Compression after sclerotherapy for telangiectasias and reticular leg veins: a randomized controlled study

Superficial Venous Disease-An Updated Review

BACKGROUND

This review article provides an updated review of a relatively common pathology with various manifestations. Superficial venous diseases (SVDs) are a broad spectrum of venous vascular disease that predominantly affects the body's lower extremities. The most serious manifestation of this disease includes varicose veins, chronic venous insufficiency, stasis dermatitis, venous ulcers, superficial venous thrombosis, reticular veins, and spider telangiectasias.

METHODS

The anatomy, pathophysiology, and risk factors of SVD were discussed during this review. The risk factors for developing SVD were related to race, age, sex, lifestyle, and certain genetic conditions as well as comorbid deep vein thrombosis. Various classification systems were listed, focusing on the most common one-the revised Clinical-Etiology-Anatomy-Pathophysiology classification. The clinical features including history and physical examination findings elicited in SVD were outlined.

RESULTS

Imaging modalities utilized in SVD were highlighted. Duplex ultrasound is the first line in evaluating SVD but magnetic resonance imaging and computed tomography venography, plethysmography, and conventional venography are feasible options in the event of an ambiguous venous duplex ultrasound study. Treatment options highlighted in this review ranged from conservative treatment with compression stockings, which could be primary or adjunctive to pharmacologic topical and systemic agents such as azelaic acid, diuretics, plant extracts, medical foods, nonsteroidal anti-inflammatory drugs, anticoagulants and skin substitutes for different stages of SVD. Interventional treatment modalities include thermal ablative techniques like radiofrequency ablationss, endovenous laser ablation, endovenous steam ablation, and endovenous microwave ablation as well as nonthermal strategies such as the Varithena (polidocanol microfoam) sclerotherapy, VenaSeal (cyanoacrylate) ablation, and Endovenous mechanochemical ablation. Surgical treatments are also available and include debridement, vein ligation, stripping, and skin grafting.

CONCLUSIONS

SVDs are prevalent and have varied manifestations predominantly in the lower extremities. Several studies highlight the growing clinical and financial burden of these diseases. This review provides an update on the pathophysiology, classification, clinical features, and imaging findings as well as the conservative, pharmacological, and interventional treatment options indicated for different SVD pathologies. It aims to expedite the timely deployment of therapies geared toward reducing the significant morbidity associated with SVD especially varicose veins, venous ulcers, and venous insufficiency, to improve the quality of life of these patients and prevent complications.

Clinical Guidelines on Compression Therapy in Venous Diseases

BACKGROUND

In recent years, compression therapy has attracted gradually increasing clinical attention in lower extremity venous diseases. However, basic concepts and clear nomenclature, standard treatment methods, and consistent product standards for pressure equipment are lacking. Therefore, developing clinical guidelines for compression therapy is essential to improving the treatment of venous diseases.

METHODS

Our panel generated strong (Grade I), moderate (Grade IIa and IIb), and weak (Grade III) recommendations based on high quality (Class A), moderate quality (Class B), and low quality (Class C) evidence, using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach and the European Society of Cardiology (ESC) grading system.

RESULTS

The panels made 30 recommendations from current evidence, focusing on seven fields of lower extremity venous disease (venous thromboembolism, post-thrombotic syndrome, chronic venous insufficiency, varicose veins, hemangioma and vascular malformations, lymphedema, and venous ulcers) and 18 topics.

CONCLUSIONS

Of the 30 recommendations made across the 18 topics, 7 were strong (Grade I) and 17 were based on high quality (Class A) evidence, highlighting the need for further research of the use of compression therapy for .

Black holes in compression therapy: A quest for data

OBJECTIVE

Although compression therapy (CT) is considered a crucial conservative treatment in chronic venous disease, strong evidence is missing for many clinical indications. This literature review aims to point out what strong evidence we have for CT and all the clinical scenarios where strong evidence still needs to be included.

METHODS

The research was conducted on MEDLINE with PubMed, Scopus and Web of Science. The time range was set between January 1980 and October 2022. Only articles in English were included.

RESULTS

The main problem with CT is the low scientific quality of many studies on compression. Consequently, we have robust data on the effectiveness of CT only for advanced venous insufficiency (C3-C6), deep vein thrombosis and lymphedema. We have data on the efficacy of compression for venous symptoms control and in sports recovery, but the low quality of studies cannot result in a strong recommendation. For compression in postvenous procedures, superficial venous thrombosis, thromboprophylaxis, post-thrombotic syndrome prevention and treatment, and sports performance, we have either no data or very debated data not allowing any recommendation.

CONCLUSIONS

We need high-level scientific studies to assess if CT can be effective or definitely ineffective in the clinical indications where we still have a paucity of or contrasting data.

Brazilian guidelines on chronic venous disease of the Brazilian Society of Angiology and Vascular Surgery

The Brazilian Society of Angiology and Vascular Surgery has set up a committee to provide new evidence-based recommendations for patient care associated with chronic venous insufficiency. Topics were divided in five groups: 1. Classification, 2. Diagnosis, 3. Conservative or non-invasive treatment, 4. Invasive treatment and 5. Treatment of small vessels. This last series is closely related to the activities of Brazilian angiologists and vascular surgeons, who are heavily involved in the treatment of small superficial veins. These guidelines are intended to assist in clinical decision-making for attending physicians and health managers. The decision to follow a guideline recommendation should be made by the responsible physician on a case-by-case basis taking into account the patient's specific condition, as well as local resources, regulations, laws, and clinical practice recommendations.

Stocking-only versus additional eccentric compression after below-the-knee truncal vein sclerotherapy: A SOVAECS prospective randomized within-person trial

OBJECTIVE

After foam sclerotherapy in the truncal saphenous vein, the clinical effects of additional eccentric compression has not yet been explored.

METHODS

Between April 2020 and February 2021, we enrolled 42 patients (84 limbs) who underwent bilateral endovenous combined therapy for great saphenous vein (GSV) reflux. Each patient received the same type of endovenous ablation in both above-the-knee GSVs (laser, radiofrequency, cyanoacrylate glue), and combined foam sclerotherapy was performed on both below-the-knee GSVs. Subsequently, we conducted a prospective randomized, single-blind, within-person study in which each patient's bilateral truncal saphenous vein of the calves underwent two different compression therapies: wearing of a regular class II compression stocking on one side (RC group) and additional eccentric compression on the other side (AC group). The primary end point was the occlusion range (score, 0-10) of the below-the-knee truncal GSV after foam sclerotherapy. The secondary outcomes were the pain score (visual analog scale score range, 0-10) of the paired limb, the required number of additional foam sclerotherapy sessions, compliance with compression therapy, and procedure-related complications.

