These guidelines are also consistent with the results of the first European guidelines for sclerotherapy dating from 2012 . These guidelines consider the current state of the literature, but not in every case the different conditions of approval of the various drugs.
Sclerotherapy is the targeted chemical ablation of a varicose vein by intravenous injection of a liquid or foam sclerosant [1, 2]. Intradermal, subcutaneous and/or transfascial (perforator) veins can be treated by this method, as well as epi-, supra- and subfascial vessels with venous malformations. The sclerosant destroys the endothelium of the vein and possibly other regions of the vein wall, and is deactivated by blood components and circulating cells [1, 2]. After successful sclerotherapy the varicose vein is transformed in the long term into a string of connecting tissue, in a process known as sclerosis [3,4,5,6]. The objective of sclerotherapy is not thrombosis of the vein, since re-channelling may occur after this process, but its transformation into a string of connecting tissue. Re-channelling of this is impossible, so the functional outcome is equivalent to removal of the vein or endovenous thermal ablation.
2 Objectives of sclerotherapy
The objectives of sclerotherapy are:
Ablation of varicose veins.
Prevention and treatment of complications of chronic vein disease.
Improvement and/or elimination of venous symptoms, improved quality of life.
Improved venous function.
Improved aesthetic appearance.
The objectives are consistent with those of other therapeutic procedures for varicose veins.
Sclerotherapy can be used for all forms of varicose veins, especially:
Other indications (e.g. varicose veins in the oesophagus, haemorrhoids, varicocele, hygroma, lymphatic cyst, Baker’s cyst) are not covered by these guidelines.
Treatment with liquid sclerosants is considered the method of choice for reticular varices and spider veins due to the stability of the available data (C1 varicose veins according to the CEAP classification) [25, 27, 29, 58, 59]. Foam sclerotherapy is an additional treatment option for C1 varicose veins [8, 28, 29, 60].
Thermal and operative procedures have been established for the treatment of varicose saphenous veins. The treatment of incompetent saphenous veins by sclerotherapy is likewise a successful and cost-efficient treatment option [18, 61,62,63,64,65,66,67,68,69,70]. It has comparatively few side effects and can be repeated as required. This is particularly true of foam sclerotherapy, as has been shown in recent years by case studies and prospective, randomised, controlled trials [5, 11, 18, 27, 65, 66, 71,72,73]. The re-channelling and recurrence rates are higher than with operative and thermal procedures [11, 14,15,16,17]; however, the improvement in quality of life achieved after 5 years is similar to that of EVLA and stripping operations .
In combination with other saphenous vein ablation procedures, sclerotherapy with percutaneous vein ablation is an option for the elimination of an accompanying varicose tributary, either in the same session or after an interval [19, 20]. The same is true of treatment of recurrent varicose veins [37, 38]. Early ablation of the incompetent saphenous vein as well as peri-ulcer sclerotherapy has proved effective in the treatment of venous leg ulcers. Foam sclerotherapy of the incompetent saphenous vein accelerates ulcer healing, comparable with endovenous thermal procedures .
The following absolute and relative contraindications for sclerotherapy shall be observed:
Known allergy to the sclerosant.
Acute venous thromboembolism.
Local infection in the region of the sclerotherapy or severe generalised infection.
For foam sclerotherapy:
Known symptomatic right-to-left shunt (e.g. symptomatic patent foramen ovale).
Lactation (if the indication is urgent, interrupt lactation for 2–3 days).
Severe peripheral arterial occlusive disease.
Poor general state of health.
High risk of thromboembolism (e.g. known history of thromboembolic events, known severe thrombophilia, active cancer).
Long-term immobility or bed-ridden patient.
For foam sclerotherapy:
Neurological disorders, including migraine, after previous foam sclerotherapy.
Anticoagulation treatment is not a contraindication for sclerotherapy per se [43, 77, 78]; however, patients should be advised that the success of the treatment may be reduced and/or several treatments may be needed.
In addition, the technical information current in Germany, the instruction leaflet or the product description for the sclerosant used should be observed.
5 Complications and risks
If correctly executed, sclerotherapy is an efficient form of treatment with few complications .
If an anaphylactic reaction is suspected, injection shall be stopped immediately and the usual emergency measures taken, including, if appropriate, administering anti-histamines, corticosteroids and epinephrine.
Extensive tissue necrosis
Extensive necrosis may appear after inadvertent intra-arterial injection [89,90,91,92]. The risk of intra-arterial injection can be minimised by ultrasound control with proper representation and identification of the arteries in the immediate neighbourhood of the target veins. If severe pain occurs during injection, the procedure should be stopped immediately. If intra-arterial injection is suspected, local anticoagulation and thrombolysis should be administered by catheter if possible. This can be complemented, if appropriate, by systemic anticoagulation. Prompt administration of systemic corticosteroids can help to reduce the inflammatory reaction [85, 89].
To avoid inadvertent perivenous or intra-arterial injection, in both foam and liquid sclerotherapy, the injection should be carried out under ultrasound control if the vein cannot be seen or felt easily and safely.
If intra-arterial injection is suspected, local anticoagulation and thrombolysis should be administered by catheter if possible; this can be complemented, if appropriate, by systemic anticoagulation. Prompt administration of systemic corticosteroids can help to reduce the inflammatory reaction.
Skin necrosis and embolia cutis medicamentosa
Skin necrosis is described both after perivascular injection of high-percentage sclerosant and in rare cases after correct intravascular injection of the sclerosant at low concentrations . However, it has been shown that subcutaneous perivascular injection of liquid or foam polidocanol is not responsible for skin necrosis after sclerotherapy of reticular varices or spider veins . In these cases a mechanism is assumed with transfer of sclerosant into a leg artery through an arteriovenous anastomosis or venoarterial reflex vasospasm [85, 95, 96]. In individual cases this has been described as embolia cutis medicamentosa or Nicolau syndrome [97, 98]. Treatment of skin necrosis should follow the recommendations for general wound treatment. Healing can sometimes be protracted.
To reduce the risk of skin necrosis, injection of large volumes at any injection point should be avoided. The sclerosant should be injected at the lowest possible pressure.
Vision disorders, headache and migraine
Transient migraine-like symptoms can be observed after all forms of sclerotherapy. They appear more frequently after foam sclerotherapy than liquid sclerotherapy [58, 80, 84, 99,100,101,102]. To date no pathological findings have been reported in ophthalmological research, and there are no reports of lasting vision disorders .
Right-to-left shunt, for example due to patent foramen ovale, occurs in around 30% of the population; discussion continues as to whether the transfer of foam bubbles into the arterial circulation plays a part in this condition [103,104,105,106,107].
Vision disorders may be accompanied by paraesthesia and dysphasic speech disorders, depending on the extent of cortical spreading depression, the pathological equivalent of migraine with aura. There is no firm proof of interdependence between foam bubbles and visual or neurological disorders. Recent data show that potentially vasospastic endothelin 1 is released from vessels into which liquid or foam sclerosant has been injected [110, 111]. Vision disorders occur in patients with a history of migraine more frequently than in patients with no such history . Multiple injections of small doses may possibly reduce rapid transfer of the sclerosant into the deep veins .
Stroke and transient ischemic attack (TIA)
In neurological disorders which occur shortly after treatment, also described in the published literature as “stroke”, the presence of intracerebral clots has not been proved. These events do not appear to reflect thromboembolic disease [84,85,86, 103, 113, 114]. In such cases air bubbles in the arteries of the brain are reported [114,115,116,117].
In cases described as stroke after sclerotherapy, we shall distinguish between two forms: those associated with a paradoxical venous thromboembolism, as a rule with delayed onset of symptoms, which have also been described after various other varicose vein treatment methods [118, 119]; and early-onset strokes with a paradoxical air embolism, a characteristic complication of foam sclerotherapy [104, 120].
It should be noted particularly that all patients with stroke resulting from a paradoxical air embolism after sclerotherapy recover completely or almost completely. To date no significant aftereffects have been reported in these cases .
Individual cases of confirmed stroke or TIA have been described after both liquid and foam sclerotherapy; they occur after an interval and are associated with paradoxical thromboembolism [103, 117, 121,122,123,124,125].
In patients who have presented neurological symptoms, including migraine, after previous sclerotherapy, the following should be considered:
The patient should remain lying down for longer after the injection.
Injection of large volumes of foam should be avoided, or liquid sclerosant should be used instead.
The patient should avoid carrying out the Valsalva manoeuvre soon after the injection.
Decide on a case-by-case basis (considering a risk–benefit analysis based on the indications).
Deep vein thrombosis (DVT) and lung embolism (LE)
In Table 1, distal DVT is included under “serious complications”, although in individual cases it may be a “benign complication”, e.g. in the case of an asymptomatic calf vein thrombus. There are insufficient published data to assess the real frequency of DVT after liquid sclerotherapy. Most studies on the effectiveness of liquid sclerotherapy are old and were carried out without duplex ultrasound examination. In most studies there is no clear distinction between symptomatic and asymptomatic DVT, although the clinical consequences are usually distinguishable .
