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364 Chapter 36 Percutaneous laser therapy of telangiectasia and varicose veins
b
c
a
532 nm 1064 nm
b
https://t.me/med1917
When administering the desired amount of laser energy
to the target vessel, the time in which it is delivered also is
crucial. According to the principle of selective photothermolysis (8), the laser pulse duration should not reach the thermal relaxation time of the target tissue. Thermal relaxation
describes the time course of heat transfer, usually by conduction, from the up-heated target structure to the cooler surrounding tissue. The equation describing this phenomenon
is an e-function with the thermal relaxation time as its time
constant. Practically, this means that if administering laser
pulses longer than the thermal relaxation time of the target
tissue, the advantage of higher absorption in the target tissue
is given away. To have an idea of the magnitude of the thermal relaxation time, it can be estimated as follows: its value
in seconds is about the square of the target diameter, e.g.,
the thermal relaxation time is about 250 ms in a 0.5-mm-diameter vessel or about 40 ms in a 0.2-mm-diameter vessel.
Actually, the thermal relaxation times are a little bit shorter
than estimated earlier, but actual pulse durations should stay
below this. However, one should not stay below the thermal
relaxation time too much. For example, for the 1064 nm
36.4 Semiquantitative display of different volume heating
effects of blood vessels caused by either 532-nm or 1064-nm
irradiation. Due to higher absorption of blood at 532 nm, larger
vessels get heated only at the most supercial parts, producing kind of a shield for more remote vessel parts, which stay
cool. 1064 nm heats the vessel more uniformly due to a lower
absorption coefcient; a = epidermis, b = dermal layer, c = subcutaneous fat.
ND:YAG laser, it has been shown that longer pulse durations between 20 and 60 ms consistently produce better clinical results than 3-ms pulse duration in vessels with a mean
diameter of 0.8 mm (16). Histopathology supported these
ndings, showing marked shrinkage of perivascular collagen
with longer pulses, while short pulses of 3 ms were only able
to produce a thrombotic occlusion of the vessel. In conclusion, it seems that substantial heat damage around the target
vein, at least a solid heat damage of the entire vessel wall, is
an absolute condition to get instant and durable vein occlusions. However, longer durations of laser pulses are more
painful than shorter pulses (14), and therefore patients’ pain
sometimes does not allow the administration of longer pulse
durations; in particular, pulses above 100 ms duration are
not tolerated by many patients.
Additionally, for successful laser ablation of leg telangiectasias, the actual penetration depth of laser light should
be considered. Interestingly, this depth is not only dependent on the wavelength of the laser light and its absorption characteristics but also on its scattering behavior.
The actual penetration depth therefore can be increased
by increasing the beam diameter (Figure 36.3). Due to
the mentioned scattering effects, the originally cylindric
laser beam forms a pencil-like tip before being completely
absorbed by surrounding tissue. However, because of the
phenomenon of forward scattering itself, the vanishing of
the laser beam takes longer and happens in greater tissue
depth with greater beam diameters.
After considering the tissue absorption of skin tissue and
hemoglobin in general, the absorption characteristics of the
target structure, the geometry of the vein vessel itself, needs
a closer look with respect to volumetric heating. When using
a wavelength that is absorbed too high by hemoglobin, at
least in vessels of larger diameter, the remote parts of the
vessel do not get heated enough because the energy is predominantly absorbed in the part of the vessel rst hit by the
laser beam. In contrast a wavelength that is absorbed more
moderately by hemoglobin is able to heat up the vessel in its
whole. Figure 36.4 displays this behavior for a 532-nm laser
beam in comparison to a 1064-nm beam. For this reason,
larger vessels with diameters on the order of 1 mm cannot
be successfully treated with short laser wavelengths like 532
nm, 585 nm, or even 595 nm.
To reduce pain and to minimize the risk of numerous
side effects elicited by heat damage of the skin, the use of
skin cooling is mandatory today. Local use of ice cubes or
administration of cooled gel before laser treatment or also
laser ring through ice cubes are historical methods, but they
cannot guarantee reproducible results. Nowadays sophisti-
a
cated dynamic spray cooling devices, chilled contact tips, or
cool air generators are available as discussed later.
c
36.3 Semiquantitative display of penetration depths of 1064
nm into human skin according to different beam diameters.
Penetration is deeper for larger beam diameters because of the
physical effect of forward scattering (Mie-scattering); a = epidermis, b = dermal layer, c = subcutaneous fat.
