10. Two-syringe TRAP technique for treating telangiectasias
KEYWORDS: Three-dimensional regenerative ambulatory phlebotherapy, ectatic capillaries, telangiectasia, hemodynamic hypertension, TRAP
Three-dimensional regenerative ambulatory phlebotherapy (TRAP) corrects hemodynamic hypertension of the venous circulation in the limbs, the anatomical cause of which is the valvular incontinence of the perforating veins. As venous pathology is three-dimensional, its treatment must also be three-dimensional. Indeed, two-dimensional techniques, sclerotherapy, phlebectomy and laser therapy are irrational; they only treat the effect of the venous pathology - the visible veins - and not the cause. These methods eliminate the outlet valve of a hemodynamic hypertension that they are unable to cure. Deprived of its natural outlet valve, this hypertension causes numerous capillaries to dilate, creating what we call “matting”.
If the reticular veins resist the dilatation caused by the hemodynamic hypertension due to the valvular incontinence of the perforating veins, telangiectasias will form. If, by contrast, the reticular veins dilate, no telangiectasias form.
In TRAP, the ectatic capillaries are injected, just as venules, reticular veins, truncular and perforating veins are injected. Indeed, there is no pathogenetic difference between a large varix and an ectatic capillary.
Only one limb at a time is treated, starting with the one with the most severe pathology. The lower limb is divided into three longitudinal regions: medial, lateral and posterior. The regenerative solution of 3% sodium salicylate in a buffered hydroglycerin vehicle is systematically injected into the visible vessels of one region, working from the bottom upwards. The solution must reach the deep veins. Up to a maximum of 12 ml of solution is injected per single injection. It is not always possible to inject effective quantities of regenerative solution (from 3 to 12 ml), as the amount depends on the dilatation and expandability of the underlying venous circulation and on the fragility of the venous walls. The operator must observe the injection site. If a wheal forms, it means that the solution has been injected outside the vessel. If this happens, the operator will compress the wheal with a finger or dilute the extravasated solution if the amount exceeds 1 ml.
A concentration of 3% of sodium salicylate solution can be obtained by diluting the 6% or 10% solution. A 20 ml syringe and two 4 ml vials of 10% solution or three 4 ml vials of 6% solution are used. Just over 1 ml of lidocaine is aspirated into the 20 ml syringe. Two 4 ml vials of 10% solution or 3 vials of 6% solution are then aspirated. The syringes are filled to 24 mL with the dilution liquid (10% Glycerol in saline or lactate Ringer's solution). To the dilution liquid we can add 2 g of EDTA in 500 ml; 48 ml of regenerative solution is injected. If the patient weighs more than 52 kg, 72 ml can be injected. These quantities act rapidly on the varicose disease.
If the telangiectasias are very fine and cannot be injected with the 25 G needle and the 20 ml syringe, the two-syringe technique is used. Before using the two-syringe technique, the operator must, in any case, have corrected the hemodynamic hypertension in the limb by injecting the 3% regenerative solution into the visible veins until they completely disappear. It should be borne in mind that the veins in the lower limbs should not be visible. Since humans began to stand upright, the lower limb has become a pump that drives blood from the foot to the right atrium, and any pump must necessarily empty its collectors.
The two-syringe technique uses one 2.5 mL syringe and one 1 mL syringe. Into the 2.5 ml syringe, we can aspirate the 6% solution of sodium salicylate in a buffered hydroglycerin vehicle; alternatively, we can aspirate 1.5 ml of 6% solution and 1.5 ml of 10% solution. Combining these two concentrations creates an 8% solution. The 10% solution can be used to treat matting and high-pressure capillaries.
We always add ½ ml of 2% lidocaine to the vials that contain the 6% solution and the 10% solution.
Into the 1 ml syringe, we put 0.20 ml of lidocaine and then fill up the syringe with the dilution liquid. 30G needles and/or 27G needles are used for both syringes.
In order to reach the effective concentration of 3% in depth, higher concentrations will be injected, as the solution is diluted in the invisible circulation. Thus, if the ectatic capillaries are very fine and under high pressure, it will be necessary to use the highest concentration and carry out several injections.
Naturally, the higher the concentration, the higher the risk of a residual skin lesion at the point of injection, where a tiny wheal almost always forms. In this case, the 1ml syringe is used to dilute the solution that has caused the wheal, thereby eliminating the risk of skin damage. The 1 ml syringe, which has a small diameter, enables the dilution solution to be easily injected into the thickness of the dermis. Dilution should be performed immediately after injection of the concentrated solution. For this reason, the 1 ml syringe must be kept within easy reach on the table.
