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Treatment of Leg Veins
INTEGRATING THERAPEUTIC OPTIONS
Treating varicosities successfully requires rational selection of interventions (Fig. 5.8). To choose the optimal
therapeutic technique, physicians must first diagnose the
origin of the reflux. Physical examination is necessary to
determine whether the surface telangiectasias originate
from a deeper source of incompetence. To make this
determination, it is necessary to have adequate knowledge
of the superficial venous anatomy and possess the proper
diagnostic tools and equipment, including ultrasound
devices. If present, reticular or larger varicose veins should
be eliminated first either surgically or through endovenous
ablation. This should be followed by sclerotherapy of the
remaining vessels, from largest to smallest. Vessels that do
not respond to sclerotherapy, that are too small to be
injected, or that remain after sclerotherapy, should be
considered for laser and light treatment. A primary indication for laser and light sources is telangiectatic matting
(Fig. 5.8).
FURTHER READING
Bergan JJ 2007 The Vein Book. Elsevier Academic Press,
Philadelphia
Breu FX, Guggenbichler S 2004 European Consensus Meeting on
Foam Sclerotherapy. Dermatologic Surgery 30:709–717
Goldman MP, Bergan JJ, Guex JJ 2006 Sclerotherapy: Treatment
of Varicose and Telangiectatic Leg Veins. Mosby, London
Hsu TS, Weiss RA 2003 Foam sclerotherapy: a new era. Archives
of Dermatology 139:1494–1496
Iafrati MD 2005 Subfascial endoscopic perforator vein surgery.
Seminars in Cutaneous Medecine and Surgery 24:209–215
Min RJ, Khilnani N, Zimmet SE 2003 Endovenous laser treatment
of saphenous vein reflux: long-term results. Journal of Vascular
Interventional Radiology 14:991–996
Palfreyman SJ, Michaels JA 2009 A systematic review of
compression hosiery for uncomplicated varicose veins.
Phlebology 24(Suppl 1):13–33
Ramelet AA 2002 Phlebectomy. Technique, indications and
complications. International Angiology 21(Suppl 1):46–51
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Sclerotherapy
David M. Duffy
INTRODUCTION
The object of this chapter is to enable the reader to
recognize a variety of clinically observable features that
underlie the occurrence of successful or unsuccessful
results following sclerotherapy. For the sake of brevity, a
number of the strategies and concepts that have evolved
and proved useful in the treatment of thousands of
patients over a 32-year period will be presented in bullet
list, table, or question and answer formats. For many
dermatologists, telangiectasias and small reticular veins
unassociated with significant venous disease will be present
in most of the patients who request treatment. Accordingly, the preponderance of information presented here
will deal with small vessel sclerotherapy.
• Variability
Sclerotherapy, which employs chemical cauterants to
scarify and obliterate vascular tissue, is very much an art
and not a science. Modalities that deliberately destroy
tissue can produce a wide range of responses that are not
always easy to predict or precisely control. An enormous
number of variables make it difficult to create uniform
treatment protocols including: (1) the inability to standardize venous tissue or treatment techniques; (2) unpredictable variation in sensitivity to sclerosants not only
from patient-to-patient, but between different vessels of
the same size on the same patient; and (3) the influence
of multiple, clinically distinguishable but largely uncharacterized venous subtypes, anatomical location, and circulatory connections between visible veins and the deeper
venous circulation. Unexplained innate variability and lack
of understanding about the multiple factors that affect it,
has provoked a great deal of controversy regarding the
‘ideal’ way to treat unwanted veins. Personal experience,
confirmed by review of tens of thousands of before and
after photographs, suggests that:
v Of all the identifiable characteristics that affect
treatment outcomes, vessel size is often the best
(but not the only) prognostic factor of treatment
outcomes and the occurrence of common
complications (Fig. 6.1).
v There is no cure for varicose or spider veins, and
good or bad results can occur using any treatment
protocol.
v What happens in the short term often changes in the
long run.
v No single treatment ‘recipe’ will consistently produce
optimum results.
v Treatment of telangiectasias 0.5 mm in diameter and
smaller will often provide the greatest range of
outcomes and patterns of response, while vessels
larger than this size usually respond to treatment
much more predictably.
v Good results can be obtained by treating
telangiectasia directly without treating reticular veins.
v Reticular veins are sometimes more fragile than
associated telangiectasia and can be destroyed with
pigmentation/matting, sometimes leaving
telangiectasia unaffected (Fig. 6.2).
v Adequately treated telangiectasia rarely recur,
photographic analysis reveals that ‘most recurrences
are in fact new vessels’.
