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CHAPTER
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14
Sclerotherapy Treatment of Telangiectasias
ROBERT A. WEISS and MARGARET A. WEISS
INTRODUCTION
Isolated small reticular veins and telangiectasias often
cause severe symptoms that are worsened by prolonged
standing or sitting and may be relieved by wearing support
hose or by elevation of the legs.1 Vein size alone does not
predict the presence of symptoms. Vessels causing symptoms may be as small as 1 mm in diameter or less.2 Besides
symptoms of pain, burning, and fatigue, women typically
curtail their activities and modify their lifestyles to avoid
situations in which their legs are easily seen. Sclerotherapy
not only offers the possibility of remarkably good cosmetic
results, but also has been reported to yield an 85% reduction
in symptoms.1 Prior experience with venipuncture helps
very little with treatment of larger veins and is completely
irrelevant in the treatment of the smallest veins. Successful
treatment requires the correct technique, the correct diagnosis, and the correct treatment plan for the type and size of
vein to be treated.
TELANGIECTASIA FROM
RETICULAR VEINS
Telangiectasia can develop due to refl ux from reticular
veins, thin-walled blue superfi cial venules that are part
of an extensive network of the lateral subdermic venous
system; a system that is separate from the saphenous
system. A typical network is shown in Figure 14.1. Reticular veins associated with telangiectasia are commonly
called “feeder” veins. Both handheld Doppler and duplex
ultrasound has been used to map the path of transmission
of venous hypertension from small reticular veins into
telangiectasia.
3,4
ISOLATED ARBORIZING WEBS
High-pressure refl ux through failed valves is at the root
of nearly all telangiectatic webs, although there are some
exceptions due to A-V malformations or shunts. This has
been estimated to occur approximately 1 in 20 times,
although this may be a high estimate.5 Typically, localized
valve failure will produce arborizing networks of dilated
cutaneous venules that are direct tributaries of underlying
larger veins. Arborization occurs through a recruitment phenomenon in which high pressure causes dilatation of a
venule, failure of its valves, and transmission of the high
pressure across the failed valves into an adjacent vein. Treatment of an arborizing system must be directed at the entire
system, because if the point source of refl ux is not ablated,
the web will rapidly recur.
PRETREATMENT INSTRUCTIONS
Patients are told to wear shorts and not to use moisturizers or shave their legs on the day of treatment. Shaving
the leg may cause erythematous streaks, making it diffi cult
to visualize patterns of reticular and telangiectatic veins. Use
of moisturizers causes poor adhesion of tape used to secure
compression following injections and causes slower
evaporation of alcohol used to prep the leg. Patients are
encouraged to eat at least a small meal beforehand in order
to minimize vasovagal reactions.
The Vein Book
133
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Copyright © 2006, Elsevier Inc.
134 Chapter 14/Sclerotherapy Treatment of Telangiectasias
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FIGURE 14.1 Typical telangiectatic web-reticular vein complex of the
lateral subdermic venous system.
FIRST TREATMENT TEST
The fi rst treatment session usually is limited to a small
number of sites in order to observe the patient for any
allergic reactions and the ability to tolerate the burning or
cramping of a hypertonic solution, to judge the effectiveness
of a particular concentration and class of sclerosing agent,
and to observe the ability to comply with compression. It also
serves to familiarize the patient with the treatment, treating
physician, clinic surroundings, and the sensation of the fi ne
needle. This allows more extensive treatment on the second
visit with the patient being familiar with the technique and
surroundings. The test site also complies with the suggestion
in the package insert of sodium tetradecyl sulfate (STS)
(SotradecolTM, Bioniche Pharma, Belleville, Ontario).
When the patient returns in four to eight weeks, the test
site or limited treatment area is compared with pretreatment
photographs. Any side effects such as matting and pigmentation can be explained to the patient. Reasonable time intervals for clearance of treated vessels can be reinforced. At
each session, all sites treated are noted in anatomic diagrams
in the chart.
FIGURE 14.2 Foam mixture of STS 0.1% comprised of liquid sclerosant
agitated with air at a ratio of 1 part liquid to 4 parts air. Here the foam is
seen injected into a reticular vein. Foam is visualized in the vein up to
arrow.
the reticular vein, with injections every 3–4 cm along the
feeder.
