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Vasculab Journal of Theoretical and Applied Vascular Research (page 1) - JTAVR 2018;3(1)

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Editorial Board


N. 01-2018 Feb, year 3

Journal of Theoretical and Applied Vascular Research

Online ISSN 2532-0831 DOI: https://doi.org/10.24019/issn.2532-0831

A Journal on Research in Vascular Diseases, published three times a year

The Official Journal of the Vasculab Foundation

Editor-in-Chief

Fausto Passariello

Editorial Board

Basic Sciences, Biology and Medicine

Giovanni Agus, Francesco Albergati, Claudio Allegra, Pier Luigi Antignani, Malika Boucelma, Alberto Caggiati,Massimo Cappelli, Mariella Catalano, Domenico Corda, Stefano Ermini, Andrea Fontanella, Claude Franceschi, GiorgioGuarnera, Arkadiusz Jawien, Mark Malouf, Ferdinando Mannello, Sandro Michelini, Waldemar Lech Olszewski, FaustoPassariello, Malay Patel, Neil Piller, Angelo Scuderi, Massimo Vaghi, Carolina Weller

History and Philosophy of Science

Alessandra Passariello

Non-animal experiments

Alessandra Passariello, Fausto Passariello

Editorial office, imagine and communication

Iolanda Palma - [email protected]

Operative Executive Board

Iolanda Palma, Alessandra Passariello, Fausto Passariello

Web Authoring

HTML, XML, XSLT, XSL-FO, Javascript, PHP, MySql, LATEX programming by Fausto Passariello

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Aquarius s.r.l.

Cover

digital image, editing by Iolanda Palma.

Editor

Fondazione Vasculab impresa sociale ONLUS, Via Francesco Cilea, 280 - 80127 Napoli - Tel/Fax+39 081 7144110 - [email protected] - https://doi.org/10.24019/issn.2532-0831

Pubblicazione quadrimestrale online. Autorizzazione del Tribunale di Napoli, n. 45 del 12 ottobre2016. Anno 3 - N. 1.

Direttore responsabile: Dott. Fausto Passariello


https://doi.org/10.24019/issn.2532-0831


Editorial Lines


Non-animal experiments

Many scientific journals deal with animal experiments, but just a few of them face the hard problem of animal replacingor sacrifice/suffer reducing or minimizing, together with the related ethical and legal topics.

Since the 1st issue, the Journal of Theoretical and Applied Vascular Research (JTAVR) hosted papers devoted to themethodology for non-animal experiments. JTAVR is open to the discussion about the controversies inside the community ofbiomedical researchers, i.e. between people who use animals as an unavoidable experimental tool and others which on the contrarypoint to different research methods.

However, a-priori positions pro or contra total animal replacement in biomedical research do not correspond at all toreality, because the solution is anchored to the ground, it is context dependent and is hidden behind a detailed study of theexperiments, aimed to provide a reliable response.

An answer which must not be black or white and must consider instead any involved methodological detail. In addition,there is the strong hope that many actions which were never done will be successful instead in the next future. For instance,consider the unexpected new frontier which in the last years turned up in the field of the organ-on-a-chip technology.

Maybe, not so far in the future, this contra opposition will be seen just as a nonsense.

History and Philosophy of Science

Working

Basic Sciences, Biology and Medicine

The Journal of Theoretical and Applied Vascular Research (JTAVR) aims at gathering contributes to vascular research,coming from biology, medicine, surgery and basic sciences like physics, fluid dynamics and bioengineering as well asbiochemistry and genetics.

A special attention is given to the cultural aspects behind medical daily work, like models, epistemology, philosophyand history.

This inter-disciplinary approach uses a wider eye/chakra, placing side by side topics which generally could never gotogether in medical journals, with the hope that it will succeed in producing new interesting fruits in research.

Editor

Fondazione Vasculab impresa sociale ONLUS, Via Francesco Cilea, 280 - 80127 Napoli - Tel/Fax+39 081 7144110 - [email protected] - https://doi.org/10.24019/issn.2532-0831



Vascular News


VASCULAR NEWS NEWS

Vascular News

© 2018 Fondazione Vasculab impresa sociale ONLUS. All rights reserved.

ABC of Vascular Laboratory

This book is a manual note of vascular protocolin Vascular Laboratory, King Khalid University Hospital.Saudi Arabia.

It is an author’s experience work to guide medicalstudent, radiological technician and technologist to ease thepath of understanding the vascular concepts and technique,Doppler and duplex uses, type of procedures that involvedin all vascular aspects in order to give a brief, easyexplanation for new students.

Index- Basic physics- Artefacts in Doppler techniques- Doppler examination- ABI and TP- RBI and FP- Arterio Venous Fistula- Duplex examination- Ultrasound equipment- Upper limp arteries- Lower limb veins

Linda Moh’d Al-wabil- Supervisor of ultrasound in dr. Suliman alhabibmedical hospital, ArRyan branch, Riyadh, SaudiArabia.- First Vascular Technologist Saudi female InVascular Laboratory In King Khalid Universityhospital, In Saudi Arabia.- Master degree in Health Care Administrationand BSc of radiological sciences. Experience inultrasound and mammography.- Member of Zahra Brest Cancer Association inSaudi Arabia.

SIMV

The Society of Vascular Medicine was finally bornin Italy on May 2019 in Rome on the initiative of a groupof medical area professionals ! in the same way than in theUnited Sates (SVM since 1989) and in Europe (ESVM since2014)

The Italian Society of Vascular Medicine (SIMVwww.simv.eu) is a transversal multi-specialist professionalno-profit association.

The extreme openness of the Society of VascularMedicine is aimed at welcoming all those which inany way, in the context of specific attributions anddisciplines, are interested and involved in the problemsof vascular pathology from the medical point of viewand in the overall management of vascular diseases,assuming that the assistance offered to patients can be betterachieved by collegial interaction and by the collaborationof a community of vascular professionals, pointing out


Vascular News


the importance of people with different backgrounds inachieving ideal standards of research and clinical practice.

The Association's goals are to improve the integrationof vascular biological advances in medical practice and tomaintain high standards of clinical vascular medicine.

The Association aims to improve the knowledge ofdiseases of the vascular system, their care and relateddiagnostics (instrumental and laboratory) and aims to bringtogether all those who are dedicated to the study ofphysiology, pathophysiology, pathology of the vascularsystem and related diagnostic and clinico-therapeuticaspects, facilitating relations between experts in the fieldinside their own association and establishing relationshipswith other scientific national and international associations(mostly Vascular Surgery).

The Founders are convinced that without a thoroughunderstand of the aetiology, pathophysiology and naturalhistory of the disease, as well as a knowledge of medical,surgical and interventional technologies, care for the patientwith vascular disease will be less than optimal.


INSTRUCTIONS TO AUTHORS


The Journal of Theoretical and Applied VascularResearch (JTAVR) publishes scientific papers on vasculardiseases, biological research, history and philosophy ofscience.

Manuscripts are expected to comply with theinstructions to authors which conform to the UniformRequirements for Manuscripts Submitted to BiomedicalEditors by the International Committee of Medical JournalEditors (www.icmje.org/).

Submission of manuscripts

Papers should be submitted directly online to theEditorial Office at the Fondazione Vasculab ONLUSwebsite: www.vasculab.eu/jtavr/submissions.htm

The journal adheres to the principles of the HelsinkiDeclaration (http://history.nih.gov/research/downloads/helsinki.pdf) about research concerning human beings andto the International Guiding Principles for BiomedicalResearch Involving Animals (http://cioms.ch/publications/guidelines/1985_texts_of_guidelines.htm) recommendedby the WHO. In addition, the journal strongly supportsalternative non-animal experiments, in order to Replace,Reduce and Refine (3Rs) animal experimental designs.

For complete information about publication termsplease contact the Editorial Office of JTAVR, FondazioneVasculab impresa sociale ONLUS, via FrancescoCilea 280 Italy - Phone +39-081-7144110 - E-mail:[email protected].

Open Access Publication

All manuscripts submitted to JTAVR are assumed to besubmitted under the Open Access publishing model. In this publishingmodel, papers are peer-reviewed in the normal way under editorialcontrol. Submission and reviewing process are not charged. When apaper is accepted for publication the author is issued with an invoicefor payment of a publication processing fee (see www.vasculab.eu/jtavr.xml). Payment of this charge allows JTAVR to recover its editorialand production costs and create a pool of funds that can be used toprovide fee waivers for selected authors, for instance for invited authors,authors of papers on history and philosophy of science and for authorsfrom lesser developed countries (see below).

Free download

Published papers appear electronically and are freely availablefrom our website. Authors may also use their published .pdf's for any

non-commercial use on their personal or non-commercial institution'swebsite.

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No articles from the JTAVR website may be reproduced, in anymedia or format, or linked to for any commercial purpose (eg. productsupport, etc) without the prior written consent of JTAVR and paymentto JTAVR of an appropriate fee.

Publication fees

Initial publications of JTAVR (up to presumably one year) arefree of charge for invited Authors and for the members or supportersof the Vasculab Foundation. For the Vasculab Foundation membershipsee www.vasculab.eu.

Article types

Editorials, original articles, review articles, systematic reviewsand meta-analyses, randomised controlled trials, research protocols,original case reports, case series, therapeutical notes, clinical images,clinical videos, letters to the Editor, guidelines, special articles (likehistory and philosophy of science), invited sessions, reprints ofhistorical papers of actual interest.

In order to submit an article online, follow the step by stepinstructions at www.vasculab.eu/jtavr/submissions.htm

Preparation of manuscripts

Footnotes or endnotes

JTAVR does not encourage the use of footnotes. Generally, theyare not used in medical journals, but they are tolerated, especially inarticles in the field of history and philosophy. Footnotes or endnotesmust be quoted in Low Caps Romans in rectangular brackets (example:

[iv] and cited as[iv]).

References

- Only cited references can be included in the bibliography. Theymust be numbered in Arabic numerals, in the exact sequence as theyare firstly cited (example: "1)").

- Bibliographical entries in the text should be quoted using

superscripted Arabic numerals (cited as1).

- References must be set out in the standard format approvedby the International Committee of Medical Journal Editors (ICMJE),as described in the document Recommendations for the Conduct,Reporting, Editing, and Publication of Scholarly work in MedicalJournals http://www.icmje.org/icmje-recommendations.pdf.

A simplified but comprehensive list is given inwww.nlm.nih.gov/bsd/uniform_requirements.html.

Citation examples

Standard journal article

List the first six authors followed by et al.

Halpern SD, Ubel PA, Caplan AL. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002 Jul 25;347(4):284-7.

As an option, if a journal carries continuous pagination throughout a volume(as many medical journals do) the month and issue number may be omitted.


www.icmje.org/

www.vasculab.eu/jtavr/submissions.htm

http://history.nih.gov/research/downloads/helsinki.pdf

http://history.nih.gov/research/downloads/helsinki.pdf

http://cioms.ch/publications/guidelines/1985_texts_of_guidelines.htm

http://cioms.ch/publications/guidelines/1985_texts_of_guidelines.htm

www.vasculab.eu/jtavr.xml

www.vasculab.eu/jtavr.xml

www.vasculab.eu

www.vasculab.eu/jtavr/submissions.htm

http://www.icmje.org/icmje-recommendations.pdf

www.nlm.nih.gov/bsd/uniform_requirements.html

INSTRUCTIONS TO AUTHORS


Halpern SD, Ubel PA, Caplan AL. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

Books and Monographs

Author(s) and editor(s)

Breedlove GK, Schorfheide AM. Adolescent pregnancy. 2nd ed. WieczorekRR, editor. White Plains (NY): March of Dimes Education Services; 2001.

Chapter in a book

Meltzer PS, Kallioniemi A, Trent JM. Chromosome alterations in humansolid tumors. In: Vogelstein B, Kinzler KW, editors. The genetic basis of humancancer. New York: McGraw-Hill; 2002. p. 93-113.

Electronic materials

Homepage/Web site

Cancer-Pain.org [Internet]. New York: Association of CancerOnline Resources, Inc.; c2000-01 [updated 2002 May 16; cited 2002Jul 9]. Available from: http://www.cancer-pain.org/.

Vasculab mailing list

Provided you know the number '#' of the message, the format of the citationhere follows, where the date of the last access is required (following the Vancouverstyle) and the symbol '#' must be replaced with the effective number of the message:

Author(s) name(s). Vasculab Yahoo Groups. The VascularList. Message '#'. https://it.groups.yahoo.com/neo/groups/vasculab/conversations/

messages/# Accessed on line on 'date of last access'. A (free) subscription to Vasculabis required.

Historical monographs

The format will be specified in next future.

File of tables

Each table should be submitted as a separate file. Formats accepted are .docand .rtf. Each table must be numbered in Roman numerals and accompanied by therelevant title. Notes should be inserted at the foot of the table and not in the title.Tables should be referenced in the text sequentially.

File of figures

Each figure should be submitted as a separate file. Formats accepted: JPEGset at 300 dpi resolution preferred; other formats accepted are TIFF and PNG. Figuresshould be numbered in Arabic numerals and accompanied by the relevant title. Figuresshould be referenced in the text sequentially.

Histological photographs should always be accompanied by themagnification ratio and the staining method.

Color illustrations

Open Access papers appear electronically. As no printed issues of JTAVRare produced there are NO additional charges for color illustrations.

However consider that many people will print them in black and white. Thusfor a better result in communicating your data, test also the black and white printingwhen choosing colors.


http://www.cancer-pain.org/

F Passariello - The great and silent revolution of the units of measure

Vasculab Journal of Theoretical and Applied Vascular Research (page 11) - JTAVR 2018;3(1):11-13

EDITORIAL

The great and silent revolution of the units of measure

F Passariello1

1Fondazione Vasculab ONLUS, via Francesco Cilea 280 - 80127 Naples, Italy

submitted: Apr 14, 2019, accepted: Apr 17, 2019, EPub Ahead of Print: Apr 18, 2019, published: Jul 7, 2019Conflict of interest: None

DOI: 10.24019/jtavr.32 - Corresponding author:Dr. Fausto Passariello, [email protected]


Maybe just a few people know that on May 20th, 2019a global revolutionary change of the units of measure willinvolve all human activities everywhere in the world.

No panic, please ! Nothing at all will really change inour daily life.

The current revolution started in France, but almostall the states of the world joined the Committee (Table I). As

an historical note, the 1st “Conférence Générale des Poids etMesures” [General Conference on Weights and Measures]

(CGPM)1 was held in 1899 in Paris2 while the 26th CGPM

was organised in 2018 in Versailles Nov 13th-16 th by the“Bureau Internationale des Poids et Mesures” [InternationalBureau of Weights and Measures] (BIPM), which published

a final document about the adopted resolution3.

In detail, the International System of Units (SI) waspreviously defined in 1960 with six basic units, replacing

the old CGS and MKS system[i] and was continuouslyupdated in the following years. The current 2018 update,taking effect from May 20, 2019, introduces new definitionsfor seven basic units, which use the three universal physicalconstants G (gravitational constant), h (quantum Planckconstant) and c (light speed in vacuum and relativisticconstant).

The differences between the current and the previousdefinitions are summarized in Table II.

The echo of the current resolution reached the

specialized public through articles4 and the organizationof events. An interesting exhibition is currently held atthe “Conservatoire National des Arts et Métiers” [National

Museum of Arts and Works]5,6. The Conservatoire was

founded in 1794 by the "Abbey Grégoire", during theFrench revolution, when the interest for the units of measurewas firstly officially stated.

The Museum hosts also the Lavoisier chemicallaboratory and one realization of the famous FoucaultPendulum (1851), used to show the rotation of the Earth andthe Coriolis effect. The exposition will be open until May

5th, 2019 - just fifteen days before the deadline for the new2019 SI change.

Visiting the exposition, we learn how the historyof the civil society is weaved together with the unitsof measure, being unexpectedly connected to the historyof taxation. Governments have a great interest inmeasurements, in order to be able to apply a certain and anundoubted fee, according to a fixed unit of measure.

Here we see displayed a lot of unit devices whichwere used in the past, for instance by the Egyptians, Greeksand Romans to document this indissoluble relationship.Other similar devices are also in exhibition from morerecent epochs, like the medieval and renaissance ages.

The need to set a supranational standard was clearlyfelt during the French revolution. At the time the units ofmeasure just then were scarcely precise and only locallyvalid. It could be hypothesized that the great interest for theunits of measure maybe rose during the French revolutionin order to provide the same scientific measurementseverywhere in the French Republic and for all the citizens,as intellectually required by the Enlightenment age.

