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Guidelines for Sclerotherapy of Varicose Veins(ICD 10: I83.0, I83.1, I83.2, and I83.9) E. RABE, MD,n F. PANNIER-FISCHER, MD,n H. GERLACH, MD,w F. X. BREU, MD,zS. GUGGENBICHLER, MD,§ AND M. ZABEL, MDk nKlinik und Poliklinik fu¨r Dermatologie der Rheinischen Friedrich-Wilhelms-Universita¨t, Bonn, Germany; wMannheim, Germany; zRottach Eger, Germany; §Mu¨nchen, Germany; and kRecklinghausen, Germany BACKGROUND. Sclerotherapy is the targeted elimination of intracutaneous, subcutaneous, and/or transfascial varicose German Society of Phlebology (Deutsche Gesellschaft fu¨r veins (perforating veins) as well as the sclerosation of subfascial Phlebologie) and adopted by the committee and scientific advisory board of the Deutsche Gesellschaft fu¨r Phlebologie by the injection of a sclerosant. With duplex-guide sclero- on June 15, 2001, and amended on December 5, 2003. The therapy and foam sclerotherapy, modified methods came guideline considers the present state of knowledge as reflected in OBJECTIVE. The objective was to create a guideline, based on CONCLUSIONS. This guideline represents the recent state of the the available publications and on the European Consensus art of sclerotherapy of varicose veins in Germany including Document on foam sclerotherapy from April 2003.
E. RABE, MD, F. PANNIER-FISCHER, MD, H. GERLACH, MD, F. X. BREU, MD, S. GUGGENBICHLER, MD, AND M.
ZABEL, MD HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.
GUIDELINES ARE systematically elaborated recom- (perforating veins) as well as the sclerosation of mendations designed to support the clinician and subfascial varicose vessels in the case of venous practitioner in his or her decision about the appropriate malformation by the injection of a sclerosant. The care of patients in specific clinical situations. Guidelines various sclerosants provoke a marked damage of the apply to standard situations and take into account the endothelium of the vessels and possibly of the entire currently available scientific knowledge regarding the vascular wall. Subsequently, a secondary, wall- case under consideration. Guidelines require permanent attached local thrombus is generated, and in the long reviews and possibly modifications, to adapt to the term, the veins will be transformed into a fibrous cord, most recent scientific findings and to the practicability that is, sclerosis.1,2 The purpose of sclerotherapy is not in daily routine. Guidelines are not intended to restrict just a thrombosis of the vessel, which, per se, is subject the doctor’s freedom to choose the appropriate method to recanalization, but the definite transformation into of treatment. Compliance with the recommendations a fibrous cord. This cannot recanalize and corresponds does not always guarantee diagnostic and therapeutic to the surgical removal of a varicose vein as far as the success. Guidelines make no claim for completeness.
The decision about the appropriateness of the action tobe taken is still in fact the responsibility of the doctorconsidering the individual situation.
Sclerotherapy is the targeted elimination of intracuta-  Treatment of varicosis and prevention of possible neous, subcutaneous, and/or transfascial varicose veins  Reduction or elimination of existing symptoms; Improvement of pathologically altered hemody- Address correspondence and reprint requests to: Prof. Dr. med.
Eberhard Rabe, Klinik und Poliklinik fu Friedrich-Wilhelms-Universita¨t, Sigmund-Freud-Strasse 25, D-53105  Achievement of a good result that satisfies aesthetic Bonn, Germany, or e-mail: [email protected].
r 2004 by the American Society for Dermatologic Surgery, Inc.  Published by Blackwell Publishing, Inc.
