The term vascular anomaly represents a broad spectrum of vascular pathology, including proliferating vascular tumours and vascular malformations. While the treatment of most vascular anomalies is multifactorial, interventional radiology procedures, including embolic therapy, sclerotherapy and laser coagulation among others, are playing an increasingly important role in vascular anomaly management. This review discusses the diagnosis and treatment of common vascular malformations, with emphasis on the technique, efficacy and complications of different interventional radiology procedures.

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Vascular anomalies: classification, imaging characteristics and implications for interventional radiology treatment approaches.

Background Endovenous thermal ablation has revolutionised varicose vein treatment. New non-thermal techniques such as mechanical occlusion chemically assisted endovenous ablation (MOCA) allow treatment of entire trunks with single anaesthetic injections. Previous non-randomised work has shown reduced pain post-operatively with MOCA. This study presents a multi-centre randomised controlled trial assessing the difference in pain during truncal ablation using MOCA and radiofrequency endovenous ablation (RFA) with six months' follow-up. Methods Patients undergoing local anaesthetic endovenous ablation for primary varicose veins were randomised to either MOCA or RFA. Pain scores using Visual Analogue Scale and number scale (0-10) during truncal ablation were recorded. Adjunctive procedures were completed subsequently. Pain after phlebectomy was not assessed. Patients were reviewed at one and six months with clinical scores, quality of life scores and duplex ultrasound assessment of the treated leg. Results A total of 170 patients were recruited over a 21-month period from 240 screened. Patients in the MOCA group experienced significantly less maximum pain during the procedure by Visual Analogue Scale (MOCA median 15 mm (interquartile range 7-36 mm) versus RFA 34 mm (interquartile range 16-53 mm), p = 0.003) and number scale (MOCA median 3 (interquartile range 1-5) versus RFA 4 mm (interquartile range 3-6.5), p = 0.002). ' Average' pain scores were also significantly less in the MOCA group; 74% underwent simultaneous phlebectomy. Occlusion rates, clinical severity scores, disease specific and generic quality of life scores were similar between groups at one and six months. There were two deep vein thromboses, one in each group. Conclusion Pain secondary to truncal ablation is less painful with MOCA than RFA with similar short-term technical, quality of life and safety outcomes.

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A multi-centre randomised controlled trial comparing radiofrequency and mechanical occlusion chemically assisted ablation of varicose veins - Final results of the Venefit versus Clarivein for varicose veins trial.

Aim:Endovenous thermal ablation (ETA) procedures are catheter-directed, ultrasound (US)-guided thermal methods for treatment in varicose veins disease. Radiofrequency, laser or steam energy thermal...

Guidelines of the First International Consensus Conference on Endovenous Thermal Ablation for Varicose Vein Disease – ETAV Consensus Meeting 2012:

Background Nonthermal, tumescentless devices are the next generation of minimally invasive devices to treat varicose veins. We aimed to investigate the effects of mechanochemical ablation (MOCA) using ClariVein (Vascular Insights, Quincy, Mass) on ex vivo great saphenous vein with histology and immunofluorescent staining. Methods Extrafascial great saphenous veins were harvested during surgery for varicose veins and were treated ex vivo for 10 to 11 minutes with either liquid sclerotherapy or the use of ClariVein, with and without 3% sodium tetradecyl sulfate. Veins were sectioned and subjected to hematoxylin and eosin staining and immunofluorescent staining for endothelial and smooth muscle cell markers (CD31 and α-actin) to assess overall damage and cell death in the vein wall compared with control sections. Results Histologic observations confirmed intimal damage from ClariVein, as has been previously shown; however, medial damage was also evident, which was not observed in control or liquid sclerotherapy sections. Immunofluorescent staining in the three sections studied showed a 42% decrease in CD31 staining and 27% mean reduction in α-actin staining up to a depth of 300 μm with liquid sclerotherapy. This cytotoxic effect was significantly enhanced by MOCA with a reduction in CD31 staining just above 60% and a 46% mean decrease in α-actin staining noted up to a depth of 300 μm. Far greater reductions in staining compared with sclerotherapy were observed up to a depth of 600 μm. Conclusions MOCA using 3% sodium tetradecyl sulfate increases the penetration of the sclerosant and its effect into the vein wall and shows superior rates of tissue destruction compared with liquid sclerotherapy alone. In this model, it appears not solely to damage the endothelium but also to shear the medial layer, creating small lesions into which sclerosant can flow and exert its cytotoxic effect.

Mechanochemical ablation causes endothelial and medial damage to the vein wall resulting in deeper penetration of sclerosant compared with sclerotherapy alone in extrafascial great saphenous vein using an ex vivo model

ObjectivesThe ClariVein® system is an endovenous technique that uses mechano-chemical ablation to treat incompetent truncal veins. This study was conducted to identify the ideal Polidocanol dosage ...

Clarivein® mechano-chemical ablation an interim analysis of a randomized controlled trial dose-finding study.

