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INJECTION TREATMENT OF VARICOSE VEINS
W. G. FEGAN, M.Ch. F.R.C.S.I.
Formerly Research Professor University of Dublin, Trinity College,
at Sir Patrick Dun's Hospital, Dublin
General Principles
Venous Drainage
There is no such thing as venous drainage in the standing, walking or sitting patient. Blood in veins drains only when the bottom of the patient's bed is considerably elevated. Blood will move only from one segment of vein to the next when there is a favourable pressure differential. The haemodynamics of the venous segment of the perfusion arch of the tissues of the lower limb is as active and more complex than is the haemodynamics within the artery. The venous pumping system has to generate with each step a high systolic pressure to allow for refilling and the development of a favourable gradient for tissue nutrient exchange.
Flow and Pressure Changes
Flow in a segment of vein can vary in eight different ways. It can flow in either direction at high pressure or low pressure, quickly or slowly, in a laminar or turbulent manner. Retrograde turbulent flow directed against one side of a vein will give rise to a blow-out while failure to develop low pressure in the venules after the commencement of walking will interfere with tissue nutrient exchange.
If varicose veins were due to an alteration in the pressure pattern within the vein, the vein would react as a vein transplanted into the arterial tree. The changes in pressure would equally affect all surfaces of the vein resulting in uniform hypertrophy and later, symmetrical dilatation. This is not the ultimate derangement in the pathological vein.
Varicosity occurs usually on alternate sides of the vein, but it may also dilate in a "barbers pole" fashion.
Valvular Incompetence
The classic saphenovarix occurs at the apex of a reflux turbulent jet of blood due to valvular incompetence (primary or secondary) at the saphenofemoral junction. Where veins are not supported by Sherman's fascia, varicosity develops sooner. Turbulence is easily detected over these veins.
Turbulence would appear to be extremely damaging or injurious to the functioning of the muscle fibres and the elastic lamina of the vein wall. The muscle fibres decrease in number and the elastic lamina fragments at the apex of the turbulent jet. The difference in the overall thickness of the veins need not be impressive as the intima at this point thickens considerably. This would appear to be due to organization of layering thrombus as a result of turbulence. Such evidence leads us to the conclusion that asymmetrical dilatation (varicosity) in varices is a result of high velocity turbulent flow in poorly supported veins1.
Flow in superficial varices is found to be turrbulent when the velocity reaches certain critical points. These are: (1) shortly after assuming the erect position and (2) at the high velocity peaks developed after the commencement of walking2.
Principles of Treatment
Treatment is dependent on the type of pathology present.
Pronounced superficial varices are quite common in the symptomless leg (varicose veins). A patient with a leg seriously embarrassed with advanced signs and symptoms of chronic venous insufficiency occasionally has no varices (postphlebitic limb).
The two conditions can coexist in the same leg. This gives rise to the erroneous idea that they are sequential. In our opinion this confused thinking is responsible for much of the misunderstanding in the diagnosis and treatment of these conditions.
Incompetent Perforating Veins
A meticulous surgical dissection of the first group of varices to appear will usually demonstrate one incompetent perforating vein. This is not sufficient to interfere with pump reserve or efficiency, but it causes insidious upward uniform dilatation in the related superficial veins. With normal functioning valves in the superficial veins, alterations in pressure patterns due to incompetent perforating valves can only ascend. The superficial dilatation due to the inadequate drop in pressure after the commencement of walking gives rise to secondary valvular incompetence in the superficial veins3 and when it involves a higher perforating vein valve a reverse high velocity circuit is established.
In some cases, if the incompetent perforating veins are tied off, the superficial varices disappear and the superficial veins return to normal, demonstrating the reversibility of secondary valvular incompetence4. Injection compression therapy takes advantage of the ability of superficial veins with secondary valvular incompetence to recover as one can give treatment and observe the effects before giving the next treatment.