ISSN: 1076-0512/04/$15.00/0  Dermatol Surg 2004;30:687–693 RABE ET AL.: GUIDELINES FOR SCLEROTHERAPY OF VARICOSE VEINS The following types of varicose veins can be If performed properly, sclerotherapy is an efficient treatment method with a low incidence of complica- tions. Nevertheless, a series of adverse events may  Varicose veins associated with incompetent perfor- occur in the context of the therapy. These are, in  Reticular varicose veins; Spider veins; and  Residual and recurrent varicose veins after inter-  Excessive sclerosing reaction (thrombophlebitis); Pigmentation;4,22–25 Sclerotherapy is considered the first-choice method for the treatment of small intracutaneous varicose veins (reticular varicose veins, spider veins).3–5 perforating veins, sclerotherapy competes with percu- taneous phlebextraction and with ligation of perforat-ing veins or endoscopic dissection of perforating Early reaction type allergy up to anaphylactic shock as well as an inadvertent intraarterial injection are very In the treatment of valvular insufficiency in truncal rare complications constituting an emergency situa- veins with elimination of the proximal leakage point and of the incompetent venous portion, surgery is Skin necroses are described after paravascular considered to be the method of first choice. Never- injection of sclerosants in higher concentrations as theless, treatment of truncal veins by sclerotherapy is well as, but rarely, after properly performed intravas- cular injection with various sclerosants, for example,0.5% polidocanol in the treatment of spider veins.22,24 In the second case, a mechanism involving transitionof the sclerosant via arteriovenous anastomoses into arterial vessels has been discussed.28 In individualcases, this was described as embolia cutis medicamen- Hyperpigmentations are described with a frequency  Acute superficial or deep vein thrombosis; of 0.3% to 10%.23–25,32 In general, they regress  Local infection in the area of sclerotherapy or severe slowly. Matting, fine telangiectasias in the area of a sclerosed vein, is an unpredictable individual reaction of the patient and can also occur after surgical removal  Advanced peripheral arterial occlusive disease (stage Nerve damage has been described experimentally after paravascular injection.16 Further transitory ap-  Hyperthyroidism (in the case of sclerosants contain- pearances after sclerotherapy are intravascular clots, phlebitis, and hematomas. Additionally, complications  Pregnancy in the first trimenon and after the 36th may arise from the compressive bandage such as, for example, formation of blisters (possibly in the area ofan applied plaster).2 Intravascular clots can be squeezed out after stab incision to reduce the devel- opment of hyperpigmentation. Sclerotherapy is an  Late complications in diabetes (e.g., polyneuropathy); intervention that requires patient information.
 Peripheral arterial occlusive disease stage II; Poor general health; Bronchial asthma;  Marked allergic diathesis; Known hypercoagulability;13 and Extended necroses occur after intraarterial injec-  Thrombophilia with history of deep vein thrombosis.
RABE ET AL.: GUIDELINES FOR SCLEROTHERAPY OF VARICOSE VEINS are used for local compression. The different techni-ques vary considerably.21 The following principles Successful sclerotherapy requires thorough planning.
Sclerotherapy is generally performed in the order ofleakage points and from the larger to the smaller  The puncture of the veins to be sclerosed can be varicose veins. Therefore, a proper diagnostic evaluation made in the standing or lying position.
should be performed prior to treatment.2,3,12 Diagnostic  The injection is commonly given with the patient in evaluation includes study of the medical history, clinical recumbent position. After puncture of the vein with examination, and Doppler ultrasonography.
the free cannula or with the syringe attached, the Additionally, functional examinations (e.g., photo- plethysmography, phlebodynamometry, venous occlu-  The intravascular injection of the sclerosant is sion plethysmography) and imaging (e.g., duplex given slowly; it can be given in fractions with ultrasonography, phlebography) can be taken into control of the intravascular position. Strong consideration. Functional examinations make it possi- pain during injection may indicate a paravascular ble to assess the improvement of venous function, which is to be expected for the elimination of varicosis.
 Immediately after injection of the sclerosant and Diagnostic imaging is especially suited for the identi- removal of the cannula, local compression is fication of incompetent communications with the performed along the sclerosed vein.1,2,33–35 deep venous system, diagnostic clarification of post-  After sclerotherapy, the treated extremity is com- thrombotic alterations, and the assessment of a pressed. When sclerosing spider veins, it is handled combined surgical treatment that may have to be in various ways. Compression can be performed with a compression stocking or with a compressionbandage.1,23,36  The local compression can be removed in the evening or on the next day. Depending on the diameter and location of the varicose vein, compres- sion is performed for hours (spider veins) to several Only one sclerosant is authorized for sclerotherapy of days and weeks after completion of sclerother- varicose veins in Germany. Aethoxysklerol with the active ingredient polidocanol at concentrations of  After the sclerotherapy session using the traditional 0.25, 0.5, 1, 2, 3, and 4%; the maximum daily technique, the patient should walk for a while to polidocanol dose is 2 mg/kg body weight.10 dilute the sclerosant after a short time of action.
