Spider Vein Treatment 2013 - 8.10.13 by VeinExperts.org

Spider Vein and Reticular Vein Treatment Manual Ron Bush, MD, FACS Peggy Bush, APN, CNS, MSN Vein Experts 2013

VeinExperts P.O. Box 768 Palm City, Florida, 34991 www.veinexperts.org 407-900-8346

Spider Veins – Anatomy & Physiology Spider veins are small-dilated veins near the surface of the skin and measure about 0.3 mm to 1.0 mm in size. They may be red, blue, purplish, or greenish in color. The medical term for spider veins is telangiectasia. Spider veins can develop anywhere on the body, but are commonly found on the face and legs. The veins (usually green in color) leading to the spider complex are reticular veins. Reticular veins are usually found 1mm or more below the skin surface. Spider veins may be the sign of deeper insufficiency. For this reason, any underlying problem contributing to spider veins must be addressed, before treatment may begin. Most spider veins are caused by venous hypertension transmitted through the reticular veins.

Normal Subcutaneous venous anatomy, Atlas of Endovascular Venous Surgery, 2012- Courtesy of Jose Almeida, MD, FACS

This simplistic drawing shows how all veins are related from deep to superficial. Transmitted pressure at one level is responsible for dilatation at a more superficial level. In the majority Of spider vein pathology, only the reticular and veins of the papillary dermis are involved.

Red Arrow Stratum corneum - Structural material making up the outer layer of human skin. Keratin- dead skin cells Blue Arrow Squamous epithelial layer Green

papillary dermis (collagen)

Orange Arrow Smooth muscle of spider vein Black Reticular dermis (fat) This histological section shows a spider telangiectasia and as can be seen in the diagram, there is hypertrophy of the smooth muscle and this is secondary to transmitted pressure from a deeper reticular vein. This vein lies about 4/10 mm (400 microns) below the skin surface. Spider veins, although superficial in visible appearance are in actuality more complex in regards to location.

5 Contributing Factors to the Development of Telangiectasia (Spider Veins) • Age • Gender – Females (80% females) • Genetics • Hormones • Pregnancy – Increased venous pressure and hormonal changes • Obesity • Occupation • Race • Sedentary lifestyle • Sun exposure • Therapeutic radiation • Trauma Symptoms of Spider Veins • Burning • Bleeding • Itching • Pain • Stinging sensations • A majority of spider veins are asymptomatic Patient Selection • • •

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Typically present with cosmetic complaints Do a thorough assessment and this includes: assessing spider veins, medical history, chief complaint, family history, and patients expectations relating to their spider veins Do a thorough ultrasound (US) if question about deeper venous disease exists, since the patient may have venous insufficiency. Scan the GSV, SSV, & thigh extension branch. Look for any perforators that may communicate through superficial branches to the spider complex. Even though insufficiency exists in a truncal vessel; in those patients with spider varicosities, simple techniques can be used such as dividing the branch leading to spider complexes, thus avoiding EVLT, if no other indication is present to treat the GSV insufficiency. Educate your patient about the benefits, risks, and alternatives to treatment Inform your patient of all potential adverse sequelae and possible complications Inform your patient that there is no cure at this time for spider veins and they can develop new spider veins Medications such as Minocycline or Isotretinoin can lead to adverse reactions, if not stopped prior to the treatment

Pre-Treatment Instructions • • • • • • •

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Have patient bring a pair of shorts for consult and every treatment May want to have disposable shorts on hand (Patients forget their shorts) Have compression stockings available for patients and ask them to bring their stockings to each visit Tell the patient not to wear lotion/oil on the day of treatment Tell the patient that spider vein treatments require 3-5 treatments, spaced one month apart before resolution Sessions are 20 minutes Laser and intense pulsed light (IPL) patients – Tell them no sun exposure or tanning bed use for 6-weeks prior to a treatment and no artificial tanner use for 2 weeks before a treatment. Increased melanin stimulation after sun exposure can cause hyperpigmentation with light or heat treatment. Tell the patient after treatment, their legs will look worse before they get better

Consult – 1st Visit It is § § § § §

essential to determine: Pathophysiology Size of vessel Dermal anatomy Most telangiectasia are in the papillary dermis or upper reticular dermis In most vessels, the depth ranges from 300-700 microns

Location means everything § Vessel size § Skin type § Vessel depth § All the above, determine the type of treatment used May need to perform an ultrasound (US) depending on the clinical presentation to rule out venous insufficiency and address first in order to provide the best cosmetic result. Remember most spider veins have a reticular vein associated with them regardless of the deeper pathology. You must treat both reticular and spider veins. Educate your patient about treatment, possible complications, post treatment and results. Do test on a small area before treating a larger area. It is important to do a test to evaluate response to the chemical solution or heat therapy used.

