Sclerotherapy in Dermatology Sacchidanand S, Nagesh TS
Note: Page numbers followed by f refer to figure and t refer to table.
Alcohol intoxication 55
Allergic reactions 86, 94
Ambulatory phlebectomy, technique of 116f
Ambulatory venous pressure 36
interpretation of 38t
Anaphylaxis 86
flare 21
joint stiffness 26
perforators 8
venous flare 19
Arterial occlusive disease, advanced peripheral 65
Arteriovenous fistula 94
Artery hypertension, pulmonary 55
Aspiration 102, 104
Asthma, bronchial 65
Atrophie blanche 19, 24
Automated foaming device turbofoam 96
Bassi's perforator 9
Bedside tests 31
validation of 34
Bicuspid valves 5
Bleomycin 47, 56
Blood coagulum, manual extraction of 95f
Blue veins 16
Body mass index 120
Brodie-Trendelenburg test 32
demonstration of 32f
interpretation of 33t
Bronchospasm 55
Cabrera's technique 75
Calf muscles 7
Calf perforators, lateral 9
Carbon dioxide 76
laser 104, 106
Cerebrovascular accidents 90
irritants 54
phlebitis post-sclerotherapy 88
Chromated glycerin 47, 54, 60
Cockett's perforators 3
after sclerotherapy, types of 43
bandage 42
application of 44
elastic 42
elastocrepe for 66
hosiery 42
therapy 41
types of 42
Compressive therapy, mechanism of action of 41
Computed tomography 34, 38
Concertina method 111
Contact dermatitis 22, 98
allergic 86
Corona phlebectatica paraplantaris 21
Cough impulse test 31
Cramps 19
Cryosurgery 102, 104
hygroma 105
lesions 100
epidermoid 100
ganglion 48
mucous 101, 102
oral mucous 100
Deep plantar arch 6
Deep vein thrombosis 64, 91
history of 65
Dermatitis 64
Detergent sclerosant 77
Diathesis, allergic 65
Disrupt vein cellular membrane 47
Distended varicose veins, persistence of 34
Dodd's and Hunterian perforators 9
Doppler ultrasonography 35, 37f, 38
Doppler ultrasound machine 36f
Dorsalis pedis 6
Duplex ultrasonography 35
Eczema 22
acute 23f
chronic 23f
Edema 20, 30, 87, 94
Embolia cutis medicamentosa 93
Embolism, pulmonary 91, 92
Endosclerosis 46
activation 17
cell 46
damage 46
Endothelium, direct caustic destruction of 47
Epinephrine 95f
Erysipelas 24
Ethanol 47, 55
deep penetration 55
Ethanolamine oleate 47, 50, 60
Excision 104
Extracellular matrix 17f
degradation 17
Fascia lata 31f
Fascial compartments of leg, superficial 1f
Fegan's technique 68, 69
Femoral vein 2
Femur, adductor tubercle of 2
Fibrin cuff theory 25
Fixed plantar flexion 27
preparation 78f
methods of 75
sclerotherapy 44, 75, 82, 86, 89, 119
advantages of 82
peroperative 75
stability 76
types of 77
perforators 8, 9
veins of 2f
Fossa ovalis 31f
Gallbladder ablation 48
Gastrointestinal bleeding, upper 48
Glycerin 58, 95f
Graduated compression stockings 43
Hemangiomas 100
Hematoma 111
Hemoglobinuria 55, 94
Hemorrhage 21
Hyperpigmentation 15, 96
post-sclerotherapy 90f, 96
Hypersensitivity reactions 86
Hyperthermia 55
Hyperthyroidism 65
saline 51, 53, 58, 71, 86
sodium chloride solution 47, 59
Hypoallergenic tape 66
Ideal compression system, properties of 41
Infection 93, 97
Ischemic attack, transient 90
Itching 19
Kaposi sarcoma 48
Keller method 111
Klippel-Trenaunay syndrome 16
Knee perforators 8
Laplace's law 77
ablation 102
treatment 119
edema 65
perforator 8
ulcers, proximity of 86
Leonardo's vein 2
Lidocaine 58, 95f
Linear bullae from tape 88f
Linton procedure 111, 115
Lipodermatosclerosis 15, 19, 23, 24f, 27, 30f
