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Chapter
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9
Clinical Methods for Sclerotherapy of Varicose Veins
Figure 9.30 Case Study 3. Varicose reticular
veins, A, from posterior midthigh to, B, posterior
midcalf. C, Posterior midthigh to, D, posterior
midcalf normalization of veins 1 year after
treatment.
A
C D
B
Case Study 4
Posterior thigh varicose GSV tributary associated with an
incompetent SFJ treated with sclerotherapy alone using
the air-bolus technique
A 36-year-old woman developed a varicose vein during her
second pregnancy, 3 years before evaluation and treatment.
The vein was symptomatic during prolonged standing, and she
reported associated ankle edema. Physical examination showed
a 5- to 8-mm diameter varicose vein coursing from the
midposterior thigh to the midcalf (Fig. 9.31A). Venous Doppler
examination demonstrated gross incompetence of the right
SFJ and a positive Trendelenburg test in the lower thigh.
The remainder of the examination was normal.
Surgical ligation and limited stripping were recommended,
but refused by the patient. Therefore, sclerotherapy of the
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involved varicose vein was performed using an air-block
technique. The air block was used in an attempt to concentrate
the sclerosing solution in the injection site without dilution or
inactivation of blood. Butterfly needles, 25-gauge, were placed
in the vein at areas of fascial depression – two sites on the thigh
and one site on the calf – while the patient was standing. These
areas were found by venous Doppler ultrasound not to
represent IPVs. With the patient lying horizontal with the leg
elevated to 45 degrees, 1 mL of STS 1.0% was injected into
each site after injection of 0.5 mL of air. STD E-pads were
immediately placed and secured with Microfoam tape, and a
single 30- to 40-mmHg graduated compression stocking was
worn continuously for 2 weeks. Follow-up examinations at 2
and 6 weeks showed persistent resolution of the vein with a
slightly palpable cord. A small amount of coagula was drained
at 6 weeks. The vein remained fibrosed 2 years after treatment
(Fig. 9.31B).
Case Histories
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A C
Figure 9.31 Case Study 4. A, Varicose vein from midposterior thigh to midcalf. B, Vein remains sclerosed 2 years after treatment. C, Recurrence of the
treated vein as well as appearance of distal reticular veins 10 years after initial treatment.
Treatment in the patient consisted of a modified Fegan and
Sigg technique. The entire varicosity was obliterated using
fascial depression areas as injection sites. The French technique
with injection of sclerosing solution into the SFJ could have
been used. However, this procedure was not performed
because of the unavailability of Variglobin. Alternatively, STS 3%
could have been injected under duplex control at the SFJ. Refer
to the articles by Raymond-Martimbeau
Ehrenburg et al40 for a description of these latter techniques.
The patient returned 8 years later (10 years after initial
treatment) with recurrence of the varicose vein as well as new
distal extensions to it (Fig. 9.31C). The vein had slowly recurred
over the past year. Venous Doppler examination demonstrated
Valsalva-positive reflux into the GSV through the SFJ. The
patient will now undergo endovenous RF closure of the GSV
with distal ambulatory phlebectomy.
The long-term follow-up is rarely reported in the literature. Most
studies on the efficacy of varicose vein treatment have 1- to
2-year follow-up and at best 3- to 5-year follow-up. Clearly, this
patient represents someone whose vein recurred 10 years after
treatment. This was expected because the cause for the
development of the varicose vein (incompetence of the SFJ)
was never addressed in the initial treatment.
B
34
and Schultz-
anterior and medial calf (Fig. 9.32A). Venous Doppler
examination demonstrated marked reflux of the right GSV
throughout the varicosity.
The patient refused surgical ligation and limited stripping.
Therefore, sclerotherapy with STS 1.0% was performed while the
patient was horizontal. One milliliter of solution was slowly
injected at each of nine separate locations, followed by
application of STD foam pads and a double layer of 30- to
40-mmHg graduated compression stockings, which were worn
continuously for 2 weeks while the patient was ambulatory. One
stocking was removed while she was sleeping. A mild phlebitic
reaction was clinically apparent 2 weeks after injection (Fig.
