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152 Chapter 15/Complications and Adverse Sequelae of Sclerotherapy
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shock fi ve minutes after injection with 1 ml despite maximal
intervention. In 1994, Kreussler reported two patients with
urticaria. In 1995, two additional patients were reported with
urticaria, two with bronchospasm, and one with angioedema.
In 1996, there were four reports of urticaria, two of anaphylactoid reactions, one with angioedema, one with pruritus,
and one with contact allergy. Therefore POL is not free from
allergy and like all sclerosing solutions, physicians must be
prepared to evaluate and treat patients who have an allergic
reaction to the sclerosing solution.
A detailed account of three serious cases of anaphylaxis
was reported from the Netherlands.55 These patients were
anaphylactic within 15 minutes after injection of POL. Two
of them received the drug for the fi rst time. One patient, a
70-year-old woman with a complicated medical history of
two heart operations, two cerebrovascular accidents, and
hyperthyroidism, was successfully resuscitated after cardiac
arrest. She was receiving multiple medications, including
digoxin, carbimazole, captopril, furosemide, mebeverine,
and acenocoumarol. She was treated without complications
four previous times with POL. The second patient showed
signs of ARDS after being treated with epinephrine and
systemic methylprednisolone for shock. The third patient
developed urticaria, dyspnea, paresthesia, headache, and
chest pain with electrocardiographic (ECG) fi ndings of
cardiac ischemia. No further studies were performed on
these patients.
The Australian Polidocanol Open Clinical Trial at two
years, with over 8000 treated patients, reported nine local
urticarial reactions and three generalized reactions, with two
patients developing a rash, for a frequency of approximately
30
0.2%. There were no cases of anaphylaxis.
After an additional 8804 patients were evaluated, an additional three
patients developed urticaria again without any additional
signifi cant adverse sequelae.56 A fi ve-year experience in
500 patients treated with POL 3% reported fi ve cases of
allergic reaction (1% incidence); one patient had nonfatal
anaphylactic shock, with the other patients experiencing
urticaria.
57
Two of 689 sequential patients were reported who developed an immediate-type hypersensitivity reaction with systemic pruritus and urticaria.58 This represented an incidence
of 0.3% in their patient population and 0.91% for the “true”
population. These two reactions occurred without prior
exposure to POL as a sclerosing agent. Since POL is used
as an emulsifying agent in preprocessed foods, patients may
have been exposed previously through ingestion. Both
patients responded easily to either a single dose of oral
diphenhydramine, 50 mg, or 0.3 ml of subcutaneous epinephrine plus 50 mg diphenhydramine IM.
One specifi c case report describes a 30-year-old woman
who underwent four separate sclerotherapy sessions with
POL. On the fourth session, 3 ml of POL 1.5% and 12 mls
of POL 0.5% were administered. The patient complained of
chest heaviness and constriction, which also appeared after
two of her other sessions but was not brought to the attention
of the medical staff. During the fourth episode she lost consciousness and was found without a pulse or blood pressure
with dilated pupils. Spontaneous respiration occurred after
two to three minutes, she began to vomit and complained of
headache and earache. She recovered and was discharged
after 10 hours well but returned the next day with dysosmia,
which lasted six weeks. Although a brain CT scan was
normal the presumed cause was cerebral.
59
The LD50 in rabbits at two hours is 0.2 g/kg, which is three
to six times greater than the LD50 for procaine hydrochloride. The LD50 in mice is 110 mg/kg. The systemic toxicity
level is similar to that of lidocaine and procaine.
60
Chromated Glycerin
CG 72% (Scleremo) is a sclerosing solution with a very
low incidence of side effects (Scleremo product information
[1987]). Hypersensitivity is a very rare complication.61
Contact sensitivity to chromium occurs in approximately
5% of the population.62 IV potassium dichromate leads to
complete desensitization in chromium-sensitized guinea
pigs. This effect occurs because chromium needs to bind to
skin proteins to become an effective antigen. This may be
related to the necessity for epidermal Langerhans’ cells to
produce an allergic response, whereas T lymphocyte accessory cooperation is not optimal with IV injection and its
resulting endothelial necrosis. Thus it is more common for
a sclerotherapist to develop an allergic contact dermatitis to
CG than it is for a patient to have an allergic reaction to IV
use of CG. Indeed, Ouvry (personal communication, 1995)
has developed an allergic contact dermatitis from CG
injected without the use of protective gloves.
