Dr. Ian Little
M.B. Ch.B., D.A., M.R.C.G.P., D.R.C.O.G.
Fellow of the Australasian College of Phlebology.
Transform clinic
0800 256 654
021 442 060
www.2lookgood.co.nz
VARICOSE VEINS AND INJECTION THERAPY
OF VEINS: SCLEROTHERAPY
(Including ultrasound guided foam sclerotherapy UGFS)
Dilated blood vessels can appear on any surface of the body but are particularly common on the legs. They may be visible as short, seemingly unconnected lines each about the size of a large hair or they may resemble a spider web or tree with branches.
These "spider" veins (called "telangiectasiae") usually occur in association with larger dilated blood vessels (often blue/green in colour) called reticular veins. Varicose veins are larger veins that bulge above the skin surface. Varicose veins are often found in association with deeper vein problems. A colour ultrasound examination will determine if you have deeper vein problems. "Sclerotherapy" is the procedure now commonly used to treat abnormal veins. It involves the injection of a solution or foam into the abnormal vein.
The solutions used by Dr. Little are "Sclerovein" and "Fibrovein" and they are specifically manufactured for sclerotherapy. Both are rapidly diluted after contact with the varicose vein wall and so do not cause any harm as they circulate through the body and are washed out. They irritate the lining if the vein causing it to swell and stick together and fade from view over a period of weeks. Sclerotherapy has been performed since the 1930's. It can be used for surface veins by direct injection or for deeper veins by injecting under ultrasound guidance.
Any abnormal blood vessels may cause aching, especially with prolonged standing. Although dilated blood vessels do carry blood, they are not very efficient and are often not necessary to the circulatory system. The body will have already established alternative routes for the blood to travel back more efficiently to the heart. Because of this they can be treated without damaging the circulation (treatment actually improves the venous circulation). Treatment will also relieve any symptoms caused by the bad veins.
Why Do People Develop Abnormal Veins?
The cause is not known, but 50% of people over 50yrs have some degree of varicose veins. Varicose veins occur in both men and women, but more frequently in women. The hormone oestrogen may play a role in their development because puberty and pregnancy often seem to bring them on. During pregnancy the enlarged uterus may also restrict blood flow from the legs contributing to their development. Spider veins may also occur after trauma to a certain area of the body or as a result of wearing tight girdles. They also appear to be associated with obesity and occupations involving prolonged standing.
When they occur on the face, spider veins may be related to chronic sun exposure, alcohol or exposure to extremes of temperature. Lasers used at this clinic are often best to treat these particular veins, sometimes in conjunction with sclerotherapy.
Can Vein Problems Be Prevented?
Wearing specialized venous support stockings may prevent some dilated blood vessels from developing further in some people. This may be important during pregnancy. A good diet, rich in antioxidants, maintaining a normal weight, regular exercise, avoiding constipation and avoiding wearing high-heeled shoes may also be helpful.
Sclerotherapy Treatment of Small Surface Veins
Depending on its size, a single blood vessel may have to be injected more than once. In each treatment session many vessels are injected but fortunately this involves minimal discomfort because of the tiny diameter of the needles.
Some injections give a feeling like an insect bite. Larger veins (reticular veins) often underlie spider veins and these vessels must be treated first and the smaller "spider" veins usually treated 4 weeks later. Generally, it is ideal to have about 4-8 weeks between treatment sessions for the same leg but the alternative leg can be treated in the meantime. Following each treatment session you will be required to wear a special venous compression stocking to assist in sealing off the abnormal veins. The length of time that the stocking will be required to be worn continuously for is usually for 3 to 7 days. This time will be determined by the size of the veins injected. It is very important to adhere strictly to the duration of compression in order to obtain the best result and reduce any risk of complications. The stocking must always cover as much of your toes as possible; otherwise you may get a swollen foot. Compression minimises the formation of haematoma (blood clot) and pigmentation, reduces the number of treatments necessary, reduces the risk of deep venous thrombosis and reduces the possibility of recurrence.
How successful is Sclerotherapy for Surface Veins?
After several treatments most patients can expect a 75% improvement in the appearance of their legs. You will initially look worse because of bruising. The improvement may be very gradual with some vessels taking up to 3 months to show maximum benefit. Sometimes there is little noticeable improvement after the first treatment session of the larger reticular veins. Sometimes treated vessels (particularly telangiectasiae) may be more noticeable after treatment because of a small amount of trapped blood. This blood will gradually dissolve.
Sclerotherapy of Surface Veins Cost?
Charges vary with the condition and the number of treatments necessary. It is difficult to be exact about the number of treatments required but it is expected that you will probably require at least 2-3 treatments. The cost of each treatment session is $450. The cost of the support stockings is from $85.
