Sclerotherapy is a primary approach for treating the small-vessel varicose disease of lower extremities. It is use for treating veins was first recorded over 150 years ago however widespread acceptance has only come about in the last 30 years or so with refinement of techniques, combined with safer sclerosants such as Sodium Tetradecyl Sulphate (STS) www.fibrovein.co.uk.
It is a procedure also used to treat malformations of the blood vessels and the lymphatic system.
Varicose veins are abnormally dilated blood vessels which appear swollen, twisted and can be painful. They occur most commonly in the legs and feet. Spider veins, also known as telangiectasia, are smaller, abnormally dilated visible blood vessels on the skin. These veins appear on the legs and calves and may be blue, purple, or red in colour.
Varicose and spider veins are common in women, and can be a result of pregnancy, trauma, obesity, and standing or sitting for long periods.
Sclerotherapy involves injecting a suitable medication directly into the vein using a very fine needle. Traditionally some quite corrosive substances were used, at Vein Remedies we will use either Aethoxysclerol or STS (Sodium Tetradecyl Sulphate). The procedure takes about 15 to 30 minutes. You may experience a pin prick sensation with mild discomfort during the injection. The solution irritates the lining of the blood vessel causing the vein to a collapse and stick together. Over time, the venous blemishes are usually absorbed and disappear over a period of 6-8 weeks. Larger veins frequently have to be injected on more than one occasion.
When treating the larger vessels Ultrasound guided foam sclerotherapy may be used.
The number of veins treated in one session will be decided by your doctor based on the size and location of the veins. The first and second treatment will be performed at an interval of two weeks and the response to the therapy will be assessed after a month.
Following each sclerotherapy session you will be required to wear class 2 surgical compression hosiery which promotes closure of the veins. These are selected after measuring your leg to give optimal compression, stronger at the ankle than the thigh. Time of stocking wear varies from several days to two weeks depending on the size of the veins injected. There is a Medicare rebate for injections of varicose veins larger than 2.5mm in diameter and for ultrasound guided procedures, veins less than 2.5mm do not attract a Medicare rebate unless they form a disfiguring lesion visible at a distance of thee meters.
Sclerotherapy slowly clears the veins of your leg. Depending on the size of the blood vessel, the problem is completely resolved in two to six months.
There are a number of possible side effects and complications including the following:
Bruises at the injection site will disappear within a few weeks. Blood trapped in a sclerosed vein can appear quite dark. This is not bruising per se, but often makes small veins more noticeable in the first few weeks following treatment.
Raised Red areas occur at the injection sites of small spider veins. They look like insect bites and disappear within hours. They are sometimes mildly itchy.
Aching in the leg can occur during the treatment and for the first day or two following treatment. It is more common following the treatment of larger varicose veins and is usually relieved by walking. Nurofen, Voltaren Rapid or Panadol tablets may be taken if necessary Diclofenac gel applied topically over the area is also helpful..
Blood trapping can form tender lumps along the course of treated varicose veins. It is harmless but may be tender, red and angry. Blood can be drained from these lumps by a needle prick. This may be up to 8 weeks after the procedure. It hastens the resolution of any tenderness and help prevent any pigmentation of the skin. Blood trapping is most common in large varicose veins.
Brown lines or marks on the skin at the site of treated veins: When blood breaks down it can leave iron behind in the skin which is incorporated into haemosiderin, an iron containing pigment. Post treatment pigmentation is more common in patients who have navy-blue spider veins treated. Generally they will disappear within months, occasionally longer. In a small percentage of patients they can persist for years.
Matting is the name given to networks of fine red veins which develop near the site(s) of previous injections (it can occur with other forms of treatment such as surgery as well). The thighs are the most common site. Some areas of matting resolve spontaneously while some resolve with further treatment. Matting is more common in patients with extensive surface veins, patients who are overweight or have a very fair complexion. Some patients may be advised to have OHMIC THERMOLYSIS treatment which uses very focused resistance heating of small surface vessels via an insulated micro needle. This has a low instance of matting. Vein Remedies is the first (and currently only) clinic to have this technology in Tasmania.
Thrombophlebitis is clotting and inflammation which most commonly occurs spontaneously in untreated varicose veins, quite independently of sclerotherapy. It is treated with anti-inflammatory medication, compression and regular daily walking. It presents as red tender areas similar to trapped blood.
Ulcers can form at treatment sites within two weeks of injecting. Sometimes they occur due to sclerosant leaking into the surrounding skin. Generally they occur due to sensitivity of the tissues to the concentration of the solution injected. Backflow of sclerosant into small arterioles can also cause ulcers. Ulcers appear to occur more frequently in patients who smoke or are overweight, those who have frail skin or are on prednisone or methotrexate tablets. They are tender, will heal slowly and leave a small, lightly pigmented scar.
Allergic reactionsto sclerosing solutions and local anaesthetics are rare. They can be serious and life threatening – swelling of lips, mouth and throat are treated by immediate injection of adrenaline. Less serious reactions are treated with antihistamines. Severe abdominal pain has been reported by some patients. Minor rashes require no specific treatment though you should notify Specialist Vascular Clinic if a reaction of any kind occurs. When allergic reactions occur, a different solution can be used for subsequent treatments. In over 150,000 injections we have had two cases of people needing an antihistamine after treatment.
Fainting, nausea, vomiting and headache are generally stress or anxiety related reactions.
Fevers and chills – with high doses of sclerosant a transient flu-like episode is possible several hours after the procedure. It is rare since the introduction of foam.
Ankle swelling can occur if many veins around the feet and ankles are injected or when huge veins are treated. The compression stocking usually prevents this.
Migraine and flashing lights are occasionally experienced, more commonly in migraine sufferers
Infection has been reported though the sclerosants are excellent antiseptics.
Deep vein thrombosis (DVT) refers to the development of a clot in the deep veins of the leg. This potentially serious problem is rare if compression stockings and daily walking are adhered to. The risk is approximately 1 in 5000 patients for superficial sclerotherapy, 1 in 1500 for UGS and 1 in 300 for laser therapy (currently 0 in ~3500 at Vein Remedies). This compares to 1 in 20 to 1 in 50 with surgical stripping. These clots can travel to the lungs and can be fatal. Approximately 1 in 4 people with a DVT have clots in their lungs. DVT has a 1-2% mortality rate.
Nerve damage – a temporary numbness of the calf may occur after injections into the saphenous veins below the knee due to nerve irritation. It takes around 3-4 months for the sensation to return to normal but is rare since the introduction of foam sclerotherapy.
Historically, large areas of skin damage have been reported from injecting varicose veins. This has occurred by injection of potent solution into small arteries. Intra-arterial injections cause gangrene, however, there are normally no arteries near varicose veins and they are readily seen on colour Duplex ultrasound scanning.
Veins treated adequately by sclerotherapy will not recur. The underlying predisposition to develop varicose veins remains, however recurrence can be avoided by adequate follow-up. It is important to maintain normal body weight and exercise regularly to minimise the development of new varicose veins. Repeat treatment is simple and more likely to ensure permanent closure.