Liquid sclerotherapy 44, 86, 89
Lobular capillary hemangioma 106
Lower leg, ulceration of 26
Lower limb
deep veins of 6f
major perforator veins of 10f
perforators of 14f
pigmentation of 22f
Lymphangioma 100, 104
cavernous 105
circumscriptum 104, 105, 107f
Lymphedema 27, 87, 94
Lymphoceles 48
Magnetic resonance imaging 34, 39, 105
Matrix metalloproteinases 17
Medial calf perforators 9
Metalloproteinase, tissue inhibitor of 17f
Micro-marsupialization technique 102
Microsclerotherapy 71
Micro-stab avulsion phlebectomy 116
Microvascular valves 10
Migraine 65, 90
Minimal invasive methods 118
Minocycline 89
Montreux technique 76, 77
Mucocele 102f, 103f
Multi-layer bandaging systems 42
Muscle cramps 30
Necrosis 92, 97
Neovascularization 89f
Nerve-3 impairment 55
injury 90
Nonsteroidal anti-inflammatory drugs 96
Ok 432 47, 56
Oliguria, transient 94
Oral lesions, percutaneous ablation of 48
Oral ranulas, treatment of 102
Orbach's air block 77
Osmotic solutions 51
Pain 30, 27, 64
Paresthesia 19
Patent foramen ovale 90
origin, varicose veins of 86
vascular lesion 39f
Percussion test 31
Perforating veins, incompetent 64, 86
ligation 115, 115f
nomenclature 8t
old and new terminologies of 14t
paratibial 9
thigh 8, 9
Periostitis 27
Peripheral arterial occlusive disease 65
Peripheral calf muscle pump 7f
Perthes test 33, 34
demonstration of 33f
interpretation of 34t
modified 33
Phlebectomy 116
ambulatory 116
Phlebitis, superficial 19
Pigmentation 22, 89, 94
post-sclerotherapy 89
Plethysmography 38
Polidocanol 47, 49, 58, 59, 68, 75, 85, 87f, 88f, 101
Polyethylene-oxide chain 49
Polyiodinated iodine 47, 55, 60
Pressure erythema 22
Protein theft denaturation 47
Pruritus 30
Pubic tubercle 31f, 113f
Pyogenic granuloma 100, 106, 108f
Q-switched laser 96
ablation 120
thermal energy 120
Ranula 101, 102, 103f
Restless legs 19
Reticular veins 15, 16, 21f, 58, 69
Rindfleisch-Friedel procedure 111
Salivary gland 101
Saphenofemoral junction 2, 3, 4f, 93, 111
incompetence 65, 114f
Saphenofemoral ligation 112
Saphenopopliteal junction 4, 5f, 93, 114
ligation 114
Saphenous nerve 10
Saphenous stripping
lesser 114
long 112
Saphenous vein
greater 2, 3f, 13, 31, 31f, 64, 111
incompetent 64, 86
inversion stripping of 114f
lesser 31, 64
short 13
small 2, 4, 5f, 91, 114
superficial 87
Scarring 15
Sclerosant 46, 65
concentration of 67, 68t
Sclerosing agents 47t, 58, 58t-60t, 78
Sclerosing solutions 46, 65, 66
Sclerotherapy 41, 43, 63-65, 69, 71, 71f, 73, 80, 85, 100, 102, 104, 105f, 106, 107, 108f, 119
complications of 85
contraindications of 86t
indications of 64, 86t
mechanism of 63
objectives of 63
over surgical procedures 108
procedure 100
purpose of 46
techniques 68
tray 67f
Sebaceous cyst 100, 101f
Sigg's technique 68, 69
irritation 30, 87, 97
necrosis 55, 93f
pigmentation 30
Smooth muscle
apoptosis dysregulation 17
cell 17, 17f
chloride solution with dextrose 47, 58, 60
morrhuate 47, 50, 59
sotradecol solution 119
tetradecyl sulfate 47, 48, 58, 59, 68, 69, 85, 101, 103f
Spider veins 16, 86
Standard varicose vein surgery, complications of 118
Static stiffness index 42
Steatocystoma multiplex 104, 104f
Stroke 90
Subdermic venous system, lateral 13
compartment of venous system of leg, anatomy of 13f
fascia, layer of 113f
vein thrombosis, acute 64
Sural nerve 10
