1

Cel pracy: Ocena mikrobiologiczna owrzodzeń żylnych kończyn dolnych oraz identyfikacja klinicznych i demograficznych czynników prognostycznych owrzodzeń z dodatnim wynikiem posiewu. Materiał i metody: Jednoośrodkowe badanie przekrojowe obejmowało 754 pacjentów z owrzodzeniem żylnym. Materiał do analizy mikrobiologicznej w postaci wymazu pobrano od pacjentów z przewlekłym owrzodzeniem, którzy nie stosowali antybiotykoterapii. Wyniki: Ogółem u 636 (84,3%) pacjentów uzyskano dodatni wynik posiewu, w tym patogeny alarmowe, głównie Pseudomonas aeruginosa (28,6%). W modelu regresji logistycznej owrzodzenia z dodatnim wynikiem posiewu były prognozowane niezależnie na podstawie wieku > 65 lat, czasu trwania owrzodzenia > 12 miesięcy i obszaru owrzodzenia większego niż 8,25 cm2. Dwa z tych czynników, czas trwania obecnego owrzodzenia > 12 miesięcy i obszar owrzodzenia > 8,25 cm2, zostały zidentyfikowane jako niezależne czynniki prognostyczne kolonizacji patogenami alarmowymi. Wnioski: Większość owrzodzeń żylnych podudzi jest kolonizowana przez drobnoustroje, ale tylko niewielka część przez patogeny alarmowe, które są najczęstszą przyczyną jawnej klinicznie infekcji.

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ANALYSIS OF THE BACTERIAL MICROFLORA OF VENOUS LEG ULCERS – SINGLE CENTER CROSS-SECTIONAL STUDY OF 754 PATIENTS Justyna Cwajda-Białasik1,2, Paulina Mościcka1,2, Arkadiusz Jawień3, Maria T. Szewczyk1,2 Department of Perioperative Nursing, Department of Surgical Nursing and Chronic Wound Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland 2 Chronic Wound Care Outpatient Department, University Hospital no.1, Bydgoszcz, Poland 3 Department of Vascular Surgery and Angiology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland 1

Objectives: The aim of the study was to evaluate the microbiological evaluation of venous leg ulcers and to identify the clinical and demographic prognostic factors of ulceration with positive culture results. Material and methods: This single-center, cross-sectional study included 754 patients with venous ulceration. We evaluated bacteria from a deep swab from patients with venous ulcers who were not receiving antibiotic therapy. Results: A total of 636 (84.3%) patients were culture positive, including alarm pathogens, mainly Pseudomonas aeruginosa (28.6%). In the logistic regression model, culture-positive ulcers were independently predicted based on age > 65 years, current ulcer duration > 12 months, and ulcer area greater than 8.25 cm2. Two of these factors, the duration of the current ulcer > 12 months and the area of the ulcer > 8.25 cm2, were also identified as independent prognostic factors for colonization with alarm pathogens. Conclusions: Most venous leg ulcers are colonized by microorganisms; but only a small part by the alarm pathogens which are the most common cause of clinically overt infection.

WPŁYW LICZBY CIĄŻ I PORODÓW NA WYBRANE PARAMETRY MORFOLOGICZNE I HEMODYNAMICZNE W UKŁADZIE ŻYLNYM JAMY BRZUSZNEJ I MIEDNICY MAŁEJ Cezary Szary, Justyna Wilczko, Dominika Plucińska, Anna Pachuta, Marcin Napierała, Anna Bodziony, Michał Zawadzki, Tomasz Grzela Klinika Flebologii, Warszawa, Polska Cel pracy: Ciąża jest jednym z powszechnie uznanych czynników warunkujących występowanie przewlekłej choroby żylnej, jednak rola stanu brzemiennego wciąż pozostaje niejasna. Liczne obserwacje wskazują, że ciąża, zwłaszcza w ostatnim trymestrze, powoduje istotne zaburzenia hemodynamiczne i w efekcie przeciążenie układu żylnego. Ich wynikiem jest poszerzenie pojemnościowych żył miednicy, które u znacznej części pacjentek może utrzymywać się również po porodzie i przy każdej kolejnej ciąży nasila się. Ponieważ dane w tym zakresie są niejednoznaczne, celem pracy było określenie zależności pomiędzy liczbą ciąż i ich wpływem na wybrane parametry układu żylnego. Materiał i metody: Analizą retrospektywną objęto dane 518 pacjentek z objawami niewydolności żylnej kończyn dolnych konsultowanych w Klinice Flebologii w latach 2017–2019, u których po wykonaniu badania USG Doppler podejrzewano niewydolność żylną miednicy. Dane uzyskane w ramach rozszerzonej diagnostyki obrazowej układu żylnego miednicy i jamy brzusznej – wenografii w rezonansie magnetycznym lub tomografii komputerowej, poddano analizie w kontekście liczby ciąż i porodów. Wyniki: Częstość występowania objawów klinicznych niewydolności żylnej miednicy była proporcjonalna do liczby ciąż donoszonych/ porodów. Ból w podbrzuszu zgłaszało 13,5% kobiet nierodzących i 22,8% kobiet po co najmniej jednej ciąży. Zaobserwowano wyraźną korelację pomiędzy liczbą ciąż i stopniem poszerzenia żył jajnikowych i splotów żylnych przymacicz. Refluks w żyle jajnikowej lewej stwierdzano u 21,4% kobiet nierodzących oraz u 90,6% po ciążach. Stwierdzono, że występowanie niewydolności żylnej w grupie nieródek uwa-

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ORIGINAL PAPER PRESENTATION ABSTRACTS

runkowane było głównie zmianami anatomicznymi w budowie układu żylnego miednicy i jamy brzusznej. Wnioski: Ciąża donoszona jest istotnym czynnikiem ryzyka rozwoju niewydolności żylnej miednicy. Wydaje się również mieć związek z powstawaniem niewydolności żylnej kończyn dolnych. Jednak ustalenie dokładnego mechanizmu tego zjawiska wymaga dalszych badań prospektywnych.

