Consensos de Flebología Mexicana ; IMF - Flebología México by Fernando Javier Vega Riveros

Consensos Mexicanos de Flebología 1° Consenso de Escleroterapia 2° Consenso de Ablación Química Endovenosa 1° Consenso de Ultrasonido Vascular Venoso

1° Consenso Mexicano de Escleroterapia

Consenso Mexicano de Escleroterapia

Primer Consenso Mexicano de Escleroterapia Vega F; Ramírez C; Lemoine C; Cázares H; Ramírez A; Jiménez E; Rendón F; Castañeda R; Arias L Academia Mexicana de Flebología y Linfología 2013

Palabras claves Escleroterapia, consenso

Resumen Antecedentes: La escleroterapia se realiza desde 1516 , siendo mundialmente aceptada y realizada, según muchas citas bibliográficas en libros y revistas. Médicos mexicanos han participado en otros consensos por lo que se obtuvieron diversos acuerdos, citas, métodos y procedimientos que son mundialmente aceptados para establecer éste documento, entre ellos el Consenso Europeo de Escleroterapia del 2003 y su última revisión en 2006, el Argentino y Latino Americano de 2012 y diversas fuentes bibliográficas. Objetivo: Elaborar con base en la bibliografía mundial y la experiencia de profesionales expertos en fleboesclerosis un documento que conjunte los conceptos, preferencias, divergencias y variaciones sobre los ejes de diagnóstico, uso, tratamiento y demás atingentes que implican la escleroterapia, dicho documento podrá tener valor referencial desde el punto de vista académico, médico práctico y legal. Método: Se establecieron las preguntas generales sobre escleroterapia:

Dirección de autor: Dr. Fernando Vega R. Clinica de varices y ulceras de Mexico Academia Mexicana de Flebologia y Linfologia E-Mail: flebologiamexico@yahoo.com.mx

Indicaciones, Contraindicaciones, Tipo de esclerosantes y concentraciones usadas, posición del paciente, Métodos de aplicación, forma de preparación y de conservación de los esclerosantes, Equipamiento necesario, Volúmenes de inyección, variables de administración, compresión, Observaciones Especiales. Para responder las preguntas se consultó la bibliografía existente y los tópicos en los que hay uniformidad en dichos reportes, así mismo se constituyó un panel de expertos que emitieron su experiencia personal con lo cual se formularon las respuestas a manera de guías clínicas o recomendaciones que se expresan de manera general, incluyendo observaciones sobre la variabilidad de los conceptos plasmados, por tal motivo las preguntas concretas tendrán respuestas concretas y un apartado de observaciones donde se explicará las posibles variaciones aceptadas a cada rubro en particular. El texto principal expresa el 100 % de consenso sobre el tema y los párrafos con barra azul las variaciones que los expertos manifestaron. Los puntos anotados se discuten en base a las substancias que podemos conseguir en México, por lo que algunos esclerosantes o equipos no son contemplados. Phlebologie 2014; 43: 37-41 DOI: 10.12687/phleb2161-1-2014 Received: August 1, 2013 Accepted: December 5, 2013 This article is available in English at www.phlebologieonline.de

Marco conceptual del consenso Existen en el mundo múltiples intentos de unificar criterios para la realización de la Escleroterapia, nuestro concepto de Consenso se plasmará en dos vertientes: • Consenso: Métodos y condiciones que se aceptan por unanimidad • Variaciones: Métodos y condiciones que varían en relación al consenso establecido, en otras palabras las variaciones permitidas o realizadas por los panelistas en relación al consenso general. Esta concepción nos permitirá establecer las pautas generales de manejo y al mismo tiempo las variaciones aceptadas en nuestro país de acuerdo a la experiencia médica y la bibliografía mundial.

Consultores Dr. Fernando Vega R, Dr. Cuauhtémoc Ramírez C, Dr. Carlos E Lemoine P, Dra. Nora Sánchez N, Dr. Marcel Salinas P Dr. Antonio Ramírez C, Dra. Evelyn Y Farfán H, Dr. Víctor Carmona, Dra. Herlinda Alba Y, Lourdes A Vega R, M. Fernando Vega D, Dra. Selva A Torres C (México, DF), Dr. Eugenio Jiménez G, Dr. Felipe G. Rendón E, Dr. Rogelio Castañeda G., Dr. José Angel López P (Monterrey, NL), Dr. Gustavo Rubio A (Guadalajara, Jal), Dr. David Bolaños C (Celaya, Guanajuato), Dr. Guillermo Uribe, Dr. Hugo F. Cázares B (Tijuana, Baja California), Dr. Jesús T Pérez RG, Dr. Fernando Torres. (Oaxaca, Oax), Dr. Román Flores (Toluca Edo, De Méx), Dr. Salvador Hurtado G, Dra. Alicia Lugo M, Jose de J Leal C (Reynosa y Matamoros, Tamps), Dr. Jesús Mendoza Adame (Chilpancingo, Gro), Dr. Luis Arias V (Xalapa, Veracruz). Phlebologie 1/2014

Consenso Mexicano de Escleroterapia

Temas del consenso 1. Generalidades 1.1 Requisitos previos 1.2 Definicion de escleroterapia 1.2.1 Formas fisicas del la aplicación de esclerosantes 1.3 Indicaciones 1.4 Contraindicaciones 1.5 Esclerosantes 1.6 Concentraciones de esclerosante 1.7 Volumenes de esclerosantes (liquido y espuma) 2. Material y equipo 2.1 Material general 2.2 Jeringas y catteteres 2.3 Agujas 2.4 Equipo 2.5 Material para compresion 3. Del paciente 3.1 Posicion 3.2 Compresion 4. Observaciones adicionales

Consenso 1. Generalidades 1.1 Requisitos previos I. Consentimiento informado II. Historia Clínica (que incluya fotos y esquema) y que cuente con diagnóstico lo más específico posible, incluyendo el sistema CEAP. III. Realizada por personal médico con capacitación en flebología y documentada. IV. Contar con el equipamiento necesario V. Contar con el equipo rojo (NOM178-SSA1–1998 Consultorio Médico) VI. Que el procedimiento se encuentre indicado de manera específica con cada paciente VII. Condiciones ambientales adecuadas

1.2 Definicion Escleroterapia Se adopta la emitida por el Consenso Latinoamericano en que participó nuestro país: “Procedimiento médico que consiste en la introducción de una substancia química intravenosa, que produce por distintos Phlebologie 1/2014

mecanismos sobre el endotelio, la lisis del mismo y un fenómeno trombótico, dando lugar a la obliteración y fibrosis de los vasos tratados.” 1.2.1 Formas fisicas de aplicación del esclerosante

Se consideran dos formas físicas para aplicar el esclerosante: a) Liquida b) Espuma La forma de espuma se prepara mediante el método de Tessari (con llave de 3 vías) con los siguientes gases: • Aire ambiente (70 % de Nitrogeno aprox.) • Mezcla de CO2-O2 • O2 (Oxigeno puro) Para dicha preparación se usa la dilución propuesta por el Dr. Tessari: 1 parte de líquido esclerosante y 4 partes de gas. Se p uede considerar también otras formas como el “Air Block”. El sistema de doble jeringa aún no está disponible en México, aunque hay otros dispositivos similares que pueden adquirirse.

