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Chapter
Hub
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9
FloLock port
FloLock release button
Infusion port
Proximal
marker
Balloon inflation port
Figure 9.19 Diagrammatic representation of the VeinRx catheter. (Courtesy VeinRx, Inc., Miami, Fla.)
Clinical Methods for Sclerotherapy of Varicose Veins
Infusion length Balloon
Distal
marker
Figure 9.20 Photograph of the proximal end of the VeinRx catheter
showing the infusion ports. (Courtesy VeinRx, Inc., Miami, Fla.)
body with infusion holes, and trifurcated hub. Figure 9.19 is
a line drawing that further illustrates the catheter design. The
FloLock trifurcated hub is designed to connect the following
three main systems of the device (Fig. 9.20). A tubing extension
incorporating a stopcock on one side of the hub is the port
used to inflate and deflate the occlusion balloon. The Luer
connection in the center of the hub is used to mount the
syringe loaded with the desired sclerosant. Opposite the
balloon port and nearest the blue button is a port for controlling the FloLock channel. The FloLock channel allows the
physician to determine accurately whether the infusion ports
are open or closed (Fig. 9.21), a feature previously unavailable in standard infusion catheters. This channel uses an
inflatable elastomeric bladder to either close or open the
infusion ports.
This feature is used to eliminate port obstruction before
and during catheter placement, support pre-purging and
holding the purge in the catheter before and during placement, and precise control of sclerosant during infusion. The
device is provided in sterile packaging for single-patient use.
The infusion catheter is manufactured with well-known and
commonly used medical-grade materials.
The distal end of the catheter incorporates a compliant
latex occlusion balloon. The balloon eliminates communication between the GSV and the SFJ and enables the sclerosant to produce maximal therapeutic action in the target
vein. With the balloon inflated, the physician can deliver a
predetermined amount of sclerosant through the catheter and
into the GSV, with subsequent flow of sclerosant into incompetent perforators and tributaries. The sclerosant chemically
254
Figure 9.21 Diagram illustrating the effusion of solution from the distal
ports on the VeinRx catheter. (Courtesy VeinRx, Inc., Miami, Fla.)
ablates the targeted segment of the vein and has the potential for providing a complete treatment within a single
procedure.
There is also the possibility of a small amount of the sclerosant entering the deep venous system through communicating perforator veins. However, this potential is relatively
insignificant when compared to femoral vein intrusion of sclerosants in the setting of direct-injection/ultrasound-guided
sclerotherapy.
The importance of having a series of infusion ports along
the lumen length is to optimize the treatment of the GSV by
localized delivery of the sclerosant. Sclerosant is uniformly
delivered when all infusion ports are patent. This design also
reduces the possibility of having excess sclerosant flow into
large communicating veins near the target vein.
Device Preparation
The VeinRx infusion catheter comes in multiple infusion
lengths. The catheter selected for a procedure is a function of
the required vessel treatment length. This is determined preoperatively during ultrasound examination. Ultrasound examination is also required to determine the amount of sclerosant
to be injected and the proper occlusion balloon inflation
volume, which is a function of the vein diameter at the desired
occlusion site, usually just distal to the SFJ. Prior to surgery,
the balloon is inflated with sterile saline using a 10-mL syringe
and inspected for leakage or damage.
The infusion lumen is prepared by purging the catheter
using foam sclerosant constituted by passing the sclerosant
back and forth between two 10-mL syringes for 10 or more
times, using a ratio of one part sclerosant to four parts air.
During proper functioning of the device, foam will exit from
all of the holes in the infusion lumen.
The infusion ports are sealed by pressurizing the FloLock
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channel with a 1-mL syringe filled with approximately 0.75 mL
of sterile saline. To insure that the bladder is properly inflated,
the operator applies low-level pressure to the infusion syringe
and visually confirms that no flow exits the infusion ports
along the marked infusion length.
Delivery of Sclerosant
After the preparation described above and percutaneous access,
the device should be introduced and advanced through the
patient’s vasculature with the leg in the horizontal and straight
position. Using ultrasound guidance, the balloon is advanced
to the most proximal treatment point, which is marked in
advance. With the leg remaining horizontal and straight, the
balloon is inflated. At this point, the foam sclerosant is injected
through the device into the patient’s target vein. The infusion
rate should be approximately 5 mL over 10 seconds.
Upon completion of the infusion, the patient’s leg should
remain horizontal and straight with the balloon inflated for 4
minutes. This is known as the ‘dwell time’. After the 4-minute
dwell time, the balloon should be deflated and the device
removed. After removal of the device, the introducer is
removed and the entry site is manually compressed for 2
minutes and dressed using traditional wound closure techniques. Proper and constant pressure during this period is
important to reduce the potential of ecchymosis at the entry
site. This is followed by compression. This technique turned
out not to yield any better results than standard foam sclerotherapy and is no longer manufactured.
