Providers

Before proceeding with the practical aspects of establishing a practice, one must decide who will deliver patient care. Most physicians agree that a physician should perform the sclerotherapy procedure; however, some clinics use nurses to treat spider telangiectasias. A survey of the membership of the North American Society of Phlebology (NASP) (now the American College of Phlebology (ACP)) found that approximately 25% of the members would allow a registered nurse and 20% would allow a nurse practitioner to perform sclerotherapy on spider veins.¹ Of NASP members surveyed, 10% would allow a registered nurse to perform sclerotherapy on varicose veins versus 7% who would allow nurse practitioners to perform this procedure. Registered nurses can legally perform intravenous therapeutic injections in most states. Physicians should check with the state licensing board for nursing for the specific requirements.

The arguments for allowing nurses to render such care are both economic and procedural. An economic benefit is realized for both the patient and the physician if a lower-salaried person performs the sclerotherapy procedure, especially in these days of cost containment. Since the injection of spider veins is primarily cosmetic and is rarely fully reimbursable under most insurance plans, cost containment can be translated into economic marketing.

Because the cannulation of a blood vessel is relatively easy to perform and few serious or life-threatening complications can arise from sclerotherapy treatment of spider telangiectasias, an argument can be made for using nonphysicians as sclerotherapists. On the other hand, although rare, serious complications can result from injection of spider telangiectasias. Anaphylactic allergic reactions have occurred with many sclerosing agents; a fatality was reported after a ‘trial’ injection of sodium tetradecyl sulfate.² Pulmonary emboli also have occurred from the injection of leg telangiectasias (see Chapter 8). Injection into an arteriovenous anastomosis usually produces a cutaneous ulceration, and cutaneous ulceration from sclerotherapy injection (extravasation or arteriolar injection) is the most common reason (in sclerotherapy) for medical malpractice litigation. Injection into a superficial artery, especially around the malleoli, can lead to arterial emboli and pedal gangrene. Duplex-guided injections into deep perforating veins can cause significant muscular necrosis requiring leg amputation. Thus, as with most of medicine, sclerotherapy is not entirely risk-free. The physician is ultimately responsible for ensuring that the nurse is properly trained both in performing sclerotherapy and in recognizing adverse sequelae. The physician, not the nurse, will be the one sued for malpractice.

In addition to being skilled at sclerotherapy technique, the sclerotherapist must have a thorough knowledge of the anatomy and pathophysiology of venous disease and of the mechanism of action of the procedure, including its potential complications. The ability to appreciate these mechanisms and immediately recognize potential complications and render preventive treatment is critical to maintaining optimal patient care. Furthermore, a thorough understanding of vascular hemodynamics, including the relationship between deep and superficial venous insufficiency, is imperative to those practicing sclerotherapy. For example, venous segments with a certain degree of incompetence are best initially treated with endovenous ablation, which removes the source of venous hypertension, thus reducing or eliminating progression of reflux to other surrounding veins.^3,4 Not being trained to recognize when endovenous ablation is a necessary portion of the overall treatment approach results in inadequate improvement following sclerotherapy. Thus, clinical judgment as well as technical skill are both essential attributes in an effective sclerotherapist.

Hallgren et al⁵ defined basic nursing assessment skills and the requirements for transfer of function of the nurse in a sclerotherapy–phlebology practice. In short, for a nurse to function as a sclerotherapist, the following must be known:

This knowledge base should also include instruction so that the nurse can do the following:

In conclusion, nurses who practice phlebology must be actively involved in the practice of nursing when delivering care. They should be able to prepare not only the operating room for the procedure, but also the patient for the procedure by answering questions, allaying fears, and documenting pretreatment disease. In addition, follow-up treatments allow the nurse the opportunity to reinforce patient teaching so that preventive measures can be emphasized. For an excellent demonstration of lower extremity superficial venous examination techniques, the reader is encouraged to refer to an educational DVD provided by the American College of Phlebology partnered with the Society of Vascular Ultrasound.⁶ Various other comprehensive textbooks on sclerotherapy, phlebectomy, and venous ultrasound techniques are available; we have referenced those textbooks that we feel are the most useful at the end of this chapter.^7–10

Facility

Endovenous laser ablation of leg veins is best performed in a non-facility setting, as this eliminates additional facility fees associated with procedures performed in a hospital or ambulatory care facility. By having his/her procedure performed in an outpatient setting, patients save money by not having to pay facility fees, and practitioners generate more revenue by not having to split reimbursement payments with a facility.¹¹

Equipment

Relatively little specialized equipment is required to perform successful sclerotherapy. Various types of lasers may also be required for treating specific types of leg veins (see Chapter 13). For now, all that is required is a needle, syringe, sclerosing solution, binocular loupe, foam pads, tape, graduated support stockings, and camera. (See online Appendix C for information on manufacturers.) Although serious adverse events are rarely encountered during the treatment of leg veins, appropriate resuscitation equipment must be readily accessible throughout the procedure. Patients occasionally experience vasovagal reactions during the treatment of leg veins; ammonium capsules as well as oxygen can help mitigate these reactions. Other equipment, including an emergency resuscitation (crash) cart as well as an electrocardiograph, should remain readily accessible throughout the procedures.¹²

