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How Many Treatments Are Necessary to Sclerose Varicose and Telangiectatic Leg Veins? MITCHEL P. GOLDMAN, MD PHLEBOLOGY: EDITORIAL
T
his issue of the Journal contains another outstanding article by Neil Sadick, MD, comprising systematic evaluation of sclerotherapy for varicose veins in 800 patients, using various concentrations of hypertonic saline. Dr. Sadick should be congratulated for performing a study of this magnitude. Physicians who practice sclerotherapy recognize the difficulty in finding patients with bilaterally symmetrical telangiectasias and varicose veins to include in a study. In his study, Dr.Sadick adheres to the modern principles of sclerotherapy. His patients with varicose veins were exqmined with the venous Doppler to rule out reflux from the saphenofemoral and saphenopopliteal junctions and incompetent perforating veins. Six weeks of graduated compression was applied to all varicose veins using the established controlled block technique of George Fegan as described by Dr. Mantese and others. The only procedural point in question was using a maximum of 2 mL of sclerosant at each session. At times, larger volumes may be necessary to sclerose the entire network of feeding, communicating reticular and telangiectatic veins. Obviously, the reason for limiting the sclerosant volume to 2 mL in the present study was to present a bilaterally symmetrical "controlled' procedure. Unfortunately, I believe that the limitation of sclerosant quantity to 2 mL resulted in the need for repetitive treatments to effect successful resolution of the varicosity. In my practice, approximately 90% of all varicose and telangiectatic veins resolve after one to two treatments. Those who do not employ sufficient graduated compression or who limit treatment sessions to a few mL of sclerosing solution usually report that multiple treatments (even up to eight) are required to produce effective sclerosis. This can be Iikened to the scenario of an intravenous drug abuser sclerosing his or her veins with repetitive injec-
tions of fluids of dubious and various composition. Because it is clear that Dr-Sadick did employ appropriate compression after his treatments, one can theorize that the reason three to four injections were required to sclerose the varicose veins is that the entire varicosity was not treated at one time, or that points of venous reflux into the varicosity were not treated completely. An alternative reason for the failure of Dr.Sadick to successfully treat the varicose vein in a single session is his choice of sclerosing solution. Osmotic solutions, like hypertonic saline, act in an extremely localized area when injected into a varicosity. The osmotic solution diffuses through the endothelial wall in an osmotic gradient at the site of injection and is rapidly diluted. This prevents its damaging effects upon the endothelium at distances greater than 10 mm or so from the injection site. Therefore, unlike the detergent type of sclerosing agents (sodium morrhuate, sodium tetradecyl sulfate, polidocanol), for hypertonic saline to be an effective sclerosing solution, it must be injected every 20-30 mm along the course of the varicose vein. It is unclear whether this was the treatment modality employed by Dr. Sadick. In summary, Dr.Sadick has presented an outstanding study on the efficacy of various concentrations of hypertonic saline in producing vein sclerosis. He concludes that an 11.7% solution is adequate for treating varicose veins up to 4 mm in diameter. It would probably be more appropriate to treat varicosities greater than 4 mm in diameter with a different class of sclerosing agent, such as the detergents. In addition, in order to effect a more efficient therapy, if one uses hypertonic solutions, it may be more appropriate to inject along the entire course of the varicosity beginning with the areas of venous reflux in order to prevent recanalization of the vessel. This should reduce the mean number of treatments required to produce effective endosclerosis.
From the Department of Dermatology, University of California, Sun Diego, California. ' No reprints are available.
0 1991 by Elsevier Science Publishing Co., Inc. 0148-0812/91/$3.50
How Many Treatments Are Necessary to Sclerose Varicose and Telangiectatic Leg Veins? MITCHEL P. GOLDMAN, MD PHLEBOLOGY: EDITORIAL
T
his issue of the Journal contains another outstanding article by Neil Sadick, MD, comprising systematic evaluation of sclerotherapy for varicose veins in 800 patients, using various concentrations of hypertonic saline. Dr. Sadick should be congratulated for performing a study of this magnitude. Physicians who practice sclerotherapy recognize the difficulty in finding patients with bilaterally symmetrical telangiectasias and varicose veins to include in a study. In his study, Dr.Sadick adheres to the modern principles of sclerotherapy. His patients with varicose veins were exqmined with the venous Doppler to rule out reflux from the saphenofemoral and saphenopopliteal junctions and incompetent perforating veins. Six weeks of graduated compression was applied to all varicose veins using the established controlled block technique of George Fegan as described by Dr. Mantese and others. The only procedural point in question was using a maximum of 2 mL of sclerosant at each session. At times, larger volumes may be necessary to sclerose the entire network of feeding, communicating reticular and telangiectatic veins. Obviously, the reason for limiting the sclerosant volume to 2 mL in the present study was to present a bilaterally symmetrical "controlled' procedure. Unfortunately, I believe that the limitation of sclerosant quantity to 2 mL resulted in the need for repetitive treatments to effect successful resolution of the varicosity. In my practice, approximately 90% of all varicose and telangiectatic veins resolve after one to two treatments. Those who do not employ sufficient graduated compression or who limit treatment sessions to a few mL of sclerosing solution usually report that multiple treatments (even up to eight) are required to produce effective sclerosis. This can be Iikened to the scenario of an intravenous drug abuser sclerosing his or her veins with repetitive injec-
tions of fluids of dubious and various composition. Because it is clear that Dr-Sadick did employ appropriate compression after his treatments, one can theorize that the reason three to four injections were required to sclerose the varicose veins is that the entire varicosity was not treated at one time, or that points of venous reflux into the varicosity were not treated completely. An alternative reason for the failure of Dr.Sadick to successfully treat the varicose vein in a single session is his choice of sclerosing solution. Osmotic solutions, like hypertonic saline, act in an extremely localized area when injected into a varicosity. The osmotic solution diffuses through the endothelial wall in an osmotic gradient at the site of injection and is rapidly diluted. This prevents its damaging effects upon the endothelium at distances greater than 10 mm or so from the injection site. Therefore, unlike the detergent type of sclerosing agents (sodium morrhuate, sodium tetradecyl sulfate, polidocanol), for hypertonic saline to be an effective sclerosing solution, it must be injected every 20-30 mm along the course of the varicose vein. It is unclear whether this was the treatment modality employed by Dr. Sadick. In summary, Dr.Sadick has presented an outstanding study on the efficacy of various concentrations of hypertonic saline in producing vein sclerosis. He concludes that an 11.7% solution is adequate for treating varicose veins up to 4 mm in diameter. It would probably be more appropriate to treat varicosities greater than 4 mm in diameter with a different class of sclerosing agent, such as the detergents. In addition, in order to effect a more efficient therapy, if one uses hypertonic solutions, it may be more appropriate to inject along the entire course of the varicosity beginning with the areas of venous reflux in order to prevent recanalization of the vessel. This should reduce the mean number of treatments required to produce effective endosclerosis.
From the Department of Dermatology, University of California, Sun Diego, California. ' No reprints are available.
0 1991 by Elsevier Science Publishing Co., Inc. 0148-0812/91/$3.50