Swelling 19
Systemic disease, severe 65
Tap test 31
Telangiectasia 15, 16, 20, 58, 71, 86, 95f
microsclerotherapy of 71
Tessari method 75, 76f
Thrombophilia 65
Thrombophlebitis, superficial 21, 87
Thrombosis, superficial 91
Thrombus formation 92f
Tissue plasminogen activator 25
Topical nitroglycerine ointment 66
Total endothelial destruction 47
Transilluminated powered phlebectomy 116, 117
Trendelenburg test 34
modified 32
Tumors, hemorrhagic 48
Ulcer 15, 24, 27, 30
healing 30f
varicose 23f, 27f
Ultrasound guided sclerotherapy 72, 72f, 85
techniques of 72
Urticaria 86
post-injection 87f
Valsalva maneuvers 98
Valves 5
dysfunction 16
Variceal bleeding 48
Varices 16
Varicoceles 48
Varicose veins 15-17, 19, 20f, 30f, 34, 39f, 41, 57, 63, 64, 86
ablation of 64
complications of 64
emptying of 34
evaluation of 29
formation 17f
large 58
pathophysiology of 13
presentation 19t
recurrent 120
residual and recurrent 64, 86
reticular 64, 86
sclerotherapy, principles of 67
surgical treatment of 111
fibrosis 64
malformation 48, 58
obliteration 64
diameter 80
examination of 36f
length 80
perforating 7, 8, 13
refluxing 86
superficial 1, 2, 5, 111
thread 16
X-ray of 35f
Venogram 35f
Venography 34, 35
anatomy 1
dilatation 16
diseases 13
chronic 64
of lower limb 1
eczema 19
hypertension 13
insufficiency 19
chronic 15, 16, 29, 38, 63
primary 15
symptoms suggestive of 29, 30
ligation, conservative 117
malformations 86
pathophysiology 15
physiology 15f
pressure 14, 42
reflux, superficial 114f
sinuses 7
of lower limbs 13, 14
superficial 72
varicosities, lateral 64
telangiectasia 19
thrombosis, superficial 24, 92
ulceration, mechanism of 25
ulcers 19, 22, 26, 63, 64
Venule 58
Venulectasia 16
Visual disturbances 90
White blood cell 25
White cell trapping theory 25
X-ray of veins 35f
Chapter Notes

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Venous AnatomyCHAPTER 1

Aniketh Venkataram
Knowledge of venous anatomy is essential for diagnosis and treatment of venous disorders of the lower limb. Venous anatomy was largely ignored in earlier anatomy textbooks, and its importance underappreciated. However, with increase in interest in venous disease and advent of newer imaging methods, much information has been gathered in this field. The unique anatomy in the lower limbs enables veins to act both as a reservoir of excess blood as well as a conduit for the return of blood to the heart.
Knowledge of fascial anatomy of the lower limb is essential to understand the venous anatomy. The veins of the lower limb can be divided into superficial and deep veins, with the deep muscle fascia separating the two. The superficial compartment consists of all tissue between the skin and the deep muscle fascia, and the deep compartment consists of all the tissue between the fascia and the bones. The saphenous compartment is a component of the superficial compartment enclosed between the saphenous fascia and the deep muscle fascia (Fig. 1.1). Communicating veins connect veins within the same compartment whereas perforator veins connect superficial and deep veins.1 With this background, we shall review the venous anatomy under the following headings: (1) superficial veins, (2) deep veins and (3) perforating veins.
zoom view
Fig. 1.1: Superficial fascial compartments of the leg.
