VOLUM DE REZUMATE Conferința Națională de Angiologie și Chirurgie Vasculară cu participare internațională Ediția 2017 ORGANIZATOR: Societatea Română de Angiologie și Chirurgie Vasculară 26-28 Octombrie, Cluj-Napoca, România ÎN COLABORARE CU:
DIABETES AND OUTCOMES OF DISTAL BYPASS SURGERY IN PATIENTS WITH PHERIPHERAL ARTERIAL DISEASE Claudia Gherman 1, Andrei Eni 2, Mariana Matei 2, Alexandru Buleandră 2 1 Surgical Clincic No 2, University of Medicine and Pharmacy Iuliu Hatieganu Cluj- Napoca, 2 Vascular Surgical Clinic, County Emergency Hospital Cluj-Napoca Surgical revascularization of the lower extremity using bypass grafts to distal target arteries is an established, effective therapy for advanced ischemia. Recent multicenter data confirm the primacy of autogenous vein bypass grafting, yet there remains significant heterogeneity in the utilization, techniques, and outcomes associated with these procedures in current practice. Experienced clinical judgment, creativity, technical precision, and fastidious postoperative care are required to optimize long-term results. The patient with diabetes and a critically ischemic limb offers some specific challenges; however, numerous studies demonstrate that the outcomes of vein bypass surgery in this population are excellent and define the standard of care. Technical factors, such as conduit, and inflow/outflow artery selection play a dominant role in determining clinical success. An adequate caliber, good quality great saphenous vein (GSV) is the optimal graft for distal bypass in the leg. This study demonstrates the importance of patient selection and technical factors to outcomes, and highlights the importance of surgical judgment and operative planning in the current practice of distal bypass surgery. PERIPHERAL ARTERIAL DISEASE AND DIABETES MELLITUS THE EXPERIENCE OF VASCULAR SURGERY DEPARTAMENT, INSTITUTE OF CARDIOVASCULAR DISEASES PROF. DR. C.C. ILIESCU Sorin Liviu Băilă, Maria-Magdalena Totir, A. Parnia, P. Platon, M. Croitoru, Anca Drăgan, A. Zaharia, Șerban-Ion Bubenek-Turconi Institul de Urgență pentru Boli Cardiovasculare Prof.Dr.C.C. Iliescu București Peripheral arterial disease (PAD) is a condition characterized by atherosclerotic occlusive disease of the lower extremities. While PAD is a major risk factor for lower-extremity amputation, it is also accompanied by a high likelihood for symptomatic cardiovascular and cerebrovascular disease 1. Diabetes mellitus (DM) is a major risk factor of peripheral artery disease (PAD), leading to increased morbidity and mortality as well as an accelerated disease course. As such, a more
thorough understanding of the multi-factorial mechanisms underlying disease etiology for both DM and PAD is justified 2. There are 415 million people with diabetes in the world and the worldwide burden is projected to increase to 642 million people by 2040. 4 In Romania, according PREDATOR Study, the overall age- and sex-adjusted prevalence of DM was 11.6%, of which 2.4% had unknown DM. 5 Total PAD disease prevalence based on objective testing has been evaluated in several epidemiologic studies and is in the range of 3% to 10%, increasing to 15% to 20% in persons over 70 years. 3 Although much is known regarding PAD in the general population, the assessment and management of PAD in those with diabetes is less clear and poses some special issues. At present, there are no established guidelines regarding the care of patients with both diabetes and PAD 1. This lecture will present our findings from a clinical review that was conducted in diabetic patients diagnosed with PAD, treated in Department of Vascular Surgery, Emergency Institute for Cardiovascular Disease Prof. Dr. C.C. Iliescu over a 5-year period. (January 1 st, 2012 to December 31, 2016). DIABETIC FOOT THE SIZE OF THE PROBLEM Christos Manes Internist-Diabetologist Chairman of the Greek Association for the Study of the Diabetic Foot Diseases Diabetes mellitus is a serious, chronic disease that occurs in 8.7% of the adult population worldwhite. The disease caused 1.5 million deaths in 2012 (WHO 2016).
Diabetes appears to dramatically increase the risk of lower extremity amputation because of infected, non-healing foot ulcers (Moxey PW. Diab Med. 2011). Rates of amputation in populations with diagnosed diabetes are typically 10 to 20 times those of nondiabetic populations and over the past decade have ranged from 1.5 to 3.5 events per 1000 persons per year. Lower limb amputation rates are 10 to 20 times higher among people with diabetes than in general population (WHO 2016). The Center of Disease Control in U.S.A estimated that the prevalence of foot ulcers in the population is 12% (CDC 2011). These lesions account for the greatest percentage of hospital admissions among diabetes patients and are the leading cause of nontraumatic lowerextremity amputations in the U.S.A. More than 60% of nontraumatic lower-limb amputations occur in people with diabetes, which amounted to 65.700 nontraumatic lower-extremity amputations in 2006 (CDC-USA) Furthermore mortality following amputation was estimated to range from 13% to 40% at 1 year, 35% to 65% at 3 years, and 39% to 85% at 5 years. Peripheral neuropathy, tissue ischemia, structural foot deformities and trauma play a crucial role in the development of acute ulcerative conditions. Some common offending agents in acute infections include gram-positive cocci and gram-negative bacilli. The development of DFUs involves many etiological factors that are important to monitor in diabetes patients. Peripheral neuropathy (PN), which is present to some degree in >50% of diabetes patients aged >60 years, is one of the most important factors in the development of DFUs. Profound PN leads to loss of protective sensation and consequently to increased vulnerability to physical and thermal trauma. Foot ulcers are more likely to be of neuropathic origin, and therefore eminently preventable in developing countries. It has to be emphasized that the developing countries will experience the greatest rise in the prevalence of type 2 diabetes in the next 20 years and face the diabetic foot problem. People at greatest risk of ulceration can easily be identified by careful clinical examination of the feet. So education and frequent follow-up is indicated for these patients (AJM Boulton, Lancet 2005) When assessing the economic effects of diabetic foot disease, it is important to remember that rates of recurrence of foot ulcers are very high, being greater than 50% after 3 years. In USA examined clinical care and related costs and found that annual incremental healthcare costs ranged from $11.710 to $16.883 per patient with a foot ulcer, or as high as $13 billion nationally, in addition to the costs associated with diabetes itself. (Becky Mc Call Diab Care 2013) Early recognition and treatment by a multidisciplinary healthcare team are necessary for complete therapeutic resolution in patients who present with acute conditions.encouragingly several studies show a 40% to 60% reduction in rates of amputations among adults with diabetes during the past 10 15 years in the United Kingdom, Sweden, Denmark, Spain, the United States of America and Australia. where multidisciplinary healthcare were organized.
