July 15, 2007
Profuse Bleeding in Patients With Chronic Venous Insufficiency
By Labas, P Cambal, M
Aim. The aim of this retrospective study was to compare the healing rates of patients where the bleeding points were sutured (n=52) against those where the bleeding was controlled using compression sclerotherapy (n=72). The incidence of re-bleeding was also followed over a 12-month period. Methods. During 1999-2003, we treated 124 patients (86 women and 38 men; mean age: 64 years, age range: 36-85 years) with profuse bleeding from varicose veins as emergency cases. Seventy-two patients (58%) were treated with compression sclerotherapy. In the suture group of 52 patients (42%) the bleeding points were treated in the emergency outpatients department. Usually a cross stitch was used and the same type of uninterrupted compression as in the sclerotherapy group was applied for 6 weeks afterwards.Results. In the group of patients where compression sclerotherapy (Fegan's method) was used to control the bleeding (65 patients), the average time taken for the wound to heal completely was 7 days (5- 13 days). There was no recurrence of bleeding in the subsequent 12 months. In the group of patients where a suture was used to control the bleednig, the average time of healing was 14 days (11-19 days) and re-bleeding occurred in 12 cases (23%).
Conclusions. Using Fegan's technique of compression sclerotherapy with a low concentration of sclerosant (0.2% sodium tetradecyl sulfate), it is possible to treat bleeding varicose veins effectively with significantly faster healing of the wound.
[Int Angiol 2007;26:64-6]
Key words: Hemorrhage - Varicose veins - Sclerotherapy.
Profuse bleeding from varicose veins is an unusually rare, well- recognized symptom for urgent treatment because it can be lethal. The aim of this study was to compare the therapeutic results of those patients whose bleeding points were sutured with those who were treated with compression sclerotherapy. Bleeding from varicose veins has been divided into three types: spontaneous, related to trauma and subcutaneous. Spontaneous, external bleeding is considered to be the most dangerous.1
Patients can die as a direct result of spontaneous bleeding and often complain of multiple bleeding episodes for months and years. Realizing the potential gravity of the condition, patients should undergo treatment after the first episode of bleeding.
Materials and methods
During 1999-2003, we treated 124 patients (86 women and 38 men; mean age: 64 years; age range: 36-85 years) with profuse bleeding from varicose veins as emergency cases.
In 94 cases (75.9%) the bleeding point was at the foot and the ankle; 28 patients (22.5%) bled from the calf and 2 patients (1.6%) from the thigh after external injury. Grouping by the CEAP classification gave the following: in class 1 (teleangiectasis or reticular veins) there were 4 patients (3%), in class 2 (varicose veins) 7 patients (6%), in class 4 (skin changes of venous disease) 53 patients (43%) and in class 5 (healed ulcer) 48 patients (38%); 12 patients (10%) suffered from active ulcer up to 3 cm in diameter. Three patients were pregnant (6th and 8th month of pregnancy) at the time of treatment and 12 patients were bleeding from the base of a venous stasis ulcer from an uncertain size of vein. In 95 patients (76%) the bleeding vein was 1 mm, but never >4 mm (1-4 mm, 24%). None of the patients had evidence of coagulopathy or congestive heart failure. In 108 patients (87%) the evidence of injury was minimal: 5 patients (4%) were injured by animals and 72 patients (58%) were treated with compression sclerotherapy using the detergent sclerosing solution Fibro-Vein (Hereford, England, sodium tetradecyl sulfate). A soft rubber ring was applied around the bleeding point. A 0.2% concentration was injected into veins around the bleeding point with a 30-gauge needle attached to a 2 mL syringe. The sclerosant was always injected with an air-bubble-foam technique. The treated leg was elevated to 30[degrees]. After several minutes bleeding stopped, the wound was covered with sterile gauze and compression of 45 mm Mercury (elastic stockings) was applied.
Uninterrupted compression was applied for 6 weeks with forced mobilization of treated patients. Injection and compression resulted in prompt local vein thrombosis in all patients.
In the suture group of 52 patients (42%) the bleeding points were treated in the emergency outpatients department. Usually a cross stitch with a non-res orbable suture material was used and the same type of uninterrupted compression as in the sclerotherapy group was applied for 6 weeks afterwards. The treatment was performed by two groups of surgeons according to their preferred technique of treatment (surgery or sclerotherapy). Both of the groups were comparable: there were no statistically significant differences in age, general condition, localization or size of bleeding point and stage of chronic venous insufficiency.
