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344 Chapter 34 Drug treatment for chronic venous disease
https://t.me/med1917
The Cochrane review included seven RCTs versus pla-
59
Leg pain was signicantly reduced in six RCTs
cebo.
comparing HCSE with placebo. The antiedema effect of
HCSE with leg volume decrease of 32.1 mL weighted mean
difference (WMD; 95% CI 13.49–50.72) was conrmed in
six of seven RCTs. One trial found an average leg volume
reduction similar for HCSE and compression groups: 43.8
mL vs 46.7 mL after 12 weeks of treatment.
60
These results
were signicant compared to placebo, and both therapies
were shown to be equivalent.
A network meta-analysis identied 10 RCTs (1025
patients) for HCSE.
44
However, because of the lack of
adequate data, only one was included in the quantitative
analysis, and HCSE was not shown as the best treatment
option.
34.4.6 Ruscus extract
Ruscus extract (R. aculeatus), from the saponin family, is
frequently combined with two other active ingredients:
hesperidin methyl chalcone (HMC) and ascorbic acid. A
meta-analysis included 10,246 patients from 20 placebo-controlled trials, ve RCTs, and six observational stud-
61
Venous symptoms were signicantly reduced (pain,
ies.
heaviness, cramps, and paresthesia) compared to placebo.
Edema decreased non-signicantly. The plethysmographic
venous capacity was signicantly reduced by 0.7 mL/100
mL (p = 0.014 vs placebo). Overall, the evidence was judged
as “a strong and objective demonstration of the clinical efcacy of Ruscus extract in treating patients with CVI.”
In a recent meta-analysis of 719 patients from 10 RCTs,
62
Ruscus vs placebo showed reduced heaviness (RR = 0.26,
p < 0.00001, NNT = 2.4), sensation of swelling (RR = 0.53,
p < 0.0001, NNT = 4), pain (RR = 0.35, p = 0.01, NNT =
5), paresthesia (RR = 0.27, p < 0.0001, NNT = 1.8), and
global symptoms (RR = 0.54, p < 0.00001, NNT = 4.3).
Ankle circumference and leg/foot volume also decreased
vs placebo. The study concluded that “Ruscus extracts
are highly effective in reducing symptoms and edema of
patients with CVD.”
62
A meta-analysis found that Ruscus extracts reduced
ankle circumference signicantly better than placebo (p
< 0.0001) and diosmin (p < 0.00001) and achieved the
second-best Z-score after MPFF.
reported that Ruscus extract was the most effective among
the VAD groups for this outcome.
42
Another meta-analysis
44
34.4.7 Red vine leaf extract
The red vine leaf extract (RVLE), used for CVI, attracted
attention due to its properties increasing synthase-dependent nitric oxide (NO) generation and decreasing the endothelial oxidative stress.
In an RCT including 71 patients with CVI,64 a 6-week
treatment with RVLE or placebo was followed by a 4-week
washout period with placebo and another 6 weeks of treatment (placebo or RVLE). Treatment with RVLE decreased
leg circumference at the ankle level by –0.39 ± 0.09 cm
versus +0.29 ± 0.09 cm; p < 0.0001 and at the calf level by
–0.54 ± 0.05 cm versus + 0.14 ± 0.05 cm; p < 0.0001. In
parallel, the microvascular blood ow values signicantly
increased, as did oxygen pressure.
63
64
In a multicenter double-blind placebo-controlled trial,
248 symptomatic CVI patients (CEAP C3–4) were treated
for 12 weeks.
65
The RVLE signicantly decreased pain (p
= 0.047), but not other symptoms (leg tiredness and sensation of tension). Leg volume in the RVLE group was
reduced by a mean of 27 ± 6.8 mL (19.9 ± 8.9 mL over
placebo, p = 0.0268). The RVLE was well tolerated.
65
In a systematic review of ve trials, the primary outcomes included symptoms (pain, leg heaviness, sensation of
tension, and tingling) and edema.
66
A signicant improvement with red vine leaf extract was reported only in some
trials. The study concluded that RVLE had a benecial
effect for CVI, but high-quality trials are needed to provide
stronger evidence.