AMPUTATIILE ÎNCOTRO? Marian Croitoru Instututul de Urgență pentru Boli Cardiovasculare Prof.Dr.C.C.Iliescu București 62 de amputatii zilnice la bolnavi cu diabet in Romania. In SUA 1 $ investit in tratamentul unui bolnav cu picior diabetic poate genera o economie pentru sistemul de sanatate de 27 pana la 51 de dolari. In urmatoarea perioada cazurile de diabet zaharat conform studiilor vor creste foarte mult. Statisticile americane constata ca ingrijirea piciorului diabetic costa mai mult decat ingrijirea bolnavilor neoplazici. Conditia bolnavilor cu ischemie critica stadiul IV este comparabila cu aceea a bolnavilor neoplazici terminali. Tratamentul endovascular este in acest moment prima optiune in rezolvarea acestor bolnavi. Noile instrumente pe care le avem la dispozitie fac ca succesul tratamentului endovascular sa mearga spre 90% si de asemenea cu procentaj foarte mare de evitare a amputatiilor. Suntem putini.. Sunt putine centre. Trebuia sa cautam a face ceva! AMPUTATIONS WHERE TO? Marian Croitoru Instututul de Urgență pentru Boli Cardiovasculare Prof.Dr.C.C.Iliescu București In Romania there are about 62 daily amputations for patients with diabetes. In USA, one dollar invested in the treatment of a patient with diabetic foot can generate an economy from 27 up to 51 dollars for the health care system. According to recent studies, In the following period the number of patients with diabetes will highly increase. American statistics reveal that diabetic foot care is comparable to the care of patients with neoplasia. The condition of patients with critical stage IV diabetic foot is very similar to patients with terminal cancers. Endovascular treatment is, at the moment, the first choice in treating these patients. New instruments make the success rate of endovascular treatment at about 90% and also help to highly decrease the number of amputations. We are few. There are very few centers. We need to do something!
MANAGING BELOW-THE-KNEE ARTERIAL DISEASE - ENDOVSCULAR THERAPY OF THE DIABETIC FOOT Lucian Mărginean Spitalul Clinic Județean de Urgență Târgu-Mureș Peripheral arterial disease (PAD) is a major medical concern, if left untreated it can lead to severe handicap. Longstanding diabetes affects walls of below-the-knee (BTK) arterial vessels in different degrees, and surgical therapy is sometimes limited by the patients overall condition, comorbidities and vessel caliber. Interventional radiology (IR) brings to light new approaches concerning the revascularization of these small caliber vessels, using minimally invasive techniques. The procedures do not require general anaesthesia, and the time spent in hospital decreases radically. BTK arterial disease is in our days, a major concern of IR, due to its high incidence and poor prognosis without treatment. Even partial revascularization has a great impact, since the only other options are radical, such as amputation, in some patients. Percutaneous transluminal angioplasty (PTA) of BTK lesions can improve symptoms and clinical outcomes, due to the fact that even vessels with a 1 mm caliber can be treated. The industry in continually developing devices that are designed for these small caliber vessels, giving us the possibility to treat the otherwise untreatable. Our experience is going back more than a decade, but we are continuously working to improve and address these patients as well as our esteemed colleagues, because there is an option to amputation. Keywords: below-the-knee, BTK, PTA, angioplasty. DIABETIC FOOT ULCERS PATHOPHYOLOGY, ASSESMENT AND THERAPY Centrul de Diabet și Nutriție, Cluj-Napoca Paula Pavel Foot problems in persons with diabetes remain a major public health issue and are the commonest reason for hospitalization. In diabetic patients the pathophysiology of foot disease is multifactorial including peripheral neuropathy, peripheral arterial disease, abnormal foot structure and biomechanics. Early and adequate recognition of the etiology of foot lesions is essential for accurate diagnosis and therapy management. Diabetic foot requires a multidisciplinary collaboration of health care specialists in order to address the glycemic control, infection, off-loading, vascular status and local wound care. Diabetic foot is classified into two major types: the neuropathic foot (neuropathy dominates) and the neuroischemic foot (occlusive vascular disease is the main factor, although neuropathy is present).
Neuropathy leads to fissures, bullae, neuropathic (Charcot) joint, neuropathic edema, and digital necrosis. Ischemia leads to pain at rest, ulceration on foot margins, digital necrosis and gangrene. Differentiating between these entities is essential because their complications are different and they require different therapeutic strategies. VASCULAR SURGERY VS. ENDOVASCULAR THERAPY IN PAD AND DIABETIC FOOT PATIENTS: WHERE DO WE STAND? Horațiu Flaviu Coman Vascular and Endovascular Surgery Clinic Martin Luther Krankenhaus, Bochum, Germany The constant development in endovascular techniques over the last years raised a fundamental question as to whether open surgery or endovascular therapy represents the optimal treatment for PAD in general and in diabetic foot patients in particular. When planning an endovascular or open surgical intervention, target vessel selection is related to the quality of the outflow vessel and its run-off. The aim of this paper is to evaluate the clinical outcomes in direct and indirect target vessel revascularization using both techniques (vascular surgery and endovascular therapy). A review of the literature data available as well as a retrospective analysis of our own experience was performed. The angiosome concept was taken into account. The endpoints evaluated were primary patency rate, limb salvage rate, complications, overall survival rate and ulcer-healing time (including adjuvant classical wound therapy alongside newest extracellular matrix wound dressing) in diabetic patients with PAD. The results show that in diabetics, according to the angiosome concept, direct endovascular revascularisation leads to significantly better wound healing and limb salvage rates compared with indirect revascularization. However in bypass surgery the artery with the best runoff should be selected as the outflow artery. In selected cases hybrid surgery, which combines both techniques, can improve the results regarding patency, limb salvage and ulcer-healing time.