36.7 LASERS AND IPL FOR
TRANSCUTANEOUS THERAPY
OF TELANGIECTASIAS
Meanwhile, treatment of telangiectatic vessels of the legs
reached a level that allows transcutaneous treatment in
most cases. In general, there was an evolutionary change in
laser parameters, particularly an increase of pulse duration
36.7 Lasers and IPL for transcutaneous therapy of telangiectasias
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365
and uence and a move from visible light to near-infrared
wavelengths. Today a variety of laser and IPL systems are
available for treatment of leg telangiectasia of any diameter
between 0.1 and 2.0 mm.
36.7.1 532-nm KTP laser
The frequency-doubled 532-nm Nd:YAG laser system is
particularly useful for the treatment of red leg telangiectasias with small diameters below 0.7 mm. It is most effective if used on skin types I–III and problematic in tanned
or dark-skinned patients because of the high absorption of
melanin at this wavelength.
The 532-nm laser was initially used with uences
between 14 and 20 Joule/cm
2
, with pulse durations of
10–15 milliseconds and with spot sizes of 3–5 mm in
50 patients with leg telangiectasia of varying diameters.
Eighty-three percent of patients showed a clearance of 50%
or more after two treatments. With the previously mentioned parameters and a chilled tip for contact cooling, the
532-nm KTP laser proved to be less painful if compared
to laser systems with longer wavelengths (17). In another
15-patient study, clinical results were corroborated on
telangiectasia below 0.75 mm in diameter. A clearance of
more than 75% was achieved after two treatment sessions
using a uence of 16 joule/cm
2
with 10-ms pulse duration
and three passes over the same treatment area each session (18). Another study conrmed the favorable pain and
side effect prole but found vessel clearance inferior to a
long pulse dye laser. The authors recommended the use of
the KTP laser system in conjunction with sclerotherapy of
larger feeding reticular veins (19). However, when using a
multipulse mode with three stacked pulses of 100 ms, 30
ms, and 30 ms duration, each separated by a gap of 250
ms, with a uence of 60 joule/cm
2
and a beam diameter of
0.75 mm, clearance in leg telangiectasia of 0.5–1.0 mm in
diameter was 85% after three and 93% after four treatment sessions, most likely taking advantage of met-hemoglobin formation during the rst of the three pulses (20).
In another study 79 areas of 20 female subjects, skin
types I–III, were treated using a 532-nm KTP laser. A
5-mm-diameter spot, uences from 13 to 15 J/cm², and a
pulse duration of 40 ms were used in two treatment session
12 weeks apart. Blinded reviewers rated a more than 50%
improvement of telangiectasias in 69%; hyperpigmentation was observed in only 2% (21).
36.7.2 578-nm copper bromide laser
The copper bromide laser is suited for red leg telangiectasia. In a study with 46 patients 75%–100% clearance
was achieved after an average of 1.7 treatments of vessels
with diameters below 1.5 mm. Fluences were in the range
of 50–55 joule/cm
2
, and a contact cooling system with a
temperature between 1 and 4°C was used (22).
36.7.3 Flashlamp-pumped pulsed dye
laser
This laser was the rst one to take advantage of the concept of selective photothermolysis and the rst one to
achieve remarkable results in very small red vessels with
diameters below 0.1 mm, like in telangiectatic matting. At
that time—with a wavelength of 577 nm and pulse durations of 360 µs—it proved to be suitable for treatment of
infantile hemangioma or port wine stains. It did not show
remarkable effects on patients with leg telangiectasia (23).
In the mid-1990s dye lasers with a 595-nm wavelength
and a pulse duration of 1.5 ms were introduced. One study
with uences of 15 or 18 joule/cm
2
after one single treatment showed clearance in up to 65% when treating vessels
between 0.6 and 1.1 mm in diameter (24).
In ten patients, more than 75% clearance after three
treatments every 6 weeks was achieved with minimal side
effects using a 595-nm dye laser with 1.5-msec pulse duration. Fluences between 15 and 20 joule/cm
2
were used on
leg telangiectasia with diameters below 1.5 mm (25). In
another comparative study on 87 patients and 257 treatment sites, 595 nm was compared to 600-nm wavelength
using 1.5-msec pulse duration and uences of 16, 18, and
20 joule/cm
2
. A clearance rate above 50% in up to 80%
of patients was noted after a single treatment. The authors
found the best results with higher uences on vessels below
0.5 mm in diameter. Pigment changes were noticed in 32%
of cases (26). The use of a dynamic cooling device in conjunction with 595 nm and 1.5-ms pulse duration treatment
reduced patient discomfort without diminishing an average
clearance rate of 68% (27). Introduction of dye lasers with
pulse durations of 40 ms allowed treatment without or at
least with diminished production purpuric lesions after
laser treatment. With the use of an extended pulse width
of 40 ms and a uence of 16 joule/cm
2
administered up
to three passes over the same location during one session,
after a total of two treatment sessions, 70% of leg vessels
showed a clearance of 75%–100%. A –4°C air cooling system was used during treatment (28). After only one treatment of submillimeter telangiectasia with the 595-nm dye
laser at 40-ms pulse duration with a uence of 25 joule/
2
cm
and spray cooling, about half of the patients had clearance of 50% or more. In the same study 532-nm KTP laser
treatment with 50-ms pulse duration and a uence of 20
joule/cm
2
and contact cooling gave similar results (29).