Scripting for Patients Spider Vein Treatment •

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After the treatment you may have o Sclerotherapy – redness, possible bruising that may last up to 2 weeks § Small lumps/bumps that may be tender. These will go away, but it may take a week or so. o Ohmic thermolysic- redness, small tracks and skin scabs which resolve o Laser - redness

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Keep the compression dressings on till the morning, remove the dressings, and shower Wear your compression stockings for 3-4 days during waking hours. You do not need to wear your compression stockings while you are sleeping. (Ohmic thermolysis/laser – compression stockings are not needed) Compression stockings may minimize discomfort and may help minimize early bruising You can return to your normal activities, right after your treatment. No leg presses during the entire treatment period. There is no cure for venous disease and you may form new veins in the future. If you have any discomfort after your treatment, you may take an over the counter pain medication that works for you. You will need to wait 4-6 weeks for your next treatment on the same leg, since this may cause a condition called angiogenesis. You do not have to wait to have your other leg treated.

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Multiple treatment options are available for spider veins and these include sclerotherapy, laser, ohmic thermolysis, and intense pulsed light (IPL) either alone, or in combination. Faster resolution occurs when you use combination therapy in most instances. Spider veins usually have “feeder veins” that need to be treated along with smaller red or blue veins that you see. Laser and ohmic thermolysis can be used on the small veins, but caution is used on patients with darker complexions as well as patients who have been tanning. It is very important that 1 month prior to the laser treatment to not tan, so no skin damage will occur. Spider vein treatment requires more than one treatment. Usually 3-4 sessions spaced at least a month apart. Treatments in shorter time frame may result in angiogenesis. Your legs will look worse, before they look better. All veins are hereditary, so while we can eliminate what you have, you may develop more veins throughout your life. The procedures are very tolerable, since the needles used are extremely small and the solution is not painful. If laser is used, it is a hot sensation but very quick and you will leave the office with no discomfort after the treatment. Some patients complain of minimal pain after ohmic thermolysic and some complaints of pinpricks.

Bring shorts and your compression stockings anytime you have spider vein treatments.

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When using any form of heat therapy, treat spider veins before reticular veins o Rationale: Decreases size of the lumen, see less staining, and use less sclerosant

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If possible, use sclerotherapy plus heat or light based therapy. This includes ohmic thermolysis and laser. o Rationale: Hastens resolution of the veins, decreases diameter of the vein that sclerotherapy is needed for and prevents or reduces the amount of staining that can occur.

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It is best if you can offer combination therapy. o Rationale: Create dual injury for better cosmetic result and faster resolution

Imaging Magnifying glasses, loupes, and lights will also help you visualize inserting the needle into the spider veins Vein Light Consider using a Vein Light of some type that Tran-illuminates the skin making the identification of reticular veins easier. You will also see the connection between the reticular vein and the spider complexes with this device.

Syris Poloarized Light - Atlas of Endovascular Venous Surgery, 2012- Courtesy of Jose Almeida, MD, FACS

Algorithm For Small Vessel Treatment • • •

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Be able to recognize patterns of spider veins Scan the patient, especially on the medial aspect of the knee, calf, and ankle, since these patterns suggest saphenous insufficiency. The lateral reticular system is not associated with truncal insufficiency, but there may be a lateral perforator that needs to be treated with phlebectomy or foam sclerotherapy. Consider a phlebectomy if > 2mm in size. Rule out truncal insufficiency and this includes GSV, SSV, AAGSV, and thigh extension branch. If truncal insufficiency is present, consider EVLT, only if other symptoms co-exist. Use a vein lite if needed If using combination therapy, use laser first, then treat with sclerotherapy. By using the laser first, you reduce the blood volume, thus reducing or preventing staining. With ohmic thermolysis, it makes no difference. Apply cotton balls and paper tape over injection site. If patient reacts to tape, use gauze and wrap with an Ace bandage. Instruct patient to wear compression stockings for 2-3 days during waking hours.

Modalities For Treating Spider Veins • • • • • • •

Sclerotherapy Laser Ohmic thermolysis Intense Pulse Light (IPL) Ohmic thermolysis Cutera Excel V Minor Surgical Techniques

SCLEROTHERAPY

Sclerosants Detergent Solutions • Sodium tetradecyl sulfate (STS) (Sotradecol) FDA approved 0.2% - 0.3%

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Polidocanol (POL) FDA approved Comes in concentrations of 0.25% & 1%

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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.

