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_3897_Библиотеки_им_академика_М_И_Перельмана
.pdf
x
Contributors
Jessica B. Michaud , Pharm.D. Antithrombosis Center,
University of Illinois at Chicago, College of Pharmacy and University of
Illinois Hospital and Health Sciences System , Chicago , IL , USA
Nick Morrison , M.D. Morrison Vein Institute , Scottsdale , AZ , USA
Edith A. Nutescu , Pharm.D. Antithrombosis Center,
University of Illinois at Chicago, College of Pharmacy and University
of Illinois Hospital and Health Sciences System , Chicago , IL , USA
Neil S. Sadick , M.D. Clinical Professor of Dermatology – Weill Cornell
Medical College , New York , NY , USA
Karun Sharma , M.D., Ph.D. Radiology Interventional Radiology,
Georgetown University Hospital , Washington , DC , USA
Suresh Vedantham , M.D. Washington University
School of Medicine, Mallinckrodt Institute of Radiology ,
St. Louis , MO , USA
Michael J. Verta , M.D. Department of Surgery ,
Northwestern University Feinberg School of Medicine ,
Chicago , IL , USA
Hugo Partsch , M.D. Medical University of Vienna , Vienna , Austria
https://t.me/med1917
1
N.S. Sadick et al. (eds.), Practical Approach to the Management and Treatment of Venous Disorders,
DOI 10.1007/978-1-4471-2891-5_1, © Springer-Verlag London 2013
1
It may be that anatomic research on the veins, and
especially on the valves in the veins, is responsible
for all of the advances of the Twentieth Century in
Cardiovascular Medicine and surgery. It is agreed
that the studies and subsequent illustrations of the
venous valves by Fabricius led Harvey to create
his mental conception of the circulation. Before
that, the Ebers Papyrus had described “certain ser-
pentine windings”, which, were not to be operated
upon lest that lead to “head on the ground” [ 1 ] .
Clearly, experience had taught that incision into
varicosities could be fatal.
Judging by the much-reproduced illustration
(see Browse, NL Diseases of the Veins and Bergan,
JJ Venous Disorders ) of the votive offering of
Lysimachidis to Dr Amynous, the ancients were
referring not to telangiectases but instead to gross
varices. It was these that certainly should not be
incised. One can only guess what treatment Dr
Amynous employed to stimulate such a grand gift.
Curious Theories
Unproven opinions about the veins and their
functioning dominated medical thought from the
eleventh to the last half of the nineteenth century.
These were obviously in fl uenced by the black
bile theory of Galen [ 2 ] . The of fi cial teaching
claimed that black bile and other bad humors col-
lected in varicose veins. Bandaging was thought
to push back these humors into the body and
cause madness or other serious illness. As a cor-
ollary, ulcers were considered to be favorable
because their function was to drain the bad
humors. Even Paré for all of his brilliance in re-
introducing the ligature and for his success in
healing the leg ulcer of his captor, Lord Vaudeville
did not always believe that ulcer healing was
bene fi cial. He did advise that in bandaging, “roule
the leg beginning at the foote and fi nishing at the
knee, not forgetting a little bolster upon the
varicose veins” [ 3 ] .
Richard Wiseman, Sergeant Surgeon to Charles
II invented the leather lace up stocking for treatment
of the symptoms of venous disease [ 4 ] (Fig. 1.1 ).
Fast forwarding to the sixteenth century, it is
remarkable to fi nd that Fabricius (1533–1620)
not only named the valves in the veins in 1603
but also stated that they were placed to delay the
blood from “ fl ooding into the feet or hands and
fi ngers and collecting there” [ 5 ] (Fig. 1.2 ).
The objectives of the modern surgical treatment
of varicose veins were described by a number of
surgeons at the end of the nineteenth century.