36.7.4 755-nm long pulsed alexandrite
laser
The long-pulsed alexandrite laser in the near infrared at
a wavelength of 755 nm proved to be most effective in
a double pulse mode (frequency 1 Hz) at a uence of 20
joule/cm
sels with diameters below 0.4 mm did not show signicant responses, while larger telangiectasia showed a 63%
reduction after three treatments in 4-week intervals. Subsequent sclerotherapy improved laser results signicantly.
Another study showed that long pulse alexandrite laser
treatment at 3 ms pulse duration and uences of 60–70
joule/cm
eter frequently caused signicant inammatory skin reaction, purpura, and telangiectatic matting. Despite that side
effect prole, only 33% of patients had more than 75%
clearance after up to three treatment sessions (31). When
using the 755-nm alexandrite laser with a uence of 90
joule/cm
and 75% of treated telangiectasia with diameters from 0.3
2
with pulse durations of 5–10 ms (30). Small ves-
2
for treatment of veins of 0.3–3.0 mm in diam-
2
, 15 of 20 patients had a clearance between 25%
36
366 Chapter 36 Percutaneous laser therapy of telangiectasia and varicose veins
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to 1.3 mm. Noticeably, in 75% of cases, hyperpigmentation was noted (32).
However, more recently, a long pulse 755-nm alexandrite laser proved similar efcacy compared to a long pulse
1064-nm Nd:YAG laser for treatment of leg telangiectasia
in Asian skin type IV (33).
36.7.5 Diode lasers between 810 nm
and 1064 nm
One study used an 810-nm diode laser with a 5-mm spot
size and a pulse protocol of four consecutive stacked pulses
(frequency 2 Hz), each of a uence of 3 to 4.5 Joule/cm
2
No side effects were observed, but neither was clearance of
leg telangiectasia (34). Inconsistent results with only 29%
of sites clearing more than 75% were also reported from
another group using an 810-nm long pulse diode laser on
vessels with diameters between 0.3 and 3.0 mm (31). Using
a 940-nm diode laser with a 1-mm spot size, a pulse duration
of 40–70 msec, and uences between 300–350 joule/cm
2
in
a single treatment resulted in a clearance of more than 75%
of treated telangiectasia in 12 of 26 patients (46%) (35). The
same group reported an additional 1-year follow-up with
further improvement of clearing rates in 35% of patients
(36). Another group from France using spot diameters
between 0.5 and 1.5 mm, a pulse duration between 10 and
70 ms, and uences slightly above 300 joule cm
2
found clearance rates superior to 75% after up to 3 treatment sessions
in only 13% of cases if vessel diameters were below 0.4 mm
and in 88% of cases if vessel diameters were between 0.8
and 1.4 mm (37). An 810-nm laser used with a 12-mm spot
size, a pulse duration of 60 ms, and uences in the range
of 80–100 joule/cm
2
managed to clear 43% of spider veins
completely after one session with two treatment passes (38).
A combination of a 915-nm diode laser with 1 MHz radiofrequency energy with up to three treatment sessions showed
more than 75% clearance in 77 % of treatment sites when
using 80–140 joule/cm
2
laser uence and 80–100 joule/cm3
of RF energy with pulses of 100–300 ms duration (39). A
980-nm diode laser that was used with a contact cooling
device, with uences between 300 and 500 Joule/cm
2
and
pulse durations of 150 ms achieved up to 50% clearance in
60% of patients; however, with such long pulse durations
pain was pronounced in the majority of patients (40). More
recently, a 1064-nm diode laser showed its feasibility to
improve vascular lesion appearance in a small series of 15
patients (41).
