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Lower Extremity Ultrasound: Diagnostic and Therapeutic Applications
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43
challenging to study. The Doppler survey is undertaken in
a segmental routine with focused attention to any flow
deviations within tributaries or from perforating veins.
Methods to provoke valve closure include use of a RCI
device or Parana maneuvers. Frequently an intersaphenous vein courses obliquely and may be a source of reflux.
The SSV thigh extension or the vein of Giacomini is
included in the investigation.
A posterolateral thigh venous system encountered may
represent a remnant of the embryonic lateral marginal
vein, the sciatic vein. A precise detail describing the
drainage of this vascular malformation is imperative.
Investigation of the saphenous vein may lead to discovery
of alternative sources of reflux, including pelvic
veins. These venous networks are complex and can frequently cross over from the contralateral pelvic area.
Patients who are suspected of pelvic reflux or pelvic
venous disease may require further investigation with
complementary imaging.
In the evaluation of patients who present following
procedural intervention, the operative and technical notes
are useful prior to an ultrasound assessment. Patients
examined under these circumstances may require an
examination outside of the standardized protocol as
described above. Frequently the venous remnants encountered require problem solving.
• Examination of perforating veins
During an investigation of the lower extremity venous
system, perforating veins are frequently encountered.
These veins accommodate both drainage and direct flow
between the superficial and deep compartments, and are
either competent or incompetent.
Diagnostic criteria relying solely on diameter measurements of perforating veins are unreliable and, in the
Author’s opinion, should be abandoned. Consider a simplistic review of the pathophysiology (in earlier text
described as hierarchy of drainage) of venous structures:
Most normal venous flow drains from the skin to superficial layers to deeper layers, in spider veins, to reticular
veins, to larger tributaries, to the GSV/SSV, or to a vein
that indeed ‘perforates’ the superficial fascia to the deep
fascia and drains blood into the deep system. Perforating
veins are a normal part of the venous system and are
critical to venous drainage. As the diameter of the perforating vein increases, the relative size suggests there may
be a flow abnormality. The size of the perforating vein is
a measurement, not a diagnosis.
Due to complexity of Doppler and drainage angles,
perforating veins can be difficult to examine with duplex
ultrasound. With the patient standing, begin with a
Doppler survey in a manner that is amenable to correctly
observing flow both in and out of the perforating vein; flow
should drain from the superficial to the deep veins. Visualize and steer the color flow box based on the concept of
systolic flow (muscular or forward contraction) whereby
flow should not observed moving outward from the deep
veins. Diastolic flow (muscular relaxation) will demonstrate flow inward toward the deep veins through functioning perforating vein. Movement of blood from the
superficial veins (diastolic flow) occurs through the perforators during muscular relaxation. This is a normal functioning perforating vein.
Previous published standards describing perforator
dimensions at the fascial margin greater than 3–4 mm as
an abnormal perforating vein may be confusing. Anatomically, we look at an increased relative size of a vein and
suspect the finding may be abnormal. However, this is
only half of the information. Flow dynamics through perforating veins is the most important detail.
Retrograde flow in abnormal perforating veins, according to Labropolous, is 0.35 seconds (Labropolous et al
2003). In the hands of an inexperienced operator, this
may easily be over-estimated. Motion artifact from the
corresponding artery or movement of the transducer can
overvalue flow patterns on spectral display. Flow in an
abnormal perforating vein is bidirectional. However, there
is no consensus reached for pathologic significance of bidirectional flow within a perforating vein. The investigation
of perforating veins should substantiate absolute abnormal
flow outwards from the deep veins towards the skin, with
critical analysis of the findings. Obstruction of the deep
veins will influence the findings of flow within perforating
veins, thus the details of the deep venous examination will
contribute to overall accurate results.
Remember, dilatation is only a measurement; it is the
‘why’ that is most important. Dilated perforators are
indicative of volume. Identify why there is increased
volume. Many perforating veins are ‘re-entry perforators’.