9.32B), and compression was maintained for another 2 weeks.
Four weeks after the first injection, multiple thrombi were
drained from the medial calf, and two more injections of STS 1%
(1 mL each) were made into persistent varicose dilations on the
medial and anterior superior calf (Fig. 9.32C). At 1-year follow-up
the leg remained pain free and showed persistent resolution of
the treated veins (Fig. 9.32D). Venous Doppler examination
disclosed an incompetent, 4-mm-diameter varicose vein just
below the right anterior tibia and another incompetent varicosis
over the inferior midposterior calf. These veins were successfully
sclerosed with STS 1%. At 2 years follow-up, multiple new
varicosities became apparent after resolution of sclerotherapyinduced hyperpigmentation. The patient has remained pain free
and is very happy with the results of treatment. Her wish is to
Case Study 5
continue sclerotherapy treatment, even with the understanding
that new or recurrent varicose veins may occur later.
Incompetent GSV varicose tributaries treated with
total-vein sclerotherapy alone
A 31-year-old woman noted the onset of varicose veins over the
right lower leg at 10 years of age. With each of her succeeding
three pregnancies, the veins enlarged and became more painful
while she was standing. Physical examination showed a
clustered varicose vein 5 to 10 mm in diameter over the right
This patient represents two common findings in the author’s
practice. First, many patients would rather undergo multiple
(perpetual?) sclerotherapy treatments than limited surgical
ligations or strippings. Second, the resolution of symptoms,
which is very important to patients, may occur despite a
reappearance of the varicose vein. It appears that incomplete
treatment is enough to alleviate symptoms in many patients.
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9
Clinical Methods for Sclerotherapy of Varicose Veins
Figure 9.32 Case Study 5. A, Clustered
varicose vein over right anterior and medial
calf. B, Mild phlebitic reaction 2 weeks after
treatment. C, Further treatment 4 weeks after
first injection. D, Resolution of vein continues at
1 year after treatment.
A
C D
B
Case Study 6
Incompetent perforator vein underlying ankle ulceration
A 27-year-old woman sought treatment after a 3-year history of
cutaneous ulceration over the right medial mallear region (Fig.
9.33A). The patient had been seen previously by a physician
from the infectious disease service and was prescribed multiple
courses of systemic antibiotic treatments that did not produce
significant change in the appearance of the ulceration. She was
also evaluated by a physician in the plastic surgery department
and had been treated with the placement of full-thickness
pinch grafts, which did not heal. Physical examination was
remarkable for pedal edema extending to the midcalf and
associated truncal varicosities. Venous Doppler examination
demonstrated a normal deep venous system and
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saphenofemoral and popliteal junctions and an IPV at the base
of the ulcer (marked X in Fig. 9.33A). The perforator vein was
injected through the ulcer. A 23-gauge butterfly needle was
inserted into the perforator vein while the patient was standing,
and the leg was elevated while the patient reclined. STS 1.0%,
1 ml, was slowly injected while the leg was blocked proximally
and distally with hand pressure 3 cm in either direction.
Immediately afterward, compression was applied with an STD
foam pad under Microfoam tape and two 30- to 40-mmHg
graduated compression stockings. The stockings were worn for
2 weeks. Double stockings were worn during the day, and the
outer stocking was removed when the patient was supine.
Follow-up examination at 3 months showed complete healing
of the ulceration and resolution of associated venous stasis
changes (Fig. 9.33B). The patient remained free of ulceration 2
years after treatment.
Figure 9.33 Case Study 6. A, Cutaneous
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ulceration over right medial malleolar region.
B, Complete healing of ulceration and resolution
of venous stasis changes 3 months after
treatment.
