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354 Chapter 35 Liquid sclerotherapy for telangiectasia and varicose veins
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35.3 Spider veins or telangiectasia of <1 mm.
35.2 Port wine stain in patient with Klippel–Trenaunay syndrome.
the soft tissue, and bone overgrowth of the extremity, may
be suggestive of congenital malformations and indicate
that further investigation may be needed with magnetic
resonance imaging.
35.2.3 Laboratory examination
The history and physical will determine whether there is a
need for further laboratory tests. If the patient has a history
of DVT or there is a history of DVT in the family (parents
or siblings), a hematology evaluation for thrombophilia
should be considered.
35.2.4 Noninvasive vascular examination
Signs or symptoms of venous insufciency, including varicose veins, require a venous duplex evaluation before any
liquid sclerotherapy is considered. A complete examination
of the deep and supercial system aims to determine if there
is any evidence of DVT, either old or new reux in the deep
or supercial system, or supercial venous thrombosis. For
patients with purely cosmetic telangiectasia, duplex imaging is rarely required if no other signs or symptoms (such
as evidence of swelling, pigmentation around the ankle, or
reports of leg fatigue) are present. Duplex mapping will be
covered in another chapter.
More detailed examination with the use of magnetic
resonance imaging or computed tomography venograms is
indicated in cases of suspected iliofemoral occlusive disease
and vascular malformations, history of DVT, or physical
ndings of varicose veins on the abdomen/abdominal wall.
Contrast venography is indicated only when considering
intervention for pelvic or iliofemoral disease.
35.4 Reticular veins of 1–3 mm.
35.3 INDICATIONS
Liquid sclerotherapy is primarily used for small varicose
veins and telangiectasias. It should not be performed until
the source of venous insufciency (if any) is appropriately
treated. Spider veins/telangiectasia of less than 1 mm in
diameter (Figure 35.3) are generally cosmetic problems,
although patients do sometimes complain of some symptoms related to them.
Small varicose veins of 1–3 mm can be treated after the
source of venous reux has been identied and taken care
of (Figure 35.4). These reticular veins frequently feed into
the spider veins, are largely asymptomatic, and are primarily of cosmetic concern.
Liquid sclerotherapy can be recommended for veins
larger than 3 mm if there is a contraindication to foam
sclerotherapy (such as right-to-left shunt) or surgical treatment.
Postoperative residual varicose veins over 3 mm can be
managed successfully with liquid sclerotherapy if all other
sources of reux are treated.
35.4 CONTRAINDICATIONS
Contraindications to liquid sclerotherapy are as follows:
Pregnancy; treatment should be delayed unless there is a
•
major indication, such as a bleeding varicosity.
35.5 Treatment 355
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• Sedentary; mobility challenges.
• Severe systemic disease.
• Peripheral artery disease (PAD) with an ankle-brachial
index of less than 0.8. The exception may be a venous
ulcer with PAD.
Febrile illness.
•
• Acute supercial venous thrombosis or DVT.
35.5 TREATMENT
The rst step in treatment involves properly identifying the
issue for which the patient is seeking care. If it is venous
insufciency, then the appropriate evaluation should be
done to determine the cause of the problem. Treatment
of venous insufciency is covered in other chapters of
this book. If venous insufciency has been treated and the
remaining complaint is related to small veins or cosmetic
concerns, as in the case of spider telangiectasias, then liquid sclerotherapy may be indicated. Before sclerotherapy
sessions begin, patients must be provided with sufcient
information so that they can give informed consent. It is
especially important that patients are aware of possible
complications and are provided with a realistic assessment
of outcomes to expect, as well as an understanding that
treatment may involve a series of appointments. Once consent is given, photographs should be taken to provide baseline documentation of the areas to be treated.
35.5.1 Sclerosing agents
Sclerosing agents (Table 35.1) are divided into groups
based on their mechanism of action. Osmotic agents work
by dehydrating the endothelial cells. Examples include
hypertonic saline 23.4%, glucose 75%, and sodium salicylate. Detergent solutions’ mechanism of action involves
damaging the surface lipids of endothelial cells. Detergent
agents include STS, PDL, sodium morrhuate, and ethanolamine oleate. Corrosive agents damage the vessel wall.
Examples of corrosive agents are sodium and potassium
iodide, benzyl alcohol, 72% glycerin, and chromated
glycerin.
35.5.2 Selection of sclerosant
In the United States, the FDA has approved several agents
for sclerotherapy. These include the detergent solutions
mentioned earlier. The two solutions currently used and
marketed for liquid sclerotherapy are STS (Sotradecol) and
PDL (Asclera). The PDL injection gained FDA approval in
2010. Hypertonic saline 23.4% and glycerin 72% are used
off-label for cosmetic spider veins.