Ramalet63 has reported seven patients who developed an
allergic reaction to CG. One patient had a vasculitis, and six
patients had an eczematous reaction. All allergic patients
demonstrated a sensitivity to topically applied chrome.
Hematuria accompanied by urethral colic has been
reported to occur transiently after injection of large doses of
CG. Ocular manifestations, including blurred vision and a
partial visual fi eld loss, have been reported by a single
author, with resolution in less than two hours.
any sclerotherapy)-induced hemolysis may not be a benign
event. Hemoglobin can exert direct cytotoxic, infl ammatory,
and pro-oxidant effects that adversely effect endothelial
function.65 Hemoglobin from destroyed red blood cells
dimerizes and is rapidly bound by the serum protein haptoglobin. The haptoglobin-hemoglobin complex causes endocytosis and degradation, which can lead to a variety of
adverse effects.
66
An additional case was reported of transient hypertension
and visual disturbance after the injection of 12 ml of 50%
CG into spider and “feeder” leg veins in a fourth treatment
64
Glycerin (or
References 153
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session.67 These symptoms occurred two and a half hours
after treatment and lasted more than three hours without
treatment. This may have represented a retinal spasm or an
ophthalmic migraine.
Although transient hemoglobinuria is common in athletes
and without known long-term adverse effects, hemoglobulinemia can cause renal failure.68 More commonly, hemoglobulinemia can cause a dose-related gastrointestinal
dystonia and pain including esophageal spasm and dysphagia. Refer to an excellent recent review that details more
clinical manifestations of hemoglobinemia.
69
Since we have been using glycerin alone without chromium but mixed 2 : 1 with 1% lidocaine with or without
1 : 100,000 epinephrine we have yet to see an allergic reaction. We have also yet to see hemoglobinuria or adverse
effects with the use of up to 12 ml of this glycerin mixture
except for a minute or two of epinephrine-induced “rush”
that can occur in rare patients who have a sensitivity to
epinephrine.
Polyiodide Iodine
Polyiodide iodine (Varigloban; Sclerodine 6) is a
stabilized water solution of iodide ions, sodium iodine, and
benzyl alcohol. Sigg et al.
70,71
reported on their experience
with over 400,000 injections with Variglobin reported an
incidence of 0.13 allergic cutaneous reactions per 1000. No
systemic allergic reactions were observed. Obvious contraindications to the use of Variglobin are hyperthyroidism and
allergies to iodine and benzyl alcohol.
Sodium Salicylate
Saliject (Omega Laboratories, Montreal) has not been
reported in a literature review to cause allergic reactions. Dr.
Beverly Kemsley has reported 1 of 6000 patients who developed an anaphylactic reaction after the use of Saliject. Thirty
patients developed localized erythema and urticaria that
responded to the oral antihistamine terfenadine 120 mg (personal communication, 1996).
Hypertonic Saline
Alone, hypertonic saline (HS) solution shows no evidence of allergenicity or toxicity. Complications that may
arise from its specifi c use include hypertension that may be
exacerbated in predisposed patients when an excessive
sodium load is given, sudden hypernatremia, central nervous
system disorders, extensive hemolysis, and cortical necrosis
of the kidneys (Mary Helenek, written correspondence,
American Regent Laboratories, Inc., May 1990). These
complications among others have led one manufacturer
TABLE 15.1 Summary of Complications of Sclerosing
Agents
Allergic
Solution Pigmentation reaction Necrosis Pain
Sodium morrhuate ++ ++ +++* +++
Sodium tetradecyl ++ + ++* +
sulfate
Ethanolamine oleate + ++ ++* ++
Polidocanol + + +* 0
Hypertonic saline + 0 +++* +++
Sclerodex (+0% + 0 + ++
saline 5%
dextrose)
Chromated glycerin 0 + 0 ++
Glycerin 0 0 0 +
Polyiodinated iodine ++ + +++* +++
+, Minimal; ++, moderate; +++, signifi cant.
