Laskimovajaatoiminnan kajoava hoito

• Pintalaskimoiden refluksia voidaan todeta jopa 98 %:lta laskimohaavaa sairastavista «Kanth AM, Khan SU, Gasparis A ym. The distribution and extent of reflux and obstruction in patients with active venous ulceration. Phlebology 2015;30:350-6 »1.
• Pintalaskimovajaatoiminnan hoito laskimonsisäisillä menetelmillä ilmeisesti nopeuttaa laskimohaavan paranemista «Pintalaskimovajaatoiminnan hoito laskimonsisäisillä menetelmillä ilmeisesti nopeuttaa laskimohaavan paranemista.»B.
  • Ainakin lyhyen seurannan perusteella arvioituna myös haavan uusiutumisriski näyttäisi tällöin pienenevän «Gohel MS, Heatley F, Liu X ym. A Randomized Trial of Early Endovenous Ablation in Venous Ulceration. N Engl J Med 2018;378:2105-2114 »2.
• Siitä ei ole näyttöä, että pintalaskimovajaatoiminnan hoito avoleikkauksella nopeuttaisi laskimohaavan paranemista, mutta haavan parannuttua avoleikkaus ilmeisesti pienentää haavan uusiutumisriskiä «Gohel MS, Barwell JR, Taylor M ym. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial. BMJ 2007;335:83 »3.
  • Tässä yhteydessä on kuitenkin syytä painottaa, että avoleikkaus tulee tällöinkin kyseeseen vain toissijaisena vaihtoehtona, jos laskimovajaatoimintaa ei ole mahdollista hoitaa laskimonsisäisillä menetelmillä (ks. Käypä hoito -suositus Alaraajojen laskimovajaatoiminta «Alaraajojen laskimovajaatoiminta»1).
• Ihomuutoksia aiheuttaneen laskimovajaatoiminnan kajoavalla hoidolla ajatellaan voitavan pienentää haavariskiä «Venous Forum of the Royal Society of Medicine., Berridge D, Bradbury AW ym. Recommendations for the referral and treatment of patients with lower limb chronic venous insufficiency (including varicose »4, «O'Donnell TF Jr, Passman MA, Marston WA ym. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. J Vasc Surg 2014;60:3S-59»5.
  • Hoitoaihe perustuu näiden ihomuutosten ja haavan välillä todettuun assosiaatioon, yhteisiin patogeneettisiin mekanismeihin ja edellä mainittuihin haavan uusiutumista koskeviin havaintoihin «O'Donnell TF Jr, Passman MA, Marston WA ym. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. J Vasc Surg 2014;60:3S-59»5, «Bergan JJ, Schmid-Schönbein GW, Smith PD ym. Chronic venous disease. N Engl J Med 2006;355:488-98 »6, «Robertson L, Lee AJ, Gallagher K ym. Risk factors for chronic ulceration in patients with varicose veins: a case control study. J Vasc Surg 2009;49:1490-8 »7, «Carpentier PH, Cornu-Thénard A, Uhl JF ym. Appraisal of the information content of the C classes of CEAP clinical classification of chronic venous disorders: a multicenter evaluation of 872 patients. »8, .
• Vajaatoimintaisten yhdyslaskimoiden sulku saattaa valikoiduissa tapauksissa olla perusteltua «Masuda E, Ozsvath K, Vossler J ym. The 2020 appropriate use criteria for chronic lower extremity venous disease of the American Venous Forum, the Society for Vascular Surgery, the American Vein and Ly»9, «Montminy ML, Jayaraj A, Raju S. A systematic review of the efficacy and limitations of venous intervention in stasis ulceration. J Vasc Surg Venous Lymphat Disord 2018;6:376-398.e1 »10, «Harlander-Locke M, Lawrence PF, Alktaifi A ym. The impact of ablation of incompetent superficial and perforator veins on ulcer healing rates. J Vasc Surg 2012;55:458-64 »11, «Reitz KM, Salem K, Mohapatra A ym. Complete Venous Ulceration Healing after Perforator Ablation Does Not Depend on Treatment Modality. Ann Vasc Surg 2021;70:109-115 »12.
  • Ensisijainen hoidon kohde on kuitenkin aksiaalinen laskimorefluksi, mikä ei ole vallan uusi ajatus «Montminy ML, Jayaraj A, Raju S. A systematic review of the efficacy and limitations of venous intervention in stasis ulceration. J Vasc Surg Venous Lymphat Disord 2018;6:376-398.e1 »10, «Linton RR. THE COMMUNICATING VEINS OF THE LOWER LEG AND THE OPERATIVE TECHNIC FOR THEIR LIGATION. Ann Surg 1938;107:582-93 »13.
• Lantion alueen syvien laskimoiden post-tromboottisen virtausesteen stenttaus saattaa valikoiduissa tapauksissa olla perusteltua «Masuda E, Ozsvath K, Vossler J ym. The 2020 appropriate use criteria for chronic lower extremity venous disease of the American Venous Forum, the Society for Vascular Surgery, the American Vein and Ly»9, «Raju S, Darcey R, Neglén P. Unexpected major role for venous stenting in deep reflux disease. J Vasc Surg 2010;51:401-8; discussion 408 »14, «Khilnani NM, Meissner MH, Vedanatham S ym. The evidence supporting treatment of reflux and obstruction in chronic venous disease. J Vasc Surg Venous Lymphat Disord 2017;5:399-412 »15, «Qiu P, Zha B, Xu A ym. Systematic Review and Meta-Analysis of Iliofemoral Stenting for Post-thrombotic Syndrome. Eur J Vasc Endovasc Surg 2019;57:407-416 »16.
  • Nämäkin toimenpiteet on kuitenkin nähtävä osana laajempaa kajoavan hoidon algoritmiä «Montminy ML, Jayaraj A, Raju S. A systematic review of the efficacy and limitations of venous intervention in stasis ulceration. J Vasc Surg Venous Lymphat Disord 2018;6:376-398.e1 »10, «Lawrence PF, Hager ES, Harlander-Locke MP ym. Treatment of superficial and perforator reflux and deep venous stenosis improves healing of chronic venous leg ulcers. J Vasc Surg Venous Lymphat Disord 2»17.