This term is used to describe the site where the abnormal
column of blood (for example, a large bulging tributary
vein) re-enters the venous drainage network. The relative
size is important. Equally important, then, is the diagnostic answer of why the perforator vein has enlarged. In
summary:
(1) Document flow direction through the perforating
vein as flow measured in systole or diastole.
(2) Diameter is an adjunctive measurement
consideration if the perforating vein has substantial
bidirectional flow.
(3) Study perforating veins to confirm direction of flow
from the superficial and deep compartment, and
determine if the perforating vein is the drainage
of a refluxing column of blood or incompetent
outward flow.
If one is performing an examination for treatment planning, the individual gathering information must recognize
what types of veins are amenable to treatment and any
contra-indications for treatment. Thermal ablation of the
saphenous vein involves placing a catheter or fiber within
the vessel at the point of access (typically the knee area
or calf) and passing it proximally to below the junction of
the deep vein. With this in mind, take note of any tortu-
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Treatment of Leg Veins
ous or valve sinus segments that may prevent or impede
passage of wires or endovenous thermal devices. Skin
burns during thermal ablation have been described (in
early reports of thermal devices), thus saphenous to skin
distances less than 1 cm should be noted. Anatomic proximity of arterial structures may potentially be of risk with
complication of formation of arteriovenous fistula and
should be noted. A venous duplex examination typically
includes a sketched diagram (mapping) portraying the
location of any valvular incompetence (reflux) and venous
flow properties between the deep, saphenous and superficial compartments. A report of the findings should
include such information as to the precise location, length
and source of reflux in the saphenous veins, relative diameter measurements along the course of the saphenous
veins, and other relevant veins that possess reflux or
retrograde drainage. Additionally, information regarding
hypoplastic, atretic, or absent veins is included. The
detailed diagram are developed and descriptive report is
undertaken with the goal of therapy to take place.
THERAPEUTIC APPLICATIONS
• Endovenous saphenous thermal ablation
The role of ultrasound for endovenous thermal ablation
begins with a preoperative ‘mapping’ of the segment of
the saphenous vein to be ablated. Visualization with ultrasound will assist in determining the intended treatment
area and access site. Consideration for the site insertion
should include ergonomics and suitable vein diameter, as
both are important for successful vein cannulation.
Because the thermal device is activated by the operator a
site well below the knee for venous entry can be utilized
if this region is the most desirable for access. The device
can simply be turned off once the heating element has
treated the segment intended, thereby eliminating the risk
of nerve damage. Ultrasound identification of the sural or
saphenous nerve is helpful to avoid injury (Fig. 4.22A,B).
The ultrasound survey will also identify any tortuous segments that may hinder thermal device advancement.
Once a suitable access site is chosen, the patient is surgically prepped and draped according to the facility’s
routine. Vein entry (access) is obtained under ultrasound
guidance (Fig. 4.23A,B), step-up wires and sheaths are
placed, and the thermal device is positioned in the saphenous vein (GSV inferior to the superficial epigastric vein
(Fig. 4.24A) or the SSV where the vein begins to terminate
to a deep venous segment (Fig. 4.24B). Accurate placement of the thermal tip is aided by the ultrasound image.
Artifacts within the vein, including trapped air bubbles,
can hinder visualization of or sometimes be mistaken for
the thermal tip. Manipulation and movement of the
thermal tip may help to validate accurate position with
certainty. Anesthesia surrounding the vein is the next
step. Needle placement within the peri-venous plane with
a very dilute anesthetic solution is accomplished under
ultrasound guidance in either a transverse or longitudinal
orientation (Fig. 4.25A,B). Once adequately placed, the
anesthetic will facilitate extrinsic compression of the vein
A B
A B
Figure 4.22 (A) Transverse ultrasound
image of the sural nerve in close proximity
of the small saphenous vein. (B) Proximal
movement of the transducer demonstrates
less proximity of the sural nerve to the SSV
and may suggest a safe placement of a
needle or thermal device within this area
Figure 4.23 (A) Longitudinal gray scale
ultrasound image of needle ‘tenting’ anterior
wall of the saphenous vein. (B) Further
advance of the needle into the vein with
successful access
A B
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A B
45
Lower Extremity Ultrasound: Diagnostic and Therapeutic Applications
Figure 4.24 (A) Longitudinal gray scale
ultrasound image of the thermal tip of a
laser fiber placed inferior to the superficial
epigastric vein. (B) Ultrasound visualization
of the thermal tip of a laser fiber inferior to
the popliteal vein
Figure 4.25 (A) Longitudinal gray
scale ultrasound image of tumescent
anesthesia with needle guidance
along the saphenous sheath.