Research to date does not appear to denitively prefer
one sclerosant over another. In a 2010 review of the literature, David M. Duffy wrote: “All sclerosants represent a
compromise between efcacy and toxicity, compounded by
practitioner sophistication, patient-to-patient variability,
and, as a practical matter, legal status.”
Carlin and Ratz reported a small randomized controlled trial comparing PDL, STS, saline 20% with heparin,
and saline 0.9% (placebo). They concluded that PDL was
as effective as STS and saline with heparin but was more
easily tolerated by patients.
9
In 2002, Goldman reported a study in which 129
patients were treated with varying concentrations of STS
or PDL. Patients had an average of 70% improvement, and
70%–72% of them were satised with their results. No signicant differences in adverse effects were reported, with
the exception of a decrease in ulcerations and swelling in
the PDL group.
10
The author concluded that both STS and PDL are safe
and effective for varicose and telangiectatic leg veins.
8
35
TABLE 35.1 Comparison of sclerosing agents
Agent Manufacturer Category FDA
Hypertonic
saline
Nonchromated
glycerin
Asclera (polidocanol)
Scleromate
(sodium morrhuate)
Sotradecol
(sodium tetradecyl sulfate)
Source: Adapted from Gloviczki P et al. J Vasc Surg 2011; 53(5):2S–48S.
Abbreviations: FDA: Food and Drug Administration.
Multiple Osmotic Off-label
Compounded
at pharmacy
Kreussler Pharma, Wiesbaden,
Germany
Glenwood, LLC,
Englewood, NJ
Viatris, Canonsburg, PA
Alcohol
agent
Detergent Approved +++ FDA approved Staining
Detergent Approved +++ FDA approved High incidence of skin necrosis and
Detergent Approved +++++ FDA approved; low
approval
usage
Off-label
usage
Strength Advantages Disadvantages
++ Low risk of allergic re-
+ Low incidence of
action; wide availability; rapid response
hyperpigmentation,
necrosis, and allergic
reaction
risk of allergic reaction;
potent sclerosant
Off-label; painful to inject; hyperpigmentation; necrosis; rapid dilution; not
recommended for facial veins
Weak sclerosing agent; typically only
used for telangiectasia
anaphylaxis
Potential necrosis with extravasation;
telangiectasia matting
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TABLE 35.2 Indications and concentrations of sclerosing
agents
Indications STS (%) Polidoca-
Varicose
veins >3 mm
Reticular
veins 1–3 mm
Telangiectasias <1.0 mm
Abbreviations: STS: sodium tetradecyl sulfate; HTS: hypertonic saline.
1.0–3.0 1.0–3.0 – –
0.5–0.75 0.5–1.0 11.7–23.4 –
0.125–0.25 0.25–0.5 11.7–23.4 48–72
nol (%)
HTS (%) Glycerin
(%)
35.5.3 Selection of the concentration
of sclerosant
Effective sclerosis of the vein depends on contact between
the appropriate concentration of the sclerosant and the
vein wall for enough time to damage the wall and induce
vasospasm. Too low a concentration or too little time may
induce only thrombosis; too high a concentration may
cause too intense a reaction, leading to a complication.
Choosing an appropriate concentration comes with experience and should tend toward the lowest effective concentration; the suggested ranges are presented in Table 35.2.
35.5.3.1 Veins >3 mm
For veins larger than 3 mm, liquid sclerotherapy is not considered to be the best treatment. Superior options include
foam sclerotherapy or surgery, which are discussed elsewhere in this book. If other methods cannot be performed,
then liquid sclerotherapy with concentrations of 1%–3%
STS or 1%–3% PDL could be attempted.
35.5.3.2 Veins 1–3 mm
For reticular veins, 0.5%–0.75% STS, 0.5%–1.0% PDL,
or 11.7%–23.4% hypertonic saline are generally accepted
concentrations. In a study measuring the efcacy of 0.2%
polidocanol diluted in 70% glucose compared to 75%
hypertonic glucose (HG) alone for reticular vein treatment,
it was determined that the combination of 0.2% polidocanol diluted in 70% glucose was more successful than HG
11
alone.
ence for complications.
Furthermore, this study found no statistical differ-
35.5 Loupes.
for extravasating of the sclerosant. If glycerin is being used,
a smaller syringe may be needed to generate the pressure
because of the high viscosity of the solution.
35.5.4.2 Needles
Very ne needles, such as 27–32 gauge, are recommended. They may be used alone or with a buttery,
which is helpful with larger veins where aspiration is
recommended.
