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Sclerotherapy
Treatment of Varicose
Telangiectatic Leg Veins
AND
Commissioning Editor: Claire Bonnett, Russell Gabbedy
Development Editor: Joanne Scott
Project Manager: Jagannathan Varadarajan
Design: Stewart Larking
Illustration Manager: Merlyn Harvey
Illustrator: Robert Britton and H.L. Studios
Marketing Manager(s) (UK/USA): Gaynor Jones/Helena Mutak
F I F T H E D I T I O N
Sclerotherapy
Sclerotherapy
Treatment of Varicose
AND
Telangiectatic Leg Veins
EDITORS:
Mitchel P. Goldman MD,
Volunteer Clinical Professor of Dermatology and Medicine,
University of California at San Diego,
Medical Director, La Jolla Spa MD, La Jolla, CA, USA
Jean-Jérôme Guex MD FACPh,
Professor, University of Nice, Nice, France
Robert A. Weiss MD,
Maryland Laser, Skin and Vein Institute, LLC.,
Aspen Mill Professional Building, Hunt Valley, MD, USA
CO N T R I BUTO R S
Albert-Adrien Ramelet MD,
Consultant and Lecturer, University of Bern, Lausanne, Switzerland
Stefano Ricci MD,
Phlebologist,
Private Practice, Corso Trtieste, Rome, Italy
Hugo Partsch,
Emeritus Professor of Dermatology, Medical University of Vienna,
Vienna, Austria
Michel Perrin MD,
Vascular Surgery,
Department Unité de Pathologie Vasculaire Jean Kunlin, Clinique du Grand Large
Chassieu, France
For additional online content visit
www.expertconsult.com
Edinburgh, London, New York, Oxford, Philadelphia, St Louis, Sydney, Toronto
Saunders an imprint of Elsevier Inc.
The
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© 2011, Elsevier Inc. All rights reserved.
First edition 1991
Second edition 1995
Third edition 2001
Fourth edition 2007
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This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary. Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or experiments described
herein. In using such information or methods they should be mindful of their own safety and the
safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products, instructions,
or ideas contained in the material herein.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Saunders
Sclerotherapy: treatment of varicose and telangiectatic
leg veins. – 5th ed.
1. Sclerotherapy. 2. Varicose veins–Treatment.
I. Goldman, Mitchel P.
616.1′43′06-dc22
ISBN-13: 9780323073677
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
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Preface
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The first edition of this text was written almost 25 years
ago at the beginning of my medical career. Although it was
thought of as an authoritative text, it merely represented a
review of the world’s literature on sclerotherapy and actually
served to teach me the basics of phlebology. The second
edition, written five years later, expanded on the theme of
an encyclopedic review of the literature and included more
practical information now gained through my early experience
in phlebology. The third edition, written five years later,
brought my co-author and teacher John Bergan to add his
depth of knowledge and expertise. The third edition again
continued in the spirit of an encyclopedic dissertation with
more practical information and case reports. The fourth
edition brought another co-editor, J-J. Guex to the text to add
both a European perspective to the text as well as include more
international knowlege and expertise. In addition Professor
Hugo Partsch, the world’s leading authority on compression
therapy re-wrote the Compression chapter and Albert-Adrien
Ramelet, MD included the first chapter on Veno-Active drugs.
For the fifth edition, we have added Robert Weiss, MD as a
co-editor to replace the retirement of our Dr. John Bergan. In
addition to adding his expertise to each chapter, Bob is
res ponsible for updating the accompanying DVD filled with
educational and practical videos to aid physicians into applying the knowledge of this text in a practical maner to their
patient practice.
Phlebology and the treatment of varicose and telangiectatic
leg veins continues to evolve significantly with the addition of
endovenous laser and radiofrequency techniques for treating
the great and small saphenous veins as well as perforator and
tributary veins. In addition, the resurgence of using foamed
sclerosing agents has expanded our treatment abilities while
minimizing adverse effects.
The world has continued to grow smaller, with the International Union of Phlebology serving to bring physicians from
all nations together every two years to share their experiences.
