Key points

• 1.
  

  Sclerotherapy is the gold standard treatment of spider and reticular veins.

  
  
• 2.
  

  Sodium tetradecyl sulfate (STS, sodium-1 isobutyl-4-ethyloctyl sulfate in 2% benzoyl alcohol) and polidocanol (hydroxyl polyethoxydodecane) are the safest and most efficacious US Food and Drug Administration (FDA)- approved sclerosing agents currently in the market.

  
  
• 3.
  

  To maximize outcome and minimize side effects, it is essential to use proper technique and chose the right concentration, volume, and type of sclerosant for each vessel size.

  
  
• 4.
  

  The treatment of leg veins should follow a logical algorithmic approach. Incompetent perforators and venous reflux should be treated before treatment of spider and reticular veins.

Varicose, reticular, and telangiectatic veins are a common complaint, appearing in one-third of patients before the age of 25 years. It is estimated that up to 55% of women and 40% to 55% of men will develop spider veins by the age of 50 years. Although most patients present with cosmetic concerns, up to 50% of patients with varicose veins and even spider veins can develop significant symptoms. These symptoms include pain, burning, aching, heaviness, itching, swelling, and restless leg. Patients with severe varicose veins and truncal venous insufficiency can go on to develop adverse sequelae, including superficial thrombophlebitis, stasis dermatitis, leg ulceration, and lipodermatosclerosis.

Sclerotherapy was described as a treatment of varicosities as early as the 1830s. Fegan, in 1963, popularized the technique of sclerotherapy. The aim of sclerotherapy is the fibrous occlusion of the vessel lumen. Rather than merely thrombosing a vessel that may be amenable to recanalization, sclerosing a vessel transforms it into a fibrous cord, which cannot be recanalized. In principle, all types and calibers of varicose veins can be treated with sclerotherapy. However, surgery is the mainstay of treatment for larger and truncal varicosities, whereas sclerotherapy remains the gold standard for small-caliber varicose veins, including reticular and spider veins. The goal of surgery and sclerotherapy is to improve venous hemodynamics to achieve a good functional and aesthetic outcome.

Venous anatomy and terminology

The venous system is complex and variable; varicose, reticular, and telangiectatic veins may communicate with the great saphenous and short saphenous veins of the superficial system. Likewise, the superficial and deep venous systems are interconnected by perforator veins. Therefore, recognition and treatment of the most proximal point of reflux is required to ensure successful outcome. Treatment should follow an algorithmic approach—the incompetent great saphenous, short saphenous, or perforator vein should be treated first, followed by varicosities, reticular veins, and then finally telangiectasias ( Fig. 1 ).

Evaluation and treatment of leg veins should follow an algorithmic approach. Incompetent perforators and venous reflux should be treated before treatment of spider and reticular veins. GSV, great saphenous vein; SSV, short saphenous vein.

Venulectasias and varicose, reticular, and telangiectatic leg veins are defined by their size ( Table 1 ). By convention, varicose veins are tortuous veins more than 4 mm in diameter. Reticular veins are bluish veins measuring between 2 and 4 mm in diameter. Venulectasias are superficial bluish vessels less than 2 mm in diameter. Telangiectasias or spider veins are flat red vessels less than 1 mm in diameter ( Fig. 2 ).

The lateral subdermic plexus responds well to sclerotherapy. The largest-diameter vessel should be treated first; reticular veins are treated with 0.2% STS foam, followed by venulectasias with 0.2% STS, and finally, spider veins with 0.1% STS.

Venous anatomy and terminology

The venous system is complex and variable; varicose, reticular, and telangiectatic veins may communicate with the great saphenous and short saphenous veins of the superficial system. Likewise, the superficial and deep venous systems are interconnected by perforator veins. Therefore, recognition and treatment of the most proximal point of reflux is required to ensure successful outcome. Treatment should follow an algorithmic approach—the incompetent great saphenous, short saphenous, or perforator vein should be treated first, followed by varicosities, reticular veins, and then finally telangiectasias ( Fig. 1 ).

Evaluation and treatment of leg veins should follow an algorithmic approach. Incompetent perforators and venous reflux should be treated before treatment of spider and reticular veins. GSV, great saphenous vein; SSV, short saphenous vein.

