Treatment for Varicose and Telangiectatic Leg Veins at a Glance
- 53% of patients over 50 years of age show some venous reverse flow.
- Pregnancy, body mass, age, and family history can all affect incidence of venous reflux.
- Sclerotherapy and laser are main cosmetic treatments for spider veins.
- For larger varicose veins, sclerotherapy, phlebectomy, endovenous occlusion by radiofrequency or laser are standard approaches.
Bulging varicose veins and unsightly “roadmap” telangiectatic webs affect millions of patients around the world. The incidence is highest in Caucasian patients in which telangiectasias comprise the most common of all cosmetic complaints. This is borne out by epidemiologic surveys in which leg telangiectasia are reported in 70% of women.1 These same 24 city studies of thousands of patients indicate that 53% of the population over 50 years of age show some venous reverse flow.1 Women are at least 4 times more likely than men to develop telangiectasia, while males have double the risk of developing large varicose veins.2 Women aged over 50 years are five times more likely than women aged 29 or less to develop large varicose veins. Pregnancy increases the risk of varicose vein development by a factor of 1.5× to 3× and is associated with higher risks following three pregnancies.1,3,4 Increased body mass index correlates with a higher risk of reverse flow or reflux which leads to pain, swelling and abnormalities of the saphenous system.5,6 A positive familial history of disease is well known to increase the risk for varicose veins. Varicose veins may cause significant morbidity including chronic stasis dermatitis, ankle edema, spontaneous bleeding, superficial thrombophlebitis, recurrent cellulitis, lipodermatosclerosis and skin ulceration on the ankle and foot.
The incidence of varicose veins increases with each decade of life. Increased incidence has led to increased demand for treatment of varicose and telangiectatic veins as the average age of the US population grows. While 41% of women in the fifth decade have varicose veins, this number rises to 72% in the seventh decade.7 Statistics for men are similar with 24% incidence in the fourth decade, increasing to 43% by the seventh decade. Six million workdays per year may be lost in the United States due to complications of varicose veins, although this number is being affected by endovenous ablation techniques.8 Treatment is now much less complicated as an outpatient procedure avoiding dreaded stripping. As such noninvasive treatments are more frequently utilized so that lost workdays may actually be decreasing, although these statistics do not exist.
The main techniques employed in the dermatologist's office for treatment of cosmetic spider veins are sclerotherapy and lasers. For larger varicose veins, dermatologic surgeons employ sclerotherapy (with or without Duplex ultrasound guidance), ambulatory phlebectomy, and endovenous ablation by radiofrequency or laser. Sclerotherapy, which is defined as the intravascular introduction of a sclerosing substance, is the most frequently utilized procedure. We recommend that the term be changed to “endovascular chemoablation” which more accurately describes the procedure, although sclerotherapy is so entrenched that this will be unlikely to occur.
Sclerotherapy gained acceptance in the United States as a highly effective treatment during the early 1990s as it can be utilized for veins of all sizes.9 With the addition of foaming the sclerosant, utility has been expanded further.10 Sclerotherapy is also an important adjunctive therapy to surgical techniques such as ambulatory phlebectomy for saphenous tributaries11,12 and endovenous ablation of refluxing saphenous veins.13,14 Knowledge of venous anatomy and physiology, principles of venous insufficiency, methods of diagnosing venous abnormality, uses and actions of sclerosing solutions and proper use of compression are essential elements of successful venous therapy.
Primitive stripping and cauterization were practiced by Celsus, while ligation was mentioned by Antillus (30 ad). In the second century ad, Galen proposed tearing out the veins with hooks, a precursor to the modern day technique of ambulatory phlebectomy originated by Swiss dermatologist Robert Muller in the late 1960s.
A crude concept of sclerotherapy appeared in 1682, as Zollikofer described injection of acid into a vein to create a thrombus. By the late 1700s, the critical role of saphenofemoral reflux in the pathogenesis of varicose veins had been recognized by a Swiss surgeon, Rima. Reports of use of absolute alcohol as a sclerosing agent appeared from 1835–1840. In 1851, Pravaz attempted sclerotherapy with ferric chloride using his new invention, the hypodermic syringe.
The foundation of modern sclerotherapy can be traced to World War I when Linser and Sicard both noticed the sclerosing effect of intravenous injections used to treat syphilis which often resulted in vein sclerosis. Tournay greatly refined the sclerotherapy technique in Europe. It was not until 1946, when a safe sclerosant, Sotradecol (sodium tetradecyl sulfate) had been tested and described that sclerotherapy began to be seriously studied in the United states.15
Another key to success and acceptance of the treatment of varicose veins by sclerotherapy was the addition of compression. Sigg and Orbach in the 1950s and Fegan in the 1960s emphasized the importance of combining external compression immediately following injections. Starting in the 1980s, Duffy promoted the technique among dermatologists and advocated the use of polidocanol (POL) and hypertonic saline as safe and effective sclerosing solutions.16 In March 1999, the first endovenous obliteration technique utilizing radiofrequency was cleared by the US Food and Drugs Administration (FDA). Dermatologic surgeons were instrumental in developing this technique.14,17,18 Goldman's first American textbook of sclerotherapy integrated the world's phlebology literature, introduced new sclerosing solutions and validated dermatology's claim to expertise in vein treatment.19 Several additional textbooks by dermatologic surgeons have firmly established phlebology within the domain of dermatology.20,21 The newest development in sclerotherapy has been the FDA approval of polidocanol (Asclera, Merz Aesthetics/Bioform, ...