Minimally invasive treatment of varicose veins of lower extremities in a patient with hemophilia A (case report)
AbstractPresented herein is a clinical case concerning successful treatment of varicose veins of the lower extremities in a patient with moderate severe hemophilia A. The patient underwent endovenous laser ablation of the great saphenous vein. According to the recommendation of a hematologist, correction of hemophilia was performed by means of infusion of blood coagulation factor VIII. Delayed sclerotherapy of the dilated tributaries was managed. Good results were achieved with neither intra- nor postoperative complications. The duration of follow-up and ultrasonographic assessment amounted to 1 year.
Funding. The study had no financial support.
Conflict of interest. The authors declare no conflicts of interest.
Authors’ contribution. Study conception and design – Borsuk D.A., Fokin A.A.; data collection and handling – Zabelinskaya D.A.; draft manuscript preparation – Borsuk D.A., Zabelinskaya D.A.; manuscript revision – Fokin A.A.
For citation: Borsuk D.A., Zabelinskaya D.A., Fokin A.A. Minimally invasive treatment of varicose veins of lower extremities in a patient with hemophilia A (case report). Angiology and Vascular Surgery. Journal named after Academician A.V. Pokrovsky. 2024; 30 (2): 137–42. DOI: https://doi.org/10.33029/1027-6661-2024-30-2-137-142
Keywords: varicose veins; endovenous laser ablation; hemophilia
References
1. Clinical guidelines of the National Society of Hematology for diagnosis and treatment of hemophilia [approved at the IV Congress of Russian Hematologists (April 2018)]. Under the leadership of academic V.G. Savchenko. (in Russian)
2. Salim S., Machin M., Patterson B.O., et al. Global Epidemiology of Chronic Venous Disease: A Systematic Review With Pooled Prevalence Analysis. Annals of Surgery. 2021; 274 (6): 971–976. DOI: https://doi.org/10.1097/SLA.0000000000004631
3. De Maeseneer M.G., Kakkos S.K., Aherne T., et al. Editor’s Choice - European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. European Journal of Vascular and Endovascular Surgery. 2022; 63 (2): 184–267. DOI: https://doi.org/10.1016/j.ejvs.2021.12.024
4. Gloviczki P., Lawrence P.F., Wasan S.M., et al. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2023; 11 (2): 231–261.e6. DOI: https://doi.org/10.1016/j.jvsv.2022.09.004
5. Gloviczki P., Lawrence P.F., Wasan S.M., et al. The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2024; 12 (1): 101670. DOI: https://doi.org/10.1016/j.jvsv.2023.08.011
6. Heger M., van Golen R.F., Broekgaarden M., et al. Endovascular laser–tissue interactions and biological responses in relation to endovenous laser therapy. Lasers in Medical Science. 2014; 29 (2): 405–422. DOI: https://doi.org/10.1007/s10103-013-1490-3
7. Aherne T.M., Ryan É.J., Boland M.R., et al. Concomitant vs. Staged Treatment of Varicose Tributaries as an Adjunct to Endovenous Ablation: A Systematic Review and Meta-Analysis. European Journal of Vascular and Endovascular Surgery. 2020; 60 (3): 430–442. DOI: https://doi.org/10.1016/j.ejvs.2020.05.028
8. Srivastava A., Santagostino E., Dougall A., et al.; WFH Guidelines for the Management of Hemophilia panelists and co-authors. WFH Guidelines for the Management of Hemophilia, 3rd edition. Haemophilia. 2020; 26 (Suppl 6): 1–158. DOI: https://doi.org/10.1111/hae.14046
9. Terlecki P., Zubilewicz T., Przywara S., et al. Minimally invasive, endovenous laser treatment of varicose veins in patients with von Willebrand disease. Annals of Agricultural and Environmental Medicine. 2013; 20 (4): 880–883.