Our typical treatment regimen is to foam or agitate STS
at 0.1 to 0.2% using a ratio of one part sclerosant to four
parts air. This foam mixture is injected into reticular veins
that are directly connected to visible telangiectasias (see
Figure 14.2). It is not advisable to treat every reticular vein
of the thigh; only those reticular veins visibly connected to
a telangiectatic web should be targeted.
As sclerosing solution/foam fl ows away from the point
of injection, it is clearly seen for a distance of several centimeters before it is diluted by blood and becomes less
potent.
When injecting a reticular vein, the sclerosing foam is
sometimes seen fl owing into the telangiectasia. When this is
observed, the telangiectasias do not need to be injected
directly. Similarly, sclerosing solution injected into a telangiectasia may be seen fl owing into the feeder vein, but
reticular veins usually still need to be injected directly,
because it is diffi cult to deliver an effective volume and
concentration of sclerosant foam to the reticular vein
indirectly.
With increasing experience and recognition of common
patterns, injection sites are based on known patterns of
refl ux. For example, reticular veins usually feed a group of
telangiectasias on the lateral thigh from a varicose lateral
subdermic venous system. During the treatment session,
treatment would begin with reticular veins from which refl ux
is suspected to arise and would proceed along the course of
TREATMENT PLAN
TECHNIQUE
The technique used for injection of small reticular feeder
veins is the direct cannulation technique used for the injection of larger, deeper reticular veins and varicose veins.
The patient is recumbent in a position that allows convenient access to the reticular veins to be treated. A 3 cc syringe
with a 27 or 30 gauge is used, and the needle is bent to an
Hand Position 135
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• 30 gauge 1/2″ disposable transparent hub needles
• Cotton balls or foam pads for compression
• Hypo-allergenic tape (synthetic silk or paper)
• Topical nitroglycerine ointment (2%)
• Sclerosing solutions (stored separately from other
injectables in the clinic)
• Magnifying loupes or lenses (2–3 ×)
The choice of syringe is a personal one. Some phlebologists
believe that a 3 cc syringe allows optimal control. Others
hold that a 1 cc syringe is preferable because the smaller
plunger offers reduced plunger friction and allows smoother
control with less jerkiness, but higher pressures may induce
quicker vessel rupture. It is worth the effort to try a variety
of syringes, as there is a marked difference in plunger
friction between different types of syringes and between
FIGURE 14.3 The position of the syringe with needle bend in the hands
of the injecting physician for injecting reticular and telangiectatic veins.
This shows the injection of 72% glycerine into telangiectasias. Some
blanching is seen.
syringes from different manufacturers.
With use of sodium tetradecyl sulfate (STS), it is recommended to use latex-free syringes. In high enough concentration, STS (0.5% and greater) will dissolve the rubber from
the plunger, thereby releasing rubber and rubber products
into solution. There is a relatively high and increasing incidence of latex allergy in the general population.6 Theoreti-
angle of 10 to 30 degrees to facilitate cannulation of the vein
(see Figure 14.3). The syringe is held in the dominant hand,
which rests on the patient’s leg, and the needle is advanced
at a shallow angle through the skin and into the reticular
cally the risk of a severe allergic reaction may be increased
with latex-containing syringes. We have not yet seen
allergic reactions to STS in over 500,000 injections since
switching to latex-free syringes in 1994.
vein. When the physician feels the typical “pop-through”
sensation of piercing the vein, the plunger is pulled back
gently until blood return is seen in the transparent plastic
PATIENT PREPARATION
hub. Typically one injects up to 2 cc of foamed sclerosant
and then massages the solution toward any associated telangiectasias. Injection must stop immediately if any signs of
leakage occur or if a bleb or bruising is noted. As the needle
is withdrawn, pressure is applied immediately either with
cotton ball then tape, or compression bandaging.
The cannulation of a reticular vein can be quite diffi cult
at times, because reticular veins can go into spasm, and may
virtually disappear during an attempt at cannulation. It is
best to avoid applying alcohol to the skin just prior to treatment as the evaporative cooling may cause venospasm of
The patient is recumbent in a position that allows convenient access to the telangiectasias to be treated. If available,
a motorized table with height adjustment will facilitate easy
access to all regions of the leg. Use of double polarized
lighting (InVu Vantage, Syris Scientifi c, Grey, ME) has also
proven to be helpful (see Figure 14.4). The neck and back
position of the treating physician must be optimal to avoid
injury over the long term to the physician. Indirect lighting
is best as harsh halogen surgical lights bleach out reticular
veins and some telangiectasias.
the reticular vein. Any resistance to injection means the
needle tip is not inside the vein. When this happens, the
injection should be terminated immediately and the needle
withdrawn. Failed cannulation will rapidly produce a bruise
at the site of injection.
