Foam Sclerotherapy (Varicose vein injections) Vascular Surgery This information is intended as a general guide only. Please ask if you have any questions relating to this information. Varicose Veins Veins with poorly or non-functioning valves enlarge and then become varicose veins. They can have a bluish colour and bulge on the leg surface. Symptoms may include heaviness, aching, throbbing, itching, cramps or tiredness in the legs. Some patients may have skin discoloration, inflammation or ulcers on the skin. How are varicose veins treated? Varicose veins that are not causing any problems do not need to be treated. In addition, many of the symptoms that people attribute to varicose veins such as heaviness, ache, cramp and swelling are also very common in patients without varicose veins and there is no certainty that treatment will help. Varicose veins can be treated with stockings, surgery, laser, radiofrequency ablation, foam sclerotherapy or a combination of these treatments depending on the size and distribution of the veins. What is Ultrasound Guided Foam Sclerotherapy? Ultrasound guided foam sclerotherapy can be used instead of surgery and radio-frequency/ laser therapy to treat varicose veins. Foam sclerotherapy is performed as a day case procedure and takes about 30 45 minutes. The sclerosant the foam is made from is Sodium Tetradecyl Sulphate (STS), otherwise known as Fibrovein. Using an ultrasound scanner a very fine needle is inserted into the varicose vein. Using the ultrasound scanner allows a surgeon to see the needle enter the vein requiring treatment. It may require between 1 10 injections at a sitting, with the number of veins being treated at any one session limited by the volume of foam the surgeon can inject. The foamed sclerosant is freshly prepared and injected into the varicose vein. Once the foam enters the varicose veins it is massaged along the varicose veins in the leg. The foam can be easily seen using the ultrasound as it is full of bubbles that show up clearly on ultrasound. Doing this allows us to ensure that the veins are filled with the sclerosant. If any foam is seen close to the deep venous system then pressure can be applied to keep this to a minimum. This is why the ultrasound is used to guide the foam sclerotherapy. Page 1 of 5
The injection causes no pain in the leg; although sometimes a mild ache can be felt as the sclerosant starts to take effect. Immediately following the injection you will be fitted for a full leg compression stocking which you must wear for at least two weeks after the procedure: Continuous (all day and all night) for the first week (i.e. do not take off for showering, etc) You can remove the stocking for short periods during the second week (i.e. to wash) Should the stocking get damp either gently pat it dry or use a hair dryer to dry it If possible, try to wear the stocking for up to three weeks after the procedure The stocking helps reduce pain and bruising and increases the success of the procedure Immediately following the procedure once your compression stocking is applied, you will be required to go for a brisk 15 minute walk and then twice daily walks for two weeks. Avoid hard physical activity (aerobics and weight lifting) for the first 48 hours. How successful is sclerotherapy? In about 85% of patients, only one foam treatment session is required; about 15% of patients require two sessions and 1 2% require three sessions. The larger and more extensive the varicose veins are, the more likely it is that more than one session will be required. The surgeons in this clinic take care to limit the amount of foam that is used at any one time and this minimises the risk of complications. The National Institute for Health and Clinical Excellence (NICE) has stated that the current evidence on ultrasound-guided foam sclerotherapy for varicose veins shows that it works well in the short term. Studies have shown the treatment to be successful in around 67 97% patients after three weeks to two years of follow up. However, the current published evidence does not provide clear evidence of the efficacy of this treatment particularly in the long-term. Website address: www.nice.org.uk/guidance/ipg182 Advantages: No general anaesthetic No cuts No nerve damage Earlier return to work Page 2 of 5