In the skin, capillaries drain into a subpapillary venous plexus which drains into a deeper reticular plexus at the dermal subcutaneous junction. Vertically oriented veins connect the reticular plexus to the superficial veins.
Few veins in the body are more variable than the superficial veins of the lower limb. They begin in the foot with the dorsal and plantar venous plexuses. On the dorsum of the foot, small superficial veins form the dorsal venous arch at the level of the proximal end of the metatarsals. This forms the great and small saphenous veins (SSVs) at its medial and lateral ends respectively (Fig. 1.2).2
Great Saphenous Vein
This begins at the medial end of the dorsal venous arch and ascends 2.5–3 cm anterior to the medial malleolus. It crosses the distal third of the medial surface of the tibia obliquely to its medial border. It ascends a little behind the medial border and crosses the knee posteromedial to the medial tibial and femoral condyles. It runs on the medial side of the thigh and enters the fossa ovalis 3 cm below and lateral to the pubic tubercle. At this point, it drains into the femoral vein at the saphenofemoral junction (SFJ). The surface anatomy is marked from this point to the adductor tubercle of the femur. The SFJ however is highly variable and the surface marking is not reliable (Fig. 1.3).3
In the calf, the great saphenous vein (GSV) has two main tributaries, the anterior and posterior arch veins.
zoom view
Fig. 1.2: Veins of the foot.
zoom view
Fig. 1.3: Great saphenous vein.
The posterior arch vein, also called Leonardo's vein (first depicted in Da Vinci's drawing) drains a fine network below the medial ankle, ascends on medial aspect of the lower half of the leg and joins the GSV just distal to the knee. The Cockett's perforators connect the posterior arch vein to the posterior tibial veins as shall be seen later. There are several other variable, unnamed communications with the SSV.
In the thigh, the GSV receives the lateral and medial accessory saphenous veins. The lateral is more consistent and drains the anterolateral aspect of the thigh. The medial vein is present in 8–20% of cases, and drains the posterior aspect of the thigh. Both veins may be mistaken for the GSV. A recent study has classified the GSV as medial dominant, lateral dominant or equal based on the drainage of these accessory saphenous veins.4
Saphenofemoral Junction
Just before the SFJ, the GSV receives the superficial external pudendal, superficial external iliac, and the superficial inferior epigastric veins. A little more distally is the drainage of the medial and lateral accessory saphenous veins. Various attempts have been made to classify the confluence of veins at the SFJ, but none are reliable due to the high variability of this confluence. Most commonly what has been described is a venous star, as shown in Figure 1.4, involving the five main tributaries. But there can be any number of patterns of the tributaries draining into each other, or separately into the femoral vein.54
zoom view
Fig. 1.4: Saphenofemoral junction.
Small Saphenous Vein
It begins on the lateral aspect of the dorsal venous arch, runs behind the lateral malleolus and ascends lateral to the Achilles tendon. In the upper third of the leg, it pierces the deep fascia between the two heads of the gastrocnemius and empties into the popliteal vein in the proximal popliteal fossa at the saphenopopliteal junction (SPJ). In a third of patients, it empties high into the femoral vein or the GSV. Its surface marking is from a point midway between the bottom of the lateral malleolus and the tendoachilles to the midpoint of the knee joint line.2
There are several communicating branches between the SSV and the GSV. In 15% of patients, there is a large communicating vein named after Giacomini which connects the proximal part of the SSV to the GSV. There are other small communications between the saphenous veins around the knee (Fig. 1.5).6
Saphenopopliteal Junction
The termination of the SPJ is highly variable. A short time ago, a universally accepted classification for the SPJ was established. Type A is the classical SPJ. Type B is when the SSV empties into the SPJ with another cranial extension into the GSV or SFJ. Type C is when there is no SPJ, but the vein empties higher up (Fig. 1.6).75
zoom view
Fig. 1.5: Small saphenous vein.
zoom view
Fig. 1.6: Saphenopopliteal junction.
