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Small%Vein%Disease%,Trea/ng%Spider% Telangiectasia%With%Sclerotherapy% Chapter%7% Peggy%Bush,%APN,%CNS,%MSN% Ron%Bush,%MD,%FACS%


Welcome'to'the'Vein'Experts'Online'Educa6onal'CME'Program.% Original'Release'Date:'10/11/13% Termina6on'Date:'1/31/2016% Price:%%25.00%for%Vein%Experts%Members%&%$40.00%for%Non, Members%,%Processing/CME%Fees% % % %


•  This%ac/vity%has%been%planned%and%implemented%in%accordance%with%the% accredita/on%requirements%and%policies%of%the%Accredita/on%Council%for% Con/nuing%Medical%Educa/on%(ACCME)%through%the%joint%providership%of% The%University%of%Toledo%and%VeinExperts.org.% %% •  The%University%of%Toledo%is%accredited%by%ACCME%to%provide%con/nuing% medical%educa/on%for%physicians.% %% •  The%University%of%Toledo%designates%this%enduring%ac/vity%for%a%maximum% of%1.00%AMA#PRA#Category#Credits™.%%Physicians%should%claim%only%credit% commensurate%with%the%extent%of%their%par/cipa/on%in%the%ac/vity.% %% '% '%


For%nurses,%we%are%also%able%to%issue%a%cer/ficate%of%aYendance%sta/ng%the%course%is%AMA% approved,%which%may%be%eligible%for%credit.%%Nurses%are%responsible%for%submiZng%the% cer/ficate%to%their%board.%%Please%note%only%one%cer/ficate%can%be%issued%for%each%purchase.% % Disclosures:% % Ronald'Bush,'MD,'FACS,%faculty%and%planning%member%discloses%he%is%on%the%Speaker’s% Bureau%for%Dornier/Refine%USA%and%is%contracted%with%Water’s%Edge%Dermatology%and% Soffer%Health.%% Richard'L.'Mueller,'MD,%faculty%and%planning%member,%discloses%he%receives%grant/research%support% from%Vascular%Insights,%LLC%

Ariel'Soffer,'MD,%FACC,%faculty%and%planning%member,%discloses%he%is%on%the%Speaker’s% Bureau%for%Cutera%,%consults%for%Angiodynamics,%&%does%research%for%BTG.% Peggy'Bush,'APN,%planning%member,%has%no%disclosures%or%financial%interests%and%is% employed%by%Midwest%Vein%&%Laser%Center.% Becky'Roberts,%planning%member,%has%no%financial%interest%or%other%rela/onships%with%any% manufacturer%of%commercial%product%or%service%to%disclose.%% % %% %


Mission:% %Our%objec/ve%is%to%provide%current%evidence%based%informa/on,%as%well%as% new%technology%that%is%being%developed%for%the%treatment%of%venous%disease% presented%in%a%virtual%format.%% %% Target'Audience:% %The%target%audience%for%this%ac/vity%includes%physicians%and%other%health%care% professionals%in%Cardiology,%Dermatology,%Interven/onal%Radiology,% Phlebology,%Surgery,%Vascular%Surgery,%Wound%Care%Specialists%who%care%for% pa/ents%with%venous%disease.%% %


CME'Credit'Instruc6ons% % Steps'to'successfully'complete'this'ac6vity:% CME'Credit'Instruc6ons% Steps'to'successfully'complete'this'ac6vity:% Register%for%CME%ac/vity%&%pay%your%CME%fees.% Read%the%Vein%Journal%Chapter%7,%en/tled%‘Small'vein'Disease'–'Trea6ng' Spider'Telangiectasia'With'Sclerotherapy.’'Take%the%post%test%(score%of%80%% or%greater%must%be%achieved.%(A%pdf%copy%of%the%exam%can%be%emailed%to%you%if% requested).% Scan%and%email%post%test%and%evalua/on%to%%pbush@veinexperts.org%or%you% can%fax%completed%paperwork%to%937,281,0200.%% You%will%be%contacted%by%the%University%of%Toledo%CME%office%for%instruc/on%of% how%to%sign%on%and%print%your%cer/ficate.%% %


