03. Case report: Three-dimensional Regenerative Ambulatory Phlebotherapy for incontinent perforating veins in patients who have already undergone multiple phlebectomies
KEYWORDS: Three-dimensional Regenerative Ambulatory Phlebotherapy (TRAP), perforating veins, solution of sodium salicylate in a buffered hydroglycerine vehicle
This patient had undergone a bilateral saphenectomy of the great saphenous vein and multiple posterior phlebectomies in both calves. In the treated areas, new varices had formed owing to the persistence of perforating veins in the regions involved. Incontinent veins had been inadequately treated by phlebectomy which, as is known, has a mainly two-dimensional action. Incontinent perforating veins had given rise to new evident venous ectasias. We viewed the sites of venous reflux by means of a spectroscopic analysis method. During the analysis, significant venous reflux was seen in the perforating veins of Cockett, Sherman and Boyd in the left leg. In the right leg, the perforating veins of Sherman and Boyd were seen to be incontinent and bulging. Numerous posterior bilateral perforating veins were seen to be feeding large varices with significant reflux.
Perforating veins in black and white (photograph taken under Veinviewer). The muscle fascia appears white. As the patient is lying down with his legs raised 45°, the veins are seen without reflux blood.
We performed Three-dimensional Regenerative Ambulatory Phlebotherapy (TRAP), which strengthens the vessel walls and narrows the veins until the calibre and consistency of a normal vessel is achieved. In this procedure, the patient lies prone on the table. The skin is disinfected with polyvinylpyrrolidone-iodine solution (Betadine) as its dark colour accentuates the in-depth infrared imaging
Perforating veins giving rise to copious reflux are clearly visible in the sural region.
TRAP is the new regenerative cure for varicose veins. Created by the plastic surgeon Sergio Capurro, TRAP induces the activation of controlled deposition of fibrous tissue in the walls of the injected incontinent veins. A sclerosing solution of sodium salicylate in a buffered hydroglycerine vehicle, diluted to a non-obliterative concentration, is injected three-dimensionally into those veins of the superficial circulation which are sites of reflux. Even the smallest perforating veins identified by means of the reflection-absorption technique must be injected. After the regenerative treatment of the walls of the perforating and superficial vessels, prolonged use of elastic stockings or bandages and normal physical activity are indispensable.
We reiterate the fact that this patient had previously undergone phlebectomies in an attempt to resolve his phebological pathology. The scars from the previous operations are clearly visible in the postero-medial region of the calves. Recurring venous swellings of considerable size are present, supplied by several perforating sural veins.
TRAP treats the incontinent perforating veins that cause venous reflux pathology. Phlebotherapy narrows the calibre and strengthens the walls of the bulging perforating veins and induces anatomo-functional restoration of the venous circulation.
During Three-dimensional Regenerative Ambulatory Phlebotherapy, the reaction of the injected vein wall is immediately visible. The reflection and absorption of infrared light shows the rarefaction of the veins and the loss of linear continuity of the walls.
To inject the regenerative solution, we use a large syringe. The large diameter of the syringe reduces the compression force that the solution applies on the reflux in the treated communicating veins and seems to us to be suitable for treating large veins with extensive venous reflux. The lower pressure of injection, which is due to the larger diameter of the syringe, reduces the dynamic turbulence at the confluence of the two fluids: the venous reflux blood and the therapeutic solution. The sodium salicylate solution in a buffered hydroglycerine vehicle is thus able to act with greater homogeneity on the entire ectatic vein wall. The viscosity of the solution helps to achieve this effect.
Moving down towards the lower sural region, we come across refluxed perforating veins under greater reflux pressure.
The possibility of effective day-surgery treatment is an enormous advantage for the patient.
After the therapy, the patient is able to walk, indeed must walk, as this allows muscle tone to be recovered in the lower legs in the regions immediately surrounding the dilated perforating veins. Where large incontinent perforating veins are present, the muscular fasciae bulge and are clearly visible on Echo-Doppler imaging, transillumination, or better still, under spectroscopic analysis with invisible infrared light at a wavelength of 740 nm projected onto the patient’s skin. The lack of homogeneity in the continuity of the fasciae is often evident on palpation.
This patient is an amateur cyclist and regained venous anatomo-functional integrity in the space of three months with three sessions of bilateral TRAP, concentrated, in accordance with the patient’s wishes, exclusively on the venous ectasias of the calves and the more frequent sites of venous insufficiency in the medial region of the lower leg.
The patient before and after TRAP
The treatment aims to restore functional muscular activity and improve performance in aerobic activity; it is always carried out with the aid of stockings with a pressure of 40 mmHg at the ankles.
This patient has momentarily postponed treatment of the whole superficial and perforating circulation, which is required by phlebotherapy to make all the visible vessels disappear, preferring to quickly resolve the subjective symptoms in the sural muscular regions: cramp-like pains in the evening and after prolonged physical effort.
Cosimi M. (2009) Case report: Three-dimensional Regenerative Ambulatory Phlebotherapy for incontinent perforating veins in patients who have already undergone multiple phlebectomies. CRPUB video journal. Phlebotherapy section. http://www.crpub.org
In this case, injecting the regenerative solution into the perforating veins, which were made visible by the Veinviewer, yielded an excellent result and shows the importance of the perforating veins in the pathogenesis of varicose disease. I wonder whether this treatment, carried out exclusively on the perforating veins, can be applied in all patients or only in cases like this.
When the Veinviewer is used, the dilated perforating veins are easy to inject. In other patients, tele-injection is used; i.e. the superficial vessels are injected and the solution is made to penetrate in depth, into the perforating and communicating veins, under manual pressure.
How much solution is injected?
As much as 3-5 ml for each single injection. There is no need to be afraid!.
Using a larger syringe – 10 ml or 30 ml – seems to be advantageous, especially in patients with large reticular veins?
Yes, it is. It enables us to inject a surely efficacious quantity of Bisclero solution, which can be prepared rapidly.
It is easy to inject the solution into the perforating veins revealed by the Veinviewer because the needle is inserted perpendicularly to the surface of the skin, which is the same direction as the vein). The operator judges whether the perforating vein has been injected correctly exclusively by the pressure applied to the plunger of the syringe. By contrast, when ectatic vessels of the superficial circulation are to be injected with the aid of these new techniques of reflection and absorption of light, a certain amount of practice is necessary. When the Veinlite is used, the blood can be seen to flow away if the solution is correctly injected into the vessel. When the Veinviewer is used, the blood cannot be seen to flow away and it is more difficult to know whether or not the needle is in the vein. What do you think?
Yes. I think the invention of these new diagnostic instruments shows that phlebological therapy is evolving towards the thorough study of the vascular territory, especially that of the small perforating veins. At one time, these veins were thought to be of little importance, as they could not be seen by means of Colour Echo-Doppler. Our current research is aimed at identifying the limits and precise indications of the new instruments available.
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