Management of reticular veins and telangiectases
Mr Philip Coleridge Smith explains the technique of sclerotherapy and how to manage results
Varicose veins is a common problem in westernised countries, affecting up to a quarter of the adult population. Reticular veins and telangiectases occur more frequently in perhaps half the population. Reticular veins (blue veins) are dilated, bluish sub-dermal veins, usually 1 to 3 mm in diameter. Telangiectases (thread veins) are collections of dilated intradermal venules less than 1 mm in calibre. The main complaint by the patient is usually the appearance, but symptoms may also arise. In the Edinburgh Vein study the highest frequency of symptoms (heaviness, swelling, aching and cramps) was present in patients with both telangiectases and varicose veins.. The main indication for treatment is a requirement for cosmetic improvement. Few significant complications arise from this type of vein.
Assessment of patients with telangiectases and reticular varices.
In patients with venous disease, history taking, clinical examination and duplex ultrasound examination are recommended by many authors.
The European Guidelines for Sclerotherapy in chronic venous disorders recommends this strategy in most patients. In some patients, these guidelines indicate that continuous wave (CW) Doppler examination may be sufficient to evaluate the venous system. Most phlebologists consider that treating incompetent saphenous veins and varices is essential before successful management of the telangiectases can be achieved. Where previous varicose veins surgery has been done, residual sections of saphenous vein or varicose tributaries may remain and contribute to the development of telangiectases. These should be identified and can be managed by ultrasound guided sclerotherapy during the treatment of the telangiectases.
Technique of sclerotherapy
Several papers in this field emphasise the importance of treating all venous disease including saphenous veins, tributaries, reticular varices and telangiectases in order to obtain a satisfactory outcome. The sequence of treatment starts with the largest varicose veins (where these are present), continuing with smaller tributaries and reticular varices and concluding with telangiectases. Injection of telangiectases alone will not lead to a satisfactory outcome since the reticular varices contain venous blood at a high pressure that will lead to early recurrence of telangiectases.
The European Guidelines on Sclerotherapy note that needles with a size of 27 – 32g are used for the treatment of reticular varices and telangiectases. These are usually combined with small syringes with a capacity of 1 – 3 mL. Numerous different methods of injection are advised though most practitioners hold the skin and underlying veins with one hand to immobilise them and manipulate the syringe with the other. In the UK a method of using a sclerotherapy injection set in which a 30 g needle is attached to the syringe using a flexible tube, in a similar design to a butterfly needle, is also used.
The European Guidelines recommend a maximum volume of sclerosant injected in any one vein of up to 0.2 mL when treating telangiectases and up to 0.5 mL when treating reticular varices. The maximum total amount of sclerosant which may be injected in any one session depends upon the sclerosant. Different manufacturers recommend different maximum doses of the sclerosant.
Sclerosant drugs used in the management of telangiectases and reticular varices.
The two most widely used sclerosant drugs for the management of varicose veins are polidocanol (Aethoxysklerol, Kreussler, Germany; Sclerovein, Resinag, Switzerland) and sodium tetradecyl sulphate (Fibrovein, STD Pharmaceuticals Ltd, UK). In most European countries, at least one of these drugs is licensed for the treatment of varicose veins. Both are also licensed in the United States. These drugs are detergents and achieve their effects by the lysis of cell membranes. Both have been used for more than half a century in the management of varicose veins.
Fibrovein is licensed in the UK at a concentration of 0.2% for the management of reticular varices and telangiectases. The maximum volume recommended to be injected by the Summary of Product Characteristics (SPC) in one session is 10 mL. Polidocanol is unlicensed in the UK but fairly widely used despite this. The SPC indicates a maximum dose of 2 mg/kg per day. The European Guidelines calculate that this would allow up to 28 mL of 0.5% polidocanol solution in a 70 kg patient in one day. The manufacturers recommend that treatment is avoided during pregnancy, lactation and in patients taking oestrogen treatment.
A double-blind comparison between polidocanol and sodium tetradecyl sulphate has been undertaken by Goldman. He found that, when used at the recommended concentrations both drugs had similar efficacy in clearing telangiectases and reticular varices with a similar incidence of adverse events.
Management following sclerotherapy
The management of the limb following sclerotherapy of telangiectases and reticular varices varies greatly between different practitioners. Kern has investigated the efficacy of compression in managing the outcome of sclerotherapy for telangiectases and reticular varices. In a randomised clinical trial he compared the outcome following three weeks compression with class two medical compression stockings, worn during the day, to a control group who wore no compression. He found that photographic assessment at 52 days following treatment showed a superior result in the compression group compared to the control subjects. Nevertheless, some phlebologists do not advise the use of compression. This is often influenced by the climate since compression stockings are poorly tolerated in hot climates. In the UK, most sclerotherapists recommend the application of compression using bandages or stockings following treatment.
Most authors recommend a series of treatments for the management of telangiectases. Intervals between treatments vary from two to eight weeks but this is not based on any detailed research. Following sclerotherapy of reticular varices as well as telangiectases, some veins remain after each treatment and these can be addressed in future sessions leading to an improved outcome. I have summarised a simplified strategy for the management of reticular varices and telangiectases in table 1.