Other Treatment Methods for small Veins
Lasers for small veins: Direct laser beams are best used for treating only the smallest of abnormal blood vessels such as seen on the face but also now used for tidying small veins on the leg. A cooling fan is used to minimize discomfort; the procedure has the added benefit of not requiring compression stockings or international flight restrictions. The cost here is usually $250 per session
The Treatment of Deeper Veins by Ultrasound Guided Sclerotherapy (UGS)
Ultrasound Guided Sclerotherapy (UGS) is a way of assessing and treating deeper veins without surgery. The procedure has been performed for approximately 20 years. The procedure may be suitable for those people who have had a recurrence of their problems after surgery. Some people are not suitable for UGS and Dr. Little will discuss your suitability with you. It is important to appreciate that varicose vein disease is a chronic condition that requires on-going maintenance and surveillance after the initial course of treatment gains control. Treatment at the earliest stage will help avoid the possible expensive and debilitating complications including leg ulcers, stasis dermatitis and thrombophlebitis. The success rate of the procedure compares very favourably to many published results of surgical treatment, radiofrequency ablation and endovenous laser treatments. Dr. Little will discuss with you the relative merits of other methods versus UGS once he has completed your assessment.
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The Procedure
Prior to the procedure, an Ultrasound scan of your legs is performed. This examination is called a mapping scan. This will familiarise Dr. Little with your leg/s and clarify any difficult areas if necessary.
The procedure is then performed with you lying on the treatment couch. The ultrasound scanner is used to locate the abnormal vein and Dr. Little then guides a fine needle to the centre of the abnormal vein and injects a precise amount of sclerosant solution or foam into the vein. This has the effect of sealing the vein off at that point. This will prevent abnormal flow down the vein. The procedure involves minimal discomfort. Usually several injections are required. Dr Little may elect to use the sclerosant medicines by foaming them, this technique is recognised now to give better results. It is however, at present, still an unregistered ‘off-the-cuff’ use of the registered medicines but may well be the safer technique.
Following the procedure you are required to walk immediately and will wear the graduated venous compression stocking for 2 weeks. As with other forms of sclerotherapy you must walk for at least 30 minutes on each day that the stocking is on. It is essential that you walk for 30 minutes immediately after the procedure and it is a good idea to walk for 30 minutes several times per day for the first 3 days following treatment (or whenever the leg aches). You must not drive your car after a treatment until you have completed your 30min walk.
It is usual for there to be some tenderness, lumpiness, hardness and bruising/discolouration along the line of the treated veins. If there are specific hard lumps close to the skin surface it may be necessary to have these released by the nurse. This is usually done in the first 6 weeks. Any deeper lumps that still remain will dissolve over time but this may take several months. In some people the treated veins may become more sore 1-6 weeks after treatment. The best treatment for this soreness is to apply heat by placing a hot water bottle on the area for 10 minutes and then massage with Deep Heat or equivalent for 10 minutes. This should be repeated 4 times per day. Anti- inflammatory medications may help and also re applying the compression stockings is recommended. If this soreness does not appear to be settling with these measures then you must consult Dr Little as soon as possible. This increase in soreness is usually due to phlebitis and may require additional treatment. Rarely is this soreness due to a Deep Vein Thrombosis but if you have any concerns do not hesitate to contact Dr. Little.
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Follow-up Appointments:
Your first review appointment will usually be 2 weeks following UGS to check your progress. A further review appointment, including a scan, will usually be after 3 months. Please take your stocking off before you come to your review appointments but always bring your stocking to every appointment. Overall, approximately 45% of people will need to have a follow-up treatment for a satisfactory result. If you have more than one deep vein that needs treatment, or very large veins, you are more likely to need a follow-up treatment, usually performed at the three month follow up visit. Once Dr. Little feels the treatment phase is complete then a further 2 scans over the following year are recommended to Follow Up progress and ensure complete removal of the treated veins. Your initial fees include the cost of follow up scans and up to 3 treatments of the smaller veins in the first year.
What are the expected fees for Ultrasound Guided Sclerotherapy (UGS)
This procedure is billed at the first session and is a capped fee.
These prices are inclusive of all further sessions and follow up appointments and scans offered and required to ensure complete closure of the truncal veins in the year following the initial treatment session. Please note that if you have multiple small veins it does not include more than 3 repeat treatments of tiny blood vessels nor laser treatments.
Other Treatment Methods for treating Large Veins.