• • •

1.4 Contraindicaciones Absolutas a) Alergia conocida al esclerosante b) Enfermedades agudas graves del paciente c) Insuficiencia arterial crónica , con índice brazo-tobillo menor 0.8, oclusión arterial grado III-IV escala de Fontaine d) Trombosis venosa aguda o subaguda (menos de 6 meses) e) Estado febril agudo f) Enfermedades sistémicas descompensadas g) Eccema agudo h) Dermatosis infecciosa i) Embarazo, usarse solo en caso de urgencia j) Pacientes inmovilizados

• • •

1.3 Indicaciones La esclerosis puede ser aplicada en cualquier tipo de vena disfuncional, varicosa o en caso de angiodisplasias o problema de angiogénesis secundaria, pueden agruparse de la siguiente manera. a) Vasos Safeneanos y sus afluentes b) Varices de tipo secundario: post quirúrgico o post traumáticos c) Telangiectasias d) Venas Reticulares e) Venas perforantes y tronculares f) Varices vulvares y síndrome de congestión pélvica g) Hemorroides estadio I – II h) Malformaciones vasculares con predominio venosos i) Varices esofágicas Pueden existir otras aplicaciones como: • Hidrocele • Uropatologia Endotelial • Varicocele Disfuncional • Varicocele-hidrocele

Dysfunctión eréctil por fuga venosa Quiste de Baker Algunos sindromes postflebiticos previa valoración

• • • • • •

Pacientes encamados o con vida sedentaria, así como con daño neurológico motriz Trombofilias primarias Pacientes con multifactores para trombosis: – Terapia hormonal – Anticonceptivos – Obesidad mórbida, – tabaquismo – EPOC severo – Vida sedentaria Foramen Oval, en caso de utilizar espumas Flebedema grado IV. Linfedema grado IV. Leucodermatoesclerosis, no modificable por compresión Movilidad reducida Hipercoagulabilidad Terapia anticoagulante Lactancia

1.5 Esclerosantes Se recomienda usar los siguientes esclerosantes: • Polidocanol (Aethoxysklerol, Lauromacrogol) • Tetradecil sulfato de sodio • Glicerina crómica (Para telangiectasias) © Schattauer 2014

Consenso Mexicano de Escleroterapia

A las dosis y volúmenes descritos en las ▶ Tab. 1 y ▶ Tab. 2. Otros pueden ser: • Glicerina • Sol. Hipertónicas (Glucosado al 50 %, NaCl 20 %) • Chlorhidrato de Lapidium (▶ Tab. 2)

1.6 Concentraciones Se recomiendan las siguientes dosis de acuerdo al tipo de vena a esclerosar (▶ Tab. 1): • Dosis máxima de polidocanol : 2mg/KG de peso • Dosis máxima de tetradecil sulfato de sodio: 4 ml al 3 %

1.7 Volumenes Se recomiendan los siguientes volúmenes de acuerdo al tipo de vena a esclerosar (▶ Tab. 1, ▶ Tab. 2).

Tab. 1

2. Material y Equipo

Tener: Papaverina y Nitroglicerina, Isosorbide, Perlas de Nifedipino

2.1 Material general El material general que se recomienda para la esclerosis es el siguiente: • Algodón • Alcohol • Guantes desechables • Micropore 1.25, 5.0 • Transpore 1.25,5.0 • Gasas 10 X 10 • Jabon antiseptico • Solucion Fisiologica 100 ml , 250 ml • Torunderos • Torundas Alcoholadas • Mesa de Trabajo • Tijeras • Cinta metrica • Marcador (Quirurgico y Endeleble) • Soporte para Elevacion del Miembro a Tratar • Llaves de 3 Vias • Lupa • Lamparas • Baumanometro • Estetoscopio • Cuña elevadora osimilar • Hojas de Bisturi del No.11

2.2 Otros Material

• •

Jeringas desechables de: 0.5, 1, 3, 5 cc Catetheres (cortos o largos) con differentes calibres de agujas

• •

Ortras Jeringas para Dilucion (10 y 20 ml) Otros Dispositivos de calibres similares (Catéteres, punzocats, mariposas, etc.)

2.3 Calibres de Jeringas Se recomiendas los siguientes calibres de agujas para las diferentes utilidades que se muestran (▶ Tab. 3). Al inyectar Espuma a través de las agujas con calibre menor a 25G, está demostrado que se rompen las burbujas y que mayormente se inyecta líquido, por lo anterior no se recomiendan agujas menores a 25G para inyectar espuma en venas de grueso calibre.

Esclerosantes, Dosis y Volumenes por Puncion recomendados de Acuerdo al Tipo de Vena (Dependiendo del diámetro). Polidocanol

Tipo Vena

Concentracion Liq. (%)

Tetradecil sulfato de sodio Concentration Espuma (%)

Vol. Max. (cc)

V. safena magna USF

Vena safena menor

Concentracion Liq. (%)

Concentracion Espuma (%)

Vol. Max. (cc)

1.5

0.85–1.5

0.5–1

Tributarias

1–3

Perforantes

1–2

1–3

Reticulares

0.5–1

0.25–0.5

0.3

0.1–0.15

0.5

Varículas

0.25–1

0.1 %-0.5

0.1–0.15

0.1

0.5

Tab. 2

Esclerosantes usados para fines cosméticos. Glic. cromada

Glucosa

Glicerina

Tipo Vena

Conc. Liq.

Vol. Max.

Conc. Liq.

Vol. Max.

Conc. Liq.

Vol. Max.

Reticulares

25 %

3 cc

50%

5 cc

24%

5 cc

Variculas

25%

2 cc

25%

3 cc

24%

4 cc

Trabajos individuales han reportado máximos de 60 ml de Espuma con Oxígeno por sesión o con mezcla de O2-CO2 , quedando a criterio del médico.

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Consenso Mexicano de Escleroterapia

2.4 Equipo

3. Del Paciente

•

3.1 Posicion

Transilluminador Es consenso general que se debe contar con equipo de transiluminación para realizar correctamente el procedimiento de esclerosis, ya sea fijo o de tipo portátil. • Minidoppler o Doppler Lineal Es indispensable contar con equipo MiniDoppler (o Doppler Lineal) para diagnóstico y verificación de la corrección de los reflujos de venas esclerosadas. • Doppler Color Si se cuenta con equipo Doppler Color, es aceptado mundialmente que es el equipo ideal para el diagnóstico y auxiliar en tratamientos como esclerosis ecoguiada. • Tanque de Oxigeno Tanque de Oxigeno con puntas nasales. Para Preparar espuma y otros usos. • Oximetro • Camara fotografica • Computadora • Lampara Equipo adicional • Glucometro • Ecodoppler • Anoscopios desechables • Extensores de Aguja • Espejos vaginales desechables • Esterilizador • Podium de exploracion

2.5 Material para Compresión

• • •

Vendas elasticas 10 y 15 cm de alta, mediana y baja compresión. Calcetín elástico de compresión mayor a los 25 mmHg Media elástica de compresión mayor a los 25 mmHg con o sin punta

Las medias pueden ser: Debajo de la rodilla, al muslo o pantimedia, según la preferencia y zona esclerosada; con punta o sin ella.

De manera General se prefiere la esclerosis con el paciente en decúbito, lo que evita accidentes por lipotimia o reacción adversa, y permite mayor confort. En casos que no se cuente con transiluminador o que en la exploración de pie del paciente se aprecien venas que desaparecen con la posición en decúbito se podrá optar por: a) Marcar las venas insuficientes con el paciente de pie y esclerosarlo en decúbito. b) Sentarlo sobre la mesa de exploración con la pierna colgando y esclerosar las venas insuficientes en ésta posición, pasando inmediatamente a la posición de decúbito.

3.2 Compresión El vendaje compresivo puede ser simple, multicapa, o con medias o calcetines. La utilidad de la compresión está descrita en múltiples trabajos, ayudando principalmente a prevenir el reflujo, favorecer el flujo venoso, disminuir la estasis, el edema y el dolor y contribuir al mejor funcionamiento del sistema linfático, mejorando también la microcirculación y favoreciendo el cierre de úlceras venosas. Es unánime la postura de aplicar compresión post-escleroterapia. El uso de cojinetes, algodón u otro sistema de compresión directa sobre las venas esclerosadas es conveniente pero no es una práctica Generalizada.