Later and gradually at the end of the XIX centuryall countries agreed to participate in setting a standard inmeasurements and joined the BIPM.


https://doi.org/10.24019/jtavr.32



International Committee for Weights and Measures (CIPM)

List of Member States

Argentina, Australia, Austria, Belgium, Brazil, Bulgaria, Canada, Chile, China,Colombia, Croatia, Czechia, Denmark, Egypt, Finland, France, Germany, Greece,Hungary, India, Indonesia, Iran (Islamic Republic of), Iraq, Ireland, Israel, Italy, Japan,Kazakhstan, Kenya, Korea (Republic of), Lithuania, Malaysia, Mexico, Montenegro,Netherlands, New Zealand, Norway, Pakistan, Poland, Portugal, Romania, RussianFederation, Saudi Arabia, Serbia, Singapore, Slovakia, Slovenia, South Africa, Spain,Sweden, Switzerland, Thailand, Tunisia, Turkey, Ukraine, United Arab Emirates,United Kingdom, United States of America, Uruguay

List of Associated States and Economies

Azerbaijan, Bangladesh, Belarus, Bolivia, Bosnia and Herzegovina, Botswana,Caribbean Community, Chinese Taipei, Costa Rica, Cuba, Ecuador, Estonia, Ethiopia,Georgia, Ghana, Hong Kong (China), Jamaica, Kuwait, Latvia, Luxembourg, Mauritius,Moldova (Republic of), Mongolia, Namibia, North Macedonia, Oman, Panama,Paraguay, Peru, Philippines, Qatar, Seychelles, Sri Lanka, Sudan, Syrian Arab Republic,Tanzania (United Republic of), Uzbekistan, Viet Nam, Zambia, Zimbabwe

Table I

Coming back to more recent times, the current changein the SI is not a simple negligible update. It is an importantrevolution instead, because several units are redefined andsome of them are substituted by the universal physicalconstants.

For instance, using the old definition of meter (basedon the standard example meter made of platinum-iridiumand kept in Sèvres, France), the development of the GlobalPositioning System (GPS) technology would never havebeen possible, while it was realized using the new unit,given by the standard speed of light in vacuum. Note that inthis case the velocity substitutes the length in the definition,while the basic physical quantity is still the length.

However, the revolution of the units of measuremainly deals with high precise technical applications, whileit does not involve any change in our ordinary dailymeasure, as the length of a table, the weight and thecircumference of the ankle of a patient.

Thus, all instruments remain valid and in the sameway all the usual daily procedures are still correct.

In this sense the new SI update is a great-but-silentrevolution in Metrology.

Fausto Passariello

Editor in Chief of JTAVR

Endnotes[i] The (centimeter, gram, second) system (CGS) was adopted

in 1873 by the British Association for the Advancement of Science asan evolution of the previous (millimetre, milligram, second) system,proposed in 1832 by Carl Friedrich Gauss. The CGS system was latersubstituted by the (meter, kilogram, second) system (MKS) during the

1st CGPM meeting in 1899. However, it was internationally accepted

only in 1940 and suddenly substituted in 1960 by the InternationalSystem of Units (SI). Today, CGS and MKS survive as non-officialsystems in specialised fields of science, where several units are feltas more practical. For instance, blood viscosity is often measured incentipoise (cP), a derived unit of the CGS system.




New revision of the International System of Units (SI)

Physical quantity Old unit New unit

Mass Platinum kilogram (Kg) Planck constant (h)Length Platinum meter (m) Speed of Light in vacuum (c)Time Second (s) Transition frequency of Caesium 133 atom (Cs)Electric charge Coulomb (C) Ampère per secondTemperature Kelvin (K) Boltzman constant (k)Mole Mole (mol) Avogadro constant (NA)

Light intensity Candela (cd) Light efficacy of a monochromatic ray (Kcd)

Table II

References

1) 26th Conférence générale des poids et mesures (GeneralConference of weights and measures, CGPM), Versailles Nov 13-16,2018. Available at the address https://www.bipm.org/fr/cgpm-2018/accessed Apr 14, 2019.

2) Compte rendus des séances de la première conférencegénérale des poids et mesures réunie à Paris en 1889 [Report of thesessions of the first general conference of weights and measures inParis 1889]. Gauthier-Villars Ed, Paris, 1990. Available at the addresshttps://www.bipm.org/utils/common/pdf/CGPM/CGPM1.pdf accessedApr 14, 2019.

3) CGPM adopted resolutions. Available at theaddress https://www.bipm.org/utils/common/pdf/CGPM-2018/26th-CGPM-Resolutions.pdf accessed Apr 14, 2019.

4) BIPM brochure. Available at the address https://www.bipm.org/fr/publications/si-brochure/ accessed Apr 14, 2019.

5) Exhibition at the “Conservatoire National des Arts etMétiers” [National Museum of Arts and Works], 60 rue Réaumur,75003 Paris. Exposition from Oct 16, 2018 to May 5, 2019. Info at theaddress http://www.arts-et-metiers.net accessed Apr 14, 2019.

6) Les unités de mesure font leur révolution [The unitsof measure make their revolution]. CNRS Le Journal. 2018summer;293:3-11.


https://www.bipm.org/fr/cgpm-2018/

https://www.bipm.org/utils/common/pdf/CGPM/CGPM1.pdf

https://www.bipm.org/utils/common/pdf/CGPM-2018/26th-CGPM-Resolutions.pdf

https://www.bipm.org/utils/common/pdf/CGPM-2018/26th-CGPM-Resolutions.pdf

https://www.bipm.org/fr/publications/si-brochure/

https://www.bipm.org/fr/publications/si-brochure/

http://www.arts-et-metiers.net

F Morganti - Animal welfare in Italy from unification to the XXI century: a recent book on the subject


NON-ANIMAL NEWS BOOK REVIEW

Animal welfare in Italy from unification to the XXIcentury: a recent book on the subject

F Morganti1

1Laboratorio Analisi Politiche e Sociali (LAPS), LUISS Guido Carli, Roma

submitted: Mar 26, 2019, accepted: Mar 26, 2019, EPub Ahead of Print: Apr 1, 2019, published: Jul 7, 2019

DOI: 10.24019/jtavr.62 - Corresponding author:Dr. Federico Morganti, [email protected]


Human concern for animal welfare – includinganimalist thinking, animal rights activism, veganism, andvegetarianism – has become more widespread across thewestern world today than it has ever been. Of course,this phenomenon did not spring out of nothing; it hasa history that dates back at least to the XIX century.Thanks to the wealth made possible by the industrialrevolution, at least some animals (not only pets, but alsothose involved in economic production) were no longer(or not always) seen as mere goods for consumption,but possessors of a subjectivity – intelligence, emotionsand, more fundamentally, the ability to perceive pain andpleasure, and thus worthy of protection. Before industrialrevolution and the growth of national income in the Westernworld, not only were pets a luxury that most people couldnot afford, but the idea of protecting “animal welfare” whenpeople could barely meet their everyday needs was muchmore problematic.

Besides, it was the XIX century that saw theintroduction of the first forms of intensive farming, whichbegan to raise ethical issues on the practice of meatconsumption. In addition to this, the increasing circulationof Darwinism undoubtedly contributed to this transitionbecause it promoted the image of non-human animals asfellow travelers resembling mankind in more aspects thanonce suspected.

The book La protezione degli animali in Italia. Storiadell’ENPA e dei movimenti zoofili e animalisti dalla metà

dell’Ottocento alle soglie del Duemila1 by Andrea Maori,deals with the history of animal protection in Italy byfocusing on the one Italian institution that represented thebattle for a more humane treatment of non-humans and,

ultimately, for the advocacy of animal rights: namely, Entenazionale per la protezione degli animali (ENPA, “NationalBoard for the Animal Protection”).

The book itself was issued by ENPA publishing press.Regardless of the publisher’s interest in the subject, thechoice of ENPA as focus for a history of animal protectionin Italy would still be perfectly legitimate. ENPA is in factthe oldest Italian organization for the protection of animals,and its history is inextricably intertwined with that of manyother relevant animalist and “zoophile” associations, whileit also influenced policy decisions on the subject over theyears.

In the first chapters we learn how the Italian interestin the subject of animal welfare – even before unification(1861) – developed more or less during the same decadesas in many other developed countries. In XIX centuryEngland paved the way, by promulgating the first legislativeacts to regulate cruelty to animals, and thanks to theproliferation of publications and associations dedicated tothe protection of animal welfare. The most important ofthese associations, the Society for the Prevention of Crueltyto Animals (founded in 1824), was later to obtain patronagefrom the crown and to become Royal Society in 1840.Soon France, Germany, Austria, Netherlands, Belgium,Switzerland and the United States would follow the samesteps.

The first law against the mistreatment of animals wasintroduced in the Italian penal code in 1889, which imposedfines on those at fault of “unnecessary abuse” towardanimals. As Maori suggests, the word “unnecessary”introduced a certain margin of discretionality to thejudiciary because the boundaries of “necessary” infliction





were left undefined. But more important is the questionof why the government felt it was time to crack down onanimal mistreatment.

With a clearly anthropocentric outlook, far fromconsidering the point of view of the suffering animals,the legislator implied that all unnecessary infliction ofpain to animals was at odds with “any sense of humanity,of compassion, of benevolence” in the perpetrator. Inother words, what mattered was the human’s feeling whenmistreating the unfortunate animal, rather than the feelingof pain in the animals themselves. As the book repeatedlymakes clear, all legislative acts in defence of animals upto the third quarter of the XX century would preservemore or less this same spirit. The decades precedingthe introduction of the law had witnessed the birth ofmany early protectionist associations in several Italianmunicipalities, but with little success, both in terms ofpublic appreciation and results. One of these associations,Società Torinese Protettrice degli Animali (“Turin Societyfor Animal Protection”, founded in 1871) was later todevelop into what we know today as ENPA.

Animal Welfare in Italy. ENPA Ed., Roma 2016.

This organization was actively involved in ensuringpublic hygiene, raising awareness among the publicopinion, ensuring the enforcement of existing laws, andlobbying for more incisive ones – in addition to supervisingthe practice of animal experimentation (then referred toas “vivisection”) in universities and research labs. Yetthere was not much success these societies could achieveby occasionally reporting infractions to the authorities. Ingeneral, the rise of these organizations and the developmentof the laws approved by the Parliament would prove verydifficult to enforce, despite all the efforts. Not even thoseassociations who had been granted the title of Ente Morale(“Moral Association”) – i.e. patronage by the crown – couldemploy their officers as public servants, and they were thusdevoid of any authority of giving fines, let alone arrestingthe infractor.

In 1913 the Italian Parliament voted for what isnow remembered as “Legge Luzzatti” (named after LuigiLuzzatti, former Prime Minister and promoter of thebill). The bill confirmed the concept of “unnecessarytorture”, thus fundamentally replicating the spirit of theformer jurisprudence on the subject. More importantly,it strengthened the function of the officers employed byzoophile societies, who could now be granted the status ofagenti di pubblica sicurezza (“Public Security Officers”).The bill also touched upon the thorny issue of vivisection,which it considered a “lesser evil” – i.e. a necessaryinstrument for scientific researchers, which was allowed,provided that it was solely performed by accredited“experts” (i.e. physicians or veterinarians). This point inparticular stimulated a heated debate between animalistgroups who demanded more restrictive protections ofanimals versus the researchers, physicians, and medicalpractitioners, who questioned such limitations as a de factostate monopoly on science and thus an infringement offreedom of research.

The efforts of protectionist societies was halted bythe outbreak of World War I, as resources were redirectedfrom civil society to military purposes. At this point,all protectionist societies scattered across the countrywere deprived of any sort of top-down coordination orlong-term strategy, and their financial resources werelimited. The situation changed under the Fascist regime,first thanks to the foundation of Federazione nazionalefra le Società zoofile (“National Federation of ZoophileSocieties”) in 1929, and then, more radically, with theinstitution of ENFPA, Ente Nazionale Fascista per laProtezione degli Animali (“National Fascist Board forthe Animal Protection”). All zoophile and protectionistorganizations, and the National Federation itself, wereat once suppressed, and their offices and duties fellunder direct control and authority on ENFPA. The Fascistpress emphasised respect toward animals as a civic duty,overtly denying that tenderness to animals could corrode




or weaken the “warrior spirit” of the nation. There wasno sentimentalism in the protection of local fauna, whichconversely constituted a unique and valuable treasure of thecountry. “He who mistreats animals”, put it bluntly by theMinister of Education Giuseppe Bottai, “cannot call himselfItalian”. Hunting, on the other hand, was granted its statusas “economic, sport, and military activity of the Nation”.

The same bill which proclaimed the constitution ofENFPA confirmed the status of Public Servants to itsofficers, who were to be authorized by the Ministry ofInterior and were fully equipped with guns and rifles. Theseofficers could supervise that animal experimentation inlabs was performed according to the existing laws. Amongother accomplishments of the fascist era, they promotedthe adoption of a gun, fabricated by ENFPA, for morehumane technique of slaughter (which they hope to makemandatory).

In the aftermath of World War II, after the Treasurygave its approval to the permanence of a nationalorganization for animal welfare – the newly-renamedENPA continued to operate more or less according to thesame guidelines hitherto followed. The following years sawa growth in public awareness concerning issues of animalwelfare, thanks to an increasing attention by the press, andof particular importance was the National TV Broadcast(Rai) dedicating some space to the topic. New organizationswere born between '50s and '60s, such as Lega Italianaper la Protezione degli Animali (“Italian League for theProtection of Animals”) and the first vegetarian society(i.e. Società Vegetariana Italiana), all relying on ENPA’sactivity as their benchmark.

The appearance of the first Italian VegetarianSociety (1952) introduced into public debate the idea of“animal rights”, which gained increasing momentum inthe following decades. The law instituting the NationalHealth Service (1978) assigned a major role to veterinarianswith regard to public hygiene as related to animals,and zootechnical economic activity in particular. Butit was ENPA that provided funds and instruments tohelp slaughterhouses comply with the law and thuslimit unnecessary infliction of pain to livestocks. Ofcourse, the evaluation of what counted as necessary orunnecessary pain could differ, which caused a number ofmisunderstandings between ENPA and local municipalities(e.g. in the event of local fairs and festival, where animalscould be employed for entertaining purposes).

In 1979, under the initiative of the governmentchaired by Giulio Andreotti and with the approval ofthe President of the Republic Sandro Pertini, ENPA wasfinally privatized, even though it had recently survived abill that was meant to cut a number of “useless” publicorganizations. From then on, it ceased to be under the

supervision of the Ministry of Interior, and their officerswere no longer “public servants”. Due to an increasingattention to animal rights, after being privatized ENPAfound new energy, and intensified its activity of demandingmore effective laws in terms of animal protection. Also, thephilosophy of animal welfare found a new alliance in thegrowing environmental movement, in so far as associationsof the likes of WWF (World Wildlife Fund) demandedpolitical action for protection of endangered species.

As an explanation for the growing concern foranimals among the public, Maori suggests that some creditis to be given to the spread of naturalistic photographyand periodicals such as National Geographic (or Airone, inItaly) and documentaries (most notably by Piero Angela),which made nature and non-human animals no longera subject solely for experts and activists, but a topicof discussion for laymen and households. Over the lastdecades, the Italian Parliament has approved several lawsof interest for those concerned about animal welfare, whichMaori describes at length in the last part of the book. Themost important is the one promulgated in 2004, whichstipulated that several kinds of animal mistreatment (e.g.torture, animal fights) were punishable as felonies.

Over the last decades, the Italian Parliament hasapproved several laws of interest for those concerned aboutanimal welfare, which Maori describes at length in the lastpart of the book. The most important is the one promulgatedin 2004, which stipulated that several kinds of animalmistreatment (e.g. torture, animal fights) were punishableas felonies.

In the author’s view, the bill – while more advancedthan previous laws on the subject – can still be criticizedunder at least two respects. First, it fails to sanction anyinvoluntary inflictions of pain to animals, and second, it isfar from granting animals with a status as bearers of rights.At the same time, Maori accepts the point made by juristFrancesco Maria Agnoli, that “such recognition would haveimplied a copernican revolution in Italian juridical system[...] with relevant consequences that should be put to effectonly on the basis of a wide social consensus, which at thetime was lacking”.

Despite the potential bias of both the author and thepublisher towards the subject of the study, La protezioneanimale in Italia fairly stands as a thorough and instructivereading, which compared to the existing literature isprobably unparalleled as to completion of information(not always depth of analysis). The last part of the booknoteworthily gathers a number of relevant documents, acts,and speeches – discussed at length in the first part of thebook – which are related the development of animalistmovements and societies throughout history.




References1) Maori A. La protezione degli animali in Italia. Storia

dell’ENPA e dei movimenti zoofili e animalisti dalla metàdell’Ottocento alle soglie del Duemila [Animal Welfare in Italy. The

history of ENPA and of Zoophile and Animalist Societies from the Mid-Nineteenth Century to the Dawn of the New Millennium]. ENPA Ed.,Roma 2016.