Technical'Support% % '% %% Email%your%ques/ons/concerns%to%pbush@veinexperts.org%%or%you%can%call%us% at%407,900,8346%and%we%will%respond%in%24%hours.% %% '% %


Small%Vein%Disease%–%Trea/ng%% Spider%Telangiectasia%With%Sclerotherapy% This%ac/vity%describes%how%to%evaluate%small%vessel%disease%and%how%to% effec/vely%treat%spider%telangiectasia%with%sclerotherapy.% ' Learning'Objec6ves:% '% As%a%result%of%this%ac/vity,%the%par/cipant%should%be%able%to:% % Diagnose%different%paYerns%of%spider%vein%pathology% % Describe%how%to%effec/vely%treat%re/cular%veins%using%foam%sclerotherapy.% % Explain%advantages%and%disadvantages%of%using%foam%sclerotherapy.%% % Describe%the%histology%of%a%spider%vein.%% % %%

%% %%


Telangiectasia/Spider%Veins% •  Small,dilated%veins%near%the%surface%of%the% skin% •  Measure%0.3%mm%in%size%to%1.0%mm%in%size% •  May%be%red,%blue,%purplish,%or%greenish%in% color% •  Medical%term%for%spider%veins%is%telangiectasia% •  Spider%veins%can%be%anywhere%on%the%body,% but%commonly%found%on%face%&%legs% (Bush,%2013)%(Parsons,%2008)%


Telangiectasia% •  Veins%leading%to%spider%complexes%are%re/cular% veins% •  Re/cular%veins%are%found%1%mm%or%below%the% skin%surface% •  Spider%veins%may%be%the%sign%of%deeper% insufficiency% •  Underlying%problems%should%be%addressed,% before%trea/ng%spider%veins% (Bush,%2013)%(Parsons,%2008)%(Zimmet,%2003)%


Telangiectasia% •  Cosme/c%concern%for%pa/ent% •  Superficial%varices%open%cause%symptoms%such% as%pain,%heaviness,%aching,%and%pruritus%

(Bush,%2013)%(Zimmet,%2003)%


Spider%Vein%Presenta/ons%

(Bush,%2013)%%


Common%PaYerns%of% Spider%Telangiectasia% •  Evaluate%for%saphenous% insufficiency%or%branch% insufficiency%from%the% saphenous%vein%

(Photo%courtesy%of%Midwest%Vein%Laser,%2013)%


Common%PaYerns%of% Spider%Telangiectasia% •  Lateral%re/cular%veins% % •  Not%connected%to%the% saphenous%vein,%but% transmiYed%pressure% from%the%femoral%vein% by%a%perforator%

(Photo%courtesy%of%Midwest%Vein%Laser,%2013)% %


Common%PaYerns%of% Spider%Telangiectasia% •  Typical%of%saphenous% insufficiency%

(Photo%courtesy%of%Midwest%Vein%Laser,%2013)% % %


Histology%of%a%Spider%Vein% •  Next%slide%shows%a%spider%telangiectasia% •  No/ce%hypertrophy%of%the%smooth%muscle% •  Vein%lies%4/10%mm%(400%microns)%below%the% skin%surface% •  All%spider%veins%are%located%in%the%papillary% dermis%

(Bush,%2013)%%


Histology%of%an%Untreated% Spider%Vein% •  Red%Arrow%,%Stratum% corneum%(dead%skin% cells)% •  Blue%Arrow%–%Squamous% epithelial%layer% •  Green%–%Papillary% dermis%(Collagen)% •  Black%–%Re/cular%dermis% (fat)% (Bush,%2013)%


