- Email: [email protected]
Cosmetic sclerotherapy
Cosmetic sclerotherapy Jennifer J. Watson, MD, RPVI, and M. Ashraf Mansour, MD, RPVI, FACS, Grand Rapids, Mich
ABSTRACT Telangiectasias and spider veins are considered a common cosmetic concern for both women and men. Sclerotherapy is a frequently used, low-risk, and highly successful method to treat these venous problems. This article reviews the pathophysiology and diagnosis of telangiectasias and reticular veins as well as the currently available agents and techniques of sclerotherapy. The possible complications and adverse outcomes of sclerotherapy are described. Standard care and follow-up for patients after the procedure are outlined. Also included are tips and tricks found to be valuable in a busy vein practice. (J Vasc Surg: Venous and Lym Dis 2017;5:437-45.)
Telangiectasias are common, and some sources assert that they are the number one cosmetic concern for women in the United States.1 Spider veins appear in more than half of women by the age of 50 years, and many men also harbor them but seem less concerned.2 For many people, visible veins influence how they dress and how they feel about themselves. Some individuals with visible veins become self-conscious and tend to modify their activities (eg, swimming, going to the beach, and dancing) to avoid exposing their legs. Telangiectasia and spider veins pose little if any risk to health; however, they can significantly affect self-confidence and cause patients to feel older or less attractive. The two most common methods of treating spider veins and telangiectasias are sclerotherapy and surface laser. Both are relatively low risk procedures with a high potential benefit in appropriately selected patients. Laser equipment can be expensive to acquire, and office personnel should be fully trained in its use and understand potential dangers and side effects. Laser therapy is beyond the scope of this review; however, it is an important and effective treatment modality of which providers should be aware. Sclerotherapy was first attempted in the 1930s3 and became popular with the discovery and use of hypertonic saline in the 1970s.4 In this article, we review currently available agents, modern tips, and techniques of sclerotherapy and describe known complications.
PATHOPHYSIOLOGY Multiple factors predispose a patient to the development of telangiectasia. Family history, age, prolonged From the Division of Vascular and Endovascular Surgery, Spectrum Health Medical Group, and Michigan State University College of Human Medicine. Author conflict of interest: none. Correspondence: M. Ashraf Mansour, MD, RPVI, FACS, Department of Surgery, Spectrum Health Medical Group and Michigan State University, 648 Monroe St NW, Ste 310dMC 88, Grand Rapids, MI 49503 (e-mail: ashraf.mansour@ spectrumhealth.org). The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 2213-333X Copyright Ó 2017 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvsv.2017.02.002
sitting or standing, obesity, lack of activity, and local trauma are all risk factors. Family history may be the strongest risk factor for development. According to one study, 90% of children with two parents who have varicose veins develop varicose veins themselves.5 Pregnancy and estrogen and progesterone supplementation are associated with vein dilation, which can lead to spider veins. Sun exposure and skin damage can also lead to telangiectasias, particularly on the face. There are hereditary and systemic conditions that can present with spider veins, including Osler-Weber-Rendu syndrome, Klippel-Trénaunay syndrome, CREST syndrome (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia), lupus, alcoholism, and several other less common diseases. This article focuses on the treatment of telangiectasias in the absence of these syndromes; however, it is important for practitioners to have an understanding of the hereditary and acquired conditions and how they may affect outcomes and recurrence after treatment. Both spider veins (<1 mm in diameter; Fig 1) and reticular veins (1-3 mm in diameter; Fig 2) are cosmetic concerns for many individuals and have similar risk factors and pathophysiologic mechanisms. Redish and Pelzer6 classified telangiectasias into four groups based on physical examination: d d d d
Sinus or linear Arborizing Spider or star Punctiform (papular)
Linear are often red and found on the face. Arborizing will have multiple feeding vessels, and complete treatment requires injections in these areas. Spider or star typically arise from a central filling or feeding vessel and thus are best treated by injection of the feeding vessel. Papular are most commonly associated with collagen vascular diseases. Other classifications have been proposed, but they offer no new insights or explanation of the etiology.6 The etiology of telangiectasia and reticular veins mimics that of varicose veins; valvular incompetence and venous hypertension are thought to be at the root 437
438
Watson and Mansour
Journal of Vascular Surgery: Venous and Lymphatic Disorders May 2017
Fig 1. Arborizing telangiectasia and small (<1 mm) reticular veins.
of their formation. Classification systems that differentiate on the basis of treatment technique seem to be the most helpful. In our practice, we record the Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) score and Venous Clinical Severity Score for all patients to ensure that more significant disease is not missed. Follow-up evaluation and accurate photographic documentation of treated lesions (in the patient’s chart) are also important to track results and to manage the patient’s expectations. Telangiectasias can be seen in isolation or in combination with varicose veins and chronic venous insufficiency. An accurate history and physical examination can clearly differentiate between cosmetic and clinically important venous disease. A phone questionnaire can be performed with the patient, before the first visit, to identify those patients presenting with clinically significant symptoms. These time-saving tips make our practice more efficient from the standpoint of both the patient and the physician. Triaging patients before their first visit enables appropriate imaging to be ordered and avoids unnecessary testing. In patients with significant symptoms, such as edema, painful varicose veins, heaviness, and achy or tired legs, a venous color flow duplex scan (CFDS) to check for reflux is advised before any treatments. This will allow formulation of a logical and
comprehensive treatment plan. Treating spider veins without consideration of the underlying disease will likely lead to suboptimal results with possible failed treatment, matting, or hyperpigmentation. Conversely, treating asymptomatic truncal or perforator veins exposes the patient to potentially unnecessary procedures, cost, and risk. Both the American College of Phlebology and the American Venous Forum recommend the treatment of truncal and perforator disease only in symptomatic patients.7,8 Our focus in this review is sclerotherapy for cosmetic spider vein treatment. However, bleeding spider veins are a common complaint in the office, urgent care facilities, and emergency departments. These bleeding episodes tend to be anxiety provoking for the patient, often an elderly individual with thin, delicate, and dry skin prone to significant bleeding from relatively minor trauma. When evaluating these patients, clinicians should have a heightened degree of suspicion for underlying disease, such as congestive heart failure or chronic venous insufficiency. History, physical examination, and CFDS are critical in reaching a diagnosis. Many patients are taking oral anticoagulants or antiplatelet agents, which also exacerbates the problem. In the acute phase, treatment consists of digital pressure followed by a compression dressing. Rarely, a nylon skin suture is required. Long term, treatment of the underlying cause (eg, venous insufficiency) and sequential sclerotherapy may be required. Patients should be instructed in how to deal with bleeding should it recur. In general, most insurance should cover treatment of bleeding spider veins because it is considered therapeutic.
DIAGNOSIS A thorough history and physical examination are essential to reach the proper diagnosis. Some authors have suggested that sclerotherapy can be performed after physical examination without further diagnostic studies as most of these patients are less likely to have underlying venous reflux.9,10 Clearly, proper selection of patients to identify those most likely to benefit from a pretreatment CFDS is desirable for judicious resource allocation. When suspected, correct identification of the feeding vessels can be helpful, and in some cases we have used ultrasound guidance to inject these feeding vessels.
TECHNIQUE
Fig 2. Small and larger (1-3 mm) reticular veins.
Sclerotherapy is a procedure performed in the office setting. It is defined as the intravascular injection of a chemical agent to cause endothelial damage and subsequent vascular occlusion of the target vessel.1 Informed consent is routinely obtained. A warm, quiet, and comfortable environment helps the patient relax and feel less apprehensive about the procedure. The patient is positioned on a comfortable examination table, either supine or prone, depending on the area being injected.
