Phlebotherapy Forum

Forum of Three-dimensional Regenerative Ambulatory Phlebotherapy (T.R.A.P.)

 

The fact that an opinion is strongly supported
does not mean that it cannot be completely absurd.
B. Russel

Questions and answers for medical professionals

Reviewer 1

Question1

There's plenty of controversy in the literature about the importance of perforating veins in the pathogenesis of varicosities. The author should explain his view of the relationship of saphenopopliteal incompetence to varicose veins.

Valvular insufficiency is dynamic. Contraction of the so-called ‘peripheral heart’, which is constituted by the leg muscles, generates the highest venous pressure: up to 300 mm of mercury (6,7). This region, which is of strategic importance for the correct functioning of the venous circulation, contains about 100 perforating veins (8), as well as the origin of the small saphenous vein, which connect the superficial circulation with the deep circulation.

Question2

Ectatic reticular veins are often associated with a network of telangiectasia, explain.

Telangiectasias form when the ectatic reticular veins are no longer able to absorb the rapid pressure increases caused by muscular contraction. Telangiectasias may form even in the absence of visible reticular veins if the capillary network is directly connected to an incontinent perforating vein.

Question3

Varicose veins routinely occur in the absence of perforator insufficiency, explain.

The functional anatomy of the venous circulation in the lower limbs reveals that the valvular insufficiency of the perforating veins and the ectasia of the truncal veins, reticular veins, venules and telangiectasias are, except for rare cases (mechanical obstructions, traumas, arteriovenous fistulas, congenital angiopathies, excessive functional performance (1), prolonged exposure to heat or sun, cortisone application, radiodermatitis, inflammation, chronic skin disorders, etc) due to congenital miopragia of the vessel walls (1, 2, 3, 4, 5).The disorder is  sustained by perforating vessels which reveal their insufficiency only when the patient runs or walks. Clearly then, the insufficiency of even a small percentage of these vessels can thwart any traditional treatment and give the erroneous impression that ectatic veins can form without a hemodynamic cause, apart from the causes listed above.

Question4

"Hemodynamic" alterations follow the obliteration of perforating veins. This statement runs counter to a large body of opinions suggesting that treatment of reticular veins? is important as a first step in eradicating small vessels. Explain your theory.

Even if obliterative techniques are applied to perforating veins that appear incontinent on color-flow doppler scanning, the problem will not be solved and the progression of the disorder will not be prevented. Indeed, hemodynamic alterations may be caused that give rise to new capillary and venular ectasias; following the obliteration of a perforating vein, the pressure on the superficial venous circulation determined by other incontinent perforating veins that cannot be revealed by means of the instrumental examinations available may increase and be manifested at the surface of the skin. It should be borne in mind that visible ectatic vessels are the result of increased pressure generated by valvular insufficiency;, some authors have focused on treating the ectatic reticular veins; these, however, represent the effect rather than the cause of the disorder.

Question5

Visible ectatic veins are the result of increased pressure generated by valvular insufficiency", in point of fact there are certainly at least several reasons why small vessels grow.

Except for rare cases (mechanical obstructions, traumas, arteriovenous fistulas, congenital angiopathies, excessive functional performance (1), prolonged exposure to heat or sun, cortisone application, radiodermatitis, inflammation, chronic skin disorders, etc) due to...

Question6

How does this novel solution produce "regenerative fibrosis confined to the vascular tree?

The wall fibrosis induced by the endoluminal injection of the solution causes thickening without disorganization of the wall; indeed, the elastic fibers within the wall remain intact.

Question7

What are the authors explanations for the molecular basis of this very special type of fibrosis which seems too good to be true.

A non-buffered solution of sodium salicylate and glycerol almost identical to 6% ******** has been tested
on an ear vein of the rabbit, producing a clinical and histological effect equivalent to that of chromic
glycerin (17). .”Chromic glycerin has been used for several decades. We feel sure that the molecular basis
of the fibrosis that it causes, which is histologically equivalent to that caused by ********, is available in the literature.”

Question8

What in vivo studies have been carried out to determine the precision of such fibrosis?

Over the six years of development of this technique, our utilization of the ******** solution
as steadily improved.