Madelung in 1880’s excised the Saphenous vein
through a groin to knee incision that entailed con-
siderable morbidity and, in those days, prolonged
hospitalization [
6 ] . Perhaps it was experience
with this that led Trendelenburg to suggest liga-
tion and division of the great Saphenous vein in
the middle third of the thigh [
7 ] . Trendelenburg
deserves acknowledgement for having introduced
Phlebology: History
and Epidemiology
John Bergan
J. Bergan , M.D.
9850 Genesee, Suite 410 ,
La Jolla , CA , USA
In the case of an ulcer, it is not expedient to stand; more especially if the ulcer be
situated in the leg. [
1 ]
– Hippocrates (460–377 BC)
https://t.me/med1917
2
J. Bergan
physiological and pathophysiological reasoning
into the fi eld of phlebology and thus was the fi rst
to employ Evidence-based Medicine. It was Mayo
and Babcock at the turn of the century that intro-
duced the stripping instruments that with minor
variation are still in use a century later [ 8, 9 ] .
It is my opinion, not shared by many that
the importance of the role of incompetent
calf perforators and other perforating veins as
stressed in many instructions on performance of
varicose vein surgery and as advocated by
Cockett and many others represents a step
backward on acceptance of evidence based
medicine in Phlebology [ 10, 11 ] . Exact hemody-
namic measurements have refuted the theory of
perforating vein importance and clinical studies
have failed to prove the importance of surgery
in, for example, the treatment of leg ulcers [ 12,
13 ] . Evidence based medicine as introduced by
Trendelenburg more than 100 years ago has had
a hard time in Phlebology.
Minimally Invasive Varicose Vein
Treatment
In an attempt to minimize postoperative discom-
fort and yet maintain the bene fi ts of Saphenous
vein ablation, electromagnetic waves have been
Fig. 1.1 Compression
therapy as delivered by
Wiseman’s laced up leather
stocking was and is effective
in ameliorating symptomatic
venous stasis
Fig. 1.2 Fabricius published his De venarum ostiolis in
1603 as an unbound folio pamphlet accompanied by eight
engraved plates, which has been described as one of the
most beautiful works in the history of anatomy
https://t.me/med1917
31 Phlebology: History and Epidemiology
applied to affect rapid thermic electrocoagulation
of the vein wall and its valves [
14, 15 ] . The
energy is supplied as radio frequency (RF) and
Laser energy (EVLT). Prolonged exposure to
such energy results in total loss of vessel wall
architecture, disintegration and carbonization.
The objective of applying electromagnetic
energy to vein intima is to remove the re fl uxing
Saphenous vein from the circulation in a manner
that minimizes patient discomfort, decreases
postoperative morbidity, provides a good long-
term outcome and allows rapid return of the
patient to normal activities [ 16 ] . Since elimina-
tion of the re fl uxing saphenous vein from the cir-
culation is the only goal of the procedure,
judgment of success can be assessed by duplex
ultrasound at any time postoperatively. Relief of
patient symptoms, time to resume normal activi-
ties, post-procedure adverse events, and improve-
ment in health-related quality of life are additional
relevant measures of the procedure outcome.
However, these are linked to successful elimina-
tion of saphenous vein re fl ux.
Unlike Saphenous vein stripping, the RF and
EVLT procedures do not require a general anes-
thetic and can be performed using local high vol-
ume or intracompartmental in fi ltration anesthesia
with or without conscious sedation. These can
usually be performed on an outpatient basis in a
surgicenter or low cost settings such as a minor
procedures room or an of fi ce setting.
Early and 5 year outcomes data and ultrasound
scans clearly show that endovenous obliterations
successfully remove re fl uxing Saphenous veins
from the circulation in approximately 90% of
treatments [ 17 ] .
Now there is Level I evidence which docu-
ments success of the technique. Furthermore,
removal of the Saphenous vein from circulation
has been carefully studied and reported in sepa-
rate series. Pichot observed that serial duplex
ultrasound scans showed the RF treated
Saphenous veins to be progressively more echo-
genic and shrunken until they were incorporated
into the surrounding tissue [ 18 ] . Twelve months
after RF treatment, vein obliteration was so
complete that total sonographic disappearance
of the saphenous vein occurred in 89% of limbs
[ 19 ] .
