08. Troncular Veins, Reticular Veins and Telangiectasia: Phlebotherapy (TRAP) an original approach
KEYWORDS: sclerotherapy, phlebectomy, haemodynamic hypertension, hydrostatic thrust, Phlebotherapy (TRAP), TRAP tumescence.
TRAP is a non-mechanistic treatment for varicose "disease"; it is easy to perform and consistently efficacious.
TRAP can be used to treat all patients: from those whose veins are not visible to the naked eye, but only by means of transillumination, to those with bulging varices, even if they have previously undergone several surgical procedures.
The objectives of TRAP are:
1) to eliminate the patient's feeling of "heavy legs";
2) to achieve permanent disappearance of all the vessels that are visible to the naked eye or by means of transillumination;
3) to shrink the caliber and strengthen the walls of the vessels of the perforating, communicating and superficial circulation, without destroying the veins.
TRAP acts safely and effectively even in those regions where sclerotherapy is risky and phlebectomy is not feasible.
The operator performing TRAP must realize that, from the pathogenetic standpoint, there is no difference between an ectatic capillary and a large varix.
The forces at play in varicose disease are haemodynamic hypertension and hydrostatic thrust.
The biological causes of varicose disease are: standing erect and the miopragia of the venous wall.
Because human beings stand erect, the lower limbs have acquired a major function as a "pump".
If this pump cannot empty the collecting tubes through which it has to aspirate blood, it cannot work properly. It therefore follows that the veins in the lower limbs must not be visible.
Finally, it should be borne in mind that our legs contain 80% of our blood. The implications of reducing the capacity of the venous circulation by means of TRAP are clear.
Equally clear are the effects of reducing both lateral pressure and haemodynamic hypertension in the venous circulation of the legs.
The anatomical cause of varicose disease is dilation of the perforating veins. Dilation of the perforating veins causes:
1) insufficiency of the valves of the perforating veins;
2) inversion of the superficial-to-deep flow;
3) haemodynamic hypertension and chronic inflammation of the venous walls;
4) ectasia of the superficial, perforating and communicating circulation;
5) increased hydrostatic thrust.
Haemodynamic hypertension can reach 300 mmHg.
Hydrostatic thrust is an absolute value. It is calculated by multiplying the hydrostatic pressure by the internal diameter of the vessel by a height of 1 cm.
A hydrostatic pressure of 76 mm Hg (100 cm H2O) yields the following values of hydrostatic thrust, according to the following diameters.
Haemodynamic hypertension is the greatest force in the limb.
TRAP treats haemodynamic hypertension not individual visible veins. The visible veins are the effect of haemodynamic hypertension; they constitute the escape valve for haemodynamic hypertension.
It must be borne in mind that the venous circulation is three-dimensional, its various parts being connected by means of the communicating veins.
For this reason, a patient may have a single large varix (the reticular vein with the most dilatable wall).
This varix constitutes the escape valve for the hypertension created by the incontinence of the various valves in the limb.
It is easy to imagine what will happen if this varix is removed or obliterated without correcting the underlying haemodynamic hypertension.
"Matting" is one of the consequences of obliterative or ablative treatments. Such treatments are unable to cure haemodynamic hypertension.
Owing to their mechanistic nature, traditional treatments eliminate the "gateways" through which haemodynamic hypertension can be treated. These "gateways" are all those vessels that are visible to the naked eye and by means of transillumination. The larger these gateways are, the more rapidly the aesthetic and functional properties of the limb can be restored.
A patient with large varices does not have telangiectasias.
A patient with reticular veins that can withstand haemodynamic hypertension without dilating will have numerous ectatic capillaries.
How TRAP does work?
Miopragia of the venous walls involves the entire perforating and superficial circulation. Venous pathology is three-dimensional; and its treatment must be three-dimensional.
In order to cure haemodynamic hypertension, we inject a regenerative solution in a three-dimensional manner into all the veins that are visible to the naked eye or with the new means of visualisation (truncular, reticular and perforating veins, venules and telangiectasias). In this way, we can treat the miopragia of the vessel walls.
Quite simply, the solution flows in the opposite direction to the formation of the varices and regenerates the perforating and superficial circulation. When we say "regenerates", we mean that the shape and function of the vessels are restored.
The solution is injected rapidly and follows the pathway of the most dilated and dilatable vessels.
What do we inject?
