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Treatment of Leg Veins
A B
Figure 6.11 Although pigmentation is common following the treatment of large vessels, these two photos reveal complete destruction of a
vessel in the 3 mm in diameter range without pigmentation. Variability such as this makes it difficult to determine the true impact of any
treatment strategy
treated veins of this type look worse before they look
better. Patients may be reassured using postoperative
photographs of patients with similar veins.
v 1–5 mm in diameter: Large greenish-blue vessels (i.e.,
the color of the veins on the backs of hands) are
there is some degree of reflux or venous hypertension.
Rapid results or a complete resistance are the rule with
vessels of this size. Recurrences and treatment failures as
a function of treatment methods have provoked a great
deal of controversy.
usually destroyed in one or two treatments, a process
that is often followed by clotting and pigmentation.
Vascular fragility is a highly individual matter.
Certain individuals will experience rapid destruction
of vessels not associated with thrombosis or
pigmentation using a wide range of sclerosant
concentrations (Figs 6.11, 6.12). Compression dressing
and hosiery are used to control thrombus size and
hopefully reduce hyperpigmentation. All patients
with vessels larger than 0.6 mm in diameter and less
than 3 mm in size can be expected to respond
quickly and accordingly can be treated more often,
at 1–2-week intervals.
MEASURING VEINS: MECHANICS
Perhaps the handiest tool for the phlebologist who treats
telangiectasia is the number 30 needle, which at 0.3 mm
in diameter is exactly the size above which resistance
rarely occurs when treating telangiectasias, and below
which resistance is relatively common. A number 25
needle, at 0.5 mm in diameter, is the size of the vessels
that are the bridge between vessels which fade slowly
following multiple treatments, and larger vessels that are
destroyed suddenly with pigmentation. The ability to
predict the occurrence of pigmentation and reassure
patients about its transient nature and the unimportance
varicose veins (4mm and larger)
When they occur in specific anatomical locations (great
and short saphenous vein), or they are tortuous size really
is important and the larger they are the better the chance
of small thrombi (we have euphemistically described
them as ‘trapped blood’). This allays patient concerns
about ‘clots breaking loose’. Patients are told to expect
palpable thrombi when treating certain types of veins they
are also told to regard the presence of these thrombi as
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A B
Figure 6.12 (A) This pretreatment photograph demonstrates varicose veins 4–5 mm in diameter. (B) 1 week after treatment, almost complete
resolution of these veins has occurred associated with minimal pigmentation. These results are a function of intrinsic variability and not
particular strategies
an excellent measure of the completeness of vein destruction. They are also told that recurrences are rare but new
telangiectasia may appear over time which will require
maintenance ‘touch ups’.
• Pitfalls in measuring vessels
All measurements are best carried out with the patient
recumbent using minimum tension to avoid effacement of
very small vessels or increases in vessel diameter produced
by tension. A generous dab of alcohol renders the skin
more transparent, permitting better vessel visibility. A
number of devices have been devised that use light to
trans-illuminate deeper vessels, but these are generally not
necessary.
• Measuring devices
Biersdorf-Jobst Inc. Charlotte, NC has fabricated an
extremely useful clear plastic ruler (Fig. 6.13). Bioform
Medical Inc. (San Mateo, CA) is currently developing a
measuring device of a more convenient size along with
instructions on how to employ it.
For measuring very small vessels precisely, some form
of magnification will be needed, which also make it easier
to cannulate telangiectasia which are often smaller
than the needle employed. The author prefers Optic-Aids
((Mattingly International Inc.); available at optometry
or specialty shops) (Fig. 6.14) at about 5×, but other
alternatives are feasible, depending on operator preference. Loupes, some with polarizers, and a variety of expensive and more cumbersome devices are also available.
