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To date, modern outpatient minimally invasive interventions for varicose veins, such as endovenous laser or radiofrequency ablation, microphlebectomy, sclerotherapy, non-thermal non-tumescent methods (NTNT), are widely introduced into clinical practice in the Russia. In the approved by the Ministry of Health of the Russian Federation in 2021 clinical guidelines "Varicose veins of the lower extremities" they are recommended as preferred over open surgery. At the same time, there are no federal regulations of preoperative examination of patients before these minimally invasive procedures for varicose veins. That is why the medical community is often forced to prescribe unnecessary diagnostic tests on the "just-in-case" principle, in order to protect itself for cases of complications and subsequent checks. This undoubtedly harms both the patients and the medical service, which has an additional useless and inappropriate burden. The purpose of the round table held on September 28, 2021 under the auspices of the Self-Regulatory Organization “The National College of Phlebology” together with the legal partner “The Faculty of Medical Law LLC” (Moscow), was to review the existing legislation on this issue and then to prepare a resolution regarding the justified preoperative examination of patients before minimally invasive interventions for varicose veins of the lower extremities. The prepared document consists of two parts. The first part presents the legal regulation of the diagnostic tests before interventions in phlebology. The second part contains the opinion of the professional community regarding the appropriateness or inexpediency of different pre-procedural examinations. In addition, based on the conclusions of legal analytics, a form of order of the chief physician has been developed, which regulates the diagnostic tests before the considered phlebological interventions in the clinic.

Introduction Pelvic congestion syndrome (PCS) may be effectively managed with conservative treatment in certain patients. Treatment with venoactive drugs is common, but supportive data are limited. This study evaluated the clinical efficacy of micronized purified flavonoid fraction (MPFF) in women with PCS. Methods In a single-blind, placebo-controlled study, women with duplex ultrasound diagnosis of pelvic varicose veins (PVV) and PCS were randomized to MPFF 1000 mg once daily or placebo for 2 months. Clinical manifestations of PCS were evaluated at baseline and end of treatment (M2) using three assessment tools: disease-specific quality of life (QoL) Pelvic Varicose Vein Questionnaire (PVVQ), Pelvic Venous Clinical Severity Score (PVCSS), and the Visual Analog Scale (VAS) for the main symptoms of the disease. Results A total of 83 women were included, 42 received MPFF and 41 received placebo. In the MPFF group, the mean global PVVQ QoL index decreased significantly from 45.1 ± 14.7 at baseline to 36.6 ± 10.6 at M2 (mean change: 8.2 ± 10.4); no significant change was observed in the control group (mean change: – 0.3 ± 4.0). The between-group difference was statistically significant (P

Recently collated scientific data on the management of C1 clinical class of chronic venous disorders; wide prevalence of the disease and high variability amongst medical practitioners in relation to managing this category of patients and absence of any regulatory documents has prompted the development of clinical guidelines for the treatment of patients with reticular varicose veins and telangiectasias of the lower extremities and various parts of the body. These guidelines have been developed by a self-regulated organization Association “The National College of Phlebology”. The purpose of the de novo guidelines is to systematize the existing evidence and offer minimal standards of care for chronic venous disorders in C1 patients.

The histological differences in the structure of the ovarian vein and saphenous veins of the lower extremities during their varicose transformation have been insufficiently studied in the modern literature. The study aims to determine the morphological parallels of the structure of varicose veins in varicose veins of the pelvis and varicose veins of the lower extremities. Fifty histological biopsy specimens of removed veins were examined in women. Of these, 25 large saphenous veins were obtained from patients with varicose veins of the lower extremities and 25 preparations of a resected ovarian vein from 25 women with varicose veins of the pelvis. The preparation was stained with hematoxylin-eosin and by the Van Gieson method, studied by light microscopy. In the study of the preparations, significant structural changes were noted in all layers of the venous wall, both in varicose veins of the pelvis and in varicose veins of the lower extremities in the form of a combination of atrophic, fibroplastic and hypertrophic processes leading to the loss of its functional properties. Depending on the decompensation of pathological processes, 3 morphological forms of lesions of the venous wall structure were revealed. The hypertrophic form was found in 17 (34%) surgery perform women, fibrous - in 13 (26%), atrophic - in 20 (40%). In the group of patients with varicose veins of the pelvis compared with the group of patients with varicose veins of the lower extremities, the prevalence of initial forms of lesion was revealed. There was a correlation between the severity of venous vascular lesions with the duration of the disease and the patient's age, the number of risk predictors and a high body mass index, which was the determining factor in the occurrence of this phenomenon. The results of this study indicate the similarity of the pathological picture of venous lesions, both in varicose veins of the pelvis and in varicose veins of the lower extremities.

This consensus statement of Russian experts is based on a review of the relevant literature on the prevalence, diagnosis, and treatment of non-thrombotic and post-thrombotic venous obstruction, as well as management of patients after venous stenting. In the Part 1 we discussed the clinical manifestations of venous obstruction, the role of duplex ultrasound scan, CT venography, MR venography, direct venography, and intravascular ultrasound scan, as well as typical findings obtained by using these methods. The authors mentioned the functional assessment of venous outflow in healthy subjects and in those with obstruction and changes in them after the intervention. In conclusion, the authors formulated the suggestions for clinical recommendations on the diagnosis of chronic venous obstruction.