10. Konovalova D.S., Yashkin M.N. Minimally invasive endovascular technologies for the treatment of a patient with varicose veins of the lower extremities and Rendu–Osler–Weber disease. Bulletin of the National Medical and Surgical Center named after. N.I. Pirogov. 2019; 14 (1): 140–143. DOI: https://doi.org/10.25881/BPNMSC.2019.25.45.025 (in Russian)
11. Szczepanik A.B., Pielaciński K., Oses-Szczepanik A.M., et al. Sclerotherapy of esophageal varices in hemophilia patients with liver cirrhosis – a prospective, controlled clinical study. Polski Przeglad Chirurgiczny. 2018; 90 (1): 29–34. DOI: https://doi.org/10.5604/01.3001.0011.5957
12. Szczepanik A.B., Dąbrowski W.P., Szczepanik A.M., et al. Sclerotherapy Of Esophageal Varices In Severe Hemophilia A Patient And High Titer Inhibitor – Case Report. Polski Przeglad Chirurgiczny. 2015; 87 (9): 464–468. DOI: https://doi.org/10.1515/pjs-2015-0089
13. Tarhan I.A., Dumantepe M., Yurdakul I., et al. Local cooling effect on perforation rates comparing the 980-1470 nm laser wavelengths used with endovenous laser ablation: double blind in vitro experimental study. Phlebology. 2014; 29 (2): 120–125. DOI: https://doi.org/10.1258/phleb.2012.012021
14. Abud B., Karaarslan K., Turhan S., Karaman Y. Is the temperature of tumescent anesthesia applied in the endovenous laser ablation important? comparison of different temperatures for tumescent anesthesia applied during endovenous ablation of incompetent great saphenous vein with a 1470 nm diode laser. Vascular. 2014; 22 (6): 421–426. DOI: https://doi.org/10.1177/1708538113518532
Благодаря современным возможностям гемостатической терапии продолжительность жизни больных гемофилией значительно возросла, ввиду чего у пациентов этой группы стали встречаться хронические заболевания, характерные для общей популяции [8]. Опубликованы наблюдения оперативного лечения варикозного расширения вен нижних конечностей у пациентов с другими геморрагическими болезнями, в частности фон Виллебранда и Рандю-Ослера-Вебера [9, 10], однако описания вмешательств на поверхностных венах у больных гемофилией мы не нашли. В то же время сообщалось о возможности склеротерапии при варикозном расширении вен пищевода у подобных пациентов с положительными результатами [11, 12].
В представленном клиническом наблюдении пациенту с гемофилией А выполнена ЭВЛО БПВ с отсроченной склеротерапией расширенных притоков. Достигнута облитерация вен с последующей резорбцией. Мы не меняли нашу рутинную практику и использовали для тумесцентной анестезии раствор комнатной температуры без добавления адреналина. Охлаждение раствора и применение адреналина, возможно, способствовало бы снижению риска развития послеоперационных экхимозов и гематомы, однако на этот счет существуют противоречивые данные [13, 14]. В представленном наблюдении каких-либо значимых осложнений или серьезных нежелательных явлений не зафиксировано.
Двухэтапный подход был избран с целью как минимизации травмы при первичном вмешательстве, так и уменьшения диаметра притоков в отдаленном периоде для более предпочтительных условий выполнения последующей склеротерапии.
Заключение
Таким образом, изолированная ЭВЛО магистральной поверхностной вены с отсроченной склеротерапией расширенных притоков при соблюдении рекомендаций гематолога (инфузии фактора свертывания VIII по приведенной выше схеме) показала эффективность и безопасность в конкретном клиническом примере у пациента с гемофилией А и варикозным расширением вен нижних конечностей.
Комментарий редакции
Редакционный совет акцентирует внимание, что современные минимально инвазивные технологии выполнения операций расширяют возможности хирургического лечения больных, в том числе с гематологическими заболеваниями и высоким риском развития послеоперационных гематом и кровотечений. Без сомнения, лечение подобных пациентов - командная работа, и выполнение рекомендаций гематолога строго обязательно.
Литература
1. Клинические рекомендации по диагностике и лечению гемофилии Национального гематологического общества (утверждены на IV Конгрессе гематологов России (апрель 2018)). Под руководством академика В.Г. Савченко.
