Sclerotherapy is an inexpensive and generally safe outpatient technique for the removal of unwanted spider (telangiectatic), reticular, and varicose veins. A concentrated saline or chemical solution is injected into the unwanted vessel using a small (30- to 32-gauge) needle. The solution washes over the vessel's endothelial cells, producing obliteration of the vessel and shifting blood into nearby healthy vessels.
Abnormal or distended veins result from increased vascular pressure transmitted to the superficial vessels. Valves in the deep veins of the lower extremity are thin and fragile, and damage to these valves reduces the unidirectional flow of blood returning to the heart. Many conditions can render the valves nonfunctional, such as the increased blood flow of pregnancy, deep venous thrombosis, venous injury, and increased abdominal pressure (i.e., excessive sitting, leg crossing, or obesity). Other influences, such as hormonal changes in the veins or congenital absence of vein valves, can also produce varicosities.
If hypertonic saline is used as the sclerosing solution, lidocaine usually is mixed with the saline to lessen the discomfort. Two milliliters of 1% lidocaine hydrochloride (without epinephrine) is added to a 30-mL bottle of 23.4% hypertonic saline, creating a final concentration of 22%. This solution is then placed into 10 to 20 tuberculin syringes, and 30-gauge needles are attached to the syringes. Alternately, physicians may choose to perform sclerotherapy with detergent solutions such as sodium tetradecyl sulfate. The syringes are only half filled (0.5 mL) with sclerosing solution so that the thumb is not extended fully during the injection and to limit the amount injected into any single vessel and prevent deep venous injection. The syringes are placed on a tray for the procedure.
One to six injections may be needed to effectively treat any vein. When spider veins are injected, interconnections among subcutaneous vessels may permit treatment of a large network over a wide area of skin. Wait at least 4 to 6 weeks before reinjecting individual vessels to permit adequate healing and to reduce postinflammatory complications.
Patients desiring sclerotherapy should undergo a pretreatment consultation (Table 28-1). The consultation is used to evaluate potential candidates, map or photograph the extent of their diseased vessels, and to educate them regarding the procedure. Education is particularly important, because less than 90% of patients of even the most experienced practitioners report full satisfaction with the outcome.
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Photography can help remind patients of the severity of the disease before therapy.
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TABLE 28-1. INITIAL CONSULTATION SESSION |
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Sclerotherapy is contraindicated if the procedure is unlikely to produce significant benefit. If a patient has significant pressure extending to superficial veins (e.g., produced by an incompetent perforating vein in the saphenofemoral junction in the groin), abnormal veins will rapidly replace those that are ablated. Incompetent perforators can be evaluated by physical examination (e.g., cough test, Brodie-Trendelenburg test) or confirmatory testing (e.g., photoplethysmography, Doppler studies). Photoplethysmography is easy to perform and gives an accurate assessment of filling time after the blood is removed from the lower leg using the calf muscle pump.
After sclerotherapy, patients should wear support hose for 3 consecutive days and 2 nights. Support hose are placed on the patient immediately after the sclerotherapy session. The use of support hose limits the refilling of treated vessels and significantly reduces complications after therapy (Table 28-2). Patients are fitted for thigh-high, 30- to 40-mm Hg support hose at the initial consultation. The first sclerotherapy session is scheduled for 2 weeks after the consultation to allow adequate time to obtain the fitted hose. Patients with leg hypostasis are encouraged to wear support hose long term to improve the health of the leg tissues and to reduce recurrences. Patients often prefer lower-pressure (over-the-counter, 10- to 20-mm Hg) support hose, but the higher-pressure type of support hose is needed to ensure adequate venous drainage and to prevent stasis complications.
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TABLE 28-2. COMPLICATIONS OF SCLEROTHERAPY |
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INDICATIONS
RELATIVE CONTRAINDICATIONS
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PROCEDURE
The patient lies flat on the treatment table (prone or supine, depending on the location of the veins being treated.) Two lights are positioned from opposite directions to highlight the vessels and to limit shadows that can interfere with visualization of the vessels.