It is estimated that more than 200 million people worldwide suffer peripheral artery disease and the rate of amputations remains at a high level. The basis of treatment is timely revascularization wherein the fraction of interventions performed endovascularly has steadily been growing both in Russia and abroad. Nevertheless, the parameters of long-term patency of endovascular reconstructions of the infrainguinal segment are still inferior to open interventions. In order to select an optimal method of revascularization and to predict the duration of patency of the reconstruction modern clinical guidelines suggest using the GLASS and WIfI scales, which may improve the remote results of the intervention. Moreover, modern paclitaxel-coated stents and balloons may help increase primary patency of the reconstruction after endovascular procedures. A not less important method of improving remote results of endovascular treatment of patients with peripheral artery disease is considered to be the use of contemporary regimens of antithrombotic therapy. The VOYAGER PAD trial showed that in patients with peripheral artery disease after endured revascularization of lower limbs rivaroxaban prescribed at a dose of 2.5 mg twice daily in a combination with conventional antithrombocytic therapy made it possible to decrease the risk of such ischaemic complications as acute limb ischaemia, major amputation, myocardial infarction, ischaemic stroke and death of cardiovascular causes.По оценкам, свыше 200 млн человек во всем мире страдают заболеваниями периферических артерий, а частота ампутаций остается на высоком уровне. Основой лечения является своевременная реваскуляризация, где доля вмешательств, выполненных эндоваскулярно, неуклонно растет как в России, так и в других странах. Тем не менее показатели отдаленной проходимости эндоваскулярных реконструкций инфраингвинального сегмента пока уступают открытым вмешательствам. Для выбора оптимального метода реваскуляризации и прогнозирования срока проходимости реконструкции в современных клинических рекомендациях предлагается использовать шкалы оценки GLASS и WIFI, что может улучшить отдаленные результаты вмешательства. Более того, современные стенты и баллоны с паклитакселом также способны помочь увеличить первичную проходимость реконструкции после эндоваскулярных процедур. Не менее важным методом улучшения отдаленных результатов эндоваскулярного лечения пациентов с заболеваниями периферических артерий считается применение современных схем антитромботической терапии. В исследовании VOYAGER PAD было продемонстрировано, что у пациентов с заболеваниями периферических артерий, перенесших реваскуляризацию нижних конечностей, назначение ривароксабана в дозе 2,5 мг 2 р/сут в сочетании со стандартной антитромбоцитарной терапией позволило снизить риск развития таких ишемических осложнений, как острая ишемия конечности, большая ампутация, инфаркт миокарда, ишемический инсульт и смерть от сердечно-сосудистых причин.

Presented in the article is a prospective study of endovascular embolization of ovarian veins in female patients suffering from primary pelvic varicose veins, with the assessment of the immediate and remote results, as well as a 1-year follow up.The aim of our investigation was a comprehensive clinical and instrumental assessment of efficacy of endovascular embolization in women with pelvic varicose veins.Our single-centre study included a total of 29 female patients presenting with pelvic varicose veins and undergoing embolization of ovarian veins using microcoils, in 5 cases the procedure was supplemented with injecting a foam sclerosant.The technical success of endovascular occlusion of ovarian veins amounted to 100%. Two women immediately after the operation were subjected to a redo intervention: in one case - resection of the ovarian vein and in the second case - repositioning of the microcoils. In the remote period, one patient due to recurrent relapses underwent repeat embolization followed by retroperitoneal resection of the ovarian vein. The findings of the clinical methods of examination demonstrated a decrease in the intensity of manifestations of pelvic varicose veins according to the pelvic venous clinical severity score and visual analogue scale, as well as improvement of the women's quality of life.Endovascular occlusion of ovarian veins is a highly effective, minimally invasive, and safe method of treatment of female patients with incompetent ovarian veins. Endovascular treatment may be regarded as a method of choice in management of the primary form of pelvic varicose veins.В статье представлено проспективное исследование эндоваскулярной эмболизации яичниковых вен у пациенток с первичной варикозной болезнью таза с оценкой ближайших и отдаленных результатов, а также годового наблюдения. Цель – комплексная клиническая и инструментальная оценка эффективности эндоваскулярной эмболизации у пациенток с варикозной болезнью таза. Материалы и методы. В одноцентровое исследование включено 29 пациенток с варикозной болезнью таза, которым была выполнена эмболизация яичниковых вен микроспиралями, в 5 случаях процедура дополнялась введением пенного склерозанта. Результаты. Технический успех эндоваскулярной окклюзии яичниковых вен составил 100%. В двух случаях непосредственно после операции осуществлено повторное вмешательство: в одном – резекция яичниковой вены, во втором – повторное позиционирование микроспиралей. В отдаленном периоде одной из пациенток вследствие повторных рецидивов проведены операции повторной эмболизации, а затем забрюшинной резекции яичниковой вены. При оценке клинических методов исследования отмечали снижение интенсивности проявлений варикозной болезни таза по шкале тяжести и визуально-аналоговой шкале, а также улучшение качества жизни пациенток. Выводы. Эндоваскулярная окклюзия яичниковых вен является высокоэффективным, миниинвазивным и безопасным методом лечения пациенток с несостоятельностью яичниковых вен. Эндоваскулярные методы лечения могут считаться методом выбора в лечении первичной формы варикозной болезни таза.

Contraction (retraction) of the blood clot is a part of the clotting process driven by activated platelets attached to fibrin that can potentially modulate the obstructiveness and integrity of thrombi. The aim of this work was to reveal the pathogenic importance of contraction of clots and thrombi in venous thromboembolism (VTE). We investigated the kinetics of clot contraction in the blood of 55 patients with VTE. In addition, we studied the ultrastructure of ex vivo venous thrombi as well as the morphology and functionality of isolated platelets. Thrombi from VTE patients contained compressed polyhedral erythrocytes, a marker for clot contraction in vivo. The extent and rate of contraction were reduced by twofold in clots from the blood of VTE patients compared with healthy controls. The contraction of clots from the blood of patients with pulmonary embolism was significantly impaired compared with that of those with isolated venous thrombosis, suggesting that less compacted thrombi are prone to embolization. The reduced ability of clots to contract correlated with continuous platelet activation followed by their partial refractoriness. Morphologically, 75% of platelets from VTE patients were spontaneously activated (with filopodia) compared with only 21% from healthy controls. At the same time, platelets from VTE patients showed a 1.4-fold reduction in activation markers expressed in response to chemical activation when compared with healthy individuals. The results obtained suggest that the impaired contraction of thrombi is an underappreciated pathogenic mechanism in VTE that may regulate the obstructiveness and embologenicity of venous thrombi.

The persistent sciatic artery is situated superficially in the gluteal region wherein it can be traumatized in normal daily activities: during a prolonged sitting position or while attempting to sit down. This leads to an early atherosclerotic lesion of the sciatic artery, to the development of aneurysmatic dilatation, and damage to the arterial wall. The present article describes a 72-year-old female patient presenting with a persistent sciatic artery of the left leg and a PSA aneurysm which consequently resulted in critical ischaemia of her left lower limb. This abnormality was detected during an examination and the woman was subjected to the operation of internal iliac-posterior tibial bypass grafting using an autologous vein with ligation of the sciatic artery. The bypass graft has been functioning for 5 months, with no events of critical ischaemia.Сохраненная седалищная артерия располагается поверхностно в ягодичной области, где может быть травмирована при нормальной повседневной деятельности: во время длительного нахождения в положении сидя, либо при попытке присесть. Это приводит к ранним атеросклеротическим поражениям седалищной артерии, развитию аневризматического расширения и повреждению стенки артерии. В этой работе представлено описание пациентки 72 лет с наличием атипичной седалищной артерии левой нижней конечности и развитием ее аневризмы, что впоследствии привело к критической ишемии левой нижней конечности. В ходе обследования данная аномалия была выявлена и проведена операция внутреннеподвздошно-заднебольшеберцового шунтирования аутовеной с лигированием седалищной артерии. Шунт функционирует в течение 5 месяцев. Явления критической ишемии купированы.