Contribu/ng%Factors%to%Telangiectasia% •  •  •  •  •  •  • 

Age% Gender% Gene/cs% Hormones% Pregnancy% Prolonged%standing% Obesity%

•  •  •  •  •  • 

Occupa/on% Race% Sedentary%lifestyle% Sun%exposure% Therapeu/c%radia/on% Trauma%

(Bush,%2013)%(Parsons,%2008)%(Sadick,%1992)%(Zimmet,%2003)%


First%Visit%Aper%Consulta/on% •  Assess%pa/ent%–%Spider%veins,%medical%history,% chief%complaint,%family%history,%allergies,%and% expecta/ons% •  Thorough%ultrasound%to%rule%out%venous% insufficiency% •  Educate%pa/ents%about%benefits,%risks,%&% alterna/ve%to%treatment% •  Inform%pa/ent%of%poten/al%adverse%sequelae% &%possible%complica/ons% (Bush,%2013)%(Parsons,%2008)%(Zimmet,%2003)%


First%Visit%Aper%Consulta/on% •  Inform%pa/ent%there%is%no%cure%at%this%/me%for% spider%veins% •  Medica/ons%such%as%Minocycline%or% Isotre/noin%can%lead%to%adverse%reac/ons,%if% not%stopped%prior%to%treatment% •  Get%informed%consent% •  Take%pre,treatment%photos%

(Bush,%2013)%(Zimmet,%2003)%


Risk%Factors%to%Consider% •  History%of%DVT% •  History%of%PE% •  Family%history%of%venous%thromboembolism,% hypercoagulable%state,%long,distance%travel,% bed%rest,%and%the%inability%to%ambulate% •  Avoid%pa/ents%who%are%pregnant,%have% systemic%illnesses,%lymphedema,%peripheral% arterial%insufficiency,%or%unrealis/c% expecta/ons% (Bush,%2013)%(Zimmet,%2003)%


Evalua/ng%Pa/ent% Essen/al%to%determine:% •  Pathophysiology% •  Size%of%vessel%% •  Dermal%anatomy% •  Skin%type% •  Vessel%depth%

(Bush,%2013)%%


Imaging% Vein%Light%–%Tran,illuminates%skin%making% iden/ďŹ ca/on%of%re/cular%veins%easier% Polarized%lights% % Loops% % (Bush,%2013)%(Parsons,%2008)%


Trea/ng%Telangiectasia%With% Sclerotherapy% % % Sclerotherapy%is%the%gold%standard%for%the% treatment%of%spider%veins%

(Bush,%2013)%(Parsons,%2004)%


Detergent%Solu/ons% FDA%Approved% •  Sodium%tetradecyl%sulfate%(STS)% •  Polidocanol%(POL)% •  Detergents%work%by%injuring%the%endothelial%cells% with%resultant%thrombosis%and%eventual%fibrosis.% Sotradecol%is%a%stronger%sclerosant%than% Polidocanol%and%will%effect%more%damage.%% '% (Bush,%2013)%(Parsons,%2008)%(Zimmet,%2003)%


Hyperosmolar/Hypertonic/Glycerin% Solu/ons% Not%FDA%approved% •  Hypertonic%saline% •  Hypertonic%dextrose% •  Glycerin%

(Bush,%2013)%(Parsons,%2008)%


Lateral%Re/cular%Veins% •  Most%typical%paYern% •  Blue%arrow%points%to%the% lateral%re/cular%vein% •  Treat%re/cular%veins%as% well%as%%spider%veins%at% the%same%seZng% •  In%this%par/cular% pa/ent,%we%would%do% phlebectomy%of%the% re/cular%veins% (Bush,%2013)%%


Using%Foam% •  Sotradecol%&%Polidocanol%are%most%commonly% used%detergent%solu/ons% •  Mixing%with%air%or%C02%produces%foam% %% •  Mechanism%of%ac/on%at%cellular%level%is%cell% destruc/on,%with%replacement%by%fibrin,% eventual%cloZng%and%scarring%of%the%lumen% •  Using%C02,%bubbles%dissolve%faster%in%the% arterial%circula/on,%reducing%risks%of%adverse% events% (Bush,%2013)%(Parsons,%2008)%


