Crossing of a critically stenosed aortic valve is a pivotal step during diagnostic cardiac catheterization to measure
the transvalvular gradient, especially in patients with discordant clinical and echocardiographic findings and also during transcatheter aortic valve replacement procedures. However, there are no data in the literature indicating whether aortic valve
crossing typically occurs during systole or diastole. We hypothesize that aortic valve crossing is a diastolic phenomenon and
describe our technique for crossing critically stenosed aortic valves.
Cardiac Measurements Guidelines | powered by EsaoteMIDEAS
Complete routine cardiac measurements Guidelines.
1) Left Ventricle:
a) Size: Dimensions or volumes, at end-systole and end-diastole
b) Wall thickness and/or mass: Ventricular septum and left ventricular posterior wall thicknesses (at end-systole and end-diastole) and/or mass (at end-diastole)
c) Function: Assessment of systolic function and regional wall motion. Assessment
of diastolic function
2) Left Atrium:
• Size: Area or dimension
3) Aortic Root:
• Dimension
4) Right Ventricle:
Size: Dimensions
Function: Systolic and diastolic function
RV & pulmonary hemodynamics
5) Right Atrium:
a) Size: Dimensions, area
b) RA pressure
6) Valvular Stenosis:
a) Valvular Stenosis: Assessment of severity, including trans-valvular gradient and area.
b) Subvalvular Stenosis: Assessment of severity, Including subvalvular gradient.
7) Valvular Regurgitation: Assessment of severity with semi-quantitative descriptive statements and/or quantitative measurements
8) Cardiac Shunts: Assessment of severity. Measurements of QP:QS (pulmonary-to systemic flow ratio) and/or orifice area or diameter of the defect are often helpful.
9) Prosthetic Valves:
a) Transvalvular gradient and effective orifice area
b) Description of regurgitation, if present
By the end of the module, you will be able to:
Define Arterio Venous Fistula and Arterio Venous Graft
Identify Complications and Management
Familiarise and use the Pre Needling Cannulation Tool
Crossing of a critically stenosed aortic valve is a pivotal step during diagnostic cardiac catheterization to measure
the transvalvular gradient, especially in patients with discordant clinical and echocardiographic findings and also during transcatheter aortic valve replacement procedures. However, there are no data in the literature indicating whether aortic valve
crossing typically occurs during systole or diastole. We hypothesize that aortic valve crossing is a diastolic phenomenon and
describe our technique for crossing critically stenosed aortic valves.
Cardiac Measurements Guidelines | powered by EsaoteMIDEAS
Complete routine cardiac measurements Guidelines.
1) Left Ventricle:
a) Size: Dimensions or volumes, at end-systole and end-diastole
b) Wall thickness and/or mass: Ventricular septum and left ventricular posterior wall thicknesses (at end-systole and end-diastole) and/or mass (at end-diastole)
c) Function: Assessment of systolic function and regional wall motion. Assessment
of diastolic function
2) Left Atrium:
• Size: Area or dimension
3) Aortic Root:
• Dimension
4) Right Ventricle:
Size: Dimensions
Function: Systolic and diastolic function
RV & pulmonary hemodynamics
5) Right Atrium:
a) Size: Dimensions, area
b) RA pressure
6) Valvular Stenosis:
a) Valvular Stenosis: Assessment of severity, including trans-valvular gradient and area.
b) Subvalvular Stenosis: Assessment of severity, Including subvalvular gradient.
7) Valvular Regurgitation: Assessment of severity with semi-quantitative descriptive statements and/or quantitative measurements
8) Cardiac Shunts: Assessment of severity. Measurements of QP:QS (pulmonary-to systemic flow ratio) and/or orifice area or diameter of the defect are often helpful.
