Guidelines for venous thromboembolism and clinical practice in Italy : a nationwide survey

INTRODUCTION: Venous thromboembolism (VTE) is a major health problem that has fostered the definition of specific guidelines by Scientific Societies. The type of procedure as well as trauma are crucial for VTE in surgical patients (General Surgery, Gynaecology and Orthopaedics). MATHERIALS AND METHODS: The project stemmed from a National grant from the Italian Ministry of research. A data-survey framework was prepared and made available as a form to be filled and was sent to 714 centres to investigate the application of the guidelines for VTE across the national territory. RESULTS: A number of 146 centres replied (20,4% of total): 48 Departments of General Surgery, 46 Departments of Ginaecology, 52 Departments of Orthopaedics. About 70% of the Centres had appropriate information about surgery as a risk factor for VTE. The answers have demonstrated an adequate knowledge of the instrumental and laboratory diagnostic pathways, useful to confirm diagnostic suspect of TE (80%). The data concerning diagnostic data waiting and morbidity/mortality have been further analyzed. Data waiting have been compared with morbidity and mortality rates related to DVT-PE that showed an increase of mortality connected to the diagnostic data timing of supply with an exponential trend linked to the data acquisition delay. CONCLUSIONS: Risk stratification and adequate application of prophylaxis and treatment devices represent a real possibility to control morbidity and mortality for VTE. Moreover diagnostic data waiting conditions adequate prophylaxis. In Italy, only the 40% of the centres is able to supply diagnostic data within 12 hours. KEY WORDS: Deep Vein Thrombosis, Pulmonary Embolism, Venous Thromboembolism, Guideline

Endo-laser and venous disease Italian group IEWG experience

Aim. In varicose vein surgery the scene is completely changed in the last 15 years. Studies on pathophisiology, and also anatomical, state a panorama of clinical-hemodinamic patterns deeply contrary to old single-culture of stripping in all cases. A remarkable new part is emerging with the endo-venous Laser treatment (E-L). An Italian Group participated activelly in the establishment of the International Endovenous-laser Working Group IEWG (1). For reasons of accountability, the members of the Italian Group decided as extremely important to pursue a working programme in which they used the same instruments and a step-by-step protocol. Methods. In a cooperative, multicenter, retrospective clinical study, 1076 patients, mean age of 54.5 years, 241 males and 809 females affected by CVI were considered eligible for surgery and stratified by CEAP classification, in a four-year period (January 1999 \u2013 December 2003). In all cases of associated varicosities there was troncular reflux at duplex scan examination. All the patients underwent surgery on the base of clinical-hemodinamic assessment to avoid different surgical indication (Ambulatory phlebectomy, CHIVA, or others). All the centres involved performed the treatment in conformity with FDA validated procedure, using endo-laser venous system kit with 810 (only in the first phase of experience)-980 nm diode laser (ELVeSTM ). Results. In the immediate post-operative period results have been impressive, with very effective closure of incompetent GSV and varicose veins treated (the early occlusion rate has been of 99%), major complications have not been detected: in particular, no DVT evaluated duplex ultrasound, above all considering the elevated medium age of the population. The patient\u2019s compliance and satisfaction to the procedure, measured from appropriate form on quality of life, has been much elevating, equal to 96,7%. No patient has expressed a null compliance to the procedure. At present we have over 6 year results but, in this study and in terms of long-time results, we considered a 36 months follow-up period. Controls have been carried out by duplex scan, according in average to a total medium in relationship to the number of treatments carried out from every centre. The total occlusion rate has been of 97%. Conclusion. Several reports have confirmed the efficacy and safety of E-L, as well as by Perrin\u2019s 2004-review (2), and the same IEWG presented a large experience in the 15th UIP World Congress (3). The present contribution confirms at mid/long-term the \uabgood\ubb result indicating some advantages with standard treatment against a sharing criticism about the no-comparison of many other Laser\u2019s techniques

Trattamento laser endovenoso : esperienze, evidenze, risultati

This study was conducted with the aim of showing the effects of Pycnogenol on controlling jet-lag symptoms. Oral Pycnogenol, 50 mg tablets 3 times/die, for 7 days starting 2 days prior to the flight was used. The study was divided into two separate parts. In study 1 the most common complaints of patients with jet-lag were evaluated with a rating scale consisting in of a scoring system. In study 2 a brain CT scan was performed after the flight in order to assess minimal brain edema (MBE) in association with typical signs and symptoms, observed in previous published flight studies. Study one included 38 subjects treated with Pycnogenol and 30 controls. The symptomatic jet-lag related total score was significantly lower (indicating a lower level of jet-lag) in the Pycnogenol group. The average duration of any jet lag symptom following the flight was significantly reduced from 39.3 (SD=0.8) hours in controls to an average of 18.2 (SD=3.3) hours in the Pycnogenol group (P<0.05). Study 2 included 34 subjects treated with Pycnogenol and 31 controls. The main observation was the brain CT scan performed within 28 hours after the end of the flight. The difference between the Pycnogenol and the control groups was statistically significant (P<0.05) for all items assessed including the cerebral edema score obtained by CT scan. The short-term memory was significantly altered in the control group and associated to edema and swelling of the lower limbs. The score (and the level of edema) was comparatively higher in a subgroup of hypertensive subjects in the control group. Minor alterations of cardiac function were observed in association with de-stabilisation of blood pressure. Fatigue was also significantly higher in the control group in comparison with the Pycnogenol group. A number of spontaneously reported symptoms was also scored and there was a statistically significant difference (P<0.05) between the Pycnogenol and control groups. In conlusion, Pycnogenol was useful to control jet-lag and minimal brain edema