*Concentration dependent.
(American Regent Laboratories) to add to its label the
warning “For IV or SC use after dilution” in bold red ink.
As discussed previously, hematuria can occur with any
sclerosing agent. Sometimes blood appears in the urine after
one or two acts of micturition and occasionally at other times
throughout the day. Usually there are no other ill effects,
and the hematuria resolves spontaneously. Hematuria
probably occurs because of hemolysis of RBCs during
sclerotherapy.
In summary, sclerotherapy with a wide variety of sclerosing solutions is a safe and effective procedure for the treatment of varicose and telangiectatic leg veins. Space does not
permit a more complete discussion of other possible adverse
effects. Table 15.1 summarizes the different adverse effects
from a variety of available sclerosing solutions. The interested reader is referred elsewhere for a complete review of
adverse effects from sclerotherapy treatment.
13
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31. Guckens J, Rabe E, Bieber T. Embolia cutis medicamendosa of the
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CHAPTER
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16
Laser Treatment of
Telangiectasias and Reticular Veins
NEIL SADICK and LIAN SORHAINDO
INTRODUCTION
The incidence of prominent venulectasias and/or telangiectasias on the lower extremities occurs in up to 41% of
women and 15% of men within the United States.1 The
current literature subdivides vascular pathology into superfi cial “spider” veins or telangiectasias, deep reticular veins,
and protuberant varicosities. Etiologies include heredity,
hormonal dysregulation, prolonged periods of standing,
obesity, pregnancy, and aging. Although patients may
present with symptoms of fatigue, aching, swelling, throbbing, and occasionally pain, patients seek treatment primarily for aesthetic concerns. With this rise in consumer demand
over the past fi ve years, there has been a subsequent increase
in the utilization of lasers and intense pulsed light (IPL)
sources for the treatment of lower extremity veins.
IDENTIFYING THE PROBLEM
The vasculature of the lower extremity is comprised of a
complex, intertwined network of superfi cial and deep venous
plexuses. The superfi cial veins, as suggested by their name,
lie directly underneath the skin surface. The deep veins, in
contrast, traverse the muscle of the leg. The individual fl ow
patterns of these two networks intertwine to such a great
degree that superfi cial spider veins may be the direct result
of increased hydrostatic pressure in the deep reticular
veins.
In contrast to the treatment of facial veins, the varying
sizes, depths, fl ow patterns, and vessel thickness of leg veins
make the treatment of leg veins more challenging. Presently,
there is no gold standard of treatment for all leg veins, and
lasers often are used as adjunctive therapy in patients undergoing phlebectomy, sclerotherapy, or vein stripping. Laser
and light source technology have become particularly useful
in the treatment of small spider veins or telangiectasias, and
also in the setting of vessels that are sclero-resistant that may
arise from prior surgical treatment as a result of telangiectatic matting or angiogenic fl ushing (see Box 16.1).2 It can
also be used in the treatment of large spider and reticular
veins; however, sclerotherapy remains the gold standard for
the treatment of these vessels. The chapter, herein, deals
specifi cally with the laser treatment of telangiectasias and
reticular veins; other modalities of treatment including
sclerotherapy, ambulatory phlebectomy, and endovenous
ablation are discussed elsewhere in the book.
PATIENT SELECTION: WHEN AND
HOW TO CHOOSE LASER/IPL
VERSUS SCLEROTHERAPY
Laser therapy is most effi cacious for treating telangiecta-
sia/venulectasia or reticular veins less than 3 mm in di-
3,4
ameter.
in patients with areas of neovascularization with telangiectactic matting or angiogenic fl ushing, with sclero-resistant/
noncannulizable vessels, and who are needle-phobic. Relative contraindications to the use of laser surgery include
tanned skin, pregnancy, the use of iron supplements or
anti-coagulation, history of photosensitivity disorder, or
hypertrophic and keloidal scarring (see Table 16.1).