THE NUMBER OF PREGNANCIES AND DELIVERIES AND THEIR ASSOCIATION WITH SELECTED MORPHOLOGICAL AND HEMODYNAMIC PARAMETERS OF THE PELVIC AND ABDOMINAL VENOUS SYSTEM Cezary Szary, Justyna Wilczko, Dominika Plucińska, Anna Pachuta, Marcin Napierała, Anna Bodziony, Michał Zawadzki, Tomasz Grzela Phlebology Department, Warszawa, Poland Objectives: Although pregnancy has been identified as one of the risk factors for venous disease, the mechanism of this interaction remains unclear. Possibly, pregnancy results in overstrain and vein dilatation, which exceed their durability and persist after pregnancy. The aim of this study was the assessment of the relationship between the number of pregnancies in women with venous disease and the selected parameters of their venous systems. Material and methods: The retrospective assessment concerned 518 patients subjected to the diagnostics of the venous system in the lower limbs and the abdomen/pelvis using ultrasound scan and magnetic resonance or computed tomography. Results: We found that the occurrence of pelvic venous symptoms increases proportionally to the number of pregnancies and is correlated with ovarian and parauterine vein dilatation/incompetence (e.g., 13.5% of nulliparous women reported pelvic pain, and reflux in left ovarian veins was detected in 21.4% of the patients from that group, whereas in women after two pregnancies, pain and reflux concerned 22.8% and 90.6% of patients, respectively). In the nulliparous group, the development of venous disease resulted from the presence of anatomic abnormalities in abdominal/pelvic veins. Conclusions: Our report proved that the number of pregnancies is correlated with the incidence of pelvic vein insufficiency. Although not specifically addressed in this study, some correlation was found with saphenous disease as well. However, further studies are necessary to provide more evidence about the role of pelvic vein insufficiency in chronic venous disease of the lower limbs.

MOŻLIWOŚCI ZASTOSOWANIA KLEJU CYJANOAKRYLOWEGO DO ZAMYKANIA NIEWYDOLNYCH ŻYŁ PRZESZYWAJĄCYCH – DONIESIENIE WSTĘPNE Joanna Borecka-Sobczak1, Marek Maruszyński2 Poradnia Flebologiczna, Gdańsk, Polska Medical Esthetic, Warszawa, Polska

1 2

Cel pracy: Ocena możliwości wykorzystania kleju cyjanoakrylowego do zamykania niewydolnych żył przeszywających goleni. Materiał i metody: W latach 2019–2021 wykonano zamknięcie klejem cyjanoakrylowym niewydolnych żył przeszywających goleni (NŻPG) u 50 chorych. Do zabiegu zakwalifikowano chorych z żyłami przeszywającymi, których niewydolność rozpoznano badaniem USG Doppler w pozycji stojącej. Kryteriami rozpoznania ich niewydolności zgodnie z wytycznymi SVS/AVF były średnica żyły przeszywającej powyżej 3,5 mm i czas trwania przepływu wstecznego (refluksu) wynoszący ponad 0,5 sek. W analizowanym materiale NŻPG rozpoznano: niewydolne perforatory piszczelowe tylne (Cocketta) – 21 (42%): C-1 (3), C-2 (9), C-3 (9); niewydolne perforatory przypiszczelowe – 18 (36%): Boyda (11), Shermana (7); boczne goleni – 5 (10%) i tylne goleni (Maya – międzybrzuścowe) – 6 (12%). U 33 chorych (66%) NPŻG występowały na jednej kończynie dolnej. U 11 chorych (22%) – był to jedyny objaw przewlekłej niewydolności żylnej.

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Wykonanie zabiegu. Po uprzednim ultrasonograficznym oznaczeniu NŻPG – w pozycji leżącej pod kontrolą USG – nakłuwano NŻPG przezskórnie bezpośrednio tuż nad powięzią. Po jednoznacznym uwidocznieniu położenia końcówki igły 045 G (długości 16 mm lub 23 mm) w NPŻG podawano (bez aspiracji!) 0,2 ml kleju cyjanoakrylowego – preparat Venex firmy VESTA. Miejsce wkłucia natychmiast uciskano przez 3 minuty bezpośrednio sondą USG. Opatrunek jałowy, nie stosowano kompresjoterapii. Kliniczne i ultrasonograficzne badania kontrolne przeprowadzano po 2 tygodniach i 2 miesiącach. Niewielkie miejscowe skutki uboczne w postaci uczucia pieczenia tuż po podaniu kleju zgłaszało 40% chorych. Objawy te znikały w trakcie ucisku sondą (u jednego chorego utrzymywały się ponad godzinę), 28% chorych podczas wizyty kontrolnej po 2 tygodniach zgłaszało niebolesne uczucie ciągnięcia w miejscu zabiegu. Każdy z leczonych podpisywał świadomą zgodę na zabieg i miał przedstawione inne metody leczenia. Wyniki: U 43 chorych (86%) z NPŻG uzyskano zamknięcie pełne w stopniu dobrym. U 7 chorych (14%) z NPŻG zwężenie bez refluksu oceniono jako zadowalające. Nie stwierdzono, aby zamknięte po 2 tygodniach NPŻG ulegały po 2 miesiącach ponownej rekanalizacji. Odnotowano niewielkie miejscowe objawy uboczne podczas ucisku. Wnioski: Wykorzystanie kleju cyjanoakrylowego do zamykania niewydolnych żył przeszywających goleni ma charakter małoinwazyjny, jest postępowaniem skutecznym, bezpiecznym, łatwym do manualnego opanowania i możliwym do wykonania w ambulatorium. Istotnym warunkiem jest właściwa kwalifikacja do zabiegu, przestrzeganie zalecanych przez producenta procedur oraz umiejętność korzystania z możliwości ultrasonografii. Konieczne są dalsze badania porównawcze, większa liczba leczonych i dłuższy czas pozabiegowej obserwacji.