A syringe of sclerosant is prepared with a 30-gauge
HAND POSITION
needle that has been bent to an angle of 10 to 30 degrees
EQUIPMENT
with the bevel up. The needle is placed fl at on the skin so
that the needle is parallel to the skin surface. The nondominant hand plays an important role in stabilization of the
• Cotton balls soaked with 70% isopropyl alcohol
• Protective gloves
• 1 cc or 3 cc disposable syringes
• 3-way IV stopcock for agitation/foaming
syringe. The injecting hand rests on the patient’s leg with
the fourth and fi fth fi nger providing stabilization in a fi xed
position to facilitate controlled penetration of the vessel. The
nondominant hand is used to stretch the skin around the
136 Chapter 14/Sclerotherapy Treatment of Telangiectasias
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needle and may offer additional support for the syringe. The
fi rmly supported needle is then moved slowly 1 to 2 mm
forward, piercing the top of the tiny vein just suffi ciently to
allow infusion of solution with the most minimal pressure
on the plunger.
A
CANNULATION OF THE VESSEL
The technique requires a gentle, precise touch, but with
practice the beveled tip of the 30 gauge (0.3 mm diameter)
needle may be used to cannulate vessels as small as 0.1 mm.
The bevel of the needle usually can be seen within the lumen
of the telangiectasias with use of 1.75 to 2× magnifi cation.
Needles smaller than 30 gauge or longer than one-half inch
are diffi cult to use because they tend to veer off course when
advanced through the skin. Depending on the patient’s skin
type, needles can become dull rather quickly, and should be
replaced whenever resistance to skin puncture is noted. This
typically occurs within three to 10 punctures. In the United
States, one must follow OSHA blood-borne pathogen guidelines when changing needles.
Once the needle tip is seen in the lumen of the vessel, a
tiny bolus of air (<0.05 cc) may be injected to help demonstrate that the needle is within the vein. With the use of
glycerine as a sclerosant we often utilize an air block technique, in which a small bolus of air (0.1 cc) is used to clear
the arborizing vessels of blood before the sclerosing solution
is infused. This is much smaller than previously
described.
7
INJECTION OF SCLEROSANTS
Concentrations of sclerosants used for telangiectasias are
less than those used for reticular veins. Typically the solutions are not foamed. We now prefer to use 72% glycerine
for the telangiectasias of a telangiectatic web-reticular vein
complex (see Table 14.1). When sclerosing solutions are
injected into telangiectasia, blood usually is fl ushed out of
the vessel ahead of the solution, thus the sclerosant usually
is not diluted at all. For this reason, the initial treatment of
telangiectatic webs begins with the minimal effective
concentration of sclerosant.8 At the next visit, the same concentration is used if sclerosis was effective, and a higher
concentration is used if sclerosis was ineffective.
B
FIGURE 14.4 Use of cross-polarized lighting to increase visualization
of telangiectasias. A. Thigh telangiectasias as seen with conventional light.
B. Group of telangiectasias in center of thigh as visualized using cross
polarized light (InVu Vantage, Syris Scientifi c, Grey, ME).
TABLE 14.1 Sclerosant Concentrations for Telangiectasia and Reticular Veins
Size of vessel Minimum effective concentration Max concentration Foamed Sclerosant
Reticular 1–3 mm 0.1% 0.25% Yes Sodium tetradecyl sulfate (STS)
Reticular 1–3 mm 0.25% 0.5% Yes Polidocanol (Laureth-9)
Telangiectasias 0.2–1 mm 0.2% 0.5% No Polidocanol (Laureth-9)
Telangiectasias 0.2–1 mm 0.1% 0.2% No STS
Telangiectasias 0.2–1 mm 72% in water Same No Glycerine 72%
Telangiectasias 0.2–1 mm 10% hypertonic saline and 25% dextrose Same No Sclerodex
The injection of telangiectasias is performed very slowly,
with minimal pressure on the syringe. A few drops of sclerosant are suffi cient to fi ll the vein and maintain contact with
the vessel wall for 10 to 15 seconds. The amount infused is
approximately 0.1 cc to 0.2 cc per site, and this often is suf-
TM
Poor Response to Treatment 137
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fi cient to produce blanching in a radius of 2 cm from the
site of injection. Rapid fl ushing of the vessels with larger
volumes of sclerosant or with higher pressures leads to problems with extravasation, tissue necrosis, and ulceration, as
well as an increased incidence of telangiectatic matting and
of hyperpigmentation.
