Alternative therapy for microvarices and telangiectasias with use of needle

Abstracts

CONTEXTO: O desenvolvimento de terapia alternativa à convencional para a destruição de microvarizes e telangiectasias sem o uso de produtos químicos tem como objetivo reduzir os efeitos colaterais, faz uso de agulha para lise mecânica dos vasos e tem como modelo experimental galinhas da linhagem Lohmann Brown. OBJETIVO: Elaborar uma nova técnica, desenvolvendo um tratamento alternativo, sem uso de produtos químicos, objetivando a redução dos efeitos colaterais. MÉTODOS: Foram utilizadas 30 galinhas da linhagem Lohmann Brown, sendo que 15 foram submetidas ao método convencional de tratamento de microvarizes e telangiectasias (grupo-controle) e as outras 15 receberam o tratamento experimental proposto (grupo experimental). O grupo experimental foi tratado com agulha de lise vascular, percorrendo todo o trajeto dos vasos escolhidos em punções escalonadas até que todo o vaso ser atingido. O grupo-controle foi tratado com oleato de monoetanolamina e glicose a 50%, puncionando-se o vaso com agulha 13 x 3 mm e injetando-se, em média, 0,3 mL da solução em cada vaso. RESULTADOS: Dos 50 vasos tratados no grupo experimental, dois apresentaram recidiva total, cinco apresentaram recidiva parcial, e 43 apresentaram destruição (lise) satisfatória; enquanto que, no grupo-controle, dos 51 vasos tratados, quatro apresentaram recidiva total, 12, recidiva parcial, 22, destruição satisfatória, e em 13 ocorreu endurecimento de trajeto. CONCLUSÃO: O presente estudo demonstrou que o método experimental proposto, com uso de agulha de lise vascular, possui mais eficiência no tratamento de microvarizes se comparado com o método convencional, devido à redução das recidivas e à ausência de hipercromia de trajeto endurecido.

Vascular; tratamento; microvarizes

ORIGINAL ARTICLE

Alternative therapy for microvarices and telangiectasias

with use of needle

Raimundo Rosendo de Oliveira^I; Eraldo Barbosa Calado^I; Diógenes Luis da Mota^II; André Filipe Vieira Pereira da Silva^III; Jennecy Sales Cavalcanti^IV

^I

^IIProfessor, Graduate Program, Department of Pathology, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil. Researcher, Laboratory of Clinical Cytology and Quantitative Histology, Department of Pharmaceutical Sciences, UFPE, Recife, PE, Brazil

^IIIResearcher, Laboratory of Clinical Cytology and Quantitative Histology, Department of Pharmaceutical Sciences, UFPE, Recife, PE, Brazil. Professor, Faculdade Maurício de Nassau, Recife, PE, Brazil

^IVProfessor, Graduate Program, Department of Pathology, UFPE, Recife, PE, Brazil

^{Correspondence}

ABSTRACT

BACKGROUND: The development of an alternative to the conventional therapy for microvarices and telangiectasias without using chemical products aims at reducing side effects, using a needle for mechanical lysis of vessels. It uses Lohmann Brown hens as the experimental model.

OBJECTIVE: To develop a new technique, creating an alternative treatment without using chemical products, aiming at the reduction of side effects.

METHODS: Thirty Lohmann Brown hens were used, 15 submitted to the conventional method of treating microvarices and telangiectasias (control group) and 15 receiving the proposed experimental treatment (experimental group). The experimental group was treated using a needle for vascular lysis, passing through the whole extension of chosen vessels in staggered punctures until the whole vessel was reached. The control group was treated with ethanolamine oleate and 50% glucose, puncturing the vessel with a 13 x 3 mm needle and injecting on average 0.3 mL of the solution in each vessel.

RESULTS: Of the 50 vessels treated in the experimental group, two presented total recurrence, five partial recurrence and 43 satisfactory destruction (lysis), whereas of the 51 vessels treated in the control group, four presented total recurrence, 12 partial recurrence, 22 satisfactory destruction and 13 presented conduit vessel stiffness.