Hyperosmolar/Hypertonic Solutions – Not FDA Approved • Hypertonic saline • Hypertonic dextrose • Sodium salicylate • Combination of hypertonic saline & hypertonic dextrose. The solution must diffuse throughout the vein wall to cause complete destruction. It has been reported in the literature that hypertonic saline causes a higher incidence of discoloration and staining. • These agents work by dehydrating the endothelial cells Chemical irritants – Not FDA Approved • Glycerin

13 SOTRADECOL DILUTION TABLE

Sotradecol Dilution using 1% with a 30 ml vial of 0.9% Normal Saline REMOVE ADD FINAL CONCENTRATION 6 ml 6 ml 0.2% 10 ml

10 ml

0.33%

15 ml

0.5%

Sotradecol Dilution using 3% with a 30 ml vial of 0.9% Normal Saline REMOVE ADD FINAL CONCENTRATION 2 ml 2 ml 0.2% 3.3 ml

3.3 ml

0.33%

5 ml

0.5%

Sotradecol Dilution using 3% with a 10 ml vial of 0.9% Normal Saline REMOVE ADD FINAL CONCENTRATION 2.5 ml 0.5 ml 0.18%

Sotradecol Dilution using 3% with a 10 ml vial of 0.9% Normal Saline REMOVE ADD FINAL CONCENTRATION 2 ml 1 ml 0.3%

Sotradecol Dilution using 2% with a 30 ml vial of 0.9% Normal Saline (Compounded) REMOVE ADD FINAL CONCENTRATION 3 ml 3 ml 0.2% 4.5 ml

4.5 ml

0.33%

7.5 ml

0.5%

Calculating Drug Concentrations

If you know this simple fact and can do a little algebra and cross-multiply, you can get any dilution form any starting concentration. If you’re a bit rusty and you have a kid in high school, your problems are solved. The strength of a solution of local anesthetics and sclerosants are given in percentages, which by definition is the number of Grams of drug per 100 units of measure (milliliters or cc’s). So a 1% solution has by definition 1 gram per 100 cc’s or 1,000 mgs per 100cc’s (10 mg/cc). A 0.5% solution has 0.5 gm/100cc or 500mgs per 100cc’s (5mg/cc). Thus, the higher the percentage the stronger the solution and the more milligrams there are in each milliliter or cc. For solutions it is important to know how many milligrams are in each ml for calculating the total dose of drug injected. Moving the decimal point 1 space to the right easily does this. Remember to the right to be correct. Example 1ml of a 1.5% solution contains 15mg/ml of the drug or 1cc of a 0.5% solution contains 5mg/cc.

Lateral Reticular Complex

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This is the most typical pattern you will see in your practice. The greenish vein in the center of the lateral thigh is the ‘lateral reticular vein.’ There is almost always a corona of spider varicosities associated with this vein when it is pathologic.

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The lateral reticular vein must always spider veins.

be treated in conjunction with the

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For larger lateral reticular veins, we use phlebectomy techniques.

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This particular patient would be a good candidate for Laser Therapy 940 to the spider veins first, followed by no more than 6 ml of 0.3% Sotradecol foam. If you do not have a laser, then foam the reticular vein first and milk as much foam as you can into the smaller veins. If the foam does not reach all of the veins, then use 0.2% liquid Sotradecol into the remaining small spider veins.

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Ohmic thermolysis should also be used for smaller veins.

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Have the patient wear compression stockings for 2-3 days. See back in one month and treat with sclerotherapy as needed.

• Illustration of a lateral venous plexus injection - Atlas of Endovascular Venous Surgery, 2012- Courtesy of Jose Almeida, MD, FACS

In the above patient, use 0.3% for the green reticular veins and ideally either ohmic thermolysis or intense pulsed light (IPL) for the small reddish veins. If you do not have light and heat treatment modalities, then you need to have meticulous technique to inject these small veins. Try using less than 0.2% concentrations. (0.1 – 0.15%)

Reticular Veins

This is a not uncommon finding and in fact a continuation of the lateral reticular system in some patients. Many patients have reticular veins that cross the popliteal fossa. In this patient, the reticular vein was treated with 0.3% Sotradecol foam and the foam was milked into the small reddish spider veins. In some patients, a 1064 Yag laser can be used for these reticular veins posteriorly. Superficial reticular veins respond better than those veins that are deeper. (Water absorption by tissue)

Post Treatment of Reticular Veins

This is the preceding patient after one treatment. (8 weeks post treatment) This is unusual because more treatments are usually necessary.