Treatment of specific problems
Treatment of large-diameter great saphenous veins
The treatment of the GSV with foam sclerotherapy has been
discussed and found to be effective depending on the method
of foam injection and the concentration and volume of solution. However, almost all of the previously cited studies set an
upper limit for the diameter of the GSV to be no more than
164
8 mm.
since non-detergent) to inject 500 GSVs with diameters of
between 6 and 12 mm measured 3 cm distal to the SFJ.
authors reported a 22% failure rate irrespective of vein diameter. Barrett et al90 reported outstanding efficacy in GSV with
diameters greater than 10 mm injected with foamed STS. This
was also found by Valsamis.
and the use of an appropriate concentration and/or type of
sclerosing solution can allow successful treatment of largediameter GSVs, although length of follow-up must be a critical
factors in all of these studies.
cannulated GSV with tumescent anesthesia placed in the surrounding facial sheath which may also lead to improved efficacy and reduce recurrences (Fig. 13).
Treatment of vulvar varicosities
Vulvar varicosities can be treated effectively with sclerotherapy.
Two problems in their treatment are sclerosis of the proximal
point of reflux and compression of the treated vein. Since
vulvar veins may arise from the internal iliac (hypogastric),
pudendal, obturator, uterine, or ovarian veins deep within the
pelvis, treatment directed at the most proximal point of reflux
cannot be attempted directly. Instead, the most proximal
visible varicosity is cannulated and sclerosing solution injected
in a proximal manner. With this technique, 1 to 2 mL of liquid
0.5% to 1.0% STS is injected slowly. Distal varicosities are then
treated. Alternatively, foamed 0.25 to 0.5% STS may be injected.
the vulvar veins (V2-supporter, Prenatal Cradle Inc, Hamburg,
Mich.). This device is worn until veins have resolved. Five
One study used Variglobin 8%–12% (non-foamed
165
The
166
Therefore, proper technique
Thibault
89
has described a technique for compressing the
A pelvic support device has been developed to compress
patients treated in this manner showed no evidence of recurrence in a 1-year follow-up.
167
Adverse sequelae have not been
noted. A 2-year follow-up of these five patients (and two
others) also demonstrated no adverse sequelae and resolution
of the varicose veins.
168
Treatment of venous malformations
(liquid sclerosant)
Venous malformations (VM), as described in Chapter 4,
consist of variably sized vessels. Sclerotherapy has proven to
be very useful in their treatment. In a study by Yamaki et al,
169
28 patients with a variety of VM on the face, neck, extremity,
and elsewhere were treated with duplex-guided sclerotherapy
with POL 3%. Eighty-two percent of the patients had effective
resolution. Pain on injection in 82%, marked swelling in 75%,
hemoglobinuria in 14%, and superficial epidermal necrosis in
10.7% were the reported adverse sequelae.
Lee et al
170
reported a 92% efficacy in treating 30 patients
with a variety of VM with absolute ethanol. Multiple sessions
were required and 24 total adverse effects occurred in the 92
sessions given. Adverse effects consisted of nerve palsy in five,
ischemic bullae in nine, tissue necrosis in two, tissue fibrosis
in two, and DVT in one. The authors proposed that this treatment helps to debulk and stabilize the VM, permitting simpler
surgical correction. An additional report on 399 sessions in
87 patients by Lee and colleagues
171
showed similar results
with long-term efficacy.
Foam sclerotherapy using the Cabrera foam on 50 patients
with VM was beneficial in 92% after an average of 12 sessions
with a mean of 30 months’ follow-up.
172
Of the 46 responders,
18 showed complete disappearance of the VM and 15 showed
a reduction of over 50% in size of the VM. Of the 39 patients
who reported pain, it disappeared in 25 and was reduced in
14. Three cases of skin ulceration occurred. For more information on foam sclerotherapy in venous malformations, please
see the above foam sclerotherapy section.
Treatment of other venous conditions
A variety of other venous conditions have been reported to
resolve with sclerotherapy. A report of complete resolution of
a venous lake of the lip after two treatments with POL 1%,
without adverse effects, has been reported.
173
Hemangioma showing late involution was successfully
shrunk with an injection of 5% ethanolamine oleate, allowing
surgical excision.
Multiple hereditary glomangiomas were treated with 0.2%
to 3% STS, depending on the size of the lesion.
174
175
An average
of two treatments where the lesions were injected with 0.5 to
1 mL of solution was required for lesion improvement.
Treatment of pyogenic granuloma with 5% monoethanolamine oleate in nine patients, who were all injected once,
resulted in complete resolution of the lesion within 2 weeks.
176
An additional study on 15 lesions in 14 patients treated with
0.5% STS (0.15–2 mL) one to five times (mean, 2.2) showed
complete resolution in 12 lesions.
177
No adverse effects were
seen in any patient.