• Divide and conquer
From the standpoint of treatment strategies and expected
outcomes it is useful to divide sclerotherapy into
three broad categories. (1) Large-vessel sclerotherapy,
which treats refluxing axial varicosities (saphenofemoral
and saphenopopliteal junctions), nonsaphenous truncal
varicosities, perforators and large (>
reticular veins. (2) Small vessel sclerotherapy which
deals with telangiectasia and reticular veins <
(3) Sclerotherapy which deals with non-lower extremity
veins i.e. veins located in other anatomical sites,
AV malformations, etcetera. Although sclerotherapy
has generally been considered to be the treatment of
choice for small lower extremity vessels, it has long been
regarded as a poor second to surgical intervention for the
treatment of junctional reflux and large varicose veins. The
use of foamed sclerosants under duplex guidance and
imaging techniques which are facilitated by the use of
foams may produce results which compare favorably with
surgery.
3 mm in diameter)
3 mm in size.
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Treatment of Leg Veins
B
A
Figure 6.1 Measurements of vessel size reveal typical variability associated with specific vessel sizes
ADVANCES IN LARGE VESSEL
SCLEROTHERAPY
• Foamed / detergent sclerosants
First described over 70 years ago, detergent foams are
generally considered to be three to four times more potent
than equivalent concentrations and volumes of liquid sclerosants. Increased potency is related to several factors,
including an increase in the effective surface area of foams
compared with liquid, and the displacement of blood from
the treated vein, which produces prolonged undiluted
intimal contact.
Foams also produce increased vasospasm and sclerosis
of veins at a greater distance from the injection site than
liquid preparations, and may be used in much smaller
volumes and concentrations (with presumably less risk of
tissue necrosis or allergies). Foams are ‘dramatically more
visible’ than liquids on duplex imaging, facilitating needle
placement and the ability to monitor sclerosant flow in
real time, they have also proved useful in a wide range of
other applications. Wollmann (2004) has exhaustively
detailed both the history and enormous number of variables (e.g., bubble size, uniformity, temperature, sclero-
sant/gas – room air versus CO2, type of sclerosant, etc.)
that impact the clinical effects of foam preparations.
Although foam sclerotherapy has the potential to revolutionize the treatment of large refluxing veins, it is at this
time very much in the early phase of integration into
common use.
For large vessels associated with significant reflux, some
combination of foam sclerotherapy, surgical intervention,
and endovenous laser or radiofrequency devices may be
employed synergistically by individuals experienced in
their use. Good results using any modality often depend
not so much upon the specific treatment employed, but
on the expertise of the practitioner.
foam disadvantages
Foam takes time to prepare, deteriorates quickly at room
temperature and is difficult to aspirate. Foam preparations
are generally not suitable for the treatment of telangiectasia and small reticular veins and are associated in that
setting with an increased tissue necrosis, pigmentation and
neovascularization (matting); phlebologists who believe
that refluxing reticular veins are the ‘cause’ of telangiectasia sometimes combine dilute foamed sclerosants to treat
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A B
Figure 6.2 (A) This reticular vein measuring 1.3 mm in diameter was cosmetically unattractive to this patient. (B) A post-treatment photograph
reveals neovascularization (matting) which was even more unattractive to the patient. Although almost nothing has been published regarding
complications following injection of reticular veins, the author has found matting to be a relatively common occurrence in this area
‘feeding’ reticular veins while using liquid sclerosants to
treat telangiectasia. No commercially produced standardized foam preparations are available; extemporaneous
preparations of foam are hard to duplicate making it difficult to establish uniform treatment protocols which
compare the efficacy of different types of foam in specific
applications. In addition, the US FDA has not scrutinized,
let alone approved, any type of foam for any purpose.
