Liquid and foam sclerotherapy techniques for lower extremity vein ablation
Deborah L Greenberg, MD, FACP
Sherry Scovell, MD, FACS
Rajabrata Sarkar, MD, PhD
Kathryn A Collins, MD, PhD, FACS
Last literature review version 17.3: Setembro 2011 | This topic last updated: Outubro 9, 2012
INTRODUCTION — Sclerotherapy is a minimally invasive percutaneous technique using chemical irritants to ablate incompetent veins [1,2]. Sclerotherapy is used primarily in the treatment of telangiectasias, reticular veins and small varicose veins, which can be symptomatic and a source of significant distress to some patients even in the absence of symptoms. Saphenous and perforator reflux can also be treated with sclerotherapy techniques.
The treatment of telangiectasias, reticular veins and varicose veins, and underlying perforator or saphenous reflux with liquid or foam sclerotherapy will be reviewed here.
Alternate approaches to treatment of chronic venous disease using cutaneous laser, endovenous ablation devices, and open surgical management are discussed elsewhere.
ANATOMY — The major superficial veins of the lower extremity include the great and small saphenous veins. Other lower extremity superficial veins have variant anatomy.
The deep veins of the lower extremity are contained within the deep muscle compartments bounded by the muscle fascia. Perforating veins are those veins which traverse the muscular fascia to connect superficial veins with the deep veins. They are located anteriorly, posteriorly, laterally and medially in both the thigh and calf.
INDICATIONS — Telangiectasias, reticular veins and varicose veins are the visible signs of venous disease and can occur in the presence or absence of either symptoms or an underlying functional venous disorder (ie, reflux) . Candidates for sclerotherapy are patients with persistent symptoms (eg, pain, aching, swelling) and signs (eg, telangiectasias, reticular veins, varicose veins, skin changes, ulceration) of venous disease after six months of medical therapy.
Sclerotherapy is used primarily to manage telangiectasias, reticular veins and varicose veins, however, sclerotherapy techniques to achieve perforator and saphenous closure are also available for patients with documented reflux (ie, retrograde flow >0.5 seconds duration) as a source of their symptoms. For patients with ulceration who are refractory to medical management, or have recurrent ulceration, ultrasound guided sclerotherapy (UGS) of perforators results can lead to significant reduction of symptoms and signs.
While telangiectasias and reticular veins can have associated symptoms the majority are asymptomatic, and these patients often find the cosmetic appearance of their veins distressing. Sclerotherapy can be performed following physical examination without further diagnostic studies as these patients are not as likely as symptomatic patients to have underlying venous reflux [2,3].
Patients with complaints of recurrent bleeding and stigmata of recent venous hemorrhage may benefit from sclerotherapy of that vein site. Sclerotherapy is successful even in the presence of venous insufficiency; therefore, duplex examination prior to treatment is not necessary . Once hemorrhage is controlled, however, duplex examination to identify underlying reflux should be performed.
CONTRAINDICATIONS — Sclerotherapy should not be performed in patients who have signs of acute thrombosis/phlebitis, due to the increased risk of deep venous thrombosis. Pregnant patients should defer until after delivery.
Diabetes and peripheral arterial occlusive disease (ankle-brachial index <0.9) are relative contraindications depending on the nature and extent of sclerotherapy due to a risk wound complications.
A history of migraine headache and patent foramen ovale are relative contraindications to sclerotherapy due to a risk for microembolism [5-10].
PATIENT COUNSELING — The decision to offer sclerotherapy depends on symptoms, response to medical therapy, extent of lower extremity disease, patient expectations, and likelihood of providing a durable benefit either with respect to appearance or improvement in symptoms.
Patients treated for cosmetic purposes need to be counseled carefully prior to treatment. The patient is informed that veins will lighten and become less noticeable but may not completely disappear, that hyperpigmentation is a relatively common complication, and that multiple treatments are typically required to achieve the desired effect.