Journal of Vascular Surgery: Venous and Lymphatic Disorders
Watson and Mansour
439
Volume 5, Number 3
Fig 3. Simple telangiectasia.
A good light source is important. Some experts prefer to use vein lights, and others routinely use magnification for better visualization of the target vessels. In the initial treatment session, a test injection, preferably in a thigh reticular vein or telangiectasia, is done to gauge the patient’s tolerance for the medication and injection. In some patients who have nearly translucent skin, it is helpful to do a test injection to see if the results are satisfactory to the patient. In our office, a special “sclerotherapy kit” has been assembled, containing all the needs for the procedure (needles, syringes, two-way stopcocks, cotton balls, paper tape). Gloves are worn, and needles are dispensed with in proper sharps containers. Before injection, the skin is prepared with isopropyl alcohol. We prefer to use 30- or 32-gauge needles attached to a 2.5-mL syringe (Fig 3). Others prefer butterfly-type needles. Bending the tip of the needle can be helpful in cannulating the target vessel and keeping the bevel up. Injection of the sclerosing agent is done slowly, at low pressure on the syringe plunger, sometimes gently massaging the injected area. In larger vessels, immediate pressure with cotton balls and tape is helpful. Some agents used in sclerotherapy can be foamed using the Tessari method. It is recommended to avoid injecting too large an area with a single injection. After completion of the session, the patient is helped in donning the compression hose while still on the examination table. In our office, sclerotherapy is performed by the physician or registered nurse supervised by the physician. A medical assistant is available to help during the procedure. Every state and hospital system has its own regulation regarding credentialing, scope of practice, and billing requirements governing who is qualified to perform cosmetic sclerotherapy.11
CURRENTLY AVAILABLE AGENTS In the United Sates, sclerotherapy is commonly performed using polidocanol, sodium tetradecyl sulfate (STS), glycerin, and hypertonic saline (Table I). Glycerin is currently used and still popular worldwide, but it is
no longer available in the United States. Glycerin (72%) is an osmotic agent that became popular because it does not cause ulceration, matting, or skin necrosis. The mechanism of action is by increasing osmotic pressure, drawing fluid out of the cells, thus causing cell rupture and reabsorption. However, it is ineffective in some cases, particularly in veins >1 mm in diameter.1,4 Many patients have larger veins or feeding veins and will require the use of a second agent for effective treatment. The maximum recommended dose is 10 mL of 72% glycerin. This amount is more than adequate for a single sclerotherapy session. This agent is useful in older patients with poor skin integrity when the provider wants to avoid the slightest risk of ulceration or skin necrosis. Obtaining this solution in the United States is difficult; it is no longer available in many locations, and if used, it is considered an off-label use. Hypertonic saline (11.7%-15%) is an alternative osmotic agent with a long track record. It was widely used, particularly in the 1970s and 1980s; however, it has fallen into disfavor because it is associated with increased pain, muscle cramping, ulceration, and hyperpigmentation. No allergies have been reported, and therefore there is no recommended maximum dose (usually limited by the patient’s tolerance).12 A test dose is also not required. With other agents, a single injection followed by a period of observation is often recommended. Many practices have now transitioned to newer agents; however, older patients will often vividly recall past painful treatments with hypertonic saline. Polidocanol (Asclera) was approved by the Food and Drug Administration in 2010 as an injectable agent for the treatment of spider veins and telangiectasias. It has become the agent of choice in our center. Asclera is available in 0.5% (indicated for spider veins <1 mm in diameter) and 1% (indicated for reticular veins 1-3 mm in diameter). Asclera was found to be successful in 95% of patients at 12 and 16 weeks, per physician reports.13 According to the Efficacy and safety of Aethoxysklerol compared to Sodium tetradecyl sulfate and Isotonic saline (EASI) study, patients reported being satisfied or very satisfied in 78% and 84% of cases at 12 and 26 weeks, respectively.14 The advantages include reduced pain and decreased ulceration and almost no skin necrosis risk. The disadvantages include allergic reactions, matting, and hyperpigmentation. The maximum recommended dose is <10 mL per session (www.asclera.com). However, increased adverse reactions have been seen with doses >3 mL.14 STS is used in concentrations of 0.25% and 0.5% for injections of spider veins and reticular veins. STS is commercially available in concentrations 1% and 3%, which requires dilution by the provider to achieve the lower concentrations. Advantages include less matting. Disadvantages include hyperpigmentation, allergic reactions, and increased ulceration or necrosis if it is injected
440
Watson and Mansour
Journal of Vascular Surgery: Venous and Lymphatic Disorders May 2017
Table I. Agents Vein size, mm
Percentage
Osmotic
<1
72
Hypertonic saline
Osmotic
<1 1-3
11.7-15 11.7-15
Polidocanol
Detergent
<1 1-3
Sodium tetradecyl sulfate
Detergent
<1 1-3
Agent
Drug class
Glycerin
Pros
Cons
No matting No ulceration No necrosis
Difficult to obtain in the United States Ineffective in larger veins Contact sensitivity Rare: hematuria Urethral colic
No allergies
Pain Muscle cramping Ulceration/necrosis Hyperpigmentation
0.25-0.5 0.5-1
FDA approved (Asclera) Rare ulceration No skin necrosis
Allergy Telangiectatic matting Hyperpigmentation
0.25-0.5 0.5-1
Less telangiectatic matting
Hyperpigmentation Ulceration/necrosis Allergies Cannot be used in asthmatics
FDA, Food and Drug Administration.
outside the vessel.12,13 Many practices use STS in higher concentrations for larger, deeper veins and thus have familiarity with the medication and a relationship with a supplier or pharmacy. This medication is used as foam 4:1 (air:STS) with air in most practices (Tessari method).15 Since the Food and Drug Administration approved Asclera, it has been the predominant agent used in our center; it does not require any special handling or mixing before use. It is individually packaged in small volumes to avoid patient-to-patient contamination and has a long shelf life, which avoids expiration and waste. We dispose of open vials immediately after use. For best results, sclerotherapy treatment should be individualized for each patient. This means that in some cases, the use of more than one medication is needed, depending on telangiectasia type, size, and skin type. Many patients have had prior treatments and may be aware of agents that work well for them or, conversely, have not been effective in the past.
POSTOPERATIVE CARE After sclerotherapy, external compression with an elastic garment is required to achieve optimal results and to keep the vessels occluded after injection.1,11 Depending on the areas injected, knee-high or thighhigh stockings or pantyhose may be required. The length of time required for compression varies by practice; however, we settled on 7 days or more. This appears to be an adequate time and is generally well tolerated by most patients. We prescribe 20 to 30 mm Hg compression or higher and typically recommend 24 hours of continuous use followed by 6 days of 8 hours a day when up and active. More time can be suggested for the patient’s comfort, to decrease hyperpigmentation in high-risk patients, or perhaps in recurrent lesions. Additional
compression can be added to particularly dark areas with cotton balls, padding, and adhesive tape, removed by the patient after 24 hours. Compliance with compression can decrease pain, angiogenesis, hyperpigmentation, and matting.1 Creams like Dermaka (http:// dermaka.com) may reduce inflammation and bruising. Such topical agents can be dispensed to the patients for daily application after treatment. Anecdotally, patients seem to be more satisfied with their treatment sooner with such interventions, but objective data are lacking. Having on-site compression garments available for purchase is a practical convenience for patients who may have forgotten to bring them and yet want to proceed with same-day sclerotherapy. Many patients seen in follow-up after other venous interventions will request same-day injection and may not have their compression garment with them. By offering a variety of sizes and types of compression on site, one can increase satisfaction of the patient and efficiency. As these are cosmetic procedures, the patient’s insurance company generally will not cover the cost of compression anyway, and going through a durable medical equipment or medical supplier is just an added step in most cases. After sclerotherapy, it is good practice to keep the patient supine on the examination table for 15 to 20 minutes for observation and to ensure that no adverse reaction has occurred because of the procedure. Patients are encouraged to walk afterward and to avoid being totally sedentary.
