Diagnosis and treatment of varicose veins: a review

Revisiting Heinz-Lippman disease as a complication of chronic venous insufficiency

Chronic venous insufficiency with and without ulceration is a common complication of varicose veins. Heinz-Lippmann disease is a potentially underreported complication of chronic venous insufficiency that involves heterotopic ossification of the peri-wound that might contribute to the chronicity of venous leg ulcers. Most commonly, heterotopic ossification is associated with traumatic injury. We report the cases of three patients with chronic venous insufficiency and no history of trauma who were found to have subcutaneous calcifications consistent with Heinz-Lippmann disease. Osteomyelitis was confirmed in two patients. Physical examination and diagnostic imaging can be helpful in determining the diagnosis. Interventions can include biopsy to rule out osteomyelitis, with subsequent treatment, if needed.

A prospective multicentre randomized clinical trial comparing endovenous laser ablation, using a 1470 nm diode laser in combination with a Tulip-TipTM fiber versus radiofrequency (Closure FAST™ VNUS®), in the treatment of primary varicose veins

BACKGROUND

The treatment of chronic venous disease, has largely shifted from high ligation and stripping to endovenous thermal ablation (EVTA) techniques, because of its comparable efficacy and lack of invasiveness. This clinical trial aimed to compare the efficacy of two thermal ablation techniques, endovenous laser ablation (EVLA) 1470-nm with Tulip-TipTM fiber and radiofrequency ablation (RFA) ClosureFastTM using a non-inferiority design for occlusion rate (primary outcome).

METHODS

A prospective multicentre randomized clinical trial randomized 280 patients for the treatment of great saphenous vein (GSV) reflux. Primary outcome was the GSV occlusion rate, secondary outcome factors were the possible side-effects of the treatment such as pain, ecchymosis, quality of Life (CIVIQ-20), revised Venous Clinical Severity Score (r-VCSS). One-year follow-up period.

RESULTS

The total occlusion rates at one year follow-up were 96.4% and 94.5% in the EVLA and RFA groups respectively (p = 0.15). Regarding secondary outcomes, such as postoperative CIVIQ-20, r-VCSS, analgesia, absenteeism, there was no significant difference between both treatment groups.

CONCLUSIONS

RFA and EVLA, using a 1470 nm laser with Tulip-TipTM fiber, of the GSV results in equal occlusion rates at one year, with comparable postoperative pain and improved quality of life.

Surgical management of a large postoperative vulvar haematoma following vulvar phlebectomy and ovarian vein embolization for vulvar varicose veins: A case report

Vulvar varicose veins (VVs) are seen in 4% of women, most of them secondary to pregnancy and usually regressing spontaneously. The treatment of choice during pregnancy is conservative and symptomatic. Management of vulvar varicosities in non-pregnant women consists of various techniques, including phlebectomy, endovascular embolization or surgical ligation of contributing veins, sclerotherapy and, recently, conservative treatment with the venoactive agent MPFF (micronized purified flavonoid fraction). We report an unusual case of a large hematoma of the right labium majus following bilateral vulvar phlebectomy and embolization of the left ovarian vein. The patient was a non-pregnant woman, who underwent incision and drainage of this rare complication. At follow-up almost a year after this procedure the patient reported comfort and cosmetic satisfaction regarding her vulvar symptoms. A multidisciplinary team approach to vulvar varicosities is important, with the involvement of gynecologists, angiologists, interventional radiologists and vascular surgeons.

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Vulvar varicose veins remains a uncommon disease with various treatments available, surgical as well as conservative

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Serious complications after treatment of vulvar varicose veins have never been reported in the literature until today

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We report a case of a large hematoma of the right labium majus following vulvar phlebectomy and ovarian vein embolization

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The hematoma was successfully treated with surgical evacuation and the patient reported comfort and cosmetic satisfaction

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Multidisciplinary team approach is essential in order to provide an optimal choice of treatment for vulvar varicose veins

Combined effect of chronic partial occlusion and orthostatic load on the saphenous vein network: A varicosity model in the rat

Objectives

We tested the combined effects of chronic flow obstacle and gravitation on the saphenous vein network of rats.

Methods

A narrowing clip (500 µm, partial occlusion) was administered on the saphenous vein main branch for 4, 8 and 12 weeks, either separately or in combination with chronic orthostatic load (tilted tube-cages for four weeks). Resulting network changes were studied on plastic casts, by video-microscopy, histochemistry–immunohistochemistry and image analysis.