We inject a solution of sodium salicylate at a non-obliterative concentration in a buffered hydroglycerin vehicle. The salicylate, which is an inhibitor of prostaglandin COX-2 tissue inflammation, restores correct cell apoptosis and stimulates the stem cells of the venous wall. The hydroglycerin vehicle enables contact to be made with the entire surface of the venous wall.
The sodium salicylate is not absorbed, as the absorption of salicylate is pH-dependent.
Any metabolites are neutralised by the alkaline vehicle.
This solution of sodium salicylate in a hydroglycerin vehicle restores the function of the venous wall.
A venous wall that is dilated by haemodynamic hypertension has non-uniform thickness, disorganised layers, inflammatory infiltrate, and a discontinuous endothelial layer.
These histological features make the action of the regenerative solution even more selective.
After regeneration, the thickness of the vessel wall is regular, the endothelial layer is continuous, there is no inflammatory infiltrate, the caliber of the lumen is reduced, and the structure of the vessel wall is consolidated.
This reduction in caliber and reinforcement of the wall are confirmed by venous echography.
starting from the most distal regions and working methodically upwards, the operator injects 48 or 72 mL of regenerative solution (3% sodium salicylate in a hydroglycerin vehicle) into all the vessels that are visible to the naked eye or by means of the modern systems of visualisation.
The limb is divided longitudinally into three regions: medial, posterior and lateral. Only one limb at a time is treated, region by region.
Treatment starts in the regions with the least evident pathology, in order to maintain the escape valves of the haemodynamic hypertension for as long as possible.
Compression must be applied for long enough to achieve anatomical stabilization.
If Doppler does not see it, is the pathology non-existent?
(From Sclerotherapy – Goldman)
In the patient you can see, venous Doppler is negative. There is no incompetence of the sapheno-femoral or sapheno-popliteal junctions or of those of the perforating veins.
Naturally, it would be foolish, as well as false, to claim that there is nothing wrong with this patient. We can clearly see that there is a pathology due to the incontinence of the perforating veins – vessels of one or 2 mm – which are not visible on venous Doppler.
In former times, serious researchers in the field of phlebology were already aware that the greatest damage was caused not by the insufficiency of the saphenous ostia, but by the incompetence of the perforating veins in the legs.
With regard to the saphenous vein, the complete absence of valves downstream of the saphenous has been documented in some subjects who do not suffer from varices. By contrast, efficient valves have been found in the external iliac vein of some subjects with varicose disease.
In TRAP, the traditional diagnostic features are minimised. The diagnosis concerns the entire area. For example: if blood emerges from a vessel after the regenerative solution has been injected into it, this vessel is connected to a dilated vein (reduced flow velocity and consequent increase in lateral pressure); a greater amount of solution therefore needs to be injected.
In conclusion, TRAP is a rational treatment for "varicose disease". In order to be effective, a treatment must consider the anatomy and the pathophysiology of the "pump" of the lower limb. Focusing exclusively on varicose veins without considering haemodynamic hypertension is a vision of phlebology that is outdated, limited, superficial and harmful.
Three 24 mL syringes of 3% sodium salicylate solution in a buffered hydroglycerin vehicle are injected. To each syringe, 1 mL of 2% lidocaine is added. The regenerative solution is injected intravenously. The solution spreads three-dimensionally and must reach the deep veins, where it becomes diluted and loses its efficacy. The solution is injected rapidly with a large-caliber needle. Any intravenous accumulations of blood should be avoided as far as possible. When TRAP is performed, it is essential to use transillumination, as this enables the operator to inject the veins that are not visible to the naked eye. The blood that seeps out from a small injected vein tells us that this vein is connected to a large-diameter vessel that imparts a high lateral pressure to it. The operator can identify these nonvisible ectatic vessels because the plunger of the syringe offers less resistance; a larger amount of solution will be injected into these vessels.
The session ends when the pre-established quantity of regenerative solution has been injected.
TRAP tumescence (10% glycerol in a saline solution + 2% lidocaine) is carried out in order to compress the most dilated veins more effectively. This solution is injected above and/or below the previously treated varix. The lidocaine exerts a powerful anti-inflammatory action. Following treatment, a bandage is applied for three days. Subsequently, an elastic stocking is worn until the regeneration is anatomically stable.
Capurro S. (2017): Troncular Veins, Reticular Veins and Telangiectasia: Phlebotherapy (TRAP) an original approach. CRPUB Medical Video Journal. Phlebotherapy section. http://www.crpub.org