Conventional Sclerotherapy (Surface Sclerotherapy)

Sclerotherapy is a procedure where veins are injected with sclerosant (usually Aethoxysklerol). Sclerosant damages the lining of the vein and this causes a blood clot to form and hence the vein is blocked. Once the vein is blocked the body should dismantle it. After injection, compression is usually applied to the area with bandages or a stocking to minimise the size of the blood clot.

There will be initial consultation where your condition will be assessed and a vascular ultrasound of your legs reviewed and explained to you. If you are suitable for surface sclerotherapy and select treatment, a separate session will be arranged. The session will take 30-45 minutes. You will lie on a couch and a series of injections will be placed directly into the surface veins which you consider important to be treated. Each injection stings a little bit. The area will then be pressed on and injections placed further up or down the leg. It may be necessary to lie on your stomach to have the veins at the back of your leg treated. If there are a lot of veins one leg will be treated, but if there are not too many than both legs can be treated.

At the end of the procedure you will usually pull on a pair of support stockings and be asked to walk around. A review appointment will be made in a few weeks to review the findings and see if a subsequent session may be necessary.

Frequently Asked Questions:

Q. Will there be any sedation or pain killing agents given?
A. These are not given and not required.

Q. Will I wear stockings or a bandage after the session?
A. Most patients wear support pantyhose for 7-10 days. For a localised area, below knee support stockings might be appropriate. Occasionally, patients with larger veins may require an initial bandage. If the bandage winds across the knee, than it may be difficult to drive a car. Bandaging will be discussed at the initial consultation.

Q. Can I bring someone with me?
A. You are encouraged to bring a friend and if they wish, they can sit in with you during the procedure. We don’t insist upon it and there will be a chaperone available in the rooms. Many of our patients have had sclerotherapy before and come alone. If you have never had a procedure before we encourage you to bring a friend or relative.

Q. What should I do after the procedure?
A. Walk down the road and have a cup of coffee and make sure your bandages or stockings feel comfortable. This is an ideal time to come back if there is a problem. After that you should go home and should walk around quite a lot in the next week. This means walking around a city block or for 10-15 minutes several times a day.

Q. I am a very keen sportsperson, what should I do?
A. We don’t recommend extreme sports for 2 weeks. We also don’t recommend spas and saunas for 2 weeks as these can open up the veins. Normal officework, walking, and short drives of the car are satisfactory. If you assume you have had a little operation and you need to limit your activity whilst in a stocking, all will go well. There is no need to limit golf, but a week away from competitive netball would be advised.

Q. If there anything I shouldn’t do after my sclerotherapy?
A. We do not recommend prolonged air travel or international travel for 6 weeks after sclerotherapy. There is a small risk of deep venous thrombosis with sclerotherapy and with prolonged airline travel and it seems inappropriate to combine them. Do not sunbake for some weeks after sclerotherapy in case your skin develops extra pigmentation at the site of injections and this can be permanent. Avoid spa baths and extreme sports.

Q. Are there any risks to the procedure?
A. Yes. The injections may cause some brown staining of the skin. This usually happens if there has been a very concentrated injection or repeated injections. This tends to fade although it can take some time. The sclerosant can cause allergy. This is uncommon and we aim to use safe and diluted sclerosants at low doses. Some patients have a reaction to bandages or stockings. Blood can accumulate in the injected area and cause a hard red lump (“superficial thrombophlebitis”) and an earlier review and evacuation of the lump may be required.

Q. I take medication, does this affect sclerotherapy?
A. You should take all your normal medications and have a normal diet. The only medication of relevance to sclerotherapy is Warfarin where there can be bleeding. It is not necessary to cease Aspirin or Plavix. If you have a question about a specific medication, please contact the rooms before the procedure.

Q. I’ve got a cold and a sprained wrist, can I still have my sclerotherapy?
A. No. Sclerotherapy is an elective procedure and to minimise the risk it is important that you walk in feeling well, lie down and have a brief period of injections and then walk out and resume your usual activities. If you are taking antibiotics, lying in bed with a cold, etc. then you can’t do this and we need to reschedule the sclerotherapy. This can be inconvenient as you may have arranged a sclerotherapy appointment well in advance. Please ring the rooms and we will do what we can.

Q. What if I feel uncomfortable during the procedure?
A. If you immediately say something than we will pause. If you have never had a procedure before, it can be a little stressful, but we would reassure you that we will do everything to make you feel comfortable. Please note you will have your legs exposed and be in a gown, but there is a degree of touching and pushing of the legs. You may be asked to position yourself from side to side or even on your tummy so that visible veins can be injected. A female will be in the room (your friend or one of our staff).