Case Histories
A
A
C
B
B
D
Figure 9.34 Case Study 7. A, Vulvar varices before treatment. B, Vulvar varices 2 months after treatment. C, Vulvar varices resolved 3 years after first
treatment. D, 19 years from initial treatment the vulvar veins have remained sclerosed and the patient remains aymptomatic. (C and D: The hypopigmented
scar on the mid medial thigh is from a liposuction procedure performed 2 years after the initial and only sclerotherapy session.)
Case Study 7
Sclerotherapy of vulvar varicosities
A 40-year-old woman developed vulvar varices with her first
pregnancy at age 18. She noted aching and pelvic fullness
during her menstrual period and when standing for prolonged
periods of time. Physical examination showed a prominent
varicose vein 6 to 8 mm in diameter extending from the vulvar
region into the GSV. The vein was incompetent throughout its
entire length from the midposterior calf to the most superior
aspect of the vulva, according to venous Doppler examination.
Two IPVs underlying fascial defects were present at the medial
knee and midposterior calf. There was no evidence of
incompetence with the Valsalva maneuver. Her SFJ was
competent according to venous Doppler examination.
Scattered reticular veins 3 mm in diameter were noted on the
anterior thigh. Scattered venules 0.4 mm in diameter were
present on the anterior and lateral calf. The opposite leg was
free of varicose or telangiectatic veins (Fig. 9.34A).
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9
With the patient lying in a slight reverse Trendelenburg
position, a total of 2 mL of STS 1.5% was injected into the two
perforator veins at the medial knee and posterior calf. These
areas were immediately compressed with an STD E-foam pad
and Microfoam tape. A total of 4 mL of STS 1.0% was injected
into the network of vulvar and superior thigh varicosities, and a
figure-of-eight wrapover foam pad was used to compress the
vulvar varices. This was followed by injection of 4 mL of STS
0.5% into the remaining reticular veins and venulectases. A
30- to 40-mmHg graduated thigh-high compression stocking
was worn continuously for 7 days. When the patient returned 1
month later, all veins were sclerosed and without audible flow
during venous Doppler examination. Multiple coagula were
drained through 22-gauge needle punctures. Clinical
appearance 2 months after treatment was excellent (Fig. 9.34B).
Clinical appearance 3 and 19 years after treatment was still
excellent, with the patient showing no evidence of recurrence
in any of the treated veins (Fig. 9.34C and D).
two perforator veins, and the leg was elevated 45 degrees.
A total of 2 mL of STS 1% solution was injected, with the
perforator points rapidly compressed with STD foam pads and
Microfoam tape. An additional 1.5 mL of STS 1% was injected
into distal aspects of the varicose vein in three separate sites.
A double layer of 30- to 40-mmHg compression stockings was
worn while she was ambulatory for 1 week, with the outer
stocking removed when she was supine. A single 30- to
40-mmHg stocking was worn for an additional 2 weeks only
while she was ambulatory. Thrombus was drained 2 weeks later,
and an additional 1 mL of STS 1% was given to a nonsclerosed
segment of the vein. Six weeks after the first injection session, the
vein was entirely sclerosed and additional coagula were drained
(Fig. 9.35B). She remained symptom free without evidence of
1
years after the first injection session (Fig. 9.35C)
recurrence
2
2
and continues to remain symptom free without evidence of
recurrence 8 years after the initial treatment (Fig. 9.35D).
Clinical Methods for Sclerotherapy of Varicose Veins
Case Study 8
Large varicose vein from incompetent perforator veins
After her second pregnancy, a 40-year-old woman developed
varicose veins in the left lower leg, which increased in severity
with her third pregnancy. Six years after her second pregnancy
she developed pain in the left calf with associated leg swelling.
The pain increased with exercising and resolved with leg
elevation. She also complained of resting pain and a generalized
tired feeling in the leg. There was a positive history of varicose
veins in her mother. Photoplethysmography was normal, with a
venous refilling time of 43 seconds and good calf muscle pump
function. Venous Doppler examination demonstrated two IPVs
at the left lateral knee and left medial posterior thigh without
reflux from the SFJ. The vein measured 8 to 10 mm in diameter
(Fig. 9.35A).
