Atlas of Primary Care Procedures, 1st Edition

Dermatology

28

Sclerotherapy

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.

TABLE 28-1. INITIAL CONSULTATION SESSION

 

1. Assess the appropriateness of the candidate. Has the patient undergone prior therapy? A history of dissatisfaction with prior therapy may predict future dissatisfaction. Is there a history of significant vein injury, clots, or predisposing factors? Is the patient taking medications (e.g., hormone therapy) that may exacerbate vein disease? Is the patient willing to wear the support hose after the procedure?

2. Educate the patient regarding the major complications of the procedure. Does the patient understand that he or she may experience some discomfort during or after the procedure? SeeTable 28.2

3. Assess major pressure influence on the superficial veins from incompetent perforator veins. Perform a cough test (i.e., patient coughs while examiner holds the examining hand over the saphenofemoral junction; if the perforator is incompetent, a pulse is felt). The Brodie-Trendelenberg test uses two examiners. The patient is laid supine, with the legs elevated to a vertical position to drain all the blood from the veins. The examiners hold pressure on the saphenofemoral junction while the patient is stood up; the veins on the posterior lower legs are observed. If there is an incompetent perforator, the veins fill rapidly (<15–20 seconds), and then a surge is noted in the filling veins when the pressure over the junction is released.

4. To perform photoplethysmography, the patient is seated, and the sensor placed on the skin 10 cm above the medial malleolus. The ankle is dorsiflexed 10 times by the examiner over 10 to 15 seconds, effectively emptying the blood from the subdermal plexus. In a normal study, refilling occurs in more than 25 seconds; intermediate refilling occurs in 15 to 20 seconds, and severe incompetence of the perforators allows the subdermal veins to refill in less than 15 seconds.

5. Record or chart the presence of abnormal veins. If photographs are obtained, perform them in an area of the office with a dark background (e.g., mounted dark felt).

6. Write a prescription for the patient to be fitted for two pairs of 30 to 40 mm Hg, thigh-high support hose. The patient must bring a pair of support hose to the first sclerotherapy session.

 

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.

TABLE 28-2. COMPLICATIONS OF SCLEROTHERAPY

 

Complications

Comments

 

Cutaneous hyperpigmentation

Occurs in about 30% of patients if hypertonic saline is the sclerosing agent

Bruising

Worsened if larger vessels are injected, when canalization fails or if lack of compression afterward

Temporary swelling

Between 2% and 5% of patients experience pedal and leg edema after the procedure

Telangiectatic matting

New appearance of fine (blush) vessels in about 25% of patients

Pain

Hypertonic saline is more uncomfortable than detergent solutions

Localized urticaria after

Allergic local reaction occurring in the first 30 minutes following sclerotherapy

Tape compression blister

Common complication when gauze is taped over injection sites

Recurrence of abnormal veins

Most patients have some new vessels in the next 5 years

Cutaneous necrosis

Can result from extravasation or inadvertent injection of an arteriole; is more common when injecting below the ankle or on the foot

Anaphylaxis

Uncommon systemic reaction

Allergic reaction to sclerosing agent

Detergent solutions can produce specific reactions

Superficial thrombophlebitis weeks

Up to 15% of patients experience this in the first 3 after injection

Deep venous thrombosis and pulmonary embolus

Rare but serious complication of the procedure

 

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INDICATIONS

  • Ablation of unwanted spider, reticular, or varicose veins
  • Elimination of the symptoms of varicosities such as aching, night cramps, or itching
  • Improvement in cosmetic appearance of legs or other affected body sites
  • Prevent the complication of leg hypostasis (e.g., dermatitis, ulceration) by diverting blood to healthy vessels

RELATIVE CONTRAINDICATIONS

  • Uncooperative patient (including refusal to wear support hose after the procedure)
  • History of allergic reaction to sclerosing solution (may use alternate solutions)
  • Severe peripheral arterial disease that may compromise healing or preclude use of support hose
  • Untreated incompetent saphenofemoral junction perforator
  • Poorly controlled diabetes

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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.

