Etiology

Although research continues to be done in this area, there is consensus today that telangiectasias result from a number of causes, alone or more likely in combination with other etiologic factors. Telangiectatic leg veins, according to the contemporary research, arise as a result of venous hypertension secondary to a number of different causes and conditions. The etiology of varicose veins and telangiectasias, for the most part, is similar. The pathophysiology of telangiectasias is usually broadly categorized as genetic/congenital, acquired and iatrogenic. Some of the genetic causes of telangiectasias include nevus flammeus (port- wine stains), nevus araneus (spider telangiectasia, which can also result from acquired diseases), and Klippel-Trenaunay syndrome. Congenital conditions associated with telangiectasias include Maffucci syndrome and Rothmund-Thomson syndrome (poikiloderma). Acquired causes of telangiectasias can arise from a primary cutaneous disorder, such as varicose veins and keratosis lichenoides chronica, or the result of a disorder with a secondary cutaneous component, such as lupus erythematosus, a collagen disorder, and mastocytosis (telangiectasia macularis eruptiva perstans). Hormonal influences (estrogen and progesterone) also play a role in the pathogenesis of telangiectasia. Pregnancy places the person at risk for the development of telangiectasia as early as a couple of weeks after conception. Birth control pills, menses, and the time just before ovulation are also associated with the development or worsening of telangiectasia, and increased venous dispensability. Topical steroids, particularly at high doses, have also been identified as a possible causative factor. Last, physical insults, like trauma (contusions) and infection, have also been implicated as causal forces. See Box 11-1 for a comprehensive listing of the many causes of lower leg cutaneous telangiectasia.

Telangiectasia is also associated with a number of other conditions and traits. These include, but are not limited to, those listed here:

Fig 11–1 Normal subcutaneous venous anatomy.

Fig 11–2 Patient with Klippel-Trenaunay syndrome.

Fig 11–3 Spider vein.

Fig 11–4 Nevus flammeus.

(From Weiss RA, Goldman MP, Bergan JJ, et al. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins. St Louis: Elsevier, 2007, Fig. 4.6, p. 76.)

Fig 11–5 Woman, 16 years old, with Klippel-Trenaunay syndrome and associated varicose veins and nevus flammeus of the right lower extremity from the toes to the buttock.

(From Weiss RA, Goldman MP, Bergan JJ, et al. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins. St Louis: Elsevier, 2007, Fig. 4.17, p. 84.)

Fig 11–6 Extensive fine red telangiectasia on the chest of a severely sun-damaged 50-year-old woman.

(From Weiss RA, Goldman MP, Bergan JJ, et al. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins. St Louis: Elsevier, 2007, Fig. 4.19, p. 85.)

Fig 11–7 This woman underwent an extensive ligation and stripping of her varicose veins at 18 years of age. She developed extensive telangiectasia around all of the surgical sites within weeks of the surgical procedure. This photograph was taken 22 years after the surgical procedure.

(From Weiss RA, Goldman MP, Bergan JJ, et al. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins. St Louis: Elsevier, 2007, Fig. 4.20, p. 86.)

Fig 11–8 Appearance of telangiectasis occurring as a result of radiation treatment on the lateral neck for laryngeal carcinoma 20 years previously.

(From Weiss RA, Goldman MP, Bergan JJ, et al. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins. St Louis: Elsevier, 2007.)

Patient Selection

Patients with spider telangiectasias typically present with primarily cosmetic complaints. Patient selection for the treatment of spider telangiectasias, as with all medical treatments, begins with a thorough assessment that includes not only an assessment of the person’s telangiectasia, but also the medical history, chief complaint, family history, and the patient’s expectations relating to his or her possible spider telangiectasias. On the basis of this assessment, the physician must determine whether or not the treatment can resolve the patient’s cosmetic complaints. At times, the telangiectasia is the result of a more generalized, systemic problem such as venous insufficiency. If venous insufficiency is present, it must be treated prior to the treatment of the spider telangiectasia; otherwise, the venous hypertension would likely thwart the desired outcome. Second, it must be determined whether the patient’s expectations are realistic and achievable. The patient must clearly understand that the treatment is elective and that it is not likely to produce any significant health benefits. The patient should also understand that multiple treatments are often necessary for optimal results. Some patients may not be willing to do this. As with all invasive procedures, the patient must be educated about the benefits, risks, and alternatives to treatment. He or she must be thoroughly aware of all potential adverse sequelae and possible complications. Last, the patient must be informed that the treatment of spider telangiectasias is not curative and that further development of telangiectatic areas is likely.