RESULTS

For the above-the-knee GSV, endovenous laser treatment (n = 44), endovenous radiofrequency ablation (n = 14), and endovenous cyanoacrylate glue ablation (n = 26) were performed. The mean subcompression pressure of the medial calf in the supine and standing positions were 16.7 ± 2.34 mm Hg and 24.5 ± 6.6 mm Hg in the RC group and 38.5 ± 5.5 mm Hg and 45.3 ± 8.2 mm Hg in the AC group, respectively (P = .000). The secondary outcomes of pain score, number of additional foam sclerotherapy sessions, and pigmentation were not significantly different statistically between the two groups. The patient-reported satisfaction scores (range, 0-10) on compression at 24 hours postoperatively were 8.03 ± 1.9 for the AC group and 7.98 ± 1.9 for the RC group (P = .317; Wilcoxon signed ranks test). In both groups, the closure rate of the above-the-knee GSV at 1 month postoperatively was 100%. No procedure-related complications were identified within 1 month postoperatively, including no deep vein thrombosis, numbness, or skin necrosis requiring additional medical attention.

CONCLUSIONS

The 24 hours of additional eccentric compression on the truncal GSV compared with the use of a conventional knee-level stocking only did not yield any clinical advantages in terms of the occlusion range, postoperative pain, need for additional sclerotherapy, or skin pigmentation after foam sclerotherapy. The decision on which type of compression therapy to perform after foam sclerotherapy in the truncal vein should be comprehensively determined.

Daily Duration of Compression Treatment in Chronic Venous Disease Patients: A Systematic Review

Background: There are no data on the daily regimen of compression therapy in patients with chronic venous disease. This systematic review aimed to establish the optimal daily duration of compression treatment. Methods: A systematic search of CENTRAL and MEDLINE was performed to identify RCTs, non-RCTs, reviews, systematic reviews, meta-analyses, and guidelines evaluating the use of compression regimens in the treatment of varicose veins. Results: Thirty-two RCTs, three non-RCTs, four observational studies, and two crossover trials reporting the duration and regimes of compression treatment fulfilled the inclusion criteria. The daily duration of compression was reported in patients after invasive treatment, for venous ulcer treatment, in patients with venous symptoms. The quality of the studies varied. We could not conduct a meta-analysis due to the heterogeneity of the research data and their quality. Twenty-three studies reported results of compression usage after invasive procedures. Eight studies reported daily duration regimens in patients with venous ulcers. Nine studies reported the impact of compression on venous symptoms and/or edema or limb volume change. One study was conducted to assess if compression improves QoL in venous patients. While there was a clear difference found in the daily duration depending on the clinical scenario, no data in support of exact regimens were found. Conclusions: There are no reliable data supporting exact daily regimens of compression treatment in various cohorts of CVD patients.

Quantitative analysis validation for sclerotherapy treatment of lower limb telangiectasias

BACKGROUND

The evaluation of sclerotherapy efficacy for lower limb telangiectasias, which is the standard treatment for such condition, is commonly assisted by scores based on before and after pictures. This method is marked by its subjectivity, which impairs the precision of studies on the subject, making it unfeasible to evaluate and compare different interventions. We hypothesize that a quantitative method for evaluating the effectiveness of sclerotherapy for lower limb telangiectasias may present more reproducible results. Reliable measurement methods and new technologies may become part of the clinical practice in the near future.

METHODS

Before and after treatment photographs were analyzed using a quantitative method and compared with a validated qualitative method based on improvement scores. Reliability analysis of the methods was performed, applying the intraclass correlation coefficient (ICC) and kappa coefficient with quadratic weights (Fleiss Cohen), for analysis of inter-examiner and intra-examiner agreement in both evaluation methods. Convergent validity was evaluated by applying the Spearman test. To assess the applicability of the quantitative scale, the Mann-Whitney test was used.

RESULTS

A better agreement between examiners is shown for the quantitative scale, with a mean kappa of .3986 (.251-.511) for qualitative analysis and a mean kappa of .788 (.655-.918) for quantitative analysis (P < .001 for all examiners). Convergent validity was achieved by correlation coefficients of .572 to .905 (P < .001). The quantitative scale results obtained between the specialists with different degrees of experience did not show statistical difference (seniors: 0.71 [-0.48/1.00] × juniors: 0.73 [-0.34/1.00]; P = .221).

CONCLUSIONS

Convergent validity between both analyses has been achieved, but quantitative analysis has been shown to be more reliable and can be applied by professionals of any degree of experience. The validation of quantitative analysis is a major milestone for the development of new technology and automated, reliable, applications.

Influence of compression therapy following varicose vein surgery: a prospective randomized study

Background

The use of compression dressings after phlebectomy is based solely on clinical experience due to the lack of a unified set of definitive recommendations, which makes clinical practice extremely heterogeneous.

Objectives

To evaluate compression therapy with elastic stockings for 7 days after phlebectomy.

Methods

We randomly allocated 104 lower limbs with disease classified as C1 and C2 to 1 of 2 groups: an intervention group (64 limbs) - wearing elastic compression stockings for the first 7 days after phlebectomy; or a control group (40 limbs) - given conventional bandaging for 24 hours postoperatively. We compared clinical response by analyzing the evolution of symptoms, hematoma formation, and preoperative vs. postoperative limb volume.

Results

Pain (median 1.0 vs. 1.5, p=0.0320) and limb volume (mean 43.7 vs. 99.8, p=0.0071) were significantly improved in patients wearing elastic compression stockings for 7 days after phlebectomy compared with controls.

Conclusions

Use of elastic compression therapy for 7 days after phlebectomy was effective for improving pain and lower limb volume.

Skin hyperpigmentation after sclerotherapy with polidocanol: A systematic review

Skin hyperpigmentation after sclerotherapy with polidocanol-containing sclerosants is a common local side effect. Sclerotherapists should be familiar with factors that trigger hyperpigmentation after sclerotherapy with polidocanol-containing sclerosants. A systematic literature review of works reporting hyperpigmentation after sclerotherapy for telangiectasias, reticular veins, side branches and truncal varices with polidocanol-containing sclerosants was performed. Reported incidence rates, follow-up periods and potentially triggering factors were assessed and analysed. The search yielded 1687 results; of these, 27 reports met the inclusion criteria. The incidence of hyperpigmentation seemed to increase with higher concentrations of polidocanol and was more evident after sclerotherapy for epifascial veins than for intrafascial truncal veins when the polidocanol concentration was more than 0.25%. Regarding sclerotherapy for telangiectasias and reticular veins, the incidence of hyperpigmentation ranged between 2% and 25% for polidocanol 0.25% (liquid and foam), between 12.5% and 67.9% for polidocanol 0.5% (liquid and foam) and between 13% and 73% for polidocanol 1% (liquid and foam). Regarding truncal veins, the incidence ranged from 7% to 45.8% for polidocanol 1% (liquid and foam), from 16% to 17% for polidocanol 2% (foam) and from 7.4% to 32.5% for polidocanol 3% (liquid and foam). Regarding the treatment of side branches, the incidence of hyperpigmentation ranged from 5.6% to 53% for both foam and liquid sclerotherapy. Regarding the duration of hyperpigmentation, there are few data describing reticular veins and telangiectasias. Hyperpigmentation persisting for more than 6 months has been reported to have an incidence of up to 7.5%. Hyperpigmentation persisting for more than 1 year after foam polidocanol 1%-3% treatment for truncal veins has an incidence ranging from 8.1% to 17.5%. Other factors such as higher volumes and compression therapy after treatment seem to have a minor influence. Data regarding hyperpigmentation after polidocanol-related sclerotherapy are poor and should be improved by higher-quality research.