Increasingly, some clinicians believe that
endovenous obliteration is a better operation than
vein stripping since endovenous treatment pre-
serves abdominal wall drainage and this prevents
neovascularization, the most common cause of
recurrence after proper vein stripping surgery
[
20 ] . Apparently the mechanism of failure is dif-
ferent for vein stripping compared to endovenous
obliteration. Vein stripping is subject to late fail-
ures by neovascularization at the groin, whereas
endovenous obliteration may fail early due to
incomplete obliteration. However, despite these
differences, separate studies report remarkably
similar duplex results with vein stripping and
endovenous ablation treatment [ 21 ] .
Ascent of Foam Sclerotherapy
After 100 years of surgical therapy for varicose
veins, a truly minimally invasive therapy has
emerged. It started as early as 1939 and has con-
tinuously been improved up to the present time.
Many lesser-known colleagues, such as Orbach
and Flückiger, have made many contributions
[ 22, 23 ] . Their publications show that remarkable
work was carried out in the fi eld of foam sclero-
therapy even before the development of Doppler
Duplex ultrasound and that many doctors have
used sclerosing foams during the past 60 years.
The use of foamed sclerosing agents in treatment
of varicose veins is not new [ 24 ] .
Administration of foamed sclerosant was re-
introduced in the early 1990s by Cabrera, who
vsummarized a broad experience in 1997 [ 25 ] .
Tessari developed an easy way of making liquid
sclerosant into foam using two syringes and a three-
way stop cock [ 26 ] and by 2000, Sica was able to
report a 3-year experience using foamed sclerosant
in treating saphenous varices [
27 ] . Emphasis in the
past 10 years of using foamed sclerosant has been
con fi ned for the most part to reports of treating
https://t.me/med1917
4
J. Bergan
varices and re fl uxing saphenous trunks but our
experience in treating CVI is very encouraging.
In treating varicose veins, all published reports
describe ef fi cacy in terms of immediate and primary
venous occlusion of better than 80% [ 27– 29 ] .
Repetition of injections in cases of initial failure
allows the results to approach 95% ef fi cacy with
three sessions. Early and mid term results to >5 years
demonstrate a recurrence rate of about 20%.
Treating recurrences by injections is as simple as
primary treatment and is at least as effective.
Epidemiology of Venous Insuf fi ciency
Olle Nelzen has said,
Epidemiology is the science dealing with the distri-
bution and frequency of diseases or disorders in the
population. To have knowledge of the epidemiology
of a certain disease is of fundamental importance in
order to be able to plan appropriate actions to coun-
teract the disease and to improve management,
including care and treatment. A good epidemiologi-
cal survey will form a very valuable baseline to cal-
culate the magnitude of needed treatment changes,
both monetary and workload for the personal, as
well as serving as useful comparison resource for
measuring any outcome changes as a result of per-
formed treatment changes. To be able to do that a
repeat epidemiological survey has to be undertaken
with a similar methodology. Further epidemiologi-
cal research can be used to assess or detect possible
risk factors for a certain disease, but to fi nally prove
a risk factor longitudinal studies are generally nec-
essary. It is of vital importance to be in control of
confounding factors, such as age distributional
changes, that may very well be responsible for
observed changes of prevalence for a certain disease
rather than treatment changes. Many new treatments
are made available only for subgroups of patients
with a disease. Will the result of such changes make
a difference for the occurrence of this speci fi c dis-
ease within the total population? An epidemiologi-
cal study of that population will probably give you
the answer. Furthermore, epidemiological studies
are used to evaluate the natural history of diseases
and can ascertain the characteristics of healthy per-
sons compared with diseased patients [
30 ] .
Criqui, in San Diego is a modern student of the
epidemiology of venous disease. His modern
approach has made a de fi nitive statement (Table 1.1 ).
