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Injection Treatment of Lower Extremity Varicose Veins
Sclerotherapy has been employed for almost a century. It involves the endoluminal delivery of a chemical to destroy venous endothelial cells to produce occlusion and fibrosis. Venous hypertension and its effects are mitigated by closure of the incompetent venous circulation. Sclerosants ideally should be efficacious without untoward side effects, provide durable and duplicable results, and be readily available at low cost.
Liquid sclerotherapy should be considered for spider telangiectasias, venectasias, and isolated reticular veins, but liquid sclerotherapy is ineffective at eradicating truncal saphenous incompetence. Ultrasound (US)-guided foam sclerotherapy has gained momentum worldwide for treating truncal saphenous incompetence, non-saphenous varicose veins, recurrent varicose veins, perforating veins, leg ulcers, and venous malformations.
Sclerosants
Sclerosing solutions are categorized according to their mechanism of action as detergent, chemical, or osmotic. Detergents denature cellular proteins, causing endothelial destruction. Examples of detergents include sodium tetradecyl sulfate (Sotradecol), polidocanol (Aethoxysclerol), sodium morrhuate (Scleromate), and ethanolamine oleate (Ethamolin). The two mostly commonly used detergents are Sotradecol and polidocanol, which are relatively safe and painless and achieve desirable results. However, these two agents injected at higher concentrations can produce tissue necrosis, hyperpigmentation, matting, and allergic reactions. Osmotic solutions dehydrate endothelial cells, ultimately resulting in cell death. Chemical irritants damage the cell wall.
Previous allergic reactions to a sclerosing agent are extremely rare, but they are an absolute contraindication to sclerotherapy. Relative contraindications are peripheral arterial occlusive disease, previous deep vein thrombosis (DVT), and thrombophilia. Minor side effects are common and include hyperpigmentation, pruritus, neovascularization, cramping, and ankle edema. Hyperpigmentation, also known as staining, is reported in about 30% of patients, is concentration dependent, and resolves within 1 year in 70% of cases.
Liquid Sclerotherapy
The effectiveness of sclerosing agents is contingent upon the concentration of the sclerosant and the diameter of the vein. Liquid sclerotherapy is typically reserved for the treatment of reticular veins and telangiectasias and commonly requires dilution with sterile water or saline to avoid adverse events. Treatments usually begin with the underlying reticular veins, followed by injection of smaller telangiectasias. The proximal portion of the limb is treated first, moving distally until the entire limb is treated. It is recommended that each site receive a maximum of 1.0 mL per injection. Compression stockings are used for 2 to 7 days following treatments.
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