Using assessment scales in clinical and research practice is one of fundamental reference methods of evaluation in human pathological states. Pelvic vein varicosity is an independent nosological entity within the framework of chronic vein diseases. Currently, the clinical methods of assessment in the aspect of a patient-oriented approach in this type of disease are largely understudied and still not duly defined.The study was aimed at analyzing clinical outcomes of surgical treatment in the form of resection of the ovarian vein in female patients with pelvic varicose veins, based on the developed specialized scale of clinical assessment of disease severity.We carried out an open prospective study of efficacy of resection of the ovarian vein in 37 women with pelvic varicose veins. The main criterion for assessment was a clinical method of determining manifestations of the disease by means of the Pelvic Venous Clinical Severity Score.According to the Pelvic Venous Clinical Severity Score, improvement of the condition was observed in 36 (97.3%) operated female patients and 1 (2.7%) woman turned out to have negative dynamics. The median of the composite score of the severity scale decreased form 11.78±5.06 points to 5.22±3.19 (p0.05). The total positive gradient of the score amounted to 6.57±3 .65 points. A significant decrease in manifestations of severity was observed for 9 of the 10 clinical descriptors of the disease.The use of the suggested scale in practical assessment of the results made it possible to prove high efficacy of resection of the ovarian vein in women with pelvic varicose veins in the form of decreased intensity of the disease's symptomatology. The VCSS is an easy-to-fill-in tool, taking up little time, ensuring no influence of the physician's personality on the answers, presenting quantitative expression of therapeutic results.Использование оценочных шкал в клинической и исследовательской практике является одним из основополагающих референтных методов оценки при патологическом состоянии человека. Варикозная болезнь таза является самостоятельной нозологической единицей в рамках хронических заболеваний вен. В настоящее время клинические методы оценки в аспекте пациент-ориентированного подхода при данном заболевании не до конца изучены и определены. Цель исследования. Клинический анализ результатов хирургического лечения в виде резекции яичниковой вены у пациенток с варикозной болезнью таза на основании разработанной специализированной шкалы клинической оценки тяжести заболевания. Материалы и методы. Проведено открытое проспективное исследование эффективности операции резекции яичниковой вены у 37 женщин с варикозной болезнью таза. Основным критерием оценки являлся клинический метод определения тяжести проявлений болезни в виде балльной клинической шкалы оценки тяжести заболевания пациентки с варикозной болезнью таза – Pelvic Venous Clinical Severity Score. Результаты. Согласно клинической шкале тяжести заболевания, улучшение состояния отмечено у 36 (97,3%) оперированных пациенток, у 1 (2,7%) больной зарегистрирована отрицательная динамика. Медиана суммарного показателя шкалы тяжести регрессировала с 11,78±5,06 баллов до 5,22±3,19 (p0,05). Суммарный положительный градиент шкалы составил 6,57±3,65 баллов. Достоверное снижение проявлений тяжести отмечали по 9 признакам заболевания из 10. Заключение. Применение предложенной шкалы в практической оценке результатов позволило доказать высокую результативность операции резекции яичниковой вены у пациенток с варикозной болезнью таза в виде снижения интенсивности симптоматики заболевания. Заполнение данной шкалы не представляет трудности, занимает минимальное количество времени, исключает влияние личности врача на ответ, представляет количественное выражение результатов лечения.

Presented herein is an original method of preparing a bypass graft (a non-reversed autovein for femoropopliteal and femorotibial bypass grafting) and assessment of quality of valvulotomy using a thermal imager. The study included a total of 31 patients. All patients subdivided into 2 groups were subjected to bypass grafting operations with the use of a non-reversed autovein. In group 1 (n=16) prior to applying a bypass graft we assessed its patency with the use of an original method by means of a thermal imaging camera. In group 2 (n=15) assessment of graft patency after destruction of valves was not performed. In group 1 there were no bypass graft thromboses in the postoperative period, whereas three (20%) patients in group 2 developed bypass graft thrombosis within the first 24 postoperative hours, requiring repeat operation. Bypass graft thrombosis was caused in all cases by insufficiently destroyed valves of the venous transplant. There were no lethal outcomes within 1 year postoperatively. Control ultrasonographic examination after 1 year revealed bypass graft thrombosis in two (13.3%) patients in group 2, leading to the development of critical ischaemia and gangrene in one (6.6%) of these patients and later on requiring limb amputation at the level of the femur. A conclusion drawn is that thermal imaging makes it possible to intraoperatively assess quality of valvulotomy in using a non-reversed autovein as a bypass graft and to improve the results of surgical treatment.Представлен оригинальный способ подготовки шунта (нереверсированной аутовены для операции бедренно-подколенного и бедренно-берцового шунтирования) и оценки качества вальвулотомии с использованием тепловизора. В исследование включен 31 больной. Всем больным, разделенным на 2 группы, проводились шунтирующие операции с использованием нереверсированной аутовены. В 1 группе (n=16) перед наложением шунта оценивалась его проходимость с использованием оригинального способа с помощью тепловизора. Во 2 группе (n=15) оценка проходимости шунта после разрушения клапанов не проводилась. В послеоперационном периоде в 1 группе тромбозов шунта отмечено не было, тогда как во 2 группе тромбоз шунта в первые сутки после операции возник у 3 (20%) больных, что потребовало выполнения повторной операции. Причиной тромбоза шунта во всех случаях были недоразрушенные клапаны венозного трансплантата. В сроки до 1 года после операции летальных исходов не было. При проведении контрольного ультразвукового исследования через 1 год у 2 (13,3%) больных во 2 группе выявлен тромбоз шунта, что привело к развитию критической ишемии и гангрены у 1 (6,6%) из этих пациентов и в дальнейшем потребовало выполнения ампутации конечности на уровне бедра. Сделан вывод, что тепловизионное исследование позволяет интраоперационно оценить качество вальвулотомии при использовании в качестве шунта нереверсированной аутовены и улучшить результаты хирургического лечения.

