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Digital Vein Mapping Guiding Laser and Injection Sclerotherapy to Treat Telangiectasias and Feeder Veins: Report of 140 Cases

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Digital Vein Mapping Guiding Laser and Injection Sclerotherapy to Treat Telangiectasias and Feeder Veins: Report of 140 Cases ARTÍCULO ORIGINAL Digital Vein Mapping Guiding Laser and Injection sclerotherapy to treat telangiectasias and Feeder Veins: Report of 140 Cases. Authors: Roberto Kasuo Miyake, MD, PhD / Rodrigo Kikuchi, MD / Flavio Henrique Duarte, MD / John Davidson, MD / Hiroshi Miyake, MD, PhD Institution: Clinica Miyake, Sao Paulo, Brazil E-Mail autor: [email protected] Fecha recepción artículo: 23/11/2008 - Fecha aceptación artículo: Marzo 2009 Abstract Resumen Background and Objective: Telangiectasias Antecedentes y Objetivo: la ineficiencia en el treatment inefficiency may occur due to tratamiento de las telangiectasias puede deber- invisible feeder veins. These veins can be made se a las venas nutricias no visibles. Estas venas discernible by use of a digital vein detection pueden hacerse perceptibles mediante el uso de device (V-V). This study evaluates a method un dispositivo digital de detección (VV). Este to treat vascular lesions by combining 1064nm estudio evalúa un método para el tratamiento laser, injection sclerotherapy, a skin cooling de lesiones vasculares mediante la combinación device (CLaCS) and the V-V. de láser de 1064nm, la escleroterapia por inyec- Materials and Methods: Patients were treated ción y un dispositivo de enfriamiento de la piel with laser and sclerotherapy, both applied (CLACS, Cryo-Laser y Cryo-Sclerotherapy)) y under cooling. V-V was used to visualize hidden el VV (The VeinViewer™). feeder veins. Material y Métodos: Los pacientes fueron trata- Results: A total of 140 patients underwent dos con láser y la escleroterapia, ambos aplicados CLaCS. In 121 patients (86%) satisfactory bajo enfriamiento con (CLaCS). El dispositivo cosmetic results were obtained avoiding digital V-V se utiliza para visualizar las venas phlebectomy. Partial ou unsatisfactory outcome nutricias ocultas. was observed in 19 patients (14%). Resultados: Un total de 140 pacientes se some- Conclusion: This more comprehensive way to tieron a CLACS. En 121 pacientes (86%) los evaluate telangiectasias extends the treatment resultados estéticos obtenidos fueron satisfac- of lesions by direct vision to those correlated torios evitándose una flebectomia. Resultados invisible vessels, guided by a digital device. parciales o insatisfactorios se observaron en 19 pacientes (14%). Conclusión: este modo de tratamiento, permite Keywords: Laser, Sclerotherapy, Telangiectasia, tratar las telangiectasias en forma másabarca- Feeder vein tiva ya que extiende la terapéutica a los vasos invisibles en forma directa, guiado por un dis- positivo digital. Palabras clave: Láser, Escleroterapia, Telangiec- tasia, venas nutricias Año 4 / Nº 10 / Enero - Abril 2009 / Páginas 569 a 576 569 Introduction 1- on the horizontal lines: which kind of varicose veins does the patient have (with The most popular trend in phlebology is foam or without reflux on saphenous veins), if injection. This technique dates from decades any? and was reassessed by the turn of this century 2- on the vertical rows: which kind of to a better and modern way. telangiectasias does the patient have (with In spite of that, we are on the opposite lane, or without feeder veins connected), if any? heading towards expensive technology. The objective of this study is to describe and All patients had to be in the range of scores discuss a series of 140 cases bearing varicosities between 6 and 4. that were treated under visual digital guidance All patients in this study read, agreed and signed in a completely different way. Sclerosis was an informed consent before treatment. achieved by combination of thermal and The study protocol conformed to the guidelines chemical agents: laser and dextrose. of the 1975 Declaration of Helsinki and was approved by our institutional review board. Methods Imaging System Patients This study was conducted between July 2005 The VeinViewer™ (V-V) Imaging System and Jan 2006 in our clinic. (Luminetx, TN, USA) allows visualization of Inclusion criterion of patients was the presence, feeder veins. The images are acquired and re- isolated or combined, of varicose veins, projected in a fraction of a second, directly telangiectasias and feeder veins (CEAP 2 or 3). onto the skin, enabling clinical practitioners Exclusion criteria were: to visualize what is not possible to the naked Reflux (longer than 1 second) in any eye. The deepest vein identified by the V-V was saphenous vein; 0.8mm in diameter and 7.8mm deep.1 Other symptomatic pathologic conditions, The V-V works by increasing the contrast of under treatment or not; veins by digitally imaging a continuous spot- Previous surgery for varicose veins; image over the skin using an infrared camera, Impossibility of follow-up (just one session enhancing the acquired image via software, without return); and then projecting the enhanced vein image in Loss of contact. green light over the same spot. The Duplex