9,10
For glycerine injection, the telangiectasia are fi lled with
solution and the injection is stopped. Glycerine has the least
risk of causing subsequent matting or pigmentation.11 When
detergent sclerosants are used, small volumes and small
areas of short duration blanching are still important to minimize side effects such as telangiectatic matting. Sometimes
there is no blanching at the site of injection, but the sclerosing solution fl ows easily through the telangiectasia or can
even be seen fl owing through adjacent telangiectasias or
reticular veins several centimeters away from the injection
site. In this case the injection is stopped after no more than
0.5 cc of sclerosant has been injected. Immediately after
injection, the treated area is gently massaged in the desired
direction of further spread of sclerosant. We strongly recommend against the use of hypertonic saline as it is painful and
highly ulcerogenic.
To minimize skin necrosis, extravasation must be avoided,
although the risks are minimized with glycerine or very low
doses of liquid 0.1% STS.12 If there is resistance to the fl ow
of sclerosant, or if a bleb begins to form at the injection site,
the injection must be stopped immediately. Extravasation of
low concentrations of polidocanol does not cause tissue
necrosis, but signifi cant extravasation of higher concentration (>0.1%) sodium tetradecyl sulfate or of hypertonic
saline will cause necrosis and ulceration.13 A randomized
study in animals found the incidence of ulceration to be
greater when attempts were made to dilute the extravasated
sclerosant by the injection of normal saline into the area.14
Vigorous massage of any blebs is recommended to minimize
the chance of necrosis. Application of 2% nitroglycerine
paste if bone white blanching is observed is applied to cause
immediate vasodilatation and minimize risks of small areas
of necrosis.
bathes and reapplies his or her stockings, wearing them for
the next two weeks except when bathing and sleeping. We
have the patient remove both stockings and cotton balls at
bedtime of the day of treatment. Compression hose are then
worn daily for two weeks except when bathing and sleeping.
Patients are encouraged to walk, and the only restrictions on
activity are those such as heavy weightlifting that result in
sustained forceful muscular contraction and venous pressure
elevation.
TREATMENT INTERVALS
Physician and patient preferences play a large role in
determining treatment intervals. New areas may be treated
at any time, but retreatment of the same areas should be
deferred for several weeks, because the immediate posttreatment appearance of telangiectasias is either bruising, matting,
or pigmentation; this will ultimately clear after two to four
weeks. Patients often are anxious to speed their course of
treatment, but allowing a longer time between treatment
sessions may minimize the number of sessions needed. We
strongly recommend waiting as long as four to eight weeks
between treatments.
The number of treatments needed depends on the extent
of the problem and the extent of areas treated at each session.
Some patients are highly responsive to treatment and can
be treated with weak sclerosants in only a few sessions.
Others are highly resistant and may require more sessions
and stronger sclerosants. The younger the patient the better
and faster the response.
After the initial series of treatments, a rest period of four
to six months will allow time for pigmentation and matting
to clear, and for any remaining reticular veins to establish
new routes of refl ux or drainage. Approximately 80% of
patients will clear to their satisfaction during the fi rst course
of treatment. Any remaining telangiectatic webs or new
telangiectasias are then reassessed to determine the best
approach for another round of treatment.