EXPECTATIONS OF THE PATIENT Managing expectations of the patient is essential to success. At our center, we provide an initial consultation, free of charge, in which the patient receives verbal and written information about the treatment plan. To be
Watson and Mansour
Journal of Vascular Surgery: Venous and Lymphatic Disorders
441
Volume 5, Number 3
Fig 4. Lower leg telangiectasia: before and after sclerotherapy with satisfactory result. Photographs are taken and kept in the patient’s chart.
completely transparent, a treatment cost and frequency estimate is also provided because, in most cases, the patient will be responsible for the bill. Billing and insurance coverage vary widely; therefore, individual practices will need to establish their own procedures. Patients may experience mild symptoms at the site of their spider veins, including mild pain, itching, skin discoloration, and temperature changes, and thus may feel that their treatment is medically necessary or should be covered by insurance. Responding to these concerns in an open, transparent, and sympathetic manner is essential.16 This consultation is most commonly performed by a specially trained provider who performs routine sclerotherapy. This allows the patient to make an informed decision. Once the patient decides to proceed, preprocedure photographs (Fig 4) are taken and compression garments are prescribed. The Society for Vascular Surgery and the American Venous Forum stress the importance of setting expectations for patients in their 2011 practice guidelines.8,17 Patients should understand that these treatments will not eliminate every visible vein but instead strive to improve appearance. Individual results tend to vary, and success is not always guaranteed. No matter when it occurs, the pretreatment discussion should address the following key points as well as possible adverse outcomes (Table II). Need for repeated injection. Depending on the numbers of veins, darkness, and size, repeated injections can be required. Repeated sclerotherapy is typically
performed 6 to 8 weeks after the initial injections.14 Additional sclerotherapy sessions come with additional cost; thus, patients should be informed and allowed to budget for this ahead of time. This will avoid an unsatisfactory outcome with incomplete treatments. We see all our patients 6 to 8 weeks after injection at no charge to determine if they need a repeated injection and to assess sclerotherapy results. Some patients may need to be seen sooner should they develop a retained coagulum (Fig 5) requiring needle evacuation. The treatment process takes time, and patients should expect that it may take months to see the final result, especially if they require multiple sessions. Final results take time. Many patients come with the false perception that they can be treated a few weeks before an event or trip and look great for their special occasion. The reality is that their legs will likely look a bit worse before they look better (bruising, mild skin irritation, hyperpigmentation; Fig 6). Once educated, many patients will postpone treatment to a time of the year when they are less likely to have their legs exposed or be away for trips or special events. In the Midwest, we and others have observed seasonal variations in patient volumes, typically an observed decline in sclerotherapy in the summer months. Marketing and advertising campaigns, if used, can be timed appropriately. Spider veins can recur. Telangiectasias and reticular veins can recur. Many of these patients have a genetic predisposition or other nonmodifiable risk factors that will predispose them to recurrence. Informing patients, educating them on modifiable risk factors, and providing contact information for the future is essential. Individual results may vary. Despite excellent technique, results vary and may not align with the patient’s expectations (Fig 7). Adverse reactions and outcomes occur in all practices. Education of the patient and a standard plan around dealing with complications and failures are essential.
Table II. Practice: tips and tricks Tips and tricks
Impact
Offer free information sessions and follow-up
Builds confidence in the practice; avoids overcharging; increased repeated injection; improved outcomes
High-quality photographic documentation
Allows patient and provider to see progress; can be used in marketing; decreases charting time
Use ultrasound
Clear identification of feeding vessels and underlying disease; improved result; rule out underlying disease
Compression available on site
Patient convenience; allows same-day injections; increased revenue
Charge patients by the syringe
Fair and predictable revenue between providers
Variety of sclerosing agent
Allows treatment of vessels of different sizes; patient-specific treatment
Fully inform patients of complications and potential adverse outcomes
Even in the best hands, these will occur; have a standard treatment plan for them when they do
442
Watson and Mansour
Journal of Vascular Surgery: Venous and Lymphatic Disorders May 2017
Fig 5. Arborized telangiectasia with coagulum after sclerotherapy.
COMPLICATIONS AND ADVERSE OUTCOMES As with any invasive procedure, complications and poor outcomes may occur. Allergic reactions including anaphylaxis have been reported for all agents except hypertonic saline. Test doses are recommended for polidocanol, STS, and glycerin.1 A test dose is an injection of <0.5 mL followed by a period of observation before proceeding with the rest of the treatment. All personnel, physicians, and advanced practice providers performing sclerotherapy should be prepared to treat anaphylaxis and have appropriate medications and equipment on site. Patients should be asked about allergies before any injection. STS is contraindicated in patients with asthma as these patients are at a higher risk for anaphylaxis. Fainting and vasovagal reactions may occur. Before any procedure, we discuss potential risks and complications and inquire about past experiences and needle phobias. Most patients will have experienced a needle stick from a previous immunization or blood draw, and how they tolerate this varies. In a patient with a significant fear of needles or recurrent vasovagal reactions, laser may indeed be a better alternative. If a patient has a vasovagal reaction or fainting spell, adjusting the tilt table (Trendelenburg position), placing an ice pack on the neck or forehead, and most of all verbal reassurance are successful in most cases. Recheck of vital signs and finger stick blood glucose determination complete the assessment and guide management of these rare and unpleasant episodes. A period of observation is required to ensure that the patient has fully recovered. Hyperpigmentation is a brownish discoloration of the skin due to extravasation of red blood cells (Fig 8). If it persists past 1 year, it is considered persistent hyperpigmentation. Most cases resolve during a matter of a few months, with 1% to 2% becoming persistent.17 Hyperpigmentation is usually linear but can be seen as a wheal at the site of injection
Fig 6. Matting in posterior thigh after sclerotherapy.
when osmotic agents are used. It is more likely to occur with increased vessel diameter, higher agent concentrations, lack of postoperative compression, and posttreatment sun exposure and in patients with a history of hyperpigmentation.17 Skin types and tones have been studied to determine which ones are more likely to stain. We and others have observed hyperpigmentation in all skin colors and tones. Small syringes (tuberculin-type syringe) have been associated with an increased risk of extravasation that leads to increased inflammation and hemosiderin deposition due to the high pressure generated. Therefore, large syringes (2.5 mL vs 1 mL) are recommended. If hyperpigmentation does not resolve after an appropriate waiting time, skin laser treatment can be considered. Because the discoloration is caused by hemosiderin and not melanin, skin bleaching treatments are less successful. Matting or fine red telangiectasias can occur at prior injection sites (Fig 6). This has also been termed flairs. The reported incidence varies greatly, with most cases resolving in 3 to 6 months. Matting is believed to be due to hypoxia-induced neovascularization. Although matting usually resolves, it can be disconcerting to patients as they see new spider veins appearing after treatment.18 We generally recommend observation as
Journal of Vascular Surgery: Venous and Lymphatic Disorders
Watson and Mansour
443
Volume 5, Number 3
Fig 7. Telangiectasia and reticular veins: before and after sclerotherapy with satisfactory result.
