In today’s post I will discuss one of the oldest treatments, which is also one of the most widely used and at the same time most controversial: the injections for varicose veins, named sclerosis or sclerotherapy.
Sclerotherapy for varicose veins
Sclerotherapy is the injection of a substance inside a vein to cause an inflammation of its wall; and this inflammation, aided by the compression stockings, will cause the vein walls to stick together, so the vein will close and disappear. Essentially, it is about causing a chemical phlebitis.
There are various drugs and agents that can be used for sclerotherapy, and in each country only the ones approved by their health authorities are available. Also, the injection can be performed in liquid form or pre-mixing the drug with certain gases or air to transform it into foam, which provides certain advantages when treating bigger size veins.
Again in this case there is a great difference in opinion among vascular surgeons. For some of them, sclerotherapy of large veins (including the great saphenous vein itself) is an effective and safe procedure, and they treat varicose veins with it successfully. For others this is unwise, since this treatment would be safe and effective only in small veins (as discussed below in the treatment of spider veins), but treating by this means veins larger than 2 millimeters in diameter increases the risk of potentially serious problems.
Available comparative studies are again poor quality ones, and do not allow us to definitely decide who is right. The methods used in these studies appear “prejudiced” (biased) very often, forgetting to look for even well known side effects of this treatment. Not unfrequently, these studies have been carried out only by sclerotherapy supporters and not by neutral scientists, so the results do not seem too reliable. In fact, the latest comparative studies among different treatment options for varicose veins show a trend against sclerotherapy, in the sense that the percentage of varicose vein recurrence after treatment seems higher than with other techniques (said otherwise, after foam sclerotherapy for removal of big varicose veins it’s more likely that they appear again after some time, compared to if they have been treated with stripping or laser, for example).
Many specialists feel (intuitively, without supporting scientific evidence, as it has already been said) that, when injecting these substances in large varicose veins, there is a risk that some of this sclerosing agent may end up going through the communicating and perforating veins into the Deep Vein System. This could lead to a deep vein thrombosis. Also, some problems have been documented happening remotely – as small emboli in the retina of the eyes – after performing sclerotherapy of large veins, but studies performed by the supporters of this treatment often deliberately ignore these side effects and do not search if in fact they are taking place, which is a concern that raises many suspicions among the rest of specialists.
For these reasons, and as we have now fortunately other new minimally invasive treatment options available (which will be discussed in the following weeks), distrust leads many of us to reject this treatment for large veins. However we use sclerotherapy with great confidence and success in spider veins, as discussed below.
Sclerotherapy for spider veins
When talking about spider veins, we should make a difference between two different types, the reticular ones (the thicker ones although always under 2mm, and of bluish-green color) and the telangiectasia (very thin and wine-red color). The reticular veins can be removed safely and effectively by sclerotherapy.
As noted, sclerotherapy involves injection of an irritating drug inside the reticular vein and applying external compression to get it closed. This point is critical, since the correct compression therapy increases the likelihood of success and decreases the chances for side effects. The injection must be virtually painless; if it’s hurting, you should notify the doctor immediately, because chances are that the sclerosing agent is not being injected in the appropriate site.
It’s desirable that the vein closes while empty, without any blood inside (which we favor by compressing it). If the reticular vein occludes while full and entraps blood inside of it, the body will dissolve and dispose of it, but this process can leave a brown pigmentation on this area of the skin. These pigmentations occur by deposit of iron salts inside the skin (from dissolved red blood cells): exactly what is done on purpose to draw a tattoo. Therefore these stains behave like tattoos: they will never go away; the best we can expect is them to slightly fade with time. That is why it’s so important the proper use of compression stockings.
Sclerotherapy is usually reasonably successful in eliminating the reticular veins (results will vary depending on the drug injected, the use of compression stockings, the experience of the physician who performs the procedure and patient singularities), but sometimes it may require some redo if with a single injection the vein does not disappear.
Side effects are usually minor, although it’s better to discuss about this particular issue with the doctor who will perform the procedure, as they can be different depending on the drug being used. In general, the worst would be the allergic reaction – a risk that is always present in any medication (and in general it’s very rare in the most commonly used drugs, especially polidocanol, but again, may vary depending on the substance to be used). The rest of the side effects are usually just cosmetic ones, being skin pigmentation – already explained – the most frequent of them, but they are generally not very usual.
There is a side effect known as matting, which I specifically mention here because it’s a special case. It is the appearance of very tiny and short telangiectasia (1-2 mm in length) around the reticular vein that has been treated. It’s not very frequent, but when it happens it is a consequence of the small inflammation caused by sclerotherapy. Such small telagiectasia usually disappear by themselves (at least partially) after several months. Another option that we have to remove them is to treat them with surface skin laser.
There are hundreds of videos about these procedures circulating in Internet, some of them quite sensationalist. As an example, I will quote one of them that seems fairly realistic, published by Dr. Aécio, to illustrate the procedure:
If you are interested in further knowledge about this disease, its causes, consequences, how it can be treated and, even better, how are we able to prevent it, you have everything explained in a very friendly and easy way in the book VARICOSE VEINS: truth & myths.