36.7.6 1064-nm long pulsed Nd:YAG laser
The wavelength of 1064 nm shows less absorption in melanin compared to shorter laser wavelengths and is less
absorbed in hemoglobin. Because of the relatively low
hemoglobin absorption, laser energy can also heat up the
larger vessels in their entirety. In 1999 Weiss reported a
study on 30 patients using a Nd:YAG laser at 1064-nm
wavelength with a pulse duration of 16 mc. They observed
a 75% improvement after a single treatment in 0.5- to 3.0mm diameter vessels (42). Another study reported 64%
clearance after a maximum of three treatment sessions
using a 1064-nm Nd:YAG laser with a contact cooling
device. The author used a 6-mm spot size, pulse durations
up to 14 msec, and a uence of 130 joule/cm
vessel diameters between 0.2 and 4.0 mm (43). The same
author achieved 75%–100% clearance when using the
Nd:YAG system only for telangiectasia of 1.0–4.0 mm in
diameter but treating 0.1- to 1.0-mm vessels with a 550nm IPL device (44). Interestingly, in comparison to Sotradecol sclerotherapy in leg telangiectasia of 0.25–3.0 mm
in diameter, the long pulse Nd:YAG laser achieved equal
results (45). Utilizing a spray cooling device, long pulse
Nd:YAG treatment of leg veins of 0.3–3.0 mm in diameter
showed clearance of more than 75% in 85% of treated
.
sites after a maximum of three sessions (46). This nding
was corroborated in vein diameters between 1.0 and 3.0
mm. With a single treatment using a uence of 100 joule/
2
and pulse duration of 50 ms, a clearance of more than
cm
75% was achieved in 66% of cases (47). In a highly interesting approach to take advantage of met-hemoglobin formation using a nonuniform pulse sequence, a French group
achieved a clearance rate of 98% after three sessions. They
used a 2-mm spot, uences between 300 and 340 joule/
2
, and a contact cooling device to treat blue leg telangi-
cm
ectasia of diameters between 1 and 2 mm (48).
36.7.7 Combination of 1064 nm Nd:YAG
laser with sclerosants
More recently, lasers have been used for combination treatment modalities after either a systemic intravenous injection of a green dye (49) or injecting the target vessel with
a polidocanol-based foam sclerosant (50). Energy from a
810-nm diode or a 1064-nm Nd:YAG laser was delivered.
In a prospective randomized trial, telangiectasias of 29
subjects were treated either in the rst arm with a 1064-nm
Nd:YAG laser with uencies between 160 and 240 J/cm–²,
a pulse duration of 65 ms, and a 5-mm spot size or in the
second arm, after intravenous injection of 4 mg per kilogram body mass of an indocyanine green dye, using an 810nm diode laser with uence from 60 to 110 J/cm–², 48- to
87-ms pulse duration, and a 6-mm spot size. Blinded investigators and the participants assessed clearance rate, cosmetic
appearance, and adverse events up to 3 months after one
single treatment session. Both investigators and participants
ranked clearance rates of the dye-augmented diode laser
treatment over those after 1064-nm Nd:YAG treatment, but
also rated the dye-augmented treatment more painful.
In a randomized controlled trial in 320 female patients
skin type II–IV, polidocanol foam sclerotherapy of leg
telangiectasia followed by 1064-nm Nd:YAG laser was
compared to polidocanol foam sclerotherapy alone (50).
Each patient received two single treatment sessions at
a 3-week intervals, with treatment of both legs in full in
each session. Up to 20 cc foam prepared from an 0.3%
polidocanol solution were injected per session. In the laser
group, depending on the vessel diameter, 2-mm spot size
was used with a uence of about 300 joule/cm² of 5-mm
spot size with a uence of around 60 joule/cm². Depending on the diameter of the vessel, the pulse duration was
chosen between 20 and 50 ms. Evaluation was performed
2
to treat
36.9 Side effects and complications 367
https://t.me/med1917
by a blinded analysis of photographs taken up to 3-years
follow-up and patients’ self-assessment in 79 control legs
and 517 legs treated with the foam–laser combination.
Depending on the vessel diameter, clearance rates of the
combination laser treatment were 89%–95%, while in the
control group after foam sclerotherapy alone, corresponding clearance rates were only 15%–18%.
A promising combination concept using laser on the
same vessels before sclerotherapy under continuous air
cooling has been described as the Cryo-Laser-Cryo-Sclero
(CLaCS) therapy (51, 52). Under continuous –20°C airow, initial laser treatment reduces the vessel diameter
before either 75% glucose or 0.3% polidocanol is injected
in the same area. The cooled air contributes to pain reduction and furthermore minimizes intravascular thrombus
formation like laser-induced diameter reduction does as
well, while elimination of 86% of vessels was achieved
(51). Different sclerosants used in this method more or less
seem to act with equal efcacy (52).
