1. A recent paper by John Opie discussed renewed interest in venous valvuloplasty and sparked debate online.
2. Venous valvuloplasty aims to reduce blood reflux and venous hypertension in chronic venous disease. It requires an experienced surgeon and careful patient selection.
3. While advances have been made, the main surgical approach for chronic venous insufficiency remains great saphenous vein ligation and stripping. However, some studies show valvuloplasty or external vein support devices can achieve long-term competence of both deep and superficial veins.
Acs0613 Surgical Treatment Of The Infected Aortic Graftmedbookonline
This document discusses surgical treatment options for infected aortic grafts. The primary goal is to remove all infected material while maintaining adequate circulation. Options include extra-anatomic bypass, aortic allografts, antibiotic-treated prosthetic grafts, and in situ replacement with a femoral-popliteal vein graft. The preferred method is in situ replacement with an autogenous femoral-popliteal vein graft due to its excellent long-term patency and resistance to reinfection. The procedure involves harvesting the vein, controlling the femoral vessels, removing the infected graft, and reconstructing with the vein graft. Meticulous technique is required to minimize complications.
This document summarizes venous thromboembolism (VTE), specifically deep vein thrombosis (DVT). It discusses how DVT is typically treated with anticoagulation to prevent further clotting, but this does not restore vein function. The document then focuses on how thrombolysis can restore flow and improve outcomes by reducing postthrombotic syndrome and recurrent DVT. For patients with iliofemoral DVT, thrombolysis often reveals underlying venous outflow obstructions that require treatment, such as with stents, to prevent reclotting and improve patency. The document provides guidance on indications for venous stenting after thrombolysis and the technique for performing stent placement.
Presentation made by Dr. Hiranya A. Rajasinghe about Popliteal Artery Aneurysms: When to Treat Inclusion and Exclusion Criteria for Endovascular Repair
Anestesia para px con aneurisma (colocación de stent)kiria5
This document discusses anesthesia considerations for patients undergoing endovascular stenting for aortic aneurysms. Endovascular stenting carries less risk than open surgery by avoiding aortic dissection, blood loss, and fluid shifts. However, long term outcomes remain uncertain compared to open surgery. Anesthesia aims to properly place the stent graft to seal tears, decompress false lumens, and reduce rupture risk while monitoring for complications. Transesophageal echocardiography is used to guide the procedure and ensure exclusion of lesions. Care is taken to exclude initial intimal tears in dissections. Endovascular stenting is generally preferred over open surgery for patients with multiple comorbidities.
This document discusses infrainguinal arterial procedures, focusing on femoropopliteal bypass surgery. It begins with an overview of preoperative testing and imaging, including duplex scanning, MRI angiography, CT angiography, and conventional angiography. The key steps of an above-the-knee femoropopliteal bypass are then described in detail, including harvesting the great saphenous vein, exposing the femoral artery, and exposing the popliteal artery distally. The bypass is performed by anastomosing the vein graft proximally to the femoral artery and distally to the popliteal artery above the knee. Precise surgical technique is important for successful bypass outcomes.
Acs0616 Repair Of Femoral And Popliteal Artery Aneurysmsmedbookonline
Femoral and popliteal artery aneurysms are the most common type of peripheral aneurysms. While rarely rupturing, they can cause limb-threatening complications like embolization and thrombosis if left untreated. The optimal treatment is elective repair and reconstruction, rather than emergency repair after complications occur. Factors like symptoms, aneurysm size, and extent of disease help determine the appropriate treatment approach. Preoperative evaluation involves imaging to characterize the aneurysm and assess inflow and outflow vessels. The goals of surgical repair are to eliminate embolic risk, prevent rupture, relieve mass effect if present, restore distal limb perfusion, and achieve durable reconstruction.
comprehensive updated review for teaching purpose
download power point presentation from this link
https://www.mediafire.com/file/r68kwhmp82f4j4g/Popliteal_artery_aneurysm.pptx/file
TCT 2010 research highlights: A slideshow presentation theheart.org
http://www.theheart.org/editorial-program/1128553.do
The 22nd annual Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium took place in Washington. Key trials presented at the meeting include: PARTNER, ZILVER PTX, ISAR-TEST 4,SORT-OUT 4, COMPARE,SPIRIT IV, HORIZONS-AMI, BIOFREEDOM, PROTECT-AF, CAP and Robotically assisted PCI
Acs0613 Surgical Treatment Of The Infected Aortic Graftmedbookonline
This document discusses surgical treatment options for infected aortic grafts. The primary goal is to remove all infected material while maintaining adequate circulation. Options include extra-anatomic bypass, aortic allografts, antibiotic-treated prosthetic grafts, and in situ replacement with a femoral-popliteal vein graft. The preferred method is in situ replacement with an autogenous femoral-popliteal vein graft due to its excellent long-term patency and resistance to reinfection. The procedure involves harvesting the vein, controlling the femoral vessels, removing the infected graft, and reconstructing with the vein graft. Meticulous technique is required to minimize complications.
This document summarizes venous thromboembolism (VTE), specifically deep vein thrombosis (DVT). It discusses how DVT is typically treated with anticoagulation to prevent further clotting, but this does not restore vein function. The document then focuses on how thrombolysis can restore flow and improve outcomes by reducing postthrombotic syndrome and recurrent DVT. For patients with iliofemoral DVT, thrombolysis often reveals underlying venous outflow obstructions that require treatment, such as with stents, to prevent reclotting and improve patency. The document provides guidance on indications for venous stenting after thrombolysis and the technique for performing stent placement.
Presentation made by Dr. Hiranya A. Rajasinghe about Popliteal Artery Aneurysms: When to Treat Inclusion and Exclusion Criteria for Endovascular Repair
Anestesia para px con aneurisma (colocación de stent)kiria5
This document discusses anesthesia considerations for patients undergoing endovascular stenting for aortic aneurysms. Endovascular stenting carries less risk than open surgery by avoiding aortic dissection, blood loss, and fluid shifts. However, long term outcomes remain uncertain compared to open surgery. Anesthesia aims to properly place the stent graft to seal tears, decompress false lumens, and reduce rupture risk while monitoring for complications. Transesophageal echocardiography is used to guide the procedure and ensure exclusion of lesions. Care is taken to exclude initial intimal tears in dissections. Endovascular stenting is generally preferred over open surgery for patients with multiple comorbidities.
This document discusses infrainguinal arterial procedures, focusing on femoropopliteal bypass surgery. It begins with an overview of preoperative testing and imaging, including duplex scanning, MRI angiography, CT angiography, and conventional angiography. The key steps of an above-the-knee femoropopliteal bypass are then described in detail, including harvesting the great saphenous vein, exposing the femoral artery, and exposing the popliteal artery distally. The bypass is performed by anastomosing the vein graft proximally to the femoral artery and distally to the popliteal artery above the knee. Precise surgical technique is important for successful bypass outcomes.
Acs0616 Repair Of Femoral And Popliteal Artery Aneurysmsmedbookonline
Femoral and popliteal artery aneurysms are the most common type of peripheral aneurysms. While rarely rupturing, they can cause limb-threatening complications like embolization and thrombosis if left untreated. The optimal treatment is elective repair and reconstruction, rather than emergency repair after complications occur. Factors like symptoms, aneurysm size, and extent of disease help determine the appropriate treatment approach. Preoperative evaluation involves imaging to characterize the aneurysm and assess inflow and outflow vessels. The goals of surgical repair are to eliminate embolic risk, prevent rupture, relieve mass effect if present, restore distal limb perfusion, and achieve durable reconstruction.
comprehensive updated review for teaching purpose
download power point presentation from this link
https://www.mediafire.com/file/r68kwhmp82f4j4g/Popliteal_artery_aneurysm.pptx/file
TCT 2010 research highlights: A slideshow presentation theheart.org
http://www.theheart.org/editorial-program/1128553.do
The 22nd annual Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium took place in Washington. Key trials presented at the meeting include: PARTNER, ZILVER PTX, ISAR-TEST 4,SORT-OUT 4, COMPARE,SPIRIT IV, HORIZONS-AMI, BIOFREEDOM, PROTECT-AF, CAP and Robotically assisted PCI
The clincs coartacion de aorta y stentsDiego Escobar
This document discusses stenting options for coarctation of the aorta. It notes that coarctation is a narrowing of the aorta that can cause hypertension and other health issues if left untreated. The document reviews the history of surgical repair and balloon angioplasty for treatment. It indicates that bare metal stents are now commonly used but have risks of aneurysm formation and injury. Covered stents have benefits of reducing aortic wall injury but require larger delivery systems. The document provides indications and guidelines for treatment, noting factors that make covered stents preferable such as aneurysms, ductus arteriosus, or older patient age.
Intraoperative Intrasac Thrombin Injection to Prevent Type II Endoleak After Endovascular Abdominal Aortic
Aneurysm Repair
(Chirurgia Vascolare-ULSS 15 Alta Padovana)
(Vascular Surgery -ULSS 15 Alta Padovana)
This document discusses procedures for revascularization of the upper extremities. It focuses on brachial embolectomy for acute arm ischemia, which accounts for one-fifth of acute limb ischemia cases. The brachial artery is the most common site of emboli. Selection of patients includes all with acute-onset arm ischemia, except those who are terminally ill or unfit for surgery. The procedure involves exposing the brachial, ulnar, and radial arteries through a lazy-S incision and removing any clots via an arteriotomy. Outcomes are generally good, with 95% of patients symptom-free after successful embolectomy, though operative mortality may be as high as 12%.
