Victor Jesron Nababan is a cardiothoracic and vascular surgeon who specializes in procedures related to the chest, heart, and blood vessels. His areas of focus include cardiac surgery, thoracic surgery to treat conditions of the lungs and chest wall, and vascular surgery for issues involving veins and arteries. Some common procedures he performs include surgery to treat congenital heart defects, coronary artery bypass surgery, varicose vein removal, and treatment of abdominal aortic aneurysms. He utilizes both open surgical techniques as well as minimally invasive endovascular approaches depending on the condition being treated.

1. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam
PENGENALAN
CAKUPAN BEDAH
TORAK, KARDIAK DAN
VASKULER

2. TORAK
 TRAUMA
 NON TRAUMA
 NEOPLASMA  DINDING DADA  ORGAN INTRA
TORAK
 INFEKSI  SPESIFIK/NON SPESIFIK
 DEGENERASI PARENKIM PARU  BLD
 KELAINAN DINDING DADA
 DIAFRAGMA
 LAIN2  PALMAR HIPERHIDROSIS (TORAKAL
SIMPATEKTOMI), RAYNAUD, TOS
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

3. KARDIAK
 JANTUNG PEDIATRI
 KELAIANAN JANTUNG BAWAAN  PDA, ASD, VSD, TOF, DORV, TA,
DLL
 KELAINAN JANTUNG DIDAPAT  RHD, IE, DLL
 JANTUNG DEWASA
 KORONER  ON PUMP, OFF PUMP
 KATUB
 ARYTMIA SURGERY  MAZE
 PACE MAKER  PERMANENT
 ASSIST DEVICE  IABP, ECMO, LVAD, RVAD, BIVAD
 AORTA  TORAKAL  DHCA
 NEOPLASMA  MYXOMA
 EMBOLI PARU
 PENYAKIT PERICARD
 TRAUMA
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

4. VASKULER
 TRAUMA
 NON TRAUMA
 VENA  CVD (VARICES, CVI), DVT, MAY
TURNER, DLL
 ARTERI 
ANEURISMA, PSEUDOANEURISMA, PAPO, DIABETIC
FOOT ULCER
 AORTA  TAA, AAA
 MALFORMASI ARTERIO VENOUS
 AKSES VAKULER  CENTRAL, PERIFER, HD AKSES
(AV SHUNT, HD CATHETER), CHEMOPORT
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

5. VICTOR JESRON NABABAN,MD
CARDIOTHORACIC AND VASCULAR SURGEON

6. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

7. Background
 Chronic venous disorders include a spectrum of
clinical manifestations extending from
telangiectasias & varicose veins to
lipodermatosclerosis & ulceration.
 Varicose veins are the most common manifestation of
primary chronic venous disease.
 varicose veins are usually differentiated from
reticular veins and telangiectasias
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

8. Terminology & New definition CVD, chronic venous disorders: embraces C1–C6.
 CVI, chronic venous insufficiency: limited to C3–C6.
 Telangiectasias:a confluence of dilated intradermal
venules of less than 1 mm in caliber. Synonyms include spider
veins, hyphen webs, and thread vein
 Reticular veins: dilated bluish subdermal veins usually
from 1 mm in diameter to less than 3 mm in diameter. They are
usually tortuous.
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

9. Definition
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

10. Epidemiology
 Varicose veins are present in 25% - 33% & chronic venous
insufficiency, with skin changes and ulceration, in 2% -
5% of Western populations.
 The prevalence of VV increases markedly with age and
they are an almost universal finding in individuals over
the age of 60 years.
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

11. Valvular Function in V V’s
Healthy Diseased
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

12. 2 venous drainage systems:
deep and superficial
 Superficial: long and short
saphenous veins
 Superficial connects to deep
system via perforators
Saphenofemoral junction 2-
4cm inferolateral to pubic
tubercle
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

13. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

14. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

15. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

16. The CEAP Classification
 C linical Classification
 E tiological Classification
 A natomical segmental localization
 P athophysiological classification
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

17. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

18. Revisi CEAP tahun 2004
Class-0
...kalau periksa jangan lama lama.....
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

19. CEAP Class 1
Hanya nampak
varises kapilaris
atau retikularis saja
Class-1
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

20. CEAP Class 2
Varise trunkal
sederhana (Grade-
II-III)
Class-2
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

21. CEAP Class 3
Edema ankle/ malelolus
kearah proksimal .
Kongesti venous
karena inkompetensi
vena safena dapat
menyebabkan edema
ortostatik.
Class-3
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