Results

A rich collateral venous network developed containing newly formed masses of retrograde conducting small veins. Their walls had less dense elastica, less contractile protein, increased cell division activity and macrophage invasion, and were more sensitive to chronic gravitational load.

Conclusions

Hemodynamic disturbance induces remodeling of the saphenous vein network. Walls of veins being in the process of flow-induced morphological remodeling are weak and more sensitive to gravitational load. Reticular vein conglomerates, veins with local dilations, and convoluted courses were observed.

The venous perforators of the lower limb - A new terminology

Latin anatomical terminology of venous perforators (communications between superficial and deep venous systems of the lower limb) was adopted as late as 2001 as an appendix to the official nomenclature following the clinicians’ request. Terminologia Anatomica, last version of the Latin anatomical nomenclature, published in 1998, unfortunately contains no terms concerning these veins. During the 14th World Congress of the International Union of Phlebology, a consensus document was laid to expand the nomenclature of the lower limb veins, above all 36 new terms for perforators of the lower limb, both in Latin and English languages. This consensus document will be incorporated in the next version of the Terminologia Anatomica. But there are more constant and well-described ones, especially in the foot, and this article reviews in particular the current knowledge on the anatomy of the venous perforators of the whole lower limb.

Vascular diseases in the mature patient

Aging results in both anatomic and physiologic changes in the skin's structure and vascular system. These vascular changes result in a wide array of dermatologic findings, ranging from the benign to the highly morbid. Herein, we review the impact of both intrinsic and common extrinsic factors of aging on cutaneous vasculature and highlight the manifestations of microvascular, venous, arterial, lymphatic, and neuropathic alterations in the geriatric population.

Comparison of microbubble presence in the right heart during mechanochemical and radiofrequency ablation for varicose veins

Objective

Mechanochemical ablation is a novel technique for ablation of varicose veins utilising a rotating catheter and liquid sclerosant. Mechanochemical ablation and radiofrequency ablation have no reported neurological side-effect but the rotating mechanism of mechanochemical ablation may produce microbubbles. Air emboli have been implicated as a cause of cerebrovascular events during ultrasound-guided foam sclerotherapy and microbubbles in the heart during ultrasound-guided foam sclerotherapy have been demonstrated. This study investigated the presence of microbubbles in the right heart during varicose vein ablation by mechanochemical abaltion and radiofrequency abaltion.

Methods

Patients undergoing great saphenous vein ablation by mechanochemical abaltion or radiofrequency ablation were recruited. During the ablative procedure, the presence of microbubbles was assessed using transthoracic echocardiogram. Offline blinded image quantification was performed using International Consensus Criteria grading guidelines.

Results

From 32 recruited patients, 28 data sets were analysed. Eleven underwent mechanochemical abaltion and 17 underwent radiofrequency abaltion. There were no neurological complications. In total, 39% (11/28) of patients had grade 1 or 2 microbubbles detected. Thirty-six percent (4/11) of mechanochemical abaltion patients and 29% (5/17) of radiofrequency ablation patients had microbubbles with no significant difference between the groups ( p=0.8065).

Conclusion

A comparable prevalence of microbubbles between mechanochemical abaltion and radiofrequency ablation both of which are lower than that previously reported for ultrasound-guided foam sclerotherapy suggests that mechanochemical abaltion may not confer the same risk of neurological events as ultrasound-guided foam sclerotherapy for treatment of varicose veins.

Deep vein thrombosis: current status and nanotechnology advances

Deep vein thrombosis (DVT) affects up to 2 million people in the United States, and worldwide incidence is 70 to 113 cases per 100,000 per year. Mortality from DVT is often due to subsequent pulmonary embolism (PE). Precise diagnosis and treatment is thereby essential for the management of DVT. DVT is diagnosed by a thorough history and physical examination followed by laboratory and diagnostic tests. The choice of laboratory and diagnostic test is dependent on clinical pretest probability. Available laboratory and diagnostic techniques mainly involve D-dimer test, ultrasound, venography, and magnetic resonance imaging. The latter two diagnostic tools require high doses of contrast agents including either radioactive or toxic materials. The available treatment options include lifestyle modifications, mechanical compression, anticoagulant therapy, inferior vena cava filter, and thrombolysis/thrombolectomy. All of these medical and surgical treatments have serious side effects including improper clot clearance and increased risk of hemorrhage occurrence. Therefore, research in this field has recently focused on the development of non-invasive and accurate diagnostics, such as ultrasound enhanced techniques and molecular imaging methods, to assess thrombus location and its treatment course. The frontier of nanomedicine also shows high prospects in tackling DVT with efficient targeted drug delivery. This review describes the pathology of DVT along with successive medical problems such as PE and features a detailed listing of various diagnostic and therapeutic modalities that have been in use and are under development.