Sclerotherapy in Aesthetic Medicine: Myths and Realities

BACKGROUND

Sclerotherapy is commonly performed for elimination of reticular and telangiectatic leg veins. There are several variations in practice, from the preparation to post-therapy directives.

OBJECTIVE

To critically examine the misconceptions of sclerotherapy for aesthetic indications.

MATERIALS AND METHODS

This review assesses evidence for and against each of the most common myths regarding sclerotherapy for aesthetic indications.

RESULTS

Sclerotherapy can be safely used to treat veins in areas other than the lower extremities, with the exception of the face. Laser therapy is not superior to sclerotherapy for the treatment of small telangiectatic veins on the lower extremities. The type of syringe used to produce foam sclerotherapy is an important procedural consideration. After sclerotherapy, graduated compression stocking usage is a vital part of the procedure. Detergent sclerotherapy agents are similar, but not equivalent. Touch-up treatments after sclerotherapy should not be performed for 2 months post-treatment. Foam sclerotherapy does not have a high risk for air emboli. It is not advisable to treat the leg veins in "sections." Finally, one cannot reliably treat the telangiectatic veins without treating the feeding reticular veins for a satisfactory result.

CONCLUSION

Many aspects of sclerotherapy have existing evidence to dictate best clinical practice.

First-generation therapy for varicose veins: medication, compression, sclerotherapy, and stripping

Background: Improving the understanding varicose veins (VV) is increasing due to life extension and concerns regarding quality of life. Recently, endovascular treatment has become more common, even in mild cases. Excessive procedures are often performed before conservative and non-surgical treatments. We aimed to explain the efficacy of medication, compression, sclerotherapy, and stripping of treatments and to consider the appropriate indications for many treatment methods, including endovascular procedures.Current Concepts: Venoactive drugs can be used as first-line agents for symptoms, such as edema, at all stages of varicose vein. These are effective adjuvant agents and can help achieve compression before and after procedures. Compression therapy is effective for skin change and ulcers and is excellent for the improvement of symptoms. Sclerotherapy has been widely used as an adjuvant treatment, but recently, its indications have been expanded for non-invasive causes. Traditional high ligation and stripping is still the recommended treatment option for recurrent or complicated varicose veins.Discussion and Conclusion: The patients’ symptoms should be evaluated more critically than assessing only the venous reflux using ultrasound. Additionally, objective evaluation of various causes of lower extremity discomfort should be considered. Treatment according to appropriate indications, such as medication, compression, sclerotherapy, stripping, and endovascular therapy, can improve the patients’ quality of life and prevent complications.

Treatment for telangiectasias and reticular veins

BACKGROUND

Telangiectasias (spider veins) and reticular veins on the lower limbs are very common, increase with age, and have been found in 41% of women. The cause is unknown and the patients may be asymptomatic or can report pain, burning or itching. Treatments include sclerotherapy, laser, intense pulsed light, microphlebectomy and thermoablation, but none is established as preferable.

OBJECTIVES

To assess the effects of sclerotherapy, laser therapy, intensive pulsed light, thermocoagulation, and microphlebectomy treatments for telangiectasias and reticular veins.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, AMED and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 16 March 2021. We undertook additional searches in LILACS and IBECS databases, reference checking, and contacted specialists in the field, manufacturers and study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared treatment methods such as sclerotherapy, laser therapy, intensive pulsed light, thermocoagulation, and microphlebectomy for telangiectasias and reticular veins in the lower limb. We included studies that compared individual treatment methods against placebo, or that compared different sclerosing agents, foam or laser treatment, or that used a combination of treatment methods.

DATA COLLECTION AND ANALYSIS

Three review authors independently performed study selection, extracted data, assessed risks of bias and assessed the certainty of evidence using GRADE. The outcomes of interest were resolution or improvement (or both) of telangiectasias, adverse events (including hyperpigmentation, matting), pain, recurrence, time to resolution, and quality of life.

MAIN RESULTS

We included 3632 participants from 35 RCTs. Studies compared a variety of sclerosing agents, laser treatment and compression. No studies investigated intensive pulsed light, thermocoagulation or microphlebectomy. None of the included studies assessed recurrence or time to resolution. Overall the risk of bias of the included studies was moderate. We downgraded the certainty of evidence to moderate or low because of clinical heterogeneity and imprecision due to the wide confidence intervals (CIs) and few participants for each comparison. Any sclerosing agent versus placebo There was moderate-certainty evidence that sclerosing agents showed more resolution or improvement of telangiectasias compared to placebo (standard mean difference (SMD) 3.08, 95% CI 2.68 to 3.48; 4 studies, 613 participants/procedures), and more frequent adverse events: hyperpigmentation (risk ratio (RR) 11.88, 95% CI 4.54 to 31.09; 3 studies, 528 participants/procedures); matting (RR 4.06, 95% CI 1.28 to 12.84; 3 studies, 528 participants/procedures). There may be more pain experienced in the sclerosing-agents group compared to placebo (SMD 0.70, 95% CI 0.06 to 1.34; 1 study, 40 participants; low-certainty evidence). Polidocanol versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD 0.01, 95% CI -0.13 to 0.14; 7 studies, 852 participants/procedures), hyperpigmentation (RR 0.94, 95% CI 0.62 to 1.43; 6 studies, 819 participants/procedures), or matting (RR 0.82, 95% CI 0.52 to 1.27; 7 studies, 859 participants/procedures), but there were fewer cases of pain (SMD -0.26, 95% CI -0.44 to -0.08; 5 studies, 480 participants/procedures) in the polidocanol group. All moderate-certainty evidence. Sodium tetradecyl sulphate (STS) versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD -0.07, 95% CI -0.25 to 0.11; 4 studies, 473 participants/procedures). There was more hyperpigmentation (RR 1.71, 95% CI 1.10 to 2.64; 4 studies, 478 participants/procedures), matting (RR 2.10, 95% CI 1.14 to 3.85; 2 studies, 323 participants/procedures) and probably more pain (RR 1.49, 95% CI 0.99 to 2.25; 4 studies, 409 participants/procedures). All moderate-certainty evidence. Foam versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD 0.04, 95% CI -0.26 to 0.34; 2 studies, 187 participants/procedures); hyperpigmentation (RR 2.12, 95% CI 0.44 to 10.23; 2 studies, 187 participants/procedures) or pain (SMD -0.10, 95% CI -0.44 to 0.24; 1 study, 147 participants/procedures). There may be more matting using foam (RR 6.12, 95% CI 1.04 to 35.98; 2 studies, 187 participants/procedures). All low-certainty evidence. Laser versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD -0.09, 95% CI -0.25 to 0.07; 5 studies, 593 participants/procedures), or matting (RR 1.00, 95% CI 0.46 to 2.19; 2 studies, 162 participants/procedures), and maybe less hyperpigmentation (RR 0.57, 95% CI 0.40 to 0.80; 4 studies, 262 participants/procedures) in the laser group. All moderate-certainty evidence. High heterogeneity of the studies reporting on pain prevented pooling, and results were inconsistent (low-certainty evidence). Laser plus sclerotherapy (polidocanol) versus sclerotherapy (polidocanol) Low-certainty evidence suggests there may be more resolution or improvement (or both) of telangiectasias in the combined group (SMD 5.68, 95% CI 5.14 to 6.23; 2 studies, 710 participants), and no clear difference in hyperpigmentation (RR 0.83, 95% CI 0.35 to 1.99; 2 studies, 656 participants) or matting (RR 0.83, 95% CI 0.21 to 3.28; 2 studies, 656 participants). There may be more pain in the combined group (RR 2.44, 95% CI 1.69 to 3.55; 1 study, 596 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Small numbers of studies and participants in each comparison limited our confidence in the evidence. Sclerosing agents were more effective than placebo for resolution or improvement of telangiectasias but also caused more adverse events (moderate-certainty evidence), and may result in more pain (low-certainty evidence). There was no evidence of a benefit in resolution or improvement for any sclerosant compared to another or to laser. There may be more resolution or improvement of telangiectasias in the combined laser and polidocanol group compared to polidocanol alone (low-certainty evidence). There may be differences between treatments in adverse events and pain. Compared to other sclerosing agents polidocanol probably causes less pain; STS resulted in more hyperpigmentation, matting and probably pain; foam may cause more matting (low-certainty evidence); laser treatment may result in less hyperpigmentation (moderate-certainty evidence). Further well-designed studies are required to provide evidence for other available treatments and important outcomes (such as recurrence, time to resolution and delayed adverse events); and to improve our confidence in the identified comparisons.

