Three years later, she was diagnosed with breast cancer which required immediate surgery. Being alone, I took care of entrusting her to a surgeon I trusted and on the day of the operation I was present in the operating room. When she woke up from the anesthesia, the Professor, seeing me present, told me with absolute seriousness, firmness and conviction: “Doctor, I’m not afraid that the tumor might return. I’m afraid that depression might return.” The depression did not return, but unfortunately the tumor returned which took her away after three years.

I wanted to begin this writing by telling you about this episode, which has remained indelible in my memory, because it gave me and perhaps can give you the measure of how atrociously
feared and feared depression is for those who have experienced it themselves and have felt its pangs. It is a disease that is talked about a lot, but little is still known, and beyond what is studied in medical books, I modestly propose to let you know about it, as I have known it, also about myself.

Know so as not to be afraid. Because we are often afraid of what we don’t know. And depression is a scary disease, when you know it, but even more so when you don’t know it.
It is scary because it is a bad disease, which causes suffering, in those affected by it, but also in those who are close to the patient and would like to help him, but do not know how, in what way to do it and therefore feel helpless.
Often even those who are affected do not know they are affected and live painfully, with difficulty, with immense burden, a life conditioned and made burdensome, at times unbearable, by an illness which, if not recognised, cannot be cured. Often the disease, however, is recognized, but is not treated, or treated inadequately, out of fear, prejudice, ignorance.
In both cases, the patient and those close to him are victims of serious and avoidable suffering, at least in part. First of all, I want to clear up a very widespread misunderstanding which is a harbinger of severe consequences.
Often and especially in these times, the terms “depression”, “sadness” and “melancholy” are used as synonyms with great and dangerous superficiality and yet they really are not synonymous. I’ll try to clarify.

Melancholy is a state of mind, often transitory, but sometimes also long-lasting and permanent, so much so that it becomes a specific characteristic of the personality (melancholic personality), which does not necessarily involve suffering, but rather is sometimes sweetly characterized,
refined and cultivated as a source of artistic inspiration (poets, musicians, painters, writers).

Sadness, on the other hand, is a real feeling, more complex, more structured, profound, long-lasting, which causes acute and permanent suffering, even serious psychological pain and physical manifestations that can be perceived and visible even to the outside.

Sadness is most often consequent and subsequent to a painful, material or moral event, recent or even long past, but current in its consequences and the pain it causes. The fundamental characteristic of sadness is therefore pain, especially psychological, but which can also take on physical aspects.

We can assimilate sadness, in the psychological context, to the physical pain we feel when we suffer trauma to the body, when we burn ourselves, for example, when we fracture a limb, or even when a tooth hurts or when we have an attack of appendicitis. In all these cases, the pain we feel represents a pressing, priority, unavoidable stimulus to understand where the pain comes from and therefore try to put an end to the cause that caused it.
Sadness works, mutatis mutandis, in the same way as physical pain, to indicate to us that something is wrong with our integrity, not physical, but psychic, stimulating us to
remedy it.

It could be an emotional disappointment, a disappointment at work, a family problem, dissatisfaction with our life. In any case, sadness is an urgent stimulus to investigate the
cause of our sad state of mind and to remedy it, acting on the cause that caused it and sustains it. So ultimately, sadness has a positive purpose, of warning that something is wrong with our psychic structure and of a peremptory invitation to remedy it. Sadness is a propulsive and decisive force, as is physical pain.
The situation is different for depression, which I consider “the sick sister of sadness”, as it does not induce us, does not stimulate us, does not force us to put an end, to resolve the cause that has caused and causes the suffering, but rather on the contrary, it seems that efforts are being made to feed it, to increase it, to magnify it, to make it increasingly unbearable. Therefore we can say that depression is a psychic suffering, similar to sadness, but which has lost its positive purpose, to induce us to know the cause that caused it and to try to remove it, but rather, on the contrary it seems that paradoxically and cruelly you try to increase the suffering caused more and more.

I will try to explain myself better with an example: let’s imagine a student who has unsuccessfully taken an exam with a negative result. The first days will be full of acute pain, suffering, perhaps even feelings of guilt for having dawdled instead of studying, but once that first moment of desperation has passed, our student, thanks to this acute suffering and disappointment, will examine his conscience from which the awareness of his own lightness and failure to fulfill his own superficiality will arise and he will take note of it and he will resume, strengthened by what he has understood, to study with renewed energy and greater awareness.
The mistake made, the awareness of this through the pain experienced and the need to no longer experience it, will lead him to study with greater commitment in the future. So the sadness and pain felt had a positive value.