Sclerotherapy Using Foam for Reticular Veins The commonly used sclerosants Sotradecol and Polidocanol are detergent solutions. When you mix them with air or C02, bubbles (foam) are produced. The mechanism of action at the cellular level is cell destruction with replacement by fibrin and eventual clotting and scarring of the lumen. C02 or Room Air We use C02 since the bubbles dissolve faster in the arterial circulation, thus reducing the risk of adverse events Tessari Method • 1 part solution to 4 parts gas • Stopcock with 2 syringes Advantages to Using Foam • Increases surface area of sclerosant, thus reducing amount of medication needed • Circumferential contact with intimal wall causes more damage/better result • Displaces blood, thus avoiding dilution of drug/increase efficacy • Use in larger veins > 1.5 mm because foam is difficult to inject into a vein with a small lumen Disadvantages • Patients with PFO may not be a candidate • Neurological deficits – Migraines, scotoma

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DVT – Clear deep system with foot dorsiflexion immediately post treatment and encourage ambulation All above complications are extremely rare, especially DVT, since Sotradecol deactivates rapidly Using too high of a concentration may cause angiogenesis

Reticular Veins Sotradecol 0.33% or Polidocanol <0.75% Supplies needed • Stopcock • 2- 3cc syringes • 25-27 gauge butterfly • Alcohol swab • Cotton balls • Paper tape • 0.3 ml liquid Sotradecol /0.5 - 0.6% Polidocanol (maximum (5) 3-cc syringes) • Light Source

Spider reticular complex visualized with a light source • • • • • •

Use a 25-gauge or 27-gauge butterfly needle Must see a blood return Gently inject with Sotradecol, 0.3% liquid or foam Should see blanching and if not, remove needle and re-cannulate Apply cotton balls & paper tape (Cotton is gentler on the skin, especially when patient puts on their compression stockings) Have patient wear compression stockings for 2-3 days

Rationale for compression stockings • Provides comfort • Minimizes bruising • • •

Patient can resume daily activities & exercise 1-2 days post treatment Follow-up with patient in 4-6 weeks Avoid sun exposure

Foam: • Supplies needed: 2 -3 ml syringes & stopcock / we use 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

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Consider doing a phlebectomy for larger reticular veins. Our policy is to do a phlebectomy for reticular veins > 2mm Rationale: Improved cosmetic results & only one treatment is needed

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Remember, if you use too strong of a solution in the reticular vessels, you will get vessel wall destruction, inflammatory changes, and staining. So use 0.3% or less of Sotradecol if appropriate. Try Polidocanol 0.5% first if you are using this medication.

Spider Veins – Up to 1 mm Sotradecol 0.2% Supplies needed • Alcohol swabs • Cotton Balls • Paper tape • Sclerosing solution • 3-cc syringe with a 30-gauge needle • Syringes vary from 1 ml tuberculin syringe to a 3 ml syringe • 3-cc syringes are commonly used because it exerts the lowest pressure during injection • Bend 30-gauge needle to a 45-degree angle • Sclerotherapy Treatment • Inject sclerosant slowly • Look for blanching • Use caution in the ankle area • Apply cotton balls & paper tape (Cotton is gentler on the skin especially when patient puts on their compression stockings) • Have patient wear compression stockings 18-20 mmHg/women for 2- 3 days • Arnica gel may hasten resolution of skin sequela Treatment Room • Consider a spa like room – aesthetically pleasing, artwork, flowers, mural on wall • Consider a spa bed – need a comfortable bed • Comfortable room temperature • Good lighting • Stool for MD/RN • Offer a magazine to your patient

Rationale for compression stockings • Provides comfort • Minimizes bruising • May hasten resolution Post • • •

Treatment Instructions Patient can resume daily activities & exercise post treatment Follow-up with patient in 4-6 weeks Avoid sun exposure – If the patient stains, sun may intensify the staining.

Sclerotherapy With Liquid Sclerosant (Histo Slide 20X)

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Absence of endothelial cells Marked fibrin deposition in vessel wall Red cell aggregate in lumen & wall vessel Notice almost total destruction of vessel at one point. If total destruction were to occur

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then more peri-vessel staining and inflammatory changes would be present. Sclerotherapy causes cellular death and eventual fibrosis of the vein wall The action of sclerotherapy at the cellular level is not well understood

We bend the needle slightly prior to treatment, since it makes it easier to cannulate the vein.

After injection, there should be a very inflamed response. If you see minimal response, you May need to use a slightly higher concentration, but wait 4-weeks before retreating.

Video: Treating Spider Veins With Sclerotherapy

Spider Vein Images – Before & After (4 Weeks Post Treatment)

4 Weeks Post Treatment – Spider Vein Treatment

LASER

Lasers Best used for veins 0.5 mm – 1.2 mm in size. (Enough blood volume must be present for the heat uptake) In our practice, one of the lasers we use is the 940 nm for the treatment of spider veins. (Dornier) The rationale for doing this is that the adjunctive use of heat therapy, causes faster resolution and if done before either foam sclerotherapy or liquid sclerotherapy, decreases the amount of sclerosant needed to treat these small veins. The diameter of the vein is reduced considerably after laser treatment. Other wavelengths used include the 532 nm and 1064 nm.

