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157
N.S. Sadick et al. (eds.), Practical Approach to the Management and Treatment of Venous Disorders,
DOI 10.1007/978-1-4471-2891-5_16, © Springer-Verlag London 2013
1 6
Introduction
With an increasing emphasis on whole body
rejuvenation as a trend in aesthetic medicine,
improvement of hand aging is playing a major role
in terms of patient practices. The hands may show
aging in terms of skin characteristic aberrations i.e.,
surface changes, pigment dyschromia or rhytids as
well as volume depletion characteristics which
include protuberant dorsal arch veins and skin lax-
ity. In this setting, the treatment of protuberant dor-
sal arch veins of the hand plays a major role.
Anatomy of the Dorsal Venous
System of the Hands
The blood supply of the rich and complex vascu-
lar network of the hand is fed by the radial and
ulnar arteries, which are branches of the brachial
artery. Additional blood fl ow comes from the
anterior interosseous artery, the posterior
interosseous artery, and the median artery, which
are branches of the ulnar artery.
The dorsal arteries of the hand originate proxi-
mally from the posterior interosseous artery and
a dorsal perforating branch of the anterior
interosseous artery. They form a dorsal carpal
arch that is the source of the dorsal metacarpal
arteries and the dorsal metacarpal artery fl aps.
These dorsal metacarpal arteries are particularly
reliable for the fi rst and second and subsidiary for
the third and fourth metacarpals.
Dorsal digital arteries were formed by arteries
that arise from the super fi cial palmar arch. They
travel along the sides and dorsal aspects of the pha-
langes of the middle fi nger, ring fi nger, and little
fi nger and communicate with the proper palmar
digital arteries. The dorsum of each digit, distal to
the proximal interphalangeal joint, is vascularized
by dorsal branches of the proper digital arteries.
The veins on the hands generally accompany
the deep arterial system as venae comitantes. In
addition a super fi cial venous system at the dor-
sum of the hand contributes to the cephalic and
basilic vein in the upper extremity.
Treatment Options
Treatment options for protuberant hand veins
include liquid sclerotherapy techniques, endovenous
laser ablations, or less commonly, ambulatory phle-
bectomy (Table 16.1 ). Combination approaches
employing lasers and radiofrequency technolo-
gies may complete the treatment program for hand
rejuvenation.
Sclerotherapy
Sclerotherapy of protuberant hand veins involves
direct instillation of sclerosants into the desired
vessels. Polidocanol and sotradecol are the
Treatment of Hand Veins
Neil S. Sadick
N. S. Sadick , M.D.
Clinical Professor of Dermatology – Weill Cornell
Medical College , New York , NY , USA
e-mail: nssderm@sadickdermatology.com
https://t.me/med1917
158
N.S. Sadick
common sclerosant agents employed by the
author. Foamed liquid sclerosant agents may also
be employed in this setting. Polidocanol 0.5% or
sodium Sotradecol 0.25% are commonly employed
by the author. When foamed preparations are uti-
lized three to four parts of air to one part liquid
sclerosant is commonly used to prepare the
foamed solutions and the concentration of sclero-
sant employed is thus reduced by 65–75% (i.e.,
polidocanol 0.04% or sotradecol 0.2%) (Fig. 16.1 ).
The procedure is performed with the hand elevated
on either a Mayo stand or surgical arm board.
The area is then cleansed with alcohol and the
veins to be treated are identi fi ed. The sclerosant
is drawn up in 3 cc syringes and a 30 gauge nee-
dle is employed for injection. Approximately
1.0–2.0 cc of sclerosant is injected per injection
site. The entire vessel is treated at each injection
session. Care is necessary in order to avoid
extravasation of sclerosant.
Compression is applied immediately after the
treatment is completed with an elastic bandage.
The author utilizes either Elastoplast
®
(Beiersdorf,
Hamburg, Germany) or Coban
®
(3M, St. Paul,
MN, USA) in this setting. Compression is man-
dated for 48 h, day and night, after the procedure.
