There are many different treatments available for varicose veins. These treatments vary based upon the size and location of the varicose veins, the presence of symptoms, or complications. Briefly, potential therapies may include:

Chemical sclerosis or endo-venous chemoablation for Varicose Veins and Spider Veins?

Chemical sclerosis or endo-venous chemoablation (sclerotherapy) is the most widely used medical procedure for abating varicose veins and spider veins. In this procedure, a sclerosing substance is injected into the abnormal vessels to produce endothelial destruction, then the formation of a fibrotic cord and, eventually, the reabsorption of all vascular tissue layers. For most veins, a sclerosing detergent agent is agitated with air to create a foam-like shaving foam. A thorough diagnostic evaluation is essential before treatment. A high degree of technical skill is necessary for effective sclerotherapy for many reasons. Local treatment of the superficial manifestations of venous insufficiency is unsuccessful if the underlying high points of reflux have not been found and treated. Even when the patient appears to have only primary telangiectasias, and the first treatment seems successful, recurrences are observed very quickly if unrecognized reflux exists in larger subsurface vessels. Missing the diagnosis of superficial truncal incompetence can cause significant complications (especially skin staining and telangiectatic matting) if spider veins and shallow tributaries are treated while high-pressure feeders still are open. Delivery of sclerosant to subsurface feeding vessels that are not visible is usually performed under ultrasonographic guidance. Missing the diagnosis of severe system disease can lead to adverse outcomes in several ways. Symptoms become at once worse if an unrecognized bypass pathway is ablated. Missing the diagnosis of underlying venous thrombosis can lead to fatal embolism. Unrecognized deep venous insufficiency can lead to the early or immediate recurrence of treated superficial disease.

The selection of the correct sclerosant and the exact volume and concentration of sclerosant depends on the type and location of disease, internal amount of the vessel to be treated, positioning of the patient, and many other factors. I should always use the minimum effective concentration and volume because sclerosant inevitably passes into the deep venous system, where endothelial injury can lead to disastrous consequences. Some sclerosants (e.g., hypertonic sodium chloride solution) are highly acidic. Extravasation of even a single drop of these agents can lead to skin sloughing and an inferior cosmetic result. Accidental injection into an arteriovenous malformation (or directly into an unrecognized underlying artery) can cause extensive tissue loss or loss of the entire limb. Accidental injection of concentrated sclerosants into the deep system can cause deep vein thrombosis, pulmonary embolism, and death. The proper use of sclerosing agents requires specialized training and extensive study at MSI Pof. Moawad used polidocanol as a detergent sclerosant. He preferred polidocanol because it has a low incidence of allergic reactions, produces a flat rate of staining and other cutaneous adverse effects, and is forgiving if extravasated. Another even newer technique is called foam sclerotherapy, Prof Moawad explains. An agent, such as a detergent or emulsifier, is agitated with air, forming foam the consistency of light shaving cream. The foam is then injected into the problematic vein, gradually causing the walls to swell and stick together, blocking off the vein. The deeper venous systems take over the blood flow. Prof Moawad, however, says he would prefer the use of foam sclerotherapy for spider veins. Varicose veins, he said, are larger bore vessels and require more aggressive therapy.

Clinical Methods for Sclerotherapy of Telangiectasias

Indications: Micro-sclerotherapy is theoretically shown 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 micro-sclerotherapy because they have more of an arteriolar component and result from active vasodilation, but they can be treated successfully. In addition, bright red telangiectasias on the leg have a rapid refilling time after diascopy (applying pressure with a glass slide) with the patient recumbent are probably also supplied through the arteriolar flow. These vessels are refractory to natural therapy and tend to recur after treatment. These arteriolar leg veins are more likely to develop overlying cutaneous necrosis if sclerosing solutions reach the arteriolar feeding loop. They may be treated more effectively with the pulsed dye laser or intense pulsed light (IPL) sources.

In most cases, spider veins connect to underlying varicose veins either directly or through tributar­ies. This is typical on the lateral aspect of the thigh when the lateral network described by Albanese is visible. Therefore, as with varicose veins, I should direct treatment first at ‘plugging’ the leaking high-pressure outflow at its point of origin. There are several advantages to this systematic approach to sclerotherapy. When sclerotherapy is performed in this manner, the spider veins often disappear without immediate treatment or decrease markedly in size, thus limiting the number of injections into the patient. The more prominent feeding vein is 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 reduce the post-sclerotherapy development of hyperpigmentation, cutaneous necrosis, telangiectatic matting (TM), and recurrence.

