Varicose veins sclerosis guided by ultrasound Poster No.:
C-1686
Congress:
ECR 2014
Type:
Educational Exhibit
Authors:
D. H. Jiménez, A. Ruiz Guanter, E. Lonjedo, J. Gomez; Valencia/ ES
Keywords:
Interventional vascular, Veins / Vena cava, Ultrasound, Sclerosis, Varices
DOI:
10.1594/ecr2014/C-1686
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Learning objectives Familiarize the radiologist in the treatment of varicose veins using the technique of ultrasound-guided sclerosis.
Background The CVI of the lower limbs is the most common vascular disorder. The varicose veins shows up as the result of a prolonged HTV. It affects from 40% to 60% of women and from 15 to 30% of men. Benign pathology with: variable clinical basis y multifactorial: Venous insufficiency valvular destruction- HTV- trophic changes- venous valves incompetence -varicose veins- idiophatic defect vein´s wall- dilation - valvular separation. Affecting the quality of the patient's life style with its proper socio economic repercussion.
The varicose veins are primary (95%) or secondary. Type of varicose veins according to their size: a) Principal Varicose veins (collateral and troncular varicose veins) b) Reticular varicose veins c) Telangiectasia (spider veins) (image 1)
Varicose veins are a v-v shunt in the anomalous direction of blood. Shunt Vanishing point:Path from one network to another in an anomalous form. Entry point It´s the point where it re-enters to the deep network (anterograde flow) (Image 2)
Images for this section:
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Fig. 1
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Fig. 2
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Findings and procedure details TREATMENT / PRIORITIES Hygienic-diet measures Pharmacological treatment Endovascular- surgical treatment : State II (CEAP)
Sclerosing solutions. Veins injection ( Endothelial destruction) Ultrasound Guide More accurate Planned exposition of the product.
Mechanism of action: dispersion of the protective fibrin sheet of the vein´s wall and the endothelium´s irreversible injury causing firstly its swelling and its subsequent fibrosis, that can be filled in a few weeks or more than six months. The objective is not the vein´s endoluminal thrombosis but its obliteration by means of a fibrosis process.
OSMOTIC hypertonic saline solution (20% and 23%) Hypertonic glucose saline (Glucosmon®) sodium salicylate absolute alcohol
Chemical iodine ointment solution Chromium glycinate (scleremo ®)
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Detergent Tetradecil sodium sulfate (trombovar®)r, Thromboject ®), Sotradecol®), Fibrovein ®) Polidocanol ( Etoxiclerol ®), Sclerovin®, aetoxisclerol®), A.E.T®), veinosclerol ®) morhuate sodium (scleromate ®)) Ethanolamine oleate (Ethamolin ®), Neovarisclerin®), Cypros ®)
Where is the sclerotheraphy done? Mechanism of action: dispersion of the protective fibrin sheet of the vein´s wall and the endothelium´s irreversible injury causing firstly its swelling and its subsequent fibrosis, that can be filled in a few weeks or more than six months. The objective is not the vein´s endoluminal thrombosis but its obliteration by means of a fibrosis process.
What sclerosing is used? Ideal sclerosing doesn´t exist , it´s necessary to choose the most adequate according to the concrete situation. Liquid or foam form . According to its quantity The foam sclerotherapy provides advantages, according to the endothelium contact, and acting power.
Micropolyurethane preparation Year Author Active principle technique 1939 Stuart Mc Ausland morhuate sodium agitacion en vial? 1944 Egmont J Orbach Ethanolamine oleate Air block 1944 Robert R. Foote Air block 1953 Arve Rose
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1957 H Mayer/ H Brucke Tetradecil sodium sulfate double barrel syringe 1963 Peter Lukenhermer Polidocanol agitación en vial? 1969 walter Chilesberger negative pressure 1984 Gerard Hauer double barrel syringe 1995 Juan Cabrera Polidocanol Microbush CO2 1997 Alan Mon polidocanol negative pressure 1998 Miguel Santos Polidocanol negative pressure 1999 Javier Garcia Polidocanol gas system 2000 Lorenzo Tessari Polidocanol three ways key 2001 Jorge uLLOA Lepidium hydrochloride three ways key
Micropolyurethane prpeparation The foam only can be formed by detergent products, being more used the Tetradecil sodium sulfate and the polidocanol. The polidocanol foam in its different presentations (0.5 to 3%) is the most used in our environment and in the risk-efficiency relation is the most favorable.
Foam sclerosis
Micropolyurethane Advatages - Increase of the endothelium´s conatct surface. - Decrease the sclerosing agent - Less concentration and it´s more homogenous. - Air block effect. - It´s visible in echograpy due to the eco refrigerant properties of the foam (gas or air)
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Micropolyurethane Advatages Increase of the sclerosing power and the produces vascular spasm Increment of the indicators spectrum to big venous trunks. It lets to decrease the total quantity of sclerosing , therefore , the derivate complications from the sclerosing liquid of big volumes injection.
Advantages V/s other techniques Measure treatment (Doppler) Very good patient´s tolerance It reaches veins in sick skin areas Outpatient treatment Therapeutic option for all patients.
Technique Basic considerations Clinic evaluation Allergies Physical examination Doppler color in every patient.
Material: ( figures 3 - 10) Syringe, , adapter, / No, needle, abocath etc Concentrations: varicula, telagiectasia , reticular 0,5-0,7% Troncular varicose veins, v.safena int/ext big tributaries: 0,7% to 2 and 3 % . These elements must be adjusted to every patient an to every tipe of varicose vein to be treated, being adjusted to its diameter.