SCLEROSANTS
‘The perfect sclerosant’, complication-free and 100%
effective has not been discovered, nor is there a gold
standard for accurately comparing different types of
sclerosants. Although complications such as matting
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Treatment of Leg Veins
Figure 6.13 Careful vein measurements are a
very effective way of predicting treatment
outcomes. This ruler, kindly provided by
Biersdorf-Jobst, is a particularly convenient way
to carry out these measurements
and hyperpigmentation have been attributed to the
type of sclerosant employed, the author’s experience suggests that sclerosant concentration and individual variability, exert the most important influences. Allergies and
tissue necrosis are related to both sclerosant type and
concentration.
Sclerosants are categorized by their primary mechanism of action: detergent, osmotic (dehydrating), and
chemical. There is no gold standard for comparing sclerosants. Although there is a great deal of controversy regarding relative efficacy and potential of various agents to
cause specific complications there is general agreement
that the use of more potent sclerosants is associated with
an increased efficacy and a concomitant increase of adverse
events. Sclerosants destroy veins by inducing thrombosis
and fibrosis. Contraindications to the use of all types of
sclerosants include hypercoagulable states, inability to
ambulate, and significant peripheral vascular disease.
Figure 6.14 Optic-Aids have proved to be the
single most comfortable method of magnifying
small vessels
Patients with serious allergies should be excluded from
treatment using detergent sclerosants. Allergies are a great
rarity following the use of modern sclerosants. Figure 6.15
documents clinical findings when serious allergies occur.
Sclerosant choices are often made on the basis of previous
experience and the biases which develop from it. Most
importantly, when variables affecting treatment outcomes
are understood, and accurate comparisons of relative sclerosant potency are established, there will be fewer arguments regarding the putative benefits or drawback of
specific types of sclerosants. Tables 6.1 and 6.2 present a
brief comparison of sclerosants.
• Detergent sclerosants
Modern detergent sclerosants enjoy worldwide use
and popularity. Although they are generally safe all
detergent sclerosants can produce serious allergic reac-
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A B
Figure 6.15 (A) Periorbital edema and respiratory difficulty occurred following this allergic response to both Polidocanol occurring in a
physicians wife following treatment with 1 mL of 1% solution. (B) Severe urtication at the injection site is also noted. In this case prompt
resolution was noted following the use of epinephrine and benedryl
77
tions (anaphylaxis), and in common with other types of
sclerosants, superficial and deep venous thrombosis,
thrombophlebitis, pulmonary emboli, tissue necrosis, and
matting. Fortunately only a handful of serious events can
be documented following decades of use. The ability to
be agitated and foamed adds another dimension to detergent sclerosant versatility.
Used by the gallon for decades, detergents such as
sodium tetradecyl sulfate (STS) and polidocanol (POL)
can be used in varying concentrations to treat veins ranging
from small telangiectasia to large varicose veins. These
agents exert their effects by disrupting intracellular
cement and extracting cell surface proteins (protein theft
denaturation). At temperatures encountered in human
tissue they exert a predictable threshold for endothelial
damage which increases with increasing concentrations.
Unfortunately when using detergent sclerosants treatment effects are not always in direct proportion to sclerosant concentration, unintended damage to interconnected
vessels at some distance from the injection site can occur.
sotradecol sulfate
While STS has never been objectively studied, it has been
used for over 60 years and ‘its safety and efficacy profile
is reassuring’. Because of its potency it is considered to be
particularly effective for the treatment of widely incompetent refluxing veins. Dilute (down to 0.1%) concentrations are used for telangiectasia and fragile reticular veins.