This has led to an increasing body of knowledge that deserves
to be organized in one source. It should therefore come as
no surprise that this fifth edition contains approx 416 new
references, a totally revised anatomy chapter co-authored with
Stefano Ricci, MD a world class historian, anatomist and phlebologist, and the surgical chapter re-written by Michel Perrin,
MD, Vice-President of the IUP, a senior internationally respected
Vascular Surgeon and Phlebologist. The addition of these
international leaders and outstanding teachers and clinicians
from France and Italy further broaden the breath of this text.
The success of the combined efforts of the new co-editor
and two additional chapter editors is represented by the
approx 84 new illustrations and 10 new tables, all of which
should increase the practicality of the fifth edition while maintaining its encyclopedic nature.
The enhancement of patient care evidenced through an
increase in successful treatment while minimizing adverse
events is the reason for our joint efforts. I thank the world
phlebological community for sharing the combined expertise
of thousands of physicians in such a selfless manner under the
encouragement of the International Union and each country’s
phlebological society.
Mitchel P. Goldman
Founder and Editor-in-Chief
2010
vi
Dedication
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To our friend, teacher and colleague, John J. Bergan. He took
the field of phlebology in the United States from completely
unrecognized to what he called ‘Cinderella’ coming out to the
ball. And phlebology found more than the glass slipper, it
became the ‘princess’ of subspecialties for doctors excited
about advancing their knowledge and treatment of varicose
and spider veins.
Dr. Bergan’s approach was to include multi-specialties
and devote himself to teaching the principles of vein surgery
to all who were interested. His keen logic and practical
approach allowed the expansion of phlebology to include
much more than his vascular surgery perspective. He clearly
excelled at making vascular surgeons aware of the importance of venous disease. But he went beyond and was willing
to explore and accept advances in sclerotherapy, ambulatory phlebectomy and endovenous ablation incorporating
advances from all fields. His spirit of cooperation and dedication kept the magic alive through his eloquent and motivating
teaching combined with his practical approach to patient
care. Physicians from all specialties throughout the world
have benefited from his teaching. But most importantly, his
greatest contribution is to millions of patients with venous
disease who have benefited from better care. So many, not
the least of which the authors, are grateful and indebted to
Dr. Bergan.
Dedication to Michael Georgiev, MD
Michael left us after a courageous but desperate fight with
cancer, like an epic exploit (symbolic but without outcome).
We had very intimate working relationships. He came in my
office to operate, together, on his patients needing saphenectomy. As it is common during these cases, we used to talk
about many non-medical questions, and our common Balkanise origins catalyzed our natural affinities. Our brotherhood lasted for many years and ran out when we oriented the
saphenous treatment toward more conservative, or at least less
aggressive, perspectives.
It was easy to collaborate; it was a bit more difficult to get
on with him. Two quarrels stay memorable in my mind: one
about politics (he supported the right wing, deeply anticommunist because of his experience in the Bulgarian regime);
the other about religion (he was ‘creationist’ without doubts).
But our discussions produced positive insights, and finally
common solid experiences remained, as the contemporary
acquisition of our first Duplex ultrasound and common
publication of the results (Georgiev M. The preoperative
duplex examination. Dermatol Surg 1998 24:433–440; Ricci
SS, Georgiev M Ultrasound anatomy of the superficial veins
of the lower limb. J Vasc Technol 2002; 26: 183–199), as well
as the employment of ambulatory phlebectomy for the treatment of varicose veins (this experience produced a book: Ricci
S, Georgiev M, with Goldman P: Ambulatory Phlebectomy. A
practical guide for treating varicose veins. Mosby St. Louis, 1995
and Ricci S, Georgiev M, Goldman M: Ambulatory Phlebectomy. A practical guide for treating varicose veins. 2
Taylor & Francis 2005 Boca Raton), as well as the participation
with a group of friends ‘affected’ by phlebology, called
Fleboclub.
Apart from communists, he hated the CHIVA method (the
conservative treatment suggested by Claude Franceschi), more
out of prejudice than for a real conviction. He brought to
several Congresses a surgical piece of a sapheno femoral junction taken from a patient operated by CHIVA method to
demonstrate the failure of this procedure, but in reality he was
employing 80% of the CHIVA concepts through ambulatory
phlebectomy. His most important phlebology paper is the
appreciation of the Femoro-Popliteal vein (today renamed
officially ‘SSV thigh extension’): Georgiev M. The femoropopliteal vein: ultrasound anatomy, diagnosis and office surgery.
