Small%Vein%Disease%,Trea/ng%Spider%Telangiectasia%With%Sclerotherapy%

Chapter%7%Peggy%Bush,%APN,%CNS,%MSN%

Ron%Bush,%MD,%FACS%

Welcome'to'the'Vein'Experts'Online'Educa6onal'CME'Program.%Original'Release'Date:'10/11/13%Termina6on'Date:'1/31/2016%Price:%%25.00%for%Vein%Experts%Members%&%$40.00%for%Non,Members%,%Processing/CME%Fees%%%%

•  This%ac/vity%has%been%planned%and%implemented%in%accordance%with%the%accredita/on%requirements%and%policies%of%the%Accredita/on%Council%for%Con/nuing%Medical%Educa/on%(ACCME)%through%the%joint%providership%of%The%University%of%Toledo%and%VeinExperts.org.%

%%•  The%University%of%Toledo%is%accredited%by%ACCME%to%provide%con/nuing%

medical%educa/on%for%physicians.%%%•  The%University%of%Toledo%designates%this%enduring%ac/vity%for%a%maximum%

of%1.00%AMA#PRA#Category#Credits™.%%Physicians%should%claim%only%credit%commensurate%with%the%extent%of%their%par/cipa/on%in%the%ac/vity.%

%%'%'%'%%

For%nurses,%we%are%also%able%to%issue%a%cer/ficate%of%aYendance%sta/ng%the%course%is%AMA%approved,%which%may%be%eligible%for%credit.%%Nurses%are%responsible%for%submiZng%the%cer/ficate%to%their%board.%%Please%note%only%one%cer/ficate%can%be%issued%for%each%purchase.%%Disclosures:%%Ronald'Bush,'MD,'FACS,%faculty%and%planning%member%discloses%he%is%on%the%Speaker’s%Bureau%for%Dornier/Refine%USA%and%is%contracted%with%Water’s%Edge%Dermatology%and%Soffer%Health.%%Richard'L.'Mueller,'MD,%faculty%and%planning%member,%discloses%he%receives%grant/research%support%from%Vascular%Insights,%LLC%Ariel'Soffer,'MD,%FACC,%faculty%and%planning%member,%discloses%he%is%on%the%Speaker’s%Bureau%for%Cutera%,%consults%for%Angiodynamics,%&%does%research%for%BTG.%Peggy'Bush,'APN,%planning%member,%has%no%disclosures%or%financial%interests%and%is%employed%by%Midwest%Vein%&%Laser%Center.%Becky'Roberts,%planning%member,%has%no%financial%interest%or%other%rela/onships%with%any%manufacturer%of%commercial%product%or%service%to%disclose.%%%%%%

Mission:%%Our%objec/ve%is%to%provide%current%evidence%based%informa/on,%as%well%as%new%technology%that%is%being%developed%for%the%treatment%of%venous%disease%presented%in%a%virtual%format.%%%%Target'Audience:%%The%target%audience%for%this%ac/vity%includes%physicians%and%other%health%care%professionals%in%Cardiology,%Dermatology,%Interven/onal%Radiology,%Phlebology,%Surgery,%Vascular%Surgery,%Wound%Care%Specialists%who%care%for%pa/ents%with%venous%disease.%%%

CME'Credit'Instruc6ons%%

Steps'to'successfully'complete'this'ac6vity:%CME'Credit'Instruc6ons%Steps'to'successfully'complete'this'ac6vity:%Register%for%CME%ac/vity%&%pay%your%CME%fees.%Read%the%Vein%Journal%Chapter%7,%en/tled%‘Small'vein'Disease'–'Trea6ng'Spider'Telangiectasia'With'Sclerotherapy.’'Take%the%post%test%(score%of%80%%or%greater%must%be%achieved.%(A%pdf%copy%of%the%exam%can%be%emailed%to%you%if%requested).%Scan%and%email%post%test%and%evalua/on%to%%pbush@veinexperts.org%or%you%can%fax%completed%paperwork%to%937,281,0200.%%You%will%be%contacted%by%the%University%of%Toledo%CME%office%for%instruc/on%of%how%to%sign%on%and%print%your%cer/ficate.%%%