Note the needle tip, fluid, and
laser fiber (placed within the vein).
(B) Transverse gray scale
ultrasound image of tumescent
anesthesia surrounding the laser
fiber (within the saphenous vein)
wall and also create a heat sink to absorb the thermal
energy. Confirmation of adequate anesthesia fluid placement is achieved with ultrasound imaging in transverse
views (Fig. 4.25B) along the course of intended treatment.
Once the anesthetic fluid is placed and confirmation of
the tip is assured, the thermal treatment begins. Due to
ultrasound artifact considerations introduced by fluid, one
can understand why the thermal tip is positioned prior to
administering the tumescent anesthesia. The thermal ablation is completed once the device has been successfully
pulled back at the appropriate speed and removed from
inside the vein. The benefit of skilled ultrasound visualization to assist treatment cannot be overstated in reducing
risks and complications. Accurate thermal tip placement
and ample anesthesia is imperative.
• Chemical ablation
Chemical ablation procedures are often referred to as
ultrasound-guided injection sclerotherapy (UGS). The
use of foam sclerotherapy (in which foam is created by
Tessari’s method of mixing 1 part sclerosant liquid and 4
parts gas, producing a stable foam consistency) has gained
interest as a method of treatment of superficial venous
disease. This method was first published in 1989 but
gained greater acceptance in 1995 when first presented by
Cabrera. Safety studies have been published by Morrison
et al (2008). The use of UGS has many practical consid-
erations, and will be further described in other chapters.
The application of ultrasound visualization during UGS
includes accurate guidance and placement of the catheter
or direct needle punctures into the vein, absolute avoidance of intra-arterial injections, and control of the foam
distribution within the vein to modify or adapt the volume
being injected. With skill and expertise, foam sclerotherapy can successfully ablate saphenous truncal and nontruncal reflux. The primary use for ultrasound-guided injection
is the precise placement of sclerosant into the abnormal
vein and observation of the high contrast foamed sclerosant. Needle observation is improved with decreased
dynamic range ultrasound settings. An absolute parallel
position of the transducer on the skin is essential. Utilizing
a cross-sectional image with the needle approach down
the long axis of the transducer (Fig. 4.26A) will facilitate
needle visualization from the skin line directly to the
target (Fig. 4.26B).
Duplications of the deep venous system are common,
including the femoral vein of the thigh, popliteal, and calf
veins. Duplications may be important during foam sclerotherapy due to migration of the foam into the deep venous
system. The duplicated vein calibers vary, and these
unique flow rates may subject these vessels as susceptible
for DVT (Fig. 4.27A,B).
• Post treatment follow up
While it is completely gratifying to obtain treatment
success, some patients do encounter treatment failure.
Additionally, there are reported complications following
venous procedures, including deep vein thrombosis
(Fig. 4.28) and superficial thrombophlebitis (Fig. 4.29A,B).
