Compression in the treatment of leg telangiectasia: a preliminary report

Sclerotherapy in Aesthetic Medicine: Myths and Realities

BACKGROUND

Sclerotherapy is commonly performed for elimination of reticular and telangiectatic leg veins. There are several variations in practice, from the preparation to post-therapy directives.

OBJECTIVE

To critically examine the misconceptions of sclerotherapy for aesthetic indications.

MATERIALS AND METHODS

This review assesses evidence for and against each of the most common myths regarding sclerotherapy for aesthetic indications.

RESULTS

Sclerotherapy can be safely used to treat veins in areas other than the lower extremities, with the exception of the face. Laser therapy is not superior to sclerotherapy for the treatment of small telangiectatic veins on the lower extremities. The type of syringe used to produce foam sclerotherapy is an important procedural consideration. After sclerotherapy, graduated compression stocking usage is a vital part of the procedure. Detergent sclerotherapy agents are similar, but not equivalent. Touch-up treatments after sclerotherapy should not be performed for 2 months post-treatment. Foam sclerotherapy does not have a high risk for air emboli. It is not advisable to treat the leg veins in "sections." Finally, one cannot reliably treat the telangiectatic veins without treating the feeding reticular veins for a satisfactory result.

CONCLUSION

Many aspects of sclerotherapy have existing evidence to dictate best clinical practice.

Clinical outcome of short-term compression after sclerotherapy for telangiectatic varicose veins

BACKGROUND

Sclerotherapy is considered to be the method of choice for the treatment of telangiectatic varicose veins (C1 veins). Whereas the use of compression stockings after sclerotherapy is recommended, little is known about the impact of compression on the outcome of sclerotherapy. The aim of this study was to assess the influence of compression on the outcome of injection sclerotherapy of C1 varicose veins.

METHODS

There were 100 legs of 50 consecutive patients with chronic venous insufficiency (C1) included. After randomization per patient, both legs were treated with sclerotherapy in a predefined area of the thigh (measuring 100 cm²), followed by eccentric compression for 24 hours. Group A received no further compression, whereas group B was additionally equipped with compression stockings of 18 to 20 mm Hg above the ankle and continued wearing these for 1 week. Photodocumentation was performed before, 1 week after, and 4 weeks after sclerotherapy, and the clinical outcome was assessed at these postprocedure follow-up dates. The photographs were reviewed by an internal unblinded rater and an independent blinded external rater.

RESULTS

There was no discernible difference between the groups in terms of clinical outcome or side effects after 4 weeks. Whereas inter-rater reliability was high, there was no correlation between the raters and patients in terms of outcome. In 55% of the treated legs, the patients deemed the result of the treatment to be good; in 27% of the treated legs, fair; and in 18%, poor. Postprocedure hyperpigmentation occurred in 13% of patients and was comparable in both groups. Compression therapy was found to be comfortable by the majority (58%) of patients.

CONCLUSIONS

One week of postinterventional compression therapy had no clinical benefit compared with no compression.

Application of Contrast-Enhanced Ultrasound (CEUS) in Lymphomatous Lymph Nodes: A Comparison between PET/CT and Contrast-Enhanced CT

Purpose

We described imaging characteristics of different types of lymphomas using contrast-enhanced ultrasound (CEUS) and summarized some simple criteria to distinguish between normal lymph nodes and lymphomatous lymph nodes for clinical diagnosis.

Materials and methods

Sixty-one lymphoma patients from 2014 to 2015 with 140 suspicious lymph nodes, who had been confirmed by histology and underwent chemotherapy, were enrolled in our study. The responses to chemotherapy were recorded by PET/CT, contrast-enhanced CT, or CEUS.

