Definition
Sclerotherapy, which comes from the Greek word “hardening”, is the treatment of varicose veins by injecting an irritating chemical into the vein. The chemical causes sterile inflammation of the vein and the formation of fibrous tissue that closes the lumen or central duct of the vein.
Objective.
There are several indications for sclerotherapy of the lower extremities: 1. It is used to close venous spider-like dilatation (a small vein that expands due to elevated venous blood pressure) for the purpose of improving the appearance of the leg. Venous spider-like dilatation is a type of capillary dilation, a red lesion of the skin caused by persistently enlarged capillaries or other small veins. The word capillary dilation comes from the Greek, they are “end (end)”, “blood vessel (blood vessel) and “streteh out (stretch out), spider veins, also called “sunburst varicose veins”, are a central red area visible to the naked eye near the surface of the skin, with the rest of the small veins extending outward like the legs of a spider. Spider veins may also appear in two other forms, small dendritic or like very thin detached threads.2. Sclerotherapy, which also treats the occurrence of small or medium sized varicose veins, relieves soreness, pain, muscle fatigue and leg cramps. Because sclerotherapy is often considered a cosmetic procedure, which is not usually covered by health insurance, patients who are using sclerotherapy for varicose veins and leg discomfort should ask their insurance company if sclerotherapy is covered, as the average cost of the treatment was $227 in 2001.
Sclerotherapy is also used as a treatment for varicose veins in the esophagus.
Demographics
The American College of Phlebolog, a group of dermatologists, plastic surgeons, obstetricians and gynecologists and general surgeons who specialize in the treatment of venous disease, believes that more than 8 million people in the United States suffer from spider veins. The American Society of Plastic Surgeons estimates that more than 50 percent of women over the age of 21 have spider veins.
Women are more likely to develop varicose veins than men, but the incidence increases with age in both sexes. A recent survey in San Diego, California, showed that 80% of women and 50% of men in middle-aged and older adults had spider veins. Men are unlikely to be an option for cosmetic treatment of spider veins, and because the color changes caused by spider veins are often covered by leg hair, male patients who are suffering from pain, burning sensations and varicose veins in the legs may benefit from sclerotherapy injections.
According to the ASPA, in 2001 there were 616,879 sclerotherapy cases in the United States, 97% of which were women and 3% of which were men, and the age range for sclerotherapy was 30 to 60 years.
Spider-like varicose veins are more likely to occur and are more pronounced in Caucasians. Hispanic Americans are more likely to have spider veins than African or Asian Americans.
Causes of spider veins
A brief description of the human venous system is helpful in understanding how sclerotherapy works. The venous system, which is part of the circulatory system, returns blood to the heart, which pumps it to the lungs for oxygenation. In contrast, the arterial system carries oxygenated blood away from the heart and to tissues throughout the body, and the smallest veins in the venous system are capillaries, which return to larger superficial veins. All superficial veins lie between the skin and a layer of fibrous connective tissue called fascia, which serves to cover and support muscles and internal organs, and the body’s deep veins lie within the muscular fascia, a distinction that helps explain why they can be treated with sclerotherapy without damaging the larger veins.
Veins contain a unidirectional valve that, when they are functioning properly, propel blood upward toward the heart. The pressure in the superficial veins is usually low, and if it rises and remains at a high level for a period of time, the valves will fail, causing the veins to dilate. The failure of the veins to function properly is called “insufficiency”. As the veins dilate, their location close to the skin surface makes them more visible, resulting in the classic spider-like varicose veins.
Some people are at higher risk of developing spider veins, and these risk factors include
Gender: Women are more likely to develop spider veins at any age group compared to men.
Genetic factors: Some people have abnormally weak vein walls or valves, and their superficial veins may develop spider veins even at low blood pressure levels.
Pregnancy; women have an increased volume of circulating blood during pregnancy, which increases the blood pressure in the venous system, in addition, hormonal changes during pregnancy cause softening of the vein walls and valves.
Contraceptives.
Obesity: excess weight increases the pressure on the veins.
Occupational factors: For people with jobs that require long periods of standing or sitting are more likely to develop spider-like varicose veins than those with jobs that require movement.
Trauma, falls, deep abrasions, cuts, or surgical incisions may lead to the formation of spider veins in or near the traumatized area.