Increasing concentrations are used for larger varicose
veins. Intravascular injections of STS are often followed
by mild aching that increases as the concentration of this
agent increases. Although STS is reputed to cause more
hyperpigmentation than other sclerosants, this is probably
a function of excessive concentrations or unexpectedly
fragile veins. The chief drawback associated with the use
of STS is its ability to produce tissue necrosis upon
extravasation (contact) with the skin using FDA approved
and manufacturer recommended concentrations. The
extent of tissue necrosis is often related to volume extravasated and concentration employed. In contrast to IV
injections of sotradecol that usually cause mild aching,
extravasation is usually heralded by extreme discomfort;
advocates of the use of STS hail this as a warning to
immediately anticipate necrosis. The deliberate injection
of 1% sotradecol mid-dermally into a volunteer produced
tissue necrosis, injections of 0.5% solution did not produce
tissue necrosis.
polidocanol (pol)
POL is probably the most widely employed detergent
sclerosant outside the US. From 1987–2005, 46 tons (210
million milliliters) have been sold; enough to treat approximately 40 million patients. More hard data may exist
regarding the fate, distribution, toxicity, safety margins,
and clinical record of POL than is known about any other
sclerosant. It has also been subjected to exhaustive scientific studies that have never been required of any other
type of sclerosant. It also has the lowest incidence
(0.0001%) of extravasation tissue necrosis of any detergent sclerosant. There is some question in my mind
whether direct contact with tissues using polidocanol can
produce tissue necrosis. Completion of FDA approval
studies utilizing this agent for reticular and spider veins
have been completed; and it should be available for legal
use in the US early in 2010 (as Asclera™ BioForm Merz
San Mateo, CA). Manufactured in Germany under the
name Aethoxysclerol™ by the Kreussler Corp., it is also
produced in other countries and under different names.
POL began life as a local anesthetic with a low incidence
of allergies and its effect on veins was initially considered
to be a complication. As a local anesthetic it is the most
comfortable to use sclerosant currently employed. It will
not produce discomfort when injected perivascularly.
When deliberately injected mid-dermally into the arm of
a volunteer 0.4 mL at 3% concentration (the equivalent
of 1% STS), it did not produce tissue necrosis (Fig. 6.16)
although it must be said that all sclerosants can produce
necrosis under certain circumstances as revealed in
Fig. 6.17. POL is extremely safe as evidenced by its use as
a mucolytic agent in pediatric applications. It is still used
in Europe as a topical anesthetic and antipruritic.
Extremely dilute POL can produce slow but complete
endothelial damage, a feature that might be exploited by
waiting longer between treatment sessions to treat certain
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Treatment of Leg Veins
LD50 In mice NA
PE, deaths not reported
Painful, weak sclerosant
CTN in concentrations
>5%, NCTN
high risk of tissue
necrosis
LD50 in mice 90
PE, reported anaphylaxis
Painful on extravasation;
±5 mg/kg
.003%, DVT, fatalities rare
can occur with low
concentration-dependent
tissue necrosis;
concentrations and
volumes; CTN ≥1%
contraindicated in
polyallergic patients
concentrations, NCTN
LD50 in mice
PE, reported anaphylaxis
Transient urticaria and
118–145 mg/kg
varies with
.003%, lowest rate of
fatalities of any detergent
pruritus; 1/3 potency of
STS; contraindicated in
publication
sclerosant extremely rare;
cardiotoxicity
polyallergic patients;
contraindicated for
patients with peripheral
arterial disease.
LD50 in mice NA
Chromated glycerin 1
Painful, viscous,
death; intravascular
hemolysis, hemoglobinuria,
renal damage,
hyperglycemia,
hyperosmolality
treatment failures.