THE MANAGEMENT OF DIABETIC FOOT CHALENGES IN ROUTINE CLINICAL PRACTICE (INTERNAL AND FAMILY MEDICINE) Sorin Crșan 5 th Medical Clinic, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, România Continuous-wave Doppler ultrasound and photoplethysmography play a key role in the early detection, severity assessment, and monitoring of peripheral arterial disease in diabetics and non-diabetics. Unfortunately, often, in routine clinical practice (internal and family medicine), these techniques are not used to their true value. The main difficulties of the diagnostic of the peripheral arterial disease and diabetic foot, discussed by the author, are the following: decreased level of awareness of diabetes-related vascular disorders among the general population, patient non adherence, minor progresses in teaching vascular medicine to medical and nursing students, reduced basic clinical skills, insufficient knowledge and understanding of current screening algorithms and of interpretation of some continuous-wave Doppler parameters (waveform shape, absolute ankle systolic pressure, and ankle-brachial index) and photopletysmographic parameters (signal aspect, absolute toe systolic pressure, and great toe and second toe-brachial index), lack of proper instrumentation, lack of reimbursement of some of time-consuming techniques, real exam costs, sometimes unreliable values in patients with medial arterial calcification. Keywords: continuous-wave Doppler ultrasound, photoplethysmography, ankle-brachial index, peripheral arterial disease, diabetic foot REVASCULARIZATION BELOW-THE-KNEE: WHAT CAN WE DO MORE FOR LIMB SALVAGE? Kiriaki Kalligianni Vascular Surgeon,,,Hygeia Hospital Athens Greece The anatomic common denominator of Diabetes and CLI is the presence of severe below-theknee arterial occlusive lesions.our purpose is to summarize new developments in revascularization and advanced surgical and endovascular techniques to treat BTK lesions especially in diabetic patients with the primary goal the re-establishment of pulsatile, straightline flow to the foot. Although the bypass procedures remain the gold standard, endovascular techniques are the new standard of care being today the first-line approach in the majority of patients presenting with CLI. Extended distal below-the-ankle bypasses, tibial endovascular interventions with antegrade or retrograde pedal access, pedal-plantar loop technique or transcollateral recanalization, angiosome directed approach and novel devices such drug coated balloons and drug eluting stents are a key part of our surgical armamentarium to achieve a complete revascularization. Increasing technical success rates, low frequency of
complications, high limb salvage rates of about 90% and amputation free survival rates even in diabetic patients with long segment and diffuse disease justify the use of advanced surgical and mainly endovascular therapy focused in this anatomic area. BTK NO LIMIT! Mihai Crețeanu Jr. Laboratorul de Radiologie și Imagistică Medicală Spitalul Clinic Județean de Urgență Sf.Ioan Cel Nou, Suceava, România Tehnicile minim invazive au fost introduse in cadrul Spitalului Judetean de Urgenta Sf. Ioancel Nou Suceava din anul 2012. Dintre procedurile endovasculare cele mai frecvent intalnite s-au dezvoltat cele de angioplastie cu balon, angioplastie cu stent in situatiile de ischemie critica in special la pacientii cu diabet. Numarul de interventii a crescut de la an la an 2013 26, 2014-31, 2015 49, 2016 95, 2017 70 iar daca initial leziunile tratate predominant (>60%) erau deasupra genunchiului, acum s-a produs o schimbare in sensulca (>75%) dintre leziuni sunt sub genunchi. Rata de success a interventiilor este de peste 95%, iar rata de complicatii sub 3%. Abordarea in echipa multidisciplinara a piciorului persoanei cu diabet(diabetolog, neurolog, chirurg vascular, chirurg generalist, ortoped, podiatru, asistent educator) a permis reducerea cu pana la 50% a numarului de amputatii majore. The minimally invasive techniques have been introduced at the Suceava County Hospital St. Ioan cel Nou since 2012. Most of these endovascular procedures were balloon or stent angioplasties in critical ischemia especially for patients with diabetes mellitus. The number of interventions increased from year to year 2013-26, 2014-31, 2015-49, 2016-95, 2017-70 and if the injuries originally treated (> 60%) were above the knee (ATK), there was a change in this sense : (> 75%) of the injuries are below the knee (BTK). The success rate of the interventions is over 95% and the complication rate below 3%. The multidisciplinary team (diabetologist, vascular surgeon, orthopedic surgeon, neurologist, podiatrist, interventionist radiologist and educational support nurse) who approaches diabetic foot of the person with diabetes have led to reduction of major amputations by up to 50%.
