Efficacy of sclerotherapy in varicose veins-- prospective, blinded, placebo-controlled study

Chronic venous insufficiency, could it be one of the missing pieces in the puzzle of treating pain?

Pain is a common complaint among patients seeking medical care. If left untreated, pain can become chronic, significantly affecting patients’ quality of life. An accurate diagnosis of the underlying cause of pain is crucial for effective treatment. Chronic venous insufficiency (CVI) is frequently overlooked by pain physicians. Moreover, many pain physicians lack sufficient knowledge about CVI. CVI is a common condition resulting from malfunctioning or damaged valves in lower limb veins. Symptoms of CVI, ranging from mild to severe, include pain, heaviness, fatigue, itching, swelling, skin color changes, and ulcers in the lower limbs. Recently, it has become more widely known that these symptoms can be attributed to CVI. Even slight or mild CVI can cause related symptoms. Pain physicians primarily consider neuromusculoskeletal disorders when assessing patients with leg pain, and often neglect the possibility of CVI. In clinical practice, when pain physicians encounter patients with unresolved leg pain, they must assess whether the patients exhibit symptoms of CVI and conduct tests to differentiate CVI from other potential causes.

Injection sclerotherapy for varicose veins

BACKGROUND

Varicose veins are enlarged and tortuous veins, affecting up to one-third of the world's population. They can be a cause of chronic venous insufficiency, which is characterised by oedema, pigmentation, eczema, lipodermatosclerosis, atrophie blanche, and healed or active venous ulcers. Injection sclerotherapy (liquid or foam) is widely used for treatment of varicose veins aiming to transform the varicose veins into a fibrous cord. However, there is limited evidence regarding its effectiveness and safety, especially in patients with more severe disease. This is the second update of the review first published in 2002.

OBJECTIVES

To assess the effectiveness and safety of injection sclerotherapy for the treatment of varicose veins.