The situation is completely different for depression. Let’s imagine that the same student, rejected in the same exam, falls, for reasons that we will discover later, instead into depression, the “sick sister” of sadness. Unfortunately he will not find in this the propulsive and productive force of sadness, as we have seen in the previous case, but instead a different feeling, depression, which will sink him more and more seriously, into despondency, desperation, mistrust in himself, in feelings of guilt, a feeling which, far from exerting a propulsive force, like sadness, will lead him to an increasingly serious psychic, but also and often physical, self- annihilation, the disease “depression”.
But what are the symptoms that characterize the disease depression? In the medical texts, which young students study, they are listed and described with a cold and disconcerting enumeration:

1 – Depressed mood most of the day, most days.
2 – Markedly decreased interest or pleasure in all or almost all activities for most of the day
3 – Significant weight loss, not due to diet, or decreased or increased appetite
4 – Insomnia or hypersomnia
5 – Psychomotor agitation or slowing
6 – Fatigue or lack of energy
7 – Excessive or inappropriate feelings of selfworth or guilt
8 – Reduced ability to think or concentrate, or indecisiveness
9 – Recurring thoughts of death
I have reported them as they are found and they are listed in the text of Psychiatry which has dictated law for years now and to which reference must be made, the famous DSM (Diagnostic and Statistical Manual of Mental Disorders) now in its fifth edition, the result of the “American Psychiatry ” of which we are servile victims.

Those who know me will recognize, in my words, the polemical intent towards this current and modern “Psychiatry” which wanted to forget its noble and profoundly valid nineteenth-century origins, especially Germanic ones, replacing them with a modern technicality which has made it, in my opinion , seriously retreating, rather than progressing.
But returning to our discussion, if these are the symptoms of the “depressive illness”, how can I as a doctor distinguish them from the non-pathological characteristics of normal sadness?

In fact, we cannot in the slightest way call depression, as we tend to do, especially in these times, in which the term has become commonly used, every oscillation of the soul in a negative, slight, but also serious and very serious sense, thus effectively abolishing , the concept of normal sadness, of even intense melancholy, of desperation, extremely painful, but the experience of which falls rightfully within the ambit of the states of mind that every human being, as such,
is subject to living and experiencing within self; the concept of depression is a concept that must in any case, and in any case, remind us and refer us, as we have seen, to a meaning of illness, to something pathological, abnormal, unnatural even if widespread, even if everyone experienceable in one’s depths, even if extraordinarily close to that normal sadness, in its intuitive gradations and its multifaceted manifestations, to which I referred earlier.
We have seen previously how, generically, normal sadness differs from pathological depression, but it is useful to recall here the criterion, which in my opinion is decisive and distinctive, between the one and the other, according to which, the normal feeling of sadness, is a pain of the soul, perfectly assimilable, comparable and comparable to a similar pain of the body, and as the latter is finalized and necessary, for self-preservation, for the defense of our bodily integrity, of our physical health, parallel to the normal sadness, aka psychic pain, is intended, intended, aimed at the development of behavioral, psychological, psychic and cognitive strategies, conscious or not, aimed at eliminating the harmful cause, obviously in this case psychic, which
caused the pain , and if this is not possible, then to understanding, to resizing the cause itself, to the transformation and mutation of this within us, in an opportunity for reflection, in-depth analysis, introspection, growth and, ultimately, maturation moral.

