2020年12月22日星期二

lidocaine for hemorrhoids,Sclerotherapy for varicose veins of lower extremities

    definition

    Hardening agent injection therapy, which comes from the Greek word "hardening" (hardening), is to inject irritating chemicals into the veins to achieve the purpose of treating varicose veins. The chemical causes aseptic inflammation of the vein, forming fibrous tissue and closing the lumen or central duct of the vein.

    purpose:

    Injection therapy of lower limb sclerosing agent mainly has the following indications: 1. It is used to close the spider veins (a small vein that expands due to the increase of venous blood pressure) to improve the appearance of the legs. The spider veins expand It is a kind of telangiectasia, which is a red skin lesion caused by continuously expanding capillaries or other small veins. The term telangiectasia comes from the Greek word. They are "end", "blood vessel" and "streteh out", spider veins, also called "sunburst varicose veins", which are close to the surface of the skin. In the central red area visible to the naked eye, the remaining small veins extend outward like the legs of a spider. Spider veins may also appear in two other forms, small branches or like very thin separate threads. 2. Sclerosing agent injection therapy can also treat small or medium-sized varicose veins, relieve leg soreness, pain, muscle fatigue and leg cramps. Because sclerosing agent injection treatment is usually regarded as a cosmetic procedure, which is usually not included in health insurance, patients who are using sclerosing agent injection to treat varicose veins and leg discomfort should ask whether the insurance company covers sclerosing agent injection treatment. In 2001, the average cost of this treatment was US$227.

    Sclerotherapy as a treatment method is also used to treat esophageal varicose veins.

    Demographic

    The American Academy of Phlebolog, a group of dermatologists, plastic surgeons, obstetricians and gynecologists, and general surgeons specializing in the treatment of venous diseases believe that more than 8 million people in the United States suffer from spider-like varicose veins. The American Association of Plastic Surgeons estimates that more than 50% of women over the age of 21 have spider veins.

    Women are more likely to develop varicose veins than men, but the incidence of both men and women increases with age. A recent survey in San Diego, California showed that 80% of women and 50% of men in middle-aged and elderly people suffer from spider veins. Men are unlikely to choose the cosmetic treatment of spider varicose veins. The color changes caused by spider varicose veins are often covered by leg hair. Male patients who are suffering from pain, burning sensation and varicose veins on the legs can suffer Benefit from sclerotherapy injection.

    According to the ASPA report, there were 616,879 sclerosing agent injection treatments in the United States in 2001, of which 97% were women and 3% were men. The age range receiving sclerosing agent injections was 30 to 60 years old.

    Spider-like varicose veins are more likely to occur and become more obvious in Caucasians. Hispanic Americans are more susceptible to spider varicose veins than African or Asian Americans.

    Causes of spider veins

    A brief introduction to the human venous system is helpful for understanding the working principle of sclerosing agent injection therapy. The venous system, which is part of the circulatory system, pumps blood back to the heart, and the heart pumps blood to the lungs for oxygenation. In contrast, the arterial system transports oxygenated blood away from the heart and transports it to all tissues throughout the body. The smallest vein in the venous system is the capillary, which flows back into the larger superficial veins. All superficial veins are located between the skin and a layer of fibrous connective tissue called fascia. This layer of fascia covers and supports muscles and internal organs. The deep veins of the human body are located in the muscle fascia. This distinction helps explain Why can it be treated with sclerotherapy without damaging the larger veins.

    Veins contain a one-way valve that, when they are functioning normally, push blood to flow upward and toward the heart toward the heart. The pressure of the superficial vein is usually low. If it rises and stays at a higher level for a period of time, the venous valve will fail and cause the vein to dilate. The failure of the veins to work is called "dysfunction". The expansion of the veins and their close proximity to the surface of the skin make them more visible, forming a typical spider-like varicose vein.

    Some people are at higher risk of developing spider veins. These risk factors include:

    Gender: Women are more likely to develop spider veins than men in any age group.

    Genetic factors: Some people have abnormally weak vein walls or venous valves, and their superficial veins may develop into spider varicose veins even at lower blood pressure levels.

    Pregnancy: The circulating blood volume in women increases during pregnancy, which increases the blood pressure of the venous system. In addition, hormone changes during pregnancy lead to softening of the vein walls and valves.

    Contraceptives:

    Obesity: Being overweight increases the pressure on the veins.

    Occupational factors: People who need to stand or sit for a long time are more likely to suffer from spider-like varicose veins than those who work in activities that require activities.

    Trauma, falls, deep abrasions, cuts, or surgical incisions can cause spider veins to form in or near the affected area.