34.4.8 Calcium dobesilate
A meta-analysis67 of ten RCTs, six with good methodological quality, included 778 patients. Improvement of symptoms compared to placebo was signicant for discomfort
and cramps. Results were better in severe over mild disease
for pain, heaviness, paresthesia, malleolar swelling, and leg
volume (–7.2% vs –1.6%). Increase of the dose from 1000
to 1500 mg daily did not result in more efcacy. Adverse
events were similar for calcium dobesilate and the placebo
groups. The authors concluded that calcium dobesilate was
benecial for CVI symptoms, especially in advanced disease.
After reports of some cases of agranulocytosis, the
drug’s safety was assessed for three indications: diabetic
retinopathy, CVD, and hemorrhoidal disease.
68
The review
included medical publications (1970–2003), postmarketing
surveillance (1974–1998), the producer of the drug, and
a pharmacovigilance database (1995–2003). The adverse
events reported were fever (26%), gastrointestinal disorders (12.5%), skin reactions (8.2%), arthralgia (4.3%),
and 13 cases of agranulocytosis (4.3%).
68
The estimated
prevalence of agranulocytosis was inferior to the prevalence in the general population, and the review stated that
the risk associated with calcium dobesilate was low.
The meta-analysis comparing the results of calcium
dobesilate RCTs with other VAD data reported that it was
the most effective treatment in reducing foot volume; mean
reduction of volume vs placebo was –85 cm
–191.46 to 21.64).
44
3
/mL (95% CI
34.4.9 Sulodexide
Sulodexide does not belong to a VAD group but is currently
used to treat patients with CVD, especially for advanced disease, in Europe and other parts of the world. It is composed
of a fast-moving heparin fraction (80%) with an afnity
for antithrombin III and a dermatan sulfate (DS) fraction
69
(20%).
and anti-inammatory effects, increased contractility, and
restoration of vein function, inducing a decrease of MMP-2
and MMP-9 endothelial levels after prolonged stretch and
providing an endothelial glycocalyx protective effect.
1901 patients with CVD for quantitative analysis.
dexide improved symptoms (pain, cramps, heaviness, and
total symptom score) and edema and decreased the inammatory mediators. Adverse events occurred in 3%, compa-
Its pharmacological properties include antiplatelet
69,70
A meta-analysis of 64 studies used 13 trials including
71
Sulo-
34.5 Drugs for venous leg ulcers 345
https://t.me/med1917
rable to placebo or heparan sulfate, and thereby conrmed
the treatment’s safety.
Another meta-analysis included observational studies
with sulodexide for CVD patients without VLU and found
a signicant impact on pain, sensation of swelling, heaviness, and paresthesia evaluated by Likert scale.
these effects could not be considered for comparative analysis with other VADs due to the methodology differences.
44
However,
34.5 DRUGS FOR VENOUS LEG
ULCERS
34.5.1 General considerations
VLUs mark the ultimate stage of CVD (CEAP C5 and C6).
Progress in compression therapy, local care, and venous
interventions has been signicant and is discussed in detail
elsewhere in this book. Because of the elevated direct and
indirect cost of VLU care, prolonged duration to healing, and high recurrence rates, it is important to consider
adjunctive therapeutic options. VADs have been proposed
as adjuvant therapy based on their mechanism of action
addressing the pathogenesis of VLU.
34.5.2 Systemic pharmacologic treatment
and nutraceutical supplements for
venous leg ulcers
34.5.2.1 Nutritional supplements
A recent systematic review addressing nutrition status in
VLU cases identied four studies.
VLU patients tend to have deciencies of zinc and vitamins
A and D. A high BMI as well as an excess of carbohydrates
and lipids was also found. These and other nutrients were
previously described as contributing factors for VLU healing.
The evaluation of oral nutritional supplementation
effects on patients with venous ulcers in a clinical trial
established values of high-calorie, high-protein, immunonutrient-enriched oral nutritional supplementation and
recommended it for adjuvant therapy.