A Maccaro - Beninese therapeutic pluralism. Historical roots and bioethical issues


HISTORY OF MEDICINE

Beninese therapeutic pluralism. Historical roots andbioethical issues

A Maccaro1,2

1PhD Philosophical Sciences, Humanities Department - University of Naples Federico II2Post- doc Social Sciences Department - University of Naples Federico II

submitted: Aug 4, 2018, accepted: Dec 3, 2018, EPub Ahead of Print: Dec 9, 2018, published: Jul 7, 2019Conflict of interest: None

DOI: 10.24019/jtavr.53 - Corresponding author:Dr. Alessia Maccaro, [email protected]


Abstract Retracing the history of the spread ofmodern medicine in the former Kingdom of Dahomey, nowthe Republic of Bénin (sub-Saharan Western Africa), aimsto provide a peculiar perspective of colonial dominationthat, as well known, has dramatically passed through theform of controlling bodies that is not wrong to define as"biopolitical". The aim of the essay is attempting to showhow the gesture aimed at trampling the cultural identityof the people of Benin. Passing through the denial oftraditional therapeutic culture - which is disregarded, asto this day the primary medical reference remains thatof traditional medicine - re-proposes itself in forms thatare apparently opposites in the attempt, only theoretical,of contemporary politics to recover and defend the local

therapeutic tradition, conjecturing hypothetical forms ofpeaceful and equal coexistence between traditional andmodern medicine. The angle of intercultural bioethics, farfrom the long-standing multiculturalism, will allow us tohave a glimpse into the emerging ethical-political dilemmasregarding this issue, as well as underline how the defenseof therapeutic traditions, ascribable to the right of culturalidentity, represents a form of guarantee of the human andof his rights. A true "white man's burden", to considerresponsibly in the perspective of an inclusive citizenship,on which in today's times it’s urgent to reflect upon.

Keywords traditional medicine, voodoo, Bénin,bioethics

IntroductionThe progressive affirmation of Western medical

knowledge in Africa has been throughout history, as wellknown, an indispensable instrument of colonial domination.The deposition of traditional medical knowledge of Africanpopulations, especially therapeutic one, has been for longtime a way of underestimating the cultural identity of agroup and of imposing Western domination.

In fact, cultural difference has often been usedto legitimate the strongest power, under the name of"mission", in order to impose its own identity, assumedideologically as superior and, therefore, to discipline otherpeople life without any guarantee of explicitly established

rules (biopolitics) (Rodotà, 20061).

On closer inspection, however, the bad habit ofthe phenomenon of assimilation, which in return of

"citizenship" - that means availability, in this case, ofmodern medical and scientific knowledge, as well as ofrights and morals -, calls for the renunciation of culturalidentity, seems to be experienced again in the contemporaryphenomenon of emancipation.

In fact, the longed-for emancipation through rights asantidotes to violence is in some way a request to populationsto tend to a universal model and, therefore, to renounce totheir own culture, which is their identity, in order to becomecitizens.

Nevertheless, as we shall see, the universality ofrights, in particular of human rights referred to, is notexclusive but inclusive, and asks people not to renounce totheir diversity, which is their specificity, but to preserve itin order to create horizons, where sharing is an option.





1Very well renowned is the closure manifested by

the European powers in the colonial era towards thecolonized cultures and their traditions, above all therapeuticones. This attitude was leaning on the Eurocentricconviction of knowledge inconsistency of the indigenouspopulations who were simplistically dismissed as magicaland superstitious practitioners. Such an attitude had theindirect aim of weakening the social, religious and evenpolitical role of healers, disliked by the colonizers (Arnold,

19882). Moreover the colonial empires engaged in anideological diffusion of the indigenous body as wild,impure, sick, bearer of physical and moral contagion, whichhad to be saved. Thus began the slow and inexorableaffirmation of rationalized, modern, western, scientificbiomedicine, as of today mostly defined as "conventional"which, through the derision, reduction and denial of theother people's culture, presented itself as a civilizingmission of the colonized population, the burden of white

man (Kipling, 18993) and his essential moral obligation

(Marks, 19974).

This is how the biopolitical control of the other began

(Foucault, 20055), also passing through the missionarymedicine with specific laws about it. A strict legislationwas imposed to all the colonies regarding healthcare policy.This legislation was oriented to a massive construction ofinfrastructures (hospitals, dispensaries, pharmacies) which,inevitably, led to a weakening of the role of traditionaltherapists who were shortly forced to operate under illegal

conditions (Comaroff, 19936).

In the aftermath of independence, in the secondhalf of the twentieth century, the situation of the formercolonies did not change much. The main efforts of thenew African governments were aimed at strengtheningthe existing health infrastructures and, at most, improvinghygiene, by addressing these interventions to propagandacampaigns purposes. Equally oriented to the affirmation ofmodern medicine were the interventions of internationalorganizations, mainly of the WHO and of the organizationsthat were involved in aid projects and internationalcooperation: a new form of colonialism was arising, alwaysmoved by the awareness of exclusive possession of the

knowledge and technical skills of the West which imposed

its supremacy (Bernardi, 1998, p. 217).

Although government actions tended to agree tothe diffusion of modern medicine, in the various Africanstates there were discordant and unclear attitudes towardstraditional therapeutic practices that went from the cleanrefusal of a legislative recognition to the informal approvalof traditional therapists, until the official recognition ofhealers' role that, however, did not clearly regulate the areasof intervention permitted to them, as in Bénin's case.

What is certain is that around the mid-70s there wasa general change in the consideration of tribal therapeuticpractices, certainly accelerated by the official recognitionof traditional African medicine by the WHO, which in 1976defined it as:

«Traditional medicine has a long history. It is the sum ofknowledge, skills, and practices based on theories, beliefs, andexperiences indigenous to different cultures, as explicable or not, aswell as used in the maintenance of health as well as in the prevention,

diagnosis, improvement or treatment of physical and mental illness»8.

Subsequently, in 1978, a declaration was issued bythe WHO in Alma Ata in Kazakhstan recommendingmember countries to promote and prefer the use oftraditional medicine, especially in those areas where itwas recognized as Primary Health Care (PHC), throughthe implementation of health programs that involved

interacting with biomedicine9. The main idea of thisproposal was that traditional medicine, with its widespreaddiffusion on the territory, could somehow meet the

deficiencies of the official health system10, above all thealmost impossible accessibility due both to costs, tooexpensive even for an African employee, and to locationsof hospitals. They are in fact, concentrated only in urbanareas, despite the majority of the African population isresiding, and still resides, in rural areas. This recovery oftraditions was then endorsed by the same African politicianswho persuaded themselves that supporting the endogenousresources with nationalistic ideological intentions couldrepresent a resource that could be spent on the level ofpolitical consensus, which, moreover, perfectly matcheswith the calculations of pharmaceutical companies.

2When the WHO requested to enhance traditional

medicine, the Bénin, a Sub-Saharan West African country,responded positively right from the start [1]. Afterindependence in 1960, it experienced a long twenty-yearMarxist-Leninist government led by General Kérekou inwhich, for ideological nature reasons, much emphasis was

placed on the enhancement of traditional, even medical,

culture (Dozon, 198711).

Here, therefore, the work of integration betweentraditional and modern medicine was undertaken promptly,encouraging the inclusion of western health workers in ruralBeninese villages. However, even though they had received




the task of making themselves available for the knowledgeof traditional practices with the aim of seeking forms ofmediation and exchange with modern medical knowledge,in fact they limited themselves to transmitting the rudimentsof basic health care to the healers and women in the role ofmidwives. This clearly suggests how the control matrix - ex.of the births - of colonial mold was prevailing against the,although proclaimed, enhancement of traditional medicine.

Moreover, integration was not limited to the actionof doctors in tribal communities, but also included theintroduction of traditional therapists, mostly voluntary, inofficial health facilities where not only they could continueto learn notions of prevention and hygiene to be spread inthe villages, but they would also have practiced their artby offering care services. In fact, in some local hospitals,as in the central hospital of the Borgou province, in 1984volunteer healers were selected, by Beninese doctors, toput their skills at disposal of patients who could havebeen given traditional treatments under the supervision ofhospital doctors. However, the experience turned out to bea total failure, since only two years later only one healerremained to offer his free consultations in the hospital,hoping to be officially included in the medical group.

The Beninese case immediately expresses one of thebasic problems of integration projects between traditionaland modern medicine, that is the one related to therole assigned to healers, mostly compared to that of anurse or paramedical staff, rather than that of a therapistto whom is recognized the possession of an effective

and autonomous knowledge (Green, 198812). In fact, theconventional medical staff has shown certain diffidencetowards traditional therapists, due to the difficulty of

accepting unorthodox medical practices (WHO, 198413).Traditional medicine thus has come to fill the void ofmodern medicine, reducing itself to basic health care with aprevalent purpose of popularizing the principles of hygieneand the importance of vaccines, which certainly has hadits advantages, but fails to do justice to what it reallyrepresents.

With respect to this attitude, traditional healersin some circumstances were reluctant to accept thesubordinate role that they wanted to impose themand showed a disinterest or refusal regarding possiblecollaborations with modern medicine, in other cases insteadthey show a clear willingness to cooperate. After all,the institutional recognition and inclusion in the officialmedical structure could not only lead to an increase in socialprestige, and sometimes economic advantages, but could

also respond to the desire of healers to improve their skills,through the acquisition of new knowledge (Beinart-Brown-

Gilfoyle, 200914).

The process of professionalization of indigenousmedicine, however, has involved a renegotiation of socialroles, a redefinition of hierarchies, to which the leadingcadres of official health were not always ready (Last-

Chavunduka, 198615).

Bénin once again exemplifies this collaborationbetween modern medicine and physiotherapeutic traditions.Even nowadays, in fact, more than 80% of the Beninesepopulation (WHO, 2002) uses traditional natural medicineto treat disease, since «in a context in which HIV, malaria,tuberculosis and many others diseases are the majorconcerns of public health and development, traditionalmedical knowledge and practices can be solutions to very

complex problems related to taking care of the disease»16.

With this in mindset, even if traditional medicine isnot yet fully integrated into the national health system,the Beninese Ministry of Health has implemented aProgramme National de la Pharmacopée et de la MédicineTraditionnelles which, in addition to offering a regulatoryframework, proposes a code of ethics and conduct for thepractice of traditional natural medicine and makes possiblenowadays «the production in commercial quantities ofstandardized traditional medicines, in order to integrate

traditional medicine into the national health system»17.

However, as we read from the Code d’Éthique desPraticiens de la Médicine Traditionnelle, healers mustkeep away from the practices of conventional medicine,they cannot use modern technical tools and cannot present

themselves as doctors or professors18. So, expropriated bythe spiritual character of their traditional role and unableto approach a modern role, they remain in an unclearlimbo: obliged to reveal the composition of their effective

medicines19, but not authorized to learn and use newones. In fact, on closer inspection, the idea of rationalizingtraditional medicine through the study of medical plantsused by healers, although it may seem a real form of openingto cultural mentality and an appropriate form of integration,in fact it leans on a prejudicial attitude. The traditionalpractices are in fact evaluated and judged on the basis ofWestern scientific criteria, which, besides reiterating theprimacy of Western scientificity, conceals a continuing willto control the activities of traditional therapists.

3It is indeed evident that the clear division between

traditional medicine of a more herbalist nature and thetraditional medicine that is more tending to a spiritual/supernatural sphere is mostly artificial and is a further




forced attempt to understand traditional medicine accordingto criteria that are familiar to the modern mentality. Healers,in fact, move between the two areas, resorting, accordingto the case, to herbalist or spiritual practices, but also theformer ones share the same symbolic set of spiritual onesand it is therefore difficult to isolate the aspects that canbe scientifically analyzed without changing the horizon ofmeaning in which they move.

Traditional medicine, as it is known, responds to thecultural systems from which it arises and does not limit thedisease to the simple biological event alone, but intends itthrough a holistic, global approach and, therefore, is able togive an overall response to an uneasiness that is at the sametime biological, existential, social and cultural (Eisenberg,

1977, p.1120).

Therefore up to now, rather than the real integrationbetween the two models of traditional and modernmedicine, there has been an attempt by official medical-health institutions to bend the ideological models andtraditional therapeutic practices to the scientific paradigms,denying the magical-religious configurations of symbolicsystems to which those practices are closely linked. Andthis, evidently, implements a real reduction rather than anenhancement of traditional knowledge.

This attitude is certainly a legacy of imperialismwhich, by operating indirect control over political elites, isthe backbone of the forms of neocolonialism that belongto our era [2]. In fact, the process of modernization,by advancing inexorably, has expanded in a way thatmarginalize the traditional system. Such system, in order toexist, must deny itself in its overall essence and show onlythat quantum that is able to the "normalization", which canonly lead to the progressive disappearance of tradition.

In this way, different and extremely delicatequestions arise: on one hand it is clear that modernmedicine, being the one whose efficacy is most proven,should spread without limits in order to guarantee everyonethe right to adequate medical treatment and the right tohealthcare; on the other hand, in order for these rights tobe guaranteed, each individual should be put in the positionto benefit from it, which means, therefore, reviewing theproblems of access to health care and free treatments ofthe health system, which are still dramatically unsolved inAfrica. However, the fact that the importance of the globaldiffusion of biomedicine is not questionable does not implythat such modernization should stifle or distort traditional

medicine, not only because this is an act of violence againstthe cultural identities that derive from it, but also becausethis would mean to deny the value not only cultural, but alsocurative of traditional practices.

Once again, the dilemma regarding the modalitiesof integration between traditional and modern medicine,becomes more and more decisive in the measure in which itseems impossible to speak of integration without distortingthe first system of care or presenting the second as animposition. The real problem is that not only it is difficultto talk about integration, but we should probably also askourselves whether it is indeed desirable an integrationconsidering that inevitably leads to the loss of identity oftradition.

In fact, all the national and international mapsreaffirm the indispensability of respect for traditions, whichnot only pertains to the sphere of freedom - understood asfreedom of conscience and worship - but is a fundamentaland inalienable right of every individual or group thatis a duty of the states to guarantee. As stated in art. 17paragraphs 3 the African Charter of Human and People'sRights composed of the Organization de l’Unité Africaine(OAU) in 1981 and ratified by Bénin on January 20, 1986:«The promotion and protection of morals of traditional

values community shall be the duty of the State»21.

It is therefore evident that it is impossible for thetraditions to be swallowed up in the process - even ifnecessary - for the diffusion of modern medicine. However,since integration does not always mean restitution ofdignity and enhancement of indigenous traditions, but,paradoxically it can contribute to their distortion andtheir disappearance, we must re-discuss the concept ofintegration since, full as it is of stereotypes and prejudices,

is operationally impractical (Benoist, 198922; Dozon-

Sindzingre, 198623). Probably more than integration weshould be content with cooperation between two semanticuniverses that are different, but complementary, which mustbegin by providing a genuine recognition of traditionalmedicine as a whole, not claiming to separate only fewtechnical aspects denying the theoretical foundations of

the entire cultural system (Habermas - Taylor, 199824).Denying the recognition of cultural traditions, denying theirdignity, is, in fact, a way of killing the other, his identity,that is no longer existent after the tragedies that history haswitnessed which degraded the real meaning of human beingand that memory would better hold back more firmly.

4Bioethical reflection then becomes necessary to the

extent that it appeals not only to morals, to medicine butalso to the right to guarantee recognition and respect for




traditions, which is a fundamental human right that has onlybeen partially guaranteed until now.

In this regard the Universal Declaration of Bioethicsand Human Rights, promoted by UNESCO in 2005, inart. 12 reads: «the importance of cultural diversity andpluralism should be given due regard. However, suchconsiderations are not to be invoked to infringe upon humandignity, human rights and fundamental freedoms, nor uponthe principles set out in this Declaration, nor to limit their

scope»25.

Therefore it seems to be possible to say that agenuine cooperation between complementary care systemsis possible only after a genuine recognition of traditions,which must first be legislative. As mentioned, in fact,traditional medicine is practiced, tolerated and evenpartially regulated by ministerial documents , but it is notlegislated. The health system, for its part, must show itselfcapable of recognizing in its complex the plural but notdiscordant souls that inhabit it: this will mean no longerimposing, but arranging the conditions to carry out areform that invests the entire health structure, that shouldbe oriented towards a decentralization of its own point ofview as well as of the cure strategies to pursue.

In this way modern medicine will be able to get closerto culture and population, but on the other hand we mustcontinue to bring traditional medicine closer to the rigor ofscience, taking into consideration not only the quantitativeaspects, but also the qualitative ones of the conceptualand philosophical system at the base of this therapeuticapproach.

From a practical point of view, decentralization willalso imply that the two offers of care must be more presentboth in urban and rural areas: this means not only yearningfor greater coverage of the national health system, but alsopreserving the presence of therapists in the area.

In this way, the real complementarities betweenthe two therapeutic options can be manifested, which in

a certain sense increases the self-determination of theindividual with respect to the choices of care, since thepatients can decide to refer now to one now the otherhealth reference always with the guarantee of the state on

the validity - even before accessibility (Anyinam, 198726),which is a different problem from the one examined - ofboth.

Therefore, regardless of the proposal of decentralizedcooperation between traditional and modern medicine, whatwould seem to be no longer postponed in our society, thatprofesses itself as pluralist, is a more convinced definitionof ethical and political strategies that are genuinely capableof guaranteeing respect for therapeutic traditions and, atthe same time, respect for the rights of care which alsothe former ones consist of. However, as we have seen, theprotection of the traditional philosophical constructs of eachpopulation goes beyond the sanitary discourse and refers tothe principles of identity, freedom and dignity, belongingto the list of fundamental human rights that cannot becircumvented by the overwhelming push of the modern,especially in those countries where the latter is not yet fullyguaranteed.

