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638 Sclerotherapy and Alternatives
is an important tool for visualizing vessel
morphology and anatomic regularities, partic-
ularly the origin of complex varicose veins,
and clarifying the relationship between the
target veins and nearby structures.
2 . Beginning sclerotherapy injections at the
highest point of re fl ux and progressing to
the next highest point in a proximal-to-dis-
tal direction . In large-vein sclerotherapy,
injection should be as close as possible to the
point of incompetence. Many advocate inject-
ing at least several \centimeters from deep
venous junctions to minimize the risk of
inducing a deep vein injury.
3 . Diameter of the treatment vein determined
by duplex ultrasonography . In general it’s
easier to sclerose a large thin-walled vein than
a minimally dilated thick-walled vein.
4 . Venous compressibility . As the veins become
more compressible, it may be slightly easier to
induce pan endothelial sclerosis. Veins with
extensive wall damage and minimal re fl ux are
easiest to sclerose.
5 . Valvular lea fl et competency . By means of
duplex ultrasound, valve lea fl ets may be
assessed with respect to mobility and coapta-
tion capabilities. Frozen or immobile valves
are commonly the result of posttraumatic or
postphlebitic syndromes.
6 . Degree of re fl ux . Both the extent and degree of
re fl ux in a large vein may be adequately visual-
ized by duplex scanning. Distal compression or
Valsalva maneuvers may be employed. Vessels
with greater degrees of re fl ux are more dif fi cult
to eradicate and are associated with an increased
recurrence rate.
Techniques of Large-Vein Sclerotherapy
Marking of veins to be treated is normally car-
ried out with the patient in a standing position.
Subsequently, injection is usually carried out in a
supine position. Standing injection leads to instil-
lation of sclerosant into veins that are maximally
dilated leading to rapid dilution of the sclero-
sant below its minimal effective sclerosing con-
centration. It also leads to injection against the
hydrostatic forces associated with gravitational
blood fl ow. This could lead to uneven distribu-
tion of sclerosant, increased non-target vessel
in fl ammation and subsequently increased risk of
thrombophlebitis from incompletely treated veins.
Additionally, standing instillation of sclerosant
may lead to retrograde fl ow of sclerosant through
perforators, causing inadvertent damage to the
deep venous system. Finally, the risk of vasovagal
reaction and subsequent injury is increased when
injections are carried out with the patient stand-
ing. For these reasons, large-vein sclerotherapy is
normally carried out with the patient supine.
Traditionally four basic techniques were
employed for the treatment of large varicose
veins. These are reviewed here for the beginner
practitioner to see the evolution of the fi eld.
1 . Fegan technique – dependent cannulation .
With the patient standing or sitting at the end
of the examination table, the varicose vein is
cannulated with a needle or butter fl y angio-
cath. Tape may be applied to keep the needle
in a steady position. The leg is then elevated
for 1–2 min by either the physician or an assis-
tant in order to ensure maximal vessel empty-
ing. Before injection, a small amount of blood
is aspirated in order to make sure that the nee-
dle remains correctly positioned.
2 . Fegan variant – needle insertion with the patient
in the recumbent or reverse Trendelenburg
position . This is also a commonly employed
technique. As in the traditional technique, the
varicosity is marked with the patient in the
standing position. However, the needle inser-
tion occurs with the patient lying supine or in
a slight reverse Trendelenburg position. This
variant in technique is more rapid and ef fi cient
to perform and minimizes movement of the leg
while the needle is being inserted. After injec-
tion, the leg can be elevated and direct compres-
sion applied.
3 . Hobbs technique – multiple punctures .
Multiple puncture sites are placed at 4–6 cm
intervals along the entire treated varicosity.
Intravascular spasm, a negative aspect of this
technique, may be minimized by multiple can-
nulations before injection is actually carried
out. The author has found this technique to be
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64
N.S. Sadick
associated with frequent vascular spasm and
lower rates of treatment success.
4 . Sigg technique – open needle cannulation with
the needle attached to the syringe. A needle is
inserted into the treated vessel and positioned
until blood return occurs. Optionally, blood
may be withdrawn until the vessel is emptied.
