Q & A

Answers to Patient Questions

Can Sclerotherapy be performed on large Varicose Veins?

Theoretically and practically, varicose veins can be treated by closing them or removing them. Therefore, trying to close varicose veins by injection sclerotherapy is certainly an option. The term “sclerotherapy” implies a deliberate injury/wounding of the inner lining of the vein – in this case - by a chemical solution delivered via multiple injections directly in the vein. Like all other forms of injuries (stab, gun shot, heat/burn/frostbite etc.) the body will heal the chemical injury. The end result of any healing process will be a fibrotic scar tissue that in this case is meant to close the vein. Pay attention: the injected chemical does not close the vein(s), YOU the patients should/will close the vein(s) meaning that the treatment results depend how you, the patient, will respond to the injury inflicted by the injected solution!

As blood can’t circulate in the closed vein(s), the varicosities should become invisible. It is known that scar tissues are harder tissues and as “hard” in Greek is “sclera”, thus “sclerotherapy” implies in lose translation “treatment by hardening”.

Please understand, several other factors need yet to be addressed. First, is the definition: what are varicose veins? I have read many times that the thread like “spider veins” that are only up to 1mm in diameter are also called “varicose”, which is incorrect and misleading. One should also know that only superficial veins can become distended, dilated and tortuous i.e. varicose. Veins belonging to the deep venous systems imbedded within the tissues (muscle, fascia) will never become varicose as they are better “supported” when compared to the much thinner skin and soft subcutaneous tissues that are supporting the superficial veins.

By definition, varicose veins are veins greater than 4-5 mm in diameter, are tortuous and bulge through the skin while standing. If they simply are branches/tributaries of one of the two - yet still normal – major (called saphenous) vein trunks harboring a normal pattern of flow (from below up), sclerotherapy could be an option, a lengthy one, as multiple injection sessions and prolonged compression maybe needed.

If however the main vein trunks of one or both legs harbor a pathologic i.e. reversed pattern of blood flow (from above down) sclerotherapy – in a liquid or foam form and ultrasound guided or not - while could be considered, in my humble opinion it is not the best option!

At the beginning of my “vein practice” willing to stay away from the dreaded traditional, traumatic in-hospital stripping, I practiced sclerotherapy for these type of veins too and I did everything possible to help the patient heal well and get the best results: the leg would be elevated well above the heart during injections (gravitational drainage) so that the sclerosing solution should not be diluted with blood existing in the varicosity; I used butterfly needles to slow down and better control the injection time and pressure and I compressed the injected leg for a continuous six, yes 6 weeks!! I got, however, very disappointed with the results mainly because of left over brown pigmentation along the injected vein and very early recurrences. Both were the consequences of formed blood clots in the injected vein caused by the same chemical injury meant to trigger vein closure. Unfortunately, not even the lengthy compression time could prevent this from occurring. Blood clots with time will shrink (lyse) and the treated vein will open up to blood flow and the varicosities will become visible again.

After four years practicing the method, I dropped sclerotherapy from my therapeutic arsenal for truncal varicose veins and reverted to surgery, using however the newly made available technique to remove veins: the completely tamed version of the traditional traumatic stripping, the minimally invasive European “Ambulatory Phlebectomy”. In my hands this procedure became doable also in an office setting, local anesthesia and with no down time/convalescence required. Since the end of the eighties, beginning of the nineties up to present I have used this procedure in over 3500 times with utmost patient satisfaction! No more multiple injections sessions, no more lengthy compression time, no more residual pigmentation no more blood clots and reopened veins, and far, far better and lasting cosmetic results as the veins are removed…

If anyone interested to read a fully illustrated protocol please refer to one of my articles the “Minimally invasive surgery for primary varicose veins: limited Invaginated axial stripping and tributary (hook) stab avulsion” published in Ann Vasc Surg 1995; 9:401-14.

PS. Of course I practice sclerotherapy for spider veins of the legs, and unwanted chest, temple, and forehead reticular/network veins.

What do I do for a (4" x 4") skin injury received after Sclerotherapy?

I have seen skin injuries after sclerotherapy but usually very small ones 2-3 mm in diameter but 4 X 4 inches should not happen! I do not know what size vein(s) have been injected and where the ”skin burn” is localized, hope not in the ankle area were the healing will be much slower. You must have been possibly injected with a too high concentration and high volume of the sclerosing agent and also possibly not injected properly into the vein but rater in the skin/tissues along the vein! Occasionally, there are open communications between veins and arteries and the possibility does exist that the sclerosing agent while properly injected in the vein crossed into a small artery and caused severe tissue damage (necrosis) responsible for the damage including skin ulceration.