For all patients, it is important to address patient expectations, potential adverse effects and complications, and to document veins photographically prior to each treatment. These photographs should be reviewed with the patient periodically.
SCLEROTHERAPY AGENTS — The most common agents used in the treatment of lower extremity telangiectasias, reticular veins, and small varicose veins are sodium tetradecyl sulfate, polidocanol, and hypertonic saline. These substances cause endothelial damage by their actions as either osmotic or detergent agents. Osmotic agents achieve their effect by dehydrating endothelial cells through osmosis. Detergents are surface active agents which damage the endothelium via interference with cell membrane lipids . In vitro, the detergent agents also exhibit procoagulant activity at lower concentrations, and anticoagulant activity in higher concentrations .
A systematic review of 17 randomized trials of injection sclerotherapy for varicosities of varying size found no evidence to support use of one sclerosant over another in the short term success of sclerotherapy . Other randomized trials comparing sclerotherapy agents in the treatment of only telangiectasias and reticular veins support this conclusion [14-16].
Sodium tetradecyl sulfate — Sodium tetradecyl sulfate is the most commonly used sclerosant in the literature . The maximum recommended dosage is 10 mL of a 3 percent solution in the United States and Canada; the volume used varies worldwide depending on formulation. Dilutions between 0.1 and 3.0 percent are used depending on the size of the vein treated.
Polidocanol — Polidocanol is also a detergent. The maximum dosage is dependent upon the weight of the patient. Dilutions between 0.25 and 5 percent are used depending on the size of the vein treated. Polidocanol is not commercially available in the United States and is subject to import restrictions. Clinical trials are underway seeking United States Food and Drug Administration (FDA) approval.
Hypertonic saline — Hypertonic saline is the most commonly used osmotic agent for lower extremity sclerotherapy. The dilution used to treat lower extremity vessels ranges from 11.7 to 23.4 percent.
Liquid — Liquid sclerotherapy can be used to treat telangiectasias, reticular veins, small non-saphenous varicose veins (less than 5 mm), residual or recurrent varicosities following endovenous ablation or surgery, and perforator veins [13,17].
Liquid injection sclerotherapy is the gold standard for the treatment of most lower extremity telangiectasias and reticular veins. The results of sclerotherapy are usually, but are not always, superior to those of cutaneous laser therapy.
Due to the risk of hypopigmentation with cutaneous laser, liquid sclerotherapy is a more appropriate choice for patients with Fitzpatrick skin types IV, V, and VI; however, laser is preferred initially for patients who have failed sclerotherapy (veins too small to access [<0.3 millimeters] or poor outcome), patients with post-sclerotherapy matting, needle phobic patients, and patients allergic to sclerosant agents. Laser is also preferred for vessels located at or below the ankle regions which are more prone to ulceration with sclerotherapy.
Foam — Foam preparations are becoming increasingly popular . Sclerosant foam was developed from the detergent sclerosants to increase the surface area of exposure, and is more commonly used in larger veins. The foam is produced just prior to injection by the Tessari method . Sclerosant foam is echogenic due to the tiny air bubbles in the foam, and are easily seen with duplex ultrasound. The expanded volume of the foam compared to liquid agents provides more surface contact, a more uniform vessel closure and use of smaller volumes of sclerosant. In principle all vein calibers are suitable for foam sclerotherapy; however, a minority of practitioners would use it for treatment of telangiectasias or reticular veins because there is no significant advantage over liquid sclerotherapy in small vessels and therefore ultrasound guided foam sclerotherapy (UGFS) is predominantly applied to the treatment of saphenous incompetence (great or small) .
TECHNIQUES — There is no consensus on specific aspects of sclerotherapy technique including: type of sclerosing agent, use of local anesthetic, use or type of local compression pad, and use or duration of compression dressing (bandage or elastic). Serial injections are often needed to address the veins of interest. Typical sessions last from 15 to 60 minutes.