Current practitioners employ variants of the
above techniques in addition to blood aspiration,
where a small amount of blood is aspirated into
the hub of the syringe to ensure that intact vein
cannulation has occurred. However, aspiration
that is too strong can lead to vein collapse.
Injections take place with the leg in an elevated
and dependent position with open cannulation
utilizing a 27–30-gauge needle or angiocatheter.
Regardless of the technique employed, the
important factors to be kept in mind in treating
large varicose veins include:
Marking the treated vein in a dependent position •
Emptying blood from the vessel prior to •
treatment
Ensuring intravascular location of the needle •
prior to injection
Kneading of sclerosant around the injection •
site immediately postcannulation to ensure
even distribution of sclerosant and maximal
endothelial sclerosant contact
Proximal-to-distal treatment approach •
Treatment of an entire varicose pathway at a •
given treatment session
Immediate and adequate postsclerotherapy •
compression
Treatment Techniques
Compression Sclerotherapy
Standard sclerotherapy set-up is given in
Table
8.3 . For the treatment of truncal (great and
small saphenous) or non-truncal (non-saphenous)
varicose veins, the following technique is used:
1. The patient stands for a few minutes in order
to allow veins to fi ll.
2. All visible and palpable vein segments in areas to
be injected are marked by an indelible marker.
3. The patient is then placed on the treatment
table in a comfortable reclined position with
the legs fl at and the back elevated 30°.
4. The patient’s leg is then elevated to empty it of
residual blood.
5. Sclerosant is then injected with the patient in
the following position s employing a multiple
puncture technique.
(a) Anterior veins are injected in the supine
position.
(b) Lateral and inner veins are injected in a
slightly rotated leg on leg position.
(c) Posterior veins are injected in a prone posi-
tion. A 3 mL syringe attached to a 27–30-
gauge needle (or 23-gauge angiocath) for
injection. Sotradecol
®
(sodium tetradecyl-
sulfate – STS) and Asclera (polidocanol) are
the primary sclerosants employed by the
author for the treatment of large varicose
veins (alternate sclerosant choices are viewed
in the preceding chapter). Polidocanol
appears to be emerging as a global leading
sclerosant product based on safety and
ef fi cacy. In published studies it has much
greater potency and standardization than
compounded formulations. The dose of
Sotradecol/Asclera depends on the site of the
veins. A maximal volume of 10 mL of scle-
rosant is employed for a given treatment ses-
sion. Cannulation sites for leg injection are
spaced 5–7 cm apart along the course of the
treated vessel in order to permit adequate
diffusion of sclerosant along the length of
Table 8.3 Sclerotherapy set-up tray
Alcohol preps
Protective gloves
3 cc disposable syringes
30 gauge disposable transparent nub needles
32 gauge needles or 33 gauge autoclavable disposable
angiocaths
Sclerosant
0.9 saline as dilutent
Clear light source, preferable with a magnifying source
Transilluminator (to aid in visualization of reticular
veins)
Nitroglycerin paste (for prolonged blanching)
Hyaluronidase (for suspected extravasation)
Anatomic region diagrammatic fl ow sheet ( fl ow sheets
with segmented numerical division of the leg are
utilized for documenting areas that are treated at each
treatment session
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658 Sclerotherapy and Alternatives
the treated vein. Blood is always withdrawn
before an injection is made in order to ascer-
tain that the tip of the needle is inside the
vein. If no blood can be withdrawn, no injec-
tion is made. The injection pressure is gentle
in order to prevent extravasation or potential
neoangiogenic matting.
6. The sclerosant is immediately massaged dis-
tally into the surrounding treatment area for a
distance of 5–10 cm.
7. Bulging areas of varicose dilation may then
wrap with either Elastoplast (Beiersdorf,
Norwalk, CT, USA) or Medi-Rip (Conco,
Rockhill, SC, USA). A graduated compres-
sion stocking class II (30–40 mmHg compres-
sion) is applied and worn for a period of
20–30 h day and night and then for 1 week
hence during waking hours.
8. Patients are encouraged to ambulate actively
immediately after treatment (high impact exer-
cise is discouraged for a period of 3 days after
each treatment session as well as no fl ying for
3 days and avoid the sun while skin is dark)
9. Patient follow-up. Patients are usually seen for a
follow-up in 1–3 weeks. One of the following fi ve
outcomes may be noted by the sclerotherapist:
(a) The vein disappears completely. A scar-
ring action was effected by successful
endosclerosis.