An antiseptic skin cleanser is used, such as alcohol. Cotton balls or gauze pads are needed for compression and
wiping up blood or the antiseptic.
35.5.4.3 Sclerosing agents
These should be clearly labeled, either in vials or syringes,
with the type and concentration indicated. A well-lit treatment room is also needed.
35.5.4.4 Magnification
This can be obtained either with loupes (Figure 35.5) or
other magnifying sources such as Syris surgical headlamps.
35.5.4.5 Emergency equipment
At a minimum, emergency supplies should include oxygen,
epinephrine, steroids, and antihistamines.
35.5.3.3 Veins <1 mm (telangiectasias)
Veins smaller than 1 mm can be treated with 0.125%–
0.25% STS, 0.25%–0.5% PDL, 11.7%–23.4% hypertonic
saline, or 50%–72% glycerin. Hypertonic saline and glycerin may be diluted with lidocaine.
35.5.4 Materials
35.5.4.1 Syringes
The choice of syringe will depend on personal preference as
well as the type of sclerosant used. Typically, a 1- to 5-mL
syringe is used. An advantage of a larger syringe is that it
creates less pressure, which in turn results in less pain for
the patient. Lower levels of pressure reduce the potential
33.5.4.5.1 Optional equipment
Optional equipment includes polarized light sources, infrared visualization equipment, or vein lights.
35.5.5 Techniques
35.5.5.1 General considerations
Treatment begins at the source of reux; typically, this
would involve either the surgical ablation or foam sclerotherapy techniques that are covered in another chapter of
this book. Liquid sclerotherapy proceeds according to the
principle of addressing larger veins rst then moving to
smaller veins, moving from proximal to distal, while using
the lowest effective concentration of sclerosant. Effective
treatment of the larger feeder veins can also result in effec-
https://t.me/med1917
tive treatment of the smaller veins as the sclerosant travels
through the system.
35.5.5.2 Large vein treatment >3 mm
Treatment of the larger veins begins only after the source
of reuxes, if any, have been addressed. As stated previously, large veins greater than 3 mm are best treated with
other methods such as phlebectomy or foam sclerotherapy.
If for some reason other methods are not available or recommended, then the sclerotherapy should start with marking the veins to be treated while the patient is standing.
This step is done because once the patient lies down, the
veins will atten and may therefore be difcult to nd. If
ultrasound guidance is being used, however, this step is not
needed.
The volume and concentration of sclerosant depend on
the size of the vein. The sclerosant is mixed with the blood
in the vein and becomes diluted. Several steps can be taken
to try to reduce the volume of blood in the vein to minimize
this dilution: (1) use the “air block” technique in which air
is injected to displace the blood immediately before the liquid is injected; (2) raise the patient’s leg immediately after
accessing the vein but before injection, as this will chase
blood from the vein; and (3) immediately after injection,
place a compression pad over the treated vein to slow the
entry of blood into the vessel.
The concentration of the sclerosant should be 1%–3%
STS or 2%–3% PDL. The volume of injection should be
approximately 0.5–1.0 mL per site but should not exceed
10 mL for the whole length of the vein. It is advisable to try
to treat the entire vein in one session to prevent thrombosis
of untreated segments. Patients should wear compression
stockings for 1 week following treatment.
35.5.5.3 Reticular veins (1–3 mm)
Treating the reticular veins that are feeding into spider veins
improves the global results. Often, reticular veins and spider veins have no obvious source of reux on ultrasound.
Sometimes on ultrasound, small perigeniculate or lateral
thigh perforator veins are identied. Veins are usually visible to the naked eye with magnication, but there are other
aids to seeing them better, such as infrared projection (Figure 33.6), vein lights, or polarized lights. When accessing
the veins, aspiration of blood conrms proper needle placement. Per site, approximately 0.1–0.5 mL of the appropriate concentration of sclerosant should be injected. The next
site of injection should be situated 5–15 cm from the previous site. This can be determined visually, as the treated
segment is usually in spasm and can no longer be identied.
Concentrations to be used are 23.4% hypertonic saline,
0.5%–0.75% STS, or 0.75%–1.0% PDL. Foam sclerotherapy can also be used in reticular veins. This is discussed in
another chapter in this book.
35.5.5.4 Spider veins (telangiectasias)
The key to treating spider veins is to visualize the needle
entering the vein. Since aspiration is usually not possible
for conrming needle placement, direct visualization is
required. It is therefore important to have excellent lighting
35.5 Treatment 357
35.6 Infrared photograph of lateral varicose and perforating veins.
without glare. Magnication is also very helpful. Other
aids include polarized lights, such as the Syris headlamp
with magnication. The volume of injection depends on
the length and size of the vein.