THE APPLICABILITY OF CYANOACRYLATE ADHESIVE FOR EMBOLIZATION OF INCOMPETENT PERFORATING VEINS – PRELIMINARY REPORT Joanna Borecka-Sobczak1, Marek Maruszyński2 Phlebology Outpatient Department, Gdańsk, Poland Medical Esthetic, Warszawa, Poland

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Objektives: The evaluation of the applicability of cyanoacrylate adhesive for the embolization of incompetent perforating veins of the calf. Material and methods: Between 2019 and 2021, cyanoacrylate adhesive embolization of incompetent perforating veins of calf was performed in 50 patients. All patients qualified for treatment were diagnosed with incompetent perforators confirmed with Doppler ultrasound tests performed in a standing position. Diagnosis criteria, in accordance with the SVS/AVF guidelines, included: the diameter of the perforating vein greater that 3.5 mm and reflux greater than 0.5 sec. The analysed perforating veins included: incompetent posterior tibial perforating veins (Cockett’s perforators) – 21 (42%): C-1 (3), C-2 (9), C-3 (9), incompetent paratibial perforating veins – 18 (36%): Boyd’s perforators (11) and Sherman’s perforators (7), lateral tibial perforating veins – 5 (10%) and posterior tibial (intergemellar perforating veins – May’s perforator) – 6 (12%). In 33 patients (66%), incompetent perforating veins were observed in one leg only. In 11 patients (22%) it was the only symptom of chronic venous insufficiency. Procedure. Preoperative USG marking of incompetent perforating veins was carried out. The entire procedure was ultrasound-guided and performed in a lying position. Incompetent perforators were punctured percutaneously directly over the fascia. When the location of the needle tip (045G; 16 mm or 23 mm in length) was accurately identified, 0.2 ml of cyanoacrylic glue was injected (without aspiration!) into the incompetent perforating vein. The agent used was Venex developed by Vesta Medical. The injection site was immediately pressed down with an ultrasound probe for 3 minutes. Sterile dressing, no compression therapy. Clinical and ultrasound examination was performed after 2 weeks and then after 2 months. 40% of patients reported minor side effects, such as a burning sensation directly after glue administration, which disappeared when pressed with a USG probe. One patient experienced a burning sensation for over an hour. During a follow-up visit after 2 weeks, 28% of patients reported painless pulling at the site of treatment.

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ORIGINAL PAPER PRESENTATION ABSTRACTS

Every patient signed an informed consent for treatment and was comprehensively informed about alternative treatment methods. Results: Complete closure – rated as a good effect – obtained in 43 patients (86%) with incompetent perforating veins. Narrowing without reflux – rated as a satisfactory effect – obtained in 7 patients (14%) with incompetent perforating veins. Both follow-up visits showed that ones the incompetent perforators were closed, no recanalization occurred. Only minor topical side effects were noted during pressure. Conclusions: Cyanoacrylate adhesive embolization in the treatment of incompetent perforating veins of calf is a minimally invasive, effective and safe procedure. What is more, it can be easily mastered and performed on an outpatient basis. For embolization to be successful, three conditions must be addressed: proper qualification for treatment, compliance with the procedures recommended by the manufacturer and skilled use of ultrasonography. It is necessary to carry out further comparative studies of other embolization techniques. It is also necessary to analyse more cases and extend the duration of postoperative observation.

79%

51% 39%

AE 0.50%

AE 1%

AE 2%

25%

AE 3%

23%

20% 15%

Zbigniew Rybak

14%

15%

AE 1%

AE 2%

9%

10%

ARS MEDICA, Wrocław, Polska Rybak-Clinics, Wrocław, Polska Zakład Chirurgii Eksperymentalnej i Badania Biomateriałów, Uniwersytet Medyczny im. Piastów Śląskich we Wrocławiu, Polska