His summary of his most recent study stated,
In a 1994–1998 cross-sectional study of a multi-
ethnic sample of 2,211 men and women in San
Diego, California, the authors estimated prevalence
of the major manifestations of chronic venous dis-
ease: spider veins, varicose veins, trophic changes,
and edema by visual inspection; super fi cial and
deep functional disease (re fl ux or obstruction) by
duplex ultrasonography; and venous thrombotic
events based on history. Venous disease increased
with age, and, compared with Hispanics, African
Americans, and Asians, non-Hispanic Whites had
more disease.
Spider veins, varicose veins, super fi cial func-
tional disease, and super fi cial thrombotic events
were more common in women than men (odds
ratio (OR) = 5.4, OR = 2.2, OR = 1.9, and OR = 1.9,
respectively; p < 0.05), but trophic changes and
deep functional disease were less common in
women (OR = 0.7 for both; p < 0.05).
Visible (varicose veins or trophic changes) and
functional (super fi cial or deep) disease were
closely linked; 92.0% of legs were concordant and
8.0% discordant. For legs evidencing both trophic
changes and deep functional disease, the age-
adjusted prevalence of edema, super fi cial events,
and deep events were 48.2%, 11.3%, and 24.6%,
respectively, compared with 1.7%, 0.6%, and 1.3%
for legs visibly and functionally normal.
Table 1.1 Visible and functional chronic venous disease in San Diego study participants
Visible disease
Normal Super fi cial disease Deep disease Total
No. % No. % No. % No. %
Normal 978 22.1 5 0.1 36 0.8 1,019 23.0
Spider veins 232 52.5 20 0.5 75 1.7 2,416 54.6
Varicose veins 164 3.7 526 11.9 92 2.1 78 17.7
Trophic changes 53 1.2 107 2.4 45 1.0 205 4.6
Total (legs) 3,516 79.5 658 14.9 248 5.6 4,422 100.0
Adapted from Criqui et al. [
31 ]
In this study, classi fi cation was based on ultrasonographic fi ndings. Of the 782 legs with varicose veins, 697 (89.1%)
also had spider veins. Of the 205 legs showing trophic changes, 188 (91.7%) also had spider veins and 141 (68.8%)also
varicose veins. Of the 248 legs showing deep functional disease, 119 (48.0%) also had super fi cial functional disease
https://t.me/med1917
51 Phlebology: History and Epidemiology
However, visible disease did not invariably predict
functional disease, or vice versa, and venous throm-
botic events occurred in the absence of either [
31 ] .
Conclusions
Recently, much has changed in the world of
phlebology. The history of Phlebology is the
history of application of the scienti fi c method
as discussed above. Among the most impor-
tant and most powerful of the changes has
been the advent of foam sclerotherapy. This is
destined to be the most important tool avail-
able to phlebology in the twenty- fi rst century.
Just as surgery has evolved into smaller and
yet more minimal invasion, so has the treat-
ment of varicose veins. While telangiectasias
have always been the target of minimal inva-
sion by needle, it is now true that even the
re fl uxing great saphenous vein and clusters of
large varicose veins are yielding to the pres-
sures of needle treatment.
Venous disorders are prevalent and many
studies of this phenomenon are available. The
most recent, that of Criqui using clinical and
duplex ultrasound techniques and summarized
in this chapter is the most informative and
accurate statement available to date [ 31 ] .
References
1. Major RH. A history of medicine. Oxford: Thomas;
1954.
2. Nutton V. The fatal embrace: Galen and the history of
ancient medicine. Sci Context. 2005;18(1):111–21.
3. Quintal D, Jackson R. Leg ulcers: a historical per-
spective. Clin Dermatol. 1990;8(3–4):4–12.
4. Browse NL, Burnand KG, Irvine AT, Wilson NM.
Diseases of the veins. 2nd ed. London: Hodder Arnold
Publishers; 1999.
5. Fabricius H. De venarum ostiolis. Padua: Jacobus De
Zetter; 1603.
6. Madelung O. Über die Ausschälung cirsoider Varizen
an den unteren Extremitäten. Verh Dtsch Ges Chir
1884;13:114–117.