There should be minimal resistance, and once resistance
is felt, the injection should stop. After the injection, the
needle can be held in position with slight pressure on the
plunger. This prevents blood from returning and increases
contact time with the vein wall and sclerosant. Injection
should be interrupted with any evidence of extravasation
of the sclerosant. Additional pressure could be then applied
after the injection to help produce apposition of the vein
wall. This can be done manually or with cotton balls. Typical concentrations of sclerosant are 0.125%–0.25% for
STS, 0.25%–0.5% for PDL, 11.4%–23.4% for hypertonic
saline, or 48%–72% for glycerin. Total volume depends
on the type and concentration of sclerosant, but 10 mL is
typical for one session.
35.5.6 Compression
Compression following sclerotherapy reduces discomfort
and side effects such as phlebitis. Compression stockings
are generally used. Extra foam pads, cotton balls, or gauze
can be placed to apply additional compression over the
treated vein. These can be held in place with tape or wraps.
This additional compression helps to coapt the vein walls
and to avoid thrombosis, thereby diminishing the risks of
postoperative pain and staining.
35.5.7 Post-sclerotherapy
microthrombectomy
Following treatment, a thrombus may form in the vein
despite adequate compression. The thrombus can be painful and could lead to staining. The unwanted effects of
this complication can potentially be reduced by draining
the thrombus in the rst 2–3 weeks after treatment.
can be done under local anesthesia and with the help of
18- to 22-gauge needles puncturing in the line along the
vein and then using cotton swaps to compress the clot
(Figure 35.7).
12
This
35
358 Chapter 35 Liquid sclerotherapy for telangiectasia and varicose veins
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lidocaine may be added to reduce the discomfort. (2) The
use of the smallest-gauge needle that can penetrate the skin
is advisable. Usually, 30- to 32-gauge needles work best.
(3) The extravasation of the solution can be avoided by
ensuring that the needle is correctly placed in the vein and
the sclerosant is not injected too strongly or too rapidly.
(4) Hypertonic saline has been associated with cramping at
the injection site, so limiting the volume of injection at any
one site may help. (5) Additional methods to reduce the
discomfort include using topical local anesthetics, blowing
cold air on the injection site, and placing ice packs immediately after the injection. It should be noted that the use of
cooling with detergent solutions may affect their efcacy.
35.6.2 Visual changes
Visual changes or migraine auras are occasionally experienced at the time of treatment. These may be caused by the
release of endothelin from the damaged endothelial cells.
Such symptoms are more common in patients with a history of migraines or who have right-to-left shunts. These
symptoms usually pass quickly.
35.6.3 Inflammatory responses
Localized inammatory responses that lead to erythema,
urticaria, and localized edema can be observed. These can
be reduced by limiting the volume of sclerosant and using
the appropriate concentration. A full-blown anaphylaxis
reaction is possible, so an emergency kit that includes oxygen, epinephrine, antihistamines, and steroids should be on
hand at the time of treatment.
35.7 Post-sclerotherapy microphlebectomy: (a) puncture of the
thrombosed telangiectatic vein with 30-gauge hypodermic nee-
(b) thrombus coming from telangiectatic vein; (c) more throm-
dle;
bus expressed from telangiectatic vein using cotton tip swab.
35.6 ADVERSE EVENTS
35.6.1 Pain
The most common complaint associated with sclerotherapy is pain. Several factors can be considered to minimize
the amount of pain the patient will experience. (1) The
choice of sclerosant will affect pain levels, with detergent
sclerosants tending to result in less pain than the osmotic
agents. If hypertonic saline—an osmotic agent—is used,
35.6.4 Hyperpigmentation
Hyperpigmentation is a brown stain related to the production of hemosiderin, which remains after the degradation of
35.8 Adverse event: staining.
the thrombus at the site of the treated vein (Figure 35.8).11
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This can be minimized by post-sclerotherapy thrombectomy and usually resolves in just a few months. In some
cases, for unknown reasons, the staining lasts much longer
(1–2 years). Several theories to explain this phenomenon
include the skin type of the patient, the use of too strong
a solution leading to an intense inammatory reaction and
postinammatory pigmentation, or the use of too weak a
solution leading to inadequate sclerosis; recanalized, persistent thrombosis; and pigmentation. Some sclerosants,
such as hypertonic saline, seem to have a higher incidence
of hyperpigmentation, possibly due to lysis of red cells.
