What Is Vein Injection Sclerotherapy?
Injection sclerotherapy is a treatment that intentionally damages the lining (endothelium) of veins by injecting a chemical into the vein and inducing chemical phlebitis or inflammation. By performing the procedure and then applying pressure, the vein walls stick together. The vein can then no longer fill with blood, and so it is obliterated. It is vital to use compression after the procedure. Sclerotherapy treatment has been around for several decades. It has risen and fallen in popularity as techniques have evolved.
Foam sclerotherapy uses a sclerosant such as STS (sodium tetradecyl sulfate) and mixes it with air or carbon dioxide to create a foam. By using STS as a foam rather than a liquid, the effect is potentiated especially in larger veins.
Ultrasound-guided foam sclerotherapy is a further development in which the foam injection is guided by ultrasound. The ultrasound probe can track the needle entering the vein and ensure the injection takes place in the appropriate place. The dispersion of the foam can then followed by ultrasound.
Microinjection sclerotherapy is used for more delicate spider veins and uses a Very fine needle. Examples of sclerosants are STS (sodium tetradecyl sulfate), 20% hypertonic saline and polidocanol. STS and polidocanol can be used as a foam, but hypertonic saline can only be used as a liquid for fine thread veins. STS and polidocanol are the commonest sclerosants in current use.
Which Varicose Veins Are Suitable For Injection Sclerotherapy Treatment?
There is a trend in recent years to less invasive treatments for varicose veins that enable a walk in-walk out service. The resurgence in injection sclerotherapy is part of that trend. Some practitioners will treat any patient with varicose veins by injection, but even amongst the sclerotherapists there is increasing recognition that primary junctional reflux (see below) and unusually large veins are probably best treated by alternative means. Some practitioners will inject any abnormal vein and use sclerotherapy exclusively of any other treatment.
Significant junctional reflux is present when the significant valves at the groin (Sapheno-femoral junction) or behind the knee (Sapheno-popliteal junction) do not function normally. If there are problems at these locations, your veins are best dealt with using other treatment methods for most patients. Sclerotherapy works most efficiently in smaller varicose veins or spider/thread veins. Sclerotherapy can be useful in any vein, but overall it tends to be less successful than other treatments with major varicose veins. For large varicose veins with faults in the valves at the groin, there is probably a 15-20% chance of the injections not working with a single treatmet5, and sclerotherapy was the least successful treatment when compared with surgery, radiofrequency ablation and endovenous laser in this situation. Although it is possible to achieve improvement with these techniques, there is also a trade-off regarding the time taken for vein resolution. A single treatment session is also unlikely to bring about the desired results. However, in the right patients, it can be beneficial.
Deciding whether your veins are suitable for injection sclerotherapy requires experience, knowledge, and practice with all modalities of treatment. It is also essential to balance the potential risks and complications against any possible benefit. In patients with multiple coexisting medical problems, it may well be more appropriate to avoid using surgical methods even in large veins.
Even if your veins are suitable for injection sclerotherapy, it is crucial that you have a frank discussion with your surgeon about the potential benefits and limitations of injections. It is essential to be clear from the beginning what will be possible and what will not be possible. In some patients with minor thread veins, injections may cause skin pigmentation. For these patients, use of false tan and camouflage cosmetics may be the best way to hide the visible veins.
Take care when reading advertisements offering injection treatments. Some of the claims are often misleading. ALL procedures have a failure rate, and injection sclerotherapy is no exception. Injection sclerotherapy may appear to be a cheaper option if you are paying personally for the treatment, but this should not be the only consideration. In the long run, expenses can be higher if a less efficient or inappropriate procedure has been used.
Before Your Vein Injection Sclerotherapy
Well, fitting compression stockings are an essential part of the post-injection regime, and you should be measured up for these before the treatment session, so they are available to put on immediately after your injections.
There is a theoretical risk that taking the oral contraceptive pill or hormone replacement therapy at the time of your injection could increase the risk of a severe thrombosis. If contraceptives are stopped before your injection treatment, it is critical to think about other contraception methods.
It is essential after the injections that you do not stand still for extended periods. If your job requires prolonged standing, it is necessary to arrange a few days off work after the injections or at least the ability to rest with your leg up when needed. Avoid commitments that force you to stand still for lengthy periods for the first few days after treatment.
The Technique Of Vein Injection Sclerotherapy
The veins that may benefit from treatment are located. For spider veins, a small amount of liquid sclerosant is injected into the spider veins usually at multiple sites. Many microinjections can be performed in one session. After the injections, the areas treated can sometimes become red and appear swollen. The resulting redness and swelling resolve with time.
Larger veins are treated with Foam Sclerotherapy. The foam is created by mixing the STS with room air in a 1 to 4 ratio, by using the Tessari Method. Some practitioners use carbon dioxide. Before injecting the vein to be treated is cannulated. Foam sclerotherapy involves placing a plastic tube or needle into the veins either under direct vision or sometimes using ultrasound guidance. The amount of foam that can be given a single injection session will depend on the number and type of veins being treated and the concentration of sclerosant being used. The procedure performed in a recumbent position, with the leg elevated.