The author usually treats one hand at a time dur-
ing each treatment session. Complications of this
procedure are mostly related to bruising. The patient
is requested to remain off platelet aggregation dis-
adhesion agents including aspirin, NSAIDs, Plavix,
herbal products and alcohol discontinuance is rec-
ommended for at least 48 h prior to the procedure.
Low energy fl uence pulse dye laser treatments
at 4–5 J/cm
2
are recommended if bruising ensues.
Extravasation necrosis is prevented by being
sure that the solution is being injected intravas-
cularly. If extravasation is suspected, fl ushing
of the treatment area is recommended utilizing
physiologic saline with appropriate wound care
measures if impending breakdown is identi fi ed.
Edema may last for up to several days and may
be minimized by appropriate compressive mea-
sures and keeping the hand elevated as much as
possible the fi rst 48 h following the procedure.
Endovenous Laser
An alternative way to treat protuberant hand vessels
is to utilize a laser generator and laser fi ber inserted
into desired treatment vessels (Fig. 16.2 ). The pro-
cedure is carried out by injecting a small amount of
lidocaine over the treatment vessels under consid-
eration to raise a small bleb. Subsequently, a 21-in.
angiocath is threaded into the vessel. Then the laser
fi ber is subsequently inserted. Following this inser-
tion, tumescent anesthesia is instilled either manu-
ally or through a peristaltic pump device according
to the following formula:
Tumescent 0.05% through the cannula bore
Lidocaine 1%, 50 cc in 1,000 cc ringers lac-
tated formula
Epinephrine 1:1,000 – 1 ampoule (1 cc)
Sodium Bicarbonate 8.4% 10 cc
This solution should encase the entire vessel
under treatment consideration in order to act as a
heat sump to prevent cutaneous thermal injury.
Duplex ultrasound guidance is not necessary
in this setting.
The laser generator is then activated and the
laser fi ber is pulled back slowly at 1 mm every
2–3 s. The fl uence is low at 3–4 J/cm
2
.
Multiple vessels utilizing multiple angiocaths
may be employed at a given treatment session.
Post-treatment compression is similar to that
described for sclerotherapy techniques in the
above section.
The major adverse event potential utilizing
endovenous laser technology for hand vein abla-
tion is super fi cial skin burn if the skin is not well
protected employing adequate tumescent anes-
thesia. If a burn does ensue appropriate wound
care measures should be carried out.
The advantage of this technique is that vessels
are eradicated consistently in a single treatment
session. The disadvantage is this technique is the
necessary instrumentation and cost of the
procedure.
Table 16.1 Hand vein rejuvenation options
Sclerotherapy, foam sclerotherapy
Endovenous laser
Ambulatory phlebectomy
Combination approaches
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15916 Treatment of Hand Veins
ab
Fig. 16.1 ( a ) Before treatment. ( b ) Two month after two treatments with 3 ml 0.25% STS foam
Fig. 16.2 Steps of an EVLH procedure: Before ( a ), insertion of cannula ( b ), activated laser fi ber ( c ), withdrawal of
activated laser fi ber ( d ), immediate post procedure ( e ), post dressing compression bandage ( f )
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160
N.S. Sadick
Ambulatory Phlebectomy
Hook avulsion of unwanted hand veins can also
be utilized to remove unwanted dorsal hand veins.
The skin is prepared utilizing Betadine as a ster-
ile scrub. Tumescent anesthesia is employed as in
the same manner for endovenous laser (see previ-
ous section). A small (1–2 mm) incision is made
utilizing a Number 11 Bard-Pasher blade.
(Becton, Dickinson & Company, Franklin Lakes,
NJ) A number 4 Mueller hook is utilized to exte-
riorize the desired vein and then through a gentle
traction and rolling technique the vein is sepa-
rated from the underlying structures.
Multiple veins may be removed at a single
treatment session. Compression considerations
are similar to those noted in the sclerotherapy and
endovenous laser sections.