Surgery for left ventricular aneurysm our experience Abdulsalam Taha
This document presents a retrospective study of 36 patients in Iraq who underwent surgery for left ventricular aneurysms caused by myocardial infarction over 12 years. Patch ventriculoplasty was the most common surgical technique used. Over 90% of patients also received myocardial revascularization. The study found that despite the small number of patients and low ejection fraction in most, the short-term outcomes were good and similar to international standards. The authors believe left ventricular aneurysm surgery should be combined with revascularization of the left anterior descending artery when possible.
This document discusses hybrid operating rooms and procedures that combine endovascular and open surgical techniques. It begins by explaining the rationale for hybrid approaches, which allow treating more complex cardiac conditions while minimizing invasiveness. A hybrid OR has capabilities for both endovascular interventions and open surgery simultaneously. Key components include cath lab and surgical equipment that can be used together. The document discusses examples like using a stent graft with open surgery for aortic aneurysm or replacing valves percutaneously along with coronary artery bypass. It emphasizes teamwork and convergence of specialties to determine the best individualized approach. Hybrid procedures may reduce recovery time compared to traditional open surgery alone.
This document discusses saphenous vein graft interventions. It covers the natural progression of saphenous vein graft disease over time, techniques for intervening on saphenous vein grafts such as thrombectomy and aspiration thrombectomy, potential complications, and the role of stents and supportive medications. Distal protection devices are mentioned as a way to prevent distal embolization during saphenous vein graft interventions. Clinical trials demonstrate reductions in adverse events when using distal protection compared to routine stenting without protection.
This document describes three case studies of endovascular embolization procedures to treat type II endoleaks. In the first case, a type II endoleak was accessed through tortuous lumbar vessels and embolized using fibered platinum coils. The second case also involved embolizing an aneurysm sac and feeding vessels through difficult lumbar anatomy using microcatheters and coils. In the third case, coils were deployed through the inferior mesenteric artery to treat an endoleak. The document discusses the technical challenges of these procedures and how fibered coil designs can help achieve stasis in large volumes.
This document discusses endovascular interventions for infrapopliteal peripheral vascular disease. Infrapopliteal disease is rising due to an aging population and increased rates of diabetes and kidney disease. Surgical and early endovascular interventions historically had high failure rates in this region. Endovascular procedures now provide an alternative to bypass surgery for treating critical limb ischemia in the infrapopliteal arteries, with the goal of establishing straight line blood flow to the foot. Success depends on factors like number of vessels opened, inflow status, and addressing more proximal disease first when needed. Complications can include access issues, vessel spasm or perforation, embolism, and contrast nephropathy.
Allograft replacement for infrarenal aortic graft infectionuvcd
This document summarizes the use of cryopreserved arterial allografts to treat abdominal aortic graft infections. It provides background on abdominal aortic graft infections, including classification, clinical manifestations, diagnosis, and standard surgical treatment involving resection and oversewing of the native aorta. The study described aimed to evaluate the safety and efficacy of using cryopreserved arterial allografts for reconstruction in 19 patients. Results found early postoperative mortality was 36.8%, including some allograft-related deaths. Late mortality was 10.53%. Complications included ruptures and thromboses. The conclusion is that cryopreserved arterial allografts seem to be a useful option for treating abdominal aortic infections.
Stent assisted reconstruction of difficult aneurysms in acute subarachnoid he...Dr Vipul Gupta
This document summarizes the experience of a single center in using stent-assisted reconstruction to treat difficult aneurysms in patients presenting with acute subarachnoid hemorrhage. It describes treating 35 aneurysms in 33 patients that were not amenable to standard coiling, balloon-assisted coiling, or surgery. Stent placement was used to support the neck of wide-neck or dissecting/blister aneurysms to avoid coil protrusion. Most patients (28 of 33) had good outcomes, while 2 had management morbidity and 3 died. The results demonstrate stent-assisted coiling is a viable option for challenging aneurysms in acute subarachnoid hemorrhage cases.
The document discusses the concept of angiosomes in the foot and its relevance to vascular surgery. It defines angiosomes as tissue fed by source arteries and notes there are typically 5-6 angiosomes in the foot from the three main leg arteries. Several studies are reviewed that compare outcomes of direct revascularization within the target angiosome versus indirect revascularization, with some finding improved healing rates with direct approaches. However, the evidence is limited by the retrospective nature of the studies. Overall, direct revascularization may provide benefits in some high-risk cases, but more prospective research is still needed.
This document discusses hybrid coronary revascularization (HCR), which combines coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). HCR was introduced in 1996 as a treatment for multivessel coronary artery disease. It aims to reduce surgical trauma while preserving long-term survival and minimizing adverse events. The hybrid approach involves using a left internal mammary artery graft for the left anterior descending artery and PCI for other lesions. This takes advantage of the excellent outcomes of the arterial graft and improvements in stents. HCR may provide benefits for higher surgical risk patients and allow shorter recovery times compared to traditional CABG. However, some debate remains around its additional complexity and costs compared to established treatments.
This document provides information on left ventricular aneurysms including:
- A timeline of important discoveries and advances in LV aneurysm research and treatment from 1757 to 1958.
- Definitions, gross pathology, microscopic pathology, location, and natural history of LV aneurysms.
- Clinical features and diagnostic criteria for LV aneurysms.
- Surgical techniques for repairing LV aneurysms including plication, linear closure, patch closure, and endoventricular circular patch repair.
This article describes a novel technique of peri-venous compression following ultrasound-guided sclerotherapy (UGS) to treat incompetent great and small saphenous veins. The technique involves injecting normal saline around the vein following foam sclerotherapy injections to compress the vein. Early results on 47 limbs treated with this method found a 10.7% re-treatment rate to fully ablate the veins, lower than rates reported in other UGS studies. No significant adverse effects were observed with this technique. The authors conclude that peri-venous compression may reduce early recurrence rates after foam UGS for saphenous vein treatment by improving contact between the sclerosant and vein walls.
1. Complete chordal preservation during mitral valve surgery aims to preserve left ventricular function and geometry by maintaining the continuity between the mitral annulus and left ventricular wall.
2. Early studies found benefits to chordal preservation such as improved cardiac output, exercise capacity, and survival rates.
3. Various surgical techniques have been developed to allow for implantation of an adequate sized prosthesis while preventing complications like left ventricular outflow tract obstruction.
This document discusses balloon-assisted coiling techniques for treating aneurysms. It notes that balloon-assisted coiling provides better immediate and follow-up occlusion rates compared to standalone coiling, though it may carry a higher risk of complications compared to standalone coiling. The document reviews the history and uses of balloon-assisted coiling, complications, techniques for different aneurysm situations, outcomes data on occlusion rates, and debates around its appropriate use compared to standalone coiling and stent-assisted coiling.
Endo vascular treatment of infected aa as is surgıcal draınage and debrıdemen...uvcd
1) Endovascular treatment of infected abdominal aortic aneurysms (AAAs) is an alternative to open surgery that provides less invasive and rapid aneurysm exclusion with prompt bleeding control.
2) Successful endovascular repair requires broad-spectrum antibiotics, adjunct procedures like surgical debridement for eliminating infection sources, and prolonged antibiotic therapy.
3) Endovascular repair alone may be sufficient for well-controlled infections, while unstable patients may require additional drainage; long-term antibiotic therapy is always needed.
This study describes the experiences of 24 patients treated for complex middle cerebral artery (MCA) aneurysms using bypass surgery combined with parent vessel occlusion. The aneurysms ranged in size from 7-60mm, with most being giant or fusiform. Bypass surgeries included extracranial-intracranial and intracranial-intracranial bypass procedures. Parent vessel occlusion involved partial or total trapping, with or without aneurysm resection. Outcomes were generally good, with 100% aneurysm obliteration and 21 patients (88%) having good functional outcomes, though permanent deficits occurred in 5 patients, most associated with M1 aneurysms. Location of the aneurysm was an important factor in planning treatment
This document summarizes recent developments in coronary intervention. It discusses newer generation drug-eluting stents (DES) with ultra-thin struts that have been shown in randomized trials to have lower target lesion failure, mortality, myocardial infarction, and stent thrombosis compared to older DES. It also summarizes the results of the RESTORE-SVD trial which found that in patients with small vessel disease, DES were superior to drug-coated balloons for reducing death or myocardial infarction at 1 year. Finally, it mentions the COACT study which found that in women with acute myocardial infarction, the use of DES during primary percutaneous coronary intervention reduced mortality at 90 days compared to plain old balloon angioplasty.
The document contains information about a student named Sandra Silva who attends The American School in Puerto Montt, Chile. Sandra Silva is enrolled in 7th grade basic education at the school. The document provides Sandra Silva's name, school, location of the school, and grade level.
The document discusses a programming assignment for a CSE340 class on principles of programming languages. It provides an overview of the assignment which involves modifying source code to implement a parser for a grammar. It includes the grammar rules to be implemented, sample code for the parser implementation, and example input programs to test the parser. It also reviews concepts like predictive parsing.
The clincs coartacion de aorta y stentsDiego Escobar
This document discusses stenting options for coarctation of the aorta. It notes that coarctation is a narrowing of the aorta that can cause hypertension and other health issues if left untreated. The document reviews the history of surgical repair and balloon angioplasty for treatment. It indicates that bare metal stents are now commonly used but have risks of aneurysm formation and injury. Covered stents have benefits of reducing aortic wall injury but require larger delivery systems. The document provides indications and guidelines for treatment, noting factors that make covered stents preferable such as aneurysms, ductus arteriosus, or older patient age.
