Sclerotherapy

Sclerotherapy involves injecting the abnormal veins with a sclerosing solution which irritates the inner lining of the vein (endothelium) causing inflammation and subsequent fibrosis and gradual disappearance of the vein over weeks to months.

“Sclerosis” literally means “a hardening of body tissues, organs or vessels as a result of inflammation and fibrosis.”

Sclerotherapy is an effective method of treatment which has been used since the 1920s for varicose veins and since the 1960s for spider veins.

Many substances have been used as sclerosing agents over the years, but the two main agents used in Australia today are:

• Sodium Tetradecyl Sulphate (Fibrovein)
• Laureth 9 (Polidocanol/Aethoxysklerol)

At the Hunter Vein Clinic, sodium tetradecyl sulphate is generally used to treat larger varicose veins and polidocanol is used to treat smaller veins. Both agents are classed as “detergent solutions” and act on the venous endothelium by reducing the surface tension of cell membranes. This leads to inflammation, fibrosis and obliteration of the vein. The solutions are rapidly diluted by the blood stream, and are extremely safe if used in the recommended dosages. There are no known long term or cumulative adverse side effects. There is a very low risk of allergy to the sclerosing solutions.

There are three main techniques of sclerotherapy used to treat abnormal veins.

1. Microsclerotherapy
   This technique refers to sclerotherapy performed on spider veins using a very fine needle (30 – 32 Gauge).
2. Sclerotherapy
   This involves injecting superficial dilated veins and varicose veins with a sclerosing solution, using direct vision by the doctor.
3. Ultrasound Guided Sclerotherapy (UGS)
   The technique of UGS uses ultrasound to visualise varicose veins so they may be injected under ultrasound guidance.

Procedure

Sclerotherapy & Microsclerotherapy
Using a very fine needle, the veins are injected with a sclerosing solution (usually polidocanol). At each point where the vein is injected, cotton pads are placed over the area to compress the vein. During and after the injections most people describe a burning or stinging sensation which lasts for 3-5 minutes. At each treatment session, many veins may be injected at multiple sites. Following treatment a compression stocking is applied and this must be worn for the recommended duration to maintain pressure on the treated veins and stop them refilling with blood. One leg is usually treated at each session, and more than one treatment may be required on each leg. Treated veins fade gradually over 6 – 12 weeks.

Ultrasound Guided Sclerotherapy (UGS)
Sometimes varicose veins may be detected on ultrasound examination but are unable to be seen on the skin surface by the doctor. These veins may be an important contributing factor to varicose or surface veins occurring elsewhere on the leg. The technique of “ultrasound guided injections” enables these veins to be “seen” using ultrasound so they can be injected.

The patient lies on an examination bed whilst the sonographer visualizes the vein. Guided by the ultrasound image on the screen, the doctor will insert a needle into the vein and inject sclerosing solution, watching it enter the vein. The sclerosing solution is usually emulsified to form a dense foam and this technique when used in conjunction with ultrasound is termed “foam echosclerotherapy”. The procedure will usually take approximately 20 minutes and some discomfort is experienced as the needle penetrates the skin. A stinging or burning sensation may be felt along the course of the treated vein. This may feel similar to the pain of a ant bite and last for 3 – 5 minutes. Following injections, a compression pad may be placed over the site of injection. A compression stocking is then applied and must be worn for the recommended duration of time.

Aftercare

After leaving the Clinic, you must walk for 20 minutes immediately and for at least 30 minutes each day. A normal lifestyle may be resumed within the confines of wearing a stocking for the recommended period of time. Although it is safe to drive a car following sclerotherapy, it is advisable for someone else to drive you home after your first treatment as ocassionally visual blurring or faintness may occur. It is normal to experience mild to moderate pain in the treated leg for the first 1-2 days and occasionally longer. This should respond to simple analgesia such as paracetamol or anti-inflammatories such as Nurofen. It is advisable to avoid vigorous sports and activities for 2 – 4 weeks following treatment.

What to Expect Following Sclerotherapy
It is normal for the treated leg to feel heavy and ache for the first 24 hours after treatment and occasionally for up to 5 days following sclerotherapy although the pain should be decreasing during this time. If pain is getting worse in the days following treatment, particularly if there is associated heat, swelling or calf muscle tenderness, please contact the clinic. Walking will reduce the aching in most cases, but simple analgesia such as panadol is advised. The injected veins may feel hard, lumpy and tender for 6 – 12 weeks following treatment. They may also look red and inflamed. Continue wearing the compression stocking while ever the veins are still inflamed or tender. Contact the clinic if you feel the inflammation or lumpiness is becoming severe. It is often necessary for the doctor to release some trapped blood using a needle puncture. Anti-inflammatory medication may be recommended and rarely antibiotics may be prescribed. It is common for bruising to persist for a week or two and areas of pigmentation along the treated vein may remain for 6 – 12 weeks or longer with large varicose veins.

Possible Adverse Effects and Complications

Phlebitis
Although a degree or phlebitis (lumpiness, soreness and inflammation) in the treated veins is normal it is ocassionally quite severe.  It may take many months to resolve completely and may require treatment with anti-inflammatory medication or antibiotics. It is a painful condition but not usually of serious consequence.

