Historical Review of Techniques

Sclerosing treatment for telangiectasias was ignored until the 1930s when Biegeleisen¹ injected sclerosing agents intradermally or subcutaneously into the general area of capillary enlargement. However, this procedure caused severe necrosis and lack of effect on the telangiectasias. Biegeleisen then developed and popularized a method of ‘microinjection’ of telangiectasias with sclerosing agents through the use of an ‘extremely fine metal needle’ (later described as a handmade 32- or 33-gauge needle).² Unfortunately, he used sodium morrhuate in the treatment of these fragile small vessels, which produced multiple complications, including pigmentation, cutaneous necrosis, and allergic reactions. Thereafter, sclerotherapy treatment of leg telangiectasias was thought of disparagingly by most practitioners³ until the 1970s when Alderman,⁴ Foley,⁵ Tretbar,⁶ and Shields and Jansen⁷ published reports of procedures that had achieved excellent results with few adverse sequelae. In these procedures, solutions less caustic to the telangiectasia were used – hypertonic saline (HS) with or without heparin and lidocaine (15% to 30%), and sodium tetradecyl sulfate (STS) 1% – as were techniques that ensured accurate placement of the solution into the blood vessels (use of 30-gauge needles).

Indication

Microsclerotherapy is theoretically indicated for any small telangiectatic vessel or venule on the cutaneous surface. Best results are obtained on superficial linear or radiating vessels on the lower extremities. Telangiectasias on the face are less reliably responsive to microsclerotherapy because they probably have more of an arteriolar component and result from active vasodilation, but they can be treated successfully (see Chapter 4).^8,9 In addition, bright-red telangiectasias on the leg that have a rapid refilling time after diascopy (applying pressure with a glass slide) with the patient recumbent (Fig. 12.1) are probably also supplied through arteriolar flow (see Chapter 3).¹⁰ These vessels are relatively recalcitrant to usual therapy and tend to recur after treatment. More importantly, these arteriolar leg veins are more likely to develop overlying cutaneous necrosis if sclerosing solutions reach the arteriolar feeding loop (see Chapter 8). They may be more effectively treated with the pulsed dye laser or intense pulsed light sources (see Chapter 13).

Figure 12.1 Bright-red telangiectasias may have an arteriolar origin. In this series the telangiectasias were located on the medial thigh. A, Appearance while the leg is raised 45 degrees. B, Blanching with pressure under a glass slide. C, Immediate reappearance on removal of the glass slide while the leg is still elevated.

The description in Chapter 9 of the injection of varicose veins by first closing off the high-pressure reflux points with sclerosing solution, followed by sclerotherapy of remaining abnormal vessels, forms the basis for the rationale of compression sclerotherapy of varicose veins. The treatment of ‘spider’ leg veins should be just as rational.

In the vast majority of cases, spider veins connect to underlying varicose veins either directly or through tributaries (Fig. 12.2) (see Chapter 3).^11–13 This is typical on the lateral aspect of the thigh when the lateral network described by Albanese is visible (Fig. 12.3). Doppler examination shows that almost all visible blue reticular veins are connected to telangiectasia.^14,15 Transillumination shows exactly the same pattern (Fig. 12.4). Therefore, as with varicose veins, treatment should be directed first at ‘plugging’ the leaking high-pressure outflow at its point of origin (Fig. 12.5). An appropriate analogy is to think of spider veins as the ‘fingers’ and the feeding varicose or reticular vein as the ‘arm’. Treatment should first be directed to the feeding arm and then, only if necessary, to the spider fingers. Mariani et al¹⁶ found that when telangiectasias were treated in this manner, 3-year follow-up of 109 patients showed enduring resolution of telangiectasias in 95%.

Figure 12.2 Simplified anatomy.

Figure 12.3 Albanese’s lateral network.

Figure 12.4 Transillumination. A, Principles. B, Reticular veins with a single cold light source. C, Connections between reticular and spider veins.

Figure 12.5 Strategy.

There are a number of advantages to this systematic approach to sclerotherapy. When sclerotherapy is performed in this manner, the spider veins often disappear without direct treatment, or decrease markedly in size, thus limiting the number of injections into the patient. The larger feeding vein is both easier to cannulate and less likely to rupture when injected with the sclerosing solution, thus minimizing the extent of extravasated red blood cells (RBCs) and solution. Theoretically, this method also should minimize the postsclerotherapy development of hyperpigmentation, cutaneous necrosis, telangiectatic matting (TM), and recurrence (see Chapter 8).

Injection Technique

Preinjection procedure

After a physical examination, including the use of noninvasive diagnostic techniques when appropriate (see Chapter 5), the patient is scheduled for a sclerotherapy session and given a questionnaire (Appendix C), consent form (Appendix D), and instructional material (Appendix G) to read and complete at home. Questions about the procedure are answered, and all reasonable and appropriate complications and adverse sequelae are addressed. An estimate of the approximate number of treatment sessions and the cost of treatment is given in writing to prevent any future misunderstandings. Insurance reimbursement policies are discussed and documented. Documentation of the relief of symptoms with compression stockings is helpful in gaining preauthorization of treatment from insurance companies, but in most cases insurance companies decide on the medical necessity for treatment based on the size (diameter) and type of vessel, not symptoms. If graduated compression stockings are planned to be applied after treatment, they are fitted at this time and given to the patient to wear before treatment. If the stockings produce a resolution of symptoms, the physician can assume that successful sclerotherapy will give the same result. In addition, wearing the stockings before treatment helps answer any questions about their fit to ensure they will be worn for the prescribed length of time after treatment.

On the day of treatment, legs should not be shaved, because a burning sensation may result when alcohol is applied to the areas that will be treated. Moisturizers should not be applied on the day of treatment since they cause unnecessary slipperiness of the skin. Patients are instructed to eat a light meal or drink juice an hour or so before the procedure in an effort to prevent a vasovagal reaction. Shorts, a bathing suit, or a leotard should be worn during the procedure to minimize both patient and physician embarrassment, since some vessels may be near the groin. Providing disposable paper shorts to patients who do not bring them into the office, is an appreciated feature.