Severe thromboembolic events (proximal DVT, lung embolism) very seldomly occur after sclerotherapy [127, 128]. The total frequency of thromboembolic events is less than 1%; the frequency of DVT reported in the meta-analyses of Jia and of Dermondy is 0.6% [129, 130]. Deep vein thrombi are mostly distal. Most cases are discovered during routine follow-up examination by duplex ultrasound and are asymptomatic [80, 84, 130]. The injection of large volumes of liquid sclerosant, and more particularly of foam sclerosant, raise the risk of a thrombus [71, 75, 113, 131]. This is equally true of patients with a known history of thromboembolism or thrombophilia . For patients with these risk factors a precise risk–benefit analysis shall be carried out and additional precautions should be taken [75, 77, 132]. Other risk factors, like overweight or insufficient mobility, should also be considered.
In patients with a high risk of thromboembolism, e.g. with a history of recurrent SVT and/or DVT or known severe thrombophilia, the following should be considered:
Use of a thrombus prophylactic drug in accordance with the recommendations on thrombus prophylaxis in current guidelines.
Physical prophylaxis (compression, exercise).
Avoid injections of large volumes of foam sclerosant.
Decide on a case-by-case basis (considering a risk–benefit analysis based on the indications).
Superficial vein thrombosis
Frequencies between 0 and 45.8% are reported in the literature, with a mean of 4.7% [80, 85, 129]. The definition of superficial vein thrombosis after sclerotherapy is controversial in the literature. An inflammatory reaction in the injected sector of vein is usually a keloid reaction to sclerotherapy, which—as long as it does not exceed a normal size—should not be interpreted as a superficial vein thrombosis; on the other hand, a superficial vein thrombosis in an uninjected vein, or which clearly extends beyond the injected sector, would meet the definition of a superficial vein thrombosis. According to this interpretation, superficial vein thrombosis does occur after sclerotherapy; however, its real frequency is unknown.
Damage to motor nerves
The incidence of nerve damage after sclerotherapy is very low, lower than with other treatment methods for varicose veins .
Transient skin pigmentation is reported with a frequency between 0.3 and 30% [93, 134]. In general the pigmentation disappears slowly over a period of weeks or months . The incidence of hyperpigmentation is probably higher after foam sclerotherapy than liquid sclerotherapy . To reduce the frequency of hyperpigmentation, intravascular clots should be removed by needle aspiration or squeezed out through a stab incision [136, 137].
To reduce the risk of hyperpigmentation, superficial clots can be removed.
Matting describes the repeated appearance of fine spider veins in the region of a vein which has already been treated by sclerotherapy or another ablation technique (stripping, laser); it is an unpredictable individual reaction of the patient. Matting  can also occur after operative or thermal ablation of a varicose vein . In many cases the cause is non-treatment or insufficient treatment of the underlying reflux. High initial concentrations or large volumes of sclerosant can likewise lead to inflammation or excessive obstruction of the veins, with resulting angiogenesis. Treatment of matting should focus on the possible underlying reflux and the remaining open veins; the best treatment is with low concentrations of sclerosant or stripping [85, 139].
Other transient general or local reactions after sclerotherapy are tightness in the chest, vasovagal syncope, nausea, metallic taste, intravascular clot, haematoma, ecchymosis at the injection site, pain at the injection site, local swelling, induration, wheals, blistering and erythema. Complications may also be caused by compression bandages, e.g. blistering in the region of a sticking plaster.
To increase the general safety of foam sclerotherapy the following should be considered:
Injection of very viscous foam in the varicose veins (C2).
The patient should not move, particularly his/her leg, for several minutes after the injection; the patient should not carry out the Valsalva manoeuvre.
The type of gas that should be used to generate the foam (air or “physiological” gas) is still in dispute. If large volumes of foam are injected, a foam sclerosant with a low nitrogen content appears to reduce the early, reversible side effects [140, 141]. In patients treated with small amounts of CO2/O2 foam or air foam, no advantages could be demonstrated for the CO2/O2 foam in terms of causation of neurological disorders [142, 143].
6 Patient information
Before sclerotherapy patients shall be informed of the following:
Alternative treatment methods with their advantages and disadvantages.
Details of the sclerotherapy procedure and post-operative treatment.
Serious risks and complications.
Frequent side effects.
Explanation of rare and minor side effects in non-medically indicated sclerotherapy.
With respect to the expected outcome of sclerotherapy, patients should be informed of the following:
Short- and medium-term controls may be necessary.
Repeat treatment may be needed in some cases, especially in treatment of large varicose veins.
Foam sclerotherapy is more effective than liquid sclerotherapy for subcutaneous varicose veins.
Ultrasound-controlled foam sclerotherapy can avoid the need for an intra-arterial injection.
Certain side effects may be more frequent with foam (see Complications and risks section).
7 Diagnosis before sclerotherapy and documentation
Successful sclerotherapy requires a methodical procedure. Treatment is usually applied in sequence from proximal to distal reflux sources, and from larger to smaller varicose veins. A comprehensive diagnosis shall therefore be carried out before treatment .
Standard diagnosis of patients with chronic vein disease includes the patient’s medical history, and clinical and duplex ultrasound examination by a trained doctor. In cases of spider veins and reticular varices, examination with uni- or bidirectional Doppler ultrasound instead of duplex ultrasound may be sufficient. However, the general trend is towards duplex ultrasound for the initial examination also in these cases.
Duplex ultrasound examination is carried out with the patient standing, and is particularly good for identifying incompetent saphenous veins, subcutaneous veins (tributaries) and connections to the deep vein system, for clarifying post-thrombotic alterations, and for planning treatment [144,145,146,147]. Duplex ultrasound should also always be used to show incompetent terminal and/or pre-terminal valves. Duplex ultrasound offers substantial advantages over Doppler ultrasound for pre-therapeutic evaluation of saphenous vein incompetence, including measuring vein diameters .
Before sclerotherapy, a diagnosis shall be obtained, including medical history and clinical and duplex ultrasound examinations. In cases of spider veins and reticular varices, examination with uni- or bidirectional Doppler ultrasound instead of duplex ultrasound can be sufficient.
Patients with new and/or recurrent varicose veins after previous treatment are recommended to have duplex ultrasound before sclerotherapy [149, 150]. In cases of vessel malformation, thorough duplex ultrasound is also recommended. In some cases further examinations are necessary to clarify the anatomical and haemodynamic situation [51, 151, 152].
Functional examinations (e.g. photoplethysmography, phlebodynamometry, venous occlusion plethysmography) should also be considered. Other imaging techniques (e.g. phlebography) should only be used in exceptional cases [62, 153, 154].
Patients with recurrent varicose veins and patients with vessel malformations shall have a duplex ultrasound examination before sclerotherapy.
It is not necessary to examine specifically for the presence of a right-to-left shunt or thrombophilia before foam sclerotherapy .
Routine examination for a right-to-left shunt or the presence of thrombophilia factors in a clot system can be omitted.
The type of treatment, the number of treatments (injections and sessions), the medicinal products injected, volumes, concentrations and the proportions of the foam ingredients should be documented, including details of the veins treated (mapping).
8 Sclerotherapy of varicose veins
Polidocanol (Lauromacrogol 400)
A variety of different sclerosants have been used to treat varicose veins in recent decades, depending on national policies and traditions. In Germany, the only product authorised for use in the sclerotherapy of varicose veins is Aethoxysklerol® (Chemische Fabrik, Kreussler & Co. GmbH, Wiesbaden, Germany) , with the active ingredient polidocanol (Lauromacrogol 400).
Polidocanol is available in the following concentrations: 0.25%, 0.5%, 1%, 2% and 3% (corresponding to 5 mg, 10 mg, 20 mg, 40 mg and 60 mg in a 2 ml ampule).
Polidocanol is a non-ionic detergent and a local anaesthetic. A dose of 2 mg polidocanol per kilogram bodyweight per day should not be exceeded (see German product information for Aethoxysklerol® ). Thus, for a patient with a bodyweight of 70 kg, a maximum of 140 mg of polidocanol can be injected for varicose vein sclerotherapy—regardless of the amount recommended for medical purposes.
140 mg polidocanol are contained in:
Aethoxysklerol® 0.25%: 56 ml injection solution.
Aethoxysklerol® 0.5%: 28 ml injection solution.
Aethoxysklerol® 1%: 14 ml injection solution.
Aethoxysklerol® 2%: 7 ml injection solution.
Aethoxysklerol® 3%: 4.6 ml injection solution.
Sclerotherapy can be carried out with or without ultrasound control and with liquid or foam sclerosant.
8.1 Liquid sclerotherapy
8.1.1 Spider veins and reticular varices (C1)
The following recommendations should be observed for liquid ablation of spider veins and reticular varices (C1):
Puncture and injection of spider veins and reticular varices are carried out with the limb in the horizontal position.
A low-friction syringe is recommended.
A small cannula (up to 32 G) can be used.
An air-block system can be used.
The outcome may be improved by repeated sessions.
In spider veins and reticular varices, discoloration of the vein immediately after the start of injection shows that the sclerosant is forcing out the blood and that the injection is intravasal.