Results

We summarized the CEUS enhancement patterns as two types when detecting lymphomatous lymph nodes, which could be the specific diagnostic criteria: (1) rapid well-distributed hyperenhancement, with 83.1% lesions exhibiting a fast-in hyperenhancement pattern in the arterial phase, and (2) rapid heterogeneous hyperenhancement, with 16.9% lesions exhibiting heterogeneous in the arterial phase. Particularly, we found that all the suspicious lesions of indolent lymphomas were rapid well-distributed hyperenhancement. CEUS successfully identified 117 lymphomatous lymph nodes, while PET/CT and contrast-enhanced CT detected 124 and 113 lymphomatous lymph nodes, respectively. CEUS had an accuracy of 83.57%, and the accuracy of PET/CT and contrast-enhanced CT was 88.57% and 80.71%, respectively (p=0.188). The false-negative rate was 16.43%, 11.43%, and 19.29%, respectively (p=0.188).

Conclusion

CEUS could be a useful tool in detecting lymphomatous nodes. A rapid well-distributed hyperenhancement pattern in CEUS could be a useful diagnostic criterion in both aggressive lymphoma and indolent lymphoma. These results can help us distinguish between lymphomatous and benign lymph nodes and make better diagnostic and therapeutic decisions.

Advances in Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins

Sclerotherapy as a treatment for varicose veins originated in the 1800s. Unfortunately, experience with this treatment modality has been fraught with complications and failures. Recent interest by the general public in this form of treatment has uncovered a lack of formal training and protocols within the medical establishment. Nevertheless, recent experience with sclerotherapy has been found to be more positive than previously realized. Three “advances” in sclerotherapy treatment for varicose and telangiectatic leg veins have occurred within the last 20 years. We term these “advances” not because they are new, but because they are newly popular—proper diagnosis prior to treatment; optimal choice of sclerosing solutions and concentrations; and ideal compression techniques to limit sclerophlebitis, recanalization and complications. These advances will be detailed in the following paper.

Results from RCTs in Sclerotherapy: European Guidelines for Sclerotherapy in Chronic Venous Disorders*

Aim

Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy.

Methods

This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7th–10th May 2012 in Mainz. The conference was organized by the German Society of Phlebology.

Results

This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, Polidocanol (POL) and Sodium tetradecyl sulphate (STS). Other sclerosants are not discussed in detail. In this paper the results from recent RCTs in sclerotherapy are reviewed.

European guidelines for sclerotherapy in chronic venous disorders

Aim

Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy.

Methods

This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7–10 May 2012 in Mainz. The conference was organized by the German Society of Phlebology. These guidelines review the present state of knowledge as reflected in published medical literature. The regulatory situation of sclerosant drugs differs from country to country but this has not been considered in this document. The recommendations of this guideline are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines.

Results

This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, polidocanol and sodium tetradecyl sulphate. Other sclerosants are not discussed in detail. The guideline gives recommendations concerning indications, contraindications, side-effects, concentrations, volumes, technique and efficacy of liquid and foam sclerotherapy of varicose veins and venous malformations.

Compression after sclerotherapy for telangiectasias and reticular leg veins: a randomized controlled study

BACKGROUND

The efficacy of wearing compression stockings on clinical vessel disappearance following sclerotherapy of telangiectasias and reticular veins has been a matter of debate for half a century.

OBJECTIVE

To determine the relative efficacy of compression following sclerotherapy and to determine its impact on general quality of life in a prospective randomized open-label trial.

METHODS

Female patients seeking treatment of telangiectasias and reticular veins and presenting comparable areas of telangiectasias on the lateral aspect of the thigh (C1AorSEPAS1PN) were randomized to wear medical compression stockings (23 to 32 mm Hg) daily for 3 weeks or no such treatment following a single session of standardized liquid sclerotherapy. Outcome was assessed by patient satisfaction analysis and quantitative evaluation of photographs taken from the lateral aspect of the thigh before and again at 52 days on the average after sclerotherapy by two blinded expert reviewers. Patients completed a quality of life questionnaire (SF-36) before treatment and again at the control.

RESULTS

Data of 96 of 100 randomized patients could be evaluated. Patient satisfaction with the outcome of treatment was similar in the two groups. Objective assessment of clinical vessel disappearance revealed a benefit of wearing stockings (P=.026) corresponding to a NNT (number needed to treat) of 4.7 patients to get a vessel disappearance score higher than 6. The interobserver agreement was very high (intraclass correlation coefficient=0.93). Compression was well tolerated with a low rate of discomfort claims (mean 17.5%). Micro-thrombi were rarely observed in either group, but still less prevalent in the compression group. The rate of pigmentation and matting was low and did not differ significantly between the two groups. Physical and mental quality of life scores in women seeking treatment of telangiectasias were similar to those of a healthy control population. Treatment had no impact on general quality of life.