Aim Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid of foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy. Methods This guideline was drafted on behalf of 23 European Phlebological Societies during Guideline Conference on 7-10 May 2012 in Mainz. The conference was organized by the German Society of Phlebology. These guidelines review the present state of knowledge as reflected in published medical literature. The regulatory situation of sclerosant drugs differs from country to country but this has not been considered in this document. The recommendations of this guiedeline are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strenght of Recommendations and Quality of Evidence in Clinical Guidelines. Results This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, polidokanol and sodium tetradecyl sulphate. Other sclerosants are dot discussed in detail. The guideline gives recommendations concerning indications, contraindications, side-effects, concentrations, volumes, technique and efficacy of liquid and foam sclerotherapy of varicose veins and venous malformations.

European guidelines for sclerotherapy in chronic venous disorders

Carboxytherapy is a supportive method in chronic wound treatment conducted by cutaneous and subcutaneous injection of medical carbon dioxide (CO2). The primary effect of the injected CO2 is the correction of tissue hypoxia due to the Bohr effect. With its effects on endothelial growth factors, it stimulates neoangiogenesis and fibroblast collagen synthesis consequently leading to better wound healing. Carboxytherapy is used in many areas from chronic wound treatment, peripheral venous and arterial diseases, dermatological diseases, to cosmetic medicine. It is minimally invasive, patients take it well, it is economically acceptable, and it can be conducted in outpatient conditions by properly trained doctors. The application of new technologic innovations in the healing processes, education and teamwork combined with developed holistic individual approach ensure good cooperation and mutual doctor-patient communication, enhance patient care and improve their quality of life.

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[Carboxytherapy - supportive therapy in chronic wound treatment].

Pojava rana, cijeljenje, odgođeno cijeljenje i pojam kronične rane možemo reći, osnovna su značajka svih živih bića. Kod čovjeka se u procesu cijeljenja događaju brojni procesi kojima se, čak i u idealnim prilikama, stvara funkcionalno manje vrijedno ožiljno tkivo uz strukturne i funkcionalne promjene. U području ožiljka na mjestima izloženosti većim silama može doći do stvaranja rana. Takve rane otežano cijele unatoč nepostojanju drugih mogućih razloga otežanog cijeljenja. Prisutnost rane kao i dugotrajnost liječenja utječu na sve sfere života bolesnika te dovode do pada kvalitete života. Prikazom bolesnika s posttraumatskom ranom u području ožiljka u našoj ustanovi opisan je model skrbi prema principu sveobuhvatne individualizirane skrbi uz biopsihosocijalni pristup. Dijagnostičko-terapijski postupci uključivali su procjenu rane, prepoznavanje biofi lma, limfedema, ocjenu psihosocijalnog statusa bolesnika, čimbenika rizika za cijeljenje te ultrazvučnu dijagnostiku, primjenu karboksiterapije kao specijalizirane adjuvantne terapije, korištenje suvremenih pokrivala za rane te primjenu kompresivne terapije. U pozitivnom okruženju tijekom liječenja provođena je suportivna psihoterapija. Partnerskim odnosom s bolesnikom utjecalo se ne samo na cijeljenje rane, što je bio primarni cilj, već i na podizanje ukupne kvalitete bolesnikova života kao i na naše profesionalno zadovoljstvo postignutim rezultatom. U skrbi za bolesnike s kroničnim ranama sudjeluju liječnici obiteljske medicine i dio su multidisciplinarnog tima stručnjaka. Za takvu skrb potrebna su dodatna specifi čna znanja i vještine kako bi se mogla pružiti sveobuhvatna kvalitetna skrb kao nadopuna postojećim znanjima, vještinama i iskustvu rada u obiteljskoj medicini.

Individualizirani pristup bolesniku s kroničnom ranom u obiteljskoj medicini

Karboksiterapija je potporna metoda liječenja kroničnih rana koja se provodi kutanim ili subkutanim ubrizgavanjem medicinskog ugljičnog dioksida (Co 2 ). osnovni princip djelovanja ubrizganog plina Co 2 je korekcija tkivne hipoksije temeljem Bohrovog efekta. Djelujući na endotelne faktore rasta potiče neoangiogenezu te stimuliraju ibroblaste na sintezu kolagena što sve zajedno dovodi do boljeg zacjeljivanja rana. Brojna su područja primjene karboksiterapije: od liječenja kroničnih rana, bolesti perifernih vena i arterija te dermatoloških bolesti do primjene u estetskoj medicini. Vrijednost karboksiterapije jest u tome što je minimalno invazivna, dobro je podnošljiva, ekonomski prihvatljiva, provediva od educiranih liječnika u ambulantnim uvjetima.

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Jadranka Kovačević

Papers

European guidelines for sclerotherapy in chronic venous disorders

[Carboxytherapy - supportive therapy in chronic wound treatment].

Individualizirani pristup bolesniku s kroničnom ranom u obiteljskoj medicini

Vrijednost karboksiterapije pri liječenju kronične rane potkoljenice

Value of carboxytherapy in chronic leg ulcer treatment