If the skin round the injection point turns white during injection, the injection shall be stopped immediately to avoid skin damage.
In liquid ablation, as a rule, the sclerosant is slowly injected intravenously, if possible in a fractionated dose and controlling the intravasal position of the cannula.
Severe pain during injection may indicate paravasal or even intra-arterial injection. In this case injection shall be stopped immediately.
Diaphanoscopy can be used to detect invisible tributary or perforator veins.
8.1.2 Varicose veins (C2)
The following recommendations should be observed for liquid ablation of varicose veins (C2):
The vein can be punctured with a free needle (“open needle”) or a cannula attached to the syringe (“closed needle”).
Avoid puncturing a perforator vein or saphenofemoral junction directly.
Low-friction syringes and cannulae of different diameters are recommended according to the indication.
Injection systems: the injection can be carried out:
with a cannula attached to the syringe (“closed needle”); the syringe is filled with sclerosant (e.g. 2.5–5 ml),
with a butterfly catheter as an option for varicose veins lying immediately under the skin (preferably with a short silicone tube due to the stability of the foam),
with a short catheter (e.g. Braunüle® [B. Braun Melsungen AG, Melsungen, Germany]) as an option for saphenous veins and with the possibility of an injection afterwards,
with a long catheter as an option for varicose saphenous veins.
After puncturing the skin with the cannula, the intravasal position is checked by allowing the blood to flow back or by aspiration, as appropriate.
Several injections can be applied per session along the treated vein.
Injection should be carried out with patient lying down.
As a rule, the sclerosant is slowly injected intravenously, if possible in a fractionated dose and controlling the intravasal position of the cannula or short catheter.
Severe pain during injection may indicate paravasal or even intra-arterial injection. In this case injection shall be stopped immediately.
8.2 Foam sclerotherapy
Sclerotherapy with foam sclerosants has been reported in the literature for many years . Since foam was formally authorised in 2009, foam sclerotherapy has been practised with improving techniques, especially for the treatment of large-diameter veins [8, 128, 155, 157].
Detergent-type sclerosants, like polidocanol, can be converted into a fine-bubble foam by special techniques. In Tessari’s method the foam is produced by turbulent mixing of liquid and air in two syringes, connected by a three-way stopcock. In Tessari’s original technique, the proportion of sclerosant to air was 1 + 4 [156, 158]. In the double-syringe system (DSS), polidocanol sclerosant is mixed with air in the proportion of 1 + 4 by turbulent mixing in two syringes connected by a special two-way connector. At low concentrations of sclerosant, the resulting foam is relatively unstable; at higher concentrations it becomes more stable and viscous. There are no reports of side effects other than those attributable to the use of unsterile air for foam production .
For all indications, a three-way stopcock (Tessari method) or a two-way connector (DSS method)—or a similarly appropriate method—should be used for production of the sclerotherapy foam.
For all indications, ambient air or a mixture of carbon dioxide and oxygen should be used for the gas component in foam production.
A mixture of liquid sclerosant and gas in proportions of 1 + 4 (one part liquid to four parts gas) or 1 + 5 should be used for sclerotherapy foam production. For treatment of large-calibre varicose veins (C2), a homogeneous, viscous, fine-bubble foam shall be used. The proportion of liquid can be increased, especially in the case of low-concentration sclerosant.
The interval between foam production and injection should be as short as possible.
In foam sclerotherapy of large veins the cannula should be no smaller than 25 G; in so far as possible, low-silicon materials should be used and if a silicon tube is used (with a butterfly), it should be as short as possible, otherwise the foam quality will be affected.
Any alteration in the physical properties (e.g. cooling or heating) can alter the safety profile of the sclerosant used.
There is no evidence-based specification for the maximum volume of foam per session. In the previous European consensus on foam sclerotherapy, the opinion of experts was that a volume of 10 ml of foam should be regarded as the safe maximum . The incidence of thromboembolic complications and temporary side effects (e.g. vision disorders) rises with larger volumes of foam [115, 131].
In routine cases a maximum volume of 10 ml of foam per day/session should not be exceeded. Larger volumes of foam may however be used after carrying out an individual risk–benefit analysis.
Concentration of the sclerosant for foam sclerotherapy
The following concentrations should be observed in proportion to the diameter of the treated vein segment. The suggested concentrations and amounts are reference values and may be adapted according to the therapist’s assessment (Table 4).
8.3 Ultrasound-guided sclerotherapy
Ultrasound-guided sclerotherapy with liquid and foam sclerosants has proved to be a useful complement to the various treatments available for varicose veins. In particular it is suitable for treatment of varicose saphenous veins (GSV and SSV), tributaries and perforator veins, and in cases of recurrent varicose veins and venous malformations [21, 30, 54,55,56,57, 165,166,167].
The following recommendations should be observed for ultrasound-controlled sclerotherapy:
The vein segment to be treated and the nearby arteries are examined in ultrasound before the puncture is made.
When treating incompetent saphenofemoral junctions and varicose saphenous veins it is recommended that the vein should be punctured in the proximal thigh region (great saphenous vein and anterior accessory saphenous vein) or the proximal calf (small saphenous vein).
In all other cases the vein should be punctured at the safest and most accessible point.
The vein should be shown in ultrasound lengthwise and/or in cross section.
The vein is punctured under ultrasound control and the point of the cannula is placed in the centre of the vessel lumen.
Backflow of blood into the cannula or catheter is checked and a few drops of liquid sclerosant or bubbles of foam are injected into the vein and controlled on the ultrasound screen before the actual injection.
The injection is performed under ultrasound control.
Foam is more suitable than liquid for ultrasound-controlled sclerotherapy because the bubbles contrast with the echo-poor vessels, allowing the sclerosant to be seen.
After injection ultrasound is used to control the distribution of the sclerosant and the reaction of the vein (including venospasm).
8.4 Mechanochemical endovenous ablation (MOCA)
Mechanochemical endovenous ablation is a combination of mechanical damage to the vein wall and a chemical sclerotherapy reaction. A wire is introduced through a catheter into the saphenous vein and pushed up to the junction; during injection, usually of liquid sclerosant, the point is rotated rapidly. The combination of mechanical damage to the endothelium of the saphenous vein and the effect of the sclerosant is supposed to result in a better vein occlusion rate [168, 169]. The maximum daily doses for sclerosant injection shall be observed.
In several case series and non-randomised studies, high initial occlusion rates and little pain were reported [170,171,172,173,174,175]. MOCA was compared with radiofrequency ablation (RFA) in a prospective randomised study . This showed that the pain was significantly less than after RFA, and occlusion rates, improvement in clinical findings and quality of life were comparable after 2 years. No longer-term outcomes are available. The side effects profile is similar to that of other sclerotherapy procedures.
Mechanochemical endovenous ablation can be used as an alternative to the other sclerotherapy methods for saphenous vein sclerotherapy.
9 Post-operative treatment after sclerotherapy
The following aspects of post-operative treatment after sclerotherapy should be considered:
Watch carefully for any signs of undesired reactions.
In addition to sclerotherapy, the treated limb can be treated with compression, either with a compression stocking or compression bandaging.
The outcome of sclerotherapy of spider veins can be improved by daily wearing of compression stockings (23–32 mm Hg) for up to 3 weeks after treatment .
Longer-term immobility after sclerotherapy can increase the risk of thromboembolic events.
Remaining clots can be punctured where possible (with or without ultrasound control) in the post-operative check-up.
Walking a long distance after sclerotherapy is widely recommended; however, there are no indications in the literature to date either for or against this measure.
10 Outcome control after sclerotherapy
Assessment of the effectiveness of sclerotherapy comprises clinical, morphological and haemodynamic aspects.
For spider veins and reticular varices, a clinical check-up is sufficient.
Clinical assessment in routine practice: presence/absence or improvement of varicose veins in the treated area, assessed by the doctor and/or patients.
The presence of venous ulcer, oedema, haemorrhage, inflammation, etc. belong to the clinical outcome.
Symptom reporting: if necessary (e.g. in the context of scientific research), differentiated and standardised symptom scores like the Venous Clinical Severity Score (VCSS) and Patient-Reported Outcome Scores can be used.
Morphological and haemodynamic outcome:
The morphology of the treated vein can be assessed with duplex ultrasound by the compressibility with the patient standing up. The appropriate settings shall be used for duplex ultrasound . The patency, occlusion (total or partial) or disappearance of the vein shall be checked. The examination should also include dynamic manoeuvres as per the UIP consensus .
See Table 5 for the findings that can be determined by duplex ultrasound.
These examination parameters can be used for all endovenous treatment procedures (laser, radiofrequency, sclerotherapy) and should make comparison easier, especially in scientific studies.
From a clinical point of view, regression of the varicose veins and/or venous symptoms is regarded as therapeutic success.
The disappearance or total occlusion of the treated vein in duplex ultrasound is regarded as the optimum therapeutic outcome.
Clinical improvement with occlusion of the treated vein, but with short open sections containing occasional circulation, can be judged a therapeutic success at least in the short to medium term.
