Sclerotherapy Treatment of Telangiectasias and Varicose Veins Steven E. Zimmet, MD Telangiectasias and/or varicose veins are present in about 33% of adult women and 15% of adult men.Although they may be only of cosmetic concern, superficial varices often cause signif- icant symptoms such as pain, aching,heaviness,and pruritus. Venous ulceration is commonly caused solely by superficial venous insufficiency. Superficialthin-walled veins may rupture and hemorrhage. Sclerotherapy is a nonsurgical procedure that can be used to treat both small and large varices of the super- ficial venous system and perforators. This involves injecting a sclerosant intraluminally to cause fibrosis and eventual oblitera- tion ofa vein.The most common sclerosants used in the U.S. include sodium tetradecyl sulfate,polidocanol,23.4% saline, and a combination of 25% dextrose with 10% saline. Treatment generally proceeds from proximal to distal and largest to smallest vein, based on a reflux map developed from physical examina- tion, Doppler, and duplex ultrasound. Sclerotherapy results can be optimized and the risk of complications minimized by choos- ing the proper sclerosant, sclerosant concentration, sclerosant volume,and injection sites for the vein(s) being treated. Post- treatment instructions, particularly compression and ambulation, are designed to improve the results and safety of sclerotherapy. Adequate understanding of an appropriate history and physical, ultrasound evaluation, anatomy, pathophysiology, knowledge of sclerosing solutions, patient selection, and post-treatment care, as wellas the ability to prevent, recognize, and treat complica- tions are required before embarking on treatment. © 2003 Elsevier Inc. All rights reserved. L ower extremity venous insufficiency is a common medical condition afflicting about 33% of women and 15% of men in the United States. 1 Gender, pregnancy, hormones, aging, and gravitational forces from prolonged standing or sitting are the most common factors that influence the appearance or worsen- ing of primary varicose veins. 2,3 Although varices often begin to appear in adolescence, veins worsen as people age. As our population ages, the number of people affected will rise signif- icantly. Although many people seek medical treatment for varicose veins because they find them unsightly, most people with var- icose veins suffer from symptoms. 4,5 Unfortunately, symptoms of primary venous insufficiency are not often recognized by patients or their physicians. Characteristic leg complaints asso- ciated with varicose veins include aching pain, pruritus, night cramps, fatigue, heaviness, and leg restlessness. Symptoms are typically worsened with prolonged standing, during the pre- menstrual period, or in warm weather. 6 Symptoms are common even if patients have only spider and reticular veins. 4 Left un- treated, nearly 50% of patients with significant superficial ve- nous insufficiency will eventually suffer from chronic venous insufficiency characterized by lower extremity swelling, ec- zema, pigmentation, hemorrhage, and ulceration. 7 Chronic ve- nous insufficiency, including venous ulceration, is caused often solely by superficial venous disease. 8,9 Thin-walled superficial veins can rupture and cause significant hemorrhage. The introduction of a medication into a vessel to cause its obliteration was first attempted by Pravaz in 1853. 10 High mor- tality and morbidity were noted from septic and embolic events. A resurgence of interest occurred during World War I after it was observed that injections of Salvarsan for syphilis caused vein sclerosis. 11 After that, interest in sclerotherapy has varied over time. Sclerotherapy has been relatively widely practiced in Europe,particularly in France, Germany,and Switzerland, since the 1940’s. There has been a tremendous increase in interest in the United States, in part because of the revolution in noninvasive diagnostic techniques, over the last 15 years. Scle- rotherapy is used to treat telangiectasias, reticular veins, and bulging varicose veins. In expert hands, incompetent perfora- tors and saphenous veins can be treated by using ultrasound- guided sclerotherapy. 12,13 Sclerosants The aim of sclerotherapy injections is to cause adequate vein- wall injury such that permanent sclerosis occurs. Many differ- ent agents have been used for sclerotherapy of leg veins. How- ever,only a few are in common use today. These are briefly reviewed below. Sodium morrhuate, although FDA-approved for sclerotherapy, is not commonly used because of a history of frequent anaphylaxis. 14 This is also true of ethanolamine oleate. Other sclerosants, such as polyiodinated iodine salt, sodium salicylate, and glycerin, are not in widespread use in the U.S and won’t be discussed. Hypertonic saline (23.4% sodium chloride) was first used as a sclerosant by Linser in 1916. 11 It is FDA-approved for other uses,but not for vein sclerotherapy. Nonetheless, it is com- monly used as a sclerosant, almost exclusively for telangiecta- sias and reticular veins. It is generally used in either 11.7% or 23.4%, depending on vein size and responsiveness. Hypertonic saline probably damages endothelium via hyperosmolar dena- turation of cell-surface proteins. 12 Its advantages include wide availability, low cost,lack of allergenicity (if unadulterated), and rapid response to treatment. 15 Its disadvantages include burning pain, rapid dilution, which limits the size of vein it can successfully treat, and a high risk of extravasation necrosis. Dextrose and hypertonic saline (25% dextrose, 10% sodium chloride) is produced in Canada under the trade name Sclero- From the Zimmet Vein and Dermatology Clinic, Austin, TX. Address reprint requests to Dr. Steven E.Zimmet,Zimmet Vein and Dermatology Clinic, 1801 N. Lamar Blvd., Suite 103, Austin, TX 78701. © 2003 Elsevier Inc. All rights reserved. 1089-2516/03/0603-0004$30.00/0 doi:10.1053/S1089-2516(03)00044-1 Techniques in Vascularand Interventional Radiology, Vol 6, No 3 (September),2003:pp 116-120 116