Question9

The assertion that this treatment restores the correct conditions of blood flow and pressure in the areas involved is not substantiated by any ofthe studies presented in this paper. Discuss your laboratory evaluations in detail.

The fact that the results obtained seem to be permanent is the most convincing proof that functional integrity has been restored 

Question10

Inflammatory matting occurring solely in areas of post sclerotherapy  hyperpigmentation must be very rare. Why is treatment of this type of matting unnecessary.

The most difficult cases of matting to treat are those with the highest pressure and those that arise even
after modest pressure increases in a context of very marked miopragia. If the former cases were treated with a two-dimensional technique, matting would inevitably recur. The rare cases of inflammatory matting resolve spontaneously
and do not require treatment. Inflammatory matting is clearly visible in areas of post-sclerotherapy hyperpigmentation. For the sake of simplicity, we have deleted the complex discussion of inflammatory
matting following timedsurgical de-epithelialisation.. It is, however, curious that most authors advise treating “inflammatory” matting by injecting a sclerosing solution that causes further inflammation”

Question11

Discuss the toxicology of salicylates and glycerol.

The LD-50 of intravenous polydocanol in the dog is 50 mg/kg. The LD-50 of intravenous sodium salicylate in the dog is 562 g/Kg. In humans, concentrations of salicylate greater than 200 mg/ml are regarded as toxic. In mice, the LD-50 of glycerol administered intravenously is 6.0 g/Kg. It should be stressed, however, that the alkalization of ******** makes the absorption of sodium salicylate at the systemic level practically nil

Question12

What studies have been carried out to assure safety when such large volumes are employed.

The recommended limit of 31.5 ml of 5% solution is determined by the duration of the treatment session, which is about 30 minutes, and by the need to keep well within the safety margins: 31.5 ml of solution contains 27 ml of 6% ******** plus 4.5 ml of 1% lidocaine, which is sufficient to treat even the most severe cases. During experimentation of the method, we injected up to twice this amount of solution (therefore 9 ml of lidocaine) without any untoward effect. In that case, the amount of sodium salicylate injected was 3.15 g  and therefore still within the 3.6 g limit of sodium salicylate used as a sclerosing solution (26).

Question13

0.5 % policodanol is a very weak sclerosant which would generally be ineffective for large varicose veins. Is this a fair comparison?

In traditional use, the efficacy of the solutions has been seen to be very similar, but the side effects are very different (see tabs 2, 3, 4). The tolerability of ******** has proved to be far superior to that of polydocanol (which used to be regarded as the best available solution) and has opened the door
to T.R.A.P.. Its efficacy is dose-dependent and therefore increases as the dose increases, even
in large varicose veins”.

Question14

Compare and contrast the complications and efficacy of 0.5 % polidocanol and the solutions you employ.


Question15

"Potential for color-flow Doppler scanning is modest." It is the opinion of most authorities that the assessment of the degree of reflux achieved by color-flow Doppler is extremely important for treating large veins.

This examination is important in the surgical treatment of large vessels, but is not routine when three-dimensional regenerative phlebotherapy is to be undertaken. Indeed, in the case of an exquisitely dynamic disorder that is manifested when the patient is in movement, the diagnostic potential of color-flow Doppler scanning is modest This assertion is supported by Fig 2.27 of the treatise Sclerotherapy by Mitchel P. Goldman (16), in which Doppler examination of a patient suffering from a severe venous disorder does not reveal any impairment of the sapheno-femoral or sapheno-popliteal junctions, nor any incompetence of the perforating veins. To our way of thinking, this is completely absurd, in that even the tiniest telangiectasia is the outward manifestation of the valvular incontinence of an underlying vessel (18), except for those rare cases already mentioned. They act exclusively on the full-blown aspects of the alteration in venous circulation, while the disorder is  sustained by perforating vessels which reveal their insufficiency only when the patient runs or walks. Clearly then, the insufficiency of even a small percentage of these vessels, which cannot be revealed by the instruments available, can thwart any traditional treatment and give the erroneous impression that ectatic veins can form without a hemodynamic cause, apart from the causes listed above.

Question16

"even the tiniest telangiectasia may or may not be a manifestation of valvular incompetence."