After sclerotherapy the findings in duplex ultrasound can present a wide spectrum of outcomes, which will not necessarily agree with the clinical outcome.
With spider veins and reticular varices (C1), the success of treatment can be assessed in the check-up after sclerotherapy from the clinical outcome. With varicose veins (C2) and venous malformations, both clinical and ultrasound examinations should be carried out.
Sclerotherapy with liquid and foam sclerosants is a safe and effective procedure for treating spider veins, reticular varices and subcutaneous varicose veins [5, 8, 9, 20, 25, 29, 34, 59, 60, 73, 164, 167].
Sclerotherapy with liquid polidocanol is the method of choice for treating spider veins and reticular varices, resulting in an improvement of more than 90% after treatment [20, 25,26,27,28,29, 58]. Foam sclerotherapy is an alternative procedure for the ablation of spider veins and reticular varices, with similar occlusion rates and side effects, as long as low concentrations are used in a rather liquid foam [8, 29].
Foam sclerotherapy is significantly more effective than liquid sclerotherapy for varicose saphenous veins [5, 7,8,9, 27]. The occlusion rate depends on the vein diameter, the concentration of the sclerosant and the volume of foam injected [19, 27]. Compared with endovenous thermal ablation and stripping operations, foam sclerotherapy has a higher medium-term rate of re-channelling [11, 12, 65, 67, 68]. The improvements in quality of life and symptoms are similar [11, 14,15,16, 65]; however, the improvement in quality of life achieved after 5 years is superior to that of EVLA and stripping operations .
There is no firm evidence for an improvement in occlusion rate or a reduction of side effects by keeping the limb raised, compression of the junction with the ultrasound probe or use of tumescent solution to reduce vessel diameter [101, 177, 178].
Sclerotherapy of veins in the region of a venous ulcer improves the healing rate [43,44,45,46,47,48,49,50]. Early ablation of the incompetent saphenous vein together with peri-ulcer sclerotherapy has proved effective in the treatment of venous leg ulcers. Foam sclerotherapy accelerates healing, comparable with endovenous thermal procedures .
Foam sclerotherapy is also effective for treating new and recurrent varicose veins after previous treatment, varicose saphenous tributaries, other superficial varicose veins and incompetent perforator veins [19, 21, 23, 31,32,33,34,35, 39].
Compression treatment with medical compression stockings or bandages improves the outcome of sclerotherapy of spider veins [187,188,189,190] and may reduce the frequency of pigmentation [188,189,190]. There is still little evidence for the effectiveness of compression after sclerotherapy of saphenous veins [191, 192]. In a study in which compression stockings of three different compression classes were worn for 3 weeks after sclerotherapy, the higher the compression pressure, the lower the need for follow-up sclerotherapy . Even selective positive eccentric compression can reduce the recurrence rate . Local eccentric compression increases the local pressure in the sclerotherapy region significantly and may improve the effectiveness of sclerotherapy . Treatment with topical corticosteroids immediately after sclerotherapy, on the other hand, apparently offers no benefits in terms of the appearance of inflammatory side effects .
Rabe E, Breu FX, Cavezzi A, Coleridge Smith P, Frullini A, Gillet JL, Guex JJ, Hamel-Desnos C, Kern P, Partsch B, Ramelet AA, Tessari L, Pannier F, Guideline Group (2014) European guidelines for sclerotherapy in chronic venous disorders. Phlebology 29:338–354
Connor DE, Cooley-Andrade O, Goh WX, Ma DDF, Parsi K (2015) Detergent sclerosants are deactivated and consumed by circulating blood cells. Eur J Vasc Endovasc Surg 49:426–431
Drake LA, Dinehart SM, Goltz RW, Graham GF, Hordinsky MK, Lewis CW, Pariser DM, Skouge JW, Webster SB, Whitaker DC, Franceschi C (1996) Guidelines of care for sclerotherapy treatment of varicose and teleangiectatic leg veins. J Am Acad Dermatol 34:523–528
Rabe E, Pannier-Fischer F, Gerlach H, Breu FX, Guggenbichler S, Zabel M, German Society of Phlebology (2004) Guidelines for sclerotherapy of varicose veins. Dermatol Surg 30:687–693
Hamel-Desnos C, Ouvry P, Benigni JP, Boitelle G, Schadeck M, Desnos P, Allaert FA (2007) Comparison of 1 % and 3 % polidocanol foam in ultrasound guided sclerotherapy of the great saphenous vein: a randomised, double-blind trial with 2 year-follow-up. “the 3/1 study”. Eur J Vasc Endovasc Surg 34:723–729
Chen C‑H, Chiu C‑S, Yang C‑H (2012) Ultrasound-guided foam sclerotherapy for treating incompetent great saphenous veins—results of 5 years of analysis and morphologic evolvement study. Dermatol Surg 38:851–857
Hamel-Desnos C, Desnos P, Wollmann JC, Quvry P, Mako S, Allaert FA (2003) Evaluation of the efficacy of Polidocanol in the form of foam compared with liquid form in sclerotherapy of the long saphenous vein: Initial results. Dermatol Surg 29:1170–1175
Alòs J, López JA, Estadella B, Serra-Prat M, Marinel-Lo J (2006) Efficacy and safety of sclerotherapy using Polidocanol foam: a controlled clinical trial. Eur J Vasc Endovasc Surg 31:101–107
Ouvry P, Allaert FA, Desnos P, Hamel-Desnos C (2008) Efficacy of polidocanol foam versus liquid in Sclerotherapy of the great Saphenous vein: a multicenter randomised controlled trial with a 2-year follow-up. Eur J Vasc Surg 36:366–370
Rabe E, Otto J, Schliephake D, Pannier F (2008) Efficacy and safety of great Saphenous vein Sclerotherapy using Standardised polidocanol foam (ESAF): a randomised controlled multicentre clinical trial. Eur J Endovasc Vasc Surg 35:238–245
Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklof B (2011) Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg 98:1079–1087
Shadid N, Ceulen R, Nelemans P, Dirksen C, Veraart J, Schurink GW, van Neer P, Vd Kley J, de Haan E, Sommer A (2012) Randomized clinical trial of ultrasound-guided foam sclerotherapy versus surgery for the incompetent great saphenous vein. Br J Surg 99:1062–1070
Williamsson C, Danielsson P, Smith L (2013) Catheter-directed foam sclerotherapy for insufficiency of the great saphenous vein: occlusion rates and patient satisfaction after one year. Phlebology 28:80–85
Davies HO, Popplewell M, Darvall K, Bate G, Bradbury AW (2016) A review of randomized controlled trials comparing ultrasound-guided foam sclerotherapy with endothermal ablation for the treatment of great saphenous varicose veins. Phlebology 31:234–240
Venermo M, Saarinen J, Eskelinen E, Vähäaho S, Saarinen E, Railo M, Uurto I, Salenius J, Albäck A, Finnish Venous Study Collaborators (2016) Randomized clinical trial comparing surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy for the treatment of great saphenous varicose veins. Br J Surg 103:1438–1444
Lawaetz M, Serup J, Lawaetz B, Bjoern L, Blemings A, Eklof B, Rasmussen L (2017) Comparison of endovenous ablation techniques, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Extended 5‑year follow-up of a RCT. Int Angiol 36:281–288
Brittenden J, Cotton SC, Elders A, Tassie E, Scotland G, Ramsay CR, Norrie J, Burr J, Francis J, Wileman S, Campbell B, Bachoo P, Chetter I, Gough M, Earnshaw J, Lees T, Scott J, Baker SA, MacLennan G, Prior M, Bolsover D, Campbell MK (2015) Clinical effectiveness and cost-effectiveness of foam sclerotherapy, endovenous laser ablation and surgery for varicose veins: results from the Comparison of LAser, Surgery and foam Sclerotherapy (CLASS) randomised controlled trial. Health Technol Assess 19:1–342
Van der Velden SK, Biemans A, De Maeseneer M, Kockaert MA, Cuypers PW, Hollestein LM, Neumann HAM, Nijsten T, van den Bos RR (2015) Five-year results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins. Br J Surg 102:1184–1194
Myers KA, Jolley D, Clough A, Kirwan J (2007) Outcome of ultrasound-guided sclerotherapy for varicose veins: medium-term results assessed by ultrasound surveillance. Eur J Vasc Endovasc Surg 33:116–121