5%

0

AE 0.50%

AE 3%

Ryc. 3. Porównanie sprzedaży w 2019 r. i 2016 r. (wzrost sprzedaży w % w roku 2019 w stosunku do sprzedaży w roku 2016 – oś X) Wyniki: Znakomita większość chorych uzyskała dobry i bardzo dobry efekt zastosowanej terapii. W początkowym okresie miałem 4 przypadki martwicy skóry, co skutkowało dodatkowym leczeniem trwającym ponad 6 tygodni. Znakomita większość pacjentów wymagała wielokrotnych sesji leczniczych. W latach 1996–2021 przeprowadziłem liczne szkolenia, w których uczestniczyło 1154 lekarzy: w szkoleniu z zakresu skleroterapii żylaków kończyn dolnych – 956 lekarzy, skleroterapii guzków krwawniczych – 151 lekarzy, w kursach organizowanych przez Akademię Flebologii – 47 lekarzy. Prowadzone szkolenia przyczyniały się do rozwoju flebologii w całym kraju, co odzwierciedla dynamika sprzedaży leku przez firmę MAGA-BIOTAL. Wnioski: Aethoksysklerol w stężeniach od 0,5% do 3% stosowany zarówno w płynie, jak i w formie piany jest skutecznym i rekomendowanym w licznych zaleceniach światowych towarzystw naukowych produktem do leczenia chorób żył o różnym nasileniu.

7000

SCLEROTHERAPY IN POLAND – THIRTY YEARS EXPERIENCE IN USE OF LAUROMACROGOL PRODUCED BY KREUSSLER-PHARMA COMPANY AND DEVELOPMENT OF METHOD IN COUNTRY OVER THE YEARS

6000

Zbigniew Rybak

8000

ARS MEDICA, Wrocław, Poland Rybak-Clinics, Wrocław, Poland Department for Experimental Surgery and Biomaterials Research Wrocław Medical University, Wroclaw, Poland

5000 4000 3000 2000 1000

76%

Ryc. 2. Porównanie sprzedaży w 2015 r. i 2011 r. (wzrost sprzedaży w % w roku 2015 w stosunku do sprzedaży w roku 2011 – oś X)

SKLEROTERAPIA W POLSCE – TRZYDZIEŚCI LAT DOŚWIADCZEŃ W STOSOWANIU LAUROMAKROGOLU FIRMY KREUSSLER-PHARMA ORAZ ROZWÓJ METODY W KRAJU NA PRZESTRZENI LAT

Cel pracy: Podzielenie się wieloletnim doświadczeniem w stosowaniu leku niemieckiej firmy Kreussler-Pharma do obliteracji żył, guzków krwawniczych odbytu, torbieli dołu podkolanowego, malformacji naczyniowych o nazwie lauromakrogol (polidokanol, aethoxysklerol). Polska firma MAGA-BIOTAL założona i kierowana przez mgr. inż. Mariana Nowakowskiego jako pierwsza w Polsce uzyskała wyłączność na sprowadzanie i sprzedaż leku stosowanego w leczeniu choroby żylnej i przewlekłej niewydolności żylnej o nazwie Aethoxysklerol. 9 kwietnia 2002 r. wydano pozwolenie na dopuszczenie do obrotu na rynku polskim czterech stężeń leku Aethoksysklerol 0,5%, 1%, 2% i 3%. W 2020 r. otrzymano rekomendację pozwalającą na stosowanie spienionego sklerozantu. Materiał i metody: W okresie 30 lat wykonałem skleroterapię żył zarówno ze wskazań życiowych, leczniczych oraz estetycznych u tysięcy chorych. Wiek pacjentów wahał się od 11 do 98 lat. W skali CEAP leczyłem całe spektrum niewydolności żylnej od wenulektazji do owrzodzeń żylnych. W pierwszym okresie stosowałem sklerozant płynny, a od około 10 lat stosuję również sklerozant spieniony. U ponad 90% chorych stosowałem komplementarną kompresjoterapię w skali od profilaktycznej do III stopnia ucisku. Oprócz leczenia zajmowałem się również szkoleniem lekarzy różnych specjalności w dziedzinie skleroterapii.

90% 80% 70% 60% 50% 40% 30% 20% 10% 0

0

1996 1997 2002 2003 2004 2005 2006 2007 2008 2009 2010 0,50% 1% 2% 3%

Ryc. 1. Dynamika sprzedaży aetoxysclerolu

Phlebological Review 2021

Objectives: Polish Company MAGA-BIOTAL founded and managed up today by mgr. eng. Marian Nowakowski as a first in Poland achieved by using exclusive distribution and purchasing of drug Aethoxysclerol used for treatment venous disease, chronic venous disease. Nine of April 2002 license was issued on four concentrations of drug: 0.5%, 1%, 2% and 3%. In 2020 was issued recommendation for use Aethoxysclerol in a form of foam.

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ORIGINAL PAPER PRESENTATION ABSTRACTS

1996–2021 I performed numbers hands on workshops in sclerotherapy. Varicose sclerotherapy of the lower limbs: 956 physicians. Sclerotherapy of hemorrhoids: 151 physicians. Workshops organized by Academy of Phlebology: 47 physicians. Total number: 1154 physicians have been trained. Targeting training contributed to development of phlebology in our country which is reflected sales dynamic of the drug by MAGA-BIOTAL. Conclusions: Aethoxysclerol in concentrations from 0.5% to 3% used either in liquid or foam form is effective and safe medical product. Many international societies reccommended this drug for treatment of different kinds of venous problems.