they usually resolve. Laser can be used for treatment of persistent cases, and there are reports of successful reinjections. However, given the size of these veins, it can be challenging to cannulate them. Ulceration, skin necrosis, and intra-arterial injection are all rare but significant complications (Fig 8).16 They can
Fig 8. Hyperpigmentation and ulceration at the site of prior sclerotherapy.
be avoided in most cases with proper training, anatomic understanding, and the use of ultrasound. It is essential that providers inject within the vein and use appropriate agents in the correct concentration for the vein size. Excessive cutaneous pressure from compression can also cause superficial ulcers or wounds. Limiting the use of tape and extensive dressing material avoids skin reactions that are manifested as blisters and other skin disruption, often confused with ulceration. Some degree of pain and itching are experienced by most patients undergoing sclerotherapy. These treatments usually require multiple sessions or going over the same anatomic area, and some sites seem to be more painful, such as the knees and ankles. Managing the patient’s expectations, limiting treatments, and providing comfort items (eye masks, music, reading material, warm blankets) are helpful. We have not found topical anesthetic creams to be useful as they cause vasospasm and make small veins more difficult if not impossible to cannulate. The type of solution, needle size, and technique all need to be optimized to reduce pain. Hypertonic saline is particularly painful, but other agents are usually well tolerated. Small needles with acutely tapered tips are preferred, and frequent needle changes to avoid a dull tip can be helpful. Even with mild agents and good technique, post-treatment soreness will occur in about 20% of patients for 1 to 2 weeks.19 Thrombotic events such as deep venous thrombosis and pulmonary embolism are rare; however, all patients should be evaluated for hypercoagulable states, and injections are not recommend for these patients. Phlebitis is much more common and occurs 1 to 3 weeks after treatment. Patients report pain, erythema, raised veins, and discoloration. Most patients can be treated with ice, over-the-counter analgesics (acetaminophen or ibuprofen), and compression. Resolution occurs in days to weeks. If phlebitis is extensive, seen with edema,
444
Watson and Mansour
Journal of Vascular Surgery: Venous and Lymphatic Disorders May 2017
AUTHOR CONTRIBUTIONS Conception and design: JW, MM Analysis and interpretation: JW, MM Data collection: JW, MM Writing the article: JW, MM Critical revision of the article: JW, MM Final approval of the article: JW, MM Statistical analysis: JW, MM Obtained funding: JW, MM Overall responsibility: MM
Fig 9. Corona phlebectatica (atrophie blanche) behind the medial malleolus.
or progressive or if it involves the thigh, a CFDS should be obtained to check for the extent of phlebitis and to rule out deep venous involvement. Systemic anticoagulation should be considered in a patient with a clot burden near perforators or other connections to the deep system as progression to deep venous thrombosis is possible. Retained coagulum is another not unexpected outcome to look for; if found, it should be drained with a 22-gauge needle to avoid hyperpigmentation or skin damage in the area. This is rarely required with small veins but occurs with increased frequency in larger veins.1 Education of the patients is important so that prompt treatment can be initiated as necessary. Thrombotic events are reduced with the use of compression, lower concentration agents, and smaller treatment areas. Corona phlebectatica (atrophie blanche) deserves mention here because it is considered a marker for underlying chronic venous insufficiency that may or may not improve by treating the cause (Fig 9). Finally, sclerotherapy with liquid and foamed solutions has been associated with rare adverse events, such as visual disturbances (scotoma), chest tightness, and shortness of breath. The reported incidence is <0.5% of patients, and most of these events have been transient in nature.
CONCLUSIONS Sclerotherapy is a popular and effective method for spider vein treatment. It is a natural adjunct to a comprehensive vein practice and meets the needs of many patients. One cannot underestimate the impact of cosmetic concerns in our patients. Key elements for a comprehensive practice include proper education of the patient, selection of patients, and setting of reasonable expectations. It is important that sclerotherapy be performed by an experienced physician or advanced practice provider with a clear understanding of venous anatomy and disease. Sclerotherapy should be a lowrisk, high-benefit procedure in appropriately selected patients.
REFERENCES 1. Goldman M, Guex J, Weiss R, Partsch H, Perrin M, Ramelet A, et al. Sclerotherapy: treatment of varicose and telangiectatic leg veins. 5th ed. Philadelphia: Saunders Elsevier; 2011. 2. Brand FN, Dannenberg AL, Abbott RD, Kannel WB. The epidemiology of varicose veins: the Framingham Study. Am J Prev Med 1988;4:96-101. 3. Biegeleisen HI. Telangiectasia associated with varicose veins: treatment by a microinjection techniques. JAMA 1934;102: 2092. 4. Alderman DB. Therapy for essential cutaneous telangiectasia. Postgrad Med 1977;61:91-5. 5. Cornu-Thenard A, Boivin P, Baud JM, De Vincenzi I, Carpentier PH. Importance of the familial factor in varicose disease. Clinical study of 134 families. J Dermatol Surg Oncol 1994;20:318-26. 6. Redish W, Pelzer RH. Localized vascular dilatation of the human skin; capillary microscopy and the related studies. Am Heart J 1949;37:106-13. 7. American College of Phlebology. Practice guidelines: superficial venous disease rev020316. Available at: http://www.phlebology.org/wp-content/uploads/2016/02/ SuperficialVenousDiseaseGuidelinesPMS313-02.03.16.pdf. Accessed January 17, 2017. 8. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011;53:2S-48S. 9. Langer RD, Ho E, Denenberg JO, Fronek A, Allison M, Criqui MH. Relationships between symptoms and venous disease: the San Diego population study. Arch Intern Med 2005;165:1420-4. 10. Criqui MH, Jamosmos M, Fronek A, Denenberg JO, Langer RD, Bergan J, et al. Chronic venous disease in an ethnically diverse population: the San Diego Population Study. Am J Epidemiol 2003;158:448-56. 11. Intersocietal Accreditation Commission. IAC standards for vein center accreditation. Available at: www.intersocietal. org/veincenter/standards. Accessed January 17, 2017. 12. Tisi PV, Beverley C, Rees A. Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev 2006:CD001732. 13. Schwartz L, Maxwell H. Sclerotherapy for lower limb telangiectasias. Cochrane Database Syst Rev 2011:CD008826. 14. Rade E, Schliephake D, Otto J, Breu FX, Pannier F. Sclerotherapy of telangiectases and reticular veins: a double-blind, randomized, comparative clinical trial of polidocanol, sodium tetradecyl sulphate and isotonic saline (EASI study). Phlebology 2010;25:124-31. 15. Tessari L, Cavezzi A. Frullini. Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg 2001;27:58-60.
Journal of Vascular Surgery: Venous and Lymphatic Disorders
Watson and Mansour
445
Volume 5, Number 3 16. Munavalli GS, Weiss RA. Complications of sclerotherapy. Semin Cutan Med Surg 2007;26:22. 17. Izzo M, Mariani F, Binaghi F, Amitrano M. Postsclerotherapy hyperpigmentation: incidence, clinical features and therapy. Phlebology 1995:550-1. 18. Bradbury AW, Bate G, Pang K, Darvall KA, Adam DJ. Ultrasound-guided foam sclerotherapy is a safe and clinically
effective treatment for superficial venous reflux. J Vasc Surg 2010;52:939-45. 19. Duffy DM. Small vessel sclerotherapy: an overview. Adv Dermatol 1988;3:221-42.