36.7.8 Intense pulsed light
Intense pulsed light (IPL) sources make use of neither
monochromatic nor coherent light emission. A polychromatic spectrum is emitted, which is dened by lters placed
between the IPL source and the patient. In its initial phase
without concomitant use of special cooling devices, side
effects like skin burns or hyperpigmentation could happen
more easily than with today’s devices.
However, even in its early days, IPL was able to achieve
clearance of leg telangiectasia. In a multicenter trial treating 349 lesions in 159 patients, a clearance of more than
75% was achieved in 79% vessels between 0.1 and 3 mm
of diameter. The rate of adverse effects was low (53).
In a more recent comparative study between Nd:YAG
and IPL, the IPL treatment was judged to be more effective
in vessels with diameters below 1.0 mm, while leg veins
of more than 1.0 mm in diameter were more effectively
treated by the Nd:YAG laser (54). Logically, treatment
approaches combining IPL treatment for smaller vessels
with diameters below 1.0 mm and Nd:YAG laser treatment
for vessels with diameters above 1.0 mm were reported to
be very successful (55, 56).
36.8 COOLING SYSTEMS
Skin cooling is crucial to minimize thermal side effects
on skin structures apart from telangiectasia. Today, icing
of the skin cannot be judged reproducible enough but is
more reliable than the use of cooled gels. Gels provide
only a temperature decrease of about 5° and can even disturb the spot geometry of the laser beam and account for
energy loss of about 35% (26). Reliable and more effective
techniques are contact cooling devices (22, 29, 43), e.g.,
sapphire handpieces, dynamic spray cooling (27, 29, 46),
and using tetrauoroethene or low-temperature air cooling devices (28, 51). Also, for IPL a collar contact cooling
device improved clinical results, allowing the delivery of
higher uences with less pain (57).
36.9 SIDE EFFECTS AND
COMPLICATIONS
To identify patients prone to idiopathic hypersensitivity reactions after laser treatment, a test treatment of a
small area is necessary before a full treatment session is
administered. Furthermore, informed consent about the
following treatment-related risks should be signed by the
patient. The most frequent side effects of laser treatment
are:
Transient or, rarely, permanent hyperpigmentation
•
• Telangiectatic matting
• Incomplete elimination of telangiectasia
• Treatment-related pain
Restricted to special laser types, particularly to the oldtype ashlamp pumped dye lasers, is the side effect of
purpura. As mentioned earlier, the long pulse alexandrite
laser therapy of leg telangiectasia under certain conditions is associated with pronounced inammatory skin
reactions. Hyperpigmentation can happen with the use of
any laser or IPL light source but is more likely to happen
after treatment of telangiectasia with shorter wavelength
lasers like 532-nm KTP devices. In general, according to a
Cochrane database systematic review, lasers seem to cause
less hyperpigmentation (RR 0.57, 95% CI 0.40–0.80;
4 studies, 262 participants/procedures) if compared to
sclerotherapy (58).
Patients with activation of their pigment system after
sunny vacations or use of sunbeds should strictly avoid
laser or IPL treatments. In addition, sun exposure and use
of sunbeds should be strictly avoided after laser therapy as
long as any skin response is visible, usually for 3–4 weeks.
Dark-skinned patients should be treated with special caution, if treated at all.
A less frequent side effect of laser treatment is thrombosis of telangiectasia mostly associated with diameters
above 1 mm. To accelerate the clearing of this phenomenon, thrombosis should be removed by needle puncture
within the rst week after treatment.
Rare complications of laser treatment include blistering
of the skin with or without subsequent scarring. These side
effects most frequently happen with overdosing of laser
energy. Overdosing of laser or IPL can happen in conjunction with:
Administration of too high uences
•
• Inadvertent pulse stacking or inadvertent overlapping of
pulses
Intended pulse stacking with too small cooling intervals
•
in between
Inappropriate cooling of the skin surface during treat-
•
ment
Also laser treatment of skin that is covered with lotions or
ointments can result in skin burns and hyperpigmentation.
Removal of all of these externals before laser treatment is
therefore mandatory.
36
368 Chapter 36 Percutaneous laser therapy of telangiectasia and varicose veins
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36.10 ALTERNATIVE TREATMENT
OPTIONS FOR LEG
TELANGIECTASIA
A serious alternative option to light-based systems or some
of the described combination treatments of leg telangiectasia is sclerotherapy with various liquid or foam sclerosants.
The technique of sclerotherapy is presented in detail in a
different chapter of this book.
36.11 FUTURE DIRECTIONS
The laser and IPL treatment of leg telangiectasia still offers
a big evolution potential. Bimodal wavelength approaches,
longer pulse durations, and improved skin cooling contributed much to more effective laser and IPL treatment of leg
telangiectasia (59).
