“Useful” Physiopathology of the venular

telangiectasic system and accessory treatments

Ermini Stefano

New investigative methods and new technological deviceshave not improved teleangiectasia treatment results

Unknown Physiopathology

http://www.ncbi.nlm.nih.gov/pubmed/: Cellulite + teleangiectasias = no match foundTelangiectasia + color doppler = no match foundTelangiectasia + duplex scan = 2 matches found ( 1993)

Unsolved problems

• Different types of teleangiectasias ( varying disposition similar to tree foliage, foliage up, foliage down )

• Location in the leg• Interactions with reticular veins ( filling or

draining )• Role of the perforator veins • Relations with the saphenous system

Perthes Test for varicose veins

Reduction of the filling gradient (Tourniquet)+

Improvement of the draining gradient ( muscle pump activity) =

Collapse of the visible varices

Every Telangiectasic tree has a filling and a draining pressure gradient

Like in a varicose system, I can resolve the telangiectasia by improving the drainage and reducing the filling gradient.

First , I must determine which reticular vein fills and which drains

• With the folliage up and reticular vein down• With folliage down and reticular vein up• With reticular veins mixed with teleangectasias

Disposition of the telangiectasic tree :

Telangiectasia

Reticular Vein Telangiectasia

Reticular Vein

Use of Hydrostatic pressure and Doppler can help us to detect the direction of the draining gradient

The hypothesis suggested by graviational law is: •When the reticular vein is up, it is a filling vein•When it is down, it is a draining vein

Filling Vein

Draining Vein

Disposition of the telangiectasic tree :

Foliage Down Telangiectasia - postural changes and function of the reticular vein above

• Hydrostatic gradient changes its direction and from a filling gradient becomes a draining gradient

In this situation the inversion of the gradient is slowed by the tortuosity of the reticular network.

Foliage Down Telangiectasia - postural changes and function of the reticular vein above

1) The reticular vein does not have a defined source2) The reticular vein originates from a refluxing point

Foliage Down Telangiectasia - Origin of the reticular network

1) Whithout escape point 2) From Point P

In every case, the sclerotherapic treatment of the reticular vein leads to telangiectasic reduction.

If this filling vein originates from the drainage of other telangectasic ones or from cellulite, its suppression increases the risk of matting occurrence

The filling vein of a foliage down telangiectasia may also be the

draining vein of a critical zone … Attention !!!

3) Emergence of matting

1) Sclerotherapy of the reticular v.

2) Reduction of the telangiectasias

If the reticular vein originates from an escape point, the situation must be investigated and treated correctly .

Subcutaneous Subfascial

Perforator vein or connection with an N2 system

Valsalva TestDiastolic retrograde flow

N3 N2

Doppler check-up for foliage down telangectasia

Valsalva testSqueezing testDynamic test

For N2 collateral veins, also check for a sistolic reflux

Patterns of refluxing perforator veins:Diastolic out-flowValsalva positive ( occasionally)

Saf.Int.

Coll.

Telangiectasias filled by a saphenous tributary refluxing during muscle systole

Result obtained by sclerotherapic treatment of the refluxing tributary

This means that, in the specific case of foliage down telangiectasia, careful investigation must be performed with a high resolution ultrasound 12-18 Mhz probe and transillumination.

Standing Lying

Foliage Up and Mixed Teleangectasia

Venous pressure in Telangiectasia = residual pressure ( emptyng rate) - draining gradient ( MP activity , dgh )

dgh

Standing Position

Foliage Up Telangiectasia - postural changes and function of the reticular vein below

worsens or does not change

Venous pressure in Telangiectasia = residual pressure ( emptyng rate) + static pressure of the reticular system

Leg up

Foliage Up Telangiectasia - postural changes and function of the reticular vein below

A B

In example B the trasmission of MP energy to Telangiectasia is reduced by the tortuosity of the reticular network.

With postural changes

Without postural changes

Postural changes of foliage up and mixed telangiectasias

Haemodynamic patterns of the re-entry perforator

• Valsalva negative• No systolic flow• Diastolic inflow

Usually the re-entry perforator is in the leg , where the muscolar pump activity is efficient.

The draining gradient in Foliage Up Telangiectasia

We have to respect the drainage system. Its closure leads to the risk of matting

The filling gradient in Folliage Up Telangiectasia

No reticular vein above the telangiectasia

Telangiectasia origin due to cellulite tissue

The fybrosis and compact structure of cellulite tissue creates an obstacle to venous drainage from the skin surface to the hypoderma and deep tissue.

PEFObstacle to Physiologic drainage

Telangiectasias represent a compensatory system around this obstacle.Their suppression creates a new obstacle to the venous flow that leads to an increase of venous pressure and to the realization of a new drainage. This is possibly one of the pathogenetic mechanisms of matting (*)

(*)= Cappelli M., Riflessioni di emodinamica sulle teleangectasie. Scleroterapia II° edizione, Ed. Minerva Medica, Torino 2006

Consideration of the physiopathology of foliage up telangiectasia

PEF

Telangectasia

New Draining system

Obstacle to Physiologic drainage

Foliage up Telangiectasia represents a vicarious circle

Elimination of the foliage up telangiectasia corresponds to the

suppression of a vicarious circle

Bad result due to excess of treatment

The more veins I close, the more new veins re-form, because I cannot modify

the residual venous pressure

Chest’ è ‘na

fessaria !

Chest’ è ‘na

fessaria !

Therefore, the problem is not to improve the efficacy of the sclerotherapic treatment, but to promote a new invisible drainage, and to prevent matting.

Tralci connettivali responsabili della “ buccia

d ’arancia”

Macronoduli e scompaginament

o trabecolare

Is the treatment of cellulite possible?

Soft sclerotherapy, timing and compression stockings work together

Sclerotherapy closes ectasic telangectasias and, step by step, worsens venous stasis in cellulite tissue.

Residual venous pressure tries to find a new drainage

Compression stockings increase tissue pressure and impede venous stretching and dilation due to increased lateral pressure .

Consequently, step by step, sclerotherapy closes, nature recreates, and the compression stocking guides.

Timing should be regulated by the restoration of a new drainage.

Therefore, the draining volume of superficial tissue is limited by the compression, and new drainage will devolop where resistance to the flow is lower, for example, away from the skin.

Soft sclerotherapy, timing and compression stockings work together

Guidelines for a good result according to these haemodinamic considerations • Timing of sclerotherapic treatments :1

treatment every 4 weeks• Light sclerotherapic agents• Medical treatment , sistemic draining drug

and topic treatment (Arnica)• Compression by a 24 mm.Hg elastic stocking

for 3 weeks (*)• Stop treatment at the right time ( before

matting !! )

(*) =Compression after sclerotherapy for telangiectasias and reticular leg veins: a randomized controlled study.Kern P, Ramelet AA, Wütschert R, Hayoz DJ Vasc Surg. 2007 Jun;45(6):1212-6. Epub 2007 Apr 27.

CONSENSO INFORMATO….. Il risultato finale dipenderà anche dalle cause e dalla estensione dei capillari e in alcuni casi non si potrà avere una completa scomparsa degli inestetismi cutanei, ma solo una loro attenuazione……

If small red telangiectasia appears: STOPsclerotherapic treatment

Aestethic improvement obtained only with elastic stocking and topical treatements without

sclerotherapy or laser

Aestethic improvement obtained only with elastic stocking and topical treatements without

sclerotherapy or laser

Matar a el toro

¿Cómo se puede matar a los capilares

www.chiva.it

Ermini Stefano

Thanks for the attention