CONCLUSION: The present study demonstrated that the experimental method using a needle for vascular lysis is more efficient for the treatment of microvarices when compared with the conventional method, due to reduction in recurrence rates and absence of hyperchromatism of conduit vessel stiffness.

Keywords: Treatment, vascular, microvarices.

Introduction

Varicose veins are one of the most ancient reported diseases, and are currently present in approximately 30–40% of the Brazilian population. Some risk factors are considered, such as occupation, pregnancy, diet, obesity, heredity and ethnic group, women being mostly affected in a 4:1 ratio. It is believed that 70% of women aged 40 years or older have varicose veins.^1–7

There are two types of varicose veins: the so–called primary varicose veins, which occur influenced by hereditary tendency, and the so–called secondary, which occur due to diseases acquired throughout life and are harder to be treated. Primary varicose veins are responsible for the nonesthetic red and blue lines, of varied sizes, which occur especially in the legs of women and also for the large–caliber varicose veins, which are more frequent. Secondary varicose veins are caused by a preexisting disease, such as arteriovenous fistulas (congenital or acquired), trauma, angiodysplasias, postphlebitic syndrome, extrinsic compressions, etc.⁸

The main theories on the etiology of primary or lower limb varicose veins are related to changes in the vein wall, modifying the structure of collagen and/or elastin, increasing the presence of elastic material with vessel thickening,⁹ local or segmental valvar incompetence and presence of arteriovenous fistulas at the microcirculation level. Secondary varicose veins are related to postphlebitic syndrome, pregnancy, traumatic arteriovenous fistulas, angiodysplasias and extrinsic compressions.¹⁰

With the advances on the knowledge of chronic venous disease, there was the need of expanding the definitions that could comprehend many of its aspects, including anatomical, physiopathological and etiologic factors. With this aim in mind, the International Committee of the American Venous Forum developed in 1994 a consensus document to classify venous diseases (Table 1), which was based on clinical status, etiologic factors, anatomical distribution and physiopathological findings, named clinical, etiologic, anatomical and physiopathological classification (CEAP).^11–16

click to enlarge

Some authors^17.18 consider the CEAP classification quite complex when used in its full form, not being used in the daily practice with patients.

In his study, Maffei¹⁹ found an 82% prevalence of telangiectasia, which led him to consider it a characteristic of the human race, becoming a disease when it is too extensive, thus representing a risk for patients who complain of pain or burn in the region,²⁰ especially women during menstruation.

Telangiectasias are small capillaries located in the skin, very thin, branched, usually reddish, made of arteriovenous microfistulas. They are also called spider veins, due to their spider web pattern, and almost always cause disorders only from the esthetic perspective.^21–22 We can affirm that telangiectasias are defined as intradermal dilatations of the veins, whose estimated diameter is approximately 1 mm.^22–23

Clinical therapy of varicose veins requires general measures, such as fighting excess of body weight, stimulating physical activity, avoiding orthostatism over long periods and using drugs such as estrogen/progesterone, thyrotrophic and calcium channel blockers.²⁴

Sclerotherapy, known as "application," is currently the treatment of choice for people with telangiectasias, being followed by a set of measures, from diet to guided physical exercises, as well as wearing elastic stockings, hormonal control and suspension of contraceptives.^25.26

The treatment aims at occluding the varicosed vein. The idea is to introduce an irritating substance in the vein, which induces an inflammatory process, leading to fibrosis and making the vessel lose its cylindrical shape, excluding it from the circulation path.²⁷

The advantage of sclerotherapy is that it can be performed in sessions at the medical office, and patients can resume their normal activities in a few days. However, its side effects are still a challenge for angiologists, of which the following stand out: clogs in treated veins, hyperchromatism, chemical ulcer, persistent pain, dyspnea and urticaria.

Treatments used for cases of telangiectasias, although at an advanced development stage, still require better results. The main discomforts are: hyperchromatic spots, small burns, recurrent varicose veins, and especially pains caused by different therapies used in medical practice.

To make the treatment of telangiectasias close to the ideal, it should have its duration reduced, not leave spots and, above all, be painless. The present study intends to develop a new technique closer to the ideal, eliminating as many discomforts as possible.