9) Prosthetic Valves:
a) Transvalvular gradient and effective orifice area
b) Description of regurgitation, if present
By the end of the module, you will be able to:
Define Arterio Venous Fistula and Arterio Venous Graft
Identify Complications and Management
Familiarise and use the Pre Needling Cannulation Tool
Can read freely here
https://sethiortho.blogspot.com/
A COMPARISON OF RECOMBINANT UROKINASE WITH VASCULAR SURGERY AS INITIAL TREATMENT FOR ACUTE ARTERIAL OCCLUSION OF THE LEGS
For the thrombolysis or peripheral arterial surgery (TOPAS) investigators RCT
The Rochester study -1994
Surgery Vs Thrombolysis for Ischemia of the Lower Extremity (STILE) - 1996
endovascular surgery
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Surat @ℂall @Girls ꧁❤8527049040❤꧂@ℂall @Girls Service Vip Top Model Safe
Chiva today 2014
1. CHIVA TODAY 2014
From theory to scientific evidence
C. Franceschi (Paris France Cremona ITALY)
2. To raise new questions, new possibilities, toTo raise new questions, new possibilities, to
regard old problems from a new angle,regard old problems from a new angle,
requires creative imagination and marks realrequires creative imagination and marks real
advance in scienceadvance in science
Albert EinsteinAlbert Einstein
5. CHIVA’S STORY
-An hemodynamic pattern
proposed 26 years ago.
-Proved 20 years later by
Controlled Randomized Trials
and COCHRANE review
6. Friedrich TRENDELENBURG 1890
Benjamin BRODIE 1846
Tomaso RIMA 1775- 1843
Everard HOME 1799
Ambroise PARE 1509-1590
CHIVA Precursors
Georg Clemens PERTHES 1900
William HARVEY 1578-1657
7. 1788-1899: Ligation of Saphena
Vein
Trendelenburg
1988: CHIVA
Varicocentric
Ablative
1906 Stripping Mayo
Babcok
1947 Sclerosis
2000 RF, Laser, Foam
Short Story
90 years90 years
blackoutblackout
Varicocentric
Ablative
Emodinamicocentric
Conservative
9. HEMODYNAMIC
CONCEPTS PUBLISHED
IN 1988.
Varicose veins and trophic changes are not the
cause but the effect of overloading pressure/flow
The consequent treatment consists of correcting
this hemodynamic impairment in order to collapse
the varicose veins, restore the tissue health and
reduce the varicose recurrence thanks to
overloading flows disconnection and draining
veins conservation, included varicose.
11. HEMODYNAMIC CONCEPTS
1-Dynamic Fractioning of the Hydrostatic Pressure
2-Closed and Open Shunts
3-Vicarious Varicose Recurrence
4-Saphena Conservation for Future Arterial By-pass
5-Anato-functional Mapping.
12. i P
o P
p P
c P
s g P
ig P
i P
o P
p P
c P
gs P
g s P
20032003
Identification of pelvic leak points: Inguinal (IP) Perinaeal (PP), Clitorudian (CP) Obturator OP) Gluteal
( SGP and IGP)
Franceschi C, Bahnini A. Treatment of lower extremity venous insufficiency due to pelvic leak points in
women. Ann Vasc Surg. 2005 Mar;19(2):284-8
ANATOMIC LOCATION OF PELVIC LEAK POINTS
17. CHIVA cure :
1/Hydrostatic Pressure column fractionning :
restore the dynamic fractionning of the hydrostatic
column during walking
2/Closed and deviated shunts disconnection :
suppresses flow/pressure overloading supplied by
the VM Pump during walking
3/Draining Veins conservation: avoids residual
pressure excesses responsible for spider veins
and varicose recurrence
4/ Venous Capital Conservation for future
possible need of arterial by-pass
19. Treatments
Venous Sysytem Impairment
Venous Blocks P.Residual P↑
Valve Incompetence Hydrostatic P ↑
Shunts VM Pump P ↑
Hemodynamic Disfunction
Trans Mural Pressure PTM
↑
causes
Genetic Malformazioni Biological
Infezione
Flebiti
Infiamazione
Iatrogenic
Veins ablation
Effects
Dilation Venous
Varicose Veins
Draiange Impairement
Edema
Hypodermitis
Ulcer
Vicious
Circle
PTM↓
Posture
Compression
Veinblock: liberation, by-
pass
Valve repair
CHIVA
Venous Hypertension
posture, obesity
according to the cause
20. Varico Centric Hemodinamico Centric
TMP REDUCTIONTMP REDUCTION
P ExtraVenous Pressure IncreaseP ExtraVenous Pressure Increase
-Compression-Compression
IntraVenous Pressure DecreaseIntraVenous Pressure Decrease
-Posture-Posture
-Liberation-Liberation
VEINS ABLATIONVEINS ABLATION
-Phlebectomy-Phlebectomy
-Sclerosis-Sclerosis
-Laser-Laser
-Radio Frequency-Radio Frequency
IMPAIRS the DRAINAGEIMPAIRS the DRAINAGE
Tissue sufferingTissue suffering
Vicarious RecurrenceVicarious Recurrence
Destruction of the VENOUSDestruction of the VENOUS
CAPITALCAPITAL
CHIVACHIVA
-HP Fragmentation-HP Fragmentation
-Shunt Disconnection-Shunt Disconnection
--Drainage respectDrainage respect
-Venous capital preservation-Venous capital preservation
TREATMENTS
21. OOSS
OO
SFSF
vv aa
MM
Flow/pressurFlow/pressur
e overloade overload
VicariousVicarious
flowflow
FistoleFistole
Artéro-Artéro-
VenosusVenosus
fistulefistule
ClosedClosed
shuntshunt
VenousVenous
malformationmalformation
TMPTMP increases with flow and pressure overload due toincreases with flow and pressure overload due to
various causesvarious causes
HydrostaticHydrostatic
PressurePressure
excessexcess
22. CHIVA is not only avaricose treatment
CHIVA is also the treatment of the cause of
the venous insuficiency
i.e the TMP excess.