27 The problem with the 560 nm is that there is a large competition with melanin and the depth of penetration is not that great. A 1064 requires in most instances cooling since the millisecond delivery is prolonged. Also, a 1064 nm is not as HgB specific as the 940 nm (See chart directly below). However, there are veins more amendable to a 1064 laser, which will be discussed later.

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940 nm wavelength Most laser pulses are less than 20-25 ms in duration Can vary pulse duration, energy, and frequency No cooling required 940 nm Diode laser, proven to be effective in the treatment of spider veins Goal is to cause vessel damage without damaging surrounding tissue

Flexi-Pulse D940nm Laser Therapy for Varicose and Spider Veins § § § §

Know the skin type of the patient Settings vary from patient to patient Chart below is a start point for treatment After pre-treatment assessment, select appropriate settings

28 § § § § §

MD/Nurse will titrate the settings to achieve the desired outcome (disappearance of vein) White dots on skin is indicative of too much heat Titrate down the joules (power) The whiting is a thermal ‘heat’ skin reaction and may result in a small scab or blister Should be transient/ adjust your setting

Leg Veins

Delay

Duration

Joules

0.5 mm spot size 500ms-1 sec. 20-25 ms

900j-1100j

1.0 mm spot size 500 ms- 1 sec 20 ms

325j-375j

Facial Veins Delay

Duration

Joules

0.5 mm spot size 500 ms- 1 sec 20-25 ms

700j- 880j

1.0 mm spot size 500 ms- 1 sec 20 ms

275j – 300j

The above charts are general guidelines in the field as common settings. The replace the judgment by the physician with regard to specifi treatment settings patients. Once settings have been selected following pre-treatment protocol, the physi titrate the settings to bring about the desired outcome.

Advantages of Using the Laser • • • •

Substantive reduction in staining Faster clearance in combined therapy Marketing addition Treats larger spider veins

Disadvantages of Using the Laser • • • •

No sun exposure No Fitzpatrick 5 & 6 Use with caution in Fitzpatrick type 4 Can cause permanent scarring

29 • •

Hypo- pigmentation / HyperCompete with melanin

pigmentation

Safety Tips for Laser or Light Therapy • • • •

Ask the right questions – Know patients heritage – Pacific Islander, American Indian, or Asian, Hispanic, use caution No sun exposure or sunless tanning – Competes with laser light Test laser at time of consultation Have patient and staff wear laser protective glasses

Laser (940)

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Absence of endothelial cells Small thrombus at maximal point of laser energy Subcutaneous water blister Collagen destruction Gaussian energy distribution Laser targets the Hgb in the blood & H20 in the tissues to effect damage

Treating Spider Veins with Diode Laser

Pre-Treatment Laser

Post Treatment Laser

This is an excellent result and exactly what you want to see. There should be no visible lumen, but an area of hyperemic response. There may be mild swelling but this quickly resolves. If the patient does not blister, you will not have hypopigmentation. Hyperpigmentation may occur with wrong skin type or too much heat. Always test a small area first and have patient come back in 2-3 weeks before starting treatment. We have had minimal complications in using this laser.

Pre-Treatment - Laser

Post Treatment - Laser

This laser is also effective for blue and red veins for the nose and face. (< 1mm) Educate patients to use sunblock one month prior to treatment and during treatment.

Cutera Excel V Laser

Many patients seek consultation for large facial veins. Very commonly these are infraorbital or they can run from the saggital sinus and empty in to the pterygoid plexus or the region of the external jugular vein. These veins are very unacceptable cosmetically to most patients. They can vary in diameter from 1-3 mm in size. Dr. Badawi, while visiting our clinic, Aug/2012, shared his excellent results.

36 Â

I treated this patient recently using Cutera excel V. The arrow points to the only remaining portion of the vein. Some veins can be treated with one application and others will require 2-3 treatments.

Using the Cutera excel V, if available is a great adjunct to treating large veins of the face. This also applies to large reticular veins of the breast and leg. At the present time, I am doing histological studies and will share the results with you when available. Lasers have come a long way in the last 10 years. Click here to see a ppt by Dr. Badawi!

Pre-Treatment

30 Minutes Post Treatment

This is another use for the Excel V laser. This laser works very well on many reticular veins as well as those spider veins suitable for its wavelength. Â

OHMIC THERMOLYSIS

Ohmic Thermolysis Radio frequency (RF) conduction by direct application Very effective on red veins 0.5 mm or less and facial veins Ignore skin type Minimal incidence of scarring or hypopigmentation Very well tolerated Newest modality available

Pre-Treatment Ohmic Thermolysis

2- Weeks Post Ohmic Thermolysis

2 – Months Post Ohmic Thermolysis

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This device is very effective for veins less than 0.5 mm in size. As with the laser, a test should be done before treating patient. Use ice application for 5-6 seconds before treating patient.