As of 2003, there is still no known way to prevent the formation of spider veins.
Sclerotherapy steps.
The treatment procedure is performed on an outpatient basis at length, with the patient lying on an examination bed wearing a pair of shorts. After disinfecting the surface of the skin, the doctor injects sclerosing agents into the patient’s veins, which disappear when the skin is pulled tight with the other hand, and injects first the veins in the leg where the varicose is obvious, followed by smaller veins. Although the patient may feel a slight tingling or burning sensation at the injection site, sclerotherapy does not require anesthesia.
The most common liquid sclerosing agents used to treat spider veins are polyethylene glycol monododecyl ether, sodium tetradecyl sulfate, and hypertonic sodium chloride at 11.7% concentration. Some physicians prefer hypertonic sodium chloride because it does not cause allergic reactions, and it is common practice to use the lowest effective concentration of sclerosing agent to close the vein.
A newer sclerotherapy injection treatment is a foam formulation injected into the vein rather than a liquid sclerosing agent. The foam formulation has several advantages: it contacts the vein wall more fully than liquid sclerosing agents, it can be used in smaller amounts, and its movement in the vein can be observed on an ultrasound screen, foam sclerosing agents have been shown to have a high success rate and lower cost, and fewer complications.
When all varicose veins in the leg have been injected, the physician covers the area with a cotton pad compression band. When the first treatment is completed, the physician should have the patient wait in the office for 20-30 minutes to ensure that the patient is not allergic to the sclerosing agent. Most sclerotherapy procedures are short, taking only 15-45 minutes.
It is more common to need a second treatment to completely eliminate the spider-like varicose veins, but a 4-6 week interval is needed between treatments.
Diagnosis.
The most important indications for deciding to treat with sclerotherapy are distinguishing between capillary dilation and severe varicose veins, and differentiating between capillary dilation and spider nevus. The physician must ensure that the patient does not have more severe venous insufficiency, as sclerotherapy can only treat small superficial veins.
A spider nevus, also known as a “spider angioma,” is a small benign lesion with a tiny artery in the center, which is derived from a small branch of the artery and surrounded by smaller, radial steps. system. To distinguish between the two, the doctor will gently press on the center of the “spider” and when the center of the spider mole is pressed, it will turn white and lose its light red color, which will return when the doctor stops pressing on it. The spider veins are not affected by this type of pressure. In addition, spider veins are common in children and pregnant women, but not in older people. Treatment is done by laser and electrodesiccation, but not by sclerotherapy.
After taking a history, the physician examines the patient from the waist down, noting both the spider-like venous dilatation site, lightly palpating the lesion, and observing for signs of other venous disease. Ideally, the examination should have a small, elevated table on which the patient can stand during the examination. While asking the patient to rotate slowly, the physician observes for scar trauma, skin swelling, skin discoloration, or other signs of chronic venous insufficiency. When touching the leg, the physician should note any changes in skin temperature, soreness, cysts, edema, etc. Next, the physician should tap the areas of the leg near the surface of the body where the larger veins are located. By gently tapping the skin surface in these areas, the physician can feel the waves of fluid in the veins and decide whether further testing for venous valve insufficiency is needed. If the patient has problems associated with severe varicose veins, they must be treated before sclerotherapy can eliminate the spider veins.
Contraindications to sclerotherapy for varicose veins include
During pregnancy and breastfeeding: Pregnant women are advised to delay sclerotherapy until three months after delivery, as some spider veins will disappear spontaneously after delivery. Lactating women should delay sclerotherapy until after the infant is weaned, as it is still unclear whether the chemicals used in sclerotherapy affect breast milk.
Diabetes
AIDS, hepatitis, syphilis or other blood-borne diseases
Heart disease
Hypertension, clotting disorders, and other circulatory disorders
Preparation
Prior to sclerotherapy, the patient should stop taking aspirin or aspirin-related medications. In addition, tell the patient not to use any moisturizers, creams, tanning lotions, or sunscreen on the legs on the day of treatment. Patients should bring a spare pair of shorts to treatment, as well as compression stockings and a pair of long pants or a long skirt to cover the treated leg.
Most physicians take photographs of the patient’s legs prior to sclerotherapy to assess the efficacy of the treatment, and in addition, some insurance companies require pre-treatment photographs for their files.