    As of 2003, there is still no known method to prevent the formation of spider veins.

    Sclerotherapy steps:

    The treatment procedure is longer than in the outpatient clinic, and the patient puts on a pair of shorts and lies on the examination table. After disinfecting the skin surface, the doctor injects sclerosing agent into the patient’s veins. When the skin is tightened with another hand, the sclerosing agent will disappear. The doctor first injects the veins with obvious varicose legs, and then the smaller veins. In most cases, every inch of spider varicose veins requires injection of sclerosing agent. A typical course of treatment will require 5 to 40 separate injections. Although the patient may feel a slight tingling or burning sensation at the injection site, sclerotherapy does not require anesthesia.

    The most commonly used liquid sclerosing agents to treat spider veins are polyethylene glycol monolauryl ether, sodium tetradecyl sulfate and 11.7% hypertonic sodium chloride. Some physicians prefer to use hypertonic sodium chloride because it does not cause allergic reactions. The usual practice is to use the lowest effective concentration of sclerosing agent to close the vein.

    A newer sclerosing agent injection treatment is a foam formulation injected into a vein instead of liquid sclerosing agent. Foam formulations have several advantages: it contacts the vein wall more fully than liquid hardener, its usage can be less, and its movement in the vein can be observed on an ultrasound screen. Foam hardener has been proven to be very high. The success rate and lower cost, and fewer complications.

    When all the varicose veins in the leg are injected, the doctor covers the area with a cotton pad compression band. When the first treatment is over, the physician should let the patient wait in the office for 20-30 minutes to ensure that the patient is not allergic to the sclerosing agent. Most sclerosing agent injection treatments are short, requiring only 15-45 minutes.

    It is more common to need a second treatment to completely eliminate the spider varicose veins, but it takes 4-6 weeks between treatments.

    diagnosis:

    The most important indication for deciding to use sclerosing agent injection treatment is to distinguish between telangiectasia and severe varicose veins, and to distinguish between telangiectasia and spider nevi. The doctor must ensure that the patient does not have more severe venous insufficiency, because sclerotherapy can only treat superficial venules.

    Spider nevus, also known as "spider hemangioma", is a small benign lesion with a small artery in the middle. It comes from a small branch of the artery and has smaller radial steps around it. Although the name is very similar, Spider veins occur in the centrifugal part of the circulatory system (arterial system), while spider veins occur in the venous system where blood flows back to the heart. To distinguish between two types, the doctor will gently press the center of the "spider". When the center of the spider mole is pressed, it will turn white and lose its reddish color. When the doctor stops pressing, the color will return. Spider veins are not affected by this pressing method. In addition, spider nevi are common in children and pregnant women, but not in the elderly. The treatment method uses laser treatment and electric drying method, and children do not need sclerotherapy.

    After taking the medical history, the doctor starts from the patient’s waist to check down, not only paying attention to the expansion of the spider vein, touching the lesion lightly, and observing for signs of other venous diseases. Ideally, the examination should have a small table that can be raised, and the patient can stand on it during the examination. The doctor asks the patient to rotate slowly while observing for scars, skin swelling, skin discoloration, or other signs of chronic venous dysfunction. When touching the legs, the doctor should pay attention to changes in skin temperature, soreness, cysts, edema, etc. Next, the doctor should percuss the parts of the legs near the larger veins on the body surface. By gently tapping the skin surface of these areas, the doctor can feel the fluid waves in the veins and decide whether to further test the need for venous valve insufficiency . If a patient has problems related to severe varicose veins, they must be treated before sclerotherapy can eliminate spider veins.

    Contraindications for sclerotherapy for varicose veins include:

    During pregnancy and lactation: Pregnant women should postpone sclerotherapy treatment until three months after delivery, because some spider veins will disappear automatically after delivery. Breastfeeding women should postpone sclerotherapy until after the baby is weaned, because it is still unclear whether the chemicals used in sclerotherapy affect the milk.

    diabetes

    AIDS, hepatitis, syphilis or other blood-borne diseases

    heart disease

    Hypertension, blood coagulation disorders, and other circulatory diseases

    ready

    Before sclerosing agent injection treatment, patients should stop taking aspirin or aspirin-related drugs. In addition, tell the patient not to use any moisturizer, cream, tanning lotion, or sunscreen on the legs on the day of treatment. During the treatment, the patient should bring a pair of spare shorts, as well as elastic stockings and a pair of long pants or a long skirt to cover the legs after treatment.