CONCLUSION

Wearing compression stockings (23 to 32 mm Hg) for 3 weeks enhance the efficacy of sclerotherapy of leg telangiectasias by improving clinical vessel disappearance.

Sklerosierungstherapie der Varikose

Sclerotherapy is a standard treatment for intradermal varicose veins and branch varicosities. In the treatment of insufficient saphenous veins, crossectomy and stripping used to be the methods of choice. In the last few years good results have also been reported for endovenous methods such as endovenous laser and radio frequency treatment. Sclerotherapy is more effective and even appropriate for larger saphenous veins when the sclerosing liquid is replaced by a foam agent. This cost-effective approach can be done on an outpatient basis without additional anesthesia. Prospective randomized studies are need to confirm the effectiveness.

Sclerotherapy basics

Sclerotherapy involves the injection of a fluid into blood vessels to eradicate them. A thorough understanding of the basics of sclerotherapy are important when beginning sclerotherapy procedures in practice. This article reviews the essential information of sclerosants, treatment of small vessel disease, and patient management.

Guidelines for sclerotherapy of varicose veins (ICD 10: I83.0, I83.1, I83.2, and I83.9)

BACKGROUND

Sclerotherapy is the targeted elimination of intracutaneous, subcutaneous, and/or transfascial varicose veins (perforating veins) as well as the sclerosation of subfascial varicose vessels in the case of venous malformation by the injection of a sclerosant. With duplex-guide sclerotherapy and foam sclerotherapy, modified methods came into use.

OBJECTIVE

The objective was to create a guideline, based on the available publications and on the European Consensus Document on foam sclerotherapy from April 2003.

METHODS

This guideline was drafted on behalf of the German Society of Phlebology (Deutsche Gesellschaft für Phlebologie) and adopted by the committee and scientific advisory board of the Deutsche Gesellschaft für Phlebologie on June 15, 2001, and amended on December 5, 2003. The guideline considers the present state of knowledge as reflected in the literature.

CONCLUSIONS

This guideline represents the recent state of the art of sclerotherapy of varicose veins in Germany including foam sclerotherapy.

Using silicone gel sheet for the treatment of facial telangiectasias with sclerotherapy

BACKGROUND

Telangiectasias are superficial cutaneous vessels that are visible to human eye and are present as a dilated venule, capillary, or arteriole. They are a common cause of concern, especially when located in face. Sclerotherapy is among the treatment alternatives, but facial telangiectasias are less responsive than those located on the leg.

OBJECTIVE

To show the effectiveness of silicone gel sheet in improving the results obtained by sclerotherapy in facial telangiectasias.

METHODS

Between 1998 and 2003, 32 patients were treated with sclerotherapy and silicone gel sheet (group 1). Twenty-six patients were treated with sclerotherapy and cotton ball (group 2), and 30 patients were treated only sclerotherapy (group 3). Patients were evaluated for 12 weeks for the degree of improvement and side effects. All complications, side effects, and number of sessions were also recorded at each follow-up visit. The number of sessions is limited to six. After the final follow-up visit, the photographs taken of each treatment site at baseline and at final visit were reviewed in a double-blinded manner based on a 0 to 4 scale by two physicians.

RESULTS

Fifty one of the 88 patients showed improvement totally. In the silicone sheet-sclerotherapy group, 22 of the 36 patients showed improvement. In the sclerotherapy-cotton ball group, 14 of the 26 patients showed improvement, and in the sclerotherapy-only group, 15 of the 30 patients showed improvement completely within the 12 weeks. The patients treated with sclerotherapy-silicone gel sheet (group 1) had more improvement than the other groups.

CONCLUSION

Combining silicone gel sheeting to sclerotherapy increases the success rate in treating facial telangiectasias, especially facial subunits, which have bone support.