Deep Venous Thrombosis (DVT)
This is an extremely rare complication of sclerotherapy and involves the formation of a blood clot in the deep veins of the leg. It is a potentially serious condition as a piece of clot may break off and travel to the lungs (pulmonary embolus) or even more rarely to the brain (stroke). Signs and symptoms include pain, heat and swelling of the calf muscle, and chest pain, shortness of breath or coughing up blood in the case of pulmonary embolus. As a later consequence of DVT the venous valves in the deep veins may be damaged, leading to continuing swelling and venous hypertension. If any of these symptoms are experienced, it is important to seek immediate medical advice. DVT or pulmonary embolus require treatment with blood thinning medication (anti-coagulants) for a period of 3-6 months. Hospitalization may be required in severe cases, and very rarely death may occur from pulmonary embolism.

Some people have an increased tendency to form blood clots (thrombophilia) and this may run in families. Please advise the doctor if this is the case as preventative medication may be required.

Long distance travel is not recommended for a period of at least six weeks after the conclusion of treatment as the risk of DVT is increased.  Other operations or surgical procedures are also contra-indicated for a period of six weeks for the same reason.

Calf Vein Thrombosis

Thrombosis may occur in the calf muscle veins or in isolated areas of the deep calf veins (posterior tibial or peroneal veins) following sclerotherapy. This may cause no symptoms to the patient, but is detected on follow up ultrasound scanning. When this occurs following sclerotherapy it does not behave in the usual way of a spontaneous DVT. A new term, “deep venous sclerosis”, has recently been used to describe this condition. Treatment is not usually necessary, but follow up ultrasound scanning is required to assess any increase or spread of the thrombosis. Rarely blood thinning medication is prescribed.

Accidental Injection of an Artery or Nerve
There is a very rare risk of inadvertent injection into a neighbouring artery or nerve. Injection into an artery may lead to loss of blood supply to an area of the leg, causing damage to muscle, fat and skin. This complication has never been experienced in our clinic where high quality ultrasound machines and extremely skilled sonographers ensure that injections are only performed where veins are accurately visualized. Inadvertent injection of a nerve may cause pain and numbness in an area of the skin. It is extremely rare, and usually improves over days to months.

Allergic Reaction
Very rarely a person may be allergic to the injection solution. Usually symptoms are mild, but occasionally may be severe and life threatening. Immediate treatment for this is available at the clinic. Please notify the doctor if you have a history of allergy to any drugs or past episodes of anaphylaxis.

Visual Blurring and Migraine
Occasionally visual blurring, partial loss of vision or “flashing lights” (such as experienced in migraine) may develop after sclerotherapy. It may occur 10 – 20 minutes after treatment and usually clears within 30 minutes. It is not usually associated with a headache but occasionally may trigger a migraine. If you experience this please notify Dr. Hunter. There have been no reported incidents of visual disturbance following sclerotherapy leading to permanent visual loss.  If you are a known migraine sufferer, please advise Dr Hunter of this prior to treatment.

Stroke or Neurological Complications

There is an extremely rare risk of neurological complications (such as stroke) following sclerotherapy.  This has not been experienced at Hunter Vein Clinic however in the world literature there have been isolated reported cases. These cases have generally followed foam echosclerotherapy and in the majority of cases the neurological deficits have completely resolved.

Ulceration
Rarely an ulcer may develop at or near the site of injection. If this occurs it is usually small and located at the site of injection of spider veins. It may be very painful and slow to heal. A scar may form, which will slowly fade in most cases. Very rarely an ulcer may be large and form a significant scar.

New Blood Vessel Formation
Clusters of fine red or blue veins, also known as matting, may develop near the site of injection of larger veins and spider veins. This occurs to varying degrees in about one third of patients and is a normal response to inflammation and the redirection of blood flow. It usually fades over many months and can be treated at a later date if it persists. The condition is not serious but may be of cosmetic concern.

Pigmentation

A brown discolouration may occur along the course of the treated vein. This is due to iron pigment from the blood entering the tissues. In most cases it disappears slowly over 6 months, but occasionally takes many years to fade.

Failure of Treatment

Very rarely a patient may feel their veins have not responded to sclerotherapy or actually look worse following treatment. This may be because of pigmentation, formation of new spider veins or a combination of many factors. Dr. Hunter is a very experienced phlebologist, and will endeavour to give each patient the best possible treatment. If you are unhappy with your results please discuss your concerns with Dr Hunter who will try to rectify the situation.

Recurrence of Veins
Treated correctly, veins should not come back, however over time new veins may develop in similar or new locations as the underlying tendency to form varicose or spider veins cannot be changed. These recurrent veins can also be successfully treated. Pregnancy usually has an adverse effect on varicose veins and hormone therapy or the oral contraceptive pill may aggravate the situation. It is important to take these factors into consideration, however the basic underlying weakness in the wall of the veins cannot be changed. Regular exercise, maintenance of a normal weight and the use of compression stockings may delay the recurrence of veins.

Compression Stockings

Wearing a compression stocking following treatment is very important as it maintains pressure on the treated veins and prevents them from re-filling with blood. For most varicose veins it is recommended to wear the stocking continuously for 4 – 7 days and during the day for a further 7 – 10 days. In practice, if the treated veins remain tender or lumpy, it is recommended the stocking be worn during the day until the veins feel comfortable. With finer veins, the stocking is usually worn for 3 – 5 days. If the stocking is not worn for the full duration recommended a poor result may occur.

Hunter Vein Clinic carries a range of compression hosiery and we take considerable care to source the market for the most comfortable, effective and durable styles. We usually recommend a Class II (20 – 30mmHg) micro-fibre stay-up style, although individual leg shape, size and patient preference is considered. Stockings are also available for the management of chronic venous insufficiency or for the prevention of deep venous thrombosis. Our trained nursing staff will be able to measure and advise what type and strength is required. We endeavour to offer hosiery at very competitive prices as a service to our patients.