FOOT SCREENING VITAL TO DIABETIC HEALTH Cynthia Formosa State Registered Podiatrist from the Department of Health, Malta The impact of diabetes-related complications and amputations on individuals, families and the society is huge. The impact on the quality of life for the individual is massive. Every 20 seconds someone in the world loses a limb to diabetes. However 4 out of 5 amputees could be prevented, given prompt and proper foot care attention, correct advice and rapid access to preventive services and screening. Every person with diabetes should receive annual checkups and foot screening in order to identify foot pathologies and deformities which places the foot at risk of ulceration and amputations. A paradigm shift on how to screen for risk factors in the high risk foot using high quality evidence is urgently required if the risk of foot ulceration and its devastating consequences are to be improved. This paper highlights how the role of the podiatrist as part of a multi-disciplinary team can help save limbs! It presents the findings of studies conducted to compare the accuracy of different physiological tests used by various health care professionals for the identification of lower limb diabetic related pathologies. MEDICAL INFRARED THERMOGRAPHY ITS USE AND FUTURE APPLICATION AS A CLINICAL TOOL Manager of Podiatry Services in Malta Alfred Gatt Thermography, the medical infrared imaging of the human body, is an emergent technology that holds a lot of potential as a possible tool for the examination of the feet of patients living with diabetes, amongst other diseases, since temperature can be an indicator of tissue perfusion. The emissivity of heat, or lack of it, from the body may be an indicator of disease processes, since infection, inflammation and decreased perfusion may alter the normal thermal pattern of the hands and feet. The basic principles of thermography together with its application to obtain normative thermographic patterns of the hands and feet, together with its application in the assessment of the diabetic foot and rheumatoid arthritis will be discussed. Furthermore, recent research in the field of peripheral arterial disease will be explored to demonstrate the possibilities of this exciting new field for medical diagnosis. The purpose of the presented study was to investigate whether heat emitted from the hands and feet of patients with diabetes (DM) and peripheral arterial disease (PAD) differed significantly from those without PAD. Out of 223 randomly selected participants (430 limbs) who were initially tested, 62 limbs were categorized as DM+PAD and 22 limbs as DM without PAD. Subjects
with evidence of peripheral neuropathy were excluded. Participants underwent thermographic imaging. Automatic segmentation of Regions of Interest extracted the temperature data. Results show a significant difference in temperature in all the toes between the two groups (p=0.005, p=0.033, p=0.015, p=0.038 and p=0.02 for toes 1-5 respectively). A Palmar/Plantar Thermographic Index composed of the mean Maximum Palm Temp/mean Minimum Forefoot Temp revealed significant difference between the two groups (p=.016). The mean forefoot temperature in DM+PAD was significantly higher than that in DM (p=.019), with DM+PAD having a higher mean temperature (28.3 o C) compared to DM (26.2 o C). Similarly, the toes of subjects with DM+PAD were significantly warmer than those of subjects with PAD alone. Contrary to expectations the mean toe and forefoot temperatures in DM patients with PAD is higher than in those without PAD. This unexpected result could be attributed to disruption of noradrenergic vasoconstrictor thermoregulatory mechanisms with resulting increased flow through cutaneous vessels and subsequent increased heat emissivity. Results from the presented studies demonstrate that thermography may have potential in detecting temperature differences associated with both PAD and synovitis. TERAPIA CHIRURGICALĂ PENTRU ANEVRISMUL ARTEREI POPLITEALE Spitalul Militar Central, București I.Droc, M.Dumitrașcu, L.Stan Anevrismul arterial popliteal (PAA) este relativ rar întâlnit într-un procent estimat de 0,1-1% din populație. Acestea reprezintă cea mai comună formă de anevrisme periferice, sunt adesea bilaterale și uneori sunt concomitent cu anevrismele abdominale sau femurale. Ele adesea sunt gresit diagnosticate și primar conferă un risc de ischemie a membrelor și pierderea membrelor. Anevrismul arterial popliteal se soldeaza mai frecvent cu pierderea membrului inferior decat a vietii. Imagistica este în primul rând realizata cu ultrasunete duplex și cu angiografia CT. Numai în câteva cazuri efectuăm angiografie pentru planificarea operativă. Reparația este recomandată pentru PAA> 2 cm diametru la pacienții cu risc crescut. Tehnica chirurgicală pentru a exclude anevrismul este legarea proximală și distală a PAA cu o revascularizare a segmentului scurt (proximal cu by-pass-ul arterial popliteal, distal folosind grefa autologă a venei sau o grefă protetică). Reparația chirurgicală deschisă este testată în timp, sigură și durabilă la pacienții selectați în mod corespunzător. Tratamentul endovascular este promițător, dar este nevoie de date pe o lungă durată.
SURGICAL THERAPY FOR POPLITEAL ARTERY ANEURYSM Central Military Hospital, Bucharest I.Droc, M.Dumitrașcu, L.Stan Popliteal arterial aneurysm (PAA) are relatively rare occurring in an estimated 0.1-1% of the population. They represent the most common form of peripheral aneurysms, are often bilateral and are sometimes concomitant with abdominal or femoral aneurysms. They are under diagnosed and primary confer o risk for limb ischemia and limb loss. Popliteeal arterial aneurysm are more often limb threatening than life threatening. Imaging is primarily with duplex ultrasonography and than CT angiography. Only in few cases we perform angiography for operative planning. Repair is recommended for PAA> 2cm in diameter in good risk patients. The surgical technique to exclude the aneurysm is proximal and distal ligation of the PAA with a short segment revascularization (proximal to distal popliteal artery by-pass using autologous vein graft or a prosthetic graft). Open surgical repair is time tested, safe and durable in properly selected patients. the endovascular treatment is promising but long term patency data is needed. THERMAL ABLATION OF POPLITEAL FOSSA PERFORATORS 1.Clinica Vascul Art Cluj, Romania, 2.Eskulap Hospital, Bydgoszcz, Poland R.Milleretˡ, M..Molski², I.Droc³ 3.Central Military Hospital -Bucharest, Romania Steam is the latest of the thermal endovenous techniques to enter clinical use. It was introduced in 2008 as a cheaper but as effective alternative to laser and radio-frequency. The principle is to inject in the vein pulses of water vapors at 120 C, each pulse delivering 60 joules of energy in the lumen. Steam is injected under pressure: the first pulse dislodges the blood, the next ones heat the vein wall. A stainless steel catheter of 5F gauge is used, it is flexible enough to navigate through tortuosities without using a guide wire. Two lateral holes close to the tip eject the steam, avoiding the risk of heating deep veins when heating the junctions. A comparative animal study by S.Thomis and all (1) showed that immediate shrinking was more pronounced with steam than with Closure Fast radio frequency catheter and 1470 nm TULIP fiber laser. Perivenous damage was less seen, although the number of cases was not sufficient to obtain statistical significance.
