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What is sclerotherapy?

"Sclerotherapy" involves using a fine needle to inject a substance directly into the vein. This solution irritates the lining of the vein, causing the vein to swell and the blood to clot. The vein then turns into scar tissue that may eventually fade from view. Sclerotherapy is typically used for spider veins and varicose veins. Veins up to 15 millimeters in diameter have been treated successfully. This is generally offered to patients who have tried compression stockings and leg elevation without much success. Today, the substances most commonly used in the United States for sclerotherapy are hypertonic saline and sodium tetradecyl sulfate (Sotradecol), and polidocanol (Aethoxysklerol, Asclera) is now also approved in the U.S. for sclerotherapy.

With sclerotherapy, after the solution is injected, the vein's surrounding tissue is generally wrapped in compression bandages for several days, causing the vein walls to stick together. Patients whose legs have been treated are put on walkingregimens, which forces the blood to flow into other veins and prevents the development of blood clots. This method and variations of it have been used since the 1920's. In most cases, more than one treatment session will be required.

Pictures of sclerotherapytreatment

What are potential side effects and complications of sclerotherapy?

In some patients treated with sclerotherapy, dark discoloration of the injected area may occur (hyperpigmentation). This usually happens because of disintegration of thered blood cells in the treated blood vessel. In the majority of cases, this discoloration will completely go away within 6 months.

Another potential problem is the formation of new spider veins near the area that was treated with sclerotherapy. This can happen in some patients, but these new vessels also typically disappear within 6 months.

Rare complications may include the formation of an ulcer around the injection site or the formation of small blood clots in the small surface veins (superficial thrombophlebitis).

Is sclerotherapy safe for everyone with varicose and spider veins?

Sclerotherapy is generally safe for most people for the treatment of varicose and spider veins. However, in certain groups of people, such as those individuals who are unable to walk (non-ambulatory), sclerotherapy should be avoided. Other contraindications for undergoing sclerotherapy include obesity, blood clots in the deeper veins, allergy to the sclerosing agent, pregnancy, and arterial obstruction (blocked blood flow in the artery near the varicose vein).

Sclerotherapy is a medical procedure used to eliminate varicose veins and spider veins. Sclerotherapy involves an injection of a solution (generally a salt solution) directly into the vein. The solution irritates the lining of the blood vessel, causing it to swell and stick together, and the blood to clot. Over time, the vessel turns into scar tissue that fades from view.

Sclerotherapy is a proven procedure that has been in use since the 1930s.

Sclerotherapy is a medical procedure used to eliminate varicose veins and spider veins. Sclerotherapy involves an injection of a solution (generally a salt solution) directly into the vein. The solution irritates the lining of the blood vessel, causing it to swell and stick together, and the blood to clot. Over time, the vessel turns into scar tissue that fades from view.

Sclerotherapy is a proven procedure that has been in use since the 1930s.

Sclerotherapy for Varicose and Spider Veins

In this article

Side Effects of Sclerotherapy

You may experience certain side effects after sclerotherapy. There are milder effects, such as itching, which can last for one or two days after the procedure. Also, you may experience raised, red areas at the injection site. These should disappear within a few days. Bruising may also occur around the injection site and can last several days or weeks.

Other Sclerotherapy Side Effects Include:

Should any of the following side effects occur, contact your doctor immediately. These include:

Allergic reactions to the fluid that's injected may occur at the time of the injection and are rarely serious. If you have a history of allergies, you have a greater chance of experiencing an allergic reaction to the agents. A minor allergic reaction will cause itching and swelling. To avoid any serious complications, your doctor will likely test the agents on a small area before applying the solutions to a larger area.

If you have any concerns or questions following this procedure, you should contact your doctor.

Sclerotherapy for Varicose and Spider Veins

In this article

What Happens After Sclerotherapy

After sclerotherapy you will be able to drive yourself home and resume your regular daily activities. Walking is encouraged.

You will be instructed to wear support hosiery to "compress" the treated vessels. If you have compression hosiery from previous treatments, you are encouraged to bring them with you to be certain they still have adequate compression. Department store support stockings will not be adequate if a heavy compression stocking is needed. Your doctor's office can recommend where to purchase heavy compression stockings.

Following the injections, avoid aspirin, ibuprofen, or other anti-inflammatory drugs for at least 48 hours. Tylenol may be used if needed.

Also, you should avoid the following for 48 hours after treatment:

Showers are permitted, but the water should be cooler than usual. The injection sites may be washed with a mild soap and tepid water.

Sclerotherapy Effectiveness

Studies have shown that as many as 50%-80% of injected veins may be eliminated with each session of sclerotherapy. Less than 10% of the people who have sclerotherapy do not respond to the injections at all. In these instances, different solutions can be tried. Although this procedure works for most patients, there are no guarantees for success.