The benet of antioxidant nutrients in chronic lower
limb ulcers was assessed in a systematic review, including
14 RCTs. The study concluded that omega-3 fatty acids;
magnesium; zinc; vitamins A, C, and D; resveratrol; and
probiotics have a positive impact on ulcer healing, especially in patients with deciencies of these nutrients. The
authors reinforced the importance of detecting and treating
malnutrition and the maintenance of adequate nutrition in
patients with chronic ulcers.
34.5.2.2 Fibrinolytic therapy
Enhanced brinolysis was a key player in the concept of
an oxygen diffusion barrier causing skin hypoxia. With
this perspective, stanozolol, an anabolic steroid with probrinolytic properties, was evaluated in VLU treatment in
one trial and quoted in a recent systematic review.
ty-ve patients were included and received either stanozolol or placebo for 420 days. The healing rates were similar
in the stanozolol and placebo group (65% vs 61.5%, NS).
72
The authors reported that
73
74
75
Seven-
Another drug with probrinolytic properties, sulodexide, contains in addition to heparan sulphate, DS, which is
a glycosaminoglycan that selectively catalyzes the inactivation of thrombin by heparin cofactor II without interacting
with antithrombin III. A Cochrane systematic review of
sulodexide in VLU patients identied four RCTs with a total
number of 463 participants, with one RCT versus placebo
and the others versus standard treatment without sulodex-
76
Only three RCT reports had full-text articles, and for
ide.
one study only the abstract was available. A meta-analysis of the three trials with full reports and a follow-up of
30–90 days demonstrated the healing rate for the sulodexide adjunctive and compression treatment group of 49.4%,
compared with 29.8% for wound care and compression
therapy alone (RR 1.66; 95% CI 1.3–2.12). The risk of
bias was non-negligeable, and the frequency of adverse
events increased in the sulodexide group: 4.4% vs 3.1%
(RR 1.44; 95% CI 0.48–4.34). The authors emphasized a
low quality of evidence, but they concluded that adjunctive
sulodexide treatment may increase VLU healing.
A comparative Bayesian network meta-analysis for
sulodexide and VADs found that sulodexide had the highest probability of being the best treatment for VLU (48%)
compared with pentoxifylline (37%) and MPFF (16%).
44
34.5.2.3 Antibiotics
Some practitioners use topical and systemic antibiotics to
eradicate the bacteria colonizing VLU. Besides obvious
cases of infected VLUs, the indication for the antibiotics
should be carefully weighted, as bacteria may not be the
core of the problem, and their use may lead to the emergence of resistant organisms in addition to adverse events.
A Cochrane systematic review evaluating the use of
antibiotics and antiseptics for VLU analyzed 45 RCTs
(4486 participants).
temic antibiotics, and the remainder the use of topical antimicrobial drugs and antiseptics. There was no evidence
supporting improved ulcer healing with routine systemic
antibiotic therapy. Even for clinically infected VLUs, the
authors could not determine whether systemic antibiotics
could promote healing and left the decision to the practitioner’s best practice judgement. Obviously, antibiotics
have their indication when a patient presents with evidence
of cellulitis, abscess, or septicemia.
77
Five trials addressed the use of sys-
34.5.2.4 Pentoxifylline
Pentoxifylline is used for patients with peripheral arterial disease and demonstrated an ability to inhibit cytokine-mediated
neutrophil activation, reduce white cell adhesion to endothelium and superoxide free radical release.
identied 12 clinical trials involving 864 patients with VLU.
In 11 trials pentoxifylline was compared to placebo or no
treatment. The drug alone showed superiority over placebo
(RR 1.70, 95% CI 1.30–2.24) in improving ulcer healing rate
by 21% (95% CI: 8%–34%). Pentoxifylline as an adjunct
to compression therapy was more effective than placebo plus
compression (RR 1.56, 95% CI 1.14–2.13). The NNT varied from 3 (95% CI: 2–12) to 11 (95% CI: 6–43), as healing
rates in the control groups ranged from 16.67% to 62.2%.
The adverse events were mainly gastrointestinal disturbances.
The authors concluded that pentoxifylline as an adjunct to
78
A Cochrane review
79
34
346 Chapter 34 Drug treatment for chronic venous disease
https://t.me/med1917
compression treatment is effective for VLU management and
“may be effective in the absence of compression.”