In general, a sclerosant liquid or foam (with or without lidocaine) is mixed into a syringe at the appropriate concentration for the vein to be treated. The syringe is attached to a 27 or 30 gauge needle (or butterfly) which is angled to assist its introduction into the vessel. The patient is placed in Trendelenburg position during injection to discourage refilling of the injected veins. Following the application of alcohol to clean the area, the needle is introduced into the vein, and blood aspirated to ensure an intraluminal needle position; the sclerosant is then injected.
The procedure is terminated when either the maximum volume of sclerosant has been injected or all the veins of interest have been treated. A light dressing and graduated compression stockings, or bandages (Coban, Elastocrepe, Ace) are applied.
The patient rested in the supine position for 15-20 minutes an then discharged, providing they have experienced no adverse reactions. The patient is counseled to ambulate normally and may return to work.
Telangiectasias, reticular veins, varicose veins — A fixed amount of sclerosant is injected depending on the size of the vein being treated. When larger underlying reticular veins are identified, these are obliterated prior to handling more superficial telangiectasias. A vein light (fiberoptic illuminator) is helpful in identifying reticular veins.
The needle is withdrawn and local compression and massage are applied to keep blood out of the lumen of the vessel and to help disperse the sclerosant. Local compression pads (eg, mole foam, sorbo pads, dental bumpers) are placed and fixed with tape to maintain compression while moving on to the next vein.
Saphenous ablation — Foam sclerotherapy to treat reflux of the great saphenous vein is performed with ultrasound guidance. The saphenous vein is cannulated in the mid to distal thigh with the needle directed toward the foot. The extremity is elevated and sclerosant foam injected until it is visualized approaching the saphenofemoral junction, whereupon the injection is discontinued. The syringe is aspirated and if blood is returned, the procedure is repeated until the aspirate becomes white, indicating that the saphenous vein is filled with foam. Compression at the level of the groin can be performed, however, some postulate that release of compression could promote microembolization.
Perforator ablation — Injection of the sclerosant solution at the level of a refluxing perforator vein can be used to ablate the perforator or to treat associated interconnected superficial veins (Fegan’s technique) . This technique has been used with good long term results and without significant complications but requires an experienced practitioner .
Following UGS of perforator veins, duplex ultrasound should be performed for surveillance in order to identify recurrent perforator veins which can lead to venous ulcer recurrence.
FOLLOW UP CARE — We advise the patient to wear their compression stockings for 48 hours continuously after which time they may be worn during the day (off at night and to bathe) for the next two weeks.
Exercise is avoided for two weeks and treated areas should not be exposed to the sun during this time period. The patient should contact the physician immediately if any ulcerations are observed at the injection sites.
Repeat injections, if necessary, are not performed for at least for a six weeks.
Patients are instructed to call their physician if they experience any visual, sensory or motor disturbances.
ADVERSE REACTIONS — The type of adverse reaction following sclerotherapy depends upon the sclerosing agent used . Common local adverse reactions to sclerosing agents include pain, ulceration, urticaria, hyperpigmentation, and telangiectatic matting . Most local reactions are transient and resolve within months following the procedure . Vasovagal reactions have also been reported.
Minor pain — Pain is common at the sclerotherapy injection site. Significant pain during injection may be an indication that the sclerosing agent has extravasated into the tissue around the vein. Polidocanol is associated with the least amount of pain upon injection , whereas hypertonic saline is the most painful especially when used without lidocaine .
Ulceration — Ulcers occur when the sclerosing agent extravasates from the vein into the subcutaneous tissue and occurs in 1 to 5 percent of patients. Care must be taken to ensure that the needle is intraluminal before injection is performed. When they occur, ulcers are usually small and most heal with local care in four to six weeks. Polidocanol is not significantly associated with skin ulceration or necrosis because it is non-toxic to tissues .