With the patient standing on an elevated platform or stool, a complete set of photographs of the legs is taken from four different views, and the individual areas that will be treated are photographed up close (Fig. 12.6). Reticular veins and telangiectasias are photographed with the patient recumbent. Photographic documentation is important because patients frequently cannot remember exactly how their legs appeared before treatment. Any pretreatment pigmentation irregularities and scars may be blamed later on the sclerotherapy treatment, since patients usually look more closely at their legs once treatment has begun. In addition, when patients return in a few years with additional veins and telangiectasia, viewing pretreatment photographs will allay concerns regarding the possibility of unsuccessful previous treatment.

Figure 12.6 Standard photographs taken before treatment begins to allow accurate determinations of treatment outcome. Four standard views are taken at an F-stop of F8; close-up views are taken at an F-stop of F11, with macro-close-ups taken at an F-stop of F16. All photographs are taken with Kodachrome ASA 64 film as described in Chapter 15. A, Frontal view. B, Rear view. C, Right side (the right foot is always in front of the left foot). The right knee is slightly bent so the left inner thigh is better visualized. D, Left side (again with the right foot in front of the left). E, Documentation of scar from previous treatment for a verruca on the right anterior tibial area, which could later be thought of as a treatment scar. F, Documentation of dermatofibroma on the right medial knee area, which later could be thought of as punctate pigmentation from treatment. G, Close-up view of telangiectasia and venules (0.2–0.6 mm in diameter) on the right lateral thigh, along with pretreatment nonspecific light-brown pigmentation, which could later be thought of as postsclerotherapy hemosiderin pigmentation.

An easy method for measuring the diameter of the telangiectasia was devised by Jerry Garden, M.D. (Chicago, Ill.). He uses various-sized needles placed next to targeted telangiectasias to compare vessel diameters.

Gauge	External diameter (mm)
30	0.30
27	0.41
26	0.46
25	0.51
22	0.71
20	0.89
18	1.27

At the end of the treatment session, the treated areas are recorded on a diagrammatic chart to help check progress at follow-up examinations (Appendix E). Patients are given written postoperative instructions about activity and the disposition of their graduated compression stockings and/or bandages.

Equipment

Needle and syringe

Although visualization of the vessel is important in ensuring proper needle placement, the examiner actually enters the vessel ‘by feel’. This is particularly true in the injection of reticular varices. In this situation it is best to pierce the skin rapidly and advance the needle superficially over the vessel at a slight angle in a ‘double-piercing’ technique. Penetration of the vessel is ‘felt’, even when the examiner uses a 30-gauge needle. Some authors state that the ‘feel’ is enhanced with the use of a 26- or 27-gauge needle but we find this unnecessary.¹⁹ In this regard, the use of a glass syringe would best reflect an impedance to flow if a vessel were not properly cannulated. However, glass syringes are more cumbersome to use and regulations regarding sterile technique and other hazards have relegated glass to undesirable. With the availability of high-quality plastic syringes, a good feel can be obtained and the risk of transmitting blood-borne diseases obviated (see Chapter 15).

Ideally, the goal of microsclerotherapy is to cannulate the vessel, injecting sclerosing solution within and not outside of the vessel wall. Usually, a 30-gauge needle suffices for most vessels, although some physicians recommend the use of a 32- to 33-gauge needle to decrease the likelihood of inadvertent perivenular injection in the treatment of the smallest diameter vessels.^20–23 The disadvantages of using a 32-gauge needle are that it dulls rather quickly and easily bends away from the targeted vein (see Chapter 15). Boxes of needles sometimes contain individually defectively sharpened and dull needles, which give a ‘scratchy’ sensation to the tip. The physician should never hesitate to change needles if a vein cannot be cannulated easily. It is usually not the ‘tough skin’ of the patient but a dull needle that makes injection difficult.

Half-inch (1.27 cm), 30-gauge needles, although 0.3 mm in diameter, are honed to an oblique bevel that permits cannulation of vessels 0.1 mm in diameter or smaller. Needles longer than half an inch are too flexible for reliable and accurate cannulation.

We find the use of a 3-mL syringe filled with 2 mL of sclerosing solution ideal. This syringe fits well in the palm of the hand and can be manipulated easily. In addition, the quantity of solution is usually satisfactory for injecting either larger venules with 0.5 mL each or multiple smaller vessels. Alternatively, for those with small hands, a 1-mL syringe filled with 0.5 mL may be easier to handle, although a large number of syringes will be needed per treatment session and a smaller barrel syringe will lead to higher injection pressures.

Injecting with a syringe of smaller diameter will increase the pressure of the liquid at the tip of the needle; this may cause more extravasation, more transparietal burn, and may increase the risk for ‘reverse flow’ injection and subsequent necrosis. It has been measured and calculated that for the same force applied to the piston, the pressure can almost double with a small syringe (Fig. 12.7).

Figure 12.7 Pressure for the same injection force applied on piston. Little syringes increase the risk of extravasation and necrosis (micro arteriovenous fistulas, countercurrent injections).

One theoretical disadvantage to multiple injections with the same needle is that the needle will become dull.²¹ However, this was found not to occur on microscopic examination of the needle tips after eight injections into the skin (see Chapter 15).

A small vein infusion set designed for sclerotherapy is available in various gauge and tubing lengths with -inch long needles (Kawasumi Laboratories, STS Pharmaceuticals) (Fig. 12.8). These sets may provide enhanced control for cannulating small veins. In addition, the kink-resistant tubing allows for flow to ensure that the needle is in a vein and not an artery.

Figure 12.8 Sclerotherapy infusion set with a 30-gauge needle developed to aid in cannulating the smallest blood vessels.

(From STD Pharmaceutical Products, Ltd, Hereford, England).

Table and lighting

Direct lighting should be avoided during treatment because it may produce a glare from the alcohol-soaked skin. Indirect lighting allows the best visualization. Sunlight or fluorescent lighting allows the best visualization of both blue reticular veins and red telangiectasia. A remote control or dimmer switch for room light is convenient since it allows dimming when using transillumination for marking or injections.