A systematic review
80
of ten publications, one pilot
RCT, and four Cochrane reviews found that of all the drugs
studied (pentoxifylline, aspirin, sulodexide, mesoglycan,
avonoids, thromboxane A2 antagonist [ifetroban], zinc,
prostaglandin, and prostacyclin analogues), pentoxifylline
was the only drug that “has promising evidence to support
its use.” Pentoxifylline was more effective than placebo to
increase VLU healing and decreased ulcer size by >60%
(RR 1.70, 95% CI 1.30–2.24).
80,81
A meta-analysis of 13 pentoxifylline RCTs with 921
participants found that pentoxifylline compared with placebo signicantly increased VLU healing rate (RR = 1.59,
95% CI 1.22–2.07, P < 0.001) and had a signicant effect
on ulcer improvement (RR = 2.36, 95% CI 1.31–4.24, P =
0.004). Time to healing was shorter (P = 0.007) and ulcer
size decrease was better in the active treatment group (P
= 0.02). The incidence of gastrointestinal side effects was
greater for pentoxifylline (RR = 2.29, 95% CI 1.04–5.03, P
= 0.04). The evidence was of moderate certainty.
81
In a Bayesian network meta-analysis for the proportion of patients with complete ulcer healing, pentoxifylline
showed the second highest probability of being the best
treatment (37%) after sulodexide (48%); the third on the
list was MPFF (16%).
44
34.5.2.5 Venoactive drugs or compounds
34.5.2.5.1 Micronized purified flavonoid fraction
In a meta-analysis, ve RCTs (723 patients) were included
with MPFF adjunctive therapy to compression and appropriate wound care.
databases in an electronic format and provided the analysis
after aggregating the data. The outcomes were VLU healing
rate and time to healing. Conventional treatment (compression and local care) in addition to MPFF was compared to
conventional treatment plus placebo in two studies (n = 309)
or with conventional treatment alone in three studies (n =
414). The primary endpoint was complete ulcer healing at 6
months. The results were expressed as reduction of the relative risk (RRR) or better chance of healing with 95% condence intervals. At 6 months, the chance of VLU healing
was 32% higher in patients treated with adjunctive MPFF
than in those managed by conventional therapy alone (RRR:
32%; 95% CI: 3%–70%). This difference was present from
the second month (RRR: 44%; 95% CI: 7%–94%) and was
associated with a shorter time to healing (16 weeks vs 21
weeks; p = 0.0034). A particular benet of MPFF was found
in the subgroup of VLU between 5 and 10 cm
40%; 95% CI: 6%–87%) and in patients with ulcers of 6–12
months’ duration (RRR: 44%; 95% CI: 6%–97%).
results conrmed that VLU healing is improved and accelerated by MPFF treatment and that MPFF is a useful adjunct to
standard therapy in large and long-standing ulcers.
34.5.2.5.2 Flavonoids
A Cochrane review on avonoids for treating VLU included
nine RCTs (1075 participants): ve studies investigated MPFF
and four HR.
patients) showed a signicantly better ulcer healing rate in
the MPFF groups (RR 1.36; 95% CI 1.07–1.74). However,
the authors considered that the only unpublished RCT was
82
An independent company collected RCT
2
in area (RRR:
82
These
83
The meta-analysis of the ve MPFF trials (723
at low risk of bias and failed to show an additional benet
of MPFF.
91
That raised the question about the possibility of
publication bias. This statement differs from the independent
MPFF meta-analysis using the pulled databases (and not publications) of the same RCT.
82
For HR, the quality of reporting
was judged as poor. Nevertheless, the analysis of three RCTs
(279 patients) showed ulcer healing was signicantly better in
the HR group (RR 1.70; 95% CI 1.24–2.34).
83
34.5.2.6 Other drugs
Some positive effects of prostaglandin E1 (PGE-1) and the
synthetic prostacyclin analog iloprost were observed in
several RCTs.
84,85
However, no further publication addressing the efcacy of PGE-1 or iloprost in the management of
VLU was found.