Technical'Support%%

'%%%Email%your%ques/ons/concerns%to%pbush@veinexperts.org%%or%you%can%call%us%at%407,900,8346%and%we%will%respond%in%24%hours.%%%'%%

Small%Vein%Disease%–%Trea/ng%%Spider%Telangiectasia%With%Sclerotherapy%

This%ac/vity%describes%how%to%evaluate%small%vessel%disease%and%how%to%effec/vely%treat%spider%telangiectasia%with%sclerotherapy.%'Learning'Objec6ves:%'%As%a%result%of%this%ac/vity,%the%par/cipant%should%be%able%to:%%Diagnose%different%paYerns%of%spider%vein%pathology%%Describe%how%to%effec/vely%treat%re/cular%veins%using%foam%sclerotherapy.%%Explain%advantages%and%disadvantages%of%using%foam%sclerotherapy.%%%Describe%the%histology%of%a%spider%vein.%%%%%%%%%

Telangiectasia/Spider%Veins%

•  Small,dilated%veins%near%the%surface%of%the%skin%

•  Measure%0.3%mm%in%size%to%1.0%mm%in%size%•  May%be%red,%blue,%purplish,%or%greenish%in%color%

•  Medical%term%for%spider%veins%is%telangiectasia%•  Spider%veins%can%be%anywhere%on%the%body,%but%commonly%found%on%face%&%legs%

(Bush,%2013)%(Parsons,%2008)%

Telangiectasia%

•  Veins%leading%to%spider%complexes%are%re/cular%veins%

•  Re/cular%veins%are%found%1%mm%or%below%the%skin%surface%

•  Spider%veins%may%be%the%sign%of%deeper%insufficiency%

•  Underlying%problems%should%be%addressed,%before%trea/ng%spider%veins%

(Bush,%2013)%(Parsons,%2008)%(Zimmet,%2003)%

Telangiectasia%

•  Cosme/c%concern%for%pa/ent%•  Superficial%varices%open%cause%symptoms%such%as%pain,%heaviness,%aching,%and%pruritus%

(Bush,%2013)%(Zimmet,%2003)%

Spider%Vein%Presenta/ons%

(Bush,%2013)%%

Common%PaYerns%of%Spider%Telangiectasia%

•  Evaluate%for%saphenous%insufficiency%or%branch%insufficiency%from%the%saphenous%vein%

(Photo%courtesy%of%Midwest%Vein%Laser,%2013)%

Common%PaYerns%of%Spider%Telangiectasia%

•  Lateral%re/cular%veins%%•  Not%connected%to%the%saphenous%vein,%but%transmiYed%pressure%from%the%femoral%vein%by%a%perforator%

(Photo%courtesy%of%Midwest%Vein%Laser,%2013)%%

Common%PaYerns%of%Spider%Telangiectasia%

•  Typical%of%saphenous%insufficiency%

(Photo%courtesy%of%Midwest%Vein%Laser,%2013)%%%

Histology%of%a%Spider%Vein%

•  Next%slide%shows%a%spider%telangiectasia%•  No/ce%hypertrophy%of%the%smooth%muscle%•  Vein%lies%4/10%mm%(400%microns)%below%the%skin%surface%

•  All%spider%veins%are%located%in%the%papillary%dermis%

(Bush,%2013)%%

Histology%of%an%Untreated%Spider%Vein%

•  Red%Arrow%,%Stratum%corneum%(dead%skin%cells)%

•  Blue%Arrow%–%Squamous%epithelial%layer%

•  Green%–%Papillary%dermis%(Collagen)%

•  Black%–%Re/cular%dermis%(fat)%

(Bush,%2013)%

Contribu/ng%Factors%to%Telangiectasia%

•  Age%•  Gender%•  Gene/cs%•  Hormones%•  Pregnancy%•  Prolonged%standing%•  Obesity%

