Last literature review version 19.3: Fri Sep 30 00:00:00 GMT 2011 This topic last updated: Thu Sep 30 00:00:00 GMT 2010 (More)

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1 19.3 Liquid and foam sclerotherapy techniques for the treatment of lower extremity veins Authors Deborah L Greenberg, MD, FACP Sherry Scovell, MD, FACS Section Editors John F Eidt, MD Joseph L Mills, Sr, MD Jeffrey S Dover, MD, FRCPC Deputy Editor Kathryn A Collins, MD, PhD, FACS Disclosures Last literature review version 19.3: Fri Sep 30 00:00:00 GMT 2011 This topic last updated: Thu Sep 30 00:00:00 GMT 2010 (More) INTRODUCTION Sclerotherapy is a minimally invasive percutaneous technique using chemical irritants to close unwanted veins [1,2]. Sclerotherapy is used primarily in the treatment of telangiectasias, reticular veins, and small varicose veins, which can be symptomatic and a source of significant distress to some patients even in the absence of symptoms. Saphenous and perforator reflux can also be treated with sclerotherapy techniques. The treatment of telangiectasias, reticular veins, and varicose veins, and underlying perforator or saphenous reflux with liquid and foam sclerotherapy will be reviewed here. Alternative approaches to treatment of chronic venous disease using cutaneous laser, endovenous ablation devices, and open surgical management are discussed elsewhere. (See "Overview and management of lower extremity chronic venous disease" and "Laser and light therapy of lower extremity telangiectasias, reticular veins and small varicose veins" and "Radiofrequency ablation for the treatment of lower extremity chronic venous disease".) ANATOMY The major superficial veins of the lower extremity include the great and small saphenous veins (figure 1A-B). Additionally, other superficial veins are present in the lower extremity, many of which have variable anatomy. (See "Classification of lower extremity chronic venous disorders", section on 'Superficial venous system (As)'.) The deep veins of the lower extremity are contained within the deep muscle compartments bounded by the muscle fascia (figure 2). (See "Classification of lower extremity chronic venous disorders", section on 'Deep venous system (Ad)'.) Perforating veins are those veins that traverse the muscular fascia to connect superficial veins with the deep veins. They are located anteriorly, posteriorly, laterally, and medially in both the thigh and calf. INDICATIONS Telangiectasias, reticular veins, and varicose veins are the visible signs of venous disease and can occur in the presence or absence of either symptoms or an underlying functional venous disorder (ie, reflux) [2]. Candidates for sclerotherapy are patients with

2 persistent symptoms (eg, pain, aching, swelling) and signs (eg, telangiectasias, reticular veins, varicose veins, pigmentary changes, and ulceration) of venous disease after six months of medical therapy. (See "Overview and management of lower extremity chronic venous disease" and "Medical management of lower extremity chronic venous disease".) Sclerotherapy may be used to treat superficial telangiectasias, reticular veins, and varicose veins. Sclerotherapy techniques to achieve perforator and saphenous closure are also available for patients with documented reflux (ie, retrograde flow >0.5 seconds duration) as a source of their symptoms. For patients with ulceration who are refractory to medical management, or have recurrent ulceration, ultrasound-guided sclerotherapy (UGS) of perforators can lead to significant reduction of symptoms and signs. (See 'Perforator ablation' below and 'Saphenous ablation' below and 'Clinical outcomes' below.) While telangiectasias and reticular veins may be symptomatic, most are asymptomatic, and patients often find the cosmetic appearance of their veins distressing. Sclerotherapy can be performed following physical examination without further diagnostic studies, as these patients are not as likely as symptomatic patients to have underlying venous reflux [2,3]. (See 'Patient counseling' below.) Patients with complaints of recurrent bleeding and stigmata of recent venous hemorrhage may benefit from sclerotherapy of that vein site. Sclerotherapy is often successful even in the presence of venous insufficiency. [4]. Duplex examination can be performed either before (if time permits) or after attempted control of bleeding. (See 'Perforator ablation' below and "Open surgical techniques for lower extremity vein ablation".) CONTRAINDICATIONS Sclerotherapy should not be performed in patients who have signs of acute thrombosis/phlebitis, due to the increased risk of deep venous thrombosis. Pregnant