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Home , Telangiectasia, Varicose veins

Central Annals of Vascular Medicine & Research

Research Article *Corresponding author Lu Xinwu, Department of , Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, Treatment of China, Email: [email protected] Submitted: 16 February 2017 and Reticular of Lower Accepted: 05 February 2017 Published: 31 March 2017 ISSN: 2378-9344 Limb: Experience with Copyright © 2017 Xinwu et al. and the Long- OPEN ACCESS

Keywords Pulsed 1064nm Nd: YAG Laser • Reticular veins • Telangiectasis • Sclerotherapy in China • Laser treatment Zhao Haiguang1,2, Zhang Xing1, and Lu Xinwu1* 1Department of Vascular Surgery, Shanghai Jiao Tong University, China 2Laser Cosmetic Center, Shanghai Jiao Tong University, China

Abstract Background and objective: The disease of reticular veins and telangiectasis of lower extremity are very common. Regular treatments of and medicines offer limited relief and are not curative. This research is to study the efficacy, safety and patient satisfaction of the combination of sclerotherapy and the long-Pulsed 1064nm Nd: YAG laser in treatment of reticular veins and telangiectasis of lower extremity in China. Methods: From January 2015 to July 2016, excluding deep and superficial veins valve insufficiency of the lower extremity through duplex ultrasonography. Patients with simple reticular veins and telangiectasis of the lower extremity were treated with sclerotherapy combined with Nd: YAG 1064nm laser therapy. Results: Of the 136 patients: cured in 87 cases, significantly effective in 45 cases, effective in 4 cases, total effective rate is 100%. There were no severe complications in all cases. Conclusion: Sclerotherapy and Nd: YAG1064nm laser are for different stages of the treatment process and different caliber of blood vessels. A combination treatment of sclerotherapy and Nd: YAG 1064nm laser for reticular veins and telangiectasia of lower extremity is safe, simple and effective.

INTRODUCTION and reticular veins are dilated visible small of Nd: YAG 1064 nm laser and sclerotherapy may have a better result [4]. Here we summarize our experience of combining Nd: YAG1064 nm laser and sclerotherapy to treat reticular veins and superficial veins which occur on skin, telangiectasias are defined telangiectasiasMATERIAL AND of lower METHODS limbs. as 0.1-1.0mm in diameter and reticular veins between 1 to 3mm [1]. They are very common disease in the population, with a Patients German epidemiology study reporting that 59% of the adult population suffer from isolated telangiectatic or reticular veins of the legs, which is more prevalent in women [2]. Telangiectasias The study was approved by the ethics committee of Shanghai and reticular veins are not only cosmetic problems but reasons ninth people’s hospital. Patients signed consent after full for pain, , burning, throbbing, itching, leg fatigue and information. All patients underwent a clinical examination and venous [3]. In China, with the improvement of living duplex ultrasound imaging of their veins. They were devoid of standards and health consciousness in recent years, the general reflux lasting more than 1 second in the deep veins, saphenous populations have paid more attention on their external image and trunk, saphenous junction, saphenous tributaries, or perforating tend to treat their reticular veins and telangiectasias. However, veins. All had fully compressible deep and superficial veins. at present the treatment of reticular veins and telangiectasias Further exclusion criteria were: (1) seriously allergic to alcohol; of lower extremities has been seldom reported in China. As for (2)recent ; (3) the ; (4) lower limb treatment methods, the golden standard is sclerotherapy, which ischemia; (5) local or systemic infection ; (7) symptomatic patent is a wide and cheap technique but still has limitations. As a new foramenMedicine ovale. and instrument technic, Nd: YAG 1064 nm laser treatment has demonstrated great therapeutic effect in blue and purple telangiectasias on lower extremities. Previous study indicated that a combination 0.5% (Aethoxysklerol; Kreussler Pharma, Cite this article: Haiguang Z, Xing Z, Xinwu L (2017) Treatment of Telangiectasia and Reticular Veins of Lower Limb: Experience with Sclerotherapy and the Long-Pulsed 1064nm Nd: YAG Laser in China. Ann Vasc Med Res 4(1): 1049. Xinwu et al. (2017) Email: Central