With liquid injections for spider veins using a low concentration of STS or polidocanol, there is rarely an issue of exceeding the maximum dose. When injecting foam, there are other concerns besides exceeding the maximum dose of STS. Foam contains thousands of tiny air bubbles which can be dangerous in excess. Most guidelines will recommend 10-15mls of foam as the maximum volume of foam that can be injected at any one sitting. This is because there is no way to contain the foam in the injected vein. Although most of the foam will remain in the vein, some will always travel into the circulation even with the best attempts to prevent foam dispersal. As long as the volume is kept low, this does not appear to cause problems, but more substantial amounts may put patients at higher risk of complications (see below). Some practitioners will inject 30-40 ml of foam at one sitting, but I would not advise or perform this treatment.
After The Vein Injection Sclerotherapy
After the injection, a cotton wool pad is wrapped throughout the injected veins followed by a stocking. After injections, patients are encouraged to n go for a short walk of approximately 30 minutes. Usual activities can begin immediately following the procedure. Try to avoid standing still for an extended period. Staying active and walking is helpful.
It’s advisable to wear stockings uninterrupted for 7-14 days of compression for significant size veins. You can shower wearing the stockings and then use a hair dryer to dry the legs.
The success of the injection treatment relies partly upon the pressure that the stockings apply to the injected area, in association with the damage caused by the sclerosant. It is important to take regular walking exercise after your treatment.
Ultrasound-Guided Foam Sclerotherapy (UGFS)
Ultrasound-guided foam sclerotherapy has been around for a long time. The sclerosant is converted into the foam and is used to obliterate varicose veins.
The technique involves technique agitating the sclerosant into the foam by mixing it with air and stirring the mixture in a syringe. Sclerosant mixed wit air looks just like shaving foam. When this is injected into the veins, it can be traced using an ultrasound scanner. Using ultrasound should improve accuracy, and the use of foam appears to maximize the effect of the injection. Because foam is required only sclerosing agents that can produce a foam can be used such as STS. In Practice, it is difficult to control the flow of foam, and it will always enter the central circulation to a greater or lesser degree. The safest technique appears to be to inject with the leg elevated and without pressure applied at the groin. There is also debate about whether it is safe to use air or whether other gases such as carbon dioxide should be used. Whether the gas injected should be sterile is also uncertain. Different types of the syringe with differing silicone contents can affect the stability of the foam.
UGFS indeed can be used initially, but its medium to long-term results are not reliably known. There are publications which claim effectiveness for the UGS technique, but frequently more than one session of injections are required for residual veins. Sclerotherapy is not very useful in treating reflux at the groin level. Foam sclerotherapy came out as the least productive treatment with a 15-20% initial failure rate. There is also evidence that initial success for foam sclerotherapy may not be as durable as other treatments. This discrepancy may at least partly be dependent on the size of the vein – larger veins being more challenging to treat.
Ultrasound-guided foam sclerotherapy can be a beneficial technique provided it is used appropriately. It is unclear whether the foam is built using air or carbon dioxide gives better results. The exact ratio of air to liquid STS, optimal concentrations of STS foam for different veins and use of syringes with differing silicone contents can all influence foam production and stability, but there is no first class evidence to favor one technique over another.
Potential Complications Of Injection Sclerotherapy
Sclerotherapy is usually a safe procedure., most patients experience minimal discomfort. Rarely the sclerosed veins can thrombose and can cause moderate pain. Occasionally the following sclerotherapy, the spider veins can initially look worse as coagulated blood in the veins seems darker. After a few weeks following the injection, residual discomfort, hardness or tenderness at the injection sites subsides. If there is excessive redness, swelling or tenderness, leg elevation helps.
Brown pigmentation of the skin around the site of the injection and along the line of the treated vein is frequently seen. Over time complete or near complete resolution occurs, but this can take up to 12 months after the injections. A persistent hard knot in the line of the vein – this usually occurs after injecting more prominent varicose veins and means a small amount of blood has clotted in the vein. It is not dangerous and will resolve.
Bruising occurs frequently and resolves entirely within one to two weeks.
Allergy – this is a rare complication.
Visual disturbance – Is a rare complication for patients undergoing foam sclerotherapy. Less than 1% of patients experience it. It presents a transient sparkling appearance in the vision and resolves after about 15 minutes. Rarely transient stroke can happen. Stroke is thought to be due to the foam bubbles traveling in the blood vessels to the brain.
Visual disturbances are more likely to occur in patients with an occult Patent Foramen Ovale (PFO). In the general population, about 25-30% of patients are thought to have a PFO which does not affect them in the day to day life, and they are usually unaware of its presence. In the study,58.8% of patients were found to have a PFO. In most patients undergoing foam sclerotherapy, foam bubbles can be seen traveling in the vein towards the heart.
Blistering and ulceration of the skin at the injection site are rare. It results from extravasation of sclerosant around the vein rather than into the vein. Its incidence is higher when using higher concentrations of sclerosant.
Sometimes the injection may fail to obliterate the vein. Deep venous thrombosis can occur rarely. More substantial amounts of foam injected close to the deeper veins may present more risk.
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