Sclerotherapy Treatment & Management

Sclerotherapy is currently the treatment of choice for telangiectasias and reticular veins. It is also commonly used as an adjunctive treatment for tributaries of the saphenous vein after saphenous obliteration by endovenous laser, radiofrequency, or surgery. Sclerotherapy (endovenous chemical ablation) can also be used as a primary treatment for nonsaphenous varicosities and saphenous veins, commonly using ultrasound assistance.

Sclerosants include the following: ^[8]

• Detergents - Disrupt vein cellular membrane (protein theft denaturation)

  • Sodium tetradecyl sulfate (Sotradecol)

  • Polidocanol (Asclera, Aethoxysclerol)

  • Sodium morrhuate (Scleromate)

  • Ethanolamine Oleate (Ethamolin)

• Osmotic agents - Damage the cell by shifting the water balance through cellular gradient (osmotic) dehydration and cell membrane denaturation

  • Hypertonic sodium chloride solution

  • Sodium chloride solution with dextrose (Sclerodex)

• Chemical irritants - Damage the cell wall by direct caustic destruction of endothelium

  • Chromated glycerin (Scleremo)

  • Polyiodinated iodine

The most commonly used agents are hypertonic saline, sodium tetradecyl sulfate, polidocanol, and chromated glycerin.

Hypertonic saline 23.4% concentration is approved by the US Food and Drug Administration (FDA), but its use in sclerotherapy is off label. The principal advantage of this agent is the fact that it is a naturally occurring bodily material with no molecular toxicity. It is not widely accepted as a sclerosing agent because it can cause pain, burning, and leg cramps upon injections; if extravasated, it likely causes significant tissue necrosis; it is highly likely to produce marked postsclerotherapy hemosiderin staining, which is cosmetically unacceptable; and it is difficult to achieve adequate sclerosis of large vessels without exceeding a tolerable salt load. Suggested hypertonic saline concentrations are 23.4% for reticular veins (2-4 mm) and venulectasias (1-2 mm) and 11.7% (half strength) for telangiectasias (< 1 mm). ^[11]

Sodium tetradecyl sulfate, a synthetic surfactant (soap), is an FDA-approved sclerosant. It is commercially available in 1% or 3% standard concentrations. This sclerosant is reliable, safe, and effective. The main clinical concerns stem out of its tendency to cause postsclerotherapy hyperpigmentation in up to 30% of patients, a high likelihood of tissue necrosis upon extravasation (especially when injected in high concentrations), and occasional cases of anaphylaxis. Suggested sclerosant concentrations are 0.25-0.4% for reticular veins (2-4 mm) and venulectasias (1-2 mm) and 0.1-0.2% for telangiectasias (< 1 mm). ^[11]

Polidocanol is a nonester local anesthetic, popular in Europe, that was approved in March, 2010 by the FDA for use in the United States. It is painless upon injection, does not produce tissue necrosis if extravasated, and has a very low incidence of allergic reactions, although few cases of anaphylaxis have been reported. Also, in some patients, it may produce hyperpigmentation. The maximum daily dosage is 2 mg/kg. Suggested sclerosant concentrations are 0.5-1.0% for reticular veins (2-4 mm) and venulectasias (1-2 mm) and 0.25-0.75% for telangiectasias (< 1 mm). ^[11]

Although 72% chromated glycerin (Scleremo) is very popular in Europe, it has not yet been FDA-approved for sclerotherapy in the United States. Compared with other sclerosants, it is very weak and is essentially useful for the treatment of small vessels. The main advantages of glycerin are that it rarely causes posttreatment hyperpigmentation, telangiectatic matting, or tissue necrosis if extravasated. On the other hand, it is very viscous, causes pain upon injection (for that reason, it is often compounded with lidocaine to decrease pain), is highly allergenic, and could lead to ureteral colic and hematuria. For spider veins and reticular veins, glycerin seems to be more effective than polidocanol, with fewer adverse effects but more pain. ^[12]

The lead principle in sclerotherapy is to cause irreversible endothelial injury in the desired vessels while avoiding damage to normal collateral vessels and surrounding tissues. The lowest effective volume and concentration of the most suitable sclerosant should be used to minimize the likelihood of adverse effects. Factors such as sclerosant concentration, volume, mixing, and procedure technique are more important factors than the choice of the sclerosant itself.

