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400 Liquid sclerotherapy for telangiectasia andvaricose veins
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the problem falls into one of the categories of primary or
familial, secondary or post-thrombotic, congenital or posttraumatic arteriovenous stula, so that an appropriate CEAP
(Clinical–Etiology–Anatomy–Pathophysiology) classication can be made.
A complete medical history must be taken to determine
if a patient has any underlying medical problems or is on
any medications that may aect treatment. It is particularly
important to be alert to a history of deep venous thrombosis (DVT), hypercoagulable states, bleeding diathesis,
or asthma. Medications that may aect results include
anticoagulants and non-steroid anti-inammatory drugs.
Hormone replacements may also increase the risk of DVT.
33.3.2 Physical examination
A careful examination should be performed of the lower
extremities to identify the locations of varicose, reticular,
and spider veins (Figure 33.1). Noting the locations of the
veins will give insight into the cause of the problem. Most
spider veins are located on the lateral medial thigh. Corona
phlebectatica at the ankle suggests saphenous insuciency.7
Evidence of bulging varicose veins deserves further evaluation with duplex examination. Other ndings, such as port
wine stains (Figure 33.2), hypertrophy of the so tissue, and
bone overgrowth of the extremity, may be suggestive of congenital malformations and indicate that further investigation may be needed with magnetic resonance imaging.
33.3.3 Laboratory examination
Figure 33.2 Port wine stain in patient with Klippel–
Trenaunay syndrome.
of DVT or there is a history of DVT in the family (parents or
siblings), a hematology evaluation for thrombophilia should
be considered.
e history and physical will determine whether there is a
need for further laboratory tests. If the patient has a history
Figure 33.1 Lateral venous plexus.
33.3.4 Noninvasive vascular examination
Signs or symptoms of venous insuciency, including varicose veins, require a venous duplex evaluation before any
liquid sclerotherapy is considered. A complete examination
of the deep and supercial system aims to determine if there
is any evidence of DVT, either old or new reux in the deep
or supercial system, or supercial venous thrombosis. For
patients with purely cosmetic telangiectasia, duplex imaging is rarely required if no other signs or symptoms (such
as evidence of swelling, pigmentation around the ankle, or
reports of leg fatigue) are present. Duplex mapping will be
covered in another chapter.
More detailed examination with the use of magnetic
resonance imaging or computed tomography venograms is
indicated in case of suspected iliofemoral occlusive disease
and vascular malformations, history of DVT, or physical
ndings of varicose veins on the abdomen/abdominal wall.
Contrast venography is indicated only when considering
intervention for pelvic or iliofemoral disease.
33.4 INDICATIONS
Liquid sclerotherapy is primarily used for small varicose
veins and telangiectasias. It should not be performed until the
source of venous insuciency (if any) is appropriately treated.
Figure 33.3 Spider veins or telangiectasia of <1 mm.
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33.6 Treatment 401
●
Peripheral artery disease (PAD) with an Ankle Brachial
Index of less than 0.8. e exception may be a venous
ulcer with PAD.
●
Febrile illness.
●
Acute supercial venous thrombosis or DVT.
33.6 TREATMENT
e rst step in treatment involves properly identifying the
issue for which the patient is seeking care. If it is venous
insuciency, then the appropriate evaluation should be
done to determine the cause of the problem. Treatment of
venous insuciency is covered in other chapters of this
book. If venous insuciency has been treated and the
remaining complaint is related to small veins or cosmetic
concerns, as in the case of spider telangiectasias, then liquid sclerotherapy may be indicated. Before sclerotherapy
sessions begin, patients must be provided with sucient
information so that they can give informed consent. It
is especially important that patients are aware of possible
complications and are provided with a realistic assessment of outcomes to expect, as well as an understanding
that treatment may involve a series of appointments. Once
consent is given, photographs should be taken to provide
baseline documentation of the areas to be treated.
Figure 33.4 Reticular veins of 1–3 mm.
Spider veins/telangiectasia of less than 1 mm in diameter (Figure 33.3) are generally cosmetic problems, although
patients do sometimes complain of some symptoms related
to them.