The patient was treated with a Fegan–Sigg technique. A
25-gauge butterfly needle was placed just distal to each of the
Case Study 9
Extensive varicosities of GSV and GSV tributaries
A 56-year-old woman noted the development of varicose veins
during her second pregnancy at age 30. They were entirely
asymptomatic, and she was seen initially for cosmetic
treatment. There was a family history of varicose veins in her
father. Physical examination showed a dilated GSV 6 mm in
diameter with vulvar varices 4 mm in diameter and an anterior
saphenous varicosity 6 mm in diameter. All varicose veins were
incompetent throughout their length as demonstrated by
venous Doppler examination but without Valsalva-induced
reflux and without reflux across the SFJ (Fig. 9.36A and B).
With the patient supine, the entire varicose system was treated
using a total of 11 mL of STS 1%. A double layer of 30- to
40-mmHg graduated compression stockings was worn during
the day, with the outer stocking removed at night, for 1 week. A
single 30- to 40-mmHg stocking was worn during the day for
the second week. Six weeks later, reticular veins 2 to 3 mm in
A C D
Figure 9.35 Case Study 8. A, Varicose veins before treatment. B, Varicose veins 6 weeks after treatment. C, Clinical appearance
treatment. D, No evidence of recurrence 8 years after initial treatment.
268
B
1
2
years after sclerotherapy
2
Case Histories
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A C
D
Figure 9.36 Case Study 9. A, Lateral aspect of varicose veins before treatment. B, Posterior aspect of varicose veins before treatment. C, Lateral aspect of
varicose veins 2 years after initial treatment. D, Posterior aspect of varicose veins 2 years after initial treatment. E, Lateral aspect of varicose veins 8 years after
initial and only sclerotherapy treatment demonstrating persistent resolution. F, Posterior aspect of varicose veins 8 years after initial and only sclerotherapy
treatment. Note new 2 mm diameter reticular veins in a new location from the veins initially treated. These new veins were treated with STS 0.25% foam (1 : 4
with air dilution) with total resolution by patient report.
B
E
F
diameter were treated with a total of 4 mL of POL 0.75% and
telangiectasia was treated with a total of 10 mL POL 0.5%. One
year later, additional reticular veins were treated with 8 mL of
POL 0.75% and telangiectasia was treated with 4 mL of POL
0.5%. Figure 9.36C and D shows the clinical appearance 2 years
after initial treatment, with resolution of all varicose, reticular,
and telangiectatic leg veins. Appearance 8 years post
sclerotherapy (Figure 9.36E, F).
Case Study 10
Development of SFJ incompetence after initial successful
treatment of varicose GSV and tributaries
A 34-year-old woman was seen initially at age 27 years with the
development of painful varicose veins during her first of four
term pregnancies. The varicosities increased in size during each
pregnancy, with the largest increase during her second
pregnancy. The leg pain was throbbing, especially just before
menses, with resolution 3 days into her menstrual period.
Throbbing was relieved with leg elevation or by wearing
graduated compression stockings. The family history included
varicose veins in her mother, aunt, and sister. Physical
examination showed a 6-mm-diameter incompetent GSV with
an incompetent midthigh (Hunterian) perforator vein without
Valsalva-induced incompetence. The SFJ was competent
(Fig. 9.37A and B).