Normal sadness therefore, I reiterate again, in all its thousand forms and gradations, even in its own, specific characteristic, of painful, sometimes very painful existential experience, very human and inalienable from our existence, possesses within itself all the presuppositions and characters, of utility, of indispensability of absolute, irreplaceable necessity, for our survival, not physical, of course, but in this case psychic and moral.
Without this painful feeling, we could survive, of course, physically, but not psychically, incapable of processing within ourselves the unpleasant experiences of life, the pain, the traumas, the frustrations that it inevitably reserves for us and pours out on us with both hands, incapable of learn to tolerate them, to put up with them, to take charge of them, to grow through them, to mature through them, through them not to succumb, but rather to become
stronger and more steadfast on our legs.
This irreplaceable character of utility, of psychological necessity, of survival tool, is instead totally lacking in depression, which, precisely because of this specific property, must, in my opinion, be considered a disease in all respects, analogous and superimposable, comparable, to all other diseases of the body, to somatic diseases, even if it affects a structure of the human body, the brain, which we struggle and have difficulty with, we hesitate and sometimes we even refuse to consider as being a full part of the body itself.
But if then, the sad mood, the melancholic or even desperate state of mind, as can unfortunately sometimes happen, represents the typical, characteristic, pathognomonic symptom of depression, let us doctors say, so much so that we base and base the our diagnosis, but it is at the same time also the nucleus of the normal feeling of sadness, melancholy, desperation, so how can we distinguish one from the other and attribute one to the disease and the other to a normal, even what if it is a painful existential condition, the prerogative of everyone and to which we are all exposed and susceptible?

While the normal feeling of sadness, melancholy, even tragic desperation, possesses within itself, contains within itself, the germ, the nucleus of its own resolution and positive evolution,
depression on the contrary, appears and probably is, as a painful, a very painful condition of the soul, which instead feeds on itself and grows, develops out of all proportion, finding, unearthing and inventing within itself the very reasons and reasons for subsisting, for enlarging, for occupying all the available space, which the immense capacity of the human soul to feel and experience suffering internally grants and allows it.
It is like a cancer, a tumor, which grows, nourishes itself, develops, at the expense and parasitizing the organism that hosts it, consuming it rapidly, to the point, sometimes, not always fortunately, of destroying it, of annihilating it, if action is not taken first and appropriately.

Anyone who has professional practice with depressed patients, or has seen depression afflict a family member, a friend, or has even experienced the pangs and suffering caused by this
disease, knows well the phenomenon, which is only apparently paradoxical, for in which it even seems that the depressed patient feeds his own depression, digs deep into himself, into his own biography, into his own past, into his own memories and past experiences, in a frantic and desperate search for reasons, opportunities, reasons, to to be depressed, to be sad, to feel guilty, to consider oneself and one’s entire life a failure, a dull succession of meaningless and
pointless days, a slow, sad going, one doesn’t know where and one doesn’t know why, an empty passage of time, waiting and often hoping for an imminent end.
According to the depressed patient there is nothing about him that can be saved, that survives, that is even just a little positive and worthy of praise, in this cruel and non-objective analysis
that he carries out of himself and of his existence, in this sadistic vivisection of one’s life, nothing worth surviving for, nothing to be remembered for, with affection or even love by others, nothing to be regretted for, when we are no longer.

Obviously, if each of us has and must have, within ourselves, reasons for discontent, regret, feelings of guilt, feelings of failure and inadequacy, otherwise, without these, we would not try to proceed, to perfect ourselves, to be different and, if possible, even better, that is, in other words, if it is true that these “morally negative presences” have an undoubted and undeniable positive purpose, of stimulus and interior exhortation, of encouragement, unfortunately
it is equally true that in depression disease, this positive purpose is on the contrary completely and totally lost, nullified, destroyed, while these sensations and states of mind are left with only and exclusively the painful connotation of suffering, of self-reproach, of rigid and profound self-censorship, of fierce disapproval for our often “non-operational” actions, of condemnation for our past and our present, but often unfortunately tragically, also for our future.
We then witness, as doctors, family members, friends, anonymous spectators, painfully helpless, that internal tragedy that takes place on a completely personal stage, constituted by the suffering soul of the depressed patient, according to a wellknown and experienced script, based
on the which the protagonist, in this case our patient with depression, despairs, cries, suffers, asks for help, but paradoxically inflicts on himself, voluntarily, the suffering he suffers,
so that he himself is a victim and tormentor, simultaneously recites the role of persecutor and persecuted and unfortunately sometimes also of executioner executing a capital sentence.