When treating patients with asymptomatic patent foramen
ovale (that occurs in around 25% of the population) foam
may lodge in the cerebral circulation resulting in temporary ischemia associated with migrainoid visual disturbances, amaurosis, and strokes. The substitution of CO
for room air (which provides better control over bubble
size and endothelial adhesion) may decrease the risk of
embolization. Complications associated with extremely
potent sclerosants should also be expected to increase
following foam sclerotherapy. These include an increased
risk of uncontrolled thrombosis and destruction of vascular tissue outside targeted veins.
duplex problems
Although real-time duplex imaging is an invaluable aid to
placing needles in the right position, it is by no means
perfect. Duplex scans, after all, are a two-dimensional
view of a three-dimensional process. In at least one case,
a lawsuit has been filed (unpublished personal communication) when severe tissue necrosis necessitating in the
amputation of a lower limb occurred despite the use of
duplex guidance during the administration of foam. The
concentration of foam in this case may have been much
greater than recommended by most authorities.
2
personal experience with foam
Over the last several years the author has treated approximately 600 patients presenting with a wide range of
vessel types using one part polidocanol (POL) to three or
four parts room air prepared using the double-syringe
method. The author has found foam preparations to be
particularly effective for refluxing vessels 4–5 mm in
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Treatment of Leg Veins
diameter but unnecessarily cumbersome and no more
effective than liquid sclerosants for smaller vessels, particularly telangiectasia. Viscous foams are difficult to
inject through a number 30 needle. The use of foam also
necessitates certain technique changes aimed at keeping
the foam in contact only with the treated areas. This
includes post treatment elevation of the treated extremities, and a several minute delay following treatment before
applying compression. These techniques may minimize
displacement of foam into areas where unintended thrombosis can occur. Spot compression using tape dressings and
padding must also be applied after a delay to avoid displacement of residual foam. When I first started using
foam a tenfold increase in the occurrence of superficial
thrombophlebitis was observed following the use of foam
compared with liquids. Ordinarily, a patient only requires
one thrombectomy to evacuate thrombi in treated vessels.
However, following the use of foam preparations, recurrent thrombi and thrombophlebitis occurring up to one
to two months after treatment necessitated multiple
thrombectomies. The use of lower volumes and sclerosant
concentration and the application of class II compression
hosiery has essentially remedied these problems.
• Small-vessel versus large-vessel
sclerotherapy
Several important differences separate the treatment of
small vessels from symptomatic large refluxing varicose
veins. Varicose veins are treated as a medical necessity,
and appropriately billed for insurance compensation.
Lower extremity small-vessel sclerotherapy and sclerotherapy for vessels located in other areas is often, but not
always, an elective cosmetic procedure (although lower
extremity telangiectasia and small reticular veins are occasionally symptomatic). Patients need to understand that
insurance companies should not be expected to pay for
cosmetic procedures. They should also be counseled
regarding the need for multiple treatments, and the
possibility of minor and sometimes major complications.
Individual risk factors for common complications should
be explained. Patients who seek treatment for cosmetic
problems sometimes express unrealistic expectations
which must be addressed by very careful oral and written
instructions, photographs, and consent forms.
ADVANCES AND ALTERNATIVES FOR
THE TREATMENT OF SMALL VESSELS
Advances in small-vessel sclerotherapy are evolutionary,
not revolutionary. Although some authorities have proposed specific guidelines, there are very few absolutes.