Dematol Surg 1996; 22:57–62; Georgiev M, Myers KA, Belcaro
G. The thigh extension of the lesser saphenous vein: from
Giacomini’s observations to ultrasound scan imaging. J Vasc
Surg 2003;37:558–563.
Michael made a name for himself as a doctor, he was a
phlebologist on an international level, and he was a sensible
husband and father. To achieve this nothing was given easily
to him. He escaped from Bulgaria, lived as a refuge for a
period, but was able to build up a career without assistance
from relatives or anyone but himself.
Paolo Zamboni tells one touching story: ‘One morning
in June 2002 Michael Georgiev was with me in Berlin at a
meeting of European Venous Forum. He asked me to accompany him to Checkpoint Charlie, the point that separated the
Eastern world from the world of Western Europe, exactly
where the guns of the tanks of the Covenant Warsaw faced
those of NATO. Michael was probably thinking about these
memories and burst into tears. I hugged him and we sat in a
café nearby. He told me about the roccambolesca escape from
Bulgaria, where he hid terrified in a trunk of a car with his
mother. Michael went first to Switzerland, where as a young
physician he learned the art of sclerotherapy from Professor
Sigg himself.’
His last days were hard, in a constant silent fight. Still
during this struggle, his mind could not stop from working
out ideas, and just the forced physical inactivity fed his last
production, this time on a theological subject: M. Georgiev.
Charles Darwin – Oltre le colonne d’ercole – Protagonisti, fatti,
idee e strategie del dibattito sulle origini e sull’evoluzione. Gribaudi
Milano 2009.
At the end of all what remains in each one of us, is the sign
we leave behind in the world we lived. Michael left us his sign
without any doubt.
nd
Edition.
Stefano Ricci
vii
C H A P T E R
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Anatomy
Stefano Ricci
1
Introduction
The anatomy Chapter in a modern text devoted to sclerotherapy is traditionally not the most fascinating aspect, as the
anatomy rarely changes and is very similar to that described
in older texts. Anatomy chapters are rarely consulted because
readers believe they know the basics of venous anatomy, but
they should be reviewed regularly and, as one uses duplex
ultrasound, the importance of understanding anatomy
increases greatly. While this Chapter reports on the images
and the concepts of the classic anatomy texts that we used
during our university medical studies, it is clear from our
experience with duplex ultrasound observations that a ‘déjà
vu’ sensation to anatomy is not entirely correct and anatomy
is more than a fixed science – new understanding has been
added.
Dissection anatomy, indeed, had its fullest expression from
the late eighteenth to the early twentieth century (Mascagni,
Gray, Sobotha, Testut, etc.) when all the aspects of dissection
anatomy where definitively studied (Fig. 1.1). In the past 50
years anatomical dissection has been little used to investigate
venous anatomy, probably because of the assumption that
there is nothing new to discover (but also because it is more
and more difficult to find cadavers for this purpose). Meanwhile, most anatomical, clinical and surgical textbooks
describe the superficial veins of the lower limb as a simple
‘tree’ formed by a few constant and recognizable veins, though
clinical experience often shows anomalies and variations
with respect to the classical anatomical description or even
the complete absence of some of these veins. Furthermore,
usually studies in the field of limb veins concern subjects with
varicose pathology and rarely subjects with a normal venous
system.
Confirming this, the official Anatomical Terminology
(Nomina Anatomica)
and does not take into account their numerous variations.
Inadequacy of official anatomy has caused many authors to
name single veins independently or even after the author’s
name, which, in the absence of an accepted interpretation
frame has added some confusion. The nomenclature consensus statement of 2001 at the Rome UIP World Congress
was organized with the purpose of solving this problem (see
Table 1.1).
Contrast phlebography, until recently the ‘gold standard’
for venous investigation, has the major drawback of being
practically never complete, but rather showing only the veins
filled by contrast media. Furthermore, it focuses mainly on
deep veins and in pathologic conditions, and thus has not
contributed much to the understanding of normal vein
anatomy.