With the patient supine, the varicose veins were injected with
2 mL of STS 1% just distal to the midthigh (Hunterian) perforator
vein, followed by a total of 16 mL of STS 0.5% to the remaining
varicosities, with approximately 0.5 mL injected every 5 cm or
so. A double layer of 30- to 40-mmHg graduated compression
stockings was worn for 1 week while the patient was
ambulatory, with the outer stocking removed when she was
supine; a single stocking was worn for a second week when she
was ambulatory. The patient became completely asymptomatic
1 month after the first sclerotherapy treatment (and remained
so 3 years later). Nine months later, an additional 16 mL of STS
0.5% was injected into multiple varicose and reticular veins that
had not resolved or were newly present, followed by an
identical post-treatment compression regimen. One year after
the second sclerotherapy treatment, all visible varicose and
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A
Clinical Methods for Sclerotherapy of Varicose Veins
D
Figure 9.37 Case Study 10. A, Posterior aspect of varicose veins before treatment. B, Medial aspect of varicose veins before treatment. C, Posterior aspect
of varicose veins 2 years after initial treatment. D, Medial aspect of varicose veins 2 years after initial treatment. E, Development of new varicose veins after
initial treatment and resolution. The saphenofemoral junction is now incompetent bilaterally.
B
E
C
reticular leg veins resolved completely (Fig. 9.37C and D).
Despite no new predisposing factors, new varicose veins were
noted 3 years after the first sclerotherapy session. At this time,
the SFJ was incompetent bilaterally to venous Doppler
examination and the patient was referred for ligation and
stripping of the GSV at the SFJ bilaterally (Fig. 9.37E and F).
Case Study 11
Symptomatic clinically inapparent varicose vein treated
with duplex-controlled sclerotherapy
A 60-year-old woman was seen initially with a complaint of pain
in the medial knee and calf area for the last 6 months. She had
undergone ligation and stripping of the GSV from the SFJ 30
years previously for treatment of varicose veins that occurred
during her only pregnancy. Clinical examination did not disclose
visible varicose or reticular veins. A color-flow duplex Doppler
examination showed normal common femoral and superficial
femoral and popliteal veins without evidence of acute or chronic
270
DVT. The deep venous system was without evidence of reflux.
An atypical vein was present 5 to 6 cm distal to the area of the
SFJ as a remnant or duplicate GSV that coursed down the medial
aspect of the thigh, terminating in the area of symptomatology.
The vein was markedly incompetent to Valsalva maneuver and
thigh and calf compression, and communicated with numerous
perforator veins along its course (Fig. 9.38A and B).
Under duplex guidance, 1 mL of STS 3% was injected into the
medial thigh varicosity through a 22-gauge needle. Correct
position was verified by open-needle insertion. The injection
was given slowly until the vein thrombosed (Fig. 9.38C). An
STD E-foam pad was placed with Microfoam compression, and
additional injections were given to two additional perforator
veins present in the area of greatest symptomatology. The
entire procedure was performed with the patient supine. A
double layer of 30- to 40-mmHg graduated compression
stocking was worn while the patient was ambulatory for 2
weeks, with the outer stocking removed when the patient was
supine. Four weeks later, examination showed complete fibrosis
and resolution of all symptoms.
Figure 9.38 Case Study 11. A, Reflux is present in
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the symptomatic vein before treatment. B, Close-up
duplex view of injection site before injection.
C, Immediately after sclerotherapy, the injected
vein is filled with echodense material and is
noncompressible (arrows).
Case Histories
A
B
A
Figure 9.39 Case Study 12. A, Appearance of hand veins before treatment. B, Appearance of hand veins treated as detailed in the case history 9 months
after treatment.
C
B
Three to four weeks later, the author injects the remaining veins
Case Study 12
with another 2 to 4 mL of STS 2%. Injections are performed with
a 27- or 30-gauge needle with a nurse providing a tourniquet
Treatment of dorsal hand veins
A 42-year-old woman complained of unsightly veins on the
dorsal hands (Fig. 9.39A). She was advised of the normality of
this appearance and the possible necessity for preserving these
veins for insertion of intravenous catheters. Nevertheless, she
insisted on their removal. Experience has demonstrated that
strong sclerosing solutions of high concentration are necessary
to eliminate these normal veins.
211
However, when the entire
superficial venous network is sclerosed in a single session, hand
edema is common and has been reported to occur in up to 82%
of patients, resolving over 7 to 10 days.