Skin breakdown may also occur in response to excessive pressure from tape or compression garments .
Larger areas of skin necrosis may be related to retrograde flow of the sclerosant through an unexpected cutaneous arteriovenous malformation or the inadvertent injection of a small arteriole. This type of skin necrosis is rare and is independent of the type of sclerosant used.
Thrombus — Thrombus forms within the vessel if blood comes into contact with the sclerosing agent. The resulting mild inflammatory reaction is a source of post-treatment pain and is more common with treatment of reticular veins and small varicose veins than telangiectasias.
Micro thrombectomy, which removes clot, significantly reduces post sclerotherapy pain and inflammation and, in one one multicenter randomized trial, reduced hyperpigmentation in vessels smaller than one millimeter . Micro thrombectomy is typically performed within three weeks following treatment by making stab incisions (22 gauge needle or No. 65 Beaver blade) along the length of the thrombosed vein with aseptic technique. Thrombus is extruded by rolling a cotton-tipped applicator along the vein, and the area is cleansed and dressed with sterile bandages. Topical local anesthesia (eg, EMLA) is not usually necessary but can be used.
Telangiectatic matting — Telangiectatic matting consists of multiple, fine dilated vessels in the area of the injection site. It is relatively common, occurring in 15 to 24 percent of patients and usually resolves within 3 to 12 months . Sodium tetradecyl sulfate is associated with a lower incidence of telangiectatic matting .
In one retrospective review of 2120 patients, significantly more patients in the matting group were overweight, on hormones (estrogen, progesterone) during sclerotherapy treatment, and had both a family history and a longer duration of abnormal veins compared to the non-matting group . If a feeding reticular vein can be identified, repeat sclerotherapy can be attempted; otherwise, the area can be treated with cutaneous laser .
Hyperpigmentation — occurs in up to 30 percent of patients following sclerotherapy. It is caused by deposition of hemosiderin in the skin as a result of extravasation of red blood cells. It usually becomes noticeable within a month following sclerotherapy and resolves spontaneously in 80 percent of patients within two years . It occurs more commonly with treatment of veins greater than one millimeter, and in patients with darker hair and Fitzpatrick skin types IV, V, and VI .
Hyperpigmentation is less frequent with sodium tetradecyl sulfate and this agent is also associated with less bruising . Treatment of telangiectasias with lower concentrations of polidocanol (0.5 versus 1.0 percent) reduced the incidence of hyperpigmentation with this agent .
Cutaneous laser therapy can be used in the treatment of post-sclerotherapy hyperpigmentation [27,30]. It is thought to cause fragmentation of pigment granules that are later removed by phagocytosis.
COMPLICATIONS — A mild inflammatory reaction is expected within the treated veins; however, intense superficial thrombophlebitis can occur and deep venous thrombosis, while uncommon, has been reported. Other complications include: microembolic events (ie, coughing, migraine-like headache, visual disturbances, paresthesias, stroke) and anaphylaxis.
For patients with severe venous disease, UGS appears to be associated with fewer skin and wound healing complications and is an attractive alternative to open interruption or subfascial endoscopic perforator vein ligation . Other complications are uncommon with this technique.
Superficial thrombophlebitis — A mild inflammatory response is expected after sclerotherapy and some patients may have urticaria at the site of injection. A more intense superficial thrombophlebitis with erythema, warmth, and pain can extend to veins neighboring the injection site.
Deep vein thrombophlebitis — Telangiectasias can communicate with the deep venous system. Contrast media directly injected into a telangiectasia entered the deep venous system in two of 15 patients in one study . While deep venous thrombosis can occur after sclerotherapy of telangiectasias, it is more likely to occur after sclerotherapy of the saphenous veins . Patients are diagnosed and treated for deep venous thrombosis following standard protocols.
