J
Vasc Bras. 2006;5(2):163-4
Surgical
treatment combined with sclerotherapy is not a new procedure. In the
1970's, a study described the surgical treatment of varicose veins
and sclerotherapy for telangiectasias performed in the same intervention.1
Nevertheless,
such strategy has apparently not become popular, possibly because
it increases surgical time and may also increase its risks and costs.
In the
article by Gaspar & Medeiros published in the previous issue of J
Vasc Bras (2006;5:53-7),2 the authors
present results obtained using this approach. In the sample description,
however, two patients were exclusively treated by chemical sclerotherapy
under anesthesia. These cases are not part of the scope and, in our
opinion, represent an increase in procedure complexity, cost, and
risk. The cost-effect analysis for both cases, including the total
cost of anesthesia, examinations, hospitalization, and staff (nursing
and anesthesiologist), shows less than reasonable results.
The
general trend for medical treatments is towards more outpatient and
less invasive procedures. Performing chemical sclerotherapy during
surgery certainly reduces patients' discomfort. However, 70% of the
patients included in the study had to perform at least one complementary
ambulatory session.
Varicose
disease has no cure. After a 1-2-year period, other vessels will dilate,
and we prefer not to indicate sedation or locoregional anesthesia
for yet another treatment of small vessels. We believe the development
of techniques such as cryosclerotherapy, transdermal laser (skin burn
safe since 1999), and the association of Cryo5™ (a device that blows
cold air at -20 ºC and numbs the skin in seconds) are the paths to
modernize the treatment of small- and medium-caliber varicose veins.
The
advantages of hypertonic dextrose have been well pointed out by the
authors. However, besides the advantages mentioned, it is worth adding
the high viscosity, thus reducing high flow injection and venous capillary
or venous-arteriolar reflux - the cause of ischemic ulcer.3,4
The authors
stress the use of safety glasses as one of the disadvantages of laser.
Such glasses efficiently filtrate the laser light, which could damage
the retina in case of accidental shot towards the pupil. Furthermore,
the transdermal laser is a noninvasive method, as opposed to the injection
sclerotherapy, in which the needle is in contact with the patient's
blood, with occasional risk of accidental contamination of the sclerotherapist.
Some cases are described of health professionals who contracted AIDS
in that manner. For this reason, the use of gloves to perform sclerotherapy
is recommended.
Several
companies worldwide invest millions of dollars every year to continue
developing transdermal lasers. The model we use (Harmony™, 1,064 nm
with 60 ms pulse length), launched in 2004, is still safer than the
previous ones. It allows the use of maximum energy with overlaping
shots in type IV non-tanned skins (Fitzpatrick classification). Light
is absorbed by the blood 30 times more than by the vessel. In our
experience, the last skin lesion caused by laser (micro scabs due
to calibration error) occurred with the Vasculight™ device (1,064
nm and 16 ms pulse length) more than 4 years ago. The Quantum™ DL
(evolution of Vasculight™) and Harmony™ lasers are even safer. After
more than 500,000 shots, we did not register any case of eschars in
our service. Therefore we emphasize that, besides being up-to-date
for endovascular conducts for arterial and venous treatments, it is
also necessary to be up-to-date for transdermal lasers.
Most
vascular surgeons have difficult access to new equipment due to its
high cost. This gives more space to dermatologists, who are present
in all congresses about laser and make big investments in the acquisition
of new equipment able to treat small vessels.
Therefore,
we must put skepticism aside and try to invest more in each area of
vascular surgery.