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There can be skin tracking and small blister when using this device. Most of these skin issues will resolve over a period of a month or two. If you use the machine properly (you must be trained on its use), very few problems will occur.

This device is excellent in the treatment of angiogenesis. You must tell your patients that they may have visible marks on the skin such as small red lines up to 2 months after the procedure. All sequale do dissipate with time. • For small fine red veins, it is a very good application to use. • •

Ohmic Thermolysis

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Absence of endothelial cells Fusion of lumen Electrodessication of tissue Small area of collateral damage

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Veins < 0.5mm, can be treated with ohmic thermolysis alone Ohmic thermolysis works by direct electrodessication and eventual fibrosis of the vein wall

Treating Spider Veins with Ohmic Thermolysis

Video using the new 'Bristle' needle by VeinGogh to Treat Spider Veins

Tips • •

Never use the ‘ballet’ needle on the leg Never use the ‘bristle’ needle on the face (Although future needles are being designed that will be smaller)

Legs • Use only 5% power • Use ice before treating/Ice roller • If you have experience & feel comfortable treating larger spider veins, use subdermal tumescent solution • If possible, do a test at consult visit, so patient will know what to expect • Do not expect complete resolution of treated area for 2-3 months and tell your patient this. • Arnica gel may decrease tracking and hasten resolution of skin sequela • Show your patients before & after images…you can use images from our site…just reference it • VeinGogh works well, if done properly and the right veins are targeted Face • • • • •

A good treatment for red veins on the face and nose Ice packs/finger cot works well Consider using a topical anesthetic around the nose, since it is extremely tender Use the ballet needle using 10-20% as long as the vessel blanches, you have adequate power Tell your patient to expect redness, small dots, but everything will revert to normal

Progression of VeinGogh Treatment

Blue veins use subdermal tumescent Red veins use ice or topical spray such as Painease®

2-Months Post Treatment

Intense Pulsed Light • • • • •

Useful adjunct Practical for small red veins < 0.3 mm Great for angiogenesis, telangiectatic matting Can vary many parameters Useful for face also

• • • • •

Filters range from 515nm – 695nm Redness – Average patient requires 3-4 treatments with periodic touch-ups Facial veins – 1-3 treatments Leg veins – combination sclerotherapy 3-5 sessions Used many times in conjunction with other lasers

Disadvantages of Using Light Based Therapy • • • •

Pigmentation issues- usually result of excessive heat Extensive training required May be more painful than other modalities Must have no sun exposure or artificial tanners

Safety Tips for Light Therapy • Skin Types I- IV • Ask the right questions • No sun exposure or sunless tanning • Test laser at time of consultation • Have patient and staff wear laser protective glasses Example of Adverse Reaction to Intense Pulsed Light

Blistering after IPL – Skin type V & too many joules

Intense Pulsed Light (IPL)

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Loss of endothelium No epithelial damage No damage to papillary dermis

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IPL is the least effective of the heat modalities, due to depth of penetration & skin type issues IPL target the Hgb in the blood & H20 in the tissues to effect damage Veins < 0.5mm, can be treated with alone

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Minor Surgical Techniques

Spider Vein Phlebectomy • •

Phlebectomies can be done for spider vein complexes Extensive training in needed

Pre-Procedure Spider Vein Complex • • • •

Consider doing the technique for patients that have large spider vein complexes or dilated spider veins May not need sclerotherapy or thermal treatments Good alternative to patients with allergies to sclerotherapy solutions Good alternative for patients that clot or stain after sclerotherapy

Surgical chemical ablation of Telangiectasia (SCAT)

Pre-treatment of large dilated spider complex. This is the ideal complex for SCAT. The blue dot represents the location of the reticular vein as it enters the complex.

0.3% Sotradecol foam injected into the complex

Tumescent solution placed subdermally under the complex

Phlebectomy of the reticular vein

55 Â

An 11 blade is used to divide the spider telangiectasia 1 inch along the course of each spider vein. This does 2 things: Interrupts the spider vein, which causes more trauma and prevents any clot retention, which provides better cosmesis post treatment

Post-treatment appearance. Each small red dot represents where the transection with the 11 blade was done.

Allergic Reactions to Sclerosants • • • • • •

Itching Anaphylaxis Coughing Headache Hives Coughing

Itching/Hives With Sotradecol • •

Systemic Steroids PO or injection, topical analgesic such as Benadryl® cream Try a test dose Polidocanol® before proceeding with sclerotherapy treatments, 3 -4 weeks after allergic reaction to Sotradecol® subsides.