Events after sclerotherapy for telangiectases and reticular varices.
Immediately following a session of sclerotherapy, an acute inflammatory reaction is provoked by intravenous injection of sclerosants. This includes a central swollen region surrounded by a red flare and comprises Lewis’s Triple Response to any noxious stimulus to the skin. This is short lived and resolves in one to two hours after treatment.
This reaction is followed by some bruising of the skin in regions which have been injected which will resolve in about one to two weeks. After this many veins appear dark in colour where thrombus has occluded the veins. Some reticular veins appear brown in colour, others become blue-green which distinguishes them from untreated veins. One problem that may arise is that the retained thrombus leads to pigmentation of the skin. It has been shown that evacuation of the thrombus from occluded veins results in a reduction in skin pigmentation.
In my own practice, I review patients two weeks following the previous session when it is clear which veins have been successfully occluded by thrombus and which require further treatment. Excess thrombus can be removed by aspirating with a 25 g needle, and residual reticular varices and telangiectases can be injected. The occluded reticular veins will usually resolve in one to three months depending up their size.
Occasional patients experience protracted skin pigmentation, especially those of Mediterranean origin. Unfortunately, there appears to be no treatment or manoeuvre which will resolve this problem more rapidly—but all skin pigmentation following sclerotherapy will fade and usually resolve completely after an extended period. Skin pigmentation may occur with excessive strength of sclerosant or the injection of too large a volume. However, some patients are especially susceptible to skin pigmentation.
Complications of sclerotherapy
The most common adverse events after liquid sclerotherapy include:
• Skin pigmentation
• Residual veins
• Minor skin necrosis
Telangiectatic matting (formation of a pink region comprised of fine telangiectases in the region of treatment).
Rare complications include:
• Embolia cutis medicamentosa (inadvertent intra-arterial injection of a skin arteriole, figure 4)
• Skin rashes due to allergy
Minor skin necrosis needs simple dressings and perhaps antibiotic treatment if clinical evidence of infection arises. Telangiectatic matting may arise in a region of previous treatment which has been subjected to vigorous treatment. These veins will resolve without intervention over a period of about three months. However, if the affected region still contains untreated veins, it is suggestive of resistance to treatment in the patient concerned.
Use of larger volumes of sclerosant or greater concentration will simply worsen the matting. A strategy has been suggested by Schuller-Petrovic which is commonly used amongst phlebologists. Using a high frequency ultrasound transducer, as search is made for underlying veins and perforators. These can be very small, typically 0.5 – 2 mm in diameter. Ultrasound guided sclerotherapy with liquid can then be used to ablate these veins. Any incompetent saphenous trunks or tributaries which are also found should be treated as well. Several sessions of this type of treatment may be required if resistant telangiectases are widespread. This ultrasound guided strategy is effective at clearing telangiectases where sclerotherapy guided by eye is not.
Inadvertent intra-arterial injection (embolia cutis medicamentosa, Nicolau syndrome) is a rare complication of sclerotherapy. This most frequently arises following visually guided sclerotherapy since ultrasound imaging usually identifies the arteries so that injection of these is avoided. The result is a very painful region around the point of injection with a dark purple or blue discolouration. Current recommendations include high dose steroids combined with anticoagulation but some tissue damage may arise despite these measures.
Severe allergic reactions (anaphylaxis) require immediate treatment with adrenaline given via intravenous or intramuscular routes, in accordance with nationally published guidelines for management. In some countries, the use of steroids is also advised. Intravenous fluids and inhaled oxygen are also recommended. Sclerotherapists should have a plan of action should this very rare complication arise.
In the longer term, patients who develop reticular veins and telangiectases continue to grow more veins even when the correct treatment has been provided. Occasional further treatments will maintain a satisfactory outcome and cosmetic appearance which is the main aim of most treatments of this type.
Alternative treatments for telangiectases
Lasers are sometimes recommended in the management of telangiectases of the lower limb. In contrast to sclerotherapy, the only veins which this can ablate are the most superficial and smallest veins which are usually pink in colour. Reticular veins are too large to be destroyed by a light beam passed through the skin. In general, lasers are much less effective than sclerotherapy in the management of reticular varices and telangiectases of the lower limb.
Sclerotherapy for the management of varicose veins has long been established as a means of treating reticular varices and telangiectases in the lower limb. Clinical and ultrasound examination is required to identify all components of the venous disease present in the limbs of patients with reticular varices and telangiectases. Any saphenous varices are treated first. Sclerotherapy for small veins commences with reticular varices and proceeds to telangiectases, usually over a number of sessions. Compression of the limb following treatment using a class two medical compression stocking has been shown to improve the outcome. Resistant telangiectases can be treated with the help of ultrasound guided injection of underlying perforating and tributary veins. Complications of treatment are few and most are readily managed by simple means.
Mr Philip Coleridge Smith is a Consultant Vascular Surgeon and Reader in Surgery and is the President of the British Association of Sclerotherapists. E: firstname.lastname@example.org