The$Histology$of$Spider$Veins$ Chapter$6$ Ronald$Bush,$MD,$FACS$ Peggy$Bush,$APN,$CNS,$MSN$
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• This$acOvity$has$been$planned$and$implemented$in$accordance$with$the$ accreditaOon$requirements$and$policies$of$the$AccreditaOon$Council$for$ ConOnuing$Medical$EducaOon$(ACCME)$through$the$joint$providership$of$ The$University$of$Toledo$and$VeinExperts.org.$ • The$University$of$Toledo$is$accredited$by$ACCME$to$provide$conOnuing$ medical$educaOon$for$physicians.$ $$ • The$University$of$Toledo$designates$this$enduring$acOvity$for$a$maximum$ of$1.00$AMA#PRA#Category#Credits™.$$Physicians$should$claim$only$credit$ commensurate$with$the$extent$of$their$parOcipaOon$in$the$acOvity.$ '$ $
For$nurses,$we$are$also$able$to$issue$a$cerOficate$of$aYendance$staOng$the$course$is$AMA$approved,$ which$may$be$eligible$for$credit.$$Nurses$are$responsible$for$submiZng$the$cerOficate$to$their$board.$$Please$ note$only$one$cerOficate$can$be$issued$for$each$purchase.$ $ Disclosure:$ $ 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.$$ $ Richard'L.'Mueller,'MD,$faculty$and$planning$member,$discloses$he$receives$grant/research$support$from$Vascular$ Insights,$LLC$
$ Ariel'Soffer,'MD,$FACC,$faculty$and$planning$member,$discloses$he$is$on$the$Speaker’s$Bureau$for$Cutera$,$ consults$for$Angiodynamics,$&$does$research$for$BTG.$ $ Peggy'Bush,'APN,$planning$member,$has$no$disclosures$or$financial$interests$and$is$employed$by$Midwest$Vein$ &$Laser$Center.$ Becky'Roberts,$planning$member,$has$no$financial$interest$or$other$relaOonships$with$any$manufacturer$ of$commercial$product$or$service$to$disclose.$$ $ $$ $
Mission:$ $Our$objecOve$is$to$provide$current$evidence$based$informaOon,$as$well$as$ new$technology$that$is$being$developed$for$the$treatment$of$venous$disease$ presented$in$a$virtual$format.$$ $$ Target'Audience:$ $The$target$audience$for$this$acOvity$includes$physicians$and$other$health$care$ professionals$in$Cardiology,$Dermatology,$IntervenOonal$Radiology,$ Phlebology,$Surgery,$Vascular$Surgery,$Wound$Care$Specialists$who$care$for$ paOents$with$venous$disease.$$ $
CME'Credit'Instruc6ons$ $ Steps'to'successfully'complete'this'ac6vity:$ CME'Credit'Instruc6ons$ Steps'to'successfully'complete'this'ac6vity:$ Register$for$CME$acOvity$&$pay$your$CME$fees.$ Read$the$Vein$Journal$Chapter$6,$enOtled$‘The'Histology'of'Spider'Veins.’' Take$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$and$evaluaOon$to$$pbush@veinexperts.org$or$you$ can$fax$completed$paperwork$to$937L281L0200.$$ You$will$be$contacted$by$the$University$of$Toledo$CME$office$for$instrucOon$of$ how$to$sign$on$and$print$your$cerOficate.$$ $
Technical'Support$ $ '$ $$ Email$your$quesOons/concerns$to$pbush@veinexperts.org$$or$you$can$call$us$ at$407L900L8346$and$we$will$respond$in$24$hours.$ $$ '$ $
The'Histology'of'Spider'Veins$ $ This$acOvity$describes$the$effect$of$different$modaliOes$commonly$used$for$ the$treatment$of$spider$veins$at$the$microscopic$level.$$ $ Learning'Objec6ves:$
'$ As$a$result$of$this$acOvity,$the$parOcipant$should$be$able$to:$ $$ Recognize$the$different$modaliOes$for$the$treatment$of$spider$veins.$$ $$ IdenOfy$complicaOons$that$may$develop$with$the$use$of$modaliOes$for$spider$vein$ treatment.$ $$ Recognize$steps$to$avoid$complicaOons$ $$ IdenOfy$the$effect$at$the$cellular$level$of$the$different$modaliOes$that$are$commonly$ used.$$$ $$