Despite a solid theoretical basis, concepts like the
exploitation of laser-induced met-hemoglobin formation are
still not fully developed (48, 60). Similarly, feedback loops
for measurement of vessel and skin temperature during laser
treatment and subsequent online adjustment of laser uence
and skin cooling are technically possible but not yet introduced in daily clinical practice. The same is true for automatic scanner systems which would direct the laser beam to
the previously traced course of the target vessel.
Combination treatments consisting of laser treatment
of telangiectatic vessels after systemic injection of a dye or
after injection of a sclerosing foam at the treatment site
look promising as well (49, 50). However, the scientic
exploration of these concepts has just begun.
36.12 CONCLUSION
• Small leg telangiectasias: For diameters below 0.5
mm and telangiectatic matting, the dye laser at 595
nm is effective (24[1C], 26[1B], 28[1C]). The KTP
laser at 532 nm is suitable on diameters below 0.7
mm (18[1C], 21[1C]). Multipass treatment (18[2C],
28[2C]) or pulse stacking (20 [2C]) may improve clinical results.
Larger telangiectasias and reticular veins up to 3 mm
•
diameter: These can be effectively treated by long pulse
Nd:YAG lasers with 1064-nm wavelength (42[1C],
46[1C], 47[1C], 48[1C]).
Combination of laser treatment of leg telangiectasias
•
with prior injection of a polidocanol foam seems to
increase clearance rates dramatically [50, 1B]; systemic
injection of an indocyanine green dye prior to laser
therapy may increase treatment success as well [49,
2C].
Effective skin cooling is mandatory to avoid thermal
•
skin damage. Appropriate cooling devices are dynamic
spray cooling (27[1C], 29[1C], 46[1C]), contact cooling (22 [1C], 29[1C], 43[1C]), or cooled air (28[1C]).
Cooled gels do not provide sufcient or homogenous
skin cooling (26[1C]).
In human skin, melanin is the main competing light
•
absorber to hemoglobin (13[1A]); therefore, laser
treatment of telangiectasias can cause long-lasting
hyperpigmentation as a side effect. An increased epidermal melanin content after sun exposure—so-called
tanned skim—therefore should be regarded a contraindication to cosmetic laser treatment of leg telangiectasias.
Guidelines 36.0 of the American Venous Forum on laser treatment of reticular veins and telangiectasias
No. Guideline Grade of recommendation Quality of evidence
36.1 For patients with symptomatic telangiectasias or reticular
veins, we suggest transcutaneous laser treatment if the
patient has a sclerosant allergy, needle phobia, sclerotherapy
failure, or small veins (<1 mm) with telangiectatic matting.
2
(weak)
B
(moderate)
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36
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CHAPTER
37
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Physician-compounded foam
sclerotherapy for ablation of superficial
truncal veins and varicose tributaries
Claudine Hamel-Desnos and Peter Gloviczki
37.1 INTRODUCTION
Endovenous methods of treating varicose veins have
been used with increasing frequency in recent years, but
foam sclerotherapy (FS), thanks to its unrivaled versatility, remains an important part of the phlebologist’s armamentarium. It is quick, inexpensive, and can be used in
the ofce setting. This chapter will address the treatment
of supercial axial veins and tributary veins with physician-compounded foam (PCF).
37.2 HISTORY
Sclerotherapy has been used to treat varicose veins since
the 1850s. However, early sclerosants were associated with
an unacceptably high incidence of serious, even life-threatening complications, such as tissue necrosis, sepsis, and
pulmonary embolism. It was not until the 1960s, with the
introduction of modern, safe sclerosants, such as sodium
tetradecyl sulfate (STS) and polidocanol (POL) that sclerotherapy gained widespread popularity. The history of FS has
been described by Wollmann
please see also Chapter 1 in this book. In 1957, Mayer
and Brücke introduced a double-piston syringe to produce
what they termed “microfoam,” likely the rst production
of foam compared to froth. In 1969, Gillesberger, a Bavarian, invented a technique by creating negative pressure in a
glass syringe so that air could enter through a gap between
the syringe piston and plunger to mix with the sclerosant,
but the ratio between air and sclerosant could not be standardized. In 1986, the Australian Grigg used two syringes
connected by a tube, and air and uid were pumped back
and forth, a prelude to the most widely used techniques
today. In 2000, Tessari published his technique for producing foam using two plastic syringes and a three-way stop-
3,4
In 1993, Garrido patented a microfoam that uses
cock.
as a carrier gas and mixed it with POL using a high-
CO
2
speed rotating brush
sclerotherapy was rst introduced by Knight in 1989,
5
1
and by Myers.2 For details,
. The concept of ultrasound-guided
6
then
became ultrasound-guided foam sclerotherapy (UGFS)
with the use of foam. Adding ultrasound guidance to FS in
the 1990s resulted in a veritable revolution.