Tessari%Method% •  1%part%solu/on%to%4%parts%gas% •  Stopcock%with%2%syringes%

(Bush,%2013)%(Tessari,%2001)%%


Advantages%to%Using%Foam% •  Increases%surface%area%of%sclerosant,%thus% reducing%amount%of%medica/on%needed% •  Circumferen/al%contact%with%in/mal%wall% causes%more%damage/beYer%result% •  Displaces%blood,%thus%avoiding%dilu/on%of% drug/increase%efficacy% •  Use%in%larger%veins%>%1.5%mm,%foam%is%difficult% to%inject%into%a%vein%with%a%small%lumen% (Bush,%2013)%%


Disadvantages%to%Using%Foam% •  Pa/ents%with%PFO%and%prior%neurological%events% are%not%candidates%% •  Migraines%and%scotoma%may%occur%with%PFO’s% •  DVT%unlikely,%however,%clear%deep%system%with% foot%dorsiflexion%post%treatment%and%encourage% ambula/on% •  Complica/ons%are%rare,%since%Sotradecol%and% Polidocanol%deac/vates%rapidly%in%blood% •  Using%too%high%of%a%concentra/on,%causes% angiogenesis% (Bush,%2013)%(Zimmet,%2003)%


Re/cular%Veins%

(Bush,%2013)%% %


(Bush,%2013)%%


Re/cular%Veins% •  Sotradecol%0.33%% •  Polidocanol%0.75%%

%

Supplies%Needed% •  Stopcock% •  2,3%cc%syringes% •  25,27%gauge%buYerfly% •  Alcohol%swab% •  CoYon%balls%% •  Paper%tape% •  Sclerosant% •  Light%source% (Bush,%2013)%(Zimmet,%2003)%


Tessari%Method%

(Bush,%2013)%(Tessari,%2001)%


Making%Foam% •  Supplies%needed:%2,3%ml%syringes%&%C02% •  Mix%STS%0.3%%0.5%ml%&%C02%2.0%ml% •  Maximum%we%use%is%6%ml%of%foam%–%European% consensus%is%10%ml% •  If%you%use%too%strong%of%a%solu/on%in%re/cular% vessels,%You%will%get%vessel%wall%destruc/on,% inflammatory%changes,%&%staining% •  Use%STS%0.3%%or%less%–%You%can%also%try% Polidocanol%0.5%% (Bush,%2013)%(Parsons,%2008)%


Trea/ng%Re/cular%Veins% •  Must%see%a%blood%return% •  Gently%inject%foam%sclerotherapy% •  Should%see%blanching%and%if%not,%remove% needle%and%re,cannulate% •  Apply%coYon%balls%&%paper%tape% •  Have%pa/ent%wear%compression%stockings%for% 2,3%days% (Bush,%2013)%(Parsons,%2008)%


Trea/ng%Spider%Veins% Up%to%1%mm% •  Use%Sotradecol%0.2%% •  Supplies% –  Alcohol% –  CoYon%balls%&%paper%tape% –  Sclerosing%solu/on% –  3%ml%syringe%with%30,gauge%needle% –  Bend%30,gauge%needle%to%45,degree%angle%

(Bush,%2013)%(Parsons,%2008)%(Zimmet,%2003)%


Spider%Vein%Treatment% •  •  •  •  • 

Inject%sclerosant%slowly% Look%for%blanching% Use%cau/on%in%the%ankle%area% Apply%coYon%balls%&%paper%tape% Have%pa/ent%wear%compression%stockings% 18,20%mmHg%for%3%days%

(Bush,%2013)%(Parsons,%2008)%


Histology%–%Sclerotherapy%With%% Liquid%Sclerosant% % •  Absence%of%endothelial% cells% •  Marked%fibrin% deposi/on%in%vessel%wall% •  Red%cell%aggregate%in% lumen%&%vessel%wall% •  No/ce%almost%total% destruc/on%of%vessel%at% one%point% (Bush,%2013)%(Bush,%2013)%


