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738 Sclerotherapy and Alternatives
bevel and the skin surface. Proper hand place-
ment is of importance. The most commonly
employed approach is a three-point tension tech-
nique where the non-dominant hand is utilized to
stretch the skin adjacent to the treated vessels in a
linear direction while the fi fth fi nger of the domi-
nant hand exerts counteraction in a forward direc-
tion as the sclerosant is being instilled with the
remainder of the dominant hand (Fig. 8.6 ). Entire
vessels should be treated at a given treatment
session.
The workhorse sclerosants utilized by the
author for treating telangiectasias are sodium tet-
radecyl sulfate (Sotradecol) 0.1–0.25% and poli-
docanol (Asclera) 0.8% for vessels 1–4 mm in
diameter and glycerin for microtelangiectasias
(1 mm in diameter). Hypertonic saline, being a
weak sclerosant as well as being associated with
a great deal of discomfort is rarely employed.
The author prefers a 3 ml syringe as it is of
adequate size, yet allows for slow, low pressure
injection of the sclerosant. Injection pressures
should be gentle utilizing low volumes (less than
0.5 mL per injection site). Rapid pushes of large
amounts of sclerosant may lead to sclerosant
localization in deeper vessels, which may lead to
deep vein thrombosis and pulmonary emboli well
as an increased potential for post in fl ammatory
hyperpigmentation and telangiectatic matting.
The utilization of smaller 1 mL tuberculin or
Fig. 8.6 Proper hand placement. A nondominant hand
stretches the skin adjacent to the treated vessels while the
fi fth fi nger of the dominant hand exerts counteraction
during injection of sclerosant
Fig. 8.5 A 30–40° injection angle, bevel up, produces
optimal results in sclerotherapy by minimizing vascular
transection
Fig. 8.4 Patient positioned
in recumbent position on a
power-assisted table ready
for the sclerotherapy
procedure
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74
N.S. Sadick
insulin syringes is commonly associated with
leakage of sclerosant and high injection pres-
sures, which may compromise results as well.
With continuous tension applied and brisk
cannulation and low injection pressure, immedi-
ate blanching will be noticed both in the treat-
ment vessel as well as adjacent tributaries. If the
needle is not within the vessel, extravasation will
ensue and either a super fi cial tissue wheal will
appear or the sclerosant will leak onto the skin
surface. In this case, immediate application of
nitroglycerin paste or instillation of hyaluroni-
dase (150 u/mL −75 u injected, Hopewell
Pharmacy, Hopewell, NJ, USA) may decrease
the extent of the adverse necrotic ulcerative reac-
tions associated with extravascular cannulation.
The quantity of solution injected should produce
effect 1–2 cm around the point of injection. Usually
no more than 0.5 mL of sclerosant per injection
site is employed in order to avoid large amounts of
in fl ammation in the venous system, which could
eventuate in an increased incidence of neoangiogen-
esis (telangiectatic matting/super fi cial thrombophle-
bitis) and post sclerotherapy hyperpigmentation.
For treating vessels less than 1 mm in diame-
ter, which are not cannulizable with the above
instrumentation or in cases of micro vessels asso-
ciated with telangiectatic matting, a 31-gauge
1 mL insulin or tuberculin syringe or a small
33-gauge angiocath (STD, Hereford, England)
may be employed. These smaller diameter sys-
tems are not practical for treatment of large sur-
face areas of vessels. However, in select situations
where micro vessels cannot be appropriately can-
nulated using conventional 30 gauge needle
attached to 3 mL syringes, and if a laser source is
not available, these are other treatment options.
There are four basic principles which
should be adhered to in the treatment of lower
extremity telangiectasias .
1 . Treat an entire vessel pattern at a given
treatment session . Treatment of an entire
vessel at a given treatment session will mini-
mize incomplete vessel disappearance and the
potential for recanalization as well as neo-
angiogenesis and telangiectatic matting.
2 . Identify and inject the most proximal
“arborizing feeder” vessel associated with a
telangiectatic cluster (Fig.
8.7 ). Treatment of
feeding arborizing foci, which feed clusters of
telangiectasias, can minimize the number of
punctures necessary to achieve desired results.