Ultrasound-guided foam sclerotherapy is safe and effective in the management of superficial venous insufficiency of the lower extremity

BACKGROUND

Superficial venous disease of the lower extremity has a significant impact on quality of life. Both truncal and tributary vein reflux contribute to this disease process. Endovenous foam sclerotherapy is a widely used technique throughout the world for the management of superficial venous reflux and ultrasound guidance improves its safety and efficacy.

METHODS

A PubMed search for ultrasound-guided foam sclerotherapy (UGFS) was conducted and all abstracts were reviewed to identify clinical trials and systematic reviews for a full-text analysis. Additional articles were also identified through searching the references of the selected studies.

RESULTS

The production of foam for sclerotherapy in a 1:3 or 1:4 ratio of air to sclerosant is optimal in a low silicone, low-volume syringe system. Physiologic gas may decrease any side effects, with the trade-off of decreased foam stability. Proper technique with appropriate sterility and cleansing protocols are paramount for safe and effective treatment. The technical success of UGFS for great saphenous vein disease is inferior to endothermal and surgical modalities and retreatment is more common. However, the clinical improvement in patient-reported quality of life is similar between these three modalities. When used for tributary veins in combination with endothermal approaches of the truncal veins, UGFS has high rates of success with excellent patient satisfaction. UGFS has demonstrated an excellent safety profile comparable with or superior to other modalities.

CONCLUSIONS

With proper technique, UGFS is safe and effective for the management of superficial venous disease.

Efficacy and safety of glucose, glucose and polidocanol combination, liquid polidocanol and polidocanol foam in the treatment of reticular veins: A randomized study in rabbits

OBJECTIVE

To compare the efficacy and safety of sclerosing agents injected in dorsal veins of rabbit ears.

METHODS

Sixty ears of 30 rabbits were randomly allocated in: 1% liquid polidocanol, 1% polidocanol foam, 0.2% polidocanol-glucose 70% solution, glucose 75% or 0.9% saline. Outcomes included efficacy (luminal occlusion), complications (phlebitis, neovascularization, ulceration at the puncture site, necrosis and local inflammation) and histology (sclerosis, recanalization vein and surrounding tissues inflammation, blood extravasation, recanalization, lymphangiogenesis, destruction of cartilage and neoangiogenesis).

RESULTS

Sclerosis was superior in Foam Group (76.9%), but also with 30.7% necrosis (p = 0.003), 46.15% ulceration (p = 0.003), and 69.2% local inflammation (p < 0.0001). Neovascularization were similar. Histology showed 38.5% phlebitis (p = 0.004) and necrosis (p = 0.03) in the foam group.

CONCLUSIONS

Sclerosis with foam and liquid polidocanol were superior to the other groups, but specially polidocanol foam at the expense of greater frequency of adverse events.

[What is evidence-based in the treatment of chronic venous insufficiency?]

Chronic venous diseases belong to the most frequent diseases. They can be asymptomatic, cause subjective symptoms or lead to objectif alterations, such as edema, cutaneous alterations and venous leg ulcers. This ultimately results in chronic venous insufficiency (CVI). Varicose veins are a progressive degenerative disease of the venous walls in the superficial venous system of the legs, which can decisively impair the quality of life of those affected. The classification of chronic venous diseases is carried out with the CEAP classification according to clinical, etiological, anatomical and pathophysiological criteria. Instruments, such as the venous clinical severity score, are used for assessment of the severity. The treatment of chronic venous diseases targets the improvement of the subjective complaints and objectifiable alterations. In addition, complications, such as phlebitis and formation of ulcers should be avoided. Invasive procedures, compression treatment and pharmaceutical treatment are complementary and a combination of these procedures can be meaningful. General physical measures, such as propping up the legs and frequent walking, are part of the basic measures for every patient with venous diseases. Compression therapy with medical compression stockings is the gold standard in the noninvasive treatment of symptomatic venous diseases, possibly supplemented by anti-inflammatory drugs. A varicose vein should be eliminated whenever possible. Stripping operations and the less invasive endovenous thermal ablation show comparable results for saphenous vein varicosis. Foam sclerotherapy and percutaneous phlebectomy are the methods of choice for elimination of side branch varicosis; however, recurrences of varicose veins are frequent.

Polidocanol Plus Glucose Versus Glucose Alone for the Treatment of Telangiectasias: Triple Blind, Randomised Controlled Trial (PG3T)

OBJECTIVE

The aim of this study was to compare the effectiveness and safety of two sclerosing agents used to treat telangiectasias in the lower limbs: 0.2% polidocanol + 70% hypertonic glucose (HG) vs. 75% HG alone.