4. Observaciones adicionales 1. Debido a la gran patología venosa que existe en el pie, sugerimos incluir en la Clasificación CEAP en el rubro de anatomía: el número (19) que correspondería a perforantes del pie. Para de-

Vena

Aguja – Cateter

Jeringa

Variculas y Reticulares

27–31 G

0.5–3 ml

Venas mayores a 4 mm

20–25 G

3–5 ml

Phlebologie 1/2014

Tab. 3 Calibres de aguja recomendados

nominar y tratar patología específica en ésta región. 2. Volumen máximo por sesión: 5 ml . Pudiendo usarse volúmenes mayores a criterio del médico y en condiciones controladas. 3. Se sugiere previo a la esclerosis: Evitar ropa ajustada, no aplicar cremas, evitar asolearse, sesiones de depilación laser. 4. Efector Adversos: La inyección de esclerosantes puede ocasionar en algunos casos alteraciones cardiacas, tos y alteraciones respiratorias, vómito, alteraciones visuales, sabor metálico, fiebre, dolor lumbar o dolor de cabeza. Además de reacciones locales como flebitis o incluso úlceras por extravasación. Como cualquier otra substancia también pueden causar efectos alérgicos como rash o incluso anafilaxia. Los efectos secundarios de la Escleroterapia son principalmente: – Equimosis – Dolor local al aplicar el medicamento – Flebitis o trombo flebitis superficial – Dermatitis, urticaria, eritema no alérgico – Necrosis local por extravasación – Lesión neurológica, neuromas, neuropraxia o neuritis – Trombosis venosa profunda (aunque no existen reportes claros) – Trombosis intravenosa – Dolor intenso contínuo – Shock anafiláctico con angioedema – Ictus y accidente cerebrovascular. Cefalea, migraña, parestesias, pérdida de conciencia, confusión, mareo, afasia, ataxia, hemiparesia, hipostesia bucal, sabor metálico, escotomas – Taquicardia, arritmias, paro cardiorespiratorio – Neovascularización post escleroterapia (Matting) – Lipotimias Embolismo pulmonar, sincope vasovagal, vasculitis, disnea, ángor pectoris, tos, trastornos del gusto, náuseas y vomito Hipertricosis, fiebre, astenia, adinamia, afección al estado general, inestabilidad de presión arterial.

Consenso Mexicano de Escleroterapia

5. Frecuencia de visita al médico para sesiones de escleroterapia: Cada semana en 90 % de los casos 6. Medicamentos empleados: Los médicos emplean medicamentos en las siguientes proporciones: – Medicamentos Antiflebíticos post escleroterapia:10% – No medicamentos Antiflebíticos post escleroterapia: 90% – Gel tópico: 10% – Analgésicos antiinflamatorios:10% 7. No se recomienda aplicar esclerosante de manera perivascular, aunque se ha descrito como una opción. 8. En Casos de extravasación: Tratar de sacar lo más posible de la substancia esclerosante de manera digital y diluir con agua o lidocaína simple. 9. Trombectomía post escleroterapia: Es necesaria posterior a la escleroterapia de manera regular una semana después de la esclerosis.

Apendices a) ▶ Historia Clinica b) ▶ Consentimiento informado

Glosario Esclerosante: Substancia externa que produce lesión en el endotelio y su posterior fibrosis Espuma (FOAM): Forma de aplicación del esclerosante preparada de diversas maneras consistente en burbujas de diferente diámetro y con diferente gas. Polidocanol (POL): Aethoxysklerol, Lauromacrogol, Hidroxipolietoxidodecano. Substancia alcohólica ampliamente conocida como esclerosante en todo el mundo. Tetradecil sulfato de sodio (TDS): Substancia esclerosante de uso principal en los E.U. y Europa (Fórmula) Glicerina (Gl) o Glicerol: Substancia esclerosante de tipo oleoso. Glicerina cromada (GC): Substancia esclerosante de tipo oleoso con un grupo Cr unido a la molécula de glicerol. Método de Tessari (TM): Método descrito por Lorenzo Tessari para la preparación de espuma de esclerosante usando llave de tres vías. Aire ambiente (AR): El aire usado de manera común para preparar espuma de esclerosante Oxígeno (O2): Gas comburente en su manera pura usado para preparar espuma de esclerosante

Dioxido de carbono (CO2): Gas fisiológico usado para preparar espuma de esclerosante Tromboembolia pulmonar (TEP): Trombosis de cualquiera de las ramas de la arteria pulmonar generalmente provocada por trombos a distancia. Trombosis venosa profunda (TVP): Trombosis del sistema venoso profundo. Trombosis venosa superficial (TVS): Trombosis del sistema venoso superficial. Safena Magna (SM): Vena que se origina en la cara interna del tobillo y desemboca en la ingle en la unión Safeno-femoral (Vena Safena interna, o Safena larga) Safena menor (Sm): Vena que se origina en la cara externa del tobillo y desemboca generalmente en la unión safeno-poplítea en el hueco poplíteo. Perforantes (Perf): Venas que comunican el sistema superficial y profundo perforando una o más facias musculares. Ultrasonido Doppler Color (DUSG): Estudio o empleo del equipo de ultrasoniudo Doppler color en flebología. Transiluminación (TI): Método por el cual se aplica luz a la piel para identificar venas que no son aparentes a simple vista.

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Consenso Mexicano de Escleroterapia

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Fig. 1

Medical record (in the original Spanish version).

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Fig. 1

Continued

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Consenso Mexicano de Escleroterapia

Consentimiento Informado

Estimado (a) paciente: La NORMA OFICIAL MEXICANA NOM 168 SSA 1 – 1988 DEL EXPEDIENTE CLINICO y LA LEY GENERAL DE SALUD sustentan que usted tiene derecho a ser informado (a) por su médico tratante sobre su estado y los procedimientos tanto con fines diagnósticos como terapéuticos que le serán realizados. Así mismo como de los beneficios y características de los mismos al igual que de los riesgos y beneficios que ellos ofrecen. A través de este documento usted: _____________________________________ otorga pleno consentimiento y autorización al Dr. __________________________________ y a su equipo médico, para realizar el procedimiento de: ___________ __________________________________________________________________________________________ Se le han explicado los riesgos y peligros que pueden existir sin en tratamiento ofrecido, así como del beneficio esperado con dicho procedimiento. Se le ha explicado y entiende plenamente tanto los beneficios esperados así como de los riesgos potenciales de realizar: ___________________________________________________, pudiendo existir riesgo de hemorragias, coágulos de sangre en venas y arterias, así como otro tipo de complicaciones que puedan en poner en riesgo la vida. En casos aislados y totalmente extremos, podría existir riesgo de fallecimiento por complicaciones raras y no habituales. Es importante que usted sepa que la prevención y la atención oportuna de dichas complicaciones constituyen la parte más importante para poder prevenir desenlaces catastróficos, por lo que da plena autorización para realizar los procedimientos pertinentes en caso de complicaciones que pudiesen llegar a poner en riesgo la vida. Por lo anterior expuesto otorga su pleno consentimiento informad0 (a) mediante la firma al calce, en compañía de testigos siempre y cuando y en todo momento se apliquen los procedimientos conforme marcan las norma oficiales mexicanas aplicables.