35.6.5 Telangiectatic matting
Telangiectatic matting is a complication in which red or
purple spider veins appear where either varicose or larger
spider veins were treated (Figure 33.9). Although the cause
cannot always be determined, inadequate treatment of an
underlying source of reux can frequently be found. Such
sources could include an undetected saphenous incompetence, perforator vein incompetence, or a reticular vein.
Ultrasound examination may help to determine the source;
vein lights or infrared imaging may demonstrate a reticular
vein not seen on ultrasound. If no source is found, the matting may resolve with time. Methods of treatment such as
laser have been tried with some success.
13
35.7 Clinical practice guidelines and systematic reviews 359
35
35.10 Adverse event: skin necrosis.
35.6.7 Thromboembolism
DVT is rarely seen with small varicose and spider veins, but
DVT must be considered if unusual pain or swelling occurs
in the postoperative period. Ultrasound should be done if
any suspicion is aroused. The incidence of DVT increases
when liquid or foam sclerotherapy is performed on larger
veins with higher concentrations of sclerosant.
35.6.6 Skin necrosis
Sclerotherapy may induce skin necrosis (Figure 35.10).
Possible causes include too high a concentration of sclerosant with extravasation, too much pressure applied to the
syringe during injection leading to blanching, or veno-arteriolar reex vasospasm. Preventive steps include use of
the appropriate strength of sclerosant, very gentle pressure
on the syringe while directly visualizing the needle entering
the spider vein, and aspiration to ensure that the injection
is done in the varicose vein. The suggested treatment for
extravasation of irritant sclerosants comprises inltration
of both hyaluronidase and isotonic uid.
14
35.6.8 Intra-arterial injections
Short of an anaphylactic reaction, intra-arterial injection
poses the greatest risk to the patient. This complication
could lead to serious tissue loss, including the possible need
for amputation. Every effort must be made to ensure that
the needle placement is in a vein and not an artery. Certain
anatomic areas, such as around the ankle where the arteries are supercial, pose particular risk. Ultrasound-guided
injections should be the rule for perforator veins or saphenous veins, as all perforator veins are accompanied by an
artery, and with saphenous veins there are several locations
where arteries are in close proximity. Ultrasound imaging
alone may not be enough to prevent intra-arterial injection.
Techniques such as aspiration of a small amount of blood
can help ensure proper needle placement in the vein; the
blood should come back very easily. Additionally, using an
open hub technique may be helpful: when the syringe used
for aspiration is taken off and replaced with a sclerosant
syringe, there would be pulsatile back-bleeding if an artery
is hit. The recommended treatment for intra-arterial injection complications may necessitate in patient treatment
with intravenous steroids, anticoagulants, thrombolytics,
and prostaglandins.
35.7 CLINICAL PRACTICE GUIDELINES
35.9 Adverse event: telangiectatic matting.
AND SYSTEMATIC REVIEWS
Current and previous clinical practice guidelines of the
Society for Vascular Surgery and the American Venous
Forum endorse sclerotherapy—either liquid or foam—for
the treatment of telangiectasia, reticular veins, and varicose
360 Chapter 35 Liquid sclerotherapy for telangiectasia and varicose veins
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15,16
veins.
choice for reticular veins of <3 mm and for telangiectasia.
In a recent Cochrane systematic review and meta-analysis
3632 patients from 33 RCTs were studied.
Liquid sclerotherapy remains the treatment of
17
Treatments
results, but polidocanol sclerotherapy was less painful than
STS, and STS had more hyperpigmentation and matting.
Liquid sclerotherapy, however, appeared to cause less mat-
ting than foam sclerotherapy.
of telangiectasias and reticular veins included sclerosing agents, laser, and compression. There was moderatecertainty evidence that sclerotherapy was better than
ACKNOWLEDGMENT
placebo (standard mean difference [SMD] 3.08, 95% CI
2.68–3.48), but it resulted in more hyperpigmentation,
matting, and pain. Polidocanol and STS had equally good
The author thanks Victoria J. White, MA, ELS, for her edi-
torial assistance.
Guidelines 35.0 of the American Venous Forum on liquid sclerotherapy for telangiectasia and varicose veins
No. Guideline Grade of recommendation Quality of evidence
35.1 For patients with symptomatic telangiectasias and
reticular veins, we recommend sclerotherapy with
liquid or foam.
1
(strong)
B
(moderate)
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★Systematic review
* Key primary papers
♦ Guidelines
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*2. McPheeters H.O. Injection treatment
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*3. Dixon F.C. The results of injection treat-
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Clin. 1930;5:41.
4. Smith F.L. Varicose veins, complications
and results of treatment of 5000 patients.
Milit Surg. 1939;85:514.