Although there are no absolute contraindications to this treatment, people taking certain medications and/or patients with some chronic illnesses, especially those that could affect the occurrence of sclerotherapy complications, should be approached with extreme caution. For example, conditions such diabetes and peripheral vascular disease may lead to serious complications, such as ulcers. Some medications, such as minocycline or isotretinoin, can lead to adverse reactions if not discontinued prior to the treatment.

Endovascular Instrumentation

The basic endovascular instrumentation used for the treatment of spider telangiectasias includes needles for access and syringes to deliver the sclerosant to the affected areas. The needles used for telangiectasia are typically 30 gauge, although a 27-gauge butterfly needle may be used sometimes for larger reticular veins. Smaller needles, as small as a 33 gauge, can also be used but they tend to bend too easily when they are penetrating the skin (Fig. 11-9).

Fig 11–9 Needles and syringes.

(Courtesy Dr. M. Nerney.)

The syringes that are typically used vary from a 1-mL tuberculin syringe to a 3-mL syringe. Most prefer a 3-mL syringe because it exerts the lowest pressures during injection, and it is also manually manipulated more precisely by the practitioner than a 1-mL syringe, especially if it is only filled to 2 mL.

The environment of care for sclerotherapy should include a comfortable table for the patient, a comfortable room temperature, and ample lighting. The treatment table height should permit the physician to sit comfortably on a stool with his or her legs under the table without having to lean over the table and the patient for access. Environmental lighting should be bright and capable of providing adequate indirect illumination without any glare on the patient’s skin (Fig. 11-10).

Fig 11–10 Table and chair.

General supplies would include alcohol swabs, cotton balls, tape, and compression supplies such as Ace wraps or Coban. Patients can supply their own stockings or they can be provided by the practice, which would require keeping a fairly large inventory (Figs. 11-11 and 11-12).

Fig 11–11 Surgical supplies.

Fig 11–12 Compression stockings.

Last, but also most important, is emergency equipment. Fortunately, life-threatening complications are very rare; however, they are always possible. Basic emergency equipment must minimally include oxygen, airway equipment, epinephrine, steroids, and antihistamines (Fig. 11-13).

Fig 11–13 Emergency equipment.

Imaging

Spider telangiectasias are primarily a cosmetic, aesthetic concern for the patient; therefore, they are primarily treated visually. Several things can be used to aid in the visualization.

First and foremost are magnifying glasses or loupes. These aids help to visualize the insertion of the needle into the smaller veins, particularly those that are less than 1 mm in diameter. Because loupes typically have times the magnification, they facilitate good visualization while the needle pierces the skin and enters the vein (Fig. 11-14).

Fig 11–14 Loupes.

A number of lighting systems are used for visualization of veins to be treated. Vein lights provide visualization of vessels just under the skin that are sometimes too deep for normal visualization. These lights create a “shadow” from the absorption of the blood in the vein. Polarized lights are also used to provide better visualization through the skin (Fig. 11-15).

Fig 11–15 Vein light.

(Courtesy Dr. M. Nerney.)

Syris polarized lights with magnification (Syris, Gray, ME) also provide better visualization through the skin (Fig. 11-16).

Fig 11–16 Syris polarized light.

(Courtesy Dr. M. Nerney.)

Infrared visualization is also done. Infrared lights allow the practitioner to see veins a few millimeters under the skin because these lights provide infrared images of the hemoglobin contained within the red cells circulating in the vessel that is then projected back onto the skin using the VeinViewer or a camera. This is particularly helpful for identifying “feeding” reticular veins that could be causing the telangiectasias (Fig. 11-17).

Fig 11–17 Vein viewer.

(Courtesy Dr. M. Nerney.)

Duplex imaging is also an invaluable tool. This imaging is primarily used for the diagnostic workup of venous insufficiency. It is also used for directing that treatment, including varicose veins. New high-frequency probes, in the 15- to 17-mHz range, can identify very small veins, as small as 1 to 2 mm, such as reticular “feeding” veins. These reticular feeding veins may demonstrate reflux that may contribute to spider telangiectasias.

Sclerosants

Sclerosants used for the treatment of spider telangiectasias can be divided into three main groups: detergents, hyperosmolar, and chemical irritants. This section will cover the most frequently used sclerosants for treatment of telangiectasias in the United States.

The detergent solutions are primarily sodium tetradecyl sulfate (STS) (Sotradecol) and polidocanol (POL). These solutions work by attacking the endothelial cells at their cell surface lipids. STS has been around since 1946. It is manufactured in the United States by BionichePharma. STS is used for the treatment of spider telangiectasias in various concentrations from 0.05% to 0.5%. It can be foamed if desired. POL, used for the treatment of spider telangiectasias, comes in concentrations of 0.25% to 1% and it, too, can be used as a foam. POL just recently became approved by the U.S. Food and Drug Administration (FDA), so experience with it is not nearly as extensive as it is in Europe.

