Varicose Veins – Sclerotherapy
Sclerotherapy is injection treatment of varicose veins. Sclerotherapy is suitable for the majority of patients. It involves injecting the abnormal veins with a sclerosing solution, which irritates the inner lining of the vein, causing it to swell and stick together. Over a period of weeks or months the veins close off and disappear. Treated veins fade gradually, over a period of 1-6 months.
Direct Vision Sclerotherapy is the treatment of small spider veins using injections of a solution (sclerosant) that causes the veins to collapse and be absorbed. This procedure is well-tolerated and does not require any anaesthetic. You may feel some discomfort (aching or stinging) a few moments after the solution enters the vein. The discomfort is transient and will settle after a few moments. This treatment takes approximately 30 minutes and you may need from 1 to 3 treatments per leg, depending on your diagnosis. Treatment success depends on age, severity, other concurrent medical conditions and healing rate, but most patients see an impressive improvement.
Ultrasound Guided Sclerotherapy (UGS) uses duplex ultrasound to precisely locate the abnormal veins as well as the adjacent structures, such as deep veins and arteries. The doctor injects a precise amount of the solution in the abnormal vein while watching the injection on an ultrasound monitor, enabling real-time visualisation and tracking of the solution. This ensures that the sclerosant is delivered to the vein rather than to the adjacent structures, increasing the safety and success of the procedure. A number of injections, all monitored by ultrasound, are usually required along the length of the vein to achieve complete sealing of the abnormal vein. This treatment takes approximately 30 minutes.
Assessment and vascular ultrasound
Clinical examination of the legs provides information as to the type, severity and location of varicose and spider veins. Photographs for medical record purposes and future comparison are taken during treatment.
An ultrasound is usually required to determine the precise abnormalities in the veins. The ultrasound takes approximately 45-60 minutes, involves minimal discomfort and enables the veins to be visualised and tested for abnormal blood flow from the groin to the ankle. The ultrasound will help determine the best method of treatment.
The Sclerotherapy procedure
On the day of your treatment, do not apply moisturiser to your legs. Wear slacks or loose trousers, and sandals or loose sho es to the clinic to allow for the thickness of the stockings.
At each treatment session, many veins can be injected at multiple sites using a very fine needle. At each point where the vein is injected, cotton pads are placed over the area to compress the vein.
During and after the treatment, most people describe a burning or stinging sensation at the site of the injection. This usually settles within 3-5 minutes. After the injections are completed, a compression stocking must be worn to maintain pressure on the veins and prevent them re-filling with blood. One leg is usually treated at each session, and more than one treatment may be required on each leg.
Although it is safe to drive a car following Sclerotherapy, some people prefer to have someone else drive them home, particularly after the first treatment.
Patients should be aware that on the day of the procedure, there is a very small chance that the Sclerotherapy procedure cannot proceed due to the veins being technically not suitable for the Sclerotherapy injection, or the vein going into spasm prior to or during the procedure. Before scheduling a patient for a Sclerotherapy procedure, every effort is made to fully assess the patient’s suitability for Sclerotherapy, using appropriate clinical review together with diagnostic vascular ultrasound. However, patients should be aware that if for any reason the doctor determines that the Sclerotherapy procedure cannot be fully or safely performed on the day scheduled, the doctor will not proceed with the Sclerotherapy.
Solutions Used for Injections
The solutions used are sclerosants including Sodium Tetradecyl Sulphate (Fibro-VeinTM) and Polidocanol (Aethoxysklerol®). The sclerosants are available in liquid form but for large veins injected under ultrasound, we may use the sclerosant in a foam form. The doctor will make up the foam during the procedure. Using the product in foam form, rather than liquid, is an off-label use of the product. However, international experience and research shows that using the sclerosant in foam form, rather than liquid, is a safer and a more effective option for the treatment of large veins injected under ultrasound.
Compression Stocking : A compression stocking will be fitted at the end of the procedure. Wearing a compression stocking is a very important part of the treatment, as it maintains pressure on the veins, preventing them from re-filling with blood. For larger varicose veins, a heavy stocking must be worn continuously for 1 – 2 weeks. This means that the stocking cannot be removed at all, including for bathing and sleeping. A plastic overstocking is available for showering purposes. With finer veins, the stocking may only need to be worn for 3-5 days. If the stocking is not worn for the full duration recommended, a poor result may occur.
Lifestyle : After leaving the Clinic, a normal lifestyle may be resumed within the confines of wearing a stocking continuously. Most people are able to return to work immediately after treatment.