Kirjallisuutta

1. Kanth AM, Khan SU, Gasparis A ym. The distribution and extent of reflux and obstruction in patients with active venous ulceration. Phlebology 2015;30:350-6 «PMID: 24681524»PubMed
2. Gohel MS, Heatley F, Liu X ym. A Randomized Trial of Early Endovenous Ablation in Venous Ulceration. N Engl J Med 2018;378:2105-2114 «PMID: 29688123»PubMed
3. Gohel MS, Barwell JR, Taylor M ym. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial. BMJ 2007;335:83 «PMID: 17545185»PubMed
4. Venous Forum of the Royal Society of Medicine., Berridge D, Bradbury AW ym. Recommendations for the referral and treatment of patients with lower limb chronic venous insufficiency (including varicose veins). Phlebology 2011;26:91-3 «PMID: 21471582»PubMed
5. O'Donnell TF Jr, Passman MA, Marston WA ym. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. J Vasc Surg 2014;60:3S-59S «PMID: 24974070»PubMed
6. Bergan JJ, Schmid-Schönbein GW, Smith PD ym. Chronic venous disease. N Engl J Med 2006;355:488-98 «PMID: 16885552»PubMed
7. Robertson L, Lee AJ, Gallagher K ym. Risk factors for chronic ulceration in patients with varicose veins: a case control study. J Vasc Surg 2009;49:1490-8 «PMID: 19497512»PubMed
8. Carpentier PH, Cornu-Thénard A, Uhl JF ym. Appraisal of the information content of the C classes of CEAP clinical classification of chronic venous disorders: a multicenter evaluation of 872 patients. J Vasc Surg 2003;37:827-33 «PMID: 12663984»PubMed
9. Masuda E, Ozsvath K, Vossler J ym. The 2020 appropriate use criteria for chronic lower extremity venous disease of the American Venous Forum, the Society for Vascular Surgery, the American Vein and Lymphatic Society, and the Society of Interventional Radiology. J Vasc Surg Venous Lymphat Disord 2020;8:505-525.e4 «PMID: 32139328»PubMed
10. Montminy ML, Jayaraj A, Raju S. A systematic review of the efficacy and limitations of venous intervention in stasis ulceration. J Vasc Surg Venous Lymphat Disord 2018;6:376-398.e1 «PMID: 29452957»PubMed
11. Harlander-Locke M, Lawrence PF, Alktaifi A ym. The impact of ablation of incompetent superficial and perforator veins on ulcer healing rates. J Vasc Surg 2012;55:458-64 «PMID: 22133452»PubMed
12. Reitz KM, Salem K, Mohapatra A ym. Complete Venous Ulceration Healing after Perforator Ablation Does Not Depend on Treatment Modality. Ann Vasc Surg 2021;70:109-115 «PMID: 32603845»PubMed
13. Linton RR. THE COMMUNICATING VEINS OF THE LOWER LEG AND THE OPERATIVE TECHNIC FOR THEIR LIGATION. Ann Surg 1938;107:582-93 «PMID: 17857163»PubMed
14. Raju S, Darcey R, Neglén P. Unexpected major role for venous stenting in deep reflux disease. J Vasc Surg 2010;51:401-8; discussion 408 «PMID: 20006920»PubMed
15. Khilnani NM, Meissner MH, Vedanatham S ym. The evidence supporting treatment of reflux and obstruction in chronic venous disease. J Vasc Surg Venous Lymphat Disord 2017;5:399-412 «PMID: 28411707»PubMed
16. Qiu P, Zha B, Xu A ym. Systematic Review and Meta-Analysis of Iliofemoral Stenting for Post-thrombotic Syndrome. Eur J Vasc Endovasc Surg 2019;57:407-416 «PMID: 30414801»PubMed
17. Lawrence PF, Hager ES, Harlander-Locke MP ym. Treatment of superficial and perforator reflux and deep venous stenosis improves healing of chronic venous leg ulcers. J Vasc Surg Venous Lymphat Disord 2020;8:601-609 «PMID: 32089497»PubMed