11. Phlebotherapy (TRAP) of telangiectasias and ectatic veins in esthetic and functional medicine
KEYWORDS: Three-dimensional Regenerative Ambulatory Phlebotherapy (TRAP), ectatic capillaries, telangiectasia, hemodynamic hypertension, hydrostatic thrust, matting
Varicose disease is a three-dimensional pathology and must be treated by means of a three-dimensional method: TRAP (Three-dimensional Regenerative Ambulatory Phlebotherapy). TRAP reduces hemodynamic hypertension in the venous circulation and corrects excessive hydrostatic thrust. A regenerative solution is injected into all the visible veins. When the solution comes into contact with the vessel walls, it narrows and strengthens the vessels; 24 ml to 72 ml of a diluted sclerosing solution is injected. Solutions of sodium salicylate in a buffered hydroglycerin vehicle are diluted to 3% with 10% glycerol in saline solution. To minimize the risk of phlebitis in subjects with a familial predisposition, we add 2 g of EDTA to the 500 ml flask of 10% glycerol, as per our patent. After only three sessions, the patient feels the functional effect of the method as the sensation of heaviness in the legs is alleviated.
With TRAP, varicose veins soon disappear. Venules and telangiectasias that are no longer subjected to hemodynamic hypertension may remain. These vessels can be treated more easily, practically without risk, by injecting the same regenerative solution, diluted to 3%, with a 3 ml syringe and a fine 30 G needle. The solution is prepared in the same way as in classic TRAP.
An 18 G needle is inserted into a vial of 2% lidocaine. A 20 ml syringe with an eccentric tip is used. Keeping the syringe inclined, the operator aspirates the lidocaine until the plunger reaches halfway between the second and third level-mark. Before aspirating, the operator carefully presses the plunger, in order to expel any air that might be contained in the syringe. The operator now opens 3 vials of sodium salicylate in a 6% buffered hydroglycerin vehicle or 2 vials of sodium salicylate in a 10% vehicle. The contents of these vials are aspirated into the 20 ml syringe. Another 20 ml syringe is now prepared. The 2% lidocaine and the three 6% vials are aspirated. An 18 G needle is inserted into a drip of 10% glycerol in saline. The previously prepared 20 mL syringes are filled with 10% glycerol up to 24 mL. A 25 G needle is fitted to one of the syringes, in order to inject large quantities of regenerative solution into the varices (classic TRAP). An 18 G needle is fitted to the nozzle of the other syringe. A 3 ml syringe is now filled with the regenerative solution, and a 30 G needle is fitted to it. This syringe will allow us to inject the telangiectasias, the finest capillaries, the venules and the veins.
As can be seen in the Phlebotherapy section of the Medical Video Journal crpub.org, there is another technique for the injection of telangiectasias: the two-syringe technique.
This technique uses a more concentrated, 6% or 10%, regenerative solution and is performed in the case of matting. Areas of matting are made up of tens or hundreds of small, high-pressure telangiectasias, which are formed when a very dilated vein is obliterated or stripped out. If an “escape valve”, such as a large vein, is removed without correcting the hemodynamic hypertension that caused it to dilate, this hypertension will cause the small capillaries to dilate. It is easy to inject these dilated capillaries because the hypertension maintains the dilation of the vessels from which they originate. A sign of underlying hypertension is that blood leaks out when the operator withdraws the needle after injecting. This phenomenon is due to lateral thrust. In areas of matting, the concentrated solution will have to be injected in several points and in good quantities, to regenerate the walls of the incontinent perforating vessel involved.
To prevent unsightly marks from remaining at the injection points, where the solution inevitably comes into contact with the tissues, a skin wheal is performed with 10% glycerol and a few milliliters of lidocaine, so as to reduce the hypertonicity of the solution.
The technique presented in this video uses the same 3% concentration commonly used in TRAP. The solution is injected into the veins and telangiectasias. However, before injecting the telangiectasias, it is always advisable to inject the reticular veins of the area, in order to reduce hemodynamic hypertension; alternatively, these veins can be injected at the same time as the telangiectasias.
In conclusion, as varicose disease is three-dimensional, it must be treated with three-dimensional techniques. Indeed, two-dimensional techniques are irrational; they merely eliminate the escape valve of the hemodynamic hypertension that they are unable to cure.
