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“Useful” Physiopathology of
the venular telangiectasic
system and accessory
treatments
Ermini Stefano
New investigative methods and new technological devices
have not improved teleangiectasia treatment results
Unknown Physio...
Unsolved problems
• Different types of teleangiectasias ( varying
disposition similar to tree foliage, foliage up, foliage...
Perthes Test for varicose veins
Reduction of the filling gradient (Tourniquet)
+
Improvement of the draining gradient ( mu...
Every Telangiectasic tree has a filling and a draining pressure
gradient
Like in a varicose system, I can resolve the
tela...
• With the folliage up and reticular vein down
• With folliage down and reticular vein up
• With reticular veins mixed wit...
Use of Hydrostatic pressure and Doppler can help us to
detect the direction of the draining gradient
The hypothesis sugges...
Foliage Down Telangiectasia - postural changes
and function of the reticular vein above
• Hydrostatic gradient changes its...
In this situation the inversion of the gradient is slowed by the tortuosity of the
reticular network.
Foliage Down Telangi...
1) The reticular vein does not have a defined source
2) The reticular vein originates from a refluxing point
Foliage Down ...
In every case, the sclerotherapic
treatment of the reticular vein leads to
telangiectasic reduction.
If this filling vein ...
The filling vein of a foliage down telangiectasia
may also be the draining vein of a critical zone
… Attention !!!
3) Emer...
If the reticular vein originates from an escape point,
the situation must be investigated and treated
correctly .
Subcutan...
Doppler check-up for foliage down telangectasia
Valsalva test
Squeezing test
Dynamic test
For N2 collateral veins, also ch...
Saf.Int.
Coll.
Telangiectasias filled by a saphenous tributary refluxing during muscle systole
Result obtained by
scleroth...
This means that, in the specific case of
foliage down telangiectasia, careful
investigation must be performed with a
high ...
Standing Lying
Foliage Up and Mixed Teleangectasia
Venous pressure in Telangiectasia =
residual pressure ( emptyng rate) -
draining gradient ( MP activity , dgh )
dgh
Standi...
worsens or does not change
Venous pressure in Telangiectasia =
residual pressure ( emptyng rate) +
static pressure of the ...
A B
In example B the trasmission of MP energy to Telangiectasia is reduced by the
tortuosity of the reticular network.
Wit...
Haemodynamic patterns of the re-entry perforator
• Valsalva negative
• No systolic flow
• Diastolic inflow
Usually the re-...
The draining gradient in Foliage Up Telangiectasia
We have to respect the drainage system. Its closure leads to
the risk o...
The filling gradient in Folliage Up Telangiectasia
No reticular vein above
the telangiectasia
Telangiectasia origin
due to...
The fybrosis and compact structure of cellulite
tissue creates an obstacle to venous drainage from
the skin surface to the...
Telangiectasias represent a compensatory system
around this obstacle.
Their suppression creates a new obstacle to the
veno...
Consideration of the physiopathology of foliage up telangiectasia
PEF
Telangectasia
New Draining
system
Obstacle to Physio...
Elimination of the foliage up telangiectasia
corresponds to the suppression of a vicarious circle
Bad result due to excess...
Therefore, the problem is not to improve the efficacy of
the sclerotherapic treatment, but to promote a new
invisible drai...
Soft sclerotherapy, timing and compression
stockings work together
Sclerotherapy closes ectasic telangectasias and, step b...
Consequently, step by step, sclerotherapy closes,
nature recreates, and the compression stocking guides.
Timing should be ...
Guidelines for a good result according to
these haemodinamic considerations
• Timing of sclerotherapic treatments :1 treat...
CONSENSO INFORMATO
….. Il risultato finale dipenderà
anche dalle cause e dalla
estensione dei capillari e in alcuni
casi n...
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
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Useful physiopathology of telangectasia

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Useful physiopathology of telangectasia

  1. 1. “Useful” Physiopathology of the venular telangiectasic system and accessory treatments Ermini Stefano
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 15. Saf.Int. Coll. Telangiectasias filled by a saphenous tributary refluxing during muscle systole Result obtained by sclerotherapic treatment of the refluxing tributary
  16. 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. 17. Standing Lying
  18. 18. Foliage Up and Mixed Teleangectasia
  19. 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. 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. 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. 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. 23. The draining gradient in Foliage Up Telangiectasia We have to respect the drainage system. Its closure leads to the risk of matting
  24. 24. The filling gradient in Folliage Up Telangiectasia No reticular vein above the telangiectasia Telangiectasia origin due to cellulite tissue
  25. 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. 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. 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. 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. 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. 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. 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. 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. 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. 34. Aestethic improvement obtained only with elastic stocking and topical treatements without sclerotherapy or laser
  35. 35. Aestethic improvement obtained only with elastic stocking and topical treatements without sclerotherapy or laser
  36. 36. Matar a el toro ¿Cómo se puede matar a los capilares www.chiva.it Ermini Stefano Thanks for the attention

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