When TMP is reduced to normal, all signs
and symptoms are cured: Varicose veins,
Edema, Hypodermitis, Ulcer
23. CHIVA doesn’t depend on
the direction of the
varicose progression ,
downwards or upwards
25. 1- Varicose Vein Surgery Stripping versus the CHIVA method:
a Randomized
Controlled Trial Josep oriol
Pares and al Annals
of Surgery * Volume 251, Number 4, April 2010 [ISRCTN52861672].[ISRCTN52861672]. (international(international
standard randomised controlled trial number )www.controlled-trials.comstandard randomised controlled trial number )www.controlled-trials.com
2- Minimally Invasive Surgical management of primary venous Ulcer vs.
Compression Treatment: a randomized Clinical Trial
P.Zamboni and all
Eur J vasc Endovasc Surg 00,1 6 (2003)
3- Clinical and random study comparing two, surgical techniques for varicose
vein treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
4-Varicose Vein Stripping vs Haemodynamic Correction (CHIVA):
a Long Term Randomised Trial.
Carandina, C. and al.
Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011
26. 1- Varicose Vein Surgery Stripping versus the CHIVA method:
a Randomized
Controlled Trial Josep oriol
Pares and al Annals
of Surgery * Volume 251, Number 4, April 2010 [ISRCTN52861672].[ISRCTN52861672]. (international(international
standard randomised controlled trial number )www.controlled-trials.comstandard randomised controlled trial number )www.controlled-trials.com
2- Minimally Invasive Surgical management of primary venous Ulcer vs.
Compression Treatment: a randomized Clinical Trial
P.Zamboni and all
Eur J vasc Endovasc Surg 00,1 6 (2003)
3- Clinical and random study comparing two, surgical techniques for varicose
vein treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
4-Varicose Vein Stripping vs Haemodynamic Correction (CHIVA):
a Long Term Randomised Trial.
Carandina, C. and al.
Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011
27. 0
10
20
30
40
50
60
70
464 465 459 453 458 457
6m 12m 24m 36m 48m 60m
%
Ph-M
Ph-ED
TC
St -MC
St -ED
TC
5ans. 550 Patients
Up to 18 months: NO differenceUp to 18 months: NO difference
Difference increases with time after 2 yearsDifference increases with time after 2 years
CHIVA
Stripp. Duplex guided
Stripp. Clinical
5 years follow up : Recurrence rate:5 years follow up : Recurrence rate:
CHIVA vs strippingCHIVA vs stripping
28. 0
10
20
30
40
50
60
70
464 465 459 453 458 457
6m 12m 24m 36m 48m 60m
%
Ph-M
Ph-ED
TC
St -MC
St -ED
TC
5ans. 550 Patients
Duplex Guided Vs Clinical : NO differenceDuplex Guided Vs Clinical : NO difference
Duplex is USLESS for strippingDuplex is USLESS for stripping
CHIVA
Stripp. Duplex guided
Stripp. Clinical
5 years follow up : Recurrence rate:5 years follow up : Recurrence rate:
CHIVA vs strippingCHIVA vs stripping
29. 1- Varicose Vein Surgery Stripping versus the CHIVA method:
a Randomized
Controlled Trial Josep oriol
Pares and al Annals
of Surgery * Volume 251, Number 4, April 2010 [ISRCTN52861672].[ISRCTN52861672]. (international(international
standard randomised controlled trial number )www.controlled-trials.comstandard randomised controlled trial number )www.controlled-trials.com
2- Minimally Invasive Surgical management of primary venous Ulcer vs.