SEARCH METHODS

For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, CINAHL, and LILACS databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registries, on 20 July 2021.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) (including cluster-randomised trials and first phase cross-over studies) that used injection sclerotherapy for the treatment of varicose veins.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed, selected and extracted data. Disagreements were cross-checked by a third review author. We used Cochrane's Risk of bias tool to assess the risk of bias. The outcomes of interest were cosmetic appearance, complications, residual varicose veins, quality of life (QoL), persistence of symptoms, and recurrent varicose veins. We calculated risk ratios (RRs) or mean difference (MD) with 95% confidence intervals (CIs). We used the worst-case-scenario for dichotomous data imputation for intention-to-treat analyses. For continuous outcomes, we used the 'last-observation-carried-forward' for data imputation if there was balanced loss to follow-up. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 23 new RCTs for this update, bringing the total to 28 studies involving 4278 participants. The studies differed in their design, and in which sclerotherapy method, agent or concentration was used. None of the included RCTs compared sclerotherapy to no intervention or to any pharmacological therapy. The certainty of the evidence was downgraded for risk of bias, low number of studies providing information for each outcome, low number of participants, clinical differences between the study participants, and wide CIs. Sclerotherapy versus placebo Foam sclerotherapy may improve cosmetic appearance as measured by IPR-V (independent photography review - visible varicose veins scores) compared to placebo (polidocanol 1%: mean difference (MD) -0.76, 95% CI -0.91 to -0.60; 2 studies, 223 participants; very low-certainty evidence); however, deep vein thrombosis (DVT) rates may be slightly increased in this intervention group (RR 5.10, 95% CI 1.30 to 20.01; 3 studies, 302 participants; very low-certainty evidence). Residual varicose vein rates may be decreased following polidocanol 1% compared to placebo (RR 0.19, 95% CI 0.13 to 0.29; 2 studies, 225 participants; very low-certainty evidence). Following polidocanol 1% use, there may be a possible improvement in QoL as assessed using the VEINES-QOL/Sym questionnaire (MD 12.41, 95% CI 9.56 to 15.26; 3 studies, 299 participants; very low-certainty evidence), and possible improvement in varicose vein symptoms as assessed using the Venous Clinical Severity Score (VCSS) (MD -3.25, 95% CI -3.90 to -2.60; 2 studies, 223 participants; low-certainty evidence). Recurrent varicose veins were not reported for this comparison. Foam sclerotherapy versus foam sclerotherapy with different concentrations Three individual RCTs reported no evidence of a difference in cosmetic appearance after comparing different concentrations of the intervention; data could not be pooled for two of the three studies (RR 1.11, 95% CI 0.84 to 1.47; 1 study, 80 participants; very low-certainty evidence). Similarly, there was no clear difference in rates of thromboembolic complications when comparing one foam concentration with another (RR 1.47, 95% CI 0.41 to 5.33; 3 studies, 371 participants; very low-certainty evidence). Three RCTs investigating higher concentrations of polidocanol foam indicated the rate of residual varicose veins may be slightly decreased in the polidocanol 3% foam group compared to 1% (RR 0.67, 95% CI 0.43 to 1.04; 3 studies, 371 participants; moderate-certainty evidence). No clear improvement in QoL was detected. Two RCTs reported improved VCSS scores with increasing concentrations of foam. Persistence of symptoms were not reported for this comparison. There was no clear difference in recurrent varicose vein rates (RR 0.91, 95% CI 0.62 to 1.32; 1 study, 148 participants; low-certainty evidence). Foam sclerotherapy versus liquid sclerotherapy One RCT reported on cosmetic appearance with no evidence of a difference between foam or liquid sclerotherapy (patient satisfaction scale MD 0.2, 95% CI -0.27 to 0.67; 1 study, 126 participants; very low-certainty evidence). None of the RCTs investigated thromboembolic complications, QoL or persistence of symptoms. Six studies individually showed there may be a benefit to polidocanol 3% foam over liquid sclerotherapy in reducing residual varicose vein rate; pooling data from two studies showed a RR of 0.51, with 95% CI 0.41 to 0.65; 203 participants; very low-certainty evidence. One study reported no clear difference in recurrent varicose vein rates when comparing sodium tetradecyl sulphate (STS) foam or liquid (RR 1.10, 95% CI 0.86 to 1.42; 1 study, 286 participants; very low-certainty evidence). Sclerotherapy versus sclerotherapy with different substances Four RCTs compared sclerotherapy versus sclerotherapy with any other substance. We were unable to combine the data due to heterogeneity or assess the certainty of the evidence due to insufficient data.

AUTHORS' CONCLUSIONS

There is a very low to low-certainty evidence that, compared to placebo, sclerotherapy is an effective and safe treatment for varicose veins concerning cosmetic appearance, residual varicose veins, QoL, and persistence of symptoms. Rates of DVT may be slightly increased and there were no data concerning recurrent varicose veins. There was limited or no evidence for one concentration of foam compared to another; foam compared to liquid sclerotherapy; foam compared to any other substance; or one technique compared to another. There is a need for high-quality trials using standardised sclerosant doses, with clearly defined core outcome sets, and measurement time points to increase the certainty of the evidence.

Mechanisms of Lower Extremity Vein Dysfunction in Chronic Venous Disease and Implications in Management of Varicose Veins

Chronic venous disease (CVD) is a common venous disorder of the lower extremities. CVD can be manifested as varicose veins (VVs), with dilated and tortuous veins, dysfunctional valves and venous reflux. If not adequately treated, VVs could progress to chronic venous insufficiency (CVI) and lead to venous leg ulcer (VLU). Predisposing familial and genetic factors have been implicated in CVD. Additional environmental, behavioral and dietary factors including sedentary lifestyle and obesity may also contribute to CVD. Alterations in the mRNA expression, protein levels and proteolytic activity of matrix metalloproteinases (MMPs) have been detected in VVs and VLU. MMP expression/activity can be modulated by venous hydrostatic pressure, hypoxia, tissue metabolites, and inflammation. MMPs in turn increase proteolysis of different protein substrates in the extracellular matrix particularly collagen and elastin, leading to weakening of the vein wall. MMPs could also promote venous dilation by increasing the release of endothelium-derived vasodilators and activating potassium channels, leading to smooth muscle hyperpolarization and relaxation. Depending on VVs severity, management usually includes compression stockings, sclerotherapy and surgical removal. Venotonics have also been promoted to decrease the progression of VVs. Sulodexide has also shown benefits in VLU and CVI, and recent data suggest that it could improve venous smooth muscle contraction. Other lines of treatment including induction of endogenous tissue inhibitors of metalloproteinases (TIMPs) and administration of exogenous synthetic inhibitors of MMPs are being explored, and could provide alternative strategies in the treatment of CVD.

