Sclerotherapy

Sclerotherapy is a minimally-invasive procedure used to treat varicose veins or spider veins.

Veins are blood vessels that carry blood toward the heart. They contain valves that prevent the backflow and stasis of blood. Varicose veins are abnormally dilated veins in the legs that become visible due to malfunction of the valves. Spider veins are small, superficial visible veins that feed varicose veins and are very thin in nature.

Sclerotherapy is a procedure that injects sclerosing agents (special chemicals) that collapse the veins, forcing the blood to flow through healthier veins. The collapsed veins are later resorbed into the local tissue and finally fade.

(Read more - Varicose veins during pregnancy)

Indications of sclerotherapy can be decided into cosmetic or medical. They are:

• Cosmetic reasons: varicose veins and spider veins are a cause of cosmetic discomfort, especially in light-skinned individuals. They are usually asymptomatic but any trauma can cause easily visible bruising of the skin. Hence, the patient desires the conditions to be treated
• Medical reasons: In advanced stages, varicose / spider veins can cause symptoms that can be troublesome to the patient. the symptoms are caused due to stasis (slowing) of the blood, especially in the veins of the legs (thighs and calves). These include:
  • Swelling in the legs, which progresses on prolonged standing
  • Pain in the legs
  • Skin changes in the leg, associated with itching
  • Non-healing ulcers (wounds) in later stages of the disease

Varicose and/or spider veins can also occur in other areas of the body such as ankles, feet, face (sides of the nose) or anus.

(Read more - Homeopathic treatment for varicose veins)

Absolute contraindications (conditions in which the procedure is not allowed) are:

• Pregnant and breastfeeding women
• Women who have given birth in the last 3 months
• Bedridden patients

Relative contraindications (procedure may be performed but there are risks associated with it) for the procedure are:

• Pre-existing conditions such as diabetes, hormonal imbalances, cardiac or blood conditions
• History of an episode of a blood clot in the past
• In patients who may require bypass surgery, the veins of such patients will be spared unless the veins are deemed unusable

(Read more - Home remedies for varicose veins)

Sclerotherapy is performed by a vascular specialist or a dermatologist.

The doctor will explain how the procedure will be done along with the outcome and associated risks. A detailed medical history of the patient is taken which includes the patient's symptoms, family history, menstrual history (if applicable), medications history and history of any comorbidities (pre-existing illness, if any). This is accompanied by a physical examination of the patient which helps assess the extent of the diseased veins.

Certain investigations are done such as:

• Routine blood tests
• Coagulation tests, to rule out coagulopathy
• Radiological investigations such as ultrasound of the veins which includes a venous doppler (a scan that assesses the blood flow in the veins)

Medications, if any, for pre-existing conditions may be altered or stopped as per the doctor's orders. These may involve anticoagulants and certain pain medications. The patient will also be advised not to apply any cream or lotion to the affected area a couple of days before surgery.

The procedure is daycare admission (i.e., the patient is admitted in the morning and discharged by the evening). It is advised that the patient arranges for a ride back home since there may be discomfort in the legs after the procedure. In rare cases, the patient may be told to stay overnight.

On the day of the procedure, the patient arrives at the hospital with all the relevant documents and reports. The patient is advised to fast for four hours prior to the procedure. Once admitted, they change into hospital attire. Hair on the affected area is shaved off. A final review of the patient is done by the doctor and nurses before the patient is shifted for the procedure.

The procedure takes place in a minor procedure room. The patient is asked to lay supine (on their back) on the procedure table. A monitor may be attached to track the vitals (heart rate, blood pressure, oxygen saturation). An IV cannula may be inserted to administer any medication, if required. The skin over the targeted veins will be cleaned. The patient will not require any anaesthesia and will remain conscious throughout the procedure.

The doctor will inject the sclerosing agent using a fine needle. The sclerosing agent is a special chemical that induces irritation in the veins that cause the veins to collapse/seal shut, forcing the blood to pass through non-diseased veins. The agent may be either a liquid or foam (usually used in larger veins).

The patient may experience minor stinging or cramping pain for one to two minutes during the needle insertion, especially in large veins. The needle is withdrawn and the doctor applies compression and massages the area to properly disperse the agent and prevent blood from re-entering the injected vein. The doctor then repeats the same steps to the next vein. The number of injections depends on the size and number of diseased veins. In deeper veins, the doctor may use an ultrasound to guide the direction of the needle into the vein.

Once all the injections are administered, gauze will be applied to the site of injections followed by a bandage to maintain the compression of the treated veins. In case of treatment in legs, an elastic compression stocking is put on the leg including the thigh; the compression will be tight but not tight enough to cause discolouration or pain in the foot.

The entire procedure usually takes 30 to 45 minutes. The procedure may have to be done multiple times depending on the severity of the condition to eliminate the disease.

The risks associated with the procedure are minimal. However, side effects may include:

• Pain, swelling and redness at the injection sites.
• Blood clots formed during the procedure within the vein. The clot may need to be removed later on if it is too large since it poses a risk of leading to deep vein thrombosis.
• Air embolism (introduction of air into the vein).
• Neovascularisation (development of new blood vessels) at the site of injection. The veins, however, disappear slowly over time.
• Larger injected veins may become lumpy and hard for several months before slowly getting better.
• Discolouration of the skin due to the spilling of blood into the surrounding tissue. This may fade over time.
• Spillage of the sclerosing agent into the surrounding tissue causes skin irritation.
• Rarely, allergic reaction to the sclerosing agent.

After the procedure is done, the patient is shifted to an observation room for a few hours. Pain is managed via oral analgesics.

A discharge summary is prepared by the doctor which includes relevant medications and advice on wound care. These typically include:

• Continue medications for pre-existing conditions, if any. Certain medications such as anticoagulants or pain medications may be stopped or altered for a few days
• Antibiotics and analgesics to prevent infection and pain, respectively
• Wear tight compression stockings (hosiery) for at least two weeks continuously, except during bathing and sleeping
• The areas of injection should be washed with soap and water gently to prevent infection
• Avoid going to saunas and swimming pools
• Apply hot compresses to the area or take hot water baths for a couple of days
• Avoid applying creams or lotions to the area until the stockings come off
• Avoid strenuous exercises such as running or weight training for a few weeks
• Avoid exposing the area to direct sunlight for a prolonged duration, since the inflammation caused due to the sclerosing agents can react with sunlight and cause dark spots on the skin.

The patient can resume their daily activities immediately after the procedure. Walking is encouraged to facilitate healing and prevent the development of clots.

Notify the doctor if the patient has the following symptoms:

• Swelling or red streaking near the groin area
• Sudden swelling of the entire leg
• Small ulcerations at the injection sites
• Fever or signs of infection at the injection sites
• Severe pain and tenderness in the calves suggest a possibility of deep vein thrombosis

The first follow up is usually after two weeks during which the doctor assesses the condition of the treated veins.

Over time the veins slowly merge with the surrounding tissues. Visual results for spider veins take 3 to 6 weeks and about 3 to 4 months for varicose veins.

Sclerotherapy is an effective, minimally-invasive treatment modality for varicose and spider veins that are causing symptoms or cosmetic discomfort. The procedure is of short duration with good results and minimal complications. However, there is a possibility of multiple repetitions of the procedure to completely treat the condition. Symptomatic relief is immediate but visual results range from a few weeks to months.