Treatment of recurrences
When unsuccessful or in case of recurrence, sclerotherapy does
not modify the initial, pretherapeutic varicose pattern, which
reappears as it was before or smaller. This is not the case with
surgery, and, very often, recurrent varices after surgery (REVAS)
are extremely difficult to manage.
be, in certain selected cases, considered as an alternative treatment after sclerotherapy failure, sclerotherapy is the usual and
most appropriate recourse for recurrence after surgery of varicose veins. The progress in ultrasound guidance and, most of
all, the use of foam sclerosing agents have revolutionized the
approach to this difficult problem.
178
Therefore, if surgery can
Injection Technique
255
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9
256
Severity and
extent of
varices
With initial
Initial
status
0
Sclerosing injection sessions
Figure 9.22 Evolution of varicose veins. Although we do not have a simple
and accurate criterion of evaluation of varicose veins’ severity and extent,
the concept is simple enough and patients can understand it easily. This
diagram represents the evolution of the varicose status and the influence of
Clinical Methods for Sclerotherapy of Varicose Veins
active management. If it is true that there is some spontaneous trend
toward worsening, the status is always better when patients are
appropriately treated by sclerotherapy, especially with maintenance
treatments (theoretical approach).
sclerosing and no
maintenance
treatment
Without any
With initial
sclerosing treatment
and maintenance
sclerotherapy
As stated in the REVAS consensus document,
rences must be completely assessed by duplex in order to map
all leaks and refluxes. After surgery of junctions, two types of
recurrence can be observed:
• Neovascularization, where very small veins have grown
through the hard connective tissue and lymph nodes and
reinject lower varicose veins
• Inappropriate ligation, where an important saphenous
stump has been left in place and where macro veins
connect the femoral or popliteal vein to the varicose
network.
Before onset of UGFS, both types were issues. Since, in
the first case, direct injection was rendered difficult by the
small diameters, and, in the second case, appropriate longterm control of reflux was doubtful. Now, both types of recurrence can be easily treated either by direct echo-guided
puncture and foam injection or by remote access through
more superficial tributaries. REVAS veins are usually prone
to sclerose since the venous wall remodeling has been severe
and since dysplasia allows easier sclerosis. Anyway, in all
these cases, attention must be paid to an annual check-up of
veins in order to take care of new recurrences as soon as
possible.
For most patients, the difference between ‘new veins’
and ‘recurrent veins’ is not obvious at all and this misunderstanding is likely to create some difficulties in doctor–patient
relationships. A simple diagram explaining evolution of
varicose veins with or without treatment can be extremely
useful (Fig. 9.22; also see Case Study 13 later in this
chapter).
Does the Menstrual Cycle Influence
Sclerotherapy?
The actions of estrogens and progestins on venous distensibility were discussed previously (see Chapters 3 and 4).
Theoretically, sclerotherapy should be performed when the
venous system is in its most contracted state so that posttreatment thrombosis is minimized. Since limb volume and
treatment
178
all recur-
Time
Figure 9.23 Turbulent flow is produced with injection of solution at the
point of discharge of sclerosant from the needle cannula. (From Green D: Semin
Dermatol 12:88, 1993.)
venous distensibility are at their least during and just after
menses and at their highest during ovulation, the optimal
window for sclerotherapy treatment is when estrogen levels
are lowest.
179
However, until appropriate studies are performed to test this hypothesis, no absolute recommendation
can be made.
Recommended Sclerosing Solution
Amounts and Concentrations for
Non-Foam Sclerotherapy
Although the exact concentration of sclerosing solution
depends on the caliber and location of the varicose vein, the
following suggestions can serve as an initial guide to therapy.
Dilution of nonosmotic sclerosing solutions with sterile water
will cause the sclerosing agent to sting with injection. Thus,
dilutions should be performed with bacteriostatic normal
saline solution, which will not impart an additional sting.
The first principle of determining solution amounts and
concentrations is that the concentrations should be strongest
at the highest point of reflux. With saphenofemoral reflux, the
concentration should be strongest at the upper thigh and
weakest at the ankle. With ankle or calf perforating veins, the
concentration should be highest at the perforator. For example,
180
Vin
recommends that 1 mL of STS 1.0% be used at the
proximal thigh, 0.5 mL of STS 1.0% be used at the medial
thigh, and 0.3 mL of STS 0.5% be used at the medial knee to
treat a moderately sized varicose vein.
The second principle, as described by Tournay in 1949, is: ‘It
is not the concentration of the sclerosing agent in the syringe
that matters, but the concentration within the vein.’
importance of this statement was discussed in Chapter 7. In
short, for sclerotherapy to be effective, the entire vein wall
must be damaged and the entire intraluminal volume of the
segment of the vein must be destroyed. This is important
because the smooth muscle portion of the vein wall theoretically can regenerate endothelium, and endothelial cells can
migrate long distances to re-establish a functional conduit.