Single Blind, Randomised Study Regarding the Treatment of the Telangiectasia of the Lower Limbs (C1EAP) Using Polidocanol 0,5%, 1%, and Nd:YAG Laser

The treatment of leg telangiectasias could be done with liquid sclerotherapy or Nd:YAG laser. We evaluated randomly, in a simple blind, the efficacy of the treatment with 0,5% polidocanol (POL-0,5), 1% polidocanol (POL-1) and Nd:YAG laser (LAS) on 132 patient (264 limbs) with telangiectasia of the lower limbs with less than 2mm diameter (C1EAP). The main objective was to evaluate the efficacy of the sclerotherapy (chemical compared with Nd:YAG-LAS). Secondary objectives were: possible major complications (deep thrombosis, severe burns, ischemic complications, etc.), the percentage of the local complications, the cosmetic aspect-evaluated by both the patient and the doctor and the grade of discomfort of the patient during and after the procedure. Comparing the treatment with Nd:YAG laser (LAS), polidecanol-0.5% (POL-0.5), polidecanol 1% (POL-1), it was noticed that telangiectasias smaller than 1mm led to good and very good results in all the cases treated with Nd:YAG laser and the same outcome was obtained in one third of the subjects treated with POL-0.5, vs. 47.81% of patients treated with POL-1. When telangiectasias were larger than 1mm diameter, good and very good results occurred in 86.36% of patients treated with LAS and 100% of the cases treated with POL-0.5 and POL-1. In conclusion, we consider that leg telangiectasias can be treated with good results using Nd:YAG laser or sclerotherapy with polidocanol, Nd:YAG laser being reccomended for telangiectasia under than 1 mm diameter while sclerotherapy in larger vessels.

Endovascular laser treatment of incompetent saphenous veins using the 1470 nm diode laser and radial fiber

Objectives

To assess the technical success, complications, and patients' quality of life (QoL) after treatment of chronic venous disease (CVD) using the 1470 nm radial fiber laser.

Methods

A total of 170 patients with chronic venous disease, classified as C2 to C4 according to CEAP classification, were treated for incompetent greater (GSV) and small (SSV) saphenous veins, using the 1470 nm radial fiber laser and application of tumescent anesthesia. Additional phlebectomies were performed through stab microincisions, while 11 patients further underwent sclerotherapy intraoperatively. Patients' QoL was recorded using a CIVIQ-20 questionnaire pre and post-operatively.

Results

Technical success regarding GSV vein occlusion was recorded at 100% and 98% during 12 and 24 month follow up respectively. SSV occlusion rates were recorded at 100% for the same period. 55% of patients were classified as C2. Mean laser application time was 401.1 ± 92.6 s and 169.4 ± 56.8 s, while an average of 3986.6 ± 934.9 and 1643.5 ± 534.1 J were applied during ablation of GSV and SSV respectively. Three incidents of postoperative pain were recorded. Two patients exhibited partial proximal GSV recanalization, while two patients reported mild post-operative temporal paresthesia. No major complications were observed post-operatively. A significant improvement in patients' QoL was demonstrated through the CIVIQ-20 questionnaires. Mean pre-operative CIVIQ-20 total score was recorded at 77 ± 3.9, with a total score of 32.8 ± 2.8 being observed during 12 month follow-up.

Conclusions

Endovascular laser treatment using the 1470 nm radial fiber laser constitutes an effective and safe modality for treatment of CVD.

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Chronic venous disease (CVD) is one of the most commonly encountered health issues regarding venous disorders.

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A paradigm shift has occurred in the 21st century regarding its treatment, offering less invasive treatment options.

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This study was conducted in a series of 170 patients who were treated for CVD the 1470 nm diode laser with radial fiber.

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Technical success rate was excellent with only a few minor incidents of post operative complications.