•  Occupa/on%•  Race%•  Sedentary%lifestyle%•  Sun%exposure%•  Therapeu/c%radia/on%•  Trauma%

(Bush,%2013)%(Parsons,%2008)%(Sadick,%1992)%(Zimmet,%2003)%

First%Visit%Aper%Consulta/on%

•  Assess%pa/ent%–%Spider%veins,%medical%history,%chief%complaint,%family%history,%allergies,%and%expecta/ons%

•  Thorough%ultrasound%to%rule%out%venous%insufficiency%

•  Educate%pa/ents%about%benefits,%risks,%&%alterna/ve%to%treatment%

•  Inform%pa/ent%of%poten/al%adverse%sequelae%&%possible%complica/ons%

(Bush,%2013)%(Parsons,%2008)%(Zimmet,%2003)%

First%Visit%Aper%Consulta/on%

•  Inform%pa/ent%there%is%no%cure%at%this%/me%for%spider%veins%

•  Medica/ons%such%as%Minocycline%or%Isotre/noin%can%lead%to%adverse%reac/ons,%if%not%stopped%prior%to%treatment%

•  Get%informed%consent%•  Take%pre,treatment%photos%

(Bush,%2013)%(Zimmet,%2003)%

Risk%Factors%to%Consider%

•  History%of%DVT%•  History%of%PE%•  Family%history%of%venous%thromboembolism,%hypercoagulable%state,%long,distance%travel,%bed%rest,%and%the%inability%to%ambulate%

•  Avoid%pa/ents%who%are%pregnant,%have%systemic%illnesses,%lymphedema,%peripheral%arterial%insufficiency,%or%unrealis/c%expecta/ons%

(Bush,%2013)%(Zimmet,%2003)%

Evalua/ng%Pa/ent%

Essen/al%to%determine:%•  Pathophysiology%•  Size%of%vessel%%•  Dermal%anatomy%•  Skin%type%•  Vessel%depth%

(Bush,%2013)%%

Imaging%

Vein%Light%–%Tran,illuminates%skin%making%iden/fica/on%of%re/cular%veins%easier%

Polarized%lights%%Loops%%

(Bush,%2013)%(Parsons,%2008)%

Trea/ng%Telangiectasia%With%Sclerotherapy%

%%

Sclerotherapy%is%the%gold%standard%for%the%treatment%of%spider%veins%

(Bush,%2013)%(Parsons,%2004)%

Detergent%Solu/ons%

FDA%Approved%•  Sodium%tetradecyl%sulfate%(STS)%•  Polidocanol%(POL)%

•  Detergents%work%by%injuring%the%endothelial%cells%with%resultant%thrombosis%and%eventual%fibrosis.%Sotradecol%is%a%stronger%sclerosant%than%Polidocanol%and%will%effect%more%damage.%%

'%

(Bush,%2013)%(Parsons,%2008)%(Zimmet,%2003)%

Hyperosmolar/Hypertonic/Glycerin%Solu/ons%

Not%FDA%approved%•  Hypertonic%saline%•  Hypertonic%dextrose%•  Glycerin%

(Bush,%2013)%(Parsons,%2008)%

Lateral%Re/cular%Veins%

•  Most%typical%paYern%•  Blue%arrow%points%to%the%lateral%re/cular%vein%

•  Treat%re/cular%veins%as%well%as%%spider%veins%at%the%same%seZng%

•  In%this%par/cular%pa/ent,%we%would%do%phlebectomy%of%the%re/cular%veins%

(Bush,%2013)%%

Using%Foam%

•  Sotradecol%&%Polidocanol%are%most%commonly%used%detergent%solu/ons%

•  Mixing%with%air%or%C02%produces%foam%•  Mechanism%of%ac/on%at%cellular%level%is%cell%destruc/on,%with%replacement%by%fibrin,%eventual%cloZng%and%scarring%of%the%lumen%

