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Questions and answers for patients Questions and answers for medical professionals From sclerotherapy to T.R.A.P. |
Questions and Answers for Patients"Two-dimensional techniques What are varicose veins, spider veins and telangiectasias?Telangiectasias and varicose veins, whether visible to the naked eye or by means of transillumination, are abnormally dilated superficial blood vessels. They represent the amount of blood that “escapes” from the incontinent perforating circulation. What causes incontinence of the valves of perforating veins?The main cause is a congenital weakness (miopragia) of the vessel walls, which is manifested because of age, hormonal factors, posture, habits, obesity, etc. When the patient runs or walks, the increase in blood pressure, which drives the blood from the foot to the right atrium, causes the miopragic perforating veins to dilate and their valves to become incontinent. Why do varicose veins, spider veins and telangiectasias form?When the perforating veins become incontinent, elevated blood pressure (up to 300 mm of mercury in the leg) forces blood into the superficial circulation, thereby dilating it. Why do we sometimes see only varicose veins, while in other cases varicose veins and telangiectasias occur together?The miopragia or weakness of the vessel walls involves the entire superficial and perforating circulation, though it may be manifested differently. If a superficial vein that has a weak wall is subjected to unnatural pressure because the valve of a perforating vein is incontinent, it will dilate until a pressure balance is reached. If, however, the superficial vein is able to withstand the increased pressure to some extent, even though it dilates, telangiectasias are also likely to form. Telangiectasias will form more easily in patients with severe capillary weakness (marked expression of miopragia in the capillary vessels). Can my varicose veins , spider veins and telangiectasias be treated?Ectatic veins can be cured by means of three-dimensional regenerative ambulatory phlebotherapy (T.R.A.P.). Visible ectatic veins are the effect of an underlying disorder. The cause of the disorder lies in the incontinent perforating veins and in the miopragia of this circulation. T.R.A.P treats the perforating circulation by reinforcing the walls of these vessels and reducing their diameter. This reduction in diameter restores continence and normalises the pressure in the superficial circulation. If, by contrast we obliterate or remove the superficial veins, then we will be acting only on the “escape valve” without treating the true cause of the disorder. Indeed, if the superficial vessels are obliterated without treating the underlying vessels, the unnatural pressure on the area will remain unchanged; this means that the obliterated veins will reopen, or else new varicose veins, spider veins and telangiectasias will form. Which patients are the most difficult to treat?Patients with evident reticular veins are the easiest to treat and to restore to a good aesthetic condition. The most difficult patients to treat are those in whom miopragia extends to the capillary network. These are patients in whom the transilluminator reveals a fine network of small vessels, venules and telangiectasias. In these cases, in which the capillaries are very fragile, a good aesthetic result cannot be guaranteed since the pressure exerted by injection is sufficient to cause dilation of the capillaries in the area. In short, the more evident the vessels are, the easier the treatment is and the better the result will be. What is meant by a “good result”?A good result means that all the visible vessels disappear from view and that there is no permanent post-sclerotherapy hyperpigmentation. Results can be graded in three categories: the vessels are no longer visible a) at a distance of 1.5 m, b) at a distance of 0.5 m, and c) with a magnifying glass. For the reason mentioned above, not all patients are able to achieve the highest grade of result. How are varicose veins treated?Visible varicose veins are treated by regenerating the walls of the underlying perforating veins that cannot be seen. A regenerative solution is injected into all the vessels that can be seen either with the naked eye or by means of transillumination, and is driven into the perforating veins; these veins become narrower, are strengthened and recover their continence. Once the superficial circulation is no longer subjected to the abnormal pressure caused by the insufficiency of the valves of the perforating veins, the superficial varicose veins are reduced in size and disappear from view. Three-dimensional regenerative phlebotherapy respects the anatomy and physiology of the circulation, while at the same time enabling a good, long-term aesthetic result to be achieved. The possibility of undertaking any ablative or obliterative procedures on larger diameter veins (saphenous veins) should, in our view, be considered only after regeneration of the non-visible circulation has been completed. This chronological order is important. For example, the great saphenous vein, even if its diameter is such that removal or obliteration is required, must nevertheless be injected with the regenerating solution, as it constitutes the “gateway” through which to treat the vessels connected to it. Why inject all the vessels visibile to the naked eye or on transillumination?The traditional methods cannot act on the entire superficial and perforating circulation, since it is not possible to obliterate or remove all the vessels. They can, however, be regenerated! If a perforating vessel is incontinent, sooner or later the effect will be seen on the surface, as the superficial vessels dilate. This dilation may be visible to the naked eye and give rise to a varicose vein; it may be visible only on transillumination, or it may be manifested as a tiny telangiectasia. Venous pathology is due to the