This document summarizes angiologia venosa (venous angiology), past, present and future seen from physics, ultrasound and venous bypass in the 21st century. It discusses key concepts and findings including: - Venous insufficiency is based more on inflammation than physics or gravity alone. - Microvenous valves are key to skin changes in venous insufficiency, with incompetence in third generation tributaries and beyond contributing. - Quantitative rather than just qualitative analysis of reflux is important, measuring total reflux volume. - At least 30cc/sec of reflux from the great saphenous vein is needed to impact the peripheral pump function. - Preserving anatomical capital and changing

1. Angiologia venosa
Pasado , presente y futuro visto desde la física , el
ultrasonido y el bypass venoso en el siglo XXI.
Dr Enrique Ferracani Ristenpart

2. Estimados Colegas
Es la FISICA mas INFLAMACION el sustrato de la
Insuficiencia venosa cronica.

3. Newton y la ley de la gravedad
• Siglo 17
• Basados en la ley de la gravedad de Newton la prueba de
Trendelemburg acepta ley de la gravedad como causa de la
insuficiencia venosa.
• El reflujo se producia por la acción de la gravedad ; por ende
deberíamos contrarrestarla cortando el árbol para que no caiga la
manzana (reflujo)

4. La safenectomia - Stripping
• Trendelemburg anulo el reflujo safeno cerrándola la VSM con un
torniquete.
Keller y Mayo, ano 1906 ,siguieron este principio.
• Anular el reflujo cortando el arbol (VSM )
• La industria bajo este concepto antifisiológico creo métodos de oclusión:
LASER . Radiofrecuencia. Burbujas de calor.
• L a safenectomia y la escleroterapiz por obvias razones costo beneficio
sigue teniendo preeminencia en el 3er mundo por costo y sencillez.
• La industria desarrollo nuevos métodos antifisiologícos del retorno venos
en etapas tempranas
• SAPHEON. Republica Dominicana ,venas promedio de 5mm. 28 % de EGIT
Dr Gerolaukos.

5. Profesor Claude Franceschi
Creador del “Concepto de preservación del capital
anatómico del paciente “
Bases : fisiología y hemodinamia versus ablación
venosa sin sustento hemodinámico.(Perthes)
No importan la dirección del reflujo sino su
drenaje ; concepto de flujo inverso.

6. Terapéuticas : Conocimiento de las leyes físicas aplicadas.
• Ecuacion de Bernouilli ASVAL ,EVLAR ,CHIVA
• Ley de Pouiselle EVLAR ,CHIVA
• Ley de Castelli Velocidad
• Presion transmural Prof Franceschi CHIVA
• Presion endovascular idem
• Presion extravascular idem
• 2da ley de termodinámica Energía potencial y kinetica
• Ley de Laplace Flujo
• Ley de compliance Insuficiencia tríceps solear
• Fenomeno Paradojal de recek Recurrencia

7. Donde queda la ley de Newton hoy después
de estos hallazgos ?

8. • Where does venous reflux start?
• Labropoulos N, Giannoukas AD, Delis K, Mansour MA, Kang SS, Nicolaides AN, Lumley J, Baker WH.
• J Vasc Surg. 1997 Nov;26(5):736-42.
• Division of Peripheral Vascular Surgery, Loyola University Medical Center, Maywood, Ill. 60153-3304, USA.
• Abstract
• This study was designed to identify the origin of lower limb primary venous reflux in asymptomatic young individuals and to compare patterns of reflux with
age-matched subjects with prominent or clinically apparent varicose veins.
• METHODS:
• Forty age- and sex-matched subjects with no symptoms (age, 15 to 35 years; 80 limbs; group A), 20 subjects (age, 19 to 32 years; 40 limbs) with prominent
but nonvaricose veins (n = 26 limbs; group B), and 50 patients (age, 17 to 34 years; 100 limbs) with varicose veins (n = 64; group C) were examined with color
flow duplex imaging. All proximal veins (above popliteal skin crease), superficial, perforator, and deep, in the lower limb were examined in the standing
position, and all the distal veins in the sitting position. Patients who had a documented episode of superficial or deep vein thrombosis, previous venous
surgery, or injection sclerotherapy were excluded from the study.
• RESULTS:
• The prevalence of reflux in group A was 14% (11 of 80), in group B 77% (31 of 40), and in group C 87% (87 of 100). In more than 80% of limbs in the three
groups, reflux was confined to the superficial veins alone. Deep venous reflux or combined patterns of reflux were uncommon even in group C. Reflux was
detected in all segments of the saphenous veins and their tributaries. In the 125 limbs that had superficial venous incompetence, the below-knee segment
of the greater saphenous vein was the most common site of reflux (85, 68%), followed by the above-knee segment of greater saphenous vein (69, 55%) and
the saphenofemoral junction (41, 32%). Nonsaphenous reflux was rare (3, 2.4%). Reflux in the lesser saphenous vein (21, 17%) was seen in all groups,
whereas involvement of both greater and lesser saphenous veins (8, 6.4%) was seen in group C alone. The incidence of multisegmental reflux was
significantly higher in group C (61 of 64, 95%) than in group A (two of 11, 18%) or group B (14 of 26, 54%). The prevalence of distal reflux was comparable in
all groups.
• CONCLUSIONS:
• Primary venous reflux can occur in any superficial or deep vein of the lower limbs. The below-knee veins are often involved in asymptomatic individuals and
in those who have prominent or varicose veins. These data suggest that reflux appears to be a local or multifocal process in addition to or separate from a
retrograde process.