Domicilio de la unidad médica

Paciente. ___________________________ Testigo: ____________________________

Phlebologie 1/2014

Testigo: ____________________________

2° Consenso Mexicano de Ablación Química Endovenosa

Original Article

2nd Mexican Consensus of Endovenous Chemical Ablation (Scleorotherapy) 2018* Zweiter mexikanischer Konsensus zur endovenösen chemischen Ablation (Sklerotherapie) 2018

Affiliations Academia Mexicana de Flebología y Linfología, Mexico City, 2018 Key words Sclerotherapy, consensus, endovenous chemical ablation (ECA) Schlüsselwörter Sklerotherapie, Konsensus, endovenöse chemische Ablation (ECA) received 03.04.2018 accepted 26.06.2018 Bibliography DOI https://doi.org/10.1055/a-0894-9896 Phlebologie 2019 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0939-978X Correspondence Dr. Fernando Vega Rasgado Xocoyahualco #78 Colonia Nueva Ixtacala Tlalnepantla Estado de México C. P. 54160 México E-Mail: imf_fer@hotmail.com ABS TR AC T

Background Sclerotherapy has been carried out since 1516 and is accepted and performed worldwide according to many references from books and journals. Mexican doctors participated in other consensuses in order to obtain various agreements, references, methods and procedures that are universally accepted to establish this document, including the European consensus of sclerotherapy 2003 and its last revision in 2006, the Clinical practice guidelines for *

Collaborators: Dr. Hugo Cázares Baruch, Dr. Guillermo Uribe, Dra. Blanca Viviana Pastrana Escudero, Dr. Román Flores, Dr. Fernando Torres, Dr. Antonio Ramírez Cadena

Rasgado FV et al. 2nd Mexican Consensus ... Phlebologie 2019

prevention, diagnosis and treatment of chronic venous insufficiency in 2009 in México, the Argentine and Latin American consensus for sclerotherapy in 2012, European sclerotherapy guidelines in chronic venous diseases of 2013,and various literature sources as well. The first Mexican consensus on sclerotherapy published in January 2014 which was reviewed and updated in this document. Objective Review and update the general bases of Endovenous Chemical Ablation (ECA) also known as Sclerotherapy, according to evidence-based medicine updating the previously published consensus. Method General questions about Endovenous Chemical Ablation (ECA) were established concerning: indications, contraindications, types of sclerosing agents and the concentrations used, patient position, methods of application, way to prepare and preserve the sclerosants, necessary equipment, injection volumes, differents administration ways, compressive therapy and special comments. To answer these questions the existing literature and the topics in which the reports showed uniformity were consulted. A panel of experts was constituted who provided their personal experience, the answers were formulated in the form of clinical guidelines or general recommendations to provide concrete answers to the specific questions, in some issues we include possible accepted variations. ZUSAMMENFA SSUN G

Hintergrund Die Sklerotherapie wird seit 1516 angewendet und ist laut Veröffentlichungen in Lehrbüchern und Zeitschriften ein weltweit akzeptiertes und durchgeführtes Verfahren zur Therapie von Varizen. Die verschiedenen Meinungen zu den allgemein akzeptierten und etablierten Methoden und Abläufen konnten mexikanische Ärzte auf Konsensus Konferenzen, wie dem „European consensus of sclerotherapy “ 2003 und 2006, der „Clinical practice guidelines for prevention, diagnosis and treatment of chronic venous insufficiency“ 2009, der „Argentine and Latin American consensus for sclerotherapy“ 2012, der „European sclerotherapy guidelines in chronic venous diseases, 2013“ und durch publizierter Literatur sammeln und in den 2. mexikanischen Konsensus einfließen lassen.

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Authors F. Vega Rasgado, J. Ángel López Paredes, J. A. Serralde Gallegos, D. Bolaños Celaya, C. Ramírez Cadena, M. Alberto Cavazos Ortega, O. Lira Rodríguez, F. Rendón Elías, F. Contreras Cisneros, A. Lugo Ramírez, E. Jiménez Gorena

Der erste mexikanische Sklerotherapie-Konsensus wurde im

Erhalt des Sklerosierungsmittels, notwendiges Equipment, In-

Januar 2014 publiziert und wurde nun überarbeitet und aktualisiert. Zielsetzung Überarbeitung und Aktualisierung des 1. mexikanischen Konsensus zur endovenösen chemischen Ablation (ECA), auch bekannt als Sklerotherapie, gemäß der Regeln der Evidenz-basierten Medizin. Methode Allgemeine Fragen und Themen zur endovenösen chemischen Ablation (ECA) wurden bearbeitet. Im Einzelnen: Indikationen, Kontraindikationen, Sklerosierungsmittel und zu verwendete Konzentrationen, Position des Patienten, Applikationsmethoden, Art und Weise der Zubereitung und

jektionsvolumen, unterschiedliche Zugangswege, Kompressionstherapie und speziellen Anmerkungen. Um diese Fragen zu beantworten, wurden die existierende Literatur und Berichte mit einheitlicher Meinung zu einem Thema herangezogen. Eine Gruppe von Experten beantwortete Fragen auf Grundlage ihrer persönlichen Erfahrung. Die Antworten wurden in Form von klinischen Leitlinien oder allgemeinen Empfehlungen formuliert, so dass konkrete Antworten auf spezifische Fragen gegeben werden konnten. In manchen Fällen wurden mehrere mögliche Variationen akzeptiert.

CONSENSUS TO PIC S

CO N C E P T UAL F R AM E WO R K

1. Overview 1.1 Prerequisites 1.2 Definition of Endovenous Chemical Ablation (Sclerotherapy) 1.3 Physical forms of sclerosing application 1.4 Indications 1.5 Contraindications 1.5.1 Absolute 1.5.2 Relatives 1.6 Sclerosing agents 1.7 Concentrations and dose of Sclerosing agents 1.8 Volumes of Sclerosants (liquid and foam)

Many worldwide attempts have been made to have standardized criteria to perform Endovenous Chemical Ablation (ECA), the concept of our consensus will be reflected in two aspects: ▪▪ Consensus: Methods and conditions ac-cepted unanimously ▪▪ Variations: Methods and conditions that can be changed according to experience of the panel in relation to the general consensus.

2. Material and Equipment 2.1 General material 2.2 Syringes and Catheters 2.3 Needles 2.4 Medical Devices 2.5 Compression devices 3. About the Patients 3.1 Position of the Patient during the ECA 3.1 Post-ECA Compression 4. Aditional Comments

This concepts will allow us to establish general guidelines to perform the ECA and at the same time, variations accepted in our country according to medical expertise and the worldwide bibliography.

G LOSSARY

Sclerosing Agent (SA): Chemical that causes damage to the endothelium and the venous wall. Polidocanol (POL): Aethoxylerol (Lauromacrogol 400), chemical substance widely known as sclerosing worldwide. (Formula) Tetradecyl Sodium Sulfate (TDS): Sclerosing substance for main use in the United States and Europe. (Formula) Glycerin (Gl): Sclerosing substance (glycerol) of oily type. (Formula) Chromed glycerin (GC): An oily-type sclerosing substance with a Chrome group attached to the glycerol molecule. Foam (FOAM): Physical form of preparing the sclerosant in different ways (bubbles of different diameter and with different gas). Tessari Method (TM): Method described by Lorenzo Tessari for the preparation of sclerosant foam using a three-way stopcock. Room Air (RA): The air commonly used to prepare sclerosant foam.

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Original Article

1.2.1 Forms of Use of Sclerosing Agents

Consensus 1. Generalities 1.1 Prerequisites I. Informed Consent II. Medical history (including photos and scheme) where the diagnosis is as specific as possible, including the CEAP system. III. Performed by medical personnel who documented Phlebology training. IV. Having the necessary equipment V. Having the red team gadget (NOM-178-SSA1–1998 Medical Office). VI. To be sure the procedure is specifically indicated with each patient. VII. Appropiate environmental conditions.