5. Weiss M.A., Hsu J.T., Neuhaus I.,
♦
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*6. Einarsson E., Eklöf B., and Neglén P.
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8. Duffy D.M. Sclerosants: A comparative
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2):1010–1025.
*9. Carlin M.C., and Ratz J.L. Treatment of
telangiectasia: Comparison of sclerosing agents. J Dermatol Surg Oncol.
1987;13(11):1181–1184.
10. Goldman M.P. Treatment of varicose
and telangiectatic leg veins: Double-blind
prospective comparative trial between
Aethoxyskerol and Sotradecol. Dermatol
Surg. 2002;28(1):52–55.
11. Matheus B., Rodrigo G.J., Regina M.,
Rafael Elias F.P., de Oliveira Mariúba J.V.,
Carlos Eduardo P.L.F., et al. Sclerotherapy
for reticular veins in the Lower Limbs.
JAMA Dermatology. 2017;153(12):
1249–1255.
*12. Scultetus A.H., Villavicencio J.L., Kao
T.-C., et al. Microthrombectomy reduces
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13. Meesters A.A., Pitassi L.H., Campos V.,
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and management strategies. Phlebology.
2022;37(9):628–643.
♦
15. Gloviczki P., Comerota A.J., Dalsing
M.C., et al. The care of patients with varicose veins and associated chronic venous
diseases: Clinical practice guidelines of
the Society for Vascular Surgery and the
American Venous Forum. J Vasc Surg.
2011;53(5):2S–48S.
♦
16. Gloviczki P., Lawrence P.F., Wasan S.M.,
et al. The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical
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Treatment for telangiectasias and reticular
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2021;10(10):Cd012723.
CHAPTER
36
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Percutaneous laser therapy
of telangiectasia and varicose veins
Thomas M. Proebstle
36.1 INTRODUCTION
According to an epidemiologic study on more than 3000
randomly assigned persons in Germany, (1) only 9.6% of
the population are free from any kind of varicosity, including reticular veins and telangiectasias, and 31.3% suffer
from clinically relevant varicose veins, venous edema, skin
changes, or venous ulcer disease, but 59% show isolated
leg telangiectasia.
Today most people are aware of varicose veins and their
associated risks like deep vein thrombosis and lung embolism, and clinical symptoms of advanced chronic venous
disorders are known to the general population. Additionally, current lifestyle demands with increased awareness of
body appearance, also focusing on the cosmetic aspect of
the legs, makes patients request treatment modalities with
excellent, if not outstanding, cosmetic results.
Currently available lasers and light sources for transcutaneous treatment of leg telangiectasia and small varicosities can comply with most of these demands.
36.2 ETIOLOGY AND PATHOGENESIS
The etiology of venous disorders, including varicose veins
and leg telangiectasia, is complex and still incompletely
understood. Besides idiopathic causes, some confounders of varicose veins are known, and in addition a variety
of different diseases can be involved in the development
of varicose vein disease (e.g., prothrombotic disorders
which may cause deep vein thrombosis and subsequently
frequently cause new varicose veins associated with
post-thrombotic deep vein reux). However, etiological
and pathophysiological aspects of venous disorders are
dealt with in preceding chapters in more detail and should
not be repeated here.
Leg telangiectasias are frequently idiopathic and mainly
of cosmetic interest to the patient. However, as shown in
Table 36.1, to the dermatologist, a variety of localized or
systemic diseases are known, which may cause the appearance of leg telangiectasia (2, 3). To know systemic diseases and conditions which may cause leg telangiectasia is
important because some of the underlying conditions may
be associated with skin hypersensitivity to light exposure,
and therefore any laser or IPL treatment would not only
be ineffective but potentially harmful to the patient and
therefore be contraindicated.
36.3 CLINICAL MANIFESTATION AND
CLASSIFICATION
The updated CEAP classication (4) offers a suitable and
well-accepted system for the description of venous disease.
However, it is less suited for categorization of these clinically insignicant but cosmetically most disturbing small
veins. The clinical stage C1, which in general represents
telangiectasia and reticular varicose veins with diameters
below 3 mm, summarizes a variety of small vessels, sometimes deserving different treatment approaches. Several
classications therefore have been proposed to provide a
more detailed view on leg telangiectasia and small varicose
veins.
Initially, leg telangiectasias have been described morphologically, naming their pattern as linear, arborized or
Besenreiser-type, spider or starlike, and punctiform or papular (5). This morphologic view frequently helps to identify
the origin of the telangiectasia, where it may be connected
through a feeder vein with the more deeply located parts
of the venous system and where any treatment probably
would be most efcient (6, 7).
