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Pacific Medicine & Surgery 72; 274-279 Sept. - Oct. 1964

 THE  TREATMENT  OF   VARICOSE  VEINS  DURING  PREGNANCY

W. G. FEGAN, M.Ch., F.R.C.S..I.

The iniquity of injection treatment for varicose veins has been impressed upon us for many years. The widespread and uncontrolled thrombosis which sometimes resulted from the injection was dangerous and terrifying. Knowledge that, 9 times out of 10, the clot recanalized convinced us that, after one had weathered the incidence of phlebitis, any relief afforded could only be temporary. However, the really sad aspect of injection therapy has been the damage done to previously normal-functioning valves. Thus indoctrinated, one would require courage to undertake to re-introduce an injection technique as a treatment for varicose veins.

We have been using an injection technique for 14 years for treating varicose veins on 15,000 patients - one-fourth of whom were pregnant at the time. Before discussing this, we must put forward a case for treating varicose veins in pregnancy.

It is frequently stated that antenatal treatment of varicose veins is an unnecessary intervention in a condition which, 4 times out of 5, resolves in the puerperium. Our reasons for treating varicose veins in the antenatal period are as follows:

1. If 20% of the patients suffering from varicose veins in pregnancy did not recover in the puerperium then this represents a large number of patients with varicose veins. One must make sure that 100% recover. In order to do this one must treat all pregnant women who have varicose veins.
2. If patients with varicose veins are not treated during pregnancy it is very likely that the condition will continue to deteriorate past the critical point beyond which recovery in the puerperium is not possible.
3. Why should a woman suffer for months with a condition which is readily amenable to a safe and simple form of treatment?
4. The greatest reason for treating varicose veins during pregnancy is the resulting absence of superficial and deep vein thrombosis and embolism in the puerperium.

In 1952, we took over the responsibility of treating varicose veins in the Rotunda Lying-in Hospital in Dublin. At that time there was a special clinic concerned solely with the treatment of varicose ulcers. At present we have no patient varicose ulceration attending the hospital, nor have we had any for over 4 years. In the past 5 years we have had 5 cases of superficial phlebitis in the puerperium in patients treated in our clinic, and no case of deep vein thrombosis or pulmonary embolism. These 5 cases were patients who did not complete treatment at the clinic. Because of the beneficial effect of prenatal treatment on the puerperal thrombotic complications we consider that a special clinic, such as the one in the Rotunda, should be attached to all large maternity hospitals.

Fifteen out of 100 patients treated by the old injection technique obtained permanent good results. Consideration of the possible factors responsible for this 15% has led to the development of our present technique. Earlier it was observed that 2 apparently different clinical reactions could follow injection: (1) in a small percentage of cases the vein appeared to go into spasm and become an inert cord; or (2) the classical reaction of phlebitis developed.

In order to help us understand these happenings more clearly we decided that it was essential to acquaint ourselves with the exact step-by-step microscopic happenings in a thrombosed vein. We searched the literature extensively to see whether this had been previously described, but could find no satisfactory description of the process of reopening of a vein following thrombosis. We, thus, had to programme for ourselves a research exercise to this end. It necessitated finding thrombosed veins and knowing the history of the thrombosis, sectioning these specimens and staining them in various ways. This involved the production on the part of the Research Registrar of some 4,000 sections.

DIAGRAM HERE

As a result of this exercise we became aware that many fundamentally different processes were taking place simultaneously in a thrombosed vein and that these vied with each other as to which would ultimately win the day, and thus determine the end-result. In some cases complete fibrous obliteration of a segment of the vein occurred. In other cases the vein reopened and dilated, becoming larger than in its pre-existing condition.

In a thrombosed vein there is a vast disparity between the volume of the thrombus and the wall of the vein. This disparity is reversed following our injection technique (Chart I).

The vital processes of organization take place from the cells in the wall of the vein. When one looks into the great disproportion between the wall and the clot it becomes obvious that if organization is ever to be completed it will take a very long time.

Figure 1 shows the invasion of a thrombus with the development of slit-like channels between the points of firm attachment and invasion. Figure 2 shows a more advanced stage of peripheral sinus formation with the development of black tarry central disintegration of the thrombus.

At varying intervals one venous channel, or a plexus of venous channels, will become established through the occlusion. The remainder of the thrombus will become organized, and displaced to one side of the new vessel, and the black tarry central substance disappears.