1.2 Definition of Endovenous Chemical Ablation (Sclerotherapy) ECA is a treatment method for venous pathology consisting of the intravenous administration of a chemical substance which damages the venous endothelium producing the subsequent inflammatory changes, triggering the formation of an expected and controlled thrombus in a selected venous segment with its subsequent defunctionalization.

Rasgado FV et al. 2nd Mexican Consensus ... Phlebologie 2019

We have two physical forms to apply the sclerosing agents: a Liquid b Foam The Foam is prepared by Tessari method using a 3-way tap and two syringes using the following gases: ▪▪ Room Air (approximately 70 % of Nitrogen) ▪▪ CO2-O2 mixture ▪▪ O2 (pure oxygen) For this preparation, the dilution proposed by Dr. Tessari is used: 1 part sclerosing liquid and 4 parts gas. Other methods can be considered as „Air Block“. The double syringe system is not yet available in Mexico, however there are other similar devices that can be achieved.

1.3 Indications of the ECA (Endovenous Chemical Ablation) ECA can be applied in dysfunctional or varicose veins, angiodysplasia or in secondary angiogenesis problems. Some books and papers talk about the Indications of this procedure, which are the following: a Saphenous vessels and their tributaries b Secondary varices: Residual or Recurrent c Other kind of varicose veins: Post-traumatic, Gestational, Post-thrombotic, post-surgical etc. d Telangiectasias e Reticular Veins f Perforating veins g Vulvar varicosis and pelvic congestion syndrome h Hemorrhoidal Disease (I-II grades) i Some Malformations and Vascular Diseases Variant: ECA, can be used in selected cases of post-thrombotic syndrome and other body areas.

1.4 Contraindications 1.4.1 Absolute a Known allergy to sclerosant b Patient with severe acute diseases c Chronic arterial insufficiency, with lower ankle-brachial index 0.6, corresponding to arterial occlusion grade III-IV Fontaine scale. d Acute or subacute venous thrombosis (less than 6 months) e Acute febrile state f Unbalanced/uncontrolled systemic diseases g Acute eczema h Infectious dermatosis i Pregnancy, use only in an emergency j Immobilized patients

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Oxygen (O2): Oxidizing gas in its pure form used to prepare sclerosing foam. Carbon Dioxide (CO2): Physiological gas used to prepare sclerosant foam. Pulmonary Embolism (PE): Thrombosis of any branch of the pulmonary artery usually caused by thrombus from a distance. Deep Venous Thrombosis (DVT): Thrombosis in the deep venous system. Superficial Venous Thrombosis (SVT): Thrombosis in the superficial venous system. Great Saphenous Vein (GSV): Vein that originates in the inner side of the ankle and empties into the groin in the Sapheno-femoral junction (Vein Safena interna, or Safena long). Small Saphenous Vein (SSV): A vein that originates on the external surface of the ankle and usually ends in the saphenous-popliteal junction in the popliteal fossa. Perforating Vein (PV): Veins that communicates between the superficial and deep system by perforating one or more muscular fasciae. Doppler Color Ultrasound (DCU): Non-invasive diagnostic method for the anatomical and functional evaluation of the venous system. Transillumination (TI): Method by which light is applied through the skin to identify veins that are not apparent to the naked eye. Polarized Light (PL): Method to visualize dermal venous branches.

Original Article

▶Tab. 1 Sclerosing, Dosing and Recommended Puncture Volumes according to the Type of Vein to be treated (Depending on the diameter).

TYPE OF VEIN

Liquid Concentration

Great Saphenous Vein & SFJ Small Saphenous Vein & SPJ Tributary Veins

1–3 %

TETRADECYL SODIUM SULPHATE

FOAM Concentration

Maximum Volume

10cc

1–3 %

5 cc

1–3 %

8 cc

Liquid Concentration

FOAM Concentration

Maximum Volume

1.5 %

6cc

1–1.5 %

4cc

0.75 – 1.5 %

3cc

Perforating Veins

1–3 %

3 cc

0.5–1 %

1cc

Reticular Veins

0.5–1 %

0.25–0.5 %

3 cc

0.3 %

0.1–0.15 %

0.5cc

Telangiectases

0.25–0.5 %

0.1–0.25 %

3 cc

0.1–0.15 %

0.1 %

0.5cc

▶Tab. 2 Sclerosing Agents Used in Small-caliber Veins. CHROMED

GLYCERIN

DEXTROSE

TYPE OF VEIN

Liquid Concentration

Maximum Volume

Liquid Concentration

Maximum Volume

Liquid Concentration

Maximum Volume

Reticular Veins

25 %

3 cc

50 %

5 cc

24 %

5 cc

Telangiectases

25 %

2 cc

25 %

5 cc

24 %

4 cc

1.4.2 Relatives ▪▪ Bedridden or sedentary, as well as with neurological motor damage ▪▪ Thrombophilia ▪▪ Multifactorial thrombosis: –– Hormone therapy –– Contraceptives –– Significant Obesity –– Smoking –– Severe COPD (Chronic Obstructive Pulmonary disease) –– Foramen Oval Permeable (in case of using foams) –– Phlebedema grade IV and Lymphedema grade IV –– Leucodermatosclerosis not modifiable by compression –– Anticoagulant therapy –– Breastfeeding –– Lactation

1.5 Sclerosing Agents There are a wide variety of Sclerosing Agents, however, the most used depending on their availability are: ▪▪ Polidocanol (Lauromacrogol) ▪▪ Tetradecyl Sodium Sulphate ▪▪ Glycerin ▪▪ Chromic Glycerin ▪▪ Hypertonic Solutions (Dextrose and Saline) In Mexico, the only sclerosing agent authorized by the sanitary authorities is “Aethoxylerol®” (Polidocanol, Lauromacrogol 400). Sclerosants: They are administered in different physical states and concentrations for which; some equipment, additives, gases

GLYCERIN

▶Tab. 3 Recommended Needle Calibers and Syringes. TYPE OF VEINS

Needle – Catheter

Syringe

Telangiectases, Spider and Reticular Veins

27–31 G

0.5–3 ml

Veins with diameter > 4 mm

20–25 G

3–5 ml

or diluents widely cited in the world literature are used, the panel endorses the following: Dosage: The use of liquid form or foam and the suggest doses and volumes are described in ▶Tab. 1 and ▶Tab. 2. Gases: Usually room air is used but pure Oxygen, CO2, and O2CO2 mixtures are also available, as described in different Works. Diluents: The most used are: Distilled Water, Bidestilated Water, 0.9 % Saline Solution, Lactate Ringer‘s Solution and 5 % Glucose. Depending on the availability of the diluent and personal experience.

1.6 Concentrations and Maximum Dose of Sclerosing Agents The following doses are recommended in relation to the type of vein to be treated, which will be directly related to their diameters (▶ Tab. 1 and ▶Tab. 2). Polidocanol (Lauromacrogol 400): It can be supplied in concentrations ranging from 0.25 % to 3 %. Currently in our country it is available in ampules of to 0.5 %, 1 %, 2 % and 3 %. Maximum dose of Polidocanol: 2 mg/Kg of bodyweight.