During the injection, the skin whitens, owing to the hypertonia of the solutions used. This whitening is due to the contraction of the pericytes of the intact capillaries. As can be seen, injection is simple. The operator sees the tip of the 30 G needle enter the capillary and presses the plunger of the syringe without exerting significant pressure. The viscosity of the solutions facilitates injection. If the tiny vessels are not clearly visible, the operator can advance the needle in small steps while maintaining a slight pressure on the plunger of the syringe. When the lumen of the needle coincides with that of the vessel, the operator can perform the injection. As always, the tip of the needle must be sharp enough to penetrate into the telangiectasias. If the tip is blunt, it will move the capillary without entering its lumen. If three consecutive attempts to enter the lumen fail, the needle will have to be replaced.
Matting caused by irrational sclerotherapy and phlebectomy procedures can also be easily eliminated by means of multiple injections and the two-syringe technique; this approach eliminates the risk of residual unsightly marks at the injection sites, even though a 10% solution is used. Multiple injections ensure that the quantity of solution delivered in depth is sufficient to regenerate the walls of the perforating vessels, thereby restoring valvular function and eliminating hemodynamic hypertension.
The use of lasers in this three-dimensional pathology is irrational, improper and ineffective.
Capurro S. (2023). Two-syringe TRAP technique for treating telangiectasias. CRPUB Medical Video Journal. Elastic Plastic Surgery section. www.crpub.org.
So telangiectasias are caused by hemodynamic hypertension?
Yes, but also by contusive injury. Miopragia of the venous walls may occur in the reticular veins or only in the capillary and venular circulation. If there are varices, there are no telangiectasias. If the reticular veins do not dilate, there are only telangiectasias. Patients who only have telangiectasias require a much greater number of sessions.
The amount of regenerative solution injected ranges from 3 to 12 ml. What determines the amount to inject?
Injecting 3 ml of 3% regenerative solution into the foot can be very effective; 12 ml injections are indicated especially in the veins of the legs, which have a very complex venous circulation. If the veins rupture easily at the beginning of the injection, even small amounts of solution can be useful, as they strengthen the venous walls and allow correct injection in subsequent sessions. It should always be borne in mind that the result is dose-dependent. To be very effective, the solution must wet the entire endothelium of the perforating veins and reach the deep veins.
You always start from the bottom. Where exactly?
In the medial and lateral regions, treatment starts from the veins and capillaries of the foot. The two-syringe technique is never used here. Only the 3% solution is injected. In the concave areas of the foot, compression can be applied by means of TRAP tumescence; alternatively, the area can be compressed with adhesive foam rubber. In the posterior region, where there is no foot, we start by injecting the first visible vein.
Which dilution liquid is preferable?
Certainly, 10% glycerol in saline solution, as it does not pollute. A 500 ml flask can be stored in the refrigerator. The 2 g of EDTA that is added to the glycerol helps to keep it sterile. Remember that sodium salicylate and lidocaine are also powerful bactericides.
What function does the EDTA have?
EDTA chelates the iron ions that are released when the blood comes into contact with the regenerative solutions, which are all hypertonic. This prevents the treatment from causing inflammation. Eliminating inflammation means preventing phlebitis in subjects who have a familial predisposition. Patients with connective tissue disease and those who have been vaccinated against Covid require particular attention. These patients should take one capsule of Angiovein in the morning, and one 100 mg tablet of cardioaspirin in the evening on alternate days. Angiovein is a herbal medicine containing 9 components which exert 64 actions. It can be taken continuously because it does not cause accumulation phenomena. Let us remember that our youth depends on that of our blood vessels.
When do you inject 72 ml of 3% regenerative solution?
In the first session, we always inject 48 ml. In the following sessions, 72 ml can be injected if the patient weighs more than 52-55 kg.
Is the second syringe always necessary when injecting telangiectasias? How much do you inject with the second syringe?
The 3% regenerative solution is injected into less fine ectatic capillaries. If the capillaries are very fine and the operator is careful, the second syringe can be avoided if the 6% solution is injected. However, if the concentration is increased to 8% or 10%, it is always advisable to use the two-syringe technique. As the second syringe has to reduce the wheal caused by the injection of concentrated solution, the operator must inject into the injection site an amount of diluent that is sufficient to reach a tissue concentration of 3% or lower.
Why do you advise against the use of lasers?
Because lasers close the access gateways through which we regenerate the underlying circulation; because a three-dimensional pathology must be treated with three-dimensional methods; because a rectilinear energy also damages tissues that must not be damaged; because lasers can leave skin scars, etc. Phlebectomy and sclerotherapy are also techniques that should not be used in the lower limbs.
So, in venous pathology of the lower limbs, are traditional techniques completely wrong?
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