Early intervention is critical and begins with identification,
which may require new or additional therapy. Interval
follow-up will reassure the patient and monitor timely
progress. The frequency of vein recurrence is due to
several factors of the disease, thus ultrasound surveillance
after treatment is warranted and suggested. The
ultrasound examiner should possess a comprehensive
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Treatment of Leg Veins
A B
Figure 4.26 (A) Photo of transverse
transducer orientation with needle access
along the long access. (B) Gray scale
ultrasound image of needle tip in the
targeted vein
A B
Figure 4.27 (A) Longitudinal gray scale ultrasound image of a duplicated femoral vein segment. (B) Color flow ultrasound image of the
duplicated femoral segment. Note that one of the two segments is occluded with absence of color flow in one of the two paired veins
Figure 4.28 Transverse color flow ultrasound image of the gastrocnemius vein and artery in the medial calf. Note the absence of color flow in
the gastrocnemius vein and increased echogenicity, which is diagnostic for deep vein thrombosis
A B
Figure 4.29 (A) Transverse gray scale image of dilated varicose vein. Note presence of marked echogenicity within the vessel loops. These
areas do not compress and are diagnostic of thrombosed segments. (B) Color flow image of the vessel with absence of flow within the vessel
lumen to confirm occlusion of the vessel segment
Figure 4.30 Transverse gray scale image of previously ablated
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saphenous vein. Typical findings at 3-month interval with mixed
echogenicity within the vessel lumen
Figure 4.31 Transverse gray scale image of previously ablated
saphenous vein with sonographic disappearance of the vessel at
9 month interval
knowledge of potential complications and expected outcomes. Gradual shrinkage of the treated veins over a
course of 6–9 months will result in their eventual disappearance from ultrasonic detection (Figs 4.30 and 4.31).
SUMMARY
A successful approach to treating patients with venous
disease includes the use of duplex ultrasound and careful
evaluation pre-, peri- and post-treatment. Critically
important factors in venous assessment are the quality of
the device utilized and the qualifications of the sonographic examiner.
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Lower Extremity Ultrasound: Diagnostic and Therapeutic Applications
FURTHER READING
Bergan JJ (ed) 2007 The vein book, Ultrasound examination of
the patient primary venous insufficiency. Academic Press,
San Diego, CA
Caggiati A, Bergan JJ, Gloviczki P et al 2005 Nomenclature of the
veins of the lower limb: Extensions, refinements, and clinical
applications. Journal of Vascular Surgery 41:719–724
Caggiati A, Bergan, JJ, Gloviczki P et al 2002 Nomenclature of the
veins of the lower limbs: an international interdisciplinary
consensus statement. Journal of Vascular Surgery 36:416–422
Cavezzi N, Labropoulos H, Partsch S et al 2006 Duplex ultrasound
investigation of the veins in chronic venous disease of the lower
limbs – UIP consensus document. Part II. Anatomy. European
Journal of Vascular and Endovascular Surgery 31:288–299
Coleridege-Smith P, Labropoulos N, Partsch H et al 2006 Duplex
ultrasound investigation of the veins in chronic venous disease of
the lower limbs – UIP consensus document. Part I. Basic
principles. European Journal of Vascular and Endovascular
Surgery 31:83–92
Dona E, Fletcher JP, Hughes MD, et al 2000 Duplicated popliteal
and superficial femoral veins: Incidence and potential
significance. Australian & New Zealand Journal of Surgery
70:438–440
Franceschi C, Zamboni P 2009 Principles of venous hemodynamics.
