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Questions and answers for patients Questions and answers for medical professionals From sclerotherapy to T.R.A.P. |
From Sclerotherapy to Three-dimensional Regenerative Phlebotherapy
The advent of three-dimensional regenerative phlebotherapy (T.R.A.P.)
calls into question most of the concepts that underlie current therapeutic
procedures in phlebology. These concepts are based on premises that are not
physiological and do not respect the anatomical and functional integrity of
the venous circulation in the lower limbs. Moreover, the preventive aspect
is currently underestimated. It is easier for me, as a plastic and
reconstructive surgeon, to appreciate that it is better to “treat” veins
rather than obliterate or remove them. This new awareness has emerged slowly
over several years of study and experimentation of this innovative technique.
What originally gave rise to T.R.A.P. was the realisation that the
traditional therapies either failed or met with only partial or temporary
success. It does not surprise me that this new technique has encountered
considerable resistance, since it conflicts with deeply rooted ideas that
pervade phlebology worldwide. Nevertheless, I trust that our research will
be able to cast a ray of light on the treatment of venous insufficiency,
which is one of the most common disorders in the world. Moreover, I am
convinced that the results achieved by three-dimensional regenerative
phlebotherapy will restore the faith of patients disappointed by traditional
therapies.” Why has three-dimensional regenerative phlebotherapy (T.R.A.P.) been created?On account of the difficulty of achieving good results by means of sclerotherapy and surgical ablation (saphenectomy and phlebectomy). The complications of the traditional therapies – areas of hyperpigmentation and pseudo-recurrences – tend to deter patients from undergoing this kind of treatment. Why pseudo-recurrences of spider veins, varicose veins and telangiectasia?Because recurrence is already implicit in the traditional methods of treatment. Why is sclerotherapy poorly efficacious and its results limited in time?Because it is obliterative and treats the effect of the disorder, not its cause. Saphenectomy, phlebectomy and RF and laser obliteration also mainly treat the effect and not the cause of the disorder. Why, except in the case of thrombophlebitis, do we not use Echo Colour Doppler for the diagnosis, nor do we check our results by means of this instrument?Because ECD is unable to pick out the pathological vessels that we are interested in; moreover, these vessels manifest their insufficiency only when the patient runs or walks. Why is the insufficiency of the valves of the great saphenous vein not in itself responsible for varicose veins?The largest superficial vein has the same pressure at the ankle regardless of whether its valves are continent or not. The literature on phlebology reports cases of patients born without valves in the saphenous vein who have not developed varicose veins. By contrast, varicose veins and venous insufficiency have been seen in patients with continent valves even in the femoral vein. In three-dimensional regenerative phlebotherapy, what is important is not the size of the vessels, but rather their pressure. It is therefore the perforators connected to the saphenous vein that concern us. The dimensions of the vessels are related to the weakness of their walls. How should we regard the dilated vessels that appear on this surface of the patient's lower limbs?Ectatic veins that are visible (even by means of transillumination) and telangiectasias are the manifestation of the quantity of blood that escapes, through the perforating veins, from the deep circulation as a result of the pressure exerted by walking and by muscle contraction. The unsightly veins that we see represent, in practice, the “escape valve” that is created by the insufficiency of the underlying perforating veins. Obliterating or removing this escape valve without correcting the insufficiency of the valves of the underlying veins is clearly irrational. Why do the veins of the perforating circulation become insufficient?On account of congenital miopragia (a congenital organic weakness) the perforating veins (there are about 150 in the leg) dilate under the haemodynamic pressure caused by walking and by muscle contraction. This may be manifested as a result of several factors (age, pregnancy, hormones, posture, obesity, etc). When the wall of a constitutionally weak vein dilates to such an extent that the valves are no longer continent, an anomalous pressure (up to 300 mm of mercury!) is exerted on the superficial circulation, thus making it ectatic. Dilation of the vessels in the area subjected to this anomalous pressure begins with those vessels whose walls are least resistant. The miopragia affects the entire superficial and perforating venous system. Obviously, it