patients should defer treatment until after delivery. Diabetes and peripheral arterial occlusive disease (ankle-brachial index <0.9) are relative contraindications to a risk for wound complications, but this depends upon the nature and extent of sclerotherapy being considered. A history of migraine headache and patent foramen ovale are relative contraindications to sclerotherapy due to a risk for microembolism [5-10]. (See 'Air microembolization' below.) PATIENT COUNSELING The decision to offer sclerotherapy depends upon symptoms, response to conservative therapy, extent of lower extremity disease, patient expectations, and likelihood of providing a durable benefit either with respect to appearance or improvement in symptoms. Patients treated for cosmetic purposes need to be counseled carefully prior to treatment. Patients are informed that veins will lighten and become less noticeable but may not completely disappear, that hyperpigmentation is a relatively common complication, and that multiple treatments are typically required to achieve the desired effect. For all patients, it is important to address patient expectations, potential adverse effects, potential failure of treatment, and the complications of treatment. (See 'Complications' below.) Patients must understand that the results of sclerotherapy are unpredictable despite expert technique, and some patients with favorable conditions (skin type I and II, ideal injections) may have unsatisfactory results. It is important to document veins photographically prior to each treatment and to review these photographs with the patient periodically.

3 SCLEROTHERAPY AGENTS The most common agents used in the treatment of lower extremity telangiectasias, reticular veins, and small varicose veins are sodium tetradecyl sulfate, polidocanol, glycerin, and hypertonic saline (table 1). These substances cause endothelial damage by their actions as either osmotic or detergent agents. Osmotic agents achieve their effect by dehydrating endothelial cells through osmosis. Detergents are surface active agents which damage the endothelium by interfering with cell membrane lipids [11]. In vitro, the detergent agents also exhibit procoagulant activity at lower concentrations, and anticoagulant activity in higher concentrations [12]. A systematic review of 17 randomized trials of injection sclerotherapy for varicosities of varying size found no evidence to support use of one sclerosant over another in the short-term success of sclerotherapy [13]. Other randomized trials comparing sclerotherapy agents in the treatment of only telangiectasias and reticular veins support this conclusion [14-16]. Sodium tetradecyl sulfate Sodium tetradecyl sulfate is the most commonly studied sclerosant [13]. The maximum recommended dosage is 10 ml of a 3% solution in the United States and Canada; the volume used varies worldwide depending on formulation. Dilutions between 0.1% and 3.0% are used depending upon the size of the vein treated (table 1). Polidocanol Polidocanol, also known as aethoxysklerol, is also a detergent. The maximum dosage is dependent upon the weight of the patient. Dilutions between 0.25% and 5% are used depending on the size of the vein treated (table 1). Polidocanol is now available for commercial use in the United States (ie, Asclera ). Hypertonic saline Hypertonic saline is the most commonly used osmotic agent for lower extremity sclerotherapy. The dilution used to treat lower extremity vessels ranges from 11.7% to 23.4% (table 1). Glycerin Chromated glycerin (eg, Chromex, Skermo ) is a potent osmotic with dilutions that range from 25% to 72%. The maximum recommended amount per session is 10 ml [17]. While very popular worldwide, it is not commercially available in the United States. PREPARATIONS Liquid Liquid sclerotherapy can be used to treat telangiectasias, reticular veins, small nonsaphenous varicose veins (<5 mm), residual or recurrent varicosities following endovenous ablation or surgery, and perforator veins [13,18]. Liquid injection sclerotherapy is the gold standard for the treatment of most lower extremity telangiectasias and reticular veins. When vessels are treated sequentially from deep to superficial and from larger to smaller veins, over 90 percent of vessels can be successfully treated. The results of sclerotherapy are usually, but are not always, superior to those of cutaneous laser/light therapy. Due to the risk of longstanding hypopigmentation from laser and light treatments, liquid sclerotherapy is a more appropriate choice for patients with Fitzpatrick skin types IV, V, and VI. Laser/light treatments are recommended for patients who have failed sclerotherapy, those with veins too small to access (<0.3 millimeters) or poor outcome, patients with postsclerotherapy matting, needle-phobic patients, and patients allergic to sclerosant agents. Laser/light treatment is also preferred for vessels located at or below the ankle regions, which are more prone to ulceration with sclerotherapy. (See "Laser and light therapy of lower extremity telangiectasias, reticular veins and small varicose veins".) Foam Foam preparations are becoming increasingly popular [19]. Sclerosant foam was developed from the detergent sclerosant agents to increase the surface area of exposure, and