Nova Science
Fronek H (ed) 2004 The fundamentals of phlebology: Venous
disease for clinicians. San Leandro, CA, American College of
Phlebology
Knight RM, Vin F, Zygmunt JA 1989 Ultrasonic guidance of
injections into the superficial venous system. Davy A, Stemmer
R (eds) Phlebologie ’89 John Libby Eurotext Ltd, pp. 339–341
Labropoulos N, Tiongson J, Pryor L et al 2003 Definition of venous
reflux in lower extremity veins. Journal of Vascular Surgery
38:793–798
Lurie F 2009 Venous haemodynamics: What we know and don’t
know. Phlebology 24:3–7
Morrison N, Neuhardt DL, Rogers CR et al 2008 Comparison of
side effects using air and carbon dioxide foam for endovenous
chemical ablation. Journal of Vascular Surgery 47:830–836
Rumack C, Wilson S, Charboneau JW (ed) 1998 Diagnostic
ultrasound, The peripheral veins. St Louis, Mosby
Tarrant G, Clarke J 2008 Differences in venous function of the
lower limb by time of day: A comparison of chronic venous
insufficiency between an afternoon and a morning appointment
by duplex ultrasound. Journal of Vascular Ultrasound 32:187–
192
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An Overview of Therapy
for Leg Veins
Jeffrey T.S. Hsu
INTRODUCTION
Depending on the size and location of the leg veins to be
treated, any of a multitude of therapeutic options may be
appropriate. While selecting the correct treatment techniques is important, management of patient expectations
prior to the treatment can be equally vital. A complete
list of topics should be discussed with every prospective
patient (Box 5.1). The patient must understand that
although improvement is expected, there is no guarantee
regarding the degree of improvement. Risks accompany
any medical procedure, and these must be discussed thoroughly. Once the physician has conveyed the necessary
information, the patient should be encouraged to ask
questions and should be provided with a detailed explanation of any concerns, as appropriate. If the patient appears
overly anxious, overly demanding, or simply unable to
understand the procedure, the patient may not be an ideal
candidate for intervention.
COMPRESSION
Use of external compression therapy (CT) is a fundamental strategy in the treatment of lower extremity venous
disease. Despite recent therapeutic advancements in leg
vein treatment, compression remains a simple, effective,
and inexpensive modality. It should be considered as the
primary treatment in many conditions, and as an adjunct
when other treatments are employed (Box 5.2).
Whether passive or active, compression improves
venous disease through several mechanisms. Compression
narrows the lumens of the veins in the superficial system,
which accelerates venous flow, decreases venous pooling,
and helps to shift venous flow from the superficial into
the deep venous system. Compression also may partially
restore valvular function, and gradually reverse degenerative changes in the veins, thus also reducing venous reflux.
COMPRESSION BANDAGES (TABLES 5.1 AND
5.2; FIG. 5.2)
• Short-stretch bandages
Various modalities are available for compression. Completely rigid inelastic bandages, like the zinc gel Unna boot
(Unna-Flex, Convatec, Princeton, NJ), and the Gelocast
(Beiersdorf Inc., Norwalk, CT), both dry to form a cast
around the leg. Short-stretch bandages such as Comprilan
(Beiersdorf, Norwalk, CT) are made of fabric that
stretches 30–50%. Inelastic bandages and short-stretch
bandages exert passive compression to treat edema, deep
vein thrombosis (DVT), or ulcerations due to chronic
venous insufficiency (CVI). They must be applied by
trained staff to ensure a proper fit and remain in place for
several days continuously. However, as edema remits and
leg circumference decreases, the inelastic nature of the
bandages fails to accommodate for this change and corresponding pressure loss can occur as early as within the
first few hours of application.
ACTIVE AND PASSIVE COMPRESSION
Compression can be either passive or active. Passive compression is applied using inelastic bandages. As muscles
contract, the bandages resist the volume increase and
thereby deliver increased pressure is delivered. As the
muscles relax, the volume decreases so that minimal pressure is applied by the bandages. On the other hand, active
compression using elastic bandages permits application of
pressure both during muscular exercise and at relaxation.
This constant pressure may not be tolerated by bedridden
or inactive patients, and may be contraindicated in arterial
insufficiency (Fig. 5.1).
• Long-stretch bandages
Long-stretch bandages, made of fabric that can stretch
100–200%, provide active compression, indicated after
surgery, sclerotherapy, or thrombophlebitis. Their main
disadvantage is the potential hazard to patients with
arterial occlusive disease. The application of bandages is
dependent on the skill of the practitioner, with experienced clinicians able to consistently apply bandages with
pressure ranging from 25–50 mmHg. The less experienced
typically achieve pressures in a broader range, from 15–
70 mmHg, and deviation on the high end can lead to arterial occlusion in those with pre-existing arterial disease.
