Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Clinical Methods for Sclerotherapy of Telangiectasias
Historical Review of Techniques
Sclerosing treatment for telangiectasias was ignored until the 1930s, when Biegeleisen injected sclerosing agents intradermally or subcutaneously into the general area of capillary enlargement. However, this procedure caused severe necrosis and lacked effect on the telangiectasias. Biegeleisen then developed and popularized a method of ‘microinjection’ of telangiectasias with sclerosing agents through the use of an extremely fine metal needle (later described as a handmade 32- or 33-gauge needle). Unfortunately, he used sodium morrhuate in the treatment of these fragile small vessels, which produced multiple complications, including pigmentation, cutaneous necrosis and allergic reactions. Thereafter, sclerotherapy for leg telangiectasias was thought of disparagingly by most practitioners until the 1970s, when Alderman, Foley, Tretbar, and Shields and Jansen published reports of procedures that had produced excellent results with few adverse sequelae. In these procedures, solutions less caustic to the telangiectasia were used—hypertonic saline (HS) with or without heparin and lidocaine (15% to 30%), and sodium tetradecyl sulfate (STS) 1%—as were techniques that ensured accurate placement of the solution into the blood vessels (use of 30-gauge needles).
Indication
Microsclerotherapy is theoretically indicated for any small telangiectatic vessel or venule on the cutaneous surface. Best results are obtained on superficial linear or radiating vessels on the lower extremities. Telangiectasias on the face are less reliably responsive to microsclerotherapy because they probably have more of an arteriolar component and result from active vasodilation, but they can be treated successfully (see Chapter 4 ). In addition, bright red telangiectasias on the leg that have a rapid refilling time after diascopy (applying pressure with a glass slide) with the patient recumbent ( Fig. 12.1 ) are probably also supplied through arteriolar flow (see Chapter 4 ). These vessels are relatively recalcitrant to usual therapy and tend to recur after treatment. More importantly, these arteriolar leg veins are more likely to develop overlying cutaneous necrosis if sclerosing solutions reach the arteriolar feeding loop (see Chapter 8 ). They may be treated more effectively with the pulsed dye laser or intense pulsed light (IPL) sources (see Chapter 13 ).
The description in Chapter 9 of the injection of varicose veins by first closing off the high-pressure reflux points with sclerosing solution, followed by sclerotherapy of remaining abnormal vessels, forms the basis for the rationale of compression sclerotherapy of varicose veins. The treatment of ‘spider’ leg veins should be just as rational.
In the vast majority of cases, spider veins connect to underlying varicose veins either directly or through tributaries ( Fig. 12.2 ) (see Chapter 3 ). This is typical on the lateral aspect of the thigh when the lateral network described by Albanese is visible ( Fig. 12.3 ). Doppler examination shows that almost all visible blue reticular veins are connected to telangiectasia. Transillumination shows exactly the same pattern ( Fig. 12.4 ). Therefore, as with varicose veins, treatment should be directed first at ‘plugging’ the leaking high-pressure outflow at its point of origin ( Fig. 12.5 ). An appropriate analogy is to think of spider veins as the ‘fingers’ and the feeding varicose or reticular vein as the ‘arm’. Treatment should first be directed to the feeding arm and then, only if necessary, to the spider fingers. Mariani et al found, in a 3-year follow-up study, that telangiectasias treated in this manner showed enduring resolution in 95% of 109 patients.
There are a number of advantages to this systematic approach to sclerotherapy. When sclerotherapy is performed in this manner, the spider veins often disappear without direct treatment or decrease markedly in size, thus limiting the number of injections into the patient. The larger feeding vein is both easier to cannulate and less likely to rupture when injected with the sclerosing solution, thus minimizing the extent of extravasated red blood cells (RBCs) and solution. Theoretically, this method also should minimize the postsclerotherapy development of hyperpigmentation, cutaneous necrosis, telangiectatic matting (TM) and recurrence (see Chapter 8 ).