R.Milleret (2) published the results of a multi center study performed in France. Obliteration rate at 6 months was 96 %. A multicenter study of tributary ablation showed, with less pigmentation and inflammatory reactions than after foam sclerotherapy with 97% closure rate at 6 months. A second generation device allows elective ablation of tributaries and reticular veins (Miravas ) In conclusion, steam ablation is a safe alternative to other thermal techniques, it can be applied to tortuous or superficial veins which could not be treated by laser of radio frequency. BOALA VENOASĂ CRONICĂ, ASPECTE PROFILACTICE Daniela Radu Clinica 1 Chirurgie, Universitatea de Medicină și Farmacie V.Babeș, Timișoara Introducere Screening-urile populationale realizate prin studii epidemiologice nationale si internationale (SEPIA, PEGAS, VEIN CONSULT) au identificat persoane cu risc crescut de a dezvolta IVC. In profilaxia acestei afectiuni sunt implicati multi factori etiologici; in acest studiu am luat in considerare doar 2 cauze importante cu risc crescut de IVC si anume: factorul genetic si pozitia favorizanta. Factorul genetic, mostenirea familiala este identificata intre 64,8% pe linie maternal si 13,9% pe linie paterna in studiul Vein Consult. Al doilea factor de risc major in aparitia bolii este ortostatismul prelungit, precum si pozitia sezanda indelungata. Acestea, intr-o perioada variabila de timp pot determina aparitia ectaziilor venoase si a insuficientei venoase cronice. Practic putem afirma ca toata populatia care are acesti factori de risc are un grad de IVC, fapt demonstrat de edemele declive, cu accentuare vesperala. Scop: identificarea si eliminarea factorilor predominanti implicati in etiologia BVC. Metoda: Studiu retrospectiv, 5 ani (2012-2016) pe pacienti dispensarizati in Cabinetul de Flebologie al SCJUPBT. Dispensarizarea generala a pacienţilor se face în grupuri distincte: persoane sănătoase, dar cu vulnerabilităţi prin vârstă, stări fiziologice speciale, persoane sănătoase cu factori de risc ereditari, pacienţi cu boli cronice sau în convalescenţă după imobilizare prelungită la pat. Am identificat 2 loturi de pacienti: primul lot: pacienti cu istoric familial de BVC si al 2 lea lot, format din pacienti care urmeaza sa fie supusi unei interventii cu risc tromboembolic crescut, neoplazici, traumatisme ale membrelor inferioare, trombofilia sau diferite afectiuni care cresc vascozitatea sanguina sau stari fiziologice cu risc trombotic (sarcina) calatoria cu avionul (tromboza calatorului). Profilaxia este diferentiata ca durata si metode. Pentru primul lot stabilirea planului de control periodic se realizează în funcţie de: stadiul afecţiunii, necesitatea ajustării tratamentului, complianţa şi respectarea indicaţiilor de către pacienţi. Periodic are loc evaluarea eficienţei monitorizării pacienţilor cu încadrarea întro categorie suplimentară a pacienţilor necomplianţi sau care nu pot respecta indicaţiile medicale din alte motive. In situatia in care, cu toata profilaxia corect aplicata, afectiunea progreseaza, se intervine cu tratament curativ conform ghidurilor si protocoalelor de terapie in functie de stadiul afectiunii. Rezultate: 72% nu au respectat/ au respectat partial indicatiile
medicului dupa momentul diagnosticarii/ tratamentului chirurgical; 34% au revenit cu IVC avansata/complicatii. In concluzie, atragem atentia asupra preventiei acestei boli care chiar daca la debut nu prezinta o simptomatologie alarmanta pentru pacient, pe viitor va necesita o terapie curativa cu costuri crescute, fiind o boala cronica evolutiva, grevata de scaderea calitatii vietii. Recomandam, in afara educatiei sanitare corecte, terapie adecvata, concordanta cu stadiul Insuficientei venoase cronice. Cu toate progresele realizate in diagnosticul si terapia acestei afectiuni, evolutia bolii depinde mult de modul in care pacientul constientizeaza existenta si gravitatea afectiunii. Profilaxia IVC si a complicatiilor este esentiala la pacientii cu risc, ea trebuie aplicata corect si complet pe toata durata riscului, la unii pacienti toata viata. Complianta pacientului depinde in mare masura de increderea in medic si este determinanta in stoparea progresiei sau aparitiei afectiunii. Recomandam, in afara educatiei sanitare corecte, terapie adecvata, concordanta cu stadiul Insuficientei venoase cronice. CHRONIC VENOUS DISEASE, PROFILATIC ASPECTS Daniela Radu Clinic 1 Surgery, University of Medicine and Pharmacy "V.Babes", Timisoara Introduction Population Screening Through National and International Epidemiological Studies (SEPIA, PEGAS, VEIN CONSULT) identified people at high risk of developing IVC. Many etiological factors are involved in the prophylaxis of this condition; in this study, we considered only 2 important causes at high risk of CVD, namely: genetic factor and favorable position. The genetic factor, family inheritance is identified between 64.8% maternal and 13.9% paternal in the Vein Consult study. The second major risk factor in the onset of the disease is prolonged orthostatism, as well as long standing position. These, over a variable period of time, can cause venous ectasis and chronic venous insufficiency. Basically, we can say that all the population with these risk factors has a IVC degree, as evidenced by declivous edema, with a vesperal accentuation. Purpose: identification and elimination of predominant factors involved in the etiology of BVC. Method: Retrospective study, 5 years (2012-2016) on dispensarized patients in SCJUPBT's Flebology Cabinet. General patient dispensing is done in distinct groups: healthy individuals but with age-related vulnerabilities, special physiological states, healthy individuals with hereditary risk factors, chronic illnesses, or convalescence after prolonged bed rest. We identified 2 batches of patients: the first batch: patients with a family history of BVC and a second batch of patients who are to undergo surgery with increased thromboembolic risk, neoplasms, lower limb trauma, thrombophilia or various diseases that increase blood viscosity or physiological states with thrombotic (pregnancy) air travel (thrombosis of the traveler). Prophylaxis is differentiated as duration and methods. For the first batch, the establishment of the periodic control plan is based on: the stage of the disease, the need to adjust the treatment, the compliance and the observance of the indications by the patients. Periodic assessment of the effectiveness of patient monitoring is carried out by fitting an additional category of non-compliant patients or failing to comply with medical indications for other reasons. If all the prophylaxis applied, the disease progresses, it is treated with curative treatment according to the guidelines and the protocols of the therapy depending on the stage of the disease. Results: 72% did not partially follow the doctor's instructions after diagnosis / surgical treatment; 34% returned with advanced IVC / complications.