The hyperosmolar, or hypertonic, sclerosant group consists primarily of hypertonic saline (HS), hypertonic dextrose, sodium salicylate, and a combination of hypertonic saline and hypertonic dextrose. These agents work by dehydrating the endothelial cells. Hypertonic saline is used in concentrations of 11.7% to 23.4%. Hypertonic dextrose comes in a concentration of 75% that can be diluted. The combination of 10% saline and 25% dextrose is sold as Sclerodex manufactured by Omega laboratories in Canada.

Chemical irritant sclerosants that are currently used in the United States are primarily limited to glycerin 72%. It works as a caustic agent on the vessel wall. Glycerin can be diluted, most frequently with lidocaine 1% with or without epinephrine (Fig. 11-18).

Fig 11–18

Pain

Pain and soreness are sometimes experienced; however, there are a number of interventions that can be used to minimize and eliminate this discomfort. The pain and discomfort are a function of several variables including the treatment site, the injection technique, the sclerosing agent, and the needle itself. The level of discomfort is typically greatest when the feet, ankles, medial knees, and/or medial upper thighs are treated. Pain and discomfort can be prevented or diminished with the use of the smallest possible gauge bevelled needle that is silicone coated, sclerosing agents with a lidocaine additive, and slow infusion followed immediately by massage.

The hypertonic solutions used for sclerotherapy are synonymous with pain and discomfort; however, the pain can be decreased without any compromise in terms of desired outcome when a 2% solution of nonacidified lidocaine is added to the sclerosing agent and no more than 0.1 mL is slowly injected into each site followed by massage. Although the effectiveness of the treatment is not compromised, the addition of lidocaine may increase the risk of an allergic response. The addition of 1% lidocaine and a limitation of no more than 0.1 mL per site are recommended for glycerin sclerosing solutions to prevent pain and cramping. STS and POL are virtually painless with proper technique; however, STS can lead to pain when it is accidentally injected into perivascular areas.

Any transient pain or discomfort can be effectively treated with properly fitting graduated compression stockings for a week or two after the treatment. The presence of severe and/or unrelieved pain signals the need to assess the patient for venous thrombosis and inflammation.

Edema

Temporary swelling can result from a number of factors, including the nature of the treated site, perivascular and intravascular space differentials, endothelial permeability, the strength of the sclerosing solution, the volume of the sclerosing solution, and the lack of proper graduated compression after the treatment (tourniquet effect).

Posttelangiectasia treatment edema is most often associated with treatment areas below the ankle; however, edema can be present in other areas as well. Limiting volume to no more than 1 mL for each ankle can prevent or minimize swelling in this area. The extent of inflammation and resulting edema in the perivascular area is affected by the strength of the sclerosing agent and the client’s unique status in terms of mast cells (sensitivity), medication profile (e.g., nonsteroidal antiinflammatory drugs [NSAIDs], corticosteroids), and a history of sclerosing agent sensitivity. The application of graduated compression stockings for up to 3 weeks posttreatment may be helpful for some patients, as is the application of a topical corticosteroid to enhance the antiinflammatory response. Patients must be educated about the proper application of their graduated compression stockings and about the signs of edema that can occur as a result of their poor application.

Urticaria

Localized urticaria, typically occurring over the injection site and lasting only a few minutes, is a result of transient irritation and the release of histamine. This transient complication, however, must be scrupulously differentiated from sensitivity and the onset of a systemic allergic response, which can be very serious.

The intensity of the localized itching tends to be positively correlated with the strength of the sclerosing agent. The incidence of urticaria is most often associated with the use of POL and STS as well as a failure to limit the volume of the agent. Prevention and treatment consist of the application of a topical corticosteroid to the injection sites immediately after treatment and limiting the volume of the solution for each injection site.

Blisters and Folliculitis

Blisters and folliculitis usually occur as the result of tape used to secure dressing pads. Blisters most commonly occur

Tapes with the greatest adhesiveness place patients at more risk for blisters than less adhesive tapes like paper tape. Although blisters are relatively harmless, they must be assessed in order to determine whether these lesions are an allergic response, infection, or a sign of early cutaneous necrosis. Blisters can be prevented with the use of a tubular support bandage, rather than tape, over the pad for stability as the compression stocking is applied. An occlusive hydroactive dressing can be placed over the blister if it does not resolve on its own.

Folliculitis, like a blister, most commonly occurs during the summer months and as a result of a tape dressing. The treatment consists of the application of a topical antibiotic, such as clindamycin or erythromycin, and/or an antibacterial cleanser such as Hibiclens. This complication is often self-limiting or effectively treated with topical antimicrobials. Folliculitis rarely requires the use of a systemic antimicrobial drug.

