Advice and Information
in Varicose & Thread [Spider] Veins
by Dr Panayiotopoulos, Consultant Vascular and General Surgeon
Essex, and Mr Joseph Mathai, Associate Specialist in Vascular
1. What are varicose veins?
are abnormally tortuous [dilated, swollen] veins which are
visible just below the skin surface, especially on the erect
position. Smaller veins in the skin itself are sometimes called
“thread veins” or “spider veins” or “teleangiectasias”. These are
more common in women and although they may be unsightly, they are
not the same as varicose veins and treatment options for these are
of a proximal faulty valve
of all tributaries
bulging veins especially when standing
predisposition in most cases
the picture they are marked just before surgery
Are not varicose veins
2. What causes
Thread veins, represent a common
cosmetic problem, affecting up to 50% of the population. There is
certainly some genetic predisposition, but the presence of
high oestrogens in the blood [pregnancy, the pill, HRT] plus the
sedentary life style, obesity and age are
thought to play a significant role. The presence of venous
hypertension may also contribute to the appearance of spider
3. How can thread
veins be treated?
Although the main
treatment for varicose veins with proximal venous reflux [leaky
valves at the junction with the deep veins] is surgery, it is not
possible to do the same for the small veins that run into the skin.
The aim of treatment is to obliterate them by not letting blood
run through them [their bluish appearance is due to the fact
that blood flows extremely slowly in them, loses the oxygen it
carries and deoxygenated haemoglobin in the red cells gives the blue
colour]. That can be achieved by a technique called sclerotherapy
[injection of a chemical into the vein that causes inflammation of
its lining, causing the walls of it to stick together, not allowing
blood to pass through], or by laser treatment [achieves the
same result, by damaging the endothelium, however, is not effective
in veins larger than1-2mm in diameter].
Sclerosant agents exert their effect on the
endothelium, causing swelling of its
lining cells, with formation of red thrombus inside the lumen. The
thrombus is gradually absorbed, but scar tissue forms, which
occludes the lumen and the vein segment becomes obliterated
[usually in 3-4 weeks].
Sclerotherapy was initially used for proper varicose veins, however,
due to the high recurrence rate it is now limited only to residual
veins following surgery or veins less than 2mm in diameter that have
to be ablated for cosmetic reasons.
Sclerotherapy may be ineffective in the presence
of superficial or deep venous reflux and
this should be treated surgically –if possible- prior to
sclerotherapy. You should also consider that
sometimes a surgical procedure to avulse small veins
2-4mm may be preferable that multiple sessions of sclerotherapy.
4. How is sclerotherapy performed?
It is usually done with the
patient supine [for comfort and avoidance of syncopal attack]. The
skin is disinfected and a small needle [30-33G] bended at
angle is used to enter the vein, with bevel away from the skin.
Surgical magnification loops [2.5x or 3.5x] are useful. Aspiration
of blood confirms entry into the vessel, but this does not always
The needle is inserted in the
direction of the vessel axis and tangential to the skin. The
injection is made slowly. If a wheal develops, the injection is
discontinued and another site is chosen. If the injection is
successful, the area blanches out.
The next injection should be
done outside the blanched area.
larger veins are treated first, followed by the smaller ones; it is
probably better to start from above and proceed to below. A small
cotton ball or dental roll is taped over the injection site to apply
Further pressure [bandage] may have to be applied at the end of the
session. Class I European [20-30mmHg pressure] or class I & II
British [14-18 & 19-24mmHg] stockings may be advisable post thread
vein sclerotherapy [to be used for 2-3 weeks].
Multiple sclerotherapy sessions may have to be
performed, each one following the previous after 1-2 weeks.
5. Does sclerotherapy have any side
Although the reported frequency
varies, 5-30% of patients [depending on the drug used] will develop
hyperpigmentation from thrombus formation. Fortunately,
haemosiderin stains fade over 6-24 months, especially if not exposed
cutaneous necrosis is rare following
sclerotherapy for thread veins, despite the fact that some
sclerosants carry a higher risk of blistering than others.
appearance of small telengiectatic vessels
may appear in 5-10% of cases after sclerotherapy. The cause is
unknown. If matting develops, laser treatment is probably the best
reactions are very rare and are more
common the stronger the sclerosant is.
6. What drugs are used for
A variety of chemical with multiple strengths can
been used, depending on the diameter and the site of the thread
veins or small varicose veins.
Sodium teradecyl [Fibrovein]
Chromated glycerin & 1% lignocaine 4:1
Polydocanol [Aethoxysclerole, Sclerovein]
Hypertonic saline & 0.4% lignocaine
7. What are the advantages and
disadvantages of these chemicals?
The iodine and fibrovein are too strong to be used
for small veins. They can cause hyperpigmentation in up to 30%,
and 1-3% skin necrosis following extravasation.
The chromated glycerin [Scleremo] is a quite weak
sclerosant and can be used only in small thread veins. May be
painful at injection, but rarely causes hyperpigmentation or skin
Polydocanol, a local anaesthetic
by itself, causes less pain at injection, it rarely causes
hyperpigmentation or reactions and does not cause necrosis in
intradermal injection. It is the safest chemical and the one mostly
used in all European countries.
Hypertonic saline is less effective than other
agents, causes pain at injection and has a
high risk of pigmentation or sclerosis after extravasation.
8. What happens after sclerotherapy?
Walking is essential and you should take a walk of
15min at least 3 times a day. In almost all of the cases some degree
of compression is needed for at least 3 days. On removal of the
compression, the veins may look unsightly and bruised and this may
last for 2-3 weeks.
You should not expect to see the final cosmetic
result of sclerotherapy before 2-3 months,
although further fading of the veins will carry on for up to 12-24
months. Overall, the final cosmetic result is excellent in 60% of
cases, while it is significantly improved in more than 80%.
The taking of regular exercise, modification of your life style, the
wear of light support stockings and the avoidance of risk factors
and becoming overweight will all help prevent you being troubled by
varicose and thread veins.
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A written referral from a general practitioner is normally required in order
to make an appointment to see a consultant specialist.