2. Salim S., Machin M., Patterson B.O., et al. Global Epidemiology of Chronic Venous Disease: A Systematic Review With Pooled Prevalence Analysis. Annals of Surgery. 2021; 274 (6): 971-976. DOI: https://doi.org/10.1097/SLA.0000000000004631
3. De Maeseneer M.G., Kakkos S.K., Aherne T., et al. Editor’s Choice - European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. European Journal of Vascular and Endovascular Surgery. 2022; 63 (2): 184-267. DOI: https://doi.org/10.1016/j.ejvs.2021.12.024
4. Gloviczki P., Lawrence P.F., Wasan S.M., et al. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2023; 11 (2): 231-261.e6. DOI: https://doi.org/10.1016/j.jvsv.2022.09.004
5. Gloviczki P., Lawrence P.F., Wasan S.M., et al. The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2024; 12 (1): 101670. DOI: https://doi.org/10.1016/j.jvsv.2023.08.011
6. Heger M., van Golen R.F., Broekgaarden M., et al. Endovascular laser-tissue interactions and biological responses in relation to endovenous laser therapy. Lasers in Medical Science. 2014; 29 (2): 405-422. DOI: https://doi.org/10.1007/s10103-013-1490-3
7. Aherne T.M., Ryan É.J., Boland M.R., et al. Concomitant vs. Staged Treatment of Varicose Tributaries as an Adjunct to Endovenous Ablation: A Systematic Review and Meta-Analysis. European Journal of Vascular and Endovascular Surgery. 2020; 60 (3): 430-442. DOI: https://doi.org/10.1016/j.ejvs.2020.05.028
8. Srivastava A., Santagostino E., Dougall A., et al.; WFH Guidelines for the Management of Hemophilia panelists and co-authors. WFH Guidelines for the Management of Hemophilia, 3rd edition. Haemophilia. 2020; 26 (Suppl 6): 1-158. DOI: https://doi.org/10.1111/hae.14046
9. Terlecki P., Zubilewicz T., Przywara S., et al. Minimally invasive, endovenous laser treatment of varicose veins in patients with von Willebrand disease. Annals of Agricultural and Environmental Medicine. 2013; 20 (4): 880-883.
10. Коновалова Д.С., Яшкин М.Н. Миниинвазивные эндоваскулярные технологии в лечении пациентки с варикозным расширением вен нижних конечностей и болезнью Рендю-Ослера-Вебера. Вестник Национального медико-хирургического Центра им. Н.И. Пирогова. 2019; 14 (1): 140-143. DOI: https://doi.org/10.25881/BPNMSC.2019.25.45.025
11. Szczepanik A.B., Pielaciński K., Oses-Szczepanik A.M., et al. Sclerotherapy of esophageal varices in hemophilia patients with liver cirrhosis - a prospective, controlled clinical study. Polski Przeglad Chirurgiczny. 2018; 90 (1): 29-34. DOI: https://doi.org/10.5604/01.3001.0011.5957
12. Szczepanik A.B., Dąbrowski W.P., Szczepanik A.M., et al. Sclerotherapy Of Esophageal Varices In Severe Hemophilia A Patient And High Titer Inhibitor - Case Report. Polski Przeglad Chirurgiczny. 2015; 87 (9): 464-468. DOI: https://doi.org/10.1515/pjs-2015-0089
13. Tarhan I.A., Dumantepe M., Yurdakul I., et al. Local cooling effect on perforation rates comparing the 980-1470 nm laser wavelengths used with endovenous laser ablation: double blind in vitro experimental study. Phlebology. 2014; 29 (2): 120-125. DOI: https://doi.org/10.1258/phleb.2012.012021
14. Abud B., Karaarslan K., Turhan S., Karaman Y. Is the temperature of tumescent anesthesia applied in the endovenous laser ablation important? comparison of different temperatures for tumescent anesthesia applied during endovenous ablation of incompetent great saphenous vein with a 1470 nm diode laser. Vascular. 2014; 22 (6): 421-426. DOI: https://doi.org/10.1177/1708538113518532
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