The functional anatomy of the venous circulation in the lower limbs reveals that the valvular insufficiency of the perforating veins and the ectasia of the truncal veins, reticular veins, venules and telangiectasias are,
except for rare cases (mechanical obstructions, traumas, arteriovenous fistulas, congenital angiopathies, excessive functional performance (1), prolonged exposure to heat or sun, cortisone application, radiodermatitis, inflammation, chronic skin disorders, etc) due to congenital miopragia of the vessel walls (1, 2, 3, 4, 5). to...

Question17

When the needle is no longer able to penetrate." Does this mean the needle has become dull? Explain.

When the needle is no longer able to penetrate easily into the telangiectasias, it must be replaced.
While a worn needle-tip is still able to penetrate a vein, it will tend to displace rather than penetrate
telangiectasias

Question18

If resistance is"weak," is it possible to the degree of resistance while encountered while injecting has as much to do with the caliber of the vein injected as the degree of incompetence? Explain.

The three-dimensional concept is clearly illustrated by the fact that 1 ml of 6% solution may be injected into an isolated telangiectasia 2 mm in length (12). This means that the pressure on the plunger of the syringe is low and that the telangiectasia is the superficial manifestation of the valvular incontinence of an underlying vein that is directly connected to it (24) and which flows into the deep circulation. The resistance felt on the plunger of the syringe is therefore not  related to the size of the visible vessel injected, but to the size of the vessels connected with it.

Question19

What are the "areas of localized subcutaneous hardening"?
Histologically - is this scar tissue?  Explain. 

These are small areas of reactive hardening which disappear within a few weeks. No histological examination of these has ever been carried out.

Question20

"Limit of 31.5cc of 6%" what is the LD-50 of this material in animal studies. How was this volume limit established? 

The recommended limit of 31.5 ml of 5% solution is determined by the duration of the treatment session, which is about 30 minutes, and by the need to keep well within the safety margins: 31.5 ml of solution contains 27 ml of 6% ******** plus 4.5 ml of 1% lidocaine, which is sufficient to treat even the most severe cases. During experimentation of the method, we injected up to twice this amount of solution (therefore 9 ml of lidocaine) without any untoward effect. In that case, the amount of sodium salicylate injected was 3.15 g and therefore still within the 3.6 g limit of sodium salicylate used as a sclerosing solution (26). The LD-50 of intravenous polydocanol in the dog is 50 mg/kg. The LD-50 of intravenous sodium salicylate in the dog is 562 g/Kg. In humans, concentrations of salicylate greater than 200 mg/ml are regarded as toxic. In mice, the LD-50 of glycerol administered intravenously is 6.0 g/Kg. It should be stressed, however, that the alkalization of ******** makes the absorption of sodium salicylate at the systemic level practically nil

Question21

explain why all patients receive antithrombotic therapy and what are the products "which are also employed" and why are they used.

All patients require anti-platelet therapy in order to limit intravascular blood accumulation and venous
thromboses.

Question23

results - Perhaps the author would entertain the possibility that not all telangiectasia occur on the basis of reduction of hemodynamic pressure.Visible ectatic veins are the result of increased pressure generated by valvular insufficiency", in point of fact there are certainly at least several reasons why small vessels grow.

Except for rare cases (mechanical obstructions, traumas, arteriovenous fistulas, congenital angiopathies, excessive functional performance (1), prolonged exposure to heat or sun, cortisone application, radiodermatitis, inflammation, chronic skin disorders, etc) due to...

Question24

Discussion - If T.R.A.P. acts on vessels that are not obviously pathological, animal studies could be used to determine the specifics of its action. Were they employed?

A non-buffered solution of sodium salicylate and glycerol almost identical to 6% ******** has been tested on an ear vein of the rabbit, producing a clinical and histological effect equivalent to that of chromic glycerin (17)

Question25

Do the authors worry about the injection of this solution into periocular areas where the effect of "regenerative fibrosis" may be unpredictable.What is the rationale for injecting telangiectasia on the face? Normalization of reflux? explain.