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Technique (images 11 - 14) Thirty minutes prowled HBPM Clexane 40 mgr 1sc/24 hours x 4 days AINES Voltaren 50 p.o 1c /12hx 5 days. Omeprazol 40 mgr po/ 24h x 5 days. Elastic sock (30-40 mmHg) Local treatment with creams. Followed in consultation.
COMPLICATIONS: Minor: Vagal symtoms (1%) Ecchymosis Venous swelling Inflammation in venous Pigmentation Telangiectatic matting Edema Toxic reaction or intoleran Migraine aura Infection Extravasation/ necrosis/ phlyctenas
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Major: Gas embolism Intra-arterial injection Anafilactic shock 2/ 1000 TVP1 / 10000 (3%). Superficial phlebitis Pain Tatoo permanent (image 14). Images for this section:
Fig. 3
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Fig. 4
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Fig. 5
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Fig. 6
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Fig. 7
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Fig. 8: equipment
Fig. 9: equipment
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Fig. 10: Technique
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Fig. 11: Technique
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Fig. 12: Technique
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Fig. 13: Technique
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Fig. 14: Tatoos
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Conclusion Sclerosis of varicose veins guided by ultrasound is a procedure that offers many advantages: Multiple indications. Simple to be done. Low Cost Minimally invasive Sure In most cases, well specified and performed provides a good aesthetic result.
Personal information References 1. Wollmann JC The history of sclerosing foams. Dermatol Surg. 2004;30:694-703. 2. Coleridge Smith P. Saphenous ablation: sclerosant or sclerofoam? Semin Vasc Surg. 2005; 18:19-24. 3 .Bergan J, Pascarella L Severe chronic venous insufficiency: primary treatment with sclerofoam Semin Vasc Surg. 2005; 18:49-56. 4. Guex JJ. Contra indications of sclerotherapy, update 2005 J Mal Vasc. 2005;30:144-9. 5. Bergan J, Pascarella L, Mekenas L. Venous diosrders: treatment with sclerosant foam. J Cardiovasc Surg 2006; 47:115-24 6. Zimmet SE .Sclerotherapy treatment of telangiectasias and varicose veins. Tech Vasc Interv Radiol. 2003 Sep;6(3):116-20 7. Rabe E, Otto J, Schliephake D, Pannier F .Efficacy and safety of great saphenous vein sclerotherapy using standardised polidocanol foam (ESAF): a randomised controlled multicentre clinical trial. Eur J Vasc Endovasc Surg. 2008 Feb;35(2):238-45.
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8. Hamel-Desnos C, Desnos P, Wollmann JC, Ouvry P, Mako S, Allaert FA. Evaluation of the efficacy of polidocanol in the form of foam compared with liquid form in sclerotherapy of the greater saphenous vein: initial results. Dermatol Surg. 2003 Dec;29(12):1170-5 9. Alòs J, Carreño P, López JA, Estadella B, Serra-Prat M, Marinel-Lo J .Efficacy and safety of sclerotherapy using polidocanol foam: a controlled clinical trial. Eur J Vasc Endovasc Surg. 2006 Jan;31(1):101-7 10. Kakkos SK, Bountouroglou DG, Azzam M, Kalodiki E, Daskalopoulos M, Geroulakos G. Effectiveness and safety of ultrasound-guided foam sclerotherapy for recurrent varicose veins: immediate results. J Endovasc Ther. 2006 Jun;13(3):357-64 11. Uurto I, Hannukainen J, Aarnio P. Single-center experience with foam sclerotherapy without ultrasound guidance for treatment of varicose veins. Dermatol Surg. 2007 Nov;33(11):1334-9 12. Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg. 2001 Jan;27(1):58-60. 13. Barrett JM, Allen B, Ockelford A, Goldman MP. Microfoam ultrasound-guided sclerotherapy treatment for varicose veins in a subgroup with diameters at the junction of10 mmor greater compared with a subgroup of less than10 mm. Dermatol Surg. 2004;30:1386-90. 14. Darke SG, Baker SJ. Ultrasound-guided foam sclerotherapy for the treatment of varicose veins. Br J Surg. 2006;93:969-74. 15. Hamel-Desnos C, Ouvry P, Benigni JP, Boitelle G, Schadeck M, Desnos P, Allaert FA. Comparison of 1% and 3% polidocanol foam in ultrasound guided sclerotherapy of the great saphenous vein: a randomised, double-blind trial with 2 year-follow-up"The 3/1 Study". Eur J Vasc Endovasc Surg. 2007 ;34:723-9. 16. Varcoe PF. Ultrasound Guided Sclerotherapy: Efficacy, adverse events and dosing - an international survey. ANZ J Phleb 2003; 7:17-24. 17. Bergan, JJ, editor. The Vein Book.London: Elsevier Science, © 2006. 18. M. McGuckin, R. Waterman, J. Brooks et al. Validation of venous leg ulcer guidelines in the United States and United Kindom. Am J Surg, 183 (2002), pp. 132-137. 19. S. Nitecki, A. Kantarovsky, I.Portnoy, A. Bass. The contemporary treatment of varicose veins (strangle, strip, grill or poison). Isr Med Assoc J, 8 (2006), pp. 411-415.
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20. N.S. Sadick, Advances in the treatment of varicose veins: ambulatory phlebectomy, foam sclerotherapy, endovascular laser, and radiofrequency closure. Dermatol Clin, 23 (2005), pp. 443-455
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