METHODS

A prospective, randomised, triple blind, controlled, parallel group trial with patients randomly assigned in a 1:1 ratio between January and December 2015, with a two month follow up, from a single academic medical centre in Brazil, was carried out. Participants were women aged 18-65 years with telangiectasias on the lateral aspect of one thigh, classified as C1EpAsPn who underwent sclerotherapy in a single session with 0.2% polidocanol + 70% HG or 75% HG alone to treat the telangiectasias on an area limited by a rectangular template. The primary effectiveness endpoint was elimination of 75% of the telangiectasias within 60 days vs. the pre-treatment pattern. The length of vessels was measured on images obtained before and after treatment using ImageJ software. Safety outcomes were analysed immediately, 7 days, and 60 days after the treatment, and included pigmentation.

RESULTS

A total of 115 patients were included, 98 of whom completed the study. Sclerotherapy with 0.2% polidocanol + 70% HG was significantly more effective than with 75% HG alone to treat telangiectasias in the target area (82.2% vs. 63.9%; p < .001); considering a minimum improvement of 75%, there was a 0.49 risk reduction (95% confidence interval 0.24-0.98; p = .047). No severe adverse events occurred in either group. Pigmentation was the most common minor adverse event and was significantly shorter in length in the group treated with 0.2% polidocanol + 70% HG (median 0 cm vs. 0.5 cm, respectively; p = .033).

CONCLUSION

Polidocanol 0.2% plus 70% HG had better results than 75% HG alone in sclerosing telangiectasias. No severe adverse events occurred. Pigmentation occurred in both groups and was shorter in length in the group treated with 0.2% polidocanol + 70% HG.

Postsclerotherapy compression: A systematic review

BACKGROUND

Compression after sclerotherapy is commonly used, although the evidence base for this practice is unclear. This study aims to summarize and assess the evidence for compression therapy after sclerotherapy to inform clinical practice.

METHODS

A systematic review was performed according to PRISMA guidelines via Medline and EMBASE databases (1946 to December 31, 2019) by two reviewers. Full-text, English-language studies comparing compression type and/or duration in adult chronic venous disease patients undergoing liquid or foam sclerotherapy were included.

RESULTS

Nine studies were identified: five using liquid sclerotherapy, three foam sclerotherapy and one using both. Studies had short follow-up periods (6-24 weeks) and reported on clinical outcomes, quality of life, side effects and complications. In C1 patients undergoing liquid sclerotherapy, any duration of stocking use significantly decreased telangiectasia and reticular vein number and size compared with no compression. No significant difference in clinical symptoms or quality of life was seen when comparing compression duration after liquid or foam sclerotherapy in tributary or truncal veins in C2 to C6 patients. Greater superficial vein resolution was seen with stockings compared with bandages in C2 patients undergoing liquid sclerotherapy to tributary veins. A comparison of stockings vs bandaging revealed differing thrombophlebitis rates but no significant difference in pigmentation. In C2 to C6 patients undergoing foam sclerotherapy, use of 35 mm Hg stockings significantly improved post-treatment symptoms compared with 23 mm Hg stockings. This review was limited by heterogeneity of outcome measurements and the variety of comparisons between compression types and durations.

CONCLUSIONS

Postsclerotherapy compression may have beneficial clinical outcomes at short-term follow-up; however, evidence is lacking regarding its type, class, length, and duration. Further trials are required to guide the optimal management of postsclerotherapy patients.

Reducing hyperpigmentation after sclerotherapy: A randomized clinical trial

OBJECTIVE

Sclerotherapy for the treatment of varicose veins is one of the most common medical procedures performed in the Western world, and hyperpigmentation is one of the most frequent, dreaded, minor adverse events. There has recently been some interest in investigating the inflammatory response of the local endothelium after sclerotherapy and the possible benefits of venoactive drugs because of their pleiotropic properties. The aim of this study was to evaluate whether adding a venoactive drug (sulodexide) to the standard sclerotherapy treatment protocol for patients with varicose veins can reduce the occurrence of postsclerotherapy hyperpigmentation.

METHODS

We carried out a prospective, multicenter, randomized controlled trial with a parallel group design. It included 720 patients with telangiectasia, reticular veins, or varicose veins who were candidates for sclerotherapy. Patients with reflux in deep system or saphenous veins were excluded. Group A consisted of 354 patients who received an oral dose of sulodexide twice a day for 7 days before scheduled sclerotherapy; the treatment then continued for 3 months. Group B consisted of 366 patients who received the standard sclerotherapy protocol. Polidocanol was used as the sclerosing agent, and 20 to 30 mm Hg compression stockings were used in both groups for 7 days. Control photographs were taken, and a follow-up examination took place after 1 month and 3 months. Computer software was used to analyze the treated area for incidence of hyperpigmentation, total area of hyperpigmentation, skin tone increase in the hyperpigmented area, vein disappearance, and incidence of major bleeding. The sample size was calculated to give a statistical power of 80%. Student t-test and the χ² test were used for comparative analyses, as appropriate. The level of significance was set at P < .05.

RESULTS

A total of 609 patients completed the 3-month follow-up: 312 in group A and 297 in group B. After 1 month, the incidence of hyperpigmentation was 8.7% in group A and 14.8% in group B (P = .01). Group A developed an average area of hyperpigmentation of 10.7% compared with 18.2% in group B (P = .01), and the skin tone of the hyperpigmented area was lower in group A than in group B (P = .02). However, the latter difference was not significant after 3 months. The overall vein disappearance rate was similar in both groups.

CONCLUSIONS

Our analysis shows that by adding a venoactive drug (sulodexide) to the standard sclerotherapy protocol, the occurrence of hyperpigmentation is reduced without affecting the desired therapeutic vein elimination response.

Clinical outcome of short-term compression after sclerotherapy for telangiectatic varicose veins

BACKGROUND

Sclerotherapy is considered to be the method of choice for the treatment of telangiectatic varicose veins (C1 veins). Whereas the use of compression stockings after sclerotherapy is recommended, little is known about the impact of compression on the outcome of sclerotherapy. The aim of this study was to assess the influence of compression on the outcome of injection sclerotherapy of C1 varicose veins.

METHODS

There were 100 legs of 50 consecutive patients with chronic venous insufficiency (C1) included. After randomization per patient, both legs were treated with sclerotherapy in a predefined area of the thigh (measuring 100 cm²), followed by eccentric compression for 24 hours. Group A received no further compression, whereas group B was additionally equipped with compression stockings of 18 to 20 mm Hg above the ankle and continued wearing these for 1 week. Photodocumentation was performed before, 1 week after, and 4 weeks after sclerotherapy, and the clinical outcome was assessed at these postprocedure follow-up dates. The photographs were reviewed by an internal unblinded rater and an independent blinded external rater.

RESULTS

There was no discernible difference between the groups in terms of clinical outcome or side effects after 4 weeks. Whereas inter-rater reliability was high, there was no correlation between the raters and patients in terms of outcome. In 55% of the treated legs, the patients deemed the result of the treatment to be good; in 27% of the treated legs, fair; and in 18%, poor. Postprocedure hyperpigmentation occurred in 13% of patients and was comparable in both groups. Compression therapy was found to be comfortable by the majority (58%) of patients.