In general, spider veins respond in three to six weeks, and larger veins respond in three to four months. If the veins respond to the treatment, they will not reappear. However, new veins may appear at the same rate as before. If needed, you may return for injections.

Insurance Coverage for Sclerotherapy

Insurance coverage for sclerotherapy varies. If your varicose veins are causing medical problems such as pain or chronic swelling, yourinsurance may offer reimbursement. If you are pursuing sclerotherapy for cosmetic purposes only, your insurance carrier most likely will not provide coverage. You should discuss your concerns with your doctor. If you have questions, call your insurance company, which may request a letter from your doctor concerning the nature of your treatment and medical necessity.

Definition

By Mayo Clinic Staff

Sclerotherapy effectively treats varicose and spider veins. It's often considered the treatment of choice for small varicose veins. Sclerotherapy involves injecting a solution directly into the vein. The sclerotherapy solution causes the vein to scar and collapse, forcing blood to reroute through healthier veins. The collapsed vein is reabsorbed into local tissue and eventually fades.

After sclerotherapy, treated veins tend to fade within a few weeks, although occasionally it may take up to a month to see the full results. In some instances, several sclerotherapy treatments may be needed.

Why it's done

By Mayo Clinic Staff

Multimedia

Sclerotherapy is often done for:

The procedure also can improve related symptoms such as:

If you're pregnant, doctors recommend waiting until after your delivery to have sclerotherapy done.

Risks

By Mayo Clinic Staff

Sclerotherapy is a fairly safe procedure with few complications.

Temporary side effects

Some side effects that may occur at the site of the injection include:

These side effects usually go away within a few days to several weeks.

Side effects that may require treatment

Other complications are less common but may require treatment. These include:

How you prepare

By Mayo Clinic Staff

Before the procedure, your doctor performs a physical exam and gathers your medical history.

Physical examination

Your doctor will:

Medical history

Your doctor will want to know your medical history, including asking about any:

If you take aspirin, NSAIDs or blood thinners, your doctor may instruct you on how to stop taking the medication for a certain amount of time before the procedure, to reduce the chances of bleeding. Your doctor may also advise you on your use of antibiotics and oral contraceptives.

The day before

For 24 hours before the procedure, avoid shaving or applying any lotion to your legs. Wear loose, comfortable clothing to your appointment. You might even consider wearing a pair of shorts so that your legs are exposed.

What you can expect

By Mayo Clinic Staff

Sclerotherapy is typically done in your doctor's office and doesn't require anesthesia. It generally takes less than an hour to complete.

During the procedure

For the procedure, you'll lie on your back with your legs slightly elevated. After cleansing the area to be treated with alcohol, your doctor will use a fine needle to slowly insert a solution into the appropriate vein. The solution, usually in liquid form, works by irritating the lining of the vein, causing it to swell shut and block the flow of blood. Eventually, the vein will become scar tissue and disappear. Some doctors may use a foam version of the solution, particularly when a larger vein is involved. Foam tends to cover more surface area than liquid.

Some people experience minor stinging or cramps when the needle is inserted into the vein. If you have a lot of pain, tell your doctor; it may be because the solution has leaked from the vein into surrounding tissue.

Once the needle is withdrawn, your doctor applies compression and massages the area to keep blood out of the injected vessel and disperse the solution. A compression pad may be taped onto the injection site to keep the area compressed while your doctor moves on to the next vein.

The number of injections depends on the number and size of veins being treated.

After the procedure

After the procedure, you rest on your back for 15 to 20 minutes. Your doctor checks your injection sites for any immediate side effects. You can then get up and walk around. Walking and moving your legs is important to prevent the formation of blood clots.

You'll be asked to wear compression stockings or bandages — usually for about three weeks — to maintain compression on the treated veins.

Most people return to their normal activities on the same day, but it may be wise to have someone drive you home after the procedure. Your doctor will probably advise you to avoid strenuous exercise for two weeks after the procedure. You'll also want to avoid sun exposure to the treated areas during that time. The inflammation caused by the injections combined with sun exposure can lead to dark spots on your skin, especially if you already have a dark skin tone.

Results

By Mayo Clinic Staff

If you were treated for small varicose veins or spider veins, you can usually expect to see definitive results in three to six weeks. Larger veins may require three to four months. Treated veins generally don't come back, but new veins may appear.

Your doctor will likely schedule a follow-up visit about a month after the procedure to check the procedure's success and decide whether further sessions are needed. Generally, you need to wait four to six weeks before undergoing another sclerotherapy session.

Studies of sclerotherapy as a treatment for varicose and spider veins indicate that it has an overall success rate of 50 to 80 percent in eliminating treated veins.

 

Background

Sclerotherapy remains the primary treatment for small-vessel varicose disease of the lower extremities. These small vessels include telangiectasias, venulectasias, and reticular ectasias. Telangiectasias are flat red vessels smaller than 1 mm in diameter. Venulectasias are blue, sometimes distended above the skin surface, and smaller than 2 mm in diameter. Reticular veins have a cyanotic hue and are 2-4 mm in diameter. Large varicosities do not respond as well as small varicosities to sclerotherapy.[1, 2] See the images below.