Compression will speed vessel clearance and reduce
staining from any vessel that protrudes above the surface of
the skin. After treatment of telangiectasias, compression is
provided by ready-to-wear gradient compression hose (15–
20 mm Hg) placed over cotton balls secured with tape at the
sites of injection. If larger reticular veins (>3 mm) are treated
at the same session, then compression consists of Class I
20–30 mm Hg compression. Some authorities recommend
that continuous compression be applied for as long as the
patient will tolerate it (usually 1–3 days). Then the stockings
are removed and the cotton balls discarded; the patient
COMPRESSION
POOR RESPONSE TO TREATMENT
When patients have had a poor response to the initial
series of treatments, the original diagnosis must always be
called into question. Unsuspected sources of refl ux can
include truncal varices, incompetent perforating veins, and
unrecognized reticular vessels. If no untreated source of
refl ux can be identifi ed, the patient must be carefully questioned about proper compliance with compression. Many
patients abandon compression immediately after sclerotherapy, and this can lead to treatment failures. The concentration and volume of sclerosant used should also be
reexamined. It is not uncommon to fi nd that the concentra-
138 Chapter 14/Sclerotherapy Treatment of Telangiectasias
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tions selected were ineffective for the size and type of vessel
being treated.
SUMMARY
When based upon a correct diagnosis and an appropriate
treatment plan, sclerotherapy is a highly effective method of
treatment for telangiectasias. Formulating an effective treatment plan requires a detailed knowledge of venous anatomy,
a thorough understanding of the principles and patterns of
refl ux, and intimate familiarity with a range of volumes and
concentrations of sclerosing solutions. The results obtained
depend greatly on the experience of the clinician, but with
care and with attention to detail, clearing rates of 90% can
be achieved in most patients. Suffi cient time must be allowed
between treatments.
Patient satisfaction is enhanced through education
and informed consent, photographic documentation, and a
measured approach to treatment. When the basic principles
of diagnosis and treatment are followed meticulously, a
successful outcome is highly likely. It is important to
educate the patient that telangiectasias may be a lifelong
problem. Development of new veins within a few years
after successful treatment does not constitute treatment
failure; rather, it demonstrates the chronicity of venous
insuffi ciency.
References
1. Weiss RA, Weiss MA. Resolution of pain associated with varicose and
telangiectatic leg veins after compression sclerotherapy, J Dermatol
Surg Onc. 1990. 16: 333–336.
2. Weiss RA, Heagle CR, Raymond-Martimbeau P. The Bulletin of the
North American Society of Phlebology. Insurance Advisory Committee Report, J Dermatol Surg Onc. 1992. 18: 609–616.
3. Weiss RA, Weiss MA. Doppler ultrasound fi ndings in reticular veins
of the thigh subdermic lateral venous system and implications for
sclerotherapy, J Dermatol Surg Onc. 1993. 19(10): 947–951.
4. Somjen GM, Ziegenbein R, Johnston AH, Royle JP. Anatomical examination of leg telangiectases with duplex scanning [see comments], J
Dermatol Surg Onc. 1993. 19(10): 940–945.
5. Bihari I, Muranyi A, Bihari P. Laser-doppler examination shows high
fl ow in some common telangiectasias of the lower limb, Dermatol
Surg. 2005. Apr; 31(4): 388–390.
6. Cheng L, Lee D. Review of latex allergy, J Am Board Fam Pract. 1999.
Jul; 12(4): 285–292.
7. Bodian EL. Sclerotherapy: A personal appraisal, J Dermatol Surg Onc.
1989. 15: 156–161.
8. Sadick NS. Sclerotherapy of varicose and telangiectatic leg veins.
Minimal sclerosant concentration of hypertonic saline and its relationship to vessel diameter [see comments], J Dermatol Surg Oncol. 1991.
Jan; 17(1): 65–70.
9. Weiss MA, Weiss RA. Effi cacy and side effects of 0.1% sodium
tetradecyl sulfate in compression sclerotherapy of telangiectasias:
Comparison to 1% polidocanol and hypertonic saline, Journal of
Dermatologic Surgery & Oncology. 1991. 17: 90–91. Ref Type:
Abstract.
10. Weiss RA, Weiss MA. Incidence of side effects in the treatment of
telangiectasias by compression sclerotherapy: Hypertonic saline vs.
polidocanol, J Dermatol Surg Onc. 1990. 16: 800–804.
11. Georgiev M. Postsclerotherapy hyperpigmentations. Chromated
glycerin as a screen for patients at risk (a retrospective study), J
Dermatol Surg Onc. 1993. 19: 649–652.