CONCLUSIONS

One week of postinterventional compression therapy had no clinical benefit compared with no compression.

Single Blind, Randomised Study Regarding the Treatment of the Telangiectasia of the Lower Limbs (C1EAP) Using Polidocanol 0,5%, 1%, and Nd:YAG Laser

The treatment of leg telangiectasias could be done with liquid sclerotherapy or Nd:YAG laser. We evaluated randomly, in a simple blind, the efficacy of the treatment with 0,5% polidocanol (POL-0,5), 1% polidocanol (POL-1) and Nd:YAG laser (LAS) on 132 patient (264 limbs) with telangiectasia of the lower limbs with less than 2mm diameter (C1EAP). The main objective was to evaluate the efficacy of the sclerotherapy (chemical compared with Nd:YAG-LAS). Secondary objectives were: possible major complications (deep thrombosis, severe burns, ischemic complications, etc.), the percentage of the local complications, the cosmetic aspect-evaluated by both the patient and the doctor and the grade of discomfort of the patient during and after the procedure. Comparing the treatment with Nd:YAG laser (LAS), polidecanol-0.5% (POL-0.5), polidecanol 1% (POL-1), it was noticed that telangiectasias smaller than 1mm led to good and very good results in all the cases treated with Nd:YAG laser and the same outcome was obtained in one third of the subjects treated with POL-0.5, vs. 47.81% of patients treated with POL-1. When telangiectasias were larger than 1mm diameter, good and very good results occurred in 86.36% of patients treated with LAS and 100% of the cases treated with POL-0.5 and POL-1. In conclusion, we consider that leg telangiectasias can be treated with good results using Nd:YAG laser or sclerotherapy with polidocanol, Nd:YAG laser being reccomended for telangiectasia under than 1 mm diameter while sclerotherapy in larger vessels.

A critical review on the three-dimensional finite element modelling of the compression therapy for chronic venous insufficiency

Compression therapy is an adjuvant physical intervention providing the benefits of calibrated compression and controlled stretch and consequently is increasingly applied for the treatment of chronic venous insufficiency. However, the mechanism of the compression therapy for chronic venous insufficiency is still unclear. To elaborate the mechanism of compression therapy, in recent years, the computational modelling technique, especially the finite element modelling method, has been widely used. However, there are still many unclear issues regarding the finite element modelling of compression therapy, for example, the selection of appropriate material models, the validation of the finite element predictions, the post-processing of the results. To shed light on these unclear issues, this study provides a state-of-the-art review on the application of finite element modelling technique in the compression therapy for chronic venous insufficiency. The aims of the present study are as follows: (1) to provide guidance on the application of the finite element technique in healthcare and relevant fields, (2) to enhance the understanding of the mechanism of compression therapy and (3) to foster the collaborations among different disciplines. To achieve these aims, the following parts are reviewed: (1) the background on chronic venous insufficiency and the computational modelling approach, (2) the acquisition of medical images and the procedure for generating the finite element model, (3) the definition of material models in the finite element model, (4) the methods for validating the finite element predictions, (5) the post-processing of the finite element results and (6) future challenges in the finite element modelling of compression therapy.

Pathophysiology of telangiectasias of the lower legs and its therapeutic implication: A systematic review

Objective Telangiectasias of the lower legs are intradermal dilatations of the subpapillary venous plexus, but their pathophysiology and risk factors are still largely unknown. The purpose of this review is to summarize the current knowledge on the pathophysiology and risk factors for telangiectasias. Methods A systematic review of the literature indexed in Medline completed with textbooks and European phlebology journals from the French, Swiss, and German phlebology societies was performed. Results A multitude of risk factors and several pathophysiological hypotheses, such as reflux, arterio-venous micro-shunts, parietal, and connective tissue abnormalities, are described in the literature. The different hypotheses are discussed and put in a clinical perspective, in particular their therapeutic implications for phlebologists. Conclusion In conclusion, pathophysiology and risk factors of telangiectasias are still largely unknown, and a better understanding could improve treatment results and reduce recurrence.

Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement

Objective Medical compression stockings are a standard, non-invasive treatment option for all venous and lymphatic diseases. The aim of this consensus document is to provide up-to-date recommendations and evidence grading on the indications for treatment, based on evidence accumulated during the past decade, under the auspices of the International Compression Club. Methods A systematic literature review was conducted and, using PRISMA guidelines, 51 relevant publications were selected for an evidence-based analysis of an initial 2407 unrefined results. Key search terms included: 'acute', CEAP', 'chronic', 'compression stockings', 'compression therapy', 'lymph', 'lymphatic disease', 'vein' and 'venous disease'. Evidence extracted from the publications was graded initially by the panel members individually and then refined at the consensus meeting. Results Based on the current evidence, 25 recommendations for chronic and acute venous disorders were made. Of these, 24 recommendations were graded as: Grade 1A (n = 4), 1B (n = 13), 1C (n = 2), 2B (n = 4) and 2C (n = 1). The panel members found moderately robust evidence for medical compression stockings in patients with venous symptoms and prevention and treatment of venous oedema. Robust evidence was found for prevention and treatment of venous leg ulcers. Recommendations for stocking-use after great saphenous vein interventions were limited to the first post-interventional week. No randomised clinical trials are available that document a prophylactic effect of medical compression stockings on the progression of chronic venous disease (CVD). In acute deep vein thrombosis, immediate compression is recommended to reduce pain and swelling. Despite conflicting results from a recent study to prevent post-thrombotic syndrome, medical compression stockings are still recommended. In thromboprophylaxis, the role of stockings in addition to anticoagulation is limited. For the maintenance phase of lymphoedema management, compression stockings are the most important intervention. Conclusion The beneficial value of applying compression stockings in the treatment of venous and lymphatic disease is supported by this document, with 19/25 recommendations rated as Grade 1 evidence. For recommendations rated with Grade 2 level of evidence, further studies are needed.

Liquid and Foam Sclerotherapy for Spider and Varicose Veins

Sclerotherapy has wide applicability in treating venous disease at every stage of clinical disease. The various sclerosant drugs and formulations each have unique properties, utilities, and side effects. Treating physicians should be aware of the differences between agents, accounting for disease presentation, vein characteristics, and patient comorbidities when selecting the appropriate sclerosing agents. Successful outcomes rely on proper patient evaluation and assessment for contraindications to sclerotherapy. Thorough patient education regarding realistic expectations with sclerotherapy in terms of symptoms relief, recurrence, and improvement in appearance is of chief importance.

Management of reticular veins and telangiectases

AIM

To review the literature related to the management of reticular varices and telangiectases of the lower limbs to provide guidance on the treatment of these veins.

