Overview
Definition:
Sclerotherapy is a medical procedure used to treat varicose veins and spider veins by injecting a solution (sclerosant) directly into the affected veins
This irritant causes the vein walls to swell, stick together, and eventually scar, leading to the closure and disappearance of the vein
It is a minimally invasive treatment option that has been used for decades and remains a cornerstone in the management of superficial venous disorders.
Epidemiology:
Varicose veins affect a significant portion of the adult population, with prevalence increasing with age
Estimates suggest that 20-40% of adults experience varicose veins, with women being more commonly affected than men
Risk factors include genetics, female gender, obesity, prolonged standing or sitting, pregnancy, and previous deep vein thrombosis
Spider veins (telangiectasias) are even more common, affecting up to 50% of the population.
Clinical Significance:
Varicose veins can cause significant discomfort, pain, and cosmetic concerns
Untreated, they can lead to serious complications such as superficial thrombophlebitis, deep vein thrombosis (DVT), venous ulcers, and skin changes (pigmentation, eczema, lipodermatosclerosis)
Sclerotherapy offers a safe, effective, and well-tolerated treatment option that can alleviate symptoms, prevent complications, and improve the aesthetic appearance of the legs, thereby enhancing patients' quality of life.
Indications
Absolute Indications:
Symptomatic varicose veins of the legs and thighs
Cosmetic concerns regarding varicose veins and spider veins
Recurrent varicose veins after surgery or other treatments
Superficial venous malformations
Small to medium-sized reticular veins.
Relative Indications:
Patients with mild symptoms but significant cosmetic concerns
Prophylactic treatment in individuals with a strong family history and early signs of venous disease
Post-thrombotic syndrome with superficial venous incompetence.
Contraindications:
Acute deep vein thrombosis (DVT) or superficial thrombophlebitis
Pregnancy and breastfeeding
Known allergy to sclerosants
Severe arterial insufficiency
Uncontrolled systemic diseases (e.g., severe diabetes, immune deficiency)
Recent prolonged immobility
Active infection.
Diagnostic Approach
History Taking:
Detailed history of symptom onset and duration
Characterize pain: aching, burning, throbbing, heaviness
Note exacerbating and relieving factors: prolonged standing/sitting, activity
Inquire about previous venous treatments, DVT, pulmonary embolism, or surgery
Assess for cosmetic concerns and impact on quality of life
Family history of venous disease
Medication history, especially hormonal therapy.
Physical Examination:
Full lower extremity examination in both standing and supine positions
Identify location, size, and distribution of varicose veins, spider veins, and reticular veins
Assess for skin changes: edema, hyperpigmentation, eczema, lipodermatosclerosis, venous ulcers
Palpate for tenderness, induration, and signs of superficial thrombophlebitis
Assess for saphenofemoral junction (SFJ) and popliteal fossa competence using Trendelenburg and Perthes tests (though less reliable than ultrasound).
Investigations:
Color Doppler ultrasonography is the gold standard for evaluating venous anatomy, reflux, and obstruction
It helps identify the source of reflux, extent of venous disease, competence of perforator veins, and rule out DVT
It is crucial for pre-treatment mapping and planning
Venography (less common now) may be used in complex cases or when ultrasound is inconclusive
Ancillary tests may include blood coagulation profiles if anticoagulation is considered.
Management
Sclerosant Agents:
Commonly used agents include: Sodium tetradecyl sulfate (STS, e.g., Sotradecol, Fibrovein) available in concentrations of 0.5% to 3%
Polidocanol (e.g., Aethoxysklerol) available in concentrations of 0.5% to 2%
Glycerin and hypertonic saline are less common alternatives
Foam sclerotherapy involves mixing the liquid sclerosant with air or gas (e.g., air, CO2, N2O) to create a foam, which increases its surface area and efficacy for larger veins.
Technique Of Injection:
The patient is positioned supine with the affected leg elevated
The skin is cleaned with an antiseptic solution
A small gauge needle (25-30G for spider veins, 23-27G for larger veins) is inserted into the vein
The sclerosant is injected slowly, observing for blanching of the vein
For foam sclerotherapy, the foam is injected under ultrasound guidance
Multiple injections may be required to treat a single vein or session
The treated area is immediately compressed.
Post Injection Care:
Compression is crucial for success
Patients are advised to wear compression stockings (usually 20-30 mmHg or higher) for 2-4 weeks post-treatment
Ambulatory activity is encouraged to promote venous return and prevent thrombosis
Avoidance of prolonged standing or sitting, strenuous exercise, hot baths, and direct sun exposure for 24-48 hours is recommended
Follow-up appointments are scheduled to assess treatment efficacy and manage complications.
Adjunctive Treatments:
For larger or more complex varicose veins, sclerotherapy may be combined with other treatments such as endovenous laser ablation (EVLA), radiofrequency ablation (RFA), or surgical ligation and stripping
These are often performed sequentially or in different sessions depending on the extent and location of the venous disease.
Complications
Early Complications:
Pain and tenderness at the injection site
Bruising (ecchymosis)
Phlebitis (inflammation of the vein)
Superficial thrombophlebitis (clot formation in the treated vein)
Skin discoloration (hyperpigmentation)
Allergic reactions to sclerosant (rare).
Late Complications:
Matting (formation of new, tiny blood vessels near the treated vein, often requiring further treatment)
Persistent hyperpigmentation
Telangiectatic matting
Deep vein thrombosis (rare but serious)
Skin necrosis or ulceration at the injection site (especially with extravasation).
Prevention Strategies:
Meticulous injection technique, avoiding extravasation
Proper dilution and dosage of sclerosant
Adequate compression post-treatment
Encouraging ambulation
Careful patient selection, avoiding contraindications
Using ultrasound guidance for larger or deeper veins.
Prognosis
Factors Affecting Prognosis:
Extent and type of venous disease
Patient's adherence to post-treatment compression and activity recommendations
Skill and experience of the practitioner
Type and concentration of sclerosant used
Presence of underlying venous reflux in deeper systems.
Outcomes:
Sclerotherapy is highly effective for treating spider veins and reticular veins, with excellent cosmetic results
For larger varicose veins, it can significantly reduce symptoms and improve appearance, often achieving complete closure in 80-90% of treated veins
Multiple treatment sessions are often required for optimal results
Recurrence rates vary but can be managed with repeat treatments or alternative therapies.
Follow Up:
Regular follow-up appointments (e.g., at 4-6 weeks, 3-6 months, and annually) are recommended to monitor for recurrence, assess treatment efficacy, and manage any delayed complications
Patients should be educated on long-term leg care and risk factor modification.
Key Points
Exam Focus:
Understanding the mechanism of action of sclerosants
Differentiating between liquid and foam sclerotherapy and their indications
Recognizing contraindications and potential complications
Knowing the importance of post-treatment compression and ambulation
Recognizing Doppler ultrasound as the gold standard for diagnosis and mapping.
Clinical Pearls:
Always aspirate before injecting to ensure you are within the vein
Inject slowly to avoid discomfort and reflux
For larger veins, consider foam sclerotherapy under ultrasound guidance
Educate patients thoroughly on post-procedure care to maximize success and minimize complications
Matting is a common and manageable complication.
Common Mistakes:
Inadequate compression post-treatment
Failure to identify and treat the source of reflux
Over-injection or extravasation of sclerosant
Treating patients with absolute contraindications
Not performing adequate duplex ultrasound mapping before complex cases
Assuming a single session is sufficient for all venous disease.