As mentioned earlier, lasers have become indicated
The Vein Book
157
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158 Chapter 16/Laser Treatment of Telangiectasias and Reticular Veins
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BOX 16.1 Indications for Laser Therapy Treatment of
Leg Veins
• Refractory noncannulable vessels
• Telangiectatic matting
• Angiogenic fl ushing
• Sclero-resistance
• Needle-phobic patients
• Vessels smaller than the diameter of a 30-gauge needle are present
TABLE 16.1 Comparison of the 1064 nm Nd:YAG, 810 nm
Diode, and 755 nm Alexandrite Lasers for Leg Veins 0.3–
3 mm in Diameter
Laser Patients achieving 75% clearance at 3 months
1064 nm Nd:YAG 88%
810 nm diode 29%
755 nm Alexandrite 33%
TABLE 16.2 Vessel Thermal Relaxation Time
Vein diameter Time (seconds)
0.1 0.010
0.2 0.080
0.4 0.16
0.8 0.6
1.0 1.0
2.0 8.0
Data from Eremia 2002.
BOX 16.2 Fundamental Properties of a Laser for Leg Veins
• Must have a wavelength proportionately better absorbed by
hemoglobin than the surrounding tissue.
• Penetration should reach the full depth of the target vessel.
• Suffi cient energy must be delivered to damage the vessel without
damaging the overlying skin.
• Energy must be delivered over an exposure time long enough to
slowly coagulate the vessel without damaging surrounding tissue.
FIGURE 16.1 Absorption spectrum of hemoglobin/deoxyhemoglobin.
FUNDAMENTALS OF LASER
TREATMENT OF LEG VEINS
Theory of Selective Thermolysis: Major
Principles and Determinants
The advent of laser technology for treatment of leg veins
began with the concept of selective photothermolysis developed in the late 1980s.
molysis states that selective damage to a tissue structure is
achieved by means of a wavelength of light preferentially
absorbed by a chromophore in light-absorbing molecules
and laser exposure time less than or equal to the object’s
thermal relaxation time (i.e., the time required for the object
to lose 50% of its thermal energy). The thermal relaxation
times of leg veins vary depending upon vessel diameter (see
Table 16.2).
6
A physician employing laser therapy should routinely
consider the utility of laser and intense pulsed light (IPL)
technologies versus that of sclerotherapy for the treatment
of lower extremity vessels.
for a laser or IPL source in the treatment of leg veins are
delineated in Box 16.2.
5
The theory of selective photother-
7
The fundamental requirements
Laser technology and its role in leg vein reduction is
rooted in the molecule hemoglobin and its absorption spectrum, which has broad peaks at 410, 540, and 577 nm and
smaller peaks at 920 and 940 nm. The spectra of oxy- and
deoxyhemoglobin differ, with bluer veins responding to
wavelengths targeting the deoxyspectrum; whereas red varicosities respond more effectively to wavelengths targeting
the oxyhemoglobin spectrum (see Figure 16.1). Generally
speaking, any vessel that is less than 3 mm in diameter
may be treated by laser and IPL technologies. However,
sclerotherapy is a more effi cient modality for eradicating
cannulable vessels, and when small, diffi cult to cannulate
vessels are present microsclerotherapy may be implemented.
Microsclerotherapy, however, is plagued by a number of
adverse sequelae, increased incidence of bruising and
pigment dyschromia, puncture marks from needle use,
microulcerations, and inconsistent results (see Table 16.3).
Given the adverse aesthetic outcomes of such procedures,
the use of lasers has gained momentum in the management
of cosmetic veins.
Lasers and intense pulse light (IPL) have not become
replacements for sclerotherapy, primarily because hydrostatic pressure considerations are not addressed by light
endothelial interactions. It is also more diffi cult to have
Fundamentals of Laser Treatment of Leg Veins 159
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suffi cient penetration of photons safely through the thick
epidermal-dermal wall surrounding the lower extremity
vessels when utilizing noninvasive treatment modalities
like laser technology; direct injection into the target chromophore is intuitively more effi cient. Furthermore, an
altered pattern of cytokine release may be observed when
using laser technology, resulting in injury to the vessel
that may lead to increased incidence of postinfl ammatory
hyperpigmentation.