Pre-Injection Procedure: After a physical examination, including the use of noninva­sive diagnostic techniques when proper, 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 is given in writing to prevent any future misunderstandings. If graduated compression stockings are planned to be applied after treatment, they are fitted and given to the patient to wear before treatment. If the socks resolve symptoms, the physician can assume that successful sclerotherapy will supply the same result. In addition, wearing the stockings before treatment helps answer any questions about their fitness to ensure you will wear them for the prescribed length of time after treatment.

It would be best if you did not shave the patient’s legs on the day of treatment because a burning sensation may result when alcohol is applied to the areas I will treat. It would be best not to use moisturizers on the day of treatment because they cause excessive skin slipperiness. Patients are instructed to eat a light meal or drink juice 1 hour before the procedure to prevent a vasovagal reaction. You should wear shorts, bathing suits, or leotards during the procedure to minimize patient and physician embarrassment because some vessels may be near the groin. Supplying 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 particular areas that I will treat are photographed up close. Reticular veins and telangiectasias are photographed with the patient’s recumbent. Photographic documentation is vital because patients often 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 added veins and telangiectasia, viewing pretreatment photographs will alleviate concerns regarding the possibility of previous unsuccessful treatment. A secure 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. 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 bandage.

Preparation and Visualization of the Vessels: Micro-sclerotherapy for spider veins is performed with the patient. 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 surface. The glistening effect of alcohol makes the skin more transparent and helps clean the injection site. In addition, alcohol may cause some vasodilation of the telangiectasias. To further enhance the visualization of the vessels, we recommend using magnifiers from ×2.25 to ×5. Other alternatives to improve the viewing of blood vessels include dermoscopy and near-infrared imaging. If the vessels are too small to inject, having the patient stand for 5 minutes and then placing them in a reverse Trendelenburg position may cause vessel dilation. Alternatively, inflating a blood pressure cuff to 40 mmHg proximal to the injection site may also result in some enlargement of the vessels. However, this will also increase the extent of vessel thrombosis and should be avoided whenever possible.

Equipment, Needles, and Syringes Although visualization of the vessel is essential to ensure proper needle placement, the examiner 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. The penetration of the vessel is ‘felt,’ even when the examiner uses a 30-gauge needle. Ideally, the goal of micro sclerotherapy is to cannulate the vessel, injecting sclerosing solution within and not outside the vessel wall. Usually, a 30-gauge needle suffices for most vessels. Half-inch (1.27-cm), 30-gauge needles, although 0.3 mm in diameter, are honed to an oblique angle that allows cannulation of vessels 0.1 mm in diameter or smaller. Needles longer than half an inch are too flexible for reliable and correct cannulation.

We find the use of a 3-mL syringe filled with 2 mL of sclerosing solution ideal. This syringe fits nicely in the palm 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 tiny hands, a 1-mL syringe filled with 0.5 mL may be easier to handle. However, I will need many syringes 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 extravasation and trans-parietal burn, increasing the risk for ‘reverse flow’ injection and later necrosis. It has been measured and calculated that the pressure can almost double with a small syringe for the same force applied to the piston.

Table and Lighting: Direct lighting should be avoided during treatment because it may produce a glare from the alcohol-soaked skin. Indirect lighting allows for the best visualization. Sunlight or fluorescent lighting allows the best viewing of both blue reticular veins and red telangiectasia. Remote control or dimmer switch for room light is convenient because it provides dimming when using trans-illumination for marking or injections. The ideal treatment table can be raised or lowered quickly to supply 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 treat a first vasovagal reaction and affect vessel dilation or contraction.

Skin Tension: The skin must be taught to facilitate cannulation of the vessel. This can be carried out with the help of an assistant who stretches the patient’s skin in at least two directions. Alter­natively, with proper hand placement, the physician alone can produce three-point tension. The non-dominant hand is used to stretch the skin next to the treated vessel in two directions. Then the fifth finger of the dominant hand exerts counter traction in a third direction. With some practice, I can bring even the laxest skin on the thighs under tension with this technique. Skin laxity varies with patient age, adiposity, and location on the leg.

Depth of Injection: The location of most leg telangiectasias is in the upper dermis. The most common error in tech­nique is to place the needle tip deep into the vessel. To enter the vessel at a less acute angle almost parallel to the skin surface, the physician should bend the needle to 145 degrees with the bevel up. If the needle is not within the vessel, the solution will leak out onto the skin or produce an immediate superficial wheal. At times, I can apply gentle upward traction as the needle is advanced to ensure superficial placement.  Injection with the bevel of the needle up has the advan­tage of minimizing the chance of transecting the vessel. Inserting the needle bevel down may be more comfortable, probably because of the vacuum produced by the bevel on the skin surface.

