Sclerotherapy of Varicose Veins

Indications

The objectives of sclerotherapy are:

• Treatment of varicosities and prevention of possible complications of varicosities

• Reduction or elimination of existing symptoms

• Improvement of pathologically altered hemodynamics

• Achievement of a good result that satisfies aesthetic and functional criteria

While, in principle, all types of varicose veins are amenable to sclerotherapy, those that are particularly amenable to treatment are:

• Saphenous veins (great, GSV) and small saphenous veins (SSV) ( Fig. 36.1 )

  

• Accessory saphenous veins and tributaries

• Varicose veins associated with perforator incompetence

• Reticular varicose veins ( Fig. 36.2 )

  

• Spider veins

• Residual and recurrent varicose veins after interventions to eliminate varicosities

• Genital and perigenital varicose veins

• Veins causing leg ulcers

• Venous malformations.

Sclerotherapy is considered to be the method of choice for the treatment of small-calibre varicose veins (reticular varicose veins, spider veins). For the obliteration of tributary varicose veins and incompetent perforating veins, sclerotherapy competes with percutaneous phlebectomy and with ligation of perforating veins or endoscopic dissection of perforating veins. In the treatment of saphenous varicose veins, foam sclerotherapy is a treatment option comparable with surgery or thermal ablation.

Contraindications

Absolute contraindications according to the European guideline for sclerotherapy are:

• Known allergy to the sclerosant

• Acute deep vein thrombosis (DVT) or pulmonary embolism (PE)

• Local infection in the area of sclerotherapy or severe generalized infection

• Permanent immobility of the patient with confinement to bed.

Additional absolute contraindication for foam sclerotherapy:

• Known symptomatic right-to-left shunt, e.g., patent foramen ovale.

Relative contraindications which need an individual risk–benefit assessment are:

• Pregnancy

• Breastfeeding (interrupts breastfeeding for 2–3 days)

• Severe peripheral arterial occlusive disease

• Poor general health

• Strong allergic diathesis

• High thromboembolic risk

• Acute superficial venous thrombosis.

Additional relative contraindication for foam sclero­therapy:

• Visual disturbances or neurological disturbances following previous foam sclerotherapy.

In addition, it is important to adhere to the current prescribing information for the sclerosants used.

Diagnosis before sclerotherapy

Successful sclerotherapy requires thorough planning. Sclerotherapy is generally performed in sequential order of leakage points, proceeding from the larger to the smaller varicose veins. Therefore, a proper diagnostic evaluation must be performed prior to treatment. Diagnostic evaluation before treatment of varicose veins or venous malformations includes history taking, clinical examination, and duplex ultrasound investigation. In spider and reticular veins Doppler investigation may be sufficient. Additionally, functional examinations (e.g., photoplethysmography, phlebodynamometry, venous occlusion plethysmography) may be considered. Functional examinations make it possible to predict the improvement in venous function that may be obtained by removing varicosities. Diagnostic imaging is especially suitable for identifying incompetent junctions within the deep venous system and for locating pathological reflux, as well as for clarifying post-thrombotic changes and for selecting the most appropriate treatment option. For the initial standardized documentation, the CEAP classification including clinical, etiologic, anatomic, and pathophysiologic issues should be used.