Prolonged increases in vein wall tension increase matrix metalloproteinases and decrease constriction in rat vena cava: Potential implications in varicose veins

BACKGROUND

Increased venous hydrostatic pressure plays a role in the pathogenesis of varicose veins. Increased expression of matrix metalloproteinases (MMPs) has been identified in varicose veins. Also, we have shown that MMP-2 inhibits venous contraction. However, the relation between venous pressure, MMP expression, and venous dysfunction is unclear. The purpose of this study was to test the hypothesis that prolonged increases in venous wall tension cause overexpression of MMPs and decreased contractility, which in turn promote venous dilation.

METHODS

Circular segments of inferior vena cava (IVC) were isolated from male Sprague-Dawley rats and suspended between two wires in Krebs solution. Preliminary vein wall tension-contraction relation showed maximal potassium chloride (KCl) (96 mmol/L) contraction at 0.5 g basal tension, which remained steady with increases in tension up to 2 g. Vein segments were subjected to either control (0.5 g) or high (2 g) basal tension for short (1 hour) or long duration (24 hours). Isometric contraction in response to phenylephrine (Phe, 10(-5) mol/L), angiotensin II (AngII, 10(-6) mol/L), and KCl was measured. The veins were frozen to determine the expression and localization of MMPs using immunoblots and immunohistochemistry.

RESULTS

In IVC segments subjected to 0.5 g tension for 1 hour, Phe and AngII produced significant contraction. At higher 2 g basal tension for 24 hours, both Phe and AngII contractions were significantly reduced. Reduction in KCl contraction was also observed at high 2 g basal tension for 24 hours, suggesting that the reduction in vein contraction is not specific to a particular receptor, and likely involves inhibition of a post-receptor contraction mechanism. In vein segments under 2 g tension for 24 hours and treated with TIMP-1, Phe, AngII, and KCl contractions were partially restored, suggesting the involvement of MMPs. IVC immunoblot analysis demonstrated prominent bands corresponding to MMP-2 and MMP-9 protein. High 2 g wall tension for 24 hours was associated with marked increase in the amount of MMP-2 and -9 relative to the housekeeping protein actin. There was a correlation between MMP expression and decreased vein contraction. Also, significant increases in MMP-2 and -9 immunostaining were observed in IVC segments subjected to high 2 g tension for 24 hours. Both MMP-2 and MMP-9 caused significant inhibition of Phe contraction in IVC segments.

CONCLUSIONS

In rat IVC, increases in magnitude and duration of wall tension is associated with reduced contraction and overexpression of MMP-2 and -9. In light of our findings that MMP-2 and -9 promote IVC relaxation, the data suggest that protracted increases in venous pressure and wall tension increase MMPs expression, which in turn reduce venous contraction and lead to progressive venous dilation.

Endovenous Laser Treatment of Saphenous Vein Reflux: How Much Energy Do We Need to Prevent Recanalizations?

The aim of this study was to report the results of high-energy endovenous laser treatment to measure the relationship between the fluence and the outcome in terms of recanalization. In 97 patients, 129 great saphenous veins were treated with endovenous laser treatment, using a 980-nm diode laser. Follow-up visits were done at 3 days, 1 month, and 6 months. The best results were noted 1 month postoperative, but at 6 months, control late recanalizations occured decreasing occlusion rate to 90.6%. Patients were divided into 2 groups according to the outcome (occlusion or recanalization) at 6 months, and statistical analysis was done. The authors found 52 J/cm2 mean fluence in the occlusion group and 43.7 J/cm2 in the nonocclusion group. This was a statistical significant difference ( P < .01). The occlusion rate on long term is fluence dependent. But recanalizations might occur even in these higher fluence treatment groups. A fluence of 52J/cm2 is advised.