Needles

The injection of telangiectasias requires a fine-gauge needle. A needle with a clear plastic hub instead of a metal hub is useful to allow visualization with aspiration. Although some physicians prefer to use a 32- to 33-gauge or 26- to 27-gauge needle, we prefer the 30-gauge needle. There are two types of 30-gauge needles. One is the Becton-Dickinson (B-D) Precision Glide needle (Becton, Dickinson & Co, Rutherford, N.J.), which has an elongated bevel on a ½-inch needle with a 45-degree angle at the tip. The needle can be easily bent at varying angles to penetrate telangiectasias. In addition, it is relatively sharp and holds up well when used for multiple punctures of the skin. The second type is a tribevel tipped needle. The Acuderm (Acuderm, Ft Lauderdale, Fla.) and Delasco (Dermatologic Lab & Supply, Council Bluffs, Iowa) 30-gauge needles have a -inch metal hub and a silicone-coated tribevel point. This type is preferred because its silicone coating and more acute angle at the tip allow it to pierce the skin with less pain. In addition, the length of the bevel is shorter than that of the B-D needle. Accordingly, extravasation of solution perivascularly while the needle is in the vessel lumen is less likely. Tribeveling of the tip also makes it harder, so it retains its sharpness with multiple injections. A comparison of the bevels of all of the recommended needles is shown in Figure 15.1. However, even with this magnified comparison, the differences between the needle tips cannot be fully appreciated. Clinical trials using each needle type are necessary to discern the subtle differences.

Figure 15.1 Comparison of bevels of recommended needles. A, Acuderm needle, 30 gauge. B, Becton-Dickinson (B-D) needle, 30 gauge. C, Yale needle (B-D), 27 gauge. D, Yale needle (B-D), 26 gauge. E, Butterfly needle (Abbott), 25 gauge. F, Butterfly needle (Abbott), 23 gauge.

In addition, the same needle may actually change from year to year if the company chooses a different manufacturer. It is best to try different needles from different companies at least once yearly to determine which brand works best. The best test is to use each needle on both a patient and yourself to determine the ease of insertion into the skin and the feel.

One objection to the use of a 30-gauge needle has been the perception that it dulls after multiple insertions into the skin. Microscopic examination of tribeveled needles used to pierce the skin up to 15 times in our patients did not show the needle tip had dulled. What is apparent is that some needles, even when unused, have burrs or are dull. Therefore, if the insertion of the needle does not feel right, change to another needle and discard the old one.

Some sclerotherapists advise the use of a 33-gauge needle to cannulate the smallest diameter telangiectasia. Multiple 31- to 33-gauge -inch needles are available (Fig. 15.2). These needles have several drawbacks. They are more expensive than 30-gauge needles and must be cleaned and sterilized between patients if they are not disposed of (this is of concern to patients who fear inadequate sterilization with the subsequent risk of blood-borne pathogens). Repetitive sterilization also dulls the needle point. In addition, the tips of these needles bend and dull more quickly than those of the 30-gauge needles, and the needle shafts are thinner and thus less stable during injections through tough skin. John Phiffer (personal communication, 1992) reported on the construction of a rigid shaft used to support the 32-gauge needle tip to help stabilize it. However, as mentioned previously (Chapter 12), we find these needles of little use.

Figure 15.2 Comparison of 33-gauge Delasco needle tip with a 30-gauge tribevel point.

Finally, some physicians prefer 26- or 27-gauge needles for injecting telangiectasias. Again, the preference arises from a perceived sharpness of the bevel, allowing easier, more painless insertion. The 27-gauge needle comes separately in a -inch length as either a Yale (Becton, Dickinson) hypodermic needle or as an allergy needle–syringe combination fixed to a 1-mm syringe. The benefit of using the 1-mm syringe is the ease of handling perceived by some sclerotherapists. The Yale 26-gauge needle also comes in a -inch length and has the advantage of a sturdy, nonbendable shaft. In short, all types have their advantages and disadvantages. The best needle is the one with which the physician is most comfortable.

Larger needles are used most often to inject varicose veins. When injecting varicose veins, it is critical to determine the proper placement of the needle. Therefore, the smallest recommended needle size is 25-gauge (23-gauge if there is any doubt whether the vessel to be cannulated is an artery or vein or if a highly caustic sclerosing solution is being used). Larger-bore needles offer no additional advantage. A 25-gauge needle easily allows retrograde blood flow through the inserted needle, which aids in determining if placement is intravenous or intra-arterial.