Compression Treatment: a randomized Clinical Trial
P.Zamboni and all
Eur J vasc Endovasc Surg 00,1 6 (2003)
3- Clinical and random study comparing two, surgical techniques for varicose
vein treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
4-Varicose Vein Stripping vs Haemodynamic Correction (CHIVA):
a Long Term Randomised Trial.
Carandina, C. and al.
Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011
30. KAPLAN-MEIR ESTIMATIONKAPLAN-MEIR ESTIMATION
1.01.0
0.80.8
0.60.6
0.40.4
0.20.2
00
1.01.0
0.80.8
0.60.6
0.40.4
0.20.2
00
00 250250 500500 500500750750 10001000
TIME (days)TIME (days)
CHIVACHIVA
compressioncompression
Minimally invasive surgical management of primary venousMinimally invasive surgical management of primary venous
ulcers vs. compression treatment: a randomized clinical trial..ulcers vs. compression treatment: a randomized clinical trial..
Zamboni Pand al A.Zamboni Pand al A. EJ V E S. 2003EJ V E S. 2003
31. 1- Varicose Vein Surgery Stripping versus the CHIVA method:
a Randomized
Controlled Trial Josep oriol
Pares and al Annals
of Surgery * Volume 251, Number 4, April 2010 [ISRCTN52861672].[ISRCTN52861672]. (international(international
standard randomised controlled trial number )www.controlled-trials.comstandard randomised controlled trial number )www.controlled-trials.com
2- Minimally Invasive Surgical management of primary venous Ulcer vs.
Compression Treatment: a randomized Clinical Trial
P.Zamboni and all
Eur J vasc Endovasc Surg 00,1 6 (2003)
3- Clinical and random study comparing two, surgical techniques for varicose
vein treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
4-Varicose Vein Stripping vs Haemodynamic Correction (CHIVA):
a Long Term Randomised Trial.
Carandina, C. and al.
Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011
32. Clinical and random study comparing two, surgical techniques for varicose vein
treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
immediate results: NO DIFFERENCE
In accordance with O.Pares where
CHIVA vs Stripping difference starts
after the 18th month!
33. 1- Varicose Vein Surgery Stripping versus the CHIVA method:
a Randomized
Controlled Trial Josep oriol
Pares and al Annals
of Surgery * Volume 251, Number 4, April 2010 [ISRCTN52861672].[ISRCTN52861672]. (international(international
standard randomised controlled trial number )www.controlled-trials.comstandard randomised controlled trial number )www.controlled-trials.com
2- Minimally Invasive Surgical management of primary venous Ulcer vs.
Compression Treatment: a randomized Clinical Trial
P.Zamboni and all
Eur J vasc Endovasc Surg 00,1 6 (2003)
3- Clinical and random study comparing two, surgical techniques for varicose
vein treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
4-Varicose Vein Stripping vs Haemodynamic Correction (CHIVA):
a Long Term Randomised Trial.
Carandina, C. and al.
Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011
35. 1 COCHRANE REVIEW
CHIVA vs Stripping
Less recurrences, less complications
Bellmunt-Montoya S, Escribano JM, Dilme J, Martinez-
Zapata MJ. CHIVA method for the treatment of chronic
venous insufficiency. Cochrane Database of Systematic
Reviews 2012 , Issue 2 . Art. No.: CD009648.
DOI:10.1002/14651858.CD009648 .
36. EVIDENCES Level Grade
meta-analyses de RCT
Ia A Strong
Au moins un RCT
Ib
Au moins une étude clinique
bien conduite sans
randomisation
IIa B Mid
Au moins un autre type
d’étude clinique bien
programmé et quasi
expérimental
IIb
Au moins un autre type
d’étude clinique bien
programmée et non
expérimentale
III
Opinions de comités
d’experts ou expérience
d’autorités reconnues
IV C Weak
Other venous technics at this level????
Stripping still Gold standard? CHIVA ?
CHIVA (4 RCT)
CHIVA (4 RCT)
+ Cochrane Library REVEW
37. Retrospective study CHIVA vs LASER
.