An alternative technique is to puncture the skin superficially, hook it, lift it a little to bring the vessel into the same axis as the needle, and then cannulate it. When using a sclerosing solution that does not cause cuta­neous necrosis on extravasation (e.g., STS 0.1–0.25%, POL 0.25–0.75%, and chromated glycerin [CG]), the physician can inject it as the needle is being inserted into the vessel. As soon as the bevel is within the vessel, the telangiectasia blanches. This technique allows the injection of vessels with diameters smaller than the diameter of the needle because the tip of the bevel is thinner than the needle shaft; with dose, the telangiectasia dilates, allowing complete insertion to occur.

Foam Technique: Another variant of the air-bolus technique that helps visualize clearing of the vessels is that of creating a foamy solution before injection. I can achieve this by using any ‘detergent’ class of sclerosing solutions such as STS or POL. We have found that foaming a detergent solution increases its potency at least twofold while decreasing its caustic toxicity fourfold when a solution-to-air ratio of 1: 4 is used. Therefore, the use of foam in treating telangiectasia less than 1 mm in diameter is tricky. Until a method is devised to standardize the size and stability of foam, the physician cannot accurately predict the foam’s sclerosing strength. We reserve the use of foam for treating reticular and varicose veins. The main difference between sclerotherapy with a solution and with foam is the longer duration of foam within the vein and the concentration of the damaging nonpolar end of the detergent molecule on the endothelial surface. This promotes the sclerosis of the treated vessel with a lower level of the sclerosing solution. Finally, and following the conclusion of the European consensus, we do not recommend the use of foam as a primary treatment of telangiectatic veins.

Quantity of Sclerosing Solution per Injection Site: In short, the physician should not inject a volume that would travel undiluted easily into the deep venous system. This is especially important because contrast material has been noted to flow from telangiectasias directly into the deep venous system. It appears reasonable to inject a solution only until the physician cannot see the further progression of blood displacement. When this point is reached, the solu­tion is traveling deeper and into perfo­rating or deep veins. The most substantial amount of sclerosing solution that can be injected into leg telangiectasias is unclear. Thrombosis and emboli can occur when amounts greater than 1 mL are inserted into a single site. It is recommended that the amount injected should be enough to produce blanching of vessels 1–2 cm around the point of injection. No more than 0.5 mL should be used to avoid the risk of starting the formation of new telangiectasias around the edge of the treated area because of excessive inflammation. In this regard, the same area should not retreat more often than every 4–6 weeks. In MSI, TM occurs more frequently if reinjections are given to a previously treated area still undergoing resolution. This unresolved state can be appreciated clinically by slight inflammation and evidence of the micro-thrombosis of vessels. Some areas, especially the ankles, should not be injected with more than 1 mL of any sclerosing solution. In this area, the skin is thinnest; the distance between the deep and superficial venous system is the least, and swelling after treat­ment is common. From a purely legal point of view, French regulations recommend not exceeding 10 mL of STS 3%, two ampules of 2 mL of POL (any dosage), and 10 mL of CG.

Concentration and Strength of Sclerosing Solutions: The most crucial concept in sclerotherapy is that of achieving optimal destruction of the blood vessel wall with the minimum level of sclerosing solution necessary; too much will lead to unnecessary complications and adverse sequelae, and too little will lead to ineffective sclerosis or recurrence from recanalization. The physician should always conservatively estimate when choosing the concentration and type of sclerosing solution. Prof Moawad recommends that leg telangiectasias less than 1 mm diameter be treated with POL 0.25–0.5%, STS 0.1–0.25%, CG, or HS 11.7%. Best efficacy and most minor adverse effects appear when using glycerin 72% mixed 2: 1 with lidocaine 1% with epinephrine.

The pressure of Injection: Another variable of technique is the pressure and rapidity of injection. If leg telangiectasias are injected under excessive force, they may rupture and result in extravasation of solution. Therefore, I should do injections with minimum pressure. This may be difficult upon the injection of sclerosing solutions of high viscosity, such as CG, because more force must push them through a 30-gauge needle. In addition, the slower the injection, the longer the solution will be in contact with the vessel wall. Finally, injection pres­sure (with equal force applied to the piston) is inversely proportional to the square of the piston radius. Therefore, I should do injections slowly enough to fill the vessel by 5–10 seconds. Often, the vessel will remain filled with a sclerosing solution if the syringe’s plunger is held with zero force while the needle remains motionless.