Submitted Oct 21, 2016; accepted Feb 3, 2017.
ABSTRACT Telangiectasias and spider veins are considered a common cosmetic concern for both women and men. Sclerotherapy is a frequently used, low-risk, and highly successful method to treat these venous problems. This article reviews the pathophysiology and diagnosis of telangiectasias and reticular veins as well as the currently available agents and techniques of sclerotherapy. The possible complications and adverse outcomes of sclerotherapy are described. Standard care and follow-up for patients after the procedure are outlined. Also included are tips and tricks found to be valuable in a busy vein practice. (J Vasc Surg: Venous and Lym Dis 2017;5:437-45.)
Telangiectasias are common, and some sources assert that they are the number one cosmetic concern for women in the United States.1 Spider veins appear in more than half of women by the age of 50 years, and many men also harbor them but seem less concerned.2 For many people, visible veins influence how they dress and how they feel about themselves. Some individuals with visible veins become self-conscious and tend to modify their activities (eg, swimming, going to the beach, and dancing) to avoid exposing their legs. Telangiectasia and spider veins pose little if any risk to health; however, they can significantly affect self-confidence and cause patients to feel older or less attractive. The two most common methods of treating spider veins and telangiectasias are sclerotherapy and surface laser. Both are relatively low risk procedures with a high potential benefit in appropriately selected patients. Laser equipment can be expensive to acquire, and office personnel should be fully trained in its use and understand potential dangers and side effects. Laser therapy is beyond the scope of this review; however, it is an important and effective treatment modality of which providers should be aware. Sclerotherapy was first attempted in the 1930s3 and became popular with the discovery and use of hypertonic saline in the 1970s.4 In this article, we review currently available agents, modern tips, and techniques of sclerotherapy and describe known complications.
PATHOPHYSIOLOGY Multiple factors predispose a patient to the development of telangiectasia. Family history, age, prolonged From the Division of Vascular and Endovascular Surgery, Spectrum Health Medical Group, and Michigan State University College of Human Medicine. Author conflict of interest: none. Correspondence: M. Ashraf Mansour, MD, RPVI, FACS, Department of Surgery, Spectrum Health Medical Group and Michigan State University, 648 Monroe St NW, Ste 310dMC 88, Grand Rapids, MI 49503 (e-mail: ashraf.mansour@ spectrumhealth.org). The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 2213-333X Copyright Ó 2017 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvsv.2017.02.002
sitting or standing, obesity, lack of activity, and local trauma are all risk factors. Family history may be the strongest risk factor for development. According to one study, 90% of children with two parents who have varicose veins develop varicose veins themselves.5 Pregnancy and estrogen and progesterone supplementation are associated with vein dilation, which can lead to spider veins. Sun exposure and skin damage can also lead to telangiectasias, particularly on the face. There are hereditary and systemic conditions that can present with spider veins, including Osler-Weber-Rendu syndrome, Klippel-Trénaunay syndrome, CREST syndrome (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia), lupus, alcoholism, and several other less common diseases. This article focuses on the treatment of telangiectasias in the absence of these syndromes; however, it is important for practitioners to have an understanding of the hereditary and acquired conditions and how they may affect outcomes and recurrence after treatment. Both spider veins (<1 mm in diameter; Fig 1) and reticular veins (1-3 mm in diameter; Fig 2) are cosmetic concerns for many individuals and have similar risk factors and pathophysiologic mechanisms. Redish and Pelzer6 classified telangiectasias into four groups based on physical examination: d d d d
Sinus or linear Arborizing Spider or star Punctiform (papular)
Linear are often red and found on the face. Arborizing will have multiple feeding vessels, and complete treatment requires injections in these areas. Spider or star typically arise from a central filling or feeding vessel and thus are best treated by injection of the feeding vessel. Papular are most commonly associated with collagen vascular diseases. Other classifications have been proposed, but they offer no new insights or explanation of the etiology.6 The etiology of telangiectasia and reticular veins mimics that of varicose veins; valvular incompetence and venous hypertension are thought to be at the root 437
438
Watson and Mansour
Journal of Vascular Surgery: Venous and Lymphatic Disorders May 2017
Fig 1. Arborizing telangiectasia and small (<1 mm) reticular veins.
of their formation. Classification systems that differentiate on the basis of treatment technique seem to be the most helpful. In our practice, we record the Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) score and Venous Clinical Severity Score for all patients to ensure that more significant disease is not missed. Follow-up evaluation and accurate photographic documentation of treated lesions (in the patient’s chart) are also important to track results and to manage the patient’s expectations. Telangiectasias can be seen in isolation or in combination with varicose veins and chronic venous insufficiency. An accurate history and physical examination can clearly differentiate between cosmetic and clinically important venous disease. A phone questionnaire can be performed with the patient, before the first visit, to identify those patients presenting with clinically significant symptoms. These time-saving tips make our practice more efficient from the standpoint of both the patient and the physician. Triaging patients before their first visit enables appropriate imaging to be ordered and avoids unnecessary testing. In patients with significant symptoms, such as edema, painful varicose veins, heaviness, and achy or tired legs, a venous color flow duplex scan (CFDS) to check for reflux is advised before any treatments. This will allow formulation of a logical and
comprehensive treatment plan. Treating spider veins without consideration of the underlying disease will likely lead to suboptimal results with possible failed treatment, matting, or hyperpigmentation. Conversely, treating asymptomatic truncal or perforator veins exposes the patient to potentially unnecessary procedures, cost, and risk. Both the American College of Phlebology and the American Venous Forum recommend the treatment of truncal and perforator disease only in symptomatic patients.7,8 Our focus in this review is sclerotherapy for cosmetic spider vein treatment. However, bleeding spider veins are a common complaint in the office, urgent care facilities, and emergency departments. These bleeding episodes tend to be anxiety provoking for the patient, often an elderly individual with thin, delicate, and dry skin prone to significant bleeding from relatively minor trauma. When evaluating these patients, clinicians should have a heightened degree of suspicion for underlying disease, such as congestive heart failure or chronic venous insufficiency. History, physical examination, and CFDS are critical in reaching a diagnosis. Many patients are taking oral anticoagulants or antiplatelet agents, which also exacerbates the problem. In the acute phase, treatment consists of digital pressure followed by a compression dressing. Rarely, a nylon skin suture is required. Long term, treatment of the underlying cause (eg, venous insufficiency) and sequential sclerotherapy may be required. Patients should be instructed in how to deal with bleeding should it recur. In general, most insurance should cover treatment of bleeding spider veins because it is considered therapeutic.
DIAGNOSIS A thorough history and physical examination are essential to reach the proper diagnosis. Some authors have suggested that sclerotherapy can be performed after physical examination without further diagnostic studies as most of these patients are less likely to have underlying venous reflux.9,10 Clearly, proper selection of patients to identify those most likely to benefit from a pretreatment CFDS is desirable for judicious resource allocation. When suspected, correct identification of the feeding vessels can be helpful, and in some cases we have used ultrasound guidance to inject these feeding vessels.
TECHNIQUE
Fig 2. Small and larger (1-3 mm) reticular veins.
Sclerotherapy is a procedure performed in the office setting. It is defined as the intravascular injection of a chemical agent to cause endothelial damage and subsequent vascular occlusion of the target vessel.1 Informed consent is routinely obtained. A warm, quiet, and comfortable environment helps the patient relax and feel less apprehensive about the procedure. The patient is positioned on a comfortable examination table, either supine or prone, depending on the area being injected.
