Introduction
Sclerotherapy of varicose veins is a simple, effective and safe method to treat telangiectasias and varicose veins in the legs. Sclerotherapy involves the injection of a solution into the vein using a very fine needle. This irritates the vein wall causing the walls to swell, collapse, stick together and eventually seal shut, shrinking the diseased veins.
This method has been commonly used for over a century. Like any other treatment, it does not prevent the future appearance of new varicose veins that are related to progression of the venous disease. Patients should plan to attend control visits and undergo later "maintenance" treatment.
Indications
This procedure is an effective treatment for varicose veins. In medical terminology, varicose veins are also referred to as superficial venous insufficiency, superficial venous incompetence, and superficial venous reflux. This procedure is most effective when no major saphenous truncal (great saphenous and small saphenous vein) reflux is present. If truncal reflux is present, this technique can be very effectively combined with other modern treatments such as endovenous laser using the Biolitec ELVeS radial system.
Before The Procedure
Patients must avoid long flights and general anaesthetics for four weeks prior to the procedure. Long flights are classified as four hours or more. For a three-hour flight the requirement is three weeks and for a two-hour flight the requirement is two weeks. There are no restrictions on a one-hour flight.
You can eat and drink as normal, ensuring you are well hydrated. Take your normal medication.
Procedure
A clinical examination and Duplex Ultrasound will be performed to specify the cause of your symptoms, origin of the varicose veins (specifically looking for truncal/axial reflux) and to define treatment.
Ultrasound Guided Sclerotherapy is very well tolerated, takes place in the Doctor’s Rooms and does not require anaesthesia. You will be placed in Class II thigh high compression stockings after the procedure.
The efficacy of sclerotherapy has been revolutionised by the introduction of foam sclerotherapy. This involves mixing the sclerosant solution with air through a 3-way-tap to create foam. This foam can be injected using ultrasound to guide the procedure. The procedure does not require you to interrupt your professional or domestic activities. The use of sclerosant in the form of foam is considered "off label" use. International experience and research shows foam is safe, if not safer, and more effective than use in the liquid form. "Off label" means the medication is being used in a manner not specified in the TGA approved packaging labels or inserts. This does not mean TGA has rejected the medication, commonly the TGA has not been asked to evaluate the indication.
Transient visual disturbance occurs in approximately 2% of patients and is probably dose related. This may happen after both foam and liquid sclerotherapy. Some patients may develop tightness in the chest or coughing after foam injection. This is probably a direct effect of the foam on the lungs and can also occur after injections of liquid sclerosant. This resolves in about 30 minutes. These side effects are those described in the literature. In our practice, Claire uses the Gian-Luigi Occlusion Technique (GLO-Technique). This technique involves careful pre-operative marking of veins to be injected, draining veins and communicating veins. During the procedure, these marks identify areas for application of local digital pressure to prevent the movement of sclerosant into areas not requiring treatment. This means we do not see the common side effects listed above and also have a very low risk of deep venous thrombosis (0.3%).
Postoperative Instructions
- Active walking is required immediately after the procedure and on a daily basis. You must walk for a minimum of 20 minutes daily for the next two weeks. It is the best and most natural way to prevent any complications, although they occur very rarely with this procedure.
- Normal daily activities can usually commence straight away, however there are some restrictions. Do not spend long periods of time on your feet and keep the leg/s elevated as much as possible when seated during the first 48 hours. For the next two weeks you must avoid long periods standing still. Strenuous activity is best avoided for 2-3 weeks. Do not fly for the first 2 weeks if the flight is more than 2 hours’ duration. Flying must be avoided for 4 weeks for flights more than 4 hours. General anaesthetics must be avoided for four weeks.
- The stockings are worn overnight for the first two nights. They can be removed in the morning for showering and immediately reapplied. After the first two nights the stockings can be removed at bedtime. They must be worn for a total of two weeks.
- Avoid hot baths or saunas for 4 weeks following treatment.
- Avoid excessive sun exposure for 2 weeks following the procedure. Avoid any direct leg treatments that may affect the skin and risk for pigmentation e.g. laser hair removal, waxing, chemical peeling. Please discuss timing of these treatments with your doctor.
- Post-procedural pain should be minimal and most patients do not require analgesia. Bruising, local swelling and some tenderness may occur after treatment. This should be temporary.
- Signs that may be of concern include tenderness associated with redness and warmth. This could indicate infection or a local inflammatory response known as superficial thrombophlebitis. Infection would generally be accompanied by systemic symptoms such as fever, loss of appetite and malaise, and is best treated with antibiotics and drainage where necessary. Infection associated with Injection Sclerotherapy is extremely rare.