Post-operative rehabilitation
Post-operative rehabilitation after sclerotherapy includes the following: medical compression stockings with a compression of 20-30 mmHg for at least 7-10 days (preferably 4-6 weeks) after treatment. Wearing compression stockings minimizes the risk of edema, skin discoloration and pain. The commonly used stockings should not be chosen because they do not provide sufficient compression to the leg.
Bandages and cotton pads used during treatment must not be removed until 48 hours after the patient goes home.
Patients should be encouraged to walk, ride a bicycle, or participate in other low-activity exercises (e.g., yoga and tai chi) to prevent deep vein thrombosis in the lower extremities, and should avoid sitting or standing for long periods of time, as well as high-activity activities, such as jogging.
Risks
From a cosmetic point of view, the main risk is the formation of new spider veins after sclerotherapy. New spider veins are formed when some of the venous blood is bypassed back into the larger vein and the vessel dilates, not a recurrence of an already sclerotic vessel. Some patients may develop telangiectatic matting, which is a network of new spider veins on the surface of the treated area. telangiectatic matting, which usually disappears after 3-12 months of sclerotherapy, can be treated further with sclerotherapy.
Other risks of sclerotherapy include.
Venous thrombosis, which is the formation of blood clots in the veins, is a serious complication.
Severe inflammation
Post-operative pain that lasts for several hours or days. The discomfort can be relieved by wearing medical compression stockings and walking briskly.
Allergic reaction to sclerosing solution or foam.
Permanent scarring.
Sensory loss due to nerve damage in the treated area.
. Edema of the foot or ankle joint. This problem is most likely to occur when a spider vein in the foot or ankle is treated. The edema usually resolves within a few days to a few weeks.
. Brown spots or color changes in the skin around the treated area These changes are caused by a buildup of iron-containing heme, which is a form of iron-storing tissue cells. These spots usually fade after a few months.
. Skin ulcers, a complication that may be caused by reactive spasm of the blood vessels, are attributed to the use of too strong a sclerosing solution or poor equipment for administering sclerosing agents. It can be reduced by diluting the sclerosing solution with saline.
. Hirsutism, a condition in which abnormal hair growth occurs in the area treated with sclerotherapy. It usually appears after 1 month of treatment and then disappears on its own. It is also known as: Hypertrichosis
Efficacy
The effects of sclerotherapy include improvement in the appearance of the legs and relief of pain or spasm associated with spider veins. It is currently believed that 3 to 4 sclerotherapy sessions are required for the complete elimination of spider veins.
Incidence of complications and mortality.
Mortality associated with sclerotherapy is virtually zero when the treatment is performed by a specialist, with varying rates of other complications, including the following.
iron-containing heme discoloration: 15-75%80 of patients, lasting more than 1 year in less than 1% of cases.
telangiectatic matting: 5-75% of patients.
Deep vein thrombosis: less than 1%.
Mild pain: 35-55%.
Skin ulcers: about 4%.
Other options
Conservative treatment
Patients who are suffering from discomfort due to spider veins may benefit from several options.
Exercise Walking or other forms of exercise can activate the muscles of the lower leg and thus can reduce painful spasms, as the movement of these muscles keeps the blood flowing to the leg veins. A frequently recommended exercise is repeated ankle flexion. Flexing the ankle 5-10 times every few minutes and walking for 1-2 minutes every half hour can prevent blockage of the veins caused by sitting and standing in the same position for a long time.
Avoid high heels When the patient walks, high heels show full flexion of the ankle joint. This restriction on the range of motion of the ankle joint makes it more difficult for the leg muscles to squeeze the venous blood to the heart.
Elevating the leg 1-2 times a day for 15-30 minutes at a time is a change in position often recommended to reduce foot and ankle edema.
Putting on compression stockings Compression stockings help reduce inflammation in the leg veins while increasing venous return. Most manufacturers of medical compression stockings now offer some relatively pure socks that are not only aesthetically pleasing but also therapeutically effective.
Medications Medications used to treat the discomfort caused by spider varicose veins include nonsteroidal anti-inflammatory drugs and vitamins C and E. One prescription drug that is used to treat circulatory disorders of the legs and feet is pentoxifylline hexacocaine, a drug that helps improve blood flow to smaller capillaries. Hexaconitine is currently sold under the brand name trendar.