In the superficial veins, bicuspid valves exist which direct blood flow towards the heart. There are larger valves at termination of venous trunks with 6strong cusps and sinusoidal dilatation of the vein wall. The GSV usually has 6–14 valves, which are more numerous in the leg than the thigh. One valve called the preterminal valve is present as it pierces the cribriform fascia. The terminal valve is present at its junction with the femoral vein. The SSV has 4–13 valves which are more closely spaced, with the highest valve at the termination of the SSV. Valves in communicating tributaries direct blood from the SSV to the GSV.8
The deep plantar arch collects blood from the toes and metatarsum. This then forms the medial and lateral plantar veins, which form the posterior tibial vein behind the medial ankle. The major dorsal deep veins (dorsalis pedis) form the anterior tibial veins.9
In the calf, these veins run in pairs. The posterior tibial veins drain the muscles of the posterior compartments and run between the flexor digitorum longus and the tibialis posterior. They drain the GSV and posterior arch veins via perforators. They then pierce the soleus and continue as the popliteal vein.
The anterior tibial veins drain the muscles of the anterior compartment. The peroneal veins form in the lower third of the leg below the flexor halluces longus. They receive peroneal perforators as well as veins form the soleus muscle. The anterior tibial and peroneal veins form the tibioperoneal trunk which drains into the popliteal vein (Fig. 1.7).2
zoom view
Fig. 1.7: Deep veins of the lower limb.
7In the popliteal fossa, the vein is deep to the artery, but it then ascends and crosses the artery from medial to lateral in a superficial position. In the adductor canal, it becomes the superficial femoral vein which drains the medial side of the thigh and is connected by perforators to the GSV. The profunda femoris vein drains the lateral thigh and receives perforators form the lateral accessory saphenous vein. About 9 cm below the inguinal ligament, it joins the femoral vein to form the common femoral vein, which receives the GSV at the SFJ. It also receives the medial and lateral circumflex femoral veins. It lies medial to the artery at the inguinal canal and continues as the external iliac vein.8
The deep veins of the foot and distal calf have many valves at 2 cm intervals. The thigh deep veins have very few valves. There is one constant valve at the junction of the superficial femoral and profunda femoris.
Venous Sinuses of Calf Muscles
These are thin walled venous reservoirs in the calf muscles, which contract during ambulation. They act as a peripheral muscle pump to aid in venous return against gravity. The soleus is rich with sinuses while the gastrocnemius has few. These sinuses are filled by superficial veins via indirect perforators and via muscular veins. They drain into deep veins via soleus and gastrocnemius veins. The sinuses themselves have no valves, but their draining veins do. These valves are vital for the efficiency of the peripheral muscle pump (Fig. 1.8).10
zoom view
Fig. 1.8: Peripheral calf muscle pump.
Perforating veins are either direct in which case they drain into deep veins, or indirect where they drain into deep veins via calf muscle sinuses. Small 8communicating branches often connect perforators to one another. There perforators usually have one to three valves which direct blood flow from superficial to deep. The number of perforating veins has been variably reported in various studies, with as many as 150 been reported.
Of these, there are four groups of significant perforators: foot, medial calf, lateral calf and thigh. These perforators were initially named after their finders (e.g., Boyd, Cockett). However, in 2001, the International Union of Angiology decided on a standard nomenclature for these to aid in information exchange and standardization.11 The direct perforators usually have a reliable anatomy while the indirect perforators are unpredictably distributed (Table 1.1).
Table 1.1   Perforator nomenclature.
Foot perforators
Dorsal foot PV or intercapitular veins
Medial foot PV
Lateral foot PV
Plantar foot PV
Ankle perforators
Anterior ankle PV
Lateral ankle PV
Leg perforator
Medial leg PV
  • Paratibial PV
  • Posterior tibial PV (Cockett PV)
Anterior leg PV
Lateral leg PV
Posterior leg PV
Medial gastrocnemius PV
Lateral gastrocnemius PV
Intergemellar PV
Para-Achillean PV
Knee perforators
Medial knee PV
Suprapatellar PV
Lateral knee PV
Infrapatellar PV
Popliteal fossa PV
Thigh perforators
Medial thigh PV
  • PV of the femoral canal
  • Inguinal PV
Anterior thigh PV
Lateral thigh PV
Posterior thigh PV
  • Posteromedial
  • Sciatic PV
  • Posterolateral
Pudendal PV
PV: Perforating veins.