Therefore if «under the title of third generation ofhuman rights sometimes is included the right to cultural

identity with its linked claims» (Kaufmann, 2009, p. 5627),the latter one, being part of the framework of humanrights, is recognized as being inalienable and, therefore,not required to mediate - unless it endangers human rightsthemselves - or compromise with modernity. However,recognizing this is only the first step to rethink the questionof the relationship among human rights and, above all,the duty of states to guarantee them in respect of socialjustice and human dignity, especially in relation to theso-called Third World countries and, in particular, to thehealth problem, becomes less and less possible to postpone

(Nussbaum - Sen, 199328).

Endnotes[1] It’s been 15 years since Africa has been celebrating

the day of traditional medicine, as proposed by the "OuagadougouResolution" on the Traditional Medicine (31 Aug 2000). Benin hasbeen celebrating it under the auspices of the Ministère de la Santé,every 17th of November. During last meeting Prof. Roch Hougnihin,Coordinator of National Program of Pharmacopeia and TraditionalMedicine underlined the importance of this day which is, accordingto him, a unique opportunity for taking stock of the situation relatedto traditional medicine in Benin, especially in relation to whatconcerns the knowledge transmitted by the ancestors, as well as theinvaluable natural resources of the country. WHO Benin. Le Bénin acommémoré la 15ieme Journée Africaine de Médecine Traditionnelle,

2017: https://afro.who.int/fr/news/le-benin-commemore-la-15ieme-journee-africaine-de-medecine-traditionnelle (nov. 2018).

[2] The studies of P. Hountondji on what he calls"mondialisation des savoirs" are particularly important in thisregard, mainly because it creates a series of interpretative andepistemological difficulties especially, and above all, towards thetheme of decolonization of African knowledge. As a matter of facts,the author shows how some African intellectuals, first supporters ofan anticolonial policy, now justify the choices of governments andcontemporary policies which, in fact, favor the diffusion of a dimensionthat is only partial to tradition.


https://afro.who.int/fr/news/le-benin-commemore-la-15ieme-journee-africaine-de-medecine-traditionnelle

https://afro.who.int/fr/news/le-benin-commemore-la-15ieme-journee-africaine-de-medecine-traditionnelle



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13) WHO. Traditional medicine and health care coverage. Areader for health administrators and practitioners. Geneva: WHO; 1984.

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http://www.who.int/traditional-complementary-integrative-medicine/about/en/

http://www.who.int/traditional-complementary-integrative-medicine/about/en/

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http://www.unesco.org/new/en/social-and-human-sciences/themes/bioethics/bioethics-and-human-rights/

http://www.unesco.org/new/en/social-and-human-sciences/themes/bioethics/bioethics-and-human-rights/

E Grenier, D Rastel, C Chaigneau - Evaluation of an accelerometer-based device to monitor compression compliance


COMPRESSION THERAPY ORIGINAL PAPER

Evaluation of an accelerometer-based device to monitorcompliance on patients wearing medical compressionstockings

E Grenier1, D Rastel2, C Chaigneau1

1SIGVARIS, Z.I. Sud d’Andrézieux, rue Barthélémy Thimonnier, BP 60223, 42170 Saint-Just Saint-Rambert, France2Vascular physician, responsible for medical device vigilance, SELURL Philangio, 30 place Louis Jouvet, 38100

Grenoble, France

submitted: Jul 16, 2018, accepted: Nov 3, 2018, EPub Ahead of Print: Dec 9, 2018, published: Jul 7, 2019Conflict of interest: D. Rastel is a private-sector vascular physician and non-exclusive consultant for medical textilemanufacturer, SIGVARIS. E. Grenier and C. Chaigneau are employed by SIGVARIS in the respective functions ofResearch Associate and Head of Advanced Studies.

DOI: 10.24019/jtavr.51 - Corresponding author:Ing. Etienne Grenier, [email protected]


AbstractI- INTRODUCTIONMedical compression, for the most part employingtextile methodology, constitutes the principal conservativetreatment prescribed in the case of venous disorders.However, its role is subject to debate in the scientificcommunity. Treatment is only effective if the orthosis isworn on a daily basis and clinical studies suffer fromsignificant bias in relation to how patient compliance ismeasured.II- AIMSAn electronic measurement device has been developedto measure patient compliance; it is based on movementdetection by an accelerometer sensor. The aim of the presentstudy is to compare objective data captured by the electronicdevice with wear times as reported by studied patients.III- METHODSThe present study was conducted on 5 patients whowere being treated for uncomplicated superficial venousinsufficiency with a medical prescription for class 2compression hose to be worn daily. Two pairs of currently-marketed stockings were provided to the patients. Onestocking of each pair was fitted with the electronicmonitoring device. The patients were requested to weartheir compression hose as normal and to note the dates andtimes of any incidents and any undesirable effects.IV- RESULTS

During the course of the study, the ten instrumentedstockings captured 34 days that were representative of wearand 48 non-wear days. The absolute mean errors (and thestandard deviation associated) calculated on the basis of thewear times reported by the patient and wear-times measuredby the devices range between 5 (5) minutes and 83 (26)minutes, which corresponds to relative errors of between 1(0.9)% and 19 (7.1)%. For 27 days, the absolute differencebetween the subjective and the objective wear-times is lessthan 60 minutes. The results gathered by the sensors duringnon-wear days are 0 minute for 4 patients, representing41 days of experimentation (85%). On the other hand,one patient's devices incorrectly wrongly recorded averagewear periods of 55 (55) minutes and 23 (16) minutes.No incidents or undesirable effects were reported by thepatients.V- CONCLUSIONThe specially-developed electronic device is based on theprinciple of detection of phases of wear as registered byan accelerometer sensor. Integration of the system in anelastic compression stocking enables acquisition, analysisand interpretation of an acceleration signal thus providingobjective monitoring of patient compliance as a function ofthe periods of wear and non-wear.

Keywords Medical compression stockings,compliance, accelerometer-based device





1 Introduction

Compression therapy remains, at the present time,

the cornerstone of lower limb venous disease treatment1,2.It decreases venous volume at rest, decreases ambulatoryvenous hypertension, increases muscle pump function

and acts positively at the microcirculatory skin level3,4.Compression therapy is mainly textile in the form ofbandages or stockings and its clinical results depends ondifferent parameters such as the level of pressure, thecumulative pressure at rest and in movement, whether the

textile is correctly applied on the leg or not5. So, amongthem, the wearing time is one of the greatest importance.A major bias in clinical studies on compression therapy is

the compliance6. If compliance can be easily checked bynurses when bandages are used it is scarcely measured withstockings. When measured, it is through questionnaires thatare firstly not validated in term of internal and externalcoherences and secondly self-administered by patients,

consequently leading to biases7.

Patients at rest do not represent to a great extent acompliance problem since in most cases they are inpatientsand hospital staffs regularly check the compression device.To solve the problem on active patients raised the idea toinsert a sensor in the stockings. A first one « Thermotrack®

» has been used in a restricted number of patients7,8

Unfortunately, this electronic device based ontemperature increase detection, cannot be used in certainclimate. As a consequence, an electronic device based onmotion detection with an accelerometer was developed. Theobjective of this work is to compare the objective results ofthe device to the wearing time reported by patients and thenadapt its use to the compliance measurement of medicalcompression stockings (MCS) in active patients.

2 Materials and methods

2.1 Electronic monitoring device

2.1.1 Technical characteristics and operatingprinciple

The electronic monitoring device is an electronicchip enabling assessment of the period of wear of acompression stocking. The system was developed by3DOuest and Feichter Electronics (Lannion, France),specialists in electronic hardware and software design,on the basis of a SIGVARIS functional specification. Itcomprises a CR1616 button cell (Lithium 3V, 55mAh),with an autonomy of around four months in active modeand three key electronic components: - a three-dimensionalaccelerometer, a microcontroller and a memory. Theaccelerometer detects movement of the device embedded in

the compression stocking and identifies the periods whenthe stocking is worn and when it is not worn.

Three parameters that are configurable when theelectronic chips are initiated are designed to optimisedetection of wear and non-wear periods. The cycle (ortime interval) between two events can be set in a rangegoing from 1 to 120 minute with a step of 1 minute.The movement detection threshold value was set at 0.3Gand the accelerometer signal averaging time was 800ms. These values were established by analysis of thedata from experiments in real conditions of use and byintegrating situations representative of product use in dailylife (standing, sitting and lying down). The purpose ofthe parameters is to optimise detection sensitivity and theaccuracy of data gathered relating to wear phases even inlengthy quasi-static situations and to minimise instances offalse detection when the stocking is not being worn.

Wear data and the associated time-stamp are recordedat regular intervals in the embedded memory. Recordingfrequency can be set when the chip is initiated.

The 256-Kbits Electrically Erasable ProgrammableRead-Only Memory (EEPROM) can store data of wearingduring 340 days with sampling every 15 minutes. Theabsolute maximum value of acceleration occurred duringeach period is stored on the first 7 bits of one byte. Theacceleration value by triggering the motion detection isused to determine the wearing state (Yes or No). Theadvantage of this technology is that all recorded data issaved even in the absence of power. Consequently, thereis no loss of data if the battery becomes discharged beforethe compliance data are extracted. Selection criteria forthe electronic components and CR1616 microcontroller-embedded software were extremely stringent in order tomeet energy-saving requirements and to ensure maximumdevice autonomy.

The electronic card lengths are 26 x 16 x 3 mm. Toensure a perfect seal, the electronic card is included intoa silicone casing which sizes lengths are 30 x 20 x 8 mm(Figure 1).

Figure 1 - From left to right: electronic monitoring chip,silicone base, device set inside the base, device sealed bypotting silicone.




Timestamp Event detected

Tue Aug 10 19:12:34 YESTue Aug 10 19:27:34 YESTue Aug 10 19:42:34 YESTue Aug 10 19:57:34 YESTue Aug 10 20:12:34 YESTue Aug 10 20:27:34 YESTue Aug 10 20:42:34 NOTue Aug 10 20:57:34 NOTue Aug 10 21:12:34 NO

Table I - Example of raw data extraction for a period oftwo hours sampled every 15 minutes.

Date Wear time Wear time(s)

Mon 5th Sep 12h30m 45000

Tue 6th Sep 7h15m 26100

Wed 7th Sep 0h0m 0

Thu 8th Sep 0h0m 0

Fri 9th Sep 11h15m 40500

Sat 10th Sep 0h0m 0

Sun 11th Sep 0h0m 0

Mon 12th Sep 5h0m 18000

Tue 13th Sep 5h30m 19800

Wed 14th Sep 6h0m 21600

Table II - Example of a summary table generated by theautomatic software routine used to analyse data recordedby electronic monitoring devices.

2.1.2 Raw data extraction

The data recorded in the monitoring device chipmemory is extracted by means of dedicated software anda communication interface linked to a computer via anUniversal Serial Bus (USB) connection. Communicationbetween the electronic chip and the communicationinterface is via the electrical contact points. Raw data aredisplayed and can be saved to a spreadsheet file (.csv) in thesoftware interface (Table I) for general analysis of patientcompliance. This file contains all wear information (Yes /No) in the "Event detected» column, along with the relevanttimestamp.

Figure 2 - Functional diagram for the automatic dataprocessing algorithm

2.1.3 Data processing, analysis and summary

To facilitate raw data analysis, a data processingroutine was developed in a programming environment(MATLAB®), comprising three functions. The mainfunction handles sequential command execution andutilises the two other functions that are dedicated to filteringand data time conversion. Figure 2 illustrates the routine'salgorithmic process.

"False negative" occurs when the device has notdetected a real wear event. Conversely, a "false positive"occurs when the device has wrongly detected a wear event.Thus, by filtering the events, it is possible to eliminatecases of incorrect detection of wear or non-wear events.The digital filter was developed to take account of twoconsecutive periods functioning as a sliding window overthe event vector. It acts as an averaging process (low-passfilter) for short and fast variations in the wear signal.

Based on the filtered signals, the programmegenerates and records two files:




Figure 3 - Example of a graphical illustration of data monitored (YES/NO) obtained by the data extraction routine.Display of the effect of filtering in the elimination of false positives (purple circle) and false negatives (green circle). Thered vertical lines represent the days of experimentation.

Figure 4 - Representation of wear times reported by the patients in comparison with wear times measured by themonitoring devices during the compression stocking wear days (n=34)

1. Daily wear time summary file (Table II). This file comprisesthree columns - event dates associated with wear times expressed inhours/minutes (unit commonly used) and seconds

2. Graphical representation of event vectors as a function ofvarious types of filtering - raw signal and filtered signal of the MCS’swearing (Figure 3). This overview and visual representation are usefulto quickly verify the raw signal recorded by the electronic device andthe result of the filtering process. Also, it would be a quick and easy wayto observe compliance data by the patient or the health professional.

Both Table II and Figure 3 document display thefindings of the same experiment.

2.1.4 Device integration in the medicalcompression stocking

The electronic chip is protected against water ingressby silicone encapsulation (moulding and potting) which isresistant to hand- and machine-washing (30°C wash and800 rpm spin cycle).




Testing was conducted to assess resistance tomachine-washing. After thirty (or so) washes in a shortcycle of 30 minutes at 30°C, the electronic chips hadnot suffered any damage. The silicone envelopes werenot damaged or torn and the electronic chips remainedoperational. This solution of silicone encapsulation cantherefore be confirmed to guarantee water-tightness anddevice protection.

The device is inserted into the reverse side of thecompression stocking and sewn in.

2.2 Protocol

Five patients receiving medical treatment foruncomplicated superficial venous insufficiency who hadbeen prescribed class 2 compression stockings for dailywear (with a pressure of 15-20 mmHg exerted on the ankle,

AFNOR9 standard G30 102 B), commercially-availableand that was fitted with a sensor. MCS used in this studyare socks composed of 50 % Aquarius Polyamide / 27%Elastane / 23% Polyamide and 36 % Polyamide / 16 %Elastane / 48 % Bamboo Viscose labelled URBAN andBAMBOU, respectively.

The patients gave their consent to participate in thestudy. As the device under test was to be ultimately usedas part of clinical trials, this patient study was conductedas part of ANSM's (Agence Nationale de Sécurité Sanitairedu Médicament - National Agency for Safety of HealthProducts) medical device vigilance programme under theresponsibility of the second author who is specificallyresponsible for elastic compression hose vigilance. Prior totesting, it was checked that the devices, once inserted intothe stocking, had not altered the compression characteristicsof the compression hose.

One stocking of the pair was fitted with the electronicmonitoring device. Two pairs of "recording" stockings weredistributed to the volunteers. The tests took place overan approximate period of one week. The patients wererequested to wear their compression stocking as normaland to note date and time information relating to variouswear events - donning and doffing, wash type (hand-washor machine-wash), stocking handling (stretching, storage,etc.), and any undesirable effects.

The monitoring devices were configured for a 10-minute sampling and recording interval for patients 1, 2 and3 and 15 minutes for patients 4 and 5.

3 Results

Stocking wear time data were extracted from themonitoring devices, processed and analysed in accordancewith the methods outlined above. Each monitoring devicewas identified by the patient number and an alphabetical

character to distinguish the stocking pairs allocated to thepatient.

The results are presented separately for the dayswhere the patients stated that they had worn their stockingand the days when they reported that they had not wornthem. We consider that the reference wear times are thosereported by the patients.

Over the course of the study, the ten instrumentedstockings enabled us to capture 34 representative wear daysand 48 days of non-wear. Figure 4 shows the wear timesreported compared to the times measured by the monitoringdevices and the theoretical straight line (dotted black line)shows a perfect relation between the two variables. It canbe noted that in 30 out of 34 cases, the measured wear timesare greater than the reported wear times.

Based on all the wear days, the averages and standarddeviations were calculated for both the reported and themeasured wear times. This data is used to determine thestocking wear time per day and after-the-event assessmentof the patients' level of compliance (number of days permonth and number of hours per day).

For example, if a wearing time of 10 hours had beenrecommended, it was observed that patient 1 was morecompliant in terms of the average daily wear duration (723(64) minutes/day for one pair and 710 (145) minutes/day forthe other pair) compared to patient 5 (486 (149) minutes/day and 405 (105) minutes /day). This observation is alsoconfirmed by the wear times measured by the monitoringdevices: 743 (71) and 732 (152) minutes/day for patient 1and 552 (122) and 443 (83) minutes/day for patient 5.

For each wear day, the absolute and relativedifferences were also calculated on the basis of the weartimes reported by the patients and the durations measuredby the devices. The absolute mean errors between thesetwo wear time types range between 5 (5) minutes and 83(26) minutes, which corresponds to errors varying from 1(0.9)% and 19 (7.1)% compared to the reported referencetime. Table III summarises all reported and measured dataand provides the results of associated comparisons. Bothcolumns contained under each patient present the resultsfrom a device integrated in MCS. For example, D1a meansDevice integrated in the first pair of the patient 1 and D1bin the other pair.

For the entire period of wear, 34 days, eighteenshow an absolute difference between the subjective andobjective wear time of less than 30 minutes. This differenceis between 30 and 60 minutes on 9 days and between 1 hourand 2 hours 45 minutes on 7 days (Figure 5).

Moreover, it is interesting to analyse the datameasured by the monitoring devices during the periodswhen the stockings were not worn. The phenomenon known




as "false negative" indicates incorrectly reports wear dataand consequently leads to overestimation of the total wearduration.

