Key words
sclerotherapy - telangiectasia - spider veins - foam sclerotherapy
Schlüsselwörter
Sklerotherapie - Teleangiektasie - Besenreiser - Schaumverödung
Introduction
Despite new development in cutaneous lasers for treatment of telangiectasias, sclerotherapy
remains the treatment of choice for telangiectasias and reticular veins (Grade 1A
recommendation per the European guidelines for sclerotherapy) [1]. In the treatment of incompetent truncal and nontruncal varicosities, foam sclerotherapy
offers a safe and cost effective alternative in selected patients to thermal and nonthermal
ablation (Grade 1A) [1]. Foam sclerotherapy has a slightly higher rates of recanalization but similar quality
of life improvements when compared to surgery and thermal ablation [2].
Sclerotherapy is the injection of liquid or foam substance that injures the endothelial
cells lining veins, creating a controlled chemical induced fibrosis. When performed
correctly, sclerotherapy produces maximum endothelial damage with minimal thrombus
formation, resulting in a fibrous cord that is not amenable to recanalization. If
there is insufficient damage, a thrombotic reaction is created that recanalizes over
time. Paramount to success is adequate contact time of a sclerosant to the endothelial
cells to cause sufficient damage to the vein while minimizing side effects. To optimize
sclerotherapy results, one needs to choose the right patient and the right vein and
then use the proper sclerosing agent and injection techniques. This paper will review
current literature on sclerotherapy, as well as tips and tricks to optimize outcome
and minimize complications.
Choosing the Right Patient and the Right Veins
Choosing the Right Patient and the Right Veins
A comprehensive clinical evaluation and preoperative duplex ultrasound examination
of the lower extremity is mandatory to exclude underlying venous insufficiency. The
most proximal point of reflux should be treated first prior to sclerotherapy of spider
and reticular veins in the area affected. Failure to address underlying venous incompetency
(saphenofemoral reflux, perforator disease) will result in higher rates of recurrence
and hyperpigmentation.
Contraindications for sclerotherapy per the European guidelines for sclerotherapy
include known allergies to sclerosants, acute deep vein thrombosis and/or pulmonary
embolism, local infection in the area of treatment, severe arterial occlusive disease,
and immobility (Grade 1C) [1]
[3]. In addition, a patient with a known symptomatic patent foramen ovale should not
be treated with foam sclerotherapy. However, it is not necessary to perform a routine
preoperative evaluation for patent formane ovale [1].
Relative contraindications include pregnancy, breastfeeding (can consider interrupting
breastfeeding for 2–3 days), mild arterial occlusive disease, strong history of multiple
allergies, high thromboembolic risk, acute superficial venous thrombosis [1]
[3]. Patients with a history of migraines especially following previous foam sclerotherapy
should be treated with caution.
It is important to properly consent and set realistic expectations from the onset
during the consultation visit. Patient should understand that multiple sessions may
be required and should be spaced at least 6 weeks apart to adequately judge the level
of improvement from the treatment. The aim is for improvement rather than perfection.
If applicable, patients should be informed that foam sclerotherapy is off-labeled
but highly effective treatment with higher risk of certain side effects (see complications).
Hyperpigmentation is expected post sclerotherapy; most cases resolve within months
with the majority disappearing within a year. Finally, photographic documentation
pre- and post- procedures are essential to ensure patient satisfaction as patients’
recall of preoperative appearance is often poor [4].
Choosing the Right Sclerosant
Choosing the Right Sclerosant
Appropriate choice of sclerosant is paramount to maximizing effectiveness while minimizing
side effects. Several variables exist with any sclerosant choice, including the type
of agent (osmotic, irritant, and detergent based), concentration, volume, and method
of preparation (liquid or gas). To minimize side effect, the principle of the least
should be used – using the lowest concentration possible with minimal amount of volume
and the lowest injection pressure.
Types of Sclerosant
Sclerosants can be classified into three main categories: hyperosmotic agents, chemical
irritants, and detergents.
Hyperosmotic agents such as hypertonic saline and dextrose cause cellular dehydration
of endothelial cells and red blood cells. The advantage of hypertonic saline is its
lack of allergenicity and low cost. While it was widely used prior to the availability
of detergent based solution, its use is less favored due to the increased risk of
ulcerations from extravasation and hyperpigmentation and the intense burning sensation
upon injection from its irritant effect on nerve endings [3].