Il ruolo dell\u2019EVLA nel trattamento endovascolare delle varici

Oggi, dopo la necessaria fase di insegnamento di base sui criteri di appropriatezza delle indicazioni, diagnostica, tecnologia, efficacia e sicurezza della metodica, ed aver creato modelli di procedura step-by-step, centinaia di migliaia di procedure vengono eseguite nel mondo. La Letteratura scientifica non \ue8 da meno con centinaia di pubblicazioni qualificate, review e meta-analisi. Il Corso sull\u2019endovascolare (RFA, EVLA e foamsclerotherapy) del Congresso Nazionale SIAPAV 2011 pertanto si pone come momento di apprendimento pratico, ma allo stesso tempo di riflessione sul cammino percorso in un decennio. In sintesi, la scelta di usare i nuovi trattamenti endovascolari permette la minor invasivit\ue0 e l\u2019ambulatoriet\ue0, e dunque i minori costi della terapia della MVC, oltre il massimo rispetto dell\u2019estetica, tutte moderne esigenze richieste da pazienti e Sistemi Sanitari. Le tecniche pi\uf9 innovative sono rappresentate dall\u2019ablazione fisica mediante RFA e EVLA. Quale laser, \ue8 preferito a diodi a varie lunghezze d\u2019onda; e su questo punto si \ue8 sviluppato maggiormente un significativo avanzamento con l\u2019introduzione di laser a lunghezza d\u2019onda di 1470nm, coniugato all\u2019uso di nuove fibre a emittenza radiale dell\u2019energia. La tecnica \ue8 semplice, a patto che si segua una buona scuola di apprendimento e criteri ben standardizzati. L\u2019introduzione nella vene safene per via percutanea o mini-chirurgica \ue8 opzione dello specialista. Risultati: la maggioranza dei casi trattati presenta percentuali di obliterazione immediate e a distanza superiori al 90% e significativa soddisfazione dei pazienti, spesso entusiastica. Il follow-up ha raggiunto oggi periodi di 10 anni (l\u2019EVLA fu riconosciuta ufficialmente dalla FDA nel 2001); e via via le numerose esperienze stanno raggiungendo il tempo necessario di validazione superiore a 3-5 anni, quanto la numerosit\ue0 casistica. In generale, si riscontrano poche controindicazioni specifiche

Some new considerations on venous valvuloplasty : an international on line debate

In 2008 a paper by John Opie, regarding the renewed role of venous valvuloplasty and an intriguing discussion took place on VASCULAB, a well known network on line with about 1300 expert members in phlebology guided by F. Passariello as conceiver and coordinator. The valvuloplasty attempts to reduce blood reflux and venous hypertension in chronic venous disease (CVD). The technique requires a skilled and experienced surgeon and a careful patient evaluation and selection. It could be a good approach in selected cases with post thrombotic syndrome (PTS). Some studies indicate in the nineties that valvuloplasty or valvular replacement is an effective treatment for venous incompetence in selective cases. After a concise valvuloplasty story from Kistner to Maleti, despite the advances in valvuloplasty, we point out that the surgical mainstay to correct CVD, deep and superficial or both, or primary varicose veins is great saphenous vein (GSV) ligation and stripping but also various conservative or endovascular treatments. Nevertheless actually some clinical studies have reported achieving long-term, effective competence of deep venous system, as well as the superficial venous system, both after valvuloplasty or by implanting an external vein support device. J. Opie identified as an optional surgical solution for the large underserved patient group of PTS a new technique: \uabmonocusp surgery\ubb. He presented a new surgical method to replace a dysfunctional aplastic / dysplastic / absent venous valve using the full thickness viable native vein wall tissue (the monocusp) and covered the defect with an ultrathin synthetic e-PTFE vascular closure patch (iVena\u2122e-PTFE patch) to successfully reverse venous insufficiency and its effects both early and long-term with limited complications. The description on monoscusp valvuloplasty by Opie in Vasculab was accurate. At the same time S. Camilli presented his technique of external stretching valvuloplasty with a new device is \uaboval shaped external support \uab(OSES), made by a Nitinol net-like framework, very smooth, elastic and flexible, available in different size. The OSES device is suitable for the terminal and pre-terminal valves of the GSV and virtually for any peripheral venous valve, on superficial and deep system, also without ligation of the possible present competent collaterals. The discussion was ample and very interesting with the contributes of C. Recek, B.B. Lee, C. Franceschi, O. Maleti and others, included J. Opie and S. Camilli. In general, R. Kistner considerations about Maleti's technique are true for all valvuloplasties: \uabI find no fault with valvuloplasty and I am anxious to see if others can duplicate the experience. Points that need to be expanded in these experiences are how many cases were evaluated and found not to be candidates for this procedure, the length of the learning curve for producing a reliably competent valve, and whether there is any sign that these new valves will degenerate with time. If this technique can be successful, the next question will be whether it can be achieved in a more minimally invasive method\ubb