Wavelength, pulse duration, and spot size are the parameters that are most infl uential during the treatment and
management of individual vessels (see Table 16.4). The
larger vessels tend to respond to longer wavelengths or the
ratio of vessel to epidermal heating increases the probability
of achieving complete vessel coagulation.8 Shorter wavelengths, in contrast, partially coagulate the vessel ultimately
increasing the incidence of treatment failures, and subsequent epidermal damage including hyperpigmentation.9
Maximum effi ciency of vessel clearance is achieved when
the penetration depth of the beam equals the vessel diameter.
TABLE 16.3 Microtelangiectasia <0.5 mm: Comparison of
Microsclerotherapy and Laser Technology
The spot size should be as large as possible, at least on the
order of 4× the optical penetration depth. An adequate spot
size minimizes scattering losses in addition to maximizing
beam penetration, which increases the probability that pan
endothelial destruction will be achieved. The disadvantage to
this, however, is that the use of larger spot sizes increases the
pain and discomfort subjectively reported by the patient.
These parameters have infl uenced and spurred the development of a bimodal, dual-wavelength approach for the
treatment of both red and blue lower extremity veins (see
Figure 16.2). For the treatment of small, reddish telangiectasias with a high degree of oxyhemoglobin, short wavelengths (500–600 nm) were found to be most effective;
longer wavelengths (800–1100 nm) were found to be most
effective for the treatment of deeper, blue telangiectasias
and reticular veins.
With continuing advances, laser technology can now
address both variations in vessel size and depth with a single
long wavelength 1064 nm Nd:Yag laser utilizing a varied
pulse width as the monomodal approach (see Table 16.5).
TABLE 16.4 Optimal Laser Parameters for the Treatment of
Leg Veins
Microsclerotherapy Laser
Number of Treatments − −
− −
−
−
Bruising − +
Discomfort − +
Clinical Effi ciency − +
Purpura − +
Pigmentation − −
− −
−
Ulceration − +
Cost + −
Patient Satisfaction − +
Physician Skill − −
− −
Wavelength 530–1064 nm
Pulse Duration 2–100 ms
Fluence 30–150 J/cm
Spot Size 1.5–10 mm
Adapted from Sadick 2002.
TABLE 16.5 Monomodal Approach to the Treatment of Leg
Veins Using the 1064 nm Nd:YAG Laser
Vessel size Spot size Fluence Pulse duration
<1 mm red Small High Short
1–3 mm (blue) Large Moderate Long
Adapted from Sadick 2003.
2
FIGURE 16.2 Pre- and post-clinical pictures of lower extremity veins using biomodal technique.
160 Chapter 16/Laser Treatment of Telangiectasias and Reticular Veins
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Delicate, red vessels <1 mm in diameter are superfi cial,
having high oxyhemoglobin saturation. Consequently, they
can be treated effectively with small spot sizes (<2 mm),
higher fl uences (350–600 J/cm2), and short pulse durations
(15–30 s). Larger blue vessels, in contrast, are typically 1–
4 mm in diameter, deeper, and possess a lower oxygenated
hemoglobin component. As a result, these veins are effectively treated with larger spot sizes (2–8 mm), moderate
fl uences (100–350 J/cm2), and long pulse durations (30–
50 ms). With the use of the Nd:YAG rapidly gaining momentum, the transition from a bimodal wavelength technique to
a monomodal approach has evolved.
TREATMENT APPROACH
Candidates for Laser Therapy
Laser therapy may be considered appropriate in patients
who are needle phobic, cannot tolerate sclerotherapy, are
plagued by legs veins that are sclero-resistant, and/or are
susceptible to telangiectatic matting (see Box 16.1). Ideal
candidates for laser treatment of leg veins previously have
undergone appropriate surgery or sclerotherapy for the treatment of varicosities, incompetent perforators, and reticular
veins, as well as sclerotherapy to clear the majority of superfi cial vessels.
TABLE 16.6 Lasers and Light Sources for the Treatment of
Leg Veins
Laser Wavelength
Pulsed Dye 585–605 nm
KTP 532 nm
Alexandrite 755 nm
Diode 810 nm
Nd:YAG 1064 nm
Intense Pulsed Light 515–1200 nm
session. Laser and light therapy should be utilized in the
treatment of any residual vessels including those that are too
small in diameter to undergo sclerotherapy with a 30–32gauge needle.