12. Martin DE, Goldman MP. A comparison of sclerosing agents: Clinical
and histologic effects of intravascular sodium tetradecyl sulfate and
chromated glycerine in the dorsal rabbit ear vein, J Dermatol Surg Onc.
1990. 16: 18–22.
13. Duffy DM. Small vessel sclerotherapy: An overview. Adv Dermatol.
1988. 3: 221–242.
14. Zimmet SE. The prevention of cutaneous necrosis following extravasation of hypertonic saline and sodium tetradecyl sulfate, J Dermatol
Surg Onc. 1993. 19: 641–646.
CHAPTER
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15
Complications and Adverse
Sequelae of Sclerotherapy
MITCHEL P. GOLDMAN
This chapter is modifi ed from: Complications and adverse
sequelae of sclerotherapy. In: Sclerotherapy treatment of
varicose and telangiectatic leg veins, 4e. Goldman MP,
Bergan JB, Guex JJ, Eds. London: Elsevier. 2006.
As with any therapeutic technique, sclerotherapy is associated with a number of potential adverse sequelae and complications. Fairly common, and often self-limiting, side
effects include cutaneous pigmentation and a fl are of new
telangiectasia. Relatively rare complications include localized cutaneous necrosis and systemic allergic reactions. This
chapter addresses the pathophysiology of these reactions,
methods for decreasing their incidence, and treatment of
their occurrence.
POSTSCLEROTHERAPY
HYPERPIGMENTATION
Cutaneous pigmentation to some degree is a relatively
common occurrence after sclerotherapy with any sclerosing
solution. It has been reported in 11% to 80%
The true incidence of hyperpigmentation is a result of many
factors, including treatment technique, sclerosing solution,
and concentration, as well as how the authors defi ne pigmentation. The defi nition of pigmentation should be, “any brown-
black staining of the skin occurring after sclerotherapy,” with
persistent pigmentation being separated out to those patients
whose brown staining is present after one year.
Pigmentation usually is temporary. Physicians report a
1% to 2% incidence of pigmentation persisting after one
4–6
Pigmentation usually is linear along the course of
year.
the treated blood vessel. We use the term ghost of the blood
vessel to explain to patients that it represents a resolving and
not functioning vessel (see Figure 15.1).
1–3
of patients.
Etiologic Factors
The cause of this pigmentation most likely results from
a combination of postinfl ammatory hyperpigmentation
(incontinence of melanin pigment) and hemosiderin deposition. However, histologic examination has demonstrated
that this pigmentation is caused only by hemosiderin staining of the dermis, irrespective of the type of sclerosing
solution used, pigmentation of the patient, or length of time
after injection
Perivascular phagocytosis of RBCs occurs either by intact
cells or piecemeal after fragmentation by macrophages.9
The intracellular fragments in the macrophage cytoplasm
are further compartmentalized into hemoglobin-containing
globules. Since hemosiderin is an indigestible residue of
hemoglobin degradation, it may appear as aggregates up to
100 μm in diameter.10 Hemosiderin has a variable concentration of these aggregates. Its elimination from the area through
phagocytosis may take years, if it ever occurs.
The incidence of pigmentation apparently is related to
multiple factors, including (1) sclerosing solution type and
concentration, (2) sclerotherapy technique, (3) gravitational
and other intravascular pressures, (4) innate tendency toward
cutaneous pigmentation (total body iron stores and/or altered
iron transport and storage mechanisms, innate enhanced
histamine release or hypersensitivity, and vessel fragility),
(5) postsclerotherapy treatment (graduated compression),
(6) vessel diameter, and (7) concomitant medication.
7,8
(see Figure 15.2).
Solution Type and Concentration
The extent of endothelial destruction with resulting
infl ammation and extravasation of RBCs is thought to
infl uence the development of postsclerotherapy hyper-
The Vein Book
139
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Copyright © 2006, Elsevier Inc.
140 Chapter 15/Complications and Adverse Sequelae of Sclerotherapy
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ABC
FIGURE 15.1 Linear pigmentation along the course of a treated blood vessel. A. Before treatment. B. Eight weeks
after treatment with POL 0.5%. C. Punctate pigmentation 8 weeks after treatment with Sclerodex. (From Goldman MP.
Adverse sequelae of sclerotherapy treatment of varicose and telangiectatic leg veins. In Bergan JJ, Goldman MP, eds.