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Treatment of Leg Veins
Box 5.1 Topics of pre-treatment discussion with patient
v Patient expectations
v Expected discomfort during treatment
v Number of treatments required
v Benefits of treatment
v Possible risks and complications of treatment
v Treatment alternatives
v Post-treatment care
v Duration and nature of recovery phase
Table 5.1 Manufacturers of compression stockings
Location and
Brand
Jobst Charlotte, NC
Sigvaris
JuZo Cuyahoga Falls, OH
Medi Whitsett, NC
Venosan
telephone number Website
1-800-537-1063
Peachtree City, GA
1-800-481-5488
1-800-222-4999
1-888-633-6334
Asheboro, NC
1-800-322-7744
www.jobst-usa.com
www.sigvaris.com
www.juzousa.com
www.mediusa.com
www.venosanusa.com
Box 5.2 Indications for leg vein compression
v DVT prophylaxis
v Active DVT treatment
v Symptomatic varicose veins
v Chronic venous insufficiency
v Venous ulcers
v Post sclerotherapy
v Post phlebectomy
v Post endovascular ablation
v Pregnancy
v Thrombophlebitis
Table 5.2 Manufacturers of compression bandages
Manufacturer Type Adherence/Name
Convatec
Princeton, NJ
Beiersdorf
Norwalk, CT
Beiersdorf
Beiersdorf Non-Stretch Cohesive/Gelocast
3M Health Care
St. Paul, MN
Convatec
Princeton, NJ
Conco Medical
Bridgeport, CT
High Stretch Nonhesive/Tubigrip
Low Stretch Nonhesive/Comprilan
Cohesive/Comprihaft
Adhesive/Elastoplast
High Stretch Nonhesive/Eloflex
Cohesive/Elohaft
High Stretch Adhesive/Microfoam
Non-Stretch Cohesive/Unna-Flex
Low Stretch Cohesive/Medi-Rip
A B
Therefore, before application, arterial flow should be evaluated by checking the ankle/brachial index, and patients
should be instructed on how to properly superimpose each
successive layer. After being washed, the bandages tend to
lose some of their compressive capability.
Skin
Superficial
vein
Deep vein
Communicating
vein
Compression
bandage
Figure 5.1 (A) Before compression.
(B) Compression shifts the venous flow
from superficial to deep system
• Multilayer bandages
Multilayer bandages are a compromise between inelastic
bandages and long-stretch elastic bandages. They are often
comprised of four superimposing layers: (1) wool padding
for comfort and to absorb exudates; (2) cotton bandage
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Table 5.3 Classes of compression stockings
51
A
B
C
Figure 5.2 (A–C) Proper application of stretch bandage post
sclerotherapy
to hold the wool in place; (3) long-stretch elastic bandage
for active compression; and finally, (4) cohesive mediumstretch bandages. The different indications for the various
bandage options are not absolute as the ultimate physiologic effect can be modified by the clinician applying
the bandage. Comparative studies assessing the utility
of particular bandages for select indications are still
inconclusive.
COMPRESSION STOCKINGS
Stockings provide an alternative to bandages. Varying
in length and by degree of compression, stockings can
be used for prophylaxis against DVT or development of
varicose veins. Stockings are also indicated after surgery,
phlebectomy, or sclerotherapy. Compression following
sclerotherapy of varicose veins and larger reticular veins is
a universally accepted intervention that encourages the
direct apposition of the vein walls so as to decrease the
likelihood of thrombus formation and subsequent recanalization of the treated vessel. The avoidance of thrombus formation also appears to limit hyperpigmentation and
thrombophlebitis and subsequent telangiectatic matting.
However, the utility of stockings following treatment of
small telangiectasias continues to be debated. After leg
Compression
class
0 10–20 Mild functional venous
I 20–30
II 30–40 Symptomatic varicose
III 40–50 Venous ulcers
IV >60 Sever symptoms, difficult
The above classification of compression classes may vary
among different countries and different brands.
