Ap Versus Compression Sclerotherapy

The combination of compression therapy with intravenous injection of a sclerosing agent for the treatment of varicose veins was introduced in 1953.28 Early studies indicated compression sclerotherapy (Sclero) would be an efficient addition to varicose vein surgery practiced at that time. Although ambulatory phlebectomy was "invented" around the same period,2 this technique required considerable time to become well-established worldwide. There is one randomized controlled trial on recurrence rates and other complications after Sclero and AP. A total of 98 operations were randomized to either AP (n = 49) or Sclero (n = 49) in a total of 82 lateral accessory varicose veins (LAVs). In this study, polidocanol was used in a 3% solution (Aethoxysclerol; Kreussler & Co., Wiesbaden, Germany), which is equivalent to 1.5% sodium tetradecyl sulfate. One year after Sclero, 12 LAVs had recurred (25%), and only one postphlebectomy LAV (2.1%). After two years, the difference in recurrence was even larger because another six recurrences developed, making a total of 18 recurrences in the Sclero group (37.5%) and only one recurrence in the AP group (2.1%). The authors of the study concluded that AP is the treatment of choice for LAV.29

AP FOR OTHER AREAS OF THE BODY Foot

In recent years there have been several publications on the use of AP for the treatment of varicose veins of the foot and ankle region.30-32 There are patients who present with serious phlebologic complaints of varicosities of the foot and ankle region that can be alleviated through simple treatment. The venous anatomy of the foot with many parallel veins is complicated; however, safe treatment is possible.

The skin of the foot is thin and fibrotic. Further, there is minimal subcutaneous fat, less protection against trauma of the skin, and important underlying tissues such as tendons, tendon sheaths, and joints. There are more small nerve branches that can be damaged by the hook. As in the popliteal space, there is greater risk of injuring an artery. Moreover, it is possible to grasp and avulse a tendon.

Eyelid

Many ophthalmic plastic surgeons and dermatologic surgeons experienced in sclerotherapy avoid the use of this agent near the eye or use it in substantially lower concentrations and volumes. This is due to fear that the solution may travel to unintended areas of venous circulation such as the central retinal vein, choroidal vortex veins, or even the cavernous sinus via valveless anastomoses.33 Blindness has been reported following STS injection into a venous malformation partially located in the orbit.34

Ambulatory phlebectomy of the periocular vein avoids the concerns regarding thrombotic phenomena within ocular, orbital, or cerebral veins possibly associated with periocular vein sclerotherapy. Weiss35 reported excellent results on 10 patients who underwent removal of periocular reticular blue veins by AP. A single puncture with an 18-gauge needle sufficed in most cases. It is important to attempt to remove the entire segment, as partial resection may lead to recurrence. The use of postoperative compression for 10 minutes reduces the incidence of bruising. The puncture sites typically disappear quickly without leaving scars.

Hands

In general, inquiries about hand vein treatment come from elderly women who find them unsightly. Often, they have had prior facelift surgery and worry that their hands need rejuvenation to complement the face. Our initial consultation stresses the importance of hand veins for reasons of intravenous access, furthermore, removal of these veins may require central venous access should the patient be hospitalized in the future. If attempts to dissuade the patient fail, we recommend AP as the procedure of choice for hand vein removal. It is performed identical to leg vein treatment, and closely resembles treating the dorsum of foot because of the thin skin overlying the area. Results have been excellent.

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