The sclerosant can also be prepared according to an Care must be taken to detect any signs of allergic individual formulation. These are, however, not finished medicinal products, so that there is no product  Intensive workout, hot baths, sauna, and strong UV liability on the part of a manufacturer. Table 1 irradiation (solarium) should be avoided during the contains values for concentrations and amounts per A smooth-moving disposable or glass syringe is required for sclerotherapy as well as a cannula with a small diameter. Cotton rolls or pads and paper plasters Sclerotherapy Guided by Duplex Ultrasonography When sclerosing saphenous junctions, truncal veinsnext to saphenous junctions, and perforating veins, duplex ultrasonography-guided sclerotherapy has re- cently been reported as an addition to the spectrum ofmethods.8,9,38–42 In this procedure, the vein to be sclerosed is visualized by duplex ultrasonography in the lying patient and is punctured during visualization.
The needle is visible in the ultrasound image, and the intravascular injection can be controlled. Some authors recommend an intermittent compression using the ultrasound transducer after injection.40–42 This allows an assessment of the contraction of the injected venous segment and the length of the sclerosed RABE ET AL.: GUIDELINES FOR SCLEROTHERAPY OF VARICOSE VEINS portion. The purpose of this method is to achieve a  Basically, indications and contraindications do not controlled procedure with fewer complications and an differ from sclerotherapy with fluid sclerosants. In the case of large varicose veins and recurrentvaricose veins, the result obtained with foamsclerotherapy are better than those with fluid sclerotherapy.53–55 Favorable results were also Sclerotherapy with foamed sclerosants has repeatedly been reported for a long time.43–46 In recent years, the  In the case of known symptomatic open oval discussion of sclerotherapy with foam was intensified foramen, special caution should be used.
again47–49 especially with regard to treatment of larger  Sclerotherapy of spider veins can be performed varicose veins. Detergent-like sclerosants such as poli- sufficiently with fluid sclerosants. If foam is used, docanol can be transformed into a fine-bubbled foam only fluid foam should be employed. Viscous foams The Monfreux technique is characterized by the  When treating larger varicose veins, a rather viscous generation of negative pressure by drawing back the plunger in a glass syringe whose tip is tightly closed.
 In the case of large varicose veins, it is recom- The resulting air inlet generates a large-bubbled, rather mended the leg be elevated during treatment (the ‘‘lighter’’ foam moves ‘‘upward’’; elevation of the The Tessari technique is characterized by the extremity impedes the fast penetration into the deep generation of a foam quality that is rather fine-bubbled and fluid in low concentrations and rather viscous in  Foam sclerosation requires fewer injections per high concentrations by turbulent mixture of fluid and session with larger distances. When treating larger air in two syringes connected via a three-way stop- varicose veins, a single puncture site is often cock. The mixing ratio for sclerosant:air is 1:4 to  Punctures should always be made at the safest and The double-syringe system technique involves tur- most easily accessible site. The puncture site in the bulent mixing of 3% polidocanol with air in a case of valvular insufficiency in the saphenous veins sclerosant: air ratio of exactly 1:5 in two syringes should have a distance of at least 10 cm away from linked via a connector. The product is a fine-bubbled,  When sclerosing large veins, irrespective of the In Germany the transformation of a sclerosing concentration, a total amount of foam of 6 to 8 solution (already approved by the health authority as mL/session (double-syringe system and Tessari liquid) into a sclerosing foam by a standardized method) or 4 mL/session (Monfreux method) procedure and the treatment is permissible if the should not be exceeded. In general, smaller amounts patient is sufficiently informed about the benefits and are required. No more than 3 mL is required for risks. The physician himself is fully responsible for the the lesser saphenous vein (double-syringe system, As a result of an international expert conference on  When treating spider veins, no more than 0.5 mL of foam sclerosation of April 4–6, 2003, at Tegernsee, Germany, the following recommendations can be  Because the foam has a stronger sclerosing action, made for sclerotherapy with foamed sclerosants: the treatment goal can be achieved with a sclerosantof a lower concentration than in the case of  According to the experts’ experience and the sclerotherapy with a fluid sclerosant.
available publications, foam sclerosation is an  After foam sclerotherapy of larger varicose veins, appropriate method for the treatment of varicosis.
higher percentages of venous spasms are seen in the It is a refinement of sclerotherapy with fluid sclerotized vein.53 There is a positive correlation sclerosants featuring a better controllability and a between spasm and good therapeutic result.
