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Injection therapy of Varicose Veins -Sclerotherapy

January 7, 2017

 

Injection Compression sclerotherapy +/- Ultrasound Guidance

 

The principle is to inject a substance which destroys the inside lining of the vein, causing it to become like a wound as the special cells that prevent "stickyness", the intima, are removed. A compression bandage then pushes the walls of the vein together so that it can seal off and heal. This secondary process takes time, this can be short with very small systens but with larger lumen veins significant collagen has to be formed to produce a strong stable bond with scar tissue. As in a simple wound this may take up to 6 weeks.

Compression is required after injection to limit blood clots inside the vein, and to oppose the walls to assist healing. Compression lasts for about three to six days for small veins and from three to six weeks for larger veins. Bandages and stockings are used in various ways.Depending on the systems treated.

 

This method has been tested in many thousands of patients in the past 40 years. In carefully chosen patients, it is safe and effective.

Injection treatment is suitable for:
  • Spider veins

  • Isolated varicose veins

  • Varicose veins which appear again after surgery

  • Occasional early trunk varicose veins

                         

 

The surgeon typically injects one leg at a time. 

The patient may then be required to make regular visits for examination and more injections may be needed at these visits.

 

Injection therapy is usually not recommended for people who:

  • Have large varicose veins, especially major trunk veins

  • Have very obese legs

  • Are not able to walk very much

  • Have had asthma or bad allergies.

 

Injection therapy has the advantages of: 
  • Avoiding surgery

  • Avoiding a general anaesthetic

  • Little or no time off work, home duties or sports.

However, a disadvantage is that treatment is longer.

 

 

 

Preparing for Injection treatment

Wash your skin well for a few days with an antibacterial such as Phisohex rather than soap.

The procedure is done in the surgeon's rooms, Treatment may be preferred during cooler months because compression bandages must be worn for days or weeks.Ultrasound guidance will be used if it has been determined there are significant deeper vessels refluxing into the affected areas, such as an incompetent lateral thigh vein. 

Tell your surgeon if you have had any allergy or reaction to stockings or bandages.

 

There is debate whether the low-dose contraceptive pill may increase the risk of blood clots during treatment. Talk to your doctor who prescribed the Pill and to your surgeon. 

Our main concern as to the risk of DVT depends on the risk of escape of the injectate into the deep veins. We control passage of entry for protracted periods so that the injectate spreads distally through the affected incompetent systems and should be controlled by the progressive attachment of pressure pads and should be inactive by the time there is any significant escape. Walking is also important to clear any microdebris.

The more major risk of DVT could occur secondary to Popliteal Vein Compression Syndrome. You will be advised to keep your knees bent if you wish to rest for prolonged periods with your legs elevated.

All patients are examined for this risk and you will be informed if this is a significant problem or not.   

 

On the day of treatment:
  • Wear loose slacks or trousers

  • Wear comfortable, low-heeled shoes or sandals They must allow the use of a compression stocking.

  • Allow 45 minutes for the appointment and a further 30 minutes for a walk to slightly loosen the bandages.

                            

 Procedure of injection treatment

The surgeon will mark out the veins which are injected with the patient lying down or possibly sitting. Ultrasound may be used for guidance. It is necessary for control of larger incompetent veins deeper in the superficial layer.

The needles used are very fine.

Patients report that the procedure is not very painful, but there may be discomfort.

The bandages and elastic stockings at first feel tight but soon loosen slightly, becoming more comfortable. Patients often have some discomfort on the first night after treatment. The patient should walk for about 30 minutes soon after the treatment.

 

Care after the treatment
  • Do not take off the bandages and stockings.

  • Walk for about half an hour every day (not including walking about the house) to reduce swelling in the treated leg. This is important.

  • While taking a shower or bath, put the leg in a plastic bag out of water. The bandages must be kept dry.

  • It is usually not necessary to take more than one day off work.

  • The compression pads are removed after seven to 10 days. If needed, other veins may then be treated.

After the pads are removed, the patient may need support stockings for a while to assist with the control of larger deeper varicose veins or if aching or swelling in the legs continues while up and about. However, in many patients, no further support is needed.

Even if the veins seem to have closed off a follow-up visit is needed a few months later so the surgeon can see if new veins have appeared which must be treated.

 

Relief of pain or discomfort

The best treatment is to do more walking. Sometimes paracetamol tablets may be required.Paracetamol comes in various brand names. If you need advice, ask your pharmacist.

 

Side effects
  • Most side effects are infrequent and do not last long. However, the surgeon will wait for a few months before judging the final result. Side effects may include the following.

  • Brown stains along the treated veins are common. These usually fade. In some patients fading can occur over many months in others it can take years. However, a few patients may have stains which are so slow to absorb that they can appear to be permanent and unsightly.

 

 

  • A few patients develop a "flare" (or blush) of very small blood vessels around the area of the injection.These can sometimes be cleared by further treatment.

  • Sore lumps can develop near the vein in spite of compression. They usually heal within a couple of months.

  • Allergic reactions (either local or widespread) are rare. They may appear as: redness and inflammation, a rash itching or swelling, pains in a joint, weakness and discomfort. Allergic reactions must be reported to your surgeon at once. They can be treated with medicines. An allergic reaction is usually a sign not to repeat the treatment.

  • At the site of the injection, a small skin ulcer can occur even with the best of care. The skin ulcer is usually small, sore and slow to heal. However, healing almost always occurs.

  • Occasionally a whitened area of skin or a fine scar may persist

  • Severe skin necrosis or gangrene (very rare) can occur if the sclerosant has a direct effect by refluxing into a wide area of capillary bed or by an unusual connection shunt into a local artery or if it spills out of the injection site in the abnormal vein wall. This is really the same as a large ulcer or blister.

 

Costs of Treatment

Your surgeon should advise you about coverage by Medicare, private health insurance and out-of-pocket costs. The Insurers do not cover any treatment for primarily cosmetic problems .Medicare will not pay a rebate for Varicose veins  which are less than 2.5 mm in diameter. 

You may want to ask for an estimate which lists the likely costs. This includes medical and hospital fees, and costs of stockings, bandages and other items. Ask if costs can be claimed on Medicare and private health insurance.

Generally, the government rebates are below par for these treatments and have been falling for many years. There is likely to be a gap of about at least 60% for any rebateable treatment.

Because of this since the actual treatment may differ from the proposed treatment, the final account may differ from the estimate.

It is better to discuss costs before treatment rather than after.

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