In conclusion, we draw attention to the prevention of this disease, which even if onset does not present an alarming symptom for the patient, in the future will require a curative therapy with increased costs, being a chronic evolutionary disease, strike by the decrease in quality of life. We recommend, besides proper health education, appropriate therapy, consistent with the chronic venous insufficiency. With all the advances made in the diagnosis and therapy of this condition, the evolution of the illness depends largely on how the patient is aware of the existence and severity of the disorder. IVC prophylaxis and complications is essential in patients at risk, it should be applied correctly and completely throughout the risk in some patients throughout life. Patient compliance largely depends on physician confidence and is determinant in stopping the progression or occurrence of the disorder. We recommend, besides proper health education, appropriate therapy, consistent with the chronic venous insufficiency. TRATAMENTUL INSUFICIENȚEI VENOASE CRONICE CU LASER ENDOVENOS I.Cazan, G. Băroi, C. Strobescu-Ciobanu, R.F.Popa Clinica de Chirurgie Vasculară, Spitalul Clinic Județean de Urgență Sf.Spiridon Iași, România In Romania, boala varicoasa are o incidenta intre 30 si 50% la populatia adulta, de regula, cu varsta cuprinsa intre 30 si 40 de ani. Tot in acest context, trebuie subliniat faptul ca femeile sunt mai afectate, raportul de incidenta pe sexe fiind de 3/2 (femei barbati). Terapia LASER endovenoasă (EVLO) îndeplineşte cele mai multe dintre dezideratele unui tratament modern al insuficientei venoase fiind: eficientă - rată de succes a EVLO de 94% la 3 ani (cea mai mare dintre terapiile endovenoase), minim invazivă, complicaţii rare (rata TVP similară tehnicii chirurgicale clasice, darcu rată de complicaţii locale mult diminuată). In aceasta lucrare vom prezenta experienta clinicii pe parcursul a 5 ani intre 2011-2016 insumand un numar de 154 de interventii EVLO. Consecutiv acestei proceduri pentru completarea tratamentului s-au efectuat flebectomii etajate sau ca opţiune de elecţie scleroterapia ecoghidată. Pacientii au fost urmariti echografic la o saptamana si la o luna postoperator, la toate intervalele de control s-a constatat persistenta inchiderii VSI. Cuvinte cheie : terapie laser endovenoasa, vena safena interna, sclerozare echoghidata. CHRONIC VARICOSE DISEASE TREATMENT WITH ENDOVENOUS LASER I.Cazan, G. Băroi, C. Strobescu-Ciobanu, R.F.Popa Vascular Surgery Clinic,Clinical County Hospital Sf.Spiridon Iași, România In Romania, varicose disease has an incidence between 30 and 50% in the adult population, with ages ranging from 30 to 40 years. In this context, we need to underline the fact that
women are more affected, the ratio being 3/2 women to men. Endovenous laser therapy (EVLO) fulfills most of the requirements of a modern treatment for venous insufficiency: efficiency success rate of 94% at 3 years (the greatest among endovenous treatment), minimally invasive, and rare complications (DVP occurrence rate similar to the classical surgical approach but with a much diminished local complications rate). In this paper we will present our clinic s experience in the course of 5 years (between 2011 and 2016) showcasing a number of 154 EVLO interventions. Subsequently to this procedure, for treatment completion, sequential phlebotomies have been performed or, optionally, echoguided elective sclerotherapy. Pacients were followed echographically at one week and one month postoperatively, and at all these control intervals persistent ISV closure was observed. Key words: endovenous laser therapy, internal saphenous vein, echoguided sclerotherapy ACTUALITĂȚI ÎN TRATAMENTUL TROMBOZEI VENOASE PROFUNDE. TRATAMENTUL TROMBOZEI VENOASE PROFUNDE ÎN CLINICA I CHIRURGIE A SPITALULUI CLINIC JUDEȚEAN DE URGENȚĂ TIMIȘOARA O STATISTICĂ PE 5 ANI MS. Murariu 1, Loredana Stroescu 2, Mihaela Avram 1, N. Pop 2, B. Magiar 2, A. Parau 2, Oana Radu 2, S. Pop 1, C. Ivan 1, Daniela Radu 1, V. Ivan 2, S. Olariu 1 1_ Clinica I Chirurgie, Departamentul X Chirurgie, Universitatea de Medicină și Farmacie Victor Babeș Timișoara, România 2 Spitalul Clinic Județean de Urgență Pius Brînzeu Timișoara, România Introducere. Tromboza venoasă profundă (TVP) şi embolia pulmonară (EP) sunt forme clinice ale tromboembolismului venos (TEV). O dată cu apariția unor noi anticoagulante, putem completa tratamentul tromboembolismului venos. Material și metodă. Am studiat opțiunile de tratament anticoagulant pentru TEV care includ heparina, heparine cu greutate moleculară redusă, antagoniști de vitamina K și utilitatea unor noi anticoagulante conform recomandărilor ghidurilor internaționale. De asemenea, am studiat cazurile cu tromboză venoasă profundă (TVP) a pacienților internați în Clinica I Chirurgie a Spitalului Clinic Județean de Urgență Timișoara în perioada 2013 2017. Ne-am orientat pe diagnosticul și tratamentul tromboembolismului venos (TEV). Rezultate. În statistica noastră de tratament al trombozei venoase profundă (TVP) nu am avut mortalitate la pacienții internați cu TVP. Concluzii. Tratamentul tradițional al TVP este eficient, dar o adaptare la folosirea noilor medicamente anticoagulante poate fi utilă pentru pacienți datorită faptului că prezintă unele avantaje. De asemenea, unele metode mecano-chimice nu trebuie să ne descurajeze în a le pune în practică dacă avem posibilitatea.
