Injections

Sclerotherapy (Injection Treatment)

 

A quick foam injection to combat spider veins.

This treatment was designed many years ago and popularised in the United Kingdom in the 1960’s. The procedure involves injection of a solution (called sclerosant) into unwanted varicose veins. The injected veins then go solid and are absorbed by the body. Injection treatments for varicose veins are based on the principle of damaging the lining of the vein to be obliterated. Over the past ten years several agents have been used to achieve this effect. The agent that is currently the most satisfactory for this treatment is known as “Aethoxysklerol” or its generic name “Polidocanol”. This agent is a surfactant, which means that it has a soap like action, which leaches the fat from the wall of the vein. This results in the vein collapsing and going solid. Pregnancy is the only contraindication for treatment with this agent .

Which Varicose Veins are suitable for injection treatment?


Veins suitable for treatment are:

  • Left over veins after Surgery, Coil treatment or Laser treatment.
  • Small surface veins that look like bruises:
    – Starburst veins
    – Spider Veins
    – Broken Capillaries
    – Dermal Venules
    – Reticular Veins

 

These veins tend to recur with time and although eliminated with treatment they regrow elsewhere on the legs. They can also occur on other areas like the face and chest. These veins can be managed by injection but facial capillaries and veins often do well with combined Laser and Sclerotherapy. Because these small veins regrow elsewhere with time, treatment is best regarded as an ongoing commitment. Laser treatment is only useful for the main surface vein, called the long saphenous vein, or small facial capillaries. It is not useful for lumpy veins or surface veins on the lower limbs.

Sclerotherapy treatment alone is only effective for small veins of less than 4mm diameter. If larger veins are treated by this technique alone, recurrence usually occurs in 12 months with secondary brown staining. Large varicose veins or veins secondary to incompetent valves only respond to injection treatment for a year or two. Brown staining, that does not fade, is the penalty of treating these high pressure veins with injections alone.

The Treatment:

You will experience minor discomfort from the needle pricks and some stinging sensation from the agent itself. Excessive pain on injection usually indicates some leakage of the agent from the vein but this stops quickly.

Multiple injections are performed sequentially until all vessels have been treated or the maximum dose of sclerosant has been reached.

Following each injection the vein is compressed by means of a cotton wool ball and a strip of adhesive tape.

Once all injections are completed a compression bandage is applied. This results in the vein walls being pushed together so that they “stick”. Compression is an important component of the treatment of larger varicose veins; smaller spider veins do not require this.

You must take your bandages off and remove the tapes and cotton wool balls either on retiring or first thing the next morning. The leg will be bruised and lumpy and somewhat tender. This is a normal response.
* You may be instructed to rebandage the legs to the knee for a further 1 – 2 days but this is an uncommon requirement. The use of elastic stockings or “Skins”may improve comfort in the days following treatment but this is not essential.

The normal events following treatment are as follows:

Bruising is common and occurs in the area of injection. This usually takes 2 – 4 weeks to resolve.

Inflammation occurs around the solidified vein as it is absorbed. This process commences after about one week and can last as long as six months. It produces a sore lumpy area in the leg.

Swelling is common after treatment, especially around the ankle region.
Any swelling extending to the level of the knee should be reported to Mr Milne’s office.

The solidified vein itself will go a dark colourwhich will fade with time. The time taken for this colour to fade away depends on the vein size and can range from six weeks to two years. The deposition of brown substance (Haemosiderin) from the absorption process of the vein often occurs in the skin and can take up to two years to resolve completely. Overall improvement in comfort and appearance usually occurs around six weeks after commencement of therapy.

Complications:

Pain: Pain can occur on injection, in the form of a stinging sensation. If the vein wall leaks sclerosant into the tissue this pain can be uncomfortable. Normally this resolves, with no untoward effects. Persisting pain usually indicates difficulties with the process and should be reported.

Ulcers/Blisters: Ulcers or blisters can arise as the agent used damages vessels. Entry or leakage of the agent into the capillaries of the skin can produce damage to a small area of the skin causing a black scab or a small ulcer. Small scabs or ulcers usually heal spontaneously within 6 weeks. The risk of this complication is 1:500 treatments. Very rarely a large area can be damaged and this may require surgical treatment.

Anaphylaxis: Severe allergy (life threatening) occurs in approximately 1:2,000,000 treatments with this agent. It happens within minutes of the treatment.

Rash: Sometimes a rash can occur. The incidence of this is approximately 1:5,000 treatments.

Deep Vein Thrombosis: There is a risk of damage occurring to the deep veins inside the leg but less than 1:10,000 treatments have resulted in this complication.