Journal of Vascular Surgery: Venous and Lymphatic Disorders
Watson and Mansour
439
Volume 5, Number 3
Fig 3. Simple telangiectasia.
A good light source is important. Some experts prefer to use vein lights, and others routinely use magnification for better visualization of the target vessels. In the initial treatment session, a test injection, preferably in a thigh reticular vein or telangiectasia, is done to gauge the patient’s tolerance for the medication and injection. In some patients who have nearly translucent skin, it is helpful to do a test injection to see if the results are satisfactory to the patient. In our office, a special “sclerotherapy kit” has been assembled, containing all the needs for the procedure (needles, syringes, two-way stopcocks, cotton balls, paper tape). Gloves are worn, and needles are dispensed with in proper sharps containers. Before injection, the skin is prepared with isopropyl alcohol. We prefer to use 30- or 32-gauge needles attached to a 2.5-mL syringe (Fig 3). Others prefer butterfly-type needles. Bending the tip of the needle can be helpful in cannulating the target vessel and keeping the bevel up. Injection of the sclerosing agent is done slowly, at low pressure on the syringe plunger, sometimes gently massaging the injected area. In larger vessels, immediate pressure with cotton balls and tape is helpful. Some agents used in sclerotherapy can be foamed using the Tessari method. It is recommended to avoid injecting too large an area with a single injection. After completion of the session, the patient is helped in donning the compression hose while still on the examination table. In our office, sclerotherapy is performed by the physician or registered nurse supervised by the physician. A medical assistant is available to help during the procedure. Every state and hospital system has its own regulation regarding credentialing, scope of practice, and billing requirements governing who is qualified to perform cosmetic sclerotherapy.11
CURRENTLY AVAILABLE AGENTS In the United Sates, sclerotherapy is commonly performed using polidocanol, sodium tetradecyl sulfate (STS), glycerin, and hypertonic saline (Table I). Glycerin is currently used and still popular worldwide, but it is
no longer available in the United States. Glycerin (72%) is an osmotic agent that became popular because it does not cause ulceration, matting, or skin necrosis. The mechanism of action is by increasing osmotic pressure, drawing fluid out of the cells, thus causing cell rupture and reabsorption. However, it is ineffective in some cases, particularly in veins >1 mm in diameter.1,4 Many patients have larger veins or feeding veins and will require the use of a second agent for effective treatment. The maximum recommended dose is 10 mL of 72% glycerin. This amount is more than adequate for a single sclerotherapy session. This agent is useful in older patients with poor skin integrity when the provider wants to avoid the slightest risk of ulceration or skin necrosis. Obtaining this solution in the United States is difficult; it is no longer available in many locations, and if used, it is considered an off-label use. Hypertonic saline (11.7%-15%) is an alternative osmotic agent with a long track record. It was widely used, particularly in the 1970s and 1980s; however, it has fallen into disfavor because it is associated with increased pain, muscle cramping, ulceration, and hyperpigmentation. No allergies have been reported, and therefore there is no recommended maximum dose (usually limited by the patient’s tolerance).12 A test dose is also not required. With other agents, a single injection followed by a period of observation is often recommended. Many practices have now transitioned to newer agents; however, older patients will often vividly recall past painful treatments with hypertonic saline. Polidocanol (Asclera) was approved by the Food and Drug Administration in 2010 as an injectable agent for the treatment of spider veins and telangiectasias. It has become the agent of choice in our center. Asclera is available in 0.5% (indicated for spider veins <1 mm in diameter) and 1% (indicated for reticular veins 1-3 mm in diameter). Asclera was found to be successful in 95% of patients at 12 and 16 weeks, per physician reports.13 According to the Efficacy and safety of Aethoxysklerol compared to Sodium tetradecyl sulfate and Isotonic saline (EASI) study, patients reported being satisfied or very satisfied in 78% and 84% of cases at 12 and 26 weeks, respectively.14 The advantages include reduced pain and decreased ulceration and almost no skin necrosis risk. The disadvantages include allergic reactions, matting, and hyperpigmentation. The maximum recommended dose is <10 mL per session (www.asclera.com). However, increased adverse reactions have been seen with doses >3 mL.14 STS is used in concentrations of 0.25% and 0.5% for injections of spider veins and reticular veins. STS is commercially available in concentrations 1% and 3%, which requires dilution by the provider to achieve the lower concentrations. Advantages include less matting. Disadvantages include hyperpigmentation, allergic reactions, and increased ulceration or necrosis if it is injected
440
Watson and Mansour
Journal of Vascular Surgery: Venous and Lymphatic Disorders May 2017
Table I. Agents Vein size, mm
Percentage
Osmotic
<1
72
Hypertonic saline
Osmotic
<1 1-3
11.7-15 11.7-15
Polidocanol
Detergent
<1 1-3
Sodium tetradecyl sulfate
Detergent
<1 1-3
Agent
Drug class
Glycerin
Pros
Cons
No matting No ulceration No necrosis
Difficult to obtain in the United States Ineffective in larger veins Contact sensitivity Rare: hematuria Urethral colic
No allergies
Pain Muscle cramping Ulceration/necrosis Hyperpigmentation
0.25-0.5 0.5-1
FDA approved (Asclera) Rare ulceration No skin necrosis
Allergy Telangiectatic matting Hyperpigmentation
0.25-0.5 0.5-1
Less telangiectatic matting
Hyperpigmentation Ulceration/necrosis Allergies Cannot be used in asthmatics
FDA, Food and Drug Administration.
outside the vessel.12,13 Many practices use STS in higher concentrations for larger, deeper veins and thus have familiarity with the medication and a relationship with a supplier or pharmacy. This medication is used as foam 4:1 (air:STS) with air in most practices (Tessari method).15 Since the Food and Drug Administration approved Asclera, it has been the predominant agent used in our center; it does not require any special handling or mixing before use. It is individually packaged in small volumes to avoid patient-to-patient contamination and has a long shelf life, which avoids expiration and waste. We dispose of open vials immediately after use. For best results, sclerotherapy treatment should be individualized for each patient. This means that in some cases, the use of more than one medication is needed, depending on telangiectasia type, size, and skin type. Many patients have had prior treatments and may be aware of agents that work well for them or, conversely, have not been effective in the past.
POSTOPERATIVE CARE After sclerotherapy, external compression with an elastic garment is required to achieve optimal results and to keep the vessels occluded after injection.1,11 Depending on the areas injected, knee-high or thighhigh stockings or pantyhose may be required. The length of time required for compression varies by practice; however, we settled on 7 days or more. This appears to be an adequate time and is generally well tolerated by most patients. We prescribe 20 to 30 mm Hg compression or higher and typically recommend 24 hours of continuous use followed by 6 days of 8 hours a day when up and active. More time can be suggested for the patient’s comfort, to decrease hyperpigmentation in high-risk patients, or perhaps in recurrent lesions. Additional
compression can be added to particularly dark areas with cotton balls, padding, and adhesive tape, removed by the patient after 24 hours. Compliance with compression can decrease pain, angiogenesis, hyperpigmentation, and matting.1 Creams like Dermaka (http:// dermaka.com) may reduce inflammation and bruising. Such topical agents can be dispensed to the patients for daily application after treatment. Anecdotally, patients seem to be more satisfied with their treatment sooner with such interventions, but objective data are lacking. Having on-site compression garments available for purchase is a practical convenience for patients who may have forgotten to bring them and yet want to proceed with same-day sclerotherapy. Many patients seen in follow-up after other venous interventions will request same-day injection and may not have their compression garment with them. By offering a variety of sizes and types of compression on site, one can increase satisfaction of the patient and efficiency. As these are cosmetic procedures, the patient’s insurance company generally will not cover the cost of compression anyway, and going through a durable medical equipment or medical supplier is just an added step in most cases. After sclerotherapy, it is good practice to keep the patient supine on the examination table for 15 to 20 minutes for observation and to ensure that no adverse reaction has occurred because of the procedure. Patients are encouraged to walk afterward and to avoid being totally sedentary.