machine used in this study was Patients were organized in groups displayed on the Pico™ (Medison). It has a linear multi- a table were each received a score from 9 to 1. frequency probe (7.5-10MHz) designed for This table helped us to organize patients based superficial examination. All saphenous vein on two questions (Table 1): reflux evaluations were performed by the Table 1: Patient stratification according to their venous lesions Combined Simple Telangiectasias Telangiectasias No Telangiectasias (Devoid of Feeder Veins) (With Feeder Veins) Complex Varicose Veins 9 8 7 (With Reflux on Saphenous Veins) Simple Varicose Veins 6 5 4 (No Reflux on Saphenous Veins) No Varicosities 3 2 1 570 Flebología y Linfología / Lecturas Vasculares authors. The operators are trained specifically (D75, pharmaceutical grade, one of the most on venous examination and perform these on common in Brazil), which is just the same as a daily basis. the intravenous solutions commonly used in hospitals, but in a higher concentration (5% and 25%). It was injected using 3ml syringes, Laser System and 27G½ needle. Patients were asked not to use any kind of creams on the day of the The Nd:YAG 1064nm laser module session. After the punctures, a handmade 3mm (Harmony™, Alma Lasers Ltd - Caesarea, cotton ball was positioned onto the skin with Israel) allows the use of different spot sizes an adhesive tape (Micropore™). (6 and 2mm), long (40, 60msec) and short Both techniques were applied with a forced (10msec) pulse durations, and fluence of up to air-cooling device. No compressions, medical 150J/cm2 and 450J/cm2 with 6mm and 2mm stockings or bandages were used. The suggested spot size, respectively. Recently developed interval between sessions was 2 weeks. transdermal lasers, like the one we use, achieved selective photothermolysis by being much more absorbed by oxi and deoxi-hemoglobin Photography and outcome analysis than melanin. The use of gel is dispensable and patient can easily tell the size of the vein by the A Tripod mounted Nikon D70 with 28-70mm generated heat on a smaller or larger vein. lens was used. The pictures were acquired in 6Megapixel RAW files, then converted to JPEG set to “Best quality” (lossless compression). Cooling System Results were analyzed by comparing before and after photos, mainly considering the The Cryo5™ cold air device (Zimmer subject’s opinion on the outcome. Response to Elektromedizin - Ulm, Germany), developed the treatment was rated on: 1. total or partial initially for physical therapy, is intended improvement with patient satisfaction (Group to minimize pain as well as decreasing the 1); 2. partial improvement or lack of resolution, sclerosant’s temperature. The Cryo5 decreases without patient satisfaction (Group 2). the air temperature to -20ºC. Cold air is blown upon the region of interest via a flexible hose with a plastic tip. It is consumable free and Statistical analysis allows pre, parallel and post cooling. This is a retrospective study. It was based on the analysis of the data that we normally collect The CLaCS treatment guided by the V-V in our files. Data are presented as mean values and results in CLaCS is an acronym for the combined each group are cited as percentages. treatment we use since 1995. It stands for Cryo- Laser and Cryo-Sclerotherapy. Initially, all veins were first treated with Results transdermal laser. Laser was applied with the 6mm spot size, 40ms pulse-width and 130J/ A total of 466 patients visited the clinic and 191 cm2 fluence (energy). If the pain was bearable, were selected to start CLaCS treatment during fluence was increased up to 150J/cm2, in 10J/ the period of the study. Exclusion criteria left a cm2 steps. For feeder veins, 60msec pulse total of 140 patients for analysis. duration was preferred. The laser session has 50 Mean age of patients was 37 years (16 to 72), to 350 shots taking 5 to 25 minutes. with prevalence of women (98%). Depending on the coverage of the laser session, No allergic reactions, systemic reactions, skin the sclerotherapy was started 5 to 25 minutes burns, post-sclerotherapy mattings, infections after photothermolysis. The sclerosing agent or crustings were observed. Ecchymosis were employed was 75% hypertonic dextrose observed in 30% of the cases, and intravenous Año 4 / Nº 10 / Enero - Abril 2009 / Páginas 569 a 576 571 coagula in 14% of them. No frostbite was to mention the incidence of hyper-pigmentation registered due to cold air blowing. and systemic complications, albeit rare. Average number of sessions for the CLaCS Nevertheless, the final choice of technique is was 3.17 (1-9) for Group 1 and 3.58 (1-10) for the therapist’s discretion. Group 2. Our practice focuses on varicose veins since Pain was described as perfectly tolerable using the 60’s. In the 70’s, patients in Brazil started to the cold air device. The clinical protocol was bring cosmetic concerns outnumbering those followed to the letter and laser fluence was not with functional symptoms. Understanding this lowered in any patient to mitigate pain. cosmetic bias, we decided to steer clear from Due to the nature of the technique, the number risks like anaphylaxis.
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