 When using foam sclerotherapy for the treatment of  Owing to the related higher risks in the case of saphenous veins, in the groin and popliteal cavity, improper use, foam sclerotherapy should be per- for the treatment of recurrent varicose veins and of formed only by colleagues who are experienced in perforating veins, a duplex-guided procedure is  The patient must be informed about the particula-  Before applying compression therapy, some minutes rities of foam sclerotherapy regarding use, efficacy, should be allowed to avoid premature displacement of the sclerosing foam into other regions.
RABE ET AL.: GUIDELINES FOR SCLEROTHERAPY OF VARICOSE VEINS  The adverse effects of foam sclerotherapy are the use of anticoagulants, like deep venous throm- comparable with sclerotherapy using fluid sclero- bosis, might be a contraindication for sclerother- sants. Transient visual disturbances, especially in apy. Anticoagulation itself is no contraindication migraine patients, seem to be a bit more frequent for sclerotherapy aside of the fact that local thrombus formation following the injection mightbe less intense. There are no controlled data After injection of foam, the foamed sclerosant remains locally in the venous segment to be sclerosed 3. Concerning complications and risks it must be for a longer period of time and provokes a stronger clarified that not all sclerosing agents cause contact necrosis at certain concentrations.66 Even polido-canol in concentrations between 0.25 and 1% maynot cause a skin necrosis by paravenous injection of 4. For the injection of the sclerosing agent, glass or There is undoubted evidence for the elimination of plastic syringes can be used alternatively. In the intracutaneous and subcutaneous varicose veins by United States and also in many other countries sclerotherapy. The results of sclerotherapy are, how- plastic syringes are used routinely. These syringes ever, inconsistent and depend on the technique, the sclerosant, and the diameter of the vein.6,7,58–60 5. In the guideline a higher risk of foam sclerotherapy Sclerotherapy is considered to be the standard treat- is proposed in the case of improper use. Using a ment for intracutaneous varicose veins (spider veins sclerosing foam one must keep in mind that the and reticular veins), allowing an improvement of up to sclerosing agent in this preparation has a prolonged contact time with the injected vein and is more Compression treatment with medical compression active. Therefore, a lower amount and lower stockings may improve the result of the treatment of concentration of the sclerosing agent are needed spider veins.25,64,65 The frequency of pigmentations compared with a liquid sclerosant. Using a higher decreases significantly.23,25 The local eccentric com- concentration and higher quantities, like they are pression significantly increases the local pressure in the used in sclerotherapy with liquid sclerosing agents, area of sclerotherapy and improves the efficacy of might cause more inflammation, hyperpigmenta- sclerosis.34 When treating saphenous veins, good tion, and skin necrosis. In addition, the sclerosing results can be achieved by duplex-guided sclerotherapy foam is diluted less quickly in the injected vein as liquid sclerosing agents are. The active foam can bemoved in the vein toward the deep venous systemor other venous regions. Improper use therefore might lead to a higher amount of deep venousthrombosis and to sclerosing activity in regions 1. It was discussed whether the use of disulfiram which are not thought to be treated.
(Antabuse) is an absolute contraindication to the 6. Foam sclerotherapy may be used for large varicose use of polidocanol. Patients intended for the veins and for spider veins. The first comparative application of disulfiram must be involved into a data67 show that for sclerotherapy of spider veins controlled therapeutic concept to treat alcoholism.
very low concentrations of polidocanol are needed.