Facial telangiectasias, if they can be injected, are part of a three-dimensional disorder. The reduction in the overall volume of the veins reduces the hemodynamic pressure on the capillary-papillary plexus, thereby enabling a more rapid and stable result to be achieved through subsequent treatment by physical means), which is always
necessary in this region in order to eliminate the vessels completely. By contrast, complete elimination of telangiectasias of the lower limbs, in our experience, does not require the use of any physical technique.The solution injected into the vessels of the cheek mainly flows toward the mandible; only in the nasal and palpebral
regions, therefore, do we apply compression during injection of the angular vein at the internal corner of the eyelid. Although the angular vein is normally valved, this maneuver is recommended on account of the possibility of anatomical alterations of the vessel. It should be borne in mind that the effect of ******** is predictable

Question26

The use of small quantities of two drops into spider veins. Aren't telangiectasia spider veins (naevi no vein)? Explain.

Spider naevi are arterial formations and should be injected with only a few drops of 6% ********

Question27

Histologic section of skin, right "Has restored uniform wall thickness", is this the biopsy of the same vein? Explain. 

(Right) Histological section of skin. The same patient, the same area and a vein of the same size seen after
 treatment with 6% ********.

Question28

Matting may represent an exaggerated form of vascular remodeling which can occur as a consequence of trauma and the release of inflammatory cytokines unrelated to "gateways and venous reflux". 

The most difficult cases of matting to treat are those with the highest pressure and those that arise even
after modest pressure increases in a context of very marked miopragia. If the former cases were treated
with a two-dimensional technique, matting would inevitably recur. The rare cases of inflammatory
matting resolve spontaneously and do not require treatment.Only hemodynamic matting is of phlebological interest. Inflammatory matting, together with pigmentations, indicates that the type and concentration of the solution are inappropriate.

Comment to Author of Reviewer 1

This is a provocative and perhaps seminal article which contains a large number of theories and potential patient risks which have not been assessed in an objective and scientific manner.
Varicose veins and telangiectasia probably occur on a multifactorial basis and this approach may be one of many which have potential importance but may not stand the test of time and comparison to other evolving technologies.

Reviewer 2

Question28

the authors state "the valvular and ostial incontinence of the great saphenous vein is of only marginal  importance."  if that is the case, how do the authors explain the functional and cosmetic improve offered by endovenous saphenous ablation procedures?

By contrast, the valvular and ostial incontinence of the great saphenous vein is of marginal importance with regard to pressure, , since the hydrostatic pressure at the ankle is 80/100 mm of mercury regardless of whether the valves are continent or not (9,10). The valvular incontinence of the largest superficial vein has a clinical significance only if it is associated to saphenopopliteal incompetence and valvular insufficiency of the perforating veins. Indeed, cases have been observed of subjects born without valves in the great saphenous vein who do not manifest any disorder, while efficient valves have been found in the external iliac vein of subjects suffering from varicose veins (11)Saphenectomy is certainly three-dimensional, but it does not respect the anatomical and functional integrity of the circulation. The improvement seen in patients following ablation of the great saphenous vein largely depends on the ligature of the major perforating veins and on the obliteration of the perforating veins that are connected to it. Surgical ablation of the saphenous vein, however, is an incomplete treatment which yields inconsistent results (12) and, from our point of view, cannot be adopted as the therapy of choice for insufficiency of the venous circulation in the lower limbs, in the majority of cases. Saphenectomy yields long-lasting, good-quality results only in those patients in whom the residual perforating veins are continent. Even in such cases, however, the developmental aspects of the varicose disorder determined by the miopragia of the vessel walls cannot be avoided. While fine-tuning T.R.A.P., we have noticed that saphenectomy patients need more sessions of phlebotherapy in order to achieve optimum results. We may hypothesize that this is due to the anatomical-functional alterations caused by the operation itself. With regard to ambulatory phlebectomy, until now this has been justified only by the absence of residual pigmentation. Obviously, the availability of a solution that does not generate permanent post-sclerotherapy pigmentation relegates this operation to the level of a second choice.

Question29

How is "********" different from other sclerosants?
How does it achieve non-obliterative regeneration of the vessels?
Is it the innate property of the "********" solution used?
Or is it simply the lower concentration used?
If it is just lower concentration that makes it non-obliterative, then can the same procedure be performed using more commonly accepted sclerosants, such as Sotradecyl or polidocanol?