Injection Technique
Preinjection Procedure
After a physical examination, including the use of noninvasive diagnostic techniques when appropriate (see Chapter 5 ), the patient is scheduled for a sclerotherapy session and given a questionnaire, consent form and instructional material to read and complete at home. Questions about the procedure are answered, and all reasonable and appropriate complications and adverse sequelae are addressed. An estimate of the approximate number of treatment sessions and the cost of treatment are given in writing to prevent any future misunderstandings. Insurance reimbursement policies are discussed and documented . Documentation of the relief of symptoms with compression stockings is helpful in gaining preauthorization of treatment from insurance companies, but in most cases insurance companies decide on the medical necessity for treatment based on the size (diameter) and type of vessel, not symptoms. If graduated compression stockings are planned to be applied after treatment, they are fitted at this time and given to the patient to wear before treatment. If the stockings produce a resolution of symptoms, the physician can assume that successful sclerotherapy will give the same result. In addition, wearing the stockings before treatment helps answer any questions about their fit to ensure they will be worn for the prescribed length of time after treatment.
On the day of treatment, the patient's legs should not be shaved, because a burning sensation may result when alcohol is applied to the areas that will be treated. Moisturizers should not be applied on the day of treatment, because they cause unnecessary slipperiness of the skin. Patients are instructed to eat a light meal or drink juice 1 hour or so before the procedure in an effort to prevent a vasovagal reaction. Shorts, a bathing suit or a leotard should be worn during the procedure to minimize both patient and physician embarrassment, because some vessels may be near the groin. Providing disposable paper shorts to patients who do not bring them into the office is an appreciated feature.
With the patient standing on an elevated platform or stool, a complete set of photographs of the legs is taken from four different views, and the individual areas that will be treated are photographed up close ( Fig. 12.6 ). Reticular veins and telangiectasias are photographed with the patient recumbent. Photographic documentation is important because patients frequently cannot remember exactly how their legs appeared before treatment. Any pretreatment pigmentation irregularities and scars may be blamed later on the sclerotherapy because patients usually look more closely at their legs once treatment has begun. In addition, when patients return in a few years with additional veins and telangiectasia, viewing pretreatment photographs will allay concerns regarding the possibility of unsuccessful previous treatment.
An easy method for measuring the diameter of the telangiectasia was devised by Jerry Garden, MD (Chicago, IL). He uses needles of various sizes placed next to targeted telangiectasias to compare vessel diameters ( Table 12.1 ).
Table 12.1
Needle Gauge Sizes and Vessel External Diameters Used by Garden
| Gauge | External Diameter (mm) |
|---|---|
| 30 | 0.30 |
| 27 | 0.41 |
| 26 | 0.46 |
| 25 | 0.51 |
| 22 | 0.71 |
| 20 | 0.89 |
| 18 | 1.27 |
At the end of the treatment session, the treated areas are recorded on a diagrammatic chart to help check progress at follow-up examinations. Patients are given written postoperative instructions about activity and the disposition of their graduated compression stockings and/or bandages.
Preparation and Visualization of the Vessels
Microsclerotherapy for spider veins is performed with the patient in the supine position. Gravitational dilation of telangiectasias is not necessary to minimize intravascular thrombosis. The skin is wiped with alcohol, making the telangiectasias more visible because of a change in the index of refraction of the skin. The glistening effect of alcohol renders the skin more transparent and helps clean the injection site. In addition, alcohol may cause some vasodilation of the telangiectasias. Alternatively, Sadick recommended that the skin be wiped with a solution of isopropyl alcohol 70% with acetic acid 0.5%. He found that this solution improves the angle of refraction better than alcohol alone.
Scarborough and Bisaccia recommended rubbing a few drops of the sclerosing solution on the skin overlying the venules with a gloved finger. They used polidocanol (POL), which also contains alcohol in water as the diluent. We agree that visualization is enhanced with this technique once the initial effects of the isopropyl alcohol have worn off through evaporation. To further enhance visualization of the vessels, we recommend the use of magnifiers from ×2.25 to ×5 (see Chapter 15). Other alternatives to improve visualization of blood vessels include dermoscopy and near-infrared imaging.
If the vessels are too small to inject, having the patient stand for approximately 5 minutes and then placing him or her in a reverse Trendelenburg position may cause some vessel dilation. Alternatively, inflating a blood pressure cuff to approximately 40 mmHg proximal to the injection site may also result in some distention of the vessels. However, this will also increase the extent of vessel thrombosis and should be avoided whenever possible.