4 is more commonly used for the treatment of larger veins. The foam is produced just prior to injection by the Tessari method (figure 3) [20]. Sclerosant foam is echogenic due to the tiny air bubbles in the foam, which are easily seen with duplex ultrasound. The expanded volume of the foam compared with liquid agents provides more surface contact, a more uniform vessel closure and use of smaller volumes of sclerosant. In principle, all vein calibers are suitable for foam sclerotherapy; however, a minority of practitioners would use it for treatment of telangiectasias or reticular veins because there is no significant advantage over liquid sclerotherapy in small vessels and, therefore, ultrasound-guided foam sclerotherapy (UGFS) is predominantly applied to the treatment of saphenous incompetence (great or small) and incompetent perforating veins [19]. TECHNIQUES There is no consensus on specific aspects of sclerotherapy technique including: type of sclerosing agent, use of local anesthetic, use or type of local compression pad, and use or duration of compression dressing (bandage or elastic). Serial injections are often needed to address the veins of interest. Typical sessions last from 15 to 60 minutes. In general, a sclerosant liquid or foam (with or without lidocaine) is mixed into a syringe at the appropriate concentration for the vein to be treated (table 1). The syringe is attached to a 27 or 30 gauge needle (or butterfly), which is angled to assist its introduction into the vessel. The patient is placed in Trendelenburg position during injection to discourage refilling of the injected veins. Following the application of alcohol to clean the area, the needle is introduced into the vein, and blood aspirated to ensure an intraluminal needle position; the sclerosant is then injected. The procedure is terminated when either the maximum volume of sclerosant has been injected (table 1) or all the veins of interest have been treated. A light dressing and graduated compression stockings (table 2), or bandages (Coban, Elastocrepe, Ace ) are applied. The patient is discharged, providing they have experienced no adverse reactions. The patient is counseled to ambulate normally and may return to work. (See 'Complications' below.) Telangiectasias, reticular veins, varicose veins A fixed amount of sclerosant is injected depending on the size of the vein being treated (table 1). When larger underlying reticular veins are identified, these are obliterated prior to addressing more superficial telangiectasias. A vein light (fiberoptic illuminator) is helpful in identifying reticular veins. The needle is withdrawn and local compression and massage are applied to keep blood out of the lumen of the vessel and to help disperse the sclerosant. Local compression pads (eg, mole foam, sorbo pads, dental bumpers) are placed and fixed with tape to maintain compression while moving on to the next vein. Saphenous ablation Foam sclerotherapy to treat reflux of the great saphenous vein is performed with ultrasound guidance. The saphenous vein is cannulated in the mid to distal thigh with the needle directed toward the foot. The extremity is elevated and sclerosant foam injected until it is visualized approaching the saphenofemoral junction, whereupon the injection is discontinued. The syringe is aspirated and if blood is returned, the procedure is repeated until the aspirate becomes white, indicating that the saphenous vein is filled with foam. Compression at the level of the groin can be performed; however, some postulate that release of compression could promote microembolization. (See 'Complications' below.) Perforator ablation Injection of the sclerosant solution at the level of a refluxing perforator vein can be used to ablate the perforator or to treat associated interconnected superficial veins (Fegan's technique) [21]. This technique has been used with good long-term results and without significant complications, but requires an experienced practitioner [22].

