Dr. Martin's Blog

Sclerotherapy Questions – Cosmetic vs Medical ?

Dr. Martin : I had a student contact me after having done my sclerotherapy course 10 years ago. She did veins for a while, but got side tracked and is now starting a sclerotherapy practice again. Her question was:

During our course, you taught us to always look for SFJ insufficiency (hand-held doppler) before any injecting, but I don’t recall that you felt colour ultrasound mapping was essential to be done in each patient, especially not those who only have small caliber (under 2mm) cosmetic superficial veins. What is your practice now? I don’t intend treating anything other than cosmetic veins of caliber as mentioned as the clinic is very much a cosmetic facility. I will of course do a physical exam (standing & supine) and will assess with a magnified polarised light system as well; do you think that it will adequately show up reticular feeders to superficial threads? And I’ll obviously test for SFJ sufficiency as you taught.

Dr. Martin’s Answer:

So wonderful to hear from you after all these years! Your question has a short answer and a long one.

Short Answer: When there is no palpable or visible sign of a vein over 2mm or venous insufficiency (swelling, phlebitis, corona, pigmentation), there is no need to undergo a full ultrasound assessment.

Long Answer: There are very few (maybe 20%) “vein” patients that fit into this category. Most have some form of varicosity underlying the spider and reticular veins.

If there is SFJ reflux then certainly, the patient needs an ultrasound and a referral to a more advanced vein clinic for consideration of either surgery, laser or ultrasound guided injection.

If there is no reflux at the SFJ, she may indeed have incompetent perforators which are creating many of the visible cosmetic veins. These varicosities must be dealt with first. If they are not treated, you risk increasing the risk of side effects including staining, phlebitis and poor treatment outcome.

As far as illumination goes, the polarized light is only good for superficial spider veins. It will miss most reticular veins. I recommend that you purchase a “veinlite” from the manufacturer in the states. The LED version is now excellent and not expensive (about $650)

I suggest strongly that you reconsider your decision not to treat any varicose veins. As a physician, you are in the ideal position to deal with the problem at it’s source. You qualify for a 50% reduction on the course cost if you want to come back to see me… Please come!

 


Question – How best to avoid brown discoloration post sclero?

There are a number of important tricks to this one. The colour is produced by tromboject itself, plus the heme in the blood that lies within the collapsed vein.

1. Adequate compression – place cotton balls all along the treated vein – not just where the injection points were. Wrap varicose for 24-48 hours and apply a stocking over top of that.

2. Avoid the sun, exercise and heat eg hot tub – 2 days for spiders, minimum of 1 week for varicose

3. After varicose, if there is a big tender lump, try piercing it with a number 19 needle to express unclotted blood.

Dr. Martin

 


Sclerotherapy

The key to great sclerotherapy lies in the compression that we can provide afterward. After the product is injected, be sure to lie cotton balls all the way along the length of the treated veins, PLUS on the path of those that were palpable before treatment, but did not specifically get an injection. In addition, apply a short stretch venosan bandage as well as a compression stockings. This technique will ensure the best sclerosis with a minimum of side effects like phlebitis and discoloration.


Veins

In Ontario, we can bill G536 twice on the same day (for different legs)


A Student Question about how we deal with varicose veins…

I have had great success with the following technique:

My objective is to locate and treat the largest vessels first. If the Greater Saphenous Vein is refluxing, then further testing with ultrasound is required in addition to more advanced techniques including surgery, laser or ultrasound guided injection.

If, however they are simple varicose veins, I alcohol off varicose veins while the patient is standing for their initial assessment, mark them with my pen then lie them down to inject the vessels. We use dilutions of Tromboject in very small amounts – such as 0.2 – .5cc in each injection, making sure that the needle is within the vein. The injections are roughly 5 cm apart. We apply cotton balls, compression dressing and put on stockings on immediately after.

The same general technique is used with a more dilute solution for reticular veins and even more dilute for spider veins. We strive to locate the large feeding abnormal vessels using a veinlight before injecting spider veins.


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