Air microembolization — Air microembolism is a relatively common phenomenon during sclerotherapy, however, symptoms occur in less than two percent of patients [5,6]. Symptoms include: visual disturbance (scotoma), migraine-like headache, cough, and neurologic deficit (usually transient). Most visual disturbances occur during the procedure, or immediately after when the patient ambulates due to rising of microbubbles in the bloodstream.
Visual disturbances have been reported following sclerotherapy of telangiectasias and reticular veins and are strongly associated with the use of air-block, and foam techniques. In one study, 20 patients of 12,173 treated with sclerotherapy experienced visual disturbances, 70 percent of which were following sclerotherapy of telangiectasias or reticular veins . Visual disturbances were associated with nausea, headache, or vasovagal fainting; all cases regressed spontaneously.
During foam sclerotherapy of the great saphenous vein, microbubbles can be detected in the right heart and pulmonary circulation, and in patients with a patent foramen ovale (PFO) in the left heart as well . Coughing following foam sclerotherapy is attributed to air microembolization into the pulmonary circulation.
In a prospective study of 33 patients, cardiac echo was performed during foam sclerotherapy with cardiac microemboli detected in every patient studied. Microemboli were also seen in the left ventricle of five patients, and each were subsequently found to have a patent foramen ovale, however, none of these patients experienced neurologic symptoms .
Given the significant prevalence (25 to 30 percent) of patent foramen ovale in the general population, it is apparent the incidence of significant neurologic sequelae following foam sclerotherapy is low. Nevertheless, caution needs to be exercised when performing foam sclerotherapy in any patient known to have a PFO. Patients who develop neurologic symptoms following foam sclerotherapy should be referred for further cardiac evaluation.
Anaphylaxis — Anaphylaxis can occur with any of the sclerosing agents with the exception of hypertonic saline. A test dose of the sclerosing agent is recommended
COMPRESSION THERAPY FOLLOWING SCLEROTHERAPY — Meta-analysis of randomized trials of injection sclerotherapy for varying sizes of varicosities identified no differences in sclerotherapy success related to method of compression therapy (elastic versus conventional bandaging) . Long term bandaging did not have any advantages over short term bandaging for cosmetic appearance, incidence of superficial phlebitis or recurrent varicose veins. Short term bandaging was better tolerated.
In contrast, the benefit of compression stockings following sclerotherapy for telangiectasias and reticular veins has been documented in numerous studies. Three studies suggested improved cosmetic outcomes with three weeks of compression rather than shorter to no compression following sclerotherapy of telangiectasias [34-36]. Compression may not be as important in the treatment of larger veins .
In one study, there was a correlation between the duration of compression and degree of improvement . A total of 40 patients with telangiectasias and/or reticular veins were treated with sclerotherapy. Ten control patients did not receive compression therapy while 30 patients in three groups of 10 received compression for 3 days, 1 week, or 3 weeks. There was a correlation between the length of time compression was applied and degree of improvement at 6 weeks, 12 weeks, and 24 weeks. Patients treated with compression for 3 days and 1 week had significantly more improvement than control patients while patients treated for three weeks of continuous compression had the most improvement.
VEIN CLEARANCE AND CLOSURE
- Clearance and closure of veins — Clearance of 60 to 80 percent of treated telangiectasias, reticular veins and small varicose veins can be expected [22,23]. Vein clearance rates and overall patient satisfaction favor sclerotherapy over cutaneous laser [37-39].
Rates of saphenous closure with ultrasound guided foam sclerotherapy (UGFS) appear to be lower compared to endovenous methods. In a prospective study significantly higher rates of great saphenous occlusion were seen in patients treated with endovenous laser compared to foam sclerotherapy (93.4 versus 77.4 percent) .
- Perforator closure — Ultrasound guided sclerotherapy of perforators is an effective and durable method of eliminating reflux in perforator veins. In one observational study, 98 percent of incompetent perforators were successfully obliterated at the time of treatment; 75 percent of limbs showed persistent occlusion of perforators up to five years .