This is a very brief description of the findings. In actual fact many ore activities are taking place. A vein wall has two sources of nutrition - the outer portion from the vasa vasorum; and the inner portion from the blood in the vein lumen. When the blood clots, the inner supply is cut off and the vasa vasorum become dilated and increase in numbers, causing a considerable hyperaemia of the outer vein wall. The inner portion of the wall now undergoes a series of changes which could be explained by reduced oxygenation.

From our histology sections it is apparent that the intima becomes permeable to cells. The subendothelial cellular elements proliferate tremendously. It appears that these latter cells are toti-potent, since they may lay down fibrous material, line new sinuses, form new capillaries or act as macrophages. At the same time serum from the thrombus would appear to pass into the wall of the vein separating the muscle fibres.

It is now apparent that if we could devise some method of (1) reducing the size of the thrombus in the vein lumen; (2) increasing the thickness of the vein wall; (3) increasing the perivascular reaction; and (4) holding this situation sufficiently long to ensure the development of mature fibrous tissue in the wall of the vein, then we would have tipped the balance, and instead of obtaining 15 fibrous cords out of 100 cases following thrombosis we could obtain 99 uncanalized fibrous cords.

In our technique we aim to replace the selected 11 " segment of vein with a fibrous cord. We consider this a more permanent and more effective restoration of the derangement of the pump than ligation with catgut, unless at the time of operation the ligation is accompanied by repair of the perforating vein orifice in the deep fascia. We isolate a short segment of vein in order to ensure minimal injury to normal-functioning valves and use a small volume of sclerosant to prevent overflow into the deep veins. This has been demonstrated by experimental radiographic studies. The "empty vein" injection technique should be used, followed by immediate compression, which should be adequately and continuously maintained after injection. We maintain this situation until satisfied that the segment can withstand any opening forces to which it may be subjected.

We would like to emphasize that before undertaking the treatment of varicose veins one must be clearly aware of the basic difficulty to be corrected. Varicose veins are not a primary disease, but the result of mechanical defect in a pumping system. The venous, return from the limb is far more complicated than the arterial delivery of blood. A series of Note - Photocopy has been cut, one or two lines missing

DIAGRAM HERE

action. The deep veins require the capacity to draw in blood from the superficial veins as well as being able to deliver it to the heart. Valvular injury in the perforator veins, which, which connect deep with superficial veins, is the most important primary lesion. It is aggravated by injury to the valves in the deep or superficial veins. The pumps must be able to reduce to near zero during walking (Chart II). The exact localization of the perforating veins containing the injured valves is the supremely important object of diagnosis. Varicose veins are reversible, as is frequently seen after delivery, and will be seen after restoration of the efficiency of the pumping system (Charts III, IV, V, and VI). Each myofascial compartment in the lower limb is a complete pumping unit. These are synchronized with each other and the proximal ones act as boosting stations for more distal compartments. They impart a linear velocity to the blood, by virtue of their coordination, pressure fluctuation, and valvular arrangement. They have a considerable reserve capacity and can easily compensate for minor derangements in adjacent compartments.

Valves which are incompetent by virtue of dilation of the vein containing them can be rendered competent once this dilation has been overcome. Valves which are ruptured or fouled up by adhesions following thrombosis can never again become effective. It is surely obvious that much restoration of function is possible, both from our knowledge of the effects of treatment and the clinical evidence in the puerperium. It is not uncommon to see a vast complex of dilated veins disappear completely after effective blocking of a leak in an incompetent perforating vein (Chart VI).

Chronic venous insufficiency can be approached surgically or by injections. Whatever the method used, the restoration of the efficiency of the pumping systems should be the objective, not the eradication of tortuous veins, which themselves may be of no clinical disability.

Surgical treatment has the disadvantages of mortality, considerable pain and morbidity, hospitalization, expense, and disruption of family life and income.

Our injection technique of treatment offers a short out-patient treatment and has a very low degree of pain and morbidity. It avoids hospitalization and all its associated disadvantages, and it is inexpensive. In 15,000 patients so treated there has been no death, nor any case of proven pulmonary embolism. In a recent survey, conducted by impartial nonmedical personnel, of patients treated over a 6 year period, a satisfactory result rate in excess of 80% is shown, which figure is comparable to the best published results of surgical treatment.

