Sclerotherapy is recognized as the "Gold Standard" for the treatment of spider veins or telangiectasia on the legs.
Sclerotherapy is a long established technique which involves precise injection of small venous blood vessels using sclerosants. Three broad classes of sclerosants are in general use around the world today. Though the method of each class of sclerosant is different, the end result is the same. Sclerosants target only the endothelial cells which layer the inside of the vein wall. These cells are peeled away by the sclerosant allowing exposure of the underlying collagen in the vein wall. The vein's attempt to repair the injury only results in the inner walls of the vein adhering together. Eventually scar tissue develops causing permanent fusion of the walls and sealing off any further blood flow in the vein. The treated vein then develops into a fibrous cord. This process is called sclerosis and is derived from the Latin word for hardening, scleroticus. The hard redundant scar tissue of the vein remnant is eventually removed by a process called apoptosis.
Spider veins develop as a result of back pressure from larger feeding veins which are seen slightly deeper under the skin. These feeding veins are called “Reticular veins” and they are usually easy to identify because they have a bluish colour and are often seen in a central position wherever there is a network of spider veins. In order to get successful results in treating spider veins, treatment of these reticular veins are also required. Poor results and complications of treatment such as “matting” are often the result of failing to identify and properly treat these reticular veins.
Treatment of spider veins with microsclerotherapy unfortunately does not provide an immediate benefit. It may require several months to complete a course of treatment depending on the extent of involvement.
Because very tiny needles are used the procedure is usually not too uncomfortable. It is usual for most patients to require more than one course of treatment. After one course of treatment there is usually a 70-80% improvement. For patients with a substantial number of spider veins then three treatment sessions spread over the course of three months are undertaken. The process that causes spider veins is a chronic condition, so there is a tendency for them to recur over a period of time, though the doctor will never be able to answer confidently how long this period will be. Therefore a maintenance treatment session may be required every few years.
There is usually a typical sequence in the treatment of spider veins where initial microsclerotherapy is targeted at the deeper reticular veins which lie just under the skin. Subsequent treatment sessions are directed at the small spider veins close to the surface of the skin. At The Leg Vein Doctor we use different types of sclerosing agents for the different levels in the skin.
Treatment sessions usually take at least an hour if we are treating both legs at the same time. After treatment your legs are cleaned and compression stockings are applied. The stockings should be worn for 3 to 5 days, depending on the extent of treatment.
Following treatment there may be a period of a few weeks where there appears to be no obvious improvement and indeed there maybe areas of bruising associated with some tender lumps where the veins are undergoing the process of sclerosis. This is not to be unexpected.
Occasionally tender lumps due to trapped blood in some of the veins may be quite uncomfortable. Release of trapped blood with small punctures (under anaesthetic) will give almost immediate relief.
Some degree of pigmentation can occur after microsclerotherapy. It may take some months to disappear but if it persists it may be due to inadequate treatment of underlying reticular veins. Release of any significant areas of trapped blood is important in minimizing the affects of pigmentation.
Another cause for excessive pigmentation after microsclerotherapy is the use of an inappropriate sclerosant. For instance the use of Fibrovein (Sodium Tetradecyl Sulphate) has a greater tendency to cause pigmentation when used on the finest of spider veins.
Matting is a well recognised complication of microsclerotherapy. Matting is the development of new very fine spider veins which have a lacy red appearance. The lateral thighs and medial knee areas are the most common areas for matting to occur. They differ in appearance to the original spider veins. Matting may appear a few months after the treatment and the original treated spider veins have mostly disappeared! They are not that uncommon - with a reported incidence of 1-5%.
There is an increased risk of developing this complication if the primary treatment of sclerosing regional reticular veins in the dependent area has been inadequate. Fortunately matting will often disappear over time with out the need for further treatment.
Thrombophlebitis is an occasional complication of sclerotherapy. The features of superficial thrombophlebitis (STP) are redness, swelling and tenderness along a segment of the treated vein. It is not a serious condition but sometimes the affected area can be very tender and painful to touch. This complication, it it occurs will often prompt patients to seek medical attention. Thrombophlebitis is an inflammatory condition - not an infectious condition. Therefore antibiotics are not indicated. The treatment involves compression, non steroidal anti-inflammatory drugs and mobilization. The pain and swelling will usually settle down in 3-4 days with these steps. Superficial thrombophebitis does not mean that there is a risk of impending DVT or pulmonary embolus.
Migraine can occasionally be provoked by sclerotherapy in patients who have this condition, particularly if they have a tendency to develop visual, sensory or neurological auras preceding the headache. To avert this risk at The Leg Vein Doctor we use Carbon Dioxide rather than air to create the foam sclerosant.
Ulceration of the skin is a rare complication and arises if the arterial circulation of the skin has been compromised. It is thought that on occasions the sclerosant triggers arterial spasm from an affect on the venous side of the circulation. Extensive ulceration of the skin due to direct injection of sclerosant into an arterial vessel is a very rare but serious complication.
Allergic reactions to sclerosants. These can be either anaphylactic or anaphylactoid in nature. Such reactions are potentially fatal but fortunately the incidence is less that 1 in 3000. A properly equipped and trained doctor is expected to be competent in the management of this rare but potentially lethal condition.
Deep Vein Thrombosis. It is strange but true that the incidence of DVT from sclerotherapy is very rare. The variously reported incidence is approximately 1 in 3000. On occasions patients present with hyper thrombotic conditions that predispose them to a higher risk so we will usually provided anti-thrombotic protection with drugs such as Clexane.
Stroke following sclerotherapy is an extremely rare event which has been reported following both liquid and foam sclerotherapy. A Review Article published in 2012 in the journal Phebology found that there had been 13 cases reported around the world since 1994 and that all patients had recovered within 24 hours.