(b) The vein disappears partially. The injec-
tion worked, but further injections are
needed with the same concentration or a
slightly stronger one.
(c) The vein remains exactly as it was before
the injection. This means that the patient’s
vein requires a stronger concentration of
sclerosant. If there has been no response
to the initial injection session, the concen-
tration of sclerosant is increased by
25–50% (i.e., STS 0.05–0.1%
increments).
The patient is then seen at 2–4 week inter-
vals. The concentration of sclerosant is
increased by 25–50% at each injection
session until the threshold concentration is
achieved to close the treatment vein under
consideration. Once the minimal sclero-
sant concentration (MSC) has achieved
successful sclerotherapeutic response, the
concentration usually remains constant
for the treatment of similar sized vessels.
(d) A cordlike fi rm structure is palpated. This
indicates that the vein has scarred down
as desired but the scar has not yet dis-
solved, as it will in a few weeks.
(e) Commonly, the treated veins are tender,
lumpy/nodular, and hyperpigmented. The
veins look worse than before treatment.
This is usually due to an intravascular
hematoma (trapped blood), which may
be evacuated employing an 18–2 5 -guage
needle or an 11 Bard Parker blade (Becton
Dickinson, Franklin Lakes, NJ, USA)
depending on the size of the vein. This
will minimize the transfer of hemosiderin
within the vein to the skin and allow the
pigmentation following sclerotherapy to
resolve quicker and with greater certainty.
Utilizing this protocol and employing MSCs
for treating truncal and branch varicosities will
produce optimal results that minimize postsclero-
therapy complications. Treatment is recorded in
an appropriate treatment fl ow sheet. A sample is
provided in Table 8.4 .
Duplex Ultrasound-Guided Sclerotherapy
Duplex ultrasound is a helpful tool in the treat-
ment of large non-junctional varicose veins in
selected circumstances:
1. Obese patients in whom varicose veins are not
easily palpable on physical examination.
2. Complex anatomic structures in which the point
of proximal re fl ux is not obvious by physical
examination and/or Doppler evaluation.
3. Cases of treatment failure where a hidden
source of re fl ux may not be obvious by physi-
cal examination, photoplethysmography, or
Doppler maneuvers.
4. Patients with previous varicose vein surgery in
whom administration of a sclerosant might
otherwise be dif fi cult.
5. Assessing treatment responses. Incomplete
endosclerosis presents a partial intravascular
thrombosis (multiple echoes) with the vein
lumen remaining patent. When sclerotherapy
has been successful, the vein wall is thickened,
noncompressible, and nonechogenic.
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66
N.S. Sadick
Duplex Sclerotherapy Protocol
Once the extent of venous disease and source of
re fl ux has been isolated, duplex ultrasound
(echography) is carried out to guide the physi-
cian to the target vein and monitor injection. It
is also used to con fi rm correct needle
placement.
1. The vein is punctured briskly with the
patient in the supine position. Echography
con fi rms needle placement, which is double
checked by blood aspiration into the hub of
the syringe.
2. If pulsating, bright-red blood appears or if
echography does not con fi rm proper needle
positioning, the needle is withdrawn.
Table 8.4 Sclerotherapy fl ow sheet – see separate table with leg diagrams
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678 Sclerotherapy and Alternatives
3. With the needle is in correct position, a small
amount of sclerosant is slowly injected.
4. Echography con fi rms that sclerosant is enter-
ing the target vein by visualizing the shadows
produced by micro bubbles in the sclerosant.
If the display shows an arterial fl ow distur-
bance or extravasation of fl uid into tissues, the
needle is immediately withdrawn.
5. If the patient complains of pain, indicating
extravascular or intra-arterial injection, the nee-
dle is removed. STS does not cause pain upon
arterial injection and this has often mixed with a
pain-producing sclerosant in performing echo-
sclerotherapy. At this point, blood is aspirated to
recon fi rm correct needle positioning and the rest
of the dosage is administered in rapid fashion.