9. • Failure of micro venous valves in small superficial veins is a key to the skin changes of venous insufficiency
• Vincent JR, Jones GR, Hill GB, van Rij AM. J Vasc Surg. 2011; 54(6) suppl: 62S-69S.by Michel Perrin, Lyon, France
• ABSTRACT
The presence of venous valves in veins of small diameter, as well as in venules, was identified a long time ago1-4; however, a recent anatomical book has denied
their existence. The purpose of this study from a team based in Dunedin, New Zealand, was to determine the role of valves—down to the sixth generation of
tributaries from the great saphenous vein—in the prevention of reflux and the related skin changes that may occur in the presence of incompetent valves
beyond those located in the saphenous trunks and their major tributaries.
• Using vascular corrosion casting, the authors clearly demonstrated the presence of valvular incompetence. The article includes beautiful and convincing images
obtained with scanning electron microscopy, which were taken in freshly amputated limbs. The investigation was conducted by injecting resin in the superficial
veins at the medial malleolus. During the process, the outflow vessels of the proximal part of the extremities were ligated to prevent the resin from leaking. In
other words, the procedure was similar to retrograde venography performed in patients, but it was undertaken in amputated limbs.
• The study showed that subjects with or without chronic venous disease may present with degenerative changes in the small veins of the skin of the legs in
the presence of incompetent valves in third-generation tributaries and beyond. However, the degenerative changes are worse in the presence of varicose
veins. According to the authors, this concept may explain why some patients with varicose veins will develop skin changes and ulcers and some will not. The
changes seen by capillaroscopy in skin affected by venous insufficiency (dilated capillary loops) are also in keeping with what the authors have described.5
• Currently only the saphenous veins and their main tributaries are investigated by ultrasound to identify reflux; consequently, refluxing distal tributaries are
not identified.
• It is worth noting that a recent discussion has broached the possibility of a distal origin for the development of incompetence and reflux,
with a subsequent ascending progression of venous incompetence.6-7
• Instrumental investigations other than the usual ultrasound examinations should be undertaken to confirm this hypothesis.
• References:
1. Popoff N. The digital vascular system. Arch Pathol. 1934;18:307-322.
2. Braverman IM, Keh-Yen A. Ultrastructure of the human dermal microcirculation IV. Valve-containing collecting veins at the dermal-subcutaneous junction. J
Invest Dermatol. 1983;8:438-442.
3. Phillips MN, Jones GT, van Rij AM, Zhang M. Micro-venous valves in the superficial veins of the human lower limb. Clin Anat. 2004;17: 55-60.

10. De Labropoulos a Takashi Yamaki
• Labropoulos.Evaluación cualitativa en segundos ; mayor de 0,5 segundos
indicador de ablación ………………… ??????
• Takashi Yamaky .Evaluación y análisis cuantitativo.
Área x pico medio de reflujo en cc/seg x Tiempo = VTR
volumen total de reflujo
• Volumen total de reflujo = índice de severidad ;CEAP 5 y 6

11. Ultrasonido y Ecografía Venosa
El ultrasonido es imprescindible : valor diagnostico y los ojos del cirujano vascular venoso.
• Reflujo Definición Cualitativa
Labropoulos N, Tiongson J, Pryor L, TassiopouloAK, Kang SS, Mansour A, Baker WH. Education Medical SchoolVascular
Medicine, University of London (1994) Definition of venous reflux in lower-extremity veins. J Vasc Surg.2003;38:793–8.
Reflujo mayor de 0,5 segundos.
------------------------------------------------------------------------------------------------------------------------
--
Consenso Hemodinámico de ROMA Dr Lee and col.
“El tiempo de reflujo no es índice valido de ablación”.
---------------------------------------------------------------------------------------------------------------
• Reflujo definición cuantitativa de severidad
Dr Takashi Yamaki ACP Los Angeles 2013
Area x tiempo de reflujo x Pico medio reflujo cc/seg = Volumen total de reflujo
Indice de SEVERIDAD del reflujo

12. Concepto cualitativo de reflujo
Concepto cualitativo, mide segundos de reflujo, no su Volumen Total cc/ seg

13. Concepto cuantitativo de reflujo y Severidad
Concepto cuantitativo mide el Volumen Total de Reflujo Venoso
AREA

14. ¿A dónde va el reflujo safeno?
• A la bomba de la pantorrilla,
corazón peroiferico ; como varices y
venas profundas
• El reflujo no puede simplemente
entrar en el bolsillo de una varice
sin re-entrar en la bomba de la
pantorrilla.