Swelling: Because the obliteration process involves inflammation, swelling can occur in the injected limb for up to 6 weeks.

Cough: A cough may occur with a feeling of tightness in the chest but this resolves in 5-10 minutes.

Migraine: A migraine headache, unusual tingling, numbness of a limb or visual aura may occur but these resolves quickly.

Bandaging: Although bandaging can cease after twelve hours a better result usually occurs if the bandages are kept on for an extra day. You will be advised as to the best option. Elastic compression stockings are useful but not essential after treatment. Smaller capillary or starburst veins do not require compression for more than a few hours.

Facial vessel injections: This treatment involves far fewer problems than those listed. Usually swelling is noticeable for 2 days and some redness for 6 weeks.

Complications: Any complication of treatment should be referred back to this office. Your local doctor will look after any normal illness but difficulties with this treatment have to be reported to Mr. Milne for correct management.

“AETHOXYSKLEROL” (Polidocanol) Study

An ongoing study of the safety and effectiveness of Polidocanol by 98 investigators in Australia injecting 16,804 limbs over 2 years.

OBJECTIVE: To evaluate the complications of Polidocanol and compare its effectiveness and complications with Sodium Tetradecyl Sulphate (STD) and hypertonic saline.
METHODS: A single-arm prospective study of Polidocanol complications and its effectiveness as a sclerosant was performed. This was compared with each investigator’s previous experience with other sclerosing agents. Patients had either varicose veins or venule ectasias and/or spider veins (telangiectasia). A total of 16,804 limbs were injected by 98 investigators. Sclerotherapy was performed with 0.5% or 1% Polidocanol for telangiectasias or spider veins, and with 3% Polidocanol for varicose veins. The effectiveness of the sclerotherapy and any complications were reported during a 2-year period.
RESULTS: There were very few complications reported with Polidocanol. There were no reported deaths or anaphylaxis. The investigators with previous experience of other sclerosants considered that the effectiveness of Polidocanol was superior to STD (85%) and hypertonic saline (84%). 90% of investigators considered that Polidocanol had less frequent complications than STD, and 80% considered that these were less severe. 74% considered that Polidocanol had fewer side effects than hypertonic saline, and 74% considered that these were less severe.
CONCLUSIONS: Polidocanol is an effective sclerosant that has few complications.

Aim of Treatment

Ultrasound guided sclerotherapy with Coil Occlusion or Laser Ablation is a further development of standard sclerotherapy (Injection treatment, also known as “Echosclerotherapy” or “Foam Echosclerotherapy”) of lower limb varicose veins. This treatment is designed as an alternative to surgery for varicose veins previously only manageable by operation. The aim is to obliterate defective veins inside the leg that are flowing in the wrong direction.

The ultrasound machine enables the surgeon to see defective veins and thus guide the treatment. Successful elimination of defective (refluxing) veins results in a decrease in the workload of the remaining normal veins in the limb and a return to a normal state. Because ultrasound guided injections alone are not very successful for long term clearance of varicose veins Coil and/or Laser insertion may be required for a long lasting result.

The largest vein that can be managed by sclerotherapy technology alone is 4mm in diameter. The largest vein that is treatable by Coil or Laser technology is 15-20 mm. Generally veins greater than 15 mm in diameter are still best managed by Surgery.

Sclerotherapy

This treatment was designed many years ago (1930’s) and popularised in the United Kingdom in the 1960’s. The procedure involves injection of a solution (called a sclerosant) into unwanted varicose veins. The injected veins then go solid and are absorbed by the body. All injection treatments for varicose veins are based on the principle of damaging the lining of the vein to be obliterated. This results in the collapse of the vein followed by solidification. The vein traps blood in the centre of the vessel which makes the vein lumpy after treatment. The body then dissolves the solid vein by creating inflammation around it.

This process leads to the redness and tenderness experienced with this treatment. The same process occurs after surgery but inflammation and bruising with injection treatment sometimes takes 6 weeks or more to settle unlike surgery where inflammation settles in 3-4 weeks. Brown staining can occur after either treatment but is more noticeable after laser/sclerotherapy than with surgery. Brown stains from absorbed veins can take up to two years to fade.

Coil Occlusion

The use of occlusion devices in vascular conditions has been employed for two decades to seal arteries and veins that are abnormal. The extension of this technology to the lower limbs has been undertaken since 1998 and has proved effective in the majority of venous conditions treated. To treat larger varicose veins and large valve leakages in the lower limb this additional treatment is sometimes used. This is known as “coil occlusion” or “coil embolisation”.