The problem of haemostasis in cardiovascular surgery is of current concern. Recent trends are towards increased use of topical haemostatic agents. Tachocomb has been used for more than 30 years in abdominal surgery and oncology. The purpose of the present publication is to analyse the literature data and formulate the indications for the use of Tachocomb in cardiovascular surgery. Multicenter randomized and local studies have demonstrated efficacy of Tachocomb in treatment of surgical haemorrhage in operations on the heart, thoracic aorta, carotid arteries and lower-limb arteries, resulting in significantly decreased time to achieve haemostasis, decreased volume of blood loss and haemotrasfusion, as well as reduced frequency of complications. Also shown was economic efficacy, including a shortened length of patients' hospital stay. This is followed by describing a wide spectrum of examples of alternative use of Tachocomb, including its use for seamless closure of defects of cardiac chamber walls, aero- and lymphostasis, prevention of formation of commissures. Convincing experimental and clinical results make it possible to formulate a series of indications for the use of Tachocomb in cardiovascular surgery.В настоящее время остро стоит проблема гемостаза в сердечно-сосудистой хирургии. В этой связи в последние годы широко применяются местные гемостатические средства. Препарат Тахокомб используется более тридцати лет в абдоминальной хирургии и онкологии. Целью настоящей публикации является анализ литературных данных и формирование показаний к использованию Тахокомба в сердечно-сосудистой хирургии. Многоцентровые рандомизированные и локальные исследования продемонстрировали эффективность Тахокомба в лечении хирургических кровотечений при операциях на сердце, грудной аорте, сонных артериях и артериях нижних конечностей. Достоверно значимо уменьшается время достижения гемостаза, объем кровопотери, гемотрансфузии и снижается количество осложнений. Также показана экономическая эффективность, в том числе в виде уменьшения времени пребывания пациента в стационаре. Также описан широкий спектр примеров альтернативного использования препарата Тахокомб, в том числе с целью бесшовного закрытия дефектов стенок камер сердца, аэро- и лимфостаза, предотвращения образования спаек. Убедительные экспериментальные и клинические данные позволяют сформулировать целый ряд показаний к применению препарата Тахокомб в сердечно-сосудистой хирургии.

We describe herein a case of surgical treatment of a 32-year-old female patient presenting with multilevel post-thrombotic occlusion of deep veins of the left lower limb. Laboratory study revealed high-risk hereditary thrombophilia (homozygous mutation of PAI-1, MTR, heterozygous mutation of MTHFR, MTRR, ITGA2). The first stage included endovenectomy from the common femoral vein with creation of an arteriovenous fistula between femoral vessels. An attempt of endovascular stenting of iliac veins was initially unsuccessful. After 3 months, the woman was rehospitalized to undergo successful endovascular operation with stenting of the iliac veins and common femoral artery on the background of the functioning arteriovenous fistula. The clinical outcome of the operation was good. Follow-up ultrasonographic examinations (ultrasound duplex scanning) were performed at 3, 6, 10 and 13 months after the second operation. The findings of ultrasound duplex scanning at 13 months showed that the stented segments of deep veins were freely patent, with the arteriovenous fistula functioning well. There were no signs of impairments of central haemodynamics, with significant regression of clinical symptoms. The total score by the Villalta scale as compared with the baseline values decreased from 13 to 5. Given the pattern of deep vein lesions, complexity of open and endovascular operations, and the presence of thrombophilia, we decided to abstain from disuniting the arteriovenous fistula. This case report demonstrates possibility, efficacy and safety of long functioning of an artificial arteriovenous fistula in a particular patient cohort.В статье описан случай оперативного лечения пациентки 32 лет с многоуровневой посттромботической окклюзией глубоких вен левой нижней конечности. При лабораторном исследовании у больной выявлена наследственная тромбофилия высокого риска (гомозиготная мутация PAI-1, MTR, гетерозиготная мутация MTHFR, MTRR, ITGA2). Первым этапом выполнена эндовенэктомия из общей бедренной вены с наложением артериовенозной фистулы между бедренными сосудами. Попытка эндоваскулярного стентирования подвздошных вен первоначально была безуспешной. Через 3 мес. больная повторно госпитализирована и ей успешно проведена эндоваскулярная операция со стентированием подвздошных вен и общей бедренной вены на фоне функционирующей артериовенозной фистулы. Клинический результат операции был хорошим. Контрольные ультразвуковые исследования (ультразвуковое дуплексное сканирование) осуществлялись в сроки 3, 6, 10, 13 мес. с момента второй операции. По данным ультразвукового дуплексного сканирования через 13 мес. стентированные сегменты глубоких вен свободно проходимы, артериовенозная фистула функционировала хорошо. Признаков нарушения центральной гемодинамики не наблюдалось. Отмечался значительный регресс клинических симптомов. Значение суммы баллов по шкале Villalta по сравнению с исходным уменьшилось с 13 до 5. С учетом характера поражения глубоких вен, сложности открытой и эндоваскулярной операций и наличия тромбофилии от разобщения артериовенозной фистулы решено воздержаться. Данное наблюдение демонстрирует возможность, эффективность и безопасность длительного функционирования искусственной артериовенозной фистулы у определенной когорты пациентов.

Aim. To study the effect of the blood components on clot contraction dynamics in vitro.Methods. The original method based on the optical detection of changes in the blood clot volume over time was used. Whole blood, as well as reconstructed samples using washed platelets, erythrocytes, purified fibrinogen, platelet-poor and platelet-rich plasma were studied.Results. Blood clot contraction has a non-linear kinetics, reflecting the complexity of the underlying mechanisms. Platelets increase the blood clot contraction, while the red blood cells have an inhibitory effect. Blocking the fibrin and platelets interaction using the RGDS peptide, an integrin αIIbβ3 antagonist, reduces the extent and rate of clot contraction. The exogenous Ca2+ is not required for contraction, but its addition stabilizes clots by inhibiting the erythrocytes. Thrombin has a dose-dependent effect and increases the rate and extent of contraction. In blood samples of patients taking warfarin, blood clot contraction was delayed.Conclusion. The blood clot contraction is a process which depends on many factors, including the blood cell composition, amount of fibrinogen, the endogenous thrombin activity and platelets interaction with fibrin; understanding the mechanisms of the blood clot contraction could form the basis for the development of novel approaches to the hemostatic disorders treatment.

