Vein Ablation: Sclerotherapy for the Treatment of Varicose Veins and Spider Veins

Vein problems are a widespread phenomenon. Nearly one in two women suffers from varicose veins as they age. In medical terms, varicose veins are also known as varices. These are dilated veins that can spread out in a net-like pattern over time. In the early stages, varicose veins are commonly known as spider veins, which tend to develop in the backs of the knees or on the lower legs.

Strawberry veins, however, are not technically varicose veins. Rather, they are simply small vein branches that are visible beneath the skin as blue or purple networks. They can, however, be the first sign of dilation in the superficial leg veins (also called saphenous veins). The saphenous veins (Vena saphena magna and parva) lie slightly deeper in the tissue than the smaller spider veins and are therefore only visible once the dilation has significantly increased.

The superficial leg veins, also known as saphenous veins, are located on the inner thigh (Vena saphena magna) and the back of the lower leg (Vena saphena parva), directly under the skin or in the subcutaneous fatty tissue. Due to upright posture and the effects of gravity, these veins are under particular strain. Blood can, so to speak, pool here, causing the venous valves within the vein to leak. Under normal conditions, the venous valves—which are present at intervals of a few centimeters throughout the saphenous vein—prevent blood from flowing downward under the influence of gravity. They essentially allow blood to flow only from the bottom upward, not in the opposite direction. 

Since connective tissue becomes more lax in women during pregnancy, they suffer from varicose veins significantly more often than men. However, standing or sitting for long periods also puts strain on the superficial veins and increases the risk of developing varicose veins. 

Patients with varicose veins should move around frequently @ Solarisys /AdobeStock

As mentioned above, spider veins can sometimes be the first signs of varicose veins. Other typical symptoms, which occur especially in the evening, include:

• swelling of the legs and ankles
• tired and heavy legs
• Pain (especially after standing or sitting for long periods)

Other, though much rarer, symptoms may include open sores on the inner ankles that do not heal or heal only very slowly. This is caused by impaired blood flow and, in particular, the poor removal of metabolic waste products, which in turn leads to an enlargement of the wound or a delay in healing.

Do varicose veins always need to be treated?

Varicose veins that do not cause any problems do not necessarily need to be treated. However, varicose veins never resolve on their own and, in the worst case, can worsen and eventually lead to serious problems such as non-healing wounds on the lower leg (ulcer). For this reason, it is recommended that every patient with varicose veins wear compression stockings. This is particularly advisable during situations that place strain on the legs, such as prolonged standing or sitting.

Various forms of sclerotherapy are available for the treatment of varicose veins and spider veins, which are used depending on the severity of the affected veins. Traditional liquid sclerotherapy uses a liquid sclerosing agent such as polidocanol, which is injected into smaller veins or spider veins, where it triggers a controlled inflammatory reaction that causes the vein walls to adhere to one another. For larger or deeper veins, foam sclerotherapy is suitable, in which the sclerosing agent is mixed with air to form a foam before injection. Due to its foamy consistency, the agent displaces blood more effectively, adheres to the vein wall for a longer period, and can achieve more effective sealing. In certain cases, sclerotherapy of larger sections of veins may also be appropriate, particularly when laser or radiofrequency procedures are not an option. All methods are performed on an outpatient basis and are considered minimally invasive treatments for varicose veins and spider veins. The key to optimal results is selecting the right method and consistently following a compression therapy regimen during post-treatment care.

• Compression therapy using bandages or stockings: This applies external pressure to the veins, allowing the venous valves to close more effectively.
• So-called endoluminal therapy using laser or radiofrequency energy: In this procedure, special probes are inserted into the vein from the outside to treat the vein wall from the inside with heat, causing the vein walls to become irritated, inflamed, and ultimately to close by adhering to one another. 
• Surgical removal of varicose veins (crossectomy and stripping): The principle behind surgical treatment is to ligate the superficial vein in the groin or behind the knee (crossectomy) and to completely remove it (stripping).
• Sclerotherapy: Here, too, inflammation and adhesion of the vein walls occur from the inside. Unlike laser and radiofrequency therapy, however, this is achieved using so-called sclerosing agents in liquid or foam form.

The sclerosing agent dissolves the cells of the inner vessel wall, and an inflammatory reaction causes the varicose veins to adhere @ Pepermpron /AdobeStock

During sclerotherapy, the sclerosing agent—usually polidocanol (Aethoxyskerol®, 0.25–3%)—is injected into the affected veins, which are then compressed from the outside. Ideally, the inflammatory reaction to polidocanol causes the vein walls to close off. For spider veins and smaller veins, this procedure (known as liquid sclerotherapy) is usually very effective.

In addition to the standard injection of liquid polidocanol, phlebology offers another method for successfully obliterating veins. This therapy is known as foam sclerotherapy. In foam sclerotherapy, the sclerosing agent is mixed with air before it is also injected under the skin. This is particularly recommended for veins with larger diameters to ensure economical use of the sclerosing agent while still effectively sealing the vein walls.

Ultimately, it is always up to the patient and the treating physician to decide which of the above-mentioned treatment methods to choose. Sclerotherapy can be used successfully, particularly for smaller vessels (spider veins). For larger vessels, there is a significant risk that the vein will not seal completely, meaning the treatment was unsuccessful. In these cases, varicose vein stripping or laser or radiofrequency treatment should be preferred. 

The procedure is usually performed while the patient is lying down. The dose of the sclerosing agent depends on the patient’s body weight. First, the injection site is carefully disinfected before the treating physician injects a tiny amount of air under the skin to displace the blood. The liquid sclerosing agent is then injected into the vein. However, the doctor must take care not to inject the medication into the surrounding tissue.

Foam sclerotherapy works in a similar way. However, the doctor mixes the medication with air before the treatment begins, before injecting the sclerosing agent into the vein. The blood is also displaced by the foamy consistency of the agent, allowing the medication to take effect. After sclerotherapy, the injection site is covered with a cotton pad. The patient must then wear compression stockings, which apply even pressure to the tissue.

In sclerotherapy, the doctor treats the patient by injecting foam or a liquid sclerosing agent, such as polidocanol @ rh2010 /AdobeStock

Although sclerotherapy is one of the standard treatments for pathologically altered vessels, the procedure is associated with certain risks.

The most common complications include:

• Inflammation
• Infections
• Bleeding due to damage to blood vessels
• Skin discoloration
• Irreparable nerve damage
• Wound-healing disorders
• Allergic reactions caused by sclerosing agents
• Fluid retention
• Blood clot formation

Minor swelling, skin redness, or skin discoloration (bruising) are completely normal after vein sclerotherapy. However, patients should see a doctor if they experience

• fever
• pain
• severe redness and swelling
• numbness or tingling in the legs and feet
• blue discoloration of the toes

.

To avoid the risk of infection, patients should refrain from sunbathing, saunas, and tanning beds while the wound is healing. Short showers are permitted, provided the injection site is covered with a bandage.

Exercise is extremely important after sclerotherapy to prevent spider veins and varicose veins. Patients must absolutely avoid standing or sitting for long periods of time. The legs should be elevated as often as possible; in addition, walking, Nordic walking, and jogging promote better blood circulation.