It also aimed at developing an alternative treatment, without using chemical products, as an attempt to reduce side effects. It tries to propose a treatment for microvarices and telangiectasias that does not use chemical products; does not generate recurrent varicose veins; is fast and easy to apply; does not cause spots; and presents immediate result.

Methods

Bioethical considerations

The project to perform this study received a favorable report from the Ethics Committee in Animal Experimentation of Universidade Federal de Pernambuco, according to the current rules in Brazil, especially the norms dealing with use of animals for scientific research.

Experimental unit

Thirty Lohmann Brownhens were used; 15 were submitted to the conventional treatment of microvarices and telangiectasias (called control group – CG), and the others received the proposed experimental treatment (called experimental group – EG).

Their growth was followed at a laboratory of Universidade Estadual do Rio Grande do Norte, where they were fed with specific, industrialized and supplemented diets according to age, being periodically weighed in precision scale.

The laboratory has a sanitary maintenance control, performed with weekly applications of ammonia, called deworming. Environment control was performed with nebulizations, with the aim of improving air relative humidity in dry periods. The animals were maintained suspended in cages of galvanized wire and iron support 1.20 cm from the ground and area of 25 x 40 cm, in a total of 1,000 cm.²

Material preparation

A 12v engine was used to attach the needle, connected to a 220V/12V transformer and a pedal system to activate the mechanism that works at a speed of approximately 240 rpm. The mechanism has an arm that, when activated, performs 30° movements, providing a longitudinal movement to the attached needle, going forward and backward. Needles of vascular lysis are non–industrial, made of 7–mm thick stainless steel, have a triple bevel, reaching the epithelium and destroying the intended vessel. For material placement, we used an auxiliary covered Mayo table in a sterile field.

Study design

To perform the procedure of vessel destruction, the hens were transported from the laboratory to the Veterinary Hospital, two in each cage.

Their feet were restrained with the aid of cotton strings. The animal was laid on the table, conventionally choosing the left side of all animals. At the surgical field where the experiment would be performed, we removed sufficient hen feathers to widen the area in which vessels were located. The studied field (left chest region) was registered with a digital photo camera for further comparison. The studied region was sterilized with an antiseptic solution (2% iodine–alcohol); next, the anesthetic agent ketamine was administered by intravascular access at 40 mg/kg. After around 4 minutes, until the animal presented signs of being totally anesthetized, the experimental treatment was started.

The EG was treated using a needle for vascular lysis, passing through the whole extension of chosen vessels in staggered punctures until the whole vessel was reached. The CG was treated with ethanolamine oleate and 50% glucose, puncturing the vessel with a 13 x 3 mm needle and injecting on average 0.3 mL of the solution in each vessel. Immediately after the treatment (classified as day zero), the area was photographed again and cooled with ice compressions. Photographs were also taken on the 7th and 13th day after the treatment.

Thirteen days after vessel destruction, both in CG and EG, a tissue was removed for biopsy, based on the site of the healing scar in the projection of the treated vessel. The biopsied material was immediately fixed after it was removed from the hen's body to prevent post–mortem changes, in Bouin, at a 1:20 ratio. The fixed tissue was later dehydrated, cleaned and paraffinized for block formation, which was cut in the microtome with a 4–micrometer blade.

The sectioned tissue was placed in the blade, deparaffinized, hydrated, placed in a Bouin solution, in a greenhouse at 56 °C for 1 hour. Next, it was washed with running water until the yellow color of the sections vanished.

The tissue was stained with hematoxylin–eosin (HE) solution for 10 minutes, and then washed in running water. After the blades were placed in 0.5% acetic water and put in distilled water, they were dehydrated in alcohol and xylol. The results were compared between themselves based on the histological sections that were analyzed in an optical microscope Zeiss, model Axioscope, using magnifications of x4, x10 and x40. These animals could be used for other activities.

Statistics

A comparison between the number of treated vessels and observed occurrences was performed. Fisher's chi–square test was used, and significance was set in 95% (p < 0.05). The software used for statistical treatment was the Epi–Info, version 6.0.4.^28.29

Results

Of the 15 animals treated in EG, eight had four treated vessels each (32 vessels), four had three treated vessels each (12 vessels), and three had two treated vessels each (6 vessels), in a total of 50 treated vessels for this group. For the CG, of the 15 animals, eight had four treated vessels (32 vessels), five had three treated vessels (15 vessels), and two had two treated vessels (four vessels), in a total of 51 treated vessels in the CG.