    Most doctors will take photos of the patient's legs before sclerotherapy treatment to assess the effect. In addition, some insurance companies require the photos before treatment as archives.

    Postoperative recovery

    Rehabilitation after sclerotherapy includes the following aspects: after treatment, wear medical compression stockings, the pressure should be 20-30mmHg, at least 7-10 days (preferably 4-6 weeks). Wearing compression stockings can minimize the risk of edema, skin discoloration and pain. It is not appropriate to choose commonly used stockings because they cannot provide enough pressure on the legs.

    Bandages and cotton pads used during treatment must be removed 48 hours after the patient returns home.

    Patients should be encouraged to walk, ride bicycles, or participate in other less active exercises (such as yoga and Tai Chi) to prevent deep vein thrombosis in the lower limbs. Sedentary or standing for a long time should be avoided, as well as heavy exercise activities such as jogging.

    risk

    From a cosmetic point of view, the main risk is the formation of new spider veins after sclerotherapy. The new spider vein is when part of the venous blood is bypassed back to the larger vein, the blood vessel is expanded and formed, and it is not the recurrence of the hardened blood vessel. Some patients may develop telangiectatic matting, which is a new network of spider veins on the surface of the treated area. Telangiectatic matting usually disappears after 3-12 months of sclerotherapy injection, but it can also be further treated with sclerosing agent injection.

    Other risks of sclerotherapy treatment include:

    Venous thrombosis. Thrombosis refers to the formation of blood clots in the veins. This is a serious complication.

    Severe inflammation

    Postoperative pain, lasting several hours or days, the discomfort can be relieved by wearing medical elastic stockings and walking briskly.

    Allergic reaction to hardener solution or foam.

    Permanent scars.

    Damage to the nerves in the treated area leads to loss of sensation.

    . Edema of the feet or ankles. This problem is most likely to occur when the spider veins in the feet or ankles are being treated. Edema usually resolves within a few days to a few weeks.

    . The brown spots or color changes of the skin around the treatment area are caused by the accumulation of hemosiderin, a form of tissue cells that store iron. These spots usually subside after a few months.

    . Skin ulcers, this complication may be caused by reactive spasms of blood vessels, due to the use of too strong a sclerosing agent solution, or the lack of equipment to manage the sclerosing agent. It can be diluted with saline solution of hardener to reduce the chance of occurrence.

    . Hirsutism, hirsutism is abnormal hair growth in the area treated by sclerotherapy. It usually appears after 1 month of treatment and then disappears on its own. It is also called: Hypertrichosis

    Curative effect

    The curative effects of sclerotherapy include improving the appearance of the legs and relieving pain or cramps associated with spider dilated veins. It is currently believed that in order to completely eliminate spider veins, 3 to 4 sclerotherapy is required.

    Complications and mortality:

    When the treatment is performed by a professional doctor, the mortality rate associated with sclerotherapy is almost zero, and the incidence of other complications varies, including the following:

    Hemosiderin discoloration: 15-75% of 80 patients, only less than 1% of cases last more than 1 year.

    Telangiectatic matting: 5%-75% of patients.

    Deep vein thrombosis: less than 1%.

    Mild pain: 35%-55%.

    Skin ulcers: about 4%.

    Other options

    Conservative treatment

    Patients suffering from discomfort caused by spider-like varicose veins may benefit from the following methods:

    Exercise Walking or other forms of exercise can activate the calf muscles to relieve pain and cramps, because the movement of these muscles keeps blood flowing to the leg veins. One exercise that is often recommended is repeated flexion of the ankle joint. Flexing the ankle joint 5-10 times every few minutes and walking for 1-2 minutes every half an hour can prevent vein blockage caused by sitting and standing in the same posture for a long time.

    Avoid wearing high heels. When the patient walks, the high heels show full flexion of the ankle joint. This restriction on the ankle joint's range of motion makes it more difficult for the leg muscles to squeeze venous blood to the heart.

    Raise the legs 1-2 times a day for 15-30 minutes each time. This postural change is often recommended to reduce edema in the feet and ankles.

    Wearing compression stockings Compression stockings help reduce inflammation in the veins of the legs and increase venous return. Most manufacturers of medical elastic stockings now provide some relatively pure socks, which are not only beautiful but also have therapeutic effects.

    Drugs used to treat discomfort caused by spider varicose veins include non-steroidal anti-inflammatory drugs and vitamins C and E. A prescription drug used to treat circulatory diseases of the legs and feet is pentoxifylline. Helps improve blood flow in smaller capillaries. Pentoxifylline is currently sold under the brand name trendar.