Telangiectasias. Telangiectasias.Venulectasias. Venulectasias.Reticular veins. Reticular veins.

Treatment of telangiectasias, venulectasias, and reticular veins may greatly improve their appearance (see the image below). Treatment may also improve the associated painful symptoms. These vascular abnormalities are common. Telangiectasias are present in up to 28.9% of men and 40.9% of women.[3]

Venulectasias after sclerotherapy treatment. Venulectasias after sclerotherapy treatment.

Guidelines commissioned by Britain’s National Institute for Health and Care Excellence, published in 2013, included the following recommendations for the interventional treatment of patients with confirmed leg varicose veins and truncal reflux[4] :

  • Offer endothermal ablation and endovenous laser treatment of the long saphenous vein
  • If endothermal ablation is unsuitable, offer ultrasonographically guided foam sclerotherapy
  • If ultrasonographically guided foam sclerotherapy is unsuitable, offer surgery

 

Etiology

Genetics and individual behavior patterns are important factors in the development venous disorders. Familial inheritance is reported in 15-40% of cases. Caucasians are most commonly affected. Pregnancy, prolonged standing, and prolonged walking also predispose people to venous disease.[5, 6]

The presence of clusters of reticular veins and telangiectasias on the lateral thigh area is called the lateral subdermic plexus of Albanese and is considered to be a remnant of embryonic development. The presence of clusters of telangiectatic veins on the medial or the lateral aspects of the ankle region is likely the result of incompetence in the great saphenous vein (medial) or the small saphenous vein (lateral). Finding a collection of telangiectatic veins along the medial thigh or knee areas should generate suspicion about an underlying incompetence in the great saphenous vein. Any concern about an underlying saphenous vessel insufficiency should warrant an investigation of the lower extremities by duplex ultrasonography.

Indications

The major indications for sclerotherapy are to improve cosmetic appearance and to reduce the associated symptoms such as pain and burning. Sclerotherapy can also be used to treatment any remnant tributaries after endovenous laser ablation of a saphenous or truncal vessel.

Visual sclerotherapy refers to the process of injecting a sclerosant into target veins without the aid of ultrasonography, whereas duplex-guided sclerotherapy (endovenous chemical ablation) is performed using duplex ultrasonography to guide the injections. This article discusses visual sclerotherapy only.

Relevant Anatomy

A thorough review the lower extremity venous system is essential before treatment is administered. Venous anatomy is very variable in some parts of the lower extremities but more constant in other parts. The lower extremity has both a superficial and a deep venous system. The deep venous system includes the femoral, popliteal, anterior tibial, posterior tibial, peroneal veins, and others. The superficial system is tremendously complex and extremely variable; it includes the great and short saphenous systems and other unnamed veins. The great and short saphenous veins occasionally connect by intersaphenous veins, such as the Giacomini vein. Several communicating vessels, called perforating veins, are present between the 2 superficial and deep systems. Occasionally, telangiectasias may communicate directly with the deep system.

Contraindications

Contraindications to sclerotherapy include pregnancy, thrombophlebitispulmonary emboli, hypercoagulable states, and allergy to the sclerosing agents.

Imaging Studies

Duplex ultrasonography is the diagnostic method of choice for diagnosing venous disease. A thorough workup is warranted in the presence of symptoms such as aching, cramps, fatigue and swelling of the lower limbs, along with a positive family history of varicose veins; in the presence of varicose veins, and in patients who have a cutaneous manifestation of an underlying venous disease (stasis dermatitis, stasis ulcers, lipodermatosclerosis, atrophie blanche).

Duplex ultrasonography is the most frequently used investigation for the diagnosis and management of chronic venous disease (both deep and superficial) in the lower extremities. It should demonstrate both the anatomical patterns of veins and abnormalities of venous blood flow in the limbs (functional impairment). Duplex ultrasonography has largely replaced handheld nonimaging (continuous wave [CW]) audible Doppler instruments to assess venous disease and confirm clinical impressions.[7] For more information, see Radiology article Deep Venous Thrombosis, Lower Extremity.

Other Tests

Other available functional tests for venous disease include photoplethysmography and air plethysmography.

Previous

Surgical Therapy

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:[5]

  • 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 (Sclermo)
    • 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).[8]

Sodium tetradecyl sulfate, a synthetic surfactant (soap), is the only FDA-approved sclerosant in the United States. 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).[8]

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).[8]

Although 72% chromated glycerin (Sclermo) is very popular in Europe, it has not yet been FDA-approved for use in the United States. Only recently has interest in its use come to pass in the United States. Compared to other sclerosants, it is very weak and is essentially useful for 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.[9]

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.[10]

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   


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