Australian Vein Clinics

Do not cease medications prior to treatment unless otherwise advised.

Do not apply moisturiser on the day of treatment.

Wear slacks or loose trousers and sandals or loose shoes to your appointment to conceal and allow for the thickness of the stockings.

Take two Panadol tablets about one hour before the appointment

Avoid treatment if you intend to fly overseas within the following six weeks.

Multiple injections are given using very fine needles.

A compression stocking is applied to reduce pigmentation, the number of treatment sessions, risk of deep vein thrombosis and risk of recurrence.

Rest for several minutes after the injections with the leg elevated.

If possible, do not drive home yourself. If you have to drive, keep the legs moving.

Wear the stockings continuously for 24 hours. Then wear stockings only through the day, remove them at night and replace them in the morning after the shower for a further two weeks.

Continue with stockings for approximately 2-3 weeks or longer if pain develops after the recommended two weeks.

Walk for 30 minutes each day. Maintain normal daytime activities. Avoid standing still for long periods of time. When sitting, elevate your legs.

Avoid strenuous physical activity such as aerobics for 3-4 weeks after treatment since this increases the risk of blood flow into the treated veins.

Complications can occur even with perfect technique.

Deep vein thrombosis (DVT). Clots can extend into deep veins but this is rare if the protocol of compression and regular daily walking is followed. It is optional to stop hormone preparations as they may increase the risk of DVT.

Allergic reaction. This is rare but can present immediately as an anaphylactic reaction with generalised rash, constriction in the throat or difficulty with breathing. This is immediately treated by injecting cortisone or adrenaline. Allergy may cause a skin rash after treatment requiring antihistamines. Allergy is slightly more common in asthmatics. Patients must stay in the building for 20 minutes after any form of treatment to ensure that no allergic reactions occur.

Pigmentation. Haemosiderin which is a form of iron from the blood can be deposited along the treated veins. This is more frequent with large surface veins but can occur with spider veins. Most disappear within 12 months but there is permanent staining in about 5% and this is of cosmetic significance. Persistent pigmentation may respond to laser treatment.

Matting. This consists of networks of fine dilated capillaries near the injection sites. It appears shortly after treatment in approximately 10% of patients. Most resolve spontaneously, some resolve with injection treatment, and a few persist.

Skin ulceration. This is very uncommon. It occurs because solution has escaped into the surrounding skin or because of an abnormal connection between small veins and arteries. Most injection ulcers are small and heal over a few weeks leaving a small pale scar.

Intra-arterial injection. This has never been encountered in our practice but has been reported resulting in muscle and skin damage.

UGS has been in use for some 25 years. UGS is used to block off smaller diameter saphenous veins or large tributaries by injection using ultrasound to guide the needle to the vein. Our results published in the European Journal of Vascular Surgery show a low risk of complications and good results but with a need to repeat treatment at a later date in some patients. Success rates for UGS compare favourably to published results for surgery. The two sclerosants used are Aethoxysklerol (polidocanol) or Fibrovein (sodium tetradecyl sulphate – STS). Both are detergents and act by washing away the lining of the vein allowing the two walls to stick together.

Worldwide the trend in recent years has been to use sclerosant made up as foam. However, it is now known that this can lead to bubbles passing to the brain and there is a small number of reported strokes. Accordingly, this practice has reverted to liquid sclerotherapy. However this may lead to a need for greater numbers of treatment sessions.

Advantages

Minimal discomfort.

No admission to hospital or anaesthesia.

No time off work nor interference with normal home duties.

Disadvantages

Each leg is usually treated separately.

There is a limit to the dose of sclerosant that can be safely given at a session.

This means that multiple treatment sessions may be required.

Approximately 40% of patients require two sessions and 5-10% require more.

Injected veins may remain inflamed for several weeks and patience is required to allow this to settle.

Advice will have been given about the type and use of stockings.

Do not shave the legs.

Do not apply moisturiser on the day of treatment.

Wear slacks or loose trousers and sandals or loose shoes to allow for the thickness of the bandages and compression garment

A sonographer may perform a limited ultrasound scan similar to the initial screening scan to familiarise us with the veins.