Presented herein are the results of using Detralex in conservative treatment of women suffering from pelvic varicose veins. Our open prospective study included a total of 30 women with various forms of the course of the disease. All patients took Detralex prescribed at a daily dose of 1,000 mg for 60 days. Dynamic assessment of clinical manifestations of pelvic varicose veins in this cohort of patients was carried out with the help of a specialized quality-of-life questionnaire, an adapted clinical scale of determining disease severity, as well as a visual analogue scale for assessment of the main symptoms of the disease manifestations. The questionnaires and scales were filled in before the beginning of taking the drug and immediately after stopping it. The obtained findings objectively confirmed efficacy of conservative therapy in the majority of the responders. Reported was a decrease in the average index of quality of life from 46.77±13.25 to 36.87±8.53 points (p=0.001). The mean score of the clinical scale of disease severity regressed from 10.8±5.06 to 6.97±3.9 points (p=0.002). The average composite score for the degree of the main symptoms of the disease according to the visual analogue scale decreased from 32.9±21.26 to 19.16±16.04 points (p=0.006). We observed a dramatic decrease in severity of manifestations of the main clinical symptoms and improvement of quality of life of women on the background of taking the drug, thus suggesting its efficacy for the pathological condition concerned. The obtained results make it possible to recommend routine prescription of Detralex to all women with detected pelvic varicose veins as one of the main components of basic pharmacotherapy.

Haemostatic disorders play an important role in the pathogenesis of acute venous thrombosis. One of the least studied reactions of blood coagulation and thrombogenesis is spontaneous contraction of blood clots, which takes place at the expense of the contractility apparatus of activated blood platelets adhered to fibrin fibres. The work was aimed at studying the parameters of contraction of blood clots, formed in vitro, in blood of 41 patients with acute venous thromboses as compared with the same parameters in apparently healthy donors. We used a new instrumental method making it possible to determine the time from initiation to the beginning of contraction, as well as the degree and velocity of clot contraction. It was revealed that in patients with venous thrombosis the ability of clots to shrink was significantly reduced as compared with the control. We detected a statistically significant retardation of and decrease in of blood clot concentration in patients with venous thrombosis complicated by pulmonary artery thromboembolism as compared with contraction in patients with isolated deep vein thrombosis, witch may be important for early diagnosis and determination of the risk of thromboembolism. Besides, we revealed a statistically significant retardation of contraction in patients with proximal thrombosis as compared with contraction in patients with distal thrombosis, with similar values of the degree of contraction. Contraction was statistically significantly reduced in acute thrombosis (less than 21 days), whereas in subacute thrombosis (more than 21 days) the parameters of contraction were closer to normal values. The obtained findings suggest that reduction of blood clot contraction may be a new, hitherto unstudied pathogenetic mechanism deteriorating the course and outcome of venous thrombosis. The clinical significance of contraction and its impairments, as well as the diagnostic and prognostic value of the laboratory test for blood clot contraction would merit further study.

The study was aimed at assessing efficacy of open thrombectomy in acute iliofemoral venous thrombosis.From January 2012 to December 2016, a total of 37 patients underwent transfemoral thrombectomy for acute iliofemoral venous thrombosis. The Control Group consisted of 24 patients receiving standard anticoagulant therapy. Six patients were subjected to a hybrid operation consisting in thrombectomy supplemented with stenting of the residual compression stenosis of the left common iliac vein (CIV). The outcomes of the operations were controlled by means of duplex scanning. Clinical efficacy of the operations was evaluated with the help of the Venous Clinical Severity Score (VCSS) and CEAP classification.Patency of the iliofemoral segment at 6 months of follow up after thrombectomy was observed in 92% of patients. At the same time, in patients receiving anticoagulant therapy recanalization of the iliofemoral segment was observed in only 21% (5/24; χ2=31, p0.01) of cases. Recanalization of the femoropopliteal segment 6 months after thrombectomy was noted to occur in 70% (23/33) of patients. The median of the composite index by the VCSS after 6 months decreased from 7 to 2 (p=0.002). The cumulative patency of the iliofemoral segment 36 months after surgery amounted to 86%. Clinical assessment of the remote results of thrombectomy according to the CEAP classification demonstrated that 90% (19/21) of patients were either free from or had weakly pronounced symptoms of post-thrombotic syndrome.Performing thrombectomy for iliofemoral thrombosis by selective indications using modern methods of restoring patency of deep veins significantly increases efficacy of treating patients presenting with this severe pathology and prevents the development of pronounced manifestations of post-thrombotic syndrome.Цель исследования. Оценка эффективности открытой тромбэктомии при остром подвздошно-бедренном венозном тромбозе. Материалы и методы. С января 2012 по декабрь 2016 гг. у 37 пациентов выполнена трансфеморальная тромбэктомия при остром подвздошно-бедренном венозном тромбозе. Контрольная группа была представлена 24 больными, получавшими стандартную антикоагулянтную терапию. У 6 пациентов проведена гибридная операция – тромбэктомия, дополненная стентированием резидуального компрессионного стеноза левой общей подвздошной вены (ОПВ). Контроль результатов операции осуществлялся с помощью дуплексного сканирования. Оценка клинической эффективности операций проводилась с помощью шкалы VCSS (Venous Clinical Severity Score) и классификации CEAP. Результаты. Проходимость подвздошно-бедренного сегмента через 6 месяцев наблюдения после тромбэктомии отмечена у 92% пациентов. В то же время у больных, получавших антикоагулянтную терапию, реканализация илиофеморального сегмента зафиксирована лишь в 21% (5/24; c2=31, p0,01) случаев. Реканализация бедренно-подколенного сегмента через 6 месяцев после тромбэктомии наступила у 70% (23/33) больных. Медиана суммарного показателя по шкале VCSS через 6 месяцев уменьшилась с 7 до 2 (P=0,002). Кумулятивная проходимость подвздошно-бедренного сегмента через 36 месяцев составила 86%. Согласно клинической оценке отдаленных результатов тромбэктомии по классификации CEAP, у 90% (19/21) больных после тромбэктомии симптомы ПТБ отсутствовали либо были слабо выраженными. Заключение. Выполнение тромбэктомии при илиофеморальном тромбозе по селективным показаниям с использованием современных методов восстановления проходимости глубоких вен существенно повышает эффективность лечения пациентов с этой тяжелой патологией и предотвращает развитие выраженных проявлений посттромботической болезни.