Small varicose veins of 1–3 mm can be treated aer the
source of venous reux has been identied and taken care of
(Figure 33.4). ese reticular veins frequently feed into the
spider veins, are largely asymptomatic, and are primarily of
cosmetic concern.
Liquid sclerotherapy can be recommended for veins
larger than 3 mm if there is a contraindication to foam
sclerotherapy (such as right-to-le shunt) or surgical
treatment.
Post-operative residual varicose veins over 3 mm can be
managed successfully with liquid sclerotherapy if all other
sources of reux are treated.
33.5 CONTRAINDICATIONS
Contraindications of liquid sclerotherapy are listed below.
●
Pregnancy; treatment should be delayed unless there is a
major indication, such as a bleeding varicosity.
●
Sedentary; mobility challenges.
●
Severe systemic disease.
33.6.1 Sclerosing agents
Sclerosing agents (Table 33.1) are divided into groups based
on their mechanism of action. Osmotic agents work by
dehydrating the endothelial cells. Examples include hypertonic saline 23.4%, glucose 75%, and sodium salicylate.
Detergent solutions’ mechanism of action involves damaging the surface lipids of endothelial cells. Detergent agents
include STS, PDL, sodium morrhuate, and ethanolamine
oleate. Corrosive agents damage the vessel wall. Examples
of corrosive agents are sodium and potassium iodide, benzyl alcohol, 72% glycerin, and chromated glycerin.
33.6.2 Selection of sclerosant
In the United States, the FDA has approved several agents
for sclerotherapy. ese include the detergent solutions mentioned above. e two solutions currently used and marketed for liquid sclerotherapy are STS (Sotradecol) and PDL
(Asclera). e PDL injection gained FDA approval in 2010.
Hypertonic saline 23.4% and glycerin 72% are used o-
label for cosmetic spider veins.
Research to date does not appear to denitively prefer
one sclerosant over another. In a 2010 review of the literature, David M. Duy wrote: “All sclerosants represent a
compromise between ecacy and toxicity, compounded by
practitioner sophistication, patient-to-patient variability,
and, as a practical matter, legal status.”
Carlin and Ratz reported a small randomized controlled
trial comparing PDL, STS, saline 20% with heparin, and
saline 0.9% (placebo). ey concluded that PDL was as
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hyperpigmentation;
necrosis; rapid dilution;
not recommended for
Off-label; painful to inject;
reaction; wide
Low risk of allergic
facial veins
Weak sclerosing agent;
availability; rapid
response
Low incidence of
typically only used for
telangiectasia
hyperpigmentation,
necrosis, and allergic
reaction
necrosis and anaphylaxis
FDA approved High incidence of skin
extravasation;
telangiectasia matting
Potential necrosis with
ofallergic reaction;
potent sclerosant
++
usage
+
usage
Off-label
agent
+++
Detergent Approved +++++ FDA approved; low risk
Agent Manufacturer Category FDA approval Strength Advantages Disadvantages
Table 33.1 Sclerosing agent comparison
Hypertonic saline Multiple Osmotic Off-label
Compounded at pharmacy Alcohol
glycerin
Non-chromated
Merz North America Detergent Approved +++ FDA approved Staining
Glenwood, LLC, Englewood, NJ Detergent Approved
(polidocanol)
Asclera
Scleromate (sodium
(distributed by AngioDynamics,
Inc., Queensboro, NY)
Bioniche USA, Lake Forest, IL
morrhuate)
tetradecyl sulfate)
Source: Adapted from Gloviczki P etal. J Vasc Surg 2011;53(5):2S–48S.
Sotradecol (sodium
Note: FDA: Food and Drug Administration.
Table 33.2 Indications and concentrations of sclerosing agents
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Indications STS (%) Polidocanol (%) HTS (%) Glycerin (%)
Varicose veins >3 mm 1.0–3.0 1.0–3.0 – –
Reticular veins 1–3 mm 0.5–0.75 0.5–1.0 11.7–23.4 –
Telangiectasias <1.0 mm 0.125–0.25 0.25–0.5 11.7–23.4 48–72
Note: STS: sodium tetradecyl sulfate; HTS: hypertonic saline.
