Shading FLOW DUPLEX IMAGING IN VENO-LYMPHATIC ULCER

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Shading FLOW DUPLEX IMAGING IN VENO-LYMPHATIC ULCER A. Cavezzi S.Benedetto del Tronto, Bologna www.cavezzi.it

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PHLEBO-LYMPHOPATHIC ULCER Causes: - Secondary Deep Venous Insufficiency (Post-thrombotic disorder) or Primary Deep Venous Insufficiency Superficial Venous Insufficiency Functional Venous Insufficiency: Muscle-Vascular Pump brokenness, heftiness, and so on. Lymphatic Dysfunction

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Serious Post-Thrombotic Syndrome with reflux in femoral, popliteal and tibial veins  supra-malleolar ulcer

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Magnusson et al EJVES 2001

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LITERATURE DATA Metanalysis 1980-1998 (1249 appendages with venous ulcers) * 92% with reflux, 8% without reflux * 45% reflux just in SVS, 12% reflux just in DVS, 43% reflux in SVS and DVS (Tassiopoulos AK, Golts E, Oh DS, Labropoulos N., EJVES ) L'incompetence of popliteal vein is a negative prognostic variable for ulcer recuperating (42 versus 10% ) ( Brittenden J, Bradbury AW, Allan PL, Prescott RJ, Harper DR, Ruckley CV, Br J Surg) C) Limbs with venos ulcer, in showdown with solid appendages, have a diminished launch portion and an expanded post-practice leftover (pump brokenness..) (Araki CT, Back TL, Padberg FT, Thompson PN, Jamil Z, Lee BC, Duran WN, Hobson RW; J Vasc Surg)

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CFDI AND SECONDARY DEEP VENOUS INSUFFICIENCY - POST-THROMBOTIC SYNDROME - conceivable industrious impediments (8%) - reflux because of post-thrombotic valvular ineptitude (33% secluded, half with thrombotic sub-occlusive changes) - morphologic and utilitarian condition of saphenous stems and of perforators - dilatation of security branches

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POST-THROMBOTIC SYNDROME

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S.P.T. - Stenosi V. Iliaca Esterna S.P.T.: DIFFERENZA ECOGRAFICA TESSUTI IN SEDE SOPRA (SX) ED ENTRO (DX) DISTROFIE CUTANEE

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Refl e/o Ostruz POST-THROMBOTIC SYNDROME: SYSTOLIC REFLUX OF SPJ AND ACTIVATION OF A SHUNT WITHIN GIACOMINI VEIN OR WITHIN SMALL SAPHENOUS VEIN

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ENLARGEMENT OF GIACOMINI VEIN IN POST-THROMBOTIC SYNDROME (PERSISTENT STENOSIS OF POPLITEAL VEIN AND SUPERFICIAL FEMORAL VEIN)

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CFDI AND SUPERFICIAL VENOUS INSUFFICIENCY Reflux/Retrograde stream in saphenous stems Incompetence of saphenous intersections or additional intersection refluxes Morphologic and haemodynamic condition of perforators Patency and capability of profound veins

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DISTRIBUZIONE SEGMENTARIA DEL REFLUSSO NELLA VGS 15 % 30 % 52 % 3 %

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FROM BJORDAL … .1971… ..

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PERFORATING VEINS : THEIR ROLE IN PRIMARY VARICOSE VEINS In essential varicose veins the lion's share of PV in the leg has a fundamental or single part of reentry in the profound venous framework Bi-directional stream in PV implies inadequacy, however not generally pathogenicity: in the "terminal" PVs of the leg the adjust (the net stream) of the bi-directional stream in the systolic stage (calf withdrawal) and in the diastolic stage (calf unwinding) is to a great extent for the reentry in the DVS: the PV might be bumbling, yet it is not pathologic … (Perthes, Bjordal, Bassi, Tibbs, Franceschi and so forth.)

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BASIC KNOWLEDGE ABOUT PERFORATORS a) solid subjects may have bi-directional stream (which were customarily considered as pathologic in the past writing ) in 20-30% of the appendages (Coleridge-Smith et al.) b) up to half of the perforators in the calf have NO valves… . , in this manner supporting an inflow or a surge as per the weight angles in the shallow and profound venous compartments (Several old and new anatomic studies)

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REFLUX MOVES FROM LSV TO A TRIBUTARY AND IT FINALLY RE-ENTERS IN THE DEEP VENOUS SYSTEM THROUGH A LARGE (5 MM DIAMETER ) RE-ENTRY PERFORATOR MINIMAL OUTWARD FLOW DURING MUSCLE COMPRESSION (SYSTOLE) AND REMARKABLE INWARD FLOW DURING MUSCLE RELAXATION (DIASTOLE)

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Color-DUPLEX INVESTIGATION IN ULCER AREA

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CFDI EVALUATION OVER ULCER AREA Rare bumbling perforators… .

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PRIMARY DEEP VENOUS INSUFFICIENCY Reflux in profound veins Reflux of saphenous veins No discoveries good with past DVT (thrombotic changes and so forth.) Generalized Dilatation of profound veins Incidence ???????

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ABOLITION OF DEEP VEIN REFLUX AFTER SURGERY/SCLEROTHERAPY OF SMALL SAPHENOUS VEIN

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Small Saphenous Vein Incompetence and Deep Vein Reflux Author/year Inc.DVS Method Somjen/1992 52% D Hauser/1993 86% D+Phleb. Sakurai/1997 44,9% (SFJ incl.) CD Brunner/1997 68,7% D+Phleb Daher/2001 39,7% D Recek/2002 100% D

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INCOMPETENCE OF SAPHENO-POPLITEAL JUNCTION AND DEEP VEIN REFLUX - Personal Experience - 162 appendages submitted to SSV surgery Pre-operation : 124 appendages (76%) retrograde stream in lower tract of shallow femoral vein and in popliteal vein (basically upper and medium tract) Post-operation : 95 appendages (77%) without retrograde stream in DVS, 27 appendages (21%) with retrograde stream enduring under 1 sec., 2 appendages with tireless retrograde stream in DVS (Cavezzi, Ta rabini, Collura, Sigismondi, Barboni, Carigi; Phlébologie 2002 )

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THE UNBEARABLE HEAVINESS OF BEING (M.Kundera returned to) … Functional Venous Insufficiency with Veno-Lymphatic Ulcer

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"Truly influenced legs (past huge ulcerations, genuine skin changes, phlebolymphoedema and so forth.) without whichever natural venous or lymphatic sickness: psychopathologic patient who lives about 20 hours a day stopping… : MUSCLE-VENOUS PUMP DYSFUNCTON… .

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