Chemical irritant such as chromated glycerin and polyiodinated iodine are caustic
agents on the vein walls. Glycerin is commonly used for fine telangiectasia due to
its low risk of skin necrosis, pigmentation, and risk for matting. It is typically
used as a 72 % solution compounded 2:1 with 1 % lidocaine with epinephrine to reduce
stinging and to cause local vasoconstriction to increase its effects[3].
Detergent based sclerosants, the most widely used are polidocanol (POL) and sodium
tetradecyl sulphate (STS) due to their long-term safety and efficacy profiles. Detergent
sclerosants cause endothelial damage by protein theft denaturing of the cell surface
lipids. They are the most commonly used agents for sclerotherapy worldwide due to
their low side effect profile. The ability to create a foam agent due to the natural
property of detergent also makes it more versatile as a sclerosant agent for a wider
range of vessel size. Cochrane review concluded no significant differences in outcome
or complication rates between STS and POL, in part due to limited available high quality
studies comparing sclerosants [5]
[6]. POL has an added benefit that it is less painful than other sclerosants with its
local anesthetic effects [5]. As these sclerosants are commercially available worldwide, compounded sclerosants
are not recommended. Several studies have reported inconsistencies in concentrations
and presence of contaminants in compounded sclerosants [3]
[7].
Concentration
One should match the sclerosant concentration to the caliber of the vessel, with increasing
concentration used for larger veins. The key to sclerotherapy is to use the minimum
effective concentration that would cause optimal fibrosis without complication. Too
low a concentration would result in inadequate endothelial damage and subsequent thrombus
formation rather than fibrosis; too high a concentration would cause iatrogenic reaction
such as hyperpigmentation and potential ulceration.
Kobayashi et al, showed that 0.1 % STS and 0.3 % POL produced equivalent effect on
cell death within 15 seconds [8]. In clinical practice, STS is approximately 2–3 × stronger than POL for the same
concentration [9]
[10]. For telangiectasia measuring < 0.5 mm, a low concentration such as STS 0.1 % or
POL 0.25 % is usually sufficient. For telangiectasia 0.5–2 mm in size, STS 0.2 % or
POL 0.5 % might be required. Reticular veins measuring 2–4 mm in size should be treated
with POL 0.1 % liquid or 0.5 % foam ([Table 1]).
Table 1
Recommended Sclerosant Concentration based on Vein Diameter
|
vein diameter
|
recommended STS concentration
|
recommended POL concentration
|
|
< 0.5 mm
|
0.1 %
|
0.25 %
|
|
0.5–2 mm
|
0.2 %
|
0.5 %
|
|
2–4 mm
|
0.5 %
|
1 %
|
|
4–6 mm
|
0.5 % Foam
|
1 % Foam
|
Volume
The volume of solution required to produce sclerosis is directly related to the vessel
size. Larger caliber veins need more volume than smaller caliber veins. Approximately
0.2–0.5 cc for spider veins and 0.5–1 cc for reticular veins is usually sufficient;
the idea is to inject until you see a 1–2 cm area of blanching in the site of injection
or sooner if you stop seeing the solution flow. Avoid getting carried away by injecting
more volume than necessary as an attempt to treat a greater area with a single injection.
Both STS and POL are inactivated by plasma proteins in blood [11], thus limiting the distal effect of the sclerosant from the point of injection.
Thus, one need to inject at multiple site along a vein cluster to introduce fresh
sclerosant to the endothelial cells. To maximize detergent sclerosant effects, one
can use an empty vein technique by leg elevation, create a foam sclerosant to displace
the blood, or inject saline first to dilute then blood followed by the sclerosant.
Total dose of POL should not exceed 2 mg/kg/d (i. e. POL 1 % = 14 mL) and STS should
be limited to no more than 4 mL of 3 % solution per session [1].
Pressure
The key is to use minimum injection pressure and slow pace. Too much pressure may
lead to vessel rupture and extravasation resulting in higher rates of hyperpigmentation.
Worse, high pressure can result in sclerosant traveling into arterioles which can
result in ulcerations. Too little pressure will result in an inadequate amount of
solution to travel the length of the affected vessel leading to additional insertion
sites. Ideally a 3 or 5-cc syringe is best for treating telangiectasia. The larger
piston in a 3- or 5 cc syringe results in lower pressure when depressing the plunger
versus a 1-cc syringe which delivers high pressure [12].
