VARICOSE VEIN INJECTIONS (INJECTION SCLEROTHERAPY)
vascular.co.nz>varicose vein injections
What is vein injection sclerotherapy?
Which varicose veins are suitable for vein injection treatment?
Before your vein injection sclerotherapy
The technique of vein injection sclerotherapy
After the vein injection sclerotherapy
Possible complications
of injection sclerotherapy
Ultrasound guided
foam sclerotherapy
Useful links
What is vein injection sclerotherapy?
Injection sclerotherapy is a treatment that intentionally damages the lining (endothelium) of small veins. By doing this and then applying pressure the vein walls stick together. The vein can then no longer fill with blood and so it is obliterated. The compression applied after the injection is an essential part of the therapy.
Sclerotherapy has been around in one form or another for well over 100 years and there are descriptions going back much further. It has risen and fallen in popularity as techniques have evolved. Foam sclerotherapy is an evolution of earlier methods that uses a standard detergent sclerosant such as STD (sodium tetradecyl sulphate) and mixes it with air or carbon dioxide in various ratios to create a foam. This foam is then injected into the veins.
Ultrasound guided foam sclerotherapy is a further development in which the foam injection is guided by ultrasound. The ultrasound probe is able to track the needle entering the vein and ensure the injection takes place in the appropriate place. The dispersion of the foam is then tracked by ultrasound.
Microinjection sclerotherapy is used for very fine spider veins and uses a very fine needle.
Examples of sclerosants are STS (sodium tetradecyl sulphate), 20% hypertonic saline and polidocanol. STS and polidocanol can be used as a foam, but hypertonic saline can only be used as a liquid for fine thread veins. STS and polidocanol are the commonest sclerosants in current use.
Which varicose veins are suitable for injection treatment?
There is a trend in recent years to less invasive treatments for varicose veins that enable a walk in-walk out service. The resurgence in injection sclerotherapy is part of that trend. Some practitioners will treat any patient with varicose veins by injection, but even amongst the sclerotherapists there is increasing recognition that major junctional reflux (see below) is probably best treated by alternative means. It is possible to find practitioners who will inject any abnormal vein and that is all they do..
Major juntional reflux is present when the major valves at the groin (sapheno-femoral junction) or behind the knee (sapheno-popliteal junction) do not function normally. If there are problems at these locations many practitioners, including myself, advise they should be dealt with using other methods for most patients. Sclerotherapy works best in smaller varicose veins or spider/thread veins. There are clinics that offer ultrasound guided sclerotherapy to all sorts of veins, even major varicose veins. For large varicose veins with faults in the valves at the groin there is probably a 20-30% chance of the injections not working with a single treatment. Although it is possible to achieve improvement with these techniques without recourse to surgery, there is a trade-off in terms of the time taken for vein resolution. A single treatment session is also unlikely to bring about the desired results. Although injection of major veins would not be my first choice treatment, in some patients this may still be the best option. In patients with multiple coexisting medical problems it may be a way of treating the veins that otherwise would not be treated.
Even if your veins are suitable for injection sclerotherapy, it is important that you have a frank discussion with your surgeon about the potential benefits and limitations of injections. It is important to be clear from the beginning what will be possible and what will not be possible. In some patients with very minor thread veins, injections may leave skin pigmentation that is worse than the actual veins themselves. In these circumstances treatment will not improve the appearance of the veins and the use of false tan and camouflage make-up may be the best way to hide the visible veins.
Take care when reading advertisements offering injection treatments. Some of the claims are often misleading. ALL treatments have a failure rate and injection sclerotherapy is no exception. Injection sclerotherapy may appear to be a cheaper option if you are paying personally for the treatment, but this should not be the only consideration. In the long run expenses can be greater if a less effective or inappropriate treatment has been used.
Before your vein injection sclerotherapy
Well fitting compression stockings are an important part of the post injection regime and you should be measured up for these before the treatment session so they are available to put on immediately after your injections.
There is a theoretical risk that taking the oral contraceptive pill or hormone replacement therapy at the time of your injection could increase the risk of a serious thrombosis. If they are stopped before your injection treatment, it is very important to think about other contraception methods.
It is important after the injections that you do not stand still for long periods. If you have a job that involves alot of standing it is important to arrange a few days off work after the injections. Avoid committments that will prevent you from resting for the first few days after treatment.
The technique of vein injection sclerotherapy
The veins that may benefit from injections are marked. For spider veins I inject a small amount of liquid sclerosant into the visible veins usually at multiple sites. For larger veins I use the STS liquid made into a foam. The foam is created by mixing the STS with air, or in some cases carbon dioxide. Before injecting I usually cannulate the veins to be treated. This involves placing a plastic tube into the veins either under direct vision or sometimes using ultrasound guidance. The amount of treatment that can be administered at a single injection session will depend on the number and type of veins being treated and the amount and concentration of sclerosant being used. The video shows spider veins being injected.
With liquid injections for spider veins using a low concentration of STS or polidocanol there is rarely an issue of exceeding the maximum dose. When injecting foam there are other concerns besides exceeding the maximum dose of STS. Foam contains thousands of tiny air bubbles which can be dangerous in excess. Most guidelines will recommend 10-15mls of foam as the maximum volume of foam that can be injected at any one sitting. This is because there is no way to contain the foam in the injected vein. Although most of the foam will remain in the vein some will always travel into the circulation even with the best attempts to prevent foam dispersal. As long as the volume is kept low this doesn't appear to cause problems, but larger volumes may put patients at higher risk of complications (see below). There are practitioners that will inject 30-40 mls of foam at one sitting but I would not advise or perform this treatment.