The major side effects of this procedure are
bruising with ecchymosis, edema and tumescent
neuropathy. Gentle technique is paramount in avoid-
ing these issues. Discontinuance of platelet aggre-
gation inhibitors is also helpful in this regard.
Follow Up
It should be noted that after any of these treat-
ments for hand veins, other super fi cial dorsal hand
veins may compensate by enlarging, with the mis-
taken impression by the patient that the surgeon
“missed” some veins. If the patient is advised of
this possibility prior to procedures, they will likely
be more accepting of it, and subsequent sclero-
therapy may help alleviate this situation.
Combination Techniques
Once protuberant hand veins have been removed
the physician can draw his attention to the other
signs of the aging hand.
In this regard, localized pigmentation may be
removed by Q-switched laser while diffuse pig-
mentation, rough skin surface and fi ne rhytids may
be addressed by super fi cial chemical peels or fi rst
generation fractional laser technologies. Skin
tightening may be accomplished by new genera-
tion radiofrequency or ultrasound modalities.
Volume depletion may be addressed utilizing
autologous fat transfer hyaluronic acid, calcium
hydroxylapatite or poly-l-lactic acid derivatives
completing a structural three-dimensional rejuve-
nation program for the hands similar to what we
utilize for the face.
Conclusion
Unwanted protuberant hand veins are an
important part of non-invasive whole body
rejuvenation programs. Multiple approaches
utilizing from liquid sclerosants, endovenous
laser fi bers and minimally invasive surgical
techniques may be employed in this regard.
Combination approaches utilizing multiple
techniques and fi ller agents round out the aes-
thetic approach to hand rejuvenation.
Patients should be counseled during the
initial visit that these vessels will no longer be
available as a source of intravascular access in
the future. Otherwise these procedures are
associated with high patient satisfaction and a
minimal adverse event pro fi le.
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161
N.S. Sadick et al. (eds.), Practical Approach to the Management and Treatment of Venous Disorders,
DOI 10.1007/978-1-4471-2891-5_17, © Springer-Verlag London 2013
1 7
Indications
Compression therapy is a treatment modality which
is several thousands years old. Based on experi-
ence it was only during the last few years that its
clinical ef fi cacy has also been proved by random-
ized controlled trials in several indications.
Indications Endorsed by Evidence-
Based Medicine
Medical Compression Stockings
Table 17.1 summarizes the indications for which
the use of medical compression stockings could
be proved by evidence-based medicine [ 1, 2 ] .
There are still indications for which clear
bene fi cial effects of compression stockings have
not been proved by randomized controlled trials,
which does not mean that they might not be
ef fi cient :
1. asymptomatic or symptomatic varicose veins,
2. prevention of varicose veins after surgery,
3. treatment of venous oedema,
4. treatment of super fi cial phlebitis,
5. therapy of postthrombotic syndrome (Table 17.2 ) .
Indications Endorsed by Experience
Examples for excellent indications for com-
pression treatment for which only few convinc-
ing randomized controlled trials are available:
the postoperative phase after surgery or
endovenous procedures; edema; and super fi cial
phlebitis.
Compression After Vein Procedures
While routine compression after sclerotherapy is
still a matter of debate, it is common practice
everywhere in the world to perform some sort of
compression after surgery or after endovenous
treatment of re fl uxing veins.
In a study based on the assessment of indepen-
dent observers, Philippe Kern et al. have demon-
strated that compression stockings in a range of
20–30 mmHg worn for 3 weeks are able to
improve the cosmetic outcome after sclerother-
apy of spider veins on the lateral thigh [
3 ] .
Many trials have been done after surgery of
varicose veins comparing different forms of com-
pression for different time-periods. However, no
single study up to now has evaluated the outcome
of compression versus no compression after
active treatment of large veins.
Daily experience has taught us that strong com-
pression after surgery and after endovenous proce-
dures of large veins reduces pain, in fl ammation and
hematoma formation more effectively than low
compression.