Zhang J, Jing Z, Schliephake DE, Otto J, Malouf GM, Gu YQ (2012) Efficacy and safety of Aethoxysklerol® (polidocanol) 0.5 %, 1 % and 3 % in comparison with placebo solution for the treatment of varicose veins of the lower extremities in Chinese patients (ESA-China Study). Phlebology 27:184–190
Guex JJ (2000) Ultrasound guided Sclerotherapy (USGS) for perforating veins. Hawaii Med J 59:261–262
Masuda EM, Kessler DM, Lurie F, Puggioni A, Kistner RL, Eklof B (2006) The effect of ultrasound guided sclerotherapy of incompetent perforator veins on venous clinical severity scores. J Vasc Surg 43:551–556
Van Neer P, Veraart JCJM, Neumann H (2006) Posterolateral thigh perforator varicosities in 12 patients: a normal deep venous system and successful treatment with ultrasound-guided sclerotherapy. Dermatol Surg 32:1346–1352
Guzelmansur I, Oguzkurt L, Koca N, Andic C, Gedikoglu M, Ozkan U (2014) Endovenous laser ablation and sclerotherapy for incompetent vein of Giacomini. Phlebology 29(8):511–516
Kahle B, Leng K (2004) Efficacy of sclerotherapy in varicose veins—a prospective, blinded placebocontrolled study. Dermatol Surg 30:723–728
Norris MJ, Carlin MC, Ratz JL (1989) Treatment of essential telangiectasias: effects of increasing concentrations of polidocanol. J Am Acad Dermatol 20:643–649
Rabe E, Schliephake D, Otto J, Breu FX, Pannier F (2010) Sclerotherapy of telangiectasias and reticular veins: a double-blind, randomized, comparative clinical trial of polidocanol, sodium tetradecyl sulphate and isotonic saline (EASI study). Phlebology 25:124–131
Uncu H (2010) Sclerotherapy: a study comparing polidocanol in foam and liquid form. Phlebology 25:44–49
Peterson JD, Goldman MP, Weiss RA, Duffy DM, Fabi SG, Weiss MA, Guiha I (2012) Treatment of reticular and telangiectatic leg veins: double-blind, prospective comparative trial of polidocanol and hypertonic saline. Dermatol Surg 38:1–9
Parlar B, Blazek C, Cazzaniga S, Naldi L, Kloetgen HW, Borradori L, Buettiker U (2015) Treatment of lower extremity telangiectasias in women by foam sclerotherapy vs. Nd:YAG laser: a prospective, comparative, randomized, open-label trial. J Eur Acad Dermatol Venereol 29:549–554
Kakkos SK, Bountouroglou DG, Azzam M, Kalodiki E, Daskalopoulos M, Geroulakos G (2006) Effectiveness and safety of ultrasound-guided foam Sclerotherapy for recurrent varicose veins: immediate results. J Endovascular Ther 13:357–364
McDonagh B, Sorenson S, Gray C, Huntley DE, Putterman P, King T, Eaton T, Martin C, Harry JL, Cohen A, Guptan RC (2003) Clinical spectrum of recurrent postoperative varicose veins and efficacy of sclerotherapy management using the compass technique. Phlebology 18:173–186
Coleridge Smith P (2006) Chronic venous disease treated by ultrasound guided foam Sclerotherapy. Eur J Vasc Endovasc Surg 32:577–583
Coleridge Smith P (2009) Sclerotherapy and foam sclerotherapy for varicose veins. Phlebology 24:260–269
Bradbury AW, Bate G, Pang K, Darvall KA, Adam DJ (2010) Ultrasound-guided foam sclerotherapy is a safe and clinically effective treatment for superficial venous reflux. J Vasc Surg 52:939–945
Darvall KA, Bate GR, Adam DJ, Silverman SH, Bradbury AW (2011) Duplex ultrasound outcomes following ultrasound guided foam sclerotherapy of symptomatic recurrent great saphenous varicose veins. Eur J Vasc Endovasc Surg 42:107–114
Darvall KA, Bate GR, Adam DJ, Silverman SH, Bradbury A (2011) Duplex ultrasound outcomes following ultrasound-guided foam sclerotherapy of symptomatic recurrent great saphenous varicose veins. Eur J Vasc Endovasc Surg 42:107–114
De Maeseneer M (2011) Surgery for recurrent varicose veins: toward a less-invasive approach? Perspect Vasc Surg Endovasc Ther 23:244–249
Pavei P, Vecchiato M, Spreafico G, Giraldi E, Ferrini M, Baccaglini U, Ancona E (2008) Natural history of recurrent varices undergoing reintervention: a retrospective study. Dermatol Surg 34:1676–1682
Sukovatykh BS, Rodionov OA, Sukovatykh MB, Khodykin SP (2008) Diagnosis and treatment of atypical forms of varicose disease of pelvic veins. Vestnik Khirurgii Imeni Grekova 167:43–45
Paraskevas P (2011) Successful ultrasound-guided foam sclerotherapy for vulval and leg varicosities secondary to ovarian vein reflux: a case study. Phlebology 26:29–31
Herwig R, Sansalone S (2015) Venous leakage treatment revisited: Pelvic venoablation using Aethoxysclerol under air block technique and valsalva maneuver. Arch Ital Urol Androl 87:1–4
Stücker M, Reich S, Hermes N, Altmeyer P (2006) Safety and efficiency of perilesional sclerotherapy in leg ulcer patients with postthrombotic syndrome and/or oral anticoagulation with phenprocoumon. J Dtsch Dermatol Ges 4:734–738
De Waard MM, Der Kinderen DJ (2005) Duplex ultrasonography-guided foam sclerotherapy of incompetent perforator veins in a patient with bilateral venous leg ulcers. Dermatol Surg 31:580–583
Hertzman PA, Owens R (2007) Rapid healing of chronic venous ulcers following ultrasound-guided foam sclerotherapy. Phlebology 22:34–39
Pang KH, Bate GR, Darvall KAL, Adam DJ, Bradbury AW (2010) Healing and recurrence rates following ultrasound guided foam sclerotherapy of superficial venous reflux in patients with chronic venous ulceration. Eur J Vasc Endovasc Surg 40:790–795
Williamsson C, Danielsson P, Smith L (2014) Catheter-directed foam sclerotherapy for chronic venous leg ulcers. Phlebology 29:688–693
Campos W, Torres IO, da Silva ES, Casella IB, Puech-Leão P (2015) A prospective randomized study comparing polidocanol foam sclerotherapy with surgical treatment of patients with primary chronic venous insufficiency and ulcer. Ann Vasc Surg 29:1128–1135
Lloret P, Redondo P, Cabrera J, Sierra A (2015) Treatment of venous leg ulcers with ultrasound-guided foam sclerotherapy: healing, long-term recurrence and quality of life evaluation. Wound Repair Regen 23:369–378
Neto FC, de Araújo GR, Kessler IM, de Amorim RFB, Falcão DP (2015) Treatment of severe chronic venous insufficiency with ultrasound-guided foam sclerotherapy: a two-year series in a single center in Brazil. Phlebology 30:113–118
Yamaki T, Nozaki M, Sasaki K (2000) Color duplex-guided sclerotherapy for the treatment of venous malformations. Dermatol Surg 26:323–328
Yamaki T, Nozaki M, Sakurai H, Takeuchi M, Soejima K, Kono T (2008) Prospective randomized efficacy of ultrasound-guided foam sclerotherapy compared with ultrasound-guided liquid sclerotherapy in the treatment of symptomatic venous malformations. J Vasc Surg 47:578–584
Blaise S, Charavin-Cocuzza M, Riom H, Brix M, Seinturier C, Diamand JM, Gachet G, Carpentier PH (2011) Treatment of low-flow vascular malformations by ultrasound-guided Sclerotherapy with Polidocanol foam: 24 cases and literature review. Eur J Vasc Endovasc Surg 41:412–417
Markovic JN, Kim CY, Lidsky ME, Shortell CK (2012) A 6‑year experience treating vascular malformations with foam Sclerotherapy. Perspect Vasc Surg Endovasc Ther 24:70–79
Van der Vleuten CJM, Kater A, Wijnen MHWA, Schultze Kool LJ, Rovers MM (2014) Effectiveness of Sclerotherapy, surgery, and laser therapy in patients with venous malformations: a systematic review. Cardiovasc Intervent Radiol 37:977–989
Chen AW, Liu YR, Zhang K, Wang T, Liu SH (2015) Efficacy of sclerotherapy with radio-opaque foam guided by digital subtraction angiography for the treatment of complex venous malformations of the head and neck. Br J Oral Maxillofac Surg 53:809–813
Horbach SER, Lokhorst MM, Saeed P, De Pontouraude CMF, Rothova A, Van der Horst CMAM (2016) Sclerotherapy for low-flow vascular malformations of the head and neck: a systematic Review of sclerosing agents. J Plast Reconstr Aesthet Surg 69(3):295–304
Kern P, Ramelet A‑A, Wutschert R, Bounameaux H, Hayoz D (2004) Single blind randomized study comparing chromated glycerin, polidocanol solution and polidocanol foam for treatment of telangiectactic leg veins. Dermatol Surg 30:367–372
Rabe E, Pannier F, Gerlach H, Breu FX, Guggenbichler S, Wollmann JC (2008) Leitlinie Sklerosierungsbehandlung der Varikose. Phlebologie 37:27–34
