Marco Cosimi - miodottore.it

Reintervento terapeutico risolutivo dopo pregresse recidive chirurgiche

Case report: Three-dimensional Regenerative Ambulatory Phlebotherapy for incontinent perforating veins in patients who have already undergone multiple phlebectomies Marco Cosimi MD KEYWORDS: Three-dimensional Regenerative Ambulatory Phlebotherapy, perforating veins, solution of sodium salicylate in a buffered hydroglycerine carrier (Bisclero). This patient underwent a bilateral saphenectomy of the great saphenous vein and multiple posterior phlebectomies in both calves. In the treated areas, new varices formed due to the persistence of perforating veins in those regions. Incontinent veins inadequately treated by phlebectomies which, as is known, have a prevalently bidimensional action. Incontinent perforating veins gave rise to new evident venous ectasias. We viewed the sites of venous reflux with a spectroscopic analysis method. During the analyses significant venous reflux was seen in the perforating veins of Cockett, Sherman and Boyd of the left leg. In the right leg, the perforating veins of Sherman and Boyd were seen to be incontinent and bulging. Numerous posterior bilateral perforating veins were seen to be feeding large varices with significant reflux.
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Vene perforanti in b/n (foto scattate dal visore).La fascia muscolare appare bianca, il paz. è sdraiato con arti sollevati di 45°, pertanto le vene si presentano prive del sangue refluo We prepare to perform Three-dimensional Regenerative Ambulatory Phlebotherapy (TRAP) which treats the vein walls, strengthening them and narrowing them until they attain normal vessel consistency. The patient is laid out prone on the table. The skin is disinfected with polyvinylpyrrolidone-iodine solution (Betadine) as its dark colour accentuates the in-depth infrared imaging. Perforating veins giving rise to copious reflux are clearly visible in the sural region. TRAP is the new regenerative cure for varicosis created by the plastic surgeon Sergio Capurro. TRAP induces the activation of a controlled deposition of fibrous tissue in the walls of the injected incontinent veins. A sclerosing solution of sodium salicylate in a buffered hydroglycerine carrier, diluted to a non-obliterative concentration, is injected three-dimensionally into those veins of the superficial circulation which are sites of reflux. Even the smallest perforating veins identified with the reflection-absorption technique must be injected. After the regenerative treatment on the walls of the perforating and superficial vessels, prolonged use of elastic stockings or bandages and normal physical activity are indispensable. We reiterate the fact that the patient had undergone phlebectomies in the past to resolve phebological pathology. The scars from previous operations are clearly visible in the postero-medial region of the calves. Currently, recurring venous swellings of considerable size are present, supplied by several perforating sural veins. Using TRAP we can treat the insufficient perforants causing the venous reflux pathology. Phlebotherapy narrows and strengthens the walls of the bulging perforating veins and induces anatomo-functional restoration of the venous circulation. During Three-dimensional Regenerative Ambulatory Phlebotherapy the reaction of the injected vein wall is immediately visible. The reflection and absorption of the infrared light shows the rarefaction of the veins and the loss of linear continuity of the walls. To inject the regenerative solution we use a large syringe. The large diameter of the syringe reduces the compression force that the solution applies on the reflux in the treated communicating veins and seems to us to be suitable for treating large veins with extensive venous reflux. The lower pressure of injection which is due to the larger diameter of the syringe reduces the dynamic turbulence in the two fluids which meet: the venous reflux and the phlebotherapeutical solution. The sodium salicylate solution in a buffered hydroglycerine carrier is thus able to act with greater homogeneity on the entire ectasic vein wall. The viscosity of the solution contributes to achievement of this aim. Moving down towards the lower sural region itself we come across refluxed perforating veins under greater reflux pressure. The possibility of effective day surgery treatment is an enormous advantage for the patient. After the therapy the patient is able to walk, and rather must walk, as this allows recovery of muscle tone in the lower legs in the regions immediately surrounding the dilated perforating veins. Where large incontinent perforating veins are present, the muscular fasciae bulge and are clearly perceivable on Ecodoppler imaging, transillumination, or better yet, under spectroscopic analysis with invisible infrared light at a wavelength of 760 nm projected onto the patient’s skin. The lack of homogeneity of the fascial continuity is often clearly appreciable by palpation. The patient is an amateur cyclist and has regained venous anatomo-functional integrity in the space of three months with three sessions of bilateral TRAP concentrated, in accordance with the patient’s wishes, exclusively on the venous ectasias of the calves and the more frequent sites of venous insufficiency of the medial region of the lower leg. clip_image004 (1) The patient before and after TRAP The treatment is aimed at functional recovery of muscular activity and improvement of performance in aerobic activity and always carried out with the aid of stockings with a pressure of 40 mmHg at the ankles. The patient has momentarily postponed the treatment of the whole superficial and perforating circulation which is required by phlebotherapy to make all the visible vessels disappear, preferring to quickly resolve the subjective symptoms in the sural muscular regions: cramp-like pains in the evening and after prolonged physical effort.

FAQ

D) L’iniezione della soluzione rigenerativa nelle vene perforanti, visibili con la chemiometria a 760 nm ha permesso di ottenere un risultato veramente notevole e dimostra l’importanza delle vene perforanti nell’eziopatogenesi della malattia varicosa. Mi chiedo se questo trattamento eseguito esclusivamente nelle perforanti possa essere applicato in tutti i pazienti o solo in questo caso. R) In questo caso, per merito della chemiometria a 760 nm è risultato abbastanza facile iniettare le perforanti sfiancate. Nella maggior parte dei pazienti le perforanti non sono così facilmente visibili, sono meno dilatate ed è pertanto necessario iniettare in tutti i vasi visibili con Chemiometria a Near Infrared Light 760 nm, una quantità di soluzione sufficiente ad entrare in contatto con il circolo perforante. D) Quanta soluzione inietta? R) Spesso anche 3 ml. D) L’iniezione nelle perforanti evidenziate chemiometricamente è semplice, perché l’ago della siringa è posizionato perpendicolare come la vena. Iniettando una perforante l’operatore si basa esclusivamente sulla pressione dello stantuffo della siringa. R) La realizzazione dei nuovi strumenti diagnostici venosi, utilizzati dalla TRAP, dall’EVLA, dalle metodologie terapeutiche transdermiche e sempre meno chirurgiche ci fa comprendere che l’evoluzione della flebologia va verso un accurato studio del territorio, soprattutto delle piccole vene perforanti insufficienti, un tempo ritenute poco importanti solo perché non facilmente visibili con l’ecocolordoppler. Il nostro attuale lavoro comparativo di imaging è stato di individuare i limiti e le precise indicazioni dei nuovi strumenti di imaging a nostra disposizione. Dal 2009 a tutto il 2010 sono stati studiati comparativamente con l’ecocolorpowerdoppler oltre 500 pazienti con Chemiometria a Near Infrared Light a 760 nm. L’imaging dei reflussi venosi superficiali e soprafasciali consente un’alta definizione fino a 60 micron di risoluzione, orientando l’approccio diagnostico al fine terapeutico in un’area vasta e tridimensionalmente fino alla fascia, con profondità di ben oltre 2 cm e non per transluminescenza ma per riflessione spettrale degli aminoacidi apolari chimicamente “riconosciuti” e costituenti il collagene della fascia muscolare. La definizione dei reflussi venosi patologici è non operatore dipendente e simil-flebografica con altissima definizione, per assorbimento della luce invisibile di 760 nm da parte della desossiemoglobina venosa.