8000 7000 6000 5000 4000 3000 2000 1000 0

1996 1997 2002 2003 2004 2005 2006 2007 2008 2009 2010 0.50% 1% 2% 3%

Fig. 1. Sales dynamic of different concentrations of the drug I would like to share my own experience in use of drug lauromacrogol ( aethoxysclerol, polidocanol ) for obliteration of diseased veins, hemorrhoids, popliteal cysts, venous malformations. Material and methods: In a period of thirty years I have performed sclerotherapy of veins either for life threatening, curative or aesthetic indications in thousands of patients. The age of patients randged from 11 to 98 years. Concerning CEAP class – I treated all spectrum of venous problems from venulectases up to venous ulcers. In initial period I used liquid form of sclerosant. From about ten years I use also foam form preparing it according to Tessari method. In over 90% of patients I used compression therapy as a supplementary procedure in the class from prophylactic to III degree of compression. In addition to therapy I was involved in teaching physicians of different specialties in the field of sclerotherapy. Results: Vast majority of patients achieved well or very well result of treatment. In an initial period of my practice I have had four cases of skin necrosis what resulted in additional treatment lasted over six weeks. Majority of treated patients required multi injection sessions. In a years

90% 80% 70% 60% 50% 40% 30% 20% 10% 0

76%

79%

51% 39%

AE 0.50%

AE 1%

AE 2%

AE 3%

Fig. 2. Aethoxysclerol sales dynamic 2015 vs. 2011 (the sale increase in % from 2011 to 2015)

25%

23%

20% 15% 10%

14%

15%

AE 1%

AE 2%

9%

5% 0

AE 0.50%

POLSKI LASER 1940 – 2 LATA DOŚWIADCZEŃ W LECZENIU SCHORZEŃ ŻYŁ. OCENA SKUTECZNOŚCI, BEZPIECZEŃSTWA I ZADOWOLENIA PACJENTÓW Zbigniew Rybak ARS MEDICA, Wrocław, Polska Rybak-Clinics, Wrocław, Polska Zakład Chirurgii Eksperymentalnej i Badania Biomateriałów, Uniwersytet Medyczny im. Piastów Śląskich we Wrocławiu, Polska Cel pracy: Ocena skuteczności, bezpieczeństwa i zadowolenia pacjentów po leczeniu niewydolnych pni żył powierzchownych kończyn dolnych polskim laserem o długości fali 1940 nm. Metrum Cryoflex, marka polskiego producenta, była rozpoznawalna w latach 1996–2010 pod nazwą METRUM-KRIO. Cryoflex jest liderem w opracowaniu i wdrożeniu aparatu AK1/Cryo-S oraz sond do kriostripingu i kriominiflebektomii. W latach 2014–2020 firma opracowała i wprowadziła na rynek pierwsze polskie diodowe lasery flebologiczne: 940 nm do przezskórnego leczenia telangiektazji oraz 1470 nm do przezskórnej wewnątrzżylnej obliteracji. W 2019 r. Metrum Cryoflex opracowało i wprowadziło na rynek światowy pierwszy laser diodowy Twist o długości fali 1940 nm. Do chwili obecnej sprzedano ponad 350 tego typu laserów, skonstruowanych i wyprodukowanych w Polsce. Głównymi odbiorcami są kliniki flebologiczne i proktologiczne w Polsce, na Litwie, w Wielkiej Brytanii, Turcji, Grecji, Zjednoczonych Emiratach Arabskich, Kuwejcie, Iranie i Meksyku. Materiał i metody: W dwóch ośrodkach ARS MEDICA oraz Rybak-Clinics we Wrocławiu było leczonych 147 chorych (67 w klasie C2, 41 – C3, 27 – C4a, 12 – C6). Do terapii wykorzystano polski laser diodowy o długości fali 1940 nm produkcji Metrum-Cryflex. Zabiegi wykonywano w znieczuleniu tumescencyjnym, stosując moc od 4 do 6 Wat oraz energię od 40 do 50 J/cm i włókno radialne jednopierścieniowe. U wszystkich pacjentów stosowano bezpośrednio po zabiegu wyroby uciskowe o II klasie kompresji. Oceniano skalę bólu w trakcie zabiegu, po zabiegu (10-stopniowa skala analogowa), efekty uboczne (przebarwienia, oparzenia skóry, krwiaki, zasinienia), zadowolenie pacjenta z efektu zabiegu (bardzo zadowolony, zadowolony, średnio zadowolony, niezadowolony). Czas obserwacji wynosił od 2 do 24 miesięcy. Wyniki: Skuteczność w zamknięciu leczonej żyły w badanym okresie wyniosła 100%. Nie odnotowano żadnego incydentu, który wymagałby przerwania zabiegu. Z efektów ubocznych odnotowano zasinienia związane z tumescencją u 11 chorych, stwardnienia w dużych zamkniętych żylakach wymagające trombektomii a spowodowane komplementarną skleroterapią u 43 chorych. Ból w trakcie zabiegu o nasileniu 3 punktów odnotowano u 21 chorych, tylko 11 chorych stosowało okazjonalnie leki przeciwbólowe w pierwszym tygodniu po zabiegu, 112 (76,19%) chorych było bardzo zadowolonych z wyniku leczenia. Reszta pacjentów oceniła stopień swojej satysfakcji jako zadowolony/a. U 12 chorych z aktywnym owrzodzeniem doszło do całkowitego wygojenia rany. Wnioski: Zamykanie niewydolnych żył powierzchownych polskim laserem diodowym Twist o długości fali 1940 nm z włóknem radialnym jest procedurą skuteczną, bezpieczną, praktycznie bezbolesną zarówno w trakcie leczenia, jak i w pierwszym tygodniu po leczeniu.