37.3 SCLEROSANTS AND
MECHANISM OF ACTION
In Europe, most phlebologists use PCF with STS or POL
microfoam. In the United States, polidocanol endovenous
microfoam (PEM) is a commercially prepared 1% POL
microfoam, approved by the Food and Drug Administration
(FDA) (see Chapter 38). Sclerosing agents cause endothelial
damage, which exposes collagen and leads to inammation
of the vein wall and activation of platelets and the intrinsic
coagulation pathway, ideally leading to obliteration of the
venous lumen and ultimately to brosis of the vein. Only
sclerosing agents in the detergent class, such as STS and POL,
can be transformed into foam. Detergents cause endothelial
damage by altering cell wall surface tension, leading to rapid
overhydration (maceration). STS is a long-chain fatty acid
salt; it is painless to inject and available at concentrations
of 0.2%, 0.5%, 1%, and 3%. POL is a urethane anesthetic
agent; it is also painless to inject in the form of foam and
thought to be less likely to produce extravasation necrosis
than STS; it is available at concentrations of 0.25%, 0.5%,
1%, 2%, and 3%. The foam form is authorized for STS and
POL in many countries other than the United States, particularly for high concentrations of 1%–3%. Practitioners
should refer to authorizations in their country. Injection of
STS or POL as a foam as opposed to a liquid result in the
displacement of blood, thus minimizing deactivation (binding) by protein and maximizing contact with the endothelium (“foam block effect”). Foam advantages over liquid
also include better adherence to the vein wall, better venous
spasm, and excellent echogenicity. All these factors contribute to the greater efcacy of this form of sclerosant, as well
as safer injection procedures when coupled with ultrasound
guidance. Both STS and POL are well tolerated, with almost
similar side effect proles.
DOI: 10.1201/9781003328971-42
371371
372 Chapter 37 PCF sclerotherapy for ablation of superficial truncal veins and varicose tributaries
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37.4 FOAM PREPARATION TECHNIQUES
The Tessari (Tourbillon) technique is probably the most
used method for reproducibly making stable microfoam,
for about 1 minute (Figure 37.1).
are connected via a three-way stopcock. Room air is drawn
into one syringe and liquid sclerosant into the other. In a
variant of this method, the three-way stopcock is replaced
with a dedicated biconnector
use of sterile air, oxygen, carbon dioxide, a mix of CO
, etc., has been advocated. However, they add cost and
O
2
complexity, and there is no evidence these adjuncts confer any benet in terms of safety or clinical effectiveness.
The air and sclerosant are mixed back and forth (usually
around 20 times) through the three-way stopcock (or
biconnector) to produce the microfoam. The three-way
stopcock can be angulated to narrow the aperture to produce smaller bubbles, and so more stable, and arguably
3
Typically, two syringes
7
(Figures 37.2 and 37.3). The
+
2
8
37.3 Foam production: 10 to 20 back-and-forth movements.
37.1 Tessari technique with three-way stopcock with two
low-silicone syringes of 2.5 mL (1 volume of sclerosant + 4 volumes of air).
37.2 Dedicated biconnector with two low-silicone syringes of
2.5 mL (1 + 4 mix).
37.4 An automated foam production system.
more effective microfoam can be prepared. The most effective and commonly used sclerosant-to-gas mix appears to
be 1 + 4, but high level of evidence is lacking. Low-silicone
syringes and connectors are preferred, as silicone destroys
the surfactant arrangement of the foam lamellae, thus
making it less stable.
9
To better standardize foam making,
an automated foam production system has recently been
introduced (Figure 37.4). Moreover, the U.S. market has
PEM (see Chapter 38), a 1% POL foam, industrialized and
37.5 Treatment tactics and technique 373
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composed of a mixture of “physiological” gases and distributed from a pressurized container. PEM bubbles are appreciably smaller than those found in “home-made” foam, and
this, together with the low nitrogen rate, may reduce the
risks of air embolism.
clinical benet in terms of safety and clinical effectiveness
compared to PCF is not available.
To date, none of the foam manufacturing methods
have proved their superiority over the others, and barring
national regulations, cost and convenience are still the
overriding considerations.
10
However, thus far, clear evidence of
37.5 TREATMENT TACTICS AND
TECHNIQUE
37.5.1 Tactics
In the 1930s–1960s, three schools of thought emerged on
the most appropriate tactics: Sigg’s Swiss school, Fegan’s
Irish school, and the French school led by R. Tournay.