In our opinion each intake of a medicinal product Otherwise the inflammatory reaction is more during and 14 days after disulfiram treatment pronounced. As in these small veins sclerotherapy should be reviewed carefully for its appropriate- with liquid polidocanol is very efficient and safe.
ness. Many of medicinal products including inject- The benefit of foam sclerotherapy should be shown abilia contain alcohol. It has not been considered to be suitable to add a disulfiram contraindication to 7. These guidelines offer no advice for the treatment each of them. Therefore, the German society does of complications in case of imminent ulcer or not see the necessity to add the use of disulfiram as paravenous injection of higher concentrations of an absolute or relative contraindication to the use polidocanol. It is recommended that the area where the extravasation is believed to have been occurred 2. There are controversial opinions on the question if be diluted. There is no consensus with respect to the use of anticoagulants is an absolute or relative protocols for the treatment of conditions such as contraindication to sclerotherapy. In the opinion of matting although in these cases laser therapy might the authors the underlying disease as a reason for RABE ET AL.: GUIDELINES FOR SCLEROTHERAPY OF VARICOSE VEINS sion and its effects on clinical outcome. Dermatol Surg 1999;25:105–8.
1. Guidelines of care for sclerotherapy treatment of varicose and 26. Van der Plas JPL, Lambers JC, van Wersch JW, Koehler PJ.
teleangiectatic leg veins American Academy of Dermatology. J Am Reversible ischaemic neurological deficit after sclerotherapy of varicose veins. Lancet 1994;343:428.
2. Rabe E, editor. Grundlagen der phlebologie 2. Ko¨ln: Auflage, Viavital, 27. Oesch A, Stirnemann P, Mahler F. The acute ischemic syndrome of the foot after sclerotherapy of varicose veins. Schweiz Med 3. Baccaglini U, Spreafico G, Castoro C, Sorrentino P. Consensus conference on sclerotherapy or varicose veins of the lower limbs.
28. Bergan JJ, Weiss RA, Goldman MP. Extensive tissue necrosis following high concentration sclerotherapy for varicose veins.
4. Conrad P, Malouf GM, Stacey MC. The Australian polidocanol (aethoxysklerol) study: results at 2 years. Dermatol Surg 1995;21: 29. Geukens J, Rabe E, Bieber T. Embolia cutis medicamentosa of the foot after sclerotherapy. Eur J Dermatol 1999;9:132–3.
5. Goldman PM. Polidocanol (aethoxysklerol) for sclerotherapy of 30. Kersting E, Hornschuh B, Bro¨cker EB. Embolia cutis medicamen- superficial venules and telangiectasias. J Dermatol Surg Oncol 1989; tosa nach varizensklerosierung mit polidocanol. Phlebologie 1998; 6. Einarsson E, Eklo¨f B, Negle´n P. Sclerotherapy or surgery as 31. Remy W, Vogt HJ, Borelli S. Embolia cutis medicamentosa—artige treatment for varicose veins: a prospective randomized study.
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32. Georgiev M. Postsclerotherapy hyperpigmentations. J Dermatol 8. Cavezzi A, Frullini A. Echosclerotherapy in the short saphenous 33. Stanley PRW, Bickerton DR, Campbell WB. Injection sclerotherapy vein insufficiency: personal experience. Sydney: Abstract UIP, 1998.
for varicose veins—a comparison of materials for applying local 9. Frullini A, Cavezzi A. Ultrasound guided sclerotherapy in the compression. Phlebology 1991;37–9.
treatment of long saphenaous vein insufficiency. Vasomed 1999; 34. Tazelaar DJ, Neumann HAM, de Roos KP. Long cotton wool rolls as compression enhancers in macrosclerotherapy for varicose veins.
10. Aethoxysklerol-fachinformation der herstellerfirma. Stand 2. Wies- baden: Chemische Fabrik Kreussler; 1996.
35. Wenner L. Improvement of immediate and long-term results in 11. Vin F. Principes de la scle´rothe´raphie des troncs saphe`nes internes.
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36. Fegan WG. Continous compression technique of infecting varicose 12. Villavicencio J, Pfeifer J, Lohr J, et al. Sclerotherapy for varicose veins: practice guidelines and sclerotherapy procedures. In: 37. Reddy P, Wickers J, Terry T, et al. What is the correct period of Glovicki P, Yao J, editors. Handbook of venous disorders. London: bandaging following sclerotherapy? Phlebology 1986;217–20.
38. Grondin L, Young R, Wouters L. Scle´rothe´rapie e`cho-guide´e et 13. Feied CF. Deep vein thrombosis: the risks sclerotherapy hypercoa- se´curite´: comparison des techniques. Phlebologie 1997;50:241–5.