Exactly in this, in my opinion, lies the paradox of depression, the cruelty of this disease so different from all the others, whether physical or psychological; in all the latter, in fact, the
suffering patient does everything, implements every strategy in his power, to free himself from the suffering, or at least alleviate its violence and aggression; only in depression, however, and cruelly, does the afflicted patient work against himself, is his own enemy, digs into his own depths and soul in search of every thought, every reason, every opportunity to accentuate and multiply the his own sufferings are unlikely, to nourish them, to feed them and finally to be a victim of them.
Obviously all this does not happen knowingly and consciously, because otherwise it would not be an illness, but a healthy masochism; it is in fact the same depressive state of mind, the same negative, melancholic intonation of the mood which reports, by analogy, which induces and evokes sad thoughts, painful memories, nostalgia, regrets, but also much more and more poignantly suffered, such as feelings of guilt, painful certainties of non-compliance, of missed actions, of things left unsaid and undone and that it is now irremediably too late to say or do, affections not given, or not sufficiently expressed, words never spoken out of fear , out of pride, out of shame, out of foolish selfishness or stupid egocentrism; all things that we knew about
ourselves, that we knew well, that were well known to us, but that we had equally well hidden, forgotten, or pretended to forget in the folds of an indulgent and comprehensive memory, and which now however suddenly come back to life, cruelly and treacherously, just when we least expect it, when our state of mind, our spirit, having become weak and fragile due to depression, is no longer able to cope with the wave, the flood of memories, of nostalgia, poignant melancholy, painful regrets and unacceptable and unforgivable sins.

Some of these will naturally be true and real, as in the life and memory of each of us, but others, some, perhaps many, will certainly be invented from scratch, created, given birth, generated by the pathologically and painfully altered imagination of suffering from depression; in fact, this strange disease can also achieve this, even making us delirious, making us believe as true what is not true, and never has been, making us accuse ourselves of faults never committed and even impossible to commit, at least on our part, as in the case of a very young patient of mine, seen a few years ago in the midst of a depressive crisis, who blamed himself, very convinced and with consequent tragic suffering, of having been solely responsible and responsible for the outbreak of the Second World War; Naturally, my timid and fruitless attempts to make him think about the simple calculation of dates and chronologies were of no avail; however, the delirogenous force of the depression prevailed until it was cured.

Obviously this represents a limit degree of seriousness, but not as infrequent as one might believe and hope, and if it is true that the absurdity of depressive delusions does not always reach such a level of unreality, which is easily and evidently graspable, it is also true that the perception of reality, our objectivity regarding it and above all our clarity of judgment is seriously and heavily altered due to depression, obviously always in a self-devaluing, self-blaming and self-punishing sense; in fact, if it happens, fortunately rarely, that depression reaches such profound levels of severity, as to make us feel guilty of facts that even occurred
before our own birth, as for example the case of my patient, it is equally true that the depressed patient always possesses the extraordinary and cruel ability, due to the illness, to select and recall, during the course of it, to find in one’s past, all those memories, those episodes, those occasions, sometimes even futile and banal, in which he did not give great proof of oneself, and with the dramatically actualizing force of depression, reliving them and not just recalling
them, as if they were there, present in that moment, in all their burning unworthiness, devoid of that pitiful protective veil, which time, the years that have passed, they had spread over them, to guard them and above all to guard our conscience.
So during the illness they come back to us, recalled and aroused by the depressive state of mind, which provides like a frame in which a painting fits perfectly and appropriately, a fertile and freshly plowed soil, in which the seeds sown to case, they find an excellent and welcoming receptacle, they come to mind, episodes from childhood, from our distant and recent past, faces, people, ghosts, images and personal episodes, very different from each other, but all made similar or identical, by the common denominator to induce us suffering, due to the content, the meaning that we attribute to them, above all the significance and relevance with which they are experienced and recalled by us ourselves.
I stop here because I hope I have given you a sufficiently exhaustive image of this cruel disease. We postpone the understanding of the biological aspect of this disease and the methods, fortunately possible, of treatment and recovery until the next episode.

Let’s start with some irrefutable scientific certainties. During embryonic and fetal life we all live in a sterile aquatic world (amniotic fluid), as in a space capsule (placenta and amniotic sac). Yes, just like a fish in an aquarium!
From our mother we receive nourishment (through the umbilical cord) and immune protection, cuddled at the right temperature by the reassuring sound of the maternal heartbeat.

The problems begin when the water sac breaks and we face external life through the birth canal. The umbilical cord is interrupted by the midwife, who cuts it and then helps us expel the amniotic fluid that we still have in the pulmonary alveoli with the first cry, which is described as a desperate cry, almost as if we realized that from that moment on we are alone interact with the immense world of fortunately invisible microorganisms. This is the ecosystem we were talking about at the beginning and which will accompany us throughout our lives and after death will contribute to the decomposition of our mortal remains.