Varicose veins: Diagnosis and treatment. 1993, St Louis: Quality Medical Publishing.)
pigmentation. The increased incidence of pigmentation with
certain concentrations of sodium tetradecyl sulfate (STS) and
hypertonic saline (HS) that produce a greater reaction than
polidocanol (POL) and glycerin confi rms this hypothesis.
1,11,12
Thus the infl ammatory response after treatment should be
kept to a minimum, and sclerosing solutions and concentrations should be altered for each treatment session so that the
minimally effective sclerosing concentration is used.
Technique
Optimal technique consists of limiting pressure into
damaged (sclerosed) veins to prevent extravasation of RBCs.
To limit the degree of intravascular pressure, larger feeding
varices, incompetent varices, and points of high pressure
refl ux should be treated fi rst. A greater incidence of pigmentation occurs if vessels distal to points of refl ux such as
reticular veins feeding into telangiectasia or vessels distal to
the saphenofemoral junction (SFJ) are treated before successful closure of the junction or feeding veins.
The degree of injection pressure is also important.
Because telangiectasia and small venules are composed
essentially of endothelial cells with a thin (if any) muscular
coat and basement membrane, excessive intravascular pressure from injection may cause vessel rupture. In addition,
endothelial pores and spaces between cells in the vascular
wall dilate in response to pressure, leading to extravasation
of RBCs. It is therefore important to inject intravascularly
13
with minimal pressure. Since injection pressure is inversely
proportional to the square of the piston radius, a syringe with
a larger radius causes less pressure. The average piston
radius is 8 mm for a 2-ml syringe and 5 mm for a 1-ml
syringe. The calculated pressure with an implied force of
250 g is 180 mm Hg for a 2-ml syringe and more than
300 mm Hg for a 1-ml syringe.14 This is one reason we recommend using a 3-ml syringe for sclerotherapy.
Gravitational and Other
Intravascular Pressures
Postsclerotherapy pigmentation appears most commonly
in vessels treated below the knee but can occur anywhere
on the leg, probably as a result of a combination of increased
capillary fragility and increased intravascular pressure by
gravitational effects in this location. Pigmentation has never
been observed in our practice after sclerotherapy on the
hands, face, or chest.
Predisposition to Pigmentation
Certain individuals appear to be predisposed to the development of pigmentation through a variety of genetic mechanisms. Vessel fragility may also result in an innate
predisposition toward pigmentation.
Patients taking minocycline may have an increased risk
for postsclerotherapy pigmentation.
15
This propensity may
Postsclerotherapy Hyperpigmentation 141
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AB
CD
FIGURE 15.2 Section stained with hematoxylin-eosin taken 6 months after injection with POL 0.75%. Note scattered
foci of golden brown pigment. A. Original magnifi cation ×50. B. Perls-stained section from the same patient as in Figure
15.1. Note scattered foci of green-blue granules within siderophages. Original magnifi cation ×200. C. Original magni-
fi cation ×50. D. Original magnifi cation × 350. (From Goldman MP, Kaplan RP, and Duffy DM. J Dermatol Surg Oncol
13:547. 1987.)
be related to the infl ammatory effects of sclerotherapy.
Unlike the golden to deep brown color characteristic of
typical sclerotherapy-induced pigmentation, pigmentation
from minocycline is typically blue-gray. Therefore it may
be prudent to withhold minocycline therapy in sclerotherapy
patients.
lumen completely with external pressure. Persistent thrombi
are thought to produce a subacute “perivenulitis” that can
persist for months.
16
The perivenulitis favors extravasation
of RBCs through a damaged endothelium or by an increase
of the permeability of treated endothelium. This provides a
rationale for drainage of all foci of trapped blood two to four
weeks after sclerotherapy. Sometimes blood can be released
Postsclerotherapy Coagula
Removal of postsclerotherapy coagula may decrease the
incidence of pigmentation. Thrombi to some degree are
thought to occur after sclerotherapy of all veins, regardless
of size, because of the inability to occlude the vascular
even two months after sclerotherapy.
Thrombi are best removed by gentle expression of the
liquefi ed clot through a small incision made with a 21-gauge
needle (see Figure 15.3). A multicentered, randomized controlled study of 101 patients with varicose veins was treated
at one to three weeks with microthrombectomy in half of
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