We do not claim that the vessel fibrosis caused by ******** is histologically different from that caused by other chemical solutions. For what concerns the ability to consistently induce efficacious fibrosis, we do not know whether this feature is exclusive to ******** or whether it can be achieved by means of other solutions. At present, we know that chromic glycerin is able to produce a similar degree of fibrosis, though we have never considered the possibility of injecting large amounts of this solution. With regard to exclusively water-based solutions, we believe that, if suitably diluted, they may be able to exert a “regenerative” effect. However, we do not know whether they are able to maintain this effect in depth, on starting from the superficial vessels, or whether they would immediately become diluted and therefore lose all efficacy.

Question30

The authors have not demonstrated how this new procedure is non-obliterative.  Only one histological comparison was offered. But it is not clear that after multiple extensive injection sessions, that the veins are not obliterated, as they are in
sclerotherapy.

The ability to cause controlled, predictable fibrosis, which is a feature of ********, can be verified by observing the superficial vessels. If small amounts of 6% solution are injected into a vein, the caliber of the vein will be reduced within a week. Further injection into the same vein will result in a further reduction in caliber within another week, and so on until the vein is no longer visible. If, by contrast, we inject enough of the solution to “regenerate” the underlying vessels, the resulting reduction in hemodynamic pressure will allow the vein to shrink until it is no longer visible after only one treatment session. This does not mean that the vein has been obliterated. Obliteration is accompanied by evident inflammation and by sclerotic hardening of the vessel. The injection of ******** does not have such effects, even in large-diameter reticular veins. Intravascular blood accumulation may occasionally occur during T.R.A.P.. However, even in such cases, the vessel is not obliterated completely. Indeed, if a vessel containing an accumulation of blood (and therefore already treated) is erroneously re-treated, it will still be able to take in a fair amount of solution, and the only indication that a vessel containing an accumulation has been injected will be the quality of the blood that seeps from the injection site.

Question31

Properly performed sclerotherapy is already very similar to the treatment process outlined by the patients.  Most phlebologist advocate treatment of veins in a logical progression, from the largest to the smaller veins.  From the highest point of reflux to the lowest.  Therefore, all layers of the superficial venous system are treated.  In this context, properly performed sclerotherapy is already "three-dimensional", not "two-dimensioanl", as suggested by the authors.

We believe that T.R.A.P. has the potential to be widely used. Indeed, alongside the rigorously obliterative approach, there exists an orientation towards a milder form of sclerotherapy that utilizes the minimum effective concentration of solution (26). Clearly, a form of sclerotherapy that is by definition obliterative cannot completely embrace our philosophy. Indeed, “obliterating” the entire superficial and perforating circulation is unthinkable; it can, however, be “regenerated”. The notion that treatment should be carried out progressively from the largest to the smallest veins is not in line with the concepts we adopt. In our view, what is important is the pressure, not the size. Indeed, size may be determined by wall weakness in a single vessel. Even telangiectasias are frequently used as gateways for the “regeneration” of perforating veins. We do not consider the perforating veins to be part of the superficial circulation.  

Question32

The authors also claim that sclerotherapy is only performed on visible and pathological veins (Table 1).  This is not correct.  Often times, in order to treat visible telangiectasia, the underlying feeding reticular veins must be eliminated first in sclerotherapy.

Only clearly pathological vessels are injected and  the reticular veins that are connected to ectatic venules
and telangiectasias. Reticular veins connected to telangiectasias are normally visible to the naked eye because they are ectatic.

Question 33

When considering complications, matting and pigmentation still is a problem with this procedure, similar to sclerotherapy.  I do not feel that the authors have demonstrated a better safety profile.

Over the six years of development of this technique, our utilization of the ******** solution has steadily improved. For instance, de-epithelialization no longer occurs. Moreover, cases of pigmentation are rare, limited to the injection sites and short-lived; from the esthetic point of view they are therefore irrelevant and, after the first session, are always avoidable. With regard to matting, we maintain that the most critical areas are the internal region of the knee and the lateral region of the thigh. Transillumination, which we have only been using for the past year, has proved very useful in completing the regenerative action in these areas and has enabled us to minimize this complication, which, moreover, normally resolves easily.

Question34

The authors admit that the proposed limit of the ******** solution of 31.5ml is based solely by the duration of the treatment session.  This is neither a scientific nor safe method to establish a such guideline.