Hyperpigmentation

Hyperpigmentation, or cutaneous pigmentation, is a relatively common occurrence after treatment, regardless of the sclerosing agent that is used (Fig. 11-26). Hyperpigmentation is often very temporary in nature; however, rare persistence can occur for a small number of patients 1-year posttreatment. Most areas of pigmentation occur along the linear aspect of the treated vein. These areas indicate that the vein is no longer functioning. Less commonly encountered occurrences, such as those found at the injection site(s), can also occur as the result of the sclerosing agent’s endothelial damage, inflammation, and red blood cell extravasation into the area. Areas below the knee and vessels from 0.6 to 1.2 mm in diameter are at greatest risk. Affected areas usually resolve within 6 to 12 months after sclerotherapy.

Fig 11–26 Hyperpigmentation.

Hyperpigmentation results from a number of factors, including the type of sclerosing agent, the concentration of the agent, the technique used, the postprocedure treatment(s), the diameter of the vessel, and pressures (gravitational and intravascular). Additionally, the risk of hyperpigmentation increases with some unique patient characteristics, including an innate predisposition for hyperpigmentation, and medication(s), particularly minocycline (Dynacin, Minocin), taken at the time of the treatment.

Prevention aims to minimize necrosis and to avoid total endothelial destruction as well as accompanying red blood cell extravasation. The incidence of hyperpigmentation can be decreased with a number of preventive measures including, but not limited to, those listed next.

Fig 11–27 Incision and drainage (I & D).

Although a number of hyperpigmentation treatments have been used, it appears that many have limited and/or questionable effectiveness, other than treatment with a Q-switched laser.

Recurrence of Treated Vessels

The recurrence of treated veins is common but also troublesome, particularly for the patient who has undergone the treatment. The practitioner may be able to rule out suspected recurrence with a thorough examination 1-year posttreatment that identifies the area(s) as new or previously untreated telangiectasia, rather than a recurrence of the treated vessels.

When it is present, the degree and extent of recurrence are positively correlated with the degree of intravascular thrombosis; therefore, the most important preventive measures aim to limit intravascular thromboses. Adequate compression for an adequate duration of time is necessary to prevent recurrence.

Other Minor Conditions

Other complications and adverse sequelae include harmless suntan fading, telangiectatic matting (as discussed earlier), staining, vasovagal reflex (stress related), localized hypertrichosis, and transient urticaria, which warrants attention because it may signal a systemic allergy.

Nerve Damage

Temporary paresthesia and permanent nerve damage can occur because of the proximity of some nerves to the sclerotherapy injection sites. Temporary paresthesia, most often lasting less than 6 months, can occur when the local inflammatory process affects superficial sensory nerves. Treatment consists of the administration of NSAIDs. Major nerve damage, although very rare, can occur. This damage occurs from poor technique and malformations or anomalies of the patient’s venous system.

Superficial Thrombophlebitis

The advent of posttreatment graduated compression has greatly diminished the incidence and prevalence of thrombophlebitis; however, it does occur on some occasions for a variety of reasons. Some patients are at risk for thrombophlebitis because they are predisposed to it as a result of an innate state of hypercoagulopathy. Other examples of predisposition are conditions and disorders such as pregnancy, genetic excesses of coagulation factor VII, and a protein C deficiency.

Superficial thrombophlebitis presents as an induration that is tender and reddened or an area of hyperpigmentation along the vein, usually from 1 to 3 weeks after treatment. For the most part, this complication can be prevented with posttreatment compression over the entire leg (not just the treated area), which is adequate in terms of both duration and degree.

When prevention is not successful, the treatment of thrombophlebitis consists of maintaining adequate compression, NSAIDs, drainage, frequent ambulation, and, at times, low-molecular-weight heparin.

Emboli and Deep Venous Thrombosis

Fortunately, pulmonary emboli and deep venous thrombosis (DVT) are rare occurrences subsequent to sclerotherapy. Nonetheless, the incidence of DVT is probably grossly underestimated because it is often overlooked and not diagnosed as such. Although many cases are not properly or promptly diagnosed, there are clinical signs that should alert the practitioner. Among these signs are the cardinal signs of inflammation (redness, heat, swelling, pain, loss of function), dilated superficial veins, some laboratory markers, such as plasma D-dimers, as well as venous Doppler and impedance phlebography results. DVT usually presents 8 to 10 hours after treatment, particularly during times when vascular stasis is greatest. Pulmonary emboli typically occur from 5 to 7 days after thrombus formation. Because the mortality rate from a DVT and pulmonary emboli, without treatment, is alarmingly high, a thorough assessment of the patient and his or her risk factors as well as careful posttreatment monitoring are essential components of care. Patient education is also important. The patient and family members must be informed about the signs and symptoms of DVT and emboli and the importance of immediately reporting their observations to the physician.