Foam
While liquid sclerosant is preferred for treating telangiectasis; foam sclerosant
is superior in treating larger varicose veins. Foam sclerotherapy is nearly 3–4 times
as effective as its liquid counterpart. The ESAF study, which was a randomized, prospective
controlled multicenter trial, showed greater efficacy with POL foam in eliminating
reflux in the GSV (69 %) vs liquid POL (27 %) with greater patient satisfaction (82 %
with foam vs 58 % with liquid).
Efficacy and safety of foam is well established. Meta-analysis of 73 studies with
over 11,000 patients demonstrated a medial rate of venous occlusion of 85 %, using
both STS and POL based sclerosants with more than 90 % of subjects reporting symptomatic
improvements [13]. A review of four randomized controlled trials in six publication comparing US guided
foam sclerotherapy with endothermal ablation by Davies et al, showed higher closure
rate with endothermal techniques (83–95 %) compared to US guided foam sclerotherapy
(54–83 %). However, patient reported outcomes such as Venous Clinical Severity Score,
Chronic Venous Insufficiency Quality of Life, etc) showed significant improvements
regardless of the modality [14].
Several factors contribute to foam’s superior results compare to its liquid counterpart.
Foam is a highly viscous solution that completely displaces blood within the vein
lumen whereas liquid sclerosant mixes with blood and is inactivated. The generation
of miniscule air bubbles also increases surface area for contact with the endothelial
cells. Foam sclerosant also produces more vasospasm than liquid sclerosants. All of
these effects result in longer contact time for foam, maximizing endothelial cell
injury and allowing for lower total volume and concentration to be used compare to
liquid sclerosant.
Attempts with foam sclerotherapy have been reported as early as 1940 s, but early
techniques were unable to produce a uniformly effective foam. Mainstream acceptance
of foam began with Cabrera in 1990 s, and further refined by Tessari and later Frullini
with the double syringe system (DSS), making foam production simple, inexpensive and
most importantly easily reproducible. The Tessari method uses a three-way stopcock
while Frullini uses a two-way connector; in both methods, an adaptor between two syringes
is used to create a turbulent flow to generate the foam.
The quality, stability and efficacy of foam is influenced by several variables including
the specific sclerosant and concentration used to create the foam, method of preparation,
the gas-to-sclerosant ratio, and the type of gas mixture used. The ideal foam should
be small microbubbles with dense consistency; this allows for localized efficacy while
limiting the duration of the bubbles and potential for distal effect [15]
[16]. Both STS and POL are widely use as the sclerosant of choice for creating foam.
Syringes with low silicone content should be used as the silicone lubricant reduces
foam lamellae and its stability [16]
[17]. No difference in foam stability was found when comparing various two vs three-way
connectors [18]. However, three-way connector does allow for partial closure which narrows the caliber
between the two syringe to create a longer-lasting foam [16]. The use of a 5 μm in-line filter for creating foam, while not necessary to prevent
bacterial contamination [19], improves foam stability [20]. Tessari et al noted that smaller needles (27 and 30 gauge) may produce a less stable
foam and advocates the use of 25 gauge for injection [16]. Subsequent study noted variability in foam stability between needle size (83 sec
for 25 gauge; 70 sec for 27 gauge, 67 sec for 30 gauge), though this is unlikely to
affect its clinical effectiveness [20]. Standard liquid- to-gas ratio is 1:4, as this produces a dense and stable foam
[16].
The stability (half-life) of foam varies depending on the type of gas used (room air,
sterile air, CO2 vs other mixture of gas). Room air which contains 72 % nitrogen,
is readily available, creates a stable foam (1–2 min) [20], but does not dissolve quickly in blood due to its nitrogen content. CO2 is more
soluble in blood but creates a less stable foam (25 sec) [20], that must be injected immediately [16]. The use of a physiologic gas with the addition of O2 creates a foam that has a
slightly longer half-life and readily diffusible in blood. Beckitt et al, in their
prospectively maintained database, noted statistically significant lower incidence
of hyperpigmentation (7.2 % vs 3.3 %) and occlusion rate (91 % vs 83 %) with the use
of physiological gas of 70 % CO2 and 30 % O2 vs room air. The authors propose that
the higher solubility of the CO2 may allow for greater endothelial damage. They found
no differences in neurologic events between the two gases, but this may be partially
due to the low overall incidence (0.7 %) [21]. European consensus guideline recommends the use of air for generating foam (Grade
1A) or mixture of CO2 and O2 (Grade 2B) [1].
