What is Ultrasound Guided Sclerotherapy?
When sclerotherapy is used to treat veins below the surface of the skin, it requires an ultrasound to visualise the veins as they are being injected (ie so the doctor can see where the injection is being placed). This deeper injection is termed Ultrasound Guided Sclerotherapy abbreviated as UGS.
How do Ultrasounds work?
An Ultrasound is a machine that can form an image of structures below the surface of the skin. To form images high frequency sound waves (higher than the human ear can detect) are transmitted from the surface of the skin inwards to bounce off internal structures. The returning sound echoes can be used to form an image of the internal structures including veins. Conventional ultrasound results in 2 dimensional black and white moving images that are called B-mode images.
The frequency of the sound waves determines which structures are imaged. The Transducer is the name of the attachment on the Ultrasound that delivers the high frequency sound waves. The frequency of a sound wave is measured in cycles per second (Hertz) and ultrasound frequencies are typically in the million of cycles per second called Mega Hertz (MHz). Depending on the frequency of the transducer will determine the depth of penetration of the sound waves. For example in imaging deep veins a transducer operating at 5-7.5 MHz is used whereas to assess superficial veins a transducer operating at 7.5- 10 MHz is used.
What type of Ultrasound is used for Sclerotherapy?
A special ultrasound called a Colour Flow Duplex Ultrasound Scanner is used for Ultrasound Guided Sclerotherapy. A Duplex Ultrasound combines Doppler blood flow information with conventional ultrasound imaging information.
Doppler refers to using reflected ultrasound waves to evaluate blood as it flows through a blood vessel. How sound waves reflect off moving objects such as blood can be used to measure the speed and direction of blood flow. The word Doppler is named after the Austrian physicist Christian Doppler who in 1842 first proposed the effect of changes in frequency of a wave relative to its source.
The Duplex Ultrasound images can be colour coded to show the speed and direction of blood flow on the conventional black and white ultrasound image.
How is Ultrasound Sclerotherapy performed?
Ultrasound Guided Sclerotherapy is performed in the rooms as a walk in walk out procedure. No anaesthetic is necessary. Gel is applied to the skin for the Ultrasound and then a fine needle is passed through the skin. By using the Ultrasound image the sclerotherapy needle can be accurately guided into the vein, and then the sclerotherapy solution can be injected through the needle to seal off the vein.
Can UGS treat all vein problems?
No one treatment can treat all leg vein problems. Surface veins are treated by one of the surface options, viz Surface Sclerotherapy, Surface Laser or Surface Radiofrequency and deeper veins are treated by one of the Ultrasound Guided procedures.
The Mapping scan done when first evaluating the nature and severity of the underlying deep vein issues is critical in terms of determining which of the Ultrasound Guided treatments is best. In some situations Ultrasound Guided Sclerotherapy is the preferred option, for example if a patient has had surgical stripping in the past and the veins have recurred, or if the deeper veins are branch veins coming off the main trunk rather than the main drainage veins themselves. In other situations Ultrasound Guided Sclerotherapy may be considered as the most cost effective option in situations where the alternative is one of the much more expensive Laser (EVLT) or Radiofrequency (VENEFIT) catheter procedures.
The advantage of attending a dedicated leg vein treatment practice is that all options are available and can be discussed in terms of advantages, disadvantages and cost effectiveness.
What is Foam Sclerotherapy?
Foam Sclerotherapy is the common method used in Ultrasound Guided Sclerotherapy but foam can also be used to treat larger surface Varicose Veins as well.
The rationale for using foam rather than liquid as a sclerosant is firstly that foam is more effective than liquid as it is more viscous and better adheres to the lining of the veins, and secondly that foam sclerosants can be seen on an ultrasound screen unlike liquid sclerosants, allowing for more accurate placement of the sclerosant.
The concept of using a foam solution rather than a liquid solution for sclerotherapy was first proposed back in the 1930s, but it wasn’t until 2000 when an Italian phlebologist, Lorenzo Tessari presented his method for producing foam that it became very popular. In the Tessari method 2 syringes are conjoined by a 3-way stopcock, and by pumping the liquid sclerosant and air back and forth between the 2 syringes, air bubbles are generated and the liquid solution is transformed into foam.
What is CLARIVEIN?
CLARIVEIN is a variation of Ultrasound Guided Sclerotherapy that combines both a chemical and mechanical method to treat deeper veins. Under Ultrasound guidance a catheter with a rotating inner wire is inserted into the vein to be treated. The wire is rotated to damage the inside lining of the vein wall allowing for the sclerosant that is injected to more effectively seal off the vein. The CLARIVEIN procedure has yet to gain widespread use in Australia, as it involves a significant added expense to Ultrasound Guided Sclerotherapy, due to the cost of the catheter, and significantly improved long term results to justify the added expense have yet to be established.
Is UGS painful?
The application of gel on the surface of the skin and use of the Ultrasound probe on the skin is painless. The needle used for Ultrasound Guided Sclerotherapy is very fine and most people describe it as only slightly uncomfortable. Most patients who have had surface sclerotherapy in the past describe Ultrasound Guided injections as less painful. Also Ultrasound Guided Sclerotherapy typically only requires a few very accurately placed injections, unlike surface sclerotherapy which may require many injections if the surface veins are widespread.