By utilizing this treatment pearl, diminished
complication pro fi les will be achieved.
3 . Empty the vein prior to injection . Emptying
of vessels under treatment consideration prior
to sclerosant solution instillation increases
sclerosant endothelial contact and thus likely
improves endosclerosis and may help to
diminish recanalization of vessels secondary
to the development of intramural thrombosis
4 . Knead the sclerosant immediately post
instillation into the surrounding injection
vessel area (Fig. 8.8 ). Local kneading or dis-
tribution of sclerosant should theoretically
lead to diminished pooling of sclerosant and
this produces uniform results. It should also
minimize the potential for sclerosant “sludg-
ing” which could lead to an increased inci-
dence of super fi cial thrombophlebitis and post
sclerotherapy hyperpigmentation.
Post Treatment Considerations
After sclerotherapy of telangiectasias utilizing
any sclerosant, burning and swelling associated
with urticaria and vein re fi lling may occur.
Fig. 8.7 Treatment of arborizing feeder veins diminishes
the number of injections required in a given sclerotherapy
treatment session, thus minimizing potential side effects
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758 Sclerotherapy and Alternatives
Cramping is particularly associated with injec-
tion of hypertonic saline while occasional scoto-
mata may ensue after instillation of Sotradecol or
Polidocanol.
Immediate post-sclerotherapy urtication does
not signify sclerosant allergy, but is actually a
local effect mediated by the release of histamine
and other in fl ammatory cytokines. Application of
a medium potency corticosteroid cream such as
hydrocortisone probutate cream (Pandel 0.1%,
Pandel, CollaGenex, Newtown, PA, USA) may
be applied immediately post treatment to mitigate
this response.
Finally, patients should remain in the sclero-
therapist of fi ce for 10–15 min following the ini-
tial treatment session if any sclerosing agent with
hypersensitivity potential (all agents other than
saline) is employed to watch for evidence of
potential type I anaphylaxis, although this adverse
event is extremely rare.
Compression post treatment of telangiectasias
that are not palpable is a point which lacks consen-
sus in terms of how much and how long. Previous
studies by the author have shown that post telangi-
ectasias treatment worn for 3 weeks may minimize
post sclerotherapy hyperpigmentation as well as
improve clinical results. Theoretically, compres-
sion should improve clinical results by causing
effective vascular lumen occlusion, diminished
recanalization and reduced risk of vascular throm-
bosis. In this setting, compression most accepted
in patients post treatment of telangiectasia is either
fashion hose 18–20 mm/Hg or Class I 20–30 mmHg
graduated support hose for up to 3 weeks. Most
companies including Sigvaris, (Branford, CT
USA) Jobst, (Charlotte, NC USA) and Medi USA
(Arlington Heights, IL USA) manufacture such
hose (Fig. 8.9 ). Graduated support hose should be
applied immediately post therapy before the
patient has left the of fi ce Localized spot compres-
sion using compression pads and gauze is no lon-
ger necessary for treatment of non-elevated
telangiectasias
In terms of treatment session programs, it is rec-
ommended to not treat a given area for 4–6 weeks
in order to assess the response to the previous treat-
ment session as maximum sclerotherapeutic results
may not ensue for this period of time.
Approaches to Treating Resistant
Telangiectasia
There are several approaches that may be taken
when expected results are not achieved after two
to four treatment sessions in a given anatomic
area utilizing an appropriate sclerosant concen-
tration (MSC) for given vessel diameter. These
include:
1. Look for areas of larger feeding vessels such
as reticular veins or perforators that may have
been overlooked on physical examination.
Treatment of these feeder sources under
duplex guidance may be helpful in this clini-
cal setting.
2. Use a stronger concentration of the same scle-
rosing agent.
3. Choose an alternative sclerosing agent
4. Move to an alternative mode of therapy such
as lasers or intense pulsed light sources.
Alternatives to Sclerotherapy: Laser
and Light Source Treatment Options
Laser light source treatment of telangiectasias is
best utilized for small super fi cial red or blue veins
particularly those which are dif fi cult to cannu-
late. Patients who are more susceptible to telangi-
ectatic matting, are sclero-resistant or have needle
phobia are ideal candidates (Table 8.8 ).