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39. Guex JJ. Ultrasound guided sclerotherapy (USGS) for perforating 14. Goldmann PM. Complications of sclerotherapy. In: Gloviczki P, veins. Hawaii Med J 2000;59:261–2.
Yao J, editors. Handbook of venous disorders. London: Chapman 40. Schadeck M. Duplex-kontrollierte sklerosierungsbehandlung der vena saphena magna. Phlebologie 1996;25:78–82.
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41. Schadeck M, Allaert FA. Re´sultats a` long terme de la scle´rothe´rapie In: Staubesand J, Scho¨pf E, editors. Neuere aspekte der sklerosier- ungstherapie. Berlin/Heidelberg/New York: Springer Verlag, 1990:p.
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16. Seydewitz V, Staubesand J. Das ultrastrukturelle substrat der wirkung paravasal und intraarteriell applizierter sklerosierungsmit- 43. Cavezzi A, Frullini A. Il ruola della mousse sclerosante nella tel: ein experimenteller beitrag zum problem iatrogener scha¨den ecosclerosi safenica e delle varici recidive: esperienza personale.
nach sklerotherapie. In: Staubesand J, Scho¨pf E, editors. Neuere aspekte der sklerosierungstherapie. Heidelberg: Springer Verlag, 44. Flu¨ckiger P. Nicht-operative retrograde varicenvero¨dung mit varisylschaum. Schweiz Med Wochenschr 1956;48:1368–70.
17. Weiss RA, Weiss MA. Incidence of side effects in the treatment of 45. Mayer H, Bru¨cke H. Zur a¨tiologie und behandlung der varizen der telangiectasias by compression sclerotherapy: hypertonics saline vs.
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46. Sigg K. Neuere gesichtspunkte zur technik der varizenbehandlung.
18. Feied CF, Jackson JJ, Bren TS. Allergic reactions to polidocanol for vein sclerosis. J Dermatol Surg Oncol 1994;20:466–8.
47. Henriet JP. One year experience with sclerotherapy of reticular 19. Feuerstein W. Schwere anaphylaktische reaktion auf hydroxypo- veins and telangiectases using polidocanol foam in daily routine: lyaethoxydodecan. VASA 1973;3:292–4.
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20. Pradalier A, Vincent D, Hentschel V, Cohen-Jonathan AM, Daniel 48. Monfreux A. Traitement scle´rosant des troncs saphe`niens et leurs E. Allergie aux scle´rosants des varices. Rev Fr Allergol 1995;35: collate`rales de gros calibre par la me´thode mus. Phle´bologie 1997; 21. Baccaglini U, Stemmer R, Partsch U. Internationale fragebogenak- 49. Sadoun S, Benigni JP La mousse de sclerosant: etat de l’art. In: Rabe tion zur praxis der vero¨dungsbehandlung. Phlebologie 1997;26: E, et al., editors. Phlebology ’99. Ko¨ln: Viavital, 1999:p. 146.
50. Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new 22. Fisher DA. Regarding extensive tissue necrosis following high sclerosing foam in the treatment of varicose veins. Dermatol Surg concentration sclerotherapy for varicose veins. Dermatol Surg 2000; 51. Tessari L. Nouvelle technique d’obtention de la scle`ro-mousse.
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25. Weiss RA, Sadick NS, Goldman MP, Weiss MA. Post-sclerotherapy 54. Gobin JP. The sclerotherapy position in recurrent varicose veins compression: controlled comparative study of duration of compres- treatment. Int Angiol 2001;20(2 Suppl 1):336.
RABE ET AL.: GUIDELINES FOR SCLEROTHERAPY OF VARICOSE VEINS 55. Hamel-Desnos C, Desnos P, Ouvry P. Nouveaute´s the´rapeutiques 61. Dover J, Sadick N, Goldman MP. The role of lasers and light sources dans la prise en charge de la maladie variqueuse: e´cho-scle´rothe´r- in thetreatment of leg veins. Dermatol Surg 1999;25:328–36.
apie et mousse. Phle´bologie 2003;56:41.
62. McCoy S, Evans A, Spurrier N. Sclerotherapy for leg telangiecta- 56. Yamaki T, Nozaki M, Sasaki K. Color duplex-guided sclerotherapy sia—a blinded comparative trial of polidocanol and hypertonic for the treatment of venous malformations. Dermatol Surg 2000; saline. Dermatol Surg 1999;25:381–6.