 

(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.

 

(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.

 

(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.

 

(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.

 

(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.

 

(6) Target larger, straighter portions of vessels to improve the rate of successful canalization.

TABLE 28-3. PRINCIPLES GUIDING INJECTION DECISIONS DURING SMALL VESSEL SCLEROTHERAPY

 

Inject proximal to distal veins.

Larger veins are treated before smaller veins.

Treat an entire vessel, if possible, at a given treatment session.

Inject the largest feeding vessel (i.e., tree trunk) when treating a telangiectatic cluster.

Empty larger veins whenever possible before injection.

 

Adapted from Sadick N, Li C. Small-vessel sclerotherapy. Dermatol Clin 2001;19:475–481.

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.

 

(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.

 

(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.

CPT® Code

Description

2002 Average 50th Percentile Fee

36468

Single or multiple injections spider veins, trunk or limb

$203

36469

Single or multiple injections spider veins, face

$165

36470*

Injection of sclerosing solution, single vein

$123

36471*

Injection of sclerosing solution, multiple veins, same leg

$229

93965

Noninvasive physiologic study bilateral extremity veins (PPG)

$205

99002

Handling and fitting of orthotics (office fitting, ordering hose)

$24

99070

Supplies and materials (support hose charge)

Fee determined by cost, markup

CPT® is a trademark of the American Medical Association.

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

Baccaglini U, Spreafico G, Castoro C, et al. Sclerotherapy of varicose veins of the lower limbs. Dermatol Surg 1996;22:883–889.

Goldman MP, Bergan JJ. Sclerotherapy: treatment of varicose and telangiectatic leg veins, 3rd ed. St. Louis: Mosby–Year Book, 2001.

Goldman MP, Weiss RA, Brody HJ, et al. Treatment of facial telangiectasias with sclerotherapy, laser surgery, and/or electrodesiccation: a review. J Dermatol Surg Oncol 1993;19:899–906.

Green D. Sclerotherapy for varicose and telangiectatic veins. Am Fam Physician 1992;46:827–837.

Hubner K. Is the light reflection rheography (LRR) suitable as a diagnostic method for the phlebology practice? Phlebol Proctol1986;15:209–212.

Imperio WA. Learn the logic behind effective sclerotherapy. Skin Allergy News 2002;33:32.

Pfeifer JR, Hawtof GD, Minier JA. Saline injection sclerotherapy in the ablation of spider telangiectasia of the lower extremities. Perspect Plast Surg 1990;2:165–170.

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Pfeifer JR, Hawtof GD. Injection sclerotherapy and CO2 laser sclerotherapy in the ablation of cutaneous spider veins of the lower extremity. Phlebology 1989;4:231–240.

Piachaud D, Weddell JM. Cost of treating varicose veins. Lancet 1972;11:1191–1192.

Sadick N, Li C. Small-vessel sclerotherapy. Dermatol Clin 2001;19:475–481.

Sadick NS, Farber B. A microbiologic study of diluted sclerotherapy solutions. J Dermatol Surg Oncol 1993;19:450–454.

Sadick NS. Predisposing factors of varicose and telangiectatic leg veins. J Dermatol Surg Oncol 1992;18:883–886.

Tisi PV, Beverley CA. Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev 2002;CD001732.

Weiss MA, Weiss RA, Goldman MP. How minor varicosities cause leg pain. Contemp Obstet Gynecol 1991:113–125.

Weiss RA, Sadick NS, Goldman MP, et al. Post-sclerotherapy compression: controlled comparative study of duration of compression and its effects on clinical outcome. Dermatol Surg 1999;25:105–108.

Weiss RA, Weiss MA, Goldman MP. Physicians' negative perception of sclerotherapy for venous disorders: review of a 7-year experience with modern sclerotherapy. South Med J 1992;85:1101–1106.