Chromated glycerin
illegal to use. Pure
glycerin ± additives
“off-label”
Table 6.1 Comparison of legal to use sclerosants
Clinical
Absolute absence of
Individual;
application Dosage Advantages Disadvantages Complications Animal studies
Abortifacient,
Sclerosant
Hypertonic saline (US)
allergies
restrict
volume in
patients with
spider, small
varicose veins
(10–30%)
Legal “off-label” use
Good empirical record;
can be used in large
volumes; can be
foamed
salt-restricted
diets
Maximum
single dose tx
in one day not
to exceed
10 mL of 3%
Varicose and
spider veins
1–3%. Other
concentrations
“off-label”
Sodium tetradecyl
sulfate (Sotradechol,
Bioniche Pharma
Group) US/worldwide
FDA approved 1946
Painless, allergies rare
(varies with
publication)
Not to exceed
Varicose and
Polidocanol
(0.1–0.3%); can be
foamed. Incidence of
NCTN .0001%. No CTN
at 3%
2 mg/kg
(10 mL 1%
for 50 kg
patients)
spider veins 0.5%
and 1%; other
concentrations
“off-label”
(Aethoxysklerol, Merz
Bioform) USA/Asclera™
FDA approved 2010
For reticular/spider
veins only
Mild sclerosant;
allergies rare; useful for
fragile small vessels; no
CTN, rare NCTN,
pigment rare.
Not to exceed
10 mL of pure
glycerin;
severe
reactions
never
reported using
low doses
Pure glycerin for
neurologic
applications;
chromate and with
additives for
spider veins
Three forms of glycerin;
Pure, Chromated
(Scleremo™) and with
epinephrine and
xylocaine
DVT, deep venous thrombosis; PE, pulmonary embolus; CTN, contact tissue necrosis; NCTN, noncontact tissue necrosis; NA, not available, STS, sotradechol.
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concentration Sclerosant
Treatment
frequency
Compression
reticular veins
POL = 0.5–0.75%
HS = 23.4%
STS = 0.2–0.3%
GLY = 72%
Predictable
Q 4–6
weeks
sometimes
useful
POL = 0.5–0.75%
HS = 23.4%
STS = 0.2–0.3%
GLY = 72%
Variable
Q 3–6
months
Compression
sometimes
useful
POL = 0.5–0.75%
HS = 23.4%
STS = 0.2–0.3%
GLY = 72%
Predictable
Q 4–6
weeks
sometimes
useful
POL = 0.5–0.75%
HS = 12.5–23.4%
STS = 0.2–0.3%
GLY = 72%
Predictable
Q 1–2
weeks
and reticular
veins
sometimes
POL = 0.5–0.75%
Predictable
Q 1–2
useful
Compression
HS = 23.4%
STS = 0.2–0.3%
weeks
and reticular
veins useful
GLY = 72%
POL = 0.75–1.5%
Predictable
Q 1–2
Compression
HS = 23.4%
STS = 0.3–0.5%
weeks
useful
POL = 1–3%
HS = 23.4%
STS = 0.5–2%
GLY = 72%
Predictable
Q 1–2
weeks
Compression
useful
POL = 1.5–3%
HS = 23.4%?
STS = 1–3%
GLY = 72%?
Predictable
Q 1–2
weeks
Compression
mandatory
79
Sclerotherapy
Pigment
and thrombi
Short-term
results
No. of
treatments
Previous
treatments
No
resistance
common
Rare Compression
resistance rare
50% Compression
Quick results;
resistance rare
a
>50%
Quick results;
resistance rare
NE 1–2
Magenta/
blue–green
b
>50%
resistance rare
>50%
resistance rare
>50%
resistance
Table 6.2 Parameters at a glance
Size (diameter) Color
0.1–2 mm Red No 2–4 Gradual fade No Compression
When telangiectasia occur in large numbers, more treatments may be necessary and the incidence of matting may be increased.
0.1–0.2 mm Red Yes 2–6 Gradual fade;
0.3 mm Red NE 2–6 Gradual fade;
0.5 mm Red/magenta NE 1–4
0.6–0.9 mm
1–1.6 mm Blue–green NE 1–2 Quick results;
1.6–2.5 mm Blue–green NE 1–2 Quick results;
3–5 mm Blue–green NE 1–2 Quick results;
NE, no effect; POL, polidocanol; HS, hypertonic saline; STS, sotradechol.