The ideal treatment table is one that can be raised or lowered easily to provide a comfortable position for the physician to ensure injection accuracy. It is helpful if the physician can easily maneuver around the table on a stool so the best approach to a given vessel is attainable. Tables that can be positioned in Trendelenburg or reverse Trendelenburg positions can help in the treatment of an early vasovagal reaction and in effecting vessel dilation or contraction.

Skin tension

The skin must be taut to facilitate cannulation of the vessel. This can be accomplished with the help of an assistant who stretches the patient’s skin in at least two directions. Alternatively, with proper hand placement, the physician alone can produce three-point tension. Figure 12.9 illustrates the recommended technique for injection. The nondominant hand is used to stretch the skin adjacent to the treated vessel in two directions. Then the fifth finger of the dominant hand exerts countertraction in a third direction. With a little practice, even the most lax skin, such as that on the thighs, can be brought under tension with this technique. Skin laxity varies with patient age, adiposity, and location on the leg.

Figure 12.9 Proper hand placement to exert three-point traction to aid in needle insertion. Injection is made into the feeding ‘arm’ of the ‘fingers’ of the spider vein.

Depth of injection

The location of most leg telangiectasias is in the upper dermis (see Chapter 1). The most common error in technique is to place the needle tip deep to the vessel. To enter the vessel at a less acute angle almost parallel to the skin surface, the physician should bend the needle to 145 degrees with the bevel up (Fig. 12.10).²⁴ If the needle is not within the vessel, the solution will either leak out onto the skin or produce an immediate superficial wheal. At times, gentle upward traction can be applied as the needle is advanced to ensure superficial placement.

Figure 12.10 Needle is bent to 145 degrees with the bevel up to facilitate accurate insertion into the superficial telangiectasia.

(Reprinted from Goldman MP, Bennett RG: J Am Acad Dermatol 17:167, 1987, with permission from American Academy of Dermatology.)

Injection with the bevel of the needle up has the advantage of minimizing the chance of transecting the vessel. Inserting the needle bevel down may be easier, probably as the result of the vacuum produced by the bevel on the skin surface. An alternate technique is to puncture the skin very superficially, to hook it, to lift it a little in order to bring the vessel in the same axis as the needle and then to cannulate it (Fig. 12.11).

Figure 12.11 How to puncture a telangiectasia.

When using a sclerosing solution that does not cause cutaneous necrosis on extravasation (e.g. STS 0.1–0.25%, POL 0.25–0.75%, and chromated glycerin (CG)), the physician can inject it as the needle is being inserted into the vessel. As soon as the bevel is within the vessel, the telangiectasia blanches. This technique permits the injection of vessels with diameters smaller than the diameter of the needle, because the tip of the bevel is thinner than the needle shaft; with injection, the telangiectasia dilates, allowing complete insertion to occur.

Air-bolus (block) or foam technique

The air-bolus technique – injecting a small amount of air to clear the vessel before instilling the sclerosing solution – is recommended by multiple physicians.^4,5,19 It is thought to minimize the risk of inadvertent intradermal injection. This, however, may not occur, since once the vessel is cleared of blood, it is more difficult to see the progress of the sclerosing solution within its lumen. Therefore, others, including ourselves, have abandoned this technique.^21,23 Another theoretical advantage of the air-bolus technique is the decreased risk of intravascular thrombosis. It is thought that if the vessel is cleared of blood by first injecting air, the risk of extravasation of RBCs may also be minimized. However, antegrade and retrograde filling of the treated vessel occurs after the injection. Thus, the air-bolus technique may not prevent or lessen the incidence of post-treatment pigmentation. It is necessary to stress the risk of visual disturbances when using the air-block technique.^25,26

Foam injection

Another variant of the air-bolus technique that helps visualize clearing of the vessels is that of creating a foamy solution before injection. This can be achieved with the use of any ‘detergent’ class of sclerosing solution such as STS or POL (see Chapter 7). Green and Morgan²⁷ added Haemacel to STS to accentuate bubble formation. It is also thought that the foam causes the sclerosing agent to interact more efficiently with the endothelium (see Chapters 7 and 9). We have found that foaming a detergent solution increases its potency at least twofold while decreasing its caustic toxicity fourfold when a solution-to-air ratio of 1 : 4 is used. Therefore, the use of foam in treating telangiectasia less than 1 mm in diameter is tricky. Until a method is devised to standardize the size and stability of foam, the physician cannot accurately predict the foam’s sclerosing strength. We reserve the use of foam for treating reticular and varicose veins.

To create foam, a small amount of a detergent solution can be drawn into a glass syringe. While the open end of the syringe is almost totally closed, the plunger is pulled back, allowing the introduction of air through the sides of the plunger and syringe. This technique produces foam of fair quality that degrades 50% over 1 to 2 minutes.²⁸ Silicone is present in syringes in order to lubricate the barrel, making for easier compression on the plunger. We have found that the foam half-life varies over 50% for different syringes.²⁹ Some phlebologists recommend using glass syringes to avoid this variability in foam half-life. The glass syringe method necessitates appropriate sterilization of the syringe between patients.

Other methods for producing long-lasting reproducible bubble diameter foam are under development and evaluation. Sclerosing foams can be made by adding air to the liquid solution or with a tensioactive agent and CO₂, according to Cabrera et al.^30,31

The main difference between sclerotherapy with a solution and with foam is the longer duration of foam within the vein and the concentration of the damaging nonpolar end of the detergent molecule on the endothelial surface. This promotes sclerosis of the treated vessel with a lower concentration of sclerosing solution. Several methods for preparation of simple sclerotherapy foam have been proposed by Monfreux,³² Benigni et al,³³ Mingo-Garcia,³⁴ Tessari,³⁵ and Frullini.³⁶ Tessari’s method makes foam with a three-way tap and two syringes.