Although the cause of DVT is largely unknown, it appears that both intrinsic patient-related factors (a hypercoagulability predisposition) and extrinsic treatment-related factors (vascular stasis and endothelial damage) have an impact on the occurrence of DVT. Limiting the volume of the sclerosing agent to only 0.5 to 1 mL per site, adequate compression with properly fitted graduated support hose (30 to 40 mm Hg pressure), and encouraging physical activity (muscular movement) immediately after the procedure will reduce thromboembolic complications. Additionally, use extreme caution when the patient has a thrombophilia to prevent this serious postsclerotherapy complication.

The treatment of DVT must be immediate, decisive, and highly effective. A rapid reduction of clots can be accomplished with peripheral or direct infusions of a thrombolytic agent such as urokinase or a tissue plasminogen activator (t-PA). Alternative treatment consists of the administration of anticoagulation therapy using intravenous heparin, which is then followed by warfarin, heparin subcutaneously, or a low-molecular-weight heparin (LMWH) preparation, such as enoxaparin sodium (Lovenox).

Air Embolism

Small amounts of air entering the venous system do not pose a threat because these minimal amounts usually absorb into the blood, without ill effect, before the bloodstream reaches the pulmonary circulation. Larger amounts of air, however, such as may occur when using foams, can potentially lead to air emboli that manifest with migraines, nausea, and visual disturbances, all of which are usually self-limiting and without any long-term adverse effects.

Distal necrosis may occur from an inadvertent injection into an artery. This complication is quite rare but it perpetually plagues the thoughts of the physician because no sclerosing treatment is totally risk free of this complication, a complication that mandates intense immediate action. Arterial injection of a sclerosing agent can lead to emboli, occlusion, blood flow stasis, and necrosis. The most vulnerable areas include the groin, the medial or posterior malleolar area, and the back of the knee.

This complication requires instantaneous action. The sclerosing agent and blood should be aspirated immediately upon the realization that this inadvertent injection has occurred. This action should be immediately followed by an injection of heparin (10,000 units) using the same needle kept in place with only the replacement of the syringe containing heparin, often a feat for only the ambidextrous, particularly when the patient is experiencing acute and severe pain. Ongoing treatment consists of the application of ice to the affected area, a heparin regimen for 6 or more days, IV dextran 10% for 3 days, and nifedipine, hydralazine, or prazosin orally for 30 days. At times, direct thrombolytic therapy is indicated.

An inadvertent injection into an artery is best prevented with arterial visualization using duplex imagery and having the patient in an upright position when the challenging malleolar area is injected (Fig. 11-28).

Fig 11–28 Arterial injection.

Allergic Reactions

Systemic allergic reactions are rare; nonetheless, they can occur. Some allergic reactions are minor and transient, whereas others can be severe and life threatening. Nonetheless, all patients with even minor allergic reactions must be assessed and monitored for any signs of a more serious reaction, including bronchospasm, angioedema, anaphylaxis, pulmonary toxicity, renal toxicity, and cardiac toxicity.

Minor allergic reactions, such as urticaria, are typically treated with an antihistamine, such as hydroxyzine (Atarax) or diphenhydramine (Benadryl). Prednisone may also be added for a brief course of therapy. Angioedema, with and without respiratory stridor, is treated with an oral antihistamine and intramuscular diphenhydramine in combination with intravenous corticosteroids, respectively. Aminophylline intravenously, an inhaled bronchodilator, corticosteroids, and antihistamines usually successfully treat bronchospasm without any further intervention; however, the practitioner must be aware of the fact that bronchospasm may signal the onset of anaphylaxis.

The earliest warning signs of impending anaphylaxis include urticaria, angioedema, itching, rising levels of anxiety, wheezing, coughing, and other more subtle warnings. The three classic signs of actual anaphylaxis, a severe life-threatening condition that requires immediate attention, are bronchospasm, respiratory airway edema, and vascular collapse (systemic vasodilation and cardiac failure). Emergency treatment and transport to an acute care facility in the community are most often necessary. This condition is treated with epinephrine to maintain blood pressure, intubation, theophylline, and oxygen to establish and maintain adequate oxygenation as well as other medications such as corticosteroids and diphenhydramine.

Some of the sclerosing agents that are most often associated with an allergic reaction include:

Cutaneous Necrosis

This most often self-limiting complication can occur, albeit rarely, irrespective of sclerosing agent type. Several factors impact on the occurrence of cutaneous necrosis. These include extravasation, injection into an arteriole, reactive vasospasm, lymphatic injection, and excessive compression.

The extent and degree of extravasation are functions of both the type of the sclerosing agent and the concentration given. Despite good technique, a small amount of the sclerosing solution may leak into the surrounding tissue as the needle is withdrawn or when numerous punctures are necessary, thus leading to extravasation. More toxic solutions pose greater threats to subcutaneous damage than less toxic ones. For example, glycerin and CG are less toxic to tissue than is STS.