Deployment of an occluding coil into a varicose vein extends the effectiveness and durability of ultrasound guided injections and Laser resulting in a much greater likelihood of long term permanent success. The majority of persons with recurrent varicose veins can now avoid further surgery and about two thirds of patients with primary varicose veins are suitable for this technology as an adjunctive therapy.

Side Effects and Risks

A sclerosing agent is always used for treatment with Laser or Coils and is of a higher concentratiuon than the agent used for surface veins. Therefore the chances of side effects are greater.

Side Effects (Transient)

Pain: Pain occurs on injection of local anaesthetic and the sclerosant in the form of a stinging sensation. When the vein wall leaks sclerosant into the tissue this pain can be uncomfortable. Normally this resolves with no untoward event. Persisting pain usually indicates difficulties with the process and should be reported. For Laser treatments about 5 injections of local anaesthetic is required in the thigh to prevent pain from the heat of the Laser. If treatment is under anaesthesia then no pain occurs.

Swelling: Because the obliteration process involves inflammation, swelling can occur in the limb that has been injected for up tp 6 weeks.

Cough: A cough may occur, with or without a feeling of tightness in the chest, but this resolves in 10-15 minutes. This can delay your departure after treatment.

Migraine: A migraine headache, unusual tingling or numbness of a limb or visual aura may occur but also resolves quickly. The sensation of numbness or weakness on one side of the body can last up to 15 minutes. No permanent complications have been documented.

Fainting: Either the injection of the vein, stimulating nerve endings in the vein wall or the agent itself can cause a feeling of faintness associated with what is known as a vaso-vagal response. If severe it will be treated with an injection of Atropine which restores your blood pressure and heart rate to normal. You will however notice blurred vision from the injection for about twenty minutes. This reaction is a very common one following any form of painful stimulus or even just the sight of a needle is enough to make some people experience this phenomenon.

Major Risks

Ulceration, infection or deep vein thrombosis are risks of the procedures. An ulcer after this treatment is rare but, if this does occur, it can be large and painful requiring hospitalization and possible skin grafting. Although not seen in this practice it has been reported by other proceduralists. The chance of disabling ulceration is 1:5000. People who have had previous ulcers from their varicose veins seem to be predisposed to this complication.

Deep vein thrombosis requires hospital admission but the risk is less than 1:5000. Infection requiring treatment has an incidence of 1:3000 treatments. People with ulcers or damaged skin are most likely to suffer this complication and it would require administration of antibiotics. No hospitalization has been required for infection or deep vein thrombosis after Laser in this practice.

The use of occlusion coils for larger vessels has dramatically reduced the incidence of side effects from injection treatment. There is also the additional benefit of reducing the total dose of sclerosing agent as well as reducing the risk of ulceration as a complication.

The risk of coils moving from the original placement site during treatment is considered to be negligible but tangible. Loss of a coil during the actual procedure, however, would require removal of the coil by x-ray control through a catheter in the vein under local anaesthetic. Surgery to remove an incorrectly placed coil should rarely be required and would consist only of a tiny incision under local anaesthetic performed at the time of the procedure.

Treatment – What you need to know

There are no special requirements beforehand except that you should wear warm clothes loose enough to go over the legs after the application of bandages. Warmth is helpful in dilating the veins so over dress or walk briskly before your visit.

The treatment itself is usually not too uncomfortable with the needle insertions and local anaesthetic injections causing minor discomfort. Inhalation of an analgesic (Penthrox) is available to lessen discomfort however, if you use this agent, you may not drive a vehicle afterwards for 12 hours. If requested a general anaesthetic can be administered but this requires a hospital admission for a few hours.

Usually a fine tube is threaded into the vein to deliver the coil, laser heat and sclerosant. You may be able to feel the tip of the catheter moving inside the leg but this is not a painful sensation.

Once the coils have been placed, sclerosant is introduced and you will feel some stinging in the surface varicose veins as they vanish. Several additional needle insertions are usually required to obliterate remaining veins on the surface.

After treatment with any of the modalities, and following injection of sclerosant, cotton wool balls and adhesive tape are applied at the injection sites. You will then be placed in compression bandages. These cover the cotton wool balls and compress the treated veins. You should leave these bandages intact for at least 8-12 hours. After treatment you should walk at least 200 – 500 metres to help circulate blood through the deeper veins of the limb. This should be repeated a few times over the next few hours.