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POLIDOCANOL (Lauromacrogol 400)

1.7 Volumes of Sclerosants (Liquid and Foam) There are several works on the volumes of foam that should be administered to each patient, it is important to note that the global variation is very wide, ranging from 1 to 60 ml; which is due to the concentration, gas used for foam, time of administration, number and type of veins to be treated and the personal experience of the physician. It is recommended to use a maximum volume each session of 10 cc of the sclerosing agent, the average volumen suggested by the panel is 5cc in both liquid or foam form (▶ Tab. 1 and ▶ Tab. 2). Remarks: This consensus DOES NOT limit the use of different concentrations or volumes, since, in differents part of the country, institution or personal experience, they can be varied according to optimizing the results for the patient. Recommendations after Endovenous Chemical Ablation (Sclerotherapy): a Elevation of the treated limb of 10–15° by 5 to 10 min. with flexion-extension exercise of the ankle. b Put on a Elastocompression system c Immediate mobilization after 5–10 minutes (see above) d Consider that adverse effects may occur e Keep in touch with the patient. f Percutaneous thrombectomy by puncture or aspiration in the next 10 days.

2. Material and Equipement 2.1 Material ▪▪ Cotton ▪▪ Alcohol ▪▪ Disposable gloves ▪▪ Adhesive Tapes ▪▪ Gauzes ▪▪ Antiseptic solutions ▪▪ Physiological Solution 100 ml and 250 ml ▪▪ Pads with Alcohol (Wipes) ▪▪ Work table ▪▪ Scissors ▪▪ Measuring tape ▪▪ Marker (Surgical and Indelible) ▪▪ 3 way keys ▪▪ Hypodermic needles ▪▪ Blood pressure cuff ▪▪ Stethoscope ▪▪ Lamps ▪▪ Elevators for the limb

2.2 Syringes and Catheters Disposable syringes of: 0.5, 1, 3, 5 and 10cc. Catheters (short or long) with different needle gauges. Other devices of similar calibers (punzocats, butterflies, etc.) 10 and 20 cc syringes are recommended only for dilutions (▶Tab. 3).

Rasgado FV et al. 2nd Mexican Consensus ... Phlebologie 2019

2.3 Needles The following needle size and syringes are recommended to puncture the veins according their diameter. (▶Tab. 3). When injecting Foam through needles with gauge greater than 27 G, the bubbles are destroyed and liquid is mostly injected, therefore no needles larger than 27 G are recommended for foam injection into large diameter veins.

2.4 Medical Devices ▪▪ Venous Transilluminator: The panel agreed that transillumination equipment is mandatory in the ECA procedure. ▪▪ Polarized Light and Magnifying Glasses: Polarized light eliminates reflections due to the refraction of light in the dermis, which allows us to observe with greater precision Telangiectasias and small caliber vessels, the magnifying glasses allow to observe not perceptible veins under conventional conditions. ▪▪ Vein Visualizer in Real Time: System that emits a near infrared light, which when absorbed by the blood, produce the reflection of it and project a digital image of the veins on the skin. ▪▪ Linear Doppler or Hand Doppler: It is essential to have Linear or hand Doppler equipment for diagnosis and verification of the arterial and venous points and verify the ankle-brachial index (ABI). ▪▪ Ultrasound Doppler Color: The Color Doppler equipment is accepted worldwide as the ideal device for the diagnosis of venous disease, being also very useful to perform punctures of the vascular system and essential to ultrasound guided ablation and sclerosis treatments. ▪▪ Oxygen Tank: Medical Oxygen can be used through nasal tips or to prepare foam. ▪▪ CO2 (Carbon Dioxide) Tank: Medical use gas which is used in a non-routine way to prepare the foam of the sclerosing agent. ▪▪ Oximeter: Useful for testing arterial saturation of the O2 after bandages. ▪▪ Photographic camera: For medical records and as clinical evidences. ▪▪ Computer Variant of Equipment and Additional Devices: ▪▪ Glucometer ▪▪ Needle Extenders ▪▪ Podium for Exploration ▪▪ Pletismograph

2.5 Material for Compression The Elastocompression system is considered as indispensable strategy after the treatment of ECA, which can be done with the following materials: ▪▪ Elastic bandages of 10 and 15 cm. (High, medium and low compression). ▪▪ Compression socks higher than 25 mmHg. For compression stockings, it can be used below the knee, thigh or pantyhose, depending on the preference and sclerosed area.

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Tetradecyl Sodium Sulfate: The literature suggests the use of concentrations ranging from 0.1 % to 1.5 %. Maximum Tetradecyl Sodium Sulfate Dose: 4 ml 3 %. (not available in México)

Original Article

3.1 Position of the Patient during the ECA It is preferred to perform the ECA with the patient in lying position, which will avoid the presence of accidents caused by lipothymia or adverse reaction to the sclerosing agent, in addition to offering greater comfort. In sometimes the evident varicosities in standing position disappear with the lying postion, then by this: a Proof if the veins can be located with Transillumination device. b Mark the insufficient veins with the patient standing before chemical ablation in decubitus. c Sit the patient on the examination table with the leg hanging and treat the insufficient veins in this position, immediately afterwards place the patient in lying position.

3.2 Compression After- ECA The usefulness of compressive therapy is described in many works auxiliary to prevent reflux, promote the venous upflow, decrease venous stasis, edema and pain, in addition to improve the lymphatic function, the microcirculation and promote the healing of venous ulcers. The placement of a venous compression system after performing ECA (sclerotherapy) is unanimous. The use of bearings, cotton or other direct compression system on the sclerosed veins is convenient but not a generalized practice.

4. Additional Observations 1. Prior to the ECA procedure it is suggested: Avoid the tight clothing, do not apply creams, avoid exposure to sunlight and laser hair removal sessions (2 weeks before). 2. Adverse, Collateral, Secondary Effects and Complications of ECA (Sclerotherapy): Injection of a sclerosant can produce in some cases: cardiac abnormalities, cough and respiratory disorders, vomiting, visual disturbances, metallic taste, fever, back pain or headache, but it can also produce local reactions such as phlebitis or even ulcers by extravasation. Like any other substance it can lead to allergic reactions such as rash, urticaria or even anaphylaxis reactions. The adverse effects of ECA are mainly: ▪▪ Ecchymosis ▪▪ Local pain when applying the sclerosing agent ▪▪ Intense and continuous pain in the treated site ▪▪ Superficial Phlebitis and thrombophlebitis ▪▪ Dermatitis, itching, non-allergic erythema ▪▪ Local necrosis and ulcers due to extravasation ▪▪ Cough and dyspnea ▪▪ Nausea and vomiting ▪▪ Neurological injuries, Neuromas, Neuropraxia or Neuritis ▪▪ Deep Venous Thrombosis ▪▪ Neovascularization post sclerotherapy (Matting) ▪▪ Lipothymia and Disorders in the gait ▪▪ Headache, Migraine and Dizziness ▪▪ Paresthesias, Aphasia, Ataxia and Hemiparesis ▪▪ Transient Loss of Consciousness and Confusion