63. Norris MJ, Carlin MC, Ratz JL. Treatment of essential telangiecta- 57. Yamaki T, Nozaki M, Fujiwara O, Yoshida E. Duplex-guided foam sia: effects of increasing concentrations of polidocanol. J Am Acad sclerotherapy for the treatment of the symptomatic venous malformations of the face. Dermatol Surg 2002;28:619–22.
64. Massay RA. Regarding the use of compression stockings after 58. Ha¨rtel SL. Fu¨nf-Jahres nachuntersuchungsergebnisse der sklerosier- sclerotherapy. Dermatol Surg 1999;25:517.
ungstherapie nach stemmer bei 118 patienten mit prima¨rer varikosis.
65. McDonagh B. Comments on the use of post-sclerotherapy compression. Dermatol Surg 1999;25:519–21.
59. Hu¨bner K. Ambulante therapie der stammvarikose mittels kros- 66. Goldman M, Weiss RA, Bergan J, editors. Varicose veins and sektomie und sklerotherapie-ein beitrag aus der praxis des teleangiectasias: diagnosis and treatment, 2nd ed. St. Louis: Quality niedergelassenen phlebologen. Phlebologie 1991;20:104–8.
Medical Publishing, 1999:p. 518–47.
60. Schultz-Ehrenburg U, Tourbier H. Doppler-kontrollierte vero¨- 67. Benigni JP, Sadoun S, Thirion V, et al. Te´langictasies et varices dungsbehandlung der vena saphena magna. Phlebol Proktol 1984; re´ticulaires traitement par la mousse d’aetoxiscle´rol a´ 0,25%: pre´sentation d’une e´tude pilote. Phle´bologie 1999;52:283–90.
ulcers on contact.1 (2) Pigmentation rarely occurs in vesselsunder a certain size; its frequency, severity, and clinical course It is appropriate to begin this special section on phlebology with are sometimes unaffected by incision, drainage, compression, or a report by the German Society of Phlebology. This article type and concentration of sclerosants.2 Neovascularization presents a current view of sclerotherapy treatment and details (matting), a common and vexatious problem, deserves more both foaming of sclerosing agents as well as the use of than a passing reference.3 (3) Noticeable by its absence is the polidocanol, which will shortly receive approval for use by fact that reflux is no longer considered to be a contraindication the United States Food and Drug Administration.
to sclerotherapy. At one time reflux was listed as an absolutecontraindication on product inserts for a variety of sclero- sants.28 Foam sclerotherapy represents a major therapeutic advance but its so far unrealized potential for seriouscomplications such as pulmonary fibrosis and thromboticphenomena suggest caution and training in its use.
In conclusion, our European colleagues should be congratu- lated for this brief and useful set of general guidelines, which The development of this excellent position statement by permit enough flexibility to incorporate protocols based on German phlebologists may have been facilitated by the medical realities of that country in which only one sclerosant isapproved, regulations for medical care are centralized, and malpractice concerns may not be as acute as in the United States. This statement attempts to unify medical opinions andreconcile an extraordinary diversity of clinical outcomes. Bynature such unanimity is established by avoiding certain issuesfor which no consensus has been achieved. If there is any criticism of these guidelines it has to do with the paucity of 1. Goldman M, Weiss RA, Bergan J, editors. Varicose veins and information regarding complications.
teleangiectasias: diagnosis and treatment, 2nd ed. St. Louis: Quality Several points are worth discussing. (1) Multiple sclerosants Medical Publishing; 1999:p. 518–47.
are used in the United States that vary in their capacity to 2. Duffy D. Vessel size: an excellent prognosticator of clinical outcomes induce necrosis on extravasation (paravenous). For example, following sclerotherapy. Paper presented at Hugh Greenway’sSuperficial Anatomy and Cutaneous Surgery, 2002 Jul 15–20, La 5% sotradecol and 3% polidocanol have been injected into the skin without necrosis. Conversely, 1% sotradecol and hyper- 3. Duffy D. Sclerotherapy-induced vascular remodeling/neovasculari- tonic saline at a variety of concentrations routinely produce

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