It should be noted that 99% of the DNA of this ecosystem is given precisely by the associated microorganisms, which will gradually inhabit the newborn in all the organs and systems. Life therefore begins as a continuous struggle for survival. Our mother will still give us help, who with colostrum and milk will provide us not only with what we need to grow, but also with many defensive antibodies, essential for our survival, as our immune system is still forming and
therefore immature. Then gradually our defensive army will be enriched with increasingly complete and efficient weapons with the increasingly numerous and safe vaccinations in childhood. Then it entrusts everything to our immune system, which matures and is enriched with antibodies and defensive cells increasingly prepared for war.

But in this very threatening world, fortunately we can also have the help of some allied “friendly bacteria”. In fact we have pact with then, based on the “do ut des” rule, so in a nutshell we help them to live, they help us in the fight against pathogenic enemies while also supporting our immune system. Alliance, symbiosis, mutual convenience, we can put it however we want. But both we and they need and benefit from each other.

But be careful, because if our body weakens, for example because it is undermined by metabolic and/or neoplastic pathologies, or even because it simply undergoes physiological aging, and our immune system loses strength, it is possible that these allies of ours also become suddenly
they too are our enemies!
“But what does it matter? – you might think – we always solve everything with antibiotics!”

Interaction of Human-Microorganisms of our Ecosystem

What has been said so far can lead us to understand how important it is to move with judgment and a “thinking mind” when giving therapies and especially when we intend to use antibiotic therapies. We know in fact that antibiotics have no effect, and are therefore useless, against viruses and fungi and that, used mostly indiscriminately, they cause deaths and injuries in enemy camps but unfortunately also in friendly camps and can also cause two other very serious effects. harmful: the selection of the most virulent and aggressive pathogenic bacteria and antibiotic resistance. Furthermore, by destroying not only the enemies but also the friendly
bacteria, for example in oral therapies the intestinal flora (intestinal microbiome), cause abdominal pain and serious diarrheal syndromes, which we have long learned can only
be resolved by reintegrating the friendly intestinal flora with lactic ferments, that is, friendly bacteria.

Biofilm: what are they?

The premise was long, but it was certainly essential to understand what relationship we have with bacteria above all, which are so many, which we must respect, which we can somehow keep under control, but which we will never be able to eliminate, because they are inside and above of us (every system has its own microbiome) and surround us like threatening and invisible presences. Hence the need to carefully take care of the health of our body and its defensive immune system.
But what you need to know doesn’t end here.

When we get an acute wound or fight for days, months or even years with a chronic wound (skin ulcer), our first concern is that we open a window, a door or even a door to bacteria with the risk of infections. It is a legitimate concern and how it will end will depend above all on our immune defenses. The bacteria in particular will enter almost timidly one by one and defenseless at first free or, as they say, in planktonic form with the risk for them of being attacked and eliminated by war machines (leukocytes and macrophages) or missiles and bombs (antibodies). A local battle will therefore be unleashed, which can obviously result in the elimination of the aggressor or, on the contrary, in his progressive reinvigoration and ever greater reproduction (first contamination and then colonisation) with an ever greater possibility of arriving at an infection that is first local and then even remotely throughout the entire organism attacked, unleashing a global war, the outcome of which could even be fatal for our organism.

The bacteria, especially the most equipped and aggressive ones, obviously will certainly not remain inert and will organize themselves better and better, building their effective defensive barriers, in which they will host more and more colonies of the same family or even of different families, sometimes even viruses and fungi. It is precisely these protective forts that we call Biofilm.

But let’s try to understand it better with a practical example.
The example that is most frequently reported comes from dentistry.
Given that biofilms form more easily where there are heterogeneous contact areas, here we come to explain the birth of biofilms at the collar of the teeth in all of us. The first bacteria arrive here and together with food residues form dental plaque, an invisible film, which we can and must remove mechanically with a toothbrush and dental floss. If we do not do this regularly after each meal, tartar will slowly form due to the incorporation of mineral salts, especially calcium, from saliva into the plaque.