When laser treatment of telangiectasia was introduced,
with the concept of the thermal relaxation time and selective photothermolysis (8), the diameter of the vessel became
probably the most important parameter. Telangiectasias
were separated into diameters below 0.2 mm, between 0.2
and 1 mm, and between 1 and 2 mm. Veins above 2 mm in
diameter are named reticular veins.
Additionally, the color of the vessel provides important
information. Vessels which are otherwise identical due to
general properties of light reection and scattering appear
more bluish if located deeper in the skin than those which
are located more supercial (9). Furthermore, it has been
demonstrated that red and blue telangiectasia differ signicantly in their oxygen saturation (10), implicating that red
vessels contain more arterialized blood than blue ones.
More recent classications of telangiectasia and visible
varicose veins (11, 12) combine different aspects of the
DOI: 10.1201/9781003328971-41
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362 Chapter 36 Percutaneous laser therapy of telangiectasia and varicose veins
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TABLE 36.1 Causes for leg telangiectasia
Primary telangiectasia
Nevus ammeus
Klippel–Trenaunay syndrome
Neavus anaemicus with telangiectasia
Angiomas and angiokeratomas
Angioma serpiginosum
Hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu
syndrome)
Ataxia telangiectasia (Louis–Bar syndrome)
Generalized essential telangiectasia
Hereditary benign telangiectasia
Spider telangiectasia
Bloom syndrome
Secondary telangiectasia
Causes associated with chronic venous disease
Idiopathic telangiectasia (C1 according to CEAP classication)
Dermatitis/capillaritis alba (C4 CEAP)
Exogenous causes
Toxic exposure to infrared radiation, UV light or X-ray
Exposure to toxic or allergenic chemicals
Microbiological agents, e.g., acute (red) and chronic (bluish)
Borrelia infection
Blunt tissue trauma
Cutaneous drug reactions, e.g., corticosteroids
Autoimmune disease
Lupus erythematosus
Dermatomyositits
Progressive systemic sclerosis
Morphea
Cryoglobulinemia
Causes with a genetic background
Xeroderma pigmentosum
Goltz syndrome
Congenital poikiloderma (Rothmund–Thomson syndrome)
Congenital neuroangiopathy (Maffucci syndrome)
Cutis marmorata telangiectatica congenital
Dyskeratosis congenita
Unilateral nevoid telangiectasia
Angiokeratoma corporis diffusum (Fabry disease)
previously mentioned criteria to be most helpful in daily
clinical use (Table 36.2).
TABLE 36.2 Classication of leg telangiectasia accord-
ing to Duffy (11) and Goldman (12)
Type 1: Telangiectasia, Spider Vein
0.1–1.0 mm diameter, color red to cyanotic
Type 1A: Telangiectatic matting
0.2 mm diameter, color red
Type 1B Communicating telangiectasia
Type 1 veins in direct communication with varicose veins of the
saphenous system
Type 2 Mixed telangiectatic/varicose veins without direct
communication with the saphenous system
Diameter 1–6 mm, color cyanotic to blue
Type 3 Nonsaphenous varicose veins (reticular veins)
Diameter 2–8 mm, color blue to blue-green
Type 4 Saphenous varicose veins
Usually diameter above 8 mm, color blue to blue-green
performed. During such a workup the sources of pathologi-
cal venous reux in the deep veins, in perforators, and in the
saphenous systems need to be identied as well as regions of
hemodynamically relevant obstruction, if there are any at all.
Additionally, other reasons for development of telangiectasia
or visible varicose veins as listed in Table 36.1 need to be
identied to prevent harm to the laser treatment candidate.
After understanding the pathology of the leg’s venous
hemodynamics, if present, saphenous and perforator reux
needs to be corrected rst before small supercial vessels are
addressed by any treatment modality. This strategy is based
on the frequent connections of visible varicosities and deeper
located incompetent veins (6, 7) and removes venous hypertension from the potentially laser-targeted telangiectasia.
36.5 PATIENT SELECTION
Any patient presenting with telangiectasia can receive
laser or IPL treatment as an alternative for sclerotherapy if
none of the contraindications as listed earlier (Table 36.1)
apply. Laser therapy is a modern, fast, and easy treatment
that offers the patient a treatment without needle injury,
without wound dressing, and—in the hands of many physicians—also without post-treatment compression stockings. Unlike with sclerosants, there is no maximum total
dose of laser light. Therefore, treatment of both legs as a
whole in one session is possible. Laser or IPL treatment of
telangiectasia is a treatment option that combines perfectly
with endovenous treatments of saphenous veins and is well
suited for patients who seek the minimum impairment of
quality of life during and after treatment.