In our experiment, according to the patients, the totalnumber of non-wear days was 48. The results obtainedfrom the monitoring devices are consistent with these

non-wear phases as the wear durations are equal to 0minutes for 4 patients out of 5, thus representing 41 daysof experimentation (85%). By contrast for the patient 1,monitoring devices recorded an average wear period of 55(55) minutes for pair A and 23 (16) minutes for pair B, whenin fact medical compression stockings were not worn (TableIV).

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5D1a D1b D2a D2b D3a D3b D4a D4b D5a D5b

Experimental dayconsidered

day 3 4 3 2 4 3 6 2 5 2

Wear TimeReported

Mean(std)

minute 723(64)

710(145)

668(139)

655(105)

634(127)

450(150)

405(150)

720(150)

486(149)

405(105)

Wear TimeMeasured

Mean(std)

minute 743(71)

732(152)

683(156)

650(90)

628(114)

483(176)

475(158)

803(128)

552(122)

443(83)

Absolutedifference

Mean(std)

minute 20(13)

22(8)

22(10)

5(5)

46(29)

47(26)

75(30)

83(26)

66(40)

53(8)

Max minute 30 30 30 10 105 85 120 105 165 60Min minute 0 10 0 0 10 20 30 60 15 45

Relativedifference

Mean(std)

% 4(0.4)

3(0.5)

3(0.6)

1(0.9)

7(3.8)

11(5.7)

19(7.1)

13(5.8)

18(15.3)

14(5.6)

Table III - Summary of stocking wear times obtained from patient reports and from data for wear days as measured bythe monitoring device. D1a means "device integrated in the first pair of the patient 1 and D1b in the other pair" and soon for the other patients.

Figure 5 - Breakdown of absolute wear time differences between patient-reported data and data captured by themonitoring devices




Patient 1 Patient 2 Patient 3 Patient 4 Patient 5D1a D1b D2a D2b D3a D3b D4a D4b D5a D5b

Experimental dayconsidered

day 4 3 4 5 3 4 4 8 5 8

Absolutedifference

Mean(std)

minute 55(55)

23(16)

0(0)

0(0)

0(0)

0(0)

0(0)

0(0)

0(0)

0(0)

Max minute 130 40 0 0 0 0 0 0 0 0Min minute 0 0 0 0 0 0 0 0 0 0

Table IV - Summary of stocking wear times obtained from patient reports and from data for non-wear days as measuredby the monitoring device. D1a means "device integrated in the first pair of the patient 1 and D1b in the other pair" andso on for the other patients.

4 Discussion

The principal outcome of the study is confirmation ofthe effectiveness of an electronic device to measure patientcompliance with prescribed wear of medical compressionstockings. During the study, measurements were recordedby an electronic chip using an accelerometer to detectmovement of the device and also records the data at regularintervals.

The central aim of the system is to help in a greaterextent a health practitioner to obtain data relating to theoverall use of the prescribed compression hose. Despitethe uncertainty of daily wear times stemming from themonitoring devices, thanks to the sensor it is possible toassess a patient's pattern of compliance, namely by takinginto consideration the days when the compression stockingsare not worn. Thus, what is the impact on the healthpractitioner's conclusions based on daily wear data thatmight include an error of one or two hours? Is currentlyour monitoring device sufficiently accurate to meet therequirements of compliance objectification or the level ofcompliance observed by the ultimate data user?

Under certain conditions of daily use, the electronicchips may incorrectly detect movement (and be confusedwith wear periods). These "false positives" may be due todifferent phases of use of the compression hose, such as,for example, washing, drying in the open air (wind effect),spare pair of stockings being carried in a handbag, stockingsbeing displaced in a wardrobe, etc. Incorrect detections maythen induce an error in the daily wear time results, theduration of which may vary as a function of the conditionsof use. Conversely, when the compression stockings areeffectively being worn, it is possible that the device does notdetect any movement during periods when the lower limbsare immobile (when taking a siesta, or sitting down readingor watching TV). However, we have no means of evaluatingsaid errors (over estimation or underestimation) measuredby the monitoring devices in relation to usage criteria andto distinguish them between true periods of use.

The reliability of the results captured by themonitoring devices was assessed by comparison with thewear times reported by the patients. In spite of strictexperimental conditions, it is possible that the reportedcompression stocking donning and doffing times are, to acertain extent, approximate, depending on the time lapsebetween the event and the moment the event is noted down.For example, it might be difficult to remember the exacttime the compression stockings are donned if the wear timesare noted down at the end of the day. The accuracy of thisdata may be questionable, which might, to a certain extent,explain the differences between the reported and measuredperiods of wear. This therefore introduces another periodrelating compression stocking wear time that is defined bythe true wear duration.

During the experiment, the interval between each datacapture of compression stocking wear was set at between 10and 15 minutes. This temporal resolution could possibly bereduced to 5 minutes in order to minimise the error inducedby false positives. The wear time results are very frequentlyoverestimated by the monitoring devices in relation tothe times reported by the patients. The overestimation isless than one hour for over three quarters of the weardays and the maximum overestimation was 2 hours 45minutes. These variations can be explained by independentor successive washing, drying and storage phases that arewrongly considered to be wear phases, due to detection ofstocking movement.

From a material point of view, the devices areencapsulated in a silicone case and it is not possibleto check the functional status during the trial withoutdestroying the device. To access recorded data or datain the course of recording, it is necessary to break intothe compression hose and the case in order to retrievethe data via the communication interface between thechip and the computer. It would be preferable to beable to interrogate the monitoring device via a wirelessconnection (Bluetooth, WiFi, ZigBee, RFID, NFC, etc.).




This functionality would not only enable us to verify theoperational status of the electronic system but also toextract and display at regular intervals the data saved inthe memory. Furthermore, the autonomy is not sufficientto enable evaluation of compliance over a 6-month period(compression hose legal guarantee period); we will haveto find solutions to overcome this difficulty. The device'scompact design constitutes a major advantage, as there isno discomfort when the compression stockings are beingworn. In a large-scale mass-production approach, powerautonomy could be increased and the dimensions couldbe very significantly reduced by the use of specific, morepowerful electronic components.

The device developed has been validated, contraryto other devices already in use. However, in the future,advancements in wear detection systems are likely to focuson physiological parameter acquisition (dermal impedance,capacitive proximity detection, etc.) that is modified solelyby textile/lower limb interaction.

5 Conclusion

We have developed an electronic device based thedetection of wear times by means of an accelerometer

associated with an algorithm to process, analyse andsummarise patient compliance reported on a daily basis. Byembedding this system in an elastic compression stocking,we have demonstrated that it is possible to objectivise thewear and non-wear phases by acquisition, analysis andinterpretation of an accelerometer sensor signal.

The trial consisted of a study conducted by 5 patientswearing medically-prescribed compression stockings inorder to evaluate the reliability of the results delivered bythe monitoring devices. We captured 34 days representativeof compression stocking wear days and 48 non-wear days.In the course of the experiment, we have demonstratedthat data relating to patient compliance with a medicalprescription for compression stockings can be acquired andrecorded over a period of several months without changingthe patients' normal lifestyle. The difference between thewear times reported by the patients and the durationsmeasured by the monitoring devices is less than 60 minutesfor 79% of the wear days. The results of the monitoringdevices also demonstrate the accuracy of the data in 85%of the days when the elastic compression stockings werenot worn. These errors could result in uncertainty as to theactual daily wear durations but do not, however, have amajor impact on objectivation of overall patient monitoring.

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Chastanet S, et al. Management of Chronic Venous Disease. ClinicalPractise Guidelines of the European Society for Vascular Society(ESVS). Eur J Vasc Endovasc Surg 2015; 49: 678-737.

2) Rabe E, Partsch H, Hafner J, et al. Indications formedical compression stockings in venous and lymphatic disorders:An evidence-based consensus statement. Phlebology 2017; doi:10.1177/0268355516689631

3) Bergan JJ, Geert W, Schmid-Schönbein PD, et al. Chronicvenous insufficiency. N Engl J Med 2006; 355: 488-98.

4) Partsch H. Mechanism and effects of compression therapy.In: The Vein Book. London: Elsevier; 2007, 103-109.

5) Partsch H. Compression therapy: clinical and experimentalevidence. Ann Vasc Dis 2012; 5: 416-22.

6) Ziaja D, Koce#ak P, Chudek J, Ziaja K. Compliance withcompression stockings in patients with chronic venous disorders.Phlebology. 2011; 26(8): 353-60

7) Allaert FA, Rastel D, Graissaguel A, Sion D, Hamel-Desnos C. Design and evaluation of the psychometric propertiesof a self-questionnaire on patient adherence to wearing elasticcompression stockings. Phlebology. 2018 Jan 1:268355518762824.doi: 10.1177/0268355518762824. Epub ahead of print]

8) Uhl JF, Benigni JP, Chahim M, Fréderic D. Prospectiverandomized controlled study of patient compliance in using acompression stocking: Importance of recommendations of thepractitioner as a factor for better compliance. Phlebology. 2018;33:36-43.

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C Recek - How to counteract the saphenous reflux recurrence


VENOUS PATHOPHYSIOLOGY SHORT COMMUNICATION

The tenacious tendency to saphenous reflux recurrenceand the possibility how to counteract it

C Recek1

1Retired, formerly Department of Surgery, University Hospital, Hradec Kralove, Czech Republic. Address: Cestmir

Recek, Mantlergasse 24, 1130 Vienna, Austria.

submitted: Jan 15, 2019, accepted: Jan 20, 2019, EPub Ahead of Print: Jan 21, 2019, published: Jul 7, 2019Conflict of interest: None

DOI: 10.24019/jtavr.60 - Corresponding author:Dr. Cestmir Recek, [email protected]


Abstract Varicose vein disease is characterizedby a tenacious tendency to recurrence irrespectiveof the therapeutic method used; recurrent reflux isinextricably linked with recurrent varicose veins andis responsible for the progressive deterioration of thehemodynamic disorders. The hemodynamic preconditionsfor the development of recurrent reflux are generatedduring calf pump activity by the pathological drainage ofvenous blood from the incompetent thigh saphenous systeminto deep lower leg veins; the consequence is relocationof the dividing line of the ambulatory pressure gradientfrom below the knee joint where it is situated in healthypeople into the thigh between the femoral vein and theincompetent thigh saphenous system, which sets off thechain of events producing recurrent reflux. This undesirableentanglement can be counteracted by interruption of thevenous drainage at the level of the knee joint, where it iseasiest and most effectively feasible. This can be achievedby surgical procedures, ablative methods or sclerotherapy.With reference to the behavior of pressure changes indeep and superficial veins of the lower extremity occurringduring calf pump activity it can be deduced that externalpressure of about 35 mm Hg applied just below theknee joint (e. g. by a rubber sleeve) might constitute analternative therapeutic possibility; its effectiveness shouldbe verified in clinical studies. If proved to be effectiveand tolerated by the patients, it would not only inhibitsaphenous reflux in varicose vein disease but impede alsothe occurrence of hemodynamic preconditions responsiblefor the development of recurrent reflux.

Keywords recurrent reflux, external compression ofthe saphenous vein

Introduction

Varicose vein recurrences were reported to occurin a wide range up to 90% depending on the length offollow-up, the mode of therapy, and the method used to

diagnose recurrence1-5. Inadequate surgery leaving behindincompetent saphenofemoral junction with tributaries orincompetent trunk of the great saphenous vein in thethigh has been claimed to cause recurrence of saphenous

reflux and varicose veins6-8. Nevertheless, recurrencesoccur also after correctly performed crossectomy and

stripping9-11. Even special measures, such as suturingthe foramen ovale and inserting mechanical barriers overthe saphenofemoral junction were not able to prevent

recurrences12-18. Some authors expressed the opinion thatrecurrent reflux in varicose vein disease was unavoidable,no matter how careful the primary procedure was carriedout, and postulated that the tendency of varicose veinsto recur might be related to unspecified hemodynamic

factors6, 19.

This article mentions the hemodynamic phenomenontriggering recurrence of saphenous reflux and reflects onmeasures how to prevent it.

The tenacious tendency to generate recurrentreflux

Varicose vein disease has a tenacious tendency

to recurrence, as documented in many papers1-18. Theprogressively increasing intensity of recurrent saphenousreflux is responsible for the gradually deterioration of





the hemodynamic disturbance and the re-occurrence ofchronic venous insufficiency. Nevertheless, in the courseof the follow-up of 34 years, only 21.6% of limbs withrecurrent reflux after primary surgery displayed congestive

symptoms severe enough to necessitate reoperation11.

Venous reflux is triggered by the ambulatory pressuregradient of 37.4 ± 6.4 mm Hg arising during calf pumpactivity between thigh veins with higher pressure and lower

leg veins with lower pressure20. Thus, the origin of refluxis situated always above the knee, the mouth/re-entry pointbelow the knee. In primary varicose veins with impeccablecompetence of deep lower leg veins the calf perforatorscan never become the source of reflux because they areconnected to the lower pole of the ambulatory pressuregradient. The dividing line of the ambulatory pressuregradient is situated in healthy people just below the kneejoint at the beginning of the popliteal vein. Abolitionof saphenous reflux in varicose vein disease eliminatesthe hemodynamic disturbance even in patients afflictedwith the severest degree of chronic venous insufficiencyand restores physiological hemodynamic values but, oddlyenough, at the same time it generates preconditions for thedevelopment of reflux recurrence and for the progressivecomeback of the previous pathological situation; this

phenomenon has been called hemodynamic paradox21.The hemodynamic preconditions for reflux recurrence areinduced during calf pump activity by the drainage of venousblood from the thigh saphenous system into the deep lowerleg veins; the consequence is relocation of the dividingline of the ambulatory pressure gradient from below theknee into the thigh between the femoral vein and theincompetent thigh saphenous system. This situation triggersthe chain of events engendering the occurrence of recurrentreflux: pressure gradient –> increased flow through thetiny communicating vessels –> increased fluid shear stresson the endothelium –> release of vasoactive agents –

> progressive dilatation of the concerned vessels22-26.The relocation of the dividing line of the ambulatorypressure gradient is the characteristic feature of varicosevein disease; it does not arise in subjects with healthyvenous system because competent valves preclude thedrainage of venous blood from the thigh into the lowerleg. Therefore, no pressure difference between the femoralvein and the superficial veins in the thigh can ariseduring calf pump activity in people with healthy veins,and no neovascularisation occurs after harvesting the greatsaphenous vein for bypass grafts

Measures counteracting the tenacioustendency to reflux recurrence

The problem-solving strategy is based on hinderingthe pathological drainage of venous blood from theincompetent thigh saphenous system into the deep lower leg

veins. This can be achieved either by invasive procedures orby conservative measures. During the surgical procedure,the easiest mode is precluding the drainage at the “strait”,i. e. at the knee level. All incompetent superficial veinsmust pass this bottleneck between the skin and the bonesor muscles and are here easiest therapeutically assailable.Together with the abolition of saphenous reflux at thesaphenofemoral junction all incompetent venous channelsidentified preoperatively by duplex ultrasonography shouldbe interrupted in this bottleneck; the surgical procedure

aiming at this goal has been published previously27.Notwithstanding, new draining channels may develop in thecourse of follow-up; they should be checked at the kneelevel during the follow-up examinations and obliterated bysclerotherapy, if necessary.

Apart from the invasive procedures, a sheerconservative measure might produce similar beneficialhemodynamic results. Based on the behavior of pressurechanges in deep and superficial veins of the lower extremityoccurring during calf pump activity, it can be deduced thatthe same goal might be achieved by the external pressureapplied in the form of a pneumatic cuff or a rubber sleeveclosely below the knee joint. The pressure of about 35 mmHg might be able to compress the saphenous system duringthe diastolic phase of the calf pump activity and impede inthis way the saphenous reflux. It follows that it would

- 1. Hinder the diastolic saphenous reflux and theoccurrence of ambulatory venous hypertension- 2. Enable the physiological systolic centripetalflow- 3. Hinder the pathological drainage from thethigh saphenous system into deep lower leg veinsoccurring during calf pump activity in the treatedpatients in whom saphenous reflux was abolished,and inhibit thereby the creation of preconditionstriggering recurrent reflux.

As mentioned above, the saphenous reflux is triggered inthe vertical/standing position by the ambulatory pressuregradient. During calf pump activity, the hydrostatic venouspressure decreases to about 25 mm Hg in the distal posteriortibial vein and to about 37 mm Hg in the great saphenousvein above the ankle; the diastolic pressure in the saphenoussystem closely below the knee may be still lower (itwas apparently not measured directly). During calf musclecontractions the systolic pressure increases by roughly 35mm Hg in the great saphenous vein above the ankle andby 50 mm Hg or more in the posterior tibial vein, so thatthe systolic centripetal flow toward the heart is guaranteed;external compression of about 35 mm Hg cannot hinder it.The Perthes test – applying a tourniquet in the thigh in orderto compress the incompetent saphenous vein – documentsthat: the bulging varicose veins in the lower leg emptyduring calf pump activity. The pressure in the popliteal veinkeeps the value of the hydrostatic pressure of 60 mm Hg; itdisplays small systolic and diastolic oscillations during calf




pump activity but does not decrease28, 29. Adding up theambulatory pressure (37 mm Hg) and the external pressure(35 mm Hg) yields the sum of 72 mm Hg, i.e. it exceedsslightly the pressure in the popliteal vein. Thus, the externalpressure of 35 mm Hg would keep the dividing line ofthe ambulatory pressure gradient below the knee, as it isdistinctive of healthy people.