If aesthetics is the patient’s primary concern, there are special formulations of cosmetics available in a variety of skin tones to cover the spider-like veins in the legs. Some of these are useful during swimming or other physical activities.
Electrodesiccation, laser treatment and pulsed light therapy
Electrodesiccation is a treatment in which the doctor delivers a weak electric current through a thin needle to the vein wall to close the small veins that cause spider veins. It seems to be more effective for spider veins on the face than for spider veins on the legs, and when used to treat spider veins on the feet and legs, it tends to leave a white depressed scar.
Laser treatment: Like the electrodrying method, it is better for treating spider veins on the face. A large focused beam of laser light generated by a laser generator heats the blood vessels, causing the blood in the veins to clot and thus closing them. Various lasers have been used to treat spider veins, including argon, KTP532nm, and emerald lasers. Different wavelengths and pulses of laser are chosen depending on the size of the vein being treated. However, argon lasers increase the patient’s risk of iron-containing heme discoloration when treating the legs, and KTP532nm lasers provide better results when treating spider veins in the legs, but are still not as effective as sclerotherapy injections.
Intense pulsed light (IPL), a system that differs from lasers because it emits light asynchronously and not monochromatically, allows physicians to treat spider veins and other skin problems, such as birthmarks, with a wider range of wavelengths and pulse frequencies. This flexibility requires a physician with skill and experience to not injure the surrounding skin.
Complementary and alternative (CAM) treatments
Dr. Kenneth Pelletier of Stanford University School of Medicine in California, former director of the Complementary and Alternative Treatment Program, says that chestnut extract is as safe and effective as long compression stockings as an alternative treatment for spider veins. Chestnut extract (hepatica hippocastanum) has been used for many years in Europe to treat problems of the synchronous circulatory system, and recent studies have been conducted in the UK and Germany. The usual dose is 75 mg, taken twice a day with meals. The most common side effect is indigestion in patients when taken orally.
Other sclerotherapy for esophageal varices, ligation and stripping of veins.
Wikipedia: Sclerotherapy
Sclerotherapy is used to treat varicose veins or vascular malformations, as well as malformations of the lymphatic system. The drug is injected into the blood vessels and closes them, and can be used in children or young people with vascular or lymphatic malformations. In adults sclerotherapy is mostly used to treat varicose veins and hemorrhoids.
Sclerotherapy is one of the methods of treating varicose veins and venous malformations along with surgery, radiofrequency and laser ablation. In ultrasound-guided sclerotherapy [2], ultrasound is used to see the deeper veins and provide monitoring for the physician’s injection. After the diagnosis of venous malformation by ultrasound, sclerotherapy should be performed under ultrasound guidance. Ultrasound-guided microbubble sclerotherapy has been shown to be effective in controlling reflux from the confluence of the femoral greater saphenous vein and the N lesser saphenous vein. However, some scholars believe that sclerotherapy is not suitable for reflux in the small and large saphenous veins. [5].
Historical aspects
Sclerotherapy has been used to treat varicose veins for more than 150 years. Like varicose vein surgery, sclerotherapy techniques have evolved over this time. Modern techniques including ultrasound guidance and foam sclerotherapy are the most recent developments in this area.
Goldman noted that the first reported attempt at sclerotherapy was by Dzollikofer in Switzerland, who in 1682 injected an acid into a vein to induce thrombosis. About 12 years after Madelung’s invention of saphenous varicose vein stripping in 1884, Debout and Cassaignaic successfully cured 16 cases of varicose veins (of patients) by injecting iodine and tannin in 1853. Sclerotherapy was popular in the late 19th and early 20th centuries, until several studies in the 1930s showed that the treatment had a high recurrence rate. At that time, with the development of surgical techniques and anesthesia, stripping became the (main) choice.
However, work continued in the 1940s to 1950s to improve the technique of sclerotherapy and to develop safer and more effective sclerosing agents. One of the most important developments was the discovery of sodium tetradecyl sulfate (STS) in 1946, which is still in use today.George FegenZ 1960 published a report of over 13,000 cases treated with sclerotherapy injections, significantly advancing the sclerosing technique from one focused on venous thrombosis and control of significant reflux to one focused on fibrosis, and emphasizing the need to compression of the treated leg. In Europe, the treatment was medically accepted at the time. However, in the United Kingdom and the United States, the treatment was poorly understood and not accepted, and in some medical communities this continues to be the case today.
