Sclerotherapy of Minor Varicosities: A Different Story

by Alessandro Frullini, MD

When I was asked to write an article on the treatment of small veins and teleangectasias with educational purposes, I recalled a great number of papers I have read on the same topic. With few exceptions, most of the articles failed to help me very much when I started this practice because they were filled with unproven dogmas or rules to be followed just because it has always been done that way.The reader can then imagine how worried I was about this task. Therefore I will try to give a different point of view on this treatment, dividing this article in five paragraphs: the patient, the veins, the material, the technique and post-treat-ment management.

The Patient

Who is the patient asking for this treatment? We can easily subdivide patient types into several groups: the young woman with teleangectasias, the male patient with teleangectasias, the patient with residual small veins
and teleangectasias after surgery or ablation of a major trunk etc. All of these individuals have the same veins but their expectations are truly different. It is obvious to me that the patient who has a surgical stripping or a chemical
or laser ablation of a great saphenous vein will be easily satisfied by a mediocre sclerotherapy of spider veins because he/she should be already happy with the treatment of larger veins. The same poor treatment in a
young woman bearing only a few teleangectasias at the ankle (where they are very visible) could be reason for disappointment. If this woman has additional aesthetic problems on her legs (obesity, cellulitis etc) that she is not able to solve, she could be very upset for a incomplete treatment of teleangectasias.So the lesson is easy: always be very careful in patient selection; this is the utmost important phase of the treatment. I don’t mean you must refuse treatment of your patient, but be very frank with them on what you can do for them and
be sure they have an understanding of your words and the process you have described to manage their concerns.
Ask yourself basically what the patient is demanding, not from you, but from him/herself. Sometimes the doctor is only the tool that people use to fulfilltheir needs, and if there is discrepancy between what the doctor can offer and what the patient is really searching for there exists the possibility for litigation, even when the doctor has done a perfect job. Therefore I think that an objective evaluation must be done and, at least in my experience, the first impression is never wrong.

The Veins

Never do something on a leg if you don’t know the anatomy and the hemodynamics of that specific leg. This means that you can’t perform any sclerotherapy (even on a single teleangectasia) without a duplex study. This exam must be properly performed (standing position, evaluation of terminal and preterminal valve on the saphenous junctions, discrimination between diastolic and systolic flow in perforators etc). I am aware that duplex is performed in many countries (like the US) by technicians and not by doctors. Although I am not against this practice, I strongly advise that the one performing the sclerotherapy should have a close connection and discussion with the person examining each patient.Let me give you an example, a typical group of red teleangectasias on the lateral aspect of the thigh with an obvious reticular vein below. The phlebologic dogma is to treat the reticular vein and then the teleangectasias. It is always so? I don’t think so; otherwise we should never see poor results or matting.These findings could be found, for example, as the first evidence of vein insufficiency in a young woman but could be also developed as the result of a sclerotherapy of an insufficient anterior saphenous vein. Hemodynamically, those conditions are very different because we could think of a small insufficient reticular vein which generates spider veins or, on the other side, an impaired flow from the skin
subsequent to the ablation of the larger vein. We often forget that superficial veins like the saphenous are the physiologic drainage pathway of venous blood coming from the skin. Their ablation could occasionally worsen skin venous drainage and therefore generate teleangectasias. I suppose that many mattings are produced this way. Thus understanding hemodynamics will help very much in avoiding poor results or complications.
The weak link between the doctor and the technician performing the duplex examination is the different perspective they have on the same subject: the first is focused on solving the problem, the second on representing the pathological condition. I do both phases and therefore the connection is easy in my case but I can imagine that sometimes the split provider approach may prove difficult. It is clear from reading Duplex reports made by other colleagues, there a general lack of understanding to this point.

The Material
Little magnification is useful. I use very cheap plastic lenses (1.8X) that give me the chance to work fast enough
while allowing more precise technique. Cheap and precise for the operator enables one to manage more patients in a day; for the patients this means less pain and shorter treatment times. This is the true reason for the use of magnification. Furthermore, with that little magnification you can virtually inject every vein despite its diameter. It is not true that very small red teleangectasias can be treated only with lasers, with proper technique every teleangectasia can be successfully injected. My advice is to use 2 or 2.5 ml syringes as larger ones
cannot be handled properly (see technique paragraph) and 30g needles. Smaller needles are occasionally utilized but not so often as they are not sharp as the 30G. My experience with small veins is mostly with polidocanol as I have found it to be the best sclerosant in such condition. Typical concentration for spi-der veins is 0.5% when used as a liquid and 0.25% when foam is used. I introduced foam sclerotherapy in the U.S. in 1999 so I believe that most of my Ameri-can colleagues think I always use sclerosing foam for smaller veins. This is not true, I usually treat larger trunks with foamed sclerosants but I use them very seldom for teleangectasias or
reticular veins. The first reason is that foam it is not necessary in these vessels, everybody can
easily notice that the injection of a liquid sclerosant is capable of blanching teleangectasias.
Therefore we don’t need a foam to separate blood from the sclerosant. Secondly, I believe that the use of foam for
teleangectasias can be cause for some side effects (visual disturbances etc.) with greater inci-
dence than for larger trunks. I have performed recently a study on endothelin 1 production after sclerotherapy with liquid and foamed polidocanol in a rat model. I observed a large endothelin production immediately after foam injection and not with liquid injection. Furthermore, the number of injections in a small vein sclerotherapy session is usually very large, with larger endothelial surface area capable of endothelin release. It is my opinion that endothelin can be related to neurological and visual disturbances after sclerotherapy so I prefer to treat
those cases with liquid. This doesn’t mean you shouldn’t expect side effects with liquid; your patient will experience them less frequently over time.Complication of focal yet heavy pigmentation following sclerotherapy of superficial vessels near the ankle.Common presentation of Albanese complexes with telangiectasia over the lateral thigh and knee.

The Technique
This is the most difficult part to teach. Usually watching (not merely seeing) somebody with more experience is
useful. I think that the attention should be focused first on the two hands, the one holding the syringe as less important. The left hand (for a right-handed practitioner) has to stabilize the skin allowing precise introduction of the needle. The syringe is placed parallel to the skin aiming to reduce maximally the angle between the needle and the skin. This is another reason not to use larger syringes as with those it is impossible to minimize that angle. Teleangectasias are entered on the same axis they run and I have not found any reason to limit the volume injected to the diameter of the area blanched by the injection. In some cases it is possible to inject large volumes, particularly for blue teleangectasias. Matting can be injected as well but in this case I enter the lesion and then I retrieve the syringe pushing gently on the piston: as soon a vessel is entered the matting disappears.
The lesson here is that nothing can replace the educational value of learning from an experienced sclerotherapist.

Post-treatment Management
Call me a heretic but I don’t use that myriad of cottoned tapes so indispensable for many colleagues. I have never
used them in 2? years of practice, avoiding a great number of blisters (often with poor aesthetical outcome) and a lot of discomfort for patients.Also, compression is somewhat debatable regarding its efficacy for sclerotherapy of teleangectasias. Anyway a 18 or 26 mmHg is usually prescribed for these patients.

Sclerotherapy of the small vessel is a very simple treatment when somebody expert is performing it, but may became terribly difficult for beginners. My advice is to watch carefully the work of experts considering every single action as part of a successful strategy. In this way everything will become automatic and you will have fun talking with your patient while your hands will make the whole work.

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