Intraoperative Intrasac Thrombin Injection to Prevent Type II Endoleak After Endovascular Abdominal Aortic
Aneurysm Repair
(Chirurgia Vascolare-ULSS 15 Alta Padovana)
(Vascular Surgery -ULSS 15 Alta Padovana)
This document discusses procedures for revascularization of the upper extremities. It focuses on brachial embolectomy for acute arm ischemia, which accounts for one-fifth of acute limb ischemia cases. The brachial artery is the most common site of emboli. Selection of patients includes all with acute-onset arm ischemia, except those who are terminally ill or unfit for surgery. The procedure involves exposing the brachial, ulnar, and radial arteries through a lazy-S incision and removing any clots via an arteriotomy. Outcomes are generally good, with 95% of patients symptom-free after successful embolectomy, though operative mortality may be as high as 12%.
Surgery for left ventricular aneurysm our experience Abdulsalam Taha
This document presents a retrospective study of 36 patients in Iraq who underwent surgery for left ventricular aneurysms caused by myocardial infarction over 12 years. Patch ventriculoplasty was the most common surgical technique used. Over 90% of patients also received myocardial revascularization. The study found that despite the small number of patients and low ejection fraction in most, the short-term outcomes were good and similar to international standards. The authors believe left ventricular aneurysm surgery should be combined with revascularization of the left anterior descending artery when possible.
This document discusses hybrid operating rooms and procedures that combine endovascular and open surgical techniques. It begins by explaining the rationale for hybrid approaches, which allow treating more complex cardiac conditions while minimizing invasiveness. A hybrid OR has capabilities for both endovascular interventions and open surgery simultaneously. Key components include cath lab and surgical equipment that can be used together. The document discusses examples like using a stent graft with open surgery for aortic aneurysm or replacing valves percutaneously along with coronary artery bypass. It emphasizes teamwork and convergence of specialties to determine the best individualized approach. Hybrid procedures may reduce recovery time compared to traditional open surgery alone.
This document discusses saphenous vein graft interventions. It covers the natural progression of saphenous vein graft disease over time, techniques for intervening on saphenous vein grafts such as thrombectomy and aspiration thrombectomy, potential complications, and the role of stents and supportive medications. Distal protection devices are mentioned as a way to prevent distal embolization during saphenous vein graft interventions. Clinical trials demonstrate reductions in adverse events when using distal protection compared to routine stenting without protection.
This document describes three case studies of endovascular embolization procedures to treat type II endoleaks. In the first case, a type II endoleak was accessed through tortuous lumbar vessels and embolized using fibered platinum coils. The second case also involved embolizing an aneurysm sac and feeding vessels through difficult lumbar anatomy using microcatheters and coils. In the third case, coils were deployed through the inferior mesenteric artery to treat an endoleak. The document discusses the technical challenges of these procedures and how fibered coil designs can help achieve stasis in large volumes.
This document discusses endovascular interventions for infrapopliteal peripheral vascular disease. Infrapopliteal disease is rising due to an aging population and increased rates of diabetes and kidney disease. Surgical and early endovascular interventions historically had high failure rates in this region. Endovascular procedures now provide an alternative to bypass surgery for treating critical limb ischemia in the infrapopliteal arteries, with the goal of establishing straight line blood flow to the foot. Success depends on factors like number of vessels opened, inflow status, and addressing more proximal disease first when needed. Complications can include access issues, vessel spasm or perforation, embolism, and contrast nephropathy.
Allograft replacement for infrarenal aortic graft infectionuvcd
This document summarizes the use of cryopreserved arterial allografts to treat abdominal aortic graft infections. It provides background on abdominal aortic graft infections, including classification, clinical manifestations, diagnosis, and standard surgical treatment involving resection and oversewing of the native aorta. The study described aimed to evaluate the safety and efficacy of using cryopreserved arterial allografts for reconstruction in 19 patients. Results found early postoperative mortality was 36.8%, including some allograft-related deaths. Late mortality was 10.53%. Complications included ruptures and thromboses. The conclusion is that cryopreserved arterial allografts seem to be a useful option for treating abdominal aortic infections.
Stent assisted reconstruction of difficult aneurysms in acute subarachnoid he...Dr Vipul Gupta
This document summarizes the experience of a single center in using stent-assisted reconstruction to treat difficult aneurysms in patients presenting with acute subarachnoid hemorrhage. It describes treating 35 aneurysms in 33 patients that were not amenable to standard coiling, balloon-assisted coiling, or surgery. Stent placement was used to support the neck of wide-neck or dissecting/blister aneurysms to avoid coil protrusion. Most patients (28 of 33) had good outcomes, while 2 had management morbidity and 3 died. The results demonstrate stent-assisted coiling is a viable option for challenging aneurysms in acute subarachnoid hemorrhage cases.
The document discusses the concept of angiosomes in the foot and its relevance to vascular surgery. It defines angiosomes as tissue fed by source arteries and notes there are typically 5-6 angiosomes in the foot from the three main leg arteries. Several studies are reviewed that compare outcomes of direct revascularization within the target angiosome versus indirect revascularization, with some finding improved healing rates with direct approaches. However, the evidence is limited by the retrospective nature of the studies. Overall, direct revascularization may provide benefits in some high-risk cases, but more prospective research is still needed.
This document discusses hybrid coronary revascularization (HCR), which combines coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). HCR was introduced in 1996 as a treatment for multivessel coronary artery disease. It aims to reduce surgical trauma while preserving long-term survival and minimizing adverse events. The hybrid approach involves using a left internal mammary artery graft for the left anterior descending artery and PCI for other lesions. This takes advantage of the excellent outcomes of the arterial graft and improvements in stents. HCR may provide benefits for higher surgical risk patients and allow shorter recovery times compared to traditional CABG. However, some debate remains around its additional complexity and costs compared to established treatments.
This document provides information on left ventricular aneurysms including:
- A timeline of important discoveries and advances in LV aneurysm research and treatment from 1757 to 1958.
- Definitions, gross pathology, microscopic pathology, location, and natural history of LV aneurysms.
- Clinical features and diagnostic criteria for LV aneurysms.
- Surgical techniques for repairing LV aneurysms including plication, linear closure, patch closure, and endoventricular circular patch repair.
This article describes a novel technique of peri-venous compression following ultrasound-guided sclerotherapy (UGS) to treat incompetent great and small saphenous veins. The technique involves injecting normal saline around the vein following foam sclerotherapy injections to compress the vein. Early results on 47 limbs treated with this method found a 10.7% re-treatment rate to fully ablate the veins, lower than rates reported in other UGS studies. No significant adverse effects were observed with this technique. The authors conclude that peri-venous compression may reduce early recurrence rates after foam UGS for saphenous vein treatment by improving contact between the sclerosant and vein walls.
1. Complete chordal preservation during mitral valve surgery aims to preserve left ventricular function and geometry by maintaining the continuity between the mitral annulus and left ventricular wall.
2. Early studies found benefits to chordal preservation such as improved cardiac output, exercise capacity, and survival rates.
3. Various surgical techniques have been developed to allow for implantation of an adequate sized prosthesis while preventing complications like left ventricular outflow tract obstruction.
This document discusses balloon-assisted coiling techniques for treating aneurysms. It notes that balloon-assisted coiling provides better immediate and follow-up occlusion rates compared to standalone coiling, though it may carry a higher risk of complications compared to standalone coiling. The document reviews the history and uses of balloon-assisted coiling, complications, techniques for different aneurysm situations, outcomes data on occlusion rates, and debates around its appropriate use compared to standalone coiling and stent-assisted coiling.
Endo vascular treatment of infected aa as is surgıcal draınage and debrıdemen...uvcd
1) Endovascular treatment of infected abdominal aortic aneurysms (AAAs) is an alternative to open surgery that provides less invasive and rapid aneurysm exclusion with prompt bleeding control.
2) Successful endovascular repair requires broad-spectrum antibiotics, adjunct procedures like surgical debridement for eliminating infection sources, and prolonged antibiotic therapy.
3) Endovascular repair alone may be sufficient for well-controlled infections, while unstable patients may require additional drainage; long-term antibiotic therapy is always needed.
This study describes the experiences of 24 patients treated for complex middle cerebral artery (MCA) aneurysms using bypass surgery combined with parent vessel occlusion. The aneurysms ranged in size from 7-60mm, with most being giant or fusiform. Bypass surgeries included extracranial-intracranial and intracranial-intracranial bypass procedures. Parent vessel occlusion involved partial or total trapping, with or without aneurysm resection. Outcomes were generally good, with 100% aneurysm obliteration and 21 patients (88%) having good functional outcomes, though permanent deficits occurred in 5 patients, most associated with M1 aneurysms. Location of the aneurysm was an important factor in planning treatment
This document summarizes recent developments in coronary intervention. It discusses newer generation drug-eluting stents (DES) with ultra-thin struts that have been shown in randomized trials to have lower target lesion failure, mortality, myocardial infarction, and stent thrombosis compared to older DES. It also summarizes the results of the RESTORE-SVD trial which found that in patients with small vessel disease, DES were superior to drug-coated balloons for reducing death or myocardial infarction at 1 year. Finally, it mentions the COACT study which found that in women with acute myocardial infarction, the use of DES during primary percutaneous coronary intervention reduced mortality at 90 days compared to plain old balloon angioplasty.