Inadvertent arteriolar injection may occur as a result of a rapid, large volume injection of a sclerosing agent into telangiectasias with microshunts. Glycerin solutions are believed to be the least offensive in terms of arteriolar injection and subsequent tissue ulceration. Likewise, lymphatic vessel injection can also lead to cutaneous necrosis, particularly if the patient has lymphovenous anastomoses and the solution is caustic. Reactive arterial vasospasm also plays a role in terms of cutaneous necrosis. Some people, for unknown reasons, tend to have a predisposition to these vasospasms. Vigorous massage, in combination with a topical nitroglycerin ointment, may alleviate or eliminate this problem. Last, cutaneous ulceration, as a result of tissue ischemia and anoxia, may occur when there is excessive localized compression. It is therefore recommended that the patient wear a graduated compression stocking of no more than 40 mm Hg when in the supine position for long durations of time. Other preventive measures include the use of double stockings during non–bed rest times and the removal of the outer one during periods of bed rest so that the pressure can be lowered to an acceptable level.

Cutaneous necrosis can be prevented with the dilution of sclerosing solutions and the injection of hyaluronidase into multiple sites around the extravasation within 60 minutes of the episode, should extravasation occur (Fig. 11-29).

Fig 11–29 Ulcer.

Summary of Complications and Adverse Sequelae

The adverse sequelae and complications associated with sclerotherapy of telangiectatic veins and varicosities can often be prevented; however, these procedures can never be devoid of inherent risks despite all preventive measures and superior technique. Some of these untoward events are minor, transient, and self-limiting, but some are life threatening and serious. Patients must be given complete information about the procedure, its benefits, risks, follow-up care, and alternatives for them to give informed consent prior to the procedure.

Comparative Effectiveness

Comparative research studies have been conducted to determine the relative effectiveness of the various sclerosants that are used for spider telangiectasias. Curlin and Ratz compared the effectiveness of STS 0.5%, POL 0.25%, and HS 20% with heparin. The results of this research indicated that POL was best tolerated while HS and STS showed fastest clearing. In terms of effectiveness, there were no statistically significant differences among STS 0.5%, POL 0.25%, and HS 20% with heparin.⁶

Goldman⁷ compared STS 0.25% and POL 0.5% and found little difference in terms of effectiveness. Another study, comparing 100% CG, POL 0.25% solution, and POL 0.25% foam, indicated that CG was associated with higher degrees of pain, better clearance, and no staining or matting, while foam POL caused the most staining and matting.⁸ Another study, by Leach and Goldman, compared 72% glycerin diluted 2 : 1 with 1% lidocaine with epinephrine and STS 0.25%. This study showed significantly better and more rapid clearance with the glycerin and less staining than the STS.⁹

Historical Perspective

The laser is a relative newcomer to the treatment domain of lower extremity spider vein treatment; however, it is gaining increased popularity and refinement. This technological newcomer’s popularity is, interestingly, primarily driven by the consumer, not the practitioner, unlike most other new advances. Lasers are particularly useful for lower extremity spider veins that arise from matting or are refractory to sclerotherapy treatment. They treatments are also useful for people who have phobias, fears, and concerns relating to needles. Despite its advantages, however, laser use has some limitations, including the fact they are an adjunctive and complementary therapy after sclerotherapy, rather than a substitute for it.

Basic Concepts and Terminology

“Laser,” an acronym for l ight a mplification by s timulated e mission of r adiation, produces a beam of monochromic, coherent, collimated light of a specific wavelength. “Pumping” is a term used to describe the process of supplying the amount of energy necessary for the amplification of the laser beam. This energy can be delivered as light, of varying wavelengths, or as an electrical current, which is measured in terms of joules (J). The amount of energy delivered to an area is referred to as “fluence,” and it can be represented as J/cm². The power with which the energy is delivered is referred to as “watts.” A watt is equivalent to one joule per second. The number of watts (W) that are delivered to a given unit area, typically indicated as W/cm², is called “irradiance.” Last, “pulse width” is the duration of laser exposure and it is documented in terms of milliseconds.

The therapeutic usefulness as well as the possible untoward effects of laser treatments are based on the fact that as a laser beam strikes the skin, it leads to four reactions: scattering, absorption, transmission, and reflection. Scattering is a function of wavelength and the presence of substances such as collagen, both of which can potentially have an impact on the occurrence of collateral, unintended tissue damage. For example, shorter wavelengths are associated with increased scattering compared to longer wavelengths. Laser photons are absorbed, and thus therapeutic, when they are not impeded by reflection, scattering, or transmission. The challenges to the practitioner arise from the fact that veins vary in terms of their ability to absorb the laser’s energy and each laser generator delivers only one wavelength without any built-in mechanisms to vary it, with one exception—the tunable dye laser. In other words, deeper veins require a longer wavelength than more superficial ones, but the wavelength of a specific generator is fixed; therefore, no variation of wavelength is possible. Only power, spot size, and pulse width can be manipulated in order to attack the full thickness and circumference of the vein wall.

