Pfeifer, John R.

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Sclerotherapy of spider veins 

BOOK REVIEWS 
J ohn  M.  Por ter ,  MD,  Book  Rev iew Sect ion Ed i to r  
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 physiol- 
ogy of spider veins as well as the venous system and goes 
through a thorough review of patient selection, examina- 
tion, 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 satis- 
faction with the procedure. Although as many as 80% of 
patients are symptomatic, in the end, the patients' evalua- 
tion 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 deci- 
sion to use compression therapy is touched on and is a 
critical part of the argument of whether we can get a 
patient o use long-term support stockings. Not enough 
emphasis i placed on the need for a custom-fitted pressure 
gradient support stocking to control ong-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 examina- 
tion 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 
JOURNAL OF VASCULAR SURGERY/September 1997 
unending surprise that can only be guessed at by other 
techniques. Consequently, we use duplex scanning rou- 
tinely in this group of patients. 
On the whole, this is an exceUent extbook, well- 
illustrated and comprehensive in its bibliography, and a 
must-read for those physicians who are interested in scle- 
rotherapy. 
John R. Pfeifer, MD 
Troy, Mich. 
Trauma 
David Feliciano, Ernest Moore, and Kenneth Mattox; 
Stamford, Conn.; 1996; Appleton & Lange; 1280 
pages; $150. 
Trauma is an encyclopedic look at the field of injury 
care that has, over three editions, assumed primacy as the 
leading textbook in this area. This recognition is, in my 
opinion, well deserved. With the third edition of Trauma, 
the tripartite ditorship has taken on a new mission. In 
contrast o the second edition where the mission of the 
volume (according to the editors' preface) was to provide a 
useful single-source reference for "health professionals 
working with trauma patients and involved in the contin- 
uum of care," the third edition seeks to target a greatly 
enlarged audience, which consists of 16 disparate groups, 
both medical and non-medical, that may have short, me- 
dium, or long-term interests in trauma. Although the mis- 
sion statement for the third edition places urgical residents 
and trauma surgeons in the middle and at the end of the 
target audience list, the volume maintains its focus on 
providing precise definitions of the standard of care for 
various injuries while providing summary statements on 
important issues uch as prevention, epidemiology, system 
design, and planning. 
Few surgeons recognize the enormous effort required 
to produce such a work. I counted 119 authors exclusive of 
the senior editors. That this new volume was produced just 
4 years after the second edition with one half of the chap- 
ters the product of new authorship is admirable indeed. 
The strengths of the book are significant, and the 
senior editors have sought o "stay with what works." The 
line drawings remain the major strengths. These are clear, 
and when combined with the tabular material, which is 
controlled in terms of size and complexity, the chapters 
become, in general, coherent and easily readable. By seek- 
ing clarity and consistency, the editors have exposed them- 
selves to certain risks. These include the fact that chapter 
authors, afraid of taking a stand, will seek to provide de- 
tailed and comprehensive rather than directed overviews of 
the subject areas. The book suffers from the effects of this. 
For example, the editors have apparently mandated algo- 
rithms for all of the clinical chapters. Some of these (diag- 
nosis and management of splenic injury, for one) include 
539 


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Sclerotherapy of spider veins

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