Postphlebitic Syndrome
When treating a patient who has primarily the postphlebitic syndrome2 and in whom the varicose veins are either absent or of little importance, all efforts should be directed towards the restoration of the pump. The signs and symptoms of the postphlebitic syndrome are primarily due to the inability of the pumps to reduce the pressure after the commencement of walking to a point at which nutrient exchange will take place. One or two incompetent perforating veins do not necessarily render the pumps incapacitated because of the very considerable reserve pumping capacity, but the more valves that are damaged, especially in the deep perforating veins, the more pumping capacity is reduced.
Management
The easiest method for the busy surgeon to distinguish these patterns from each other, is on the basis of symptoms. Patients with symptomless varices rarely have pump damage. Patients with signs and symptoms of the postphlebitic limb arising from venous derangement always have damage to the valves in the deep and perforating veins despite the presence or absence of varicose veins. The ideal management for both types of patient is, in our opinion, injection, compression and ambulation, but with meticulous palpation sites of incompetent perforators come to light which are subsequently injected.
Patients with symptomless varices can, with confidence, be promised a complete cure. Those with the postphlebitic syndrome can be rendered symptomless and thus clinically cured, but with the degree of normal pumping efficiency present before the first episode of deep-vein thrombosis, can never be fully restored. These patients must be observed periodically and advised to maintain their pump muscles by walking and to remove unnecessary strain on the vein wall and valves by the avoidance of standing. The judicious periodic use of elastic stockings is advisable.
Pregnant patients who have varicose veins are treated routinely as frequently their veins do not return to normal in the puerperium and may continue to deteriorate past the point of recovery. Initially immediate supportive therapy is provided and any localized incompetent perforations are treated.
Specialist Clinic
A clinic devoted entirely to the diagnosis and injection treatment of varicose veins is essential to ensure that the technique is carried out to perfection. It should be adequately staffed by the right proportion of experienced nurses, doctors and secretaries for maximum efficiency.
History
A history is taken with particular not of any past injury to the leg, thrombophlebitis or any previous episodes of deep-vein thrombosis. The patient is weighed and if overweight is strongly advised to diet. A blood sample is taken for the following tests: blood film, haemoglobin, W.R., Kahn white cell count and ESR and the patient is given written instructions to carry out throughout treatment.
Contraindications
Treatment
1. Materials
Stool and couch with swivel trays underneath containing bandages, sorbo rubber pads and lint are required. A tray containing four to six all-glass or disposable syringes with transparent shanks fitted with fine disposable needles and filled with sclerosant (0.5 ml of sodium tetradecyl) is at hand as after commencing treatment the surgeon cannot move away from the patient.
2. Varicose Veins
Standing on the stool the patient shows typical varicose veins involving the long saphenous system with some perforator valvular incompetence.
3. Inspection and Palpation
Veins are marked by inspection. Percussion of a dilated vein, while the other hand palpates the surface of the limb, will bring still more veins to light and when this mapping process is completed it is sometimes possible to suspect the site of the site of the perforating veins with incompetent valves.
4. Areas of Fascial Deficiency
The patient lies down with the heel comfortably supported on the surgeon's shoulder. The limb is palpated with the flat of the hand until the muscles become flaccid. Now the surgeon's fingers are flexed and the tips should
comb the leg in an effort to detect areas of fascial deficiency. These are marked with a grease pencil of a different colour.
5. Likely Sites of Retrograde Filling
The tips of the fingers are pressed into as many as possible of these areas or orifices of fascial weakness.
6. Filling of Veins
The patient is now requested to stand and the lowermost fingers are removed first. If filling of the veins in the lower leg does not take place then it is reasonable to assume that there is no incompetent perforator at the site of this apparent fascial weakness but instead the fat in this area has been displaced by a bunch of dilated veins, creating the impression of fascial weakness.
7. Selection of sites for Injection
If, on the other hand, the veins fill immediately then it is reasonable to suspect that there is an incompetent perforator in this area. It is perhaps wise to consider these as the sites at which pressure will control the filling of the superficial system. These we choose as the ideal sites for injection.
