Stefano Ricci
Varicose veins treatment by ambulatory phlebectomySome readers could be surprised to find a phlebology technical article in a special issue devoted to dermatology. Because of the necessity of looking to the origin of several venous stasis cutaneous complications, every dermatologist is obliged to be involved in varices. Many are those practicing intravenous injections called sclerosants and perform subsequently skin incisions for thrombectomies. In any case, either cutaneous local or general allergic reactions, or erosions, or macerations, or other types of cutaneous irritations will highly benefit from dermatologic experience of the practitioner.
|
Still from the beginning of medicine there has been a search for varices elimination, either for esthetical or for clinical reasons. Hippocrates’s writings of about 400 years BC report: When in the front of the leg or inside the tissues a varice is present and the front of the leg is black and it seems necessary to pull out some blood, you will not do scarifications, as the most often big ulcers will appear due to the blood flow toward the varices, but you must transfix from time to time the same varice according to the opportunity. Then on the raised limb, you will put on the bandage avoiding to leave coagula inside the incisions, after placing a double folded compress and immersed in wine and over it cleen wool soaked in some oil.
Plutarcus, one century BC, tells that Marius, the roman general and consul, submitted to varices operation for cosmetic reasons. Each incision being cauterized by red-hot iron, Marius refrained from the second limb operation, affirming that the treatment was worst that the disease.
Aurelius Cornelius Celsus, a contemporary of Christ (he died 7 AD when he was 60 years old), described a very interesting technique: All along the varice, at four transverse fingers regular intervals, small longitudinal incisions are made, the wound is opened (Divaricata), red iron cauterization is done, the varice is hooked and extracted the most possible by stripping. No venous ligation is done and no cutaneous suture. A compressive dressing is enough. Empirically the good practitioner could obtain an asepsis and antisepsis (cauterization and clean dressing), although partial and ligated to mastery skill. Even if patient assumed an alcoholic solution of jusquiame and opium, out of few qualified masters obtaining admirable results, this procedure remained abominable. Nowadays, at the opposite, provided the exclusion of the junction and the proximal third of the GSV, in an aseptic way, in local anesthesia, absolutely without red iron cauterization, this technique of ambulatory phlebectomy is easy, radical and extremely cosmetic requiring only a limited skill.
All along 2000 years ancestors like Claudius Galenus (II century), Aetius (VI century), Paulus Aeginata (VII century) and Guy de Chauliac (XIV century), all great surgeons involved in varices treatments, could not add any fundamental advancement in treating reticular varices. Against the saphenous reflux varices, the progressing knowledge of veins anatomy and physiology induced the elimination of the crural saphenous stem (Paolus Aeginata around 650) and finally, at the end of XIX century, of the GSV Junction.
Celsius’ technique was forgotten or, in any case, none practiced; moreover, in the middle of the past century the so-called sclerosing injections were invented.
In contrast to the habit, an immodest use of the singular first person will be done. Conceiving ambulatory phlebectomy has been a personal and autodidactic adventure lasting about 15 years. All the phlebological knowledge that I acquired from my dermatologic formation in Berne Hospital was a dogma: Never touch to the varices secondary to post thrombotic disease, never touch to all the varices in men after the sixties and in women after the forty fives. I had never performed sclerotherapy; I knew, but had never had experience of it, that the best treatment for superficial thrombophlebitis is local anesthesia, incision, thrombectomy and compression bandaging, the patient being required to walk as much as he can. Doing this treatment for the first time to a young delivering lady, at the anterior aspect of the thigh for a superficial thrombophlebitis about 5 cm long, I was astonished for the ease of the operation and the quality of the outcome.
Before this famous thrombectomy I was involving in those injections called sclerosing, and following Dr.Blanchod’s and Prof. Sigg’s experience, I begun to perform some thrombectomies some days after the injection. In fact the endogenous inflammation cause by the agent is nothing else than a thrombophlebitis; we could even say thrombosing injection instead than sclerosing. I employed the Blanchod’s method during several years adding to it the compression according to Sigg, but I applied a modification that I thought important: local anesthesia. This allowed me to go through varices more and more difficult: very big, very small, and very tortuous, at the knee or the foot. I was however unsatisfied: I observed a recanalization of the varicose tract either after the spontaneous thrombophlebitis or the sclerosis injection. The new varice was at times worst that the previous and the same tract could redo a thrombophlebitis. Furthermore, very often a dyschromic pigmentation persisted and, also, a fibrous, sensible cord with irregular recanalisation. I tried to find a solution to this problem; it was simple and La Palisse like: Take profit of the small thrombectomy incisions to pull out the same varice so performing a phlebectomy.