Can I have UGS during pregnancy?
All Sclerotherapy treatments, both surface and Ultrasound Guided, and all catheter procedures, are deferred during pregnancy and until after breast feeding.
This is partly because leg vein treatments are less effective during pregnancy, due to an increased pressure in the veins and hormonal changes. Also veins that develop or worsen during pregnancy typically improve after delivery and hence may not need any treatment if you wait. In addition, pregnancy is a recognised time of increased risk for Deep Vein Thrombosis (DVT) and many doctors feel it is unwise to add sclerotherapy as an additional risk factor for DVT in pregnancy.
Probably most important though is that the safety of sclerosing solutions during pregnancy has not been established. As a general principle if a drug enters the bloodstream during pregnancy it can potentially affect the baby in unknown ways. Whilst there have been no reports of adverse effects of sclerosants during pregnancy, their safety has not been established. Tests for the safety of drugs in pregnancy are time consuming and costly and there has been no testing of commonly used sclerosants to prove their safety. Hence, it is accepted current medical practice, to not perform sclerotherapy treatments during pregnancy or whilst breast feeding.
What are the possible complications of UGS?
Common side effects after Ultrasound Guided Sclerotherapy are local reactions such as bruising, tender lumps (trapped blood) and brownish pigmentation (iron staining from haemosiderin in the blood). These minor effects usually resolve over several weeks although pigmentation can occasionally be longer lasting and if it is a concern laser treatment can be used to clear the pigment.
The main complication to be aware of is the risk of Deep Vein Thrombosis (DVT). The risk of this complication will vary with past history, family history, general health and certain medications. The risk of DVT is significantly reduced with daily steady walking and the use of compression stockings after treatment. Patients at an increased risk of DVT may need to have an anticoagulant injection at the time of treatment (Clexane).
A very rare complication to also be aware of is the risk of a cerebrovascular accident after Ultrasound Guided Sclerotherapy. This seems to be a rare occurrence that can occur when Ultrasound Guided Sclerotherapy is performed on patients with a septal defect in their heart (hole in the heart), and in patients with a known septal defect, the risk of this rare complication needs to be discussed.
Whilst it needs to always be kept in mind that unknown or unpredictable problems can occur with any medical treatment many large International studies have shown Ultrasound Guided Sclerotherapy to be a very safe method for treating varicose veins. The complication rates with Ultrasound Guided Sclerotherapy are much lower than when surgery and general anaesthetics were used in the past for the treatment of deeper Varicose Veins.
How many treatments are necessary?
The number of Ultrasound Guided treatments varies on a case by case basis, but typically it requires 1 or 2 treatments on a leg. Sometimes both legs need to be treated and sometimes multiple different drainage areas need to be treated on the same leg. The Mapping Scan done initially provides the necessary information to give an accurate indication of the number of treatment sessions.
What happens after UGS treatment?
It is very important that after Ultrasound Guided Sclerotherapy that a steady walk of 30 minutes is undertaken straight after treatment. This is to get blood moving through the deeper veins and reduce the risk of Deep Vein Thrombosis (DVT) occurring. It is recommended that a steady walk of 30 minutes is undertaken daily for 2 weeks after Ultrasound Guided Sclerotherapy.
Compression stockings will need to be worn after Ultrasound Guided Sclerotherapy but the duration will vary depending on the exact nature of the treatment. It is not uncommon for patients to be instructed to wear compression stockings for 2 weeks after Ultrasound Guided treatment (the first week continuously and the second week during the day).
Normal activities can be resumed immediately after treatment but vigorous exercise that involves repeated pumping of your legs, such as aerobics, stepper or long runs, should be avoided for one week after treatment to optimise results and minimise bruising. Strenuous activities that involve straining, such as weight lifting, should also be avoided for at least 1 week after Ultrasound Guided treatments to minimise pressure to the deeper veins that might reduce the effectiveness of the treatment.
There is no issue with sun exposure following Ultrasound Guided Sclerotherapy but long hot baths, spas or saunas should be avoided in the first week.
The exact recommendations for airplane travel after Ultrasound Guided Sclerotherapy can vary depending on the type of veins being treated, the type of treatment, the duration of the air flight and whether there are other risk factors for DVT. A general guide is that any air travel should be avoided for 2 weeks after Ultrasound Guided Sclerotherapy and any long haul flights ( ie over 4 hours) should be avoided for 4 weeks after Ultrasound Guided Sclerotherapy. Any plans to fly in the 4 weeks after Ultrasound Guided Sclerotherapy should be discussed with the treating doctor and specific advice can be given.
What are the costs?
The costs of Ultrasound Guided Sclerotherapy will be fully discussed at the time of the Mapping Scan but there will be some out of pocket expenses. Medicare will provide a rebate for Ultrasound Guided Sclerotherapy and because there is a Medicare rebate GST is not applicable. There is no rebate from Private Health Insurance Funds for out of hospital procedures such as Ultrasound Guided Sclerotherapy but depending on the level of cover there may be some rebate for compression stockings that are used after treatment.