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Sclerotherapy in Varicose & Thread [Spider] Veins
by Dr Panayiotopoulos, Consultant Vascular and General Surgeon Essex, and Mr Joseph Mathai, Associate Specialist in Vascular Surgery.

1. What are varicose veins?

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 different.

Varicose veins:

·    Insufficiency of a proximal faulty valve

·    Dilatation of all tributaries

·    Prominent bulging veins especially when standing

·    Often bilateral development

·    Familial predisposition in most cases

·    On the picture they are marked just before surgery

 

·         Intradermal veins

·         Thread veins

·         Teleangiectasias

     Are not varicose veins

 

 

2. What causes thread veins?

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 veins.

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 10-30° 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 happen.

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.

The 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 some pressure.

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 effects?

a.                   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 to sunlight.

b.                  Blistering and cutaneous necrosis is rare following sclerotherapy for thread veins, despite the fact that some sclerosants carry a higher risk of blistering than others.

c.                   Matting, 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 option

d.                  Allergic reactions are very rare and are more common the stronger the sclerosant is.

6. What drugs are used for sclerotherapy?

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.

  Veins 4-8mm 2-4mm 1-2mm 0.1-2mm max dose
Iodine 4-8% 4-8%      
Sodium teradecyl [Fibrovein] 3% 1-3%     10ml 3%
Chromated glycerin & 1% lignocaine 4:1       1% 5ml
Polydocanol [Aethoxysclerole, Sclerovein]   1-3% 0.5-1% 0.5% 2mg/kgr
Hypertonic saline & 0.4% lignocaine   23.4% 18.7% 11.7% 10ml

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 problems.

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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Please note:
A written referral from a general practitioner is normally required in order to make an appointment to see a consultant specialist.

 

This page was last updated on 01/10/2006

Vascualr surgeon for varicose veins, renal and general surgical conditions and procedures