This document discusses the pathophysiology of venous telangiectasias and potential accessory treatments. It begins by noting the unknown pathophysiology and lack of improved treatment results from new methods. It then explores various aspects of telangiectasia types, locations, interactions with other veins, and relations to perforating veins. The author proposes that telangiectasias can be resolved by improving drainage and reducing filling gradients, similar to treating varicose veins. Various techniques using hydrostatic pressure, Doppler, and postural changes are suggested to identify filling and draining veins and gradients. Guidelines for sclerotherapy timing and use of compression stockings are provided to help prevent new telangiectasia formation ("matting").

1. “Useful” Physiopathology of
the venular telangiectasic
system and accessory
treatments
Ermini Stefano

2. New investigative methods and new technological devices
have not improved teleangiectasia treatment results
Unknown Physiopathology
http://www.ncbi.nlm.nih.gov/pubmed/:
Cellulite + teleangiectasias = no match found
Telangiectasia + color doppler = no match found
Telangiectasia + duplex scan = 2 matches found ( 1993)

3. 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

4. Perthes Test for varicose veins
Reduction of the filling gradient (Tourniquet)
+
Improvement of the draining gradient ( muscle pump activity)
=
Collapse of the visible varices

5. 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

6. • 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

7. 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 :

8. 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

9. 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

10. 1) The reticular vein does not have a defined source
2) The reticular vein originates from a refluxing point
Foliage Down Telangiectasia - Origin of the
reticular network
1) Whithout escape point 2) From Point P

11. 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

12. 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

13. 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 Test
Diastolic retrograde flow
N3 N2

14. Doppler check-up for foliage down telangectasia
Valsalva test
Squeezing test
Dynamic test
For N2 collateral veins, also check for a sistolic reflux
Patterns of refluxing perforator veins:
Diastolic out-flow
Valsalva positive ( occasionally)

15. Saf.Int.
Coll.
Telangiectasias filled by a saphenous tributary refluxing during muscle systole
Result obtained by
sclerotherapic treatment of
the refluxing tributary

16. 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.

17. Standing Lying

18. Foliage Up and Mixed Teleangectasia

19. 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

20. 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

21. 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

22. 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.

23. The draining gradient in Foliage Up Telangiectasia
We have to respect the drainage system. Its closure leads to
the risk of matting

24. The filling gradient in Folliage Up Telangiectasia
No reticular vein above
the telangiectasia
Telangiectasia origin
due to cellulite tissue

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

26. 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

27. Consideration of the physiopathology of foliage up telangiectasia
PEF
Telangectasia
New Draining
system
Obstacle to Physiologic
drainage
Foliage up Telangiectasia represents a vicarious circle

28. 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 !

29. 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
scompaginamento
trabecolare
Is the treatment of
cellulite possible?

30. 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 .

31. 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

32. 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 D
J Vasc Surg. 2007 Jun;45(6):1212-6. Epub 2007 Apr 27.

33. 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:
STOP
sclerotherapic
treatment

34. Aestethic improvement obtained only with elastic stocking
and topical treatements without sclerotherapy or laser

35. Aestethic improvement obtained only with elastic stocking
and topical treatements without sclerotherapy or laser

36. Matar a el toro
¿Cómo se puede matar a los
capilares
www.chiva.it
Ermini Stefano
Thanks for the attention