15. El reflujo máximo potencial y Duplex Medido reflujo vs. GSV Diámetro
(n = 119)
• Todos los miembros
excepto 1 con reflujo
medido > 30cc tiene
un diámetro = 5,5
mm.
• Es necesario al menos
30 cc/seg de reflujo
para afectar la bomba
periférica del triceps
sural

16. Es el tratamiento del reflujo safeno necesario
en pacientes con safenas menores a 5mm y
estadio C2-C3?
Dr. Seshadri Raju.
AVF Orlando EEUU 2016
Al menos 30 cc de reflujo/seg dela VSM son necesarios para alterar la
bomba de la pantorrilla.
NO

18. Volúmen Total de Reflujo = Congestión Tisular.

19. Cirugia de preservación ASVAL Dres Pittaluga
y Chastanet
Aplicación fisica de la ecuación de Bernouilli
para reducir la energía kinetica y su
consecuencia ,el Shear Stress, provocado por
las venas extra-fasciales.

21. Ecuacion de Bernouilli
Tributaries Inflow.
E = Pressure x Volume
SHEAR STRESS

22. Fundamentos del método CHIVA
Preservar el “capital anatómico”
Cambiar el “punto de reentrada”
Preservar ,aun en sentido inverso, la función del
sistema venoso .
Conducir la sangre de retorno, al corazón

23. Bases físicas de la Remodelación con Bajo
LEED. EVLAR
Ley de Laplace, su base física
Q (flujo) = Presión / Resistencia

24. Endovascular remodeling with LASER low leed
24 J / cm. Dr Parikov

25. VALSALVA pressure 37mmHg
P (k) 37mmhg / R = RQ (reflux)
Ley de Laplace (flujo)

26. P1 P2
Ley de Pouiselle

27. La reducción de los diámetros venosos dilatados,
actúa como resistencias en serie.
Contrarrestan el frente de presión de Valsalva.
Reducen el Volúmen Total de Reflujo y su Pico
Maximo al consumir su enegia kinetica.
(La reduccion a la mitad del area, incrementa CUATRO veces la
Resistencia al re-flujo )

28. Aumento en sístole
de la presión del
SVP
Cochrane Sys Rev. 2015; recurrencia
luego de la oclusion de la VSM.
Reapertura de
vasos epifasciales

29. Impedir el drenaje venoso fisiológico es causal de
Recurrencia.
• Fenomeno paradojal de Recek : hipertension venosa profunda sistolica
muscular post crosectomia .
• Cochrane Database Syst Rev. 2015 Jun 29;(6)
CHIVA method for the treatment of chronic venous insufficiency.
Bellmunt-Montoya S1, Escribano JM, Dilme J, Martinez-Zapata .
Risk ratio: 66% (metodos conservadores) versus Risk Ratio 78% (tecnicas
ablativas

30. RECURRENCIA
Las condiciones clinicas del paciente mejoran despues de la cirugia
pero persisten (Dr Recek. Condiciones de recurrencia)
Las causas de recurrencia se deben : la progresion de la enfermedad
23 % , neovascularizacion post ablacion 29 % , error tactico 49 %
( munon largo, circuitos no drenados o mal drenados) .

31. Desde el Dr Rene Favaloro al Dr Dreifalt
• Porque tuvo sustento en el mundo flebologico la
destrucción sistemática de la VSM (venas de 5mm
con reflujo VTR minimo ?)
• Por la baja permeabilidad alejada del bypass venoso
en posición coronaria.

32. La baja tasa de permeabilidad del bypas
safeno coronario se debió a pelar la vena
safena magna y anular su nutrición ; los vasa
vasorum .

35. Ann Card Anaesth. 2016 Jul-Sep;19(3):481-8. doi: 10.4103/0971-
9784.185537.
Novel no touch technique of saphenous vein harvesting: Is great graft patency
rate provided?
Papakonstantinou NA1, Baikoussis NG2, Goudevenos J3, Papadopoulos G4,
Apostolakis E5.
Abstract
Coronary artery bypass grafting surgery effectively relieves signs and
symptoms of myocardial ischemia. The left internal thoracic artery (LITA) graft
is the gold standard having 90-95% patency rate at 10 years, whereas only
50% of saphenous vein (SV) grafts are patent at 10 years. However, there is a
novel "no touch" technique in order to harvest an SV complete with its
cushion of surrounding tissue, thus maintaining its endothelium-intact.
Significantly superior short- and long-term graft patency rates comparable to
LITA grafts can be achieved. Consequently, the SV may be revived as an
important conduit in coronary artery bypass surgery.

36. No es lo que no sabemos lo que conduce al error.
Su causa ES lo que creemos que sabemos , oponernos al
cambio sin basamento en la evidencia científica.
¿Are real the disclosures or faked statements ?

37. La industria ha mercantilizado la medicina en algunos
ámbitos permeables .
Es lo que el filosofo Zigmunt Bauman llamo
La Vida liquida.
Todo debe ser construido para ser inmediatamente
consumido, destruido y carecer de valores trascendentes.
Todo es relativo: falsa interpretación de la ley de la
relatividad. o

38. Los invito a debatir los conceptos
presentados.
Gracias por vuestra atención.
Dr Enrique Ferracani Ristenpart

40. Las técnicas ablativas generan recurrencia.