Surgery versus sclerotherapy for the treatment of varicose veins

BACKGROUND

Varicose veins are a relatively common condition and account for around 54,000 in-patient hospital episodes per year. The two most common interventions for varicose veins are surgery and sclerotherapy. However, there is little comparative data regarding their effectiveness.

OBJECTIVES

To identify whether the use of surgery or sclerotherapy should be recommended for the management of primary varicose veins.

SEARCH STRATEGY

Thirteen electronic bibliographic databases were searched covering biomedical, science, social science, health economic and grey literature (including current research). In addition, the reference lists of relevant articles were checked and various health services research-related resources were consulted via the internet. These included health economics and HTA organisations, guideline producing agencies, generic research and trials registers, and specialist sites.

SELECTION CRITERIA

All studies that were described as randomised controlled trials comparing surgery with sclerotherapy for the treatment of primary varicose veins were identified.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted and summarised data from the eligible studies using a data extraction sheet for consistency. All studies were cross-checked independently by the reviewers.

MAIN RESULTS

A total of 2306 references were found from our searches, 61 of which were identified as potential trials comparing surgery and sclerotherapy. However, only nine randomised trials, described in a total of 14 separate papers, fulfilled the inclusion criteria. Fifty trials were excluded and one trial is ongoing and is due for completion in 2004. The trials used a variety of outcome measures and classification systems which made direct comparison between trials difficult. However, the trend was for sclerotherapy to be evaluated as significantly better than surgery at one year; after one year (sclerotherapy resulted in worse outcomes) the benefits with sclerotherapy were less, and by three to five years surgery had better outcomes. The data on cost-effectiveness was not adequately reported.

REVIEWERS' CONCLUSIONS

There was insufficient evidence to preferentially recommend the use of sclerotherapy or surgery. There needs to be more research that specifically examines both costs and outcomes for surgery and sclerotherapy.

JOBST® Opaque compression hosiery in the management of venous disease

Prevention of leg ulceration is a simple process involving assessment, accurate measurement of the leg and application of appropriate compression hosiery along with appropriate care of the skin. Persuasion of at-risk individuals to be aware of and follow prevention options needs to be incorporated in the ongoing health promotion activities of the practitioner (Price and Harding, 1996). This product focus examines the potential contributions of the new JOBST Opaque gradient compression hosiery (with the innovative JOBST soft care yarn) in prevention and management of venous disease and deep vein thrombosis, without sacrificing comfort and style in order to promote patient concordance.

Varicose veins: a qualitative study to explore expectations and reasons for seeking treatment

BACKGROUND

Patients experience a wide range of symptoms from varicose veins and are seeking treatment from health care providers. However, there is little data on the relative effectiveness of the treatments available. Patients are therefore often confronted with a choice regarding treatment that they are ill-equipped to make. This lack of certainty and the resultant potential for variability in treatment decisions can mean that patients have expectations that are unrealistic or unfulfilled.

AIMS AND OBJECTIVES

The aim of our study was to explore patients' expectations and reasons for seeking treatment for varicose veins. Additional aims included the exploration of symptoms associated with varicose veins and their impact on quality of life.

DESIGN

Qualitative study conducted in a large NHS Trust.

METHODS

A total of 16 patients, who had been referred to a specialist vascular service for the treatment of varicose veins, were recruited. Semi-structured interviews were used to explore the patients' reasons for seeking treatment. Framework analysis was used to analyse the data from the anonymized transcripts.

RESULTS

Participants attributed a wide range of symptoms to their varicose veins, and were actively seeking treatment with the expectation that they would gain symptom relief. The symptoms attributed to their varicose veins had a significant negative impact on their quality of life and lifestyle. Improving the cosmetic appearance of their legs was seen as a secondary benefit.

CONCLUSIONS

The perceived symptoms of varicose veins can impact on lifestyle and quality of life. Patients seek treatment with the expectation of treatment outcomes that are not supported by robust clinical evidence. Appropriate education and management of such expectations are an essential step in caring for this group of patients.

RELEVANCE TO CLINICAL PRACTICE

Nurses are caring for patients with varicose veins in a range of clinical settings. When caring and providing information for this group of patients, nurses need to be aware of the impact of varicose vein symptoms and to understanding that patients may have unrealistic expectations or invalid reasons for seeking treatment.

