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Introduction

Mitchel P. Goldman and Robert A. Weiss Phlebology and Treatment of Leg Veins

Chapter Contents

Venous Anatomy, Physiology, and Pathophysiology�����������������������������2650

Physical Examination of the Phlebology Patient��������������������������������������2651

Laboratory Evaluation of the Superficial Venous System���������������������2652

Compression in Sclerotherapy and Venous Disease������������������������������2653

Sclerosing Solutions������������������������������������������������������������������������������������������2654

Techniques for Treating Telangiectasias and Reticular Veins���������������2656

Larger Varicose Veins�����������������������������������������������������������������������������������������2657

Postsclerotherapy Compression��������������������������������������������������������������������2660

Complications�����������������������������������������������������������������������������������������������������2660

Ambulatory Phlebectomy��������������������������������������������������������������������������������2662

Targeting the Saphenofemoral Junction ��������������������������������������������������2663

Key features

„Superficial telangiectasias, reticular veins, and varicose veins of the lower extremities are interconnected and develop after impairment of venous return

„Poor venous return results from venous valvular incompetence or primary muscle pump failure

„A pretreatment physical examination to assess the extent and cause of the venous abnormalities should be performed with the patient in a standing position

„The physical examination should be supplemented by duplex ultra- sonography when saphenous vein reflux is suspected

„Both preoperative and postoperative compression are important in the management of venous insufficiency

„Sclerosing agents should destroy the entire vascular wall, producing permanent fibrosis of the vessel

„The minimal concentration and volume of sclerosing agent needed to achieve the desired results should be used

„All affected portions of the superficial venous system should be treated, ideally in one session and starting with the most proximal

„Large veins should be treated before smaller veins, and veins should be treated from proximal to distal

„FDA-approved sclerosing agents include sodium tetradecyl sulfate and polidocanol, both liquid and microfoam formulations

„Hypertonic saline (11.7%–23.4%) and glycerin (72% mixed 2:1 with

1% lidocaine, with or without epinephrine) are not FDA-approved for vein sclerosis, making their usage off-label

„The most common local side effects following injection of sclerosing agents are hyperpigmentation and telangiectatic matting and much less often cutaneous ulcers

„Patients generally require one to three sclerosant injection treatment sessions, spaced at 6- to 8-week intervals

„Utilizing tumescent anesthesia, incompetent saphenous veins and large tributaries over 4 mm in diameter can be effectively treated by ambulatory phlebectomy, radiofrequency or laser thermal ablation, or cyanoacrylate adhesive closure