5 Following UGS of perforator veins, duplex ultrasound should be performed (three to six weeks after sclerotherapy) for surveillance to identify recurrent perforator veins which can lead to venous ulcer recurrence. (See 'Clinical outcomes' below.) FOLLOW UP CARE We advise our patients to wear compression stockings continuously for 48 hours after treatment, after which time they may be worn during the day (off at night and to bathe) for the next two weeks. (See 'Compression therapy following sclerotherapy' below.) Exercise is avoided for two weeks and treated areas should not be exposed to the sun during this time period. Alternatively, sunscreen with a high sun protection factor ( SPF 30) may be applied to the treated areas. The patient should contact the physician immediately if they are experiencing increasing pain or if any ulcers are observed at the injection sites. Repeat injections, which are frequently needed, are not performed for at least six weeks. Patients are instructed to call their physician if they experience any visual, sensory, or motor disturbances. (See 'Air microembolization' below.) ADVERSE REACTIONS The type of adverse reaction following sclerotherapy depends upon the sclerosing agent used (table 1) [13]. Common local adverse reactions to sclerosing agents include pain, ulceration, urticaria, hyperpigmentation, and telangiectatic matting (table 1) [23]. Most local reactions are transient and resolve within months following the procedure [24]. Vasovagal reactions have also been reported. Minor pain Pain is common at the sclerotherapy injection site. Significant pain during injection may be an indication that the sclerosing agent has extravasated into the tissue around the vein. Polidocanol is associated with the least amount of pain upon injection [13], whereas hypertonic saline and glycerin are the most painful, especially when used without lidocaine [25]. Ulceration Ulcers may occur when the sclerosing agent extravasates from the vein into the subcutaneous tissue. The reported incidence is 1 to 5 percent of patients treated (picture 1A). Care must be taken to ensure that the needle is intraluminal before injection is performed. (See 'Techniques' above.) When ulcers occur, they are usually small and most often heal with local care in four to six weeks. However, they may result in scarring. Polidocanol is rarely associated with skin ulceration or necrosis because it is non-toxic to tissues [11]. Skin breakdown may also occur in response to excessive pressure from tape or compression garments [23]. Larger areas of skin necrosis may be related to retrograde flow of the sclerosant through an unexpected cutaneous arteriovenous malformation or the inadvertent injection of a small arteriole. This type of skin necrosis is rare and is independent of the type of sclerosant used. Thrombus Thrombus forms within the vessel if blood comes into contact with the sclerosing agent. The resulting mild inflammatory reaction is a source of post-treatment pain and is more common with treatment of reticular veins and small varicose veins than telangiectasias. Micro-thrombectomy, which removes clot, significantly reduces post-sclerotherapy pain and inflammation and, in one multicenter randomized trial, reduced hyperpigmentation in vessels smaller than one millimeter [26]. Micro-thrombectomy is typically performed within three weeks following treatment by making stab incisions (18 to 22 gauge needle or No. 65 Beaver blade) along the length of the thrombosed vein with aseptic technique. Thrombus is extruded by rolling a cotton-tipped applicator along the course of the vein, and the area is cleansed and

6 dressed with sterile bandages. Topical local anesthesia is not usually necessary but may be helpful in some individuals. Telangiectatic matting Telangiectatic matting consists of multiple, fine dilated vessels in the area of the injection site (picture 2). It is relatively common, occurring in 15 to 24 percent of patients and usually resolves within 3 to 12 months [27]. Sodium tetradecyl sulfate is associated with a lower incidence of telangiectatic matting [13]. In one retrospective review of 2120 patients, significantly more patients in the matting group were overweight, on female hormones (estrogen, progesterone) during sclerotherapy treatment, and had both a family history and a longer duration of abnormal veins compared with the non-matting group [27]. If a feeding reticular vein can be identified, repeat sclerotherapy can be attempted; otherwise, the area can be treated with cutaneous laser [28]. (See "Laser and light therapy of lower extremity