Endovenous laser treatment to promote venous occlusion

BACKGROUND AND OBJECTIVES

Current treatment methods of superficial venous insufficiency (SVI) can be painful or result in incomplete occlusion. The objective of this study was to evaluate a technique for laser endovenous ablation with a newly developed diffuser fiber.

STUDY DESIGN/MATERIALS AND METHODS

Six lateral saphenous veins in three goats were used. A specifically designed diffuser laser fiber tip was employed in all trials to deliver a wavelength of 1,064 nm. Each segment was treated with a different energy fluence by changing the power setting of the laser or the withdrawal rate of the fiber. Energy fluence was calculated by dividing the Joules employed for each segment over the internal surface area of the vessel. Segments were evaluated with ultrasound and histologically.

RESULTS

Seventy-five percent of the segments were occluded when an energy fluence of greater than 85 J/cm2 was employed. No perforations were observed, but perivascular changes were more common at higher energy fluence.

CONCLUSIONS

Endovenous laser occlusion of veins with minimal perivascular effects can be achieved with laser wavelengths of 1,064 nm if an energy fluence of 84.9-224 J/cm2 is employed and circumferential effect is achieved.

Venae perforantes: a clinical review

BACKGROUND

Although many articles on perforating veins have been published, much knowledge about these veins is lacking.

OBJECTIVE

In this review relevant facts about the clinical importance of perforating veins in venous disease are described.

METHODS

A literature search on English, French and German articles has been performed using literature databases like Medline, Embase and Cochrane.

RESULTS

Selection criteria are described.

CONCLUSION

A few conclusions are drawn: incompetent perforating veins can be of haemodynamic importance, especially in venous ulceration and (recurrent) varicose veins. The current definition of incompetent perforating veins is reflux more than 0,5 seconds (detected by Duplex ultra-sonography). Good anatomical and clinical classifications are published and should be integrated in the CEAP classification. Based on the clinical classification treatment options are described for the different types of incompetent perforating veins. Two different treatment modalities for incompetent perforating veins are surgery (SEPS) and sclerotherapy. SEPS seems to be of benefit in patients with venous ulceration and advanced CVI. Sclero-therapy (especially ultra sound guided sclerotherapy) is promising and worth further evaluation.

Treatment of varicose veins: an assessment of intraoperative and postoperative compression sclerotherapy

Since thrombotic complications, such as superficial thrombophlebitis and subsequent skin pigmentation, are common after sclerotherapy, we conducted a study to evaluate whether combining sclerotherapy with ligation of varicose veins minimizes complications and what timing for sclerotherapy would be most beneficial-accompanying surgery or several weeks postsurgery. Surgical intervention and compression sclerotherapy were performed consecutively on 111 limbs (group A), and sclerotherapy was performed 28 days after surgical intervention on 87 limbs (group B). The volume of sclerosant used and the frequency of complications (thrombus formation and pigmentation) were analyzed. Plasma levels of thrombin-antithrombin III complex (TAT) and D-dimer (DD), as markers for activation of coagulation, were compared. In group A, the total volume of sclerosant used in patients with complications was significantly higher than that in patients without complications. The frequency of thrombus formation and of pigmentation was significantly lower (p <0.01) in group B (10% and 18%, respectively) than in group A (21% and 37%, respectively). The plasma levels of TAT 7 days after treatment were significantly lower in group B (3.4 +/- 1.2 mg/L) than in group A (4.9 +/- 1.1 mg/L). Performing compression sclerotherapy 28 days after surgical intervention is effective for reducing complications and a good alternative for patients with an underlying hypercoagulable state.

Chronic leg ulceration in homozygous sickle cell disease: the role of venous incompetence