33.6 Treatment 403
eective as STS and saline with heparin, but was more easily
tolerated by patients.
9
In 2002, Goldman reported a study in which 129 patients
were treated with varying concentrations of STS or PDL.
Patients had an average of 70% improvement, and 70%–72%
of them were satised with their results. No signicant differences in adverse eects were reported, with the exception
of a decrease in ulcerations and swelling in the PDL group.10
e author concluded that both STS and PDL are safe and
eective for varicose and telangiectatic leg veins.
33.6.3 Selection of the concentration
ofsclerosant
Eective sclerosis of the vein depends on contact between
the appropriate concentration of the sclerosant and the
vein wall for enough time to damage the wall and induce
vasospasm. Too low a concentration or too little time may
induce only thrombosis; too high a concentration may cause
too intense a reaction, leading to a complication. Choosing
an appropriate concentration comes with experience and
should tend toward the lowest eective concentration; the
suggested ranges are presented in the Table 33.2.
33.6.3.1 VEINS >3 MM
For veins larger than 3 mm, liquid sclerotherapy is not considered to be the best treatment. Superior options include
foam sclerotherapy or surgery, which are discussed elsewhere in this book. If other methods cannot be performed,
then liquid sclerotherapy with concentrations of 1%–3%
STS or 1%–3% PDL could be attempted.
that it creates less pressure, which in turn results in less pain
for the patient. Lower levels of pressure reduce the potential
for extravasating of the sclerosant. If glycerin is being used,
a smaller syringe may be needed to generate the pressure
because of the high viscosity of the solution.
Needles: Very ne needles, such as 27–32 gauge, are recommended. ey may be used alone or with a buttery, which is
helpful with larger veins where aspiration is required.
An antiseptic skin cleanser is used, such as alcohol.
Cotton balls or gauze pads: ese are needed for compression and wiping up blood or the antiseptic.
Sclerosing agents: ese should be clearly labeled, either in
vials or syringes, with the type and concentration indicated.
A well-lit treatment room is needed.
Magnication: is can be obtained either with loupes
(Figure 33.5) or other magnifying sources such as Syris sur-
gical headlamps.
Emergency equipment: At a minimum, emergency supplies should include oxygen, epinephrine, steroids, and
antihistamines.
33.6.4.1 OPTIONAL EQUIPMENT
Optional equipment includes polarized light sources, infrared visualization equipment, or vein lights.
33.6.5 Techniques
33.6.5.1 GENERAL CONSIDERATIONS
Treatment begins at the source of reux; typically, this would
involve either the surgical ablation or foam sclerotherapy
33.6.3.2 VEINS 1–3 MM
For reticular veins, 0.5%–0.75% STS, 0.5%–1.0% PDL,
or 11.7%–23.4% hypertonic saline are generally accepted
concentrations.
33.6.3.3 VEINS <1 MM (TELANGIECTASIAS)
Veins smaller than 1 mm can be treated with 0.125%–0.25%
STS, 0.25%–0.5% PDL, 11.7%–23.4% hypertonic saline, or
50%–72% glycerin. Hypertonic saline and glycerin may be
diluted with lidocaine.
33.6.4 Materials
Syringes: e choice of syringe will depend on personal
preference as well as the type of sclerosant used. Typically, a
1–5-mL syringe is used. An advantage of a larger syringe is
Figure 33.5 Loupes.
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techniques that are covered in other chapter of this book.
Liquid sclerotherapy proceeds according to the principle of
addressing larger veins rst then moving to smaller veins,
moving from proximal to distal, while using the lowest
eective concentration of sclerosant. Eective treatment
of the larger feeder veins can also result in eective treatment of the smaller veins as the sclerosant travels through
the system.