7. Trendelenburg F, Bryant T. Ueber die Unterbindung der
Vena saphena magna bei Unterschenkelvaricen. Tübingen:
Verlag der H. Laupp’schen Buchhandlung; 1890.
8. Mayo C. Treatment of varicose veins. Surg Gynecol
Obstet. 1906;2:385–8.
9. Babcock W. A new operation for the extirpation of
varicose veins of the leg. N Y Med J. 1907;86:153–6.
10. Cockett FB, Jones DEE. The ankle blow-out syn-
drome; a new approach to the varicose ulcer problem.
Lancet. 1953;1(6749):17–23.
11. Dodd H, Cockett FB. The pathology and surgery of
the veins of the lower limb. Edinburgh: Churchill
Livingstone; 1976.
12. Recek C. Impact of the calf perforators on the venous
hemodynamics in primary varicose veins. J Cardiovasc
Surg (Torino). 2006;47(6):629–35.
13. Gohel MS, Barwell JR, Taylor M, Chant T, Foy C,
Earnshaw JJ, Heather BP, Mitchell DC, Whyman MR,
Poskitt KR. Long term results of compression therapy
alone versus compression plus surgery in chronic
venous ulceration (ESCHAR): randomised controlled
trial. BMJ. 2007;335(7610):83.
14. Navarro L, Min RJ, Boné C. Endovenous laser: a new
minimally invasive method of treatment for varicose
veins – preliminary observations using an 810 nm
diode laser. Dermatol Surg. 2001;27(2):117–22.
15. Weiss RA, Weiss MA. Controlled radiofrequency
endovenous occlusion using a unique radiofrequency
catheter under duplex guidance to eliminate saphen-
ous varicose vein re fl ux: a 2-year follow-up. Dermatol
Surg. 2002;28(1):38–42.
16. van den Bos R, Arends L, Kockaert M, Neumann M,
Nijsten T. Endovenous therapies of lower extremity vari-
cosities: a meta-analysis. J Vasc Surg. 2009;49(1):230–9.
17. Nwaejike N, Srodon PD, Kyriakides C. 5-years of
endovenous laser ablation (EVLA) for the treatment of
varicose veins – a prospective study. Int J Surg. 2009;7(4):
347–9.
18. Pichot O, Sessa C, Chandler JG, Nuta M, Perrin M. Role
of duplex imaging in endovenous obliteration for primary
venous insuf fi ciency. J Endovasc Ther. 2000;7(6):
451–9.
19. Pichot O, Kabnick LS, Creton D, Merchant RF,
Schuller-Petroviae S, Chandler JG. Duplex ultrasound
scan fi ndings two years after great saphenous vein
radiofrequency endovenous obliteration. J Vasc Surg.
2004;39(1):189–95.
20. Zan S, Contessa L, Varetto G, Barra C, Conforti M,
Casella F, Rispoli P. Radiofrequency minimally inva-
sive endovascular treatment of lower limbs varicose
veins: clinical experience and literature review.
Minerva Cardioangiol. 2007;55(4):443–58.
21. Merchant RF, DePalma RG, Kabnick LS. Endovascular
obliteration of saphenous re fl ux: a multicenter study.
J Vasc Surg. 2002;35(6):1190–6.
22. Orbach EJ. Clinical evaluation of a new technic in the
sclerotherapy of varicose veins. J Int Coll Surg. 1948;
11(4):396–402.
23. Flückiger P. Non-operative retrograde sclerosing of
varicose veins with varsyl foam. Schweiz Med
Wochenschr. 1956;86(48):1368–70.
24. Wollmann J-CGR. The history of sclerosing foams.
Dermatol Surg. 2004;30(5):694–703; discussion 703.
25. Cabrera Garrido JR, Cabreara Garcia-Olmedo JR,
Garcia-Olmedo Dominguez MA. Elargissement des
limites de la sclérothérapie: Nouveaux produits sclé-
rosants. Phlebologie. 1997;50(2):181–7.
https://t.me/med1917
6
J. Bergan
26. Tessari L. Nouvelle technique d’obtention de la
sclero-mousse. Phlebologie. 2000;53:129.