This is clearly visible, yellow or black in color and is tenaciously adhered to the teeth up to the gums and if left there it grows and detaches the gums themselves, also affecting the tooth enamel. Result: cavities form and increasingly serious gingivitis is triggered (local inflammation-infections) with the great risk of losing one or more teeth, sometimes even all (complete edentulism due to pyorrhea). To remove the tartar we must resort to a real mechanical debridement by our trusted dentist, never let our guard down, because the tartar easily reforms again.
We remember that more and more medical publications testify to us that oral hygiene is fundamental for our health and that sometimes the presence and persistence of calcific bacterial plaque, which we have seen to be a biofilm, can favor the appearance of even fatal ischemic events (stroke and myocardial infarction) due to the circulation by the bacteria, which live and reproduce actively here, of fibrin-like protein substances which favor intravascular blood coagulation (thrombosis).
This example of biofilm demonstrates that especially many pathogenic bacteria defend themselves from aggressive-defensive actions by evading our immune system, creating dangerous alliances with other families of bacteria, viruses and fungi and above all shielding and neutralizing the antibiotics administered especially locally, making this therapy useless. This gives rise to real condominiums of hostile microorganisms, which proliferate threateningly,
as they are protected by a glycoprotein capsule (glycocalyx) produced by themselves as if it were a wall.

Conclusive Considerations

When all this happens in a skin ulcer, to avoid even fatal dangers we only have three weapons:

1. A targeted antibiotic therapy on culture swab with antibiogram, which allows us to selectively target often multiple pathogens with the right weapons, simultaneously replacing the friendly bacterial flora with the use of lactic ferments.
2. A selective local disinfection avoiding traditional iodine-based products, which create scorched earth all around, killing, even for a short time, good and bad bacteria and destroying the repairing granulation tissue. Less aggressive products left as a local compress for a few minutes and then rinsed thoroughly: this is what not only the expert vulnologist, but all the healthcare personnel who work around our patients should suggest.
3. A mechanical-chemical debridement to break down the walls of illegal condominiums built by the most aggressive microorganisms (Biofilm) to allow antibiotics chosen in a targeted and selective way and administered mostly systemically (orally, intramuscularly or intravenously) to work better and subsequent application of silver, copper or medical honey antiseptic dressings.

In conclusion we must put it out of our minds

• to heal an acute or chronic skin lesion it is necessary to destroy all the microorganisms that pass through it, because this is practically impossible, except for a few
  minutes, and even harmful, because by putting everything on fire we risk losing the allied forces, made up of the microbes who are friends of our microbiomes.
• all wounds should be flooded with strong local disinfectants and antibiotics, because enemy bacteria defend themselves inside biofilms and are mostly unassailable, as the condominium in which they live (glycocalyx) hides them from the radar of our immune system (evasion) and we can only hope to bring down these walls with a direct action (debridement). Furthermore, the disinfectant substances that we generally use, mostly iodine-based, oxidize, therefore essentially destroy, the repairing granulation tissue. It is certainly better to use more delicate disinfectants, using them only in case of real necessity and rinsing them thoroughly with physiological solution, after leaving them to act for a few minutes as a compress.
• swabs for culture and antibiogram examinations are useless. This may be true in the case of well-cleansed and granular wounds, while it is absolutely not true if the wounds show clinical signs of infection (redness, heat and perilesional edema, pain and bad odor). Indeed, in these cases they are indispensable for promptly establishing selective and targeted antibiotic therapy, mostly systemic and not local, without needlessly shooting in vain.

Finally, I underline the need to support our general health and our immune system, giving great importance to the right nutrition and hydration and treating and keeping underlying pathologies and co-pathologies under control.
Why?
I’ll just give you an explanatory example: an ulcer caused by a venous pathology will never heal in a stable way if we don’t treat the chronic venous insufficiency that caused it with drugs, elastic compression and/or surgery.

This technology needs a specific device that send data to a PC software, then it shows 3D images.
We can use it for diagnosis and follow up in patients with Superficial Vein Thrombosis (SVT) and Deep Vein Thrombosis (DVT), mapping of Great Saphenous Vein and Small Saphenous Vein before termoablation and/or sclerotherapy. It allows also the realization of models with 3D
printing.

We have quantified the gravity of venous thrombosis with extreme precision (with the evaluation of dimensions, in cubic millimeters, of the thrombus, vascular area occluded
from the thrombus and free vascular area) and evaluated recurrences with certainty.

For vascular mapping, we have used this program for surgical planning and for follow – up of patients treated with sclerotherapy with foam.

