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Sclerotherapy is a procedure used to
treat blood vessels or blood vessel
malformations (vascular malformations)
and also those of the lymphatic system.
A medicine is injected into the vessels,
which makes them shrink. It is used for
children and young adults with vascular
or lymphatic malformations. In adults,
sclerotherapy is often used to treat
spider veins, smaller varicose veins,
and hemorrhoids.
Sclerotherapy
is one method, along with surgery,
radiofrequency and laser ablation, for
treatment of spider veins, occasionally
varicose veins, and venous
malformations. In ultrasound-guided
sclerotherapy, ultrasound is used to
visualize the underlying vein so the
physician can deliver and monitor the
injection. Sclerotherapy often takes
place under ultrasound guidance after
venous abnormalities have been diagnosed
with duplex ultrasound. Sclerotherapy
under ultrasound guidance and using
microfoam sclerosants has been shown to
be effective in controlling reflux from
the sapheno-femoral and
sapheno-popliteal junctions. However,
some authors believe that sclerotherapy
is not suitable for veins with reflux
from the greater or lesser saphenous
junction, or for veins with axial reflux
Historical
aspects. Sclerotherapy
has been used in the treatment of spider
veins & occasionally varicose veins for
over 150 years. Like varicose vein
surgery, sclerotherapy techniques have
evolved during that time. Modern
techniques including ultrasonographic
guidance and foam sclerotherapy are the
latest developments in this evolution.
The first reported attempt at
sclerotherapy was by D Zollikofer in
Switzerland, 1682 who injected an acid
into a vein to induce thrombus
formation. Both Debout and Cassaignaic
reported success in treating varicose
veins by injecting perchlorate of iron
in 1853. Desgranges in 1854 cured 16
cases of varicose veins by injecting
iodine and tannin into the veins. This
was approximately 12 years after the
probable advent of great saphenous vein
stripping in 1844 by Madelung. However,
due to high rates of side-effects with
the drugs used at the time,
sclerotherapy had been practically
abandoned by 1894. With the improvements
in surgical techniques and anaesthetics
over that time, stripping became the
treatment of choice.
Work continued on alternative
sclerosants in the early 20th century.
During that time carbolic acid and
perchlorate of mercury were tried and
whilst these showed some effect in
obliterating varicose veins,
side-effects also caused them to be
abandoned. Prof. Sicard and other French
doctors developed the use of sodium
carbonate and then sodium salicylate
during and after the First World War.
Quinine was also used with some effect
during the early 20th century. At the
time of Coppleson's book in 1929, he was
advocating the use of sodium salicylate
or quinine as the best choices of
sclerosant.
Further work on improving the technique
and development of safer more effective
sclerosants continued through the 1940s
and 1950s. Of particular importance was
the development of sodium tetradecyl
sulfate (STS) in 1946, a product still
widely used to this day. George Fegan in
the 1960s reported treating over 13,000
patients with sclerotherapy,
significantly advancing the technique by
focussing on fibrosis of the vein rather
than thrombosis, concentrating on
controlling significant points of
reflux, and emphasizing the importance
of compression of the treated leg.
The procedure became medically accepted
in mainland Europe during that time.
However it was poorly understood or
accepted in England or the United
States, a situation that continues to
this day amongst some sections of the
medical community.
The next major development in the
evolution of sclerotherapy was the
advent of duplex ultrasonography in the
1980s and its incorporation into the
practise of sclerotherapy later that
decade. Knight was an early advocate of
this new procedure and presented it at
several conferences in Europe and the
United States. Thibault's article was
the first on this topic to be published
in a peer-reviewed journal.
The work of Cabrera and Monfreaux in
utilising foam sclerotherapy along with
Tessari's "3-way tap method" of foam
production further revolutionised the
treatment of larger varicose veins with
sclerotherapy. This has now been further
modified by Whiteley and Patelto use 3
non-silicone syringes for more long
lasting foam.
Methods. Injecting the
unwanted veins with a sclerosing
solution causes the target vein to
immediately shrink, and then dissolve
over a period of weeks as the body
naturally absorbs the treated vein.
Sclerotherapy is a non-invasive
procedure taking only about 10 minutes
to perform. The downtime is minimal, in
comparison to an invasive varicose vein
surgery.
Sclerotherapy is the "gold standard" and
is preferred over laser for eliminating
large spider veins (telangiectasiae) and
smaller varicose leg veins. Unlike a
laser, the sclerosing solution
additionally closes the "feeder veins"
under the skin that are causing the
spider veins to form, thereby making a
recurrence of the spider veins in the
treated area less likely. Multiple
injections of dilute sclerosant are
injected into the abnormal surface veins
of the involved leg. The patient's leg
is then compressed with either stockings
or bandages that they wear usually for
two weeks after treatment. Patients are
also encouraged to walk regularly during
that time. It is common practice for the
patient to require at least two
treatment sessions separated by several
weeks to significantly improve the
appearance of their leg veins.
Sclerotherapy can also be performed
using microfoam sclerosants under
ultrasound guidance to treat larger
varicose veins, including the great and
small saphenous veins. After a map
of the patient's varicose veins is
created using ultrasound, these veins
are injected whilst real-time monitoring
of the injections is undertaken, also
using ultrasound. The sclerosant can be
observed entering the vein, and further
injections performed so that all the
abnormal veins are treated. Follow-up
ultrasound scans are used to confirm
closure of the treated veins, and any
residual varicose veins can be
identified and treated.
Complications,
while rare, include venous thromboembolism, visual disturbances,
allergic reaction, thrombophlebitis,
skin necrosis, and hyperpigmentation or
a red treatment area.
If the sclerosant is injected properly
into the vein, there is no damage to the
surrounding skin, but if it is injected
outside the vein, tissue necrosis and
scarring can result. Skin necrosis,
whilst rare, can be cosmetically
"potentially devastating", and may take
months to heal. It is very rare when
small amounts of dilute (<0.25%) sodium
tetradecyl sulfate (STS) is used, but
has been seen when higher concentrations
(3%) are used. Blanching of the skin
often occurs when STS is injected into
arterioles (small artery branches).
Telangiectatic matting, or the
development of tiny red vessels, is
unpredictable and usually must be
treated with repeat sclerotherapy or
laser.
Most complications occur due to an
intense inflammatory reaction to the
sclerotherapy agent in the area
surrounding the injected vein. In
addition, there are systemic
complications that are now becoming
increasingly understood. These occur
when the sclerosant travels through the
veins to the heart, lung and brain. A
recent report attributed a stroke to
foam treatment, although this
involved the injection of an unusually
large amount of foam. More recent
reports have shown that bubbles from
even a small amount of sclerosant foam
injected into the veins quickly appear
in the heart, lung and brain. The
significance of this is not fully
understood at this point and large
studies show that foam sclerotherapy is
safe. Sclerotherapy is fully FDA
approved in the USA
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