- More commonly (1 in 10), superficial thrombophlebitis can occur. This appears at 2-4 weeks post treatment as a firm, tender, painful lump and may have associated redness. This is not accompanied by constitutional symptoms.
Superficial Thrombophlebitis is best treated with:
- Further compression and massage to the area.
- Hirudoid cream – massage into the affected area morning and night.
- Walking (half an hour each day).
- Anti-inflammatory medication such as Nurofen – for 48 hours.
- At your review, any areas of thrombophlebitis may be treated with gentle expression of the thrombus via a small needle prick.
If bleeding appears on the stockings, please elevate your leg and apply local compression. Dr Campbell should be contacted via mobile phone 0412 509 504, at the Rooms on 9429 4111, or via the Epworth Hospital on 9426 6666.
Risks
Allergic Reaction
Allergic reactions are exceptional and have never occurred, to date, in our practice. Minor reactions such as itch are common and usually settle within 30 minutes. A more serious form of allergy is anaphylaxis which can be life threatening. This has been estimated to occur in 0.001% (1 in 100,000) people. We are always prepared for this and have emergency resuscitation drugs and equipment in the consulting rooms.
Pigmentation
This is brown pigmentation that forms along the course of the injected vein. This is caused by the release of haemosiderin from extravasated red blood cells. Pigmentation is usually temporary. 1 in 100 people (1%) will have persistence of pigmentation at 1 year. Laser therapy can be effective in removing this pigmentation in about 50% of people.
Telangiectatic Matting
This can occur in up to 30% of patients and represents the appearance of previously unnoticed fine red telangiectasia. The incidence can be reduced to 5% with wearing of compression for 2-3 weeks after treatment. Telangiectatic matting usually resolves spontaneously over 3-12 months. It may persist longer than 1 year in less than 1% of people.
Scarring from local skin ulcer
This is rare and usually limited, occurring in less than 0.1% (1 in 1000) patients. This can occur if the sclerosant solution leaks from the veins. This is usually detectable and can be treated promptly to prevent ulcer formation. This may also occur if sclerosant is injected into an arteriole or from reactive spasm of the vessel. Warning symptoms would be significant pain e.g. wakes you from sleep, within 1-5 days post treatment.
Deep Venous Thrombosis
People with varicose veins are more susceptible to deep vein thrombosis. These blood clots can also form in the deep veins as a result of treatment of your varicose veins. This is extremely rare, occurring in less than 1% of patients, especially if patients follow instructions regarding stockings and walking. If you are unable to perform the required walking please discuss this with your doctor prior to your procedure.
Deep venous thrombosis is most likely to occur in patients who have significant risk factors for thrombosis. This includes those who are smokers, overweight, have poor mobility, do not comply with post-procedure orders such as walking and compression, hormone intake (HRT and OCP) and those patients who have a past history of deep venous thrombosis or a thrombophilic disorder.
Your risk of DVT is doubled if you are taking any form of hormone treatment such as the oral contraceptive pill, hormone replacement therapy or a hormone containing IUD, such as Mirena. You may consider ceasing the hormone treatment one month prior to treatment and for one-month post treatment to reduce the elevated risk of DVT. However, the consequences of unplanned pregnancy and return of menopausal symptoms must be considered. Safety of sclerotherapy during pregnancy has not been proven and if sclerotherapy is performed whilst pregnant it may affect the foetus.
Nerve Injury
Nerves can be injured during injection either via direct trauma from the needle or from the sclerosant. More commonly, however, the nerve can become inflamed secondary to vein inflammation (thrombophlebitis). This can result in localised numbness that is usually temporary and recovers within 6 months. Rarely, this loss of sensation is permanent or painful, however, it should not affect function of the leg and diminishes with time.
Stroke
A small number of reports have been published in medical literature of people suffering stroke at the time or within 48 hours of sclerotherapy. Extensive review has been undertaken internationally and foam sclerotherapy continues to be a widely accepted practice. The mechanism is thought to be paradoxical embolisation of foam from the right to left side of the heart via a patent foramen ovale / hole in the heart. Millions of people around the world have undergone foam sclerotherapy and continue to do so without complication, however, allowing for the possibility of unpublished case reports the risk of stroke with foam sclerotherapy is estimated to be 1 in 10,000. This possible complication we believe is significantly reduced with use of the GLO-Technique.
Related Information
Dr Claire Campbell
Compression Fitting Service
Endovenous Laser Therapy
Haemosiderin Staining
Ultrasound
Lipodermatosclerosis
Spider and Reticular Veins
Superficial Thrombosis and Thrombophlebitis
Varicose Veins