    If aesthetics is the patient's primary concern, there are currently specially formulated cosmetics for various skin tones to cover the spider veins in the legs. Some of them are useful during swimming or other sports activities.

    Electric desiccation, laser therapy and pulsed light therapy

    Electric desiccation is a treatment method in which the doctor sends a weak current through a fine needle to the vein wall to close the small veins that cause the spider vein. Compared with the spider veins on the legs, the electric drying method seems to be more effective for the spider veins on the face. When used to treat the spider veins on the feet and legs, it tends to leave white sunken scars.

    Laser treatment: Like the electric drying method, it can better treat the spider veins on the face. The large focused laser beam generated by the laser generator heats the blood vessels, causing blood coagulation in the veins to close the veins. Various lasers have been used to treat spider veins, including argon, KTP532nm, and emerald lasers. Choose lasers with different wavelengths and pulses according to the size of the vein to be treated. However, argon laser treatment of the legs increases the risk of hemosiderin discoloration. KTP532nm laser can get better results in the treatment of spider veins in the legs, but it is still not as good as sclerotherapy.

    Intense pulsed light (IPL), the system is different from lasers because the light it emits is asynchronous and not monochromatic. The IPL system allows doctors to use wider wavelengths and pulse frequencies to treat spider veins and other skin problems, such as moles. This flexibility requires skilled and experienced doctors to prevent damage to the surrounding skin.

    Complementary and Alternative (CAM) Therapy

    The former leader of the complementary and alternative treatment program, Dr. Kenneth Pelletier of Stanford University School of Medicine in California, chestnut extract is as safe and effective as compression stockings as an alternative treatment for spider veins. In Europe, chestnut extract (Aesculus hippocastanum) has been used to treat synchronous circulatory problems for many years, and recent studies have also been carried out in the UK and Germany. The usual dose is 75 mg, twice a day, taken with meals. The most common side effect is dyspepsia when taken orally in patients.

    Other sclerosing agents treat esophageal varices, ligation and stripping of veins.

    Wikipedia: Sclerotherapy injection treatment

    The sclerosing agent injection therapy department is used to treat varicose or vascular malformations, as well as the lymphatic system. The drug is injected into the blood vessels and closed the blood vessels. It can be used for children or young people with vascular or lymphatic malformations. In adults, sclerotherapy is mostly used to treat varicose veins and hemorrhoids.

    Sclerotherapy, like surgery, radiofrequency and laser ablation, is one of the methods to treat varicose veins and venous malformations. In ultrasound-guided sclerosing agent injection therapy [2], ultrasound is used to see deep veins and provide monitoring for doctors' injections. After the venous malformation is diagnosed by B-ultrasound, sclerosing agent injection treatment should be performed under ultrasound guidance. Ultrasound-guided microbubble sclerosing agent injection therapy has been proven to effectively control the reflux from the confluence of the saphenous veins of the thigh and the saphenous veins of the popliteal. However, some scholars believe that sclerosing agent injection therapy is not suitable for large and small saphenous vein reflux. [5]

    Historical aspect

    Sclerotherapy has been used to treat varicose veins for more than 150 years. Like varicose vein surgery, sclerosing agent injection treatment techniques have also evolved during this time. Modern technologies including ultrasound guidance and foam sclerosing agent injection therapy are the latest developments in this area.

    Goldman pointed out that it was Dzollikofer of Switzerland who first reported an attempt on sclerosing agent injection therapy. In 1682, he injected an acid into the vein to promote thrombosis. About 12 years after Madelung invented varicose vein stripping in 1884, in 1853, Debout and Cassaignaic injected iodine and tannins and successfully cured 16 cases of varicose veins. Sclerotherapy was popular in the late 19th century and early 20th century, and several studies until the 1930s indicated that the treatment had a high recurrence rate. At that time, with the development of surgical techniques and anesthesia techniques, dissection became the (main) choice.

    However, from the 1940s to the 1950s, the work on improving the technology of sclerosing agent injection therapy and developing safer and more effective sclerosing agents continued. The most important development was the discovery of sodium tetradecyl sulfate (STS) in 1946, which is still in use today. George FegenZ published a report on the treatment of more than 13,000 cases with sclerosing agent injection in 1960, which significantly advanced the sclerotherapy technique from focusing on venous thrombosis and controlling obvious reflux to focusing on fibrosis transition, and emphasized that the treated legs must be treated. Pressurize. In Europe, this treatment method was accepted medically at the time. However, in the United Kingdom and the United States, people know very little about this treatment and do not accept it. In some medical communities, this situation continues to this day.