Of the 50 vessels treated in the EG, two presented total recurrence, five partial recurrence and 43 satisfactory destruction (lysis), whereas of the 51 vessels treated in the CG, four presented total recurrence, 12 partial recurrence, 22 satisfactory destruction and 13 presented vessel hardening (Figure 1).

In the EG, satisfactory destruction was more frequent, with lower frequency in cases of total recurrence, partial recurrence and vessel hardening, in which there was no episode. Comparing frequencies between groups, there was significant statistical difference (p = 0.00003).

Macroscopic analysis

A macroscopic analysis of the 30 Lohmann Brown hens was performed, 15 being treated with ethanolamine oleate and 15 with the experimental method, using a needle for vascular lysis in days zero, 7 and 13.

The hens in the EG had ecchymosis of the treated region, with mean duration of 16 days (three animals, 18 days; nine animals, 16 days; and three animals, 14 days). In the vessels in which there was satisfactory destruction, wound–healing fibrosis of the treated vessels remained visible for 26 days in average. In the CG, the hens had ecchymosis of the treated region, with mean duration of 21.2 days, 11 in 22 days, three in 20 days and one in 16 days. In the vessels in which there was satisfactory destruction, wound–healing fibrosis of the treated vessels remained visible for 31 days in average.

Histological analysis

In the preparations stained with HE, there were, in the EG, areas of tissue repair and reepithelization with fibrinoid material in the surface. In the skin, there was infiltrate of inflammatory cells, presence of mononuclear cells (macrophages) and signs suggesting degeneration of small blood vessels, which showed modified histological structure. These aspects were not seen in the CG, in which the vessel remained integer, but collapsed and occasionally with presence of entrapped erythrocytes.

Discussion

Patients who have microvarices and who are submitted to conventional treatments, whether sclerotherapy or laser therapy, are often subject to varied complications,³⁰ such as hyperchromatism of the treated vessel, allergy, skin necrosis and recurrence in the previously treated vessel, frequently leading to an unpleasant esthetic result.³¹ Among the most used conventional techniques in clinical practice are those that use ethanolamine oleate, herein compared with the proposed experimental method, based on mechanical destruction using a needle for vascular lysis.

The objective of conventional methods is to cause a chemical phlebitis, vessel obliteration and posterior absorption by the organism.³² The proposed method was designed with the aim of directly destroying the vessel, without going through the stages of phlebitis and obliteration, thus facilitating vessel absorption and minimizing side effects.

The present study demonstrated that the proposed experimental method, using a needle for vascular lysis, is more efficient for the treatment of microvarices, reducing recurrences and avoiding hyperchromatic spots.

The treatment performed by mechanical destruction using a needle promoted immediate lysis of venous vessels and extravasation of erythrocytes, which avoids deoxygenated erythrocytes, entrapped in the vessel, from releasing their iron molecules, thus leading to formation of hyperchromatic spots that are hard to be treated, besides undesired esthetic results.³³

In case of recurrence, even occurring in the EG treatment, the values were significantly lower than those of the CG, because the mechanical destruction causes an action of direct lysis on the vessel. Recurrences in the EG were probably due to technical failure in covering the whole vessel extension with the needle for vascular lysis, as well as to vessel depth in relation to the epidermis.

Evaluation of pain³⁴ requires more elaborated experiments, comprehending analysis of neurosensorial mechanisms, since the animals in this study were submitted to effects of general anesthetics. With the use of topical anesthetics in the vessel to be treated, we could destroy the vessel without needing general anesthesia, but this does not occur in the conventional treatment, because the use of such artifice normally leads to vasoconstriction^19.20 and difficulty in puncture to inject the sclerosing agent.³⁴

Reports of similar experiment to ours were not found in the scientific literature. To cause a future use of the proposed treatment, it is necessary to perform experiments under varied situations, in different groups of epidemiological risk^1,5,35 and in different physiological variations,^36.37 which can be observed through a comparison study in different animal models. With that, it is possible to establish guidelines³² to apply this method in humans. Even the combination of techniques³⁸ can be the best solution for the treatment of varicose veins.