Understanding of vein anatomy did not progress much
until ultrasound imaging (USI), specifically duplex scanning
2
1
includes only a limited number of veins
(DS), became an established technique for clinical investigation of patients with venous diseases. Technology simplifications and low costs have allowed its widespread use.
Ultrasound imaging makes it easy to observe the veins of
the lower limb, unlike anatomical dissection and phlebography. Examination is non-invasive, repeatable and relatively
low in cost. Veins can be observed at full distension, with the
patient in a standing position, so that, unlike with anatomical
dissection, their real volumetric relationship with the surrounding tissue is readily appreciated. Ultrasound images
show not only the veins (as contrast phlebography does), but
their relation to surrounding anatomical structures, in particular muscle and fascial layers. This allows precise anatomical
identification of the observed veins (Fig. 1.2). Therefore, USI
is a unique tool for the study of vein anatomy (US dissection)
and makes it possible to verify data obtained from anatomical
dissections. In addition, DS allows the detection of blood flow
in the observed veins with assessment of their function and
involvement in venous pathology. Interestingly, USI was first
employed for the clinical identification of pathologically
changed veins. Later it was used for collecting data on normal
vein anatomy.
In this Chapter vein anatomy is first described from the
traditional point of view, and successively as observed by USI
with special reference to the superficial veins of the lower limb
in relation to varicose vein disease and sclerotherapy. For this
purpose an interpretation key is emphasized, which makes it
possible to categorize the extreme variability of the superficial
veins of the lower limb into a limited number of specific
anatomical and varicose patterns.
3
Nomenclature
Nomenclature used throughout the textbook conforms to that
developed at the Venous Consensus Conference Classification
in 1994.
and definitions are used, which were developed at the Nomenclature Congress in Rome in 2001 (Table 1.1).
saphenous vein is referred to by the English-Latin term great
(GSV). The short saphenous vein is referred to using the
English-Latin translation small (SSV), avoiding the term
‘lesser’ as the L could be confused with the term ‘long’. Veins
that ‘perforate’ the fascia are termed perforator veins. Veins
that connect to other veins within a fascial plane are referred
to as communicating veins. The principal deep vein of the
thigh is termed the superficial femoral vein, now properly
called the femoral vein. The superficial femoral vein actually
has turned out to be a potentially lethal misnomer. It has been
found that the use of this term is hazardous to patients suspected of having deep venous thrombosis. Many primary care
physicians have not been taught and are not aware of the fact
that the superficial femoral vein is actually a deep vein of the
thigh and that acute thrombosis in this vessel is potentially
life threatening.
4
In addition, the newest revisions of nomenclature
2,5
The long
6
Chapter
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1
Anatomy
A
Figure 1.1 Three plates from the ‘Piccola anatomia’, which was published in a reduced size because of the high printing costs of the time, are shown here.
These demonstrate that anatomical knowledge was already complete 200 years ago. (The ‘Grande Anatomia’ of Paolo Mascagni was published between
1823 and 1831 by Nicolò Capurro in Pisa).
B C
Table 1.1 Summary of important changes in nomenclature of lower
extremity veins
Old Terminology New Terminology
Femoral vein Common femoral vein
Superficial femoral vein Femoral vein
Sural veins Sural veins
Soleal veins
Gastrocnemius veins (medial and lateral)
Hunterian perforator Midthigh perforator
Cockett’s perforators Paratibial perforator
Posterior tibial perforators
May’s perforator Ankle lateral and medial perforators
Gastrocnemius point Intergemellar perforator
Modified from Sherman RS: Ann Surg 130:218, 1949.
Figure 1.2 Ultrasound imaging shows the veins and their relationship to
the surrounding anatomical structures, in particular other vessels, lymph
nodes, bones, muscles and fascial layers. This allows precise anatomical
identification of the observed veins.
General Considerations
The veins of the lower limbs are traditionally described as
consisting of two systems: one within the muscular compartment and its fascia, the deep system, and one superficial to
the deep fascia, the superficial compartment (Fig. 1.3).
The lower limb deep venous system is found inside the
muscles within the muscular fascia. This allows it to feel the
2
effects of the tonus variations during contraction–relaxation,
being the only structure able to vary its volume.