In the Swiss “bottom-up” technique, varicose veins were
rst sclerosed distally, and the treatment was completed by
obliterating the feeder trunks. Meticulous compression was
essential after each treatment, and this slow, cautious method
required many sessions. The Irish technique was based on
a different concept, giving a primordial role to the perforators, which were sclerosed as a priority, usually ignoring
the trunk and junction. Postprocedural compression was
also imperative here. The French technique, also called the
“top-bottom” technique (“proximal to distal”), consisted of
rst treating the highest or most important leakage points,
the saphenofemoral (SFJ) or saphenopopliteal junctions
(SPJ), saphenous trunks, perforators, etc. Tributary varicose
veins were initially ignored and only injected if they persisted after treatment of the trunks. Unlike the two previous
schemes, compression was not an integral part of the procedure here since inammation post-sclerotherapy was much
less frequent. This could historically explain the differences
between the positions of French practitioners and those in
other countries regarding post-sclerotherapy compression.
The top-down technique is now the reference and most
widely used in many countries.
tioners still apply strong compression, contrary to the original description, which does not include any compression.
This could also historically explain why some practitioners
rst inject incompetent trunks and only treat tributary
veins later, if still necessary. This concept applies to thermal
ablation as well.
14,15
However, many practi-
37.5.2 Techniques
Injections can be made using needles, buttery needles,
cannulas, long catheters, etc., but two main principles exist
for sclerotherapy: UGFS and visual sclerotherapy.
There is a simple but essential safety rule in sclerotherapy: a “nonvisible” varicose vein should never be treated
without ultrasound guidance. Consequently, the saphenous
trunks must always be treated under ultrasound guidance,
while certain tributary veins can sometimes be injected
under visual control. Purely cosmetic treatments are not
discussed in this chapter.
2,11,13
Prior to any treatment of varicose veins, the patient’s
expectations, the history-taking, the pathological venous
network, and its implications must be carefully identied
during clinical and ultrasound examinations.
Successful sclerotherapy requires thorough planning.
The decision to treat varicose veins with sclerotherapy must
be shared with the patient. Clear information and a waiting period are therefore necessary. An initial treatment session is then planned. During each session, the clinical and
duplex ultrasound scanning (DUS) of the varicose veins to
be treated is rst carried out in the standing position, then
the patient is asked to lie down. The practitioner should
be aware of the anatomical and ultrasonic congurations.
The ultrasound ndings help to choose the most appropriate puncture sites in terms of safety and efcacy. DUS is
performed with a high-frequency probe (10–15 MHz). The
diameters of the target trunks or varicose veins are measured at the beginning of the session while the patient is
standing. The concentrations of the sclerosant will be chosen according to these diameters (Figure
37.1 for suggested concentrations.)
37.5). (See Table
37.5.2.1 Direct puncture
In the direct puncture technique, a needle is attached
directly to a syringe containing foam to perform the injection. A 2.5- or 3-mL low-silicone syringe is used. For
UGFS, the needle is 22 or 23 gauge (30- or 40-mm length);
for visual sclerotherapy, we use a 26-gauge (12-mm length)
needle. Sclerotherapy is generally performed in the order
of proximal to distal leakage points, proceeding from the
larger to the smaller varicose veins.
sion, the injections are therefore staggered from top to bottom, repeated progressively or not, depending on whether
the foam lls the target veins.
37.5.2.1.1 Direct puncture UGFS
Direct puncture UGFS is by far the most widely used
technique in France and has been accurately described
by one of the authors (CHD) and by other French
experts.
and makes the injection, while the second hand holds the
ultrasound probe throughout the procedure, the two hands
acting independently but in a coordinated manner.
injection site may differ depending on the extent of GSV
incompetence. In axial reux, the rst injection should be
made in the proximal part of the thigh, approximately 10
cm from the groin; the second injection is made farther
down the thigh, depending on how well the foam lls the
vein. With this technique, the GSV in the calf is not treated
during the rst session
rst injection is made in the interfascial segment of the
vein, and the small saphenous vein (SSV) is punctured in
the proximal third of the calf or mid-calf
stages:
1. Ultrasound identication of the venous segment to be
7,15–20
In this technique, the dominant hand punctures the vein
For a great saphenous vein (GSV), the choice of the rst
15
(Figure 37.6).
For the anterior accessory saphenous vein (AASV), the
A direct puncture UGFS procedure has seven essential
15–20
injected and of the neighboring arterioles to choose the
14,16,17
During the ses-
7
(Figure 37.7).
37
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