Mixing a detergent sclerosing agent with a gas (commonly air) results in foam formation. Foam is obtained after repeated alternate passages from one syringe to another through a connector. Compared to traditional liquid sclerotherapy, foam sclerotherapy has certain advantages including a smaller volume of the sclerosing agent needed for injection, lack of dilution with blood (dilution decreases efficacy), homogeneous effect along the injected veins, and ultrasound echogenicity. The use of foam sclerotherapy is generally reserved for larger vessels and not spider veins. ^[13]

A controlled, observational study by Moreno-Moraga et al reported that only two sessions of combined sclerotherapy/laser treatment for varicose veins—in which polidocanol microfoam injection was immediately followed by 1064-nm Nd:YAG laser therapy—were needed to produce high clearance rates and a high degree of patient satisfaction. The results were determined at 5-year follow-up. ^[14]

A retrospective study by Jimenez et al involving patients in whom sclerotherapy with polidocanol microfoam was administered for symptomatic superficial axial and tributary vein reflux, indicated that the use of adjunctive techniques during such procedures reduces thrombotic complications. Among the adjunctive techniques employed, the limb was elevated intraoperatively to more than 45°, large perforator veins were mapped ultrasonographically and digitally occluded, the volume of foam per session was limited, sterile saline was injected before treatment, and the limb was compressed in the elevated position. ^[15]

Basic principles of treatment

Proximal sites of reflux should be treated first, and larger veins are treated before smaller vessels. In other words, an incompetent saphenofemoral or saphenopopliteal junction should be addressed first, then the varicosities, then the reticular veins, and, finally, the telangiectasias. An entire varicosity should be treated at a given treatment session. Adequate compression should be applied immediately after therapy, ^[16] and posttreatment ambulation should begin right away.

A detailed history and physical examination should be performed. All of the patient's medications should be reviewed, with attention to hormone replacement, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), vitamin E, steroids, and herbal medications.

Symptoms that may be related to arterial or venous insufficiency must be investigated, and lower-extremity duplex ultrasonography may be necessary.

Review with the patient the number of treatment sessions that are required and the duration of treatment. Discuss the limitations in activity that may be necessary after each session. Discuss the sclerosants to be used, including potential adverse reactions.

Take pretreatment photographs for documentation and for comparison with the postoperative results. The photographs help the patient evaluate his or her progress. Also, many patients forget what their legs looked like before treatment. ^[17]

Informed consent should be obtained prior to commencing treatment. The elements of the consent should include the indications for sclerotherapy, available alternative treatments, potential complications and sequelae, and the need for multiple treatment sessions.

Treatment sessions for the same anatomic locations are typically carried out at intervals of 2-8 weeks. Symptomatic improvement usually occurs quickly after sclerotherapy, whereas cosmetic improvement may be more gradual. Physicians must discuss with the patient that new vessels are likely to develop over time and that repeat treatment may be necessary.

Both the physician and the patient should be comfortable. To perform the procedure, ensure excellent lighting. Use 30-gauge needles, which should be inserted bevel up so the depth of needle penetration can be accurately assessed. The injection should be precise and slow. Severe pain or burning is often a sign of extravasation. If this occurs, inject the site with normal sodium chloride solution or lidocaine to dilute the sclerosant. Hyaluronidase 75 U decreases the rate of ulceration after extravasation. ^[18] Hyaluronidase and nitroglycerin paste can be used for prolonged blanching.

The pretibial area and ankle skin have the highest propensity for ulceration. Treatment in these locations should not be first and should be limited in each session.

Each injection is usually 0.1-0.4 mL. The 1-mL syringe allows the physician to accurately feel the injection resistance and to control the injection volume. As one gains experience, 3-mL syringes speed the injections. Small injection volumes and low injection pressure minimize adverse effects such as telangiectatic matting, ischemic ulceration, and extravasation. The injections are carried out at 2-3 cm intervals until the entire vessel has been cleared.