Endovenous Laser Ablation (EVLA) By threading a wire with ultrasound image guidance into the unwanted vein and directing either laser or radiofrequency energy directly down the unwanted vein it can be destroyed. Although it is more involved and is slightly more expensive, this technique has advantages of efficacy with a single treatment when treating long large straight veins. It can be performed on its own or with sclerotherapy on the lower veins. We will advise you if it is suitable in your case. We do often recommend and perform this service so please ask for a further information pamphlet if you would like to explore this option.
Surgery: Tying veins off ("ligation"), pulling them out ("stripping") or removing by small punctures ({"stab avulsions") are surgical procedures for treating leg veins and generally have more risks and greater recovery times than equivalent treatments with sclerotherapy. With the newer techniques many phlebologists feel these surgical operations will become obsolete, however good surgery from a good surgeon is an option worthy of consideration.
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Normal Effects from Sclerotherapy
* Bruises at injection sites. These will disappear in a few weeks and are probably related to the fragility of blood vessel walls. Blood trapped in the treated vein may result in the vein becoming more noticeable in the first few weeks following treatment. This is an early sign that the treatment has been successful.
* Aching in the leg for the first few days after treatment. This is more likely if you have varicose veins treated. It is usually relieved by walking. You may also take Panadol to relieve this aching.
* Phlebitis: This is an inflammation of the treated veins, which may also be associated with tender lumps along the line of the treated veins. THESE LUMPS ARE NORMAL and are due to the reaction of the sclerosant on the blood vessel wall and the trapping of "old" blood. It is more likely if you have varicose veins treated. When it occurs to a large or prolonged extent, it may be treated by draining the blood out of the painful lumps by small needle punctures. Other treatments for this may included anti-inflammatory medication, heat packs, massage with an anti-inflammatory cream, compression stocking and regular walking. The lumps will always disappear with time but this may take several months.
Possible Side Effects with Sclerotherapy
Even when a highly experienced physician is performing the treatment, there are a number of possible side effects that are listed below. If you have had previous episodes of deep clots (thrombosis) in your leg, this may mean that you are unsuitable for treatment. Dr Little will discuss this with you. There is some suggestion that the taking of the oral contraceptive pill, hormone replacement therapy (for menopause) and Tamoxifen during treatment increases the risk of Deep Vein Thrombosis. However, the risks are small and are probably not a reason to stop taking these medications during treatment. Similarly, people who smoke have a slight increase in risks. Sclerotherapy is not suitable for pregnant women or breast feeding mothers.
Pigmentation:
This is the appearance of brown marks on the skin after treatment corresponding to where the veins were treated. It is considered to be a normal consequence of having varicose veins treated. Some studies showing an incidence as high as 16% at 6 months and 5% at 2 years. These pigmented areas are mainly composed of haemosiderin (a form of iron stored in the blood) and result when blood escapes from treated veins. Pigmentation is more likely to occur in patients who have larger veins treated or those patients who have a lot of bruising. In most cases they disappear completely within a year. Persistent pigmentation may respond to laser treatment. Aspirin may increase the chance of pigmentation.
Matting:
This is the development of networks of fine red blood vessels near the sites of injection and is more likely on the thighs. Most resolve spontaneously, some resolve with injection treatment, and a few persist. Matting is more common in patients with extensive surface veins, deep vein problems, patients who have a family history of surface veins and in obese patients who have poor muscle tone.
Ulcers:
Very occasionally there is the formation of small, painful ulcers at treatment sites within 2 weeks of injection. These may occur because the solution has escaped into the surrounding skin or sometimes because there is an abnormal connection between the small veins that are injected and the nearby arteries, or by inadvertent injection of small arterioles. Ulcers are more common in patients who smoke cigarettes. They heal slowly and may leave a small pale scar. If the ulcer becomes infected an antibiotic is prescribed.
Allergic Reactions:
Although on rare occasions (1 per 5,000 treatments) such reactions may be serious, they can be treated by immediate injections of adrenaline. Less serious reactions are treated with antihistamines. Minor rashes require no specific treatment but you should inform Dr Little if they occur.
Deep Vein Thrombosis (clot in a deep vein):
This can occur but is uncommon if compression and regular daily walking are adhered to.
*Intra-Arterial Injection:
This is an extremely uncommon complication that may result in muscle and skin damage.
Paraesthesia:
As many of the veins we treat are close to nerves in the lower limb, the nerves may be irritated by the injection process or inflammation that ensues following a sclerosant injection. The irritation usually takes the form of numbness and may last several months before finally resolving completely without any treatment required. Dr. Littles' personal experience of this leads him to believe this occurs in about 0.5% of people treated.
Visual Disturbance:
(Visual Scotoma) can occur during or immediately after sclerotherapy and may be associated with headache. It settles with simple analgesia and is probably more common in people who suffer from Migraine.