Sackmann
182
expanded on this principle by demonstrating
in polyvinyl tubes the local conditions of ‘time and space’
regarding contact of the sclerosing solution with the vessel
wall were also important. He showed the zone of contact
diminishes as the caliber of the vessel increases. In tubes with
a diameter of less than or equal to 4 mm, the liquid flowed
in a laminar fashion. In tubes with a diameter of greater than
or equal to 8 mm, turbulent flow was produced. In tubes
6 mm in diameter, a mixed flow occurred, with a transition
between a laminar and turbulent appearance (Fig. 9.23). In
contrast, the caliber and position of the needle, the speed of
injection, and the viscosity of the solution did not seem to
influence the time of contact of the sclerosing solution with
the tube.
181
The
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A
B
Figure 9.24 Nonlaminar flow occurs distal to the point of injection in an
empty vein. A, Needle inserted into empty vein. B, The force of the
advancing injected solution dilates the vein and produces turbulent flow.
(From Green D: Semin Dermatol 12:88, 1993.)
183
Green
used Poiseuille’s formula to describe resistance to
fluid flow in a varicose vein:
Rl= 84κ πn r
9.3
where
R = resistance
κn = viscosity of the solution
l = length of the vein
r = radius of the vein.
From this formula it is apparent that the most important
factor in determining resistance of flow is the vessel diameter
(radius). At the point of injection into an empty vein, expected
flow of sclerosing solution would be nonlaminar (Fig. 9.23).
This may account (along with increased localized concentration; see the following paragraph) for a greater incidence of
vessel damage and blowout at the point of injection (see
Chapter 8). Nonlaminar flow also occurs downstream of
injection in an empty vein in which resistance is still high,
since the pressure generated by the physician on the syringe
plunger is much greater than intravascular pressure, which
would approach zero in an empty vein, especially if the limb
were elevated (Fig. 9.24).
184
Guex
has worked out that the concentration of sclerosing
184
solution can be calculated based on the diameter of the vein
by the following formula:
Cm = × ×v C n rπ
2
9.4
Cs
Aggressive concentration
Effective concentration
Ineffective concentration
0
Injection site
Figure 9.25 Injection at one site with a high concentration but low
volume of sclerosing solution. Note localized excessive concentration.
(From Guex JJ: J Dermatol Surg Oncol 19:959, 1993.)
Ci
Cs
0
Figure 9.26 Injection at one site with large volume of a dilute
concentration of sclerosing solution. Note that a longer segment of vein is
sclerosed without any one point of excessive concentration.
Dermatol Surg Oncol 19:959, 1993.)
Sclerosis
Inflammatory reaction
Injection site
Varicose vein
Aggressive concentration
Effective concentration
Ineffective concentration
Sclerosis
Varicose vein
x
x
(From Guex JJ: J
Recommended Sclerosing Solution Amounts and Concentrations for Non-Foam Sclerotherapy
where
Cm = mean concentration of solution
v = volume of injected sclerosing solution
C = concentration of sclerosing solution
n = number of injections
r = radius of the injected vein.
Thus, if 0.5 mL is injected into a varicose vein 2 mm in
diameter, the sclerosing solution will fill a 16-cm length of
vein. In reality, the concentration of sclerosing solution at the
injection site is maximal and decreases with distance from
each point when small volumes of solution are injected (Fig.
9.25). The concentration of sclerosing solution along the
entire course of the vein can be equalized either by injecting
a larger volume in a single site or by injecting small volumes
A study by Cornu-Thenard
ing concentrations for varicosities of various diameters:
• 4 mm = STS 0.25%
• 5 mm = STS 0.5%
• 6 mm = STS 1.0%.
185
suggests the following scleros-
Ci
Aggressive concentration
Cs
0
Injection site
Figure 9.27 Multiple injections with low volumes of low concentrations of
sclerosing solution. This technique theoretically provides the safest method
for treating long lengths of vein.
1993.)
Injection site Injection site
Effective concentration
Ineffective concentration
Sclerosis
(From Guex JJ: J Dermatol Surg Oncol 19:959,
x
257
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9
Clinical Methods for Sclerotherapy of Varicose Veins
258
Table 9.7 Indicative concentrations and volumes for polidocanol foam
First
Vein
Thigh GSV 1.5 3 Up to 8
GSV main tributary 0.5 1 Up to 4
SSV 1.5 3 Up to 4
Perforators 1 2 Up to 2
Nonsaphenous 0.5 1 2 per site
GSV, great saphenous vein; SSS, small saphenous vein.
Session (%)
Second
Session (%)
Volume
(cm3)
He recommends 0.5-ml injections be placed every 6 to
10 cm along the varicose vein. Additional recommended
concentrations for injection of other sclerosing solutions
into various types and diameters of vein can be found in
Chapter 7.
The third principle is the amount of sclerosing solution
injected into a single site should not be more than 1.0 mL
(usually 0.5 mL). Venographic studies of direct injections into
varicosities of the leg have demonstrated that if more than
1.5 mL of solution is injected at a single site, it is likely to spill
over into the deep veins.
49,186
In addition, the patient should
not move the leg for a few minutes so that the sclerosing solution can remain in contact with the varicose vein, because any
movement of the leg will rapidly move the sclerosing solution
into the deep venous system.