7
The superficial veins are in an extrafascial position with respect to the
muscles, although the most important (i.e. saphenous veins)
are found with superficial fascia duplication.
The lower legs’ deep venous system cannot be seen as an
independent entity, separated from the superficial veins. The
venous function’s first purpose is to organize the anti-gravity
blood backflow to the right heart, taking advantage of it’s
volume capacity (three times as much as in arteries), it’s low
pressure and it’s compliance, so that the reservoir (the interstitium, depending on lymphatics) may not be involved.
Other primary important functions, although more localized,
are tissue drainage and thermoregulation. These three functions are assured in all different body positions and activity,
otherwise ‘venous insufficiency’ occurs.
8
Tissue drainage and the maintenance of volume flow are
based on valvular and, more importantly, muscle function.
Both systems strictly integrate with the venous reservoir function, the respiratory function and the filling ‘vis-a-tergo’ due
to the capillary network.
7
Venous backflow represents about 10% of the total flow at
rest, but increases heavily during dynamic conditions due
to the physiologic alternate contraction–relaxation of the
7
1
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Figure 1.3 According to traditional description, superficial veins are
separated from deep veins by muscular fascia. (Adapted from Kubik S.
Das Venensystem der unteren Extremitat
– Der informierte Artz 4:31, 1985)
2
3
4
6
7
8
9
10
Figure 1.5 In the leg two deep veins for each of the three arteries
communicate by means of transverse bridges. At the knee and thigh, deep
veins flow into the collecting system ‘popliteal-femoral veins’. Several other
secondary veins are present that can ensure a natural bypass when
obstruction occurs to the femoral vein. 1: obturator vein, 2: common
femoral vein, 3: medial circumflex femoral vein, 4: profunda femoris vein, 5:
perforating veins, 6: descending genicular vein, 7: popliteal vein, 8: posterior
tibial vein, 9: proximal portion of the posterior tibial venous axis (common
trunk), 10: posterior tibial veins, 11: peroneal (interosseous veins), 12: short
saphenous vein, 13: posterior subcutaneous femoral vein, 14: ischial vein,
15: inferior gluteal vein.
Extremitat
5
5
5
– Der informierte Artz 4:31–38, 1985)
15
14
13
12
11
(Adapted from Kubik S. Das Vevensystem der unteren
Deep Venous System
Figure 1.4 Physiologically, alternate contraction–relaxation of the
flexor–extensor muscles acts as a peristaltic pump and as a dynamic
reservoir, conditioning either the squeezing (contraction) or the distension
(relaxation) of the deep veins and the normal emptying of the superficial
veins, provided there is normal valvular function.
Sabiston DC, Davies MG et al, Varicose veins, venous disorders, and lymphatic problems in
the lower limbs, Oxford University Press, 1997.)
flexor–extensor muscles. These act as a peristaltic pump and
as a dynamic reservoir, conditioning either the squeezing
(contraction) or the distension (relaxation) of the deep veins
(with action on the venous sole of the foot and, above all,
ankle joint movement of particular amplitude conditioning
the most important calf pump (Fig. 1.4).
(Adapted from: Tibbs DJ,
Deep vein communications, mutual or with superficial
veins, are extremely frequent so that the postural and the rest
phases may address the venous backflow through less resistant
pathways, typically the deep veins in the physiologic
situation.
7
Deep Venous System
The structure of the deep venous system is shown in Figure
9
1.5.
There are at least two deep veins for each of the three
arteries (anterior and posterior tibial arteries and peroneal
artery), mutually communicating by transverse bridges (like a
ladder). The extremely rich muscular plexus (also connected
to the superficial veins) drains into these axial veins placed
parallel to arteries. At the foot, axial veins are prevalent in the
plantar region, where the first pump mechanism is present
(Léjars sole) (Fig. 1.6).
At the soleus and gastrocnemius sites the veins are even
larger in number and arranged in a spiral shape, due to the
longitudinal excursion amplitude of the muscles between contraction and relaxation. This creates a volume reservoir (pump
chamber), and the relative muscles (soleus and gastrocnemius) are responsible for both movement/standing position
as well as pump function (the second and most important
10–12
3
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