EXPECTATIONS OF THE PATIENT Managing expectations of the patient is essential to success. At our center, we provide an initial consultation, free of charge, in which the patient receives verbal and written information about the treatment plan. To be
Watson and Mansour
Journal of Vascular Surgery: Venous and Lymphatic Disorders
441
Volume 5, Number 3
Fig 4. Lower leg telangiectasia: before and after sclerotherapy with satisfactory result. Photographs are taken and kept in the patient’s chart.
completely transparent, a treatment cost and frequency estimate is also provided because, in most cases, the patient will be responsible for the bill. Billing and insurance coverage vary widely; therefore, individual practices will need to establish their own procedures. Patients may experience mild symptoms at the site of their spider veins, including mild pain, itching, skin discoloration, and temperature changes, and thus may feel that their treatment is medically necessary or should be covered by insurance. Responding to these concerns in an open, transparent, and sympathetic manner is essential.16 This consultation is most commonly performed by a specially trained provider who performs routine sclerotherapy. This allows the patient to make an informed decision. Once the patient decides to proceed, preprocedure photographs (Fig 4) are taken and compression garments are prescribed. The Society for Vascular Surgery and the American Venous Forum stress the importance of setting expectations for patients in their 2011 practice guidelines.8,17 Patients should understand that these treatments will not eliminate every visible vein but instead strive to improve appearance. Individual results tend to vary, and success is not always guaranteed. No matter when it occurs, the pretreatment discussion should address the following key points as well as possible adverse outcomes (Table II). Need for repeated injection. Depending on the numbers of veins, darkness, and size, repeated injections can be required. Repeated sclerotherapy is typically
performed 6 to 8 weeks after the initial injections.14 Additional sclerotherapy sessions come with additional cost; thus, patients should be informed and allowed to budget for this ahead of time. This will avoid an unsatisfactory outcome with incomplete treatments. We see all our patients 6 to 8 weeks after injection at no charge to determine if they need a repeated injection and to assess sclerotherapy results. Some patients may need to be seen sooner should they develop a retained coagulum (Fig 5) requiring needle evacuation. The treatment process takes time, and patients should expect that it may take months to see the final result, especially if they require multiple sessions. Final results take time. Many patients come with the false perception that they can be treated a few weeks before an event or trip and look great for their special occasion. The reality is that their legs will likely look a bit worse before they look better (bruising, mild skin irritation, hyperpigmentation; Fig 6). Once educated, many patients will postpone treatment to a time of the year when they are less likely to have their legs exposed or be away for trips or special events. In the Midwest, we and others have observed seasonal variations in patient volumes, typically an observed decline in sclerotherapy in the summer months. Marketing and advertising campaigns, if used, can be timed appropriately. Spider veins can recur. Telangiectasias and reticular veins can recur. Many of these patients have a genetic predisposition or other nonmodifiable risk factors that will predispose them to recurrence. Informing patients, educating them on modifiable risk factors, and providing contact information for the future is essential. Individual results may vary. Despite excellent technique, results vary and may not align with the patient’s expectations (Fig 7). Adverse reactions and outcomes occur in all practices. Education of the patient and a standard plan around dealing with complications and failures are essential.
Table II. Practice: tips and tricks Tips and tricks
Impact
Offer free information sessions and follow-up
Builds confidence in the practice; avoids overcharging; increased repeated injection; improved outcomes
High-quality photographic documentation
Allows patient and provider to see progress; can be used in marketing; decreases charting time
Use ultrasound
Clear identification of feeding vessels and underlying disease; improved result; rule out underlying disease
Compression available on site
Patient convenience; allows same-day injections; increased revenue
Charge patients by the syringe
Fair and predictable revenue between providers
Variety of sclerosing agent
Allows treatment of vessels of different sizes; patient-specific treatment
Fully inform patients of complications and potential adverse outcomes
Even in the best hands, these will occur; have a standard treatment plan for them when they do
442
Watson and Mansour
Journal of Vascular Surgery: Venous and Lymphatic Disorders May 2017
Fig 5. Arborized telangiectasia with coagulum after sclerotherapy.
COMPLICATIONS AND ADVERSE OUTCOMES As with any invasive procedure, complications and poor outcomes may occur. Allergic reactions including anaphylaxis have been reported for all agents except hypertonic saline. Test doses are recommended for polidocanol, STS, and glycerin.1 A test dose is an injection of <0.5 mL followed by a period of observation before proceeding with the rest of the treatment. All personnel, physicians, and advanced practice providers performing sclerotherapy should be prepared to treat anaphylaxis and have appropriate medications and equipment on site. Patients should be asked about allergies before any injection. STS is contraindicated in patients with asthma as these patients are at a higher risk for anaphylaxis. Fainting and vasovagal reactions may occur. Before any procedure, we discuss potential risks and complications and inquire about past experiences and needle phobias. Most patients will have experienced a needle stick from a previous immunization or blood draw, and how they tolerate this varies. In a patient with a significant fear of needles or recurrent vasovagal reactions, laser may indeed be a better alternative. If a patient has a vasovagal reaction or fainting spell, adjusting the tilt table (Trendelenburg position), placing an ice pack on the neck or forehead, and most of all verbal reassurance are successful in most cases. Recheck of vital signs and finger stick blood glucose determination complete the assessment and guide management of these rare and unpleasant episodes. A period of observation is required to ensure that the patient has fully recovered. Hyperpigmentation is a brownish discoloration of the skin due to extravasation of red blood cells (Fig 8). If it persists past 1 year, it is considered persistent hyperpigmentation. Most cases resolve during a matter of a few months, with 1% to 2% becoming persistent.17 Hyperpigmentation is usually linear but can be seen as a wheal at the site of injection
Fig 6. Matting in posterior thigh after sclerotherapy.
when osmotic agents are used. It is more likely to occur with increased vessel diameter, higher agent concentrations, lack of postoperative compression, and posttreatment sun exposure and in patients with a history of hyperpigmentation.17 Skin types and tones have been studied to determine which ones are more likely to stain. We and others have observed hyperpigmentation in all skin colors and tones. Small syringes (tuberculin-type syringe) have been associated with an increased risk of extravasation that leads to increased inflammation and hemosiderin deposition due to the high pressure generated. Therefore, large syringes (2.5 mL vs 1 mL) are recommended. If hyperpigmentation does not resolve after an appropriate waiting time, skin laser treatment can be considered. Because the discoloration is caused by hemosiderin and not melanin, skin bleaching treatments are less successful. Matting or fine red telangiectasias can occur at prior injection sites (Fig 6). This has also been termed flairs. The reported incidence varies greatly, with most cases resolving in 3 to 6 months. Matting is believed to be due to hypoxia-induced neovascularization. Although matting usually resolves, it can be disconcerting to patients as they see new spider veins appearing after treatment.18 We generally recommend observation as
Journal of Vascular Surgery: Venous and Lymphatic Disorders
Watson and Mansour
443
Volume 5, Number 3
Fig 7. Telangiectasia and reticular veins: before and after sclerotherapy with satisfactory result.