Unfortunately, there is not much one can do as eventually all will heal but it will take a few months. Most probably a scar for life will remind you of the “experience”.

The injured area should be keep clean and covered with a dry gauze to prevent any possibility of infection. If the area is by now clean namely not infected one should discuss with the practitioner the possibility of applying a colloid dressing called Duoderm. Compression stocking the knee is mandatory to prevent swelling which is the biggest enemy of any wound healing. Whenever just possible one should elevate the leg about the level of the heart; this should also reduce swelling by gravitational drainage. Any creams you may want to apply should never cover the ulcerated skin, just beyond its margins. In conclusion, be patient, it will go away but very slowly. How it is in Spanish : "Con paciencia se gana il cielo" or "Heaven is won with patience".

How long is compression needed after sclerotherapy?

One has to first understand why is compression need at all. Sclerotherapy implies injection a chemical directly in the vein with the purpose to try to close the vein. Once blood can’t any longer circulate/flow in the vein the vein becomes invisible too.

Unfortunately, none of the available chemicals used are able to close a vein. All they do is to inflict a chemical injury to the inner lining (tissue) of the vein. Once the vein is injured the vein will heal - as any other injury - by the body generating a fibrotic scar tissue that will close the vein. So basically the body’s response to the chemical injury is responsible for closing the vein. Please note, in case the solution chosen and concentration was accurate and also properly delivered directly in the vein the treating physician has ended his/her role. It will be the patient body’s response to the chemical injury that will be deliver the desired results i.e. closure of the vein. Obviously, some patients will respond better than others… thus some maybe happier with the results than others. We physicians have no direct means to influence the patient’s response to injury.

Unfortunately, there is an undesirable effect happening as well when the vein’s inner lining is injured by the injected solution: blood clotting is happening too and this has to be prevented. Yes, a blood clot will close the veins but this is temporary as with passage of weeks/ months the clot will “dissolve” (lyse) and the vein will be open and visible again. For long-term results we need a fibrotic scar occlusion of the vein and NOT by blood clot. (As scar tissue is a stronger and harder tissue and since in Greek “ hard” is “sclera” sclerotherapy basically means “therapy by hardening”).

Another unwanted effect of excessive clot formation in the injected vein is brown pigmentation of the skin. Indeed as red cells (in the blood clot) die and are decomposed, iron existing in the hemoglobin molecule is given up by the dying red cells and stains the skin brown, stain, that can remain for long, long time. Therefore, the best way to prevent clot formation is by a judicious compression. Its shape and form and length will be different from practitioner to practitioner being dependent by the type of veins injected and their location on the leg.

Personally, I use sclerotherapy mainly for spider veins that have maximum 1mm in diameter and in great majority of such cases do not compress anymore. Yes, I have used compression for spider veins at the beginning of my practice some 29 years ago…. However, in course of the years I realized it is not needed. That does not mean I am against it, therefore, it is not a mistake to use it for few days after each injection session as some practitioners do.

I also use sclerotherapy for veins that are to small to remove by the minimally invasive office ambulatory hook phlebectomy. If they are to many of these type of veins called network or reticular veins (1-3mm in diameter) I will use after injecting them a 30-40 mmHg surgical compression stocking for maximum 1-3 days after each injection session. If they are present in just one to two spots only, I may use just a local compression with either an ace bandage or Coban dressing also for 1-3 days.

As to sclerotherapy for full blown varicose veins a lengthy compression protocol is mandated as the larger the vein the bigger the clot. When I used the procedure at the beginning of my practice I used a continuous 6 weeks compression protocol.

I dropped the procedure long, long time ago in favor of minimally invasive surgery called ambulatory phlebectomy, as the injection sclerotherapy results were simply unacceptably bad for these types of veins yet I am sure the procedure is still performed by practitioners that use ultrasound guided sclerotherapy in which case the sclerosing agent is delivered in a foam or solution form. Personally, I prefer ambulatory phlebectomy were I am in full control and the results depend on my skills only. As previously mentioned in any form of sclerotherapy the results are patient dependent as well.

Do you wear stockings 24/7 day and night after a DVT?