The surest method of determining proper needle placement is to insert an open needle into the vein. With this technique, blood flow from the needle serves as the indicator of arterial versus venous injection. Butterfly needles are connected to clear tubing that allows visualization of blood flow, avoiding or minimizing blood exposure. In an effort to avoid blood exposure, some sclerotherapists attach a syringe to the needle and withdraw to determine flow. Still others combine the needle with a glass syringe to ‘feel’ for proper intravascular placement.

To take advantage of the safety of a large-gauge needle without incurring the risk of blood contamination, a 23-, 25-, or 27-gauge butterfly needle may be used. The needle length is inch, and the tubing is 30 cm. The plastic tubing on the proximal end of the needle allows visualization of arterial versus venous flow without risking blood exposure. The tubing takes up 0.41 mL of fluid. Some physicians fill the needle tubing with sclerosing solution to prevent clotting of blood within the needle tubing. However, this is unnecessary if the injection is performed within a few minutes of blood aspiration.

Small vein infusion sets are also available. Kawasumi Laboratories have designed a 27-gauge -inch needle on a short (-inch) catheter tubing. The priming volume with this short length is 0.05 mL. The female Luer-Lok connector has a flange for easy grip. STD Pharmaceuticals (Hereford, UK) have a 30-gauge needle set with the needle attached to the tubing without wings and the other end of the tubing connected to a standard clear plastic female Luer-Lok [0].

Syringes

Although glass syringes had been used in the past to allow easy detection of an arterial puncture, modern plastic syringes have a feel comparable to that of glass syringes. Disadvantages of using a glass syringe are that it requires practice both to fill and to use smoothly as well as the fact that it must be cleaned and sterilized between patients.

The 3-mL plastic syringe, Luer-Lok (Becton, Dickinson), is used exclusively in our practice. This syringe allows the use of an ideal quantity of solution, and when filled to a 2-mL capacity, it fits easily in the palm of the hand. However, a non-Luer-Lok syringe has the advantage of possessing a needle hub that is able to separate from the syringe if resistance, which indicates noncannulation of a vessel, is encountered. Each syringe manufacturer coats the inner portion of the syringe with silicone to allow smooth action by the plunger. The addition of silicone to coat the barrel of the syringe has also been shown to decrease the half-life of bubbles when foam is generated in the syringe (see Chapter 9). If using foam, one may wish to use a syringe with the least amount of silicone coating. The physician should evaluate different types of syringes to determine which has the best feel for his or her use.

If one does not bend the needle to facilitate penetration of the vein, the Plastipak eccentric syringe (Fig. 15.3) is useful. With this syringe, the hub is eccentrically placed at the syringe tip so that it abuts the skin surface. It is available in sizes of 1, 2, 5, and 10 mL.

Figure 15.3 Plastipak eccentric syringe by Becton-Dickinson. Note eccentrically placed hub.

Binocular loupes

Protective eyeglasses are necessary equipment for the physician who performs any surgical procedure. These glasses should be constructed to prevent the splatter or spray of body fluids (blood) as well as sclerosing solution from coming in contact with the orbital tissues, thus helping to prevent the physician’s contamination with infectious, blood-borne disease. When cannulating small diameter telangiectasia, it is common to begin injecting solution as one enters the skin. This allows the needle hub to enter the vessel and expand it to allow full insertion of the needle hub and sclerosing solution. During this process a spray of sclerosing solution is possible. Protective glasses should be worn when performing sclerotherapy.

The injection treatment of varicose veins does not require magnification of the surgical field. However, for cannulating venulectases or telangiectasias, magnification of the treatment site is important. The enhanced detail that magnification affords a more accurate placement of the needle within the vessel lumen, which prevents extravasation of the sclerosing solution into extravascular spaces.

Normally, to magnify the field of vision, one moves closer to the viewed object to enlarge its field on the retina. Moving closer to an object requires the eyes to refocus and converge more. The consequences of maintaining this close focusing distance are eye strain and back muscle stress. Eye tension and muscle fatigue may then occur, which tends to reduce efficiency. Optical magnification offers an alternative to such strain and allows maintenance of a more comfortable working distance.

The magnifying loupe allows the focusing and converging systems of the eye to relax. The loupe also allows switching back and forth between normal vision and magnified vision as necessary. This versatility is relaxing to the eyes. Viewing through magnification for long periods is not harmful and cannot damage vision. The only question concerns how much magnification is necessary.

The ideal magnifier provides a wide field of view with distortion-free magnification within a reasonably long working distance and ergonomic viewing angle (Fig. 15.4). Unfortunately, with currently available optics, the higher the magnification, the smaller the field of view and depth of field. Complex, multilens binocular magnifiers overcome some of the limitations of short working distances. Some of these magnifiers are detailed online in Appendix C. An independent evaluation of magnifiers appears in another source.^14,15

Figure 15.4 Several key optical features, including working distance, working range, convergence angle, field of view, and viewing angle, are shown.

(Courtesy of General Scientific Corporation, Ann Arbor, Mich.)

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