The document contains information about a student named Sandra Silva who attends The American School in Puerto Montt, Chile. Sandra Silva is enrolled in 7th grade basic education at the school. The document provides Sandra Silva's name, school, location of the school, and grade level.
The document discusses a programming assignment for a CSE340 class on principles of programming languages. It provides an overview of the assignment which involves modifying source code to implement a parser for a grammar. It includes the grammar rules to be implemented, sample code for the parser implementation, and example input programs to test the parser. It also reviews concepts like predictive parsing.
This chapter discusses various types of gross income that are taxable under the US tax code. It covers 15 common items that are included in gross income, such as compensation, business income, interest, rents and royalties. It also examines specific types of income in more detail such as prizes and awards, scholarships, below-market interest loans, rental income, and alimony. The chapter provides examples and explanations of the tax treatment for each type of income.
The document summarizes the benefits of stationary fuel cell systems for commercial real estate. Fuel cells provide clean, efficient distributed energy generation that can significantly reduce energy costs and carbon emissions compared to grid power. They operate at a lower cost per kWh than utility rates and can provide both electricity and heat for buildings. Various incentives are available to support the installation of fuel cell CHP systems.
This document outlines an earning opportunity through the sale of E-Protect registration kits and cards. It details various package options that can be purchased and resold to earn commissions. Consultants can earn direct sales bonuses for each kit and card sold, as well as fast start and repeat order bonuses. Higher ranks of gold, platinum, and diamond provide unilevel bonus commissions on downstream sales. The program offers perks like discounts, a business website and SMS system to help run the business.
The document outlines the details of a wedding ceremony and reception, including strands of lights and tealights in trees for the ceremony, a dress and bridesmaids for the bride, photography, invitations with calligraphy, programs, decorations with centerpieces possibly including artichokes and ferns, a cake and beverages, a mashed potato or grits bar for food, departure in a land rover or classic car with tin cans and birdseed, and favors such as turtles, recipe cards, coozies, and marshmallow bags for the overall theme.
This document discusses evaluating venoactive drugs for treating venous disease. It notes that while efficacy was proven for some drugs, medical utility was deemed insufficient, leading to de-reimbursement. It advocates demonstrating long-term benefits to prevent complications to convince health authorities, while also showing relief of symptoms and improved quality of life to satisfy consumer patients who now pay out-of-pocket. Validated questionnaires could evaluate patients' satisfaction with treatment effects, safety, and willingness to purchase again. As patients become consumers, their satisfaction may need more emphasis in efficacy evaluation.
The document introduces the EProtect memorial service prepaid card, which provides affordable funeral services and accidental death benefits. Key details include:
1) The prepaid card costs only P2.74 per day and provides standard funeral arrangements including transport, preparation, a casket, viewing areas, and assistance with permits.
2) In the event of accidental death, beneficiaries receive P100,000 in cash benefits plus the funeral services.
3) Coverage is available for ages 10-65 and accidental death benefits are effective immediately upon enrollment.
This document summarizes key aspects of itemized deductions allowable on Schedule A of the US federal income tax return. It discusses categories of itemized deductions including medical expenses, taxes, interest, charitable contributions, and miscellaneous deductions. Examples are provided to illustrate how to calculate the deductible amounts for medical expenses, taxes, and charitable contributions. The phase-out of itemized deductions for high-income taxpayers is also explained with an example.
Tracking Objects To Detect Feature Dependencieslienhard
This document proposes tracking object flows at runtime to detect feature dependencies. It explains that object aliasing can cause dependencies that are not evident from object creation alone. The approach tracks how references to objects are transferred between features to identify dependencies. An example of detecting dependencies for an IRC client's "Receive Message" feature is provided. The approach is shown to more accurately detect dependencies than prior work.
Slides boekpresentatie 'Sociale Media en Journalistiek'Bart Van Belle
De slides die gebruikt werden bij de presentatie van het boek Sociale Media en Journalistiek van Bart Van Belle en Michael Opgenhaffen.
Meer info over het boek http://www.facebook.com/pages/Sociale-media-en-journalistiek/292894527427953?sk=app_190322544333196
This document provides an overview and introduction to Domain-Driven Design (DDD). It discusses what DDD is, why it is used, and its main building blocks. DDD is an approach to software development that bases the design around the domain model. The document outlines key DDD concepts like entities, value objects, aggregates, repositories, and services. It also discusses patterns like ubiquitous language, bounded contexts, and anticorruption layers. Examples are provided throughout to illustrate DDD concepts and how they apply to complex domain models.
McDonald's first entered the Chinese market in 1990 by opening its first restaurant in Shenzhen. By 2002 there were 460 McDonald's locations across China, growing to 600 locations by 2004 and nearly 1,000 locations by 2008. McDonald's strategy in China involves tailoring its menu to local tastes at affordable price points while maintaining convenience. It aims to continue expanding its presence, with a goal of reaching approximately 2,000 locations across China. McDonald's success in China can be attributed to adopting the right strategies for the local market while retaining core brand elements like its 24-hour operations and drive-thru service.
El documento habla sobre cómo la industria cinematográfica usa afiches de películas para promocionar las películas y convencer al público de comprar entradas. Explica que los afiches suelen usar poses estereotipadas y clichés reconocibles para representar héroes, villanos, romances y géneros como el terror. También analiza cómo los diseñadores a veces arruinan buenos diseños originales para ajustarse a expectativas comerciales.
This document provides recommendations for things to do in Sonoma, California including visiting the Sonoma Plaza, eating at a cafe next door to a hotel, going to a fun wine tasting one night, enjoying an oyster bar at the Ledson Hotel, and exploring old book stores and a store filled with whimsy.
The document provides information about programs and services offered by the San Diego LGBT Community Center, the second oldest and third largest LGBT community center in the US. The Center has over 50 programs that serve thousands in the LGBT community each year, including programs focused on youth, families, counseling, and advocacy. Key youth programs discussed include a youth center, housing project, and scholarships to support LGBT youth and families.
This document provides an overview of the history and development of vascular access for hemodialysis. It discusses:
- The early development of hemodialysis and use of arteriovenous shunts by Scribner in the 1960s.
- Research in the 2000s that showed much higher rates of AV fistula use and better patient outcomes in Europe and Japan compared to the US. This led to the "Fistula First" initiative in the US to increase AV fistula rates.
- Guidelines for vascular access including the preference for autogenous AV fistulas over prosthetic grafts when possible, with radiocephalic fistulas as the first choice.
- Common complications of AV fist
This document discusses varicose vein surgery. It provides an overview of the indications for varicose vein surgery, including pain, swelling, skin changes, ulceration, and appearance. It describes the importance of preoperative evaluation using duplex ultrasound mapping to identify refluxing veins and develop a surgical plan. Finally, it outlines procedural considerations for varicose vein treatment, including the goals of ablating reflux from deep to superficial veins and removing all branch varicosities.
This document summarizes a study on the use of keystone flaps (KF) for reconstructive procedures. Some key points:
1) KFs allow for reconstruction using similar tissue to the defect in an efficient and reliable manner without the need to identify specific perforators or vessels.
2) The study evaluated KF procedures performed between 2014-2016 and found no total or partial flap losses. Advancement of up to 90% of the flap was possible by narrowing the "pedicular area".
3) Advantages of KFs include short procedure times, use of similar tissues, and low complication rates. They provide an alternative to free flaps or skin grafts for reconstructing entire areas.
The document discusses blocked epidural catheters, including potential causes and prevention/management strategies. Some common causes of blockade include blood clots, kinking or knotting of the catheter, and manufacturing defects. Prevention strategies focus on careful catheter placement and fixation to avoid migration, coiling or knotting. If blockade occurs, gentle traction and flushing may help, or the catheter may need to be replaced. Proper technique and inspection of catheters and connectors can avoid many cases of blocked epidural catheters.
Acs0626 Medical Management Of Vascular Diseasemedbookonline
This document discusses vascular access for hemodialysis patients. It covers:
1) Assessment of the venous system includes checking for stenosis, thrombosis, or damage from prior procedures that could impact access placement. Adequate veins for access need a diameter over 2.5 mm.
2) Assessment of the arterial system involves checking pulses, blood pressure differences between arms, and the Allen test to ensure adequate inflow. Arteries need a diameter over 2 mm.
3) Noninvasive testing like ultrasound can map arteries and veins to identify optimal conduits and mark skin to aid surgery. The goal is to increase autogenous fistulas that have the best outcomes.
A fresh look at vascularized flexor tendon transfersOTTO
This document summarizes a study on vascularized flexor tendon transfers for secondary flexor tendon reconstruction. The authors present results from their surgical experience using vascularized tendon transfers in 71 cases over 20 years. Their technique is based on an understanding of the sliding mechanisms and microvascular architecture of flexor tendons. By transferring living, vascularized tendons, they are able to transfer the sliding capability while avoiding the traditional two-stage reconstruction process. Results show better outcomes than traditional techniques with considerable time savings. Vascularized tendon transfers provide biological and physical advantages for improved secondary reconstruction outcomes.
Laparoscopic pyeloplasty can be performed via either a transperitoneal or retroperitoneal approach. The transperitoneal approach involves mobilizing the colon to access the retroperitoneum. Trocar placement is typically in a triangular configuration. The procedure involves dissecting the ureter and renal pelvis, transecting the UPJ, spatulating the ureter, placing a stent, and performing an anastomosis with absorbable sutures to create a tension-free repair. Variations include a transmesenteric approach and retroperitoneal approach via a flank position. Success rates of laparoscopic pyeloplasty match those of open surgery.