Emergency Equipment/Meds You Should Have Available • • • • •

Airway equipment Antihistamines Epinephrine Oxygen tank Steroids

Interventions • • • • • • • •

Check B/P Benadryl 25 mg PO Ventolin inhaler If symptoms don’t abate within 10 minutes, administer EpiPen IV access/solution available Ambu bag with 02 tank Prescribe Medrol dose pack X5 days Rationale: Prevents delayed allergic response

Adverse Sequelae • • • • • • • •

Hyperpigmentation Swelling Angiogenesis or matting Pain Localized uticaria Compression blister (tape) Vasovagal Recurrence

Complications • • • • • • •

Allergic reactions Cutaneous necrosis Deep vein thrombosis Migraine Nerve injury Scotoma Superficial thrombophlebitis

Cutaneous Necrosis • Etiology is multi-factorial Migraines •

•

If the patient has a history of migraine headaches, this is not a contraindication to foam sclerotherapy, but we do counsel the patient on the possibility of migraines occurring with foam sclerotherapy. If the patient develops a migraine post treatment with foam, try liquid. Liquid also may produce migraines, secondary to the endothelial release factor.

Pregnancy • • •

If possible, treatment of any veins should be postponed until no further pregnancies are contemplated. Veins will reoccur with pregnancy, undoing the previous treatments. However, some conditions will require treatment such as spontaneous bleeds or blood clots.

Staining • • • • • • • •

Varies by Fitpatrick skin type Usually less staining with skin types III & IV Etiology of staining is hemosiderin deposition and may be outside or inside the treated vein More significant staining is outside the vein wall, due to red cell deposition after destruction of vessel wall (Higher concentration of sclerotherapy) Many times staining regresses spontaneously, however, in some patients may persist for long periods Try heat induced injury by laser or IPL, may hasten resolution May see less staining with Polidocanol,® because it is a weaker sclerosant Iron supplements can increase staining

Telangiectatic Matting • • • • •

Use lower sclerosant concentrations If matting occurs, evaluate for the cause May have unidentified truncal insufficiency Incompetent branch Untreated reticular branches

CLINIC FORMS Consent – Sclerotherapy of Varicose and Spider Veins Procedure – Sclerotherapy is the injection of medication with a needle into unwanted veins. The goal is to irritate and scar the veins from the inside such that these abnormal veins close and no longer fill with blood. Several treatments may be needed to obtain maximum improvement. Treatment – There are generally no major risks if I elect not to have treatment. I am aware that alternative treatments exist and can include no treatment, compression therapy, surgery to remove the veins, and thermal ablation using a laser or radiofrequency device.

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Risks – There are risks associated with sclerotherapy. I realize that complications can occur and include but are not limited to these listed below: Brownish discoloration. This is not uncommon, but is usually temporary. It could take several months or longer to resolve. It is uncommon for discoloration to be permanent. Clusters of spider veins (matting). Matting may resolve spontaneously or you may need treatment to clear them. Bruising is common and typically resolves over a few days to weeks. Blistering, redness, itching, irritation, swelling or pain can occur, but are usually temporary. Infection is extremely rare. Ulceration and scarring may occur, but are extremely rare. Allergic reactions are rare. They range in severity from mild to serious reactions and treated immediately. Inflammation around a vein can occur. This may be tender, but generally resolves without treatment. Tenderness, bruising, or firmness in the treated area can occur and may be long lasting, but rarely permanent. Deep venous thrombosis (blood clots) and pulmonary embolism (clot in the lungs) are rare. Other side effects are possible, although unknown. Benefits – This procedure may decrease discomfort and other symptoms from leg veins, and may provide improved cosmetic appearance. I am aware that no available treatment for spider, reticular and/or varicose veins is successful 100% of the time. Multiple treatments may be required. Treated veins may fail to close, or may close and then re-open. Additional or alternative treatments may be required. Results are not guaranteed.

I have discussed and have been given the opportunity to ask questions about my condition, alternative forms of treatment, risks of non-treatment, and the procedures to be used, and the risks and hazards involved. I believe I have sufficient information to give this informed consent. I certify that I am not pregnant or breast-feeding. I certify that I do not have a history of asthma.