After the vein injection sclerotherapy
After the injection a rubber or cotton wool pad is applied over the course of the injected veins followed by a stocking. After your injections you should go for a short walk of approximately 15-20 minutes. After that time you can carry on normal daily activities. Try to avoid standing still for long periods. If you are on your feet it is better to keep walking and if sitting to keep your legs elevated.
If wearing bandages, your surgeon will advise how long this is required. Stockings should be worn at all times day and night for the first one to two weeks. You can shower wearing the stockings and then use a hair dryer to dry the legs. Advice on the exact compression regime will vary and this may depend on many factors.
The success of the injection treatment relies upon the pressure that the bandages and stocking apply to the injected area, in association with regular exercise. It is important to take regular walking exercise after your treatment.
Ultrasound guided foam sclerotherapy (UGFS)
Ultrasound guided foam sclerotherapy is the latest development in the sclerotherapy field. The principle is the same as conventional sclerotherapy. The sclerosant is used to obliterate varicose veins.
The new points in this technique are that the liquid sclerosant is agitated to produce a foam-like mixture which is basically air that is mixed with sclerosant. When this is injected into the veins it can be traced using an ultrasound scanner. Using ultrasound should improve accuracy and the use of foam appears to maximise the effect of the injection (Alos et al, 2006). Because a foam is required only sclerosing agents that can produce a foam can be used such as STD. In practice it is difficult to actually control the flow of foam around the junction. The safest technique appears to be to inject with the leg elevated and without pressure applied at the groin. There is also debate about whether it is safe to use air or whether other gases such as carbon dioxide should be used. Whether the gas injected should be sterile is also uncertain.
This video shows an ultrasound guided injection
Unfortunately, there are no good trials that have compared surgery with UGFS. UGFS certainly can be effective initially (Darke SG, Baker SJA, 2006), but its medium to long term results are not reliably known. There are publications which claim effectiveness for the UGS technique, but frequently more than one session of injections are required for residual veins. It is also difficult, if not impossible, with UGS to perform a chemical sapheno-femoral ligation that is equivalent to the surgical treatment at this site. Ineffective treatment at this site is known to cause and to be a predictor for varicose vein recurrence. In fact for groin reflux there is probably a 20-30% initial failure rate for foam sclerotherapy. This may at least partly be dependent on the size of the vein - larger veins being more difficult to treat.
Ultrasound guided foam sclerotherapy can be a very effective technique, but there are still many unknowns regarding the technique. For instance it is still not clear whether air or carbon dioxide gives better results. The exact ratio of air to liquid STS, should the gas be sterile, optimal concentrations of STS foam for different veins and use of syringes with differing silicone contents can all influence foam production and stability but there is no first class evidence to favour one technique over another.
Possible complications of injection sclerotherapy
Sclerotherapy is also not without complications. For the vast majority of patients it is very safe, but apart from the complications mentioned above, there is also a small risk of allergy. There are also rare instances of transient stroke reported (Forlee MV et al 2006). This is thought to be due to the foam bubbles travelling in the blood vessels to the brain. In most patients undergoing foam sclerotherapy to major veins, bubbles can be seen travelling in the blood to the heart. For the majority of patients this does not appear to be a concern, but because of these risks I prefer to reserve UGFS for patients without major junctional reflux and keep the volume injected to a minimum.
Over the first few weeks following the injection, any slight discomfort, hardness or tenderness at the injection site(s) should gradually subside. If there is excessive redness, swelling or tenderness, this means you should rest more, with the leg raised so that the heel is higher than the hip. If you are concerned see your surgeon. Large varicosities injected with foam do become hard and usually slightly tender. This is normal and will gradually dissipate but can take some time.
Brown staining of the skin around the site of the injection - this is quite common and will quite often remain permanent. Some resolution can occur in the 12 months after the injections.
A persistent hard "cord" in the line of the vein - this usually occurs after injecting bigger varicose veins and means a small amount of blood has clotted in the vein. It is not dangerous.Ulceration of the skin at the injection site - this is rare but usually means the fluid has been injected around the vein rather than into the vein. It is much more likely to occur when using higher concentrations of sclerosant.
The injection may fail to obliterate the vein.
Deep venous thrombosis - although the risk of this is low it does occasionally occur. It may be related to the volume of sclerosant, particularly foam, that is injected. Larger volumes of foam may present more risk.
Bookmark this on Delicious 
reddit 
facebook
References
Alos J et al.
Efficacy and safety of sclerotherapy using polidocanol foam: a controlled
trial. Eur J Vasc Endovasc Surgery 2006; 31: 101-107.
Darke SG,
Baker SJA. Ultrasound-guided foam sclerotherapy for the treatment of
varicose veins. Brit J Surg 2006; 93: 969-74.
Forlee MV, Grouden M,
Moore DJ, Shanik G. Stroke after varicose vein foam injection
sclerotherapy. J Vasc Surg 2006; 43: 162-164.
Last updated> 23 May, 2010