Rao J, Wildemore JK, Goldmann MP (2005) Double-blind prospective comparative trial between foamed and liquid Polidocanol and Natrium Tetradecyl Sulfate in the treatment of varicose and telangiectatic leg veins. Dermatol Surg 31:631–635
Bullens-Goessens YIJM, Mentink LF et al (2004) Ultrasound-guided sclerotherapy of the insufficient short saphenous vein. Phlebol Ger 33:89–91
Schultz-Ehrenburg U, Tourbier H (1984) Doppler-kontrollierte Verödungsbehandlung der Vena saphena magna. Phlebol Proktol 13:117–122
Vin F (1997) Principes de la Sclérothéraphie des Troncs Saphènes Internes. Phlebologie 50:229–234
Gohel MS, Epstein DM, Davies AH (2010) Cost-effectiveness of traditional and endovenous treatments for varicose veins. Br J Surg 97:1815–1823
Biemans AAM, Kockaert M, Akkersdijk GP, van den Bos RR, de Maeseneer MGR, Cuypers P, Stijne T, Neumann MHA, Nijsten T (2013) Comparing endovenous laser ablation, foam sclerotherapy, and conventional surgery for great saphenous varicose veins. J Vasc Surg 58:727–734
Rasmussen L, Lawaetz M, Serup J, Bjoern L, Vennits B, Blemings A, Eklof B (2013) Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy, and surgical stripping for great saphenous varicose veins with 3‑year follow-up. J Vasc Surg Venous Lymphat Disord 1:349–356
Carroll C, Hummel S, Leaviss J, Re S, Stevens JW, Cantrell A, Michaels J (2015) Systematic review, network meta-analysis and exploratory cost-effectiveness model of randomized trials of minimally invasive techniques versus surgery for varicose veins. Br J Surg 101:1040–1052
Nesbitt C, Bedenis R, Bhattacharya V, Stansby G (2014) Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD005624.pub3
National Institute for Health and Care of Excellence (2013) Ultrasound-guided foam sclerotherapy for varicose veins. NICE interventional procedure guidance [IPG440]
Siribumrungwong B, Noorit P, Wilasrusmee C, Leelahavarong P, Thakkinstian A, Teerawattananon Y (2016) Cost-utility analysis of great saphenous vein ablation with radiofrequency, foam and surgery in the emerging health-care setting of Thailand. Phlebology 31:573–581
Varisolve European Phase III Investigators Group, Wright D, Gobin JP, Bradbury AW et al (2006) Varisolve® polidocanol microfoam compared with surgery or sclerotherapy in the management of varicose veins in the presence of trunk vein incompetence: European randomized controlled trial. Phlebology 21:180–190
Cavezzi A, Frullini A, Ricci S, Tessari L (2002) Treatment of varicose veins by foam sclerotherapy: two clinical series. Phlebology 17:13–18
Hamel-Desnos C, Ouvry P, Desnos P et al (2003) Sclérothérapie et thrombophilie: Démarche pour un consensus dans la sclérothérapie chez les thrombophiles. Phlebologie 56:165–169
Gohel MS, Heatley F, Liu X, Bradbury A, Bulbulia R, Cullum N, Epstein DM, Nyamekye I, Poskitt KR, Renton S, Warwick J, Davies AH (2018) A randomized trial of early endovenous ablationin venous ulceration. N Eng J Med 378:2105–2114
Breu FX, Guggenbichler S, Wollmann JC (2008) 2nd European Consensus Meeting on Foam Sclerotherapy, 28–30 April 2006, Tegernsee, Germany. Vasa 37(Supplement 71):1–32
Guex JJ (2005) Les contre-indications de la sclérothérapie, mise à jour 2005. J Mal Vasc 30:144–149
Hamel-Desnos CM, Gillet J‑L, Desnos PR, Allaert FA (2009) Sclerotherapy of varicose veins in patients with documented thrombophilia: a prospective controlled randomized study of 105 cases. Phlebology 24:176–182
Gachet G, Spini L (2002) Sclérothérapie des varices sous anticoagulants. Phlebologie 55:41–44
Rathbun S, Norris A, Stoner J (2012) Efficacy and safety of endovenous foam sclerotherapy: meta-analysis for treatment of venous disorders. Phlebology 27:105–117
Guex JJ, Allaert F‑A, Gillet J‑L (2005) Immediate and midterm complications of sclerotherapy: report of a prospective multicenter registry of 12,173 sclerotherapy sessions. Dermatol Surg 31:123–128
Guex JJ (2010) Complications of sclerotherapy: an update. Dermatol Surg 36:1056–1063
Munavalli GS, Weiss RA (2007) Complications of sclerotherapy. Semin Cutan Med Surg 26:22–28
Weiss RA, Weiss MA (1990) Incidence of side effects in the treatment of telangiectasias by compression Sclerotherapy: hypertonics saline vs. polidocanol. J Dermatol Surg Oncol 16:800–804
Gillet JL, Guedes JM, Guex JJ et al (2009) Side effects and complications of foam sclerotherapy of the great and small saphenous veins: a controlled multicentre prospective study including 1025 patients. Phlebology 24:131–138
Cavezzi A, Parsi K (2012) Complications of foam sclerotherapy. Phlebology 27(Suppl 1):46–51
Sarvananthan T, Shepherd AC, Willenberg T, Davies AH (2012) Neurological complications of sclerotherapy for varicose veins. J Vasc Surg 55:243–251
Feied CF, Jackson JJ, Bren TS, Bond OB, Fernando CE, Young VC, Hashemiyoon RB (1994) Allergic reactions to Polidocanol for vein sclerosis. J Dermatol Surg Oncol 20:466–468
Pradalier A, Vincent D, Hentschel V et al (1995) Allergie aux sclérosants des varices. Rev Fr Allergol 35:440–443
Hannaford PKP (2016) Intra-arterial injection of sclerosants: report of three cases treated with systemic steroids. Phlebology 31:241–250
Oesch A, Stirnemann P, Mahler F (1984) The acute Ischemic syndrome of the foot after Sclerotherapy of varicose veins. Schweiz Med Wochenschr 114:1155–1158
Grommes J, Franzen EL, Binnebösel M, Toonder IM, Wittens C, Jacobs M, Greiner A (2010) Inadvertent arterial injection using catheter-assisted sclerotherapy resulting in amputation. Dermatol Surg 37:536–538
Hafner F, Fröhlich H, Gary T, Brodmann M (2013) Intra-arterial injection, a rare but serious complication of sclerotherapy. Phlebology 28:64–73
Goldman MP, Sadick NS, Weiss RA (1995) Cutaneous necrosis, telangiectatic matting and hyperpigmentation following Sclerotherapy. Dermatol Surg 21:19–29
Schuller-Petrović S, Brunner F, Neuhold N, Pavlović MD, Wölkart G (2011) Subcutaneous injection of liquid and foamed polidocanol: extravasation is not responsible for skin necrosis during reticular and spider vein sclerotherapy. J Eur Acad Dermatol Venereol 25:983–986
Bergan JJ, Weiss RA, Goldman MP (2000) Extensive tissue necrosis following high concentration sclerotherapy for varicose veins. Dermatol Surg 26:535–542
Bihari I, Magyar É (2001) Reasons for ulceration after injection treatment of telangiectasia. Dermatol Surg 27:133–136
Geukens J, Rabe E, Bieber T (1999) Embolia cutis medicamentosa of the foot after sclerotherapy. Eur J Dermatol 9:132–133
Ramelet AA, Parmentier L (2010) Delayed Nicolau’s Livedoid dermatitis after ultrasound-guided Sclerotherapy. Dermatol Surg 36:155–158
Van der Plas JPL, Lambers JC, van Wersch JW, Koehler PJ (1994) Reversible ischaemic neurological deficit after sclerotherapy of varicose veins. Lancet 343:428
Künzelberger B, Pieck C, Altmeyer P, Stücker M (2006) Migraine ophthalmique with reversible scotomas after sclerotherapy with liquid 1 % polidocanol. Derm Surg 32:1410
Hill DA (2014) Neurological and chest symptoms following sclerotherapy: a single centre experience. Phlebology 29:619–627
Willenberg T, Smith PC, Shepherd A, Davies AH (2013) Visual disturbance following sclerotherapy for varicose veins, reticular veins and telangiectasias: a systematic literature review. Phlebology 28:123–131
Parsi K (2012) Paradoxical embolism, stroke and sclerotherapy. Phlebology 27:147–167
Parsi K (2011) Venous gas embolism during foam sclerotherapy of saphenous veins despite recommended treatment modifications. Phlebology 26:140–147
Morrison N, Cavezzi A, Bergan J, Partsch H (2006) Regarding “stroke after varicose vein foam injection sclerotherapy”. J Vasc Surg 44:224–225
Passariello F (2007) Sclerosing foam and patent foramen ovale. The final report. In: Word Congress of the International Union of Phlebology; Int Angiol, vol 26, p 87
Wagdi P (2006) Migräne und offenes Foramen Ovale: nur ein vorübergehender Hoffnungsschimmer? Kardiovasc Med 9:32–36
Gillet JL, Donnet A, Lausecker M, Guedes JM, Guex JJ, Lehmann P (2010) Pathophysiology of visual disturbances occurring after foam sclerotherapy. Phlebology 25:261–266