Venulectasias and varicose, reticular, and telangiectatic leg veins are defined by their size ( Table 1 ). By convention, varicose veins are tortuous veins more than 4 mm in diameter. Reticular veins are bluish veins measuring between 2 and 4 mm in diameter. Venulectasias are superficial bluish vessels less than 2 mm in diameter. Telangiectasias or spider veins are flat red vessels less than 1 mm in diameter ( Fig. 2 ).

The lateral subdermic plexus responds well to sclerotherapy. The largest-diameter vessel should be treated first; reticular veins are treated with 0.2% STS foam, followed by venulectasias with 0.2% STS, and finally, spider veins with 0.1% STS.

Selecting the ideal patient for sclerotherapy

As with most cosmetic procedures, choosing the ideal patient is paramount to success. A proper evaluation should be performed before sclerotherapy. Evaluation includes history taking, clinical examination and, if necessary, Doppler or duplex ultrasonographic investigation. Patients with isolated spider and reticular veins will be effectively treated with sclerotherapy. Similarly, reticular and telangiectatic veins distributed on the lateral thigh are amenable to sclerotherapy alone. This lateral subdermic plexus is considered to be an embryonic remnant and is not associated with incompetence in the superficial or deep venous system (see Fig. 2 ).

The presence of palpable varicosities, veins greater than 5 mm, or prominent spider veins along the medial malleolus (a sign called corona phlebectasia, Fig. 3 ) are signs of possible truncal insufficiency. Likewise, spider veins that are refractory to multiple sclerotherapy treatments may be associated with incompetent perforators. Even in the absence of palpable veins, patients with significant symptoms (such as cramping, aching, fatigue, stasis dermatitis, or swelling) may have reflux disease. These patients should undergo diagnostic duplex ultrasonography to evaluate for valvular incompetence (see Fig. 1 ).

The presence of corona phlebectasia and stasis dermatitis along the medial malleolus suggests possible venous insufficiency along the great saphenous vein. Before treatment of these spider veins, this patient should undergo ultrasonography to evaluate for valvular incompetence.

Great or short saphenous vein incompetence is best managed with endovenous laser or radio frequency ablation. With the use of local tumescent anesthesia, these minimally invasive techniques have outperformed traditional ligation and stripping, which were historically associated with higher morbidity. Patients can ambulate immediately after the endovenous ablation procedure, and most patients can resume normal activities within 24 to 48 hours. Varicose veins, especially elevated vessels more than 4 mm in diameter, can be treated using ambulatory microphlebectomy. Veins are permanently removed using a vein hook through small incisions (1–2 mm in length). Unless the source of incompetence is addressed first, sclerotherapy in these patients is often ineffective and frustrating.

Patient consent, complications, and risks

When performed properly, sclerotherapy is associated with a low incidence of complications. Proper patient education including pretreatment and posttreatment instructions will help ensure patient understanding and compliance. Physicians should review potential risk of sclerotherapy ( Table 2 ). Patients should be reminded that several treatment sessions are usually required and that final results may not be apparent for weeks to months. Maintenance treatment is usually necessary over time. This information should be explained by written consent and information sheet.

Pigmentation, matting, and more uncommonly, thrombophlebitis and skin ulceration may occur. The risk of these complications depends on the sclerosant used, its concentration, the volume injected, and the technique of the injector. The risk of pigmentation ranges from 0.3% to 10% and is related to hemosiderin deposition and/or melanogenesis from excessive inflammation. Pigmentation can be reduced by using the lowest effective sclerosant concentration and volume necessary (see Table 1 ). The use of compression stockings for 1 to 3 weeks after treatment may reduce the risk of pigmentation and improve clinical outcome. Intravascular coagulum may occur, especially after treatment of larger-caliber vessels; prompt evacuation with a No. 11 blade stab incision reduces the development of hyperpigmentation and thrombophlebitis. When pigmentation occurs, it can take months to resolve. Superficial thrombophlebitis can be treated with compression and nonsteroidal antiinflammatory drugs. Most recently, a rare phenomenon of localized hypertrichosis after sclerotherapy has been reported.

Telangiectatic matting, which occurs in 2% to 4% of cases, is the result of neovascularization likely related to excessive volume or concentration of sclerosant. Matting usually responds to gentle sclerotherapy with low sclerosant concentration. This is one instance when laser therapy may be superior to sclerotherapy for treating telangiectatic matting. If significant matting occurs, ultrasonography may reveal underlying reflux disease. If matting persists despite treatment, it should be left alone because it generally resolves spontaneously over several months.