•  Using%C02,%bubbles%dissolve%faster%in%the%arterial%circula/on,%reducing%risks%of%adverse%events%

(Bush,%2013)%(Parsons,%2008)%

%%

Tessari%Method%

•  1%part%solu/on%to%4%parts%gas%•  Stopcock%with%2%syringes%

(Bush,%2013)%(Tessari,%2001)%%

Advantages%to%Using%Foam%

•  Increases%surface%area%of%sclerosant,%thus%reducing%amount%of%medica/on%needed%

•  Circumferen/al%contact%with%in/mal%wall%causes%more%damage/beYer%result%

•  Displaces%blood,%thus%avoiding%dilu/on%of%drug/increase%efficacy%

•  Use%in%larger%veins%>%1.5%mm,%foam%is%difficult%to%inject%into%a%vein%with%a%small%lumen%

(Bush,%2013)%%

Disadvantages%to%Using%Foam%•  Pa/ents%with%PFO%and%prior%neurological%events%are%not%candidates%%

•  Migraines%and%scotoma%may%occur%with%PFO’s%•  DVT%unlikely,%however,%clear%deep%system%with%foot%dorsiflexion%post%treatment%and%encourage%ambula/on%

•  Complica/ons%are%rare,%since%Sotradecol%and%Polidocanol%deac/vates%rapidly%in%blood%

•  Using%too%high%of%a%concentra/on,%causes%angiogenesis%

(Bush,%2013)%(Zimmet,%2003)%

Re/cular%Veins%

(Bush,%2013)%%%

(Bush,%2013)%%

Re/cular%Veins%

•  Sotradecol%0.33%%•  Polidocanol%0.75%%

%

Supplies%Needed%•  Stopcock%•  2,3%cc%syringes%•  25,27%gauge%buYerfly%•  Alcohol%swab%•  CoYon%balls%%•  Paper%tape%•  Sclerosant%•  Light%source%

(Bush,%2013)%(Zimmet,%2003)%

Tessari%Method%

(Bush,%2013)%(Tessari,%2001)%

Making%Foam%

•  Supplies%needed:%2,3%ml%syringes%&%C02%•  Mix%STS%0.3%%0.5%ml%&%C02%2.0%ml%•  Maximum%we%use%is%6%ml%of%foam%–%European%consensus%is%10%ml%

•  If%you%use%too%strong%of%a%solu/on%in%re/cular%vessels,%You%will%get%vessel%wall%destruc/on,%inflammatory%changes,%&%staining%

•  Use%STS%0.3%%or%less%–%You%can%also%try%Polidocanol%0.5%%

(Bush,%2013)%(Parsons,%2008)%

Trea/ng%Re/cular%Veins%

•  Must%see%a%blood%return%•  Gently%inject%foam%sclerotherapy%•  Should%see%blanching%and%if%not,%remove%needle%and%re,cannulate%

•  Apply%coYon%balls%&%paper%tape%•  Have%pa/ent%wear%compression%stockings%for%2,3%days%

(Bush,%2013)%(Parsons,%2008)%

Trea/ng%Spider%Veins%Up%to%1%mm%

•  Use%Sotradecol%0.2%%•  Supplies%– Alcohol%– CoYon%balls%&%paper%tape%– Sclerosing%solu/on%– 3%ml%syringe%with%30,gauge%needle%– Bend%30,gauge%needle%to%45,degree%angle%

(Bush,%2013)%(Parsons,%2008)%(Zimmet,%2003)%

Spider%Vein%Treatment%

•  Inject%sclerosant%slowly%•  Look%for%blanching%•  Use%cau/on%in%the%ankle%area%•  Apply%coYon%balls%&%paper%tape%•  Have%pa/ent%wear%compression%stockings%18,20%mmHg%for%3%days%

