Sclerotherapy – Treatment for Varicose Veins: What It Is and How It Works

What is it and how it works? It is a type of surgical therapy

It is currently the treatment of choice for telangiectasias and reticular veins. It is also commonly used as an adjunct treatment for affiants of the saphenous vein after saphenous obliteration by intravenous laser, radiofrequency or surgery.

Sclerotherapy (endovenous chemical ablation) can also be used as a primary treatment for non-saphenous varicosities, usually with the help of ultrasound.

Treatments accepted in Sclerotherapy

Sclerosants include the following:

  • Sodium tetradecyl sulfate (Sotradecol)
  • Polidocanol (Asclera, Aethoxysclerol)
  • Sodium Morruato (Scleromato)
  • Oleato de ethanolamine (Ethamolin)
  • Osmotic agents – to damage the cell by displacing the water balance through dehydration of the cell gradient (osmotic) and denaturation of the cell membrane
  • Hypertonic sodium chloride solution
  • Sodium chloride solution with dextrose (Sclerodex)
  • Chemical irritants – which damages the cell wall by the direct destruction of the caustic endothelium
  • Chromium glycerol (Sclermo)
  • Polyodated iodine

The most commonly used agents are hypertonic saline, sodium tetradecyl sulfate, polidocanol, and chromated glycerin.

The hypertensive lasalin concentration of 23.4% is approved by the Food and Drug Administration of the United States (FDA), but its use in sclerotherapy is off label.

The main advantage of this agent is the fact that it is a natural body material that has no molecular toxicity. However, it is widely accepted as a sclerosing agent, as it can cause pain, burning and cramping in the legs after injections.

If the dose is extravasated, it probably causes significant tissue necrosis; it is very likely that it produces a marked staining of postclerotherapy hemoserin, which is cosmetically unacceptable; and it is difficult to achieve adequate sclerosis of large vessels without exceeding a tolerable salt load.

The suggested hypertonic saline concentrations are 23.4% for reticular veins (2-4 mm) and venulectasias (1-2 mm) and 11.7% (medium intensity) for telangiectasias (<1 mm).

Tetradecyl sodium sulfate, a synthetic surfactant (soap), is the only sclerosing agent approved by the FDA in the United States.

It is commercially available in standard concentrations of 1% or 3%. This sclerosant is reliable, safe and effective.

The main clinical concerns stem from its tendency to cause postclerotherapy hyperpigmentation in up to 30% of patients, a high probability of tissue necrosis due to extravasation (especially when injected in high concentrations), and occasionally cases of anaphylaxis.

Suggested sclerosing concentrations are 0.25-0.4% for reticular veins (2-4 mm) and venulectasias (1-2 mm) and 0.1-0.2% for telangiectasias (<1 mm).

Polidocanol is a local anesthetic, popular in Europe, which was approved in March 2010 by the FDA for use in the United States.

It is painless after injection, does not produce tissue necrosis if extravasated and has a very low incidence of allergic reactions, although few cases of anaphylaxis have been reported. Also, in some patients, it can cause hyperpigmentation. The maximum daily dosage is 2 mg / kg.

Although 72% chromium glycerin is very popular in Europe, it has not yet been approved by the FDA for use in the United States. Only recently has he had interest in its use in the United States. And in comparison with other sclerosants it is very weak, but essentially useful for the treatment of small vessels.

The main advantages of glycerin are that it rarely causes post-treatment hyperpigmentation, telangiectatic mat or tissue necrosis if extravasated.

On the other hand, it is very viscous, causes pain when injected (for this reason, it is often combined with lidocaine to reduce pain), it is also highly allergenic, which can cause ureteral colic and hematuria.

For veins reticular veins, glycerin seems to be more effective than polidocanol, with fewer adverse effects, but more pain.

In this sense, it must be said that one of the objectives of sclerotherapy is to cause an irreversible endothelial lesion in the desired vessels, while avoiding damage to normal collateral vessels and surrounding tissues.

The lowest effective volume and the most appropriate sclerosing concentration should be used to minimize the likelihood of adverse effects. Factors such as sclerosing concentration, volume, mixing and procedure technique are more important factors than choosing the sclerosant itself.

Foam treatment

Mixing a sclerosing agent such as the detergent with a gas (commonly air) results in foaming. The foam is obtained after repeated alternate passages from one syringe to another through a connector.

Compared to traditional liquid sclerotherapy, sclerotherapy with foam has certain advantages, including a smaller volume of sclerosing agent needed for injection, lack of dilution with blood (dilution decreases efficacy), homogeneous effect along the veins injected and ultrasound.

The use of foam sclerotherapy is usually reserved for larger vessels and not so much in the so-called venous spiders.

Pre-operative details to take into account with regard to Sclerotherapy

A detailed history and a physical examination must be done. All the patient’s medications should be reviewed, with attention to hormone replacement, aspirin, nonsteroidal anti-inflammatory drugs, vitamin E, steroids and herbal medicines.

Symptoms that may be related to arterial or venous insufficiency should be investigated, and duplex ultrasound of the lower extremities may be necessary.

Review with the patient the number of treatment sessions required and the duration of treatment. Discuss the limitations on activity that may be necessary after each session. Discuss the sclerosants that will be used, including possible adverse reactions.

Take pre-treatment photographs for documentation and to compare with postoperative results. The photographs help the patient to evaluate his progress. In addition, many patients forget what their legs looked like before treatment.

Informed consent must be obtained before beginning treatment. The elements of consent should include the indications for sclerotherapy, alternative treatments available, possible complications and sequelae, and the need for multiple treatment sessions.

Treatment sessions for the same anatomical locations are typically carried out at 2-8 week intervals.

Symptomatic improvement usually occurs rapidly after Sclerotherapy, while cosmetic improvement may be more gradual. Physicians should discuss with the patient that new vessels are likely to develop over time and that repeat treatment may be necessary.