Post-thrombotic iliac vein lesion is one of the causes of secondary pelvic varicose veins (PVV) in women. Endovascular treatment of this cohort of patients requires further studies.The study was undertaken to investigate the aspects of endovascular treatment of female patients diagnosed as having PVV secondary to post-thrombotic alterations of the iliac veins.Presented herein are the results of diagnosis and treatment of nine women suffering from PVV in obstructive lesion of the iliac veins. All patients underwent phlebography with stenting of the iliac veins, followed by clinical and instrumental assessment of efficacy of treatment.The technical success rate of stenting amounted to 100%. In the early postoperative period thrombotic complications developed in two women and in the remote period in one. The operation was followed by a decrease in the intensity of PVV manifestations, as well as chronic venous insufficiency of the lower limbs, which was confirmed by clinical and instrumental methods of objectification and visualization. The composite index of quality of life was noted to decrease from 47±5.3 to 27.8±3.3 points (p0.05). The median of the composite value of the Pelvic Venous Clinical Severity Score decreased by 8.6±1.8 points (p0.05). The average value of the composite index of the Venous Clinical Severity Score (VCSS) diminished by 6.8±1.4 points (p0.05) and that of the Villalta score by 8.3±1.6 points (p0.05).Pelvic varicose veins appear to develop in two of three women after endured thrombosis. The experience with stenting of the iliac veins demonstrated good efficacy and safety. Efficiency of the intervention was determined by improved quality of life of the patients and positive dynamics of the clinical course of the disease.Посттромботическое поражение подвздошных вен является одной из причин возникновения вторичной варикозной болезни таза (ВБТ) у женщин. Эндоваскулярное лечение этих пациенток требует дальнейших исследований. Цель - изучение аспектов эндоваскулярного лечения пациенток с вторичной ВБТ, обусловленной посттромботическими изменениями подвздошных вен. Материалы и методы. Приведены результаты диагностики и лечения девяти пациенток с ВБТ при обструктивном поражении подвздошных вен. Всем пациенткам выполнена флебография со стентированием подвздошных вен с последующей клинической и инструментальной оценкой эффективности лечения. Результаты. Технический успех стентирования составил 100%. В раннем послеоперационном периоде тромботические осложнения развились у двух пациенток, в отдаленном - у одной. После операции отмечали снижение интенсивности проявлений ВБТ, а также хронической венозной недостаточности нижних конечностей, доказанное клиническими и инструментальными методами объективизации и визуализации. Зарегистрировано уменьшение глобального индекса качества жизни ? с 47±5,3 до 27,8±3,3 балла (p0,05). Снижение медианы суммарного показателя клинической шкалы оценки тяжести ВБТ составило 8,6±1,8 балла (p0,05). Среднее значение суммарного показателя клинической шкалы оценки тяжести хронической венозной недостаточности нижних конечностей (Venous Clinical Severity Score - VCSS) снизилось на 6,8±1,4 балла (p0,05), по шкале Виллалта (Villaltа) - на 8,3±1,6 балла (p0,05). Заключение. Варикозная болезнь таза развивается у двух женщин из трех после перенесенного тромбоза. Опыт стентирования подвздошных вен показал хорошую результативность и безопасность. Эффективность вмешательства обусловлена улучшением качества жизни пациенток и положительной динамикой клинического течения заболевания.

The study was aimed at bettering therapeutic outcomes in patients with acute arterial lower-limb insufficiency by means of improving the method of selective thrombolysis (STL). We analyzed both immediate and remote results of treating a total of 118 patients presenting with acute lower limb ischaemia of not more than grade 2B (according to I.I. Zatevakhin, 2002) within the terms up to 2 months from the onset of the disease. The Study Group patients (n=67) were subjected to STL and the Control Group patients (n=51) underwent standard open surgical interventions. The remote results of treatment were assessed within the terms up to 1 year in 38 patients of the Study Group and in 31 patients of the Control Group. The main criteria for efficacy of treatment were the incidence rate of amputation and mortality. In the immediate postoperative period in the Control Group, the frequency of amputations of lower limbs was more than 5-fold higher as compared with the Study Group (p0.005); no significant differences on lethal outcomes were revealed (p0.05). In the remote period of follow up, the incidence of amputations in the Study and Control Groups did not statistically differ (p0.05), whereas mortality in Control Group was 4.3-fold higher as compared with the Study Group (p0.05).

Analysed herein are the results of examining and treating a total of 290 patients presenting with relapses of varicose disease, including 198 women and 92 men. The patients' age averaged 51.6 ± 8.7 years, with the mean term of the appearance of relapses after surgery amounting to 4.8 ± 1.4 years and that of reoperation - 11.1 ± 7.5 years. According to the CEAP classification, the patients were subdivided as follows: C2 - 36 (12.4 %), С3 - 117 (40.4 %), С4 - 103 (35.5 %), С5 - 20 (6.9 %), С6 - 14 (4.8 %). All patients underwent ultrasound duplex scanning. Relapses in the basin of the great saphenous vein were revealed in 205 (70.63 %) patients, in the basin of the small saphenous vein in 65 (22.4 %) subjects. Neoangiogenesis was observed in 62 (21.3 %) cases, pathological reflux from pelvic veins as a cause of relapses - in 31 (10.7 %) patients, varicosity-altered tributaries of the great and small saphenous veins, not connected with the pathological stump or unremoved trunk - in 52 (17.9 %) cases. Based on the results of diagnosis, treatment was carried out in 241 patients. 179 patients underwent various types of interventions, of these, 94 with the use of minimally invasive therapeutic technologies. 76 patients were subjected to different methods of phlebosclerosing treatment, of these 62 in outpatient conditions. The study showed negative influence of axial reflux along through deep veins on the appearance and course of varicose veins relapses. The remote results of treatment at terms from one year to 9 years (mean 4.9 ± 2.6 years) were studied in 76 patients. Good results were noted in 52 (68.5 %) patients, satisfactory outcomes were observed in 22 (28.9 %), and unsatisfactory results - in 2 (2.6 %) patients.

