Adverse Effect and Complications related to Sclerotherapy
Sclerotherapy is a minimally invasive medical procedure used to treat varicose veins. This non-surgical technique involves the injection of a sclerosant directly into the affected veins. The solution causes endothelial injury and endo-sclerosis on the injected vein. Endothelial destruction is both dose and time -dependent. Following are the potential complications and side effects related to sclerotherapy. Following are adverse effect related to various sclerosant used in sclerotherapy.¹
(Terminology associated with varicose veins, CEAP classification, different categories of sclerosant and other publications can be seen by clicking on the link.)
| Adverse Effect | Frequency | Mechanism | Keypoints | Management/Prevention (if any) |
|---|---|---|---|---|
| Hyperpigmentation | Frequent | 1. Post-inflammatory hyperpigmentation 2. RBC hemolysis and diffusion of hemosiderin across the damaged endothelium 3. Duration - 6 months to 1 year | 1. Depends on Sclerosing agent and it's concentration 2. Sclerotherapy Technique - limiting pressure on damaged /sclerosed vein (esp. in telangiectatic vessels) to prevent extravasation of RBC 3. More common in below knee vessels 4. Raised Serum Ferritin can predict patients at risk of pigmentation. 5. Raised vessel fragility 3 to 5 days prior and 2 days after menses and during ovulation. 6. Patients on Minocycline have increased risk to pigmentation 7. Pigmentation > 1 year = Untreated reflux advise doppler evaluation. | 1. Pre treatment (in patients with previous history of pigmentation): Medications to limit or block histamine effects e.g- Catecholamines Norepinephrine, Corticosteroids 2. Q switched Laser 3. Post-sclerotherapy graduated compression (20-30 mmHg) for up to 3 weeks 4. Nd:YAG Laser treatment 5. Spontaneous resolution - as the pigmentation gradually decreases over year, patient counselling and size documentation cane be done. |
| Teleniectatic Matting | Frequent | 1. Hypoxia induced neovascularization 2. Duration 3-6 months | 1. Risk factors - Obesity, Pregnancy, Estrogen containing hormones, family history of telangiectatic veins | 1. Protamine - prevents neovascularization (local or systemic) 2. Pentoxifylline - minimize angiogenesis 3. Nd:YAG laser |
| Temporary Swelling | Frequent | Increased gravitational pressure and decreased perivascular fascia | 1. Depends on Sclerosing agent and it's concentration 2. Most common in below ankle vessels | 1. Concomitant medications may promote odema e.g- Antihistamines, Corticosteroids and NSAIDS 2. History of asthma - patient more prone to odema 3. Post-sclerotherapy graduated compression (20-30 mmHg) for up to 3 weeks 4. β-receptor agonists - terbutaline and theophylline. 5. Odema distal to compression bandage = Tourniquet effect (remove dressing) |
| Pain | Frequent | 1. Distension of vessel and associated endothelial cell separation = perivascular nerve stimulation | 1. More common in hypertonic solutions 2. Rule out if pain is secondary to thrombophlebitis | 1. Slow infusion of sclerosant during sclerotherapy 2. Adding lidocaine to to sclerosing agent (preferably use single dose nonacidified lidocaine) |
| Urticaria | Rare | Endothelial irritation | Transient | 1. Topical steroids after sclerotherapy 2. Graduated compression stockings |
| Cutaneous Necrosis | Very Rare | 1. Extravasation of a sclerosing solution into perivascular tissue 2. Excessive compression pressure 3. Intra-arterial injection | 1. Can also occur with ideal injection technique | 1. Dilution of sclerosing agent 2. Dilution with hyaluronidase (for 3% STS) 3. Pentoxifylline 4. Graduated compression of more than 30 mm Hg at calf level especially in recumbent patients. |
| Anaphylaxis | Very Rare | Ig E mediated | 1. Can be minor like urticaria 2. Can be severe and life threatening | 1. Oral Antihistaminic for minor reaction 2. Major Reaction - Epinephrine 0.2 - 0.5 ml at 1:1000 SC 3. Maintenance of systolic blood pressure above 90-100 mg Hg 4. Corticosteroids for reoccurring symptoms 5. Theophylline for asthmatic patients. 6. O2 support if required |
| Superficial thrombophlebitis | Rare | More common when post sclerotherapy compression is not applied | 1. Tender erythematous induration over injected vein | 1. Graduated compression for atleast 2 weeks post sclerotherapy 2. NSAIDS for pain and inflammation 3. Anticoagulation if DVT develops post sclerotherapy. |
| Deep vein thrombosis (DVT) and Pulmonary Embolism (PE) | Rare | 1. Endothelial damage 2. Vascular stasis 3. Hypercoagulability 4. Women on oral contraception and estrogen replacement therapy | 1. DVT alone or in combination with PE can occur 2. Look for provocative and non-provocative causes 3. Thrombophilia profile can help diagnose hypercoagulable state | 1. Graduated compression for atleast 2 weeks post sclerotherapy 2. NSAIDS for pain and inflammation 3. Anticoagulation if DVT develops post sclerotherapy. |
| Nerve Damage | Very Rare | 1. Proximity to vein 2. Perivascular inflammation extending from vein to adjacent nerve | 1. Saphenous and Sural nerve are most commonly injured | 1. Spontaneous regression, sometimes up to 3-6 months 2.Use of NSAIDs to decrease inflammation |
| Air Embolism | Very Rare | When using Foam Techniques / airblock technique | Small amount of air is absorbed from the blood stream | 1. Spontaneous resolution noted in reported cases |
| Visual disturbances with or without Headache and migraine | Very Rare | When using Foam Techniques | 1. Probably reflect temporary ischemic cerebrovascular events | 1. Spontaneous resolution noted in reported cases |
| Vasovagal Reflex | Occasional/Rare | During vein cannulation or during sclerotherapy | Symptoms include - light-headedness, nausea, and sweating | 1. Supine or Trendelenburg position 2. Atropine 0.4 mg SC |
2. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins 6th edition