This principle could set a new therapy modality in thetreatment of varicose vein disease. It would be meritoriousto verify this theoretical idea and specify the value of theexternal pressure necessary to achieve the designated aim.

Similar effect could be theoretically achieved bythe so called hydrostatic therapeutic device consistingof a small sleeve of plastic material applied below theknee joint; the sleeve is connected to a small-caliber flatincompressible tube reaching into the axilla. If the wholedevice is filled with water, it exhibits in the standingposition hydrostatic pressure of about 60 mm Hg belowthe knee joint; this pressure is able to effectively compressthe saphenous system during the diastolic phase and hinderthereby the saphenous reflux taking place during thediastolic phase. Another advantage of this device – incontrast to the pneumatic cuff or rubber sleeve - is that thepressure in the hydrostatic device decreases in the sittingposition and reaches near zero in the recumbent position.

Progressive elastic compression stockings

The effect of the so called progressive elastic

compression stockings published by Mosti and Partsch30

conforms to the same principle. The authors usedplethysmography under a standardized walking test andreported that significantly better improvement of ejectionfraction was found in patients with higher pressure over thecalf than above the ankle, in comparison with conventionalgraduated pressure profile with higher pressure in the gaiterarea and lower pressure in the calf. The progressive elasticcompression stockings exerting compression pressure of 33mm Hg in the gaiter area and 46 mm Hg at the calf level ledto a pronounced improvement of the venous hemodynamicsand returned the ejection fraction to or near the normalrange.

Conclusion

Drainage of venous blood from the incompetentthigh saphenous system into deep lower leg veins arisingduring calf pump activity creates preconditions for thedevelopment of recurrent reflux and is responsible for thetenacious tendency to reflux recurrence. The interruptionof this drainage would keep the dividing line of theambulatory pressure gradient below the knee, as it isdistinctive of subjects with healthy veins, and would hinderthe emergence of recurrent reflux. This can be achieved bysurgical procedures, ablative methods, and sclerotherapy.

Based on the results of the pressure measurements insuperficial and deep veins of the lower extremity it canbe deduced that external pressure of about 35 mm Hgapplied closely below the knee joint would be able to inhibitsaphenous reflux occurring in the diastolic phase of the calfpump activity and, in addition, antagonize the tenacioustendency to the development of recurrent reflux.

References

1) Fischer R, Linde N, Duff C, et al. Late recurrentsaphenofemoral junction reflux after ligation and stripping of thegreater saphenous vein. J Vasc Surg 2001; 34:236–240.

2) Kostas T, Ioannou CV, Touloupakis E, et al. Recurrentvaricose veins after surgery: a new appraisal of a common and complexproblem in vascular surgery. Eur J Vasc Endovasc Surg 2004; 27:275–282.

3) Winterborn RJ, Foy C, Earnshaw JJ. Causes of varicose veinrecurrence: late results of a randomized controlled trial of stripping thelong saphenous vein. J Vasc Surg 2004; 40:634–639.

4) Hartmann K, Klode J, Pfister R, et al. Recurrent varicoseveins: sonography-based re-examination of 210 patients 14 years afterligation and saphenous vein stripping. Vasa 2006; 35:21–26.

5) Allegra C, Antignani PL, Carlizza A. Recurrent varicose veinsfollowing surgical treatment: our experience with five years follow-up.Eur J Vasc Endovasc Surg 2007; 33:751–756.

6) El Wajeh Y, Giannoukas AD, Gulliford CJ, et al.Saphenofemoral venous channels associated with recurrent veins arenot neovascular. Eur J Vasc Endovasc Surg 2004; 28:590–594.

7) Geier B, Stücker M, Hummel T, et al. Residual stumpsassociated with inguinal varicose vein recurrence: a multicenter study.Eur J Vasc Endovasc Surg 2008; 36:207–210.

8) Bradbury AW, Stonebridge PA, Callam MJ, et al. Recurrentvaricose veins: assessment of the saphenofemoral junction. Br J Surg1994;81:373–375.

9) Frings N, Nelle A, Tran P, Glowacki P. Unavoidablerecurrence and neoreflux after correctly performed ligation of thesaphenofemoral junction: neovascularization? (German). Phlebologie2003:32:96- 100.

10) Frings N, Nelle A, Tran P, et al. Reduction of neorefluxafter correctly performed ligation of the saphenofemoral junction. Arandomized study. Eur J Vasc Endovasc Surg 2004:28:246-252.

11) Fischer R. Unde N, Duff C, Jeanneret C, et al. Late recurrentsaphenofemoral junction reflux after ligation and stripping of thegreater saphenous vein. J Vasc Surg 200;34:236-240.

12) Glass GM. Prevention of sapheno-femoral and sapheno-popliteal recurrence of varicose veins by forming a partition to containneovascularization. Phlebology 1998:13:3-9.

13) Sheppard M. A procedure for the prevention of recurrentsaphenofemoral incompetence. Aust NZJ Surg 1978;48:322-326.

14) Gibbs PJ, Foy DM, Darke SG. Reoperation for recurrentsaphenofemoral incompetence: a prospective randomised trial usinga reflected flap of pectineous fascia. Eur J Vasc Endovasc Surg1999:18:494-498.




15) De Maeseneer MC, PhilipsenTE, Vandenbroeck CP, et al.Closure of the cribriform fascia: an efficient anatomical barrier againstpostoperative neovascularisation at the saphenofemoral junction? Aprospective study. Eur J Vasc Endovasc Surg 2001;34:361- 366.

16) Earnshaw JJ, Davies B. Harradine K. Heather BP.Preliminary results of PTFE patch saphenoplasty to preventneovascularization leading to recurrent varicose veins. Phlebology1998;13:10-13.

17) Bhatti TS, Whitman B, Harradine K, et al. Causes ofre-recurrence after polytetrafluorethylene patch saphenoplasty forrecurrent varicose veins. Br J Surg 2000;87:1350-1360.

18) Winterborn RJ, Earnshaw JJ. Randomized trial ofpolytetrafluorethylene patch insertion for recurrent great saphenousvaricose veins. Eur J Vasc Endovasc Surg 2001:34:367-313.

19) Turton EP, Scott DJ, Richards SP, et al. Duplex-derived evidence of reflux after varicose vein surgery: neoreflux orneovascularisation? Eur J Vasc Endovasc Surg 1999; 17:230-233.

20) Recek C, Pojer H. Ambulatory pressure gradient in the veinsof the lower extremity. VASA 2000; 9:187-90.

21) Recek C. The hemodynamic paradox as a phenomenontriggering recurrent reflux in varicose vein disease. Int J Angiol2012;21:181-185.

22) Schaper W. Collateral circulation: past and present. BasicRes Cardiol 2009;104:5-21.

23) Pipp F, Boehm S, Cai WJ, et al. Elevated fluid shear stressenhances postocclusive collateral artery growth and gene expression inthe pig hind limb. Arterioscler Thromb Vasc Biol 2004;24:1664-1668.

24) Schaper W, Scholz D. Factors regulating arteriogenesis.Arteriosler Thromb Vasc Biol 2003:23:1143-1151.

25) Resnick N, Gimbrone MA Jr. Hemodynamic forcesare complex regulators of endothelial gene expression. FASEB J1995;9:874-882.

26) Schierling W, Troidl K, Troidl C, et al. The roleof angiogenic growth factors in arteriogenesis. J Vasc Res2009;46:365-374.

27) Recek C. Hemodynamics-based treatment of varices: Atherapeutic concept counteracting the intrinsic tendency of varicoseveins to recur. Phlebology 2016;31:704-711.

28) Arnoldi CC. Venous pressure in the leg of healthy humansubjects at rest and during muscular exercise in nearly erect position.Acta Chir Scand 1965;130:573-583.

29) Arnoldi CC. Venous pressure in patients with valvularincompetence of the veins of the lower limb. Acta Chir Scand 1966;132:628–645.

30) Mosti G, Partsch H. Improvement of venous pumpingfunction by double progressive compression stockings: higher pressureover the calf is more important than a graduated pressure profile.Eur J Vasc Endovasc Surg. 2014 May;47(5):545-9. doi: 10.1016/j.ejvs.2014.01.006. Epub 2014 Feb 10.


FP Faccini, JMC Souza, AL Arendt - Popliteal occlusion after focused ultrasound


HIGH INTENSITY FOCUSED ULTRASOUND CASE REPORT

Occlusion of the popliteal artery after focused ultrasoundtreatment - a case report

FP Faccini1, JMC Souza2, AL Arendt3

1Vascular Surgery - Hospital Moinhos de Vento and Instituto de Cardiologia, Porto Alegre, Brasil2Clínica Angiovasc, Aracaju, Sergipe, Brasil3Vascular Surgery - Hospital Moinhos de Vento and Instituto de Cardiologia, Porto Alegre, Brasil

submitted: Jun 20, 2019, accepted: Jul 2, 2019, EPub Ahead of Print: Jul 3, 2019, published: Jul 7, 2019Conflict of interest: None

DOI: 10.24019/jtavr.65 - Corresponding author:Dr. Felipe Puricelli Faccini, [email protected],[email protected]


Abstract The use of focused ultrasound and high-intensity focused ultrasound (HIFU) is common in physicaltherapy and medical procedures. The ultrasound producesheat and can be used to treat several diseases. We report acase of a 49-year-old male that had a knee injury after mildtrauma. The patient started physical therapy sessions to treatthe injury. Ipsilateral calf claudication started a few hoursafter the focused ultrasound was used to heat the poplitealarea progressing to symptoms of acute arterial occlusionin two weeks. We started anticoagulation and confirmedpopliteal thrombosis with duplex scan and computedtomography. The 5 years follow up showed good clinicalrecovery and recanalization of the artery. This case remindsus that the focused ultrasound should not be consideredharmless and life-threatening complications may occur.The inadvertent heating of neighboring structures andrecanalization of the heated vessel may happen.

Keywords High intensity focused ultrasound,Acute arterial occlusion, Popliteal artery occlusion,Thermoablation, Recanalization

Introduction

Focused ultrasound and High-Intensity FocusedUltrasound (HIFU) have been increasingly used in vascularsurgery to control hemorrhage and to produce thermaldamage in vessels when it is desirable. In the mid twentiethcentury various conditions were considered possibilities for

using the mechanism of tissue heating1. Over the followingdecades, scientific advances allowed the development ofbetter methods for effective treatment of several disease.Since the 1970's, the use of therapeutic ultrasound wasestablished for kinesiotherapy. The continuous ultrasoundwaves produce localized heating and consequently protein

denaturation causing thermal ablation2. The more the power

the more the likelihood and magnitude of bioeffects1.The use for hemostasis of punctured arteries has achieved

promising results in animal studies3,4. Spleen and liverhemostasis have also been successfully achieved using

HIFU in animals5-7. The long term effects of mostFocused Ultrasound and HIFU treatments are still unknownand knowledge about complications of its use is scarce.The ultrasound technology has been proved to perform

thermal ablation on veins8 and recently the techniqueis being performed to obtain thermal ablation of thesaphenous and varicose veins. The focus of the ultrasoundbeam is pivotal to obtain the expected results withoutcomplications. Although the ultrasound is considered safe,the produced heat can cause injury to structures not intended

to be damaged1, like arteries and nerves that usually areanatomically close to veins. This possibility was considered

by Henderson et al and described in an ex-vivo study9.

The use of focused ultrasound in physical therapyis well established and complications are rare, althoughthe level of efficacy is modest and patient benefits are





uncertain1. We report a case of popliteal artery thrombosisafter focused ultrasound therapy. Ultrasound biophysics,complications and uses in vascular surgery of both focusedand high-intensity focused ultrasound are discussed.

Case report

A 49-year-old male presented to the clinic with leftleg pain, coldness and paleness with no sensory loss, nomuscle weakness and audible arterial and venous Doppler.We noticed an unusual coloring at the skin of the poplitealregion only, not related to areas of ischemia. Medicalhistory showed a mild fall injury to the knee 4 monthsbefore and focused ultrasound during physical therapysessions for bone healing two weeks before the vascularappointment. The patient referred intermittent claudicationand leg coldness starting a few hours after a session ofphysical therapy in which the focused ultrasound was used.

The progression to severe symptoms of ischemiahave happened 2 weeks later. The duplex scan (Figure 1)showed popliteal thrombosis and computed tomographyshowed 8 cm of unusual obstruction of the popliteal arteryat the knee region (Figure 2). As we did not operate thepatient, no histologic sample is available. Initially, weconsidered that the cause of arterial occlusion was eitherarterial trauma or burning from the ultrasound used to heatthe region. Literature review about arterial damage afterknee injury suggests that the onset of arterial occlusion waslate to blame trauma alone. Most literature reports and caseseries present occlusion in the first hours or few days after

trauma10 and our patient presented occlusion more than 4months after trauma.

Although, we consider that the trauma might havebeen an adjunct factor due to the possibility that a hematomachange the position and mobility of the artery. Embolismand atherosclerosis were excluded by careful cardiac andarterial evaluation. The symptoms prior to the focusedultrasound were articular pain depending on the position ofthe knee and changed completely after the session.

We started anticoagulation and close observation.The symptoms of acute ischemia improved in a few hours.After the improvement of the first days we suspendedheparin and started clopidogrel. The patient remained withintermittent claudication for long distances after 1 weekuntil now and continued stable for the last 5 years.

We decided to avoid invasive treatment with patient’sagreement. We do not have large experience with burningarterial lesions and decided to avoid further treatmentbecause the symptoms were stable and not bothering thepatient. One year after the treatment the patient had anotherCT scan that showed complete recanalization of the arterywith 2 narrowing areas of 2 cm each (Figure 3). No surgical

or endovascular treatment was performed. Concerning theequipment and protocol used to perform the session ofkinesiotherapy with focused ultrasound, they are pivotalto better understand the damage. The probe used in theknee region had a frequency of 1,0 MHz using continuousultrasound and surface power density of 2.0 w/cm². Thepatient told us the duration of ultrasound was close to 30minutes but we could not obtain the complete details.

Figure 1 - No flow with Color Doppler in the poplitealartery at the first access.

Discussion

Ultrasonic energy can provoke biological effectscreating heat that can be used to treat diseases. Additionally,ultrasound causes cavitation with microbubbles, increase ofgas body activation, radiation force (mechanical stress), and

other undetermined non-thermal processes1,11. All theseeffects create desired and undesired biological responsesduring the medical application of ultrasound.

The diseases in which ultrasound is used fortreatment are kidney stones with the lithotripsy; lensremoval with the phacoemulsification; bone fracture withthe low intensity US; plantar fasciitis and epicondylitiswith the extracorporeal shockwaves therapy; uterinefibroid ablation, glaucoma, laparoscopic tissue ablation orlaparoscopic or open surgery - all this with HIFU, among

others uses1.

The rate of serious complications after the focusedultrasound is considered very low and the procedures are

common, although no large studies on safety are available1.Serious complications as injury to artery, nerves or veinsare considered rare. We have not found any report in theliterature of popliteal artery occlusion caused by ultrasound.




Figure 2 - Computed tomography image confirming theobstruction at the popliteal artery.

Figure 3 - Computed tomography 1 year after the firstexamination with focal stenosis at knee level.

This is probably an extremely rare complicationbecause most focused ultrasounds are not used nearimportant arteries or structures. In our isolated clinical casewe have noticed that the symptoms in the occlusion afterultrasound were not abrupt as in most arterial occlusions,maybe because the processes developed with progressivetissue edema before the full occlusion. The use of HIFU forvenous ablation has been studied for a few years. Hendersonet al described a portable equipment that successfully

ablated veins in an ex-vivo study9. Experimental studieshave also searched for ways to focus the damage to specific

vessels by echo contrast and beam control, but the results

are still initial12. One experimental study in rabbits showedthat the HIFU can close by thermal ablation veins as large

as 6 mm with 15 days of follow up13. Obermayer hasrecently shown that HIFU can cause thermal ablation ofvaricose veins, perforators and great saphenous veins. Nolong term results are available to ensure the safety and

benefit for the patients using the method14. In our case, thepatient had complete occlusion of the popliteal artery afterultrasound and full recanalization in months, this might




happen with the veins closed. We expected a definitivearterial occlusion, but time proved we were wrong.

High intensity focused ultrasound HIFU is newer thanfocused ultrasound and the procedures are still being madeunder controlled trials in the majority of fields. There is noavailable data for the safety of HIFU in vascular procedures.Obermayer treated varicose veins and reported 4 legs out of50 with dysesthesias suggesting damage to nerves. No deepvein thrombosis, pulmonary embolism or arterial damage

were reported in the initial cases14. Our case reminds us thatthe energy created by ultrasound can damage neighboringstructures as well as the treated vessel.