Conclusion

The proposed experimental model, using a needle for venous lysis, is more efficient for the treatment of microvarices, reducing recurrences, avoiding hyperchromatism in the treated vessel and proving to be more efficient regarding minimization of esthetic disorders, often observed in the conventional technique with 5% ethanolamine oleate.

For clinical application of the proposed model, experiments should be carried out evaluating different physiological situations, observed in varied risk groups. This technique can be easily applied, and materials can be easily obtained at a low cost.

Since the stages of chemical phlebitis and vessel obliteration were eliminated from this experiment, the treatment is faster and there are less side effects compared with the conventional treatment. The blood extravasated from the vessel after mechanical lysis is completely absorbed, without leaving any skin spots.

References

Manuscript received August 29, 2006, accepted February 21, 2007.

• 1. Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol. 2005;15:175-84.
• 2. Cleave TL. Varicose veins, nature's error or man's? Some implications of the Darwinian theory. Lancet. 1959;2:172-5.
• 3. Cornu-Thenard A, Boivin P, Baud JM, De-Vincenzi I, Carpentier PH. Importance of the familial factor in varicose disease. Clinical study of 134 families. J Dermatol Surg Oncol. 1994;20:318-26.
• 4. Evans CJ, Fowkes FG, Ruckley CV, Lee AJ. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. J Epidemiol Community Health. 1999;53:149-53.
• 5. Iannuzzi A, Panico S, Ciardullo AV, et al. Varicose veins of the lower limbs and venous capacitance in postmenopausal women: relationship with obesity. J Vasc Surg. 2002;36:965-8.
• 6. Maffei FH, Magaldi C, Pinho SZ, et al. Varicose veins and chronic venous insufficiency in Brazil: prevalence among 1755 inhabitants of a country town. Int J Epidemiol. 1986;15:210-7.
• 7. Sadick NS. Predisposing factors of varicose and telangiectatic leg veins. J Dermatol Surg Oncol. 1992;18:883-6.
• 8. London NJ, Nash R. ABC of arterial and venous disease. Varicose veins. BMJ. 2000;320:1391-4.
• 9. Azizi MAA. Morfometria das fibras elásticas em colaterais varicosas do sistema de veias safenas [dissertação]. Rio de Janeiro: UERJ; 2005.
• 10. Johnson Jr. G, Rutherford RB. Varicose veins: patients selection and treatment. In: Rutherford RB, editor. Vascular surgery. 5th ed. Phliladelphia: WB Saunders; 2000. p. 2033.
• 11. Beebe HG, Bergan JJ, Bergqvist D, et al. Classification and grading of chronic venous disease in the lower limbs. Aconsensus statement. Eur J Vasc Endovasc Surg. 1996;12:487-91; discussion 491-2.
• 12. Kistner RL, Eklof B, Masuda EM. Diagnosis of chronic venous disease of the lower extremities: the "CEAP" classification. Mayo Clin Proc. 1996;71:338-45.
• 13. Kistner RL. Definitive diagnosis and definitive treatment in chronic venous disease: a concept whose time has come. J Vasc Surg. 1996;24:703-10.
• 14. Labropoulos N, Giannoukas AD, Delis K, et al. Where does venous reflux start? J Vasc Surg. 1997;26:736-42.
• 15. Porter JM, Moneta GL. Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Disease. J Vasc Surg. 1995;21:635-45.
• 16. Vin F. Varices, varicose veins. EMC Cardiologie Angéiologie. 2005;2:1-26.
• 17. Rutherford RB. Vascular surgery--comparing outcomes. J Vasc Surg. 1996;23:5-17.