Important notes: (1) Vessels change color where they cross fascial gaps; (2) compression and/or reticular vein injections may both decrease number of injection sites and/or
Vessels 0.6–0.9 mm in diameter occur commonly in patients over 60 years of age, and may require lower sclerosant concentrations, particularly when vessels are thin-walled,
minimize thrombi and pigmentation in fragile telangiectasia; (3) thin-walled reticular veins 2.5–3 mm in diameter involving the lateral thighs/popliteal fossae or located over perforating
veins are often a sign of venous reflux, particularly when associated with clusters of elevated tortuous 0.6–0.9 mm in telangiectasias as in corona phlebectasia.
a
b
elevated or tortuous. Telangiectasia of this size often reflect the presence of venous reflux.
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Figure 6.16 Author’s right arm. Direct injection of 3% polidocanol into
the mid-dermis did not produce ulceration
types of fragile vessels. As with lidocaine, cardiotoxicity
can occur rarely following the use of high volumes of very
dilute solutions and following the use of high concentrations as well. The possibility of cardiotoxicity makes it
important to follow the manufacturer’s highly conservative guidelines. As an aside, I have personally used volumes
twice those recommended, in many patients, without any
problems at all. In contradistinction, large volumes of
dilute STS are not associated with cardiotoxic effects
permitting the treatment of large numbers of telangiectasia at one sitting.
detergent sclerosants: in
vitro
studies
In vitro studies comparing the effects of STS and POL on
cultured endothelial cells have established what appear to
be three cardinal principles: (1) both agents produce cell
death more quickly at high concentrations than at lower
concentrations; (2) 0.1% STS and 0.3% POL appear to
produce equivalent effects, both produce delayed cell
death within 15 seconds; and (3) dilutional effects. At
extremely low (but clinically relevant) concentrations
POL remains lethal to endothelial cells and STS does not.
These studies suggest that very dilute POL may produce
this effect by inducing sublethal cellular injury which triggers apoptosis. Figure 6.18 demonstrate the clinical implications of this phenomenon photographically.
Figure 6.17 Agents that will not produce tissue necrosis on contact
can nevertheless produce ulcers under certain circumstances. In this
case in the injection of 0.25% polidocanol was followed by a small
ulcer. The ankles are particularly prone to ulceration and these
photographs, side-by-side, document the fact that any sclerosant can
cause tissue necrosis
• Osmotic sclerosants
hypertonic saline (hs)
This osmotic agent has only two redeeming virtues. Firstly,
in its pure form the absence of allergies, and secondly
FDA approval for its use as an abortifactant makes it legal
to use off-label in the US. Uncomfortable to use (although
this can be minimized with good technique) and capable
of producing massive tissue necrosis upon extravasation of
very small volumes, HS use mandates meticulous technique. Slow healing extravasation ulcers following use of
HS are a leading cause of malpractice suits following sclerotherapy in the US. Hypertonic saline can produce tissue
necrosis at 5% concentrations and must be labeled or
segregated from other premixed solutions to prevent misidentification or mishaps that occur on a regular basis.
Unlike detergents, the effects of osmotic solutions such
as HS are confined to small, localized areas. Red blood cell
hemolysis and indiscriminant destruction of all cells within
the osmotic gradient may increase hyperpigmentation.
Potential complications also include hypertension in predisposed patients, cortical necrosis of the kidneys, occasional CNS disorders, and painless hematuria. HS in good
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A B
Figure 6.18 (A) Pretreatment photograph; (B) 17 months after treatment these photographs reveal an absolute lack of pigmentation in vessels
of this size ordinarily associated with this complication. This is another striking example of patient variability
hands is still a useful substitute for the treatment of telangiectasia in patients with significant allergies who are
not suitable candidates for the use of detergent sclerosants. Although HS is considered to be a weak sclerosant
it can sometimes be used effectively to treat larger varicose veins.