Bandages: Following application of compression bandages you will be given instructions as to exactly how long to wear them. Normally you will wear the compression bandages until the following morning. You must remove the bandages and then shower and remove the cotton wool balls and adhesive tape from the limb. (Removal of the cotton wool and adhesive tape is essential within 12-24 hours to prevent skin blisters). Following the shower you should re-apply the bandages to compress the legs (not the thighs) for a further few days. This period may be shorter and you will be advised accordingly. The purpose of the bandages is to try to compress the vein walls together so that there is very little trapped blood. Without compression the veins tend to be big and bulky when solidified and thus they take longer to absorb. Sometimes the thigh bandages tend to unravel rapidly in which case they can be left off but bandages below the knee should be reapplied. If the bandage is too painful then it should be loosened a little or reapplied more comfortably.

After Treatment

There will be some tendency for the ankles or legs to swell. Any dramatic increase in swelling should be reported to Mr. Milne. An unusual degree of pain following treatment should also be reported. There is no limitation on your activity following treatment and you should carry on all your normal sporting and work related activities. Discomfort usually settles with analgesia such as Panadeine.

In the weeks following treatment swelling of the ankles will settle, if it has occurred at all. you will feel some hard lumpy areas where the veins have solidified and these become tender as the absorption process gets under way. The veins will become red and inflamed as part of the absorption process. Simple anti inflammatory agents such as Aspirin, Nurofen, or Naprogesic may be used.

When the veins are completely absorbed (usually within 6 months) there may be some brown staining left on the surface of the skin. This goes away slowly with time, sometimes as long as 2 years. The coils are virtually impalpable and are not visible except on x-ray. The veins will disappear as completely as they would with surgical treatment.

The Sclerosant

Over the past ten years several agents have been used as sclerosants The agent that is currently the most satisfactory is known as “Aethoxysklerol” or its generic name “Polidocanol”. This agent is a surfactant, which means that it has a soap like action which leaches the fat from the wall of the vein, resulting in the vein collapsing and going solid. Pregnancy and breast feeding are the only contraindication for treatment with this agent.

Possible side effects are as follows:

Allergy: This is very rare and life threatening allergy has not been reported in Australia. A 1:5000 chance of a rash is the only allergic risk.

Local Skin Ulcers: These are rare and tend to be very small and heal rapidly. Occasionally excision of an ulcer with suturing may be necessary and this will leave a scar.

Deep Vein Thrombosis: This is rare if the correct dosage is followed and the injection is associated with compression bandaging and mobilisation. Walking more than usual is the best means of reducing this risk. Current risk 1:5000 treatments.
* Being overweight or a smoker increases the chance of this complication to a substantial degree. If you have had a deep vein thrombosis in the past or a family history of same we will assess your risk and manage this with post procedure tablets.

The Coils if Used


The devices commonly called “coils” are made either of chrome alloy and polyester or platinum and polyester. The devices used for this treatment are T.G.A. approved for use in Australia and have a long documented history of safe deployment. Like surgical clips they are inert after implantation.

There is a very small risk of infection (less than 1:10,000) with these devices. Infection would require removal of the coil, normally under local anaesthetic.

After treatment the coils are visible on plain x-ray and appear very much like surgical clips commonly used for abdominal surgery. They will not trigger a metal detection device such as those commonly used at airports. They are MRI compatible for MRI scanning. These coils, once implanted, are completely inert with less than 1:10,000 rejection rate.

Permanence: Surgery is normally 95% effective in removing large veins for 10 years. Laser treatment appears reliable at 5 years. Small surface veins occur with time after either treatment and can be managed with sclerotherapy in the office. Recurrence of varicose veins in the calf is not uncommon after either surgical or coil treatment and can be managed by further injection treatment. Although many patients are permanently free of major varicose veins after surgery it is usual to have some form of recurrence in the future. Most recurrent veins can be managed by injection treatment in the office or under ultrasound guidance.

Brown Discolouration: This occurs after blood is absorbed from destroyed veins and occurs after either surgery or injection/coil treatment. It is more common and more intense after non-surgical techniques. Fading time is longer for darker skin than light skin and can take as long as two years. Most fading occurs in 6 months.

Lumps and Bruising: These occur after any form of treatment but lumpiness, redness and bruising can take 6-8 weeks after injection treatment compared to 2-4 weeks for surgery.

Any difficulties with treatment should be reported immediately by phone to this practice, rather than your local doctor. The result of your treatment, and/or significant complications, must be reviewed by Mr Milne before you can be discharged to your referring medical officer.

Costs

Our office will issue an estimate for your treatment. Substantial gaps between your fund rebate and Mr. Milne’s fee may occur and this will be shown on your quote. Rebates vary between fealth funds so your out of pocket cost is fund dependant. Laser treatment is more expensive at present as the rebates from insurers does not reflect costs of the equipment. Charges for ultrasound, anaesthetic and assistant services are additional to your procedure costs.