Chronic leg ulceration is a common cause of morbidity in Jamaican patients with homozygous sickle cell (SS) disease. Ulcers heal more rapidly on bed rest and deteriorate on prolonged standing, suggesting a role of venous hypertension in their persistence. This hypothesis has been tested by Doppler detection of venous competence in SS patients and in matched controls with a normal haemoglobin (AA) genotype in the Jamaican Cohort Study. Venous incompetence was significantly more frequent in SS disease [137/183 (75%)] than in non-pregnant AA controls [53/137 (39%)]. Past or present ulceration occurred in 78 (43%) SS patients, with a highly significant association between leg ulceration and venous incompetence in the same leg (P < 0.001). Prominence and/or varicosities of the veins and spontaneous leg ulcers were more common among patients with multiple sites of incompetence. The association of venous incompetence with chronic leg ulceration identifies a further pathological mechanism contributing to the morbidity of SS disease. The cause of venous incompetence is unknown but the sluggish circulation associated with dependency, turbidity and impaired linear flow at venous valves, hypoxia-induced sickling, the rheological effects of high white cell counts, and activation of components of the coagulation system may all contribute. Venous hypertension in SS patients with leg ulceration suggests that firm elastic supportive dressings might promote healing of chronic leg ulcers.

Autologous vein transplantation for correction of dermal atrophic changes

BACKGROUND

Many filling substances are useful in correcting dermal defects and/or wrinkles.

OBJECTIVE

To describe a novel autologous dermal implant.

METHOD

Unwanted leg/hand veins and/or varicose veins are extracted in an ambulatory phlebectomy technique. The veins are then either chopped into pieces and injected into the defect or inserted whole after cellular destruction with 23.4% hypertonic saline.

RESULTS

Excellent correction of dermal defect has been obtained with long-lasting and possible permanent results. No complications have occurred.

CONCLUSION

Autologous vein collagen transplantation can correct dermal defects with long-lasting and perhaps permanent results.

Current approaches to venous ulcers and compression

BACKGROUND

Venous ulcers affect as many as 2.5 million people in the United States and can cause substantial pain and loss of function.

OBJECTIVE

To review current approaches to venous ulcers and compression.

METHOD

Treatment options that have been proposed in the literature are discussed utilizing the Cochrane library database, Medline, and the author's clinical experience.

RESULTS

Diagnostic findings and management strategies for venous ulcers are reviewed.

CONCLUSION

Good wound care and compression therapy will heal the majority of small venous ulcers of short duration. For ulcers that are slow to heal, other approaches such as venous surgery and grafting with conventional or bioengineered skin substitutes should be considered.

Pregnancy-induced changes in lower extremity superficial veins: an ultrasound scan study

OBJECTIVE

The purpose of this study was to follow changes in superficial veins of the lower extremities during pregnancy and the postpartum period in women with varicose veins.

METHODS

This was a prospective study with the use of duplex scanning during the first and third trimesters of pregnancy and postpartum period. Competent veins were defined as veins with an absence of reflux, and incompetent veins were defined as veins with reflux. The diameter of the competent or incompetent greater saphenous vein (GSV) and lesser saphenous vein (LSV) was measured. The diameter of the largest varicose dilatations was measured in all three networks: GSV and its tributaries, LSV and its tributaries, and nonsaphenous varicose veins.

RESULTS

Sixty-six women were studied prospectively (mean age, 32.2 +/- 4 years; 85 affected extremities). The diameter of competent and incompetent GSVs and competent LSVs increased between the first and third trimester (P <.001) and decreased between the third trimester and the postpartum period (P <.001). The diameter of the largest varicose dilatations of the GSV and its tributaries and nonsaphenous networks increased between the first and third trimester (P <.001) and decreased between the third trimester and the postpartum period (P <.001). No statistically significant variation of the diameter was demonstrated for any of these veins between the first trimester and the postpartum period.

CONCLUSION

The diameters of competent and incompetent superficial veins increased during pregnancy and decreased during the postpartum period to return to their baseline values.

Reticular veins, incompetent reticular veins, and their relationship to telangiectases

BACKGROUND

The pathological role that reticular veins, or their incompetent variants, play in the development and progression of telangiectases has been a subject of debate. The implications of their treatment on the disappearance of telangiectases has been a source of confusion.

OBJECTIVE

This article explores the anatomical and functional relationship of reticular veins with telangiectases. The evidence for any pathological role that reticular veins, or their incompetent counterparts, play in the appearance of telangiectases is examined.

METHODS

Medical literature on reticular veins of the lower extremity was reviewed. The consequences of their treatment on existing contiguous telangiectases and on the development of new telangiectases is discussed.

RESULTS

Telangiectases occur both in the absence and presence of incompetent reticular veins. Incompetent reticular veins often exist without any associated telangiectases present. However, when telangiectases and reticular veins, or their incompetent counterparts, appear in close proximity, their intraluminal channels are, almost invariably, in direct communication.