There are no known long term side effects of the sclerotherapy agents, the products are all biodegradable.
Will Treated Veins Recur?
The veins treated adequately by sclerotherapy will not recur. However, the underlying condition will persist and therefore new vessels often parallel to treated veins may appear with time. It is important to avoid prolonged standing, maintain normal body weight, exercise regularly, avoid constipation and minimise the wearing of high-heeled shoes to minimise the development of abnormal dilated veins. If you have severe problems with abnormal veins then ideally support stockings should be worn every day. These stockings are not as "heavy" as the stockings used after treatments but offer more support than normal stockings. These can be purchased from this clinic. A yearly "check up" is recommended to detect the development of new veins, which can then be treated easily.
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What to Do before Treatment
Do not use fake tanning products for at least 2 weeks prior to treatment. If possible do not expose your legs to the sun without 30+ sun block for at least 1 week prior to treatment. Avoid using oils or moisturizers on your legs on the day of your treatment. You may prefer to wear trousers to your appointment, as they will conceal the compression stockings. Please wear flat shoes or sports shoes so that you may walk comfortably after the procedure. Please make sure you are familiar with all the information in these notes.
It is advisable to bring a driver for the first treatment, if you are coming from out of town.
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What to Do After Treatment
In order to ensure the success of the treatment it is essential that you observe the following instructions:
1. As soon as you leave the clinic you must walk for half an hour. Each day following your treatment, whilst you are wearing a stocking, you must walk at least once for a period of at least 30 minutes. Walking, by using calf muscles, reduces the pressure in the superficial veins. Walking is also helpful in preventing phlebitis and deep venous thrombosis. YOU CANNOT DO TOO MUCH WALKING. Do not confine yourself to bed.
2. Avoid standing still for long periods of time and when you are sitting please have your legs elevated if possible. Avoid Aspirin for at least 1 week following treatment (Please discuss this with Dr. Little if you take regular aspirin medication) and alcohol should be in moderation for at least 3 days following treatment.
3. Avoid vigorous or strenuous activities (e.g. running, squash, high impact aerobics) or heavy lifting for the first 3 days after treatments. Light weight workouts, swimming, golf and low intensity tennis are OK. You will able to carry on with your normal work or house duties.
4. You may experience slight pain in the legs during the first few days after treatment. If this happens take 1 or 2 Panadol tablets, do not rest your legs, and continue walking as before. In the very unlikely situation where you notice any severe or continuous pain please contact Dr Little (021 442 060) immediately.
If after treatment you have discomfort in your foot at night which disturbs your sleep, remove the stocking whilst in bed and put it on again before getting up next morning. If you have any soreness or swelling of the calf, any shortness of breath, chest pain or other chest problem this may be due to Deep Vein Thrombosis and you should contact Dr Little immediately. In the unlikely event that Dr Little cannot be contacted you should go immediately to your local emergency department or general practitioner.
5. When larger surface vessels are treated you are required to leave the stocking on for 3 days. The stocking must be left on uninterruptedly. During this time you will be able to shower by rolling the stocking down about 10cm (4 inches) and covering the stocking with a plastic bag. If your deeper veins have been treated by UGS you are required to leave the stocking on for 2 weeks. As an alternative to covering the stocking you can let the stocking get wet and then either towel dry, blow dry or allow the stocking to dry naturally. You can swim whilst wearing the stocking. If you get any soreness behind the knee from the stocking pressure, put some cotton wool or a rolled up sock down the stocking to relieve the pressure.
6. After the first treatment you usually need to come for a review appointment in approximately 2 weeks. Please bring your stocking.
7. Please advise Dr Little if you are planning to fly soon after treatment and appropriate instructions will be given. It is not advisable to commence treatment in the week following an overseas flight or to have treatment in the month before flying.
8. Always bring your compression stockings along for every appointment.
9. Please contact or visit Dr Little at any time if you are unhappy with your progress.
IF YOU ARE A CARRIER OF AIDS or HEPATITIS, OR HAVE BEEN EXPOSED TO AIDS, HEPATITIS, or other bloodborn diseases, THEN YOU MUST ADVISE DR LITTLE PRIOR TO TREATMENT SO THAT EXTRA PRECAUTIONS CAN BE TAKEN. THESE DISEASES ARE HIGHLY COMMUNICABLE AND DR LITTLE AND HIS NURSE ARE AT RISK THROUGH A NEEDLE INJURY OF CONTRACTING THESE DISEASES.
IF YOU HAVE ANY CONCERNS AFTER THE TREATMENT DO NO HESITATE
TO TELEPONE DR. LITTLE ON 021 442 060 OR FILL IN THIS FORM.
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