Video-assisted thoracoscopic surgery (VATS) is a minimally invasive surgical procedure used to diagnose and treat conditions in the chest cavity. It uses specialized instruments and a video camera inserted through small incisions or ports. VATS is used for procedures such as biopsy, bullectomy, pleurodesis, wedge resections, and lobectomy. It has advantages over open thoracotomy such as less pain, shorter recovery time, and smaller incisions. Common indications for VATS include diagnosis of lung masses or effusions, treatment of pneumothorax, bullectomy, and resection of early stage lung cancers. Contraindications include inability to tolerate single lung ventilation and advanced lung cancers.
This document describes three case studies of endovascular embolization procedures to treat type II endoleaks. In the first case, a type II endoleak was accessed through tortuous lumbar vessels and embolized using fibered platinum coils. The second case also involved embolizing an aneurysm sac and feeding vessels through difficult lumbar anatomy using microcatheters and coils. In the third case, coils were deployed through the inferior mesenteric artery to treat an endoleak. The document discusses the technical challenges of these procedures and how fibered coil designs can help achieve stasis in large volumes.
Endoscopic techniques have been widely adopted in sinus and skull base surgery replacing the traditional intracranial/extracranial approaches. However, one of the most common complication is an iatrogenic Cerebrospinal Fluid (CSF) leak, which places the patient at risk for meningitis, pneumocephalus and brain herniation. The instant intraoperative CSF leak diagnosis and consequent repair is crucial to avoid these complications. Traditionally, intrathecal fl uorescein injection was utilized to aid in the diagnosis. However, this technique is not FDA approved and encompasses major drawbacks (seizure, lower extremity paresis, cranial nerve palsies and patient discomfort).The purpose of this case series is to introduce a new diagnostic paradigm using topical fl uorescein strips “FLUORETS”. It has shown promising prospects due to its safety, accuracy and sensitivity in identifying CSF leaks.
The document discusses complications that can arise with arteriovenous (AV) access for hemodialysis and their management. It covers types of complications such as hematomas, significant steal syndrome, non-maturing fistulas, venous outflow stenosis, aneurysmal degeneration, and central venous stenosis. It describes techniques for managing these complications, including balloon angioplasty, coil embolization, stent graft placement, and open surgery. The overall message is that timely intervention is important to address access complications in order to maintain patency and usability of AV access for hemodialysis.
The document discusses complications that can arise with arteriovenous (AV) access for hemodialysis and their management. It covers types of complications such as hematomas, significant steal syndrome, non-maturing fistulas, venous outflow stenosis, aneurysmal degeneration, and central venous stenosis. It describes techniques for managing these complications, including balloon angioplasty, coil embolization, stent graft placement, and open surgery. The overall message is that timely intervention is important to address access complications in order to maintain patency and usability of AV access for hemodialysis.
vascular access for dialysis access: seminarMd Rahman
This document discusses vascular access for hemodialysis. It describes the different types of access including fistulas, grafts, and catheters. Fistulas are the preferred type as they last longest and have lowest risk of complications. Grafts are also used but have shorter lifespan. Catheters are not ideal for permanent access but can be used immediately while other access matures. The document outlines how to place and care for each type of access. Complications of catheters include higher risk of infection due to direct bloodstream access. Proper placement of catheter tips in the superior vena cava or right atrium is also discussed.
This study evaluated three stent designs for treating patient-specific bifurcation aneurysm phantoms using angiographic imaging:
1) A "middle-flap wing stent" (Type 1) that covers the aneurysm ostium with a wing.
2) A "two-tapered-wing-ended stent" (Type 2) that creates a bridge across the aneurysm neck with short wings.
3) A modification of Type 1 where a standard stent anchors the wing tightly against the aneurysm (Type 3).
Angiography found that contrast inflow was reduced by 25% for Type 1, 63% for Type 2, and 88% for Type 3 compared to untreated phantoms.
This document summarizes endovascular treatment options for large and giant cerebral aneurysms 15mm or larger. It discusses techniques like parent vessel occlusion with coils or balloons, selective coil occlusion with or without supporting devices, and occlusion with Onyx. Factors like aneurysm location, size, and anatomy determine the best approach. Internal carotid artery occlusion is commonly used for cavernous aneurysms. Vertebral and basilar trunk aneurysms can now often be treated with selective coiling and stenting rather than parent vessel occlusion. Bypass surgery is rarely needed preceding endovascular parent vessel occlusion.
1. The document outlines the history and evolution of surgical techniques for treating transposition of the great arteries (TGA).
2. Early techniques included atrial septal defect creation (Blalock-Hanlon) and atrial switch operations by Senning and Mustard using flaps or baffles.
3. The arterial switch operation was first successfully performed by Jatene in 1975 and modified by Lecompte, allowing coronary artery transfer.
4. Advances now allow arterial switch in neonates and extended to 6 months with support like ECMO.
Cardiac Interventions in Pediatric Cardiology: The FutureApollo Hospitals
Pediatric cardiac interventions have advanced significantly, with balloon angioplasties and devices now used routinely to treat conditions like atrial septal defects, ventricular septal defects, and patent ductus arteriosus. Newer interventions still in clinical trials include muscular VSD and perimembranous VSD device closure, flow restrictor implantation as an alternative to pulmonary artery banding, and components of the Norwood procedure in the catheterization lab. While short term outcomes are encouraging for many procedures, long term data is still needed to fully evaluate safety and efficacy. Continued innovation holds promise for more pediatric heart conditions to be treated using minimally invasive techniques.
This document discusses various medical and surgical management strategies for different types of hydrocephalus and associated conditions. It covers:
1) Medical management of hydrocephalus using diuretics and steroids to decrease CSF production.
2) The history of surgical drainage methods for hydrocephalus dating back to Hippocrates. Modern methods include ventriculostomies, shunt placements in various cavities, and endoscopic procedures.
3) Complications associated with different surgical procedures and how newer endoscopic techniques are improving outcomes compared to traditional shunting.
4) Specific guidelines for treating different causes of hydrocephalus like TB meningitis, hematocephalus, and congenital cases
This document discusses the history and technique of atrial septostomy. It describes how William Rashkind first developed the procedure in 1966 as a way to create an atrial septal defect without surgery. The document outlines the common indications for atrial septostomy in various congenital heart conditions. It provides details on the technical aspects of the procedure, including types of catheters, approaches, positioning, and success criteria. Complications are also mentioned, such as cardiac perforation which occurred in one case and was managed with surgery.
This document describes initial experiences with ILV (Internal LASER valvuloplasty) and EVLAR (Endovenous LASER Remodeling) using a 1470 nm laser to treat venous disease. It was conducted in three phases on 5 patients to reproduce diameter reduction, assess intraoperative reflux control with ultrasound, and follow up with ultrasound. Preliminary results found the laser approach reduced reflux by remodeling dilated veins without complications and results remained stable at 6-12 months follow up. Larger studies are needed to fully assess the reliability of this new ILV and EVLAR approach for treating venous disease.
The document discusses francophone seances for the 2014 JIFA conference. It lists the names N. Gaye, XL Modedero, V. Arfi, and M. Bouayed, suggesting they are presenters or participants. In 3 sentences or less, the summary provides a high-level overview of the topic and purpose while maintaining essential information from the original text.
This document summarizes several studies investigating the relationship between smoking and venous thromboembolism (VTE) risk. The studies found:
1) Current smoking was associated with a higher risk of VTE compared to never smokers, with a positive dose-response relationship. Former smokers had the same risk as never smokers.
2) Heavier smokers (>20 pack-years) had higher risks of total and provoked VTE compared to never smokers. The risk of provoked VTE increased with more pack-years of smoking.
3) The modestly increased risks of VTE in current or former women smokers were attenuated after adjusting for smoking-related diseases and decreased physical activity, suggesting an indirect relationship between smoking
1. 52 PHLÉBOLOGIE
Some new considerations on venous
valvuloplasty: an international on line
debate
Giovanni B. AGUS
Professor and Director of Section of Vascular Surgery and Angiology, Department of Specialist Surgical Sciences,
University of Milan, Italy
Abstract tions. The description on monoscusp valvuloplasty by Opie
in Vasculab was accurate.
In 2008 a paper by John Opie, regarding the renewed role At the same time S. Camilli presented his technique of
of venous valvuloplasty and an intriguing discussion took external stretching valvuloplasty with a new device is « oval
place on VASCULAB, a well known network on line with shaped external support « (OSES), made by a Nitinol net-like
about 1300 expert members in phlebology guided by F. framework, very smooth, elastic and flexible, available in
Passariello as conceiver and coordinator. different size. The OSES device is suitable for the terminal
The valvuloplasty attempts to reduce blood reflux and and pre-terminal valves of the GSV and virtually for any
venous hypertension in chronic venous disease (CVD). The peripheral venous valve, on superficial and deep system,
technique requires a skilled and experienced surgeon and a also without ligation of the possible present competent col-
careful patient evaluation and selection. It could be a good laterals.
approach in selected cases with post thrombotic syndrome The discussion was ample and very interesting with the
(PTS). contributes of C. Recek, B.B. Lee, C. Franceschi, O. Maleti and
Some studies indicate in the nineties that valvuloplasty others, included J. Opie and S. Camilli.
or valvular replacement is an effective treatment for venous In general, R. Kistner considerations about Maleti’s tech-
incompetence in selective cases. After a concise valvulo- nique are true for all valvuloplasties: « I find no fault with
plasty story from Kistner to Maleti, despite the advances in valvuloplasty and I am anxious to see if others can duplicate
valvuloplasty, we point out that the surgical mainstay to the experience. Points that need to be expanded in these
correct CVD, deep and superficial or both, or primary vari- experiences are how many cases were evaluated and found
cose veins is great saphenous vein (GSV) ligation and strip- not to be candidates for this procedure, the length of the
ping but also various conservative or endovascular treat- learning curve for producing a reliably competent valve, and
ments. Nevertheless actually some clinical studies have whether there is any sign that these new valves will dege-
reported achieving long-term, effective competence of deep nerate with time. If this technique can be successful, the
venous system, as well as the superficial venous system, next question will be whether it can be achieved in a more
both after valvuloplasty or by implanting an external vein minimally invasive method »
support device.