Moreover, traditional techniques have no pathophysiological basis. Stripping out the veins, burning them with a laser or obliterating them with sclerotherapy not only eliminates the escape valve of hemodynamic hypertension, it also eliminates the “gateways” through which the walls of the non-visible veins can be treated. In addition, as Doppler study cannot visualize the pathology, patients with multiple incontinent perforating veins are regarded as having no dysfunction. In the lower limbs, however, even the smallest telangiectasia is caused by hemodynamic hypertension.
Given that Doppler study must be excluded, what remains is the study of the territory, which reveals the existence of two types of telangiectasias: those with high lateral pressure and those with low lateral pressure. The former are iatrogenic and, if there are no reticular veins to be injected in the area, they must be treated with higher concentrations of regenerative solution and by means of the two-syringe technique. The latter must be treated with the 3% solution and by means of the esthetic-functional technique.
Another concept to bear in mind is that the entire circulation is connected. Thus, all visible vessels must be injected: veins, venules and telangiectasias.
The lower limb acts as a pump and must function as such. TRAP restores this pumping action and the “respiration” of the tissues.
Capurro S. (2024). Phlebotherapy (TRAP) of telangiectasias and ectatic veins in esthetic and functional medicine. Phlebotherapy section. www.crpub.org.
How did you develop this method, which I believe is the only rational therapy for varicose disease?
Basically, it's a matter of common sense, a quality that is often lacking in those who are not self-critical and slavishly follow what they have been taught by outdated masters. Remember, mistakes are passed down from generation to generation and from book to book.
This method was taught to me by my father, who directed the Institute of Human Anatomy and founded the Institute of Histology. Anatomy must be considered first. Next come physiology and pathophysiology, and finally the therapy is planned. My colleagues need to answer this question: is the venous circulation two-dimensional or three-dimensional? Obviously, it is three-dimensional, and this rule out all the irrational and harmful two-dimensional therapies, such as sclerotherapy, phlebectomy, burning with lasers and gluing with Loctite. Indeed, it is a great mistake to eliminate the “gateways” through which the non-visible circulation can be treated. The “escape valves” of hemodynamic hypertension must not be eliminated without having first eliminated the incontinence of the perforating veins, which is the anatomical cause of varicose disease. Weakening of the venous walls creates valvular incontinence in the perforating veins, causing reflux that dilates the vessels. The dilated vessels are therefore subjected to excessive hydrostatic thrust (which causes leg ulcers). In a dilated vessel, the blood flows less quickly, owing to the laws of conservation of energy; thus, lateral pressure increases, which dilates all the vessels connected to it.
The regenerative solution enters the circulation through the "gateways" of the veins, venules and telangiectasias, and travels to the most dilated and dilatable vessels; it narrows and strengthens these vessels by reducing the capacitance of the circulation. In just a few treatment sessions, the feeling of “heavy legs” is alleviated.
The principles that my father (Anatomy first) taught me also allowed me, as a plastic surgeon, to perform mastopexy without touching the mammary gland. After modeling the breasts by means of de-epithelialization, I implant two or three elastic threads, one of which is an elliptical suspension thread which raises the breasts, even heavy ones, and enhances the volume of the upper pole. This procedure, like all the others that I have designed, is based on anatomical concepts. In the case of mastopexy, I have recreated a sort of Cooper's ligament that is more functional and more resistant to gravitational ptosis.
We see a lot of needles in the video
When telangiectasias are injected, the needle has to be changed frequently; if the tip of the needle is not sharp, it displaces the small vessels, making intraluminal injection difficult.
Why is EDTA added in subjects predisposed to phlebitis?
I add a very small amount of EDTA in order to exploit its chelating action on the free iron that is formed when the regenerative solution comes into contact with the blood. This stratagem eliminates generalized inflammation of the circulation. EDTA also exerts a considerable antioxidant action. It should be noted that all the components of the regenerative solution (Sodium Salicylate, Lidocaine, Glycerol, EDTA) are bactericidal.
If all the capillaries do not disappear with this method, what can be done?
To create the regenerative solution, you can use the 10% pure solution (2 vials instead of 3) and fill the syringe up to 20 ml and not 24 ml. Again, this solution must be injected into the small, dilated capillaries.
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