6. If extravasation is suspected and blanching is
observed, the area may be fl ushed with normal
saline to decrease the rate of ulceration and
dilute the sclerosant. Nitroglycerin paste 1–2%
may also be used. If blanching persists
hyaluronidase 75 U may be used as studies
show that it decreases the rate of ulceration
after extravasation.
7. Keys to preventing intra-arterial injection are
aspiration prior to injection and examination
of duplex to rule out pulsations in B-mode.
Pearls and Pitfalls – Varicose Veins
Multiple large varicose veins are best approached •
with ambulatory phlebectomy, which may be
associated with increased treatment ef fi cacy and
reduced complication pro fi les.
Sclerotherapy of large varicose veins is always •
followed by 2–3 weeks of compression and
later removal of trapped blood
Combination approaches of ambulatory phle-•
bectomy/foam sclerotherapy may be utilized
in select settings.
Keys to Success – Varicose Veins
Always treat axial re fl ux of great saphenous •
vein/small saphenous vein prior to treating
tributary varicosities.
Abolishing re fl ux sources will reduce many •
varicosites prior to direct treatment of
tributaries.
Patient compliance with compression is man-•
datory to reduce adverse events and pigmenta-
tion changes.
Advise against platelet aggregation inhibitors •
for at least 3–5 days prior to treatment.
Large truncal varicose veins should be treated •
before progressing to smaller diameter reticu-
lar veins and telangiectasias.
Reticular Veins
Reticular veins are green or blue, usually
1–4 mm (3 mm is the UIP de fi nition) in diam-
eter and are located parallel to the skin surface.
These vessels are most prominent over the pos-
terolateral aspects of the thigh and the lateral
aspects of the calf and most commonly will
drain toward the popliteal fossa with associ-
ated telangiectasias appearing in a centripetal
fashion. Many studies have substantiated the
fact that these vessels are commonly in com-
munication with telangiectasias.
Indications for treatment of reticular veins
include removal of direct communications with
high-pressure re fl ux from main truncal varicosi-
ties, removal of communicating sources of
incompetent perforating veins, and to diminish
the number of treatments of associated arborizing
foci of telangiectasias.
Another important clinical point is that
reticular vessels tend to be extremely fragile, par-
ticularly in the elderly population. When approac-
hing these vessels clinically and therapeutically,
fastidiously gentle technique is of paramount
importance.
Pretreatment Considerations
A thorough examination of the lower extremity
to determine all sites of reticular vessels should
be performed both by direct observation as well
as palpation, looking for associated interconnection
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68
N.S. Sadick
with feeding truncal and perforating varicosities,
as well as feeding mats of arborizing telangiecta-
sias. Vein marking is recommended after reticu-
lar veins are visualized as some veins present
while standing may not be subsequently visual-
ized in the supine position (Fig.
8.1 ).
The fi nal part of the evaluation after inspec-
tion, palpation and marking is the utilization of
a transillumination source to scan the treatment
limb, in order to identify potential hidden retic-
ular veins that are not visible to the eye and
may be sources of occult hidden re fl ux. This
may ultimately alter the phlebologist’s thera-
peutic approach.
Most cases of identi fi cation of reticular vein
incompetence are usually obvious to physical
examination techniques as described above.
However, occasionally more sophisticated maneu-
vers, such as use of transillumination devices or
duplex ultrasound, may be necessary in order to
identify such occult causes.
Appropriate Sclerosant Concentrations
for Treating Reticular Veins
Because of the inherently fragile nature of reticu-
lar veins, there is an increased incidence of scle-
rosant extravasation through these fragile vein
walls, leading to an increased incidence of both
hyperpigmentation and ulceration. Because of
these phenomena, two major tenets are of great
importance:
1. Fastidious technique with gentle injection of
small amounts of sclerosant.
2. Selection of the lowest concentration of
sclerosant that will produce effective endo-
sclerosis with minimal in fl ammation and vas-
cular spasm.
Suggested choices of sclerosant solutions with
concentrations appropriate for the injection of
reticular veins are presented in Table 8.5 .
Treatment Plan/Suggested Approaches
The following sequence and principles are rec-
ommended in the treatment of reticular veins.
1. Treatment proceeds from proximal to distal.
2. Areas of proximal re fl ux are addressed and
treated initially.