22. CEAP Class 4
Pigmentasi kulit
tungkai bawah medial
(lipodermatosklerosis).
Deposit hemosiderin
menentukan warna
perubahan kulit dan
bisa menjadi tanda
keradangan kronis
yang menyebabkan
proses fibrosis
Class-4
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

23. CEAP Class 5
Ulkus venous yang
MENYEMBUH .
Kenaikan tekanan vena
menyebabkan hipoksia
jaringan yang
menyebabkan
kerapuhan kulit dan
terjadi ulserasi.
Class-5
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

24. CEAP Class 6
Ulkus venous
terbuka/ aktif. ulcer.
Hipertensi venous
menyebabkan
periubahan gradien
tekanan yang
menyebabkan
ulkus.
Class-6
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

25. Beware : CEAP-6 in a diabetic
patient
Treated (personally) with
diabetic wound dressing....
(more than 2 months)
Then treated with Pasta-Unna
wound dressing.... (2 weeks)
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

26. Risk Factors
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

27. Symptoms
 Great majority of individuals with VV are
asymptomatic
 A wide variety of lower limb symptoms have been
attributed to VV. These include:
 1. aching
 2. heaviness and tension
 3. a feeling of swelling
 4. tiredness
 5. restless legs
 6. nocturnal cramps
 7. itching.
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

28. Physical Examination
 Position
 The patient should be examined standing in a good light in a
warm room.
 Inspection
 dilated, elongated, tortuous, and sacculated vein
 signs of CVI include
 corona phlebectatica,
 lipodermatosclerosis, and
 open ulceration
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

29. Physical Examination (1)
 Palpation
 Percussion over a varix while palpating with the other hand
at a higher or lower level will help trace out the pattern (the
“tap” test of Chevrier).
 Particularly helpful in the obese.
 There may be a cough impulse, even a thrill over a large
varix, particularly a saphena varix in the groin.
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

30. Physical Examination (2)
 Tredelenburg Test
 Purpose: to identify the level and location of deep to
superficial reflux.
 Value in circumstances in which duplex scanning is not
readily available.
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

31. Physical Examination (3)
 Tredelenburg Test
 The test comprises two parts :
 Part 1:
 The patient lying down the leg is elevated to 45° and
 A tourniquet or the examiner’s hand compresses the GSV in the
high thigh.
 With compression in place, the patient stands in a well-lit room.
 Previously noted superficial veins are then carefully observed for
filling with blood
 Part 2:
 The compression is then released.
 The superficial veins are then carefully observed for increased
filling with blood.
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

32. Physical Examination (4)
 Interpretation of Tredelenburg Test
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

33. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

34. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

35. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

36. Physical Examination (3)
 Ulcer Examination
 This should include
 1. a description of the ulcer, concentrating on the
 2. pulse status and ankle–brachial index
 3. gait and, in particular, ankle mobility
 4. general physical examination
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

37. Diagnostic Tools
 Diagnostic Vascular Laboratory
 Non invasive test
 Indirect : Plethysmography
 is used in the assessment of the amount of reflux, the efficiency of the calf muscle
pump, and obstruction.
 Direct: Duplex scan
 can determine the presence of anatomic obstruction with a sensitivity and specificity
of over 90%
 Radiologic Imaging
 Computed tomography or (MRI)
 Invasive
 Phlebography
 IVUS
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

38. RULE # 1
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

39. RULE # 2
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

40. Sign of the egyptian EYE
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

41. Management
Medical Ablation
Compression
Sclerotherapy
Drugs
Surgery
Percutaneous Laser
RF ablation
Stripping
Babcock excision
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

42. Medical Management
 Compression tx
 standard first-line treatment for CVI and venous ulcer
 Goal: to facilitate ulcer healing, provide rapid ulcer healing,
and prevent recurrence
 Including:
 elastic compression stockings,
 paste gauze boots (Unna’s boot),
 and multilayer wraps,dressings, and bandages.
 Pneumatic compression devices
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

43. Medical Management
 Drugs treatment
 No drug will cure varicose veins, although some drugs benefit
venous edema & ulceration.
 Some phlebotonic drugs improve the symptoms and edema
associated with venous disease. These could be used in
association with compression for the management of
troublesome symptoms.
 Drugs for venous ulcer:
 Fibrinolytic tx
 Drugs that modify Leukocyte metabolism
 Platelet inhibitors
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

44. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

45. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

46. Medical Management
 Sclerotheraphy
 Indication:
 Superficial venules, “venous spiders” (veins < 1 mm of internal
diameter), venous lakes, and other venous blemishes.
 Varicosities 1–3 mm in diameter in the absence of detectable valvular
reflux as evidenced by duplex examination.
 Postoperative residual veins are those < 3 mm in Ø that the surgeon
chose not to excise in order to limit the number of incisions.
 Incompetent perforating veins (< 4 mm)
 Bleeding varicosities (varicorrhage)
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

47. Medical Management
 Sclerotheraphy
 Contraindication:
 Pregnancy
 Elderly and sedentary patients
 Generalized, severe systemic disease
 Advanced rheumatic disease, osteoarthritis or any disease of the
musculoskeletal system that interferes with the patient’s mobility.
 Arterial insufficiency of the lower extremities
 Patients with history of severe allergic disease or bronchial asthma
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

48. Medical Management
 Sclerotheraphy
 Contraindication:
 Febrile illnesses
 Acute superficial thrombophlebitis or deep vein thrombosis
 Obesity.
 Varicose veins in communication with a source of venous reflux,
demonstrated by duplex ultrasound,
 Patients on anticoagulants
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

49. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

50. Medical Compression Stockings
CLINICAL
SITUATIONS
COMPRESSION in mmHg
10-20 20-30 30-40
C0s, C1s
C1 Post-Injections
C2s Pregnancy
C3 Prevention
C4b
C5
C6
The efficacy of MCS have been proved in a lot of
clinical situations, even leg ulcers
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

51. Surgical Management
 3 principle goals
 The varicosities must be permanently removed and the
underlying cause of venous hypertension treated
 the repair must be done in as cosmetic a fashion as possible
 complications must be minimized.
 Indication:
 Truncal varicose vein gr III-IV
 Contraindication
 Pts with VTE
 Pts with anesthetic complication
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

52. Surgical Management
 Early Complication:
 discomfort
 bruising
 bleeding
 wound infections
 deep venous thrombosis
 nerve injury
 Technique:
 Stripping GSV or SSV
 Phlebectomy
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

53. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

54. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

55. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

56. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

57. PHLEBECTOMY
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

58. Main RULES Phlebectomy
1. Small incisions (1-2 mm)
2. Longitudinal
3. Hooks
4. Steristrips
5. compression
Phlebectomy can replace all the component parts of
the operation except flush ligation
Good practical experience is necessary
Can rescue the operation
Spare wheel
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

59. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

60. • Simplifies Surgery (recurrences)
• Makes it less traumatic
• Goes where surgeon cannot go:
• lympho-nodal networks of the groin
• Deep and long, dystrophic perforators
• Recurrent VV inside the saph. compartment
* Creton D. et Uhl JF EJVES 1998;15:412-5
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

61. Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

62. 70 incisions
Mean number :
30 incisions per operation
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

63. Endoluminal radiofrequency/laser ablation of
the great saphenous vein: methods
Photograph courtesy of VNUS medical Technologies, San Jose, CA.
Percutaneous access to the
greater saphenous vein
most commonly at the
level of the knee under
duplex ultrasound
guidance
Bola Pratt P&S MS 4
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

64. Endoluminal radiofrequency ablation of the
great saphenous vein: methods
Photographs courtesy of VNUS medical Technologies, San Jose, CA.
1) A guidewire is then advanced to
the saphenofemoral junction over
which the closure catheter is passed
2) catheter prongs are extruded to
contact the intimal lining of the
vessel wall
3) radiofrequency generator allows
the tip of the catheter
and the prongs to attain a
temperature of 85 degrees C.
CFA = common femoral artery
CFV = common femoral vein
SEV= superficial epigastric vein
SFJ = saphenofemoral junction
Bola Pratt P&S MS 4
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

65. FEMORAL BLOCK
EPIDURAL - SPINAL
GENERAL anesthesia
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

66. TUMESCENT
anesthesia
The best technique +++++
Only one technique
For varicose veins surgery
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

67. - a solution of iso Bicar (500 ml) Klein pump
+
+ 20 ml 1% lidocain + 2% adrenalin
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

68. Take home message
 Anesthesia by Blocks possible but
 Tumescent Anesthesia is the best ++
Avoid general or peridural anesthesia For GSV surgery
 risk, bleeding , early walk
 quick return to normal activity +++
complication nerve injury
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

69. Thank you!
Any Questions?
Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam