1. Avoiding Complications in Liquid Sclerotherapy
Lowell S. Kabnick, MD
NYU Langone Medical Center
Divison, Vascular and Endovascular Surgery

2. Disclosure I disclose the following financial relationship(s):
Lowell Kabnick, M.D., FACS, FACPh
I disclose the following financial relationship(s):
Research: Bard
Ownership Interest: AngioDynamics, Vascular Insights; Veniti
Consultant/Advisory Board: AngioDynamics, BSN Jobst, Vascular Insights

3. Everything is Connected in a Hierarchical Way
Reproduced from: “Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins, 4th Edition” Goldman, MP, Bergan JJ, Guex JB (Eds.), Elsevier, Inc

4. Spider Vein Anatomy
Commonly associated with an underlying varicose vein, reticular vein, or arteriole
Reproduced from: “Ambulatory Phlebectomy, 2nd Edition” Ricci S, Georgiev M, Goldman MP (Eds.), Taylor & Francis, 2005

5. Lateral Subdermic Venous System (anterolateral)
Originally described by Albanese
Vasc Surg 1969; 3:81-89.
Reticular veins at a depth just below the dermis
Longitudinally traverse lateral thigh and lateral calf
Complex communications at lateral knee
Femoral Vein
Lateral Subdermic Venous System
Knee Perforating Veins

6. Lateral Subdermic Venous System
LSVS
Spider Vein
Reticular Vein

7. Avoiding Failure Managing expectations Testing patient
Know proper technique

8. Patient Selection Start with a thorough HISTORY and PHYSICAL EXAM
Evaluate results of Vascular testing (if needed)
Take PHOTOGRAPHS
DISCUSS results and EXPECTATIONS

9. Managing Expectations
This is not a one “shot deal” it is a process
Arrows indicate veins
(patient self-application)

10. Technique of Injection
Use gauge needles ½ inch long
Inject volume until blood disappears and before blanching (size of vein matters)
Avoid forceful pressure DRIP DRIP

11. Technique of Injection (cont.)
Do not inject more than a few centimeters away from the puncture site
Apply pressure after injection
Apply compression stocking
Length of time = controversial

12. Fiber Optic Based Transilluminator
The Gold Standard in Phlebology

13. Adverse Sequelae
Pigmentation
Telangiectatic Matting
Ulcer
Recurrence

14. Pigmentation 2 - 30% regardless of solution 10% lasts 6 months
1 - 5% persists for > 1 year

15. Post Sclerotherapy Hyperpigmentation

16. Pigmentation Etiology
Sclerosing solution and concentration
Sclerotherapy technique
Innate tendency
Total body iron stores
Hemachromatosis does not develop pigmentation
Altered iron transport and storage
Innate enhanced histamine release or hypersensitivity
Vessel fragility
No graduated compression post Rx
Vessel diameter
Concomitant medication
Minocycline

17. Watch Out for These Patients
Individual patient tendency towards post-inflammatory hyperpigmentation
UV exposure
Skin types IV-VI

18. Pigmentation in Elderly Patients
Pigmentation is more common in elderly patients with thin skin and protruding deep blue or purple telangiectasia

19. This patient chose Duplex-guided sclerotherapy over AP; coagula seen at 3 weeks were drained
Pre-Treatment
2 Months
6 Months

20. POL vs. STS in Treating Varicose Leg Veins: Pigmentation
< 1 mm 1-3 mm_ 3-6 mm_ ALL
STS 63% % 78% %
POL 32% % 77% %
Goldman MP: Treatment of varicose and telangiectatic leg veins: Double blind prospective comparative trial between
Aethoxysklerol and Sotradecol. Dermatol Surg 2002;28:52

21. 2 Months After Ruby Laser x 2
Ruby Laser: Results
Pigmentation 1 Year
2 Months After Ruby Laser x 2
Reproduced from: “Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins, 4th Edition” Goldman, MP, Bergan JJ, Guex JB (Eds.), Elsevier, Inc

22. Post Sclerotherapy Thrombectomy

23. Hyperpigmentation Avoid sunlight Use compression
People of color tend to pigment more.
Be aggressive with mini thrombectomy
Laser removal – Q-switch ruby

24. Ulcer

25. Arteriolar Injection Intravenous injection of 2 mL POL 0.5%
Reproduced from: “Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins, 4th Edition” Goldman, MP, Bergan JJ, Guex JB (Eds.), Elsevier, Inc

26. Cutaneous Necrosis Extravasation Injection into dermal arteriole
Reactive vasospasm
Excessive non-graduated compression

27. Arterial Injection Under Duplex Guidance STS 1%, 3 weeks
Goldman, Bergan, Weiss: Dermatol Surg 2000; 26:535
Reproduced from: “Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins, 4th Edition” Goldman, MP, Bergan JJ, Guex JB (Eds.), Elsevier, Inc

28. Minimizing Necrosis Minimal sclerosant concentration
Meticulous technique
Drip, drip, drip
Massage at site of bleb formation
Eliminate blanching
Apply nitroglycerine paste
Injection of diluent at site of bleb
Consider hyaluronidase (with hyperosmolars)
Avoid excessive compression
Closure of artery with excessive compression

29. Matting

31. How to Avoid Matting Use the lowest concentration that is effective
Make sure you have treated the underlying problem—reticular vein
DRIP SCLEROSANT

32. Telangiectatic Matting
Pre-Treatment
6 Weeks After Rx
8 Weeks Later
Reproduced from: “Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins, 4th Edition” Goldman, MP, Bergan JJ, Guex JB (Eds.), Elsevier, Inc

33. Telangiectatic Matting: Treatment
Photography/Chronotherapy
Re-injection
Glycerin?
Laser
Long Pulse Dye
532 nm long pulse
Intense Pulsed Light
1064 nm Long Pulse Nd:YAG
Ohmic Therapy

34. Anaphylaxis Sodium Morrhuate 3 - 10% of patients
Sotradecol – non-Bioniche (1946)
% of patients
6 fatalities in approximately 1 million patients/year
Polidocanol (1966)
0.2 – 1% of patients
2 fatalities in approximately 2 million patients/year

35. Summary: The right results The right patient The right reasons
The right veins
The right solutions
The right doctor
The right results