(Bush,%2013)%(Parsons,%2008)%

Histology%–%Sclerotherapy%With%%Liquid%Sclerosant%

%•  Absence%of%endothelial%cells%

•  Marked%fibrin%deposi/on%in%vessel%wall%

•  Red%cell%aggregate%in%lumen%&%vessel%wall%

•  No/ce%almost%total%destruc/on%of%vessel%at%one%point%

(Bush,%2013)%(Bush,%2013)%

Spider%Vein%Treatment%

•  Aper%injec/on,%see%inflamed%response%

•  If%minimal%response,%may%need%slightly%higher%concentra/on%

•  Wait%4,weeks%before%re,trea/ng%

(Bush,%2013)%(Zimmet,%2003)%

(Bush,%2013)%%

References%%•  Bush%R.%%Histological%Analysis%Of%Sclerotherapy,%Laser%940,%Ohmic%Thermolysis,%

And%Intense%Pulsed%Light,%On%Leg%Vein%Telangiectasias.%Conference;%2013%Sep%8,13;%Boston.%

•  Bush%R,%Bush%P%Spider%vein%treatment.%Vein%Journal.%Retrieved%online%9/27/13%from%www.veinexperts.org.%

•  Images.%Retrieved%online%9.26.13%from%www.veinexperts.org.%•  Parsons%M.%Sclerotherapy%basics.%Dermatol#Clin.%2004:22:501,508.%•  Sadick%N.%Predisposing%factors%of%varicose%and%telangiecta/c%leg%veins.%J#

Dermatol#Surg#Oncol%1992;18:883,6.%•  Tessari%L,%Cavezzi%A,%Frullini%A.%Preliminary%experience%with%a%new%sclerosing%

foam%in%the%treatment%of%varicose%veins.%Derm%Surg%2001;27(1):58,60.%•  Zimmet%S.%Sclerotherapy%treatment%of%telangiectasias%and%varicose%veins.%Tech%

in%Vasc%&%Interven%Rad%2003;6:116,120.%%%%%

Exam%Complete'the'exam'&'evalua6on'below'and'email'your'results'to'pbush@veinexperts.org'along'with'your'contact'informa6on.'%'%A'score'of'80%'or'greater,'must'be'achieved'on'the'post]test'and'be'completed'in'less'than'3'a^empts.''%When'you'see'spider/re6cular'veins'on'the'medial'aspect'of'the'knee,'it'may'be:'

a.%%Associated%with%a%perforator%b.%Saphenous%insufficiency%c.%%Spontaneous%bleed%%

%%

Exam%All'are'contribu6ng'factors'to'telangiectasia'except:'

a.%%Gender%b.%%Hormones%c.%%Crossing%your%legs%d.%%Pregnancy%

Pregnant'pa6ents'can'be'safely'treated'with'sclerotherapy:'a.%%True%b.  False%

Most'spider'veins'are'located'in'the:'a.%%%Squamous%epithelium%b.  Papillary%dermis%c.  Re/cular%dermis%

%%

Evalua/on%%%How%well%did%this%ac/vity%present%the%objec/ves?%%%Excellent%%Good% % %Sa/sfactory% % %Poor%%%%%%How%do%you%rate%the%overall%usefulness%of%the%online%material%to%mee/ng%your%needs?%%%%Excellent%%Good% %% %Sa/sfactory% % %Poor%%%%%%How%do%you%rate%the%overall%presenta/on%material?%%%%Excellent%%Good% % %Sa/sfactory% % %Poor%%%%%

Was%any%commercial%bias%presented%in%the%material?%%%No% %Yes%(Please#explain)#%%____________________________________________________%%%%I%will%be%able%to%change%my%clinical%prac/ce%as%a%result%of%par/cipa/ng%in%this%ac/vity.%%%Yes% %No%%%%%%What%topics%about%venous%disease%would%you%like%to%hear%about%in%the%future?%%%%____________________________________________________%%%%%%%%

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