ULTRASOUND GUIDED SCLEROTHERAPY (UGS)

Ultrasound Guided Sclerotherapy (UGS) for venous disease has been in use for many years. This is a very successful therapy, especially when used in the treatment of medium to small sized veins, although it can also be used to treat the Great or Small Saphenous Veins and their tributaries, depending on their size.

Using ultrasound guidance, a medicine is injected into the vein. Success rates for the Ultrasound Guided Sclerotherapy procedure compare favourably to published results of surgery. The two products that we use are Polidocanol (Aethoxysklerol) or Fibrovein (Sodium tetradecyl sulphate). Both are detergents and act by washing away the lining of the vein, allowing the two walls to stick together.

This is typically performed by mixing the medicine with air or carbon dioxide to form a foam.

What are the advantages and disadvantages of UGS?

Admission to hospital and anaesthesia are not required. There is usually no need to take time off work and you are able to continue with your everyday activities. The Small Saphenous Vein often responds better to EVLA than to Sclerotherapy. There is a dose limit to the amount of sclerosant that can be injected in a single session and so, on occasion, several sessions may be needed to effectively treat all the diseased veins. This will vary from patient to patient and whether one or both legs are being treated in a single session.

As UGS is best used on small and medium sized veins, larger veins are often better treated with Endovenous Laser Ablation, Ambulatory Phlebectomy or surgery, alone or in combination.

Does the injection procedure hurt?

This is not a particularly uncomfortable procedure and is well tolerated, although the amount of discomfort will vary with the individual. The needles used are extremely fine (similar to acupuncture needles) and many are hardly felt at all, while the injected solution can sting slightly for short periods of time. If EVLA (Endovenous Laser Ablation) is used or Phlebectomy performed, then minimal discomfort is experienced as these are performed under local anaesthetic.

What should you do before UGS?

Avoid sun exposure and tanning for 1-2 weeks before and after treatment to avoid pigmentation problems
Do not apply moisturiser to your legs on the day of treatment
Wear loose fitting clothing and sandals or loose shoes to allow for the thickness of the stockings applied after treatment

What happens during UGS?

Prior to the procedure at our Melbourne clinic, a Sonographer will perform an ultrasound of your leg, similar to the one done at your initial screening, to familiarise us with the veins. Injections are performed with you lying on a treatment couch, which may be tilted at stages through the treatment.

The needles used are very fine and produce minimal discomfort and ultrasound is used to track the injected medicine along the veins that are being treated. After completion, a stocking will be applied to the treated leg. Occasionally, a subcutaneous injection of the anticoagulant drug Clexane may be given.

What should you do after UGS?

You will be asked to go for a 20-30 minute walk immediately after treatment.

You can drive to and from the practice on the day of treatment.

Walk for 20-30 minutes each day for 1-2 weeks. Maintain normal daytime activities and avoid standing still for long periods. Avoid strenuous physical activity such as aerobics for 2-3 days after treatment since this increases the risk of blood flow returning into the treated veins. You are required to avoid any flights of longer than 2-4 hours duration for 4 weeks and any flights of greater than 4 hours duration for 6 weeks after treatment. If travel is unavoidable, then anticoagulants should be administered prior to the flight.

The stocking are typically worn continuously for 4 days. They are then worn for a further 3 days through the day, removing them at night and replacing them in the morning after your shower (1 week in total). It is routine practice to perform an ultrasound scan at 2 weeks (occasionally earlier) after treatment to determine that the treated veins have been 100% successfully treated and to exclude the small risk of DVT. If any residual veins are shown, these may require further UGS at a subsequent appointment. It may be necessary to come back once or twice at weekly/fortnightly intervals complete treatment of all veins.

What can you expect following UGS?

The following features are expected, are transitory and may not occur at all. They are not a cause for concern, although they should be reported at review:

Mild pain or discomfort may persist for several days and shows that the injections are working. The degree of discomfort will, in part, be related to the initial size of the veins. Relief can be obtained by walking or by taking Paracetomol or Ibuprofen. Rubbing from the bandage or stocking can result in soreness behind the knee.
Any discolouration or tender lumps are usual experienced early on. Red raised areas over treated veins are due to “trapped blood” and usually disappear within four to six weeks. At the 2 week review, these areas may be pricked to release this trapped blood. While not occurring in every patient, this is so common as to be considered a normal event that occurs as part of treatment.
Phlebitis, or inflammation of the treated veins, can occur due to reaction to the sclerosant. It is treated by further compression, anti-inflammatories and regular walking. It does not represent infection and does not require treatment with antibiotics.
Migraines may be provoked by the injection foam sclerosant therapy in patients who are known migraine sufferers. These patients should take their usual migraine treatment an hour or so prior to treatment in the hope of preventing the onset of a migraine.

What are the possible complications from UGS?

Adverse reactions for UGS are similar to those for EVLA. Complications can occur even with perfect technique.

These include:

Deep vein thrombosis (DVT)
A blood clot can form and extend into the deep veins. The risk is less than 1:2,000 compared to the background risk of about 1:9,000. This potentially serious complication is very uncommon if the protocol of compression and regular daily walking is followed.
Although DVT post procedure is most uncommon, we at Specialist Vein Care perform Duplex scans routinely on all patients post Sclerotherapy/Endovenous Laser Ablation therapy to exclude this complication
Allergic reaction
Allergy to the anaesthetic solution can occur. This is rare! It can present immediately as an anaphylactic reaction with generalised rash, itchiness or difficulty with breathing. Our practice is equipped and ready to deal with this circumstance if it arises
Swelling of the leg or ankle (2:100)
This is usually a temporary phenomenon and is due to inflammation.
Matting or formation of small spider veins in response to therapy. Published range of risk = 6% – 75%. Accepted standards are about 20%. Of these about 6% can be permanent.
Pigmentation (1:10)
Brown marks can appear near or along a treated vein and are due to haemosiderin, a form of iron from the blood. Most disappear within 3-12 months but in about 5% of patients, this can persist past 12 months. This is of cosmetic importance only and persistent pigmentation may respond to laser treatment
Nerve injury (3:1,000)
Irritation of surface sensory nerves rarely occurs and will usually disappear within a few weeks
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 but has never been seen in our practice. It would result in muscle and skin damage.