miopragia of the perforating circulation. Injecting all the vessels is therefore advantageous, in that treating the largest possible area of the endothelial surface minimises that progressive aspect of the disorder which has prompted all schools of phlebology to declare that “the disorder cannot be permanently cured”. Unlike other treatment modalities, three-dimensional regenerative phlebotherapy (T.R.A.P.) is able to treat the entire perforating circulation, thereby achieving permanent results. Should regenerative phlebotherapy be applied to both lower limbs?As the disorder is caused by the miopragia of the walls of the veins, it is advisable to treat both lower limbs, not least because regenerative phlebotherapy is also a preventive measure. However, it is not advisable to treat both limbs at the same time; for haemodynamic reasons, it is preferable to complete the treatment of one limb before proceeding to treat the other. This approach also enables the patient to check the efficacy of the procedure by comparing the treated limb with the untreated one. I suffer from varicose veins. Is it possible to prevent the onset of this disorder in my daughter?Not only is it possible to prevent the onset of the disorder, it is advisable to do so by regenerating the miopragic perforating circulation with the aid of transillumination, which is able to pick out the dilated vessels that are not visible to the naked eye. Transillumination enables the operator to see varices that are not yet visible to the naked eye, but which are destined to become visible in the future. Preventing venous pathology in the lower limbs in predisposed subjects is one of the ambitious aims of T.R.A.P. What is a venous ulcer?Long-standing, serious valve insufficiency can impair tissue nutrition and give rise to a skin ulcer. The treatment of venous ulcers must, in the first place, be vascular. Today, T.R.A.P. can be used experimentally to prevent the onset of this serious and invalidating disorder, and constitutes a rational treatment in full-blown cases. Methods of treatmentIs echo colour Doppler examination useful?Venous echo colour Doppler examination is not routine in regenerative phlebotherapy. Those who perform T.R.A.P. learn to “see” the disorder at the skin level, and have at their disposal a diagnostic tool that is much simpler than echo colour Doppler: the syringe. The degree of venous insufficiency in a given area can be recognised through the pressure that the operator perceives on the plunger of the syringe. The weaker the vessel walls and the greater the incontinence of the valves, the less the pressure on the plunger of the syringe when the regenerative solution is injected. The greater the resistance to the plunger, the more continent the circulation. Although echo colour Doppler is able to visualise the great veins, saphenous veins and larger perforators, it is unable to pick out the numerous small perforators, which constitute, even in terms of volume, the true hidden cause of the disorder. Finally, it should be borne in mind that the insufficiency of the valves of the perforating veins is manifested when patients run or walk, not when they are immobile. Echo colour Doppler visualises the larger vessels, which may be regarded as the tip of the iceberg and not the chief cause of the disorder. In our view, the cause is to be found in the 100 small perforators that the Doppler examination cannot pick out (see fig. 2 of Sclerotherapy). The use of an instrument to diagnose a disorder that the instrument itself is unable to see has diverted attention from the vessels in which the blood pressure is higher to those that are larger. Echo colour Doppler is, nevertheless, useful in complex cases, in the event of deep thrombosis, when ablative procedures are undertaken, and for the purposes of legal medicine or scientific research. What is sclerotherapy?Sclerotherapy is the treatment of varicose veins by injecting a chemical substance into them; this destroys and obliterates the veins. Sclerotherapy is not curative as it acts almost exclusively on the effect of the disorder rather than on its cause. Sclerotherapy cannot yield permanent results as it does not act on the entire perforating circulation and therefore does not treat the miopragia. Clearly, it is not possible to obliterate the entire perforating circulation, as this constitutes the pathway by which the blood flows from the superficial to the deep vessels, and from here is pumped to the right atrium. Indeed, obliteration of the superficial veins and ectatic capillaries hinders, albeit temporarily, the use of these vessels as gateways for the regeneration of the underlying veins. Moreover, unlike phlebotherapy, sclerotherapy may cause side-effects (pigmentation, oedema, pain etc) even when it is properly carried out. It can, however, be used to treat portions of varices that do not respond to T.R.A.P. because they are sclerotic or too fine. How useful are laser therapy and radiofrequency in closing veins?Like sclerotherapy, laser therapy and radiofrequency are obliterative methods. In our view, they may be useful second-line treatments. Our general therapeutic approach, however, involves discovering procedures that are increasingly efficacious and less aggressive. In orthopaedic and general surgery, for instance, the use of endoscopy has led to fewer skin incisions and less invasive operations. Moreover, in aesthetic surgery it is now possible to perform suspensive elastic face-lifting without blunt dissection and making only a few 3 mm incisions. Likewise, in phlebology, regenerative phlebotherapy constitutes an approach that is less aggressive and more respectful of the anatomy and function of the venous circulation. What is phlebectomy like?In the past, the only reason for performing phlebectomy was the absence of pigmentation. Clearly, the advent of a method that does not leave behind any pigmentation and is able to treat the cause of the disorder makes phlebotomy