Some physicians do not limit the volume of sclerosing
solution at a single site.
187
Green
187
reports infusing from 3 to
12 mL of STS into each injection site. Concentrations ranged
from 0.75% to 3.0% depending on vein size. He reports treating more than 3000 patients in this manner without encountering a single case of DVT. He also reports enhanced efficacy
with this technique, having near 100% efficacy with followups of up to 5 years. He uses class II compression for 2 to 8
weeks. Other details of his technique are not specified. Green
claims that ‘the widely varying success rates reported in the
literature are usually a reflection of the technique of the practitioner and not any inherent limitation of the procedure.’ The
authors believe that this statement is somewhat correct but
still caution against the use of excessive volumes of sclerosing
solution in a single site, since many cases of DVT have been
reported by other reputable physicians (see Chapter 8).
Histologic examination of peripheral veins may provide
assistance in determining the optimal concentration of sclerosing solution. Corcos et al
188
have determined through biopsy
of the dorsal pedal vein that the degree of intimal thickening,
ectasia, muscular hyperplasia, medial fibrosis, fragmentation,
and dissociation of the internal elastic membrane and intimal
fibrous plaques correlate with the concentration of sclerosing
solution necessary to effect endosclerosis of varicose veins.
This finding is supported by the theory that varicosis is a systemic disease (see Chapter 3).
The use of foam has very much simplified the approach of
concentration and the current trend is to decrease the concentration in half when using foam as opposed to liquid sclerosing solution. Guex
62
has suggested the values shown in Table
9.7, which remain open to adaptation and discussion.
Postsclerotherapy Compression
After injection of varicose or telangiectatic veins, the treated
veins are immediately compressed to minimize significant
thrombosis. The patient is instructed to walk immediately
after the injection session to help prevent DVT and reduce
venous reflux into the treated veins. Calf muscle movement
produces a rapid blood flow in the deep venous system, which
dilutes any sclerosing solution that may have migrated into
the area.
Postsclerosis compression is perhaps the most important
advance in sclerotherapy treatment of varicose veins since the
introduction of relatively safe synthetic sclerosing agents
in the 1940s. Primarily, compression eliminates a thrombophlebitic reaction and substitutes a ‘sclerophlebitis’ with
the production of a firm fibrous cord.
12
The advantages of
postsclerotherapy compression are discussed in detail in
Chapter 6.
In addition to providing external compression to the treated
vessel, one should try to minimize forces that act to distend
the vessel. Since taking hot baths or saunas dilates the cutaneous venous network, they should be avoided for 2 to 6 weeks
after sclerotherapy or until such time as the treated vessel is
fully sclerosed. In addition, any activity that increases abdominal pressure may act to force blood in a retrograde manner
through the SFJ or IPVs, producing venous dilation. Heavy
weight lifting therefore must be discouraged, along with any
exercises that use the abdominal musculature, unless the legs
are elevated during abdominal exercise. One such activity that
increases abdominal pressure by approximately 22 mmHg is
running, with pressure apparently being produced to splint
the trunk and pelvis.
189
Therefore, aerobic exercises, jogging,
and running should be limited for 1 to 2 weeks.
Patients should be examined 2 weeks after injection so any
area of thrombosis can be evacuated early.
190
Each individual
area should not be treated again sooner than 6 to 8 weeks after
initial injection in order to allow adequate healing between
treatments.
Contraindications to Treatment
Knowing and applying contraindications to sclerotherapy is
an important part of phlebological practice. The principle of
precaution is increasingly applied when using a treatment or
a drug – when its use has not been specifically determined,
registered, and officially approved, its use is unlawful. Official
contraindications are very often unclear, false or inaccurate,
outdated, or worse. Contraindications should remain under
medical control and managed by specialists.
Pregnancy
Besides the risk of absorption of the sclerosing solution by the
fetus, pregnancy is associated with dilation of the entire
venous system through multiple mechanisms that do not normalize until 3 months postpartum (see Chapter 3).
Therefore, although sclerotherapy can be and has been
performed successfully by many physicians on pregnant
women,
the desired contraction of the treated varicose vein (see
Chapters 3, 4, and 8). Finally, varicose veins may decrease in
size and disappear after delivery (see Chapters 3 and 4).
Thus, waiting may eliminate the need for the procedure.
nancy is the presence of significant and painful vulvar varicosities, which develop in approximately 2% of pregnant
women.
more likely in multiparous women. Although they rarely
thrombose, they are painful, especially with walking. Bed rest,
leg elevation, and localized compression are usually effective
in alleviating symptoms, but sclerotherapy may be necessary
in severe cases.
any combination of the following: obturator vein; internal
194–198
the increase in venous distensibility counteracts
One situation that may justify sclerotherapy during preg-
200
They usually occur by the second trimester and are
Venography has shown that vulvar varices arise from
191
192,193
199
pudendal vein; inferior gluteal vein; external iliac, uterine, and
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ovarian veins; obturator vein; presacral veins; common
femoral vein; and the GSV.