Equipment
Needle and Syringe
Although visualization of the vessel is important to ensuring proper needle placement, the examiner actually enters the needle into the vessel ‘by feel’. This is particularly true in the injection of reticular varices. In this situation, it is best to pierce the skin rapidly and advance the needle superficially over the vessel at a slight angle in a ‘double-piercing’ technique. Penetration of the vessel is ‘felt’, even when the examiner uses a 30-gauge needle. Some authors state that the ‘feel’ is enhanced with the use of a 26- or 27-gauge needle, but we find this unnecessary. In this regard, the use of a glass syringe would best reflect an impedance to flow if a vessel were not properly cannulated. However, glass syringes are more cumbersome to use and regulations regarding sterile technique and other hazards have relegated glass to being an undesirable choice. With the availability of high-quality plastic syringes, a good feel can be obtained and the risk of transmitting blood-borne diseases can be obviated (see Chapter 15).
Ideally, the goal of microsclerotherapy is to cannulate the vessel, injecting sclerosing solution within and not outside the vessel wall. Usually, a 30-gauge needle suffices for most vessels, although some physicians recommend the use of a 32- to 33-gauge needle to decrease the likelihood of inadvertent perivenular injection in the treatment of the smallest diameter vessels. The disadvantages of using a 32-gauge needle are that it dulls rather quickly and easily bends away from the targeted vein (see Chapter 15). Boxes of needles sometimes contain individually defectively sharpened and dull needles, which give a ‘scratchy’ sensation to the tip. The physician should never hesitate to change needles if a vein cannot be cannulated easily. It is usually not the ‘tough skin’ of the patient but a dull needle that makes injection difficult.
Half-inch (1.27-cm), 30-gauge needles, although 0.3 mm in diameter, are honed to an oblique bevel that permits cannulation of vessels 0.1 mm in diameter or smaller. Needles longer than half an inch are too flexible for reliable and accurate cannulation.
We find the use of a 3-mL syringe filled with 2 mL of sclerosing solution ideal. This syringe fits well in the palm of the hand and can be manipulated easily. In addition, the quantity of solution is usually satisfactory for injecting either larger venules with 0.5 mL each or multiple smaller vessels. Alternatively, for those with small hands, a 1-mL syringe filled with 0.5 mL may be easier to handle, although a large number of syringes will be needed per treatment session and a smaller-barrel syringe will lead to higher injection pressures.
Injection with a syringe of smaller diameter will increase the pressure of the liquid at the tip of the needle. This may cause more extravasation and more transparietal burn and also may increase the risk for ‘reverse flow’ injection and subsequent necrosis. It has been measured and calculated that for the same force applied to the piston, the pressure can almost double with a small syringe ( Fig. 12.7 ).
One theoretical disadvantage to multiple injections with the same needle is that the needle will become dull. However, this was found not to occur upon microscopic examination of the needle tips after eight injections into the skin (see Chapter 15).
A small vein infusion set designed for sclerotherapy is available in various gauge and tubing lengths with 3/8-inch-long needles (Kawasumi Laboratories, Tampa, FL) ( Fig. 12.8 ). These sets may provide enhanced control for cannulating small veins. In addition, the kink-resistant tubing allows for flow to ensure that the needle is in a vein and not an artery.
Table and Lighting
Direct lighting should be avoided during treatment because it may produce a glare from the alcohol-soaked skin. Indirect lighting allows the best visualization. Sunlight or fluorescent lighting allows the best visualization of both blue reticular veins and red telangiectasia. A remote control or dimmer switch for room light is convenient because it allows dimming when using transillumination for marking or injections.
The ideal treatment table is one that can be raised or lowered easily to provide a comfortable position for the physician to ensure injection accuracy. It is helpful if the physician can easily maneuver around the table on a stool so that the best approach to a given vessel is attainable. Tables that can be positioned in Trendelenburg or reverse Trendelenburg positions can help in the treatment of an early vasovagal reaction and in effecting vessel dilation or contraction.
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here