Hennet³⁷ used 3-mL glass syringes into which 0.3 to 0.4 mL of POL is made up as a 0.5% solution and then diluted with 0.1 to 0.2 mL of physiologic serum. The foam is stated to last for approximately 1 minute with this technique. The syringe is withdrawn until 0.6 to 1.3 mL of foam fills the syringe. The foam, as it is injected, prevents the secondary back-bleeding and is therefore in contact with the vessel wall. Hennet reported treating 10,262 patients with over 70,000 injections between November 1995 and September 1998. Less than 0.5 mL of foam was given in each injection, and compression was not used. He reported excellent results without significant adverse sequelae.

With Frullini’s method, the foam is simply produced in a disposable vial with the air contained in the vial or, preferably, with prior withdrawal of most of the sclerosing solution. A small connector is inserted into the vial, and simply pulling and pushing the liquid produces the foam (Figs 12.12 and 12.13). The key point is to generate a turbulence that produces the foam. Foam can be produced even without the connector by directly fitting the cone of the syringe into the rubber of the cap of the vial. However, the connector makes the maneuver easier and permits reuse of the system on the same patient in order to reproduce the foam for a second injection.

Figure 12.12 Syringe inserted into a vial containing approximately 0.2 mL of sodium tetradecyl sulfate 3%.

(From Frullini A: Dermatol Surg 26:705, 2000.)

Figure 12.13 Foam produced by rapid movement of the plunger in and out of the vial is stable for 5–10 min.

(From Frullini A: Dermatol Surg 26:705, 2000.)

Benigni and Sadoun³⁸ compared the efficacy and adverse-effect profile of 0.25% POL foam with 0.25% POL liquid in treating telangiectasia. They reported a 20% improvement in efficacy with foam versus liquid, without an increase in adverse effects. This is contrary to Weiss,³⁹ who found an increased incidence of pigmentation and TM when 0.1 or 0.2% STS foam was used as compared with liquid STS. Forty percent of patients treated with STS 0.1 or 0.2% foam into telangiectasia of less than 1 mm had 76% to 100% improvement and 82% had greater than 50% improvement. The incidence of pigmentation and TM increased to 20% each if a second treatment was required. Kern⁴⁰ has shown that more pigmentation occurs with foam, and we have demonstrated⁴¹ that more side effects were observed with foam. Finally, and following the conclusion of the European consensus,⁴² we do not recommend the use of foam as primary treatment of telangiectatic veins.

Quantity of sclerosing solution per injection site

The maximum quantity of sclerosing solution that can be injected safely into a single site during treatment of varicose veins is detailed in Chapter 9. In short, the physician should not inject a volume that would travel undiluted easily into the deep venous system. This is especially important because contrast material has been noted to flow from telangiectasias directly into the deep venous system in 2 of 13 patients (13.3%) with digital subtraction phlebography (Fig. 12.14).⁴³ It appears reasonable to inject solution only until the physician cannot see further progression of blood displacement. When this point occurs, the solution is most likely traveling deeper and possibly into perforating or deep veins.

Figure 12.14 Main collector of telangiectatic vessels (small arrow) drains into the femoral vein (arrow head) through a perforator vein. (Large arrow, great saphenous vein.)

(From Bohler-Sommeregger K et al: J Dermatol Surg Oncol 18:403, 1992.)

The maximum amount of sclerosing solution that can be injected into leg telangiectasias is unclear. Although Duffy²¹ placed little emphasis on limiting the amount of solution injected at a single site, and Lary⁴⁴ recommended the injection of up to 3 mL at a single site when injecting a reticular 3-mm diameter vein, multiple complications can and do occur from this technique. Excessive inflammation and inadvertent flow of the solution into a feeding varicose vein or arteriole can produce ulceration with injection and damage to the deep venous system. Thrombosis and emboli can occur when amounts greater than 1 mL are injected in a single site. For example, injection of 0.5 mL of solution into a 2-mm diameter vessel fills a length of 16 cm (see Chapter 8).

Ouvry and Davy⁴⁵ recommend that the amount injected should be sufficient to produce blanching of vessels 1 to 2 cm around the point of injection. No more than 0.5 mL should be used to avoid the risk of initiating the formation of new telangiectasias around the edge of the treated area because of excessive inflammation. In this regard, the same area should not be retreated more often than every 4 to 6 weeks. In our practice it appears that TM occurs more frequently if reinjections are given to a previously treated area that is still undergoing resolution. This unresolved state can be appreciated clinically by slight inflammation and evidence of microthrombosis of vessels.

In addition to limiting the inflammatory reaction of sclerotherapy treatment, limiting the amount of solution may prevent pain and cramping when hypertonic solutions are used. Sadick¹⁷ has found that volumes greater than 0.3 mL of HS 23.4% caused the most pain and cramping. One way to minimize the pain from injection of HS is to dilute the HS with lidocaine to the appropriate concentration. One study noted a decrease in pain of 30% with use of this dilution technique.⁴⁶

Some areas, especially the ankles, should not be injected with more than 1 mL of any sclerosing solution. In this area, the skin is thinnest, the distance between the deep and superficial venous system is the least, and swelling after treatment is common (see Chapter 8). From a purely legal point of view, French regulations (dictionnaire Vidal, Vidal Ed. Paris 2009) recommend not to exceed 10 mL of STS 3%, 2 ampules of 2 mL of POL (any dosage), and 10 mL of CG.

Post-Treatment Techniques

Immediately after injection of the sclerosing solution, the perivascular tissues may swell, producing a clinically visible occlusion of the vessel, or the vessels may go into spasm. This usually occurs if the injection is given slowly and if the sclerosing solution is of adequate strength. Indeed, several authors recommend that a given vessel be treated until such an effect occurs.¹⁹ This may require a second injection of a more concentrated solution (125%) into the same vessel during the same sclerotherapy session.

