What is the treatment for varicose veins using sclerotherapy?

Sclerotherapy for 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

• 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
• The procedure involves inserting a needle into the vein lumen and injecting the sclerosing agent, often with air to create foam that displaces blood and reacts with the vascular endothelium 1
• Common sclerosing agents include hypertonic saline, sodium tetradecyl sulfate (Sotradecol), and polidocanol (Varithena), with no evidence that any agent is superior in terms of effectiveness or patient satisfaction 1

Treatment Algorithm for Varicose Veins

• First-line treatment for symptomatic varicose veins with documented valvular reflux is endovenous thermal ablation (radiofrequency or laser), which has been shown to be effective with success rates of 90% at 1 year 2
• Second-line treatment is sclerotherapy, particularly for small to medium-sized veins (1-5 mm) 1
• Third-line treatment is surgery, according to the National Institute for Health and Care Excellence clinical guidelines 1

Indications and Patient Selection

• Sclerotherapy is primarily indicated for small (1-3 mm) and medium (3-5 mm) varicose veins 1
• For sclerotherapy to be considered medically necessary, vein size must be ≥2.5mm in diameter, measured by recent ultrasound, and documented reflux duration ≥500 milliseconds in the veins to be treated 3
• Recurrent varicose veins after surgery are also an indication for sclerotherapy 1
• Foam sclerotherapy, including Varithena, is considered a secondary treatment for tributary veins or as an adjunct to primary treatment of the saphenofemoral junction 2

Efficacy and Outcomes

• Foam sclerotherapy has occlusion rates varying from 72% to 89% at 1 year when used appropriately 2, 3
• In clinical trials, polidocanol (Varithena) demonstrated significant improvement in vein appearance with 95% treatment success at 12 weeks and 26 weeks compared to 8% and 6% for placebo, respectively 4
• Patient satisfaction was significantly higher with polidocanol treatment (87% satisfied or very satisfied) compared to placebo (14%) at 12 weeks 4
• The treatment sequence is important for long-term success, with multiple studies showing that chemical sclerotherapy alone has worse outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation or surgery 2

Post-Treatment Care

• Patients should wear compression stockings or support hose on the treated legs continuously for 2 to 3 days and for 2 to 3 weeks during the daytime following treatment 4
• Adequate post-treatment compression may decrease the incidence of deep vein thrombosis 5

Potential Complications

• Common side effects include phlebitis, new telangiectasias, and residual pigmentation 2
• Severe adverse local effects, including tissue necrosis, may occur following extravasation; therefore, extreme care in intravenous needle placement and using the minimal effective volume at each injection site are important 5
• Allergic reactions, including fatal anaphylaxis, have been reported, though they are rare 5
• Deep vein thrombosis is a potential complication, with rates potentially slightly increased compared to placebo 2, 6
• Arterial embolism, stroke, transient ischemic attack, myocardial infarction, and impaired cardiac function have been reported in close temporal relationship with STS administration 5

Important Considerations and Precautions

• Thorough preinjection evaluation for valvular competency should be carried out and slow injections with a small amount (not over 2 mL) of the preparation should be injected into the varicosity 5
• Deep venous patency must be determined by noninvasive testing such as duplex ultrasound before treatment 5
• Venous sclerotherapy should not be undertaken if tests show significant valvular or deep venous incompetence 5
• Treating the saphenofemoral junction with thermal ablation or ligation provides better long-term outcomes than foam sclerotherapy alone, with a success rate of 85% at 2 years 2
• Emergency resuscitation equipment should be immediately available during the procedure 5

Special Populations

• Clinical studies of sclerosing agents like Asclera (polidocanol) did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects 4