201,202
Because of this variable and
extensive system of reflux and the thin-walled, fragile nature
of these veins, sclerotherapy is preferred over surgical excision
or avulsion (see Case Study 7 later in this chapter).
Inability to ambulate
Walking after treatment is very important because it ensures
rapid dilution of the sclerosing solution, which may enter
normal deep veins. In addition, stagnation of blood flow is
avoided, and the possibility of excessive thrombosis lessened,
by the liberation of thrombolytic factors during muscle contraction when walking. Walking also decreases physical distention of the vein caused by reflux.
A corollary to the contraindication just mentioned is the
performance of sclerotherapy during surgical ligation.
Although this procedure has been performed by many surgeons and was advocated by de Takats in 1930,
203
it was
usually limited to a point distal to the SFJ on the GSV and
therefore was performed on an ambulatory basis. In 1934,
204
Faxon
modified this technique to include ligation at the SFJ
with retrograde injection of the GSV. He achieved good results
(although follow-up was poor) in his series of 117 cases except
for one case of fatal PE, which was attributed to faulty technique by a resident surgeon. In more recent times, Conrad
reports great success with this technique when used in conjunction with ligation at the SFJ. Hubner
206
reported similar
205
success without mention of complications in 413 patients followed for more than 1 year. Patients treated with POL 4% had
an 83% success rate, whereas patients treated with Variglobin
4% had a 94% success rate. However, Hubner separates the
two procedures by a few hours to a day because his patients
had the ligation performed by a surgeon in a separate office
and return to him for sclerotherapy. This latter scenario ensures
that the patient is ambulatory for both procedures.
In spite of the above-mentioned successful results, there are
potential complications that call for separating the two procedures. First, many varicose veins will resolve after surgical
treatment of the high-pressure reflux points, so subsequent
sclerotherapy is minimized or not necessary.
207
Secondly, the
surgical period is often one of minimal ambulation because
of postoperative pain and the use of general or regional
anesthesia. The delay in adequate ambulation may allow the
sclerosing solution to migrate to the deep venous system
where unwanted damage could occur (see Chapter 8).
200
The
authors recommend postoperative sclerotherapy be delayed
for 2 to 3 weeks.
History of thrombophlebitis and deep
vein thrombosis
Patients with a history of certain venous diseases may be predisposed to the development of excessive thrombosis with
injection of a sclerosing agent (that is, development of an
excessive phlebitic reaction; see Chapter 8).
Patients with low-risk thrombophilia (activated protein C
resistance, hyperhomocysteinemia especially, factor II, factor
V Leiden) can be treated with sclerotherapy. A prospective
study in progress will determine the best prophylaxis (see
Chapter 8).
Regarding patients already treated with oral anticoagulation, the contraindication is more dependent on the disease
treated by anticoagulation than on anticoagulation itself.
Patients treated for atrial fibrillation can be sclerosed without
inconvenience; most of the time, the course of their treatment
is simpler than for normal patients.
Also, in rare patients, the dilated superficial system may
serve as a conduit for carrying blood to the heart. Interruption
of the superficial system may then increase venous insufficiency. Therefore, PPG, both with and without application of
a superficial tourniquet or a trial of 30- to 40-mmHg graduated compression stockings, helps determine which patients
will benefit and which may be harmed by sclerotherapy
treatment.
Another simple test to determine if the varicosity resulting
from DVT is a necessary conduit is a modification of the
Perthes’ test (see Chapter 5). A tensiometer cuff is inflated to
110 mmHg, and the patient is asked to walk quickly for 5
minutes. If the patient complains of heavy pain, or if the leg
becomes livid, or both, the varicosity is necessary as a collateral channel. This test has allowed, without complication,
surgery on 53 limbs with varicose veins in 52 patients with
prior DVT.
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Allergic reaction
Patients are rarely allergic to a sclerosing solution, but a different solution can usually be substituted. If the allergic reaction consists of generalized urticaria, with or without an
erythematous papulosquamous appearance, French authors
advocate continuing treatment with the offending sclerosing
solution with the addition of antihistamines before and after
treatment (see Chapter 8).
Infrequently, patients develop periorbital edema and a
maculopapular cutaneous eruption even with the use of
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unadulterated hypertonic saline solutions. In this case, ‘allergic reaction’ may be the result of histamine release by
intravascular basophils or perivascular mast cells that are
directly damaged by the sclerosing solution (see Chapter 7).
Under this circumstance, administration of antihistamines
before and after the procedure appears safe while therapy is
continued.
Patients taking disulfiram
Patients taking disulfiram (Antabuse) should not be treated
with POL or Sclerodex, since these sclerosing solutions contain
ethyl alcohol.
Patients taking tamoxifen
As described in Chapter 8, tamoxifen is often responsible for
extensive superficial phlebitis in patients treated by sclerotherapy, even of reticular or spider veins. We consider it to be
a relative contraindication.
