Feature: Ultrasound Guided Sclerotherapy - By Michael S. Krivda, Contributing Editor A safe and effective alternative to surgery for the treatment of varicose veins. W hile there may be little agreement among physicians as to the underlying cause of varicose veins, there is little disagreement among patients that the condition is unsightly, may be quite uncomfortable and can even become very painful. In some cases, varicose veins can threaten the health of the patient. For many decades, the traditional treatment for varicose veins has been ligation and stripping, a surgical process that involves tying off and removing the affected veins. More recently, sclerotherapy has gained wide acceptance as a treatment option. While less painful and more convenient for patients, this treatment produces no better long-term results than the surgical option and can only be used for smaller surface veins. In the last decade, a variation of sclerotherapy has appeared: ultrasound guided sclerotherapy. Unlike surgery where the vein is surgically stripped, ultrasound guided sclerotherapy seals off all of the weakened tributaries draining back into the superficial veins. With this technique, ultrasound equipment is used to both map the veins and guide the physician during the injection of the sclerosing agent. The ultrasound map enables the precise anatomic location of abnormal veins and their tributaries, so that injections of sclerosing agents can be accurately delivered directly into these veins. “The real advantage to ultrasound guided sclerotherapy is that we can identify and close all of the tributary veins causing reflux back into the failed vein,” said Charles Mok, D.O., Medical Director of the Allure Medical Spa in Shelby Township, MI. “Prior treatments could only address the veins that could be seen on the surface and many of the failed tributary veins are deep below the skin. As a result, the incidence of recurrence after treatment was high.” Choosing a Sclerosing Solution - In a study to compare the safety and efficacy of using a glycerin solution versus a traditional sclerosing solution known as sodium tetradecyl sulfate (STS), Mitchel P. Goldman, M.D., treated 13 patients with spider veins with both sclerosing solutions, one in each leg. The study, which was published in the January 2003 issue of Dermatologic Surgery, found that the glycerin solution was more effective than STS in clearing spider veins with less pain and fewer side effects. In a follow-up after 2 to 6 months, Dr. Goldman found that the legs treated with the glycerin solution had greater clearance of spider veins by a margin of seven to one than the legs treated with STS. Dr. Goldman also found that the side effects in the legs treated with glycerin solution were fewer. Performing Ultrasound Guided Sclerotherapy The first step in ultrasound guided sclerotherapy is to use the ultrasound equipment to map the veins of the legs. “The mapping takes about an hour to an hour and a half and we end up with an extremely detailed view of every vein in the leg,” said Dr. Mok. “The map shows us the location of the veins, the size of each vein, the valves, the points of reflux, and any disease.” While the ultrasound device is not an extremely specialized device, Dr. Mok explained that the technique requires a device that is sensitive enough to detect all the necessary structures. Dr. Mok uses a GE LOGIQ Book ultrasound device in his practice. Using the map, Dr. Mok determines the locations to be injected as well as the amount and type of sclerosant that is required. Once the locations are determined, the ultrasound device is used again to guide the injections to the precise locations. Typically, he injects about 1 cc to 3 cc of agent using a small needle at each identified location, and can inject about three locations during each treatment. “When treating a patient, we address the saphenous vein in the initial treatment and some patients may require more than one visit, which we space about 1 week apart.” Once satisfied that the deeper veins have all been addressed, Dr. Mok said he brings the patient back about a week later to inject the surface varicose veins. Dr. Mok then has patients in for follow-up ultrasounds at 4 months, 6 months and a year. He does additional injections if the follow-up ultrasounds indicate the need. Prominent varicosity before treatment (left photo). Picture at right is the patient 7 days after undergoing treatment with ultrasound guided sclerotherapy. Photos courtesy of Dr. Charles Mok. After the procedure, the patient walks for about 10 minutes and then typically wears medical compression hose for 2 days, depending upon the patient and the extent of the procedure. According to Dr. Mok, not only are the results superior, but the procedure is virtually painless, requires significantly less recovery time and can be done in his office, which is far more convenient and less costly than a surgical procedure. While this procedure differs from more traditional approaches to treating varicose veins, Dr. Mok said it is a treatment option for nearly all patients with varicose veins. “Most patients who have varicose veins or spider veins can be treated with this procedure,” said Dr. Mok. “Those who can’t undergo treatment are those who can’t endure other treatments as well — the elderly, those with other conditions and so on. In short, anyone who is a candidate for any type of varicose vein treatment can be treated using this technique.” Though most patients seeking treatment for their venous diseases may be appropriate candidates for this treatment, Neil Sadick, M.D., a New York City-based Dermatologist and Past President of American College of Phlebology and an internationally recognized expert in sclerotherapy, said he believes that there are many patients who may not benefit from or require this procedure. “It is a treatment option for patients who do not want to have any endovascular or surgical procedures to treat incompetence of the saphenous veins or for patients who have not responded well to other forms of treatment,” said Dr. Sadick. “However, it is not necessarily the treatment of choice or necessary for other non-saphenous varicosities.” Benefits of Ultrasound Guide Sclerotherapy over Other Treatments While it is difficult to call ultrasound guided sclerotherapy a cure for varicose veins since there is a wide-range of factors that contribute to the condition, Dr. Mok said he considered the results achieved by ultrasound guided sclerotherapy to be significantly longer lasting because the technique can, in many cases, eliminate the