CURRENT TREATMENT OF DEEP VEIN THROMBOSIS. TREATMENT OF DEEP VEIN THROMBOSIS IN THE FIRST SURGICAL CLINIC OF THE EMERGENCY COUNTY HOSPITAL PIUS BRÎNZEU TIMISOARA - 5 YEARS STATISTICS MS. Murariu 1, Loredana Stroescu 2, Mihaela Avram 1, N. Pop 2, B. Magiar 2, A. Parau 2, Oana Radu 2, S. Pop 1, C. Ivan 1, Daniela Radu 1, V. Ivan 2, S. Olariu 1 1 First Clinic of Surgery, Department X of Surgery, University of Medicine and Pharmacy Victor Babeș Timișoara, România 2 Emergency County Hospital Pius Brînzeu Timișoara, România Introduction. Deep vein thrombosis (DVT) and pulmonary embolism (PE) are clinical forms of venous thromboembolism (VTE). As new anticoagulants appear, we may complete the therapeutic treatment of VTE. Material and method. We studied the anticoagulation options for acute VTE which include unfractionated heparin, low molecular weight heparin, the vitamin K antagonists (VKAs) and the utility of the new antithrombotic drugs as recommended by the international Guidelines. Also, we studied the cases with deep vein thrombosis (DVT) of the hospitalized patients in the First Surgical Clinic of the Emergency County Hospital Timisoara Pius Brînzeu Timișoara in the period between 2013-2017. We focused on the diagnosis and treatment of venous thromboembolism (VTE). Results. In our 5 years statistic of treatment of DVT we have no mortality at the hospitalized patients with DVT. Conclusions. The traditional treatment of DVT is effective, but an adjustment for using the new antithrombotic drugs may be useful to the patients because they have some advantages. Also, some mechanical-chemical methods must not discourage us from putting them into practice if we have the possibility. GHIDURILE DE PROFILAXIE A TROMBOZEI VENOASE PROFUNDE ÎN CHIRURGIA CLASICĂ SUNT VALABLE ÎN CHIRURGIA MODERNĂ? Avram M.F. 1, Cădariu Fl. 1, Avram I.O. 2,Koukoulas D. 3, Murariu M. 1,Olariu S 1 1 Clinica 1 Chirurgie, UMF V.Babeș, Timișoara, România 2 CaritasKlinikum Saarbrücken, Germania 3 Spitalul Municipal Lugoj, România Introducere: Fără efectuarea profilaxie riscul de tromboză venoasă profundă (TVP) și tromboembolism pulmonar (TEP) este de 10% în intervențile de chirurgie generală, de 30% în chirurgia ginecologică și ajunge la 50% în chirurgia ortopedică și chirurgia oncologică
majoră. În prezent chirurgia laparoscopică a câștigat teren în fața procedurilor chirurgicale clasice, deschise. Material şi metodă:. Am analizat beneficiile profilaxiei TVP în chirurgia laparoscopică.am analizat 648 de pacienți operați laparoscopic în Clinica Chirurgie 1. În timpul intervențiilor laparoscopice am identificat ca fiind factori de risc specifici pentru TVP: poziția pacientului și presiunea crescută indusă de pneumoperitoneu. Anticoagularea postoperatorie a fost introdusă la toți pacienții a căror operație a durat peste 2 ore și nu au avut risc de sângerare considerabil. Toți pacienții au fost examinați clinic postoperator, căutându-se semne locale de TVP și a fost efectuat doppler vascular în cazul paciențiilor a căror intervenție a fost mai lungă de 2 ore. Rezultate: Au fost confirmate eco-doppler 4 cazuri de TVP, dar nici unul din acești pacienți nu a avut acuze subiective sau semne clinice de tromboză. Luăm în discuție și ghidurile și recomandările de profilaxie a TVP și TEP elaborate de American College of Chest Physicians și de The Society of American Gastrointestinal and Endoscopic Surgeons subliniind aspectele legate de chirurgia endoscopică. Concluzii: Riscul relativ de TVP și TEP în chirurgia laparoscopică față de cea clasică nu este bine definit.studii extinse, bine conduse sunt necesare pentru elaborarea unor ghiduri specifice intervențiilor laparoscopice. ARE THE GUIDELINES FOR DEEP VEIN THROMBOSIS PROFILAXY IN CLASICAL SURGERY SUITABLE FOR MODERN SURGERY? Avram M.F. 1, Cădariu Fl. 1, Avram I.O. 2,Koukoulas D. 3, Murariu M. 1,Olariu S 1 1 Surgery Clinic no. 1, UMF V.Babeș, Timișoara, România 2 CaritasKlinikum Saarbrücken, Germany 3 Lugo Hospitalj, România Introduction: When no prophylaxis is made, the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) is 10% after general surgery interventions, 30% in gynecologic surgery and 50% in orthopedic surgery and major interventions for malignancies. Nowadays surgical procedures are mainly laparoscopic, open surgeries becoming less frequent than in the past. Material and method: We analyze and discuss the benefit of DVT prophylaxis in laparoscopic procedures. We included in the study 648 patients that underwent laparoscopic surgery. During the operation the position and the high intraabdominal pressure are risk factors for DVT. Therefore we introduced postoperative anticoagulation to all cases that lasted more than 2 hours and had no important hemorrhagic risk. We clinically checked all the patients for signs of DVT, we performed vascular echo Doppler examination to all patients with surgery that lasted longer than 2 hours.
