Sclerotherapy For Varicose Veins - Better Than Surgery!

For me sclerotherapy for varicose veins has always been a major pillar in treatment. Initially for total management. Now as part of endovenous laser treatment. Internationally it is still preferred ahead of surgery.

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Why?

As varicose veins are naturally such tortuous liquid-filled channels using a liquid to shut them down makes logical sense. Nothing else can track as accurately.

Sclerotherapy for varicose veins represented by this array of different concentrations of treatment solution ready for treatments

Range of dilutions at ready for a sclerotherapy session

Some might be concerned that introducing a chemical irritant into blood vessels is going to cause unwanted effects throughout the body.

Imaging with ultrasound at the time of treatment has shown elements of the solutions do appear through the body, being shown in the heart within a few seconds of injecting it. How can it be safe? Read on.

Basis Of Sclerotherapy

Sclerotherapy, coming from Greek and Latin root words for hardening of tissue, aims to create a scar reaction inside target vessels. As scar tissue heals it shrinks, pulling closing walls together.

With tissue remodelling by the body they often disappear with time.

Surface vessels frequently show this almost immediately. The deeper ones, suspended in tissue, take longer. Often months to a few years in some cases.

The aim of sclerotherapy for varicose veins is to create a fine graze inside the complete wall of the vein.

These raw surfaces then heal together. Akin to the same effect that can be produced by removing skin from the tips of your index finger and thumb. If they are held together as the skin heals, they will fuse.

As sclerotherapy relies on a chemical breakdown of the surface of the cells lining the vein, it causes quite a shallow injury.

In contrast to that produced by the heat generated by laser-tissue interaction. That spreads over a certain depth. Scar tissue reaction will be more aggressive with the deeper injury.

Sclerotherapy for varicose veins parallels treatment the ancient Greeks used. By piercing varicose veins and rubbing the inside with a piece of wire, disrupting its surface, they could produce an improvement.

Agents Used In Sclerotherapy For Varicose Veins

A number sclerosants have been used over the years. With a variety of chemical effects.

Chemical Irritants

There have been direct irritants of which iodine and chromated glycerine are both still occasionally used in some places. Sodium morrhuate was used many years ago.

High concentration alcohol, ethanol, has also been used. At times it still is by some operators for complex vascular problems.

These agents will cause damage to surrounding tissues as well as inside the vein if they leak beyond it.

Iodine can be difficult in use with occasional allergy. More from being a dark solution making it tricky to see blood drawn back in the syringe or hub to confirm the needle is in the target vein.

Chromated glycerine is quite a weak sclerosing agent, limiting its application.

Osmotic Agents

Then there are osmotic agents that create changes due to their higher concentration than that in tissues. Hypertonic saline and glucose are examples of this.

Hypertonic saline is noxious to surrounding tissue. It also creates quite a sting when injected. Like you may have experienced with salt contact on grazed skin areas.

Concentration limitations tend to affect the usefulness of these agents in sclerotherapy for varicose veins. On the positive side, allergies will not develop towards their use.

Detergent Structured

Then there are the detergent type agents. As all cell walls have a fatty or lipid outer surface these agents work by attaching to the lipid portion at one end of the molecule.

The water soluble end interacts with water in the blood. The outer cell barrier is broken.

Sclerotherapy for varicose veins with the two detergent type agents that I use in my work - sodium tetradecyl suphate, my most commonly used, and polidocanol

Two solutions I tend to use

This creates the fine surface graze of the agent.

In seeking to heal the injury, the surfaces scar together as I mentioned above.

The limiting factor in this is blood becoming incorporated in the scar tissue. The body will break this down in time creating a recanalisation.

Sodium Tetradecyl Sulfate

Sodium tetradecyl sulfate was developed in the 1940s specifically for treating veins. Its long history and extensive use gives significant reassurance about freedom from any long term unexpected effects.

It is the one I prefer to use in my work with sclerotherapy for varicose veins, using the Fibrovein version.

Polidocanol

In being developed initially as an anaesthetic agent polidocanol was found to damage veins and therefore abandoned. Later this unwanted effect lead to its being adopted as a further detergent sclerosing agent.

Being anaesthetic in effect its total dosage has to be titrated against body weight to avoid side effects on the heart.

The highest available concentration of polidocanol does not create the same beneficial results as that for STS. Which limits its usefulness in larger veins.

But it does serve as a good alternative for the few people who develop an allergy to STS.

Allergic Reactions To Agents

Allergy to any medication is always a possibility. Usually this would require some prior exposure to create the sensitivity.