Repeat Treatment Sessions

All patients are informed that successful treatment of given telangiectasia may require more than one treatment (in general and on each treatment site). Patients easily understand that, as for wall painting, two or three thin layers give a better result than a thick one. As previ­ously mentioned, the same vessel or the immediate area does not retreat for 4–6 weeks to allow resolution of the endo-sclerosis or controlled phlebitis to occur. Waiting also allows appreciation of the effectiveness of treatment with a given solution and concentration. If little change is appar­ent six weeks after injection, the second treatment can be performed with a more potent sclerosing agent or a more con­centrated solution. Different areas can be treated as often as every day. Still, the leg’s venous system is a complex interwoven network, so treatment of only one part may not prevent reflux pressure from another part promoting con­tinued blood flow through the treated area. This leads to an increased incidence of complications from blood flow through a damaged endothelial system. Thus, in the treatment of superficial reticular and telangiectatic leg veins, the only real limiting factor is patient and physician motivation for treatment and adher­ence to using the most significant daily recommended amounts of sclerosing solution that can be injected. In addition, if compression is used, it may be best to wait until the pressure stocking has been removed for a few days before treatment is continued on the same leg.

Transcutaneous pulsed dye laser and intense-pulsed-light (IPL) therapy have proven effective for the tiniest surface vessels (e.g., those found on the face), but this modality is not helpful as initial therapy for the treatment of spider veins of the lower extremity. For most patients, the laser pulses are significantly more painful than the 30-gauge needles used for micro-sclerotherapy. Most spider veins have associated feeding vessels that must be treated by some other means before the tiny surface vessels are amenable to laser or IPL treatment. The primary goal of surgical therapy is to improve venous circulation by correcting venous insufficiency through the removal of significant reflux pathways. Conventional surgical approaches to the large-vein varicose disease include ligation of the saphenofemoral junction with vein stripping, phlebectomy performed through microinjections, endo-venous radiofrequency thermal ablation, and endo-venous laser thermal ablation. The first surgical approach to small-vein disease is by micro-incisional phlebectomy, followed by sclerotherapy.

Sclerotherapy for facial telangiectasia has proved to be effec­tive and safe. However, there is a poten­tial for sight-threatening complications from periocular vascular manipulation. Accidental intra-arterial injection of corticosteroid sus­pensions in the periocular region has been reported to lead to embolic occlusion in the ophthalmic artery distribution, causing blindness. Because it is not a suspension, distal embolic phenomena would not be expected to result from an injection of STS. However, as an intravascular scle­rosant agent, it clearly presents a danger if it gains inadver­tent access to healthy vessels supplying the eye in therapeutic concentrations through the production of an embolus com­posed of denatured endothelial cells and blood cell ele­ments.  Presently accepted standards of injection technique, including careful placement of the needle, repeated aspiration, and cautious stabilization of the syringe, do not guarantee that the physician can detect if the bevel is against or within the vessel wall if the vessel is constricted, or if there has been any intra-arterial placement of the needle. Current treatments for cosmetically objectionable lower eyelid veins include direct cautery application through small cutaneous incisions and direct cautery plus surgical vein transection. These procedures pose no known risks to the rest of the vascular system but could be compli­cated by cutaneous scars. Surgical removal of the vein through a 2-mm incision with a phlebectomy hook has also been shown to be effective. The vein can be tied off with an absorbable 6-0 suture with minimal bruising. However, this technique requires practice to avoid damage to perivas­cular tissue. We recommend using minimum quantities of dextrose, sodium chloride, and phenethyl alcohol (Sclerodex) for treating facial telangiectasias and prominent periorbital veins. The tech­nique is the use of 1 mL or less of sclerosant solution for 24 hours after proximal vein ligation with a 6-0 Prolene suture. The suture prevents the backflow of the solution into the retro-orbital venous system. This allows vigorous massage of the area and complements direct compression. Laser technologies, including the long-pulsed, dynami­cally cooled 1064-nm Nd YAG has been reported to treat periorbital vessels 1–2 mm in diameter with near 100% efficacy. Lasers of lower wavelength would not be expected to deliver suffi­cient energy at the correct depth to thermos coagulate a vessel of this size without producing excessive cutaneous thermal damage. Also, I prefer to use the same laser for treating facial telangiectasia or facial spider veins.