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Patients' quality of life was drastically improved as it was recorded using a CIVIQ-20 questionnaire.

Endovenous laser ablation of varicose veins after direct percutaneous puncture: early results

BACKGROUND

Although endovenous laser ablation has been demonstrated to effectively occlude incompetent saphenous veins, it does not treat branch varicosities directly.

OBJECTIVE

The objective was to evaluate the technical feasibility and early results of the direct ablation of branch varicosities using a 980-nm diode laser.

MATERIALS AND METHODS

From July to August 2005, 17 patients (21 limbs; male:female ratio, 7:10; mean age, 50.1 years; range, 24-62 years) with varicose veins were enrolled in this study. Endovenous laser ablation was performed in incompetent saphenous veins. Thereafter, branch varicosities were percutaneously punctured and a direct laser ablation was performed using a 400-microm laser fiber. Patients were evaluated at 1 week and at 1-, 3-, and 6-month intervals.

RESULTS

Technical success in branch varicosities was achieved in 11 of 15 limbs (71.4%). Continued closure of treated saphenous veins was evident in 11 of 11 limbs (100%) at 1-month follow-up. Successful ablation in varicose tributaries was seen in 6 of 11 limbs (54.5%) at 1-month follow-up and ablation failed in 5 limbs. One of the 11 limbs (9%) had a skin burn that required treatment.

CONCLUSION

Despite partly successful occlusion, we suggest that direct laser ablation cannot replace classic methods of treating branch varicosities, because of its high failure rate and the risk of skin burns.

Outcomes and side effects of duplex-guided sclerotherapy in the treatment of great saphenous veins with 1% versus 3% polidocanol foam: results of a randomized controlled trial with 1-year follow-up

BACKGROUND

Eighty subjects were treated with either 1 or 3% polidocanol foam to compare the efficacy and adverse sequelae of each concentration of polidocanol foam.

OBJECTIVE

The objective was to compare the effects of two different concentrations of polidocanol foam.

MATERIAL AND METHODS

During a 6-month period, we treated 80 consecutive patients with primary incompetent great saphenous veins in combination with saphenofemoral junction incompetence. These patients were treated with foam of either 1 or 3% polidocanol. Duplex analyses were made before treatment and in follow-up visits to determine the presence or absence of reflux.

RESULTS

After 1 year, there was a clinically relevant difference in percentage of patients with occlusion of the treated great saphenous vein between both groups: 69.5% in the 1% foam group versus 80.1% in the 3% foam group; however, this difference was not statistically significant (p=.249). After 1 year of follow-up, patients in the 3% polidocanol group noticed a larger cosmetic improvement than patients in the 1% group.

CONCLUSIONS

In the treatment of primary incompetent greater saphenous veins, 3% polidocanol foam seems to be more effective than 1% polidocanol foam. The side effects were approximately similar in both groups.

Dose- and time-dependent liquid sclerosant effects on endothelial cell death

BACKGROUND

Intravenous sclerotherapy solutions can induce endothelial cell death.

OBJECTIVE

The objective was to determine the relationship between sclerosant concentration and minimum contact time required for in endothelial cell death.

METHODS

Cultured bovine aortic endothelial cells were exposed to a broad range of concentrations of two liquid sclerosants, polidocanol and sodium tetradecyl sulfate. Fluorescence microscopy was used to study cells using dyes specifically indicating changes in intracellular calcium levels, nitric oxide production, and loss of cell membrane integrity after sclerosant exposure. Fluorescence intensity measurements were used to identify the timing of cell death.

RESULTS

Calcium signaling and nitric oxide pathways were activated by the administration of the sclerosants and were followed by cell death. The time to the activation and the cell death was dependent on the concentration of sclerosants. At 0.3% polidocanol or 0.1% sodium tetradecyl sulfate, cell death occurred within 15 minutes. At less than 0.003% polidocanol and at 0.005% sodium tetradecyl sulfate, cells remained alive after 60 minutes.

CONCLUSION

Both sclerosants rapidly led to cell death at sufficiently high concentrations. At low sclerosant concentrations, cell viability was maintained beyond the recording time of the experiment. The timing of endothelial cell death is predictable based on sclerosant concentration during exposure.