telangiectasias, reticular veins and small varicose veins".) Hyperpigmentation Hyperpigmentation occurs in up to 30 percent of patients following sclerotherapy (picture 1A-B). It is caused by deposition of hemosiderin in the skin as a result of extravasation of red blood cells. It usually becomes noticeable within a month following sclerotherapy and resolves spontaneously in 80 percent of patients within two years [29]. It occurs more commonly with treatment of veins greater than one millimeter in diameter, and in patients with darker hair and Fitzpatrick skin types III through VI (table 3) [23]. Hyperpigmentation is less frequent with sodium tetradecyl sulfate, and this agent is also associated with less bruising [13]. Treatment of telangiectasias with lower concentrations of polidocanol (0.5 versus 1.0 percent) reduced the incidence of hyperpigmentation with this agent [30]. (See 'Follow up care' above.) It is important for patients who experience hyperpigmentation to avoid sun exposure to the treated areas. Laser/light therapy may be tried in the treatment of post-sclerotherapy hyperpigmentation, but the results are unpredictable and occasionally pigmentation is worsened [28,31]. (See "Laser and light therapy for cutaneous hyperpigmentation".) COMPLICATIONS A mild inflammatory reaction is expected within the treated veins; however, intense superficial thrombophlebitis can occur and deep venous thrombosis, while uncommon, has been reported. Other complications include: microembolic events (ie, coughing, migraine-like headache, visual disturbances, paresthesias, stroke) and anaphylaxis. For patients with severe venous disease, UGS appears to be associated with fewer skin and wound healing complications and is an attractive alternative to open interruption or subfascial endoscopic perforator vein ligation [32]. Other complications are uncommon with this technique. Superficial thrombophlebitis A mild inflammatory response is expected after sclerotherapy and some patients may have urticaria at the site of injection. A more intense superficial thrombophlebitis with erythema, warmth, and pain can extend to veins neighboring the injection site. The diagnosis and treatment of superficial phlebitis is discussed in detail elsewhere. (See "Superficial thrombophlebitis of the lower extremity".) Deep vein thrombophlebitis Telangiectasias can communicate with the deep venous system. Contrast media directly injected into a telangiectasia entered the deep venous system in 2 of 15 patients in one study [33]. While deep venous thrombosis can occur after sclerotherapy of telangiectasias, it is more likely to occur after sclerotherapy of the saphenous veins [34]. Popliteal vein thrombosis has been reported with foam sclerotherapy of the small

7 saphenous vein [35]. Patients are diagnosed and treated for deep venous thrombosis following standard protocols. (See "Approach to the diagnosis and therapy of lower extremity deep vein thrombosis".) Air microembolization Air microembolism is a relatively common phenomenon during sclerotherapy; however, symptoms occur in less than two percent of patients [5,6]. Symptoms include: visual disturbance (scotoma), migraine-like headache, cough, and neurologic deficit (usually transient). Most visual disturbances occur during the procedure, or immediately after when the patient ambulates, due to rising of microbubbles in the bloodstream. Visual disturbances have been reported following sclerotherapy of telangiectasias and reticular veins and are strongly associated with the use of air-block, and foam techniques. In one study, 20 patients of 12,173 treated with sclerotherapy experienced visual disturbances, 70 percent of which were following sclerotherapy of telangiectasias or reticular veins [34]. Visual disturbances were associated with nausea, headache, or vasovagal fainting; all cases regressed spontaneously. During foam sclerotherapy of the great saphenous vein, microbubbles can be detected in the right heart and pulmonary circulation, and in patients with a patent foramen ovale (PFO) in the left heart as well [9,36]. Coughing following foam sclerotherapy is attributed to air microembolization into the pulmonary circulation. In a prospective study of 33 patients, cardiac echo was performed during foam sclerotherapy with cardiac microemboli detected in every patient studied. Microemboli were also seen in the left ventricle of five patients, and each was subsequently found to have a patent foramen ovale; however, none of these patients experienced neurologic symptoms [9]. Given the significant prevalence (25 to 30 percent) of patent foramen ovale in the