Q. Will I need another session?
A. Patients may need from 1 to 4 sessions, depending on the severity of their disease. It is rare to inject a patient more than 3 times a year in my practice. The 4th session is usually kept for “clean up” of the residual veins of both legs, sometime on the following winter if the patient wishes. Most sessions are 8 weeks apart. If you have had 1 or 2 sessions and are satisfied and don’t wish to have any more, that is completely satisfactory.

Q. How much will it cost?
A. We will try to give you an accurate estimate of the number of sessions required before you start treatment and hence the cost. Stockings are provided at cost. The sclerotherapy isn’t covered by private insurance, but there is a Medicare rebate which can be applied 6 times per year. Written session cost estimate information is provided.

Q. How effective is conventional sclerotherapy?
A. It is very effective in eliminating veins that can be seen 2 or 3 feet away, e.g. if you are walking past people on the beach or at the pool. Closer inspection will always reveal small veins and we don’t usually encourage treatment of those. It is said to be 75% effective indicating it is a good, but not an excellent treatment.

Q. Could the veins come back?
A. Yes. The actual act of destroying veins can stimulate the body to form more veins. If there are new varicose or lumpy veins this is called neo-vascularisation. If they are new small surface veins, this is called matting. Both of these are your body’s response to injury. In the case of matting, if injections to the area are ceased the matting usually settles down. The cause of these veins isn’t certain, but there is significant genetic element. The treatment of sclerotherapy deals with the faulty veins at the time of treatment but doesn’t prevent further faulty veins.

Q. What can I do to prevent further faulty veins?
A. We usually recommend wearing some light support stockings when you are on your feet at work, e.g. Kolotex sheer relief pantyhose or below knee stockings. For men we have a range of support socks. Avoid prolonged standing and keep your total body weight moderate.

Q. Are there any alternatives to conventional sclerotherapy?
A. These veins tend not to be medically dangerous so the alternative is to leave them alone. If they or other veins enlarge than treatment can be initiated. The other alternative is to try support stockings if your legs ache from veins and you may find some relief. There are no tablets or creams which are effective in removing these veins. Laser treatment has been tried for the veins, but currently isn’t very effective or widely available.

Q. I have some veins on my chest and face, could these be injected?
A. These are not ideal areas for injection, but in this area laser does work reasonably well. The vessels are finer in the areas to be treated and smaller. It appears laser is especially effective on the face. That treatment is not part of my practice, but I can suggest Doctors who practise this professionally.

Q. My legs ache, but is it due to my veins?
A. A difficult question. Sclerotherapy will improve the appearance of your legs, but whether it will remove the aching in your legs is a very difficult question which is a matter of opinion and will be discussed with you at your initial consultation. If you wear support stockings on your legs and find some relief from aching it is suggestive that veins are the cause of that aching. This can be a simple, useful test to try with a pair of light support pantyhose.

Q. I don’t understand something about this procedure?
A. Call our rooms and ask. If it is a logistic question the office staff will be able to handle it. If it is a medical question, then I will reply.

Q. I don’t think the veins have decreased much after my first sclerotherapy?
A. After the first session patients are frequently asked to come for a review appointment at three or four weeks. This is to judge if they have inflammation and when the next session can proceed. That is usually another four weeks down the track. Some patients don’t develop inflammation. The main concern of patients often is that there doesn’t seem to be much visible effect from the first session of sclerotherapy. Partly this is real, i.e. the first treatment is with diluted sclerosant in most cases to avoid severe reactive inflammation which can lead to hyperpigmentation and even skin ulceration and permanent scarring. The second reason is perceptual i.e. each session of sclerotherapy seems to improve the situation around about 10-20%. In the 2nd session or 3rd session stronger concentrations of Aethoxysklerol are often used and the effect is cumulative. This is the reason why the patient may say that the first session didn’t work but the 2nd or 3rd did.

The aim of the practice is to give the patients an idea of how many sessions they would require in total to get to a 70-80% improvement in the small vein appearance on their legs. It can be hard for the patient to gauge the progress. If this is of concern please let us know because then the options are:

1. Explain the progress and continue as planned.
2. Refund all out of pocket costs and cease treatment.
3. Discuss both at a consultation charged at Medicare rebate.

Most sclerotherapy is with Aethoxysklerol and the reactions are different from that used at most cosmetic practices. Patient perception that the first session didn’t work is not necessarily a reason for the practice to add a free extra session to prove that the treatment did work. The aim of the practice is patient satisfaction but that often involves a series of cumulative treatments over a period of time. Shorter courses of treatment may be offered at other practices. This practice keeps in contact with latest techniques and applies those which seem appropriate.

GREG SELF
Vascular Surgeon
© 2010