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• This$CME$acOvity$deals$with$histology$of$ spider$veins$and$the$effect$of$different$ treatment$modaliOes$ • First,$a$spider$vein$is$simply$a$dilated$ subcutaneous$vessel$laying$in$the$papillary$ dermis$ • Figure$1$shows$the$histologic$appearance$of$a$ spider$vein.$Note$the$muscle$wall$hypertrophy$
Untreated$Spider$Vein$ Red'Arrow$$Stratum$Corneum$ L$Structural$material$making$up$ the$outer$layer$of$human$skin.$ KeraOnL$dead$skin$cells$ $$ Blue'Arrow''Squamous$ epithelial$layer$ $$ Green'$$papillary$dermis$ (collagen)$ $$ Orange'Arrow'$Smooth$muscle$ of$spider$vein$ $$ Black$$ReOcular$dermis$(fat)$
Histology$of$Spider$Veins$ • Spider$veins$dilate$due$to$transmiYed$ pressure$from$a$deeper$region$ • ReOcular$veins$are$usually$associated$with$ spider$veins$and$are$the$source$for$pressure$ transfer$ • ReOcular$veins$may$be$the$sole$eOology$or$ associated$with$axial$reflux$or$perforator$ incompetence$
Histology$of$Spider$Veins$ • Spider$veins$are$300L700$microns$below$the$ squamous$epithelium$ • Surrounded$by$collagen,$which$is$the$ predominant$content$of$the$papillary$dermis$ • Spider$veins$contain$a$thin$layer$of$ endothelium,$muscular$layer,$and$advenOOa$
Lasers$For$Spider$Veins$ • Knowing$the$depth$of$a$spider$vein$allows$you$ to$use$appropriate$therapy$ • 532$nm$to$560$nm$laser$affects$the$small$veins$ close$to$the$surface$ • Blue$spider$veins$are$deeper$and$need$a$ higher$wavelength$ • More$energy$must$be$delivered$to$affect$ damage$due$to$blood$volume$
Lasers$For$Spider$Veins$ • Target$is$endothelium$ • With$endothelial$damage,$thrombosis$can$ occur$ • Cellular$infiltraOon$similar$to$that$described$ aper$thermal$ablaOon$then$occurs$ • Collateral$flow$may$cause$revascularizaOon$ before$collagen$replacement$of$the$thrombus$
(Parsons,$2004)$(Bush,$2008)$
Lasers$For$Spider$Veins$ • Laser$therapy$by$itself$is$usually$an$adjunct$for$ treaOng$spider$veins$ • The$goal$is$to$decrease$the$luminal$diameter$ • Less$sclerotherapy$is$then$needed$ • For$small$red$veins,$less$than$0.5$mm$in$size,$ laser$can$be$the$definiOve$treatment$if$the$ skin$type$is$appropriate$
Lasers$For$Spider$Veins$ • In$the$next$slide,$the$effect$of$a$940$laser$on$a$ spider$vein$is$demonstrated$ • Note$the$affect$of$the$laser$on$collagen$in$the$ papillary$dermis$ • The$effect$of$lasers$on$reOcular$veins$will$be$ discussed$in$another$CME.$$
940LLaser$Used$
Sclerotherapy$ • Damages$done$by$endothelial$wall$destrucOon$ • Higher$concentraOons$also$can$destroy$vessel$ wall$ • Smooth$muscle$wall$may$be$destroyed$by$ higher$concentraOons$ • When$smooth$muscle$wall$is$destroyed,$there$ is$an$extravascular$inflammatory$response$ with$the$possibility$of$staining$or$angiogenesis$ (Parsons,$2004)$
Ohmic$Thermolysis$ • Heat$damage$delivered$by$conducOon$through$ a$small$needle$ • Collateral$damage$to$the$squamous$ epithelium$occurs$also,$however,$heals$within$ a$month$ • Endothelial$destrucOon$occurs$within$vessel$ wall$and$many$Omes$vessel$wall$fusion$occurs$ • Most$effecOve$for$veins$<$0.5$mm$
Absence$of$endothelial$cells$ Fusion$of$lumen$ ElectrodessicaOon$of$Ossue$ Small$area$of$collateral$ damage$ • Veins$<$0.5mm,$can$be$ treated$with$ohmic$ thermolysis$alone$ • Ohmic$thermolysis$works$by$ direct$electrodessicaOon$ and$eventual$fibrosis$of$the$ vein$wall$ $$ • • • •
Intense$Pulsed$Light$ • Filtered$light$waves$above$a$certain$ wavelength$ • This$modality$is$useful$for$very$small$veins$ close$to$the$skin$surface$ • Appropriate$skin$type$must$be$determined$ • Modality$associated$with$most$possible$ complicaOons$