Fig. 8.8 Kneading of sclerosant postsclerotherapy
improves sclerosant-endothelium contact, optimizing
potential sclerosant ef fi ciency
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76
N.S. Sadick
It is important to note that any laser or intense
pulsed light source (IPL) is not a substitute for
sclerotherapy. Hydrostatic pressures are not
addressed by this technology and it is inherently
more dif fi cult to deliver protons safely and
effectively through leg extremity vessels which
are deep in location, are large and have increased
basal laminas compared to facial telangiectasias.
Inherently injections into a target vessel are
more ef fi cient.
Fig. 8.9 Class 1 20- to
30-mmHg support hose,
light and fashionable in
texture and color, may be
applied immediately
postsclerotherapy
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778 Sclerotherapy and Alternatives
The absorption spectrum of hemoglobin has
major absorption peaks at 410, 540 and 577 nm
with smaller peaks at 920 and 940 nm (Fig. 8.10 ).
Optimal treatment parameters for treatment are
listed in Table 8.9 .
Advances in external light technology for
treatment of leg telangiectasias have improved
clinical results because of:
Cooling technologies •
Laser wavelengths •
External pulse duration •
Variable spot sizes •
Accurate matching of fl uence with blood ves-•
sel size and color
A list of common lasers utilized to treat lower
extremity telangiectasias is presented in Table 8.10 .
The depth of penetration of lasers in terms of
management of lower extremity telangiectasias is
based upon the wavelength and the degree of
scattering and absorption of the surrounding skin.
Higher wavelengths are associated with dimin-
ished scattering and greater skin penetration,
which is necessary to treat deeper vessels. Also,
larger spot sizes penetrate more deeply into the
skin and thus optimizes energy delivery to the
vessel. Larger diameter vessels require longer
pulse durations to slowly, affectively heat the
entire vessel.
These concepts led to the early development
of a bimodal dual wavelength approach for the
treatment of both red and blue lower extremity
venous as described by the author. Utilizing
this approach, short wavelengths (500–600 nm)
were found to be effective in the treatment of
small, reddish telangiectasias, which manifest
a high degree of oxyhemoglobin, while longer
wavelengths (800–1,000 nm) were shown to
be effective in the treatment of deeper blue
telangiectasias and reticular veins. The prob-
lem to this approach is that multiple laser sys-
tems must be used to obtain optimal results,
which is not practically feasible for most
phlebologists.
In this stead, the author further developed a
modi fi ed monomodal approach to external laser
leg vein treatment (Table 8.11 ).
Table 8.8 Role of lasers in the treatment of telangiectasias
Refractory non-cannulizable vessels
Telangiectatic matting “neovascularization”
Angiogenic fl ushing
Scleroresistance
Needle-phobic patients
15
10
5
0
480 500 520 540 560 580 600 620 640 660
Oxyhemoglobin
Deoxyhemoglobin
Wavelength (nm)
Relative absorbance
Fig. 8.10 Absorption
spectrum of hemoglobin/
deoxyhemoglogin
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78
N.S. Sadick
This approach addresses differences in vessel
size and depth utilizing single 1,064 nm Nd:YAG
laser. Small red vessels <1 mm in diameter, which
are usually super fi cial in location and have a
high-degree of oxyhemoglobin saturation, and
can be effectively treated with small spot sizes
(<2 mm) high fl uencies (350–600 J cm
2
), and
short pulse durations (15–30 ms cc) (Fig. 8.11 ).
Lasers such as the KTP laser, pulsed dye laser,
alexandrite laser and diode lasers have all been
utilized in the past. However, the higher wave-
length technologies have recently taken the lead
in treatment of telangiectasias because of the rea-
sons outlined above.
Another novel approach is the combination of
diode laser, plus radiofrequency technology for
treating lower extremity telangiectasias. This
combination approach produces endoluminal
targeting of hemoglobin plus radiofrequency
heating of the outer vein. The author, in studying
this technology has found excellent results in
treating larger diameter blue vessels 2–4 mm in
diameter (Fig. 8.12 ).