After hypertonic solutions are injected, the injected area should be massaged to minimize the stinging and help alleviate the associated muscle cramping by rapidly diluting the hyperosmotic solution outside of the treated vessel.^21–2355 The slower the injection, the less the cramping. When the needle is withdrawn, a small amount of sclerosing solution may be deposited under the skin, causing a burning sensation. This usually occurs only with hypertonic solutions and CG. Massaging for 30 to 60 seconds alleviates the pain and prevents necrosis from the HS solution.²²

All sclerosing solutions, even unadulterated HS (see Chapter 8), produce some degree of erythema or urtication or both with injection. Pruritus may be associated with this effect, especially when associated with urticarial lesions. This probably occurs as a result of histamine release caused by perivascular release of mast-cell mediators because of perivascular irritation or as a result of intravascular degranulation of basophils and other white blood cells destroyed by the direct toxic effects of the sclerosing solution. This reaction and its associated pruritus can be minimized by the application of a potent topical corticosteroid cream, thereby providing relief to the patient, especially if injected areas will be occluded with compression pads or stockings.

For telangiectasias that do not respond to standard compression sclerotherapy, added vasoconstriction induced by cold temperature may be helpful. Orbach⁵⁶ found that vessels respond better to the injection of refrigerated sclerosing solution. Marteau and Marteau,⁵⁷ using similar logic, advised applying cold compression pads after injection. Although these two techniques seem logical, we have not found them helpful as detergent sclerosants are theoretically more ‘active’ at higher temperatures.

Post-treatment bruising is common and bothersome to patients, even if its disappearance occurs over a few weeks without residual discoloration. It may be useful to recommend application of topical creams like Hirucrème (contains Hirudo medicinalis extract) or Hirudex, which has demonstrated efficacy on mild bruising.⁵⁸ In case of local discomfort, anti-inflammatory nonsteroidal creams can be applied as well.

Post-treatment compression

For many phlebologists, compression of the sclerosed vessel with a 30- to 40-mmHg graduated compression stocking should be maintained for a minimum of 24 to 72 hours after treatment of leg telangiectasias.⁵⁹ Postsclerosis compression serves a number of purposes. First, the pressure helps seal the irritated vascular lumen. Second, the pressure helps decrease the likelihood of recanalization of the sclerosed vessel, especially if compression is maintained for 1 to 2 weeks. Third, the possibility of clinical and symptomatic thrombosis is minimized, thus minimizing hyperpigmentation, TM, and recanalization after sclerosis. Although some physicians do not advocate postsclerosis compression,^{7,17,22,25,57,60} and consider that its only use is to protect against side effects of an inappropriate technique,⁶¹ the procedure is simple, safe, and its benefits likely, so its routine use may be recommended. In addition, most patients actually like the feel of the compression stocking while they are ambulatory. (A complete discussion on the use of compression in the treatment of varicose and telangiectatic leg veins is presented in Chapter 6.)

A second aspect of compression is represented by the local dressing applied on the injected vein. It usually consists of a cotton ball or pad and adhesive tape. It exerts double compression: perpendicular (by application of Laplace’s law) and tangential (by direct traction on the skin on both sides) (Fig. 12.15). This type of compression may be stronger than compression exerted by stockings. How long to keep it in place is unknown: advice ranges from 1 hour to more than 24 hours. This type of compression has at least one obvious advantage: it stops bleeding. Although bleeding is not usually a problem, especially if feeding reticular veins are treated first, some patients who have a decreased coagulability may benefit from local compression.

Figure 12.15 Lateral (tangential) and Laplace’s (perpendicular) pressures exerted by local compression.

Microthrombectomy

Spider veins (especially those bigger than 0.6 mm in diameter) and reticular veins are likely to form microthrombi after being injected. This phenomenon is less frequent with glycerin than with detergent solutions, especially foam. As discussed in Chapter 8, to prevent pigmentation, microthrombectomy is carried out as early as 1 to 2 weeks after injection. Microthrombectomy is easily executed with any needle, the important point being to puncture every millimeter of the ‘blue line’ of the microthrombi (Fig. 12.16A–C). In very small venules, manual pressure is unnecessary; a cotton ball is applied and kept in place for several hours with an adhesive tape.

Figure 12.16 Microthrombectomy.

Repeat Treatment Sessions

All patients are informed that successful treatment of a given telangiectasia may require more than one treatment (in general, and also on each treatment site). Patients easily understand that, like for wall painting, 2 or 3 thin layers give a better result than a thick one. As previously mentioned, the same vessel or the immediate area is not retreated for 4 to 6 weeks to allow resolution of the endosclerosis or controlled phlebitis to occur. Waiting also allows appreciation of the effectiveness of treatment with a given solution and concentration. If little change is apparent 6 weeks after injection, the second treatment can be performed with a stronger sclerosing agent or more concentrated solution. Different areas can be treated as often as every day, but the venous system of the leg is a complex interwoven network, so treatment of only one part may not prevent reflux pressure from another part promoting continued blood flow through the treated area (see Chapter 1). This leads to an increased incidence of complications from blood flow through a damaged endothelial system (see Chapter 8). Thus, in the treatment of superficial reticular and telangiectatic leg veins, the only real limiting factor is patient and physician motivation for treatment and adherence to using the maximum daily recommended amounts of sclerosing solution that can be injected (see Chapter 7). In addition, if compression is used, it may be best to wait until the pressure stocking has been removed for a few days before treatment is continued on the same leg.

Poor Results of Microsclerotherapy: How to Analyze the Reasons

Objective poor results present in many forms (Fig. 12.17); they differ from subjective poor results, where patients are not satisfied despite a satisfactory outcome. Most poor results are related to an inappropriate treatment. Two types of error are possible:

Figure 12.17 Objective bad results: two types.

The bad strategic approach is usually due to an inadequate physical examination and/or duplex ultrasound assessment. If varicose veins are left untreated, although known and identified, microsclerotherapy alone is unlikely to produce a satisfactory result and may even lead to the production of new lesions.

When the technique is deficient, it can have three consequences. First insufficient delivery of active drug in the spider network is responsible for a lack of efficacy. Second, excessive power of the sclerosing agent (too high a concentration and/or injection pressure and/or volume) results in a transparietal burn and subsequent inflammation (matting) and blood deposit with pigmentation. The third possibility is an imprecise injection, outside the vein lumen. This can result in inflammation or necrosis.