Intense$Pulsed$Light$(IPL)$ Loss$of$endothelium$ No$epithelial$damage$ No$damage$to$papillary$dermis$ IPL$is$the$least$effecOve$of$the$ heat$modaliOes,$due$to$depth$ of$penetraOon$&$skin$type$ issues$ • IPL$targets$the$Hgb$in$the$ blood$to$effect$damage$ • Veins$<$0.3$mm,$can$be$ treated$with$this$modality$ alone$ • Usual$waveLlength$560$ $$ • • • •
CombinaOon$Therapy$ • • • •
When$possible,$use$combinaOon$therapy$ Dual$injury$occurs$ Quicker$resoluOon,$less$chance$of$staining$ Using$appropriate$parameters,$this$is$quite$ safe$as$shown$in$next$slide$
CombinaOon$Therapy$
Conclusion$ • SclerotherapyL$Loss$of$endothelium,$vessel$wall$ destrucOon,$depending$on$concentraOon$and$ Ome$to$inacOvaOon$ • LaserL$Loss$of$endothelium$and$vessel$wall$ constricOon$with$collagen$injury$to$papillary$ dermis$ • Ohmic$thermolysis$–$Loss$of$endothelium,$vessel$ wall$constricOon,$vessel$wall$fusion$may$occur,$ depending$on$size$of$vessel$and$joules$of$injury$
Conclusion$ • IPL$–$Loss$of$endothelium,$only$used$on$ superficial$vessels,$appropriate$skin$type,$and$no$ damage$to$collagen$ • The$goal$of$combinaOon$therapy$is$to$deliver$ sclerotherapy$to$a$constricted$vessel$treated$with$ some$type$of$heat$modality$ • This$requires$less$sclerotherapy$soluOon$and$ based$on$our$center’s$studies,$appears$to$cause$ faster$resoluOon$with$less$adverse$sequelae$
References$ $$ Bush$R,$Shamma$N,$Hammond$K.$Histological$changes$occurring$aper$ endoluminal$ablaOon$with$two$diode$lasers$(940$and$1319$nm)$from$acute$ changes$to$4$months.$Lasers#Surg#Med.$2008;40:676L679.$$ $ Bush,$R.$$Histological$Analysis$Of$Sclerotherapy,$Laser$940,$Ohmic$ Thermolysis,$And$Intense$Pulsed$Light,$On$Leg$Vein$Telangiectasias$ Conference;$2013$Sep$8L13;$Boston.$ $ Images.$Retrieved$online$9.26.13$from$www.veinexperts.org.$ $ Parsons$M.$Sclerotherapy$basics.$Dermatol#Clin.$2004:22:501L508.$ $
Exam$ Complete'the'exam'&'evalua6on'below'and'email'your' results'to'pbush@veinexperts.org'along'with'your' contact'informa6on.'$ '$ A'score'of'80%'or'greater,'must'be'achieved'on'the' post^test'and'be'completed'in'less'than'3'a_empts.'$ The$primary$target$of$any$modality$is$
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a.$$Vessel$wall$ b.$$Endothelial$cells$ c.$$Hemoglobin$ d..Mast$cells$
Exam$ What$modality$has$the$least$effect$on$the$target$vessel?$ a.$$Ohmic$thermolysis$ b.$$Laser$ c.$$Sclerotherapy$ d.$$Intense$pulsed$light$ $$ A$major$cause$of$spider$vein$recanalizaOon$is$ a.$$Collateral$flow$ b.$$Injury$to$surrounding$Ossue$ c.$$Lack$of$HgB$target$ $$ CombinaOon$therapy$is$$ a.$$Not$safe$ b.$$Is$associated$with$less$staining$ c. Prolongs$the$resoluOon$of$the$treated$complex$ $$
EvaluaOon$ $$ How$well$did$this$acOvity$present$the$objecOves?$ $$ Excellent$$Good$ $ $SaOsfactory$ $ $Poor$$ $$ $$ How$do$you$rate$the$overall$usefulness$of$the$online$material$to$meeOng$your$needs?$$ $$ Excellent$$Good$ $$ $SaOsfactory$ $ $Poor$$ $$ $$ How$do$you$rate$the$overall$presentaOon$material?$$ $$ Excellent$$Good$ $ $SaOsfactory$ $ $Poor$$ $$ $
Was$any$commercial$bias$presented$in$the$material?$$ $ No$ $Yes$(Please#explain)#$$ ____________________________________________________$$ $$ I$will$be$able$to$change$my$clinical$pracOce$as$a$result$of$parOcipaOng$in$this$acOvity.$ $$ Yes$ $No$$ $$ $$ What$topics$about$venous$disease$would$you$like$to$hear$about$in$the$future?$$ $$ ____________________________________________________$$ $$$ $$ $
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