27. Sica M, Benigni J. Écosclérosea la mousse: trois ans
d’expérience sur les axes saphéniens. Phlebologie.
2000;53:339–42.
28. Henriet J. Expérience durant trois années de la mousse
de polidocanol dans le traitement des varices réticulai-
res et des varicosités. Phlebologie. 1999;52:277–82.
29. Hamel-Desnos C, Desnos P, Ouvry P. Nouveautes
therapeutiques dans la prise en charge de la maladie
variqueuse: echo-clerotherapie etmous. Phlebologie.
2003;56:41–8.
30. Nelzén O. Epidemiology of venous ulcers. In: Bergan
JJ, Shortell CK, editors. Venous ulcers. Burlington:
Academic Press; 2007. p. 27–41.
31. Criqui MH, Jamosmos M, Fronek A, Denenberg JO,
Langer RD, Bergan J, Golomb BA. Chronic venous dis-
ease in an ethnically diverse population: the San Diego
Population Study. Am J Epidemiol. 2003;158(5):
448–56.
https://t.me/med1917
7
N.S. Sadick et al. (eds.), Practical Approach to the Management and Treatment of Venous Disorders,
DOI 10.1007/978-1-4471-2891-5_2, © Springer-Verlag London 2013
2
Who Should Perform Sclerotherapy
Sclerotherapy is routinely performed only by
licensed physicians in most countries, but whether
other medical providers are allowed to do so may
vary according to individual governmental regu-
lations. In many states in the U.S., registered
nurses are allowed to do sclerotherapy, while oth-
ers authorize sclerotherapy by physician assis-
tants and nurse practitioners. Permitting only
physicians to perform sclerotherapy while exclud-
ing the practice by nurses, seems to fl y in the face
of the fact that nurses routinely inject patients
with potentially lethal medication as a matter of
standard nursing practice. The reason it makes a
difference as to who should be doing sclerother-
apy is that in a phlebology practice, the physi-
cian’s time can be much more productive
performing more complex procedures than scle-
rotherapy. Certainly the physician should be quite
adept at sclerotherapy, since many of the skills
required to do sclerotherapy are directly related
to the performance of other phlebologic proce-
dures. But as patient volume in a phlebology
practice grows, sclerotherapy is one of the tasks
that may readily be assumed by other members of
the staff, leaving the physician time to interact
with patients in consultations, perform diagnostic
testing as needed, and treat patients using more
complicated modalities that do not lend them-
selves to performance by other staff members.
However it is necessary to consult governmental
regulations to be certain the phlebology practice
is operating within appropriate guidelines.
It is dif fi cult for anyone to acquire the skills
necessary to successfully perform sclerotherapy
without a direct hands-on approach. One can
learn the theory of sclerotherapy, the risks, com-
plications, and treatment of complications, but
the skill itself must be learned by direct experi-
ence. And it is clear that some individuals have
the manual dexterity and hand-eye coordination
necessary to acquire the skill quickly, while oth-
ers will be slower learners, and some may never
be able to do sclerotherapy with acceptable
results. Those who already possess the skill to do
venapunctures or start intravenous lines will
likely be quicker to learn sclerotherapy, although
there is enough difference between these skills
and sclerotherapy that learning sclerotherapy is
not necessarily easy. Sclerotherapy does not
require cannulation of a vein, merely gaining
access to the vein is suf fi cient. This distinction is
more dif fi cult to appreciate than the inexperi-
enced sclerotherapist imagines.
