Donnees physiopathologiques dans l IVC, limites OSCAR MALETI

Transcription

1 Donnees physiopathologiques dans l IVC, limites OSCAR MALETI President of Italian College of Phlebology Vice-President of European Board of Phlebology (UEMS) Chief of Vascular Surgery CardioVascular Surgery Dept. Hesperia Hospital Modena

2 Chronic Venous Insufficiency (C3-C6) Superficial venous system Perforators system Deep venous system Incompetence Deep venous system Obstruction Without incompetence and obstruction

3 Obstruction - stenosis - rigidity of the venous wall - valve malfunction Increased resistance to flow Incompetence - valve damage - valve malfunction Reflux Perrin M, Gillet JL, Guex JJ. Syndrome post-thrombotique. Angéiologie 2003;19 (2040):12. EMC (Elsevier Masson SAS, Paris)

4 These haemodynamic disorders reduce the efficacy of the muscle pump

5 Calf pump inefficacy Ineffective pump due to high volume Ineffective pump for joint and muscular disorders

6 Muscle pump components are: capacity compliance ejection volume residual volume

7 The muscle pump can adsorb the reflux increasing capacity and/or ejection volume

8 Little increments in volume (capacity) can lead to significant pressure increase

9 We can reduce the calf volume by means of: Compression therapy Treatments of Superficial venous system reflux Perforator system reflux Deep venous system Obstruction Reflux

10 OUTCOME depends on: Correction of isolated disorders - Improvement Partial correction in associated disorders - Improvement - Transitory improvement - No improvement

11 CVI PTS Primary Isolated lesion Associated lesions Isolated lesion Associated lesions

12 In POST THROMBOTIC SYNDROME In 2/3 of CVI symptomatic cases, obstruction and reflux are associated Neglen P, Hollis KC, Olivier J, Raju S. Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical and hemodynamic results. J Vasc Surg 2007;46:

13 Obstructive lesions Extraluminal Intraluminal

14 Extraluminal lesions - Loss of compliance - Rigidity and stenosis of the valve ring determining reflux

15 - Extrinsic compression due to fibrosis

16 Intraluminal lesions - Fibrosis

17 These lesions are correlated with increased resistance

18 Proximal obstruction is rarely compensated (Ο 16 mm 256 O 4mm)

19 Without IVUS we can: - Underestimate obstructive lesions - Overestimate collateral pathways Venogram Versus Intravascular Ultrasound for Diagnosing and Treating Iliofemoral Vein Obstruction (VIDIO): Report From a Multicenter, Prospective Study of Iliofemoral Vein Interventions. Gagne P. et al. J Vasc Surg Venous Lymphat Disord Sep;5(5):

20 Reducing proximal resistance and distal volume it is possible to restore a re-equilibrium of the leg, despite persistence of reflux, in about 50% of patients

21 ROLE OF REFLUX in PTS Outcomes obtained treating only the reflux and ignoring obstruction, proves the role of reflux correction The improvement is frequently transitory

22 A partial correction of the haemodynamic disorder can lead to symptoms remission even if obstruction and reflux remain uncorrect

23 When we decide to treat the reflux: - Transposition - Valve Transplant - Neovalvole

24 The risk is to increase the RESISTANCE

25 Transposition The confluence of two different axialisation increased significantly the resistance

26 Valve Transplant F=P/R The discrepancy in caliber is the principle cause of thrombosis

27 Neovalvole The need to prevent re-adhesion can reduce the opened surface

28 PRIMARY CVI Isolated Obstruction Reflux Superficial Deep Primary Associated Deep ostruction + Reflux (deep and/or superficial) Reflux Superficial Deep

29 In deep primary reflux the valves are present but malfunctioning Superficial system OVERLOAD Superficial reflux

30 Deep Symmetrical cusps Asymmetrical cusps

31 Symmetrical cusps First treatment: Superficial ablation (the reduction of overload can restore the deep vein competence) Maleti O, Lugli M, Perrin M. After superficial ablation for superficial reflux associated with primary deep axial reflux, can variable outcomes be caused by deep venous valve anomalies? Eur J Vasc Endovasc Surg 2016

32 Asymmetrical cusps First treatment: Deep valvuloplasty (the reduction of overload is not followed by restored deep vein competence) Maleti O, Lugli M, Perrin M. After superficial ablation for superficial reflux associated with primary deep axial reflux, can variable outcomes be caused by deep venous valve anomalies? Eur J Vasc Endovasc Surg 2016

33 In isolated primary incompetence Valvuloplasty has to restore the valve continence without streatching the free border of the cusps Kistner RL. Surgical repair of a venous valve. Straub Clin Proc 1968;24:41-3.

34 Valvuloplasty without flebotomy MUST BE abandoned - with flebotomy - without flebotomy Maleti O, Lugli M, Perrin M. Chirurgie du reflux veineux profond. Enciclopedie Medico-Chirurgicales (Elsevier Masson SAS, Paris), Techniques chirurgicales Chirurgie Vasculaire, , 2009

35 Our research aim to ceate a device able to avoid increased resistance, correcting the reflux at the same time VALVOLATED STENT - It is based on a physiological competing flow - Transcutaneous access

36 - Pathology classification - Method of research - Instrumental Follow-up Improve physiopathological knowledge consequently improve therapeutic addresses

37 LIMITS

38 When several haemodynamic disorders are associated, it will be useful to distinguish the more significant one, in order to correct the decompensating element We do not know how to distinguish the respective role of obstruction and reflux Nicolaides A, Clark H, Labropoulos N, Geroulakos G, Lugli M, Maleti O.Quantitation of reflux and outflow obstruction in patients with CVD and correlation with clinical severity. Int Angiol 2014;33(3):

39 We don t know the exact role of overload Maleti O, Lugli M, Perrin M. After superficial ablation for superficial reflux associated with primary deep axial reflux, can variable outcomes be caused by deep venous valve anomalies? Eur J Vasc Endovasc Surg 2016

40 We don t know why... Some patients present advanced disease without disease progression

41 The inflammatory processes involving the venous segment after a thrombotic event are not yet sufficient clear

42 The significance of - Increment of rest pressure - Short reduction of deambulatory pressure is not well know

43 Knowledge on microcirculatory anomalies, even if in rapid evolution, are not yet exhaustive

44 Thank you