Lasers work by emitting the pulse of light that is absorbed by the hemoglobin in the blood vessel with just enough heat to the vein to cause irreparable, desired, damage to the vein but not enough to damage the skin as a result of the laser’s absorption by melanin.

Ideally, the laser should deliver the precise amount of energy needed to damage the intended vein target but not cause any damage to the surrounding tissue, including the skin. It should also be capable of delivering this energy for precisely the correct duration in order to slowly coagulate the vessel’s full thickness and entire circumference without rupturing it. In the real world, however, perfect techniques and equipment are not a reality, so the typical laser wavelength used is between 600 and 900 nm.

The shape of the beam and the wavelength of the emitted light for each type of laser give it its unique and specific characteristics. The use of lasers has some advantages in terms of telangiectasias treatment, and many of the complications that are associated with sclerotherapy are not likely to occur with noninvasive laser treatment. Furthermore, this diminished risk is not solely limited to the drug introduced into the body.

Shorter wavelength lasers have very good hemoglobin absorption but they do not penetrate very deeply. They also have higher melanin absorption, something that competes with the hemoglobin. Longer wavelengths have both less hemoglobin absorption and less melanin absorption. They penetrate the skin more deeply. Deeper and larger spider telangiectasias respond better to longer, rather than shorter, wavelength lasers, and they are much better tolerated by darker skin tones, which are more tolerant and more forgiving than lighter skin tones.

Other factors are also important for the practitioner’s consideration. For example, how much energy should be given (joules), and how will that energy be delivered? Will it be given using a short burst or using a long pulse? Lasers also offer us a limited number of other variables that can be manipulated to optimize results. For example, stacking pulses allow cooling of the skin between pulses to take full advantage of the different heat specificities between skin and hemoglobin. Additionally, there are methods to cool the skin in order to protect it from burns (cold air, ice packs, cold solutions through clear glass, and a cryogen spray).

Many different lasers have been used for the treatment spider veins, but this section briefly addresses the most common lasers used today.

Types of Lasers

With rare exception, the primary lasers used today for leg veins are light sources and pulsed lasers. Included in these categories are the following types of lasers.

KTP and frequency-doubled Nd:YAG 532 nm lasers provide a very short pulse that works exceptionally well on the fine red spider veins. The shorter wavelength, however, does not penetrate very deeply, and it is absorbed by the melanin in the skin, making it NOT the treatment of choice among patients with darker skin types.

Diode lasers come in multiple wavelengths. The wavelengths used for the treatment of spider veins are 810 nm, 940 nm, and 980 nm. These spectrums have considerable hemoglobin absorption, lesser degrees of melanin absorption, and deeper penetration; thus, they are suitable for the treatment of veins up to 1 mm in diameter.

The Nd:YAG 1064-nm laser has become the most widely used laser for the treatment of leg telangiectasias. It provides deeper penetration and less melanin absorption than the other wavelengths. It also has less hemoglobin absorption; however, it also increases water absorption. Higher energies are required with this laser, but these energies are well tolerated because they absorb low levels of melanin. Pain is a commonly occurring phenomenon, however, with this laser. A cooling intervention, such as cold air, cold water between glass, or cryogen spray, is frequently used to reduce any patient’s discomfort. A topical anesthetic with lidocaine, for vasodilation, is also effective to combat the pain.

Regardless of the laser equipment used, however, there are some pitfalls and concerns that are common to all; therefore, the physician should resist the temptation of overtreating the vessels by delivering unnecessary passes and/or greater than necessary fluences. These actions may lead to blanching, hypopigmentation, and/or necrosis with hyperpigmentation (Fig. 11-30; see Fig. 6-1).

Fig 11–30 Laser wavelength penetration.

Operative Steps

As previously discussed, the initial steps in laser treatment include a patient assessment, a thorough discussion of the benefits and potential risks of treatment, and photographic documentation. Next, the practitioner must decide which laser to use and what settings should be used for the particular patient.

As discussed previously, smaller red spider veins are typically very superficial veins; therefore, shorter wavelength lasers are the treatment of choice. For example, the KTP 532-nm laser has been used successfully on these fine red spider veins. On the other hand, the Nd:YAG 1064-nm laser works better than the KTP 532-nm laser on larger veins up to, and including, the small reticular veins.