As for aspirin, a Cochrane review concluded that there
is no quality evidence of its effect on healing and recurrence of VLUs.
not support aspirin as adjuvant treatment for VLU.
86
The ndings of later RCTs vs placebo did
87,88
The effects of the oral thromboxane A2 receptor antagonist
ifetroban on VLUs has been studied in a well-designed RCT
with a placebo-controlled multicenter study.
89
The authors
failed to demonstrate any drug impact on ulcer healing.
34.6 PERIOPERATIVE USE OF
VENOACTIVE DRUGS
A systematic review on VAD effects on recovery after surgery, endovenous ablation, and sclerotherapy included ve
clinical trials, two observational studies, and three RCTs,
all with unblinded open-label design, including a total
of 848 participants.
started 2 weeks before the procedure in all studies, and
in one study sulodexide was utilized with MPFF perioperatively. The authors found signicantly less postinterventional pain and greater symptomatic improvement in the
three studies with MPFF. No signicant effect on pain was
observed in one MPFF/sulodexide study. Less hematoma
and signicantly decreased analgesic consumption were
reported in one trial. The review concluded that “appropriate treatment with MPFF may help reduce post-procedural
pain, hemorrhage, and CVD-specic symptoms.”
An open study in 132 consecutive patients undergoing varicose vein surgery (RFA, stripping, crossectomy, or
phlebectomy) reported no signicant effect of VAD postoperative therapy on symptoms and QoL.
nding is not unexpected, since VAD treatment often needs
2 weeks to reach optimal efcacy.
Sulodexide was investigated in an RCT that enrolled 40
patients with varicose veins (great saphenous vein insufciency) belonging to the CEAP clinical C4 class.
dexide was prescribed for a month after intervention in a
20-patient group. The authors reported signicantly better
results for QoL with the CIVIQ-20 questionnaire, VCSS
score, and increase in tissue perfusion and microcirculation
in the sulodexide group compared to the controls.
Another prospective multicenter RCT in 720 patients
with telangiectasia, reticular veins, or varicose veins investigated sulodexide as adjunctive treatment to sclerother-
93
Sulodexide was administrated for 7 days before the
apy.
procedure in one group (n = 354 patients) and compared
90
The administration of MPFF was
91
However, this
92
Sulo-
92
34.7 Conclusion 347
https://t.me/med1917
to the control group (n = 366 patients). Standard treatment included sclerotherapy with polidocanol and 7 days
of 20–30 mmHg compression stockings. Patients were
examined and photographs were taken at 1 and 3 months
after intervention. Only 609 patients completed the study.
A computer software program was used to evaluate hyperpigmentation. At 1 month, follow-up assessment revealed
an 8.7% incidence of hyperpigmentation in the sulodexide
group vs 14.8% in the control group (p = 0.01). The average area of hyperpigmentation for sulodexide was 10.7%
vs 18.2% in the control group (p = 0.01). In the sulodexide
group, the skin tone of the hyperpigmented area was less (p
= 0.02) at 1 month, but at 3 months the difference between
groups was not signicant. Both groups had similar results
for vein disappearance. The authors concluded that sulodexide effectively reduced hyperpigmentation.
93
A nonrandomized, controlled DEFANCE (Daon 500
mg (MPFF) Assessment of Efcacy and Safety for Combined
Phlebectomy) study included 245 varicose vein (CEAP C2)
patients who were candidates for GSV stripping.
94
Two hundred patients received MPFF 1000 mg for 14 days before
and 30 days after surgery and were compared to 45 control
patients. For 4 weeks after intervention, all participants were
treated with compression class 2 stockings. In the postoperative 7-day follow-up, MPFF signicantly decreased pain
(2.9 vs 3.5, p < 0.05; 10 cm VAS) and hematoma score (3.4
vs 4.6, p < 0.05; 12-point scale).
94
This difference persisted
at day 14 and 30 of the follow-up. Similar results were
reported for heaviness and fatigue.
34.7 CONCLUSION
• Several VADs improve the symptoms and edema related
to CVD. These could be used in patients with CVD in
association with compression and interventions.