Exercise and Walking : It is very important to have a 30 to 60 minute walk each day at a moderate pace. Walking reduces the risk of blood clotting as it promotes the movement of blood through other vessels. Walking more than an hour a day is not recommended. If you have to sit down for lengthy periods of time, please take time to stretch your legs and walk. Be sure to get adequate rest and avoid prolonged standing, as this may lead to blood re-filling in the veins. Between treatment sessions, the use of support stockings during prolonged standing is recommended. Vigorous sports and aerobic activity are best avoided until after the stocking is removed. This includes jogging, weight lifting, lap swimming and other heavy muscular activities. Pilates, Yoga and other stretching leg exercises should not be done for 4 weeks after the treatment.
Pregnancy, Oral Contraceptive & HRT : Make sure you do not get pregnant during the treatment period. The oral contraceptive pill or hormone replacement therapy should be stopped four weeks prior to the treatment. If you have recently stopped your oral contraceptive, please arrange an alternate method of contraception. With regards to HRT, a non-oestrogen based alternative can be recommended by your general practitioner or gynaecologist. You can recommence your contraceptive or HRT one month after the end of all treatments.
What to expect following Sclerotherapy
Sclerotherapy is a very safe and effective method of treatment which has been used since the 1960’s for spider veins, and much longer for varicose veins. Most people can expect a 50-80% improvement, depending on the type and severity of the veins. However, the process is gradual and perfection is seldom achieved. The underlying tendency to develop varicose or spider veins cannot be changed.
The treated veins will look worse before they improve. The injection-associated discolouration and bruising may last for a few weeks and there will be some darkening of the veins due to retained blood within the treated vessel. In the first month, the treated leg may look worse, but is mostly covered by the compression stocking. In the second month, when the leg is out of compression, patients may notice ‘hot spots’ or phlebitis (inflammation of the vein) along the course of the treated vein. This settles with short-term compression and anti-inflammatory medications. If required, these should only be taken on the advice of your treating doctor. From the third month onwards, the treated vein will progressively soften and clear. Spider veins and small green veins will clear within 2-3 months. Large varicose veins may take up to 6 months or more to fully resolve.
The following features are expected, and you do not need to notify our rooms if they occur:
Bruising : following treatment, you may notice bruising which will settle down after a few days. It is important not to use creams such as Lasonil or Hirudoid before or after the treatment.
Mild to moderate pain : In general, the procedure is fairly painless. When the doctor is treating you, you may feel some stinging for a few minutes. However, perception of pain is a personal issue and varies from one person to another. Following the treatment, you may have some pain along the treated veins for a few days. Aching can persist for up to 2 weeks, and this shows that the procedure is working. Walking and paracetamol can help with pain relief. Soreness behind the knee can result from rubbing by the bandage or stockings. Make sure you adjust the stocking and pull it up, to avoid a blister.
Darkening of the Veins : In some patients, the treated veins become darker immediately after treatment. It is a good sign and indicates the success of the treatment. Once darkened, the veins will disappear over 3 weeks, with improvements continuing for up to 3 months.
Tender lumps : With the treatment of larger veins, blood may get trapped within the treated veins. You may feel tiny tender lumps along the treated vein, or you may feel the whole length of the treated vein as a palpable long line. This is not a complication. If it occurs, the doctor may decide to release the trapped blood at the time of your next appointment. This happens by simply pricking the vein and letting the trapped blood out. If it is not released, trapped blood will eventually be absorbed. This may take a few weeks. The doctor may release the trapped blood if it is causing pain, discomfort or discolouration.
Possible Complications from Sclerotherapy
Matting : Tiny capillaries may develop on the skin surface following the treatment. These usually resolve within 4 to 6 months, but may take years to resolve. This is one of the reasons it is advisable to stop taking the oral contraceptive pill or hormone replacement therapy before your treatment, and to use compression stockings after your treatment. It is also important to stop taking vitamin E supplements and fish oil, and to avoid applying creams containing vitamin E to your legs during your treatment.
Phlebitis or inflammation : This is inflammation of the treated superficial veins and presents as tender, red and swollen lumps. It is commonly confused with an infection. Infection is not an associated risk of Sclerotherapy; the hot, red lumps are almost always due to phlebitis. This complication can be avoided, especially if compression stockings are used appropriately after the treatment. Excessive exercise during the treatment period, lack of compression, loose stockings, excessive walking, and hormones such as HRT are the common risk factors for phlebitis. If you experience redness, heat and pain along the treated vein, please telephone our rooms. The doctor will treat this by further compression, anti- inflammatory medications, such as Naprosyn or Nurofen, and regular walking. If required, the doctor will prescribe this medication for you. Please do not take these medications without the doctor’s approval.
