Comment to: La technique START (Sclerotherapy in tumescent anaesthesia of reticular veins and telangiectasias) by Ramelet AA. Phlebologie 2012

(Also appeared as: Sclerotherapy in tumescent anesthesia of reticular veins and telangiectasias. Dermatol Surg 2012;38:748–51.)

Stefano Ricci

Abstract

Having observed that treating telangectesias during the same phlebectomy session gave better results, the Authors began to associate to the sclerotherapy (Polidicanol foam 0.25-0.50%) a tumescence made with Ringer solution, in some cases adding lidocaine-epinephrine. This is carried out either before, during or after sclerotherapy, usually with a 20-50 mL syringe or by a perfusion pump. After the procedure, the patient rests for a few minutes, and then puts on 20-30 mmHg stockings; these will be used for three weeks.
During the last six years, 300 patients presenting refractory telangectasias (not disappearing after 3 treatments) or large telangectatic areas otherwise needing several sessions, were selected. Patients who preferred to receive the sclerotherapy treatment in local anesthesia were also included.
The results were very good; the majority of the patients needed only one session, and a stable outcome was achieved. Complications, such as hematoma, thrombosis, pigmentation, small necrosis and matting, although a possible complication with Polidocanol, were more frequent than usual, probably due to the higher risk associated with this difficult pathology. The efficacy of this technique may be related to the high perivenous pressure achieved during and after treatment, lasting at least an hour, similar to that suggested by Thibault and Parsi (i.e. infiltration of the saphenous space after saphenous injection).

Comment by Stefano Ricci

In the field of telangectasias, one of the most difficult areas of phlebology, novelties are rare, and when one is announced, it is usually associated to some expensive technology. That is why the simple method suggested by Ramelet is particularly interesting: it is easy, not expensive, rational and (according to the Author) effective.
My personal experience of sclerotherapy in areas previously treated with phlebectomy confirms that the fading effect on telangectasias is enhanced. In my mind, this has been related to a sort of reaction (edema, hyperemia, inflammatory activation) of treated tissues making the sclerosis more efficient, but the tumescence theory is possibly another aspect of this.
It would be interesting to know, from the Author’s experience, if also other types of sclerotherapy (liquid, Scleremo) behave similarly. Chromated glycerine for example, being more gentle, could cause less inconvenience than Polidicanol in foam.
Finally, a better definition of refractory telangectasias would be interesting, not forgetting that areas that underwent several previous treatments may respond positively to further treatment for cumulative effect.

Reply by the Author

- I have used START with Scleremo or liquid Polidicanol without problems, but I particularly like foam, a matter of choice and habit.

- The definition of refractory telangectasias is difficult.
Refractory to what?
To not repeating the treatment?
Because it has been badly managed?
Is inadequate?
In order to simplify, I mean refractory to several sessions by an experienced physician.

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