Conclusion

In conclusion, the focused ultrasound and high-intensity focused ultrasound (HIFU) are important

techniques that can be used in a variety of medicalconditions. The use of the ultrasound wave is generallysafe but serious complications might happen and weshould always consider that the neighboring structuresmight be affected by the heating effect or non-thermaleffects. Therefore, It is important to accurately determinethe location and control the treatment zone with the

ultrasound system8. The possibility to treat venous diseaseby ultrasound is exciting and should be deeply studied.Although, we should keep in mind that undesirable and evenlife-threatening conditions can occur. Safety studies on thenew techniques are imperative to validate their use bothin terms of safety and long-term benefit of the treatment.In our case we observed both the undesirable occlusionof an important artery and its fast recanalization withoutintervention

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2) Webb H, Lubner MG, Hinshaw JL. Thermal ablation. SeminRoentgenol [Internet]. 2011 Apr;46(2):133–41. Available from: https://doi.org/10.1053/j.ro.2010.08.002 at the date of Jun 20, 2019.

3) Zderic V, Keshavarzi A, Noble ML, Paun M, ShararSR, Crum LA, et al. Hemorrhage control in arteries using high-intensity focused ultrasound: A survival study [Internet]. Vol. 44,Ultrasonics. 2006. p. 46–53. Available from: https://doi.org/10.1016/j.ultras.2005.08.002 at the date of Jun 20, 2019.

4) Martin RW, Vaezy S, Kaczkowski P, Keilman G, Carter S,Caps M, et al. Hemostasis of punctured vessels using Doppler-guidedhigh-intensity ultrasound [Internet]. Vol. 25, Ultrasound in Medicine& Biology. 1999. p. 985–90. Available from: https://doi.org/10.1016/s0301-5629(99)00027-7 at the date of Jun 20, 2019.

5) Noble ML, Vaezy S, Keshavarzi A, Paun M, Prokop AF,Chi EY, et al. Spleen Hemostasis Using High-Intensity Ultrasound:Survival and Healing [Internet]. Vol. 53, The Journal of Trauma: Injury,Infection, and Critical Care. 2002. p. 1115–20. Available from: https://doi.org/10.1097/00005373-200212000-00014 at the date of Jun 20,2019.

6) Burgess S, Zderic V, Vaezy S. Image-guided acoustichemostasis for hemorrhage in the posterior liver. Ultrasound MedBiol [Internet]. 2007 Jan;33(1):113–9. Available from: https://doi.org/10.1016/j.ultrasmedbio.2006.07.025 at the date of Jun 20, 2019.

7) Vaezy S, Vaezy S, Starr F, Chi E, Cornejo C, CrumL, et al. Intra-operative acoustic hemostasis of liver: productionof a homogenate for effective treatment. Ultrasonics [Internet].2005 Feb;43(4):265–9. Available from: https://doi.org/10.1016/j.ultras.2004.07.002 at the date of Jun 20, 2019.

8) Jiang C-P, Wu M-C, Wu Y-S. Inducing occlusion effectin Y-shaped vessels using high-intensity focused ultrasound: finite

element analysis and phantom validation. Comput Methods BiomechBiomed Engin [Internet]. 2012;15(4):323–32. Available from: https://doi.org/10.1080/10255842.2010.535521 at the date of Jun 20, 2019.

9) Henderson PW, Lewis GK, Shaikh N, Sohn A, WeinsteinAL, Olbricht WL, et al. A portable high-intensity focused ultrasounddevice for noninvasive venous ablation. J Vasc Surg [Internet].2010 Mar;51(3):707–11. Available from: https://doi.org/10.1016/j.jvs.2009.10.049 at the date of Jun 20, 2019.

10) Kim J-W, Sung C-M, Cho S-H, Hwang S-C. Vascularinjury associated with blunt trauma without dislocation of the knee.Yonsei Med J [Internet]. 2010 Sep;51(5):790–2. Available from:https://doi.org/10.3349/ymj.2010.51.5.790 at the date of Jun 20, 2019.

11) O’Brien WD Jr. Ultrasound-biophysics mechanisms. ProgBiophys Mol Biol [Internet]. 2007 Jan;93(1-3):212–55. Available from:https://doi.org/10.1016/j.pbiomolbio.2006.07.010 at the date of Jun 20,2019.

12) Tokarczyk A, Rivens I, van Bavel E, Symonds-Tayler R, ter Haar G. An experimental system for the studyof ultrasound exposure of isolated blood vessels. Phys Med Biol[Internet]. 2013 Apr 7;58(7):2281–304. Available from: https://doi.org/10.1088/0031-9155/58/7/2281 at the date of Jun 20, 2019.

13) Barnat N, Grisey A, Lecuelle B, Anquez J, Gerold B,Yon S, et al. Noninvasive vascular occlusion with HIFU for venousinsufficiency treatment: preclinical feasibility experience in rabbits.Phys Med Biol [Internet]. 2019 Jan 7;64(2):025003. Available from:https://doi.org/10.1088/1361-6560/aaf58d at the date of Jun 20, 2019.

14) Obermayer A. Ultrasound-Guided High-IntensityFocused Ultrasound Extracorporeal Treatment of SuperficialLower Limb Veins: Preliminary Results and MethodDescription. Journal of Vascular Surgery: Venousand Lymphatic Disorders [Internet]. 2018;6(4):556–7.Available from: https://www.jvsvenous.org/action/showCitFormats?pii=S2213-333X%2818%2930168-9&doi=10.1016%2Fj.jvsv.2018.05.007 at the dateof Jun 20, 2019.


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https://doi.org/10.1016/j.ultras.2005.08.002


https://doi.org/10.1016/s0301-5629(99)00027-7

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https://doi.org/10.1097/00005373-200212000-00014

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https://doi.org/10.1016/j.ultrasmedbio.2006.07.025



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https://doi.org/10.1080/10255842.2010.535521

https://doi.org/10.1016/j.jvs.2009.10.049

https://doi.org/10.1016/j.jvs.2009.10.049

https://doi.org/10.3349/ymj.2010.51.5.790

https://doi.org/10.1016/j.pbiomolbio.2006.07.010

https://doi.org/10.1088/0031-9155/58/7/2281

https://doi.org/10.1088/0031-9155/58/7/2281

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Memorial pages


Memorial pages


In memory of Prof. Claude Gillot

JF Uhl1

* Vascular surgeon, member of the French Academy

of Surgery. URDIA research unit EA4465 - Laboratory

of Anatomy (Paris cité Sorbonne University). Research

Director, UNESCO Chair of Digital Anatomysubmitted: Jul 02, 2018, accepted: Jul 02, 2018, EPubAhead of Print: Dec 9, 2018, published: Jul 7, 2019

DOI: 10.24019/jtavr.50 - Corresponding author:Prof. Jean François Uhl, [email protected],[email protected]

© 2018 Fondazione Vasculab impresa sociale ONLUS.All rights reserved.

Figure 1 - Prof. Claude Gillot

FRANCAIS

Nous nous devons tous de rendre un vibrant hommageà notre Maître et ami le Professeur Claude GILLOT quivient de nous quitter.

Médecins, Phlébologues, Chirurgiens vasculaires,échographistes et anatomistes utilisent en effet au quotidienl’énorme quantité de connaissances qu’il a accumulé surl’anatomie en général, et le système veineux en particulier.Claude GILLOT était un grand croyant fasciné par la beauté

et la perfection du corps humain en tant que création divined’où sa passion pour l’anatomie.

C’est pourquoi il a dédié toute sa vie à l’étude del’anatomie, à l’enseignement et à la recherche.

Claude était un enseignant hors du commun quijusqu’a 91 ans allait tous les matins donner son cours auxjeunes étudiants de la faculté de médecine des Saints pères,puis il allait disséquer l’après-midi…

Ses qualités de chercheur étaient tout aussiremarquables, réexaminant inlassablement son énormecollection de coupes anatomiques et ses photos dedissection. Il avait mis au point la technique de lasegmentation colorée pour les rendre accessibles à tous.Ceci représente un travail titanesque: Lavage puis injectiondes veines au latex, dissection anatomique, identificationpuis peinture de chaque veine avec une couleur spécifique.Ce travail qui demande des centaines d’heures pourchaque membre inférieur, et il l’a réalisé sur plus de 400membres…

Figure 2 - Couverture de l'Atlas-livre de C Gillot. [Coverof the Atlas-book of C Gillot]

Un des travaux majeurs de Claude Gillot est son atlasd'anatomie du réseau superficiel des membres inférieurs.

C'est un très grand livre, par sa taille et soncontenu. Claude Gillot a réalisé là l'étude la plus complètesur les veines superficielles. Les nombreuses planchessont dessinées d'après des dissections réelles. (Editionsphlébologiques Françaises - épuisé)

Un CD-Rom a été fait à partir de cet Atlas enFrançais - Anglais -Espagnol téléchargeable sur mon site



Memorial pages


internet (www.jfuhl.com), un must à recommander à tousles amateurs de veines

Figure 3 - Planche colorée in-folio d'après dissectionreprésentant le réseau veineux superficiel de cuisse. Lasegmentation colorée permet aisément d'identifier le troncde la grande veine saphène (bleu clair), celui de lasaphène accessoire antérieure (mauve) et de la saphèneaccessoire postérieure (grenat). [Coloured in-folio tableaccording to a dissection representative of the superficialvenous network of the thigh. The coloured segmentationeasily allows the identification of the trunk of the greatsaphenous vein (light bleu), the ones of the anterioraccessory saphenous vein (purple) and posterior accessorysaphenous vein (dark red).]

Mais le plus remarquable est sans doute sa passionpour la recherche qui l’a conduit jusqu’au dernier jour à denouvelles découvertes.

C’est ainsi qu’après 90 ans, il se passionnait pourle canal de Hunter, les arcades veineuses du semi-membraneux et tout dernièrement les perforantes osseusesdu genou qu’il a mis en évidence en examinant des coupesdatant de plus de 20 ans: “En anatomie, le plus difficile c’estde voir ce que l’on a sous les yeux” aimait-il répéter.

Claude a gardé jusqu’au dernier moment, malgré sessoucis de santé, une ouverture d’esprit qui devrait nousservir d’exemple à tous…

Enfin, Claude GILLOT était un homme d’une grandemodestie et d’une immense gentillesse, et pour cette raison,aimé de tous.

Je mesure pleinement la grande chance qui m’a étédonnée d’être son élève, me permettant de partager sesimmenses connaissances en anatomie humaine, ce qu’ilfaisait avec humilité et simplicité.

Au revoir, mon cher Claude, tu seras présent à jamaisdans notre cœur.

ENGLISH

We all must pay a trembling tribute to our Masterand friend, Professor Claude GILLOT who recently passedaway.

Physicians, phlebologists, vascular surgeons, ultra-sonographers and anatomists practically adopt daily thegreat amount of knowledge that He collected generallyabout anatomy and especially about the venous system.Claude GILLOT was a great believer, fascinated by thebeauty and the perfection of the human body as a divinecreation, therefore his passion for anatomy.

That’s the reason why He committed all his life to thestudy of anatomy, to teaching and to research.

Claude was an outstanding teacher, who until 91 yowent every morning to give his class to young students ofthe Department of Medicine of Saints Pères, thereafter Hewent to make dissections in the afternoon…

His traits of researcher were all also remarkable, re-examining tirelessly his huge collection of anatomical slicesand his dissection photos. He developed the technique ofcoloured segmentation in order to make it available toeveryone. It is a titanic work: washing and then venousinjection with latex, anatomic dissection, identification,then painting each vein with a specific colour. This workrequires hundreds of hours for each lower limb, and Hecarried out more than 400 limbs…

One of the main works of Claude Gillot is his Atlasof anatomy of the superficial network of the lower limbs.

It is a very great book, I mean very big dimensionsand great content. Claude Gillot carried out the mostcomplete study on the superficial veins. The many tablesare drawn in agreement with real dissections. (Editionsphlébologiques Françaises – out of stock)

A CD-Rom was produced from the Atlas in French– English – Spanish, downloadable on my web site(www.jfuhl.com), a «must » recommended to all venousfans.

But undoubtedly the most impressive was his passionfor the research, which drove him until the last day of hislife to new discoveries.

It is in this way that aged more than 90 years Hewas captivated by the Hunter’s canal, the venous arches ofthe semi-membranous muscle and ultimately by the kneebony perforating veins, which He highlighted examininganatomic slices dating to more than 20 years: “In anatomy,the most difficult job is to see what is under our own eyes”He loved to repeat.

Though his health problems, Claude preserved untilthe last moment his open-mindedness, which should be anexample to everyone…


Memorial pages


Finally, Claude Gillot was a man of great modestyand immense kindness and, for that reason, loved by all.

I wholeheartedly consider the great opportunitywhich I was gifted being his disciple, allowing me to sharehis immense knowledge in human anatomy, that he did withhumility and simplicity.

‘Au revoir, mon cher Claude’, you will be foreverpresent in our heart.

Docteur Jean-François UHL

Professor Paolo Fiorani: “Maestro” of ageneration of vascular surgeons

Prof. Paolo Fiorani: ricordo di un allievo

C Spartera1

1 Emeritus Professor of Vascular Surgery. Univerisity of

L'Aquila, Italysubmitted: Oct 17, 2018, accepted: Oct 17, 2018, EPubAhead of Print: Dec 9, 2018, published: Jul 7, 2019Conflict of interest: none

DOI: 10.24019/jtavr.52 - Corresponding author: Prof.Carlo Spartera, [email protected]


ITALIANO

Dal maggio scorso non è più tra noi il Professor PaoloFiorani, chirurgo vascolare, maestro di scienza e di vita.(Fig. 1)

Il suo curriculum e la sua carriera sono noti atutti, essendo stato un punto di riferimento accademico echirurgico in questi ultimi 50 anni, periodo eccezionalmenteinnovativo nel campo medico e chirurgico, in particolarenella chirurgia vascolare.

Il Professor Fiorani ha vissuto questi anni in primalinea, da protagonista.

L’avventura inizia negli anni '60, periodo in cui tregrandi ed illuminati chirurghi, Malan a Milano, Stefaninia Roma e Zannini a Napoli, capiscono che è arrivato ilmomento in cui alcune specialità, come la chirurgia deitrapianti, la chirurgia toracica e la chirurgia vascolare,si rendano indipendenti sia dal punto di vista clinico-chirurgico che accademico.

In quegli anni il Prof Fiorani frequenta come “fellow”il Baylor College of Medicine a Houston, presso ilDipartimento di Chirurgia Cardio-vascolare diretto dalgrande Prof Michael De Backey.

Tornato in Italia, Egli porta nella chirurgia vascolareitaliana quanto appreso e sperimentato negli StatiUniti, dando così il via alla ricerca clinica nei settoridella chirurgia vascolare in veloce espansione (chirurgiadell’arteria renale e ipertensione renovascolare; chirurgiadella carotide ed insufficienza cerebrovascolare; patologiaarteriosa degli arti). Inoltre, può essere considerato pionieredella chirurgia dell’aorta addominale in Italia.

Il Prof Fiorani è stato sicuramente uno dei padri dellachirurgia vascolare italiana e ne ha rappresentato i valoriin Europa e nel mondo, instaurando scambi costruttivicon i maggiori rappresentanti del settore quali Courbier eKieffier in Francia, Balas in Grecia, Vollmar in Germania,Greenhalgh in Inghilterra, Imparato, Wiley e Veith negliStati Uniti con i quali ha contribuito al grande sviluppo dellaChirurgia Vascolare Open.

Quando poi, negli anni '90, sono state introdotte letecniche mini invasive, sia chirurgiche che endovascolari,egli ha subito capito l’importanza di tali tecniche,riconoscendone l’impatto positivo nella pratica clinica enella ricerca.

Infatti nella Chirurgia Vascolare della 2° clinicachirurgica dell’Università la Sapienza di Roma è stataimpiantata una endoprotesi aortica (una delle prime inItalia) con l'ausilio del suo inventore argentino prof. Parodi.

Con la sua esperienza e sotto la sua guida si è formata

la Scuola di Chirurgia Vascolare Romana[i] (Fig. 2) edinoltre Egli ha partecipato fattivamente alla fondazionedella Società Italiana di Chirurgia Vascolare.

E’ stato il primo italiano ad essere Presidente dellaSocietà Europea di Chirurgia Vascolare, conosciuto estimato anche da colleghi di altre specialità con i qualiha collaborato in varie ricerche, tra cui importantissimi glistudi sul circolo cerebrale che ha condiviso con gruppi diricerca internazionali, quali quello di Lassen in Danimarca,con la collaborazione e la grande competenza specifica delProf Pistolese

E’ stato il primo italiano Socio Onorario della SocietàAmericana di Chirurgia Vascolare.

Con Lui scompare un pilastro dalle fondamenta dellachirurgia vascolare italiana e noi allievi, G. RaimondoPistolese Università Tor Vergata Roma, Vittorio Faraglia epoi Maurizio Taurino al Sant’Andrea Roma Università laSapienza, Francesco Spaziale al Policlinico Università laSapienza Roma ed il sottoscritto all’Università de L’Aquila,che abbiamo iniziato sotto la sua spinta energica la carriera



Memorial pages


di chirurghi vascolari, ricorderemo sempre la sua sagacia,il suo impulso quotidiano a migliorarsi, la sua curiositàscientifica, le sue intuizioni geniali, doti che hanno fatto diLui un vero Maestro.