Sclerotherapy Treatment of Facial Telangiectasia

Sclerotherapy treatment of facial telangiectasia has proved to be effective and safe (see Case study 12).⁸ However, there is a potential for sight-threatening complications from periocular vascular manipulation. This topic was reviewed and is abstracted here.⁶²

Inadvertent intra-arterial injection of corticosteroid suspensions in the periocular region has been reported to lead to embolic occlusion in the ophthalmic artery distribution, causing blindness.⁶³ Inadvertent intra-arterial injection is the likely factor permitting steroid particulate emboli to reach the retinal circulation. Severe visual loss has also been reported following intralesional steroid injection into a chalazion, again apparently causing retinal and choroidal embolic occlusion, presumably as a consequence of inadvertent intra-arterial injection.⁶⁴ Since it is not a suspension, distal embolic phenomena would not be expected from an injection of STS. However, as an intravascular sclerosant agent it clearly presents a danger if it gains inadvertent access to normal vessels supplying the eye in therapeutic concentrations through the production of an embolus composed of denatured endothelial cells and blood cell elements (see Chapter 8). Presently accepted standards of injection technique, including careful placement of the needle, repeated aspiration, and careful stabilization of the syringe, do not guarantee that the physician can detect if the bevel is against or within the vessel wall if the vessel is constricted, or if there has been any intra-arterial placement of the needle.⁶⁵

Although Green⁶⁶ reports that despite the numerous and variable anastomoses between the superficial facial and deep orbital venous systems, injection into superficial eyelid veins is ‘highly unlikely’ to reach the orbit, his technique uses comparatively large volumes (1–3 mL) of STS. Since venous pressure is quite low, it is not inconceivable that intravenous eyelid injection could reach the orbit (where there are no venous valves) and hence the ocular adnexae, the central retinal vein, the choroidal vortex veins, or even the cavernous sinus through these anastomoses. Monocular blindness has been reported following STS injection into a venous malformation partially located in the orbit.⁶⁷ Green’s technique uses compression only after delivery of the sclerosing solution. At that point, compression could conceivably force the solution into the orbital vessels through the variable anastomotic channels. Since the purpose of his compression is to delay the return of blood into the treated vein, the sclerosing solution forced upstream or downstream would not be significantly diluted necessarily and could be potentially dangerous.

Current treatments for cosmetically objectionable lower eyelid veins include direct cautery application through small cutaneous incisions and direct cautery plus surgical vein transection.⁶⁸ These procedures pose no known risks to the remainder of the vascular system but could be complicated by cutaneous scars. Surgical removal of the vein through a 2-mm incision with a phlebectomy hook has also been shown to be effective.⁶⁹ The vein can be tied off with an absorbable 6-0 suture with minimal bruising. However, this technique requires practice to avoid damage to perivascular tissue.

Our technique of sclerotherapy of lower eyelid veins has been reported previously as part of larger series.⁸ We recommend using very small quantities of Sclerodex (dextrose, sodium chloride, phenethyl alcohol) for treating facial telangiectasias and prominent periorbital veins. The technique is the use of 1 mL or less of sclerosant solution for 24 hours after proximal vein ligation with a 6-0 Prolene suture. The suture prevents backflow of the solution into the retro-orbital venous system. This allows vigorous massage of the area and complements immediate compression. Use of a hypertonic solution provides for effective sclerosis of the vein within the concentration gradient of the solution. A detergent sclerosing solution like STS may travel for many centimeters from the site of injection into areas that should not be sclerosed (see Chapters 7 and 8). This technique demonstrates a 90% to 100% improvement in 70% of patients after one treatment.⁷⁰ No adverse effects have been reported.

Laser technologies, including the long-pulsed, dynamically cooled 1064-nm Nd:YAG laser (CoolTouch Varia, New Star Lasers, Rosemont, Calif.) has been reported to treat periorbital vessels 1 to 2 mm in diameter with a near 100% efficacy.⁷¹ Lasers of lower wavelength would not be expected to deliver sufficient energy at the correct depth to thermocoagulate a vessel of this size without producing excessive cutaneous thermal damage.⁷²

Sclerotherapy Treatment of Essential Telangiectasia

Vessels of essential telangiectasia are extremely small, usually measuring less than 0.1 mm in diameter, and are often associated with a feeding arteriolar component (see Chapter 4). Lasers and intense pulsed light (IPL) are the easiest techniques to cause their involution (see Chapter 13). However, sclerotherapy may also be used to decrease the extent of the lesion. Sclerotherapy should be performed with a dilute solution. Lim and Kossard⁷³ have successfully treated a 56-year-old patient with STS 0.08% with good efficacy and no adverse effects.

Conclusion

It is clear that sclerotherapy is the ‘gold standard’ for treating leg telangiectasia. In certain cases, lasers or IPL therapy is also effective and recommended (see Chapter 13). The lay press is filled with products that patients can apply to the legs to eliminate leg telangiectasia. A scientific evaluation of one of these products showed conclusively that a vitamin K-containing cream touted to eliminate vessels has no effect compared with placebo when used daily over 33 days.⁷⁴ Although we as physicians think of medicine as a science, it is also an art. Therefore, the sclerotherapy technique just mentioned should not be perceived as dogma. Rather, it should serve as a logical outline for the physician in planning individualized treatment.

Case Study 1 Traumatic telangiectatic patch

A 46-year-old woman was accidentally hit by a tennis ball while she was ‘playing the net’. A telangiectatic patch on the posterior medial thigh developed after resolution of the bruise 4 to 6 weeks after the initial injury and did not change in size or color over the following 4 years (Fig. 12.18A). The patch was treated on one occasion only, with injections of POL 0.5% in three locations to blanch the lesion completely. A total of 1 mL was used. A localized pressure dressing with an STD foam pad was placed and secured with adhesive tape for 3 days. Figure 12.18B, shows the same area 10 months after initial treatment.

Figure 12.18 Case Study 1. A, Telangiectatic patch on posterior medial thigh. B, 10 months after treatment.