FINDINGS

Very few randomised clinical trials are available in this field. A European Guideline has been published on the treatment of reticular varices and telangiectases, which is largely based on the opinion of experts. Older accounts written by individual phlebologists contain extensive advice from their own practice, which is valuable in identifying effective methods of sclerotherapy. All accounts indicate that a history should be taken combined with a clinical and ultrasound examination to establish the full extent of the venous disease. Sclerotherapy is commenced by injecting the larger veins first of all, usually the reticular varices. Later in the same session or in subsequent sessions, telangiectases can be treated by direct injection. Following treatment, the application of class 2 compression stockings for a period of up to three weeks is beneficial but not used universally by all phlebologists. Further sessions can follow at intervals of 2-8 weeks in which small residual veins are treated. Resistant veins can be managed by ultrasound-guided injection of underlying perforating veins and varices. Other treatments including RF diathermy and laser ablation of telangiectases have very limited efficacy in this condition.

CONCLUSIONS

Sclerotherapy, when used with the correct technique, is the most effective method for the management of reticular varices and telangiectases.

Compression therapy for venous disease

For centuries, compression therapy has been utilized to treat venous disease. To date it remains the mainstay of therapy, particularly in more severe forms such as venous ulceration. In addition to mechanisms of benefit, we discuss the evidence behind compression therapy, particularly hosiery, in various forms of venous disease of the lower extremities. We review compression data for stand-alone therapy, post-intervention, as DVT prevention, post-thrombotic syndrome and venous ulcer disease. We also review the data comparing compression modalities as well as the use of compression in mixed arteriovenous disease.

Leg Rejuvenation: A Combination Approach: A Review and Our Experience

BACKGROUND

Patients increasingly seek to enhance the appearance of their legs. Elimination of unwanted leg veins, reduction of epidermal photo-aging changes such as solar lentigines and keratoses, tightening of skin laxity and reduction of adipose tissue are among the most commonly requested goals. Many patients require a combination approach to address their concerns. It is important for dermatologists to be aware of the multitude of procedures that can be performed, often in combination, to rejuvenate the leg.

OBJECTIVE

The purpose of this review article was to discuss procedures for improving the appearance of the leg and to share the authors experience, especially in the combination approach to leg rejuvenation.

METHODS

A literature search was performed to investigate cosmetic procedures being performed on the leg, with an emphasis on controlled or randomized studies. In addition, the authors contributed their personal experience.

RESULTS

Our discussion of the literature review highlights the treatments for leg veins, unwanted fat, cellulite, and photodamage of the legs that are most supported in peer-reviewed publications.

CONCLUSION

A synergistic, combination approach to leg rejuvenation works best. This includes the use of injectable agents, energy-based devices, and more invasive surgical procedures.

French sclerotherapy and compression: Practice patterns

Based on the recommendations of experts, and supported by a low level of proof, compression after sclerotherapy is applied all over the world.

OBJECTIVE

Investigating the practice of French vascular physicians for sclerotherapy and the use of post-sclerotherapy compression.

METHODS

A questionnaire concerning their practices was sent to French vascular physicians through their regional vascular medicine professional development associations.

RESULTS

A total of 366 vascular physicians replied to the questionnaire, of whom 63% (229/366) were in private practice, 6% (21/366) in hospitals and 31% (115/366) had a mixed private-hospital practice. Sclerotherapy was practised by 88% (323/366) of them. Two-thirds of the vascular physicians used sclerosing foam and practised sclerotherapy using ultrasound guidance. Less than one-third of the vascular physicians regularly applied compression after sclerotherapy. When compression was applied, it was usually after treatment of saphenous or accessory saphenous veins and, in most cases, medical compression stockings of 15-20 mm Hg were used. With respect to the period recommended for wearing compression, this ranged from 48 h to 1 week for 65% (193/299) of the vascular physicians questioned.

CONCLUSION

The great majority of vascular physicians who answered the questionnaire employ ultrasound guidance to perform sclerotherapy and use sclerosing foam. Compression after sclerotherapy is diversely applied in France and does not comply with the recommendations of the French Health Authorities who recommend wearing a stocking of 15-20 or 20-36 mm Hg for a period of 4-6 weeks. Thus, less than one-third of the vascular physicians regularly used elastic compression and when they did, it was usually a medical compression stocking of 15-20 mm Hg, for 1 week or less.

Therapeutic effect of compression stockings versus no compression on isolated superficial vein thrombosis of the legs: a randomized clinical trial

OBJECTIVE/BACKGROUND

Leg compression is considered basic treatment for superficial vein thrombosis (SVT), although scientific proof for its efficacy is lacking. The aim of the study was to evaluate the therapeutic effect of compression stockings on isolated SVT of the legs.

METHODS

This was a single-center randomized controlled trial. Eighty patients with isolated SVT of the legs were instructed to wear compression stockings (23-32 mmHg) (CG) or no compression (NCG) for 3 weeks. All patients received low molecular weight heparin (LMWH) at prophylactic dosage. Non-steroidal anti-inflammatory drugs (NSAIDs) were allowed. The primary outcome variable was the reduction of pain as assessed by a visual analog scale (VAS) and the Lowenberg test. Secondary outcomes were the consumption of analgesics, thrombus length, skin erythema, D-dimer, and quality of life (QoL).

RESULTS

Seventy-three patients completed the study. Clinical symptoms and QoL significantly improved from baseline to day 21 in both groups (p < .001 for VAS, Lowenberg test, thrombus length, and erythema; p < .006 for QoL), and consumption of analgesics and D-dimer significantly decreased (p < .001). There was no significant difference between the groups for all tested variables. At day 7, patients in the CG revealed a significantly faster thrombus regression (p = .02).

CONCLUSION

Adding compression stockings for 3 weeks to LMWH and NSAIDs does not bring significant additional benefit in the treatment of isolated SVT. When worn for 1 week, compression stockings stimulate significantly faster thrombus regression.

Treatment of lower extremity telangiectasias in women by foam sclerotherapy vs. Nd:YAG laser: a prospective, comparative, randomized, open-label trial

BACKGROUND

Telangiectasias of the lower extremities are very common. There are no blinded, randomized, controlled clinical trials comparing laser modalities with the gold standard sclerotherapy, while the few available studies encompass small patients cohorts.

OBJECTIVE

This prospective, randomized, open-label trial compares the efficacy of sclerotherapy with polidocanol vs. long-pulsed neodymium-doped yttrium aluminium garnet (Nd:YAG) laser in the treatment of leg telangiectasias.

PATIENTS AND METHODS

Fifty-six female patients with primary leg telangiectasias and reticular veins (C1A or SEpAS1PN) were included in the study. One leg was randomly assigned to get treatment with the multiple synchronized long-pulsed Nd:YAG laser, while the other received foam sclerotherapy with polidocanol 0.5%. The patients were treated in two sessions at intervals of 6 weeks. The patients were evaluated by the handling physician after 6 weeks and 6 months. Two investigators assessed blindly at the end of the study the photographs for clearing of the vessels using a six-point scale from 1 (no change) to 6 (100% cleared). Patients reported about pain sensation and outcome satisfaction.