Finally, we have reproduced, with 3Dprinting, models of pathological veins. For our experience, we can confirm that in venous field, 3D ultrasound can evaluate with better precision SVT, DVT and varicose pathology. It can be use for planning saphenous treatment and for venous malformations, where it can show afferent and efferent vessels, optimizing treatment outcomes.

Finally, the use of 3D printing let to realise more precise and realistic models, that can be use for surgical planning and training.

Three points have been pointed out to obtain a useful post-operative DUS examination:
• Pre-treatment DUS assessment should be available to
better evaluate the post-operative findings
• Details of treatment (traditional surgery, endothermal
ablation, Ultrasound guided Foam Sclerotherapy etc) should be
known
• Timing of DUS follow up.

DUS can detect the early stages of recurrent varicose veins and can help to comprehend the clinical evolution of the disease after any treatment for CVD. Furthermore, long term follow up using DUS allows to understand the natural history of CVD.

Timing of DUS follow up:
Post treatment DUS evaluation should be performed within 1-4 weeks (Immediate Follow up) to assess if the intervention has achieved the desired goal and late to assess the appearance of any recurrencies or of new varicose veins.

Than the follow up could be at short term (within 1 year), mid term (2-3 years after treatment), long term (>5 years after treatment) if possible till 10 years.
A correct DUS should describe the presence of neovascularization at the sapheno-femorale and sapheno-popliteal junction, the presence of a residual stump or of an incompetent anterior accessory saphenous vein.

It is essential evaluating a possible progression of thrombosis beyond the valvular plane with the deep system (EndoThermal Heat-Induced Thrombosis or EITH). The term EHIT was first introduced in 2005 by Kabnick et al.

This classification includes 4 stages of EHIT:

• thrombus propagating to the sapheno-femoral or sapheno-popliteal junction;
• thrombus propagating into the adjacent deep vein but less than 50%;
• thrombus propagating into the adjacent deep vein but greater than 50%;
• occlusive deep vein thrombosis.

A good occlusion of the GSV (great saphenous vein) may be flush with the epigastric vein. An acceptable saphenous stump should not exceed 2-3cm.
Finally, All the records should be reported to allow the detection of any recurrent varicose vein and to address the best re-treatment.

Superficial venous reflux can be explained as retrograde flow of a column of blood in continuity with a normal competent venous system. It is considered pathologic if it lasts > 1 second. For reflux to occur, a conduit is required together with a provocation maneuver.

The conduit consists of one or more upper feeding points, a refluxive pathway, and lower drainage points. Studies on the mechanism of refluxive filling and cessation are fundamental in the understanding of venous insufficiency because reflux cessation is the primary aim of all the treatment strategies.

The majority of clinically relevant venous refluxes of the superficial veins requiring invasive treatment occur in the great saphenous vein (GSV) territory.
The GSV, similarly to other veins, is equipped with valves that preclude venous reflux, i.e. a backward flow. In the area of the SFJ two valves are especially important: the terminal valve, which is located next to the junction with the femoral vein, at a mean distance of 0.4 cm from the junction, and the preterminal valve, which is located more distally from the SFJ, usually at
a distance of sev- eral centimetres from the femoral vein and distally from the above-mentioned tributaries.

Venous anatomy of the region should be evaluated and several questions should be answered:
• Are all veins visible?
• Are the valves of the GSV visible, and are their leaflets capable of moving during the blood flow
• Are the valves of the SFJ competent?
• Which tributaries are visible?
• Is the GSV dilated?

Assessment of venous flow in the area of the SFJ should preferentially be performed in the standing position.
The provocation maneuver can be pressure from above, like the Valsalva maneuver, or a calf release or toe elevation maneuver from below.

In a case of incompetent valves of the SFJ an upward flow during muscular systole and backward flow during diastole will be found, with duration of such a backward flow longer than one second. Flow characteristics in the area of SFJ: in the CFV, and the GSV and its tributaries can be assessed using colour Doppler mode. Flow characteristics should be documented in the
CFV, and the SFJ and tributaries using PW-Doppler mode.

DUS examination should be performed:
• Standing
• Morphology Longitudinally and Cross Section
• Colour Duplex Exploration: Reflux source, reflux path, PW to document the findings
• Manoeuvres: At least two out of Valsalva, Toe elevation and Calf compression