The vein extraction became rapidly the most important and most efficient act. During few years I went on in doing injections previously, but I felt that it was useless as it caused a more difficult extraction without giving any haemostatic advantage; so I eliminated this injection. Empirically I defined the details: instruments, incisions numbers, intervals, dimension, longitudinal direction, selective compression, bandaging, etc. What a deception was to discover two years later that I had restored the Aurelius Cornelius Celsus technique described two thousand years ago.
i. Preparation
a) Marking
b) Disinfection
c) Anesthesia
ii. Operation
a) Incisions
b) Varice preparation
c) Extraction
iii. Bandaging
a) Cleaning
b) Incisions closure
c) Compression
iv. Convalescence
a) First Day
b) Light dressing
c) Elastic bandage
Acknowledgement: the employed material is reported with its commercial name unbeknonst of society and representative. It may be replaced by any similar material. The Author had never any financial relation with manufacturers. He uses the best items he personally knows.
i. Preparation
a) Marking: the patient stands up weight bearing on the treating limb for a good varices filling up. Marking is of capital importance and should be precise. Cotton rolled tapered buffer, soaked of potassium permanganate 5%. The varice is palpated, perforators are identified; the varice caliber is indicated by the marking width. The good marking will ease the operation.
b) Disinfection: the patient is lies down. Orange Merfen. The air is disinfected by ozone during the whole day. Since this machine is in use, infection is practically absent (despite the absence of towels and even of sterile gloves). Once we had one (benign) infection over 200 incisions, now less than one over 5000.
c) Anesthesia: it is the painful phase but acceptable. Xylocaine 0.5% (16 times less toxic than 2%) with epinephrine, 50 to 90 mL between the skin and the varice all along the segment to treat. Wait at least 10 minutes.
ii. Operation
Four instruments are sufficient: i) pointed knife, ii) curved toothed small forceps, iii) curved toothed mosquito, and iv) Kocher forceps. The small forceps, when closed, is used like a hook for the varice preparation and pulling; when opened it helps to grasp and extract the vein: it works like a fingers prolongation. The Mosquito forceps has a similar function but is stronger and less precise: it works like a hand prolongation. Finally the Kocher forceps allows pulling out the vein avoiding its rupture, doing the heavy job.
Before starting the patient is positioned in Trendelemburgh position to prevent cerebral ischemic syncope (very frequent in case of arterial emotion hypotension) and to avoid any bleeding from emptied varices. It is possible to pull out 140 cm of vein with no more than a spoonful of blood. Small caliber shunts (arteriovenous communications) are frequent and bleed shortly. Large caliber shunts are exceptional and cause a bit longer bleeding, although not pulsating. It is necessary to compress a while before proceeding waiting for the shunt to spontaneously close.
a) Incisions: from 10 to 40, longitudinal (occlusion will be eased) as small as possible (0.5-1 mm, rarely bigger) to avoid scars. Experience only allows stating the incisions interval. In a young subject, fine skin, thin, with early varices never treated before (an easy case), intervals will be from 5 to 15 cm. At the opposite in an aged subject, thick skin, obese, with old varices especially after a thrombophlebitis or so called sclerosing injections (a difficult case), spaces between incisions will not be longer than 2 to 4 cm as the varice will break down easily and will be encircled by an irregular fibrotic layer, at times (very rare) even calcified.
b) Varice preparation: in the easy cases it is minimal: you pull the varice, it comes out easily and freely. In difficult cases the varice must be separated from its fibrotic layer rotating by the fingers the small forceps or opening and closing the mosquito.
c) Extraction: the most satisfying and gratifying part is this one. Varicose fragments length varies from 50 cm (easy cases) to 0.5 (very difficult one). When an incompetent perforator is found, Bassi’s procedure is employed: the perforator is grasped by the mosquito at the aponeurosis level and the forceps is slowly turned. The varice brakes by torsion with minimal bleeding.
iii. Bandage
a) Cleaning: blood and disinfectant are wrapped out with a cotton Tampon imbibe by ether passing directly over the incisions that are going to be covered.
