Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3661_Библиотеки_им_академика_М_И_Перельмана
.pdf
104
https://t.me/med1917
Treatment of Leg Veins
comfort, including a deeper, more intense pain that is
below the level of effect of topical anesthetic. As long as
patients are advised of this in advance, virtually all are able
to complete treatment without additional anesthesia.
When the patient and physician are ready to begin, the
treatment area should be cleansed with alcohol and the
physician, patient and any assistants should don appropriate protective eyewear.
When treating smaller telangiectasias with the 532 nm
KTP laser, fluences of 12–20 J/cm2 delivered with a spot
size of 3–5 mm and a pulse duration of 10–15 ms yield
excellent results (Aura; Laserscope, San Jose, CA). Skin
cooling should be used before, during, and after treatment
to prevent thermal damage to surrounding tissues and
decrease patient discomfort. Individual laser pulses separated by at least 1–2 mm should then be traced along the
length of the vein, with the operator being careful not to
overlap or double pulse (Fig. 7.7). It is important to apply
only minimal pressure with the hand piece so as not to
physically compress the target vessel (Fig. 7.8). The treatment goal should be either vessel spasm with immediate
clearance or thrombosis with darkening of the vessel.
Studies by Ross and Domankevitz (2005) have shown that
small vessels have transient bluing (representing cyanosis)
and microcoagula when treated at lower radiant exposures. The vessels may appear clinically normal within
seconds due to reperfusion, or the microcoagula may
adhere to the wall and halt blood flow, making it appear
that the vessel has closed. As radiant exposures increase,
small vessels have a more robust constriction and fixed
coagula without return of flow. Complete stenosis is
usually observed in only very small vessels. Larger vessels
will show transient bluing or no immediate clinical effect
at all. One must be careful not to increase laser fluences
in an attempt to get a clinical response in the vessel as
high radiant exposures can cause full-thickness necrosis.
Clinical resolution of vessels may occur after one treatment session; however, it is generally necessary to perform
two to three treatments at least 1 month apart for maximal
improvement.
For the treatment of reticular veins or telangiectasias
1 mm, the long-pulsed Nd:YAG is the laser of choice.
>
Several 1064 nm lasers have the advantage of variable spot
sizes and pulse width parameters to treat a wide range of
leg veins including small telangiectasias. For superficial
vessels <
1 mm in diameter, a 1.5 mm spot, 15–30 ms pulse
duration, and 350–600 J/cm2 is optimal (Lyra; Laserscope,
San Jose, CA). For reticular veins measuring 1–4 mm in
diameter, a 2–8 mm spot, 30–60 ms pulse duration, and
100–370 J/cm2 should yield successful results (Lyra; Laserscope, San Jose, CA). In general, lower fluences work
better for larger vessels and higher fluences are required for
vessels smaller than 0.5 mm. It has also been reported that
longer pulses may provide gentler heating of treated vessels
and a greater ratio of contraction to thrombosis.
Cooling before, during and after the pulse should
always be used to prevent epidermal damage with the use
of higher fluences and to increase patient comfort. While
the treatment of small-caliber vessels is similar to the
KTP, it is useful to apply mild pressure with the handpiece when treating reticular veins to minimize the diameter and the amount of hemoglobin in the lumen. This
will allow greater vessel penetration with less total heat
and reduced thermal damage to the surrounding skin.
A B C
Figure 7.8 Levels of pressure of the 1064 nm handpiece against the skin. (A) The optimal level of pressure is to hold the handpiece gently
against the skin with slight pressure. (B) Hovering the handpiece above the skin without complete contact may result in inadequate cooling and
untoward side effects such as burns or ulceration. (C) Pressing too hard with the handpiece may compress the vein, causing inadequate
treatment secondary to paucity of the target chromophore hemoglobin
Laser Surgery
https://t.me/med1917
105
Box 7.4 Common pitfalls
v Avoid immediately re-treating or double pulsing vessels
when no instantaneous changes are present
v Allow treated areas to cool before attempting a second
pass
v
Always use the lowest possible effective fluence
v Space adjacent laser pulses at least 1–2 mm apart to
reduce excessive thermal damage
While immediate clearance is often seen with small
vessels, larger telangiectasias and reticular veins may yield
no visible change during the treatment but should improve
over weeks to months.