DETAILS OF INJECTION TECHNIQUE

Following upon accurate localization and marking of the incompetent perforating veins, the patient sits up on an examining couch with her legs horizontal. The doctor takes a 2 ml. syringe fitted with a very sharp No. 18 gauge needle and containing 1 ml. of sclerosant (sodium tetradecyl), and introduces the needle into the superficial vein over the site of an incompetent perforating vein. A drop of blood is withdrawn into the syringe to ensure that the needle is within the vein. The patient now lies down, and the leg is elevated while the doctor carefully holds the syringe against the limb in order that the needle remains within the vein lumen. The superficial veins are now given time to collapse, indicating that they are almost empty of blood.

Holding the syringe in one hand, the index finger of the other hand is placed on one side of the needle, and the ring finger on the other side in such a way that these fingers isolate the segment of vein which is to be injected.

The sclerosant is now injected into the isolated segment of vein which is almost devoid of blood. At the beginning of injection the isolating fingers are gently spread apart, and are brought together again as injection proceeds in order that the isolated segment of vein may accommodate the sclerosant and decrease the likelihood of spill into the deep veins. The middle finger of this hand rests gently over the tip of the needle in order that an inadvertent extravascular injection may be palpably detected. It is never necessary or desirable to inject more than 1 ml. of sclerosant at any one site, and often half this volume will produce the desired effect.

Following the injection the needle is withdrawn, and a 3" strong cotton crepe bandage

(non-elastic) is applied, first below and then above the injection site. The isolating fingers having imprisoned the sclerosant for at least 30 seconds are then removed, a turn of bandage is taken over the injected segment, and a bevelled pad of sorbo rubber is placed flat side down over the injected segment and bandaged securely and comfortably in position. The end of the crepe bandage is secured by a strip of sticking plaster.

Other incompetent perforating veins are injected in a similar fashion, and often 3 or 4 injections can be given at the same visit into one limb. The leg should always be bandaged from the base of the toes up to above the highest injection before the patient is allowed to stand. A two-way stretch full length elastic stocking is applied immediately over the bandages, and secured by a suspender belt. The patient is then instructed to walk as much as possible, and to avoid standing still. Less than 10% of patients develop pain after injection provided they keep their bandage in position and walk for at least 1 hour every day. Should pain occur it is essential that the patient walks. Under no circumstances must they be confined to bed.

The ideal is to inject the most distal perforating vein first, and work proximally but to do this may cause spasm of a higher perforating vein in the Hunterian region. Therefore, if this is an important site of perforator incompetence, as is often the case, it is wise to inject it first to ensure its occlusion. Following such an injection it is quite possible to insert a needle into empty collapsed veins in the distal part of the limb and to complete the injections.

Extra vascular injection is dangerous and should never be attempted until one becomes expert in the technique. It is, however, safe provided that only a small volume of sclerosant is injected, preferably in the form of froth and diluted with blood, and that the injection is not performed near nerve trunks, periosteum or arteries. The application of a rubber pad and instructions to walk are soon effective in dispelling the pain of such an injection.

The bandages and elastic stocking remain undisturbed until the patient attends for his next visit, in 1 to 2 weeks time. At this visit previous injection sites are examined, and are usually found to be short firm painless cords. Any remaining incompetent perforating veins are injected, and the leg is rebandaged with rubber pads over all injection sites, and the elastic stocking is worn over the bandages.

Compression must be maintained over injection sites for at least 6 weeks from the date of injection, or until all tenderness has disappeared indicating the presence of mature fibrous tissue. After this period bandages may be removed, and the patient advised to wear the elastic stocking for a further 6 weeks.

This technique involves meticulous care being paid to small details, especially to the application of the bandages which must be firm, secure and comfortable and capable of remaining undisturbed for 4 to 6 weeks. Most doctors become expert in the technique after working in our clinics for a few weeks.

A necessary prerequisite to injection is accurate diagnosis of the sites of incompetent perforating veins. Following this, a few well-placed injections may well rid a limb of a vast complex of varices.

If our injection technique is not properly carried out, phlebitis results, and one is back to the old discredited injection therapy. Meticulous care is required to maintain sufficient pressure after injection to prevent the development of phlebitis as we understand it clinically.

Note: I would like to express my appreciation to my Research Registrars, Dr. D. E. Fitzgerald and Dr. W. H. Beesley, who have been in receipt of full-time research fellowships from the Medical Research Council of Ireland, and whose work has been invaluable to me.

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