09. Tumescence TRAP to compress the veins
KEYWORDS: varicose veins, Phlebotherapy TRAP, tumescence, sclerotherapy, phlebectomy, endovenous laser ablation, endovenous radiofrequency ablation
Tumescence TRAP is one of the complementary procedures of Three-dimensional Regenerative Ambulatory Phlebotherapy (TRAP).
As is known, TRAP has revolutionized phlebological treatment by replacing irrational techniques, such as sclerotherapy, phlebectomy, saphenectomy, so-called functional ligature, burning by means of laser and HF currents, and the recent absurd procedures of gluing the veins.
TRAP is not a mechanistic method; it is a biological technique that treats the venous walls, making the veins continent once again. Its action is three-dimensional, extending to the perforating, communicating and superficial circulation. TRAP treats the hemodynamic hypertension of the venous circulation in the lower limbs.
By using light that is close to infra-red, we are able to locate the veins that constitute the "gateways" to the circulation. We inject a regenerative solution of 3% sodium salicylate in a buffered hydroglycerin vehicle into all of these "gateways", or visible vessels, in sequence, in the three regions of the leg: posterior, lateral and medial.
This three-dimensional treatment restores the form and function of the veins of the superficial circulation and of the non-visible venous circulation.
Illumination with light that is close to infra-red (VeinViewer) has revealed that numerous dilated veins are located in the popliteal cavity, an anatomical area that is difficult to compress. Compression is indispensable, both during and after TRAP, to counteract hemodynamic hypertension and to allow regeneration of the venous walls. Moreover, in the first few hours after treatment, compression reduces intravenous collections of blood, which may form after the regenerative solution has been injected into large-caliber veins.
In this patient, following three-dimensional regenerative ambulatory phlebotherapy, we will perform tumescence TRAP to compress the veins of the popliteal cavity, which are difficult to compress with bandages.
As always, TRAP begins from the foot. Transillumination is used to reveal all the vessels, which are injected in sequence.
We use a 20 ml syringe filled up to 24 ml and a 25G needle. During the procedure, the needle is changed several times. In each session, 48 ml or 72 ml of solution is injected, according to the severity of the pathology and the weight of the patient. The session ends when the pre-established quantity of regenerative solution has been injected. Up to 12 mL can be injected per single injection.
Injecting small amounts of solution is not efficacious, as the solution needs to reach the deep veins within a short time in order to act on the entire internal surface of the perforating vessels. Moreover, injection must be rapid. The regenerative solution reaches the sites where it is needed: the most dilated and most dilatable veins. In 99% of cases, echo-Doppler examination is useless, as it cannot see the pathology located in perforating vessels of 1 or 2 mm in diameter.
In order to make up the regenerative solution, we need two 4 ml vials of 10% solution or three 4 ml vials of 6% solution. We place 1 ml of 2% lidocaine in the 20 ml syringe. The syringe is then completely filled up with 10% glycerol in saline solution, up to the level of 24 ml. In Italy, 10% glycerol is available in 500 ml bottles. Following Three-dimensional Regenerative Ambulatory Phlebotherapy, the "regenerated" veins become continent; the valves function once again and prevent back-flow. The hemodynamic hypertension is corrected and the hydrostatic thrust, which causes the sensation of heaviness in the legs, normalizes. All this is achieved without losing the elasticity of the vessels, which disappear from view. Since the leg is a sort of pump, the veins must not be visible; a pump that cannot empty its collectors makes no sense.
Since the concession of a recent further patent for our sclerosing solution, we have added 2 g of EDTA to the 500 ml bottle of 10% glycerol.
The solution of sodium salicylate diluted to 3% is hypertonic; on contact with the blood, it elicits hemolysis, with the release of ions of free iron.
These ions continue to circulate in the bloodstream for days, creating a generalized inflammation, which may cause phlebitis in predisposed subjects. The free iron is immediately removed by the chelating action of the EDTA that is added to the diluent of the regenerative solution. The simple addition of EDTA has eliminated this generalised inflammation, and no further cases of phlebitis have occurred. This safety and tranquillity means that the operator can try to achieve the best possible efficacy by injecting the most appropriate amounts of regenerative solution.
Once the three-dimensional injection of the regenerative solution has been completed, tumescence TRAP is carried out in the popliteal region, in order to compress the numerous ecstatic vessels that have been injected. A syringe of a different caliber has been prepared before the session of phlebotherapy. This syringe contains 4 ml of lidocaine and 20 ml of glycerol solution with the addition of EDTA. After the first injection, we replace the 25 G needle with a 21 G needle, which enables us to inject more rapidly.
Tumescence is created in the subcutaneous tissue above or below the veins that have been injected, in order to compress them. Lidocaine is anti-inflammatory, while EDTA is both anti-inflammatory and antioxidant. The potent chelating action of the EDTA, together with the compression exerted by the glycerol, minimizes intravenous collections of blood and the pigmentations caused by the free iron.
We use transillumination to identify the sites where tumescence is to be created.
The tumescence TRAP solution maintains the pasty consistency of the tissues for more than 20 hours, a time that is more than sufficient to prevent stagnation of the blood in the large-caliber vessels injected.
Tumescence TRAP is carried out in the concave areas of the foot, which are difficult to compress by means of bandages, in large varices of the lower leg and thigh, and in the popliteal cavity. If large amounts of solution are to be injected, it is advisable to add a small quantity of epinephrine, in order to avoid rapid absorption of the lidocaine and its consequent vagal effects.
In the patient that we see here, only dilated reticular veins are present; these constitute the "escape valve" for the hemodynamic hypertension. If the reticular veins had been able to withstand dilatation, numerous telangiectasias would have formed.
This clearly illustrates how illogical it is to close or remove the visible dilated veins – which are the escape valves for the hemodynamic hypertension – without restoring the continence of the non-visible perforating and communicating veins.
In conclusion, tumescence TRAP is an excellent complementary procedure of TRAP, which today constitutes the only rational treatment for varicose disease.
Capurro S. (2021): Tumescence TRAP to compress the veins. CRPUB Medical Video Journal. Phlebotherapy section. http://www.crpub.org
In Three-dimensional Regenerative Ambulatory Phlebotherapy, is the tumescence TRAP solution only used to compress the dilated veins that have been injected which are situated in regions that are difficult to compress?
No. It is also used to cleanse the veins, to dilute any of the regenerative solution that might end up outside the veins, and to reduce post-sclerotherapy patches.
What can be done about these patches?
We can perform TRAP, which restores the venous walls and corrects hemodynamic hypertension; we can perform tumescence TRAP, which chelates the free iron that is present, and, finally, we can perform Electroporo-Cosmesis, followed by the application of a saturated solution of resorcin, which is left in situ. This latter form of mixed peeling helps to reduce melanin pigmentation. If the patch is small, we can use 0.5 mixed peeling, which permeabilizes the epidermis.
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