Sclerotherapy is the process of using a sclerosing agent, commonly a liquid or foam, that is injected into the targeted veins either under direct visualisation or ultrasound guidance but does require the short-term use of compression dressings/stockings to maximise venous occlusion. These agents act by disrupting the venous endothelium resulting in transforming the treated vessel into a thin fibrous cord[18].
Indications: Sclerotherapy has been demonstrated to be successful in treating small intradermal (Spider/reticular veins) subcutaneous (incompetent truncal (GSV/SSV) or tributary veins) and/or transfascial (perforating) veins. However, as the recurrence can be as high as 90% by 6 years when used to treat incompetent GSV, current international guidelines recommend sclerotherapy be used as a second-line agent to treat small tributaries, Spider veins and reticular veins and tributaries after treatment of the incompetent truncal veins (GSV/SSV) by another modality[11].
Contraindications to Sclerotherapy[18]: previous allergy to sclerosant, acute thrombosis (DVT/PE), localised or systemic infection; long-term immobility. If a foam agent is being used the additional contraindication is a cardiac right-to-left shunt, such as a patent foramen ovale. Relative contraindications include pregnancy, breast feeding (interrupt feeding for 2-3 days after treatment), severe peripheral artery disease, high-risk thromboembolic diseases, acute venous thrombosis/thrombophlebitis, poor general health. Care should be taken with patients suffering headache/migraines or migraines following previous sclerotherapy.
Complications and risks
Sclerotherapy is considered relatively safe, however there are documented complications[18].
- Common complications include residual pigmentation and matting. Residual pigmentation can occur in up to 30% of patients in the initial post-treatment phase. The pigmentation discolouration does decrease with time and can be reduced by removing any intravenous clots in the treatment area at time of treatment. Matting, or the occurrence of new fine telangiectasia in the treated area, is unpredictable and can occur in up to 10% of patients. The main risk factors relate to inadequate or no treatment of the main underlying venous reflux disease and large volumes of sclerotherapy agent being used in any one treatment session.
- Other less common, but more serious complications include[18]: 1) anaphylaxis has been reported and is related to intra-arterial injection; 2) skin necrosis either localised to injection site due to injection or leak of sclerosant into the adjacent tissues. There are individual case reports of embolia cutis medicamentosa and large-area tissue necrosis relating to the either the passage of sclerosant from venous injection into the arterial system or injections into the arterial system resulting in reflex vasospasm and tissue necrosis; 3) DVT and PE are rare occurring in less than 0.01-0.1% of treated cases; 4) Visual disturbances, headaches and migraines, are very rare (<0.01%) but well documented complications to sclerotherapy related to right-to-left shunt of sclerosant. Isolated cases of TIA and stroke after sclerotherapy cases have been reported, likely related to passage of sclerosant and/or air embolus passing into the arterial system via a similar mechanism.