they usually resolve. Laser can be used for treatment of persistent cases, and there are reports of successful reinjections. However, given the size of these veins, it can be challenging to cannulate them. Ulceration, skin necrosis, and intra-arterial injection are all rare but significant complications (Fig 8).16 They can
Fig 8. Hyperpigmentation and ulceration at the site of prior sclerotherapy.
be avoided in most cases with proper training, anatomic understanding, and the use of ultrasound. It is essential that providers inject within the vein and use appropriate agents in the correct concentration for the vein size. Excessive cutaneous pressure from compression can also cause superficial ulcers or wounds. Limiting the use of tape and extensive dressing material avoids skin reactions that are manifested as blisters and other skin disruption, often confused with ulceration. Some degree of pain and itching are experienced by most patients undergoing sclerotherapy. These treatments usually require multiple sessions or going over the same anatomic area, and some sites seem to be more painful, such as the knees and ankles. Managing the patient’s expectations, limiting treatments, and providing comfort items (eye masks, music, reading material, warm blankets) are helpful. We have not found topical anesthetic creams to be useful as they cause vasospasm and make small veins more difficult if not impossible to cannulate. The type of solution, needle size, and technique all need to be optimized to reduce pain. Hypertonic saline is particularly painful, but other agents are usually well tolerated. Small needles with acutely tapered tips are preferred, and frequent needle changes to avoid a dull tip can be helpful. Even with mild agents and good technique, post-treatment soreness will occur in about 20% of patients for 1 to 2 weeks.19 Thrombotic events such as deep venous thrombosis and pulmonary embolism are rare; however, all patients should be evaluated for hypercoagulable states, and injections are not recommend for these patients. Phlebitis is much more common and occurs 1 to 3 weeks after treatment. Patients report pain, erythema, raised veins, and discoloration. Most patients can be treated with ice, over-the-counter analgesics (acetaminophen or ibuprofen), and compression. Resolution occurs in days to weeks. If phlebitis is extensive, seen with edema,
444
Watson and Mansour
Journal of Vascular Surgery: Venous and Lymphatic Disorders May 2017
AUTHOR CONTRIBUTIONS Conception and design: JW, MM Analysis and interpretation: JW, MM Data collection: JW, MM Writing the article: JW, MM Critical revision of the article: JW, MM Final approval of the article: JW, MM Statistical analysis: JW, MM Obtained funding: JW, MM Overall responsibility: MM
Fig 9. Corona phlebectatica (atrophie blanche) behind the medial malleolus.
or progressive or if it involves the thigh, a CFDS should be obtained to check for the extent of phlebitis and to rule out deep venous involvement. Systemic anticoagulation should be considered in a patient with a clot burden near perforators or other connections to the deep system as progression to deep venous thrombosis is possible. Retained coagulum is another not unexpected outcome to look for; if found, it should be drained with a 22-gauge needle to avoid hyperpigmentation or skin damage in the area. This is rarely required with small veins but occurs with increased frequency in larger veins.1 Education of the patients is important so that prompt treatment can be initiated as necessary. Thrombotic events are reduced with the use of compression, lower concentration agents, and smaller treatment areas. Corona phlebectatica (atrophie blanche) deserves mention here because it is considered a marker for underlying chronic venous insufficiency that may or may not improve by treating the cause (Fig 9). Finally, sclerotherapy with liquid and foamed solutions has been associated with rare adverse events, such as visual disturbances (scotoma), chest tightness, and shortness of breath. The reported incidence is <0.5% of patients, and most of these events have been transient in nature.
CONCLUSIONS Sclerotherapy is a popular and effective method for spider vein treatment. It is a natural adjunct to a comprehensive vein practice and meets the needs of many patients. One cannot underestimate the impact of cosmetic concerns in our patients. Key elements for a comprehensive practice include proper education of the patient, selection of patients, and setting of reasonable expectations. It is important that sclerotherapy be performed by an experienced physician or advanced practice provider with a clear understanding of venous anatomy and disease. Sclerotherapy should be a lowrisk, high-benefit procedure in appropriately selected patients.
REFERENCES 1. Goldman M, Guex J, Weiss R, Partsch H, Perrin M, Ramelet A, et al. Sclerotherapy: treatment of varicose and telangiectatic leg veins. 5th ed. Philadelphia: Saunders Elsevier; 2011. 2. Brand FN, Dannenberg AL, Abbott RD, Kannel WB. The epidemiology of varicose veins: the Framingham Study. Am J Prev Med 1988;4:96-101. 3. Biegeleisen HI. Telangiectasia associated with varicose veins: treatment by a microinjection techniques. JAMA 1934;102: 2092. 4. Alderman DB. Therapy for essential cutaneous telangiectasia. Postgrad Med 1977;61:91-5. 5. Cornu-Thenard A, Boivin P, Baud JM, De Vincenzi I, Carpentier PH. Importance of the familial factor in varicose disease. Clinical study of 134 families. J Dermatol Surg Oncol 1994;20:318-26. 6. Redish W, Pelzer RH. Localized vascular dilatation of the human skin; capillary microscopy and the related studies. Am Heart J 1949;37:106-13. 7. American College of Phlebology. Practice guidelines: superficial venous disease rev020316. Available at: http://www.phlebology.org/wp-content/uploads/2016/02/ SuperficialVenousDiseaseGuidelinesPMS313-02.03.16.pdf. Accessed January 17, 2017. 8. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011;53:2S-48S. 9. Langer RD, Ho E, Denenberg JO, Fronek A, Allison M, Criqui MH. Relationships between symptoms and venous disease: the San Diego population study. Arch Intern Med 2005;165:1420-4. 10. Criqui MH, Jamosmos M, Fronek A, Denenberg JO, Langer RD, Bergan J, et al. Chronic venous disease in an ethnically diverse population: the San Diego Population Study. Am J Epidemiol 2003;158:448-56. 11. Intersocietal Accreditation Commission. IAC standards for vein center accreditation. Available at: www.intersocietal. org/veincenter/standards. Accessed January 17, 2017. 12. Tisi PV, Beverley C, Rees A. Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev 2006:CD001732. 13. Schwartz L, Maxwell H. Sclerotherapy for lower limb telangiectasias. Cochrane Database Syst Rev 2011:CD008826. 14. Rade E, Schliephake D, Otto J, Breu FX, Pannier F. Sclerotherapy of telangiectases and reticular veins: a double-blind, randomized, comparative clinical trial of polidocanol, sodium tetradecyl sulphate and isotonic saline (EASI study). Phlebology 2010;25:124-31. 15. Tessari L, Cavezzi A. Frullini. Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg 2001;27:58-60.
Journal of Vascular Surgery: Venous and Lymphatic Disorders
Watson and Mansour
445
Volume 5, Number 3 16. Munavalli GS, Weiss RA. Complications of sclerotherapy. Semin Cutan Med Surg 2007;26:22. 17. Izzo M, Mariani F, Binaghi F, Amitrano M. Postsclerotherapy hyperpigmentation: incidence, clinical features and therapy. Phlebology 1995:550-1. 18. Bradbury AW, Bate G, Pang K, Darvall KA, Adam DJ. Ultrasound-guided foam sclerotherapy is a safe and clinically
effective treatment for superficial venous reflux. J Vasc Surg 2010;52:939-45. 19. Duffy DM. Small vessel sclerotherapy: an overview. Adv Dermatol 1988;3:221-42.
Submitted Oct 21, 2016; accepted Feb 3, 2017.