All patients refused any treatment for chronic venous insufficiency over the next 12 months and all of them were followed up in the outpatients department at 3 and 12 months. In addition to clinical investigation of bleeding points duplex sonography was done during the check-up controls in all patients.
For statistical analysis we used Mikulecky et al.'s, computer program.2 The program includes a test of homogeneity, test of differences and ?2 test with Yates correction. Statistical results were considered significant when the P value was
In the group of patients treated with compression sclerotherapy (n=72) the bleeding wound had healed completely within an average of 7 days (513 days). In patients treated surgically (n-52) the average time of healing was 14 days (11-19 days). All patients (100%) of both groups were checked after 3 and 12 months. There was no recurrence of bleeding in the treated area for the compression sclerotherapy group, despite the fact that they were not treated for chronic venous insufficiency post-treatment. In the group of patients treated surgically (stitch and suture) (n=52) there were 12 recurrent bleedings (23%) in the treated areas. The differences are significant (P
Discussion and conclusions
Bleeding is an unusual indication for the treatment of varicose veins, but it is a phlebological emergency,3 which could be lethal. Evans et al.4 found that most of the fatal outcomes involved elderly patients with chronic ankle ulceration and signs of chronic venous insufficiency. Compression sclerotherapy provides a safe, cost- effective, outpatient treatment with excellent results, which could be used in pregnant and elderly patients. There is general agreement that variceal bleeding should be treated, but little has been written detailing the techniques.5
The current approach has been to use a surgical procedure (stitch and removal of large varicosities). Fegan's technique of compression sclerotherapy makes it possible to complete sclerotherapy on all pathological reflux points in 1-2 visits not only with good results, but also as a day case that does not interrupt the patients work IOUtine.6-8
Suture and ligature of the bleeding site showed delayed healing when compared with simple compression sclerotherapy. Concomitant injection/ compression sclerotherapy proved to be a successful and permanent method of treating these veins. No recurrent bleeding developed in any of the patients, even in those with previous episodes of bleeding.
Varicose veins are known to worsen during pregnancy and bleeding can occur not only from venous ulcers, but also from other veins. Compression sclerotherapy using sodium tetradecyl sulfate is safe with no fatal toxicity after the 4th month of pregnancy.
Initial treatment of the bleeding blue bleb requires not only compression of the tiny open vessel, but strictly intravenous injection of low concentration sclerosant to close the nearby localized reflux point.9 Later complete compression sclerotherapy provides a permanent method of obliterating the thin-walled veins and prevents future bleeding. It is essential to treat the entire incompetent venous system as well as the bleeding site itself. Compression sclerotherapy for profuse bleeding from varicose veins is an easy, safe and reliable emergency procedure, especially in patients refusing further investigation and proper treatment of chronic venous insufficiency.
Received November 1, 2005; acknowledged November 7, 2005; sent for revision December 7, 2005; resubmitted July 4, 2006; accepted for publication September 14, 2006.
1. McCarthy WJ, Dann CH, Pearce WH, Yao JS. Management of sudden profuse bleeding from varicose veins. Surgery 1993;! 13:178-83.
2. Mikulecky M, Komornik J, Ondrejka P. Statistical estimates and tests based on the binomial distribution. Bratislava; Computer program, Com Tel; 1998.
3. Pannier F, Rabe E. [Emergencies in phlebology], Hautarzt 2004;55:533-42.
4. Evans GA, Seal RM, Evans DM, Craven JL. Spontaneous fatal haemorrhage caused by varicose veins. Lancet 1973:2:1359-62.
5. Norgren J. Chronic venous insufficiency, a well-known disorder with many question marks. Angiology 1997;48:23-6.
6. Fegan WG. Conservative treatment of varicose veins. Prog Surgi 973; 11:37-45.
7. Fegan G. Varicose veins, compression sclerotherapy. Hereford: Berrington Press; 1990
8. Labas P, Ohradka B, Cambal M, Ringelband R. The results of compression sclerotherapy. Comparative study of two techniques and two sclerosants. Phlebologie 2000;29:137-41. 9. Tretbar L. Treatment of small bleeding varicose veins with injection sclerotherapy. Bleeding blue blebs. Dermatol Surg 1996;34:78-80.
P. LABAS, M. CAMBAL
1st Department of Surgery, University Hospital Bratislava, Bratislava, Slovakia
Address reprint requests to: Assoc. Prof. P. Labas, M.D., Ph.D., I Department of Surgery, University Hospital Bratislava, Mickiewiczova 13, 813 69 Bratislava, Slovak Republic. E-mail: firstname.lastname@example.org and email@example.com
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