Foot Perforators
The foot usually has around 10 perforators. One large one in the first web space connects the superficial venous arch to the dorsalis pedis. On the medial aspect, perforators connect the GSV to the dorsalis pedis. On the lateral aspect, perforators connect the SSV to the lateral plantar deep vein. The ankle perforators were previously named after May and Kuster.9
Medial Calf Perforators
The medial calf perforators are clinically the most significant. They were formerly named after Cockett into three groups; Cockett I (behind malleolus), Cockett II (7–9 cm from tip of medial malleolus) and Cockett III (10–12 cm from malleolus). These are all located 2–4 cm from the medial edge of the tibia and average 7–8 in number. These connect the GSV and posterior arch vein with the posterior tibial veins. In the upper half of the leg, perforators are located more closely to the tibia and are called paratibial perforators. They are usually seen in three groups; at distances of 18–22, 23–27 and 28–32 cm from the medial malleolus. The 18–22 cm group was also called the 24 cm perforator due to its distance from the sole. These perforators drain the GSV, and its tributaries into the posterior tibial veins. Just distal to the knee, there is another consistent set of perforators formerly called Boyd's perforators which connect the GSV to the popliteal veins.12
Lateral Calf Perforators
On the lateral calf, the peroneal perforators connect the SSV to the peroneal vein. Named ones include the Bassi's perforator at 5–7 cm from lateral malleolus and the 12 cm perforator at 12–14 cm from the lateral malleolus. More proximally, perforators are usually indirect. On the anterior calf, the perforators of note include the premalleolar and midcrural ones which drain GSV into anterior tibial vein.13
Thigh Perforators
In the thigh, direct perforators are less frequent. They include the Dodd's and Hunterian perforators to the popliteal and superficial femoral respectively. Several indirect perforators to the muscular veins exist (Fig. 1.9).14
The vein wall is made up of three layers; the intima, media and adventitia. The intima consists of a single layer of endothelial cells lying on connective tissue. Valves are made up of connective tissue with intima on both sides.10
zoom view
Fig. 1.9: Major perforator veins of the lower limb.
The media is made up of smooth muscle cells and connective tissue. Larger veins have more smooth muscle and are resistant to varicosity. Smaller tributaries have less muscle and are more prone for varicosity. The adventitia is poorly demarcated and contains vessels, nerves and lymphatics.15
Previously, it was thought that valves are absent in smaller veins, but recent studies have proven otherwise. Microvascular valves have been demonstrates in collecting venules and smaller caliber veins up to 1,000 microns. The functional significance of this finding is as yet incompletely understood.16
Saphenous Nerve
The saphenous nerve descends with the superficial femoral artery, deep to the sartorius. It gives an infrapatellar branch to supply the skin medial to the knee. The main nerve pierces the fascia lata above the knee and becomes superficial between the gracilis and sartorius, at which point it is deep and posterior to the GSV. Below this point, it becomes more superficial and anterior, and is eventually juxtaposed with the GSV, around 2–3 cm below and medial to the tibial tuberosity. The nerve then travels close to the GSV, which makes vein removal almost impossible without nerve injury. Eventually it terminates by supply skin over medial leg and foot.
Sural Nerve
This nerve arises from the tibial nerve in the popliteal fossa, descends in the posterior leg to the back of the lateral malleolus. It lies on the lateral head of the 11gastrocnemius and then lies in the groove between the two heads, lateral to the SSV. It usually pierces the deep fascia with the SSV and then courses close to the SSV. It terminates by supplying the skin over posterior half and lateral foot.17
In conclusion, venous anatomy of the lower limb is one of the most variable and unpredictable in the entire body. A thorough knowledge of the most common patterns enable us to identify variations when they arise; thereby ensuring adequate identification and treatment of various venous disorders.
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