8. Removal of Pressure
The illustration shows a further distension of the superficial system after removing the pressure from an incompetent Hunterian perforator.
9. Insertion of Needle
With the patient lying horizontal it is quite easy to enter the vein and withdraw blood (the plunger of the syringe having been tested for freedom of movement). It should be noted here that the blood should not enter the syringe but only the transparent shank of the needle.
10. Injection of Sclerosant
The leg is elevated and placed against the shoulder or upper chest of the surgeon. The injection is given into a segment of vein isolated by the ring and index fingers compressing on either side in an attempt to restrict the sclerosant fluid (sodium tetrtadecyl) to the selected site. This would appear a pious hope but when the area is examined some weeks or months later the segment of superficial vein involved in the fibrous matches exactly the gap between the ring and index fingers.
11. Bandaging
The syringe is withdrawn and bandaging above, below and over the site of injection is commenced. It is usually possible to apply one or two turns of the bandage above and below the compression fingers before re-moving them.
12. Sorbo Rubber Pad
A bevelled sorbo rubber pad is bandaged immediately into position over the site of injection.
13. The Importance of Bandaging
The remainder of the bandage is applied to the foot excluding the toes. The bandager should not have a preconceived pattern into which he visually forces the bandage. The contour of the patient's leg should determine the pattern of the bandage and the pressure of both borders of the bandages should be exactly the same. Bandaging is more a sensory art using proprioceptive sensation rather than a visual art. It is the secret of the success of this technique and if the bandages have fallen off or have to be adjusted before the return visit then the surgeon has not mastered the technique and instead of a short segment of hard painless fibrotic veins patients will develop random areas of painful superficial thrombophlebitis which is certainly not the desirable end result.
14. Prevention of Abrasion of the Skin
To prevent the bandage in the region of the knee cutting the skin over the hamstring tendons it is necessary to place a sorbo rubber pad in the popliteal fossa. This becomes an absolute necessity if pressure over the termination of the short saphenous controls the filling in the superficial veins; this is a frequently overlooked common incompetent perforator which responds very well to injection and compression.
15. Traumatization of the Long Saphenous Vein and Thrombophlebitis
A pad is shown placed over an injected superficial vein in the region of the lower Hunterian incompetent perforators. It is important that the rubber pad protrude above the upper edge of the bandage; otherwise the bandage will roll down and form a sharp ropelike border which traumatizes the long saphenous vein and gives rise to the complication of ascending thrombophlebitis. Some-times it is wise to use adhesive strapping to make sure that the bandage does not roll, nor the rubber pad slip out.
16. Elastic Stocking
An elastic stocking is applied immediately after the last bandage is firmly anchored in position. It is most important that the patient should be able, fit and prepared to walk within seconds after the completion of treatment. Appointments for a return visit in 1-2 weeks should be made prior to commencement of treatment. We are convinced that the lack of complications in our clinic is due to the commencement of walking for one hour immediately following injection.
Complications
The most common difficulty, particularly for an inexperienced surgeon, is massive venous bleeding while dissecting out the saphenofermoral junction.
When this occurs, mild finger or swab pressure on the spot will control the haemorrhage while the table is tilted to raise the feet. When pressure is released after a few minutes bleeding is usually reduced to a trickle and can be accurately controlled either with an artery forceps or fine suture. Blind clamping should never be done as there is a real risk of further damage to the femoral vein or even the femoral artery.
Occasionally the stripper may pass into the deep vein via a wide short perforating vein. This occurs only when stripping up and it is therefore safer to pass the stripper downwards and always be able to feel the stripper beneath the skin.
Excessive sharp dissection in the groin, especially in large wounds, may disrupt some lymphocele. This should be aspirated.
Slight damage to cutaneous nerves is difficult to avoid completely. Therapy involves explaining to the patient the unavoidability and harmlessness of this small impairment. It will then be forgotten.
Arterial injuries, though serious, are extremely rare. They must be promptly identified and treated. An inexperienced operator must be able to identify them and transfer the patient to a vascular surgeon for urgent repair.
References