Pain evaluation and control during and following the treatment of hypertrophic scars and keloids by contact and intralesional cryosurgery--a preliminary study.

BACKGROUND: Intralesional cryosurgery effectively treats hypertrophic scars and keloids (HSK), but pain experienced by the patient during treatment can limit the application of cryosurgery. OBJECTIVES: To characterize the pain response during cryosurgical treatment of HSK, and to evaluate the pain experienced during contact and intralesional cryosurgery that employs a pain-control protocol. METHODS: Twenty-nine patients (17 women, 12 men) aged 17 years and older (mean ages 31.9±12.5 and 38.9±18.6 years, respectively, P=0.24), who were treated for a total of 36 HSKs by intralesional (n=20; 22 cryotreatments) or contact (n=9; 14 cryotreatments) cryosurgery were evaluated. The pain-control protocol involved oral pain-relief tablets (Dipyrone) and translesional local anaesthesia with Bupivacaine hydrochloride 0.5%. Pain evaluation according to the Visual Analogue Scale (VAS) (0-10 cm) was compared between the two groups at three time points: during cryosurgery, immediately after it, and 4 h later. Scores ≤3 cm were considered to define the 'zone of analgesic success'. These results were compared with control data (contact cryosurgery without a pain-control protocol; n=56). RESULTS: Pain in the intralesional group was significantly lower than that in the contact group during and immediately after cryotreatment. During: mean VAS=1.68±2.21 vs. 5.07±4.01 cm; median VAS=0.5 vs. 5.5 cm, respectively; P<0.0001. Immediately after: mean VAS=1.22±1.77 vs. 5.38±3.81 cm; median VAS=0 vs. 6.0 cm, respectively; P=0.001. The control group had more pain during treatment (mean VAS=5.34±2.31, median=6.0) and 4 h later (mean=3.79±2.35, median=4.0) than the intralesional group (P<0.0001 and P=0.988, respectively). The pain level in the control group during the cryotreatment did not differ from that in the contact group (P=0.988). In the intralesional, contact and control groups analgesic success (VAS ≤3 cm) was achieved in 77.3%, 35.7% and 33.9%, respectively, of cases (P=0.002) during cryotreatment, and in 54.5%, 42.9% and 33.9%, respectively, of cases 4 h after treatment (P=0.24). CONCLUSIONS: The pain-control protocol significantly reduced pain severity to tolerable levels (VAS ≤3 cm) during and following intralesional and contact cryosurgery. Intralesional cryosurgery caused the least pain during and immediately after treatment.

Ultrasound-guided direct basilic-axillary approach in preoperative venography for hemodialysis access.

PURPOSE: Hemodialysis patients with suspected central vein stenosis or occlusion require venographic assessment before access surgery. Conventional venography may be unsatisfactory because of the limited ability to image central veins via peripheral arm veins that are inadequate or that have been damaged by multiple cannulations. Imaging of the central veins requires high flow contrast injection, which may be unattainable through small peripheral veins. We suggest a simple technique to improve central vein imaging by ultrasound-guided direct puncture of the basilic vein at its entry to the axilla. METHODS: We studied 20 patients in whom upper limb venography via peripheral veins was inadequate for the satisfactory demonstration of central vein anatomy and they underwent direct basilic-axillary vein puncture with Doppler ultrasound guidance. A 4Fr micropuncture catheter was used for manual injection of the contrast agent to image the central veins. RESULTS: All patients had inadequate upper limb venography via peripheral vein cannulation, and stenosis could not be ruled out due to poor visualization of the central veins. In all cases, venography by Doppler ultrasound-guided direct basilic-axillary vein puncture was very easy for both the radiologist and the patient, consistently providing high quality imaging without the need for repeated attempts at cannulation and without the need for infusion pumps. No complications were noted during or after the procedure. CONCLUSIONS: Venography by Doppler ultrasound-guided direct basilic-axillary vein puncture is a simple and rapidly performed technique that improves the visualization of the central veins.

Intra-operative central vein angioplasty during arteriovenous access creation.

Central vein stenosis or occlusion due to prior use of central vein hemodialysis catheters may lead to disabling extremity edema or cause early failure after arteriovenous access construction. Our integrated program for arteriovenous access management enables us to identify these stenoses pre-operatively. We carried out intra-operative angiography and angioplasty during arteriovenous access creation in 3 patients with good immediate and long-term results. Intra-operative endovascular therapy is a new application of peripheral vascular surgery techniques for patients with significant central vein stenosis undergoing access surgery, which exploits the high postoperative flow state to maintain patency after angioplasty. It may also be applicable in situations such as proximal arterial stenosis with anticipated steal syndrome and other conditions that may compromise access patency.