SCLEROTHERAPY FOR VARICOSE VEINS 2

Preparation (sclerotherapy for varicose veins): Patients are asked to discontinue aspirin or aspirinrelated products for a week before sclerotherapy. Further, they are told not to apply any moisturizers, creams, tanning lotions, or sunblock to the legs on the day of the procedure. Patients should bring a pair of shorts to wear during the procedure, as well as compression stockings and a pair of slacks or a long skirt to cover the legs afterwards. Most practitioners will take photographs of the patient’s legs before sclerotherapy to evaluate the effectiveness of treatment. In addition, some insurance companies request pretreatment photographs for documentation purposes.

Aftercare
Aftercare following sclerotherapy includes wearing medical compression stockings that apply either 20–30 mmHg or 30–40 mmHg of pressure for at least seven to 10 days (preferably four to six weeks) after the procedure. Wearing compression stockings minimizes the risk of edema, discoloration, and pain. Fashion support stockings are a less acceptable alternative because they do not apply enough pressure to the legs. The surgical tape and cotton balls used during the procedure should be left in place for 48 hours after the patient returns home. Patients are encouraged to walk, ride a bicycle, or participate in other low-impact forms of exercise (examples: yoga and tai chi) to prevent the formation of blood clots in the deep veins of the legs. They should, however, avoid prolonged periods of standing or sitting, and such high-impact activities as jogging.

Risks
Cosmetically, the chief risk of sclerotherapy is that new spider veins may develop after the procedure. New spider veins are dilated blood vessels that can form when some of the venous blood forms new pathways back to the larger veins; they are not the original blood vessels that were sclerosed. Some patients may develop telangiectatic matting, which is a network of new spider veins that surface around the treated area. Telangiectatic matting usually clears up by itself within three to 12 months after sclerotherapy, but it can also be treated with further sclerosing injections.

Other risks of sclerotherapy include:
• Venous thrombosis. A potentially serious complication, thrombosis refers to the formation of blood clots in the veins.
• Severe inflammation.
• Pain after the procedure lasting several hours or days. This discomfort can be eased by wearing medical compression stockings and by walking briskly.
• Allergic reactions to the sclerosing solution or foam.
• Permanent scarring.
• Loss of feeling resulting from damage to the nerves in the treated area.
• Edema (swelling) of the foot or ankle. This problem is most likely to occur when the foot or ankle is treated for spider veins. The edema usually resolves within a few days or weeks.
• Brownish spots or discoloration in the skin around the treated area. These changes in skin color are caused by deposits of hemosiderin, which is a form of iron that is stored within tissue cells. The spots usually fade after several months.
• Ulceration of the skin. This complication may result from reactive spasms of the blood vessels, the use of overly strong sclerosing solutions, or poor technique in administering sclerotherapy. It can be treated by diluting the sclerosing chemical with normal saline solution.
• Hirsutism. Hirsutism is the abnormal growth of hair on the area treated by sclerotherapy. It usually develops several months after treatment and goes away on its own. It is also known as hypertrichosis.

Normal results
Normal results of sclerotherapy include improvement in the external appearance of the legs and relief of aching or cramping sensations associated with spider veins. It is common for complete elimination of spider veins to require three to four sclerotherapy treatments.

Morbidity and mortality rates
Mortality associated with sclerotherapy for spider veins is almost 0% when the procedure is performed by a competent doctor. The rates of other complications vary somewhat, but have been reported as falling within the following ranges:
• Hemosiderin discoloration: 10%–80% of patients, with fewer than 1% of cases lasting longer than a year.
• Telangiectatic matting: 5%–75% of patients.
• Deep venous thrombosis: Fewer than 1%.
• Mild aching or pain: 35%–55%.
• Skin ulceration: About 4%.

Alternatives
Conservative treatments
Patients who are experiencing some discomfort from spider veins may be helped by any or several of the following approaches:
• Exercise. Walking or other forms of exercise that activate the muscles in the lower legs can relieve aching and cramping because these muscles keep the blood moving through the leg veins. One exercise that is often recommended is repeated flexing of the ankle joint. By flexing the ankles five to 10 times every few minutes and walking around for one to two minutes every half hour throughout the day, the patient can prevent the venous congestion that results from sitting or standing in one position for hours at a time.

• Avoiding high-heeled shoes. Shoes with high heels do not allow the ankle to flex fully when the patient is walking. This limitation of the range of motion of the ankle joint makes it more difficult for the leg muscles to contract and force venous blood upwards toward the heart.

• Elevating the legs for 15–30 minutes once or twice a day. This change of position is frequently recommended for reducing edema of the feet and ankles.

• Wearing compression hosiery. Compression benefits the leg veins by reducing inflammation as well as improving venous outflow. Most manufacturers of medical compression stockings now offer some relatively sheer hosiery that is both attractive and that offers support.

• Medications. Drugs that have been used to treat the discomfort associated with spider veins include nonsteroidal anti-inflammatory drugs (NSAIDs) and preparations of vitamins C and E. One prescription medication that is sometimes given to treat circulatory problems in the legs and feet is pentoxifylline, which improves blood flow in the smaller capillaries. Pentoxifylline is sold under the brand name Trendar.

If appearance is the patient’s primary concern, spider veins on the legs can often be covered with specially formulated cosmetics that come in a wide variety of skin tones. Some of these preparations are available in waterproof formulations for use during swimming and other athletic activities.

Electrodesiccation, laser therapy, and pulsed light therapy
Electrodesiccation is a treatment modality whereby the doctor seals off the small blood vessels that cause spider veins by passing a weak electric current through a fine needle to the walls of the veins. Electrodesiccation seems to be more effective in treating spider veins in the face than in treating those in the legs; it tends to leave pitted white scars when used to treat spider veins in the legs or feet.

Laser therapy, like electrodesiccation, works better in treating facial spider veins. The sharply focused beam of intense light emitted by the laser heats the blood vessel, causing the blood in it to coagulate and close the vein.

Various lasers have been used to treat spider veins, including argon, KTP 532nm, and alexandrite lasers. The choice of light wavelength and pulse duration are based on the size of the vein to be treated. Argon lasers, however, have been found to increase the patient’s risk of developing hemosiderin discoloration when used on the legs. The KTP 532nm laser gives better results in treating leg spider veins, but is still not as effective as sclerotherapy. Intense pulsed light (IPL) systems differ from lasers because the light emitted is noncoherent and not monochromatic. The IPL systems enable doctors to use a wider range of light wavelengths and pulse frequencies when treating spider veins and such other skin problems, as pigmented birthmarks. This flexibility, however, requires considerable skill and experience on the part of the doctor to remove spider veins without damaging the surrounding skin.

Complementary and alternative (CAM) treatments
According to Dr. Kenneth Pelletier, the former director of the program in complementary and alternative treatments at Stanford University School of Medicine, California, horse chestnut extract is as safe and effective as compression stockings when used as a conservative treatment for spider veins. Horse chestnut (Aesculus hippocastanum) has been used in Europe for some years to treat circulatory problems in the legs; most recent research has been conducted in Great Britain and Germany. The usual dosage is 75 mg twice a day, at meals. The most common side effect of oral preparations of horse chestnut is occasional indigestion in some patients.