Â 61 Â I certify that this information has been explained to me, that I have read it or have had it read to me, and that I understand its contents. I voluntarily consent to this procedure. I do ____ do not____ consent to the taking of photographs/videos for use regarding my care as well as for educational or scientific purposes. Patient Signature _____________________________ Date________________________________ Witness_____________________________________ Date________________________________ Physician___________________________________ Date________________________________

Spider Vein Pre-Treatment Instructions Water's Edge Dermatology 600 Village Square Crossing, Palm Beach Gardens, FL 33410 561-694-9493 Pre-treatment Instructions For Spider Vein Treatment – Sclerotherapy & Ohmic Thermolysis • • • • • • •

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Wear or bring shorts for the treatment session. Eat a light meal or snack 1-½ hours before your appointment. Bring your compression stockings anytime you have a treatment. Wear loose fitting/comfortable clothing. Do not use lotions, creams, or oils the night before or day of your treatment. Do not shave your legs the day of your treatment. Do not take Plavix, Aspirin, or NSAID’s (Ibuprofen, Motrin, Alleve, Naproxyn) products or other blood thinning medications (Vitamin E, Gingko Giloba) three days before and three days after your treatment. (Plavix – 5 days) Inform the doctor/nurse if you are taking birth control pills or estrogen. Inform the doctor/nurse if you are pregnant or breastfeeding. Inform the doctor/nurse if you have a history of migraines or asthma. Inform the doctor/nurse if you have allergies to latex. On average, you may need 3-5 treatments spaced a month apart before resolution. You should arrive at least 15 minutes before your appointment. Spider vein sessions are 20 minutes long. Approximately 10 minutes to get dressed and check out of the office. Photographs will be taken before and after each treatment to document progress and/or for the purpose of medical education, research, or scientific publications. You will not be identified in the photographs and your consent will be obtained before you are photographed.

Compression Stockings • Women’s panty hose $________

Men’s thigh-high $ __________

Spider Vein Treatment Options The treatment of spider veins has greatly improved in the last ten years. Several different treatment types are used to treat spider veins: sclerotherapy, laser, ohmic thermolysis, and intense pulse light (IPL). Most patients require a combination of treatments for the best results. Dr. Bush & nurses, use sclerotherapy and ohmic thermolysis. Sclerotherapy This technique involves injecting a problem vein with a chemical solution (sclerosant). This is simple to do, performed in the office, minimal pain (bee sting) and requires no anesthetic. The chemical solution causes the blood vessel to close and it will eventually disappear. Sclerotherapy is the gold standard for treating spider veins and is also used to treat certain varicose veins. How Does Sclerotherapy Work? A chemical solution is injected, using a needle, into a dilated blood vessel. The chemical solution causes inflammation, which makes the walls of the vein stick together. Because of this, the treated vessel can no longer hold blood and it

63 scars up and is eventually reabsorbed by the body. There are two types of sclerotherapy used, liquid and foamed. Mixing a sclerosing medication with air or C02 makes foam. The type of medicaiton used depends on the size of the vein or your presenting problems. What Can I Expect After My Treatment? • You can return to your normal activities right after your treatment. • You can go back to work after being treated. You will look worse before you look better. • With sclerotherapy, there is always bruising and clotting of treated veins. Some people clear up in 1-2 treatments and some people require 5-6 treatments. Complications and risks of sclerotherapy are rare, but may include the following: • Staining • Incomplete closure of the vein • Allergic reaction • Blood clot • Scabbing or scarring • Small skin ulcers • Formation of new blood vessels around treated area Ohmic Thermolysis • This relatively new treatment is done by directly placing a small needle in the spider vein and focusing heat energy (radio frequency). This device is safe for all skin types. It works better than all other methods of treatment for small reddish veins that are difficult to inject. You may experience some pain, but ice & other methods are used to minimize pain. Complications • Prolonged (tracking of the skin) and may take 2 -3 months for resolution. • A tiny pit may occur where the needle was inserted, but this is rare. • What Can I Expect After My Treatment? • You can return to your normal activities right after your treatment • You can go back to work after being treated. You will look worse before you look better. Call the office for any questions or concerns before or after your spider vein treatment. (561-694-9493)

Spider Vein Pre-Treatment Instructions Water's Edge Dermatology 600 Village Square Crossing, Palm Beach Gardens, FL 33410 561-694-9493 Post Sclerotherapy Treatment •

Resume normal activities and you may go back to work

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Wear compression stockings for three days and taking them off when you sleep. Stockings do help with comfort and may minimize bruising.

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Avoid high impact aerobics, jogging, running, leg weight lifting and sit-ups the day of the treatment.

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Protect the treated areas from sun exposure by using sunscreen

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You may drive after your treatment

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Limit Aspirin or Ibuprofen products for 2 days after treatment to reduce bruising. You can take Tylenol for any discomfort.

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Avoid iron supplements

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Avoid sun bathing/exposure or tanning beds for at least two weeks.

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Follow-up appointments are every four to six weeks.

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Call the office for any questions or concerns before or after your spider vein treatment. (561-694-9493)

Post ohmic thermolysis treatment

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Resume normal activities & you may go back to work

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Arnica cream twice a day may help with healing

References www.bushvenouslectures.com - ppts/blog www.veinexperts.org Almeida, Jose. Atlas of Endovascular Surgery