Patients taking hormones
Hormonal replacement as discussed previously is not considered a contraindication to sclerotherapy. If a patient is at risk
for venous thrombosis they should not be on hormonal
replacement in the first place.
Other contraindications
Warm Weather
Treating patients in summer is not a contraindication, provided they can wear compression and do not sunbathe during
the treatment.
Travel
Administering sclerosing injections immediately prior to a
long flight or trip (more than 4 hours) is not recommended
as the patient is at slightly increased risk for thromboembolic
events from the inactivity in flight. Additionally, it is not very
prudent for a patient to be unavailable for examination immediately after treatment.
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Contraindications to Treatment
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Clinical Methods for Sclerotherapy of Varicose Veins
Age
Many venous malformations are currently treated with
sclerosing foam; young age does not forbid sclerotherapy.
Conversely, the elderly are good candidates for sclerotherapy
since they are often not candidates for surgery. Since their
veins are especially dysplastic, they usually respond better to
injections. We do not limit our treatments in these patients,
except when life expectancy is short.
Case Histories
The following case histories demonstrate the authors’ technique of sclerotherapy for different varicose veins (Box 9.1).
Case Study 1
Incompetent perforator veins treated with
Fegan’s technique
A 35-year-old woman developed varicose veins during the
second trimester of her second pregnancy and wore an
over-the-counter light compression stocking during the
remainder of her pregnancy. At delivery she developed
thrombophlebitis that was treated with hot packs only. She
came for evaluation and treatment 6 months after delivery.
Physical examination showed a 4- to 6-mm varicose tributary
of the GSV originating at the medial midthigh and extending
to the medial calf with continuation across the anterior tibia
(Fig. 9.28A and B). Venous Doppler examination revealed a
continuous venous sound with distal augmentation at the level
of the posterior tibial vein at the left ankle. There was no
evidence of saphenofemoral reflux or other abnormalities.
Photoplethysmography revealed a normal venous refilling time
in the right leg and an abnormal refilling time in the left leg (20
seconds). The venous refilling time normalized with placement
of a tourniquet at the level of the left upper calf and left lower
thigh. Therefore, the physical and noninvasive examinations
were consistent, showing incompetence of the midthigh
(Hunterian) perforator.
Because of the localized abnormality (IPVs) producing the
varicose vein, Fegan’s technique of perforator interruption was
used. Sclerotherapy was performed with the injection of 0.5 to
1.0 mL of STS 1.0% at the midthigh, medial superior calf, and
anterior distal tibial point of fascial depression. The needles
were inserted with the patient standing, and the patient then
assumed the supine position with the leg elevated to 45
degrees. After aspiration to confirm proper needle placement,
the sclerosing solution was injected while proximal pressure
was maintained. STD E-foam pads were placed over the entire
course of the varicose vein and secured with Microfoam tape. A
30- to 40-mmHg graduated compression stocking was applied
and worn continuously for 7 days, after which it was worn for
an additional week only while the patient was ambulatory.
The patient was seen 2 weeks later, at which time physical
examination revealed total resolution of the varicosity at the
midthigh (Fig. 9.28C) and persistence of a thrombosed
varicosity at the anterior tibial level (Fig. 9.28D). It was drained,
and the pressure stocking was prescribed for use while the
patient was ambulatory for another week. On follow-up
examination 6 weeks later, the vessel had resolved (Fig. 9.28E).
One-year follow-up demonstrated total obliteration of the
varicosity and post-treatment hyperpigmentation (Fig. 9.28F
and G). This case illustrates Fegan’s principle that interruption
of the IPVs alone causes normalization of the entire varicose
vein.
One year later (2 years after her initial sclerotherapy), the patient
became pregnant with her third child and noted the
development of new varicose and telangiectatic leg veins
during her first trimester. Despite wearing 30- to 40-mmHg
graduated support stockings for much of her pregnancy, she
developed incompetence of the SFJ bilaterally, with new
incompetent GSV bilaterally and new vulvar varicosities.
Interestingly, the previously sclerosed veins just above the
medial knee and on the anterior tibial surface did not reappear
(Fig. 9.28H and I). Ligation and stripping were performed 18
months postpartum when breastfeeding was discontinued,
followed 2 weeks later with sclerotherapy of reticular veins, with
excellent results (Fig. 9.28J).
This patient illustrates many important points. Sclerotherapy is
very effective in treating large varicose veins when the SFJs are
competent. However, varicose veins represent a disease of the
venous system that is often progressive. So, initial success may
be met with new disease over time, especially if additional
aggravating events (pregnancy) occur. Fortunately, treatment is
both effective and cosmetic.