33.6.5.2 LARGE VEIN TREATMENT >3 MM
Treatment of the larger veins begins only aer the source of
reuxes, if any, have been addressed. As stated previously,
large veins greater than 3 mm are best treated with other
methods such as phlebectomy or foam sclerotherapy. If for
some reason other methods are not available or recommended, then the sclerotherapy should start with marking
the veins to be treated while the patient is standing. is step
is done because once the patient lies down, the veins will atten and may therefore be dicult to nd. If ultrasound guidance is being used, however, this step is not needed.
e volume and concentration of sclerosant depend upon
the size of the vein. e sclerosant is mixed with the blood
in the vein and becomes diluted. Several steps can be taken
to try to reduce the volume of blood in the vein to minimize
this dilution: (1) use the “air block” technique in which air is
injected to displace the blood immediately before the liquid
is injected; (2) raise the patient’s leg immediately aer accessing the vein but before injection, as this will chase blood
from the vein; and (3) immediately aer injection, place a
compression pad over the treated vein to slow the entry of
blood into the vessel.
e concentration of the sclerosant should be 1%–3%
STS or 2%–3% PDL. e volume of injection should be
approximately 0.5–1.0 mL per site, but should not exceed
10 mL for the whole length of the vein. It is advisable to try
to treat the entire vein in one session to prevent thrombosis
of untreated segments. Patients should wear compression
stockings for 1 week following treatment.
33.6.5.3 RETICULAR VEINS (1–3 MM)
Treating the reticular veins that are feeding into spider veins
improves the global results. Oen, reticular veins and spider veins have no obvious source of reux on ultrasound.
Sometimes on ultrasound, small perigeniculate or lateral
thigh perforator veins are identied. Veins are usually visible to the naked eye with magnication, but there are
other aids to seeing them better, such as infrared projection
(Figure 33.6), vein lights, or polarized lights. When access-
ing the veins, aspiration of blood conrms proper needle
placement. Per site, approximately 0.1–0.5 mL of the appropriate concentration of sclerosant should be injected. e
next site of injection should be situated 5–15 cm from the
previous site. is can be determined visually as the treated
segment is usually in spasm and can no longer be identied. Concentrations to be used are 23.4% hypertonic saline,
0.5%–0.75% STS, or 0.75%–1.0% PDL. Foam sclerotherapy
Figure 33.6 Infrared photograph of lateral varicose and
perforating veins.
can also be used in reticular veins. is is discussed in
another chapter in this book.
33.6.5.4 SPIDER VEINS
e key to treating spider veins is to visualize the needle
entering the vein. Since aspiration is usually not possible
for conrming needle placement, direct visualization is
required. It is therefore important to have excellent lighting without glare. Magnication is also very helpful. Other
aids include polarized lights, such as the Syris headlamp
with magnication. e volume of injection depends on the
length and size of the vein.
ere should be minimal resistance, and once resistance is
felt, the injection should stop. Aer the injection, the needle
can be held in position with slight pressure on the plunger.
is prevents blood from returning and increases contact
time with the vein wall and sclerosant. Injection should be
interrupted with any evidence of extravasation of the sclerosant. Additional pressure could be then applied aer the
injection to help produce apposition of the vein wall. is
can be done manually or with cotton balls. Typical concentrations of sclerosant are 0.125%–0.25% for STS, 0.25%–0.5%
for PDL, 11.4%–23.4% for hypertonic saline, or 48%–72% for
glycerin. Total volume depends on the type and concentration of sclerosant, but 10 mL is typical for one session.
33.6.6 Compression
Compression following sclerotherapy reduces discomfort
and side eects such as phlebitis. Compression stockings are
generally used. Extra foam pads, cotton balls, or gauze can
be placed to apply additional compression over the treated
vein. ese can be held in place with tape or wraps. is
additional compression helps to coapt the vein walls and
to avoid thrombosis, thereby diminishing the risks of postoperative pain and staining.
33.7 Adverse events 405
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33.6.7 Post-sclerotherapy
microthrombectomy
Following treatment, a thrombus may form in the vein
despite adequate compression. The thrombus can be
painful and could lead to staining. The unwanted effects
of this complication can potentially be reduced by draining the thrombus in the first 2–3 weeks after treatment.11
This can be done under local anesthesia and with the
help of 18–22-gauge needles puncturing in the line along
the vein and then using cotton swaps to compress the clot
(Figure 33.7).