Swelling, urtication or erythema around treated vessels
is common post procedure. The application of ice packs
or a topical steroid will speed resolution and lessen the
risk of post-inflammatory hyperpigmentation. Compression stockings are generally considered unnecessary after
the treatment of small telangiectasias. They may improve
results when worn for 1 week after the treatment of larger
telangiectasias and reticular veins by preventing vessel
refilling.
• Troubleshooting
In the laser treatment of leg veins, a few common pitfalls
exist (Box 7.4). In order to avoid excessive thermal
damage, the treating physician must be careful not to
re-treat or double pulse vessels when no instantaneous
changes are apparent. It can take several minutes after
treating an area at appropriate parameters for thermocoagulation to occur.
Retreating an area without allowing the tissue to cool
creates excessive thermal injury, which may lead to scarring and ulceration. It is better to work on a separate
treatment area and return to the stubborn vessel after
5–10 minutes have passed. Similarly, the lowest possible
fluence that will effectively treat a particular vessel should
be used to minimize complications. It is always safer to
start low and increase to higher energies as needed
depending on the vessel response. Blanching of the skin is
a sign of excessive thermal injury and should be avoided.
Finally, the physician should be aware of the lateral
spread of thermal energy, particularly with the longer
wavelength 1064 nm laser. Vessels connected to or adjacent to the treatment pulse area may receive enough
thermal damage to effectively coagulate. For this reason,
pulses should be separated by at least 1–2 mm.
• Side effects, complications, and alternative
approaches
Complications of laser therapy for leg veins include epidermal damage, thrombosis, hyperpigmentation, telangiectatic matting, and incomplete clearance (Box 7.5,
Box 7.5 Side effects
v Transient hyperpigmentation
v Purpura
v
Telangiectatic matting
v Pain
v Thrombosis
v
Epidermal damage
v Incomplete clearance
Fig. 7.9). Patients often find the procedure uncomfortable,
but rarely complain of postoperative discomfort. Those
who develop telangiectatic matting or incomplete clearance should either undergo re-treatment with the laser or
sclerotherapy as appropriate. Localized areas of thrombosis may resolve on their own or can be easily expressed
with an 18 gauge needle. Post-procedure hyperpigmentation is generally temporary and the incidence has decreased
with the use of longer wavelengths and improved epidermal cooling. As with any laser, meticulous wound care
should follow any epidermal damage that occurs to
decrease the incidence of scarring. Such wound care may
include copious emolliation with a bland petrolatumbased ointment, and crusting and erosions may require a
brief course of potent topical steroids.
ADVANCED TOPICS: TREATMENT TIPS FOR
EXPERIENCED PRACTITIONERS
1. The monomodal wavelength, varied pulse duration
approach is a straightforward, effective method of
treatment of leg veins.
2. Wait at least 8 weeks between treatments with laser
technologies.
3. Post-treatment compression is not needed for laser
treatment of nonelevated leg veins.
4. Artificial tanners may increase post-inflammatory
hyperpigmentation from laser treatment of leg veins.
5. The optimal endpoint of therapy of laser treatment
for leg veins is immediate pigment darkening and
vasoconstriction, however sometimes no immediate
clinical effect will be seen.
6. Combined laser/sclerotherapy treatments in a single
treatment session may have additive effects.
7. To further reduce the low risk of thrombosis,
patients should whenever possible discontinue the
use of oral contraceptives prior to receiving laser
treatment for leg veins.
CASE STUDIES
See Figures 7.10–7.13 for examples of treatment of reticular leg veins and treatment of spider telangiectasias.