Of course you wear the compression stocking! It should be on the leg during entire daytime. At night i.e. during sleep, it is not needed. Compression, while upright, helps lowering the elevated venous responsible for swelling (edema) of calf and ankle in the presence of a deep vein clot. Compression also speeds up the return of blood back to the heart preventing possible further clot formation. At nighttime the horizontal position achieves all of the above therefore compression is not needed. I usually prescribe a knee level (most cases sufficient) open toe and 30-40 mmHg gradient ankle pressure stockings. For lengthy treatment it is advised to purchase two even three pairs and alternate. This way the stocking will last longer time. After hand washing they should be never dried in a drier.

Regarding how long time is compression needed, it can be weeks, months even years depending if the clot was/is localized in the superficial or deep veins as well as the specific localization along the leg: calves, thighs or even beyond. Certainly, a clot in the deep veins will necessitate a lengthy compression time (besides an early mandatory blood thinning medications) rarely for life if the deep system, in spite of timely and correct treatment of the acute phase, remains partially obstructed and also leaking i.e. incompetent leading to a potentially severe condition called the post phlebitic syndrome: indurated skin in the gaiter area, brown pigmentation and even overt (stasis) ulceration.

Why do I feel "pins and needles" in my leg while wearing the compression stockings?

While I have occasionally heard the same complaint, please check the following:

First, it is possible that the fitted stocking size was wrong namely you got a much to smaller stocking for the size of your legs. It is also possible that a much too high gradient pressure stocking was prescribed that may “choke” the circulation of the lower leg causing relative ischemia of the soft tissues, peripheral nerves included thus the sensation of “pins and needles” which is always nerve irritation. It is also possible, in case you have been fitted with an open toe stocking, that your instep is too large for the “narrow” stocking. Try to stretch the stocking at the foot level by inserting two fingers on each side and give it a good, good stretch.

Secondly, one should check your arterial circulation of the leg(s). This is especially needed if you have diabetes or you are 50 years of age and above and have elevated BP. Peripheral ankle pulses should be checked manually and possibly with ultrasound (US pulse velocity recordings) inclusive a BP readings at the ankle and arm levels.

If pulses are bounding and bi-phasic by US and if the recorded ankle BP values are equal or even slightly higher that the arm reading, all is well. If the results are not clear enough, a vascular surgeon should further do some testing on you. In case pathology is found, you should probably not wear compression stocking besides being guided what to do with your arterial circulation.

Which compression stocking do you usually recommend and any tricks to handle them?

Good question!. The area needed most to be covered are the calves and of course the ankles will be automatically included. Mostly knee length stockings should be prescribed, as in majority of cases beyond the knee stockings would be basically redundant. Gradient ankle pressure I prefer should to be 30-40 mmHg. One should get at least 2-3 (!) pairs open toe stockings to be able to alternate between them. This way the stocking’s built in compression life will last longer. Stockings should be hand washed in cold water using a gentle ivory soap and only air dried. One should shower in the evening to have dry skin in the morning and use of kitchen rubber gloves with a rough surface on the palm is highly indicated to pull them up the leg. Baby powder on the skin is helpful too. Use of some gentle oils on the skin is advised as a long term stocking regimen may cause dry skin and scaling and possible itching making it difficult to comply with a long term therapeutic compression regimen.

PS. A good and inexpensive stocking is obtainable calling Ames Walker Co (Venosan stockings) 877.525.7224. Give them your ankle circumference, length desired (usually knee level) and ask for open toe stocking. They will deliver it by mail.

Is Sclerotherapy and accepted procedure for unwanted hand veins?

Yes, it is, however, ask how many procedures the practitioner has done and ask to speak with patients who had the procedure already performed. Personally, I have seen the results for the hand veins performed by a very well known specialist. It is a lengthy procedure as several injection sessions may be needed at the end of which not all veins will be gone and residual left over dark skin pigmentation could be very bothersome in certain cases. I never used the method as I use sclerotherapy for small, mainly spider veins only. Big and bulging veins of legs and hands I remove by ambulatory (hook) phlebectomy. I have done many dozen procedures of the kind: elegant, one single session for both hands (done in the same time), local anesthesia and no down time, excellent results and never witnessed one recurrence in almost 20 years of using the method.

What is your take on Ambulatory Phlebectomy?

You asked the right person as I perform it for over 20 years and my article on the subject in 1991 was a first in the American peer-reviewed surgical literature. Look it up in Google: “Surgery for truncal varicose veins: the ambulatory stab avulsion phlebectomy” and published in Am J Surg 1991; 162:166-74. It is performed by me ONLY in local anesthesia and office setting however many surgeons prefer to still do it in general anesthesia and I do not know why.

