When dealing with lower extremity varicose veins, a prsctioner shou= ld first exclude or treat truncal saphenous reflux first

TransLite Application Note Number 1<= /o:p>

Using the Veinlite for Varicose Veins Treatment

Asad R. = Shamma, M.D. Nizar A. Mul= lani B.S.

Introduction

Veinlite is a relatively new device for transilluminating superficial veins and assist in the treatment of these veins. Transillumination, i.e. shining light through an object to make the tissue tra= nsluscent, has been used for many years to aid in the visualization of superficial vei= ns. However, this classical transillumination method is achieved by shining lig= ht through the body and is of limited use for imaging thick areas of the body. Light is absorbed by body tissue within a few mm and can not pass through thicker bo= dy parts. Therefore, classical transillumination has not been used very much in many medical applications.

Side-Transillumi= nation

A new patented transillumination method (3), called Side-Transillumination, removes the need to transmit light through an object. Unlike classical transillumination, side-transillumination or oblique angle transillumination, shines light into the skin at an angle from outside the area of interest. A circular array of bright fiberoptic light is directed to the circle’s center at an oblique angle, so that the light is focused a few millimeters = below the skin surface. The focused light creates a conical volume of illuminatio= n, with the central focus point being very bright and acting as a virtual light source under the skin. This technique achieves uniform transillumination of= a small region of percutaneous tissue, anywhere o= n the body. The light transmitted through the skin is orange to red in color and = is very sensitive to absorption by deoxygenated hemoglobin. The result is that= percuteneous blood vessels are seen with great contra= st up to a depth of 5 mm or more depending on the size of the blood vessels.=

Veinlite Design

The Veinlite is designed as a circular array of light sou= rce with an opening in one end to provide access to the vein during visualizati= on as shown in Figure 2. It uses a very bright ring of cold fiber optic light = that is directed at an angle towards the center of the ring, to form a virtual light source at a depth of approximately 1 cm. The virtual light source under the skin makes t= he circular area within the ring to become translucent. Blood vessels are seen= with great clarity. Varicose and feeder veins are easily identified and can be accessed through the opening in the ring. The concept of side-transillumina= tion is shown in Figure 2 below.

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Figure 1. Side-Transillumination Method Showing the Direction of t= he Light Towards the Center of the Ring to Form a Virtual Light Source a Few Milimeters Below the Skin Surface. This Makes the Skin Area Within the Ring Translucent.

Using the Veinlite for Varicose Veins Treatments

Varicose veins are enlarged venous blood vessels = that that can range in size from a fraction of a millimeter to several millimete= rs in diameter. These enlarged blood vessels are characterized by poor blood f= low and often have retrograde blood flow, which can cause bulging or blood clot= s. Superficial varicose veins such as spider veins, reticular or feeder veins = that feed these spider veins, or the larger superfici= al veins can be easily seen using the Veinlite transilluminator.

The Veinlite can be u= sed in several ways to aid the physician in treating varicose veins. These are

Treatment of superficial spider veins and reticular or feeder v= eins with sclerotherapy
Mapping of the venous network of large superficial varicose vei= ns for mini ambulatory phlebectomy to assist = with surgical planning
Aiding in visualization and evacuation of trapped blood in bulg= ing veins
Determining reflux of blood flow in superficial veins
Education of the patient of the extent of the disease

Veinlite<= span style=3D'font-size:14.0pt;font-family:Arial'> Assisted Sclerotherapy of Reticular and Spider Veins

Reticular veins, or feeder veins as they are often referred to, are often associated with superficial spider veins and feed a network of tiny superficial veins that are varicosed. Depending on skin color and extent of adipose tissue, reticular veins may be difficult to see with the naked eye. Unlike larger varicosities, they are difficult to palpate as they do not bulge. The Veinlit= e is an excellent device that can help visualize these reticular veins and as= sist in accessing these deeper veins for the treatment of superficial varicositi= es.

When dealing with lower extremity varicose veins,= the physician should first exclude truncal saphenous reflux, or treat it if present. Following this, the patient is typically le= ft with a combination of bulging varicosities, reticular veins, and spider vein complexes. These are mostly of cosmetic concern but need to be treated to a= void future complications from developing.

While bulging varicosities may be treated by phlebectomy or sclerotherapy, it is universally agreed that reticular veins are best treated by sclerotherapy. These subdermal reticular veins, which appear blue, are often referred to as ‘feeder veins’, as they supply the more visible spider vein complexes. By treating them, the spider vein complexes are weakened and often disappear a= fter a single injection of sclerosant.