Venous clinical severity — Sclerotherapy of telangiectasias, reticular veins and varicose veins is effective in relieving pain in the treated veins with high rates of patient satisfaction [13,21,41].
As a method of eliminating incompetent perforator veins, ultrasound guided sclerotherapy results in significant reduction of symptoms and signs as determined by venous clinical scores . Clinical improvement was sustained with a mean follow-up of 20.1 months in the only available long term patients series.
Vein recurrence — Recurrence of telangiectasias and reticular veins is uncommon and when they occur are more attributable to inadequate technique . The development of new veins (ie, neovascularization) and telangiectatic matting are more typical.
Randomized trials suggest that sclerotherapy is less effective than surgery for larger veins [42-45]. Long-term recurrence rates with sclerotherapy are as high as 65 percent in five years, however, with retreatment common when veins recur.
Recurrence rates following saphenous vein sclerotherapy are significant (up to 65 percent) and related to saphenous recanalization. Foam sclerotherapy is associated with less recanalization compared to liquid sclerotherapy, however, for either therapy, recurrence of clinical symptoms may be less [13,46,47].
In one prospective trial, saphenous vein recanalization occurred in 27 and 64 percent of patients treated at one and five years, respectively . However, 70 percent of patients did not have worsened clinical symptoms. Repeat UGFS treatment was performed in 16.5 percent of patients between one and two years, and fewer than 10 percent in subsequent years (up to five years).
Venous ulcer healing — Surgical trials have demonstrated reduced ulcer recurrence rates with saphenous stripping [48-50]. Successful application of other methods of saphenous ablation may also be beneficial (eg, sclerotherapy, endovenous ablation), however, there are no randomized trials comparing techniques.
In a small observational study, ultrasound-guided foam sclerotherapy of the saphenous vein resulted in healing of 79 and 96 percent of ulcers at one and three months, respectively .
Recurrence of reflux in perforator veins following saphenous ablation is known to be a risk factor for venous ulcer nonhealing or recurrence [48,52]. UGS of perforating veins is associated with fewer complications compared to surgical management of perforators (ie, SEPS) and is clinically appealing for this indication, however, few clinical studies have been performed.
In an observational study evaluating ulcer healing with ultrasound guided sclerotherapy, ulcer healing was ultimately observed in in 32 of 37 limbs treated by ultrasound guided perforator sclerotherapy. This group of patients did not have concomitant axial vein reflux. More than one treatment session due to the development of recurrent perforators was required in 12 of 37 limbs treated .
COST — Sclerotherapy of telangiectasias and reticular veins are generally considered a cosmetic treatment and is not typically covered by insurance, though occasionally it will be reimbursed when treating veins which have hemorrhaged. The average cost of sclerotherapy in the US in 2007 was $342 .
SUMMARY AND RECOMMENDATIONS
- Dilated veins can occur in the presence or absence of either symptoms or an underlying functional venous disorder. Telangiectasias, reticular veins, and varicose veins can cause symptoms, and are often a source of significant distress to the patient even in the absence of symptoms.
- The presence of lower extremity telangiectasias, reticular veins, or varicose veins in the lower extremities may indicate an underlying functional venous disorder, especially when associated with symptoms (aching, swelling, heaviness).
- Symptomatic patients should undergo further evaluation with venous duplex to identify the presence of superficial or deep venous insufficiency, which alters treatment options.
- Common local adverse reactions to sclerotherapy include pain, ulceration, telangiectatic matting, and hyperpigmentation and are dependent on the agent used.
- Cosmetic measures of sclerotherapy success are similar regardless of the agent used (sodium tetradecyl sulfate, polidocanol or hypertonic saline).
- For lower extremity telangiectasias, reticular veins, and small varicose veins large enough to admit a 27 or 30 gauge needle, sclerotherapy is the treatment of choice. Sclerotherapy results in improved clearance of treated veins.
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