specific instances of varicose veins. “Since we can identify and seal all of the incompetent veins causing the reflux into the varicose vein, we can achieve superior results,” said Dr. Mok. “And because we can target deeper veins, we can in many cases, correct the problem at its source, resulting in better and more long lasting results.” Dr. Mok went on to say that since the technique does not involve removal of the larger veins, the body is less likely to regenerate veins, which can lead to a recurrence of the problem. “I think that ultrasound guided sclerotherapy will virtually render surgical ligation and stripping of the saphenous vein obsolete when treating the underlying cause of the varicose veins.” said Dr. Mok. “There is less risk, greater patient acceptance, with no pain, and the patients can walk almost immediately after the procedure.” On the other hand, based on his experience, Dr. Sadick said he has observed a higher recurrence rate for this procedure when compared to other endovascular treatments such as the laser, radiofrequency or ligation and stripping procedures. However, he agreed that it may be the treatment of choice for many because it’s less demanding on the patient and is considerably less expensive. At left is the patient before treatment of a large varicose vein. At right is the patient 3 weeks after treatment with ultrasound guided sclerotherapy. Photos courtesy of Dr. Charles Mok. The risks of this procedure are similar to those associated with surgical procedures, including blood clots, phlebitis, infections and skin ulcerations, although they are lower than for surgery. “The risks associated with this procedure are extraordinarily rare when compared to the risks of surgery, probably less than one in a thousand,” said Dr. Mok. “The risks for surgery to treat the same problem are probably 10 times as great or more.” Patients also benefit by avoiding X-ray contrast studies (venography), while eliminating the targeted veins without the disadvantages of surgery, including greater risks and costs, longer recuperation time and scarring. The Advantage of Foam - The recent development of a technique to foam the sclerosant prior to injection has Charles Mok, D.O., excited because it allows for treatment of larger, deeper veins that are often the root cause of the surface varicose veins. Converting the sclerosant into a foam is done at the time of the procedure with a special technique that involves mixing the solution with air. “In the last couple of years, we found that foaming the standard sclerosant is extremely effective with larger veins, and these large veins are the root of the trouble,” said Dr. Mok. “With the foam sclerosant, we can get an effectiveness approaching 95% for long-term success, far better than conventional stripping and surgery. Mitchel P. Goldman, M.D., the Medical Director of the La Jolla Spa in La Jolla, CA, studied the use of a foaming sclerosing solution to treat large varicose veins. The study analyzed the efficacy of an ultrasound guided foam sclerotherapy in treating 100 randomly chosen legs with varicose veins. The study, which was published in the January 2004 issue of Dermatologic Surgery, found that while 31% of the legs with varicose veins required a second treatment to completely resolve the condition, after 3 months following the initial treatment, 100% of the patients studied felt that their legs were successfully treated with this procedure. Working with an Ultrasound Specialist Although ultrasound guided sclerotherapy is a difficult procedure for the physician, and really requires a well-trained specialist to perform, it is easier for the patient and seems to produce good results. Dr. Mok warned that physicians should not try to perform this surgery without the aid of an ultrasound technician. “To really be successful, you need to work with a highly skilled ultrasound technician and not operate the ultrasound and perform the injections alone,” said Dr. Mok. “The technique requires precise location of the injections and excellent eye-hand coordination and focus. It’s difficult for me to see how a physician can do both activities at once.” Dr. Sadick agreed that the sophisticated procedure should be left in the hands of highly trained specialists. “It is a very technical procedure that requires a physician who can correctly interpret the ultrasound map and who can perform the extremely subtle movements required to locate the injections properly.” An Important Tool for the Treatment of Varicose Veins Today, varicose vein disease is not a curable condition and even patients who have their veins treated, risk reoccurrence of the varicose veins if conditions such as obesity, lack of exercise and chronic hypertension persist. However, varicose veins can be treated successfully with a variety of procedures, and the primary mechanism of the disease, saphenous vein incompetence and the resulting reflux, can be successfully addressed with treatments such as ultrasound guided sclerotherapy. Nevertheless, the condition demands continuous monitoring and regular maintenance after initial treatment. Ultrasound Guided Sclerotherapy is a safe, effective outpatient procedure that addresses the deeper failed veins that have traditionally required surgical removal. Neither surgery nor sclerotherapy can prevent new varicose veins from developing as a result of the natural progression of this chronic condition. However, ultrasound guided sclerotherapy offers a less traumatic, less costly alternative to surgical treatments. “Ultrasound guided sclerotherapy is a very important tool in the doctor’s kit to for the treatment of varicose veins,” said Dr. Sadick. “It may be a more effective treatment option for many patients.” With ultrasound guided sclerotherapy, both the varicose veins and the underlying root veins that lead to varicose veins can be treated. Large varicose veins generally disappear quickly and completely without surgery, although additional procedures may be required. Patients benefit from improved appearance, as well as elimination of the cause of painful veins. “Ultrasound guided sclerotherapy has about a 90% success rate (about the same as surgical vein removal). We achieve that rate because we address the problem’s root cause and eliminate the primary point or points of reflux,” said Dr. Mok. “However, we’re doing a simple, in-office procedure that has virtually no pain or recovery time. Our patients leave the office and immediately carry on with their lives.” Skin & Aging - ISSN: 1096-0120 - Volume 13 - Issue 10_2005 - October 2005 - Pages: 76 - 80