Technique for Treating Reticul= ar Veins with the Veinlite

The Veinlite is much more than a visualizing aid for superficial veins. Its C shaped ring with an access port is designed to

(a) sequester the vein,

(b) isolate the area being treated, and =

The best way to achieve successful treatment of a varicose vein is to first visualize= the vein to be treated using the Veinlite. Foll= owing that press lightly on the skin wi= th the Veinlite ring and pull it back, stretching the skin in the direction opposi= ng the opening in the ring. This action is the key to successful sclerotherapy as with the Veinlite as it achiev= es two vital objectives. First, it stabilizes the vein and facilitates accurate en= try of the needle into the stabilized vein that does not ‘run away’ from the needle. Second, it tightens the overlying skin and permits an almo= st painless entry through the skin into the vein, which would be difficult otherwise, especially if the skin is loose and or redundant. This is particularly useful when treating older patients, with sagging skin, and is vital when doing sclerotherapy on reticular breast veins. See Figure 2.

Figure 2, Vein Stabilization and Injection Tech= nique

After securing entry into the vein, confirmed by blood return, gradually release = some of the pressure applied to the skin by pressing on the Veinlite ring. Then,= using a 3cc luer lock syringe with a 30 gauge needle, and with minimal force on t= he plunger, gently inject sclerosing agent. As soo= n as you see the vein segment within the ring blanch, re-exert pressure on the s= kin by pressing on the Veinlite ring and keep your thumb firmly on the plunger = for around 10 seconds. This minimizes the rapid refilling of the vein with blood and allows the sclerosing agent to stay in contact with the intima for long= er interaction time.

In treating the whole leg with the Veinlite assist= ed scleroptherapy, start with the patient in the supine position and work on the anterior limb, from just above the ankle up to the groin. Then, ask the patient to roll (one quarter turn) laterally and do the same procedure on the outside of the limb. The patient rolls again to lie p= rone and treat the posterior limb. Finally, after the patient rolls again, perfo= rm the procedure on the inside of the limb.

Compression stocking is used after the treatment, applying a light, thigh high liner un= der it. The liner allows for easier application of the stocking and keeps it cl= ean.

To help the Veinlite ring slide easily over the skin, advise the patient not to apply any lotion to their legs on the day of treatment. Prior to starting t= he procedure spray the skin with 70% alcohol. Between patients, the ring is cleaned using lint free gauze and 70% alcohol.

Limitations of the Veinlite = for Sclreotherapy

For the technique to be most effective, a tight seal is needed between the ring= and the skin. This is difficult when treating over bony prominences such as the= ankle, anterior shin or knee cap. This limitation may be overcome by using a small= er ring on these difficult areas. However, the smaller ring is more difficult = to use, owing to its smaller opening.

The second limitation is that the phlebologist is obliged to perform the aspira= tion of blood and the injection of sclerosing agent, with a one hand technique, = as the other hand is holding the ring. While this is easy for some of us, othe= rs find it more difficult. Fortunately, there are new devices that facilitate = the one hand injection technique.

Mapping of Veins Prior to Ambulatory Phlebectomy

A preferred method for treating bulging varicosities is mini-phlebectomy. This procedure minimizes the trapping of blood in the bulging veins that often accompanies sclerotherapy.

To best achieve this procedure, the sites of puncture must be accurately marke= d on the skin. Most of physicians do this with the patient standing. However, wh= en the patient lies down to undergo the phlebectomy, the skin marks applied wh= en standing become inaccurate as the skin moves with respect to the v= ein. This is demonstrated in Figure 3, which shows the position of the mark appl= ied when standing and the vein position in the operating position. <= /span>

So use the Veinlite to accurately mark the stab si= tes with the patient in the operating position and the leg positioned exactly a= s it will be after the skin is prepped and the leg draped. This will result in accurate positioning of stab positions for the excision of the vein.

Figure 3, Marking the locations of stab punctures durin= g phlebectomy with the patient in the operating position rather than standing up.

Aiding in Evacuation of Trapped Blood<= /b>

Occasionally, blood becomes trapped in a treated vein. This can be painful and or annoyin= g to the patient and may cause skin discoloration. The recommend procedure for t= his is to evacuate the trapped blood by performing a stab with an 18 or 20 gauge needle. While this is often easy to do, because the vein is hard and palpab= le, you can achieve a more exact and less painful stab if you use Veinlite to g= uide your way. The trapped blood in the bulging veins is viewed as much darker in color than normal vein due to the lower level of oxygen in the blood.

Patient Education

The Veinlite is an excellent tool to educate the pa= tient on the extent of the disease in the patient. By transi= llumating the skin, the physician can show the patient the network of veins and the feeder veins responsible for the overlying spider vein complex. Once the pa= tient can see the feeder vein it makes it easier to explain the logic behind trea= ting the reticular veins. The Veinlite is also excel= lent for showing the patient the larger varicosed ve= ins and discussing the impact of these on venous circulation in the leg.

Conclusions=

The Veinlite device has changed the way we examine = and treat varicose veins. Its ability to transilluminate the superficial veins so that they are easily seen by the physician and the patient has made it an extremely important diagnostic too. However, the use= of the Veinlite for identifying and assisting in t= he treatment of reticular veins has clearly changed the way we treat spider ve= ins.