How to utilize compression after sclerotherapy

BACKGROUND

Although much has been published on the effects of compression on the venous system in patients with venous ulcers, relatively few studies address compression following sclerotherapy of telangiectatic webs associated with reticular veins.

OBJECTIVE

To describe my method for using compression after sclerotherapy treatment of varicose and telangiectatic leg veins.

METHODS

Review of my techniques and the rational for compression.

CONCLUSION

I believe that compression after sclerotherapy is beneficial.

Post-sclerotherapy compression: controlled comparative study of duration of compression and its effects on clinical outcome

BACKGROUND

Although much has been published on the effects of compression on the venous system, relatively few studies address the duration of compression following sclerotherapy of telangiectatic webs associated with reticular veins.

OBJECTIVE

To perform a controlled study comparing the effects of different durations of compression following sclerotherapy of reticular veins and telangiectasias in similar locations.

METHOD

This study consisted of a total of 40 patients, 30 patients who received compression therapy and 10 control patients who did not receive compression therapy. The compression group consisted of 10 in each of three duration groups: 3 days, 1 week, and 3 weeks. Patients were evaluated at 1 week, 2 weeks, 6 weeks, 12 weeks, and 24 weeks for degree of improvement and side effects.

RESULTS

The three compression groups showed significantly greater improvement at 6 weeks (p = .004). There was a strong correlation between the length of time compression was applied and degree of improvement at 6 weeks, 12 weeks, and 24 weeks of clinical follow-up; r = .74, p = .0006, r = .59, p = .006, r = .66, p = .0001, respectively. The patients treated with compression for 3 days and 1 week had more improvement than the control patients while the patients treated for 3 weeks of continuous compression had the most improvement. In terms of side effects, the 1 week and 3 week compression groups experienced the least amount of post-sclerotherapy hyperpigmentation.

CONCLUSIONS

Compression enhances the results following sclerotherapy in a statistically significant way and is directly correlated with duration of compression. Three weeks of continuous compression leads to the best results, although even 3 days of compression results in greater improvement than no compression. Compression leads to a statistically significant reduction of post-sclerotherapy hyperpigmentation.

Diagnosis and treatment of varicose veins: a review

Varicose veins are superficial vessels that are abnormally twisted, lengthened, or dilated and are usually caused by inefficient or defective valves within the vein. They represent a medical condition accompanied by symptoms deserving treatment. Varicose veins are a manifestation of venous disease that may precede later severe complications. Varicosities cause cutaneous disease in addition to complications specific to the venous system. This article reviews the epidemiology, adverse sequelae, anatomy, pathophysiology, evaluation, and treatment of varicose veins.

Pulsed-dye laser treatment of leg telangiectasia: with and without simultaneous sclerotherapy

Thirty consecutive female patients with red leg telangiectasia less than 0.2 mm in diameter were treated with a Candela SPTL-1 Pulsed Dye Laser (PDL) tuned to 585 nm with a pulse duration of 450 microseconds at energies ranging from 6.0 to 8.5 J/cm2 delivered through a 5-mm spot size to the entire length of the telangiectasia. Seven patients with 25 patches of telangiectatic matting after previous sclerotherapy were also treated. Twenty-seven patients with symmetrical telangiectatic patches or a large "starburst" telangiectatic flair that could be divided into two separate treatment sites were treated at one site with PDL alone, and at the other site with a combination of PDL followed immediately by sclerotherapy (SCL) with Polidocanol 0.1-0.25 ml per injection site at a concentration of either 0.25%, 0.5%, or 0.75%. PDL treatment is efficacious for both essential telangiectasia and vessels that arise through the phenomena of telangiectatic matting. Sixty-five percent of vessels are completely faded with treatment. PDL alone has a remarkably low incidence of adverse sequelae. Treatment is most efficacious if all vessels larger than 0.2 mm in diameter, especially varicose and reticular feeding veins, are treated first. Treatment results are not affected by vessel location. And post-treatment compression of this type of vessel appears unnecessary. Combination PDL/SCL treatment appears to offer no advantage to sclerotherapy treatment alone and has a significant degree of complications when treatment is limited to red telangiectasia less than 0.2 mm in diameter with the laser parameters utilized.