Large Vein Sclerotherapy
Sclerotherapy for large varicose veins, called chemical ablation, may be used for primary treatment of varicose veins due to incompetent perforator, saphenous, or branch veins. Injections are usually guided by ultrasound. Foamed sclerosant (Sotradecol, sodium tetradecyl sulfate) is typically used. Compression stockings are required for 2 weeks afterwards.
Small Vein (Cosmetic) Sclerotherapy
Small vein sclerotherapy is performed primarily for cosmetically unpleasant spider and dilated reticular veins. Spider veins are unsightly dilated networks of tiny skin vessels that appear most commonly on the legs. They can be red, blue or purple, and when extensive, sometimes cause leg discomfort. Reticular veins are slightly larger and located deeper in skin; when their tiny valves fail they dilate, become tortuous, and produce localized backward blood flow; they often appear as unattractive networks of blue or purple streaks. Incompetent reticular veins typically feed one or more clusters of spider veins. Unlike varicose veins, spider and reticular veins do not bulge on the skin surface. Nonetheless, many women are bothered by their appearance and avoid wearing shorts, skirts and bathing suits. Early treatment not only eliminates existing ones but can prevent new ones that are in the process of forming.
Patients with varicose vein disease often have extensive spider veins. Although their appearance usually improves after endovenous ablation, the spider veins typically do not entirely go away without direct treatment.
How Is Sclerotherapy Performed?
Sclerotherapy involves injecting abnormal veins with one of several sclerosant medications, depending on the size of the vessel. Hypertonic saline is relatively ineffective, painful, and therefore no longer used in most vein centers. We use ultra fine needles that are virtually painless. Sclerosant medications cause veins to spasm and permanently close over the course of days to weeks. Some veins close with a small blood clot inside that temporarily makes them more prominent until the clot is absorbed by the body. Graduated compression stockings are worn for 1-2 weeks after injections to help keep the injected veins empty and minimize clot formation until permanent closure. Some veins may need to be injected a second time. The majority of patients need 2-4 injection sessions spaced 4 weeks apart. One or both legs may be treated during each session. In the first session, injections are mostly into incompetent, feeder reticular veins. These vessels frequently can only be visualized with a special bright light (Veinlite). Injecting only surface spiders and leaving feeder vessels intact decreases the efficacy of treatments and results in only short term improvements. Once feeder veins are closed, injections are primarily direct at any remaining spider veins.
Sclerotherapy is an art that is very dependent on technique and proper selection of solutions. Serious complications such as severe allergic reactions are extremely rare. Common side effects are temporary and mild. These include slight stinging during injection, temporary skin discoloration or tenderness, and a blush near injected areas (matting).
Modern sclerotherapy primarily utilizes foamed solutions (Sotradecol, sodium tetradecol sulfate) for larger reticular veins and liquid solutions such as Sotradecol and glycerin for smaller spider networks. Foaming solutions enhance effectiveness and minimize side effects, such as skin hyperpigmentation and matting. Polidocanol is the most commonly used agent in the world probably because it has local anesthetic properties and may cause less discoloration than Sotradecol. Glycerin is preferred for small spider vein networks because it is less likely to cause matting.