The recommended limit of 31.5 ml of 5% solution is determined by the duration of the treatment session, which is about 30 minutes, and by the need to keep well within the safety margins: 31.5 ml of solution contains 27 ml of 6% ******** plus 4.5 ml of 1% lidocaine, which is sufficient to treat even the most severe cases. During experimentation of the method, we injected up to twice this amount of solution (therefore 9 ml of lidocaine) without any untoward effect. In that case, the amount of sodium salicylate injected was 3.15 g and therefore still within the 3.6 g limit of sodium salicylate used as a sclerosing solution (26). )  . The LD-50 of intravenous polydocanol in the dog is 50 mg/kg. The LD-50 of intravenous sodium salicylate in the dog is 562 g/Kg. In humans, concentrations of salicylate greater than 200 mg/ml are regarded as toxic. In mice, the LD-50 of glycerol administered intravenously is 6.0 g/Kg. It should be stressed, however, that the alkalization of ******** makes the absorption of sodium salicylate at the systemic level practically nil

Comments to Author of Reviewer 2

I congratulate the authors on this innovative paradigm in the treatment of venous insufficiency. But I feel that in promoting this new concept, the authors have understated, or simply overlooked the benefits of properly performed sclerotherapy and other well-established procedures:Clearly this procedure is still in its infancy.
As the authors state, only when it is performed more widely and in more extreme cases can we understand the limits and the long term benefits.
A more revealing study would be a side-by-side comparison between sclerotherapy and "phlebotherapy".  As it is now, I doubt this information will change the clinical practice of most phlebologists. But the value of this manuscript is still undeniable; this new "regenerative" treatment concept encourages phlebologists to view the treatment of venous reflux from an entirely different angle.


Re: RE : [vasculab] R: More physiological appraisal [dicember 2007]
vasculab@yahoogroups.com

Capurro)
In a previous e-mail, I asked colleagues where they thought the problem of
venous insufficiency lay. Indeed, in order to solve a problem, I think the
first thing to do should be to agree on what the origin of the problem is.
I probably made a mistake in sending the message, which was not delivered.
Please forgive me for interfering, but this question intrigues me. In order
to explain my thoughts in simple terms, let me start from the observations
made by Franceschi.

According to Franceschi...
Franceschi)
...the danger is that we might “look at the smoke
(varices) and ignore the fire (haemodynamic condition) beneath it”. His
Theory and Practice were described in a book that is still available in
French, English and Italian: Claude Franceschi: cure CHIVA :
http://www.editions-armancon.fr/ , in which the author states: “When drugs
repair walls and venous valves, CHIVA will disappear.”

Capurro)
Franceschi locates the problem in the walls of the veins. But of which
veins ? In other words: where is the fire? Clearly, not in the superficial
vessels, which merely manifest the effect of the disease: “the smoke”, as
Franceschi puts it.
If this is correct, obliterating or removing the effect of the disease does
not seem to be a good idea, as it does not address the cause; moreover, it
eliminates the “escape valve” of the underlying hypertension (as well as
subverting the natural anatomy and physiology of the circulation, of
course).
Franceschi locates the problem in the walls of the veins. But which veins ?
Clearly, not the great saphenous vein (the innocence of which emerges from
the literature; indeed, many individuals are born without valves in the
great saphenous vein and femoral vein, and yet they do not develop varices).
Rather, the problem lies in the veins that cannot be seen: the perforating
veins, which are subjected to the highest haemodynamic pressure. It seems
to me that, in any system of pipes, what is important is not the dimensions
of the vessels, but the pressure, which is determined by the weakness of
their walls. Indeed, in the leg, the pressure may reach 300 mmHg! If all
of this is true, what happens? The walls of the perforating vessels dilate
when the patient walks, the valves cannot withstand the pressure, and an
anomalous pressure is exerted on the superficial circulation, the vessels of
which become dilated. If the walls of the reticular veins are particularly
weak, classic varices will develop; if the reticular veins can withstand the
pressure, then the venules will dilate; if the venules can withstand the
pressure, then the telangiectasias will dilate. These are three aspects of
the same phenomenon. Obviously, an insufficient perforating vessel may be
manifested on the skin in the form of an isolated telangiectasia. If these
concepts are correct, it is necessary to strengthen the walls of the
perforating veins, where the anomalous pressure originates. Naturally, the
entire perforating circulation must be treated; it is irrational to think
that wall miopragia should be located in a small area of the limb. The
whole limb must be treated. How? The simplest approach is to follow the
same pathway in the opposite direction. This involves injecting a solution
that is not obliterating but “regenerative” (regeneration = restoration of
function) into the vessels that are visible to the naked eye and on
trans-illumination, and pressing it into the perforating veins (most of
which cannot be visualised by colour Echo Doppler). The perforating veins
will be strengthened, will shrink slightly, and will once again become
continent. In this way, the anomalous pressure exerted on the superficial
circulation will be relieved, and the vessels will disappear permanently
from view. For what concerns the valves, once they have been destroyed,
they cannot be restored. It is therefore advisable to avoid destroying the
valves through the use of improper methods, to prevent phlebitis, and, in
subjects with a familial predisposition, to undertake preventive measures
before vessels visible to the naked eye develop.