The study was based on the findings of examination and treatment of fifty-four 19-to-55- year-old female patients (mean age 35.3 ± 7.3 years) presenting with varicosity of small pelvis veins. Of these, seventeen women with stenosis of the left renal vein were subjected to the following reconstructive operations on small pelvis veins: creating proximal ovarian-iliac anastomoses - 10 procedures, establishment of sapheno-ovarian anastomoses - 5 operations, one procedure of prosthetic repair of the left renal vein and one operation of transposition of the left renal vein. All interventions were completed with resection of the distal segments of the ovarian vein. A further 19 women with idiopathic reflux along the ovarian veins underwent uni- or bilateral embolization thereof, with multi-stage embolization of the branches of the internal iliac vein performed in one patient. The remaining eighteen endured the following interventions: unilateral resection of the left ovarian vein performed in twelve cases (3 endoscopic operations), bilateral resection in four cases (3 endoscopic resections). In seven cases the operations were supplemented with microphlebectomy of the varicosely altered perineal veins. Two patients underwent operations of crossectomy and resection of the pathologically altered internal pudendal vein. Five-year follow up showed that good-to-satisfactory results were obtained in 45 (83.3%) cases, with a disease relapse revealed in seven cases.

The authors share herein their first experience gained in stenting for stenosing and occlusive lesions of the iliac-femoral segment veins, reporting the outcomes of treating a total of thirteen patients subjected to balloon angioplasty and stenting of iliac veins for chronic venous obstruction. While treating non-thrombotic venous lesions, stenting was successfully performed in 100% of the patients concerned. Inpost-thrombotic lesions therapeutic outcomes were successful in 9 (75%) patients. No immediate postoperative complications were observed. The remote results were followed up in eleven out of the 13 patients. Patency within the terms up to 16 months amounted to 81.1%. Clinical improvement was noted in 12 (92.3%) patients. According to the VCSS scale, there was a reliable decrease in the intensity of chronic venous insufficiency manifestations along all parameters. The integral index decreased from 6.56+/-0.71 to 4.45+/-0.65 (t=3.82, p0.002). The malleolar volume decreased from 275.3+/-6.7 to 241.6+/-6.1mm (t=12.3, p0.001). Hence, angioplasty and stent-grafting of iliofemoral veins turned out to be a minimally invasive, safe, and highly efficient therapeutic modality. The efficacy of the procedure was confirmed by a considerable improvement of the limb's condition and good remote results concerning patency of the reconstructed segments of the venous bed. Endovascular methods may be considered as a promising modality of treatment for this patient cohort.

The authors analysed a total of 152 surgical interventions on the brachiocephalic arteries (BCAs) performed in 142 patients. All the patients were subjected to intraoperative monitoring of cerebral haemodynamics by means of transcranial Doppler (TCD) ultrasonography simultaneously accompanied by electroencephalography (EEG). Additionally, the state of the reconstructed carotid arteries was controlled by means of ultrasonographic duplex scanning (USDS). Comparing the findings of the TCD recording and EEG made it possible to single out 5 groups of the operated patients. The EEG technique turned out to have more informative value as compared with TCD ultrasonography in determining the degree of cerebral ischaemia during clamping of the carotid arteries (CAs). Nine (5.9%) patients demonstrated lower tolerance of the brain to ischaemia, and the operation on the BCA was performed with the use of a temporal intraluminal bypass graft. Microembolic signals (MES) were registered in 54.6% of cases. Single MES were detected in six patients, sporadic MES--in 53, and multiple MES--in 24. Mention should be made that the--MES associated with the placement of the bypass graft appeared to be multiple and were registered in all the operated patients. Diffusion-weighted magnetic resonance tomography revealed fresh foci of lacunar cerebral infarctions in 14 (25%) of the 56 patients thus examined. Intraoperative USDS of the reconstructed carotid arteries revealed floatation of the residual remnants of the intima in two patients, which was the cause of a repeat intervention. Combined monitoring of cerebral haemodynamics makes it possible to timely prevent cerebral ischaemia, to narrow the indications for placement of an intraluminal bypass graft, and to dramatically decrease the rate of postoperative complications.

The article deals with a new method of diagnosis of venous thromboses, which is based on ultrasonographic scanning of the area of the valvular sinuses of the femoral vein. The authors examined a total of two hundred and forty-nine people; of these, 100 patients were diagnosed as having varicose disease, 99 subjects had acute venous thrombosis, and 50 people constituted the control group. All the patients were examined by means of ultrasonographic angioscanning, and also had the D-dimer level measured in them. The carried out study resulted in a description of an ultrasonographic phenomenon consisting in the presence of echo-positive inclusions within the area of the valvular sinuses, which was called the sludge phenomenon. The authors developed a classification of this phenomenon, describing three degrees of sludge. Degree 1 sludge is a physiological one and reflects the fact that the area of the valvular sinuses is the most thrombogenic zone. Degree 2 sludge is characterized as a pathological one, being indicative of the presence of a prethrombotic condition and may serve as one of the earliest prognostic factors for the development of venous thrombosis. Degree 3 sludge reflects thrombosis of the valvular sinus. The carried out studies made it possible to reveal a correlation between the presence of a sludge, its degree, the presence of a venous thrombosis, and the values of the D-dimer level.

In order to work out the indications for surgical and endovascular treatment of floating thromboses in the system of the inferior vena cava (IVC) and to evaluate the therapeutic outcomes obtained we examined a total of one hundred and forty-five 17-to-85-year-old patients presenting with acute thrombosis in the system of the IVC. Of these, floating thromboses were revealed in ninety-five patients. The most frequently encountered localization of the floating thrombus was the common femoral vein (CFV). In 77 patients, thrombosis originatedfrom the femoral vein (FV), and in 12 instances -from the saphenofemoral junction. The signs of pulmonary thromboembolism (PTE) were diagnosed in 22 cases. Instrumental studies included ultrasonographic duplex scanning (USDS), roentgenopaque and computer-assisted phlebography, and perfusion-mediated scintigraphy of the lungs. Thrombectomy from the common iliac vein (CIV), external iliac vein (EIV) and common femoral vein (CFV) with resection of the femoral vein was performed in forty-seven patients; of these, the procedure was combined with establishing a temporal proximal arteriovenous fistula (AVF) in sixteen subjects. The femoral vein was resected in nineteen instances. Thrombectomy form the IVC with the help of the "TREKS" device was carried out in six patients. Cava filters were implanted in a total of eighty-four patients. Of these, ten devices were intended and had to be 3 left for permanent implantation, with the remaining seventy-four patients having received retrievable ones. Rethromboses in the early postoperative period were observed to occur in four patients. The patients with the AVFs applied had no thromboses. PTE occurred in four patients, with one lethal outcome. Another patient died due to myocardial infarction. Temporary cava filters were successfully retrieved in sixty-eight patients within the terms from 10 to 56 postoperative days long-term results up to 2 years were followed up for thirty-eight patients, with good outcomes noted in twenty-six cases, satisfactory in ten, and poor results seen in two patients. An active therapeutic policy pursued in management of floating embolus-hazardous thromboses is the only efficient measure making it possible to reliably prevent the development of both PTE and post-thrombotic disease.