•
In symptomatic patients with varicose veins who are
not candidates for intervention, or who are waiting for
intervention or have symptoms after intervention, we
suggest MPFF or Ruscus extracts for treatment of vein
related pain, leg heaviness and/or sensation of swelling.
•
In symptomatic patients with varicose veins who are
not candidates for intervention, or who are waiting
for intervention or have symptoms after intervention,
we suggest hydroxyethylrutosides, calcium dobesilate,
horse chestnut extract, red vine leaf extract, or sulodexide for treatment of vein-related pain, leg heaviness,
night cramps and/or sensation of swelling.
•
Nutritional deciencies should be investigated and
treated in patients with VLUs.
•
VLUs may benet from treatment with either MPFF,
pentoxifylline, sulodexide, or hydroxyethylrutosides
used in combination with compression and wound care.
•
In patients with symptomatic varicose veins who
undergo intervention, we suggest MPFF therapy for 2
weeks before a procedure and continued for 30 days
following the intervention concomitantly with compression. For sclerotherapy, we suggest 7 days of sulodexide,
where available, prior to and 30 days after injections
adjunctive to compression therapy.
34
Guidelines 34.0 of the American Venous Forum on the drug treatment of chronic venous disease
No. Guideline Grade of recom-
34.1 We recommend micronized puried avonoid fraction (MPFF), rutosides, horse
chestnut seed extract (escin), and Ruscus for patients with symptoms and
edema due to chronic venous disease.
34.2 We suggest diosmin, calcium dobesilate, and red vine leaf extract for patients
with symptoms and edema due to chronic venous disease.
34.3 We suggest sulodexide for patients with symptoms and edema due to chronic
venous disease.
34.4 In symptomatic patients with varicose veins who are not candidates for intervention, or who are waiting for intervention or have symptoms after intervention, we suggest MPFF or Ruscus extracts for treatment of vein related pain,
leg heaviness and/or sensation of swelling.
34.5 In symptomatic patients with varicose veins who are not candidates for intervention, or who are waiting for intervention or have symptoms after intervention, we suggest hydroxyethylrutosides, calcium dobesilate, horse chestnut
extract, red vine leaf extract, or sulodexide for treatment of vein-related pain,
leg heaviness, night cramps and/or sensation of swelling.
34.6 We recommend nutrition assessment and, if needed, nutritional supplementation addressing nutritional deciencies in patients with venous leg ulcers.
34.7 We recommend in venous leg ulcers either MPFF, or pentoxifylline, as
adjunctive treatment with compression, early intervention, and wound local care.
34.8 We recommend in venous leg ulcers sulodexide as adjunctive treatment with
compression, early intervention, and wound local care.
34.9 We suggest in venous leg ulcers hydroxyethylrutosides as adjunctive treatment
with compression, early intervention, and wound local care.
mendation (1:
strong; 2: weak)
1 A
2 B
2 C
2 B
2 C
1 B
1 A
1 B
2 C
Grade of evidence (A:
high quality; B: moderate quality; C: low or
very low quality)
348 Chapter 34 Drug treatment for chronic venous disease
https://t.me/med1917
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Superficial and perforating veins
https://t.me/med1917
Edited by Cynthia K. Shortell
35 Liquid sclerotherapy for telangiectasia and varicose veins
Edward G. Mackay
36 Percutaneous laser therapy of telangiectasia and varicose veins
Thomas M. Proebstle
37 Physician-compounded foam sclerotherapy for ablation of supercial truncal veins and varicose tributaries
Claudine Hamel-Desnos and Peter Gloviczki
38 Endovenous microfoam sclerotherapy for ablation of supercial truncal veins and varicose tributaries
Juan Carlos Jimenez and Peter F. Lawrence
39 Phlebectomy
Mikel Sadek and Lowell S. Kabnick
SUB-PART
B
40 Open surgical treatment for supercial truncal incompetence
Michael C. Dalsing
41 Saphenous-preserving surgical interventions: CHIVA and ASVAL
Tristan R. A. Lane, Sarah Onida, and Alun H. Davies
42 Radiofrequency treatment of the incompetent saphenous vein
Alan M. Dietzek and Emilia Krol
43 Endovenous laser treatment of supercial truncal veins