211
To minimize edema,
the author’s method of treatment involves injecting half of the
dorsal veins with STS 2% in one session (usually 2 to 4 mL).
on the midforearm until the injection is completed. The hand is
then elevated, the dorsal aspect is padded with cotton balls,
and an Ace bandage is wrapped from the distal hand to the
proximal forearm. The Ace wrap is left in place for 2 days, during
which time the patient may vary the compression to avoid
numbness of the fingers. Patients usually have near total
resolution of the visible veins with this technique (Fig. 9.39B).
Hand edema occurs in 20% of patients. To date, no episodes of
pigmentation or telangiectatic matting have been seen.
Although Duffy has reported superficial necrosis with probable
extravasation of solution in one patient,
paresthesia persisting for 2 weeks in another patient,
212
and numbness and
211
this
procedure is remarkably free from adverse sequelae.
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9
A
Clinical Methods for Sclerotherapy of Varicose Veins
C
Figure 9.40 Case Study 13. A, Varicose cluster of the left popliteal fossa and medial upper third of the lower leg. B, Duplex-guided injection of polidocanol
0.5% through a butterfly needle. C, Appearance 1 month after treatment.
Case Study 13
Duplex-guided injection
This 35-year-old male presented with a painful isolated varicose
cluster of the left popliteal fossa and medial upper third of the
lower leg (C2s Ep As Pr). Varicose veins were fed by a popliteal
fossa perforating vein and drained into a GSV tributary (Fig. 9.40A).
The vein was treated with one injection of 4 cm3 of POL 0.5%
through a butterfly needle (Fig. 9.40B), and massage with the
ultrasound probe to fill up the whole varicose network.
Compression was realized with knee-high class II medical
stockings and a popliteal foam pad.
At 1 month, no visible varicose veins remained; several small
indurations (3–4 mm, not visible on pictures) were palpable and
were punctured (Fig. 9.40C).
Case Study 14
VeinRx catheter foam sclerotherapy of the GSV
Rodrigo González Zeh, MD, Santiago, Chile
A 99-kg, 1.62-m, 49-year-old male presented with a varicose
vein on the left lower leg, pain in the left leg, night cramps, and
272
B
ankle edema (Fig. 9.41A). His CEAP classification was C3 Ep As
Pr; the venous clinical severity score (VCSS) was 5.
Ultrasound examination showed a normal deep venous system.
The GSV was incompetent from the SFJ to the midthigh. The
GSV diameter at 2 cm from the SFJ was 11 mm, with a mean
diameter of 14 mm. The length of the refluxing segment
measured 28 cm (Fig. 9.41B).
The procedure was performed under local anesthesia with
2 mL of lidocaine placed at the vein access site. Access to the
GSV was made 34 cm from the SFJ. The VeinRx catheter was
placed 1.5 cm distal to the SFJ. The leg was elevated 30
degrees for 2 minutes to allow for drainage of venous blood.
The VeinRx catheter balloon was inflated with 2.6 cm3 of
saline 2 cm distal to the SFJ. Ten milliliters of 3% foam (made
with the Tessari technique, 2 mL of 3% STS + 8 cm3 of air) was
infused into the catheter and allowed to stay in the GSV for 4
minutes. The intravascular balloon was deflated and a foam
pad was placed over the treated GSV. A class II graduated
compression stocking was then applied. One day after the
procedure a duplex examination was performed and no
evidence of thrombosis extension into the SFJ or deep
venous system was noted (Fig. 9.41C). The GSV was
noncompressible. Foam pads were removed and the
compression stocking was worn for another 6 days and
Case Histories
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C
A
D
B
E
F
Figure 9.41 Case Study 14. A, Varicose vein on the left lower leg. B, The length of the refluxing
segment measured 28 cm. C, Duplex examination 1 day after VeinRx catheter foam sclerotherapy,
showing no evidence of thrombosis extension into the saphenofemoral junction or deep venous
system. At 12 months, D,
saphenous vein showed firm sclerosis, with echogenicity similar to surrounding tissue.
vein size was 1.2 mm, E, the epigastric vein was patent, and, F, the great
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