Case Study 2
Box 9.1 Sclerotherapy of varicose veins
Sequence of events
1. Physical examination
2. Noninvasive diagnostic examination
3. If findings are abnormal, consider duplex scanning,
varicography, or photoplethysmography
4. Eliminate the high-pressure inflow points
5. Saphenofemoral-saphenopopliteal junction
6. Incompetent perforators
7. Sclerotherapy of the largest diameter varicose veins
8. Sclerotherapy of perforator or reticular veins that feed ‘spider’
telangiectasia
9. Sclerotherapy of ‘spider’ telangiectasia
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Incompetent perforator vein at the midcalf treated with
modified Fegan technique
A 40-year-old woman noticed the gradual development of a
varicose vein over 4 years without any predisposing factors.
Physical examination showed a varicose tributary of the GSV 3
to 5 mm in diameter extending from the midanterior tibial
surface to the medial calf and thigh and ending in the lower
anterior thigh (Fig. 9.29A and B). Venous Doppler
xamination was remarkable only for an IPV at the right
midmedial calf.
Since fascial depressions could not be felt, the classic Fegan
technique could not be performed. Therefore, 25-gauge
butterfly catheters were placed randomly into the varicosity at
the level of the anterior midtibia, medial superior tibia, and the
lateral knee with the patient standing. After the patient
Figure 9.28 Case Study 1. A, Varicose
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tributary of the great saphenous vein
originating at medial midthigh and,
B, extending to medial calf and
continuing across the anterior tibia.
C, Two weeks after sclerotherapy, total
resolution of varicosity is shown at
midthigh, but, D, persistence of
thrombosed varicosity is visible at
anterior tibial level. E, Complete
resolution 6 weeks after sclerotherapy.
F, Lateral views of vein normalization
1 year after treatment.
Case Histories
A
C
B
D
E
F
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Clinical Methods for Sclerotherapy of Varicose Veins
G
I J
Figure 9.28, cont’d Case Study 1
an incompetent saphenofemoral junction. Note that previously treated veins remain sclerosed. J, Clinical appearance, 6 months after ligation and stripping
of GSV followed by sclerotherapy of reticular veins.
G, Anterior views of vein normalization 1 year after treatment. H and I, New varicose great saphenous vein (GSV) from
H
assumed the supine position, STS 0.5% was injected into these
sites after proper needle placement was confirmed with blood
aspiration. A total of 0.5 mL was injected at the anterior
midtibia, 1 mL at the medial superior tibia, and 2 mL at the
lateral knee while pressure was maintained on the vein
proximally. STD E-foam pads were placed over the entire vessel
and were secured with Coban tape applied with moderate
pressure. A 30- to 40-mmHg graduated compression stocking
was applied, with two stockings worn on top of each other
while the patient was ambulatory and one stocking worn at
night for 1 week. During the second week, the dressing was
removed, and the graduated support stocking was worn for
another week only while the patient was ambulatory. The
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varicosity was completely resolved on follow-up examination at
2 weeks, and a few thrombi were drained. The photographs in
Figuse 9.29C and D were taken 11 months after treatment.
The latter technique used the principles of Fegan, except
the entire area of presumed perforator incompetence was
sclerosed. If Sigg’s technique had been used, the sclerosing
solution would have been more randomly injected throughout
the entire course of the varicose veins. The classic Fegan technique
could have been performed if the sites of IPVs were localized with
duplex imaging. Duplex-controlled injections may have limited
the quantity of sclerosing solution injection to very specific sites
but probably would not have affected the clinical outcome.
Figure 9.29 Case Study 2. A, Varicose tributary
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of great saphenous vein extending from
midanterior tibial surface to, B, medial calf
and thigh ending in lower anterior thigh.
C, Midanterior tibial surface and medial calf and
thigh and, D, lower anterior thigh views of vein
normalization 11 months after treatment.
Case Histories
A
C D
B
Case Study 3
Reticular varicosities without perforator vein
reflux treated with total-vein sclerotherapy
(Sigg’s technique)
A 34-year-old woman first noticed the appearance of varicose
veins with her second pregnancy, 3 years before treatment.
The veins were symptomatic after prolonged standing and
were thought to have enlarged over the past year. Physical
examination showed a set of 3- to 4-mm varicose reticular veins
coursing from the posterior midthigh to the posterior midcalf
bilaterally (Fig. 9.30A and B). There was no evidence of
incompetence in either the perforator veins or the SFJs on
venous Doppler examination.
While the patient was lying horizontal on her abdomen, multiple
injections of STS 0.5% were made into the varicose veins.
Approximately 0.5 mL was injected into each site every 4 to 6 cm
for a total of 8 mL of solution per leg. Continuous compression
was maintained for 7 days only with 30- to 40-mmHg graduated
compression stockings overlying STD E-foam pads over the varicose
veins. Follow-up examination did not disclose excessive bruising
or pigmentation. No thrombosis occurred. Figure 9.30C and D,
shows the appearance of the treated vessels at 1-year follow-up.
Since points of venous reflux could not be found either at the
SFJ or in perforator veins, it was assumed that the varicose vein
was essential in nature. As it was serving no useful function, it
was obliterated in its entirety. This forms the rationale for Sigg’s
technique.
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