The full range of allergic reactions can occur. But the more severe anaphylactic ones will usually show up during the treatment. Management can be immediate and effective.

Other Side Effects

What other side effects can occur in sclerotherapy for varicose veins?

Visual Disturbance

With detergent-based ones the more common have been a visual disturbance. Much like a shimmering area similar to migraine that moves across your field of vision.

Usually it settles within about twenty minutes.

Headache

Most people do not get get a headache following it. But very occasionally migraine sufferers do.

Other Brain Mediated Effects

Some people have had localised loss of function similar to a transient ischaemic attack.

Again it usually settles quite rapidly.

Causes Of Brain Related Side Effects

There has been debate about the cause of these brain vasculature related changes.

Some feel it is due to localised bubbles passing through vessels in the brain. Others that some of the breakdown tissue particles are briefly blocking flow in the affected small vessels.

Comparison With Diving Effects

Diving medicine specialists raised the question of whether this was not a nitrogen bubbles bends-type effect. In sclerotherapy for varicose veins there is no relative external pressure change as occurs in diving.

But for some time operators had been aware people on heart bypass machines during cardiac surgery would quite commonly suffer long term brain damage put down to air bubbles accumulating in the pump area being passed on through to the patient.

I had seen at least one person I had cared for in general practice family medicine no longer being able to live on their own due to long term cerebral damage associated with a heart valve replacement.

Prepared solutions

My Assessment Of Such Risks

Yet a thorough audit of patients managed by sclerotherapy for varicose veins over period of months showed no deterioration noted by patient, partners, family nor myself.

If anything they reported an improvement in performance.

Trapped Blood

In treated leg veins as blood vessels finally close through a sequence of changes small pockets of blood can become trapped with no other outlet.

The body will clear these sections over time. But in doing so the segments often swell a little and seem to become bigger. They can feel tender on pressure.

Occasionally they may become hot and red in a more aggressive breakdown effect. Although it may look like an infection, it hardly ever is.

Simple local release by a needle can speed clearance of the target blood.

Brown Staining

As the body clears the blood it tends to leave any residual iron from the red cells in the area. This will show as a brown pigmented-looking patch.  

Over time the body will utilise the iron and clear it completely. For two thirds of people this is within a year once the blood has cleared. The other third will gradually clear over another year.

Red Cell Breakdown

At times people would develop a generalised muscle ache and fever sensation. Usually within a couple of hours of sclerothearpy for varicose veins lasting for a couple of hours.

At the same time they would pass darkened urine.

The colour was from red haemoglobin pigment from red blood cells. Due to the solution breaking down walls of the red cells, releasing their internal oxygen carrying haemoglobin.

Generally it seemed dose related. Higher amounts of the sclerosant would produce the effect.

With careful observation and monitoring no long term consequences were found. Including in the kidneys.

Cough And Other Respiratory Symptoms

A cough and sensation of mild chest tightness could also occur, often as people moved around during and especially at the end of a treatment. With foam use, which I cover below, this could be even more common.

It appears to be related to gas and breakdown elements passing through the lungs causing small, short term interruptions in local blood flow and the ability of your lungs to absorb oxygen at those points.

Inadvertent Arterial Injection

Aside from this inadvertent injection into an artery during sclerotherapy for varicose veins will cause local tissue damage, even loss. 

The most common of these is injecting the veins at a too high pressure. This can allow sclerosing agent to track into an unexpected arterial connection, blocking it and causing a small area of skin loss.

It would usually heal quite well. But takes time.

Matting Blood Vessel Reaction

Too strong concentrations of the agents can produce a fine small vessel reaction in the skin above. Known as matting it can settle spontaneously over a few months.

Or it may persist and need treatment as well.

Careful titration of the strength of the injected solutions markedly reduces the chance of this occurring.

Sclerotherapy for varicose veins showing a trolley set up with gear and a range of solution dilutions

Sclerotherapy trolley set up

With detergent solutions appropriate flexible dilutions are relatively easy to achieve.

Achieving Accurate Concentrations

Within the actual veins dilution of the agent in a solution forming during sclerotherapy for varicose veins was one of the challenges.

As the vessels in an area are injected the agent mixes with the blood within the vein. The further from the injection site the more dilute it became.

Its effectiveness was lowered.

Beginnings Of Foam

For years people had created some forms of foam with sclerotherapy for varicose veins in an attempt to overcome this. For detergent agents foaming is a natural property.

