Sclerotherapy, the gold standard of treatments, involves injecting veins with a safe solution that causes the body to absorb the vein without harming the rest of your body. The success of the treatments is dependent on many factors, including the solution used, the technique of the physician, the general health of the patient, and the anatomy of the particular vein. Tiny needles are used, and complications are extremely unusual. The treatment involves no significant limitations or downtime, and the patient may go immediately back to work following their appointment.
Sclerotherapy has made a major evolution with the introduction of Microfoam. Traditional sclerotherapy causes damage to the lining of the vein, causing it to collapse and making the walls of the vein then stick together. The vein is then slowly reabsorbed and disappears. Foam Sclerotherapy works in the same way only it is much more efficient. Foam is made by adding air to a liquid sclerosant such as the detergent Polidocanol (Asclera). The liquid and the air are agitated to produce a foam mixture. The foam is then injected directly into the vein. Foam is not diluted like the conventional sclerosant, so much less is needed and it remains in the vein for a longer period of time. Foam also works better because it pushes the blood out of the vein and makes a better contact with the vein walls. This enables us to treat much larger veins with liquid Sclerotherapy.
Another advantage to using foam is that it is very echogenic, making it very easy to see on ultrasound. We can track the entire vein that has been treated. We also track the travel of the foam in a particular vein and stop the flow by applying pressure with the ultrasound probe, then flow can then be redirected if necessary. The selective treatment of veins with foam is more complete than with surgical removal or microphlebectomy.
Ultrasound Guided Sclerotherapy
Ultrasound guided sclerotherapy improves the safety, accuracy and efficacy when injecting large varicose veins. The ultrasound accurately maps the veins to be injected and helps guide the needle tip to the targeted vein. The sclerosing agent is then injected into the vein by continuous monitoring and also helps the phlebologist control the direction of the injection. Ultrasound guided sclerotherapy should only be performed by a phlebologist who has undergone specialized training, and is experienced in the procedure. We use micro foamed detergent type sclerosants for the procedure, such as polidocanol. UGS makes it possible to easily treat the large trunk veins that are left after an endovenous laser ablation. It is also very useful to treat the large complex varices that can develop after vein stripping. Varicose vein disease is ongoing and even after an endovenous ablation procedure, patients sooner or later will probably develop collateral veins UGS makes it possible to easily treat these reoccurrences, before they become more of a problem, like phlebitis, ulcers, or dermatitis. We like to see all of our patients yearly after they have been treated for chronic venous insufficiency. UGS makes it easy to treat a small varicose vein if any have developed.
Sclerotherapy vs. Laser when treating spider veins
Many laser centers offer laser treatment for spider veins, unfortunately laser treatment are not very effective for spider veins. With laser treatments it is impossible to get to the feeding veins that are actually causing the spider veins. There may also be a risk of burning the skin with laser treatment for spider veins.
If you are fortunate to have success with laser, they usually return because the underlying cause was not addressed. Laser are seldom as effective as injections for this reason. Sclerotherapy when performed properly is still the gold standard for treatment of spider veins. Successful treatment requires expertise in the art of sclerotherapy, the correct diagnosis and the correct treatment plan for the type and size of vein to be treated. Even small spider veins can sometimes be caused by underlying large veins that are incompetent. All sources of reflux should be ruled out by duplex ultrasound before proceeding with sclerotherapy even on small spider veins and webs. If not high failure rates can be expected and complications such as matting, hyperpigmentation and early recurrence can be expected.
If your doctor offers only laser therapy, be prepared for mediocre results.
Complications of Sclerotherapy
Sclerotherapy is an extremely safe and effective procedure when performed properly. As with any medical procedures complications can occur. I will review the most common and rare complications.
- Localized urticaria are small raised hive like bumps that may appear at the injection site, they may feel itchy and may appear red. They will usually resolve in a few minutes. Usually patients don’t notice them as soon as they put stockings on.
- Hyper pigmentation is a brownish discoloration that occurs over the treated vein. It usually appears a few weeks after treatment. Hyper pigmentation is due to a hemosiderin (iron) deposition in the skin. Most staining clears gradually in about six months. Sometimes it will last up to a year and rarely over a year. Hypertonic saline causes more staining and if a sclerosant is too strong there is more risk of staining. Sometimes if areas of reflux are not treated (feeding veins) staining can occur. Certain people with high iron stores are more prone to staining and patients with more pigment in their skin tend to be more prone to staining. Also patients who are on Minocycline tend to stain. It is important to drain any trapped blood in treated veins, as the blood is the source of iron. Treatment for staining is usually tincture of time. IPL and some laser treatments may speed up the resolution. Bleaching agents are usually of no help.
- Matting is an area of blushing or redness that can appear after sclerotherapy. Matting is made up of very small red telangiectasias or tiny red vessels. The cause of matting is unknown. Factors such as obesity or a family history of matting, excess estrogens may predispose to matting. Sometimes a vein that has not been completely closed may cause matting. Too strong of a sclerosant, such as hypertonic saline may cause matting and using too much pressure when injecting may cause matting. Most matting will resolve on its own but at times can remain permanent. When matting occurs meticulous search for a cause should be sought, this includes ultrasound exam and transillumination to find small feeding veins that may have been missed. Laser may also work to remove matting
- Cutaneous ulceration is a very rare complication of sclerotherapy. It is occurs with the use of hypertonic saline most commonly. Hypertonic saline is a sclerosant that we feel should not be used. It is not very effective and has numerous drawbacks. Ulceration can occur with other sclerosants but is very rare. If a small ulcer develops, they are usually small and will heal within a few weeks. Ulcers can leave dark shallow scars.
- Deep venous thrombosis is a very rare complication of sclerotherapy. Studies have shown that the incidence of DVT is less than the incidence that occurs in the untreated general population. Important steps to avoid DVTs after sclerotherapy include wearing compression hose and being active.
- Allergic reactions are very rare complications of sclerotherapy, but can occur with the use of any sclerosant.