Pressure
(mmHg) Common indications
insufficiency
Chronic venous
insufficiency, symptomatic
varicose veins, DVT
veins, DVT, venous ulcers
to control edema,
significant skin fibrosis
surgery or phlebectomy, stockings help prevent hematomas. During pregnancy, stockings forestall the development of varicose veins that would otherwise proliferate
further due to increased venous pressure and hormonal
influences. Pressure stockings are also a key element in the
treatment of superficial thrombophlebitis.
There are five stocking compression classes, designated
0 to IV (Table 5.3). In each class, there are available
various lengths, ranging from socks, to thigh-high, to fulllength pantyhose. Proper selection is contingent on the
indication and the patient’s ability to tolerate compression. Elderly patients may have difficulty putting on the
stockings, especially the high-compression stockings, and
devices have been developed to assist these individuals.
An alternative strategy is to superimpose two pairs of
compression stockings, with, for example, two pairs of
Class 0 stockings offering the same pressure as one pair
of Class I stockings. The two separate stockings are easier
to pull on. Stockings tend to lose pressure with routine
use and washing, and may need to be replaced every
6 months.
Class 0 stockings are indicated in mild functional
venous insufficiency that results in minimal varicose veins
with associated mild edema or leg fatigue. Chronic venous
insufficiency and more severely symptomatic varicose
veins should be treated with either Class I or II stockings.
Class I or II stockings are also indicated in the outpatient
management of DVT as they relieve pain and edema, and
enhance thrombus adhesion. Leg ulcer treatment requires
Class II or III stockings in addition to local skin treatment.
Alternatively, ulcerations may be amenable to other types
of compression treatment such as multilayer bandages or
inelastic bandages. Class IV is reserved for those with
severe symptoms, difficult to control edema and significant skin fibrosis.
There is no consensus on the duration or degree of
compression needed after surgery. Although one study has
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Treatment of Leg Veins
shown equal efficacy between high and low pressure compression stockings in minimizing incidence of bruising and
thrombophlebitis after varicose vein surgery, high compression stockings are clearly necessary after sclerotherapy. However, there appears to be no difference between
Class I and Class II compression stockings in controlling
the objective and subjective parameters of venous insufficiency. Weiss et al studied the duration of compression
after sclerotherapy and found that subjects with the most
improvement used 3 weeks of compression, followed
by the group with 1 week of compression, followed by
the group who only used compression for 3 days. All
treatment groups had significant improvement compared
to the control group that did not receive compression.
The 1-week and 3-week groups also experienced less
sclerotherapy-associated hyperpigmentation than the
3-day group and the control group.
TREATMENT OF SMALL VESSEL DISEASE
When larger truncal varicose veins are present, the associated telangiectasias cannot be successfully treated without
addressing the underlying hydrostatic pressure elevation.
In cases of great saphenous vein (GSV) incompetence,
surgical techniques or endovenous ablative techniques
may be required. Ambulatory phlebectomy allows treatment of virtually all large varicose veins while sclerotherapy can be used to treat large varicose veins and
reticular varicose veins. Only after the reticular, varicose,
and deep incompetent veins have been treated should
attention turn to treating the superficial telangiectasias
with sclerotherapy or with laser- or light-based devices. In
patients with only isolated telangiectasias without pressure problems in larger vessels, sclerotherapy or laser/light
therapy may be used primarily (Fig. 5.3).
• Sclerotherapy
The goal of sclerotherapy is to intravascularly infuse a
chemical irritant to cause irreversible endothelial cellular
destruction, which leads to vascular fibrosis and obliteration. Virtually any foreign substance can be utilized to
induce venous endothelial damage, and several sclerosing
solutions are commercially available for this purpose
(Table 5.4). The selection of solution type, concentration,
and quantity is dictated by the type and site of the varicosity (Fig. 5.4).
post-sclerotherapy compression
To decrease the incidence of thrombus formation, which
may lead to subsequent recanalization and post-sclerosis
pigmentation, compression is also an essential adjunct to
sclerotherapy of large varicose veins. Moreover, direct
apposition of vein walls due to external compression
increases the duration of sclerosant contact with the
endothelium, thus making the procedure more effective.