While there is no evidence based limit on maximum volume of scleroant foam per session,
the European Consensus meeting recommended a maximum of 10 mL (Grade 2B), in part
out of concern for rare neurologic and pulmonary events, especially in patients with
known patent foramen ovale [1].
My Sclerotherapy Technique
My Sclerotherapy Technique
Patient Positioning
I prefer to have patients lying sideways, with one leg draped over the other ([Fig. 1]). This is a comfortable and stable supine position for most patents and allow for
visualization of the lateral and posterior aspect of one leg and medial and anterior
aspect of the other. Once treatment is done on this side, the patient simply turns
to the other side allowing for full treatment of the legs without having the patient
in an uncomfortable prone position.
Fig. 1 My preference for patient positioning – this allows for visualization of the lateral
and posterior aspect of one leg and medial and anterior aspect of the other.
Sclerotherapy tray
My sclerotherapy tray consists of pre-drawn syringes of liquid sclerosant clearly
labeled and separated into their own basin (POL 0.25 % and 0.5 % or STS 0.1 % and
0.2 %). When the plunger is completely pulled back and the syringe is filled to 3 mL,
one has minimal dexterity and control. Thus, I prefer to draw only 2 mL of sclerosant
agent in each 3-mL syringe. Cotton balls and a basin with alcohol are used for cleanse
the skin. Extra 3-mL syringes, 30G needles, 25G butterfly needle, and three-way stopcock
are set aside for foam sclerotherapy ([Fig. 2]).
Fig. 2 My sclerotherapy tray setup. Pre-drawn 2 mL sclerosant in each 3-mL syringes, clearly
labeled with concentration and separated in their own trays. Silver basin with isopropyl
alcohol and cotton balls for cleansing the skin. An empty basin for discarded sharps.
Extra syringes, three way stopcock and needles for foam sclerotherapy.
Approach to Telangiectasia and Reticular veins
Transillumination devices and duplex ultrasound should be used to visualize reticular
and perforator veins; these often accompany telangiectasia in a significant percentage
of cases [22]. Comprehensive treatment should be directed at both the telangiectasia and the underlying
varices. I treat the reticular veins first, followed by the venulectasias and then
final the associated telangiectatic web [23].
The skin is first cleansed with isopropyl alcohol on cotton balls. Placing a small
drop of sclerosant on the skin before injection can improve visibility by reducing
light scatter. Alternatively, one can use special devices with polarizing light to
help visualize the veins. Using a 30–32G needles on a 3-cc syringe, the needle should
be bent approximately 30–45° angle to facilitate a near parallel approach of the vein.
The nondominant hand should be used to stretch the skin taut. Slow injection with
low volume is key to reduce the risk of extravasation, skin necrosis, matting and
hyperpigmentation. One should see the flow of sclerosant temporarily displacing the
blood in the telangiectasia. I usually inject between 0.2–0.5cc to create a 1–2 cm
diameter of clearing.
When treating reticular veins, I will occasionally aspirate and look for slight venous
return at the needle hub to ensure proper placement before injecting. Note that one
should not allow too much blood to mix with the sclerosant in the syringe as this
will inactivate the sclerosant [11]. If there is resistance to flow or if a bleb forms at the site of injection, stop
immediately and find a nearby branching vessel to inject.
Foam Sclerotherapy
I create foam using two 3-cc syringes, one syringe is filled with 0.5 ml of liquid
sclerosant and the second with 2 cc of room air to create an optimal ratio of 1:4
of liquid to gas. While there are several choices for gas, I primarily use room air
because it is readily available and unlikely to cause any major side effects with
low volume (less than 10 mL). Luer Lock connection is preferred to minimize accidental
syringe pop-off due to the pressure when created foam sclerosant. I prefer to use
a three-way stopcock, rotated 45° from the fully opened position to create a narrower
caliber opening, which creates a denser longer lasting foam. The sclerosant and gas
is agitated back and forth between the two syringes approximately 10–20 times to produce
a smooth consistent microfoam. As the foam tends to degrade within 1–2 minutes, it
should be mixed immediately before injecting using either a butterfly needle or direct
puncture in 0.5–2 ml aliquots. When treating reticular and small varicose veins, I
prefer to do direct puncture with a 30G needle, either with direct visualization or
ultrasound guidance when the vessel is not visible. While literature has suggested
that small needles may disrupt fine microbubbles, this is unlikely to be of consequence
when treating small caliber vessels [20].