cmWiesbaden, Germany), long-pulse Nd: YAG laser system reactions disappeared a few hours after treatment, 2 cases (GentleYAG,2 Candela), pulse width 3-100 ms, energy 20-500 mJ/ extended to 3 days after treatment, 4 cases had granular blister. , spot diameter 3 mm, repeat frequency of 2 Hz, with dynamic Most blisters turned thin or dry within 7 days. The pigmentation coolingProcedure (DCD) system. after sclerotherapy was evident for some days, weeks, and rarely up to 5 months after treatment. No special treatment was needed after treatment. There were no serious complications, Injections were performed with a 2 ml silicone syringe and such as deep thrombosis and pulmonary . Mild a 30 G needle. Here we used sclerosing foam of polidocanol, local pigmentation still remained in 2 cases, no pigment loss or the method to prepare sclerosing foam is the same as what scar. Pictures before and after treatment as shown in Figure (l- Tessari reported in 2000 [4]. The liquid: gas (room air) ratio 2). Complications after sclerotherapy and laser treatment are for production of the foam was 1:4, the exact volume at each shown in table 1 and satisfactory degree of patients to treatment site of injection depended on the range of the telangiectasias isDISCUSSION shown in Table (2). and reticular veins. The maximum volume of foam given at each injection site was 1ml. Reticular feeding veins were injected prior to injection of the telangiectasias. Patients remained supine The treatment of telangiectasia and reticular veins of lower for 5 minutes after the last injection. A thigh-length stocking extremities has drawn much attention. Conventional treatment (23 to 32 mm Hg) was applied respecting the individual lower like compression stockings is usually ineffective, while drugs like limb dimensions. Patients were asked to wear the compression sodium aescinate have no effect. The prevalence of telangiectasia stockings all the time for 1 week, then to wear it in the day and to and reticular veins of lower limb is high [2]. The etiology is not remove it during night time for another 3 weeks. clear and it may be associated with hormone secretion conditions and lack of physical activity, standing/sitting for long periods. After one month, a high peak power, long-pulse Nd: YAG There is an increasing population especially young female laser system (Gentle YAG, Candela) was applied to treat residual seeking to treat their telangiectasia and reticular veins because telangiectasias. The laser has a wavelength of 1064 nm, a of health and cosmetic reasons. maximum peak power of 26,33 W, and pulse duration ranging from 0.25 to 300 ms. Maximum2 fluence that can be delivered Compression Sclerotherapy has been used in the treatment by this system is 600 J/cm . Spot sizes are adjustable from 1, 5 of venous disease for decades of years. Orbach reported foam to 18 mm at the level of the hand piece. Epidermal cooling was sclerotherapy treatment in 1944. In 1997 it was reported that achieved with cryogen cooling system that is administered to using foam sclerotherapy to treat truncal venous disease made tissue by the hand piece. The patients were reviewed and treated the clinical effect better because the foam displaces blood and atAssessment 4-week intervals.

At least 2 experts blinded to the interventions studied the photographs taken before and one month after treatment. Assessment was made according to degree of reduction of the blood vessels . Grade of response were categorized on four classifications: 1. Clear; 2. marked improvement; 3. Partial response; 4. poor response or no change. The total effective rate = (clear cases + marked improvement cases + Partial response)/ total number of cases. Each patient was given a questionnaire, asking their satisfaction with the treatment effect (very unhappy Figure 1 andRESULTS dissatisfied, satisfied and very satisfied). Female, 26 years old, with reticular veins of lower limb.

Between January 2015 to July 2016, a total of 136 female patients with telangiectasias and reticular veins were included in our hospital. Of all the 136 patients, every patient need 1 injection, the average volume of foam injected was 8ml and the maximum volume was 10ml per patient. 82 patients underwent later laser treatment. 41 patients had 1 laser treatment, 28 for twice, 10 for 3 times and 3 for 4 times. Of 136 cases, cleared for 87 cases (63.97%), 40 cases were markedly improved (29.41%), partial response in 9 cases (6.62%), the total effective rate was 100%. During the treatment, none of the patients suffered serious Figure 2 adverse events. Immediately after laser, the urticarial reaction Female, 30 years old, with telangiectasia and reticular veins was often observed and swelling was self-limited. Urticarial of lower limb.