Case Study 2 Unassociated telangiectasia

Figure 12.19A, shows the appearance of linear telangiectasia on the medial thigh of a 46-year-old woman, which was noted during her second pregnancy 22 years previously. The area was asymptomatic, and treatment was requested for cosmetic improvement. The appearance 6 months after a single treatment using approximately 3 mL of POL 0.5% is shown in Figure 12.19B. A 30- to 40-mmHg graduated compression stocking was worn for 3 days after the injection. Note some mild hyperpigmentation in one of the treated vessels.

Figure 12.19 Case Study 2. A, Linear telangiectasia on medial thigh. B, 6 months after treatment.

Case Study 3 Reticular vein unassociated with the saphenous system

A reticular vein 2 to 3 mm in diameter on the popliteal fossa in a 32-year-old woman is shown in Figure 12.20A. The same area 18 months after one treatment with 1 mL of POL 0.75% is shown in Figure 12.20B. The area was compressed for 72 hours after treatment with an STD foam pad under a 30- to 40-mmHg graduated compression stocking, after which the compression stocking alone was worn for 1 more week while the patient was ambulatory. In the intervening 18 months, the patient wore a 20-mmHg graduated compression stocking on a fairly consistent basis while she was ambulatory.

Figure 12.20 Case Study 3. A, Reticular vein on popliteal fossa. B, 18 months after treatment.

Case Study 4 Mixed reticular and telangiectatic veins

Reticular veins approximately 2 mm in diameter associated with multiple telangiectasias on the lateral distal thigh in a 32-year-old woman appeared during her second pregnancy 10 years previously (Fig. 12.21A). The patient requested treatment because of a dull aching that occurred in the area during menses and after prolonged standing. The treated veins are shown immediately after a total injection with 0.5 mL of POL 0.75% in Figure 12.21B, and Figure 12.21C shows the treated area 1 day after injection after removal of the STD pad and a 30- to 40-mmHg graduated compression stocking. Note the ecchymosis induced by the pressure dressing. Figure 12.21D, shows the area 1 week after injection. Intravascular thrombi were noted and drained at that time. Eight weeks after injection, the vessels were almost totally resolved. Some mild pigmentation was present in the distal aspect in which thrombosis was most extensive (Fig. 12.21E). Finally, Figure 12.21F, shows the area 22 months after initial treatment, demonstrating sustained resolution of the telangiectasia, reticular veins, and pigmentation.

Figure 12.21 Case Study 4. A, Reticular veins associated with multiple telangiectasias on lateral distal thigh. B, Immediately after injection. C, 1 day after injection and removal of pad and graduated pressure stocking. D, 1 week after injection. E, 8 weeks after injection. F, 22 months after treatment, with complete resolution.

Case Study 5 Extensive reticular and telangiectatic veins

A 53-year-old woman had a 30-year history of asymptomatic reticular and telangiectatic leg veins that had been stable in appearance since her last of two pregnancies 20 years previously. She sought treatment for cosmetic reasons (Fig. 12.22A). A total of 10 mL of POL 0.75% was injected into all feeding reticular veins on the proximal and distal lateral thigh. Policocanol 0.5%, 2 mL, was injected into the portion of the telangiectatic mats on the lateral calf and knee, which did not blanch with the previous injection. STD foam pads were placed under a 30- to 40-mmHg graduated support stocking that was worn continually for 7 days after the procedure. When the stocking was removed, multiple small thrombi were drained. Figure 12.22B, shows the appearance of the treated area 25 months after the single treatment session.

Figure 12.22 Case Study 5. A, Reticular veins on the proximal and distal lateral thigh. B, 25 months after treatment.

Case Study 6 Treatment of cherry hemangiomas

A 48-year-old woman had multiple cherry hemangiomas on her abdomen and thighs and a 4-mm-diameter hemangioma located on her anterior thigh (Fig. 12.23A). Figure 12.23B, shows the appearance 5 months after injection with 0.1 mL of POL 0.75%. Note the slightly indented and hypopigmented scar, which was acceptable to the patient.

Figure 12.23 Case Study 6. A, Multiple cherry hemangiomas on anterior thigh. B, 5 months after injection.

Case Study 7 Lateral subdermal plexis

A 59-year-old woman was seen initially with a leg ache from the lateral thigh veins that had been increasing in severity over the previous 2 years. Reticular and telangiectatic veins had been present since age 16. The lateral subdermal plexus, noted as having 2- to 3-mm diameter reticular veins, was incompetent to venous Doppler examination (Fig. 12.24A). Sclerotherapy began with injection of a total of 4 mL of POL 0.75% to all reticular veins on the left leg while the patient was supine. All telangiectasias that did not become inflamed after reticular vein injection were then sclerosed with a total of 6 mL of POL 0.5%. The leg was compressed for 72 hours with a 30- to 40-mmHg graduated compression stocking. A second treatment to the same leg was given 4 months later with 4 mL of POL 0.75% injected into reticular veins and 2 mL of POL 0.5% injected into remaining telangiectasias. The leg was compressed as previously described, and all veins and bruising resolved within 2 months. Figure 12.24B shows total resolution of all veins 1 year after the second treatment.

Figure 12.24 Case Study 7. A, Clinical appearance before sclerotherapy. B, Clinical appearance 1 year after treatment (see text for details).

Case Study 8 Long-term follow-up of sclerotherapy treatment of telangiectasia

A 43-year-old woman presented with dilated pretibial reticular veins 2 to 4 mm in diameter (Fig. 12.25A). She gave a history of playing tennis and working on a hard floor. No evidence of truncal vein incompetence was found. She was treated with one session of sclerotherapy using 2 mL of 0.5% STS and then wore 30- to 40-mmHg graduated compression stockings 24 hours a day for 7 days. She reported complete resolution of her veins after 6 to 8 weeks and did not recall any post-treatment pigmentation. She presented 16 years later for treatment of new veins on her thighs (Fig. 12.25B).

Figure 12.25 Case Study 8. A, Dilated pretibial reticular veins. B, Presentation with new veins 16 years after treatment.

