Sclerotherapy E-Book

Treatment of Varicose and Telangiectatic Leg Veins (Expert Consult)

Mitchel P. Goldman, Robert A Weiss

• Publisher: Elsevier
• Year: 2016
• ISBN:
  9780323377270
• Edition: 6
• Topic: Medizin
• Subtopic: Dermatologie

This classic resource by Drs. Mitchel P. Goldman, Robert A Weiss, and Jean-Jerome Guex provides highly practical, up-to-date guidance for the effective management of varicose veins and other vascular anomalies. It is an indispensable reference for a wide audience including dermatologists, invasive radiologists, family practitioners, vascular and cosmetic surgeons. Clearly written by global experts, Sclerotherapy, 6th Edition, helps those new to the field to gain a firm understanding of successful techniques, as well as showing seasoned practitioners how to improve and hone their skills with today's best and newest approaches. Case studies and detailed color illustrations offer step-by-step visual guidance.

• Covers everything you need to know with a practical approach, from the pathogenesis of varicosities to diagnostic and treatment options, including evidence-based decision making.
• Helps you optimize outcomes and improve your surgical, injection, and laser techniques with comprehensive, visual guidance, including coverage of common pitfalls and "tricks of the trade."
• Consult this title on your favorite e-reader, conduct rapid searches, and adjust font sizes for optimal readability.

• Features hot topic coverage of endovenous glue and new endovenous ablation techniques, as well as updated techniques for optimal use of foam sclerotherapy and uses for solutions recently available on the market.
• Discusses new concepts for treating areas other than the legs, including rejuvenation of the hands and chest.

1

Anatomy

Stefano Ricci

Introduction

The anatomy chapter in a modern text devoted to sclerotherapy is traditionally not the most fascinating aspect, as the anatomy rarely changes and is very similar to that described in older texts. Anatomy chapters are rarely consulted because readers believe they know the basics of venous anatomy, but they should be reviewed regularly, and as one uses duplex ultrasound, the importance of understanding anatomy increases greatly. While this chapter reports on the images and the concepts of the classic anatomy texts that we used during our university medical studies, it is clear from our experience with duplex ultrasound observations that a ‘déjà vu’ sensation to anatomy is not entirely correct and anatomy is more than a fixed science—new understanding has been added.

Dissection anatomy, indeed, had its fullest expression from the late eighteenth to the early twentieth century (Mascagni, Gray, Sobotha, Testut, etc.) when all the aspects of dissection anatomy were definitively studied (Fig. 1.1). In the past 50 years, anatomical dissection has been little used to investigate venous anatomy, probably because of the assumption that there is nothing new to discover (but also because it is more and more difficult to find cadavers for this purpose). Meanwhile, most anatomical, clinical and surgical textbooks describe the superficial veins of the lower limb as a simple ‘tree’ formed by a few constant and recognizable veins, though clinical experience often shows anomalies and variations with respect to the classical anatomical description or even the complete absence of some of these veins. Furthermore, studies in the field of limb veins usually concern subjects with varicose pathology and rarely subjects with a normal venous system.

Figure 1.1 Three plates from the Piccola Anatomia, which was published in a reduced size because of the high printing costs of the time, are shown here. These demonstrate that anatomical knowledge was already complete 200 years ago. (The Grande Anatomia of Paolo Mascagni was published between 1823 and 1831 by Nicolò Capurro in Pisa).

Confirming this, the official Anatomical Terminology (Nomina Anatomica)¹ includes only a limited number of veins and does not take into account their numerous variations. Inadequacy of official anatomy has caused many authors to name single veins independently or even after the author's name, which, in the absence of an accepted interpretation frame, has added some confusion. The nomenclature consensus statement of 2001 at the Rome UIP World Congress was organized with the purpose of solving this problem (see Table 1.1).²

Table 1.1

Summary of Important Changes in Nomenclature of Lower Extremity Veins

Old Terminology	New Terminology
Femoral vein	Common femoral vein
Superficial femoral vein	Femoral vein
Sural veins	Sural veins Soleal veins Gastrocnemius veins (medial and lateral)
Hunterian perforator	Mid-thigh perforator
Cockett perforators	Paratibial perforator Posterior tibial perforators
May perforator	Ankle lateral and medial perforators
Gastrocnemius point	Intergemellar perforator

Modified from Sherman RS. Ann Surg 1949;130:218.

Contrast phlebography, until recently the ‘gold standard’ for venous investigation, has the major drawback of being practically never complete, but rather showing only the veins filled by contrast media. Furthermore, it focuses mainly on deep veins and in pathologic conditions, and thus has not contributed much to the understanding of normal vein anatomy.

Understanding of vein anatomy did not progress much until ultrasound imaging (USI), specifically duplex scanning (DS), became an established technique for clinical investigation of patients with venous diseases. Technology simplifications and low costs have allowed its widespread use.

Ultrasound imaging makes it easy to observe the veins of the lower limb, unlike anatomical dissection and phlebography. Examination is noninvasive, repeatable and relatively low in cost. Veins can be observed at full distention, with the patient in a standing position, so that, unlike with anatomical dissection, their real volumetric relationship with the surrounding tissue is readily appreciated. Ultrasound images show not only the veins (as contrast phlebography does), but their relation to surrounding anatomical structures, in particular muscle and fascial layers. This allows precise anatomical identification of the observed veins (Fig. 1.2). Therefore, USI is a unique tool for the study of vein anatomy [ultrasound (US) dissection] and makes it possible to verify data obtained from anatomical dissections. In addition, DS allows the detection of blood flow in the observed veins with assessment of their function and involvement in venous pathology. Interestingly, USI was first employed for the clinical identification of pathologically changed veins. Later it was used for collecting data on normal vein anatomy.³

Figure 1.2 Ultrasound imaging shows the veins and their relationship to the surrounding anatomical structures, in particular other vessels, lymph nodes, bones, muscles and fascial layers. This allows precise anatomical identification of the observed veins.

In this chapter vein anatomy is first described from the traditional point of view, and successively as observed by USI with special reference to the superficial veins of the lower limb in relation to varicose vein disease and sclerotherapy. For this purpose an interpretation key is emphasized, which makes it possible to categorize the extreme variability of the superficial veins of the lower limb into a limited number of specific anatomical and varicose patterns.

Nomenclature

Nomenclature used throughout the textbook conforms to that developed at the Venous Consensus Conference Classification in 1994.⁴ In addition, the newest revisions of nomenclature and definitions are used, which were developed at the Nomenclature Congress in Rome in 2001 (Table 1.1).^2,5 The long saphenous vein is referred to by the English-Latin term great (GSV). The short saphenous vein is referred to using the English-Latin translation small (SSV), avoiding the term ‘lesser’ as the L could be confused with the term ‘long’. Veins that ‘perforate’ the fascia are termed perforator veins. Veins that connect to other veins within a fascial plane are referred to as communicating veins. The principal deep vein of the thigh is termed the superficial femoral vein, now properly called the femoral vein. The superficial femoral vein actually has turned out to be a potentially lethal misnomer. It has been found that the use of this term is hazardous to pat...