There are also indications for laser treatment in patients
unable to receive sclerotherapy; typical reasons listed are:
36.4 PRETREATMENT DIAGNOSTICS
AND REQUIREMENTS
Before starting treatment of any venous disorder, a diagnostic workup, including a physical examination, a patient
interview, and a duplex-Doppler ultrasound, should be
Needle-phobic patients
•
• Sclerotherapy-resistant telangiectasia
• Telangiectatic matting
• Patients with pronounced hyperpigmentation after
sclerotherapy
Intolerance to sclerosant
•
36.6 Fundamentals of light–tissue interaction 363
532 nm
b
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TABLE 36.3 Confounders of successful laser or IPL treatment of telangiectasia
• Selection of wavelength according to the absorption characteristics of the target and overlying tissue.
2
• Sufcient dosing of the laser energy in terms of laser uence (joule/cm
• Selection of laser pulse duration not to exceed the thermal relaxation time of the target.
• Oversizing of the beam diameter to the correct penetration depth for scattering losses.
• Achievement of homogenous volumetric target heating with an optimum combination of wavelength selection, adjustment of laser
uence, and pulse duration.
• Adjustment of pulse duration with respect to patient’s pain perception.
• Surface cooling for pain reduction and epidermal rescue.
) to achieve reliable vessel closure.
36.6 FUNDAMENTALS OF LIGHT–
TISSUE INTERACTION
Successful treatment of telangiectasia by the use of lasers
or intense pulse light sources has to meet a number of conditions, which are given by the physics of light–tissue interaction. The most important parameters and conditions are
listed in Table 36.3.
The selection of a wavelength determines principally
whether the light energy can pass overlying skin tissue
and hereby reach the target tissue—here a venous vessel of
any given diameter at all. Between approximately 600 and
1200 nm, the human skin as a whole has a so-called optical
window, an absorption minimum of the skin with an average absorption coefcient on the order of 5 cm
evant chromophores of human skin which are responsible
for absorption of electromagnetic energy in this part of the
spectrum are hemoglobin in the dermis and melanin in the
overlying epidermis. Water only starts to contribute at the
infrared end of this part of the spectrum with wavelengths
above 1000 nm. Figure 36.1 displays the most important absorption curves. Two examples of epidermal light
absorption are given for fair skin and moderately tanned
skin with an epidermal volume fraction of melanocytes f
of 3% and 15%, respectively, calculated as described elsewhere (13). In the dermis, already the baseline absorption
is characterized by the absorption prole of hemoglobin.
Figure 36.1 shows the curve with an estimated dermal
blood content of 0.2% and a hemoglobin concentration in
the blood of 10 mmol/l. However, along the whole range
of wavelengths, this absorption is about a hundredfold
weaker than the absorption of blood alone, which is the
laser target in any transcutaneously treated vessel. Easily
visible, the 532-nm wavelength is about 100-fold better
absorbed by hemoglobin (231 cm
–1
) wavelength (14). The same is true for melanin, which
cm
absorbs the 532-nm wavelength about eight-fold better
(approximately 400 cm
(approximately 50 cm
–1
) than the 1064-nm wavelength
–1
). Water absorption does not play a
–1
) than the 1064-nm (2.2
role for both wavelengths. In summary 532 nm penetrates
signicantly less deeply than 1064 nm both in blood and in
bloodless skin (14) (Figure 36.2).
The amount of laser energy that nally reaches the target vessel determines whether the vessel will be permanently
closed. When treating supercial veins, a sufcient uence
will elicit an immediate visible reaction like shrinkage or
thrombosis of the vessel (14). Proper ranges of uence are
–1
. The rel-
36.1 Absorption spectrum of blood with oxygenated and
deoxygenated hemoglobin at a concentration of 10 mmol/l.
Epidermal absorption of moderately tanned and fair skin calculated with a melanosome volume fraction of 15% and 3%,
respectively. Dermal absorption calculated with a blood volume
fraction of 0.2% and oxygenated hemoglobin at a concentration of 10 mmol/l. All curves are given in the wavelength range
between 250 and 1000 nm.
mel
36.2 Semiquantitative display of penetration depths of 532 nm
and 1064 nm into human skin according to absorption characteristics shown in Figure 36.1; a = epidermis, b = dermal layer,
c = subcutaneous fat.
1064 nm
wavelength dependent and start from 4 joule/cm
lamp pumped dye lasers (FPDLs) when treating supercial
vessels of 0.1 mm diameter (15) and can reach 580 joule/
2
in long pulse Nd:YAG systems (16).
cm
2
for ash-
36
a
c
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