Compression Therapy
Hugo Partsch
H. Partsch, M.D.
Emeritus Professor, Medical University of Vienna,
Austria
e-mail: Hugo.Partsch@meduniwien.ac.at
https://t.me/med1917
162
H. Partsch
The underlying principle is the collapse of the
treated veins and their tributaries in order to
empty the veins as much as possible and to pre-
vent intra- and extra-venous blood – clots which
are the basis for later recanalization. The pressure
required to achieve this goal depends on the body
position and on the location along the limb. While
in the supine position thromboprophylactic stock-
ings exerting a pressure of about 15 mmHg are
able to narrow the veins, in the upright position
much higher pressures coming close to the intra-
venous pressure will be needed [
4 ] .
Figure
17.1 shows the intravenous pressures
in the lower extremity during quiet standing. If
we want to occlude a vein, the external compres-
sion pressure has to be higher than the intrave-
nous pressure, which is 60–90 mmHg in the leg
and 30–60 mmHg in the thigh in the standing
position.
These pressure ranges are clearly above those
of compression stockings. Especially in the thigh
region the usual postoperative compression
therapy is far away from being effective. The
pressure at thigh level exerted by a compres-
sion stocking as it is usually applied after an
endovenous procedure is around 10–15 mmHg.
With such pressures only a very small narrow-
ing effect on the great saphenous vein could be
seen by Duplex in the upright position [ 4 ] .
There are two alternatives to obtain effective
compression on the thigh:
1. to apply a strong circular adhesive bandage,
2. to use pressure pads or rolls which are able to
increase the local pressure (so-called “eccen-
tric compression”) by decreasing the local
radius (Law of Laplace). Details are described
under Pearls and Pitfalls.
Compression in the Acute Phase of
Super fi cial and Deep Vein Thrombosis
An immediate pain-relieving effect of good com-
pression is observed in patients with acute
super fi cial and deep vein thrombosis. Especially
strongly applied inelastic bandages will enable
patients to walk normally, even when they come in
limping because of pain. As shown in several stud-
ies the fear of dislodged clots being the reason for
putting such patients into bed is not justi fi ed [
5 ] .
Table 17.1 Indications for medical compression stockings proved by EBM
Light compression stockings (<20 mmHg) Improvement of venous symptoms in patients with CEAP
C0s–C1s and in varicose veins of pregnancy
Prevention of leg swelling related to prolonged sitting and
standing (“occupational leg oedema”)
Prevention of venous thromboembolism in bed-ridden patients
especially after general surgery
Medical compression stockings (20–30 mmHg) Better results and less adverse outcome after sclerotherapy of
small telangiectasias (C1)
Improvement of subjective symptoms in varicose veins of
pregnancy
Less pain and swelling in the acute phase of deep vein thrombosis
Medical compression stockings (30–40 mmHg) Better outcome after sclerotherapy of large veins (C2) compared
to light bandages
Reduction of lipodermatosclerotic areas on the leg (C4b)
Improved healing of (small) venous leg ulcers (C6)
Prevention of ulcer recurrence, higher pressure ranges seem to be
superior
Prevention of PTS after proximal DVT
Table 17.2 Summarizes indications for compression
bandages proved by evidence based medicine
Compression
bandages
Reduction of haematoma after
varicose vein surgery
Therapy of choice in venous leg
ulcers
Improvement of swelling and
pain in deep vein thrombosis
Initial treatment in lymphedema
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16317 Compression Therapy
In patients with an acute phlebitis at the junction
of the great saphenous vein , surgery does not
result in a better outcome compared with conser-
vative treatment [ 7 ] . Anticoagulation with thera-
peutic doses of low molecular weight heparin is a
basic requirement in acute deep vein thrombosis.
In patients with super fi cial thrombosis extending
close to the junction, low molecular weight hepa-
rin or Fondaparinux are recommended for
4–6 weeks [ 8, 9 ] .
Immediate mobilization of mobile patients
with acute proximal deep vein thrombosis has
also been shown to reduce the incidence of post-
thrombotic sequelae [
10 ] .
