Sclerotherapy for Varicose Vein (Detergent Solutions)
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 few examples of detergent sclerosant available and their key points.¹
(Terminology associated with varicose veins, CEAP classification , adverse effect of sclerotherapy and other publications can be seen by clicking on the link.)
| Agent | Chemical Composition | Keypoints | Adverse Effect |
|---|---|---|---|
| Sodium Morrhuate (SM) | 1. Na salts of saturated and unsaturated fatty acid in CoD liver oil 2. pH = 9.5 | Generally not recommended for telangiectasias | 1. Anaphylactoid Reaction (Management - IV dexamethasone and IM Diphenhydramine) 2. Cutaneous Necrosis - therefore not recommended for telangiectasis |
| Ethanolamine Oleate (EO) | 1. Synthetic mixture of ethanolamine and oleic acid 2. pH = 8.0-9.0 | 1. Only injectable through 30 G needle after dilution 2. Low allergic reaction (compared to STS and SM) and low risk of cutaneous necrosis 3. Min Lethal IV dose (Rabbit model) = 130 mg/kg 4. Used in esophageal varices | 1. Pulmonary Toxicity 2. Unacceptable eschar, ulceration and pigmentation when used for telangiectasis < 1 mm diameter 3. Hemolytic Reaction (with dose over 12 ml of 0.5% EO) - Rare 4. Acute Renal Failure with spontaneous recovery (over 15 to 20 ml) - Rare |
| Sodium Tetradecyl sulfate (STS) | 1. Sodium 1-isobutyl-4-ethyloctyl sulfate 2. pH = 7.9 | 1. Interval between treatments 5-7 days 2. STS + other anaesthetic agent = New compound 3. STS + Heparin = Incompatible (therefore don't mix in same syringe) | 1. Epidermal Necrosis - with extravasation of concentration higher than 1% 2. Post-Sclerotherapy hyperpigmentation - occurs in proportion to concentration of STS 3. Carbitol Content - Toxicity similar to ethylene glycol when ingested - Lethal dose = 90 - 120 ml |
| Polidocanol (POL) | 1. Hydroxypolyethoxydodecane dissolved in water and 96% ethanol (for emulsification of POL micelles and decreasing foaming during production) 2. 2 mg polidocanol per kilogram bodyweight per day should not be exceeded | 1. Most versatile and safest sclerotherapy agent 2. Initially used as topical anesthetic 3. Lack aromatic ring - a non-cyclic chemical structure unlike other anesthetic agents. 4. Obliteration of vessel injected with POL was a initially documented side effect and then later used as sclerotherapy agent. 5. Potential to activate early phase of intrinsic pathway 6. Prolongs aPTT - proportional to fall of factor XII and prekallikrein activity 7. Painless, low allergic reaction and low risk of cutaneous necrosis. 8. Nain Excretion via respiration (80%) other routes - urine and feces. | 1. POL is weaker agent than STS and therefore shows less injection site thrombosis comapred to STS 2. Urtication is the worst in POL as compared to other sclerosant 3. ContraIndication to POL = Known allergy to POL and Acute thromboembolic disease 4. Alcohol-Disulfiram Reaction (Patient's personal history and patient taking Disulfiram should be informed of the potential side effect) |
2. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins 6th edition