The next most significant development in sclerotherapy was the advent of ultrasound intervention in the 1980s and its application to the practice of sclerotherapy a decade later. knight was an early advocate of this line of technique and presented his ideas at numerous conferences in Europe and the U.S. Thibault’s article in peer -reviewd journal first published an article on this idea.
Cabrera and Monfreaux made a revolutionary advance in the treatment of larger varicose veins based on the “3-way tap method” of Tessari’ foam products.
The method
Injection of a sclerosing solution into the diseased vein causes its immediate contraction, and over the next week the target vein dissolves and is naturally absorbed by the body, thus achieving the goal of treatment.
Sclerotherapy has become the “gold standard” for eliminating larger spider veins (capillary dilation) and smaller varicose veins, surpassing laser treatment. Unlike laser treatment, sclerotherapy also closes the subcutaneous “venous branches (of the spider veins)” and therefore reduces the recurrence of spider veins in the treated area. The patient should be placed in an elastic stocking or bandage for 2 weeks after treatment. During this time the patient is encouraged to walk regularly. It is common practice to require 2 sessions several weeks apart to significantly improve the appearance of the veins in their legs.
Sclerotherapy can also be ultrasound-guided treatment of larger varicose veins, which include large and small saphenous veins, with microfoam sclerotherapy.
Foam sclerotherapy by injection
Foam sclerotherapy is a technique in which a “foam sclerosing agent” is injected into the blood vessels using a syringe. The sclerosing drug (sodium tetradecyl sulfate or polyethylene glycol monododecyl ether) is mixed with air or physiologic gas (carbon dioxide) in a syringe or mechanical pump, which increases the surface area of the drug. Foam sclerosing agent is more effective than liquid sclerosing agent in causing sclerosis (thickens the vessel walls and clogs the vessels) because he does not mix with the blood in the vessels but replaces it, thus avoiding the dilution of the drug and maximizing the effect of the sclerosing agent. Therefore, he is also more suitable for larger vessels. Foam sclerotherapy specialists can create a “toothpaste” like thick foam that has revolutionized the non-surgical treatment of varicose veins and venous malformations including Klippel Trenaunay syndrome.
Clinical evaluation
A 1996 study by Kanter and thibault reported a 76% success rate in treating femoral saphenous junction and saphenous vein incompetence with a 3% sodium tetradecyl sulfate solution over 24 months. .
A review from the Cochrane Collaboration concluded that “the evidence in clinical practice for sclerotherapy supports that it is usually limited to the treatment of recurrent varicose veins and linear vessels after surgery.”
A second review from the Cochrane Collaboration comparing surgical and sclerotherapy concluded that sclerotherapy provides better short-term benefits, while surgery provides better long-term outcomes. Sclerotherapy was superior to surgery based on treatment success, complication rates, and costs within one year, but surgery was superior after 5 years. However, the evidence is not of good quality and more research is needed.
A health technology assessment found that sclerotherapy provided less benefit than surgery, but appeared to provide less benefit in the absence of combined saphenous vein reflux or N saphenous vein reflux. He did not compare the benefits of surgery and sclerotherapy in the presence of varicose veins in the presence of confluent reflux.
In 2003, the European Consensus Conference on foam sclerotherapy concluded that “skilled physicians can treat larger varicose veins, including the saphenous trunk, with foam sclerotherapy injections.”
Complications
Complications are rare and include venous thromboembolism, visual impairment, allergic reactions, blood clots, skin necrosis, and hyperpigmentation.
Sclerotherapy injections, if done properly into the vein do not damage the surrounding skin. However, if he is injected outside the vein, the tissue necroses and scars form. The incidence of skin necrosis is about 0.2% to 1.2% and is cosmetically “potentially devastating”, which often cannot be stopped and may take months to heal. This is rare when using small amounts of diluted (<0.25%) rather than using high concentrations (3%) of sodium tetradecyl sulfate (STS). Skin burns often occur when STS is not injected into arteries (small arterial branches). telangiectatic matting development or microvascularization is unpredictable and usually must be treated with repeated sclerotherapy or laser therapy.
A recent report appeared that foam sclerotherapy appeared to be a stroke, but this was due to an unusually large amount of foam being injected.