• Chemical sclerosants
glycerin and chromated glycerin
The effect of glycerin compounds on vasculature is
complex; it may involve both chemical denaturation and
detergent effects. Both glycerin and chromated glycerin
(Scleremo™) are mild sclerosants that are popular outside
the US for the treatment of telangiectasia. Viscous,
uncomfortable to use (although less so than hypertonic
saline), it is difficult to inject using a 3 mL syringe and a
number 30 needle. Employing a one-half full 1 mL syringe
facilitates the injection of this agent. Recent peer reviewed
reports (that fail to discriminate between fragile and nonfragile telangiectasia) suggest glycerin to be more efficacious than any other agents currently employed. Personal
experience suggests that glycerin has the same efficacy and
incidence of pigmentation as that seen following the use
of 0.5% POL which is more comfortable to use. Occasionally, and perhaps fortuitously, glycerin based compounds
seem to be ideal sclerosants for extremely fragile telangiectasia. At least one expert uses glycerin compounds
‘in patients who are prone to hyperpigmentation’. By
removing the chromium moiety (a source of sometimes
intractable contact dermatitis) and adding epinephrine
and lidocaine efficacy is increased, discomfort and viscosity are decreased. Unfortunately the addition of
epinepherine and local anesthetics may be associated with
cardiovascular effects and the rare occurrence of allergies.
Although one case of fatal anaphylaxis has been reported
following the use of chromated glycerin, allergic complications have not been reported following the use of pure
glycerin. In common with other weak sclerosant tissue
necrosis and pigmentation are rare. Deliberate injections
of Scleremo™ into the skin of a volunteer did not produce
tissue necrosis. Glycerin is incorporated into the Emden
Myerhoff pathway resulting in an increase in serum
glucose concentrations; it must be used with caution in
diabetic patients. This complication seems to be of only
theoretical concern when using low (10 mL <of 72%
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volumes). Mild hematuria, and ureteral colic (which was
minimized by the addition of chromium) has also been
reported. The availability of pure glycerin (glycerol) as an
osmotic agent for the treatment of intracranial pressure
makes it legal to use this agent in the US. Scleremo™
(chromated glycerin) is not legal to use.
• Clinical comparisons
All sclerosants can produce highly variable results in specific clinical settings. The author has compared commonly
used sclerosants side-by-side on the same patients. These
studies confirm a two- to threefold increase in the efficacy
of STS over POL. A 0.75% POL solution is the equivalent
of 23.4% hypertonic saline or 0.25% sotradecol. Glycerin
has the approximate sclerosing potency of 0.5%–0.75%
POL. As a general rule treatment failures increase and
complications decrease when lower concentrations of
sclerosants are used. Certain individuals will develop identical outcomes using both low and high concentrations of
sclerosants (Figs 6.7–6.9). Box 6.1 summarizes factors that
influence the choice of higher or lower sclerosant concentrations. In general the potency of any sclerosant is related
to its concentration and mechanism of action. However,
there remains an absolutely stunning degree of patient-topatient variation in terms of fragility or resistance to sclerosants (Figs 6.8 and 6.9).
• FDA approval
Physicians in the US face an astonishing Hippocratic
conundrum in which the legality for using older sclerosants is largely unrelated to the dangers associated with
their use. Agents that have been employed for almost a
century such as sodium morrhuate and ethanolamine
oleate have never been tested or approved for lower
extremity veins. Although both can be used without sanctions they are simply too complication prone for any reasonable person to use in the 21
physicians can be prosecuted for using nonapproved drugs
that are demonstrably safer. Sodium sotradecol, which has
never been subjected to rigorous safety and efficacy trials
is the only sclerosing agent ever approved specifically for
the treatment of lower extremity venous disease. Any
modification of approved protocols using this agent includ-
Box 6.1 Factors affecting choice of sclerosant concentration
v Higher concentrations
v Younger patients
v Thick-walled vessels (use palpation)
v Hand/feet/pretibial veins
v Breast veins
v Vessels >4 mm in diameter to compensate for dilution
v Lower concentrations
v Age >60 years
v 0.6–0.9 mm in diameter elevated spider veins
v Thin-walled vessels
v Easy bruisability
v History of spontaneous bleeding following minor trauma
st
Century. Conversely,
ing dilution or failure to test patient tolerance first makes
the use of STS ‘off label’. The decision to use a particular
type of sclerosant must take into account patient safety,
medicolegal liability, and the advantages of a particular
agent in a specific application. Certain insurance carriers
will not cover the use of non-FDA-approved medications
and in at least one case a physician’s license was revoked
when he treated patients whose medical insurance specifically prohibited the use of non-FDA-approved agents
(personal communication).