Spider%Vein%Treatment% •  Aper%injec/on,%see% inflamed%response% •  If%minimal%response,% may%need%slightly% higher%concentra/on% •  Wait%4,weeks%before%re, trea/ng%

(Bush,%2013)%(Zimmet,%2003)%


(Bush,%2013)%%


References% % •  Bush%R.%%Histological%Analysis%Of%Sclerotherapy,%Laser%940,%Ohmic%Thermolysis,% And%Intense%Pulsed%Light,%On%Leg%Vein%Telangiectasias.%Conference;%2013%Sep% 8,13;%Boston.% •  Bush%R,%Bush%P%Spider%vein%treatment.%Vein%Journal.%Retrieved%online%9/27/13% from%www.veinexperts.org.% •  Images.%Retrieved%online%9.26.13%from%www.veinexperts.org.% •  Parsons%M.%Sclerotherapy%basics.%Dermatol#Clin.%2004:22:501,508.% •  Sadick%N.%Predisposing%factors%of%varicose%and%telangiecta/c%leg%veins.%J# Dermatol#Surg#Oncol%1992;18:883,6.% •  Tessari%L,%Cavezzi%A,%Frullini%A.%Preliminary%experience%with%a%new%sclerosing% foam%in%the%treatment%of%varicose%veins.%Derm%Surg%2001;27(1):58,60.% •  Zimmet%S.%Sclerotherapy%treatment%of%telangiectasias%and%varicose%veins.%Tech% in%Vasc%&%Interven%Rad%2003;6:116,120.% % % %


Exam% Complete'the'exam'&'evalua6on'below'and'email'your'results'to' pbush@veinexperts.org'along'with'your'contact'informa6on.'% '% A'score'of'80%'or'greater,'must'be'achieved'on'the'post]test'and'be' completed'in'less'than'3'a^empts.'' % When'you'see'spider/re6cular'veins'on'the'medial'aspect'of'the'knee,'it' may'be:' a.%%Associated%with%a%perforator% b.%Saphenous%insuďŹƒciency% c.%%Spontaneous%bleed%

%%

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Exam% All'are'contribu6ng'factors'to'telangiectasia'except:' a.%%Gender% b.%%Hormones% c.%%Crossing%your%legs% d.%%Pregnancy% Pregnant'pa6ents'can'be'safely'treated'with'sclerotherapy:' a.%%True% b.  False% Most'spider'veins'are'located'in'the:' a.%%%Squamous%epithelium% b.  Papillary%dermis% c.  Re/cular%dermis%

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Evalua/on% %% How%well%did%this%ac/vity%present%the%objec/ves?% %% Excellent%%Good% % %Sa/sfactory% % %Poor%% %% %% How%do%you%rate%the%overall%usefulness%of%the%online%material%to%mee/ng%your%needs?%% %% Excellent%%Good% %% %Sa/sfactory% % %Poor%% %% %% How%do%you%rate%the%overall%presenta/on%material?%% %% Excellent%%Good% % %Sa/sfactory% % %Poor%% %% %


Was%any%commercial%bias%presented%in%the%material?%% % No% %Yes%(Please#explain)#%% ____________________________________________________%% %% I%will%be%able%to%change%my%clinical%prac/ce%as%a%result%of%par/cipa/ng%in%this%ac/vity.% %% Yes% %No%% %% %% What%topics%about%venous%disease%would%you%like%to%hear%about%in%the%future?%% %% ____________________________________________________%% %%% %% %


%

% Addi/onal%Comments/ Recommenda/ons%% %

%% ____________________________________________________% %% %%%___________________________________________________%


Contact'Informa6on% % '% Name%&% Creden/als_______________________________________________% %% Address% ________________________________________________________% %% Phone%Number% ___________________________________________________% %% Email%address%___________________________________% %%

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Chapter 7 small vein disease treating spider telangiectasia with sclerotherapy