106
https://t.me/med1917
Treatment of Leg Veins
A B
C D
E F
Figure 7.9 Complications resulting from laser surgery of leg veins. (A) Purpura 1 day post-treatment with the pulsed-dye laser (elliptical spot).
(B) Blisters. (C) Transient hyperpigmentation. (D) Hypopigmentation occurring in a patient with tanned skin. (E) Telangiectatic matting.
(F) Ulceration
Laser Surgery
https://t.me/med1917
107
A B
Figure 7.10 (A) Reticular leg vein pre-treatment. (B) Post-treatment with long pulsed Alexandrite laser 8 mm spot, 70 J/cm2, 3 ms,
three passes (GentleLase, Candela corporation, Wayland, MA) (Photo courtesy of Dr Arielle Kauvar)
A B
Figure 7.11 (A) Reticular leg vein pre-treatment. (B) Post-treatment with long-pulsed 1064 nm laser (Courtesy of Dr Thomas E. Rohrer)
108
https://t.me/med1917
Treatment of Leg Veins
A B
Figure 7.12 (A) Larger leg telangiectasia pre-treatment. (B) Post-treatment with pulsed-dye laser 3 × 10 mm elliptical spot, 10 ms, 18 J/cm2,
50/20 DCD (Vbeam, Candela corporation, Wayland, MA) (Photos courtesy of Dr Thomas E. Rohrer)
A B
Figure 7.13 (A) Spider telangiectasias pre-treatment. (B) Post three treatments at 8-week intervals with the long-pulsed 1064 nm laser
(Courtesy of Dr Thomas E. Rohrer)
Laser Surgery
https://t.me/med1917
109
FURTHER READING
Bernstein EF 2001 Clinical characteristics of 500 consecutive
patients presenting for laser removal of lower extremity spider
veins. Dermatologic Surgery 27:31–33
Coles CM, Werner RS, Zelickson BD 2002 Comparative pilot sudy
evaluating the treatment of leg veins with a long pulsed
Nd:YAG laser and sclerotherapy. Lasers in Surgery and
Medicine 30:154–159
Dover JS, Sadick NS, Goldman MP 1999 The role of lasers and
light sources in the treatment of leg veins. Dermatologic Surgery
25:328–336
Eremia S, Li C, Umar SH 2002 A side-by-side comparative study
of 1,064 nm Nd:Yag, 810 nm diode and 755 nm Alexandrite for
treatment of 0.3–3 mm leg veins. Dermatologic Surgery
28:224–230
Galeckas KJ 2008 Update on lasers and light devices for the
treatment of vascular lesions. Seminars in Cutaneous Medicine
and Surgery 27:276–284
Kauvar AN 2000 The role of lasers in the treatment of leg veins.
Seminars in Cutaneous Medicine and Surgery 19:245–252
Kono T, Yamaki T, Ercocen AR, et al 2004 Treatment of leg veins
with the long pulse dye laser using variable pulse durations and
energy fluences. Lasers in Surgery and Medicine 35:6237
Levy JL, Elbahr C, Jouve E, Mordon S 2004 Comparison and
sequential study of long pulsed Nd:Yag 1,064 nm laser and
sclerotherapy in leg telangiectasias treatment. Lasers in Surgery
and Medicine 34:273–276
Omura NE, Dover JS, Arndt KA, Kauvar AN 2003 Treatment of
reticular leg veins with a 1064 nm long-pulsed Nd:Yag laser.