a second-choice treatment. It may nevertheless be used to remove varices that do not respond to regenerative therapy. Why is the great saphenous vein not in itself responsible for the venous disorder?The literature on phlebology reports cases of patients born without valves in the saphenous vein who have not developed varicose veins. By contrast, severe venous disorders have been seen in patients with continent valves even in the femoral vein. At the ankle, the pressure in a continent saphenous vein (about 80 mm of mercury) is equal to the pressure in a saphenous vein with incontinent valves. The saphenous vein is not in itself responsible for the onset of the varicose disorder; rather, it is the incontinent perforators connected with it that can aggravate an already compromised situation caused by the incontinence of perforators in the leg. Nevertheless, an ectatic saphenous vein can aggravate the haemodynamic situation. Does the size of the vessels have any bearing on the varicose disorder?No, the size of the vessels, which is mainly determined by the intrinsic weakness of their walls, is not important. What is important is the pressure in the vessels. This consideration leads us to focus chiefly on the leg perforators, in which the contraction of the gastrocnemius muscles develops the greatest pressure (up to 300 mm of mercury!). Why is it important to wear elastic stockings during T.R.A.P.?Elastic stockings help to regenerate the perforating circulation. They should be worn during regenerative phlebotherapy and for a few weeks after treatment. Is there no role for sclerotherapy?Sclerotherapy, like phlebotherapy, is merely an instrument that the physician uses when necessary. Sclerotherapy is useful in the treatment of some congenital vascular formations and in obliterating any residual varicose vessels that might remain after regeneration. This, however, is a rare occurrence as T.R.A.P. almost always succeeds in making all the vessels disappear from view. Like ablative or obliterative surgery, obliterative sclerotherapy is utilised when a portion of a superficial varix remains visible. This happens when the wall of the residual ectatic vessel is too thin and/or sclerotic to respond to the action of the regenerating solution. Another possible option, however, is to increase the time that the patient remains immobile on the bed, thereby enhancing the efficacy of the regenerating solution. Areas of matting are also obliterated by injecting an obliterating solution. For this purpose, we use 10% sodium salicylate. The obliterative sclerotherapy of telangiectasias of the limbs may be justified, for example, if the patient requires rapid treatment, and in very small vessels. In such cases, however, the patient must of course be informed that the treatment is palliative and not curative of the underlying vessels. CONCLUSIONTreatment of the superficial and perforating circulation, which is carried out by injecting a non-obliterating, regenerating solution into all the vessels visible to the naked eye or by means of transillumination, should be undertaken as the first-line therapy. In a high percentage of patients, this treatment achieves the desired functional/aesthetic result in a short time. If residual varices remain, or if intervention on trunk vessels is necessary, these can be treated after T.R.A.P by means of traditional obliterative methods. In this way, once the hypertension caused by the insufficiency of the valves of the perforators (which are not visible on ECD) has been eliminated, a permanent aesthetic/functional result can be achieved. Questions and answers for patientsIs there any known contraindication of plebotherapy in pregnancy and/or known contraindication of pregnancy with regard to the veins that have previously undergone phlebotherapy?Like sclerotherapy, phlebotherapy is contraindicated in pregnancy. There is no contraindication of pregnancy in patients who have undergone phlebotherapy. We maintain that phlebotherapy, if performed before pregnancy, can prevent the onset of varicose veins. Would you advise postponing the treatment until after the pregnancy?It must be remembered that phlebotherapy utilises sodium salicylate. It must not, therefore, be undertaken during breast-feeding, as the sodium salicylate will pass into the mother's milk. Is there any specific age that phelobotherapy is particularly well suited for or better suited for?Patients who have a predisposition for venous insufficiency would be well advised to undergo phlebotherapy as early as possible, in order to prevent the onset of varicose veins. Indeed, prevention is always better than cure. Are phlebotherapy-treated veins brought back to full function, i.e. can their elasticity be restored?Phlebotherapy does not damage the elastic fibres of the vessel walls, which maintain their elasticity. The elastic fibres adapt to the reduced diameter of the vessel (if they did not, they would not be elastic). Is phlebotherapy as well suited for arms/hands as it is for feet/legs?Phlebotherapy is able to shrink and strengthen the veins of the
hands and forearms. It limits the excessive dilation of the veins
which is characteristic of exposure to heat. In the hands, the
visibility of the veins is conditioned by the subcutaneous tissues.
If these tissues are scant, they should be increased. For this
purpose, we use Adipofilling. The procedure that we have created
restores a permanent youthful appearance to the hands. Would it be possible to assess the number of treatment sessions required and associated costs based on high resolution photographs?If the veins are very evident, 3 treatment sessions are required
for each region, which means 18 sessions for both limbs. The number
of sessions can be halved if the amount of solution injected is
doubled (40 ml). Could hot weather have any adverse effect on the result of treatment?No, none at all. |
Three-dimensional Regenerative Phlebotherapy Fleboterapia tridimensional Regenerativa |