Disadvantages: Overall treatment can take a little longer as only one leg is treated at a time and multiple treatments are sometimes needed. The skin over the treated varicose vein can turn brown. This can take a few months (sometimes up to year) to disappear and may, unusually, be permanent. The fading process is gradual and not often perfect. In order to keep the treated varicose veins empty of blood while they seal off, it is necessary to wear compression stockings after each treatment. Lumpiness: It is normal, especially in patients with large veins, to be able to still feel some lumpiness beneath the skin. Depending on the size of vein this disappears over a few months. Will treated veins recur? It is common after any form of treatment for varicose veins for them to recur. The recurrence rate after injection is higher than after surgery or laser therapy/radiofrequency ablation but the injection is easier to perform, does not require anaesthesia and requires no time off work. If the veins recur they can be treated by further injections. Before each appointment Do not apply moisturiser, suntan lotion or any creams to your legs on the day of your appointment for foam sclerotherapy. Side effects to sclerotherapy Common: During the treatment you may feel an aching sensation this usually settles quickly once the stocking is applied and you go for a walk. You may feel some discomfort after your treatment. You may take pain tablets 4 6 hourly. If there is significant pain or discomfort, remove and re-apply the stocking. Bruises at the injection site usually disappear within a few weeks. Lumpiness and Skin Staining The injected veins may become hard and lumpy with redness over them, and occasionally may be painful. If this occurs treatment with paracetamol and an anti-inflammatory drug such as ibuprofen helps. The redness is almost never due to infection but is simply an inflammation as the vein closes. The redness then fades to a brown stain. Both the lumps and the skin staining then fade over a period of time. The lumpiness, redness and tenderness (also known as thrombophlebitis) is normal and indicates the treatment is working. It is difficult to predict how long the brown staining and lumps will stay. It is important to protect the brown staining from the sun as it is believed that this may make it permanent. In most people the staining has faded to a hardly noticeable area by four months. Page 3 of 5
However, it may take up to two years for the final appearance and approximately 5% of patients will have permanent staining. Avoid sunbathing initially after treatment, for four weeks after microsclerotherapy and for four months after foam sclerotherapy. Matting Fine red blood vessels ( matting ) and further thread veins may develop over the area where the larger veins were. This matting usually fades with time but may be permanent. It is unusual for this to be very noticeable. If you have thread veins already you are more likely to develop these. If you have thread veins then injecting the larger veins may improve their appearance but this is not predictable. Rare: Ulcers Painful ulcers may form immediately following or within a few weeks of the treatment. Please inform your doctor if these occur. These ulcers will heal and leave a small scar. Allergic Reactions Allergic reactions to the sclerosant are rare. Migraines Patients with migraine may experience an attack immediately after the treatment and are advised to bring their usual medication with them. They should also consider whether they need to have someone to accompany them in the event of an attack. Numbness due to bruising of the nerves supplying the skin. It occurs much less frequently than after surgery but may rarely occur. If so it may take 6 12 months to settle. Deep Venous Thrombosis (DVT) Clots in the deep veins have been reported following all treatments for varicose veins. This may present as a swollen, sore and red leg. If you have any concerns please see your GP as soon as possible. (<1%, less than 1 in 100 patients) Pulmonary Embolus (PE) Rarely clots from the leg can move to the lungs causing pulmonary embolus. (<1%, less than 1 in 100 patients) Heart Attack There have been case reports from around the world of patients suffering heart attacks following foam sclerotherapy. (<1%, less than 1 in 100 patients) Stroke There have been case reports from around the world of patients suffering a stroke following foam sclerotherapy. It is an extremely rare complication and requires a defect in the heart in order to occur (i.e. hole in the heart). Please inform your doctor if you are known to have any heart problems or prior heart surgery before undergoing foam sclerotherapy. (<1%, less than 1 in 100 patients) There are a number of rare and alarming complications which only last for a short time, these include: visual disturbance (1%, 1 in 100 patients) chest tightness confusion It must be stressed these are unusual and not long lasting. Page 4 of 5
The surgeons take care to limit the amount of foam that is used at any one time and this minimises the risk. Flying If you are flying or have major surgery planned for within six weeks of your treatment, it is very important that you notify your doctor before the procedure. We recommend no flying for four weeks prior to treatment and for six weeks after treatment. Oral Contraceptive Pill If you are taking an oestrogen based contraceptive pill, we would advise stopping this 4 6 weeks prior to foam sclerotherapy, to reduce the risk of deep vein thrombosis (DVT). Developed by Dr S Suttie and reviewed by the Vascular Surgical Team and patients Reviewed: 07/2017 Review: 07/2019 LN1097 Page 5 of 5