E. Shaidakov, I.Sonkin, V.Bulatov St. Petersburg, Russia THE ROLE OF ENDOTHELIUM FUNCTIONAL STATE IN TRUNCAL VEIN FOAM SCLEROTHERAPY EFFICACY IN PATIENTS OF DIFFERENT AGE GROUPS

- There is no common view among specialists on the surgical management of chronic venous diseases of the aged. -Clinical picture of this group of patients is commonly aggravated by various decompensated accompanying pathological states. -The risk of carrying out any invasive procedure in this case is associated with the possible development of severe complications.

REQUIREMENTS FOR SURGERY ON VARICOSE VEINS - Minimal injury ! - Minimal complication risk (combined with significant decrease of infection risk at C5 and C6 stages)! - Recurrence - No nerves damage and sensitivity disturbances -Simplicity of performance - Procedure duration reduction - Rehabilitation period reduction and earlier patient performance restoration ! - Maximal cosmetic effect

The American Venous Forum, 2009 While sclerotherapy with liquid hardener and classic stripping are likely to remain the gold standard in the XXI century, new technologies, such as EVLA and foam sclerotherapy appeared for further simplification and/or improvement of these techniques results. (HANDBOOK OF VENOUS DISORDERS. THIRD EDITION. Guidelines of the American Venous Forum. – Third edition. 2009)

During 2001 – 2006 we examined and operated 279 patients with decompensated varicose vein disease (C4-C6). All the patients were divided according to their age into two groups: the first – patients of the elderly and senile age (65 years and older), 176 individuals; the second – 203 patients belonging to other age groups.

ANCIENT CHINESE CLASSIFICATION (IV B.C.) … Youth up to 20 years Age at marriage up to 30 years Public duties performance up to 40 years Knowledge of own misapprehension up to 50 years The last period of creative activity up to 60 years Desirable age up to 70 years Senility from 70 years

AGE CLASSIFICATION BY PYTHAGOR (VI B.C.) Infancy 0-20 years (“spring”) A young man years (“summer”) A man in the prime of life years (“autumn”) An old and fading man years (“winter”)

 CLASSIFICATION BY  St. Petersburg Institute for Bioregulation and Gerontology Russia Academy of Medical Sciences (2010) Infancy from birth to 3 years Early childhood 3-6 years Childhood 6-12 years Adolescence years Youth years Mature age years Elderly age from 65 and so forth

ACCOMPANYING PATHOLOGY Accompanying pathology Group The condition after acute 6(9%) 3(6%) cerebrovascular accident Primary hypertension 50(78%) 14(31%) Nephropathy 11(17%) 2(4%) Coronary heart disease: postinfarction cardiosclerosis 38(59%) 8(18%) Diabetes mellitus 14 (22% 5(11%)) Heart rhythm disorder 8(13%) 2(4%)Chronic Obstructive Pulmonary Disease 7(11%) 4(9%) Gastrointestinal diseases accompanied by constipation 16(25%) 5(11%)

. All patients underwent truncal vein foam sclerotherapy with Muller's phlebectomy of various types.

The following long-term (5 years) factors were evaluated: - target vein obliteration degree; -quality of life by CIVIC scale; -disease severity degree by VCSS scale. Long-term outcomes by three score scale were estimated as - “good” in 86% of the first group patients In the second group: - 53% of patients had “poor” outcomes -28% - “satisfactory” ones. - “good” in 19%!!!

Considering, that the primary point of sclerosing agent administration is venous wall endothelium, we arrived at a conclusion that specific functioning of endothelium in patients belonging to different age groups needs further studying

- Surgical material (40 pathological samples) of 20 patients, who underwent combined stripping for varicose vein disease (VD) at the С4-С6 stages, has been studied. - Patients’ age varied from 28 to of them were females, 11- males. Venous wall endothelium from GSV ostial valve has been investigated in all patients using the same method. Intraoperative material was harvested from the venous valve sine endothelium using brush-biopsy technique.

In order to evaluate morphological-functional properties and viability of endothelium the following findings were investigated: - the number of intact nuclei and vacuolization (survivability and adaptive properties of endothelium); - nuclear polymorphism (the rate of cell physiologic process intensity); - chromatin condensation intensity (synthesis intensity and proliferative endotheliocyte activity); eosinophility (the rate of cytoplasm changes) and the number of necrotic modified endotheliocytes. All counts were made in a standard visual view.

 Бобрик И. И. и др., 1991

ENDOTHELIOCYTE WITH INTACT NUCLEUS

Nuclear polymorphism (the rate of cell physiologic process intensity)

Chromatin condensation intensity (synthesis intensity and proliferative endotheliocyte activity)

Conclusions: -Endotheliocyte survivability declines with aging. -Physiologic process activity in cell decreases, as does endotheliocyte proliferative activity. -Adaptive cellular properties deteriorate. - Satisfactory outcomes of truncal catheter scleral obliteration in the treatment of varicose vein disease in the patients of the elderly and senile age groups are due to age-related changes occurring in vein wall endotheliocytes.

IN THE CASE OF RECURRENCE ONE SHOULD ASK FOR “ FOAM TOPPING-UP”!