COMPRESSION
Compression both in the form of dressings and graduated
hosiery, essential when treating large vessels, is also
reputed to confer a number of advantages when treating
telangiectasia. Claimed benefits include reduction of pigmentation and thrombosis, faster treatment results, and
longer lasting improvement. Recent articles published in
peer reviewed journals recommend that class II hosiery
(30–40 mmHg of compression) should be worn 24 hours
a day for one week followed by another three weeks of
continuous compression with class I (hosiery 20–
30 mmHg). Unfortunately compression methods of all
types have their own set of problems.
High compression hosiery can produce vascular compromise when recumbent. In a recent case (unpublished
data) a 74-year-old woman without signs or symptoms of
peripheral arterial disease (PAD) developed what appeared
to be reduced arterial perfusion followed by reactive
hyperemia, observing ‘my feet turned black’, after removing 15–20 mmHg compression hosiery that she had worn
continually for two days. There were no other symptoms.
The patient is a heavy smoker who may not exercise
enough to unmask PAD symptoms. When treating patients
with elevated risk factors for PAD a particularly careful
evaluation should be carried out. This might include
testing for the presence of hypercholestrolemia, a careful
review of symptoms associated with PAD coupled with
inspection and palpation for physical signs of PAD
(absence of pedal pulses).
Tape dressings that use microfoam tape occasionally
produce folliculitis or allergies and require a waterproof
covering when the patient bathes. Problems also occur
when prescribing graduated (tighter around the foot and
ankles) hosiery to treat patients who have podiatric disorders such as bunions, diabetic neuropathy and neuromas.
Particular caution is imperative when prescribing compression hosiery for these individuals. Compliance is also
a problem. Very few patients will wear this hosiery during
the summer months. Pantyhose are associated with vaginal
candidiasis, a difficult problem particularly for those who
have had previous infections. Some patients complain
about abdominal pressure and difficulty breathing. The
prescription of thigh-high hosiery, even though it often
requires garters or It-Stays™ adhesive (AllegroMedical.
com), sometimes circumvents both problems. SigVaris™
(Peachtree City, GA) and others fabricate hosiery that has
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an adhesive inner band. For patients unable to tolerate
heavier compression around the feet, it is sometimes beneficial to cut the feet out of the hosiery and stitch the
fabric so it does not unravel. This method can only be used
when veins are located where compression remains adequate with the hosiery feet removed.
To determine the importance of compression hosiery
when treating vessels ≤
carried out side-by-side comparisons using 20–30 mmHg
graduated compression hosiery on one leg and no compression on the other. In this study which involved 50
patients, no significant difference in treatment outcomes
was observed. Compression appears to be most useful in
treating varicose veins that occur below the knees. Kneehigh hosiery, although easy to don and less uncomfortable
in hot weather, must be properly fitted to avoid circulatory compromise. When prescribing knee-high hosiery,
the physician should ensure the availability of trained
fitters and discuss with patients the signs and symptoms
of circulatory compromise (pain, numbness, tingling or
swelling). When this occurs patients are told to discontinue wearing the hosiery and call the office for advice.