Controversies regarding small-vessel sclerotherapy
involve the importance of venous reflux and venous hypertension, the need (or lack thereof) to treat large vessels
before small, and the importance of compression when
treating telangiectasia. Current orthodoxy designates
refluxing reticular veins as a prime etiologic factor for the
development of telangiectasia; although Green (1998) and
others have presented credible arguments which challenge
this concept. Transdermal lasers which need to traverse
the skin, work very well for facial telangiectasia. For the
treatment of lower extremity veins, although heavily promoted, lasers are expensive, painful, time consuming, and
decidedly inferior alternatives to sclerotherapy as noted
(Figs 6.3, 6.4). Their use should be reserved for patients
who are allergic to sclerosants, are needle phobic, or have
veins too small for inexperienced phlebologists to cannulate. Lasers have also been advocated for the treatment of
telangiectasia that have proved unresponsive to previous
sclerotherapy (matting) or to treat patients ‘prone’ to
matting. Unfortunately lasers are often unsuccessful in all
these settings. In contrast, endovenous radiofrequency
and laser devices are becoming more popular for the
treatment of refluxing axial varicosities and certain
types of reticular veins. Some of this popularity may be
due to favorable insurance reimbursement policies which
promote the use of these modalities.
CLASSIFYING VEINS, NEW PARADIGMS
In 1988, the author formulated a classification system
which included approximate vessel size, anatomical features, color, and relationship to the saphenous system.
This classification in an expanded more sophisticated form
has resurfaced in later publications. Although this earlier
scheme has proved useful for categorizing and optimizing
treatment of specific types of veins it neither factors in
the existence of a large number of other variables which
affect treatment outcomes, nor acknowledges the relationship of vessel size to intrinsic patterns of long and
short-term responses to sclerotherapy. In addition, it fails
to emphasize the clinical importance of a specific class of
extremely resistant telangiectasia (usually 0.2 mm and
smaller), which develop after previous sclerotherapy
treatments. This phenomenon may represent persistent
long-lasting vascular remodeling initiated by the trauma of
sclerotherapy in patients with poor control over vessel
growth. Vessels of this type are a source of great frustration for patients.
• Basic patterns of response
Although a large number of interactive variables affect
treatment outcomes, three fundamental patterns of
response can be predicted largely on the basis of vessel
size. Since almost all patients present themselves with
veins of various calibers a mixture of these patterns is
commonplace.
1. Gradual destruction (telangiectatic pattern) in which
small telangiectasia fade and fragment, a process not
usually not associated with pigment or palpable
thrombi occurring following multiple treatments over
several months (small vessel pattern; Fig. 6.5).
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A B
Figure 6.3 These photographs present results obtained following one injection. Sclerotherapy is less painful, faster and less expensive than
laser treatments for lower extremity veins
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A B
Figure 6.4 These photographs present results obtained following three treatment sessions using both intense pulsed light and the 1064
Nd:YAG laser. In this case, $200,000 dollars worth of electronic gadgetry produced results that could have been duplicated with $0.25 of
sclerosing solution and a lot less pain
Extremely dilute sclerosants can sometimes produce
these effects more slowly with fewer complications
(and more treatment failures).
2. Rapid destruction (large vessel pattern) are typically
associated with pigment and palpable thrombi,
this pattern can occur within hours after treatment
(Fig. 6.6). In contrast to the treatment of small
telangiectasia which are relatively insensitive to
changes in sclerosant concentrations, outcomes
obtained following treatment of large telangiectasia,
reticular veins, and varicose veins, are sensitive to
changes in sclerosant type, concentration and the use
of compression.
3. Resistance (two types). Although veins of any size
can fail to respond to treatment there is a clear
difference between dilutional resistance that occurs
following treatment of larger vessels and
microtelangiectatic resistance that occurs in very
small vessels. Dilutional resistance can often be
overcome using more concentrated sclerosants,
foams, or more vigorous compression. In contrast,
resistance occurring in very small telangiectasia
(0.1–0.2 mm in diameter) is usually unaffected or
worsened by increasing sclerosant concentrations.
This type of resistance is poorly understood. It has
been attributed to venous hypertension, failure to
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A B C
Figure 6.5 (A) Pretreatment appearance of vessels involving the inner knee, varying in size from 0.1 mm to approximately 0.5 mm in diameter.
(B) This photograph taken 3 months after two treatments reveals complete disappearance of the large vessels with substantial fading in the
smaller ones, a typical pattern. (C) This photograph taken 10 months after the second treatment reveals almost complete resolution. The inner
knees are an area subject to matting and should be treated cautiously with low concentration of sclerosants
A B
Figure 6.6 (A) These pretreatment photographs reveal fragile, thin-walled, elevated tortuous vessels 0.6–1.0 mm in diameter. (B) This photo
demonstrates pigmentation, which can occur following low sclerosant concentrations when treating vessels of this type
treat reticular veins, or to employ compression.