Results: In 4 patients the diagnosis of DVT was confirmed, although no clinical signs or symptoms were present. We also discuss the current DVT prophylaxis guidelines elaborated by the American College of Chest Physicians as well as the recommendations elaborated by The Society of American Gastrointestinal and Endoscopic Surgeons highlighting the aspects regarding endoscopic surgery. Conclusions: The relative risk of DVT in laparoscopic surgery versus open procedures is not well defined. Laparoscopic intervention specific guidelines based on large, well conducted studies are needed. CHIRURGIA DE ZI FLEBOLOGICĂ EVOLUŢIE ŞI MANAGEMENT Cădariu Florentinaˡ, Enache Alexandra², Avram Mihaelaˡ, Olariu Sorinˡ 1 UMFT, Clinica Chirurgie 1, Timişoara, România 2 UMFT, Institutul de Medicină Legală, Timişoara, România Introducere: Lucrarea prezintă, pornind de la experiența personală, posibilităţile de management ale bolii varicoase în sistemul chirurgiei de zi și beneficiile economice aduse de aceasta Material şi metodă: Din totalul consultaţiilor chirurgicale acordate pacienţilor în Cabinetului Medical Chirurgie şi Flebologie Dr. Cădariu Florentina consultaţiile flebologice au reprezentat 14,7% din activitate. Având în vedere existenţa relativ recentă a flebologiei şi a chirurgiei ambulatorii, majoritatea cazurilor nou înregistrate prezintă insuficienţă venoasă cronică în stadii avansate IV-VI, cu leziuni trofice. Rezultate: Situaţia pacienţilor dispensarizati la nivelul cabinetulul se prezintă astfel: Etiologic: Varice hidrostatice 93,6%, Sindrom posttrombotic 6,4%; Evolutiv: IVC Clasa I-II 25%, IVC Clasa III-IV 57,5%, IVC Clasa V-VI 17,5%. Tratamentul complex al bolii varicoase este individualizat, costul total al acestuia crescând proportional cu stadiul evolutiv al bolii, fiind de până de zece ori mai mare decât costul profilaxiei primare. Concluzii:Activitatea în sistemul chirurgiei de zi necesită introducerea unor protocoale de selecţie a pacienţilor, protocoale şi ghiduri terapeutice, protocoale de colaborare cu MF, spital. În elaborarea acestor documente este necesară colaborarea între specialişti, asociaţiile profesionale şi instituţiile naţionale chirurgic, anestezişti, Colegiul Medicilor, Ministerul Sănătăţii, CNAS.
PHLEBOLOGICAL DAY SURGERY - EVOLUTION AND MANAGEMENT Cădariu Florentinaˡ, Enache Alexandra², Avram Mihaelaˡ, Olariu Sorinˡ 1 UMFT, Clinica Chirurgie 1, Timişoara, România 2 UMFT, Institutul de Medicină Legală, Timişoara, România Introduction: The paper presents, based on personal experience, the possibilities of management of varicose disease in the day surgery system and the economic benefits brought by it. Material and method: Of the total surgical consultations given to patients in "Cabinet Medical Surgery and Flebology Dr. Cădariu Florentina" phlebological consultations accounted for 14.7% of the activity. Given the relatively recent existence of phlebology and ambulatory surgery, most newly recorded cases have chronic venous insufficiency in advanced IV-VI stages with trophic lesions. Results: The situation of dispensary patients at the cabinet level is as follows: Etiologic: Hydrostatic varicose veins 93.6%, post-thrombotic syndrome 6.4%; Evolution: IVC Class I-II 25%, IVC Class III-IV 57.5%, IVC Class V-VI 17.5%. Complex treatment of varicose disease is individualized, with its total cost increasing proportionally to the evolutionary stage of the disease, up to ten times higher than the cost of primary prophylaxis. Conclusions: Activity in the day surgery system requires the introduction of patient selection protocols, protocols and therapeutic guides, collaboration protocols with the family doctors, hospital. The elaboration of these documents requires good collaboration between the specialists, the professional associations and the national institutions - surgical, anesthetists, the College of Physicians, the Ministry of Health, the CNAS. ACTUALITĂȚI ÎN TRATAMENTUL ANTITROMBOTIC AL ARTERIOPATIEI CRONICE OBLITERANTE Olinic D., Tătaru D., Homorodean C., Spînu M., Olinic Maria Secţia de Cardiologie II (Cardiologie Intervenţională), Spitalul Clinic Judeţean de Urgenţă Cluj, Universitatea de Medicină şi Farmacie Iuliu Haţieganu Cluj-Napoca Această lucrare acoperă actualitățile în tratamentul antitrombotic pentru arteriopatia cronică obliterantă a membrelor inferioare (ACOMI). Terapia dublă antiplachetară cu ticagrelor (60 mg b.i.d) și aspirină (75-100 mg zilnic) asigură o reducere semnificativă a evenimentelor
adverse cardiovasculare majore și poate fi luată în considerare la pacienții cu ACOMI simptomatică și cu antecedente de infarct miocardic. Utilizarea unui nou antagonist al receptorului de trombină, denumit vorapaxar, în asociere cu aspirină și / sau clopidogrel, reduce riscul de ischemie acută și de revascularizare periferică la pacienții cu ACOMI simptomatică, dar cu costul unui risc crescut de sângerare. Rivaroxaban (2,5 mg b.i.d) plus aspirină (100 mg pe zi) este prima asociere antitrombotică care a demonstrat un beneficiu semnificativ pentru pacienții cu ACOMI, în ceea ce privește obiective importante: mortalitatea totală și mortalitatea cardiovasculară. Prin urmare, această asociere are cele mai puternice dovezi pentru prevenție secundară. UPDATES IN ANTITHROMBOTIC TREATMENT IN PERIPHERAL ARTERY DISEASE Olinic D., Tătaru D., Homorodean C., Spînu M., Olinic Maria Interventional Cardiology, County Emergency Hospital Cluj, University of Medicine and Pharmacy Cluj-Napoca, România This review covers updates in antithrombotic use for peripheral arterial disease (PAD). Dual antiplatelet therapy with ticagrelor (60 mg b.i.d) and aspirin (75-100 mg daily) provides a significant reduction in major adverse cardiovascular events and may be considered in symptomatic PAD patients with prior myocardial infarction. The use of a new thrombin receptor antagonist, vorapaxar, on top of aspirin and/or clopidogrel, reduces the risk of acute limb ischemia and peripheral artery revascularization in patients with symptomatic PAD, at the cost of an increased risk for bleeding. Rivaroxaban (2.5 mg b.i.d) plus aspirin (100 mg daily) is the first antithrombotic association that proved significant benefit for PAD patients, in terms of strong endpoints: total mortality and cardiovascular mortality. Therefore, this association has the strongest evidence for secondary prevention. TRATAMENTUL ENDOVSCULAR AL ANEVRISMULUI DE AORTĂ TORACICĂ - PREZENTARE DE CAZ Spitalul Militar Central, București I. Droc,.l.Vlad,,L.Stan Pacient in varsta de 45 de ani, hipertensiv, dislipidemic, consumator cronic de alcool, internat pe sectia noastra in urma cu 5 luni cu anevrism de aorta toracica post-traumatic (dupa un