What are the indications and contraindications for sclerotherapy?

Sclerotherapy: Indications and Contraindications

Primary Indications for Sclerotherapy

Sclerotherapy is the treatment of choice for small-caliber varicose veins, specifically spider veins (≤1 mm diameter), reticular veins (1-3 mm diameter), and uncomplicated varicose veins up to 3 mm in diameter. 1, 2

Vessel Size Requirements

• Minimum vein diameter of 2.5 mm is required for adequate treatment success 3, 4
• Vessels smaller than 2.0-2.5 mm demonstrate only 16% primary patency at 3 months compared to 76% for larger veins 3
• FDA-approved polidocanol (Asclera) is specifically indicated for veins ≤3 mm diameter 1
• Foam sclerotherapy achieves 72-89% occlusion rates at 1 year for appropriately sized vessels 5, 3

Clinical Indications

• Spider veins and telangiectasias (cosmetic and symptomatic) 6, 7, 8
• Reticular varicose veins (1-3 mm diameter) 1, 2
• Tributary veins as adjunctive treatment following thermal ablation of main saphenous trunks 3, 4
• Symptomatic varicose veins causing pain, heaviness, aching, or pruritus 8
• Residual or recurrent veins after surgical treatment 9
• Pelvic varices and pelvic congestion syndrome (using foam sclerotherapy techniques) 5

Required Pre-Treatment Criteria

• Documented reflux duration ≥500 milliseconds on duplex ultrasound performed within past 6 months 3, 4
• Failed 3-month trial of conservative management including medical-grade compression stockings (20-30 mmHg), leg elevation, and exercise 3, 4
• Symptomatic presentation with pain, swelling, or functional impairment affecting daily activities 3, 4

Critical Treatment Algorithm

When Sclerotherapy Should NOT Be Used Alone

Sclerotherapy should never be used as primary treatment for saphenofemoral or saphenopopliteal junction reflux—this represents a critical treatment error. 5, 3

• Endovenous thermal ablation must precede tributary sclerotherapy when junctional reflux >500ms is present 3
• Chemical sclerotherapy alone has significantly worse outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation (20-28% recurrence rates) 3, 4
• Untreated junctional reflux causes persistent downstream pressure leading to tributary vein recurrence even after successful sclerotherapy 3

Proper Treatment Sequence

1. First-line: Endovenous thermal ablation for main saphenous trunks with diameter ≥4.5 mm and reflux ≥500ms 3, 4
2. Second-line/Adjunctive: Sclerotherapy for tributary veins 2.5-3.0 mm diameter 3
3. Third-line: Surgical intervention when endovenous techniques fail or are not feasible 3

Absolute Contraindications

Sclerotherapy is absolutely contraindicated in patients with known allergy to polidocanol or other sclerosing agents and those with acute thromboembolic disease. 1

Additional Contraindications

• Active deep venous thrombosis (superficial or deep) 6
• Pregnancy 6
• Acute thromboembolic diseases 1
• Known hypersensitivity to sclerosing agents 1, 6
• Severe arterial disease 6
• Immobility or bedridden state 6
• Myocardial decompensation 6

Relative Contraindications Requiring Caution

• Hypercoagulable states 6
• Migraine history (particularly for foam sclerotherapy, which shows higher incidence of transient migraine headaches) 2
• Diabetes mellitus 6
• Dependency edema 6
• Serious systemic illness 6

Special Considerations for Pelvic Venous Disease

For pelvic congestion syndrome, foam sclerotherapy demonstrates 75% symptomatic improvement when combined with embolization techniques. 5

• Stop-flow foam sclerotherapy with balloon occlusion optimizes sclerosant delivery in high-flow pelvic varicoceles 5
• Common transient colic-like pain occurs but resolves within 5 minutes 5
• Risk of coil migration <2% when combined with embolization 5

Common Complications and Risk Mitigation

Frequent Minor Complications

• Hyperpigmentation (most common, resolves over weeks to months) 6, 9
• Telangiectatic matting (new small vessel formation) 6, 9
• Local urticaria and allergic dermatitis 6, 2
• Phlebitis 3

Rare but Serious Complications

• Deep vein thrombosis (0.3% incidence) 3
• Pulmonary embolism (0.1% incidence) 3
• Anaphylaxis (rare) 2
• Cutaneous necrosis (from extravasation or intra-arterial injection) 6
• Nerve damage 6

Risk Reduction Strategies

• Use ultrasound guidance for all non-superficial vessels to ensure accurate intraluminal injection 5, 3
• Select appropriate sclerosant concentration based on vessel size 6, 8
• Apply proper compression therapy post-treatment 6, 8
• Avoid treating vessels <2.5 mm diameter due to poor outcomes 3
• Ensure early postoperative duplex scanning (2-7 days) to detect complications 3

Critical Pitfall: Primary Prevention in Cirrhosis

Sclerotherapy should NEVER be used for primary prevention of variceal hemorrhage in cirrhotic patients—this is associated with significantly higher mortality. 5

• A VA cooperative trial was terminated early due to significantly higher mortality in the sclerotherapy group versus sham therapy 5
• This represents a Class III recommendation (should not be done) with Level A evidence 5
• Nonselective beta-blockers or endoscopic variceal ligation are appropriate alternatives for variceal prophylaxis 5