AE 3%

Fig. 3. Aethoxysclerol sales dynamic 2019 vs. 2016 (the sale increase in % from 2016 to 2019)

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Phlebological Review 2021


ORIGINAL PAPER PRESENTATION ABSTRACTS

POLISH LASER 1940 NM – TWO YEARS OF EXPERIENCE IN THE TREATMENT OF VENOUS DISEASES. ASSESSMENT OF EFFECTIVENES, SAFTY AND SATISFACTION OF PATIENTS Zbigniew Rybak ARS MEDICA, Wrocław, Poland Rybak-Clinics, Wrocław, Poland Department for Experimental Surgery and Biomaterials Research Wrocław Medical University, Wroclaw, Poland Objectives: Metrum Cryflex the brand of polish producer was recognized in the years 1996–2010 as a METRUM-CRIO, Cryoflex as a leader in creating and implementing AK1/Cryo-S apparatus and devices for cryostripping and cryominiphlebectomy of insufficient veins. In the years 2014–2020 company create and introduced on the market first polish diode lasers for phlebology : 940 nm intradermal laser for treatment of telangiectasie and 1470 nm laser for endovenous procedures. In 2019 Metrum Cryoflex create and introduced on the market worldwide first diode laser “TWIST” 1940 nm. Up to now company sailed over 350 lasers. Main customers are clinics dealing with phlebology and proctology in Poland, Lithuania, UK, Turkey, Greece, Arab Emirates, Kuwait, Iran and Mexico. The aim of the study was assessment of effectiveness, safety and satisfaction of patients following treatment insufficient superficial trunks of the veins in the lower legs with polish laser 1940 nm. Material and methods: 147 patients (67 in class C2, 41 – C3, 27 – C4a, 12 – C6) were treated in two medical centers ARS MEDICA and Rybak-Clinis in Wrocław. Treatment was performed with polish laser 1940 nm. Produced by Metrum-Cryoflex. Procedures were performed in local anesthesia with tumescencet analgesia. During procedure we used laser power form 4 to 6 W and energy from 40 to 50J/cm, one ring radial fiber. All patients had compression immediately following procedure with second class compression stockings. After ablation the following parameters were assessed: pain (during and after procedure – 10 points analog scale ), side effects (discoloration of the skin, burns, hematomas, bruising), patient satisfaction (very satisfy, satisfy, more – less, unsatisfy). Follow up period lasted from 2 to 24 months. Results: All treated veins were occluded in studied period – 100% efficacy. There have not been recorded any incident for interruption of the procedure. Among the procedure adverse events, only bruising related to tumescent analgesia was reported – 11 patients. Indurations along the obliterated varices due to sclerotherapy as a supplementary procedure were observed in 43 patients. Pain during procedure of an intensity of 3 points was noticed in 21 patients. Only 11 patients have taken pain killer pills occasionally in the first week following procedure. 112 (76.19% ) of patients were very satisfy after treatment, the rest was satisfy. In 12 patients with active ulcer a total healing was achieved. Conclusions: Ablation of insufficient superficial veins of the lower legs with polish diode laser “TWIST” 1940 nm, radial fiber is a safe, efficient procedure, almost painless either during or one week following procedure. 1940 nm laser ablation with the use of axial optical fibre as an effective and safe method of treating superficial truncal venous insufficiency of the lower limbs.

ABLACJA LASEREM 1940 NM Z ZASTOSOWANIEM WŁÓKNA OSIOWEGO JAKO SKUTECZNA I BEZPIECZNA METODA LECZENIA NIEWYDOLNOŚCI PNIOWEJ ŻYŁ POWIERZCHOWNYCH KOŃCZYN DOLNYCH Michał Rogozik1,2, Włodzimierz Hendiger1 1 2

Oddział Chirurgii Naczyniowej, Szpital MSWiA w Łodzi, Polska Prywatna Praktyka Lekarska Michał Rogozik, Łódź, Polska

Cel pracy: Ocena skuteczności ablacji termicznej laserem 1940 nm niewydolnych żył pniowych oraz przebiegu pooperacyjnego przy zastosowaniu światłowodów osiowych.

