by Mark Issacs, MD
Twenty years ago, an especially persuasive patient convinced me to treat her prominent hand veins, despite my dire warnings that this was unknown territory for me and that the potential complications were uncertain. I searched the medical literature, and at the time could find nothing to reassure me. Since then, I’ve treated many hundreds of patients for their cosmetically objectionable hand veins and have been satisfied that the treatment is both safe and effective. As is always the case, however, knowledge of the relevant anatomy, appropriate use of sclerosants and a thorough informed consent procedure are essential for good results and a happy patient.
Anatomically, the veins of the hand and arms can be visualized as having deep and superficial components similar to the leg, though this analogy has its limits. Unlike in the lower extremities, there is no fascial layer separating the two systems, and there are many communicating veins connecting them.
The deep system vein can be thought of as starting along the palmar aspect of the hand, while the superficial veins originate on the dorsal aspect. Viewing the hand from the palmar aspect, there are paired radial and ulnar veins accompanying the arteries of the same name. Above the elbow, these veins combine to form the brachial vein, which may also be paired, one portion lying on either side of the brachial artery. These veins, in turn, combine to form the axillary vein which then becomes the subclavian vein in the chest. Because these veins have such a straight, direct route to the central circulation, I make it a rule not to treat any of these veins, no matter how charming or persuasive the patient might be.
The superficial system includes the bulgy veins on the dorsal aspect of the hand, the dorsal venous network, that are most commonly the object of the patient’s concern. This network is drained by the cephalic vein at the base of the thumb and the basilic vein along the lateral wrist. Though the cephalic vein is considered superficial, this designation is somewhat arbitrary in that it is a large vein that connects with the “deep” veins in the forearm and in the antecubital fossa. This, then, is another vein I avoid injecting directly. Both the cephalic and basilic veins eventually drain into the axillary and subclavian veins, though their routes are more indirect than the palmar deep veins.
Relative to the veins of the lower extremity, the hydrostatic pressure in the upper extremity veins is low. Failure of valves is rare, so bulging veins cannot be considered pathologically varicose, nor is the treatment medically necessary unless a congenital venous malformation is present. Interestingly, though, I had one patient who swore her hand “arthritis” pain disappeared after treatment.
Patient selection is mostly a matter of self-referral. There are no strict criteria for selecting candidates for treatment in that the treatment is cosmetic. Prominent dorsal hand veins are felt by many women to make their hands look like “old lady hands.”Possibly the one contraindication is the presence of unrealistic expectations. The patient who believes she will look 40 years younger simply by eliminating bulging hand veins is bound to be disappointed and resentful.
Informed consent should include a discussion of possible complications, most of which are identical to those that occur with leg vein treatment. Trapped blood requiring aspiration, post-treatment pain, edema, neuropathy, discoloration and ulceration are all possible. Telangiectatic matting and inadvertent arterial injection, however, are probably very rare. I also include in my informed consent a discussion of the necessity of hand and arm veins for easy IV access in the case of the future need for emergency fluid administration. Alternative treatments might include heat catheter ablation or surgery, though these strike me as very big guns for a small problem. Laser is ineffective due to the size and depth of the target veins. I warn the prospective patient that it is not unusual to have to do more than one treatment, despite the small area of veins being injected.
The technique of treatment is similar, but not identical, to treatment of leg veins. Because the valves in these veins are intact, treatment should begin with the most distal veins then progress proximally. In my experience and the in the experience of others, a slightly higher concentration of sclerosant must be used for a given diameter of vein than would be used in the leg, possibly due to a relatively increased volume-of flow through these veins. While STS .5-1% and PDA 1-2% work well for most hand veins in the 3-6 mm diameter range, more and more I have found myself favoring .5% STS foam with 1:4 air. It’s worth noting, however, that foam currently remains an “off-label” use of sclerosant.
I tend to avoid treating veins above the level of the wrist unless I am convinced that there is no significant route of direct drainage into the deep veins. I also tend to use smaller volumes per injection than I would in the leg, typically .2 - .5 cc, in order to keep the zone of sclerosant effect limited.
There is no data in the medical literature documenting the need for compression after hand vein treatment, but my preference is to use tapes and cotton balls for at least a day. Should the patient experience significant pain or swelling after treatment, both elevation and cold packs are helpful. Follow-up evaluation is scheduled for 2-6 weeks, at which time both further treatment and evacuation of “trapped blood” can be accomplished. In general, the hands tend to heal somewhat faster than the legs, though final cosmetic results may still take weeks to months.
Hand vein treatment is not recommended for the novice phlebologist, but for someone with experience and skill it is a gratifying application of sclerotherapy. Knowledge of the underlying anatomy, appropriate application of sclerosant and an informed patient are requirements for safe and successful treatment.
Dr. Mark Issacs is Board Certified in Phlebology and a Fellow of the American College of Phlebology. He has served on the faculty of the American College of Phlebology and the Union Internationale de Phlebologie. Dr. Issacs received his medical training from the University of California San Francisco School of Medicine and completed his residency training at an affiliated hospital with the University of Minnesota.