Lastly, the reduced thrombotic and subsequent inflammatory phlebitic events may also minimize telangiectatic
matting. Some authors argue that telangiectasias <
require no compression after injection, but there is general
agreement that sclerotherapy of larger telangiectasias,
venulectasia, reticular veins, and varicose veins must be
followed by several days of compression therapy. During
sclerotherapy, elastic bandages are commonly applied
immediately after the last sclerosant injections. Cotton
balls or rubber cushions may be placed under these bandages to provide additional pressure at points of reflux or
over larger veins to prevent thrombosis. Since the bandages gradually lose the compressive force as they are
loosened with patient movement, many clinicians prefer
1 mm
A B C
D E
Figure 5.3 (A) Visualization of the leg vein.
(B) Two-point counterpressure applied to the
injection site. (C) Placement of the needle into
the vein at 30 degrees. (D) Steady injection
producing immediate blanching of vessel.
(E
) Immediate application of cotton ball and
tape
An Overview of Therapy for Leg Veins
https://t.me/med1917
Figure 5.4 Sclerotherapy tray consisting of:
rubbing alcohol, needles and syringes, various
sclerosants (shown here: 72% glycerin, 0.5%
sodium tetradecyl sulfate, 0.2% sodium tetradecyl
sulfate, and 0.1% sodium tetradecyl sulfate),
compression bandage, three-way stopcock,
gauze, tape. Not shown are cotton balls
Table 5.4 Common sclerosing agents
Solution Category Advantages Disadvantages Brands
53
Sodium
tetradecyl sulfate
Polidocanol Detergent Painless; rare necrosis;
Hypertonic saline Hyperosmolar
Glycerin Toxin
Detergent Painful only with
extravasation; capable
of sclerosing larger
veins; FDA approved
FDA approved
Nonallergenic
solution
Rare matting,
pigmentation, necrosis
compression stockings for bandages after sclerotherapy,
or they will advise patients to replace the bandages with
stockings a few hours after the procedure.
patient selection
Before embarking on sclerotherapy, a pertinent medical
history should be obtained. Specifically, history of lower
extremity infections, diabetes, anaphylaxis, and severe
asthma should be elicited. Coagulopathies, pregnancy,
history of recurrent DVT, and inability to ambulate are
contraindications for sclerotherapy. Laboratory tests are
usually not necessary except when hypercoagulable states
are suspected. Diagnostic studies such as duplex scanning
should be reserved for patients with symptomatic varicosities, varicose veins larger than 4 mm in diameter, or
Necrosis if extravasation
with >0.25% solution;
pigmentation, matting
Urticaria at injection site; no
pain to warn of arteriolar
injection
FDA: off-label; painful
injections, necrosis,
pigmentation, matting
Too weak for large veins;
more viscous; possible
allergy; FDA off-label
Sotradecol
(Angiodynamics,
Quensbury, NY) Fibrovein
(STD Pharmaceuticals Inc,
Hereford, UK)
Asclera (Merz, San Mateo,
CA)
Aethoxysklerol (Kreussler,
Germany)
None
Scleremo (Lab Therica,
France)
Box 5.3 Expected and minor sequelae of sclerotherapy
v Hyperpigmentation (for reticular veins >3 mm)
v Edema
v Matting
v
Pain with injection
v Localized urticaria
v Vasovagal reaction
v Thrombophlebitis
v
Recurrence of treated vessels
large numbers of spider telangiectasias that are collectively
indicative of venous hypertension.
Prior to treatment, patients must understand the procedure and its limitations (Boxes 5.3 and 5.4). The patient
must be told that ‘perfect legs’ are not possible, although
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