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Table 1: and laser treatment. List of complications of all patients underwent sclerotherapy effect for lesion on face, but not suitable for telangiectasia of Complications No. (%) of patients lower extremities because of its limited penetration ability. On Patients received sclerotherapy alone this point, 1064 nm Nd: YAG laser shows its advantage. (number=54) Parlar and his colleagues carried on a prospective, Pain and erythema 41 (75.9 %) comparative, randomized, open-label trial on treatment of lower extremity telangiectasias in women by foam sclerotherapy vs. BruisingTransient postinflammatory 42 (77.8 %) Granularhyperpigmentation blister Nd: YAG laser, the conclusion is telangiectasias of the lower 0 (0 %) extremities can be successfully treated with either synchronized 1(1.85%) long-pulsed Nd: YAG laser or sclerotherapy [5]. However, in one Patientsfocal thrombosis received sclerotherapy in 15 (27.8 %) previous small pilot study involving fourteen patients, the best erosion and crusting 3(5.6 %) combination with the laser (number=82) results seemed to be achieved when sclerotherapy is first used followed by a laser treatment [6]. Pain and erythema 68 (82.9 %) For the patients of our study, the residual telangiectasia after Transient postinflammatory hyper 59(72.0 %) Bruising sclerotherapy injection was treated with 1064nm Nd: YAG laser. Granularpigmentation blister 3 (3.6 %) This helped to make up with the deficiency of sclerotherapy and 3(3.6%) achieved good effect. The laser’s dynamic cooling system can Focal thrombosis 16 (19.5 %) prevent skin burns and other postoperative adverse reactions. Erosion and crusting 5 (6.1 %) Our past experience shows that blister often develops in Table 2: patient who has dark and thin skin. In addition, improper laser Patient satisfaction The satisfactory3 months degree of patients. 12 months parameters also lead to blister, including wavelength, spot Size, 0 pulse duration and multilayer overlapping. 1 Very Dissatisfied 2 In China, with the development of economy and the Dissatisfied 8 101 improvement of living standards, people’s cosmetic demand is Satisfied 59 28 increasing. More pursue treatment of telangiectasia and reticular Very Satisfied 67 veins of lower extremities for social life needs. In this study, the sclerotherapy was applied combined with 1064 nm Nd: YAG this increased the interaction with the vessel wall area, which laser. These two methods play roles at different stages in the reduced the concentration and dosage of agent and made the treatment process for different diameter of blood vessels, which treatment safer by reducing the volume of liquid sclerosant obtained satisfactory effect. In the future there should be more required. Whereas foam sclerotherapy may lead to higher risks REFERENCESresearch with more cases and with longer follow-up time. of hyper pigmentation than liquid sclerotherapy, which clears 1. spontaneously within 6–24 months in most cases [5]. Most doctors nd prefer to use liquid sclerotherapy rather foam sclerotherapy for Rutherford RB. Rutherford’s vascular surgery. Vol 1. Cronenwett JL, the treatment of leg telangiectasia. There exists debate between KW Johnston. 2 Eds. Saunders 2003. foam sclerotherapy and liquid sclerotherapy, but in our practice, 2. Rabe E, Pannier-Fischer F, Bromen K, Schuldt K, Stang A, Poncar Ch, foam sclerotherapy showed its safety and convenience, which et al. Bonn Vein study of the German Society of Phlebology [Bonner made us, chose foam sclerotherapy. Tessari reported a method Venenstudie der Deutschen Gesellschaft fur Phlebologie]. Phlebologie. 2003; 32: 1-14. to prepare foam in 2000, which was very simple and practical. We also used this method here. 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Cite this article Haiguang Z, Xing Z, Xinwu L (2017) Treatment of Telangiectasia and Reticular Veins of Lower Limb: Experience with Sclerotherapy and the Long-Pulsed 1064nm Nd: YAG Laser in China. Ann Vasc Med Res 4(1): 1049.

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