Chan, C.-Y.a , Chen, T.-C.b , Hsieh, Y.-K.a , Huang, J.-
H.c
Retrospective comparison of clinical outcomes between
endovenous laser and saphenous vein-sparing surgery
for treatment of varicose veins (2011) World Journal of
Surgery, 35 (7), pp. 1679-1686.
Conclusion: The CHIVA patients had less pain
postoperatively and a significantly higher sclerotherapy-free
period compared to patients in the EVL group.
38. GUIDELINES
• The care of patients with varicose veins and associated chronic venous
diseases: Clinical practice guidelines of the Society for Vascular Surgery and
the American Venous Forum
• Peter Gloviczki, MD, and al. JVS 2011
• Results with preservation of the saphenous vein. Results with CHIVA. Two
RCTs188,191 compared standard treatment(compression or high ligation, stripping,
and phlebectomy) with CHIVA approaches with specific anatomic patterns of reflux
(types I and III shunts). For the specific venous anatomy evaluated in these
trials, such techniques were better than compression in preventing ulcer
recurrence and were at least equivalent to stripping of varicose veins. Although
the first two RCTs focused on a small group of patients with varicose veins, the trial of
Pares et al deserves credit for including the full spectrum of patients with primary
varicose veins. CHIVA is a complex approach, and a high level of training and
experience is needed to attain the results presented in this RCT. However, the
results achieved by a few outstanding interventionists does not support offering this
procedure to all practitioners.Although CHIVA has called attention to the importance
of directing surgical procedures toward the patient’s venous anatomy and function, it
still requires considerable education of venous interventionists willing to learn
this approach.
39. CHIVA requires considerable education of venous
interventionists willing to learn this approach” (Peter
Gloviczki, MD, and al. JVS 2011) because it relies on new
hemodynamic concepts of the venous pathophysiology and
a proper DUS assessment method. CHIVA performed by
who doesn’t know enough about them is not CHIVA and
leads to failure as a study demonstrated it (Milone M,
Salvatore G, Maietta P, Sosa Fernandez LM, Milone
Recurrent varicose veins of the lower limbs after
surgery. Role of surgical technique (stripping vs.
CHIVA) and surgeon's experience.F. G Chir. 2011 Nov-
Dec;32(11-12):460-3).So, conservation is possible in all
the patients and CHIVA
40. …..today, treatments are
performed in accordance
with the evidence based
medicine supplied by
Randomized Controlled
Trials ….and after a
comprehensive
information and consent
of the patient.
President of
Medicine
Academy
41. CHIVA preserves the GSV for future arterial bypass
Optimal management of infrainguinal arterial occlusive disease
Authors: Pennywell DJ, Tan TW, Zhang WW
Full text: available on http://www.dovepress.com/article_18926.t34346121
Risk factors:Age is the most important, nonmodifiable risk factor for PAD, with a
prevalence of 0.9% in people under age 50 and 23.2% in people over the age of
80.1
Open reconstruction:The most important determinant of success of an
Infrainguinal lower extremity bypass (LEB) is the type and quality of conduit
selected.2,17,52 Autogenous vein is superior to synthetic graft as conduit for
LEB,2,53–55 and the great saphenous vein (GSV) is superior to other
autologous alternatives.2,55,56 An essential step in preoperative planning is
evaluation of the GSV with duplex mapping and identification of alternative vein
conduits, if needed. An ideal vein conduit should be soft, compressible, at least 3
mm in diameter, and should not be calcified or sclerotic. If the ipsilateral GSV is
unsuitable or unavailable, the contralateral GSV should be used.
Conclusion
Open infrainguinal bypass remains the gold standard for revascularization
in CLI, especially for patients at appropriate surgical risk and with suitable bypass
conduit.
42. Is it professional not to give the best
scientifically proved treatment to the
patient?
Is it honest to tell the patient his
saphena wouldn’t be usefull in case of
arterial by-pass necessity?
Editor's Notes
Chap12 Fig 6 Ulcer recurrences a 3 years after CHIVA I or CHIVA I+II performed for venous ulcers, straight line, and by standard compression, interrupted line.
Chap12 Fig 11 Hobbs score (best 1 worse 4) was significantly better after 10 years in the haemodynamic CHIVA group ( 1.9 vs 2.2 , P< 0.038).