Skin necrosis may occur with extravasation of a high concentration of sclerosant into the perivascular tissue. It is most commonly associated with hypertonic saline. The ankle, popliteal fossa, and pretibial areas are more prone to ulceration. Rarely, extensive skin necroses have been reported after properly performed intravascular injection. In these cases, the presence of aberrant arteriovenous anastomoses from chronic venous hypertension may allow the sclerosant to pass from the veins directly into the arterial circulation, inadvertently causing arterial thrombosis. The development of a porcelain-white blanching is typically an early sign of an arteriolar injection and impending skin necrosis. Recommended treatments include the use of massage; injection of normal saline, lidocaine, or hyaluronidase; as well as the use of topical 2% nitroglycerin paste.

Although rare, reports of visual disturbance, chest tightness, deep venous thrombosis (DVT), and coughing have been associated with both liquid and foam sclerotherapies, but they are more frequently reported after using foam sclerosants. According to the French multicenter registry, of 12,173 sessions, the rate of serious complication per session with liquid sclerosant is 0.22% and with foam sclerosant is 0.58%. Most serious complications occur immediately after treatment (51%) or within 4 weeks of treatment (23.5%). Three cases of delayed adverse reaction (more than 4 weeks since treatment) were reported in the French registry; 1 case was related to pigmentation and 2 were related to muscular vein thrombosis.

Prospective studies have shown that the risk of DVT is higher in patients with a previous history of thromboembolism or thrombophilia and when larger volumes of foam sclerosant are used in treating perforator and truncal veins. The incidence of DVT ranges from 0.09% in the French registry (reviewed >10,000 patients) to 1.8% in a smaller series (reviewed 332 patients). Patients who are not ambulating and who receive inappropriate compression are also at a higher risk of DVTs. Anticoagulation prophylaxis may be appropriate in patients with a high risk of thromboembolism and known thrombophilia. In most cases, thromboembolic events diagnosed in routinely performed duplex ultrasonography after sclerotherapy are asymptomatic. Therefore, specific tests for thrombophilia before sclerotherapy are not considered necessary unless clinical history suggests further investigation.

Neurosensory complications including visual disturbances, headaches, dizziness, and migraines have been documented in the literature and may be dose-related. Whereas isolated cases of transient ischemic attacks (TIAs) and strokes have been reported, in the large French registry of 12,173 sessions, no stroke or TIAs were observed. Transient visual disturbances, such as scotoma, are the most commonly reported complication; incidence ranges from 0.25% to 1.75% with foam sclerosants and 0.05% to 0.07% with liquid sclerosants. This disturbance generally resolves within 30 minutes in most patients and is likely to recur with subsequent sessions.

Recent reports have focused on the association of patent foramen ovale (PFO) and neurologic adverse events during foam sclerotherapy. Morrison and colleagues studied 20 patients who described visual or respiratory symptoms after foam sclerotherapy. A transthoracic echocardiogram of these patients during foam sclerotherapy showed the presence of foam sclerosant in the left atrium in 65% of these patients. Of 9 patients who then underwent transcranial Doppler during foam sclerotherapy, 5 had evidence of foam in the middle cerebral artery. The investigators concluded that PFO may allow gas bubbles injected during sclerotherapy to reach the arterial cerebral circulation, although most cases are benign and resolve quickly. In cases of known PFO or a history of neurologic symptoms with sclerotherapy, only low volumes of foam should be used. These patients should remain lying down for 30 minutes to avoid any calf muscle contraction or Valsalva maneuvers, which may allow the foam to migrate to the cerebral circulation. Whereas the prevalence of PFO has been estimated at 27% of the general population, the incidence of neurologic complications associated with foam sclerotherapy is very rare given that millions of injections have been administered over the years. Considering the transient nature and infrequency of adverse events, the European consensus meeting does not advocate PFO screening before foam sclerotherapy.

Severe allergy is very uncommon; urticaria, asthma, hay fever, and anaphylactic shock have been reported after sclerotherapy. The incidence of an allergic reaction is 0.3%, and such reaction may occur with any sclerosant agent. An allergic reaction is the least likely with hypertonic saline. The highest incidence is with ethanolamine oleate. Patients with a history of multiple allergies and asthma may be at a higher risk of allergic complications.