Zouitina TM, Hyra M, Seryer D, Chillon J‑M, Bugnicourt J‑M (2014) Prolonged acute migraine with aura and reversible brain MRI abnormalities after liquid sclerotherapy. J Headache Pain 15:1–4
Frullini A, Felice F, Burchielli S, Di Stefano R (2011) High production of endothelin after foam sclerotherapy: a new pathogenetic hypothesis for neurological and visual disturbances after sclerotherapy. Phlebology 26:203–208
Frullini A, Barsotti MC, Santoni T, Duranti E, Burchielli S, Di Stefano R (2012) Significant endothelin release in patients treated with foam sclerotherapy. Dermatol Surg 38:741–747
Yamaki T, Nozaki M, Sakurai H, Takeuchi M, Soejima K, Kono T (2008) Multiple Small-Dose Injections can reduce the passage of sclerosant foam into deep veins during foam sclerotherapy for varicose veins. Eur J Vasc Endovasc Surg 37:343–348
Forlee MV, Grouden M, Moore DJ, Shanik G (2006) Stroke after varicose vein foam injection sclerotherapy. J Vasc Surg 43:162–164
Busch RG, Derrick M, Manjoney D (2008) Major neurological events following foam sclerotherapy. Phlebology 23:189–192
Leslie-Mazwi TM, Avery LL, Sims JR (2009) Intra-arterial air thrombogenesis after cerebral air embolism complicating lower extremity sclerotherapy. Neurocrit Care 11:97–100
De Laney MC, Bowe CT, Higgins GL III (2010) Acute stroke from air embolism after leg Sclerotherapy. West J Emerg Med 11:397
Ma RWL, Pilotelle A, Paraskevas P, Parsi K (2011) Three cases of stroke following peripheral venous interventions. Phlebology 26:280–284
Harzheim M, Becher H, Klockgether T (2000) Brain infarct from a paradoxical embolism following a varices operation. Dtsch Med Wochenschr 125:794–796
Caggiati A, Franceschini M (2010) Stroke following endovenous laser treatment of varicose veins. J Vasc Surg 51:218–220
Gillet JL (2011) Neurological complications of foam sclerotherapy: fears and reality. Phlebology 26:277–279
Deichman B, Blum G (1995) Cerebrovascular accident after sclerotherapy. Phlebologie 24:148–152
Kas A, Begue M, Nifle C, Gil R, Neau JP (2000) Infarctus cérébelleux après sclérothérapie de varicosités des membres inférieurs. Presse Med 29:1935
Hanisch F, Müller T, Krivocuca M, Winterholler M (2004) Stroke following variceal sclerotherapy. Eur J Med Res 9:282–284
Picard C, Deltombe B, Duru C, Godefroy O, Bugnicourt JM (2010) Foam sclerotherapy: a possible cause of ischaemic stroke? J Neurol Neurosurg Psychiatry 81:582–583
Hahn M, Shulz T, Juenger M (2010) Late stroke after foam sclerotherapy. Vasa 39:108–110
Guex JJ (1996) Thombotic complications of the varicose disease. J Dermatol Surg 22:378–382
Hamel-Desnos C, Desnos P, Ferré B, Le Querrec A (2011) In vivo biological effects of foam sclerotherapy. Eur J Vasc Endovasc Surg 42:238–245
Fabi SG, Peterson JD, Goldman MP, Guiha I (2012) An investigation of coagulation cascade activation and induction of Fibrinolysis using foam Sclerotherapy of reticular veins. Dermatol Surg 38:367–372
Jia X, Mowatt G, Burr JM, Cassar K, Cooke J, Fraser C (2007) Systematic review of foam sclerotherapy for varicose veins. Br J Surg 94:925–936
Dermody M, Schul MW, O’Donnell TF (2015) Thromboembolic complications of endovenous thermal ablation and foam sclerotherapy in the treatment of great saphenous vein insufficiency. Phlebology 30:357–364
Myers KA, Jolley D (2008) Factors affecting the risk of deep venous occlusion after ultrasound-guided Sclerotherapy for varicose vein. Eur J Vasc Endovasc Surg 36:602–605
Reich-Schupke S, Doerler M, Altmeyer P, Stücker M (2013) Foam sclerotherapy with enoxaparin prophylaxis in high-risk patients with postthrombotic syndrome. Vasa 42:50–55
Zipper SG (2000) Nervus peronäus-Schaden nach Varizensklerosierung mit Aethoxysklerol. Versicherungsmedizin 4:185–187
Reich-Schupke S, Weyer K, Altmeyer P, Stücker M (2010) Treatment of varicose tributaries with sclerotherapy with polidocanol 0.5 % foam. Vasa 39:169–174
Georgiev MJ (1990) Postsclerotherapy hyperpigmentations: a one-year follow-up. Dermatol Surg Oncol 16:608–610
Scultetus AH, Villavicencio JL, Kao TC, Gillespie DL, Ketron GD, Iafrati MD, Pikoulis E, Eifert S (2003) Microthrombectomy reduces postsclerotherapy pigmentation: multicenter randomized trial. J Vasc Surg 38:896–903
Goldman MP, Kaplan RP, Duffy DM (1987) Postsclerotherapy hyperpigmentation: a histologic evaluation. J Dermatol Surg Oncol 13:547–550
Davis LT, Duffy DM (1990) Cutaneous necrosis, telangiectatic matting, and hyperpigmentation following sclerotherapy. Etiology, prevention, and treatment. J Dermatol Surg Oncol 16:327–330
Ramelet A‑A (2010) Phlébologie esthétique. Télangiectasies : possibilités thérapeutiques. Cosmétologie et Dermatologie esthétique. EMC (Elsevier Masson SAS), Paris
Morrison N, Neuhardt DL, Rogers CR, McEown J, Morrison T, Johnson E, Salles-Cunha SX (2008) Comparisons of side effects using air and carbon dioxide foam for endovenous chemical ablation. J Vasc Surg 47:830–836
Morrison N, Neuhardt DL, Rogers CR, McEown J, Morrison T, Johnson E, Salles-Cunha SX (2010) Incidence of side effects using carbon dioxide oxygen foam for chemical ablation of superficial veins of the lower extremity. Eur J Vasc Endovasc Surg 40:407–413
Beckitt T, Elstone A, Ashley S (2011) Air versus physiological gas for ultrasound guided foam Sclerotherapy treatment of varicose veins. Eur J Vasc Endovasc Surg 42:115–119
Hesse G, Breu FX, Kuschmann A, Hartmann K, Salomon N (2012) Sclerotherapy using air- or CO2-O2-foam: post-approval study. Phlebologie 41:77–88
Mercer KG, Scott DJ, Berridge DC (1998) Preoperative duplex imaging is required before all operations for primary varicose veins. Br J Surg 85:1495–1497
Blomgren L, Johansson G, Bergquist D (2005) Randomized clinical trial of routine preoperative duplex imaging before varicose vein surgery. Br J Surg 92:688–694
Coleridge-Smith P, Labropoulos N, Partsch H, Myers K, Nicolaides A, Cavezzi A (2006) Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs—UIP consensus document. Part I. Basic principles. Eur J Vasc Endovasc Surg 31:83–92
De Maeseneer M, Pichot O, Cavezzi A, Earnshaw J, van Rij A, Lurie F, Smith PC (2011) Duplex ultrasound investigation of the veins of the lower limbs after treatment for varicose veins—UIP consensus document. Eur J Vasc Endovasc Surg 42:89–102
Rautio T, Perälä J, Biancari F, Wiik H, Ohtonen P, Haukipuro K, Juvonen T (2002) Accuracy of hand-held Doppler in planning the operation for primary varicose veins. Eur J Vasc Endovasc Surg 24:450–455
Franco G (1998) Explorations ultrasonographiques des récidives variqueuses post-chirurgicales. Phlebologie 51:403–413
Jiang P, van Rij AM, Christie R, Hill G, Solomon C, Thomson I (1999) Recurrent varicose veins: patterns of reflux and clinical severity. Cardiovasc Surg 7:332–339
Lee BB, Do YS, Byun HS, Choo IW, Kim DI, Huh SH (2003) Advanced management of venous malformation with ethanol sclerotherapy: mid-term results. J Vasc Surg 37:533–538
Bihari I, Tasnadi G, Bihari P (2003) Importance of subfascial collaterals in deep-vein malformations. Dermatol Surg 29:146–149
Brunken A, Rabe E, Pannier F (2009) Changes in venous function after foam sclerotherapy of varicose veins. Phlebology 24:145–150
Darvall KAL, Sam RC, Bate GR, Adam DJ, Bradbury AW (2010) Photoplethysmographic venous refilling times following ultrasound guided foam Sclerotherapy for symptomatic superficial venous reflux: relationship with clinical outcomes. Eur J Vasc Endovasc Surg 40:267–272
Kreussler: Fachinformationen Aethoxysklerol® 0,25 %/0,5 %/1 %/2 %/3 % Stand August 2015, Chemische Fabrik Kreussler & Co GmbH
Wollmann JC (2004) The history of sclerosing foams. Dermatol Surg 30:694–703
Sadoun S, Benigni JP, Sica M (2002) Étude prospective de l’efficacité de la mousse de sclérosant dans le traitement des varices tronculaires des membres inférieurs. Phlebologie 55:259–262
Tessari L, Cavezzi A, Frullini A (2001) Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg 27:58–60
De Roos KP, Groen L, Leenders AC (2011) Foam sclerotherapy: investigating the need for sterile air. Dermatol Surg 37:1119–1124