Journal of the American Academy of Dermatology 48:76–81
Parlette EC, Groff WF, Kinshella MJ, et al 2006 Optimal pulse
durations for the treatment of leg telangiectasias with a
neodynium YAG laser. Lasers in Surgery and Medicine
38:98–105
Ross EV, Domankevitz Y 2003 Laser leg vein treatment: a brief
overview. Journal of Cosmetic and Laser Therapy 5:192–197
Ross EV, Domankevitz Y 2005 Laser treatment of leg veins:
Physical mechanisms and theoretical considerations. Lasers in
Surgery and Medicine 36:105–116
Sadick NS 2003 Laser treatment with a 1064 nm laser for lower
extremity class I–III veins employing variable spots and pulse
width parameters. Dermatologic Surgery 29:916–919
Sadick NS, Makino Y 2004 Selective electro-thermolysis in
aesthetic medicine: a review. Lasers in Surgery and Medicine
34:91–97
Sadick NS, Trelles MA 2005 A clinical, histological, and computer-
based assessment of the Polaris LV, combination diode and
radiofrequency system, for leg vein treatment. Lasers in Surgery
and Medicine 36:98–104
Sadick NS, Weiss RA, Goldman MP 2002 Advances in laser surgery
for leg veins: bimodal wavelength approach to lower extremity
vessels, new cooling techniques, and longer pulse durations.
Dermatologic Surgery 28:16–20
8
https://t.me/med1917
Ambulatory Phlebectomy
Albert-Adrien Ramelet
INTRODUCTION
Already described in Roman times and in the Middle
Ages, and rediscovered by the Swiss dermatologist Robert
Muller, ambulatory phlebectomy (AP) is a safe and effective surgical technique that enables the removal of incompetent saphenous veins (except the saphenofemoral and
in most cases the saphenopopliteal junctions), their major
tributaries, perforators, and reticular veins, including the
feeding veins of telangiectasias, or even blue telangiectasias. Ambulatory phlebectomy may also be used in varicophlebitis and superficial phlebitis, or for veins in other
locations, for instance dilated periorbital, temporal or
frontal venous networks, as well as venous dilatation of
the abdomen, arms or dorsum of the hands.
AP is indicated in almost all patients, including the
elderly. Most of the procedures are performed in truly
ambulatory patients, but the technique may also be used
in conjunction with other surgical procedures in ambulatory or stationary patients.
The goal of ambulatory phlebectomy is to secure definitive treatment of the varicose veins, once the underlying
cause of reflux has been treated and eliminated. In some
cases, the goal may be only partial or short-term improvement. Examples include avulsion of a single painful varicose vein in a young mother unwilling or unable to consider
more extensive treatment, or in an elderly patient, removal
of a single symptomatic varicose segment or of a feeding
vein causing a leg ulcer.
THE PROBLEM BEING TREATED
This chapter will clarify how to select patients who may
benefit from AP and how to safely and effectively perform
the procedure. However, AP cannot be learned solely
from a textbook, and being able to perform the procedure
independently requires observing an experienced phlebologist treat different kinds of varicose veins as he or she
carefully explains the successive steps of infusing anesthesia, operating and bandaging.
Every patient should be carefully interviewed and
examined, with the examination including at least a continuous wave Doppler, but preferably duplex ultrasound
(DUS), before selection of the most appropriate procedure (Box 8.1). Side-transillumination (episcopy) is a
useful tool for detecting reticular varicose veins and
feeding veins associated with overlying telangiectasias.
PATIENT SELECTION
Patients of all ages may be treated with AP. All types of
primary or secondary varicose veins (saphenous, reticular,
perineal, telangiectatic, veins and perforators corresponding to classes C1–C6 of the clinical, etiologic, anatomic,
pathophysiologic classification (CEAP)) may be removed
by AP (Boxes 8.2, 8.3; Figs 8.1–8.3). Further special indications are discussed at the end of this chapter.
Regional venous networks particularly appropriate for
ambulatory phlebectomy include accessory saphenous
veins of the thigh, groin pudendal (perineal) veins, reticular varicose veins (popliteal fossa, lateral thigh and leg, as
described by Albanese), veins of the ankles, and the dorsal
venous network of the foot.
While most procedures are performed in ambulatory
patients, the technique may also be used in conjunction
with other surgical procedures such as high ligations (crossectomy), stripping of incompetent saphenous veins and
endovenous ablation (laser or radiofrequency) in ambulatory or stationary patients.