Juan Cabrera

In the 1990s Juan Cabrera, a Spanish vascular surgeon, had been experimenting with a foam he developed with his pharmacist wife.

He produced dramatic results beyond the normal range of sclerotherapy for varicose veins. Complex vascular anomalies, a challenge to treat any other way, had responded amazingly.

He went on to license his method to a pharmaceutical company.

Essentially he had used polidocanol, which seems to be favoured by surgeons, with carbon dioxide gas. In the process though he had added other agents.

As he had effectively changed the basic product BTG, the company involved, had to put it through a full new medication work up. Release of the product was delayed many years.

Carbon dioxide is an excellent gas to produce a foam agent from. The body readily absorbs and eliminates it.

The Italian Connection - Frullini And Cavezzi

While sclerotherapists waited for its release, others started to experiment with other versions.

Two Italians, Alessandro Frullini and Attilio Cavezzi, produced their take on foam for sclerotherapy for varicose veins.

They opted for one using sodium tetradecyl sulfate.

Gases For Foam Sclerotherapy

Most found that using carbon dioxide as the carrier gas produced a very short-lived foam.

I had shown this working with the local university engineering department.

Also an STS foam was more stable than polidocanol.

Natural air created a much more long lasting foaming agent.

As this new mix was demonstrated and discussed at conferences throughout the world, it was rapidly adopted.

Benefits Of Foam

There were many benefits.

Much less of the active solution needed to be used.

This meant both legs could be treated at the same session by slerotherapy for varicose veins if required. Total dosage limited this in the past.

Foams tend to displace blood which greatly decreased previous dilution effects.

There was better contact with the vein’s target walls. More effective closure was possible.

General Foam Sclerotherapy Usage

These days foam sclerotherapy has become effectively the standard.

I use it on all except spider veins. Injecting it through the smaller diameter needles required for such narrow channels tends to break the foam down prematurely. Liquid solution coats them effectively anyway.

Side Effects Of Foam

One side effect many of us found I mentioned earlier.

That of cough and at times some chest tightness. All other side effects appeared no greater in incidence than with liquid.

The flu-like effect noted with solutions almost never occurred. It may be related to the total dose. More likely it is the space displacing effect of the foam that reduces the extent of contact with the blood cells.

But lung symptoms seemed a little more common. It could be rather disconcerting. But never long lasting.

Using Oxygen In Forming Foam

Due mainly to this effect I started considering using pure oxygen as the gas for the foam rather than straight air. A couple of others around the world had started trying this and found a much lower incidence of side effects.

I began trialing it on all new cases and any that had suffered side effects before.

Using oxygen to make foam for sclerotherapy for varicose veins

Only twice in many years did I have anybody get any apparent problem. Those were the visual ones. Never cough. In those two there may well have been a little residual air present in the syringe before mixing.

It now is my standard practice.

Pure Sclerotherapy Results

Initially, before endovenous laser was available, I managed all veins with sclerotherapy for varicose veins.

The deeper saphenous, related veins and perforators were treated with the strongest solution available. More superficial ones with lower concentrations.

Results were good.

But there was around a 25% chance of those slightly deeper segments recanalising. Presumably as retained blood areas in the scar were broken down.

Following people up over months to years I would pick up these changes. Then re-treat them them as part of the original cost.

Unless something totally new arose.

Adding Endovenous Laser

Once laser became available, I began using that for the deeper saphenous, related veins and perforators. Initially for the larger ones only.

Then all smaller and surface vessels I treated with sclerotherapy for varicose veins. With the tortuous nature of surface varicosities there is no way a laser fibre could track through them. But foams would.

With only a few minor adjustments for the technique, this combination produced a superb result.

It is now my method of choice for even smaller deeper veins. Increasing skill developing over time means it becomes easier to canalise quite small vessels.

Later recanalisation of these vessels is less than 5%.

Cost would be the only limiting factor for people to not chose the laser option.

International Recommendations For Best Practice

As experience has grown with all these techniques, internationally the recommendations of best practice has changed.

For some years now endovenous laser has been recognised as the best approach.

A complete sclerotherapy for varicose veins approach is in second position.

Surgical options, which I will cover further, are now ranked as the third choice.

I will cover why this is so in the surgical section.

Sclerotherapy for varicose veins is therefore always used with endovenous laser.

It is appropriate as a stand alone option, especially if cost is a factor. As such it still rates ahead of surgery.

Like the laser approach there is no need for general anaesthesia, there is less down time, and generally a more comfortable and active post treatment recovery.