One or more injections of the sclerosant are given with you lying flat on a treatment couch.

The sonographer will then bounce on the vein to enhance the action of the sclerosant

Compression is then applied by a combination of bandages and compression garments.

Walk for 15 minutes immediately after treatment.

Arrange for someone to drive you home or go by public transport � it is essential that the patient does not drive on the day of treatment. Driving can resume on the following day.

Walk or keep the leg elevated as much as possible for the first 24 hours and walk for 15 minutes each day.

Wear the bandages and compression garments continuously for 24 hours. Then wear support garments only through the day, remove them at night and replace them in the morning after the shower. Some find it easier to wear them continuously and wash the stockings in the shower. Continue this for approximately 7-10 days or longer if pain develops after they are discarded.

Maintain normal daytime activities and avoid standing still for long periods. Continue with normal exercise activities.

Avoid flights of greater than 4 hours duration for 6 weeks after treatment. If travel is unavoidable, then the flight should be covered by subcutaneous heparin injections given before departure and after arrival.

Return for a check ultrasound scan within the first two weeks after treatment to ensure that the treated vein is occluded, determine whether any further veins require treatment, and exclude the small risk of deep vein occlusion.

Bring your compression garments to every follow-up visit.

Complications can occur even with perfect technique.

Deep vein thrombosis. Clots extending into the deep veins can occur. This potentially serious complication is very uncommon if the protocol of compression and regular daily walking is followed. Minor clots develop in deep calf veins in less than 2% of our patients. If this is demonstrated on the postoperative scan then you may require treatment with daily heparin injections until further scans show the clot is resolving.

Allergic reaction to the solution. This is rare. It can present immediately as an anaphylactic reaction with generalised rash, constriction in the throat or difficulty with breathing, and this is successfully treated by injecting cortisone or adrenaline. Allergy may cause a skin rash requiring antihistamines. Allergy is slightly more likely in asthmatics. Patients must stay in the building for 20 minutes after any form of treatment to ensure that no allergic reactions occur.

Pigmentation along the treated veins consists of haemosiderin, a form of iron from the blood. Most disappears within 12 months but there is permanent staining in about 2-3% and this is of cosmetic significance. Persistent pigmentation may respond to laser treatment.

Skin ulceration is very uncommon with foam. It occurs because solution has escaped into the surrounding skin or because of an abnormal connection between small veins and arteries. Most ulcers are small and heal over a few weeks leaving a small pale scar.

Intra-arterial injection. This is a very rare complication that has been reported. It would result in muscle and skin damage.

Nerve damage. We are not aware of any reports of damage to major nerves. Damage of surface sensory nerves can occur but this usually returns to normal within weeks to months.

Stroke. There are a small number of reported cases, all with complete recovery. This is from the hundreds of thousands of patients treated each year worldwide. However, it appears to be more common with sclerosant prepared as foam, so we no longer perform foam Sclerotherapy and only use liquid sclerosant even although this may require more treatment

The following features are expected. They are not a cause for concern although they should be reported at review:

Mild pain persists for several days and shows that the injections are working. The degree is related to the initial size of the veins. Pain is usually improved by walking or by Panadol or Nurofen. Soreness can occur behind the knee from rubbing by the bandage or compression garments.

Discolouration and tender lumps over tributaries are usual early on. They usually disappear within 4-6 weeks. This indicates that treatment has been successful. Lumps may need to be pricked to let out “trapped blood”.

Phlebitis or inflammation can occur at any time after treatment due to reaction to the sclerosant. It is treated by further compression and regular walking. It does not represent infection and does not require treatment with antibiotics.

Migraine symptoms. Patients with a history of migraine headaches occasionally develop prodromal visual symptoms within a few minutes after treatment. Patients may wish to take their usual migraine treatment an hour or so prior to treatment in the hope of preventing this.

Recurrence. Treated veins can reopen or new veins can develop. For this reason, ultrasound surveillance is offered at yearly intervals so that recurrent veins can be detected and easily treated by UGS before they become too large.