CONCLUSIONS

A causal role for reticular veins, or their incompetent counterparts, in the development or progression of telangiectases has not been established. Furthermore, the successful eradication of telangiectases does not depend on the prior or simultaneous eradication of any reticular veins with which they may communicate. Failure to eradicate telangiectases is not due to the persistence of the reticular veins but to inadequate treatment of the telangiectases.

Sclerotherapy for varicose veins of the lower legs in patients with dysplasminogenemia

Sclerotherapy combined with ligation has become a widely accepted treatment for varicose veins; however, it is associated with some risk of the serious complications of deep vein thrombosis (DVT). We investigated the incidence of thrombophilia in 164 consecutive patients undergoing treatment for varicose veins and determined the activities of antithrombin-III, protein C, and plasminogen. Of the 164 patients, 10 were diagnosed as having dysplasminogenemia (DPG), showing an incidence of 6.1%, in accordance with previous reports. DVT was not found to be caused by DPG in any patient, and no difference was found between patients with and those without DPG, suggesting that DPG is not a risk factor for varicose veins. We also investigated the activation of coagulation by measuring the thrombin-antithrombin III complex (TAT). The activation of coagulation after sclerotherapy was inhibited when ligation was performed 1 month prior to sclerotherapy, whereas it was increased when sclerotherapy and ligation were performed simultaneously. Of the 10 patients with DPG, 5 were treated uneventfully, and their TAT level increased to 4.0 micrograms/l, which was comparable to the level after sclerotherapy and ligation. These findings indicate that sclerotherapy can be performed safely in the majority of patients with DPG, and that the temporal separation of sclerotherapy and surgery is an alternative for these patients to prevent the activation of coagulation.

The possible risk of lower-limb sclerotherapy causing an extended hypercoagulable state

The risk of thrombosis after lower-extremity sclerotherapy is still an unresolved issue. This study was conducted to investigate the influence of sclerotherapy on coagulation and fibrinolysis by examining 20 patients who underwent surgical procedures, 10 of whom were treated by surgery alone (control group), while the other 10 were given sclerotherapy using 1% hydroxypolyaetoxydodecan as polidocanol (sclerotherapy group). Sex, age, and severity of disease was comparable between the two groups. No significant difference was found in the transient elevation of acute phase proteins, C-reactive protein (CRP), or fibrinogen. Thrombin antithrombin III complex (TAT), a marker of coagulation, transiently increased following treatment. In the control group, TAT peaked 3 days after treatment, whereas in the sclerotherapy group the elevation was prolonged, peaking 7 days after treatment. Elevation of the markers of fibrinolysis, plasmin plasmin inhibitor complex (PIC) and fibrin degradation products (FDP), was slower than that of TAT, peaking 7 days after treatment in both groups, the plasma PIC being significantly enhanced 7 days after treatment in the sclerotherapy group. A significant decrease in the platelet count was observed 3 days after treatment in the sclerotherapy group. These results suggest that sclerotherapy may enhance coagulation or fibrinolysis after surgical procedures.

Hemostasis activation during sclerotherapy of lower extremity varices

The influence of compression sclerotherapy upon hemostasis activation was investigated in 41 consecutive patients with lower extremity varices by serial measurement of thrombin-antithrombin III complexes (TAT), D-dimer, fibrinogen and C-reactive protein (CRP). Blood sampling was carried out before operation and on the 7th and 28th post-operative day in patients randomly assigned to either the control group (n = 18), in which high ligation of sapheno-femoral junction and local excision of varices were performed, or the sclerotherapy group (n = 23) in which the comparable surgical intervention and compression sclerotherapy using hypertonic saline were performed simultaneously. In both groups, the TAT, D-dimer and fibrinogen concentrations at day 7 were significantly elevated compared to the value before operation while CRP showed no significant change during the observation period. In the sclerotherapy group, higher incidence of superficial thrombosis was observed and the TAT concentration at day 7 was significantly higher than that in the control group (p < 0.01), and the TAT at day 28 was still significantly elevated compared to the pre-operative level (p < 0.05). However, no relationship between TAT and D-dimer concentrations and the extent of superficial thrombosis was observed. We conclude that compression sclerotherapy for lower extremity varices causes latent activation of coagulation system and can be a risk factor for venous thromboembolism.