Alessandra Puggioni
44 Cyanoacrylate glue treatment of incompetent supercial truncal veins
Raghu Kolluri and Andrew Pollard
45 Mechanical occlusion chemically assisted ablation (MOCA) and high intensity focused
ultrasound (HIFU) for chronic venous disease
Raymond Kennedy and Steve Elias
46 The management of incompetent perforating veins
Mary A. Binko, Misaki M. Kiguchi, Peter F. Lawrence, and Eric S. Hager
47 Management of thrombotic complications of endovenous ablations
Peter F. Lawrence, Juan Carlos Jimenez, and Kellie R. Brown
48 Treatment algorithm for management of varicose veins
Christopher Montoya, Christopher Chow, and Jose I. Almeida
49 Etiology and management of recurrent varicose veins
Tina Koutsos, Connie Koutsos, Pamela S. Kim, Angela A. Kokkosis, and Antonios P. Gasparis
https://t.me/med1917
CHAPTER
35
https://t.me/med1917
Liquid sclerotherapy for telangiectasia
and varicose veins
Edward G. Mackay
35.1 INTRODUCTION
In recent years, many new treatment options for varicose
veins have emerged, including endovenous thermoablation,
microfoam sclerotherapy, mechanical chemical ablation, and
cyanoacrylate glue ablation. These options are covered in
other chapters. Despite the new possibilities, however, liquid
sclerotherapy serves as the main treatment option for small
varicose veins (<3 mm) and for telangiectasia, also known
as spider veins. In addition, liquid sclerotherapy may be
indicated for larger veins in situations where other options
are not well suited. Although problems in small veins are
generally considered to be cosmetic, they are nonetheless
extremely important to patients. Additionally, some patients
do describe symptoms of pain, burning, or swelling.
In the nineteenth
sclerosants, such as quinine and urethane,
but had poor outcomes. In the intervening years, improved
administration techniques of sclerosants and the introduction of different sclerosants, such as sodium tetradecyl
sulfate (STS) and polidocanol (PDL), resulted in enhanced
sclerotherapy.
study on compression sclerotherapy and surgical treatment, which yielded initially positive results. However,
after 5 years, the treatment failure rate was much higher
in the compression sclerotherapy group (74%) than in the
surgery group (10%).
1
and early twentieth centuries, various
4,5
By 1993, Einarsson et al. published their
6
2,3
were tested,
A complete medical history must be taken to determine
if a patient has any underlying medical problems or is on
any medications that may affect treatment. It is particularly
important to be alert to a history of deep venous thrombosis (DVT), hypercoagulable states, bleeding diathesis, or
asthma. Medications that may affect results include anticoagulants and nonsteroid anti-inammatory drugs. Hormone replacements may also increase the risk of DVT.
35.2.2 Physical examination
A careful examination should be performed of the lower
extremities to identify the locations of varicose, reticular,
and spider veins (Figure 35.1). Noting the locations of
the veins will give insight into the cause of the problem.
Most telangiectasias are located on the lateral medial thigh.
Corona phlebectatica at the ankle suggests saphenous
insufciency.
further evaluation with duplex examination. Other ndings, such as port wine stains (Figure 35.2), hypertrophy of
7
Evidence of bulging varicose veins deserves
35.2 DIAGNOSIS AND EXAMINATION
35.2.1 Clinical history
Patients often seek treatment for reticular veins (1–3 mm
in diameter) and telangiectasias or spider veins (<1 mm)
for cosmetic reasons, but a complete history and physical
are necessary to determine any underlying issues related to
the patient’s concerns. A careful history may reveal important information, such as reports of leg swelling, which
may suggest potential venous insufciency. It will also help
determine whether the problem falls into one of the categories of primary or familial, secondary or post-thrombotic varicosity, congenital or post-traumatic arteriovenous
stula, so that an appropriate Clinical-Etiology-AnatomyPathophysiology (CEAP) classication can be made.
DOI: 10.1201/9781003328971-40
35.1 Lateral venous plexus.
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