Non-phlebological Indications
for Compression Therapy
Bene fi cial effects of compression are well known
and appreciated in several non-phlebological
areas of practical medicine.
Some examples
1. posttraumatic edema (e.g. ankle sprains,
hematomas),
2. burns and scars,
3. vasculitis, erysipelas (cellulitis).
In the lower extremities the in fl uence of gravity
on the local circulation may cause speci fi c prob-
lems concerning skin nutrition. Compression coun-
teracting gravity is therefore the adequate basis for
treating skin lesions associated with a whole vari-
ety of clinical conditions. Examples are any kind of
in fl ammatory skin diseases, skin defects of non-
venous origin, e.g. ulcers in obese or haematologi-
cal patients or surgery performed on the leg which
will result in better scarring if compression is
applied postoperatively (Fig. 17.2 ).
Compression is not only effective when
applied to the extremities but also an important
treatment modality in other body regions, for
instance for treating mid-line lymphoedema,
burns, scars or keloids.
Fig. 17.1 The intravenous
pressure in the standing
position corresponds to
the weight of the blood
column between the
measuring point on the leg
and the right heart.
To compress leg veins a
pressure between 60 and
90 mmHg is necessary in the
standing position
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164
H. Partsch
Compression Stockings or Bandages?
The deciding factors in choosing between stock-
ings and bandages are the exerted pressure and
the elastic property of the textiles. Most medical
compression stockings exert a pressure between
15 and 40 mmHg in the distal leg. Stockings with
pressure higher than 40 mmHg are dif fi cult to
apply and prescribed mainly made -to-measure in
special indications, like lymphoedema. If higher
pressures are required, e.g. 40–60 mmHg, strong
compression bandages are recommended [
11 ] .
Such high pressure will only be tolerated in the
resting position if the elastic property of the fi nal
bandage is stiff. Stiff, “inelastic” material is char-
acterized by a low elasticity which is the capabil-
ity to recover its length after stretch. Therefore
the pressure of such bandages with a minimal
recoiling force depends mainly on the force
exerted during wrapping. Applied with a tolera-
ble resting pressure, stiff bandages do not give
way during walking but rather create high pres-
sure peaks (= high “working pressure”)
(Fig.
17.3 ). When several layers and components
of elastic textiles are applied over each other the
fi nal bandage will act like an inelastic bandage
(Table 17.3 ) [ 12 ] .
Deciding factors for the choice to use medical
compression stockings or bandages are shown in
Table 17.4 .
Contraindications
Peripheral arterial occlusive disease is the most
important contraindication for conventional com-
pression treatment. As a principle rule a sustained
external compression pressure should never
exceed the intra-arterial pressure.
Measurement of Systolic Ankle Pressure
The intra-arterial pressure in the lower limb can
easily be measured by a pocket-Doppler instru-
ment. Figure 17.4 shows the practical procedure:
A blood pressure cuff is applied to the distal
leg just above the ankle while the patient is in a
recumbent position. If there is ulceration in this
region the skin defect is covered by a thin protec-
tive dressing for the duration of the measure-
ment. Using a conventional CW-Doppler probe
the sound over the tibial posterior artery behind
the medial malleolus and the dorsalis pedis artery
should be clearly audible and biphasic. The
blood pressure cuff is in fl ated over the point at
which no arterial signals can be heard any more.
By slowly releasing the pressure the fi rst audible
arterial pulsation corresponds to the systolic
ankle pressure which normally will be higher
than the systolic arm pressure. The relation
between ankle pressure and arm pressure, the so
called ABPI (arterial brachial pressure index) in
a healthy subject is >1.0.
ABPI values between 0.6 and 0.8 are indicative
of arterial obstructions proximal to the distal leg.
Fig. 17.2 Posttraumatic haematoma over the knee. When
the trauma happened the patient wore a knee-length com-
pression stocking because of his varicose veins which pro-
tected the leg from haematoma
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16517 Compression Therapy
Values of 0.5 and less are a sign of severe isch-
emia. In patients with mediasclerosis (mainly dia-
betics or patients with severe kidney-disease)
ABPI values of more than 1.3 may be measured
because of the non-compressibility of the sclero-
sed peripheral arteries.