The authors experience suggests that this type of
resistance is more complex and may be unassociated
with any of the ‘predisposing’ conditions. A more
detailed description of this type of resistance will be
presented later in this chapter.
• Vessel size: The new golden rules
Vessel size is by far the most meaningful prognosticator
for treatment outcomes although many other variables
affect the process. This is not to say that veins will always
respond stereotypically on the basis of vessel size alone.
The concentration of sclerosant necessary to destroy veins
varies a great deal from person-to-person, while vessels of
the same size will sometimes display similar patterns of
response despite wide variations in sclerosant concentrations (Figs 6.7, 6.8). Given this degree of variability it is
prudent to consider typical patterns rather than make
precise predictions. When treating telangiectasia 0.5 mm
and smaller, miniscule (0.1 mm) changes in vessel size can
produce fundamental differences in both treatment
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A B
Figure 6.7 (A) Pretreatment photograph, vessels measured 0.6–1.0 mm in diameter were elevated and tortuous. (B) Results were seen 1 week
after one treatment with 0.5% polidocanol
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Figure 6.8 This photograph reveals thrombosis and pigmentation
noted 6 weeks after one treatment with 3% polidocanol. Equivalent
results can often be obtained using vastly different sclerosant
strengths. Accordingly, strategies relating vessel size to sclerosant
concentrations are a highly individual affair
response patterns and the occurrence of common complications. Although sclerosant concentrations and other
factors can alter treatment responses, careful measurement of vessel size will often accurately predict:
v Whether vessels will respond gradually to repeated
treatments (usually without associated pigment or
thrombi).
v Whether vessels respond rapidly (often associated
with thrombi and pigmentation).
v Be resistant to treatment.
v The number of treatments necessary.
v How long vessels have been present.
v Complications (pigment, thrombi, resistance).
v Likelihood of underlying reflux/venous hypertension.
v Optimal sclerosant concentrations.
v Sensitivity to changes in sclerosant concentration.
v The need for compression.
• A word about the literature and vessel size
definitions
By convention, tortuous, dilated veins 4 mm and larger in
diameter are defined as varicose veins. The term reticular
vein designates veins between 1–3 mm in size. Telangiectasia are defined as veins between 0.1–1 mm in
diameter, although the terms capillaries, telangiectasia,
and venulectasia are used interchangeably.
telangiectasia
Phlebology literature at large views all vessels between
0.1–1 mm in diameter as a homogenous entity. One
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Treatment of Leg Veins
author notes that the only difference between varicose
and telangiectatic leg veins is size. In truth, telangiectasia
constitutes a extremely heterogeneous group of vessels
both from the standpoint of etiology and response to
treatment. They do not always respond to treatment like
tiny varicose veins. There are at least seven categories of
lower extremity telangiectasia between 0.1 mm and
0.9 mm in diameter. Each exhibits a more or less typical
pattern of response and sensitivity to sclerosants as well
as distinct differences involving a host of other variables.
When practitioners attribute optimal results (particularly the number of treatments to eradicate telangiectasia
and/or occurrence of pigmentation or thrombosis) to some
technique strategy, their observations have limited utility
unless the specific size of the telangiectasia is duly noted
in 0.1 mm increments. Telangiectasia (≤0.3 mm in
diameter) routinely require several treatments for eradication. The use of higher concentrations will often not
produce more rapid results, pigmentation, or palpable
thrombi. Concentrated sclerosants will, however, routinely produce more neovascularization (matting). Conversely, telangiectasia ≥
respond more quickly with more pigmentation and thrombi
when higher concentrations of sclerosants are employed.