Deep Venous Thrombosis (blood clot in the deep veins of the leg) in the deep vein (Deep Vein Thrombosis) : DVT is an extremely rare complication associated with Sclerotherapy treatment. If DVT occurs, some clot may travel to the lungs, resulting in a life-threatening condition called pulmonary embolism. This may be related to genetic tendencies towards clotting (thrombophilia). If you have a past history or family history of clotting, please let the doctor know so th at appropriate testing can be arranged before treatment. Using compression stockings and walking immediately after the treatment and on a daily basis is essential in reducing the risk of DVT. We also advise against long distance travel (air, car, coach) or extensive periods of immobility within 4 weeks before or after UGS or CDS. To prevent clotting, please stop all hormonal medications (Oral Contraceptive Pill or Hormone Replacement Therapy) 4 weeks before the treatment. If a DVT occurs, the doctor will treat you with injections of heparin to resolve the clot.
Extensive DVT may require a hospital admission. If you develop pain and swelling in the calf muscle, chest pain and shortness of breath after the treatment, please inform the doctor immediately. If these symptoms occur outside of business hours, you should present at the Emergency Department at Sir Charles Gairdner Hospital. If these symptoms are experienced, it is important to seek immediate medical advice. Please note that a DVT is a completely different condition to a clot in the superficial venous, which is not usually a serious problem.
Staining of the skin (pigmentation) : This may occur along the treated veins and is due to deposition of iron pigments (haemosiderin) in the skin. It is important to stop taking iron supplements before your treatment. If this discolouration occurs, most staining will disappear within 12 months. However, there is permanent staining in approximately 5% of patients. Staining is of cosmetic significance only. Any underlying veins which may contribute to the pigmentation will be identified and treated.
Ulcers and Tissue Loss : Rarely, small arterioles adjacent to treated veins go into spasm resulting in formation of a small ulcer. The ulcer will heal after 2-3 months but may leave a scar. An intra-arterial injection (injection of the sclerosant in the arteries) can cause a much bigger ulcer and tissue loss (fat, muscle, etc) and the associated complications of such tissue loss. Not all intra-arterial injections cause an ulcer, but they usually cause some tissue loss, either of the fat or the adjustment muscles and nerves. This is a major complication of Sclerotherapy, but the risk is less with ultrasound guided procedures.
Migraine and Neurological Symptoms : Patients who normally suffer from migraines might experience the same symptoms shortly after the treatment. Those with a hole in the heart (Patent Foramen Ovale) may experience neurological symptoms such as flashing lights, headaches or other symptoms. These are transient, lasting up to 2-3 hours, and have no long-term consequences. There are documented cases of stroke after Sclerotherapy in patients with a PFO. If you have a history of heart problems, holes in the heart or previous strokes, please let the doctor know.
Allergic Reaction : Very rarely, a patient may be allergic to the solution used. The risk of allergic reaction might consist of simple hives and itchiness or even anaphylaxis (severe allergic reaction) and death. If you have a history of allergies, please let the doctor know. If you are allergic to one solution, we can use a different solution to treat your veins.
Numbness : In very rare cases, an area of skin may develop numbness. This is due to inflammation of the nerves close to the treated veins. It usually resolves 3-6 months after the treatment, but may take up to 1 year and, rarely, even longer to resolve.
Swelling : After the treatment of large veins, swelling of the ankles may follow. It settles down with the use of compression, elevation of the leg and walking, but it may last for up to 3 months.
Pregnancy and breast feeding : There have been no studies to show if this treatment has any effects on pregnancy or the baby. In general, we do not recommend this type of treatment during pregnancy or breast feeding. It is your responsibility to ensure you do not fall pregnant during the treatment.
Stroke : Although there have been a very small number of cases of stroke following Sclerotherapy, this is amongst hundreds of thousands of patients every year who are treated with Sclerotherapy, and is a very rare complication.
What may happen to untreated varicose veins?
In the case of large varicose veins, spontaneous blood clots may develop in these veins. Also, skin changes including pigmentation, hardening of the skin and underlying fat (lipodermatosclerosis) and, eventually, ulcers may develop in the lower legs. Rarely, these ulcers become cancerous. If you decide not to have any intervention, we strongly recommend you wear compression stockings on a regular basis to prevent worsening of your varicose veins.
Spider veins are mostly cosmetic and may become more prominent with time, but rarely cause a problem otherwise.
Recurrence of Veins
New varicose and spider veins may develop over time, as a patient’s underlying tendency to form varicose veins cannot be changed. These recurrent veins can also be successfully treated. Factors which may prevent or delay recurrence include maintaining a healthy weight, avoiding prolonged standing, undertaking regular exercise and using compression stockings. Pregnancy usually has an adverse effect on varicose veins, and hormone therapy may aggravate the situation. It is important to take these factors into consideration, however, the basic underlying weakness in the wall of all the veins cannot be changed.
It is important to follow up the treated vein with ultrasound imaging to detect signs of early recurrence in branch veins. The follow-up protocol includes ultrasound examinations at 2 weeks, 3 months. We have a strict follow-up protocol, and all patients are advised to adhere to this protocol.
All post-procedure ultrasounds are bulk-billed, with a valid Medicare Card, as a service to our patients.