Injection Treatment of Lower Extremity Varicose Veins Jose I. Almeida and Cristal Boatright Sclerotherapy has been employed for almost a century. It involves the endoluminal delivery of a chemical to destroy venous endothelial cells to produce occlusion and fibrosis. Venous hypertension and its effects are mitigated by closure of the incompetent venous circulation. Sclerosants ideally should be efficacious without untoward side effects, provide durable and duplicable results, and be readily available at low cost. Liquid sclerotherapy should be considered for spider telangiectasias, venectasias, and isolated reticular veins, but liquid sclerotherapy is ineffective at eradicating truncal saphenous incompetence. Ultrasound (US)-guided foam sclerotherapy has gained momentum worldwide for treating truncal saphenous incompetence, non-saphenous varicose veins, recurrent varicose veins, perforating veins, leg ulcers, and venous malformations. Sclerosants Sclerosing solutions are categorized according to their mechanism of action as detergent, chemical, or osmotic. Detergents denature cellular proteins, causing endothelial destruction. Examples of detergents include sodium tetradecyl sulfate (Sotradecol), polidocanol (Aethoxysclerol), sodium morrhuate (Scleromate), and ethanolamine oleate (Ethamolin). The two mostly commonly used detergents are Sotradecol and polidocanol, which are relatively safe and painless and achieve desirable results. However, these two agents injected at higher concentrations can produce tissue necrosis, hyperpigmentation, matting, and allergic reactions. Osmotic solutions dehydrate endothelial cells, ultimately resulting in cell death. Chemical irritants damage the cell wall. Previous allergic reactions to a sclerosing agent are extremely rare, but they are an absolute contraindication to sclerotherapy. Relative contraindications are peripheral arterial occlusive disease, previous deep vein thrombosis (DVT), and thrombophilia. Minor side effects are common and include hyperpigmentation, pruritus, neovascularization, cramping, and ankle edema. Hyperpigmentation, also known as staining, is reported in about 30% of patients, is concentration dependent, and resolves within 1 year in 70% of cases. Liquid Sclerotherapy The effectiveness of sclerosing agents is contingent upon the concentration of the sclerosant and the diameter of the vein. Liquid sclerotherapy is typically reserved for the treatment of reticular veins and telangiectasias and commonly requires dilution with sterile water or saline to avoid adverse events. Treatments usually begin with the underlying reticular veins, followed by injection of smaller telangiectasias. The proximal portion of the limb is treated first, moving distally until the entire limb is treated. It is recommended that each site receive a maximum of 1.0 mL per injection. Compression stockings are used for 2 to 7 days following treatments. Foam Sclerotherapy In 1944, Orbach realized foam was created by simply agitating a sclerosant with air. In veins greater than 3 mm diameter, liquid sclerosants become rapidly diluted when introduced into the blood stream. Foam, on the other hand, interacts intimately with the endothelial wall of a vein less than 12 mm in diameter. Extended contact time amplifies the efficacy of the sclerosant, making foam more desirable than liquid. Foam is composed of minute particles of gas surrounded by a tensioactive liquid, making foam highly interactive. In veins greater than 12 mm in diameter, the foam floats to the surface, leaving the posterior venous wall untreated. Saphenous veins greater than 12 mm in diameter respond best to thermal ablation. Factors such as sclerosant concentration, particle size, type of gas, and ratio of gas to liquid also influence the efficacy of the agent. US-guided foam sclerotherapy reduces the possibility of intraarterial injection and extravasation, allows the vein length to be estimated, and allows visualization of deeper nontarget structures. Various types of microfoam production techniques have been described; the most popular uses two syringes connected to a three-way stopcock to mix the sclerosant with air. Foam also can be composed of sclerosant, CO2, and an unspecified tensioactive agent. There are several advantages of foam. Blood readily dilutes liquid sclerosants, reducing the efficacy of the agent. Foam displaces blood, allowing enhanced interaction with the venous endothelium. Foam preparations allow a lower concentration of sclerosant, decreasing the possibility of local adverse events. Patients tolerate foam extravasation easier than they tolerate liquid Foam is easily visualized through duplex guidance, and thus increases the accuracy of placement. There are three technical approaches to treating large veins. Proximal veins are treated after distal perforators are injected; the saphenous trunk and its junctions are not addressed. Proximal sites of reflux are treated, including junctions, followed by distal injection. Distal varicosities are treated, moving proximally until all points of reflux are treated. Sclerotherapy for Superficial Varices and Telangiectases Small veins are best managed with liquid sclerosants. Superior outcomes are only achieved