The next decision-making point is determining spot size or the diameter of the laser beam needed to treat the area. The smaller the spot diameter, the more concentrated is the energy—therefore, less energy is needed. Smaller veins can be treated with small spot sizes as low as 1 mm. Larger spider veins, of about 1 mm, require a 2- to 4-mm spot size in order to effectively cover the vein. Larger veins, that is, those over 1 mm, are best treated with 6-mm spot size.

Following are determinations regarding the best pulse duration, the best duration between pulses, and the amount of energy to use. Pulse duration is another variable that can be manipulated in order to achieve optimal results based on the particular vein that will be treated. Smaller veins heat up more quickly than larger veins; therefore, very short pulses are necessary to alleviate this potential hazard when treating the smaller veins. Larger veins take longer to heat up so longer pulses are needed to achieve desired outcomes.

Some lasers will stack pulses allowing for cooling intervals between pulses; therefore, a delay time between pulses may be part of the settings, something that may have to be adjusted according to the unique needs of the patient. Darker skin tones have to cool longer between pulses then lighter skin tones. Energy settings can be by watts or by joules; joules take into account the pulse duration while watts do not. Most lasers are set by joules. Again, larger veins need more energy.

Finally there are different cooling devices from which the practitioner must choose. Some of these choices include cooled air blown on the skin, ice packs, and cryogen air. Regardless of choice, however, each alternative must be carefully implemented either just before and/or just after the pulse of laser light. Pulsed cryogen air timing has to be scrupulously managed because too liberal use may lead to vasospasm and a decrease in the amount of hemoglobin necessary for light absorption. Because cooling prevents or alleviates patient discomfort and it also provides protection against skin injury, it should be a routine aspect of laser treatment.

The most frequently encountered complication associated with cutaneous lasers is a skin burn that could result in a blister, pigmentary changes, and/or scarring. The extent of any burn is affected by several factors, including the wavelength used, the amount of energy delivered, the patient’s skin type, and sun exposure prior to the treatment. Shorter wavelengths are more likely to injure the skin than are longer ones because shorter wavelengths have a higher degree of melanin absorption. For this reason, short wavelength lasers should be used with caution in darker skin types.

The amount of energy delivered is also a factor that impacts on the occurrence and extent of any skin injury. Enough energy at virtually all wavelengths will cause skin injury. Joules, again, are calculated as watts per second; therefore, 100 J given in over 100 msec is very different than 100 J given over 20 msec. More optimal results are sometimes achieved by treating darker skinned individuals with the long pulsed 1064-nm Nd:YAG laser, especially for larger spider veins.

Darker skin types have more melanin, and melanin absorbs energy from light as well as hemoglobin. People with darker skin tones are more likely to have an injury from laser treatment and therefore should be approached with caution. Possibly even more important than skin type, however, is recent sun exposure. Sun exposure stimulates melanin production, so even people with light-colored skin may have increased melanin after sun exposure, thus increasing the risk of injury with laser treatment. The patient should be advised to avoid sun exposure for at least 2 weeks before the anticipated treatment and to continue sun avoidance for at least 2 weeks postprocedure.

Eye injury, for both the patient and the practitioner, is also a potential complication of laser treatment. It is essential, therefore, that adequate protective eyewear be worn in order to block the laser wavelength. Lead shields are also used, especially if the laser is used near the eyes (Figs. 11-31 to 11-33)

Fig 11–31 Laser treatment Dornier 940 nm.

(Courtesy Dr. R. Bush.)

Fig 11–32 Sciton Nd:YAG laser.

Fig 11–33 Sciton screen settings.

Comparative Effectiveness

To date, there have been only a few studies comparing cutaneous laser treatment of spider telangiectasia and sclerotherapy. In 2002, research supported the fact that lasers were more effective for sclerotherapy than for spider telangiectasia.¹⁰ A second study led to similar results, but a greater degree of patient satisfaction was observed with sclerotherapy.¹¹ In 2004, a sequential study comparing Nd:YAG 1064-nm laser treatment followed by sclerotherapy and sclerotherapy followed by laser treatment. The results of this research suggested that the best results were achieved with sclerotherapy followed by laser treatment.¹²

The current consensus is that sclerotherapy remains the primary treatment of choice for leg telangiectasias, but some are convinced that a combination of sclerotherapy and laser may have synergistic effects. This belief was challenged, however, in 1990 by Golman and Fitzpatrick.¹³ This research indicated that there were no statistically significant improvements in terms of outcome with this combination. Furthermore, increased complications were observed when compared with the complications encountered with sclerotherapy alone.

In summary, current data do not support laser treatment as the preferred modality for the treatment of leg telangiectasias when compared with sclerotherapy. It can and should be used as an adjunct to it or with “needle phobic” patients and those with allergies to the commonly used sclerosants.