general population, it is apparent that the incidence of significant neurologic sequelae following foam sclerotherapy is low. Nevertheless, caution needs to be exercised when performing foam sclerotherapy in any patient known to have a PFO. Patients who develop neurologic symptoms following foam sclerotherapy should be referred for further cardiac evaluation and are advised to avoid future sclerotherapy. (See "Patent foramen ovale" and "Atrial septal abnormalities (PFO, ASD, and ASA) and risk of cerebral emboli in adults".) Anaphylaxis Anaphylaxis can occur with any of the sclerosing agents with the exception of hypertonic saline. A test dose of the sclerosing agent is recommended (table 1). (See "Anaphylaxis: Rapid recognition and treatment".) COMPRESSION THERAPY FOLLOWING SCLEROTHERAPY Meta-analysis of randomized trials of injection sclerotherapy for varying sizes of varicose veins identified no differences in sclerotherapy success related to method of compression therapy (elastic versus conventional bandaging) [13]. Long-term bandaging did not have any advantages over short-term bandaging for cosmetic appearance, incidence of superficial phlebitis or recurrent varicose veins. Short-term bandaging was better tolerated. Most trials have evaluated compression bandaging schemes for liquid sclerotherapy, but it appears that short-term compression therapy for foam sclerotherapy is also favored. One trial randomly assigned 128 patients with varicosities to 24 hours of compression bandaging followed by anti-embolism stockings, or to five days of bandaging [37]. No significant differences were found in phlebitis scores or pain scores at two weeks follow-up. At six weeks, vein occlusion rates, skin changes and venous severity measures were also no different. Another trial randomly assigned 60 patients undergoing foam sclerotherapy of the saphenous vein, to compression stockings or no compression and found no significant differences in vein

8 closure rates, side effects or patient satisfaction between the groups at 14 days and one month follow-up [38]. In contrast, the benefit of compression stockings following sclerotherapy for telangiectasias and reticular veins has been documented in numerous studies. Three trials suggested improved cosmetic outcomes with three weeks of compression rather than shorter or no compression following sclerotherapy of telangiectasias [39-41]. In one of these studies, there was a correlation between the duration of compression and degree of improvement [40]. A total of 40 patients with telangiectasias and/or reticular veins were treated with sclerotherapy. Ten control patients did not receive compression therapy while 30 patients in three groups of 10 received compression for 3 days, 1 week, or 3 weeks. There was a correlation between the length of time compression was applied and degree of improvement at 6 weeks, 12 weeks, and 24 weeks. Patients treated with compression for three days or one week had significantly more improvement than control patients, while patients treated for three weeks of continuous compression had the most improvement. VEIN CLEARANCE AND CLOSURE Dilated veins Clearance of 60 to 80 percent of treated telangiectasias, reticular veins and small varicose veins can be expected [42-44]. Vein clearance rates and overall patient satisfaction favor sclerotherapy over cutaneous laser [42,43,45]. (See "Overview and management of lower extremity chronic venous disease".) Rates of saphenous closure with ultrasound-guided foam sclerotherapy (UGFS) appear to be lower compared to endovenous methods. In a prospective study, significantly higher rates of great saphenous occlusion were seen in patients treated with endovenous laser compared with foam sclerotherapy (93.4 versus 77.4 percent) [46]. For the small saphenous vein, closure rates of 91 percent at 12 months follow up were reported in one moderately-sized study (86 patients) [35]. Perforators Ultrasound-guided sclerotherapy of perforators is an effective and durable method of eliminating reflux in perforator veins. In one observational study, 98 percent of incompetent perforators were successfully obliterated at the time of treatment; 75 percent of limbs showed persistent occlusion of perforators up to five years following treatment [32]. CLINICAL OUTCOMES Venous clinical severity Sclerotherapy of telangiectasias, reticular veins and varicose veins is effective in relieving pain in the treated veins with high rates of patient satisfaction [13,22,47]. As a method of eliminating incompetent perforator veins, ultrasound-guided sclerotherapy results in significant reduction of symptoms