• 18. Rutherford RB, Padberg FT Jr., Comerota AJ, Kistner RL, Meissner MH, Moneta GL. Venous severity scoring: an adjunct to venous outcome assessment. J Vasc Surg. 2000;31:1307-12.
• 19. Maffei FHA. Contribuição para o conhecimento da epidemiologia das varizes e da insuficiência venosa crônica dos membros inferiores [tese]. Botucatu: UNESP; 1982.
• 20. Maffei FHA, Lastoria S, Yoshida WB, Rollo HA. Doenças vasculares periféricas. 3Ş ed. Rio de Janeiro: MEDSI; 2002.
• 21. Moraes L, Puech-Leão LE, Toledo OM. Varizes e telangiectasias. Utilidade da microangiografia na orientação terapêutica. Rev Ass Med Bra. 1962;1:5-9.
• 22. Mello NA. Síndrome das Varizes. In: Melo NA. Síndromes vasculares. São Paulo: Byk; 1999. p. 265-94.
• 23. Thulesius O, Said S, Shuhaiber H, Neglen P, Gjores JE. Endothelial mediated enhancement of noradrenaline induced vasoconstriction in normal and varicose veins. Clin Physiol. 1991;11:153-9.
• 24. Rose SS, Ahmed A. Some thoughts on the aetiology of varicose veins. J Cardiovasc Surg (Torino). 1986;27:534-43.
• 25. Pitta GBB, Castro AA, Burihan E, editores. Angiologia e cirurgia vascular: guia ilustrado. Maceió: UNCISAL/ECMAL; 2003. Disponível em: http://www.lava.med.br/livro
• 26. Ungethuem ULG. Escleroterapia de varizes de membros inferiores por retropunção usando oleato de ethanolamina diluída em glicose hipertônica - análise de 12.560 casos. Anais do XII Congresso Internacional de Medicina Estética; 2003.
• 27. Pinto-Ribeiro A. Varizes dos membros inferiores - 38 E. Escleroterapia de varizes. In: Maffei FH. Doenças vasculares periféricas. Rio de Janeiro: MEDSI; 1987.
• 28. Centers for Disease Control and Prevention. Epi Info's home page. Disponível em: http://www.cdc.gov/epiinfo/Epi6/EI6dwni.htm Acessado: 15/10/2006.
• 29. Dean AG. Epi Info™ and Epi Map: current status and plans for Epi Info™ 2000. J Public Health Manag Pract. 1999;5:54-7.
• 30. Breu FX, Guggenbichler S. European Consensus Meeting on Foam Sclerotherapy, April, 4-6, 2003, Tegernsee, Germany. Dermatol Surg. 2004;30:709-17.
• 31. Beale RJ, Gough MJ. Treatment options for primary varicose veins--a review. Eur J Vasc Endovasc Surg. 2005;30:83-95.
• 32. Rabe E, Pannier-Fischer F, Gerlach H, et al. Guidelines for sclerotherapy of varicose veins (ICD 10: I83.0, I83.1, I83.2, and I83,9). Dermatol Surg. 2004;30:687-93.
• 33. Correia ME, Oliveira AP. Complicações em escleroterapia. In: Pitta GBB, Castro AA, Burihan E, editores. Angiologia e cirurgia vascular: guia ilustrado. Maceió: UNCISAL/ECMAL; 2003. Disponível em: http://www.lava.med.br/livro
• 34. Green RM. An update on the diagnosis and treatment of varicose veins. Prim Care Update Ob/Gyns. 1995;2:107-10.
• 35. Sparey C, Haddad N, Sissons G, Rosser S, de Cossart L. The effect of pregnancy on the lower-limb venous system of woman with varicose veins. Eur J Vasc Endovasc Surg. 1999;18:294-9.
• 36. Golledge J, Quigley FG. Pathogenesis of varicose veins. Eur J Vasc Endovasc Surg. 2003;25:319-24.
• 37. Jiang P, van Rij AM, Christie RA, Hill GB, Thomson IA. Venous physiology in the different patterns of recurrent varicose veins and the relationship to clinical severity. Cardiovasc Surg. 2000;8:130-6.
• 38. Psaila J, Melhuish J. Viscoelastic properties and collagen content of the long saphenous vein in normal and varicose veins. Br J Surg. 1989;76:37-40.

Publication Dates

• Publication in this collection
  19 July 2007
• Date of issue
  Mar 2007

History

• Accepted
  21 Feb 2007
• Received
  29 Aug 2006