b) Incisions occlusion: every incision is powdered by Nèhacetine powder and covered by Tricosteril (6 cm in length). No vascular ligation; no skin suture. In subject allergic to the adhesive, over the powder a small piece of Copoline is placed (non tissue cellulose compress), fixed by a Band-Aid or Blenderm. This is not done systematically being a bit longer procedure.
c) Compression: it will be more effective if selectively performed. A thick cellulose cord is build up and applied all along the avulsed varicose tract; it is fixed by Band-Aid 2.5-3.8 wide. But pay attention! Don’t put it with excessive tension, to avoid skin blistering. These blisters and erosions are very painful; they may be treated by Terra-Cortril Gel + a Copoline compress + Band-Aid. At thigh a plastic glue (Nobecutane spray) is vaporized to avoid bandage slipping. This glue is well tolerated having observed only 3-4 cases of allergic reaction.
A first compression, done by a Copoline bandage (12 cm/10 m) adheres to Nobecutane and helps for a good pressure distribution, but overall, it protects the skin against the adhesive bandage glue, so avoiding toxic irritations, maceration and contact eczema. Popliteal crease must be protected by a cotton pad. Compression is repeated by a colored adhesive 8 cm Por Elast bandage. The adhesive layer is non continuous and thin to allow skin transpiration, particularly appreciated in summer time. The patient must not touch it; he will be able to walk and work without bandage slipping. We will get out the bandage two to eight days apart.
Finally, we add a strong Durelastic colored 10 cm/7.5 m (at thigh) or 8 cm/7.5 m (at leg). This bandage is pulled as much as the patient sustain it; it is taken out at evening and repositioned each morning, crossing in the front and turning in the back of the leg. We recommend the patient to wear it before getting up during the first night only. If he goes to toilet without it and performs a strong Valsalva during defecation, a sudden endovenous hypertension will be created and a possible hemorrhage will happen. When doing a phlebectomy at the thigh, the bandage should be started at the thigh root and continued downwards, similarly than for thrombophlebitis, so avoiding to push any thrombus toward the heart.
iv. Convalescence
It starts at the end of the bandaging. The patient gets up and walks without stepping. He gets home and rests in bed the first day (in case of large perforator, big artero-venous shunt, SSV junction, Cockett perforator), or simply avoids efforts (in every other cases). The following day on he will restart his normal life and usual job, trying to walk the most he can. Some courageous patients even practice sports like ski, horse riding, long walking distances. The only taboo is the treated leg washing. The small incisions heel rapidly; two to eight days after the big bandage is cut out. Some Nebacetine powder is applied over the still delicate incisions that are covered by Band-Aid pieces (1.25 cm wide). Hematomas will spontaneously disappear, their resolution being enhanced by assuming a protein lythic enzyme.
Every evening the patient takes off the elastic bandage and every morning he puts it on. Convalescence ends at the 21st day by bandage elimination and first washing (bath or shower).
If it was possible to correctly avulse the varice (the most of the cases), there will be no recurrence; at times a nodular recurrence may happen in treating shunt or perforators.
From the cosmetic point of view, this method offers the better results achievable nowadays. It is noteworthy that the procedure is a completion of the GSV crossectomy and external stripping (according to Mayo); it is not in opposition to surgery. In Neuchatel, the surgeon and the phlebologist work in collaboration for the good of the patient. At the opposite, this method excludes the sclerosing injections.
The operation is benign and efficient, eliminating the toxic and allergic accidents of sclerosing agents. It avoids residual pigmentations, so unpleasant. Very rarely you may observe a small hemorrhage or, exceptionally, a limited infection. Treatment is economical: in a series of 3-6 sessions we can eliminate as many varices as in 50-60 sessions (programmed in three years).
Finally, the Aurelius Cornelius Celsus method is easy, an initiation only being sufficient for achieving good results. Through training it is possible to perfectly eliminate big fingers size or string like small varices, from abdomen till below the foot. We can efficiently avulse all varices except the GSV junction and its proximal part, and in particular, the varices secondary to PTD when deep veins are not reanalyzed.
I made a detailed movie about this technique and remain at disposition to colleagues for comments.
I am pleased to thank Prof. Delacretaz, Director of Lousanne Dermatologic University Clinic for his encouraging, interest and acceptance.
[TOP]