LASER TREATMENT SYSTEMS
A compilation of laser and intense pulsed light sources
utilized in the setting of laser treatment of legs veins are
presented herein and summarized in Table 16.6. The wavelengths of light range from 515 nm to 1064 nm, depending
on the treatment system employed. As mentioned earlier in
the chapter, the longer the wavelength, the greater the depth
of penetration, as illustrated in Figure 16.4.
Patient Interviews
Diagnosis of spider or varicose veins begins with a thorough medical history detailing potential risk factors or etiologies for vascular pathology such as hormones, prolonged
standing associated with occupation, obesity, pregnancy,
heredity, or aging.
Physical Examination
All potential candidates for laser treatment of leg veins
should undergo a thorough physical examination. During the
exam, the physician should evaluate the type and size of the
leg veins, and the presence/absence of refl ux or incompetent
valves. The treatment algorithm (see Figure 16.3) suggests
that larger varicose veins with refl ux should be treated fi rst
in an effort to avoid the unsuccessful treatment of smaller
telangiectasias and complications such as dyspigmentation
and telangiectatic matting.
In keeping with the treatment algorithm in Figure 16.3,
initial treatment should include surgical removal, stripping,
or ambulatory phlebectomy of varicosities and large feeder
vessels. Sclerotherapy should then follow proceeding from
large to small vessels. Adhering to this treatment strategy
will obliterate, on average, 80 to 90% of vessels in a single
578 nm Copper Bromide (CuBr)
Yellow Light Laser
A new yellow light laser employing a copper bromide
medium has demonstrated effi cacy in the treatment or red
lower extremity telangiectasia that are less than 2 mm in
size. An average of 1.7 patient sessions produced signifi cant
clearing of 75% to 100% in 71.8% of patients. The positive
results have been confi ned to the treatment of red vessels
(1 mm).
10
PULSED LASERS AND LIGHT SOURCES
Potassium-Titanyl-Phosphate Laser
For small telangiectatic leg veins in fair-skinned patients,
the pulsed KTP laser has become the treatment of choice.
The Versapulse KTP laser (Lumenis, Santa Clara, California, U.S.) uses the following parameters: a spot size of 3–
5 mm, pulse duration of 10–15 ms, and fl uences of 14–20 J/cm2,
which have proven to be effective. A 4ºC chilled tip provides
epidermal protection. Side effects include transient erythema,
crusting superfi cially, and purpura. When administering the
pulsed KTP laser, lower fl uences must be employed in the
Pulsed Lasers and Light Sources 161
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Physical Examination
Varicose Veins
Non-invasive Testing
Doppler / Duplex / Plethysmography
Reflux
Incompetent Perforators
or
Saphenofemoral Junction
Surgical Ligation
or
Compression Sclerotherapy
Treat Varicosities and Reticular Veins with Compression
Sclerotherapy or Ambulatory Phlebectomy
No Reflux
Spider Telangiectasia
FIGURE 16.3 Systematic approach to the treatment of leg veins.
FIGURE 16.4 Wavelength and depth of penetration.
Superficial Sclerotherapy or
Laser or Light Therapy of
Superficial Telangiectasia,
Residual Vessels and of Sclerotherapy Induced Matting
darker skinned or tanned patient because of their increased
melanin and its absorption of green light. This increased
absorption is more likely to increase the risk of epidermal
damage. Treatment failure, consequently, is higher in this
subset of patients because the lower fl uences are not very
effective in coagulating the target vessel. Patient acceptance
of this laser treatment system is high with minimal treatment
discomfort of the longer penetrating wavelengths and a
relatively uncomplicated postoperative course.
11
Other
technologies including the Aura (Laserscope, San Jose,
California, U.S.) have produced comparable results.
Flashlamp-Pumped Pulsed Dye Laser
The pump pulsed dye laser was the fi rst laser to achieve
notable results in the treatment of leg veins in the 1980s.
This treatment system utilizes short wavelength technology,
at a wavelength of 577 nm. This has become acceptable
for treatment of leg vessels <1.0 mm, but cannot be
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