▪▪ Metallic Flavor and Hypoesthesia and/or Oral Dysesthesia (Orofacial) ▪▪ Scotoma and Transient disturbance of the vision ▪▪ Alteration into the General Condition (Fever, Asthenia, Adynamia) ▪▪ Hypertrichosis Complications of ECA (sclerotherapy) described in the literature worldwide: ▪▪ TIA ▪▪ Stroke ▪▪ Anaphylactic Shock and Angioedema ▪▪ Tachycardia, Arrhythmias and Cardio Respiratory Arrest ▪▪ Tako-Tsubo Syndrome and other cardiac complications ▪▪ Venous Thromboembolic Disease (Pulmonary Embolism) ▪▪ Instability of blood pressure (Hypotension-Hypertension) ▪▪ Ischemia in the limbs by intra arterial application of the sclerosant ▪▪ Vasovagal Syncope ▪▪ Angina Pectoris ▪▪ Vasculitis 4. Evaluation and therapeutic continuity is recommended from 1 to 4 weeks. 5. Medications and Local Measures after ECA: Physicians use drugs after Endovenous Chemical Ablation in the following proportions: ▪▪ Anti-phlebitic Medications: 10 % ▪▪ Non-Pharmacological Agents with Anti-phlebitic Effect (naturist): 90 % ▪▪ Topical gels: 10 % ▪▪ Analgesics and Oral Anti-inflammatories: 10 % ▪▪ Local Cold: 15 % 6. It is not advised to apply sclerosants via the perivascular route, although this is described as an option. 7. Post-sclerotherapy thrombectomy is ussually required by Percutaneous puncture or Aspiratiion within the first 10 days after the treatment and at any time that is necessary. 8. In México, it is mandatory to collect the following documents, before conducting sessions of Endovenous Chemical Ablation (Sclerotherapy): a Complete Medical Record (Printed or Electronic) b Medical history according to NOM-004-SSA3–2012 of the Medical Record c Phlebological Background Format d Informed Consent to treatment e Specific Registry of each medical and therapeutic session f Authorization to obtain sensitive data and to take photographs

Annexes A) Medical history Phlebological record Format

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3. About the Patients

B) Informed Consent Authorization for the procedure, collect sensitive data and take pictures.

[14] Bullens-Goessens YIJM, Mentink LF et al. Ultrasoundguided sclerotherapy of the insufficient short saphenous vein. Phlebologie Germany 2004; 33: 89–91 [15] Busch RG, Derrick M, Manjoney D. Major neurological events following foam sclerotherapy. Phlebology 2008; 23: 189–192

This 2. Mexican consensus on sclerotherapy is valid for Mexican doctors only. In Germany the European guidelines for sclerotherapy in chronic venous disorders are valid (Rabe et al. Phlebology 2014; 29(6): 338–354).

Conflicts of interest The authors declare that they have no conflicts of interest.

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Original Article

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1° Consenso Mexicano de Ultrasonido Vascular Venoso

Revista Iberoamericana de Cirugía Vascular

Iberoamerican Journal of Vascular Surgery - Vol 2, nº 3. 2014

REVISIONES

CONSENSO PARA EL DIAGNÓSTICO ULTRASONOGRÁFICO VENOSO DE MIEMBROS INFERIORES. ACADEMIA MEXICANA DE FLEBOLOGIA CONSENSUS FOR DIAGNOSIS OF VENOUS ULTRASONOGRAPHIC OF LOWER LIMBS. MEXICAN ACADEMY OF PHLEBOLOGY Vega Rasgado F, Escalante Rodríguez E, Cavazos Ortega MA, Lira Rodríguez O, Serralde Gallegos JA. REVISION AGOSTO 2014

_______________________________________________________________ JUSTIFICACIÓN El tratamiento actual de la insuficiencia venosa de miembros inferiores requiere del apoyo diagnóstico y en ocasiones como herramienta para el tratamiento del USG dúplex, sin embargo en nuestro país se requiere uniformar los criterios para la realización, interpretación y reporte de dicho estudio, ante la gran variabilidad de enfoques y modos para realizarlo. Por otra parte el costo del equipo lo hace inaccesible para la mayoría de los médicos que atienden patología venosa por lo que lo difieren a laboratorios que no tienen la uniformidad en el reporte, por otra parte la mayoría de éstos médicos utilizan el Doppler de bolsillo (Mini-Doppler) como herramienta básica para establecer sus diagnósticos de patología venosa. Por lo anterior se hace necesaria una guía sobre la realización, interpretación y reporte del USG venoso, ya sea Duplex o lineal.

UNIFORMIDAD DE CRITERIOS Para uniformar los criterios para la realización, interpretación y reporte del USG venoso debemos aclarar varios aspectos: • • • •

Anatomía Fisiología Parámetros USG Conceptos universales

Por lo que se describe a continuación, los conceptos mínimos de cada área que el médico debe dominar para la realización, interpretación y reporte del USG venoso. Son los siguientes:

Anatomía: Las estructuras venosas que se mencionan a continuación son las más frecuentes pero no las únicas, no se mencionan las venas perforantes del pie, glúteo o región vulvar. Sistema Superficial: - Safena mayor. - Safena accesoria antero externa. - Safena accesoria antero interna. - Safena menor. - Venas geniculares. Sistema Profundo: - Vena Tibial Anterior. - Vena Tibial posterior. - Tronco Venoso Tibio-Peroneo. - Vena Peronea Vena Poplítea. - Vena Femoral. - Vena Iliaca. Sistema de perforantes: • Muslo: - Perforante de Hunter o Vena perforante medial interna del muslo. - Perforante de Dood o Vena perforante distal interna del muslo. - Perforante de Hatch o Vena perforante anterior del muslo. - Vena perforante ciática o Vena posterior del muslo. - Vena perforante de la región pudenda. - Vena perforante lateral del muslo.

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Parámetros Ultrasonográficos:

• Pierna: - Vena perforante de Boyd o Vena perforante medial de la rodilla. - Venas perforantes de Cockett I, II y III o Venas paratibiales posteriores superior media e inferior. - Vena perforante de Sherman o Vena perforante anterior de la tibia. - Vena perforante lateral de la pierna. - Vena perforante de May o Vena perforante intergemelar. - Vena perforante de Bassi o Vena perforante para aquiliana. • Tobillo:

•

Válvula ostial: Se localiza en la unión de la safena magna con la vena femoral e impide el reflujo hacia la safena.

•

Válvula pre-ostial: Se localiza unos centímetros antes de la unión safeno-femoral, impide el reflujo desde las venas tributarias al cayado de la safena.

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Unión safeno-femoral: La región anatómica comprendida en la unión de la vena safena magna con la vena femoral.

•

Unión safeno-poplítea: Unión de la safena menor con la vena poplítea, habitualmente en el hueco poplíteo pero con variaciones anatómicas significativas. Desembocadura de la vena epigástrica superficial: Sitio anatómico de referencia para cirugía venosa endoscópica, ubicado generalmente a 1.5 cm de la unión safeno-femoral. Segmerto Ilio-femoral: Sitio anatómico de referencia para cirugía venosa endoscópica, ubicado generalmente entre 1.5 y 2 cm de la unión safeno-femoral,

Fisiología: Los conceptos básicos consideración son los siguientes: • • • •

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•

bajo.

Definiciones:

•

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Flujo: Movimiento sanguíneo en la dirección fisiológica normal. Reflujo: Flujo en sentido contrario a la dirección fisiológica normal. Para considerar reflujo patológico, debe mantenerse más de 1 segundo a maniobras de esfuerzo. (Valsalva, Paraná). Flujo invertido: Flujo en sentido inverso al normal sin repercusiones patológicas y debido a compensación fisiológica (Inspiración-espiración).

El sonido Doppler de la arteria es pulsado, bifásico y de tono más agudo.

- Venas perforantes de la red maleolar interna - Venas perforantes de la red maleolar externa

•

El sentido normal del flujo venoso es de abajo hacia arriba y de superficial a profundo. La Insuficiencia venosa profunda de manera crónica puede ocasionar aumento del diámetro de las venas tibiales. El flujo venoso en posición supina puede ser muy lento. La obstrucción de una vena se acompaña de la triada de Virchow desde su inicio y sigue la historia natural de la enfermedad, no necesita ser una obstrucción total.

El sonido Doppler de la Vena es fásico y de tono más

El Doppler color evidencia reflujos de manera “Cualitativa”, una vez identificado el vaso. La onda Doppler lineal puede evidenciar reflujos y cierre valvular y permite medir la duración de éstos eventos. La medición del diámetro venoso en reposo y con maniobras de Valsalva permite evidenciar la compliancia de la vena y observar los flujos, es valorable con el paciente de pie. En decúbito el diámetro disminuye. La compresibilidad se pierde en vasos trombosados. Diámetro mayor a 3 mm en las venas tibiales o perforantes es sugestivo de hipertensión venosa.