Regardless of the light source technology uti-
lized to treat lower extremity telangiectasias,
similar histopathologic fi ndings have been noted;
intravascular thrombosis associated with vessel
fragmentation (Fig. 8.13 ).
Treatment Technique – Laser therapy
1. Deeper penetrating wavelengths utilizing high
fl uency may produce some degree of patient
discomfort. Zimmer cooler (Lasermed L.L.C.,
Shelton CT) may be utilized to reduce pain
sensation.
2. All treating staff should wear appropriate pro-
tective eyewear.
3. Approximate laser treatment settings are
reviewed in Tables 8.9 and 8.11 .
4. Each laser device employed should have ade-
quate cooling devices built in. Cooling is
highly recommended to protect the epidermis.
5. Use mild pressure on the hand piece when
treating larger diameter vessels to minimize
the diameter and amount of hemoglobin in the
lumen. This allows greater vessel penetration
with reduced thermal damage to surrounding
skin.
6. Endpoints of therapy: immediate urtication,
vessels spasm and post treatment vessel pig-
ment darkening. Immediate clearance may be
noted when treating smaller vessels, larger
areas may show no immediate change; how-
ever, continue to show improvement up to
12-weeks after treatment.
Swelling and urticaria around treated vessels may
ensue. Usually this resolves spontaneously.
However, medium potency corticosteroids and
ice packs may ameliorate these symptoms. This
Table 8.11 Monomodal approach to the treatment of leg
veins using the 1,064 nm Nd:YAG laser
Vessel size Spot size Fluence Pulse duration
<1 mm (red) Small High Short
1–3 mm (blue) Large Moderate Long
Table 8.10 Lasers and light sources for the treatment of
leg veins
Laser Wavelength (nm)
Pulsed dye 585–605
KTP 532
Alexandrite 755
Diode/RF 810
Nd:YAG 1,064
Intense pulsed light 515–1,200
Table 8.9 Optimal laser parameters for the treatment of leg veins
Laser type Vessel diameter Settings
Fluence (J/cm
2
) Spot size (mm) Pulse duration (ms)
532 nm KTP 3–5 mm 12–20 1 10–15
1,064 nm Nd:YAG Super fi cial red
<1 mm
350–600 1.5 15–30
Blue/reticular
2–4 mm
100–370 3–8 30–60
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798 Sclerotherapy and Alternatives
ab
Fig. 8.11 ( a , b ) Three treatments – 3 month follow-up
may also limit the incidence of post in fl ammatory
hyperpigmentation. The authors have shown in
recent studies that compression post laser treat-
ment does not affect results or complication
pro fi les in this setting.
Avoiding Complications
When treating telangiectasias with light sources,
re-treatment is not recommended for 8–12 weeks
because of the extensive cytokine release gener-
ated from the light sources following treatment.
This can lead to excess in fl ammation and post
in fl ammatory hyperpigmentation if vessel treat-
ments are spaced too closely. It is important to
not retreat or double pulse stack vessels when the
physician does not see an immediate effect as it
may take a few minutes after treatment for appro-
priate thermocoagulation to ensue.
Do not retreat a given area until the tissue has
cooled down because excess heat can lead to skin
burns. It is better to wait 10–15 min and then
return to the area while another segment of ves-
sels is treated. Use the lowest fl uence which will
effectively treat a given vessel. Pulses should be
separated by 1–2 mm as lateral spread of thermal
energy can thermocoagulate surrounding adja-
cent vessels without actually interacting with the
treatment handpiece.
Finally, in dark skin phenotype V-VI individu-
als spot sessions may be employed to be sure that
there is not an increased susceptibility to the devel-
opment of post in fl ammatory hyperpigmentation.