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(1) The patient lies flat on the treatment table. |
Pour a colorless antiseptic solution (i.e., benzalkonium chloride [Zephiran] or alcohol) into a basin containing cotton balls. Apply the solution with the cotton balls to render the skin more transparent and to make the veins easier to visualize.
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(2) Apply a colorless antiseptic solution with cotton balls to render the skin more transparent and to make the veins easier to visualize. |
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The injection needle is bent with the bevel up before initiating an injection. Initially identify the bevel; use magnification (1 to 3 diopter glasses) if needed. Position the bevel upward from the horizontally held crossbar (Figure 3A). Bend the needle to a 30- to 45-degree angle (Figure 3B) so that the needle can enter next to a vein horizontal to the skin surface. Injections should only be performed with the bevel up; this helps to prevent sclerosing fluid from leaking into the tissue. Injections must be intraluminal to prevent complications.
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(3) Perform injections with the bevel up to help prevent sclerosing fluid from leaking into the tissue. |
PITFALL: The most common mistake made by novice sclerotherapists is to attempt entry into small vessels with the needle held at a angle to the surface of the skin. If the needle is at an angle, the tip frequently passes through a small vessel and deposits the solution in the tissues.
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Position the hands to provide three-point traction before injecting a vein. The nondominant hand applies traction using the thumb and index (second) finger. The injecting (dominant) hand's fifth finger is used to provide the third point.
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(4) Hands should be positioned to provide three-point traction before injecting a vein. |
Injections are administered slowly. If the needle tip is intraluminal, the solution will flow easily into the vessel. Observe the needle tip and vessel closely. If a small bleb (or bubble) develops at the injection site (Figure 5A), extravasation is likely. The injection should be terminated immediately and the bleb milked back to the puncture site to mechanically attempt removal of any fluid in the tissue (Figure 5B). Some physicians advocate infiltrating around extravasation sites with normal saline, but most minimal extravasations do not produce skin necrosis or other complications.
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(5) If a small bleb develops at the injection site, the injection should be terminated immediately, and the bleb should be milked back to the puncture site to mechanically attempt removal of any fluid in the tissue. |
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Target larger, straighter portions of vessels to improve the rate of successful canalization (Table 28-3). Proper injection technique results in visible blanching of the vessel (i.e., washout effect). Because vessels can have significant connections beneath the surface of the skin, continue the injection if the solution is flowing easily and if there is no evidence of extravasation.
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(6) Target larger, straighter portions of vessels to improve the rate of successful canalization. |
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TABLE 28-3. PRINCIPLES GUIDING INJECTION DECISIONS DURING SMALL VESSEL SCLEROTHERAPY |
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Immediately after the injection, place pressure on the site with gauze. The nurse can hold pressure to the site for 30 to 60 seconds while the physician injects another site. The number of injections performed during any one session depends on many factors, including the extent of disease, time available for the procedure, and the patient's tolerance.
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(7) Immediately after the injection, place pressure on the site with gauze for 30 to 60 seconds. |
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Fitted support hose are applied while the patient is supine, before standing and refilling the veins. Do not tape gauze on the skin. The 2 * 2 inch gauze can be held over the injection sites as the support hose are rolled up the leg. This technique allows the gauze to absorb drainage, while avoiding tape allergies and tape blistering. The patient is instructed to ambulate for 20 minutes after application of the support hose to prevent pooling of sclerosing agents into the deep vein circulation.
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(8) Apply fitted support hose while the patient is supine, and have patient ambulate for 20 minutes to prevent any pooling of sclerosing agents into the deep vein circulation. |
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CODING INFORMATION
If bilateral procedures are performed during the session, then add the -50 modifier when reporting codes 36468, 36470, and 36471.
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INSTRUMENT AND MATERIALS ORDERING
Hypertonic saline, sodium tetradecyl sulfate, and benzalkonium chloride solution can be obtained from local surgical supply houses or pharmacies. The photoplethysmography machine (Hemodynamics AV-1000 light reflection rheography), vein light (i.e., transillumination device for veins), and 30-gauge sclerotherapy needles can be ordered from Sam Wagner, Middlebourne, WV (phone: 304-758-2370;http://www.veinsonline.com).
BIBLIOGRAPHY
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