    Next, the main development of sclerosing agent injection therapy was the advent of ultrasound interventional therapy in the 1980s, and it was applied to the practice of sclerosing agent injection therapy 10 years later. Knight is an early advocate of this line of technology, and he has published his opinions at many conferences in Europe and the United States. Thibault's article was first published in the peer-reviewd magazine about this point of view.

    Cabrera and Monfreaux have made revolutionary progress in the treatment of large varicose veins based on the "3-way tap method" of Tessari’s foam products.

    method

    Injection of sclerosing agent solution into the diseased vein causes it to shrink immediately. In the next week, the target vein will dissolve and be absorbed by the body naturally to achieve the purpose of treatment.

    Sclerosing agent injection therapy is more effective than laser therapy in eliminating larger spider veins (telangiectasia) and smaller varicose veins, and has become the "gold standard". Unlike laser treatment, sclerosing agent injection treatment also closes the subcutaneous "venous branch (spider vein)", thus reducing the recurrence of spider veins in the treated area. The patient should wear elastic stockings or bandages within 2 weeks after treatment. Encourage patients to walk regularly during this time. The usual practice is to require 2 courses of treatment several weeks apart to significantly improve the appearance of their leg veins.

    Sclerotherapy can also be used to treat larger varicose veins, including the large and small saphenous veins, with microbubble sclerosing agents under ultrasound guidance.

    Foam hardener injection therapy

    Foam sclerotherapy is a technique of injecting "foam sclerosing agent" into blood vessels with a syringe. The sclerosing agent drug (sodium tetradecyl sulfate or polyethylene glycol monolauryl ether) is mixed with air or physiological gas (carbon dioxide) in a syringe or mechanical pump, which increases the surface area of ​​the drug. Foam hardener is more effective than liquid hardener in causing hardening (thickening the blood vessel wall and blocking the blood vessel), because it will not mix with the blood in the blood vessel, but replace the blood, thus avoiding the dilution of the drug. The greatest effect of hardener. Therefore, he is also more suitable for larger blood vessels. Foam sclerosing agent injection therapy specialists can create thick foam like "toothpaste", which has revolutionized the non-surgical treatment of varicose veins and venous malformations including Klippel Trenaunay syndrome.

    Clinical evaluation

    A 1996 study by Kanter and Thibault reported that the success rate of treating the femoral saphenous vein junction and great saphenous vein incompetence with a 3% sodium tetradecyl sulfate solution within 24 months was 76%. Padbury and Benveniste found that ultrasound-guided sclerotherapy can effectively control the reflux of the small saphenous vein.

    A review from the Cochrane Collaboration concluded that "the evidence supports the treatment of sclerotherapy in clinical practice, which is usually limited to the treatment of recurrent varicose veins and linear blood vessels after surgery."

    A second review from the Cochrane Collaboration by comparing surgery and sclerosing agent injection treatment concluded that sclerosing agent injection can achieve better benefits in the short term, while surgery can achieve better long-term results. According to the treatment success rate, complication rate and cost within one year, sclerotherapy is better than surgery, but after 5 years, surgery is more advantageous. However, the evidence is not of good quality and more research is needed.

    A health technology evaluation found that sclerosing agent injection therapy provides less benefits than surgery, but it seems that less benefits can be obtained when there is no combined femoral saphenous reflux or popliteal saphenous reflux. He did not compare the benefits of surgery and sclerotherapy injections for varicose veins in the presence of confluence reflux.

    In 2003, the European Consensus Conference on foam sclerosing agent injection therapy concluded that “skilled doctors can use foam sclerosing agent injection to treat larger varicose veins, including the main saphenous vein.”

    complication

    Complications are rare and include venous thromboembolism, visual disturbances, allergic reactions, thrombosis, skin necrosis, and pigmentation.

    Sclerotherapy injection, if it enters the vein properly, it will not damage the surrounding skin. But if he is injected outside the vein, the tissue will die and scars will be formed. The incidence of skin necrosis is about 0.2% to 1.2%, which is "potentially destructive" in beauty, which is often impossible to prevent and may take several months to heal. This is rare when using a small amount of dilution (<0.25%) instead of using a high concentration (3%) sodium tetradecyl sulfate (STS). Skin burns often occur when STS is injected into an artery (small artery branch). The development of telangiectatic matting or tiny blood vessels is unpredictable and usually must be treated with repeated sclerotherapy or laser treatment.

    A recent report showed a stroke with foam hardener treatment, but this was due to an abnormally large amount of foam injected.

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