J. Opie identified as an optional surgical solution for the Key-words: Valvuloplasty – Vein surgery – Chronic
large underserved patient group of PTS a new technique: venous disease
« monocusp surgery ». He presented a new surgical method
to replace a dysfunctional aplastic / dysplastic / absent
venous valve using the full thickness viable native vein wall Résumé
tissue (the monocusp) and covered the defect with an ultra-
thin synthetic e-PTFE vascular closure patch (iVenaTMe-PTFE En 2008, un article de John Opie sur le rôle remis au goût
patch) to successfully reverse venous insufficiency and its du jour de la valvuloplastie veineuse et l’intéressante dis-
effects both early and long-term with limited complica- cussion qu’il suscita, fut diffusé sur le site VASCULAB, un
ANGÉIOLOGIE, 2009, VOL. 61, N° 2
2. PHLÉBOLOGIE 53
réseau réunissant plus de 1300 experts internautes. F chaine question pourra concerner la mise au point d’une
Passariello en était l’initiateur et le coordinateur. méthode encore plus mini-invasive ».
Le but de la valvuloplastie est de diminuer le reflux san-
guin et l’hypertension veineuse dans les affections vei- Mots-clés : valvuloplastie, chirurgie veineuse,
neuses chroniques (AVC). La technique nécessite un chirur- affections veineuses chroniques.
gien expérimenté avec une sélection et une évaluation
rigoureuse des patients. Elle peut avoir tout son intérêt dans * * *
des cas bien sélectionnés de syndrome post-thrombotique
(SPT). A recent paper by John Opie, regarding the renewed role
Plusieurs études datant de la fin du siècle dernier ten- of venous valvuloplasty (1) and an intriguing discussion
dent à prouver que la valvuloplastie ou le remplacement took place on VASCULAB (2), a well known network on line
valvulaire est un traitement efficace de l’incontinence vei- with about 1300 expert members in phlebology guided by F.
neuse dans certains cas. En reprenant l’historique de la val- Passariello as conceiver and coordinator.
vuloplastie, de Kistner à Maleti, malgré les progrès réalisés,
on note que la conduite chirurgicale pour traiter les AVC, Venous Valvuloplasty story
profonde ou superficielle ou associant les deux, reste la
ligature / crossectomie des saphènes avec aussi quelques The valvuloplasty attempts to reduce blood reflux and
traitements variés conservateurs ou endovasculaires. venous hypertension in chronic venous disease (CVD). The
Néanmoins, aujourd’hui, des études cliniques ont démontré technique requires a skilled and experienced surgeon and a
une efficacité à long terme avec une continence correcte, careful patient evaluation and selection. It could be a good
aussi bien des veines superficielles que profondes après val- approach in selected cases with post thrombotic syndrome
vuloplastie ou implantation de manchons externes prothé- (PTS).
tiques. Some studies indicate in the nineties that valvuloplasty
J.Opie propose une option chirurgicale pour la large or valvular replacement is an effective treatment for venous
cohorte de patients présentant un SPT, et pour lesquels on incompetence in selective cases (3). The repair of incompe-
a peu de solutions à proposer actuellement ; cette tech- tent femoral vein valves in patients with primary valve
nique s’appelle la « chirurgie monocuspide ». Cette nouvelle incompetence was first developed by R. Kistner in 1968 (4).
méthode chirurgicale traite les valvules incompétentes, The original method involved a venotomy in the femoral
aplasiques, dysplasiques ou absentes en utilisant la paroi vein with the placement of sutures to shorten the vein
veineuse recouverte d’un patch en PTFE. Cela donne de bons cusps under direct vision, and others successful variations
résultats dans l’insuffisance veineuse, précocement ou à of open valve repair have been reported (5, 6, 7). The femo-
long terme avec peu de complications. ral vein valve repair was also carried out under direct vision
Parallèlement, S.Camilli a présenté sa technique de val- without venotomy with the use of angioscopy (8).
vuloplastie externe avec la prothèse OSES, élastique, Initially was a report by Garcia-Rinaldi from Houston,
flexible et disponible en plusieurs tailles. Elle convient par- more than 20 years ago with prosthetic bovine monocusp
faitement aux valvules terminales et pré-terminales de la patches in the superficial femoral and great saphenous
veine grande saphène et théoriquement à toutes les val- veins for CVD (9), and Sante Camilli from Rome in early
vules veineuses périphériques, des réseaux profonds et 1990 repeated the performance in a few cases, by applying
superficiels, sans ligature des collatérales compétentes qui a bovine pericardium monocusp (hand-made) into a super-
peuvent être présentes. ficial femoral vein (10).
La discussion a été très fournie et très intéressantes en Unfortunately, the « open vein » techniques (like Kistner,
particulier avec les contributions de C. Receck, BB.Lee, Raju, Sottiurai, etc) are difficult and challenging.
C.Franceschi et J.Opie et S.Camilli. Closed valvuloplasty was also developed by R. Kistner as
Les considérations de R.Kistner au sujet de la technique external venous repair. This technique involves complete
d’O. Maleti sont vraies pour toutes les valvuloplasties : « Je dissection of the femoral vein up to 4-10 cm in order to
ne trouve pas de faute dans la valvuloplastie et je suis impa- place sutures on both sides of the vein wall at the level of
tient de voir si d’autres peuvent répéter cette expérience. the valve commissures (11).
Les points à développer concernent le nombre de patients A technique for repair of incompetent venous valves
candidats à cette intervention et le nombre de récusés, la with an implantable device developed to restore venous
durée de l’apprentissage pour réussir cette technique, et s’il valve competence by reducing the vein circumference was
existe un signe quelconque témoignant d’une usure de ces proposed by D. Hallberg for deep veins in 1972 (12) and by
valvules au fil des années. Si les résultats sont bons, la pro- Hetènyi and Pahoky for superficial veins in 1985 as « the
ANGÉIOLOGIE, 2009, VOL. 61, N° 2
3. 54 PHLÉBOLOGIE
tunnel graft of greater saphenous vein » in Dacron (13) and the « final solution » but could reach a more satisfying out-
in other way experimented with success in two animal come than usual.
models with a silicone device named « venocuff » (14). Actually some clinical studies have reported achieving
Similar technique reinforce the commissure adaptation long-term, effective competence of deep venous system, as
based on the principle V. Krylov from Moscow introduced to well as the superficial venous system, both after valvulo-
B.B. Lee to perform a few case on the femoral vein after plasty or by implanting an external vein support device.
Kistner’s simple external valvuloplasty but wasn’t quite suc- For the deep incompetence recently we had a review
cessful with residual reflux. The intermediate results of all about valvuloplasty, indications and results by R. Kistner
three cases were dismal within a year as mentioned by B.B. (20) and we have a good analysis in french language by
Lee in Vasculab discussion (2). M. Perrin (21, 22) but from epidemiological point of
G. Belcaro in 1989 proposed an external valvuloplasty as wiew the CVD is enormously more frequent than the pri-
« plication » of the sapheno-femoral junction for primary mary venous insufficiency, and superficial reflux more
varicose veins (15), and after a plication of superficial femo- than deep reflux.
ral vein for deep incompetence (16). Finally, was developed About the indication and patients selection in CVD, the
a device comprised of expanded polytetrafluoroethylene suggested today are people suffering (a) GSV junctional
(ePTFE) with an embedded Nitinol alloy wire frame to pro- reflux with (b) movable and symmetric leaflets and (c) mild
vide a better basis for fixation. The device is wrapped to moderate PVV, but also (d) in secondary varicose veins. In
around the vein at the valve site to restore competency to secondary varicose veins, you may bring back the natural
an incompetent venous valve by remodeling the vein at the deterioration history by stopping the reflux and - at the
valve site, and/or by preventing local dilatation of the vein same time - you maintain the forward flow. Of course, it is
to which it is applied (17). suitable in primary deep venous insufficiency (PDVI) for (e)
Since more than 20 years in some series is performed a deep venous system external valvuloplasty as well.
competent-valve venous segment transplantation (18). From the technical point of view the main problems are
Another experience was presented in the 2000 with the to see both the commissures and a precise stitch applica-
Ven-Pro endo-prosthesis, following Quijano’s ideas, whose tion just at the apex of them. Should it be difficult to see
clinical trial was stopped because of unacceptable rate of the commissure apex, you may trans-illuminate the vein by
thrombotic complication. a small glassfibre inside.