Guex JJ, Hamel-Desnos C, Gillet JL, Chleir F, Perrin M (2008) Sclérothérapie des varices par mousse écho-guidée: techniques de mise en œuvre, indications, résultats publiés. Phlebologie 61:261–270
Yamaki T, Hamahata A, Soejima K, Kono T, Nozaki M, Sakurai H (2012) Prospective randomised comparative study of visual foam Sclerotherapy alone or in combination with ultrasound-guided foam sclerotherapy for treatment of superficial venous insufficiency: preliminary report. Eur J Vasc Endovasc Surg 43:343–347
Blaise S, Bosson JL, Diamand JM (2010) Ultrasound-guided sclerotherapy of the great saphenous vein with 1 % vs. 3 % Polidocanol foam: a multicentre double-blind randomised trial with 3‑year follow-up. Eur J Vasc Endovasc Surg 39:779–786
Ceulen RPM, Bullens-Goessens YIJM, Pi-Van De Venne SJA (2007) Outcomes and side effects of duplex-guided sclerotherapy in the treatment of great saphenous veins with 1 % versus 3 % Polidocanol foam: Results of a randomized controlled trial with 1‑year follow-up. Dermatol Surg 33:276–281
Yamaki T, Nozaki M, Iwasaka S (2004) Comparative study of duplex-guided foam sclerotherapy and duplex-guided liquid sclerotherapy for the treatment of superficial venous insufficiency. Dermatol Surg 30:718–722
Kanter A, Thibault P (1996) Saphenofemoral incompetence treated by ultrasound-guided sclerotherapy. Dermatol Surg 22:648–652
Grondin L, Young R, Wouters L (1997) Sclérothérapie écho-guidée et sécurité: comparaison des techniques. Phlebologie 50:241–245
Schadeck M, Allaert FA (1997) Résultats à long terme de la Sclérothérapie des Saphènes internes. Phlebologie 50(2):257–262
Elias S, Raines JK (2012) Mechanochemical tumescentless endovenous ablation: final results of the initial clinical trial. Phlebology 27:67–72
Whiteley MS, Dos SSJ, Lee CT, Li JM (2017) Mechanochemical ablation causes endothelial and medial damage to the vein wall resulting in deeper penetration of sclerosant compared with sclerotherapy alone in extrafascial great saphenous vein using an ex vivo model. J Vasc Surg Venous Lymphat Disord 5:370–377
National Institute for Health and Care Excellence (2016) Interventional procedure overview of endovenous mechanochemical ablation for varicose veins. NICE, London (https://www.nice.org.uk/guidance/ipg557/documents/overview.)
Mechanochemical Venous Ablation for Varicose Veins (2017) Center for evidence-based policy. Oregon Health & Science University, Portland (www.ohsu.edu/policycenter)
Ramon R, van Eekeren JP, Boersma D, Konijn V, de Vries JP, Reijnen MM (2013) Postoperative pain and early quality of life after radiofrequency ablation and mechanochemical endovenous ablation of incompetent great saphenous veins. J Vasc Surg 57:445–450
Khor SN, Kam JW, Kum S, Tan YK, Tang TY (2018) ClariVein™—One year results of mechano-chemical ablation for varicose veins in a multi-ethnic Asian population from Singapore. Phlebology. https://doi.org/10.1177/0268355518771225
van Eekeren RR, Boersma D, Konijn V, de Vries JP, Reijnen MM (2013) Postoperative pain and early quality of life after radiofrequency ablation and mechanochemical endovenous ablation of incompetent great saphenous veins. J Vasc Surg 57:445–450
Witte ME, Holewijn S, van Eekeren RR, de Vries JP, Zeebregts CJ, Reijnen MM (2017) Midterm outcome of mechanochemical endovenous ablation for the treatment of great Saphenous vein insufficiency. J Endovasc Ther 24:149–155
Lane T, Bootun R, Dharmarajah B, Lim CS, Najem M, Renton S, Sritharan K, Davies AH (2017) A multi-centre randomised controlled trial comparing radiofrequency and mechanical occlusion chemically assisted ablation of varicose veins—Final results of the Venefit versus Clarivein for varicose veins trial. Phlebology 32:89–98
Devereux N, Recke AL, Westermann L, Recke A, Kahle B (2014) Catheter-directed foam Sclerotherapy of great Saphenous veins in combination with pre-treatment reduction of the diameter employing the principals of perivenous tumescent local anesthesia. Eur J Vasc Endovasc Surg 47:187–195
Ceulen RPM, Jagtmann EA, Sommer A, Teule GJJ, Schurink GWH, Kemerink GJ (2010) Blocking the saphenafemoral junction during ultrasound guided foam sclerotherapy—assessment of a presumed safety-measure procedure. Eur J Vasc Endovasc Surg 40:772–776
Brodersen JP (2007) Catheter-assisted vein sclerotherapy: a new approach for sclerotherapy of the greater saphenous vein with a double-lumen balloon catheter. Dermatol Surg 33:469–475
Wildenhues B (2005) Catheter-assisted foam sclerotherapy. A new minimally invasive method for the treatment of trunk varicosis of the long and short saphenous veins. Phlebologie 34:165–170
Hahn M, Schulz T, Jünger M (2007) Sonographically guided, transcatheter foam sclerotherapy of the great saphenous vein. Medical and oeconomic aspects. Phlebologie 36:309–312
Bidwai A, Beresford T, Dialynas M, Prionidis J, Panayiotopoulos Y, Bowne TF (2007) Balloon control of the saphenofemoral junction during foam sclerotherapy : proposed innovation. J Vasc Surg 46:145–147
Kölbel T, Hinchliffe RJ, Lindbal B (2007) Catheter-directed foam sclerotherapy of axial saphenous reflux. Early results. Phlebology 22:219–222
Parsi K (2009) Catheter-directed sclerotherapy. Phlebology 24:98–107
Cavezzi A, Tessari L (2009) Foam sclerotherapy techniques: different gases and methods of preparation, catheter versus direct injection. Phlebology 24:247–251
Chapman-Smith P, Browne A (2009) Prospective five year study of ultrasound guided foam sclerotherapy in the treatment of great saphenous vein reflux. Phlebology 24:183–188
Kern P, Ramelet AA, Wütschert R, Hayoz D (2007) Compression after sclerotherapy for telangiectasiastelangiectasias and reticular leg veins. A randomized controlled study. J Vasc Surg 45:1212–1216
Weiss RA, Sadick NS, Goldman MP, Weiss MA (1999) Post-sclerotherapy compression: controlled comparative study of duration of compression and its effects on clinical outcome. Dermatol Surg 25:105–108
Goldman MP, Beaudoing D, Marley W, Lopez L, Butie A (1990) Compression in the treatment of leg teleangiectasia: a preliminary report. J Dermatol Surg Oncol 16:322–325
Nootheti PK, Cadag KM, Magpantay A, Goldman MP (2009) Efficacy of graduated compression stockings for an additional 3 weeks after sclerotherapy treatment of reticular and telangiectatic leg veins. Dermatol Surg 35:53–58
Hamel-Desnos C, Guias BJ, Desnos PR, Mesgard A (2010) Foam sclerotherapy of the saphenous veins. Randomised controlled trial with or without compression. Eur J Vasc Endovasc Surg 39:500–507
El-Sheikha J, Carradice D, Nandhra S, Leung HC, Smith GE, Campbell B, Chetter IC (2015) Systematic review of compression following treatment for varicose veins. Br J Surg 102:719–725
Zarca C, Bailly C, Gachet G, Spini L (2012) ClassMousse 1 study: compression hosiery and foam Sclerotherapy. Phlebologie 65:11–20
Ferrara F, Bernbach HR (2009) La compression écho-guidée après sclérothérapie. Phlebologie 62:36–41
Stanley PRW, Bickerton DR, Campbell WB (1991) Injection sclerotherapy for varicose veins—a comparison of materials for applying local compression. Phlebology 6:37–39
Friedmann DP, Liolios AM, Wu DC, Goldman MP, Eimpunth S (2015) A randomized, double-blind, placebo-controlled study of the effect of a high-potency topical corticosteroid after Sclerotherapy for reticular and telangiectatic veins of the lower extremities. Dermatol Surg 41:1158–1163
Conflict of interest
Documentation and declarations pertaining to potential conflicts of interest are available online at http://www.awmf.org/leitlinien.
For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.
The supplement containing this article is not sponsored by industry.
This S2k guideline was published online by the AWMF in early 2019 with registration number 037-015. The guideline is valid until 30.12.2023.
About this article
Cite this article
Rabe, E., Breu, F.X., Flessenkämper, I. et al. Sclerotherapy in the treatment of varicose veins. Hautarzt 72 (Suppl 2), 23–36 (2021). https://doi.org/10.1007/s00105-020-04705-0