After the needle is removed, compression with cotton balls and tape may be used, or a graduated compression stocking can be worn.

Compression garments may be beneficial after treatment to improve the results and to decrease the risks of complications such as pigmentation, edema, and deep vein thrombosis. Graduated compression stockings with strengths of 20-30 mm Hg (class I) or 30-40 mm Hg (class II) should be worn the first night and then daily for 1-3 weeks, depending on the vessel size treated. A recently published article demonstrated that wearing compression stockings (23-32 mm Hg) for 3 weeks enhances the efficacy of sclerotherapy of leg telangiectasias by improving clinical vessel disappearance. ^[19]

Patients are generally asked to perform lower extremity exercises immediately following sclerotherapy and then on a daily basis. Many practitioners also recommend that patients avoid aggressive exercise or activity for up to 4 weeks.

Bruising is transient and clears with time. ^[20]

Hyperpigmentation is usually transient and is less common in small vessels than in large ones. Compression garments decrease the incidence of hyperpigmentation.

Allergic reactions include urticaria and possible anaphylaxis. The incidence is 0.3%, and these reactions may occur with the use of any sclerosant (highest incidence is ethanolamine oleate). The medical staff should have adequate knowledge and skills about basic resuscitation techniques and emergency medications.

Edema is prevented with compression garments.

Telangiectatic matting is due to injections that are administered too rapidly or in which the sclerosant concentration is too high. It usually resolves spontaneously over several months but may be permanent. It usually responds to gentle sclerotherapy and treatment of hidden feeding veins (reticular veins, perforators, saphenous veins).

Superficial thrombophlebitis usually occurs in large vessels. Treatment is with compression and NSAIDs. The evacuation of the liquefied thrombus is helpful. Prophylactic low molecular weight heparin should be considered if superficial thrombophlebitis of the proximal great saphenous vein occurs.

Tissue necrosis is the leading cause of malpractice acts after sclerotherapy; this complication is more common with hypertonic saline. The cause may be extravasation or injection into an arteriole. The development of a porcelain white blanching is the typical early sign in the case of an arteriolar injection or spasm. Some phlebologists recommend massage, topical 2% nitroglycerin ointment, or both in the case of white blanching. Immediate treatment with hyaluronidase (75 units in 3 mL) is advisable in the case of extravasation of a large volume or a high concentration of a sclerosant. Injections of normal sodium chloride solution, lidocaine, or both have also been advocated.

Patients who develop deep venous thrombosis should be evaluated for a hypercoagulable state, and systemic anticoagulation should be commenced immediately.

Foam sclerotherapy shares all of the above adverse effects with traditional liquid sclerotherapy; however, foam-specific adverse effects have also been noted. Some of the unique adverse events noted after foam sclerotherapy include pulmonary symptoms (cough), visual (amaurosis) and neurologic events (in the presence of a patent ductus arteriosus), and higher likelihood of localized inflammatory phlebitic reactions and posttreatment hyperpigmentation. ^[21]

A study by Gillet et al indicated that sclerotherapy can be safely carried out in older patients. The study, which included 176 patients aged 75 years or older and 242 patients under age 75 years, found that one case of vasovagal syncope occurred in the former group, while one case of asymptomatic distal deep vein thrombosis confined to the medial gastrocnemius veins occurred by 1-month follow-up in both groups. ^[22]

The amount of compression therapy necessary after sclerotherapy of telangiectasias and reticular veins is a controversial issue. Use of at least a minimally graduated compression hose is recommended for the first few days and possibly for 7-10 days after sclerotherapy sessions. This compression theoretically helps to improve the results and minimizes adverse effects, such as edema and postinflammatory hyperpigmentation. Class I (20-30 mm Hg) or class II (30-40 mm Hg) compression is best. For patients who cannot tolerate this level, a class I fashion hose support can be used. After treatment, the patient can continue low-impact exercises, such as walking or riding bicycles, but direct isometric exercise to the lower legs should be avoided for at least 1 week.

Advancements and refinements in foam sclerotherapy are expected to revolutionize the management of venous disorders.