The consequences especially regarding sus-
tained compression therapy are summarized in
Table 17.5 .
A sustained pressure is exerted mainly by
elastic products (elastic bandages and compres-
sion stockings) while stiff, short stretch products
44
44
INELASTIC
ELASTIC
Lying Stand Kneebends Lying
60 90 32
47 54 40
Fig. 17.3 Interface pressure measured in the medial gaiter
area under a stiff bandage ( top ) and an elastic, long-stretch
bandage ( bottom ). Both bandages were applied with a com-
parable resting pressure of 44 mmHg. Dorsi fl exions induce
much higher pressure peaks with the inelastic than with the
elastic bandage. Standing up leads to an increase of pres-
sure to 60 mmHg under the inelastic and to 47 mmHg .
Knee-bends show higher pressure amplitudes with the
inelastic than with the elastic bandage
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166
H. Partsch
can be applied without stretch and will lose pres-
sure immediately after application.
In spite of peripheral arterial occlusive disease
(PAOD), compression may be very bene fi cial
especially when edema inhibits the nutritional
circulation in addition to the reduced arterial
in fl ow. Reducing the edema will lead to an
improvement of the arterial blood fl ow. Bene fi cial
effects have been shown with intermittent pneu-
matic compression, even in patients with severe
stages of arterial occlusive disease [
12 ] . Stiff
compression material may have a similar effect
when massaging pressure peaks occur during
exercise (Figs. 17.3a and 17.10 ).
Severe cardiac failure is a contraindication for
applying whole leg compression bandages to
both lower extremities because of the increase of
the preload of the heart [
13 ] . However, in patients
with cardiac edema resistant to diuretics cautious
compression of the lower legs may induce
diuresis.
Pearls
Compression Therapy in Venous
Ulceration
Compression is the basic treatment in patients
with leg ulcers [ 14 ] . Additional abolishment of
venous re fl ux by surgery, endovenous proce-
dures or sclerotherapy should be considered in
each individual case. Many reports advocate
such procedures for patients in the acute stage
of venous ulceration (Fig. 17.5 ) [ 15, 16 ] , but
up to now solid evidence exists only for a
reduction of the recurrence rate after ulcer-
healing [ 6 ] .
Table 17.4 Medical compression stockings versus bandages with high stiffness
Medical compression stockings Bandages with high stiffness
“Moderate” pressure (mm Hg) 20–30 20–40
“Strong” pressure 30–45 40–60
Main indications Maintenance therapy following ulcers,
DVT, postthrombotic syndrome,
lymphedema
Active treatment in venous ulcers,
phlebitis, DVT, lymphedema.
After vein-surgery and endovenous
procedures
Worn Day-time Day and night
Changed Every day Every several days
Practicability Mobile patient can do it Trained staff needed
Action during walking Working pressure is only slightly higher
than resting pressure
High pressure peaks during walking,
strong massaging effect
Main effects Edema reduction, improvement of
dermal blood fl ow
Narrowing of veins and hemodynamic
effects
When the ulcer is situated behind the
ankles, local pressure can be increased by
the application of specially designed rub-
ber foam pads (e.g. Komprex
®
, Lohmann &
Rauscher, Jobst Rubber Pads
®
) (Fig. 17.6 ).
Table 17.3 Examples for compression material with low
and with high stiffness [
12 ]
Low stiffness High stiffness
Single layer compression
stockings
No-stretch bandages (zink
paste, Unna boot), Velcro
band devices, pumps
Single component elastic
bandages (e.g. Ace
®
bandage)
Short stretch bandages
(e.g. Comprilan
®
,
Rosidal
®
)
Cohesive and adhesive
bandages (e.g. Panelast
®
,
Actico
®
)
Multicomponent
bandages (e.g. Profore
®
,
Coban 2
®
)
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