Ma non posso fare a meno, in questa circostanza, diricordare il lato umano del Prof Fiorani: egli amava la vitae la convivialità e lo ha dimostrato aprendo la sua casa pertante cene postcongressuali, con il supporto costante dellamoglie Paola con cui ha formato una splendida famiglia con5 figli.

Ci legava il tifo romanista ed era anche un grandesportivo: amava lo sci, il mare e la barca a vela, buontennista e ottimo golfista nel quale sport si racconta diaccanite partite col suo grande amico Raimondo Pistolese.

Ora non c’è più, ma credo che il Professor Fioranimancherà molto a tutto il mondo scientifico ed accademicoitaliano ed internazionale.

Figure 1 - Prof. Paolo Fiorani

Figure 2 - Fiorani P, Pistolese GR, Spartera C, FaragliaV. Elementi di Patologia e Chirurgia Vascolare. [Basicsof Pathology and Vascular Surgery]. Antonio Delfino Ed.,1988. ISBN: 8872870348.

ENGLISH

Since last May, Professor Paolo Fiorani, vascularsurgeon, Maestro of science and of life, has no longer beenwith us. (Fig. 1)

His curriculum and his career are known to all,his having been an academic and surgical reference pointduring the last 50 years, an exceptionally innovative period

in the field of medicine and surgery, in particular in vascularsurgery.

Professor Fiorani lived these years on the front line,as a protagonist.

His adventure starts in the 1960s, a period inwhich the great and farsighted surgeons Malan in Milan,Stefanini in Rome and Zannini in Naples, understood thatthe time had come for some specialities, like transplant


Memorial pages


surgery, thoracic surgery and vascular surgery, to becomeindependent both from a clinical-surgical point of view andacademically.

In those years Prof. Fiorani was a Fellow of theBaylor College of Medicine in Houston, at the Departmentof Cardiovascular Surgery directed by the great Prof.Michael De Backey.

Having returned to Italy, he brought what he hadlearnt and experienced in the United States to Italianvascular surgery, thereby setting off clinical research infast-expanding sectors of vascular surgery (surgery ofthe renal artery and renovascular hypertension; carotidsurgery for cerebrovascular insufficiency; peripheralarterial disease). Besides, he may be considered the pioneerof abdominal aorta surgery in Italy.

Professor Fiorani was certainly one of the fathers ofItalian vascular surgery he represented its values in Europeand the world, setting up constructive exchanges with majorrepresentatives of the sector like Courbier and Kieffer inFrance, Balas in Greece, Vollmar in Germany, Greenhalghin England and Imparato, Wiley and Veith in the USA, withwhom he contributed to the notable development of OpenVascular Surgery.

In the 1990s, when both surgical and endovascularmini-invasive techniques were introduced, he immediatelyunderstood the importance of such techniques, recognisingtheir positive impact in clinical practice and in research.

In fact, in the Vascular Surgery Unit of the 2ndDepartment of Surgery of La Sapienza University in Romean aortic endoprothesis was implanted (one of the first inItaly) with the assistance of its Argentine inventor Prof.Parodi.

With his experience and under his guidance the

Roman School of Vascular Surgery[ii] (Fig. 2) formed andhe also actively participated in the foundation of the ItalianSociety of Vascular Surgery.

He was the first Italian to be President of the EuropeanSociety of Vascular Surgery, and was also recognised and

esteemed by colleagues from other specialities, with whomhe collaborated in various research projects, among themost important of which were the studies of the cerebralblood flow that he shared with the international researchgroups, like that of Lassen in Denmark, with cooperationand great specific competence of Prof Pistolese.

He was the first Italian to be an Honorary Member ofthe American Society of Vascular Surgery.

His passing is also the disappearance a foundationpillar of Italian vascular surgery, and we, his formerassistants and then colleagues, G. Raimondo Pistolese atTor Vergata University of Rome, Vittorio Faraglia and thenMaurizio Taurino at Sant’Andrea La Sapienza Universityof Rome, Francesco Speziale at Policlinic of La SapienzaUniversity of Rome, and the undersigned at the Universityof Aquila, that initiated our careers as vascular surgeonsunder his energetic impetus shall always remember hiswisdom, his daily efforts to better himself, his scientificcuriosity and his brilliant insights, gifts that made him a trueMaestro.

But in this circumstance, I cannot but recall thehuman side of Prof. Fiorani: he loved life and convivialityand demonstrated this by opening his house for numerouspost-congress dinners, with the constant support of his wifePaola, with whom he had made a splendid family with fivechildren.

We were linked by being fans of Rome F.C. and hewas also a great sportsman: he loved skiing, the sea andsailing, was good at tennis and a fine golfer, a sport in whichthere are stories of tough matches with his great friendRaimondo Pistolese.

Now he has passed away, but I believe that ProfessorFiorani shall be greatly missed by the entire Italian andinternational scientific and academic world.

Prof. Carlo SparteraEmeritus Professor of Vascular Surgery.Univerisity of L'Aquila, Italy

Endnotes[i] Mi fa piacere aggiungere al ricordo del Prof. Fiorani la

foto del frontespizio di un libro edito alla fine degli anni '80. E' unapubblicazione di circa 500 pagine, con schemi anatomici, foto di esamidiagnostici e documentazioni intraoperatorie indirizzata agli studentie agli specializzandi in chirurgia vascolare, edito da Delfino, alloraall'avanguardia nell'editoria medico-scientifica. Il volume rappresenta,almeno in parte, ciò che ha significato, per gli autori, vivere la nascita,la giovinezza e la maturità della chirurgia vascolare italiana. Infatti,il volume racchiude l'esperienza di 20 anni del gruppo di chirurgiavascolare romano vissuta sul campo ed affronta i diversi aspettidella fisiologia e fisiopatologia della clinica, della diagnostica e della

terapia delle patologie vascolari, arteriose e venose. Naturalmente,da quegli anni la chirurgia vascolare ha fatto passi da gigantinella modernizzazione dell'approccio e della soluzione di molteproblematiche che allora sembravano insormontabili. Tuttavia, credoche il libro possa essere ancora molto utile a chi affronta, per la primavolta, tale settore scientifico-disciplinare.

[ii] I am pleased to add this photograph of the cover of a bookpublished at the end of the 1980s to the commemoration of Prof. Fiorani.It is a publication of about 500 pages, with anatomical diagrams,photos of diagnostic exams and intraoperative documentation aimed


Memorial pages


at students and at doctors specialising in vascular surgery, publishedby Delfino, then in the avant-garde of the medical-scientific press. Atleast in part, the volume shows what it meant, for the authors, to livethrough the birth, growth and maturity of Italian vascular surgery. Infact, the volume captures the 20-year experience in the field of theRoman vascular surgery group and deals with the different aspectsof the physiology and physiopathology of the clinical presentation,

diagnostics and therapy of arterial and venous vascular pathologies.Naturally, since that time vascular surgery has made giant steps in themodernisation of the approach and the solution of many problems thatthen seemed insurmountable. However, I believe that the book may stillbe very useful to anyone approaching this scientific-disciplinary sectorfor the first time.


Congress reports


Congress reports


In October and November 2018 two importantscientific events were organized in the "new world", Chinaand Russia.

In the Beijing congress there were 350 speakersand more than 3000 delegates, working for 39 sessionsand simultaneously in 9 halls. In the Ulyanosk congressinstead more than 2000 delegates attended to the event, with

plenary sessions, round tables and master classes on severaltopics of rehabilitation.

Both were very big congresses, able to testify thegreat potential of these countries (Russia, China and otherAsian emerging countries), which are becoming more andmore important actors in the world of vascular events.

XXVIII World Congress of theInternational Union of Angiology

October 18-21, 2018, Beijing, China

PL Antignani1

1Director, Vascular Center, Nuova Villa Claudia, Rome,

Italysubmitted: Nov 19, 2018, accepted: Nov 19, 2018, EPubAhead of Print: Dec 19, 2018, published: Jul 7, 2019Conflict of interest: none

DOI: 10.24019/jtavr.55 - Corresponding author: Prof.Pier Luigi Antignani, [email protected]


The XXVIII world congress of International Union ofAngiology was held in Beijing from 18th to 21th of October2018.

This event was held in conjunction with the 14thChinese Capital Vascular Symposium (CCVS), which isrecognized as one of the most influential congresses ofvascular surgery in China and brings together vascularsurgeons, interventionists and diabetic foot specialists.

The conference was organized by Prof. Yong-quanGu, Chief of Department of Vascular Surgery of the Beijing

University, who defined this event "a vascular meetingwithout borders".

Whole spectrum of vascular sciences and practiceswas discussed and presented from the distinguished facultyof international and Chinese experts: an update on theuse of conventional and newer anticoagulants in vascularmedicine and surgery, development of treatment of lowerextremity peripheral arterial diseases, recent advances inthe management of acute ischemic stroke, aortic dissection,microcirculation in vascular skin changes, vasculitis,



Congress reports


advances in antiplatelet drugs, news in endovasculartreatment of aortic diseases, conceptual approach tothe venous malformation management, development andchallenge of carotid artery stenting for carotid arterystenosis, approach to reperfusion therapy for acute ischemicstroke: mechanical thrombectomy, clinical challengesin chronic venous diseases, vicious circle of chronicvenous diseases pathophysiology, an update on themanagement of DVT and post thrombotic syndrome,unusual arterial diseases, treatment for vena cava disease,arterial and venous thrombolysis diagnosis and treatment,venous thromboembolism, treatment of non-thromboticiliac vein compression syndrome, EVAR complications,management of visceral arterial disease, Buerger’s disease,lymphatic malformation and lymphedema, translationalmedicine, arterial science and innovation, vascularultrasound, diabetic foot, stem cells and regenerativetreatments, exercise in assessment and treatment of vasculardiseases, wound repair.

A lot of space was dedicated to Nursing andtechnicians.

This Congress was certainly a landmark in thedevelopment of the International Union of Angiology andthe perfect illustration of its commitment as the "WorldVascular Forum".

The organizing committee made a great scientificmeeting as well as a unique cultural and human experience:a thorough scientific program with a distinguished facultyof international and Chinese experts, a convenient venuewith all the needed facilities nearby the Olympic Stadium,and of course the thoughtful Chinese hospitality.

The next congress will be organized in Rome underthe Presidency of Prof. PL Antignani, President elect ofIUA.

Prof. Pierluigi AntignaniPresident electInternational Union of Angiology (IUA)

The Organizing Committee of the XXVIII IUA MeetingYou are invited to join the XXIX IUA Meeting in Rome.

All-Russian scientific-practicalconference with internationalparticipation. Nexus Medicus 2018:Modern approaches to rehabilitation

Nov 9-10, 2018, Ulyanovsk, Russia

L Belova1, V Mashin1, N Belova2, N Ilina1

1 The Ulyanovsk State University, Ulyanovsk, Russia2 The Research Centre of Neurology, Moscow, Russiasubmitted: Nov 19, 2018, accepted: Nov 19, 2018, EPubAhead of Print: Dec 19, 2018, published: Jul 7, 2019Conflict of interest: none

DOI: 10.24019/jtavr.56 - Corresponding author: Prof.Liudmila Belova, [email protected]


All-Russian scientific-practical conference withinternational participation “Nexus Medicus 2018: Modern

approaches to rehabilitation” was held in Ulyanovsk onNovember 9-10, 2018. Over 1,211 medical specialists and



Congress reports


512 young scientists from different cities of Russia took partin the event. Talks by leading scientists from Russia, Italy,Uzbekistan, United States were given.

The conference was organized by the UlyanovskState University, Union of Rehabilitologists of Russia,National Training Foundation, Federal Agency for YouthAffairs, Ministry of Health of the Ulyanovsk Region,Research Center of Neurology, Association of ClinicalPhlebologists of the Ulyanovsk Region.

«Nexus Medicus» has been held since 2013 andgathers in Ulyanovsk scientists and doctors of variousspecialties from Russia, Italy, USA, Brazil, Argentina,Israel, to discuss issues of medicine. This year, the maintopics of the conference were prospects for the developmentof medical rehabilitation in Russia and abroad, high-techmeans of rehabilitation.

Agreement between the University of Ulyanovsk,represented by the Chancellor, Prof Boris Kostishko andthe Chief Specialist in Medical Rahabilitation of theRussian Federation, Prof Galina Ivanova.

Youth session on “Building a socially significant project inthe field of rehabilitation”.

Opening the conference, the Chairman of theGovernment of the Ulyanovsk Region Alexander Smekalinnoted that the discussion within the framework of NexusMedicus of the issues of returning the affected economicindependence and social usefulness is extremely important.It is full-fledged rehabilitation that contributes to reducingthe number of people with disabilities and increasing theduration of the quality of life of the population.

Professor Boris Kostishko, the rector of theUlyanovsk State University, welcomed the participants. Hetold about the history of “Nexus Medicus”, that in fiveyears the project has turned into a large-scale movement,consolidating the ideas of talented scientists from aroundthe world. “It is particularly encouraging that students whohave the opportunity to contribute to the development ofthe best practices of modern medicine participate in thismovement on an equal footing with recognized scientists,”said Boris Kostishko.

Professor Galina Ivanova, Chief Specialist in MedicalRehabilitation at the Ministry of Public Health of theRussian Federation, emphasized: “The purpose of suchconferences is to build a medical rehabilitation system sothat our citizens receive the maximum help based on thecapabilities of national health care. Medical rehabilitation isa mandatory part of the provision of medical care to patientsin any profile. A complete chain of care should work notonly when the patient was rescued from death and operatedon, but also to provide him with a high quality of life. Thisis not only rehabilitation, but also palliative care”.

According to Sergey Panchenko, Minister of Healthof the Ulyanovsk Region, “Nexus Medicus” attractsspecialists from all over the world. “The subject matter ofthe conference is extremely relevant - rehabilitation helpsto bring to life people with severe illness and receivedvery active, sometimes even aggressive treatment. It is veryimportant to conduct this work based on the best federal andinternational level.”


Congress reports


One of the brightest impressions of the conferencewas the presentation by Pier Luigi Antignani, Professor,Director of the Vascular Center Nuova Villa Claudia,Honorary President of the Italian Society for VascularInvestigation, President Elect of International Union ofAngiology, with the reports: “The Consensus of theInternational Union of Phlebologists for the Rehabilitationof Patients with Chronic Venous Diseases of the LowerLimbs” and “Consensus of the International Union ofPhlebologists on Congestive Pelvic Syndrome: what's newin treatment and rehabilitation?” and the master class“Ultrasound examination in chronic venous insufficiency ofthe lower limbs.”

Doctors of various specialties dealing with theproblems of venous pathology once again discussed theneed for a systematic approach to patients with venousdisorders and an individual approach to the development

of an algorithm for rehabilitation measures for each groupof patients, taking into account the severity of venousinsufficiency, age, physical activity, associated diseases,mental health.

The conference participants had the opportunityto attend the round table “Principles of organizingrehabilitation help in Russia” and “Training specialists fora multidisciplinary rehabilitation team”, a master class on“Positioning patients with focal brain lesions”, a youthsession “Forming a socially significant project in the fieldof rehabilitation”, a poster session, a volunteer session.

The exhibition demonstrated to doctors modernmedicines, physiotherapeutic devices and balneologicalequipment, advanced technical means of diagnostics andrehabilitation, auxiliary means for rehabilitation and care.

L Belova, V Mashin, N Belova, N Ilina



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Table of contents


Journal of Theoretical and Applied Vascular ResearchThe Official Journal of the Vasculab Foundation

Volume 3 Feb 2018 Issue 1

Editorial Board ............................................................................................................................. 3

Editorial Lines .............................................................................................................................. 5

Vascular News ............................................................................................................................. 7INSTRUCTIONS TO AUTHORS ............................................................................................... 9

The great and silent revolution of the units of measureF Passariello .............................................................................................................................. 11

Animal welfare in Italy from unification to the XXI century: a recent book on the subjectF Morganti ................................................................................................................................ 15

Beninese therapeutic pluralism. Historical roots and bioethical issuesA Maccaro ................................................................................................................................ 19

Evaluation of an accelerometer-based device to monitor compliance on patients wearing medicalcompression stockingsE Grenier, D Rastel, C Chaigneau ......................................................................................... 25

The tenacious tendency to saphenous reflux recurrence and the possibility how to counteract itC Recek .................................................................................................................................... 33

Occlusion of the popliteal artery after focused ultrasound treatment - a case reportFP Faccini, JMC Souza, AL Arendt ...................................................................................... 37

Memorial pages .......................................................................................................................... 41In memory of Prof. Claude Gillot JF Uhl

Professor Paolo Fiorani: “Maestro” of a generation of vascular surgeons C Spartera

Congress reports ......................................................................................................................... 47XXVIII World Congress of the International Union of Angiology PL Antignani

All-Russian scientific-practical conference with international participation. Nexus Medicus 2018: Modernapproaches to rehabilitation L Belova, V Mashin, N Belova, N Ilina

Table of contents ....................................................................................................................... 54


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