Case Study 9 Long-term follow-up of sclerotherapy treatment of telangiectasia

A 52-year-old woman presented with scattered telangiectasia in patches without obvious feeding reticular veins on her anterior thigh (Fig. 12.26A). Veins measured 0.2 to 0.4 mm in diameter. She was treated with one session of sclerotherapy using 1.5 mL of 0.25% STS and then wore 30- to 40-mmHg graduated compression stockings 24 hours a day for 7 days. She reported complete resolution of her veins after 4 to 6 weeks and did not recall any post-treatment pigmentation. Figure 12.26B, shows the appearance of the treated area 6 years later when she presented for treatment of new veins on her calves.

Figure 12.26 Case Study 9. A, Scattered telangiectasia in patches without obvious feeding reticular veins on the anterior thigh. B, Presentation 10 years later with persistent resolution of the treated veins.

Case Study 10 Treatment of telangiectasia and resulting telangiectatic matting

A 66-year-old woman was seen initially with extensive telangiectasias and venules 0.2 to 0.6 mm in diameter over the left lateral knee (Fig. 12.27A). These veins developed when she was near 40 years of age after she began estrogen replacement therapy. There was no previous family history of varicose veins. In addition to the cosmetic appearance that was disturbing when she wore shorts while playing golf, her legs ached continuously, especially over the telangiectasias. These vessels were treated with POL 0.5%, 2 mL, with the development of TM 4 weeks after treatment (Fig. 12.27B). Examination 3 months after initial treatment showed a ‘feeding’ reticular vein in the telangiectatic area. The feeding reticular vein, 2 mm in diameter, was treated with POL 0.75%, 1 mL, and the TM vessels were then treated with CG mixed 1 : 1 with lidocaine 1% with epinephrine, 1 mL, with resolution occurring in approximately 4 weeks. When the woman was examined 1 year later, the telangiectasia and leg pain had both resolved (Fig. 12.2C).

Figure 12.27 Case Study 10. A, Clinical appearance before sclerotherapy. B, Developmental of telangiectatic matting after sclerotherapy. C, Resolution of telangiectasia 1 year after treatment (see text for details).

Case Study 11 Treatment of facial telangiectasia

A 40-year-old man with a 20-year history of a prominent periorbital vein requested treatment (Fig. 12.28A). Physical examination showed a 2-mm venule in the lateral infraorbital region. A 6-0 Prolene suture was placed in the lateral canthal crease to close the vein circumferentially, and 0.2 mL of Sclerodex was injected slowly into the bulging vein. Immediate handheld pressure was applied with an ice pack and maintained by the patient for 5 minutes. The suture was removed the next day. Figure 12.28B, shows the appearance 8 weeks after treatment. A tiny coagulum is present in the resolving vein. Follow-up examination 12 years later showed continued elimination of the vein (Fig. 12.28C).

Figure 12.28 Case Study 11. A, Periorbital vein prior to treatment. B, Appearance 8 weeks after treatment. C, Continued elimination of the vein 12 years after treatment.

(From Goldman MP, Weiss RA, Brody HJ, et al: J Dermatol Surg Oncol 19:899, 1993.)

Case Study 12 Treatment of facial telangiectasia

A 65-year-old man presented with prominent perinasal red telangiectasia (Fig. 12.29A). A slow infusion of POL 0.5% was given into the telangiectasia, and the solution was held in place until the vessel went into spasm. A total of 0.5 mL of solution was given in a single treatment session into nasal vessels. Three weeks after treatment, the vessels had resolved (Fig. 12.29B). When the patient was seen in follow-up 15 years later, the treated vessels were not present. New red telangiectasias were present but not as prominent as before treatment (Fig. 12.29C).

Figure 12.29 Case Study 12. A, Perinasal telangiectasia before treatment. B, Appearance 3 weeks after one treatment with 0.5 mL of polidocanol 0.5%. C, Appearance 15 years after initial treatment. Note persistent resolution of treated telangiectasia with appearance of new telangiectasia.

Case Study 13 Facial telangiectasias and venous malformation

An 8-year-old boy had been treated 4 years before for an extensive venous malformation of the right cheek. The initial treatment had included embolization with Ethiblock and subsequent surgical removal of remaining material. A perilesional network of spider veins outlining the remaining scar was still present (Fig. 12.30A). Injection of 1 mL of 0.5% POL foam in three different points was challenging since the patient had also requested local anesthesia with EMLA cream, inducing a venous spasm. Two sessions gave a nice improvement, and patient satisfaction.

Figure 12.30 Case Study 13. Facial telangiectasias and venous malformation: A, before, and, B, after treatment with polidocanol foam.

Case Study 14 Sclerotherapy of telangiectasias on venous malformation

A 12-year-old girl presented with an extensive venous malformation of the left limb. Lesions were present at birth. One can observe the development of large competent superficial veins: great saphenous vein and accessory anteromedial extrafascial tributary (Fig. 12.31). A wide but light-pink port-wine stain extended the length of the limb, but both legs had the same length and circumferences. The girl was mainly concerned with the development of telangiectatic and reticular veins on the anterior, medial, and lateral aspects of the limb. Since reflux had not been detected, neither in the deep nor in the superficial venous networks, careful microsclerotherapy with POL 0.5% foam was carried out, improving the lesions with patient satisfaction after four sessions.

Figure 12.31 Case Study 14. Telangiectasias on venous malformation.

Case Study 15 Treatment of reticular chest veins

A 40-year-old woman developed dilated reticulated veins on her chest shortly after breast augmentation (Fig. 12.32A). Sclerotherapy was performed using STS 0.25% foam made by using 1 mL of STS and 4 mL of air. A total of 8 cm³ of foam (2 mL of solution) was used to infiltrate the entire anterior chest venous network. Figure 12.32B, shows the appearance 3 months after treatment.

Figure 12.32 Case Study 15. A, Dilated reticulated veins on the chest. B, Appearance 3 months after sclerotherapy using sodium tetradecyl sulfate 0.25% foam. C, Appearance 5 years after treatment. Note persistent resolution of the treated veins.