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Sclerotherapy of spider veins

      Sclerotherapy of spider veins
      Victoria Vitale-Lewis; Boston; 1995; Butterworth-Heinemann; 142 pages; $125.
      This brief textbook serves as an excellent primer for those physicians interested in the management of spider veins. Dr. Vitale-Lewis reviews the anatomy and physiology of spider veins as well as the venous system and goes through a thorough review of patient selection, examination, and testing. The description of injection technique is as precise as one can be in a field where most of us develop our own technical concepts. The results and complications omit none of the major problems in the management of this vexing patient complaint. The discussion of results rightfully emphasizes the great importance of patient satisfaction with the procedure. Although as many as 80% of patients are symptomatic, in the end, the patients' evaluation of results has a profound effect on their desire to continue in the treatment protocol. It is patient satisfaction with the procedure more than anything else that results in their continuing in a treatment program.
      The author fairly reviews both sides of the compression controversy, but stops short of recommending a long-term compression program, which we have found indispensable in decreasing recurrence. The effect of climate on a decision to use compression therapy is touched on and is a critical part of the argument of whether we can get a patient to use long-term support stockings. Not enough emphasis is placed on the need for a custom-fitted pressure gradient support stocking to control long-term recurrence.
      A minor point of issue is the initial use of a cotton ball at the injection site to provide additional pressure. We have pointed out in previous publications the importance of compressing not the needle entry point, but the entire length of vein that has been filled with sclerosing agent, thus necessitating a more comprehensive type of gauze pad.
      The major problem with the book is in the area of preoperative noninvasive testing. The Doppler examination is well-illustrated and adequately described, but the usefulness of bidirectional Doppler is not considered. The handheld Doppler scan can be expected to identify some sites of incompetence, but probably not all. Neither can it identify anatomic variations, duplicate veins, or enlarged tributary veins that may overlie smaller underdeveloped named veins.
      The author chooses to dismiss duplex technology as bulky, cumbersome, and expensive, but it is difficult to argue with its ability to measure, localize, and classify a wide range of conditions. Duplex technology in patients who have exclusively spider veins has shown us a surprising range of large reflux points that would not have been detected and quantified without the duplex scan. The frequency and wide range of venous anomalies remain an unending surprise that can only be guessed at by other techniques. Consequently, we use duplex scanning routinely in this group of patients.
      On the whole, this is an excellent textbook, well-illustrated and comprehensive in its bibliography, and a must-read for those physicians who are interested in sclerotherapy.