RESULTS

According to the handling dermatologist, at the last follow-up, there was an improvement of 30-40% with a median of 3 (IQR 2) and a good improvement of 50-70% with a median of 4 (IQR 2) after laser treatment and sclerotherapy respectively. In contrast, according to the blinded investigators, there was a median of 5 (IQR 1) with a very good improvement of >70% after both therapies. Improvement was achieved more quickly by sclerotherapy, although at the last follow-up visit there was no difference in clearance between the two groups as assessed by the blinded experts (P-value 0.84). The degree of patient's satisfaction was very good and similar with both therapeutic approaches. There was a significant difference (P-value 0.003) regarding pain perception between the types of therapy. Laser was felt more painful than sclerotherapy.

CONCLUSION

Telangiectasias of the lower extremities can be successfully treated with either synchronized long-pulsed Nd:YAG laser or sclerotherapy. The 1064-nm long-pulsed Nd:YAG laser is associated with more pain and is suitable especially in case of needle phobia, allergy to sclerosants and in presence of small veins with telangiectatic matting, while sclerotherapy can also treat the feeder veins.

Results from RCTs in Sclerotherapy: European Guidelines for Sclerotherapy in Chronic Venous Disorders*

Aim

Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy.

Methods

This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7th–10th May 2012 in Mainz. The conference was organized by the German Society of Phlebology.

Results

This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, Polidocanol (POL) and Sodium tetradecyl sulphate (STS). Other sclerosants are not discussed in detail. In this paper the results from recent RCTs in sclerotherapy are reviewed.

Current status of surgery in dermatology

An article titled "Current issues in dermatologic office-based surgery" was published in the JAAD in October 1999 (volume 41, issue 4, pp. 624-634). The article was developed by the Joint American Academy of Dermatology/American Society for Dermatologic Surgery Liaison Committee. A number of subjects were addressed in the article including surgical training program requirements for dermatology residents and selected advances in dermatologic surgery that had been pioneered by dermatologists. The article concluded with sections on credentialing, privileging, and accreditation of office-based surgical facilities. Much has changed since 1999, including more stringent requirements for surgical training during dermatology residency, and the establishment of 57 accredited Procedural Dermatology Fellowship Training Programs. All of these changes have been overseen and approved by the Residency Review Committee for Dermatology and the Accreditation Committee for Graduate Medical Education. The fertile academic environment of academic training programs with interaction between established dermatologic surgeons and fellows, as well as the inquisitive nature of many of our colleagues, has led to the numerous major advances in dermatologic surgery, which are described herein.

European guidelines for sclerotherapy in chronic venous disorders

Aim

Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy.

Methods

This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7–10 May 2012 in Mainz. The conference was organized by the German Society of Phlebology. These guidelines review the present state of knowledge as reflected in published medical literature. The regulatory situation of sclerosant drugs differs from country to country but this has not been considered in this document. The recommendations of this guideline are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines.

Results

This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, polidocanol and sodium tetradecyl sulphate. Other sclerosants are not discussed in detail. The guideline gives recommendations concerning indications, contraindications, side-effects, concentrations, volumes, technique and efficacy of liquid and foam sclerotherapy of varicose veins and venous malformations.

Post-treatment compression: duration and techniques

BACKGROUND

Compression treatments used the following intervention for varicose veins range from no compression, to elastic stockings and compression bandaging. There is no consensus on the strength or duration of compression which should be applied following a particular treatment. The author reviews the evidence that has led him to reach his own viewpoint on this subject.

SUMMARY

Compression stockings are often prescribed after treatment of varicose veins, but these in general exert a much lower pressure in the thigh compared with firm inelastic compression bandages. It has been shown by objective investigation that it takes a pressure of 10-15 mmHg in the supine position and 40-50 mmHg in the standing position to occlude a superficial vein in the thigh. The author has published a study in which three groups of patients were studied following varicose vein surgery. One group received a strong medical compression stocking, the second group an inelastic bandaging system which achieved 63 mmHg compression in the standing position and an eccentric compression system which achieved 98 mmHg in the standing position. Adverse events after surgery were most frequent in the stocking group with fewer in the inelastic compression bandage group and fewest in the eccentric compression group. A further study has been published by another author in which elastic compression has been compared with eccentric compression following endovenous laser ablation of the saphenous vein. Eccentric compression reduced postoperative pain. Unfortunately, very little data are available to indicate the period for which compression should be applied following varicose vein treatment.

CONCLUSIONS

In comparison to compression treatments following varicose vein surgery where the actual level of compression has been measured, higher levels of compression are more effective than lower levels in moderating postoperative pain and complications. Strong compression can be achieved by inelastic bandaging or by eccentric compression systems. Far fewer data are available to indicate the duration for which postoperative compression is required.

Pesquisa sobre escleroterapia líquida em varizes dos membros inferiores

INTRODUÇÃO: A escleroterapia é um dos procedimentos mais realizados pelos angiologistas e cirurgiões vasculares brasileiros. O princípio básico é eliminar a veia varicosa, destruindo a sua parede interna. No Brasil, há uma diversidade de condutas que envolvem este tratamento, principalmente quanto ao tipo de esclerosante, associação com laser, uso de luva durante o procedimento, tempo recomendado de repouso, exposição ao sol, prática de atividade física, uso de compressão pós-escleroterapia, entre outros. OBJETIVO: conhecer as mais variadas condutas e técnicas desta modalidade terapêutica, muito praticada entre os angiologistas brasileiros. MÉTODO: A pesquisa foi realizada entre angiologistas membros da Sociedade Brasileira de Angiologia e Cirurgia Vascular - SBACV, que responderam um questionário sobre as técnicas e indicações da escleroterapia em varizes dos membros inferiores no Brasil. O link (www.iniciacaocientica.com.br/pne) foi disponibilizado com questões de múltipla escolha. RESULTADOS: Duzentos e trinta e dois médicos responderam ao questionário proposto. Luvas durante o procedimento são usadas por 79,74% dos médicos; a compressão é utilizada por 52,59%; quanto à atividade física pós-escleroterapia, 46,12% não restringem e 52,59% liberam após 1 a 3 dias; mecanismos para diminuir a dor durante o procedimento são utilizado por 43,53% dos entrevistados; a glicose 75% foi o esclerosante mais utilizado em 35,34%; a complicação sistêmica mais frequente foi a lipotimia com 7,76% e o local mais frequente foi a hipercromia com 66,38%; em relação à liberação para sol depois do procedimento: 28,02% liberam após a escleroterapia com filtro solar, 24,57% liberam após 15 a 30 dias e 25,43% liberam com menos de 15 dias. CONCLUSÃO: A pesquisa revelou que, apesar da escleroterapia ser amplamente utilizada na prática diária do angiologista brasileiro, há pouca concordância em pontos relevantes, como, por exemplo, o uso de compressão, liberação para atividade física e exposição ao sol.