With best regards,

Sergio Capurro

Inviato: lunedì 3 dicembre 2007 6.27
A: vasculab@yahoogroups.com


Simka)
Uzytkownik Sergio Capurro <sergio.capurro@fastwebnet.it> napisal:
Let me comment on that,
My opinion is that pathophysiology of varicose veins cannot be explained exclusively by means
of haemodynamics. Not regarding the cellular and molecular aspects of this pathology (yet,
affected by impaired haemodynamics) is the easiest way to create a new dogma in phlebology.


Marian Simka


Franceschi)
Dear Marian, I agree with you about neo angigenesis but which is the trigger? Why not
haemodynamic phenomenon? If it is, suppressing the haemodynamic trigger should avoid neo
angiogenesis. Haemodynamic is not a dogma but a necessary ( even if not sufficient) cause of
venous insufficiency.
Regards

Claude Franceschi


Simka)
Dear Claude,
I agree with you in the point that likely it is haemodynamics, which triggers all these events.
However, in a current phlebology there exists macroscopic approach (surgery, diagnostic
imaging, haemodynamic assessment, etc.) and microscopic approach (genetics, cell biology, etc).
The both could be potentially regarded as two sides of the same coin (like Newton&#8217;s
mechanics and quantum mechanics in the physics). Hopefully, investigations focused on the role
of a pathology in a macrophlebology on microphlebological level, and vice versa, could explain
some not yet solved problems.
Best regards


Marian Simka



Capurro)
Cellular and molecular aspects concern miopragia, which, as we have said, is the cause of
venous wall dilation in subjects with a familial predisposition to varicose disease. As yet,
we cannot act upon this familial disposition; we can only make recommendations regarding
lifestyle and diet. There is no pill that a mother can take during pregnancy in order to
eliminate the predisposition to varicose veins in her child.
By contrast, when ectatic vessels begin to manifest themselves – even those visible only by
means of transillumination – we can functionally correct the congenital and acquired cellular
and molecular aspects of the vessel walls, which, as they dilate, give rise to valvular
insufficiency.
In order to understand the concept of the regenerative treatment of the superficial and
perforating circulation, it must be borne in mind that even a tiny telangiectasia (except for
rare cases of mechanical obstructions, traumas, arteriovenous fistulas, congenital
angiopathies, prolonged exposure to heat or sun, cortisone application, radiodermatitis,
inflammation, chronic skin disorders, etc.) is caused by valvular insufficiency.
In reality, essential varices do not exist (this concept stems from inefficacious diagnosis).
Our intervention aims to re-establish proper hemodynamics by exerting an effect, which is
logically molecular and cellular, on the walls of the vessels responsible (perforating veins);
in this way, the vessels shrink, are strengthened and become continent once more, without
losing their elastic properties. The procedure must be carried out on the entire superficial
and perforating circulation in order to reduce all anomalous pressures. The pumps must recover
their functional status, without leaks, especially where the pressure is highest.
If the smallest telangiectasia is caused by valvular insufficiency, the functional result and
the aesthetic result evidently coincide. For this reason, our treatment terminates when there
are no longer any vessels visible to the naked eye or on transillumination. This means that
the entire circulation has been “cured” and that the result will remain permanent.

Best regards

Sergio Capurro