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

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

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

Magnusson et al EJVES 2001

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)

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

POST-THROMBOTIC SYNDROME

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

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

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

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

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

FROM BJORDAL … .1971… ..

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.)

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)

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)

Color-DUPLEX INVESTIGATION IN ULCER AREA

CFDI EVALUATION OVER ULCER AREA Rare bumbling perforators… .

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 ???????

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

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

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 )

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

"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… .