Contraindications are rare or relative: critical arterial
ischemia, infections, allergy to local anesthetics, bedridden status, and impaired blood clotting or immunity.
AP is usually not performed during pregnancy or immediately postpartum, as varicose veins frequently regress
spontaneously.
EXPECTED BENEFITS
Since Muller’s first writings in 1966, AP has been considered a very effective and economical technique that
affords outstanding cosmetic results.
Long-term results tend to be excellent as long as the
most proximal source of reflux is eliminated, however
evidence-based objective data confirming this widely
accepted conclusion continue to be sparse. A single
112
https://t.me/med1917
Treatment of Leg Veins
Box 8.1 Diagnostic methods
v Patient interview
v Clinical examination while the patient is in the supine
position
v
Episcopy (side-transillumination)
v Doppler or duplex ultrasound
Box 8.2 C classes in CEAP (2004)
C0 No visible or palpable signs of venous disease
C1 Telangiectasias or reticular veins
C2 Varicose veins; distinguished from reticular veins by a
diameter of 3 mm or more
C3 Edema
C
Changes in skin and subcutaneous tissue secondary to
4
chronic venous disorders (CVD)
C4a Pigmentation or eczema
C4b Lipodermatosclerosis or atrophie blanche
C5 Healed venous ulcer
C6 Active venous ulcer
Each clinical class is further characterized by a subscript for the
presence of symptoms (S = symptomatic) or absence of symptoms
(A = asymptomatic). Symptoms include aching, pain, tightness,
skin irritation, heaviness, muscle cramps, and other complaints
attributable to venous dysfunction. (Adapted from Eklof B, et al 2004
Revision of the CEAP classification for chronic venous disorders:
consensus statement. Journal of Vascular Surgery 40:1248–1252)
Box 8.3 Indications for AP
v Saphenous and saphenous tributaries
v Varicose veins of the lateral aspects of the leg
v Reticular varicose veins
v Perineal varicose veins
v Veins of the dorsal aspect of the foot
v Varicose pearls
v Perforators (with some limits)
Phlebectomy of an isolated portion of a saphenous vein should
not be conducted if the termination is insufficient. Phlebectomy
of the perforators is to be envisaged with caution. The results are
good if the hook is used to remove the medial perforators of
the thigh and small perforators of the lateral surface of the
legs. The results are mediocre with respect to the medial perforators of the lower leg
OTHER INDICATIONS
v
Curettage of telangiectasias
OTHER ESTHETIC INDICATIONS
v
Facial, palpebral and arm veins, etc.
A B
Figure 8.1 (A) Pretibial varicose veins (C2).
(B) 6 weeks after AP
Ambulatory Phlebectomy
https://t.me/med1917
113
A
B
Figure 8.2 (A) Saphenous accessory
varicose veins, incompetence of Dodd’s
perforator (C2). (B) 6 weeks after AP
A
B
Figure 8.3 (A) Reticular varicose veins
(C1). (B) 6 weeks after AP
114
https://t.me/med1917
Treatment of Leg Veins
randomized, controlled trial by de Roos (2003) has recently
been published and found excellent long-term results of
AP and verified its superiority to sclerotherapy for treatment of the anterior thigh accessory great saphenous vein.
A recent extensive study demonstrates satisfying longterm results of phlebectomy, even with conservation of a
refluxing saphenous vein (Pittaluga 2009).
Improvement in anesthetic technique with the advent
of tumescence has resulted in greatly reduced pre- and
postoperative pain as well as complications. As AP is
usually performed in the friendly environment of an office
rather than in the operating room, it is mostly experienced
as ‘quite comfortable’ by patients.
The technique is safe, as noted by several publications
that have reviewed reported complications of AP. The
side effects of this procedure will be discussed later.
