What is the role of sclerotherapy in the treatment of varicose veins and spider veins (telangiectasia)?

Updated: Feb 28, 2018
  • Author: Robert Weiss, MD; Chief Editor: William D James, MD  more...
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Answer

Chemical sclerosis or endovenous chemoablation (sclerotherapy) is the most widely used medical procedure for ablation of varicose veins and spider veins. [1] In this procedure, a sclerosing substance is injected into the abnormal vessels to produce endothelial destruction that is followed by formation of a fibrotic cord and eventually by reabsorption of all vascular tissue layers. For most veins, a detergent sclerosing agent is agitated with air to create a foam similar to shaving foam. A thorough diagnostic evaluation is essential prior to treatment. A high degree of technical skill is necessary for effective sclerotherapy many reasons.

Local treatment of the superficial manifestations of venous insufficiency is unsuccessful if the underlying high points of reflux have not been found and treated. Even when the patient appears to have only primary telangiectasias and the initial treatment seems to be successful, recurrences are observed very quickly if unrecognized reflux exists in larger subsurface vessels.

Missing the diagnosis of superficial truncal incompetence can cause significant complications (especially skin staining and telangiectatic matting) if spider veins and superficial tributaries are treated while high-pressure feeders remain open.

Delivery of sclerosant to subsurface feeding vessels that are not visible is usually performed under ultrasonographic guidance.

Missing the diagnosis of deep system disease can lead to bad outcomes in several ways. Symptoms become immediately worse if an unrecognized bypass pathway is ablated. Missing the diagnosis of underlying venous thrombosis can lead to fatal embolism. [10] Unrecognized deep venous insufficiency can lead to early or immediate recurrence of treated superficial disease. [11]

Selection of the correct sclerosant and the correct volume and concentration of sclerosant depends on the type and location of disease, internal volume of the vessel to be treated, positioning of the patient, and many other factors. The minimum effective concentration and volume should always be used because sclerosant inevitably passes into the deep venous system, where endothelial injury can lead to disastrous consequences.

Some sclerosants (eg, hypertonic sodium chloride solution) are highly caustic. Extravasation of even a single drop of these agents can lead to skin sloughing and a very poor cosmetic result.

Inadvertent injection into an arteriovenous malformation (or directly into an unrecognized underlying artery) can cause extensive tissue loss or loss of the entire limb.

Inadvertent injection of concentrated sclerosants into the deep system can cause deep vein thrombosis, pulmonary embolism, and death.

The proper use of sclerosing agents requires special training and extended study. Specific dosing and technique recommendations for the administration of sclerosants are beyond the scope of this article.


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