Prior to ultrasound guided injection of a perforator vein or a vein that is not clinically
visible, I always check for the presence of arteries near the injection site. The
needle should be clearly visible on the ultrasound during the initial puncture to
confirm its location in the vein lumen. When treating larger veins, I prefer to elevate
the leg slightly to reduce its size and use 25G butterfly needle for access. This
allows me to gain access first and then affix the newly created foam syringe on the
other end of the tubing without disturbing the placement of the needle. Intravenous
position is confirmed by aspiration of blood at the hub of the needle. Foam only lasts
approximately 60 sec, and altered foam with liquid and large bubbles should not be
used.
When treating a perforator veins with foam sclerotherapy, it is safer to inject the
varicose veins connected to the perforator vein rather than the perforator vein directly.
The ultrasound should follow the progression of the foam during treatment and injection
should stop when foam is visualized entering the perforator vein.
Postsclerotherapy Care
Compression regimen recommendation varies greatly among established guidelines and
individual practitioners [24]. There are few studies on this subject, with one showing greatest efficacy and least
hyperpigmentation with three weeks of stockings [25] while another showed no cosmetic improvement between 8 hours vs 6-weeks of compression
[26]. As per the European guidelines, I prefer to place patients in Class 2 (23–32 mmHg)
stockings for 1–3 weeks [1]. I advise my patients to walk after treatment but avoid heavy impact activities
(such as aerobic exercise) for one week.
Minimizing Complications
Complications following sclerotherapy are generally predictable and manageable. Pigmentation
and matting are the most common side effects and patients should be counseled to expect
these changes after their treatment. Small skin ulcerations (less than 5 mm) are rare.
Neurosensorial complications, chest tightness, and dry cough have been reported but
their incidence is likely less than 0.01 % [1]. Fortunately, there have only been isolated cases of severe adverse effects such
as large area of skin necrosis, pulmonary embolism, and anaphylaxis [27]. When performed properly, sclerotherapy has a low incidence of complications.
Hyperpigmentation and Microthrombus
Pigmentation from sclerotherapy occurs in about 10–30 % of patients and is primary
due to hemosiderin staining from red blood cell extravasation or trapped blood (intravascular
microthrombus) in a sclerosed vessel rather than post inflammatory hyperpigmentation
from melanocytic alteration [28]. While we often attribute hyperpigmentation to overtreatment (such as injection
too high volume or concentration), undertreating a vein can also result in inadequate
endothelial damage and subsequent thrombus formation rather than fibrosis.
Proper apposition of the vein wall post treatment is essential to allow of fibrosis
rather than thrombosis. This can be accomplished preoperatively by leg elevation to
reduce the size and empty the vein. Post-procedural compression stocking is recommended
to minimize side effects such as thrombophlebitis and pigmentation (Grade 2B) [29]. Even with meticulous technique, intravascular microthrombi can occur and drainage
with a needle or small incision 2–4 weeks post treatment is recommended to reduce
pigmentation [1]
[3].
Matting
Telangiectatic matting, in which new fine capillary networks develop in the area of
a sclerosed vein, can occur in 15–24 % of cases [3]. This neo-angiogenesis is often due to inadequate treatment of an undiagnosed underlying
venous incompetence. In some cases, matting is a result of excessive inflammation
due to high concentration or volume used; hence one should always match the strength
and volume of sclerosant to the vessel size. Transillumination to look for underlying
reticular veins and an ultrasound to evaluate for perforator reflux should be performed
in the area of the matting. Proximal reflux should be treated first with subsequent
gentle sclerosant with lower concentration and volume. For patients who are prone
to matting, one can consider the use of glycerin as a sclerosant or cutaneous laser
devices for these fine vessels [3]. Finally, if matting persist despite treatment, it should be left alone. The majority
of telangiectatic matting will resolve; a tincture of time is often all that is necessary.
Skin necrosis
Cutaneous necrosis following sclerotherapy have a reported incidence between 0.2 %-1.2 %.