and signs as determined by venous clinical scores [32]. Clinical improvement was sustained with a mean follow up of 20.1 months in the only available long-term patient series. Vein recurrence Recurrence of telangiectasias and reticular veins is uncommon and most often attributable to inadequate technique [22]. The development of new veins (ie, neovascularization) and telangiectatic matting are more typical. (See 'Adverse reactions' above.) Randomized trials suggest that sclerotherapy is less effective than surgery for larger veins [48-51]. Recurrence rates following saphenous vein sclerotherapy are significant (up to 65 percent) and related to saphenous recanalization. Foam sclerotherapy is associated with lower

9 rates of recanalization compared with liquid sclerotherapy; however, for either therapy, recurrence of clinical symptoms may be less [13,52,53]. In one prospective trial, saphenous vein recanalization occurred in 27 and 64 percent of patients treated at one and five years, respectively [52]. However, 70 percent of patients did not have worsened clinical symptoms. Repeat UGFS treatment was performed in 16.5 percent of patients between one and two years, and fewer than 10 percent in subsequent years (up to five years). Venous ulcer healing Surgical trials have demonstrated reduced ulcer recurrence rates with saphenous stripping [54-56]. Successful application of other methods of saphenous ablation may also be beneficial (eg, sclerotherapy, endovenous ablation); however, there are no randomized trials comparing techniques. In a small observational study, ultrasound-guided foam sclerotherapy of the saphenous vein resulted in healing of 79 and 96 percent of ulcers at one and three months, respectively [57]. A small randomized trial found healing of venous ulcers in 17/22 patients treated with fourlayer compression bandages alone and 12/13 patients treated with compression bandaging plus foam sclerotherapy to incompetent truncal veins; the difference was not significant [58]. Recurrence of reflux in perforator veins following saphenous ablation is known to be a risk factor for venous ulcer nonhealing or recurrence [44,54]. UGS of perforating veins is associated with fewer complications compared with surgical management of perforators (ie, SEPS) and is clinically appealing for this indication; however, few clinical studies have been performed. In an observational study evaluating ulcer healing with UGS, ulcer healing was ultimately observed in 32 of 37 limbs treated by ultrasound-guided perforator sclerotherapy. This group of patients did not have concomitant axial vein reflux. More than one treatment session due to the development of recurrent perforators was required in 12 of 37 limbs treated [32]. COST Sclerotherapy of telangiectasias and reticular veins is generally considered a cosmetic treatment and is not typically covered by insurance, though occasionally it will be reimbursed when treating veins which have hemorrhaged. The average cost of a sclerotherapy session in the US in 2007 was $342 [24]. SUMMARY AND RECOMMENDATIONS Dilated veins can occur in the presence or absence of either symptoms or an underlying functional venous disorder. Telangiectasias, reticular veins, and varicose veins can cause symptoms, and are often a source of significant distress to the patient even in the absence of symptoms. (See 'Indications' above.) The presence of lower extremity telangiectasias, reticular veins, or varicose veins may indicate an underlying functional venous disorder, especially when associated with symptoms (aching, swelling, heaviness). (See 'Indications' above and "Classification of lower extremity chronic venous disorders".) Symptomatic patients should undergo further evaluation with venous duplex to identify the presence of superficial or deep venous insufficiency, which alters treatment options. (See 'Indications' above.) Common local adverse reactions to sclerotherapy include pain, ulceration, telangiectatic matting, and hyperpigmentation and are dependent upon the agent used (table 1). (See 'Adverse reactions' above.)

10 Cosmetic measures of sclerotherapy success are similar regardless of the agent used (ie, sodium tetradecyl sulfate, polidocanol, hypertonic saline). (See 'Clinical outcomes' above.) For lower extremity telangiectasias, reticular veins, and small varicose veins large enough to admit a 27 or 30 gauge needle, sclerotherapy is the treatment of choice. Sclerotherapy results in improved clearance of treated veins compared with other forms of treatment (eg, laser). Use of UpToDate is subject to the Subscription and License Agreement.