The last landmark report of an exciting approach to defi- The rationale for sapheno-femoral external valvuloplasty
nitive treatment of late post thrombotic deep vein reflux is based on the histological finding that in the initial stages
(PTS) in highly selected patients was the case series of the valve cusps are still healthy but are incompetent because
endovascular neovalve construction by O. Maleti. Valvular of dilation of the vessel walls. It must be shown echographi-
cusps were created at the femoral site by dissecting the cally that the cusps are mobile and not atrophic in the ter-
thickened venous wall to obtain material with which to minal and/or subterminal part of the great saphenous vein.
fashion a new monocuspid or bicuspid valve (19). The aim is to bring the valve leaflets back together, closing
up the dilated vessel walls. This can be done by either sutu-
Venous superficial or deep valvuloplasty ring the wall directly or by « buckling » the vessel with some
sort of external prosthetic belt in silicone, Dacron, e-PTFE.
Despite the advances in valvuloplasty, the surgical Competence should be tested during the operation using the
mainstay to correct chronic venous insufficiency (CVI), deep milking maneuver or a Doppler scan, or both.
and superficial or both, or primary varicose veins (PVV) is After more than a decade in the experimental stage, this
great saphenous vein (GSV) ligation and stripping but also approach can now boast encouraging results from multi-
various conservative o endovascular treatments. center randomized clinical trials, as long as the surgical
For the superficial insufficiency many phlebologist today indications are respected and external valvuloplasty is fea-
have been convinced, by their own practice and literature, sible (23, 24, 25, 26, 27), and the Italian College of
that conservative strategy, when applicable, has a better Phlebology Recommendations are: external valvuloplasty of
outcome than ablative one in varicose veins treatment. At the terminal and/or subterminal valve of the great saphe-
the same time, even if the first reason of recurrent varicose nous vein, after thorough preoperative assessment, and
veins may be a genetic-hormonal one, but the second cer- with careful intraoperative checks, is a good way to treat
tainly is hemodynamic - to be precise, the GSV ablation saphenous reflux in 5-8% of patients. Grade B (28).
itself. At the present conservative approaches (e.g. CHIVA Really, both the Gore-EVS (now out of the market in
technique, collateral selective ligation, endovascular treat- Europe for economics reasons) and the Venocuff are unfit-
ments) with a reliable valvuloplasty technique may be not ting in several cases, and - anyway - they are of unpredic-
ANGÉIOLOGIE, 2009, VOL. 61, N° 2
4. PHLÉBOLOGIE 55
table result because they bundle up valve leaflets on a blind by the patient around 3 years. As a result, for this reason
way. Moreover, these devices need collateral ligation which J. Opie identified as an optional surgical solution for this
involves the collateral stump deforming the valve wall’s large underserved patient group a new technique: « mono-
shape. New devices may be applied around the junctional cusp surgery ». He presented a new surgical method to
valves (terminal and pre-terminal) without collaterals invol- replace a dysfunctional aplastic/dysplastic/absent venous
vement. valve using the full thickness viable native vein wall tissue
(the monocusp) and covered the defect with an ultrathin
The Opie’s and Camilli’s proposals synthetic e-PTFE vascular closure patch to successfully
reverse venous insufficiency and its effects both early and
Deep venous thrombosis (DVT) induced CVI, and about long-term with limited complications. He moved around
5% of the population have this ghastly, aggressive illness. that by formally redefining the operation, using these
Previous reparative valvular surgical options directed at terms to book surgery: (a) CFV valvuloplasty (monocusp);
reconstructing damaged common femoral vein (CFV) (b) CFV patch venoplasty.
valves associated with pathological CVD have not succee- Make sure the diagnosis is correct have a duplex in the
ded in reliably managing CVD. In consequence, venous ORs if you want and have anesthesia Valsalva before and
valvuloplasty is rare and most patients are managed after implant. It’s quite interesting duplex with a sterile
conservatively. sheath right on the CFV. You have to get the duplex head
Maleti’s techinque gives today great credit but the same below the monocusp (Fig. 1).
author points out the intrinsic limits for clinical indications The description on monoscusp valvuloplasty by Opie in
in absence of valve flaps and PTS, and technical feasibility. Vasculab was accurate.
Probably for these reasons we have now interest for the two Clean off the adventitia, liberally coat the CFV early and
new proposals by Opie for frequent PTS patients and by frequently with papaverine as it wants to spasm. Don’t let
Camilli for more frequent CVD patients. that occur.
J. Opie published (1) and discussed in Vasculab (2) that Draw the lines on the CFV before you place any clamps.
current external compression treatments are largely a Make the cuts as potbellied as convenient. Each cut is about
giant expensive failure. The secret here is to continuously as long as the vein’s diameter - has to reach the back and
control (normalize) internal distal venous hypertension - if side walls. Don’t over do that however, minor monocusp
you do that successfully, external compression is not leaks are well tolerated.
necessary anymore and normal venous physiology is res- Make sure the patient is fully heparinized before clam-
tored. Over time the results are startling. Symptoms ping.
resolve, ulcers heal, swelling resolves, compression hose The external aspect of the CFV between the distal and
are support devices of the past (Opie’s point of view). proximal clamps was examined for any indication of valvu-
Hemosiderin starts to resolve commencing around 2 years lar sinuses and to avoid injuring a valve that might be repai-
and liposclerosis also resolves, and is particularly noticed rable.
Fig. 1 - Monocusp technique: a representative
echo, before the monocusp. Grade 4 CFV reflux
by Valsalva (with permission J. Opie)
ANGÉIOLOGIE, 2009, VOL. 61, N° 2
5. 56 PHLÉBOLOGIE
Fig. 2 – In a view of stylized CFV illustration of
the monocusp operation and proper valve func-
tion.
(A) View of the monocusp looking down at the incisions and
sutures. (B and C) Transverse view of the monocusp while
open and closed, respectively. (D) View of the completed
operation with the iVenaTM e-PTFE vascular patch covering
the monocusp. (E and F) Lateral views of the monocusp
while open and closed, respectively. Arrows denote the
direction of venous blood flow (with permission J. Opie).
Three necessary incisions were made to construct the
monocusp valve (Fig. 2), on the anterior surface of the
clamped CFV in the manner of a trap door with an uncut
distal hinge.
Each incision should have a 1–2 mm convex outward
track so as to conform to the rounded, filled vein when the
vein re-expands to its circular, tubular shape after the ope-
ration was completed.
If no repairable valve was identified at the site of the
incision, the monocusp operation should be continued. All
incisions were as long as the diameter of the vein.
Make the leading edge sutures long enough so that the
monocusp can function - both open and close, but do not
let those leading edge sutures get too long - that will allow
the leading edge of the monocusp to approximate the e- Fig. 3 - Appearance of the iVena TM e-PTFE vascular patch
PTFE patch (iVena TM). If that occurs, the monocusp and the after suturing into the correct position (with permission
patch will tend to adhere and the operation will fail. That J. Opie).
has happened once to us and we had to redo above. Think
of these leading edge sutures as similar to the chords Put the patient on coumadin for 6 months, then convert
restraining the mitral valve. to ASA for life. Major venous surgery has much more poten-
The Lateral Edges (LE) suture length is the most impor- tial of DVT in comparison to arterial surgery.
tant and it is also the most frustrating. Once they are both
placed, check the monocusp excursion and replace if too The role of Camilli’s technique
excessive or insufficient. That is part of the art involved.
Some lateral leaking is not rare, but usually it has no clini- Recently S. Camilli from Rome has reported a new tech-
cal effect. nique: the external stretching valvuloplasty. The preliminary
One way of assessing the LE suture length is to place the trials, both experimental and clinical, gave positive out-
two corner sutures fold the moncusp to closed, have your comes in terms of safety and efficacy, and was presented to
assistant hold it there and tie the back wall sutures usually the Italian Society of Vascular and Endovascular Surgery
around 7 and 5 o’clock at the level of the proximal cut (29). This is an innovative working principle which aims to
against the resistence. But remember the vein wall with give a stretching action on the opposite inter-commissural
stretch and these sutures can become too short. Don’t tie walls, and parallel to the free edge of the valve cusps, to
these sutures with too much pull that will drag the vein into modify the cross section of the valve so that the cusp’s free
a closed position must avoid that. edge extralength is reabsorbed. A new device has been
This operation works well when done right. developed, working as a surgical implant around the incom-
ANGÉIOLOGIE, 2009, VOL. 61, N° 2
6. PHLÉBOLOGIE 57
Fig. 4 - Here is the same patient 1 hour later.
I.E. monocusp now in place (with permission J.
Opie).
Fig. 5 - The stretching action of
OSESTM (with permission S.
Camilli): vein wall axial view;
Oval Shaped External Support;
slackened valve cusps; cusp’s
coaptation and function recovery;
OSESTM stitched.
petent venous valve which increases the inter-commissural Discussion
diameter and, inthis way, resulting in the valve cusp’s coap-
tation and function recovery (Fig 5). The new device is an First, C. Recek put some questions and a comment
Oval Shaped External Support (OSESTM), made by a Nitinol addressed to colleagues who perform valvuloplasty: the
net-like framework, very smooth, elastic and flexible, avai- necessity to perform selective valvuloplasty with additional
lable in different size (3 sizes just now) (Fig. 6). The OSESTM procedure and the necessity to verify the results plethys-
device is suitable for the terminal and pre-terminal valves mographically to achieve normalization of the venous
of the GSV, also without ligation of the possible present hemodynamics. As concerns the indication to valvuloplasty,
competent collaterals. Virtually the Camilli’s device can be it must be distinguished between PVV and PTS. In PVV could
useful for any peripheral venous valve, on superficial and be taken into consideration for valvuloplasty the incompe-
deep system, obviously when the valves are present. tent CFV and the incompetent GSV. As concerns the femo-
ANGÉIOLOGIE, 2009, VOL. 61, N° 2
7. 58 PHLÉBOLOGIE
management is treatment of the superficial varicose veins
by ELT, RF, stripping, phlebectomy, foam etc whatever is the
preferred method of the surgeon. Monocusp is certainly not
indicated with such conditions. However, if PVV and CVI
exist at the same time in the same patient, he chose to cor-
rect the superficial varicose vein conditions first, and see
how the patient does. If the CVI is still an issue then he
recommends a valvuloplasty - if usable valves are encoun-
tered then can do a Kistner type repair (this is quite uncom-
mon in secondary CVI). If no valves or no usable valves are
encountered then Opie proceed with a monocusp.