So how does one go about acquiring sclero-
therapy skills? Hands-on training within resi-
dency or postgraduate programs will be available
to some, while others may need to acquire the
skills in less formal settings. Certainly the best
way to start is to watch a skilled sclerotherapist
who can also describe exactly how they are going
Setting Up Sclerotherapy
in a Phlebology Practice
Nick Morrison
N. Morrison , M.D.
Morrison Vein Institute ,
Scottsdale, AZ , USA
e-mail: nickmorrison2002@yahoo.com
https://t.me/med1917
8
N. Morrison
about accessing a vein. The next step might be to
begin by practicing on friends under the watchful
eye of a skilled sclerotherapist. Set aside some
off-hours time to invite volunteer friends into the
of fi ce for sclerotherapy without charge, with a
skilled sclerotherapist side-by-side to help teach
the techniques. Prescreening these volunteers
will be very helpful in excluding those with tiny
telangiectasias, as successful sclerotherapy in
these individuals will be an exercise in frustration
for the novice. Choose patients with venulecta-
sias and larger telangiectasias, to help gain
con fi dence. And limit each patient to 30 min or
so, to allow a break, since the novice will fatigue
mentally and physically more quickly than some-
one more experienced. Limit the learning ses-
sions to three to four patients, again to avoid the
inevitable fatigue that will occur and degrade
performance. After two to three such sessions,
one can move onto sclerotherapy on “real”
patients by doing injections along side an experi-
enced sclerotherapist, but only with the patient’s
knowledge and consent. The experienced sclero-
therapist can inject the smaller, more dif fi cult
veins, leaving the larger, easier veins for the
learner. Once suf fi cient skill has been acquired,
one can do sclerotherapy alone, but continued
monitoring will be helpful until one has mastered
the techniques.
And fi nally, clearly written protocols for scle-
rotherapy should be an integral part of the phle-
bology practice, so that every sclerotherapist
involved delivers consistently safe and effective
treatment.
What to Use for Sclerotherapy
Liquid sclerosants have been discussed in an
earlier chapter, but whichever sclerosants are
selected, one should be thoroughly familiar with
the appropriate concentrations and volumes, and
be prepared to handle any side effect or untow-
ard sequelae of the chosen agent. It is apparent
there is a direct correlation between the strength
of sclerosing agent, the pressure used to inject,
and the volume used in each injection, and the
incidence of these unwanted post-injection
problems [
1 ] . Commonly used sclerosing agents
include hypertonic saline, sodium tetradecylsul-
fate, glycerin, Polidocanol, and sodium mor-
rhuate. One should keep in mind that the use of
a non-approved drug may be contrary to the
policy of governmental agencies and insurance
carriers, and use of such drugs may be illegal, or
may even constitute fraud if reimbursement is
received on behalf of a patient from an insur-
ance carrier. There should be a variety of scle-
rosing agents in the phlebology practice, the
appropriate use of each being dictated by indi-
vidual circumstances such as allergy, skin type,
previous sensitivity, etc. [
2 ] .
Converting any of the detergent sclerosants
into a foam, using air or other gases, will change
the drug and render it substantially different from
the liquid form, and in some countries will
increase the medicolegal exposure associated
with the use of a non-approved or “off-label”
drug. Most importantly, a foamed sclerosant is
much more potent, requiring less volume and
lower concentration than in liquid form to suc-
cessfully sclerose a given vein [ 18 ] . Furthermore
foam sclerotherapy is associated with a small but
higher risk of complications than liquid sclero-
therapy, such as headache, visual disturbances,
chest discomfort, and changes in neurologic or
mental status (Table 2.1 ) [ 21 ] .
These complications may be seen more fre-
quently in patients with right-to-left shunts
(e.g., patent foramen ovale – PFO) that are usu-
ally undiagnosed prior to treatment [
15 ] . It is
important to realize the increased risk or the risk
Table 2.1 Side effects/complications of foam
sclerotherapy
Injection site itching Chest discomfort
Localized leg pain Dizziness
Localized burning Nausea
Tingling Headache
Localized erythema Visual disturbance
Dry cough Circumoral paresthesia
Metallic taste Respiratory dif fi culty
Changes in mentation Hyperpigmentation
Occular migraine Cutaneous necrosis
Deep vein thrombosis Super fi cial thrombophlebitis
https://t.me/med1917
92 Setting Up Sclerotherapy in a Phlebology Practice
of different side effects with the use of foam vs
liquid, and address these risks with patients
undergoing such procedures [ 16 ] . These compli-
cations and side effects are nearly always short-
lived, but while ongoing, may be of considerable
concern to both the patient and sclerotherapist.
