“Useful” Physiopathology of the venular
telangiectasic system and accessory treatments
Ermini Stefano
New investigative methods and new technological deviceshave not improved teleangiectasia treatment results
Unknown Physiopathology
http://www.ncbi.nlm.nih.gov/pubmed/: Cellulite + teleangiectasias = no match foundTelangiectasia + color doppler = no match foundTelangiectasia + duplex scan = 2 matches found ( 1993)
Unsolved problems
• Different types of teleangiectasias ( varying disposition similar to tree foliage, foliage up, foliage down )
• Location in the leg• Interactions with reticular veins ( filling or
draining )• Role of the perforator veins • Relations with the saphenous system
Perthes Test for varicose veins
Reduction of the filling gradient (Tourniquet)+
Improvement of the draining gradient ( muscle pump activity) =
Collapse of the visible varices
Every Telangiectasic tree has a filling and a draining pressure gradient
Like in a varicose system, I can resolve the telangiectasia by improving the drainage and reducing the filling gradient.
First , I must determine which reticular vein fills and which drains
• With the folliage up and reticular vein down• With folliage down and reticular vein up• With reticular veins mixed with teleangectasias
Disposition of the telangiectasic tree :
Telangiectasia
Reticular Vein Telangiectasia
Reticular Vein
Use of Hydrostatic pressure and Doppler can help us to detect the direction of the draining gradient
The hypothesis suggested by graviational law is: •When the reticular vein is up, it is a filling vein•When it is down, it is a draining vein
Filling Vein
Draining Vein
Disposition of the telangiectasic tree :
Foliage Down Telangiectasia - postural changes and function of the reticular vein above
• Hydrostatic gradient changes its direction and from a filling gradient becomes a draining gradient
In this situation the inversion of the gradient is slowed by the tortuosity of the reticular network.
Foliage Down Telangiectasia - postural changes and function of the reticular vein above
1) The reticular vein does not have a defined source2) The reticular vein originates from a refluxing point
Foliage Down Telangiectasia - Origin of the reticular network
1) Whithout escape point 2) From Point P
In every case, the sclerotherapic treatment of the reticular vein leads to telangiectasic reduction.
If this filling vein originates from the drainage of other telangectasic ones or from cellulite, its suppression increases the risk of matting occurrence
The filling vein of a foliage down telangiectasia may also be the
draining vein of a critical zone … Attention !!!
3) Emergence of matting
1) Sclerotherapy of the reticular v.
2) Reduction of the telangiectasias
If the reticular vein originates from an escape point, the situation must be investigated and treated correctly .
Subcutaneous Subfascial
Perforator vein or connection with an N2 system
Valsalva TestDiastolic retrograde flow
N3 N2
Doppler check-up for foliage down telangectasia
Valsalva testSqueezing testDynamic test
For N2 collateral veins, also check for a sistolic reflux
Patterns of refluxing perforator veins:Diastolic out-flowValsalva positive ( occasionally)
Saf.Int.
Coll.
Telangiectasias filled by a saphenous tributary refluxing during muscle systole
Result obtained by sclerotherapic treatment of the refluxing tributary
This means that, in the specific case of foliage down telangiectasia, careful investigation must be performed with a high resolution ultrasound 12-18 Mhz probe and transillumination.
Standing Lying
Foliage Up and Mixed Teleangectasia
Venous pressure in Telangiectasia = residual pressure ( emptyng rate) - draining gradient ( MP activity , dgh )
dgh
Standing Position
Foliage Up Telangiectasia - postural changes and function of the reticular vein below
worsens or does not change
Venous pressure in Telangiectasia = residual pressure ( emptyng rate) + static pressure of the reticular system
Leg up
Foliage Up Telangiectasia - postural changes and function of the reticular vein below
A B
In example B the trasmission of MP energy to Telangiectasia is reduced by the tortuosity of the reticular network.
With postural changes
Without postural changes
Postural changes of foliage up and mixed telangiectasias
Haemodynamic patterns of the re-entry perforator
• Valsalva negative• No systolic flow• Diastolic inflow
Usually the re-entry perforator is in the leg , where the muscolar pump activity is efficient.
The draining gradient in Foliage Up Telangiectasia
We have to respect the drainage system. Its closure leads to the risk of matting
The filling gradient in Folliage Up Telangiectasia
No reticular vein above the telangiectasia
Telangiectasia origin due to cellulite tissue
The fybrosis and compact structure of cellulite tissue creates an obstacle to venous drainage from the skin surface to the hypoderma and deep tissue.
PEFObstacle to Physiologic drainage
Telangiectasias represent a compensatory system around this obstacle.Their suppression creates a new obstacle to the venous flow that leads to an increase of venous pressure and to the realization of a new drainage. This is possibly one of the pathogenetic mechanisms of matting (*)
(*)= Cappelli M., Riflessioni di emodinamica sulle teleangectasie. Scleroterapia II° edizione, Ed. Minerva Medica, Torino 2006
Consideration of the physiopathology of foliage up telangiectasia
PEF
Telangectasia
New Draining system
Obstacle to Physiologic drainage
Foliage up Telangiectasia represents a vicarious circle
Elimination of the foliage up telangiectasia corresponds to the
suppression of a vicarious circle
Bad result due to excess of treatment
The more veins I close, the more new veins re-form, because I cannot modify
the residual venous pressure
Chest’ è ‘na
fessaria !
Chest’ è ‘na
fessaria !
Therefore, the problem is not to improve the efficacy of the sclerotherapic treatment, but to promote a new invisible drainage, and to prevent matting.
Tralci connettivali responsabili della “ buccia
d ’arancia”
Macronoduli e scompaginament
o trabecolare
Is the treatment of cellulite possible?
Soft sclerotherapy, timing and compression stockings work together
Sclerotherapy closes ectasic telangectasias and, step by step, worsens venous stasis in cellulite tissue.
Residual venous pressure tries to find a new drainage
Compression stockings increase tissue pressure and impede venous stretching and dilation due to increased lateral pressure .
Consequently, step by step, sclerotherapy closes, nature recreates, and the compression stocking guides.
Timing should be regulated by the restoration of a new drainage.
Therefore, the draining volume of superficial tissue is limited by the compression, and new drainage will devolop where resistance to the flow is lower, for example, away from the skin.
Soft sclerotherapy, timing and compression stockings work together
Guidelines for a good result according to these haemodinamic considerations • Timing of sclerotherapic treatments :1
treatment every 4 weeks• Light sclerotherapic agents• Medical treatment , sistemic draining drug
and topic treatment (Arnica)• Compression by a 24 mm.Hg elastic stocking
for 3 weeks (*)• Stop treatment at the right time ( before
matting !! )
(*) =Compression after sclerotherapy for telangiectasias and reticular leg veins: a randomized controlled study.Kern P, Ramelet AA, Wütschert R, Hayoz DJ Vasc Surg. 2007 Jun;45(6):1212-6. Epub 2007 Apr 27.
CONSENSO INFORMATO….. Il risultato finale dipenderà anche dalle cause e dalla estensione dei capillari e in alcuni casi non si potrà avere una completa scomparsa degli inestetismi cutanei, ma solo una loro attenuazione……
If small red telangiectasia appears: STOPsclerotherapic treatment
Aestethic improvement obtained only with elastic stocking and topical treatements without
sclerotherapy or laser
Aestethic improvement obtained only with elastic stocking and topical treatements without
sclerotherapy or laser
Matar a el toro
¿Cómo se puede matar a los capilares
www.chiva.it
Ermini Stefano
Thanks for the attention
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