when employing the methods used by European phlebologists. Duplex US should be performed to account for possible underlying causes, which, left untreated, could lead to inadequate results. Underlying feeder veins, such as reticular veins and incompetent saphenous veins, must be treated along with smaller telangiectasis. Traditional liquid sclerotherapy is employed for the treatment of small superficial varices once truncal saphenous incompetence has been ruled out. The use of US guidance is unnecessary. Patients typically present with reticular varices and telangiectasias. Reticular varices can be removed by phlebectomy, but sclerotherapy can achieve superior results. In general, treatment intervals are every 2 to 3 weeks. Reticular veins feeding an area of telangiectasias should be injected with 0.5% polidocanol liquid. Sclerosants can be observed traveling into telangiectasias, signifying reticular vein incompetence. Satisfactory results can be obtained without treating reticular veins; however, outcomes are typically short lived. Once the reticular veins have been treated, the remaining telangiectasias are carefully injected with small amounts of 0.5% polidocanol using 0.1 to 0.2 mL at each site. Small needles (25 G to 33 G) are used to treat small reticular veins and telangiectasias. The technician must only inject 0.25 to 0.5 mL at each location, moving to the next site a few centimeters away until the entire vessel is treated. Excessive force will rupture delicate telangiectasias and increase the risk of sclerosant’s crossing the capillary bed and traveling into arterial circulation, which can result in cutaneous necrosis. Foam sclerotherapy can create more telangiectasias or increase the possibility of adverse events. There is a lack of consensus regarding the use of compression therapy following sclerotherapy. A randomized trial demonstrated the advantage of class 2 compression stockings for at least the first 3 days following a session, but other information claims that compression use fails to improve recurrence rates, symptoms, or cosmesis. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Technical Aspects of Percutaneous Carotid Angioplasty and Stenting for Arteriosclerotic Disease In-Situ Treatment of Aortic Graft Infection with Prosthetic Grafts and Allografts Treatment of Acute Upper Extremity Venous Occlusion Intraoperative Assessment of the Technical Adequacy of Carotid Endarterectomy Stay updated, free articles. Join our Telegram channel Join Tags: Current Therapy in Vascular and Endovascular Surgery Jul 15, 2018 | Posted by admin in CARDIOLOGY | Comments Off on Injection Treatment of Lower Extremity Varicose Veins Full access? 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Injection Treatment of Lower Extremity Varicose Veins Jose I. Almeida and Cristal Boatright Sclerotherapy has been employed for almost a century. It involves the endoluminal delivery of a chemical to destroy venous endothelial cells to produce occlusion and fibrosis. Venous hypertension and its effects are mitigated by closure of the incompetent venous circulation. Sclerosants ideally should be efficacious without untoward side effects, provide durable and duplicable results, and be readily available at low cost. Liquid sclerotherapy should be considered for spider telangiectasias, venectasias, and isolated reticular veins, but liquid sclerotherapy is ineffective at eradicating truncal saphenous incompetence. Ultrasound (US)-guided foam sclerotherapy has gained momentum worldwide for treating truncal saphenous incompetence, non-saphenous varicose veins, recurrent varicose veins, perforating veins, leg ulcers, and venous malformations. Sclerosants Sclerosing solutions are categorized according to their mechanism of action as detergent, chemical, or osmotic. Detergents denature cellular proteins, causing endothelial destruction. Examples of detergents include sodium tetradecyl sulfate (Sotradecol), polidocanol (Aethoxysclerol), sodium morrhuate (Scleromate), and ethanolamine oleate (Ethamolin). The two mostly commonly used detergents are Sotradecol and polidocanol, which are relatively safe and painless and achieve desirable results. However, these two agents injected at higher concentrations can produce tissue necrosis, hyperpigmentation, matting, and allergic reactions. Osmotic solutions dehydrate endothelial cells, ultimately resulting in cell death. Chemical irritants damage the cell wall. Previous allergic reactions to a sclerosing agent are extremely rare, but they are an absolute contraindication to sclerotherapy. Relative contraindications are peripheral arterial occlusive disease, previous deep vein thrombosis (DVT), and thrombophilia. Minor side effects are common and include hyperpigmentation, pruritus, neovascularization, cramping, and ankle edema. Hyperpigmentation, also known as staining, is reported in about 30% of patients, is concentration dependent, and resolves within 1 year in 70% of cases. Liquid Sclerotherapy The effectiveness of sclerosing agents is contingent upon the concentration of the sclerosant and the diameter of the vein. Liquid sclerotherapy is typically reserved for the treatment of reticular veins and telangiectasias and commonly