33.7 ADVERSE EVENTS
33.7.1 Pain
e most common complaint associated with sclerotherapy
is pain. Several factors can be considered to minimize the
amount of pain the patient will experience. (1) e choice of
sclerosant will aect pain levels, with detergent sclerosants
tending to result in less pain than the osmotic agents. If
hypertonic saline—an osmotic agent—is used, lidocaine
may be added to reduce the discomfort. (2) e use of the
smallest-gauge needle that can penetrate the skin is advisable. Usually, 30–32-gauge needles work best. (3) e extravasation of the solution can be avoided by ensuring that the
needle is correctly placed in the vein and the sclerosant is
not injected too strongly or too rapidly. (4) Hypertonic saline
has been associated with cramping at the injection site, so
limiting the volume of injection at any one site may help. (5)
Additional methods to reduce the discomfort include using
topical local anesthetics, blowing cold air on the injection
site, and placing ice packs immediately aer the injection. It
should be noted that the use of cooling with detergent solutions may aect their ecacy.
(a)
(b)
(c)
33.7.2 Visual changes
Visual changes or migraine auras are occasionally experienced at the time of treatment. ese may be caused by the
release of endothelin from the damaged endothelial cells.
Such symptoms are more common in patients with a history
of migraines or who have right-to-le shunts. ese symptoms usually pass quickly.
33.7.3 Inflammatory responses
Localized inammatory responses that lead to erythema,
urticaria, and localized edema can be observed. ese can
be reduced by limiting the volume of sclerosant and using
the appropriate concentration. A full-blown anaphylaxis
reaction is possible, so an emergency kit that includes oxygen, epinephrine, antihistamines, and steroids should be on
hand at the time of treatment.
Figure 33.7 Post-sclerotherapy microphlebectomy: (a)
puncture of the thrombosed telangiectatic vein with 30
gage hypodermic needle; (b) thrombus coming from
telangiectatic vein; (c) more thrombus expressed from
telangiectatic vein using cotton tip swab.
33.7.4 Hyperpigmentation
Hyperpigmentation is a brown stain related to the production of hemosiderin, which remains aer the degradation of
the thrombus at the site of the treated vein (Figure 33.8).
is can be minimized by post-sclerotherapy thrombectomy and usually resolves in just a few months. In some
11
406 Liquid sclerotherapy for telangiectasia andvaricose veins
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Figure 33.8 Adverse event: staining.
cases, for unknown reasons, the staining lasts much longer
(1–2 years). Several theories to explain this phenomenon
include the skin type of the patient, the use of too strong a
solution leading to an intense inammatory reaction and
post-inammatory pigmentation, or the use of too weak a
solution leading to inadequate sclerosis, recanalized, persistent thrombosis, and pigmentation. Some sclerosants, such
as hypertonic saline, seem to have a higher incidence of
hyperpigmentation, possibly due to lysis of red cells.
Figure 33.9 Adverse event: telangiectatic matting.
while directly visualizing the needle entering the spider vein,
and aspiration to ensure that the injection is done in the varicose vein.
33.7.7 Thromboembolism
DVT is rarely seen with small varicose and spider veins, but
DVT must be considered if unusual pain or swelling occurs
in the post-operative period. Ultrasound should be done if
any suspicion is aroused. e incidence of DVT increases
when liquid or foam sclerotherapy is performed on larger
veins with higher concentrations of sclerosant.
33.7.8 Intra-arterial injections
33.7.5 Telangiectatic matting
Telangiectatic matting is a complication in which red or
purple spider veins appear where either varicose or larger
spider veins were treated (Figure 33.9). Although the cause
cannot always be determined, inadequate treatment of an
underlying source of reux can frequently be found. Such
sources could include an undetected saphenous incompetence, perforator vein incompetence, or a reticular vein.