Conceptos Universales: El USG venoso funcional se realiza con el paciente en posición supina siempre y cuando la condición del paciente lo permita. En ocasiones especiales y para recabar datos anatómicos más que funcionales puede hacerse con el paciente sentado e incluso en decúbito dorsal o prono, según convenga para demostrar lo que se pretenda. En ocasiones puede hacerse con el paciente sentado para poner en evidencia patología específica, deberá señalarse en el reporte. Lo más deseable es que el estudio lo realice el médico tratante para elaborar el mapeo y diseño del probable tratamiento • Mapeo: Dibujo esquemático de las alteraciones encontradas en el USG Doppler color, se utilizarán símbolos convencionales fáciles de entender, se sugieren los siguientes de manera estandarizada:

Revista Iberoamericana de Cirugía Vascular

Iberoamerican Journal of Vascular Surgery - Vol 2, nº 3. 2014 - Líneas de color Negro para trayectos trombosados. - Líneas de color rojo para señalar reflujos. - Líneas de color azul para trayectos atípicos o variantes - Línea punteada para segmentos ausentes. Símbolo de perforante: - Flechas para señalar el sentido del flujo, en caso de reflujo la flecha señalará ambos sentidos. Algún otro requerimiento deberá señalarse claramente, tales como: - Ausencia de Flujo. - Trombo. - Fleboneogénesis. - Oclusión Venosa. - Obstrucción Venosa. - Compresión Venosa. - Recanalización. - Permeabilidad Venosa. - Suficiencia e Insuficiencia venosa. Cuando se solicita el estudio a otro médico debe especificarse la probable patología esperada o lo que es preciso enfatizar en la búsqueda. Deben evitarse las solicitudes de: “USG Doppler color de Miembros inferiores”, sin diagnóstico concreto de tipo anatómico y funcional. En caso de recanalización se realiza un flebografía de estrés para descartar la presencia de compresiones extrínsecas que puedan, en un futuro, conducir a la retrombosis del vaso. Cuando no existe tal compresión se procede a realizar tratamiento anticoagulante durante 3 a 6 meses. En caso tal de que se evidencie una compresión, lo correcto es un tratamiento etiológico mediante cirugía descompresiva. En estos casos existe cierta discrepancia sobre si la cirugía debe ser diferida, tras el restablecimiento de la integridad del endotelio para evitar •

Clasificación CEAP: Es la clasificación utilizada por el médico que remite y quien hace el estudio para referir al paciente. (Consultar: Journal of Vascular Surgery 2004. 40:6.1248-1252 publicada por el American Venous Forum).

Parámetros Ultrasonográficos: La forma de realizar la exploración se reporta en diversos artículos que avalamos, en especial el consenso de la UIP parte I y parte II. Enfatizamos puntos básicos: - Debe realizarse con el paciente de pie, siempre y cuando la condición clínica lo permita, de lo contrario deberá señalarse en el reporte y considerar las variaciones de inexactitud que pueden presentarse.

- Debe hacerse siguiendo un orden específico: Cefálico a caudal o viceversa, superficial a profundo, por regiones anatómicas, etc. - Deberá enfatizarse en las zonas que clínicamente se aprecian alteradas y buscar el origen del trastorno hemodinámico de ellas. - Deberá comprobar la funcionalidad y permeabilidad de la circulación profunda en su totalidad. - Deberá confirmar la funcionalidad e integridad del sistema superficial (safena mayor y safena menor con todas sus ramificaciones en el muslo y en la pierna). - Deberá confirmar el estado funcional de las principales perforantes en cada segmento y las ramificaciones que se deriven de éstas. - Deberá señalar las zonas de obstrucción con la mayor precisión posible. - En caso de úlceras, deberá hacer hincapié en el sistema superficial, profundo y de perforantes que confluyen o afectan el territorio afectado. - Deberá anexar imágenes relevantes que muestren de mejor manera la alteración o integridad que se pretende poner en evidencia. - Se debe completar con un rastreo de la cavidad pélvica, siendo conveniente explorar la vena iliaca. - Explorar la zona vulvar y perineal cuando clínicamente se justifique. Deberá explorar en todo su trayecto: Sistema Superficial: - Unión safeno-femoral. - Vena safena mayor o magna y ramificaciones. - Unión safeno-poplítea. - Vena safena menor o parva y sus ramificaciones. Sistema Profundo: - Vena Iliaca. - Vena Femoral. - Vena Poplítea - Tronco tibio-peroneo venoso. - Venas Tíbiales anteriores. - Venas Tíbiales posteriores. - Venas Peroneas

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señalando su localización lo más precisamente posible e indicar el sentido del flujo.

- Perforante de Hatch. - Perforante de Hunter. - Perforante de Dood. - Perforante de Boyd. - Perforante de Sherman. - Perforantes: Cockett I, II y III. - Perforante de May. - Perforante de Bassi.

- Permeabilidad y suficiencia del sistema venoso profundo específicamente en: V. Femoral, V. poplítea, V. tibiales anteriores y venas tibiales posteriores. - Suficiencia de la V. safena menor y verificar la extensión del reflujo hasta el tobillo, así como su desembocadura. - Describir los sitios no comunes donde se encuentren alteraciones.

Con las anteriores referencias se podrá tener una idea general del estado funcional hemodinámico de la pierna.

- Verificar intencionalmente las zonas que clínicamente se encuentren alteradas y describir los hallazgos.

• Indicaciones: El diagnóstico por USG es el estudio más frecuente para diagnosticar y dar seguimiento a problemas de insuficiencia venosa de miembros inferiores, el estudio con mini-Doppler o de bolsillo debe realizarse en todos los pacientes que tengan problemas de várices, edema, sospecha de trombosis y como valoración inicial. En aquellos lugares donde no se cuente con el auxilio del USG Duplex la exploración con mini Doppler es absolutamente necesaria en todo paciente con enfermedad venosa de los miembros inferiores. El Estudio de USG Doppler Duplex se indica para el diagnóstico de las alteraciones hemodinámicas venosas (obstrucción o reflujo) en pacientes con Insuficiencia Venosa clínica o sintomática, pacientes con troncos varicosos, edema y desde grados C2 en delante de la clasificación CEAP.

- Para lo anterior se recomiendan los esquemas siguientes, que pretenden ser un estándar para dicho reporte y usar los signos convencionales mencionados con anterioridad. *Esquemas de Reporte de Ultrasonido Venoso continúa en las páginas 132 y 133.

BIBLIOGRAFÍA: 1. 2.

Es mandatorio en todo paciente programado a cirugía venosa o diagnóstico de trombosis. Es el método de control indicado posterior a cirugía, esclerosis u otro procedimiento terapéutico venoso. En aquellos casos en que se sospeche de alteración anatómica o funcional del sistema venoso (malformaciones).

Reporte:

El reporte del USG Venoso deberá indicar al menos los siguientes puntos: - La posición en que se realiza el estudio. - Anatomía y función de la unión safeno-femoral (USF), así como los diámetros de las venas: femoral, safena mayor. - Sitios de reflujo a lo largo de la safena magna.

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- La localización de las venas perforantes incompetentes,

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** Bibliografía del consenso para el diagnóstico ultrasonográfico venoso de miembros inferiores continúa en la página 134.

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REPORTE DE ULTRASONIDO VENOSO (ESQUEMAS)

• Dibujar las venas clínicamente y posteriormente señalar los hallazgos funcionales.

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