Phlebological Review 2021

Materiał i metody: Analizie poddano grupę pacjentów operowanych od kwietnia do grudnia 2020 r. Do ablacji zastosowano laser MetrumCryo Twist 1940 nm oraz światłowody osiowe 600 um. Zabieg przeprowadzano z nakłucia obwodowego niewydolnej żyły i wprowadzenia koszulki naczyniowej Prelude 5F 11 cm. Światłowód wprowadzano przez cewnik Merit Straight Flush 5F, pozycjonując końcówkę włókna pod kontrolą USG. Zastosowano znieczulenie tumescencyjne w połączeniu z krókotrwałym dożylnym. W ocenie pooperacyjnej wzięto pod uwagę nasilenie dolegliwości bólowych w skali VAS w pierwszej dobie i w ciągu 7 dób pooperacyjnych, rekanalizację żył na kolejnych wizytach kontrolnych po 1, 3, 6 i 12 miesiącach (pełny okres obserwacji zakończyło 10 pacjentów), obecność objawów neurologicznych w miejscu operowanym oraz obecność zakrzepicy żył głębokich w okresie pooperacyjnym. Wyniki: Badaną grupę stanowiło 81 pacjentów (59 kobiet i 22 mężczyzn), średnia wieku 43,93 lat (25–72 lat). Ablacji poddano 103 żyły w tym 90 żył odpiszczelowych i 13 żył odstrzałkowych. Średnica żyły wahała się od 5 do 16 mm (średnia 9,96 mm). Pacjentów podzielono na 2 grupy w zależności od średnicy żyły < 10 mm i > = 10 mm. W grupie < 10 mm zastosowano przy ablacji 50 j/cm naczynia, w grupie > = 10 mm 80 j/cm. W okresie pooperacyjnym nie obserwowano objawów uszkodzenia nerwów obwodowych i wystąpienia zakrzepicy żył głębokich. Dolegliwości bólowe pacjenci ocenili jako mało uciążliwe, oceniając je w skali VAS średnio na 2 (mediana 2, zakres 1–6) w pierwszej dobie oraz 1,815 w ciągu pierwszych 7 dni (mediana 2, zakres 1–6). W ocenie efektywności ablacji stwierdzono u 2 pacjentów w grupie > 10 mm po okresie 6 miesięcy rekanalizację żyły wymagającą ponownego leczenia. Wnioski: Połączenie lasera 1940 nm ze światłowodem osiowym jest skuteczną i bezpieczną metodę leczenia niewydolności pniowej z akceptowalnym odsetkiem nawrotów (1,9%) i niskim poziomem dolegliwości bólowych. Nie obserwowano opisywanych wcześniej przy połączeniu długości fali 810 nm i 1470 nm ze światłowodem osiowym powikłań neurologicznych w miejscu operowanym. Ocena skuteczności długoterminowej wymaga dalszej analizy danych.

1940 NM LASER ABLATION WITH THE USE OF AXIAL OPTICAL FIBRE AS AN EFFECTIVE AND SAFE METHOD OF TREATING SUPERFICIAL TRUNCAL VENOUS INSUFFICIENCY OF THE LOWER LIMBS Michał Rogozik1, Włodzimierz Hendiger2 Vascular Surgery Department, MSWiA Hospital in Łódź, Polska Private Medical Practice Michał Rogozik, Łódź, Polska

1 2

Objectives: Assessment of the effectiveness of 1940 nm thermal laser ablation on truncal venous insufficiency as well as postoperative course using axial optical fiber. Material and methods: The analysis covered a group of patients operated on between April 2020 and December 2020. 1940 nm MetrumCryo Twist laser and 600 um axial optical fiber were used for the ablation. The surgery was performed with peripheral puncture of inefficient vein and 5F 11 cm Prelude vascular introductor was inserted. Optical fibre was inserted through the Merit Straight Flush 5F catheter, positioning the ending of the fibre under the ultrasound supervision. Two kinds of anesthesia, tumescenceal and short-acting intravenous, were used simultaneously. The postoperative assessment took into account: pain exacerbation, using the VAS scale on the first day and within the next seven days after the operation, vein recanalization during the follow-up visits after 1, 3, 6 and 12 months (10 patients completed the full observation period), presence of neurological symptoms in the operated area as well as deep vein thrombosis. Results: The group of study subjects consisted of 81 patients (59 women and 22 men) with an average age of 43,93 (age range between 25 and 72 ). The ablation was performed on 103 veins, in which 90 were great saphenous veins and 13 small saphenous veins. The diameter of the vein was between 5mm and 16 mm (on average 9,96 mm). The patients were divided into 2 groups, depending on the vein diameter < 10 mm and > = 10 mm. In the < 10 mm group, 50 J/cm of the vessel was used for

69


ORIGINAL PAPER PRESENTATION ABSTRACTS

the ablation and in the latter one (> = 10 mm group) 80 J/cm. Neither peripheral nerve injury nor deep vein thrombosis were observed in the postoperative period. Patients rated their pain as not bothersome, rating it on average as 2 on the VAS scale (median 2, range 1–6) on the first day and 1,815 within the next 7 days (median 2, range 1–6). In the assessment of the effectiveness of the ablation, there were 2 cases in which, after 6 months from the procedure, vein recanalization took place and further treatment was needed. Conclusions: The combination of 1940 nm laser and axial optical fiber is an effective and safe method of treating truncal venous insufficiency with an acceptable percentage of relapse (1,9%) and low pain level. There were no neurological complications in the operated area described earlier while using 810 nm and 1470 nm waves with axial optical fibre. The long-term assessment requires further data analysis.

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Phlebological Review 2021


Instructions for authors Phlebological Review is the official journal of the Polish Phlebological Society and an international journal that features peer-reviewed articles on research related to venous and lymphatic diseases. The journal also publishes papers on related topics such as molecular biology, biochemistry, genetics, biophysics, medical technology and imaging dealing with disorders of the veins and lymphatic vessels. All of the articles in Phlebological Review are published on an open access basis. Published articles are available (full text) in PDF and HTML format. Papers should be submitted to the Editorial Office on-line by the Editorial System: www.editorialsystem.com/pr

Preparation of manuscripts

Articles must be written in English with American or British spelling used consistently throughout. Authors not entirely familiar with English are advised to have their style corrected by professional language editors or native English speakers. • The length of original articles should not exceed 20 printed pages including text, illustrations, tables, and references. •E ach article should contain a structured abstract (200-250 words). • The manuscript body should be organized in a standard form with separate sections: Introduction, Material and methods, Results, Discussion, and References. Review articles should be divided into sections and subsections as appropriate without numbering. • All dimensions and measurements must be given in the metric system. • Th e source of any drug and special reagent should be identified. • Particular attention needs to be paid to the selection of appropriate analysis of data and the results of statistical tests should be incorporated in the Results section. • The nomenclature used should conform to the current edition of the Nomina Anatomica or Nomina Anatomica Veterinaria. • Acknowledgements should be made in a separate sheet following Discussion and before References. These should contain a list of dedications, acknowledgements, and funding sources. •L egends of figures and tables should be prepared as a separate file. • Th e editor reserves the right to make corrections.