Regarding the last point, B.B. Lee disagreed with Recek’s
quotation of absence of valves in the femoral vein, and in
the same way Opie, quoting a Canadian pathologist study in
«nonvenous» patients that founded the absence of valves in
CFV in only 21% (34), replied that a competent valve(s)
lower down the leg in the femoral vein may well control CVI
even if the CFV valves are leaking. All it takes is one deep
valve to remain competent and CVI will not occur. As
concerns the absence of competent valves in deep
veins above the SFJ in PVV, Recek opposed that
« Trendelenburg is correct, pathologist Basmajian not »,
confirming unequivocally Trendelenbug´s findings by
venous pressure measurements and registration of pressure
Fig. 6 - Oval Shaped External Support by S. Camilli (with waves (35). A pathologist can recognize the valves, but he
permission S. Camilli). is not able to credibly assess whether the valve is compe-
tent or not. This is possible and convincing in the standing
position in a live person.
ral vein, from the hemodynamic point of view it does not Considering that we need to make an effort, aiming to a
matter whether the femoral vein is competent or not: the more conservative and even reconstructive approach to vein
ambulatory pressure in this vein is in both cases the same, surgery S. Camilli exposed the opinion the time is mature,
reminding the work of Höjensgard and Stürup that the the technique also, the technology a bit less for valvulo-
hydrostatic pressure in the femoral and popliteal veins plasty, opposing Recek’s some statements.
remains uninfluenced during the activity of the calf muscle The on line discussion was also stimulate by an agree-
venous pump (30). On the other hand, when GSV reflux is ment on the term venous hypertension remembering that
accompanied with CFV incompetence, abolition of saphe- there are two kinds of venous hypertension: the hydrostatic
nous reflux alone, without influencing the femoral incom- one and the ambulatory one. But Opie added a third kind of
petence, restores the disturbed venous hemodynamics to «malignant» venous hypertension, the « constant » venous
normal (31, 32). Analogously, cases with incompetence of hypertension (WBCs and RBCs accumulate via the super
the small saphenous vein (SSV) are very often accompanied high constant venous pressure expanded desmosomes and
with incompetence of the popliteal and femoral vein and the end result is first hemosiderin staining followed by
abolition of the SSV reflux alone restores the disturbed liposclerosis followed by skin break down and venous ulcers
venous hemodynamics to normal (33). Finally, Recek development potentialy eliminable repairing a valve in the
emphasized that deep vein incompetence of the iliac, femo- CFV).
ral and popliteal veins per se do not cause CVI provided the C. Franceschi presented his practical heamodynamics: (a)
valves in the lower leg veins are competent, the outflow mechanical venous valve competence is not a problem
pathway is patent and no shunting of blood in superficial because it can be achieved according to various techniques;
venous system is present. (b) mechanical venous valve challenge is to be not des-
Regarding the Recek’s standpoint valvuloplasty of any troyed by DVT; (c) mechanical venous competent valve effi-
kind indicated or not with varicose veins treatment, Opie ciency cannot be different from a natural one in terms of
replied that if the PVV are due to GSV or SSV and/or acces- haemodynamic outcomes; (c) mechanical venous compe-
sory vessel incompetence and no CVI exists, the correct tent valve has to be located at an haemodynamic strategic
ANGÉIOLOGIE, 2009, VOL. 61, N° 2
8. PHLÉBOLOGIE 59
point which requires an appropriate and tailored strategy. full capacity to 100% endothelialize its external surface due
Hydrostatic pressure fractioning is obviously more efficient to the different receptors triggered by now becoming intra-
to lessen the ankle pressure when the valve is located at the vascular rather than being programmed by the extravascu-
popliteal vein than at the CFV. Anyway, the dynamic frac- lar tissue milieu. He figures that will have occurred by 5-6
tioning at the CFV is efficient proportionally to its height; months. For those reasons he gives coumadin for 6 months
(d) accurate hemodynamic assessment permits to apply and then switch it out to daily ASA 81 mg for life. By then
deep CHIVA strategy with good long term outcomes but the external surface of the monocusp is likely fully endo-
only when closed shunts are usable for disconnexion (36, thelized and actively secreting NOS and TM, and the inner
37). surface of the iVena e-PTFE patch will also be covered by
O. Maleti remembered that the inward flexing of a some form of deposited intimal tissue with +/- hormone
venous segment in order to create a flap working as a valve capacity. All it would likely require is an antiplatelet drug
was first suggested by Karagoz in 1993 (38); the segment (ASA). Doing this he has not encountered any late DVTs now
used by Karagoz was the terminal end of the GSV. Opie out to 5.5 years with zero support device management and
creates a flap fixed only in one extremity and free in both all patients are living an unrestricted lifestyle.
lateral edge fixed by two stiches. Maleti thinks that such a B.B. Lee asked for critical fact claimed by Opie: «the
flap presents some serious fixing problems. It is in fact well external surface once exposed to blood will acquire an
known that the valve is subject to an important pressure, endothelium and produce the antithrombotic hormones
and the best results are obtained when a very large flap is within 4 months », asking also for references in this regard.
used, being able to create a « sailing effect ». The same hap- If so, it is revolutionary! What mechanism controls these
pens in nature: valves are not simple diaphragms anchored developments? The Opie’s reply was: « I suspect it is hormo-
in a single point, otherwise the side pressure would cause nal-receptor based and whatever microenvironments act on
the vein to expand, and a blood leakage caused by poor those blood vessel wall progenitor cells. In the blood it pro-
fixing would inevitably occur. Valves are true pockets which grams the living vein wall to grow endothelium. I suspect
inflate following to the expansion occurring at the sinus that if you place the adventitial side of a living blood vessel
venous level, and it is just such mechanism that ensures the inside the blood stream over time it will react to the new
continence effect, as F. Lurie has widely explained in his hormonal environment and it will become lined with endo-
hemodynamics researches. Opie’s technique would greatly thelium because it is alive ».
benefit from increasing the diameter of the flap inserted to According to R. Kistner and M. Perrin, the major risk after
the extent of two thirds of its circumference, fixing it on the neovalve and any other deep venous reconstruction proce-
edges and increasing the length of the flap itself. In such a dure is not related to postoperative thrombosis as far as the
case, the patch will cover the circumference by 2/3. Opie patient is postoperatively fully anticoagulated but recur-
agree with Maleti’s thoughts here. The monocusp is by no rence or persistence of deep reflux in the other deep venous
means as clever nor as good as a native valve with sinuses system mainly the profunda femoral vein or secondary valve
etc, but it is a viable structure and if the iVena patch is used, reconstruction degradation.
it (the patch) bulges anteriorly when the clamps are remo- Regarding these Opie suggests a name change from CVI
ved and an anterior sinus is created. How long that bulge - which infers the condition is incurable and chronic to DVI
remains Opie doesn’t know. It is easy to make the flap long (Deep) meaning that now with additional input from scien-
simply by extending the vertical incisions - not so easy to tific minds, we actually have a good chance at beating this
make it widewide the diameter of the vein limits. ancient curse with what appears to be a low-risk long-term
Opie stressed the tendency to form a DVT will be present effective, easy to complete operation (DVI is similar to DVT).
to some extent in all venous reconstructive surgeries and
that tendency will be likely a constant situation if non- Conclusion
viable tissue (such as an intimal dissected flap) or a pros-
thesis is placed into the venous circuit. Constant anticoa- Fausto Passariello, Vasculab Moderator, concluded that
gulation is probably required here. The reason why Opie we understand that actually 3 valvuloplasty methods must
choses a full thickness vein wall structure is that with one be compared, the ones by Opie, Maleti and Camilli, already
side being uncut that means the flap is vital. That infers tested in living humans. Franceschi method was tested only
several hypothetical very beneficial activities: (a) the mono- in vitro and is mechanically highly efficient (39).
cusp will secrete nitric oxide synthase (NOS); (b) the mono- Other methods, which are worth citing for historical rea-
cusp will secrete thymomodulin (TM); both powerful local sons, have however a high rate of failure. At the end of this
vessel wall anti-thrombotic micro hormones/enzymes; discussion, a very interesting topic was started, about the
(c) because of its vitality, the monocusp will likely have the functional value of venous valves in the deep venous sys-
ANGÉIOLOGIE, 2009, VOL. 61, N° 2
9. 60 PHLÉBOLOGIE
tem, and superficial too. However, cited papers are often 14. Jessup G, Lane RJ Repair of incompetent venous
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claim for a new physiopathological interpretation. 296-300.
R. Kistner considerations about Maleti’s technique are 16. Belcaro G, Ricci A, Laurora G, Cesarone MR, De
true for all valvuloplasties: « I find no fault with valvulo- Sanctis MT, Incandela L Superficial femoral vein valve repair
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