Complications of laser therapy for leg
veins include epidermal damage, thrombosis,
a
b
Fig. 8.12 ( a , b ) Before and after with light and RF technology
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80
N.S. Sadick
a
b
Fig. 8.13 ( a , b ) Lyra low
and high power view
of a large vein with
extensive thrombosis H&E
(×4d) (Courtesy of
Dr. Victor Prieto)
hyperpigmentation and telangiectatic matting
(Table
8.12 ). Telangiectatic matting may be
addressed utilizing re-treatment with lower
fl uences or if associated with fl ushing, with an
intense pulsed light source. Local areas of throm-
bus may be expressed with a number 9 Bard-Parker
blade or 18-gauge needle. Hyperpigmentation is
usually transient. However, when persistent, it
may be treated with 3–4% hydroquinone com-
pounds. Finally, epidermal crusting secondary
to overheating may be addressed by fastidious
wound care including petrolatum-based and top-
ical antibacterial ointments.
Pearls and Pitfalls – Telangiectasias
Utilize fastidious technique. Always be sure •
sclerosants are injected intravascularly
Be sure to address larger vessels and all •
points of re fl ux prior to treating telangiec-
tasias.
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818 Sclerotherapy and Alternatives
Increase the sclerosant concentration or choose •
an alternative sclerosant if vessels are refrac-
tory to a given agent.
Treat arborizing feeding foci when clusters of •
telangiectasias are present
Treat entire vessels at a given session •
Glycerin is a useful sclerosant for treatment of •
micro telangiectasias <1 mm in diameter
Lasers are helpful for management of micro-•
telangiectasias <1 mm.
Compression hose are helpful following scle-•
rotherapy of telangiectasias ( for at least 3 days,
preferably up to 3 weeks), but are not neces-
sary following laser treatments.
Following laser treatments avoid immediately •
retreating or stacking pulses when no instanta-
neous changes are noted
Avoid re-treatment of a given vessel for at •
least 6 weeks following laser therapy.
Allow treated areas to cool before attempting •
a second pass
Use lowest possible effective fl uence. •
Space adjacent laser pulses at least 1–2 mm •
apart to reduce excessive thermal damage.
Arti fi cial tanners may increase post-in fl ammatory •
hyperpigmentation from laser treatment of leg
veins.
Do not use lasers on suntanned skin •
Spot laser test sites may be helpful when •
employing light sources for treatment of Type
V-VI phenotypes.
Keys to Success – Telangiectasias
Utilize minimal sclerosant concentration of a •
given sclerosant which will effectively treat a
vessel of given diameter
Identify and treat re fl ux points prior to treating •
telangiectasias ( i.e., feeding perforators and
reticular veins).
Take appropriate pre and post photographs to •
show clinical results to patients.
Utilize a diagrammatic fl ow chart to document •
previously treated areas.
Employing fastidious technique and minimal •
number of needle punctures.
The monomodal wavelength varied pulse •
duration approach is the most effective method
to treat leg veins utilizing a single long wave-
length laser
The endpoint of therapy of laser treatment of •
leg veins is immediate pigment darkening and
vasoconstriction.
Combined laser/sclerotherapy treatments in a •
single session may have additive effects.
When possible discontinue oral contraceptive •
usage prior to laser or sclerotherapy treatment
of telangiectasias in order to minimize the
incidence of thrombosis and telangiectatic
matting
Conclusion
The evaluation and management principles
for treatment of varicose veins are similar
for reticular veins as well as telangiectasias.
Abolishment of feeding sources of re fl ux
and recognition of the fragile nature of
these vessels, particularly in the elderly
population are keys to success in the man-
agement of patient’s presenting with these
clinically relevant vessels types. By adher-
ing to the basic principles stated in this
chapter, the phlebologist may achieve grati-
fying results in treating tributaries of the
lower extremities. Appropriate choice of
sclerosant, utilization of the minimal scle-
rosant concentrations (MSC), consideration
of anatomic variation, re fl ux principles, the
practice of fastidious technique, adequate
compression, and a varied pulse width mon-
omodal wavelength laser approach are the
cornerstones of success. Combined laser/
sclerotherapy techniques remain the gold
standard of this approach.
Table 8.12 Side effects associated with laser IPL treat-
ment of telangiectasias
Transient hyperpigmentation
Purpura
Telangiectatic matting
Pain
Thrombosis
Epidermal damage
Incomplete clearance
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82
N.S. Sadick
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