Tables

• Tables numbered in Roman numerals require a brief but descriptive heading. • The major divisions of the table should be indicated by horizontal rules. • Explanatory matter should be included in footnotes, indicated in the body of the table in order of their appearance. • Tables must not duplicate material in the text or in illustrations. • Tables must be prepared as a separate file.

Illustrations

All figures should be supplied electronically at a resolution of 300dpi in all standard formats (tiff, jpg, Adobe Photoshop, Corel Draw, and EPS). Name your figure files with “Fig” and the figure number, e.g., Fig1.tif • The maximum figure size is 84 mm or 174 mm for use in a single or double column width, respectively. • When possible, group several illustrations in one block for reproduction. Like all other figures, the block should be prepared within a rectangular frame to fit within a single or double column width of 84 and 174 mm, respectively, and a maximum page height of 226 mm. • Each figure should include the scale magnification bar; do not use magnification factors in the figure legends. • All figures, whether photographs, graphs or diagrams, should be numbered using Arabic numerals and cited in the text in consecutive numerical order.

References

The list of references (written on a separate page) should include only those publications that are cited in the text. Avoid citation of aca-

demic books, manuals and atlases. References must be numbered consecutively. References should be given in square brackets and the consecutive number, e.g. [3, 4, 6-12]. References should be written as follows: Journal papers: initials and names of all authors, full title of the paper, journal abbreviation (according to Index Medicus), year of publication, volume (in Arabic numerals), first and last page (examples below): 1. Valverde F. The organization of area 18 in the monkey. Anat Embryol 1978; 154: 305-334. 2. Uray N.J., Gona A.G. Calbindin immunoreactivity in the auricular lobe and interauricular granular band of the cerebellum in bullfrogs. Brain Behav Evol 1999; 53: 10-19. Book and monographs: initials and names of all authors, full title, edition, publisher, place, year (examples below): 1. Pollack R.S. Tumor surgery of the head and neck. Karger, Basel 1975. 2. Amaral D.G., Price J.L., Pitkänen A., Carmichael S.T. Anatomical organization of the primate amygdaloid complex. In: Aggleton JP (ed.). The amygdala. Wiley-Liss, New York 1992; 1-66. Reference to articles that are accepted for publication may be cited as “in press” or Epub.

Ethical requirements

When reporting experiments on human subjects, authors should indicate whether the procedures followed were in accordance with the Helsinki Declaration of 1975, as revised in 2000 (concerning the ethical principles for the medical community and forbidding releasing the name of the patient, initials or the hospital evidence number) and with the ethical standards of the responsible committee on human experimentation (institutional and national). Information regarding the ethical committee approval for conducting the research and the informed consent of patients to participating in the studies should be included in the Methods section of those articles, in which the diagnostic intervention or the treatment result from non-routine procedures. The authors presenting case studies are obligated not to disclose patients’ personal data. Regarding photographs, in case of any doubt that the picture inadequately protects the patient’s anonymity his consent is required for publication.

Conflict of interest

Authors are expected to describe sources of the research funding, a role of the potential sponsor in planning, executing and analysis of the study, and the influence (bias) the funding organization had on the content of the article. Other relationships (such as employment, consultancies, stock ownership, honoraria, paid expert testimony) providing potential sources of conflict of interest in relation to the submitted article should also be revealed.

Review process

Received manuscripts are first examined by the Phlebological Review editors. Manuscripts with insufficient priority for publication are rejected promptly. Incomplete submissions or manuscripts not prepared in the advised style will not be sent for a peer review until the correct and complete submission has been provided. The registered manuscripts are sent to 2-3 independent experts for scientific evaluation. We encourage authors to suggest the names of possible reviewers in the Editorial System, but we reserve the right of final selection. Submitted papers are accepted for publication after a positive opinion of the independent reviewers. The Polish Phlebological Society acquires all copyrights, on an exclusive basis, to manuscripts published, including the right to publish in print, using electronic carriers or others, and on the Internet. Abstracts may be published without the Publisher’s permission.



VIII KONFERENCJA

FLEBOLOGIA ESTETYCZNA

ONLINE / 22–23 PAŹDZIERNIKA 2021

KOMITET ORGANIZACYNY prof. dr hab. n. med. Zbigniew Krasiński prof. dr hab. n. med. Tomasz Urbanek KOMITET NAUKOWY dr n. med. Aleksandra Jaworucka-Kaczorowska prof. dr hab. n. med. Zbigniew Rybak dr n. med. Adam Zieliński PATRONAT MERYTORYCZNY I NAdZóR NAUKOWY Polskie Towarzystwo Flebologiczne

ORGANIZATOR lOGIsTYCZNY I MERYTORYCZNY Wydawnictwo Termedia

BIURO ORGANIZACYJNE Wydawnictwo Termedia | ul. Kleeberga 2 | 61-615 Poznań | szkolenia@termedia.pl