3. Larger caliber veins area treated prior to
smaller caliber veins.
4. The entire reticular vein is treated at a given
session.
5. Injections are best begun at the proximal pos-
terior thigh with the patient lying prone.
6. Injections proceed distally towards the ankle.
7. The patient is then placed in a lateral position,
where again injections are carried out in a
proximal to distal sequence.
Fig. 8.1 Marking of a reticular vein with patient in a
standing position
Table 8.5 Sclerosant concentrations for treating reticular
veins
Sodium tetradecyl sulfate
a
0.1–0.6%
Hypertonic saline
a,b
23.4%
Polidocanol
a
0.5–1.5%
Polyiodide iodine 2–3%
a
FDA-approved
b
FDA-approved for non-sclerotherapy indications
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698 Sclerotherapy and Alternatives
This type of systemic approach minimizes the
chance of producing “skip zones” in treating
desired vessel sites and assures maximal vessel
obliteration. Technique recommendations for
reticular veins include the blood-aspiration tech-
nique and the puncture-feel technique, where the
practitioner is able to feel the vein under the sur-
face of the skin and able to head and feel the
puncture of the endothelium during injection.
Infra-red illumination devices are helpful in this
scenario.
Treatment Technique
1. The patient is placed in a supine position after
marking and after identi fi cation of reticular
veins localization has been documented.
2. A 3 mL disposable syringe fi lled with appro-
priate sclerosant is connected to a 27–30-
gauge needle (Becton-Dickinson, Franklin
Lakes, NJ, USA, Air-Tite of Virginia, Inc.,
Newport News, VA USA)
3. The skin is cleansed with alcohol or 1:1 mix-
ture of alcohol and acetic acid.
4. The needle may be bent to a 30° angle with the
bevel facing the skin surface. Injection with
the bevel facing the skin will minimize the
possibility of vascular transection by decreas-
ing the vacuum produced by the bevel and the
skin surface.
5. Three fi nger traction of the skin is employed
in order to ensure tautness and is accomplished
by the opposite hand
6. The skin is pierced briskly and a second motion
is employed to accurately cannulate the veins
(Puncture-feel technique, see section on treat-
ment for leg telangiectasias) (Fig.
8.2 ).
7. If the phlebologist is not sure that the vein has
been cannulated, a small amount of blood may
be aspirated into the hub of the syringe in
order to ensure intravascular access. Too much
negative pressure should be avoided because
this may lead to intravascular spasm and sub-
sequent compromise of results.
8. Injection is subsequently carried out with a
low injection pressure, utilizing not more than
0.5 mL of sclerosant at a given injection site.
9. If resistance is encountered or vascular spasm
(vessel blanching) occurs, the needle is with-
drawn and cannulation is repeated at a distal site.
10. Injections are performed at intervals of
3–6 cm along the entire treated reticular
varicosity.
11. The sclerosant is then propelled along the
entire vein under treatment consideration by
gentle hand kneading in order to ensure even
distribution and subsequent uniform sclero-
sant endothelial contact.
Immediately following treatment of reticular
veins, treated vessels will undergo spasm and
in fl ammation may be noted as well. If associated
telangiectasias blanch or become erythematous
during treatment of reticular veins, it is likely that
sclerosant has had distal effect in these vessels
and as such, no further treatment is indicated to
these vessels at this time. On the other hand, if
these vessels do not disappear in the expected
time; they can be re-injected at a later date.
If injection is carried out in the veins already
in fl amed secondary to fi lling, via treatment of
associated reticular veins, this may eventuate in
an increased incidence of post sclerotherapy
pigment dyschromia and an increased incidence
of extravasation and subsequent ulceration.
Employing the aforementioned techniques,
excellent results may be achieved when treating
reticular veins (Fig.
8.3 ).
Fig. 8.2 Traction on the skin directly over reticular vein
with rapid cannulation of the skin surface and subsequent
endothelium (puncture feel technique) is the technique of
choice in treating reticular veins
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70
N.S. Sadick
Post Treatment Compression
Considerations
For vessels that are not elevated above the skin,
the author at present does not employ spot local-
ized compression maneuvers. In the treatment of
larger reticular veins, compression is an integral
part of the treatment program. Class II
30–40 mmHg graduated compression stockings
are recommended by the author post treatment.