Ultrasound examination may help to determine the source;
vein lights or infrared imaging may demonstrate a reticular
vein not seen on ultrasound. If no source is found, the matting may resolve with time. Methods of treatment such as
laser have been tried with some success.
12
33.7.6 Skin necrosis
Sclerotherapy may induce skin necrosis (Figure 33.10).
Possible causes include too high a concentration of sclerosant with extravasation, too much pressure applied to the
syringe during injection leading to blanching, or injection
of an arteriole. Preventive steps include use of the appropriate strength of sclerosant, very gentle pressure on the syringe
Short of an anaphylactic reaction, intra-arterial injection
poses the greatest risk to the patient. is complication
could lead to serious tissue loss, including the possible need
for amputation. Every eort must be made to ensure that
the needle placement is in a vein and not an artery. Certain
Figure 33.10 Adverse event: skin necrosis.
References 407
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anatomic areas, such as around the ankle where the arter-
33.8 CLINICAL PRACTICE GUIDELINES
ies are supercial, pose particular risk. Ultrasound-guided
injections should be the rule for perforator veins or saphenous veins, as all perforator veins are accompanied by an
artery, and with saphenous veins there are several locations
where arteries are in close proximity. Ultrasound imaging
alone may not be enough to prevent intra-arterial injection.
Techniques such as aspiration of a small amount of blood can
Current and previous clinical practice guidelines of the
Society for Vascular Surgery and the American Venous
Forum endorse sclerotherapy—either liquid or foam—for
the treatment of telangiectasia, reticular veins, and varicose veins.13 Liquid sclerotherapy remains the treatment of
choice for reticular veins of <3 mm and for telangiectasia.
help ensure proper needle placement in the vein; the blood
should come back very easily. Additionally, using an open
ACKNOWLEDGMENT
hub technique may be helpful: when the syringe used for
aspiration is taken o and replaced with a sclerosant syringe,
there would be pulsatile back-bleeding if an artery is hit.
Guidelines 4.5.0 of the American Venous Forum on liquid sclerotherapy for telangiectasia and varicose veins
No. Guideline
4.5.1 We recommend liquid or foam sclerotherapy for
telangiectasia, reticular veins, and varicose veins.
4.5.2 For the treatment of the incompetent saphenous vein,
we recommend endovenous thermal ablation over
chemical ablation with foam.
e author thanks Victoria J. White, MA, ELS, for her editorial assistance.
Grade of
recommendation (1:
strong; 2: weak)
1 B
1 B
Level of evidence (A: high
quality; B: moderate quality;
C: low or very low quality)
REFERENCES
●
= Major review articles
★
= Key primary papers
◆
= Guidelines
●
1. Schwartz L and Maxwell H. Sclerotherapy for lower
limb telangiectasias. Cochrane Database Syst Rev
2011;(12):CD008826.
★
2. McPheeters HO. Injection treatment of varicose
veins by the use of sclerosing solutions. Surg
Gynecol Obstet 1927;45:541–7.
★
3. Dixon FC. The results of injection treatment of varicose veins. Staff Meet Mayo Clin 1930;5:41.
4. Smith FL. Varicose veins, complications and results of
treatment of 5000 patients. Milit Surg 1939;85:514.
◆
5. Weiss MA, Hsu JT, Neuhaus I, Sadick NS, and Duffy
DM. Consensus for sclerotherapy. Dermatol Surg
2014;40(12):1309–18.
★
6. Einarsson E, Eklöf B, and Neglén P. Sclerotherapy
orsurgery as treatment for varicose veins: A prospective randomized study. Phlebology 1993;8(1): 22–26.
7. Uhl JF, Cornu-Thenard A, Satger B, and
CarpentierPH. Clinical analysis of the corona
phlebectatica. J Vasc Surg 2012;55(1):150 –3.
8. Duffy DM. Sclerosants: A comparative review.
Dermatol Surg 2010;36(Suppl. 2):1010–25.
★
9. Carlin MC and Ratz JL. Treatment of telangiectasia:
Comparison of sclerosing agents. J Dermatol Surg
Oncol 19 87;13(11) :1181 – 4.