would be impossible to obliterate or remove all the perforating veins. On the contrary, they can be “regenerated”, thereby also reducing the excessive capacity of the circulation. “Regeneration” of the superficial and perforating circulation has enabled us to achieve an aesthetic and functional result in all of the cases that have come to our attention. By acting upon the entire superficial and perforating circulation, three-dimensional regenerative phlebotherapy is able both to block the progression of the varicose disorder and to prevent its onset. Naturally, in order to understand this method fully, preconceived notions must be abandoned; first of all, we have to realise that the results of sclerotherapy and surgical procedures are both modest and unpredictable. Almost 90 years have passed since sclerotherapy made its first appearance, and yet the field of phlebology is still ruled by the same short-sighted concepts! Only by questioning these erroneous concepts can we begin to understand how the venous circulation in the lower limbs works. Only then will it become clear how wrong it is to attack the venous circulation by means of ablative and obliterative techniques that alter the anatomical-functional structure of the venous circulation in the limb. Today, the venous circulation in the lower limbs should be treated in such a way as to respect its functional anatomy. In this way, side-effects are minimised, the correct capacity and continence are restored and telangiectasias disappear, along with the sensation of heavy legs, leaving a limb without visible veins and telangiectasias.
Histological picture before and after injection of the regenerating solution. The vessel wall, which formerly displayed alterations and inflammatory infiltrate, is now seen to be of regular thickness and free from inflammatory infiltrate. Continuity of the endothelium has been restored. The solution has rendered the vessel wall uniformly thick, reduced the lumen and consolidated the connective structure. All these effects of non-obliterative fibrosis have been summed up under the term "regeneration". “Regeneration” of the superficial and perforating circulation constitutes the first true cure for venous insufficiency. (The histopatologic feature of an evident inflammatory infiltrate in the wall of ectatic venular vessels in biopsy sperimen from teleangiectasie appears in coherence with the eziopatogenetic review recently published by The New England Journal of Medicine. The authors support a strict correlation between changes in pressure and especially geometric and dynamic features of blood flow and induction of inflammatory molecules, primarily ICAM-1, on the endothelial sheath of venous and vaenular vessels. They emphasize the role of “shear stress” of a laminar flow of blood tangential to glycocalyx and cell wall of endothelial cells to preserve their anatomical and immunologic, physiologic features. They also explain a dynamical model of linear flow, with gradient of speed and pressure, which ensure anatomo-functional integrity of the valves in veins when strictly associated with a limited, peripheral vorticous flow restricted to the geometrical space inside the concavity of vein valves. So, the etiopatogenetic setting of this review claims the intention of carring out a non surgical therapy of venous insufficiency which try to normalize the geometric and compliance characteristic of dilated venous vessels. The histological speciments”, confirms the vanishing of inflammatory and degenerative change in the wall, with endothelial cells, of teleangiectasic/reticular venous vessels when the action of regenerative solution has restored normal, geometrical features of dilated veins, inducing physiologic blood flow).
The right leg seen a week after the second session of three-dimensional regenerative phlebotherapy; this involves injecting the regenerating solution into all the vessels that are visible to the naked eye or by means of transillumination. Treatment begins with the varicose veins of the foot (phlebectatic corona ) and terminates at the base of the thigh, moving from lower-pressure to higher-pressure vessels. The limb is divided into three regions: medial, posterior and lateral. In the first session, the medial region is treated, followed by the posterior and lateral regions in the second and third sessions, respectively. In the fourth session, the medial region is again treated, and so on until all the visible vessels have disappeared from view. Treatment of one limb is completed before beginning treatment on the contralateral limb. The result is immediately visible and the benefits of improved functioning become apparent straightaway. In each session, from 14 to 31.5 ml of 6% sodium salicylate in a buffered hydroglycerin vehicle is injected, according to the gravity of the disorder. |
Three-dimensional Regenerative Phlebotherapy Fleboterapia tridimensional Regenerativa |
