Post-thrombotic syndrome in the Middle Age

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John J. Bergan, 1927-2014

John Bergan was born on August 4, 1927 and graduated in Medicine at the University of Indiana in 1954. He spent the residency in surgery at the Chicago Wesley Memorial Hospital and in 1960 was certified in the American Board of Surgery. The body of his academic career took place at the North Western University in Chicago, where he devoted himself to vascular surgery and also to its applications in transplantation surgery. Scrolling through the records of the North-Western Registry, it turns out that John performed his first kidney transplant as the first operator in 1964, and was Director of the program till 1976. However, for the European phlebologist John was the ambassador of Phlébologie in the United States of America. Two were his key meetings in the field. The first was with Geza de Takats, a forerunner of the modern Phlebology, who operated for long time in Chicago. John was in strong contact with this Mentor, to the point that he wrote the obituary on Surgery in 1986, when he died. The second was the stellar conjunction with James S. T. Yao at the NorthWestern University. Together they released the first complete text-book of Phlebology in the United States, Venous Problems, at the end of the 70's. In the 80's, he was one of the Founding Fathers of the American Venus forum, at the famous first meeting at the hotel of Coronado, and, subsequently, President. But he also served as President the American College of Phlebology. This because was an eclectic and multi-core phlebologist, equally interested and curious about the new features in outpatient practice, as well as in cutting-edge research applied to the venous system. The last years of his academic career were actively spent in a climate much more favourable compared to Illinois, at the University of California San Diego, in La Jolla, where he continued to work and publish on veins. Few years ago Claude Franceschi and me taught venous haemodynamics, at a course organised in Arizona by our common friend Nick Morrison. I will never forget that he sat smiling and enthusiastic between the desks of the trainees. He was a giant in Phlebology, but always curious about new things, and was not afraid to get into the game.John was a true gentleman, with whom it was nice to have a discussion or even dispute a controversy, thanks to his unforgettable elegance.Paolo Zamboni University of Ferrara, Ital

Imaging the lymphatic system.

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The discovery of the brain lymphatic system

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extracranial veins in multiple sclerosis is there a role for vascular surgery

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In memory of Leonardo Corcos

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What are the ideal characteristics of a venous stent?

Historically, the stents used in the venous system were not dedicated scaffolds. They were largely adapted arterial stents. An essential feature of a venous stent is compliance, in order to adapt its crosssectional area to the vein. It should also be crush resistant, corrosion resistant and fatigue resistant. The material should be radiopaque, for follow-up. Another characteristic of the ideal venous stent is flexibility, to adapt its shape to the vein, not vice versa. The scaffold should be uncovered too, in order to avoid the occlusion of collaterals. The ideal venous stent should not migrate, so it is necessary a large diameter and a long length. The radial force is important to prevent migration. However, current stents derived from arterial use display high radial force, which could affect the patency of the thin venous wall. Alternatively, if the stent has an anchor point, that permits a passive anchoring, the radial force required to avoid migration will be lower. Dedicated venous stents were not available until very recently. Furthermore, there is a preclinical study about a new compliant nitinol stent, denominated Petalo CVS. Out of the commonest causes of large veins obstruction, dedicated venous stent could also treat other diseases described more recently, such as the jugular variant of the Eagle syndrome, JEDI syndrome and jugular lesions of the chronic cerebrospinal venous insufficiency that result unfavorable for angioplasty according to Giaquinta classification

Influence of chronic cerebrospinal venous insufficiency on demyelinating diseases

We analyzed all the arguments against chronic cerebrospinal venous insufficiency (CCSVI) as a medical entity, and its association with a disabling demyelinating disease, multiple sclerosis (MS). We revised all the findings suggesting a possible connection between these two entities. By comparing the results obtained by different study groups, we noted a great variability in prevalence of CCSVI in MS patients, ranging from 0 to 100%. Overall the reported prevalence is respectively 70% in MS vs. 10% in controls, and a recent meta-analysis assessed an over 13 times increased prevalence in MS. Postmortem studies show a higher prevalence of intraluminal defects in the main cerebral extracranial vein in MS patients respect to controls. Several pathophysiological studies demonstrate correlation between CCSVI and neglected vascular aspects of MS. Particularly, global hypo-perfusion of the brain, as well as reduced cerebral spinal fluid dynamics inMS was shown to be related to CCSVI. After careful review of all obtained data we can conclude that great variability in prevalence of CCSVI in MS patients can be a result of different methodologies used in vein assessment, training, application of unapproved diagnostic criteria, or different approach to the problem itself. By many studies it has been shown that CCSVI can be inserted in the list of multiple factors involved in pathogenesis ofMS, aswell as other neurodegenerative diseases

Laser-assisted strategy for reflux abolition in a modified CHIVA approach

The aim of this study was to assess feasibility and efficacy of an endovenous laser (EL) assisted saphenous-sparing strategy in chronic venous disease (CVD). Fourteen CVD patients (C2,3,4s Ep As Pr1,2,3) underwent a saphenofemoral junction (SFJ) treatment by EL just from below the superficial epigastric vein downward for a limited tract, together with a flush ligation of the incompetent tributaries of the great saphenous vein (GSV) along the leg. The following GSV parameters were assessed 15 cm below the SFJ: reflux time, caliber, peak systolic velocity (PSV), end diastolic velocity (EDV), resistance index (RI). Venous clinical severity score and the Clinical, Etiological, Anatomical, and Pathophysio logical (CEAP) classification clinical classes were assessed. At 1 year follow up 3 cases were considered failures because of a GSV thrombosis, even if they presented a GSV recanalization with a laminar flow within at the 2 years follow-up. Eleven procedures succeeded because neither minor nor major peri-procedural complications were reported, apart 2 cases of self-healing bruising. In these last 11 cases the procedure led to a GSV reflux suppression (from 3.1±0.4 s to a retrograde laminar draining flow), to a GSV caliber reduction (from 9.4±0.5 to 3.1±0.2 cm, P<0.001), to a PSV reduction (from 50.2±4.6 to 18.4±3.5 cm/s, P<0.001), to a RI reduction (from 0.9±0.2 to 0.51±0.2, P<0.005) and to an oscillatory flow suppression (EDV from -8.9±1.6 to 6.2±2.3 cm/s, P<0.001). Both CEAP and venous clinical severity score improved from 3 to 1 (P<0.001) and from 7±2 to 2±1 (P<0.05), respectively. The GSV flow reappeared below the shrunk tract draining into the re-entry perforator. Sapheno-femoral reflux suppression can be obtained by just a GSV segmental closure. An almost 80% of success rate of the present investigation paves the way for an even wider diffusion of endovenous techniques, moreover erasing the surgical requirements for those who would like to perform a saphenoussparing strategy. In this way new devices could be used inside equally innovative strategies