Extravasation of hypertonic saline is commonly associated with skin necrosis. However,
extravasation alone is unlikely the cause of skin ulcerations with detergent based
sclerosants, when using recommended sclerosant concentrations and low volumes [12]. Subcutaneous injections of liquid and foamed POL to mimic extravasation did not
result in cutaneous necrosis with volume less than 0.5 mL [30]. Rather, inadvertent passage of sclerosant into small arterioles is likely the cause
of most skin necrosis. This can occur when injection pressure exceeds capacity of
the vein, causing venous-capillary reflux into the surrounding arterioles [31].
To minimize the risk, one should inject low volume under minimal pressure while visualizing
the needle tip and flow of the solution into the vessel. Avoid injection directly
over the bony prominence of the medial and lateral malleolus as these areas are prone
to ulceration. Instead one can usually find an alternative access point in the adjacent
skin. A skin bleb is consistent with extravascular injection and one should stop injecting
immediately. The development of a porcelain white blanching and pain may indicate
sclerosant entering the arterioles. Recommended treatments include massage, injection
of normal saline or hyaluronidase, and topical nitroglycerine [3]. Fortunately, most cases of skin necrosis result in small 2–5 mm ulceration that
often heal with minimal sequelae. Nevertheless, they can be rather painful and protracted;
local wound care with vaseline/bandage or hydrocolloid dressing provides a moist wound
environment for healing.
True intra-arterial injections can result in extensive tissue necrosis and is an emergency.
Ultrasound guidance should be used to identify neighboring arteries when injecting
a vein that is not clinically visible or palpable [1].The presence of severe pain upon injection should prompt immediate cessation and
evaluation of possible intra-artierial injection. Catheter-directed anticoagulation
and thrombolysis, as well as systemic anticoagulation and steroids have been recommended
as treatment [1].
Neurological Events
The prevalence of neurosensorial complications (visual disturbances such as blurred
vision, double vision, or scotoma with or without associated paraesthesia and dysphasic
speech) following sclerotherapy ranges from 0.09 % to 2 % in large case series of
more than 500 patients and from 0 % to 4.5 % in prospective randomized controlled
trials [32]. These symptoms can occur with any kind of sclerotherapy, though more commonly associated
with foam than liquid sclerotherapy sessions [33]. It has been reported with the use of either POL or STS.
In the past, authors attributed these neurosensorial complication to paradoxical microbubble
embolism through a patent foramen ovale or intrapulmonary shunts. Echocardiography
and transcranial doppler studies during foam sclerotherapy showed that bubbles common
reach the right heart and cerebral circulation; their presence did not correlate with
visual disturbances. Recent evidence has shown that these transient neurological events
are likely migraines with aura rather than transient ischemic cerebrovascular events.
When endothelial cells are damaged during sclerotherapy, there is local release of
multiple inflammatory mediated factors, including endothelin-1, which travels systemically
to the brain resulting in vasospasm [34] or cortical spreading depression in susceptible patients [32]
[35]. Patients with a history of migraine with aura or known patent foramen ovale may
be at higher risk of visual disturbances and should be properly informed prior to
treatment. Routine screening for patent formane ovale prior to foam sclerotherapy
is not necessary [1].
Almost all reported cases of neurosensorial complications are during treatment of
truncal vessels using large volumes of foam [36]. One should limit total foam volume to less than 10 mL per session as recommended
by the European consensus guideline and consider multiple smaller volume injections
rather than one bolus [1]. Some authors have advocated specific maneuvers such as manual compression of the
saphenofemoral junction at the time of the injection [37], leg elevation before and after treatment, immobility post sclerotherapy, use of
CO2-O2 gas and filters to generate microfoam; none of these maneuvers prevented bubble
emboli to the heart [38]. Morrison noted lower incidence of visual disturbance with high volume injections
(25–27 mL) when using CO2 foam rather than room air foam (8.2 % vs 3.1 %) [39]. Recent studies showed no difference in neurologic disturbances in low volume injections
(less than 10 mL) between physiological gas (CO2-O2) vs air [21].
Summary
Selecting the ideal patient and veins along with proper counseling and preoperative
planning are paramount to effective sclerotherapy. One should match the concentration
and type of sclerosant to the caliber of the vessel. The lowest concentration, pressure
and volume should be used to maximize outcome and minimize side effects. Successful
sclerotherapy requires meticulous technique. When performed properly, sclerotherapy
produces excellent results that is visually satisfying for both the practitioner and
the patient.
