References

Medial Literature Slides

Treatment


Venous insufficiency clinically present in the form of varicose veins and the various forms of venous telangiectasia. All forms of telangiectasia occur through the release or activation of vaso-active substances under the influence of a variety of factors with a resultant capillary or venular neogenesis. Management therefore involves treatment of both venous insufficiency and its sequels, which are varicose veins and the various forms of venous telangiectasia.

Treatment of Varicose Veins
All patient should have a detailed physical exam including duplex scanning.

Asymptomatic patients
Treated conservatively

Symptomatic patients
Best method for the treatment of varicose veins is the minimally invasive form of surgery; high ligation PIN (perforation-invagination) stripping in conjunction with tributary Phlebectomy by phlebo-extractor hooks. PIN stripping permits selective surgery of defined segments of the long saphenous or short saphenous veins and circumvenes the open surgical approach at the distal end of saphenectomy. Compared to the conventional stripping (blind ankle to groin stripping) PIN stripping substantially reduces trauma of the skin and the subcutaneous structures. It produces very little pain and is performed under local anesthesia as an ambulatory procedure. Troublesome lesions of sensory nerves following stripping the lower leg as well as unsightly distal scars are almost completely avoided.


Top


Treatment of Venous Telangiectasia
Telangiectasia of the legs are almost always of venous origin (venous valvular incompetence) and a large percentage of these patients have associated symptoms and most often the venous telangiectasia lesions are directly or indirectly connected to larger reticular or varicose feeding veins which may not be visible to the naked eye, but can be detected with specialized examination using duplex ultrasound or transillumination with intense light. If not treated these telangiectasia are responsible for the persistence and progression of the underlying disease process (venous insufficiency).

Most commonly used method of treatment is sclerotherapy, but the results are very poor.

Treatment using electromagnetic energy (laser, intense pulsed light) is very effective. These modalities destroy the lesions directly, non-invasively. Many recent studies have shown permanent results with these modalities, which are also well tolerated with minimal minor complications.


Top


Other Less Effective Modes of Therapy
Results of closure technique are poor and associated with high complication rate, also highest portion of long saphenous vein difficult to treat, being too close to the main femoral vein.

– Results of sclerotherapy are also poor. Recurrence rate 80-100%
– Power Phlebectomy- more traumatic


Top


A Case Against Sclerotherapy
Long before the era of Doppler and duplex examinations, Tom Meyers from the mayo clinic, (who introduced the flexible introluminal stripper) was quotes on the pages of pageant of April 1967 as saying that "sclerotherapy (for varicose veins) is a return to the dark ages of medicine"

The first to publish disappointing results of the injection compression method was Hoblse in 1974. There were, at least, six years follow-up, 65% failure rate for compression sclerotherapy versus only 20% for conventional stripping.

A randomized study by Jokobsen, published in 1979, reported three year failure rate for sclerotherapy was 63% versus only 10% after surgery. Eianarsson, Eklof and Neglan who for the first time used clear objective hemodynamic (foot voluntary) criteria in assessing their results, reported in 1993 on the pages of Journal of Phlebology a disappointing 74% five year failure rate following injection sclerotherapy versus only 10% failure rate for convention surgery.

Very poor results of injection therapy are clearly demonstrated in recent publications that used objective duplex imaging for assessment of the therapeutic outcome of injection sclerotherapy in lieu of the "traditional" visual assessment coupled with finger palpation of the injected veins, a method that invariably produce, so called, excellent results.

In the first study, Bishop, Fronek and Fronek, in 1991 found that injection sclerotherapy control of the proximal escape points, such a sapheno-femoral junction, will fail in 80% of cases in a mean short-year follow up.

Gongalo et at, also in 1991, using similar duplex objective criteria, recorded the re-establishment of reflux and thus a failure of injection compressions sclerotherapy also in a short two-year follow up period in up to 60% of cases.

More recently, Biegeleiseu, in 1994 using the most advanced technology available (angioscopy) to guide the delivery of sclerosant to follow up, (in conjunction with duplex imaging), the effect of treatment, shows an invariable 100% failure rate to control the valvular incompetence and axial reflux existing in the long saphenous varicosities. This became evident after only one-year follow up period

In conclusion, injection compression sclerotherapy with 60%- 100% failure rate is not to be considered a viable primary therapeutic option for varicose veins.

Moreover, with close to 80% of the cases clearly harboring detectable escape points and axial refluxes, the only viable therapeutic alternative for primary varicose veins to be promoted and performed remains surgery but in its new and tamed form, i.e. that is the invaginated (and limited) axial stripping in conjunction with stab avulsion (hook) phlebo-extraction of the varicose tributaries. Without compromising hemodynamic principles, the method is performed under local anesthesia in an ambulatory setting.


Top