It should be noted that in order to obtain good results
and prevent recurrences, AP must only be performed
when it is indicated. When this procedure is selected, it
must consist of removal of all segments of varicose veins,
including feeding perforators, to prevent relapses or
unsightly complications, such as telangiectatic matting.
AP is an easy and inexpensive procedure to perform.
A skilled practitioner may remove an extensive array of
varicose veins in a short period of time, generally lasting
20–90 minutes, with both legs being operated upon in a
single session. A simple, streamlined operative approach
by a well-trained practitioner is much more effective and
economical than ‘high-tech’ new modalities.
Sclerotherapy may initially appear to be even easier to
perform and more economical than AP, but for veins
larger than superficial telangiectasias, the number of sessions required and the high rate of recurrence exclude this
option (Box 8.4).
OVERVIEW OF TREATMENT STRATEGY
• Treatment approach and major
determinants
Major treatment modalities in phlebology include compression therapy, sclerotherapy, AP, endovenous ablation,
surgery, and laser treatment. Each technique has its own
indications and advantages, although there are some areas
of overlap.
For most indications, the procedure most similar to AP
is sclerotherapy. Sclerotherapy is principally indicated in
Box 8.4 Principal indications of sclerotherapy and AP
v Sclerotherapy: telangiectasias and reticular varicose
veins
v Ultrasound-guided sclerotherapy:
networks, including the small saphenous veins
v Ambulatory phlebectomy: from reticular to large,
epifascial varicose veins
a
These indications are debatable. The choice of the method
depends first on the skill of the practitioner and local traditions.
intrafascial varicose
a
the treatment of telangiectasias and reticular varicose
veins. New modalities, such as foam sclerotherapy
and ultrasound-guided sclerotherapy, afford excellent
results in the treatment of intrafascial varicose networks,
including post-operative relapse, the small saphenous
veins, or saphenous and accessory saphenous veins of the
thigh.
AP is superior to sclerotherapy in the treatment of
medium to large, epifascial varicose veins. With AP, there
are fewer recurrences, and no risks of inadvertent intraarterial injection, skin necrosis (due to extravasation of
sclerosant or unpredictable arteriovenous anastomosis
injection), or residual hyperpigmentation.
PATIENT INTERVIEWS
Elicitation of patient histories is discussed in a previous
chapter. Recording of structured case histories permits
appropriate weighting of the various symptoms and venous
risk factors, and improved estimation of prognosis.
The physician must be especially receptive to the
patient’s complaints and expectations, as postoperative
patient disappointment is often less a matter of technical
failure than the result of unrealistic patient expectations
that were unchallenged prior to treatment.
Careful analysis of the patient’s history and symptoms
may enable the physician to differentiate venous problems
from arterial lesions, nerve root irritation syndrome, osteoarticular or muscle-tendon disease, and more generalized
diseases such as fibromyalgia. Some symptoms, such as
muscle cramps and restless legs, are not very specific.
Treatment of varicose veins is unlikely to result in the
resolution of these symptoms, and the patient should be
made aware of this.
The prognosis and likely evolution of chronic venous
disease in each particular patient should also be discussed.
Depending on the predominant type of varicose veins, the
severity of the disorder, and presence of specific risk
factors, patients may be likely to encounter different
clinical courses in the future.
CLINICAL EXAMINATION
This is an essential part of the treatment, as good AP
results depend on the accuracy of the diagnosis and of a
thorough evaluation of the exact origin and extent of the
varicose veins. Clinical examination should be supplemented by Doppler and/or duplex ultrasound, as described
in Chapter 3 (Box 8.1).
TREATMENT TECHNIQUES
• Equipment
Only a few surgical instruments and forms of equipment
are required (Box 8.5) for AP. Among the types of
hooks that have been marketed for vein grasping and
extraction are the Müller, Oesch, Ramelet, Tretbar, and
Varady (Figs 8.4–8.7).
Соседние файлы в папке Библиотека им академика М.И. Перельмана