10. Goldman MP. Treatment of varicose and telangiectatic leg veins: Double-blind prospective comparative trial between Aethoxyskerol and Sotradecol.
Dermatol Surg 2002;28(1):52–5.
★
11. Scultetus AH, Villavicencio JL, Kao T-C etal.
Microthrombectomy reduces postsclerotherapy pigmentation: Multicenter randomized trial. J Vasc Surg
2003;38(5):896–903.
12. Meesters AA, Pitassi LH, Campos V, WolkerstorferA,
and Dierickx CC. Transcutaneous laser treatment of
leg veins. Lasers Med Sci 2014;29(2):481–92.
◆
13. Gloviczki P, Comerota AJ, Dalsing MC etal. The
care of patients with varicose veins and associated
chronic venous diseases: Clinical practice guidelines
of the Society for Vascular Surgery and the American
Venous Forum. J Vasc Surg 2011;53(5): 2S–48S.
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34
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Percutaneous laser therapy of telangiectasia
and varicose veins
THOMAS M. PROEBSTLE
34.1 Introduction 409
34.2 Etiology and pathogenesis 409
34.3 Clinical manifestation andclassification 409
34.4 Pre-treatment diagnostics andrequirement 410
34.5 Patient selection 411
34.6 Fundamentals of light–tissue interaction 411
34.7 Lasers and IPL for transcutaneous therapy
oftelangiectasia 413
34.1 INTRODUCTION
According to an epidemiologic study of more than 3000
randomly assigned persons in Germany,1 only 9.6% of the
population are free from any kind of varicosity, 31.3% suer
from clinically relevant varicose veins, venous edema, skin
changes, or venous ulcer disease, and 59% have isolated leg
telangiectasia.
Today, most people are aware of varicose veins and
chronic venous diseases, with their associated risks such
as deep vein thrombosis and lung embolism. e clinical
symptoms and signs of advanced chronic venous disorders
like pain and ulcers are known to the general population.
Additionally, the development of a certain lifestyle during
the last decades with increased awareness of body appearance, focusing on the cosmetic aspect of the legs, makes
excellent if not outstanding cosmetic results an absolute
requirement for many patients.
During the last decade, technology has progressed to
such a degree that lasers and light sources for transcutaneous treatment of small varicosities and catheter-based
systems for percutaneous treatment of clinically relevant
varicose veins now meet most of these demands.
34.2 ETIOLOGY AND PATHOGENESIS
e etiology of venous disorders, including varicose veins
and leg telangiectasia, is complex and still incompletely
34.8 Cooling systems 416
34.9 Side effects and complications 416
34.10 Alternative treatment options for leg
telangiectasia 416
34.11 Future directions 416
34.12 Summary 417
References 417
understood. Besides idiopathic causes, some acquired risk
factors of varicose veins are known, and dierent diseases
can also be involved in the development of varicose veins.
For example, thrombophilia disorders may trigger deep
vein thrombosis and subsequent new varicose veins associated with post-thrombotic deep vein reux. Regarding the
etiology and pathophysiology of varicose veins, the reader
should consult Chapters 4 through 6. Leg telangiectasias are
frequently idiopathic and mainly of cosmetic interest to the
patient. However, as shown in Table 34.1, dermatologists are
aware of a number of localized or systemic diseases, which
may cause leg telangiectasia.
diseases is important because some of their underlying
conditions may be associated with skin hypersensitivity
to light exposure and therefore any laser or intense pulsed
light (IPL) treatment would not only be ineective, but also
potentially harmful to the patient, and therefore should be
contraindicated.
2,3
To know of these systemic
34.3 CLINICAL MANIFESTATION
ANDCLASSIFICATION
e CEAP classication4 oers a well-accepted system for
the description of venous disease. However, it is less suitable for categorization of the clinically insignicant but
cosmetically disturbing small veins. In the clinical stage
C1, telangiectasia and reticular varicose veins with diameters below 3 mm represent a variety of small vessels that
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