What is the role of sclerotherapy in treating varicose veins?

Role of Sclerotherapy in Treating Varicose Veins

Sclerotherapy is an effective second-line treatment for small to medium-sized varicose veins (1-5 mm) and is recommended after endovenous thermal ablation but before surgery according to current guidelines. 1

Mechanism and Procedure

• Endovenous sclerotherapy involves ultrasound-guided injection of a sclerosing agent into superficial veins, causing inflammation of the endothelium, resulting in fibrosis and occlusion of the vein 1
• A needle is inserted into the vein lumen and the sclerosing agent is injected, often with air to create foam that displaces blood and reacts with the vascular endothelium 1
• Common sclerosing agents include hypertonic saline, sodium tetradecyl (Sotradecol), and polidocanol (Varithena), with no evidence that any agent is superior in terms of effectiveness or patient satisfaction 1, 2

Indications and Patient Selection

• Primarily indicated for:

  • Small (1-3 mm) and medium (3-5 mm) varicose veins 1
  • Recurrent varicose veins after surgery 1
  • Treatment of telangiectasias (spider veins) 3

• Before performing sclerotherapy, thorough evaluation is essential:

  • Venous duplex ultrasonography to assess valvular competency 4
  • Evaluation of deep venous patency using noninvasive testing 4
  • Sclerotherapy should not be undertaken if significant valvular or deep venous incompetence is present 4

Efficacy and Outcomes

• A 2014 Cochrane review concluded that foam sclerotherapy is as effective as surgery for great saphenous vein varices 1
• Clinical studies show treatment success rates of approximately 95% at 12 weeks and 26 weeks when using polidocanol as the sclerosing agent 2
• Patient satisfaction rates are high, with 84-87% of patients reporting being satisfied or very satisfied with sclerotherapy treatment using polidocanol 2
• In a comparative study, sclerotherapy showed 70% complete occlusion of treated veins compared to 93.3% with phlebectomy, and had a higher recurrence rate (26.7% vs 6.7%) 5

Treatment Algorithm

1. First-line treatment for symptomatic varicose veins with documented valvular reflux is endovenous thermal ablation 1
2. Second-line treatment is sclerotherapy, particularly for:
   • Small to medium-sized veins (1-5 mm) 1
   • Residual or recurrent veins after other treatments 6
3. Third-line treatment is surgery (according to 2013 National Institute for Health and Care Excellence clinical guidelines) 1

Post-Treatment Care

• Patients should wear compression stockings or support hose on treated legs:
  • Continuously for 2-3 days after treatment 2
  • During daytime for 2-3 weeks 2
• Adequate post-treatment compression may decrease the incidence of deep vein thrombosis 4
• Patients should be followed up to assess for the development of deep vein thrombosis 4

Potential Complications

• Severe adverse local effects, including tissue necrosis, may occur following extravasation 4
• Risk of thrombosis extension into the deep venous system 4
• Possibility of allergic reactions, including anaphylaxis (rare but serious) 4
• Development of deep vein thrombosis and pulmonary embolism have been reported 4
• Arterial embolism events (stroke, TIA, myocardial infarction) have been reported, particularly when using foam created with room air 4

Special Considerations

• Emergency resuscitation equipment should be immediately available during the procedure 4
• As a precaution against anaphylactic shock, it is recommended to initially inject a small test dose (0.5 mL) and observe the patient before administering larger doses 4
• Slow injections with small amounts (not over 2 mL) of the preparation should be used 4
• The safety and efficacy of sclerosants foamed with room air has not been established and its use should be avoided 4

Sclerotherapy offers a minimally invasive, cost-effective, and ambulatory treatment option for varicose veins that can be performed on an outpatient basis without additional anesthesia 7, 8. While it may not be as effective as phlebectomy for certain patients, it remains an important tool in the management of varicose veins, particularly for smaller veins and as part of a comprehensive treatment approach 5.