Compression stockings should be applied while
the patient is still on the treatment table immedi-
ately post treatment. Because of the fragile nature
of the reticular vessels, compression is of prime
importance in order to minimize post treatment
bruising, pigmentation and ulceration. Compression
may also minimize post treatment discomfort.
Suggested post reticular vein sclerotherapy com-
pression guidelines are outlined in Table
8.6 .
Repeat Treatment Sessions/Treatment
Follow-Up
Repeat treatment session for reticular veins
should be spaced at 4–6 week intervals for a given
vessel in order to ensure that maximum endo-
sclerosis will ensue and so that the phlebologist
may assess the results of the previous treatment
Fig. 8.3 Pre/Post sclerotherapy of reticular veins employing sodium tetradecyl sulfate 0.25% (4 cc total injection)
Table 8.6 Compression considerations in the treatment
of reticular varicose veins
1. No localized spot compressions for non-elevated
vessel
2. Class II (30–40 mmHg) compression stockings worn
continuously for a period of 21 days
3. If a patient is intolerant of this regimen, compression
stockings may be removed nightly starting with the
second night; however, they are worn during the day
for a period of 21 days
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718 Sclerotherapy and Alternatives
session. If expected results do not ensue following
one to two re-treatment sessions, occult sources
of re fl ux should be investigated by duplex ultra-
sound and/or transillumination devices as previ-
ously described. Such investigations may reveal
occult re fl uxing perforators and truncal veins, or
less obvious, re fl uxing reticular vessels.
If the source of occult re fl ux is isolated, the
area may be re-injected using a slightly higher
concentration of a given sclerosant, using a foaming
technique, employing a different class of sclero-
sant, or ultrasound guided sclerotherapy.
Finally, in resistant cases, micro ambulatory
phlebectomy utilizing small precise hooks may
produce satisfactory functional and cosmetic
results. Long pulsed 1,064 nm Nd: YAG lasers
may also be effective in select cases.
Pearls and Pitfalls – Reticular Veins
Transillumination may be helpful in identify-•
ing occult sources of re fl ux associated with
reticular veins.
When telangiectasias associated with reticular •
veins appear to be affected by reticular vein
injections, wait 1–6 weeks to see if the telang-
iectasias resolve. Only retreat them if they do
not resolve after this observation period.
In resistant cases or treatment failures look for •
occult sources of re fl ux, attempt to utilize
increased concentrations of sclerosant, an
alternate sclerosant, or possibly ultrasound
guided sclerotherapy.
Finally, micro ambulatory phlebectomy ver-•
sus long-pulsed 1,064 nm Nd: YAG lasers
may be utilized in resistant cases.
Vein depth – It is often dif fi cult to determine the •
depth of reticular vessels and misguided injec-
tions may lead to inadvertent vessel transection.
Vein fragility – reticular veins have fragile •
walls, which may lead to sclerosant or eryth-
rocyte diapedesis, which may be associated
with hyperpigmentation, bruising and extrava-
sation necrosis.
Adherence to minimal sclerosant concentra-•
tion for vessel size and low injection pressure
will minimize these untoward sequelae.
Keys to Success – Reticular Veins
Remember the extreme fragile nature of reticu-•
lar veins, particularly in the elderly population.
Identify and treat re fl ux sources before treat-•
ment of reticular veins
Do not treat a given area of reticular vessels •
repeatedly for at least 4 weeks to assess results
of previous treatment sessions.
Assess patients in both supine as well as stand-•
ing positions in order to ensure treatment of
all involved vessels.
Keep patients off platelet inhibitors (i.e., ASA, •
NSAIDS, Plavix) for at least 7 days prior to
treatment in order to minimize bruising asso-
ciated with increased vascular fragility.
Utilization of multiple needles, ensuring a •
constant sharp source may be helpful in mini-
mizing bruising and pigment dyschromia
when treating fragile reticular veins.
Minimize puncture site and utilize the mini-•
mal sclerosant concentration (MSC) when
treating fragile reticular veins.