The term ambulatory phlebectomy comes from Greek: phleba/os =vein and ectome = excision/removal).

One word of caution to you: I hope that you have been properly examined by ultrasound ( Doppler/duplex imaging) and in a standing position too. Your tributary varicose veins existing on the thigh or calf may be connected to a main axial vein trunk (most cases not even visible, localized in the thigh or calf or rarely both) harboring a wrong i.e. reversed pattern of flow (from above-down rather from down-above). This main vein trunk could be stretching either from the groin to below knee/calf of from behind the knee to ankle. If this should be the case the practitioner has to deal with this pathological conditions as well and in the same time. Ambulatory phlebectomy alone could lead to quite early recurrences.

Imagine you have in your kitchen a dripping faucet creating a wet sink. You will never be able to dry the sink at least not for long time without taking care of the faucet and the stream of water hitting the sink.

In conclusion, the minimally invasive Ambulatory Phlebectomy is my preferred procedure for varicose veins of the leg as well as unwanted hand veins.

If anyone interested to read a fully illustrated protocol please refer to one of my articles the “Minimally invasive surgery for primary varicose veins: limited Invaginated axial stripping and tributary (hook) stab avulsion” published in Ann Vasc Surg 1995; 9:401-14.

What do you suggest for ankle veins?

Any unwanted vein any place on the body has three correctible options:

Option 1. Do nothing: in case there is no pain /discomfort/edema and also no cosmetic concern. Option 2. Close the vein by sclerotherapy. With vein closed blood unable to low though it renders the unwanted vein invisible. Option 3. Remove the vein(s) by ambulatory (hook) phlebectomy and achieve the same results.

Personally, if the veins are up to only 1m in diameter (spider veins) and/or 2-3 mm in diameter (reticular/network) veins I prefer injection (chemical) sclerotherapy. If the veins are 3-4 mm in diameter and beyond (probably varicose veins) I would remove them by the ambulatory (hook) phlebectomy, a minimally invasive surgical procedure done in local anesthesia and by me also as an office procedure with no associated down time.

Whatever option was suggested to you I have a word of caution. I hope that you have been (or will be) properly examined by at least a Doppler US (better even a duplex imager and in a standing position too). Tributary/branch varicose veins, if that what you have on your ankle, could be connected (as branches) to a main vein trunk (most cases not even visible) that is harboring a wrong i.e. reversed pattern of flow (from above-down rather from down-above). This main vein trunk could be stretching either from the groin to below knee/calf even ankle of from behind the knee to ankle. If this should be the case any practitioner, regardless of the therapeutic preference, has to deal with these pathological conditions as simple sclerotherapy or phlebectomy alone will lead to very early recurrences. Imagine you have in your kitchen a dripping faucet creating a wet sink. You will never be able to dry the sink at least not for long time without taking care of the faucet and the stream of water hitting the sink. While I will prefer a minimally invasive surgical protocol performed in my office and local anesthesia, other practitioners will suggest “thermal” sclerotherapy by laser (EVLT) or by radio frequency (RF) current (Closure) methods I am not fond off because it sometimes performed in several sessions for jus financial gains and not medical necessity, because the dangers of a blood clot in the deep veins (DVT), because much inferior cosmetic results and also because of early recurrences.

How long after delivery should I treat my Varicose Veins?

Personally, I prefer to wait until the monthly cycles are back to normal. In most cases (not all cases) this will happen after ending breast-feeding.

The reason for the delay being that sometimes visible veins during pregnancy (especially the 1st one) may disappear once the periods return and the elevated hormonal levels - that distended the veins - come down to normal. Moreover, if one considers having another child soon namely back to back, I would wait with treatments until the end of that pregnancy. I would however highly suggest wearing elastic daytime compression during the entire pregnancy to try to prevent excessive deterioration of the condition. A knee level 30-40 stocking open toe stocking for the first two trimesters, maternity pantyhose for the last trimester. Exception to the rule would be already a very painful experience during the just ended pregnancy. If left untreated one could have a miserable time during an immediate subsequent pregnancy necessitating some times full bed rest and the possibility if blood clots.

If however, there is no immediate plan for a subsequent pregnancy, maybe just after several years, and the varicosities are bothersome, one should go ahead with the treatment.

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