Compression (20–30 mmHg) is routinely used for
vessels >2 mm in diameter, and for all patients who are
symptomatic, or have obvious reflux. Class II hosiery
(30–40 mmHg) is worn during the day and TED hosiery
is worn at night after treating large refluxing vessels using
foam. For patients with very fragile vessels (0.6–0.9 mm
in diameter), there may be some value in using compression as well. Light compression hosiery (8–20 mmHg) is
an excellent adjunct for reducing fatigue and enhancing
long-term treatment results and reducing discomfort for
patients whose work requires long periods of standing or
sitting. Patients with varicose veins should not be treated
if they plan to take extended trips sooner than thirty days
post treatment. They are also advised to wear hosiery
during the travel process, avoid alcohol and coffee (they
are diuretics) and drink copious amounts of liquids. They
are also encouraged to take aspirin or ibuprofen and ambulate while they’re in the plane if the trips are over two
hours. They are also counseled to avoid placing luggage or
other items which inhibit their ability to ambulate. Ambulation is also facilitated by avoidance of high-heeled shoes
which reduce calf muscle function when walking. Lawsuits have been filed when patients developed thrombophlebitis or pulmonary emboli on long flights 1–2 weeks
after treatment (personal communication).
2 mm in diameter, the author
TELANGIECTASIA CLINICAL PRESENTATIONS
AND OUTCOMES
Patients who present with extensive telangiectasias will
often require more treatments, even though every vessel
is sclerosed at each treatment session. These patients
probably have a defect in the control of vessel growth and/
or reflux or venous hypertension. Patients with numerous
large telangiectasias (>
0.6 mm in diameter), particularly
those which are elevated or patients with any veins 3 mm
in size or over are likely to have reflux or venous hypertension. Patients who present with small numbers of previously untreated telangiectasias generally enjoy more rapid
results, commonly require fewer treatments, and develop
less matting or second-generation vessels than those who
present with large numbers of telangiectasias.
• Common complications
hemosiderotic hyperpigmentation etiology
A variety of theories have been proposed regarding the
etiology and histological findings in hyperpigmentation. It
has been attributed to a large number of factors including
specific sclerosant types, excessive sclerosant concentrations, failure to use compression, skin color, and failure to
drain thrombi. It has also been attributed to excessive
levels of hemoglobin or serum ferritin, but does not occur
more frequently in patients with hematochromosis.
Patients who are being treated with minocycline also may
develop a specific type of hyperpigmentation. The finding
that hemosiderotic hyperpigmentation occurs very rarely
following the treatment of veins of certain anatomical sites
has never been explained. To my knowledge there is only
one anecdotal case of pigmentation reported following the
treatment of hand veins and I have never observed it following the treatment of vessels of any size located on the
breast, hands, or torso. Hemosiderotic hyperpigmentation
is usually temporary, resolving slowly in 80% of treated
patient between six months and two years. Although some
authorities suggest that melanocytes play a role, to date
no biopsies carried out in the US reveal the presence of
melanocytes. Accordingly, bleaches of various types
appear to be ineffective in treating it. For persistent
hyperpigmentation Q-switched and pulsed dyed lasers
have been successfully although generally this is an unnecessary and expensive alternative.
• Clinical subtypes
The author’s experience suggests that pigmentation occurs
in two clinical settings. Firstly, within several hours after
treatment, when fragile veins are suddenly and completely
destroyed tattooing insoluble hemosiderin in surrounding
tissues. This type of pigmentation occurs so quickly that
it is probably unaffected by compression or subsequent
thrombectomy. Secondly, gradual (seepage) pigmentation in which hemosiderin slowly leaks into the surrounding tissue as a result of partial destruction of the vessel
walls. This type of pigmentation may be improved by
expressing thrombi, or the use of post treatment compression. The injection of reticular veins to minimize hyperpigmentation and telangiectasia has been advocated as a
means of reducing hyperpigmentation. Unfortunately as
noted earlier reticular veins may be more fragile than
associated telangiectasia responding with quick destruction and pigmentation using sclerosant concentrations that
have no effect on very small telangiectasia.
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