requires dilution with sterile water or saline to avoid adverse events. Treatments usually begin with the underlying reticular veins, followed by injection of smaller telangiectasias. The proximal portion of the limb is treated first, moving distally until the entire limb is treated. It is recommended that each site receive a maximum of 1.0 mL per injection. Compression stockings are used for 2 to 7 days following treatments. Foam Sclerotherapy In 1944, Orbach realized foam was created by simply agitating a sclerosant with air. In veins greater than 3 mm diameter, liquid sclerosants become rapidly diluted when introduced into the blood stream. Foam, on the other hand, interacts intimately with the endothelial wall of a vein less than 12 mm in diameter. Extended contact time amplifies the efficacy of the sclerosant, making foam more desirable than liquid. Foam is composed of minute particles of gas surrounded by a tensioactive liquid, making foam highly interactive. In veins greater than 12 mm in diameter, the foam floats to the surface, leaving the posterior venous wall untreated. Saphenous veins greater than 12 mm in diameter respond best to thermal ablation. Factors such as sclerosant concentration, particle size, type of gas, and ratio of gas to liquid also influence the efficacy of the agent. US-guided foam sclerotherapy reduces the possibility of intraarterial injection and extravasation, allows the vein length to be estimated, and allows visualization of deeper nontarget structures. Various types of microfoam production techniques have been described; the most popular uses two syringes connected to a three-way stopcock to mix the sclerosant with air. Foam also can be composed of sclerosant, CO2, and an unspecified tensioactive agent. There are several advantages of foam. Blood readily dilutes liquid sclerosants, reducing the efficacy of the agent. Foam displaces blood, allowing enhanced interaction with the venous endothelium. Foam preparations allow a lower concentration of sclerosant, decreasing the possibility of local adverse events. Patients tolerate foam extravasation easier than they tolerate liquid Foam is easily visualized through duplex guidance, and thus increases the accuracy of placement. There are three technical approaches to treating large veins. Proximal veins are treated after distal perforators are injected; the saphenous trunk and its junctions are not addressed. Proximal sites of reflux are treated, including junctions, followed by distal injection. Distal varicosities are treated, moving proximally until all points of reflux are treated. Sclerotherapy for Superficial Varices and Telangiectases Small veins are best managed with liquid sclerosants. Superior outcomes are only achieved when employing the methods used by European phlebologists. Duplex US should be performed to account for possible underlying causes, which, left untreated, could lead to inadequate results. Underlying feeder veins, such as reticular veins and incompetent saphenous veins, must be treated along with smaller telangiectasis. Traditional liquid sclerotherapy is employed for the treatment of small superficial varices once truncal saphenous incompetence has been ruled out. The use of US guidance is unnecessary. Patients typically present with reticular varices and telangiectasias. Reticular varices can be removed by phlebectomy, but sclerotherapy can achieve superior results. In general, treatment intervals are every 2 to 3 weeks. Reticular veins feeding an area of telangiectasias should be injected with 0.5% polidocanol liquid. Sclerosants can be observed traveling into telangiectasias, signifying reticular vein incompetence. Satisfactory results can be obtained without treating reticular veins; however, outcomes are typically short lived. Once the reticular veins have been treated, the remaining telangiectasias are carefully injected with small amounts of 0.5% polidocanol using 0.1 to 0.2 mL at each site. Small needles (25 G to 33 G) are used to treat small reticular veins and telangiectasias. The technician must only inject 0.25 to 0.5 mL at each location, moving to the next site a few centimeters away until the entire vessel is treated. Excessive force will rupture delicate telangiectasias and increase the risk of sclerosant’s crossing the capillary bed and traveling into arterial circulation, which can result in cutaneous necrosis. Foam sclerotherapy can create more telangiectasias or increase the possibility of adverse events. There is a lack of consensus regarding the use of compression therapy following sclerotherapy. A randomized trial demonstrated the advantage of class 2 compression stockings for at least the first 3 days following a session, but other information claims that compression use fails to improve recurrence rates, symptoms, or cosmesis. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Technical Aspects of Percutaneous Carotid Angioplasty and Stenting for Arteriosclerotic Disease In-Situ Treatment of Aortic Graft Infection with Prosthetic Grafts and Allografts Treatment of Acute Upper Extremity Venous Occlusion Intraoperative Assessment of the Technical Adequacy of Carotid Endarterectomy Stay updated, free articles. Join our Telegram channel Join