Telangiectasias
Telangiectasias are leg veins less than 1 mm that
are non-bulging. Treatment options for this ves-
sel class include sclerotherapy as well as adju-
vant lasers and light sources. Treatment of such
small diameter vessels should only ensue after
treatment areas of re fl ux and associated larger
diameter vessels have been addressed. From a
practical treatment plan, telangiectasias are the
last vessels to be considered in the treatment cas-
cade (Table 8.1 ). As stated previously, if larger
diameter vessels are present or painful symptoms
are elicited at the initial consultation, then con-
sideration of duplex ultrasound evaluation to rule
out axial re fl ux should be carried out.
In the management of telangiectasias the ques-
tion arises as to whether or not to institute sclero-
therapy or a light source i.e., (laser, intense pulsed
light, plus radiofrequency as an initial approach).
In general, the approach taken by the author is to
utilize sclerotherapy when vessels are cannuliz-
able and secondarily, to employ light sources to
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72
N.S. Sadick
treat residual vessels which are dif fi cult to accom-
plish via needle puncture because of their small
diameter, or in sclero-resistant vessels in areas of
new angiogenesis manifested by telangiectatic
matting or fl ushing.
Pretreatment Considerations
The phlebologist should go over several factors
with the patient prior to instituting treatment of
telangiectasias:
1. It is preferred the patient shave the areas under
treatment consideration on the morning of the
procedure.
2. It advised to dress in loose fi tting clothing and
comfortable shoes in order to accommodate
post sclerotherapy compression garments.
3. Be prepared to ambulate following the sclero-
therapy procedure.
4. Consideration for pre-and post-treatment
Arnica or topical vitamin K cream if there is a
history of easy bruising.
Choosing the Appropriate Sclerosant
Concentration for Treating
Telangiectasias
When treating telangiectasias one should follow
the concept of utilizing the minimal sclerosant
concentrate (MSC) for treating a vessel of given
diameter. This concept is of particular importance
in treating small diameter vessels where the risk
of extravasation necrosis, hyperpigmentation and
telangiectatic matting is greater. A suggested
guide to choosing the initial concentrations of
sclerosing agents for treating telangiectasias is
listed in Table 8.7 .
Treatment Technique – Sclerotherapy
for Telangiectasias
The patient is placed in a supine position table on
the treatment table. The injecting physician is
usually positioned at or below the level of the
patient’s knee (Fig. 8.4 ). Inaccessible vessels on
the lateral posterior thigh may be treated with the
patient in the prone position.
Proper visualization of the treatment site
requires bright, shadow-free lighting and is
aided by the use of a lighted, high-intensity
magnifying head lamp, magnifying glass loupes
(2–5× magni fi cation) or a trans-illumination
device. The skin may be cleansed with either
an alcohol swab or 1:1 compound of 70% alco-
hol compounded with 1% acetic acid solution.
The glistening effect of alcohol may be syner-
gistically augmented with the addition of ace-
tic acid making the skin more transparent by
changing the skin’s refraction co-ef fi cient, thus
allowing improved visualization of super fi cial
telangiectasias.
Injections are usually performed employing a
27–30-gauge ½ inch disposable needle (Benton-
Dickinson and Co., Franklin Lakes, NJ, USA,
and AirTite, Newport News, VA, USA). In addi-
tion, 31, 32, and 33 gauge needles are available
for microtelangiectasias injections; however,
these needles clog easily upon repeated usage
and lose their sharpness upon repeated cutaneous
puncture. The needle is inserted at a 30–40° angle
with the bevel side up (Fig. 8.5 ). Injection with
the bevel of the needle facing the skin surface
will minimize the possibility of vascular transec-
tion by decreasing the vacuum produced by the
Table 8.7 Suggested guide for sclerosant concentrations
utilized in the treatment of telangiectasias
Vessel diameter Sclerosant concentration
<1 mm Hypertonic saline 11.7%
Sodium tetradecyl sulfate 0.1%
Polidocanol 0.25%
Scleremo 100%
Polyiodide iodine 1%
Sclerodex
Ethanolamine oleate 2%
Sodium morrhuate 1%
1–3 mm Hypertonic saline
Sodium tetradecyl sulfate 0.25%
Polidocanol 0.75%
Polyiodide iodine 1%
Ethanolamine oleate 5%
Sodium morrhuate 2.5%
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