0.4 mm in diameter will often
• Categorizing vessels by size / effect of
previous treatments upon microtelangiectasia
There are two types of very tiny telangiectasia which
although they look alike respond quite differently to
treatment.
responsive microtelangiectasia
v 0.1–0.2 mm in diameter: Previously untreated
(virgin) veins in this size range can usually be
effectively treated. They often require at least three
treatments to induce a slow process of fading, which
may involve the body’s own genetic machinery to
destroy partially damaged cells in the vessel walls
(apoptosis). The use of higher concentrations often
will not produce faster results and may lead to more
matting. This type of vessel often occurs in the
absence of reflux. Compression and the injection of
reticular vein does not appear to be of any value
when treating this type of vessel. Treatment is
usually carried out at 4–6-week intervals. Resistance
is extremely uncommon in previously untreated
vessels measuring <
is extremely rare for all vessels in this size range
(Fig. 6.5).
0.2 mm in diameter. Pigmentation
resistant telangiectasia (matting/
second-generation vessels)
v 0.1–0.2 mm in diameter: Vessels in this size range
which remain or occur after previous treatments,
are often refractory to treatment within a given
time frame, and are the number one cause of
dissatisfaction following small-vessel sclerotherapy
(Fig. 6.9). This type of vasculature is most common
on the inner and outer thighs within 25 cm of the
knees. The author’s experience suggests that vessels
A B C
Figure 6.9 (A) Pretreatment photographs reveal vessels varying in size from 0.2–0.8 mm in diameter. (B) This photograph, taken approximately
1 year later reveal extensive neovascularization resistant to several treatments carried out over a 6-month period. (C) 1 year later these
neovascular vessels had resolved spontaneously. Deferred treatments are often the best way to approach neovascularization (matting)
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73
of this type are best treated by tincture of time,
being treated no more than two to three times
yearly. With sufficient time these vessels may resolve
spontaneously or become responsive to sclerotherapy
and other modalities. Once again, compression and
injection of reticular veins or elimination of reflux do
not appear to result in predictable benefits.
v 0.3–0.5 mm in diameter: Good news begins at
0.3 mm. These vessels usually require several
treatments and fade slowly over several months
without pigmentation or thrombi. The usual
treatment interval for vessels in this size range is
every 4–6 weeks, whether or not the patient has
been treated before. As vessels become fractionally
larger, a second (large-vessel pattern) supervenes. At
0.4 mm and 0.5 mm in diameter, pattern overlap
occurs. Vessels of this size can undergo the smallvessel fading pattern or be destroyed rapidly, a
process sometimes associated with pigmentation and
thrombosis. About 25% of vessels measuring 0.4 mm
and about 50% of those measuring 0.5 mm will
respond rapidly. Changes in concentration may
affect rapidity of this process. Higher sclerosant
concentrations are routinely associated with more
rapid results associated with increased thrombosis
and pigmentation (Figs 6.8, 6.10). In some cases,
injection of reticular veins that are in direct
communication with clusters of larger telangiectasia
produce dilutional effects that may reduce
hyperpigmentation in fragile telangiectasia. This
technique also permits fewer needle sticks. In other
patients, injecting the reticular veins does not appear
to modify outcomes one way or another. Although
experts ‘feel’ that sclerosing reticular (feeder) veins is
a uniformly good way to treat telangiectasia. No one
has ever carried out long-term studies to determine
if reticular veins have been sclerosed and if so,
how long.
v 0.6–0.9 mm in diameter: Vessels in this size range
are often purple or blue–green in color. They can be
extremely fragile and often have been present for
many years (Fig. 6.6). Clusters of elevated and
tortuous vessels of this size suggest longstanding
venous hypertension or reflux. Their presence should
prompt a thorough evaluation. These vessels usually
require only one treatment. It may also be beneficial
to employ more dilute sclerosants and/or
compression to minimize pigmentation and clotting
that routinely follows treatment. A constellation of
bruising, thrombi, and pigmentation often makes
A B
Figure 6.10 (A) Pretreatment photographs, vessels 0.5–0.8 mm in diameter elevated and tortuous. (B) This post-treatment photograph taken
3 months after two treatments using 0.06% polidocanol produced a more gradual destruction with less thrombosis than a single injection of
0.5%, an eightfold difference in concentration.
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