The purpose of this study was to assess the outcomes of using a mini-approach in surgery of carotid arteries. From September 2006 to December 2007, one hundred and twenty-nine patients (with a total of 139 operations sustained) underwent interventions on the carotid bifurcation for atherosclerotic lesions and pathological tortuosity of the carotid arteries. The patients were subdivided into two groups. Group A consisted of those operated on from the standard access to the carotid arteries, with Group B comprising the patients undergoing interventions on the carotid bifurcation from a mini-approach (a cutaneous incision less than 5 cm long, averaging 4.7 +/- 0.3 cm). The control Group C was composed of forty-two patients having endured operations on the carotid arteries from the conventional access performed at other specialised departments. In the patient groups referred to above, we compared the incidence rate of perioperative complications (stroke/death), lesions of the cranial and cervical nerves, as well as wound complications. In Group A patients, there were two patients with stroke, one of whom had eventually died. Neuropathies of the cranial and cervical nerves in this group of patients were observed to have developed in eight (6.2%) and ninety-two (71.3%) cases, respectively, and in Group C patients--in eleven (28.0%) cases. Cervical haematoma was observed in fourteen (10.9%) subjects. The average duration of the postoperative hospital stay amounted to 6.8 +/- 1.1 days. Amongst the Group B patients, cervical haematoma was noted in two (3.2%, P0.0001) cases only. A lesion of the cranial nerves (that of the superior laryngeal nerve) took place in two patients (P0.0001), and that of the cervical nerves--in four patients (P0.0001). No cheloid cicatrices were observed. The patients reported excellent and aesthetically pleasing surgical outcomes. The average duration of the postoperative hospital stay amounted to 2.8 +/- 0.69 days (P = 0.002). Hence, operations on the carotid bifurcation may be successfully performed from a mini-approach, with thus discomfort kept at a minimum and rapid rehabilitation of patients.

The purpose of the work was to assess the diagnostic significance of combined bolus magnetic resonance angiography (MRA) and two-dimensional time-of-flight MRA of lower limb arteries as compared to radioangiography in patients with occlusive diseases of lower limb arteries.Twenty-six patients with the symptoms of lower limb ischemia of varying severity were provided bolus MRA with prolonged manual injection of contrast substance and transposition of the MR-tomograph table. Additionally, all the patients underwent two-dimensional time-of-flight (2D TOF) MRA of the leg arteries.The statistic processing of bolus MSA for visualization of the pelvic segment has demonstrated its high sensitivity and specificity (97.74% and 92.31% respectively). On visualization of the femoral artery segment the sensitivity of this modality accounted for 97.57%, the specificity for 94.57%. In patients with severe ischemia, visualization of the leg arteries was difficult. Consequently, the specificity of the modality accounted for 44.58%. However, when this technique was combined with two-dimensional time-of-flight MRA of the leg arteries, the sensitivity and specificity of the modality reached 96.38% and 91.92% respectively.Bolus MRA of lower limb arteries is marked by the high sensitivity and specificity for visualization of the arteries of the iliac and femoral segments. To visualize the leg arteries in patients with severe forms of lower limb ischemia, this modality should be supplemented by two-dimensional time-of-flight MRA.

Combined atherosclerotic involvement of the brachiocephalic arteries (BCA) and lower limb arteries has been analysed in 107 patients (56 females and 51 males) with a verified diagnosis of ischemic heart disease (IHD). BCA atherosclerosis was detected in 83.9% females and 93.1% males. 75.8% examinees had no murmur. It is suggested that arterial hypertension and obesity in females with IHD may be risk factors of BCA kinking. Frequency of combined affection of extracranial arteries and lower limb arteries reached 23.2% females and 96% males. Therefore, it is necessary to screen these arteries for atherosclerosis in all IHD patients.

The aim of the present work was to study the causes of post-operative recurrences of varicosity and to define approaches to their optimal correction. Duplex scanning (DS) with Color Doppler Imaging of the blood flow was used to examine 126 patients (136 extremities) with recurrences of varicosity. The patients were distributed according to the CEAP clinical classification. Altogether 76 patients (78) extremities with recurrences of varicosity were operated on. 27 persons received different variants of sclerotherapy including echoscleroobliteration. According to the DS data, the most frequently obtained finding in patients with recurrences of varicosity was identification of the perforating veins with valvular insufficiency, namely in 120 (or in 88.2%) extremities. The long stump of the greater saphenous vein (CSV) was discovered in 86 (63.2%) extremities, the long stump of the lesser saphenous vein (LSV) in 6 (4.4%), ectasia of LSV trunk was recognised in 20 (14.5%), incompetence of the valves of the sural veins in 12 (8.8%) extremities. Incompetence of the valves of the deep veins was present in 73 (53.6%) patients. No sources of pathological veno-venous runoff were identified in 12 (8.1%) cases. A good agreement was established between the incidence of valvular incompetence of the deep veins and the disease severity. The indications for surgical correction of valvular insufficiency were worked out. It has been demonstrated that sclero-obliteration is the method of choice in the treatment of the recurrences of varices. The long-term results of operations for recurrences of varicosity were followed up in 62 patients over the period of one to 15 years. Good and satisfactory results were obtained in 60 (96.8%) cases. The authors believe that the majority of varicosity recurrences arise from an inadequate assessment of the status of lower extremity venous bed as well as from technical and methodological faults of the operating surgeon. DS in an indispensable component of preoperative examination of patients with varicosity recurrences.

Varicose vein disease (VD) of the lower extremities is the most common pathology of the peripheral vessels: 26-38% of women and 10-20% of men of working age suffer from it. The annual increase of new cases of VD among the inhabitants of industrialized countries reaches 2.6% among women and 1.9% among men. Its course is accompanied by a number of complications and a high level of disability of patients, which, in turn, is associated with significant economic costs. These circumstances make the development of an effective system for diagnosing VD an important medical and social problem.