Known right-to-left shunts or previous symptoms
suspicious of such a condition probably consti-
tute at least a relative contraindication to the use
of foam sclerosing agents [
13 ] , and may require
further investigation (e.g. bubble study to rule out
shunt). Reports of the safety of foam sclerother-
apy are abundant [ 7, 11– 14, 17, 19, 20, 22– 24 ] ,
but there are at least several published reports in
the world literature of signi fi cant neurologic
adverse events following foam sclerotherapy,
including a patient having sclerotherapy for
telangiectasia [ 8– 10, 25 ] . Therefore caution is
advised for the inexperienced sclerotherapist.
The sclerotherapy equipment is not compli-
cated and is easily obtained, but as one gains
sclerotherapy experience, personal preferences
will be established. The practice should start with
a variety of sclerosing agents as well as a variety
of syringes, needles, compression pads, etc.
Syringes will vary in the “feel” of the piston,
some smoothly advancing and others producing a
shuddering action that will lead to displacement
of the needle tip from the vein during injection.
The manufacturing technique will even vary
within the same company, causing untoward dif-
ferences in function; so as personal preferences
emerge, work closely with the supplier to be sure
you receive exactly the same equipment with
each delivery. Likewise needle sharpness and
durability will vary among manufacturers; exper-
imenting with different needle manufacturers
will allow comparison so favorites can be chosen.
A variety of needle sizes, from larger caliber
25–27 guage needles used during ultrasound
guide sclerotherapy, to smaller caliber 30–33
guage needles for telangiectasias will be neces-
sary to accommodate different size veins.
Remember, a needle dulled by repeated use will
be more painful for the patient, and make it more
dif fi cult for the sclerotherapist to successful inject
a vein. Changing needles frequently will avoid
such problems.
Similarly, a variety of sclerosing agents and
concentrations should be available for appropri-
ate treatment of different vein sizes, areas on the
body, and depth of veins. One may use a very
dilute sclerosant (e.g., 0.1% sodium tetradecyl-
sulfate) for telangiectasias, very concentrated
sclerosant (e.g., 3% sodium tetradecylsulfate) for
truncal veins, and a wide assortment of concen-
trations and agents for intermediate-sized veins.
In some practices the skin of the entire leg is
prepped with antiseptic prior to the sclerotherapy
session while in others the antiseptic is used
locally before each injection; and in still others
no prep is used at all. Infection is extremely
uncommon following sclerotherapy, so individu-
als should decide with which method they are
most comfortable. According to infectious dis-
ease specialists, patients with foreign body
implants, or those with underlying medical con-
ditions which demand antibiotic prophylaxis
prior to invasive surgery or dental work do not
need such treatment prior to sclerotherapy.
Where to Perform Sclerotherapy
Sclerotherapy can and should be considered an
of fi ce-based procedure, whether it is liquid scle-
rotherapy for telangiectasias, or ultrasound
guided sclerotherapy for large truncal veins.
Sclerotherapy is a benign treatment for a rela-
tively benign disease, and as such can be safely
performed out of the hospital or surgical suite.
A standard patient examination room with good
fl orescent or indirect sunlight (if adequately
available) is quite acceptable. Both sclerothera-
pist and patient must be able to achieve a com-
fortable position, which means one, or even
both, may use a mechanically adjustable chair
or table. The patient will likely be lying on a
table for as long as an hour, so comfort will be
very important. If the room temperature is kept
quite cool, a blanket over or heating pad under
the patient will go a long way toward patient
comfort and improving vein visiblity. Adjustable
equipment height will also help save muscle and
joint strain for the sclerotherapist during a long
day of patient treatment. The sclerotherapist
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана