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TREATMENT OF SMALL VEINS

CHRISTI SILER, R.N.SENTARA COSMETIC AND LASER TREATMENT CENTER

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Examples of Small Veins

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Etiology of Venous Disease

• Heredity- Primary cause

• Pregnancy

• Obesity

• Standing or sitting for long periods of time

• Trauma

• Incidence- 80% female & 20% male

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Microanatomy of Venous System

Spider Veins

Reticular Vein

Perforator

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Algorithm for Small Vessel Treatment

• Rule out truncal insufficiency- plan to correct if present

• Determine system involved

• Identify associated reticular veins

• Perform appropriate treatment

• Compression for 5-7 days

• Follow-up & re-treat in 4-6 weeks

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Lateral Reticular Vein with associated telangiectasia

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Small Vein Treatment Options

• Sclerotherapy- still the Gold Standard

• Lasers- great adjunct to treatment

• Non lasers- IPL, Ohmic Thermolysis, Vascutouch

• Microphlebectomy- for large reticular veins

• Combination Therapy- BEST OPTION for quickest and cosmetically superior results

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The Ideal Sclerosant

• Non-allergenic/ Non-toxic

• Painless• No risk of

hyperpigmentation• No risk of telangiectatic

matting• No ulceration• FDA approved

• UNFORTUNATELY, no sclerosant meets all of this criteria

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Detergent Properties

• Efficient sclerosant- causes intimal inflammation thrombus formation fibrous tissue vein obliteration

• Painless

• Low rate of allergies

• Low rate of pigmentation

• Extravasation tolerated at low amounts

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Reticular Veins

• R/O truncal insufficiency/ incompetent perforators

• Inject reticular veins first

• Follow with laser/ sclerotherapy to telangiectasias

• Compression dressing post tx facilitates clotting

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Why Combination Therapy?

Vessel damage d/t heat

Laser spider veins first

Decreased intimal lumen

Less sclerosant neededLower incidence of hyperpigmentation

TWICE THE DAMAGE MEANS TWICE AS FAST!

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Lasers- Not All are Created Equal

• 940 nm and 1064 nm most common for treatment of telangiectasias

• Goal is to cause vessel damage without damaging surrounding tissue

• No sun exposure or sunless tanning prior to tx

• Test laser and sclerotherapy at consultation to assess response and candidacy for treatment

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Superior Cosmetic Result with Combination Therapy

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Foam Sclerotherapy

• CO2 vs. Room Air– CO2 bubbles dissolves faster in arterial

circulation, thus reducing the risk of adverse event

• Tessari Method-– 1 part solution: 4 parts

gas– Stopcock, 2 syringes

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Foam Sclerotherapy

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•Advantages-•Increases surface area of sclerosant, thus reducing amount

of drug needed

•Circumferential contact with intimal wall causes more damage/

better result

•Displaces blood, thus avoiding dilution of drug/ increases efficacy

•Disadvantages-•Patients with PFO may not be candidate

•Neurological deficits-•Migraine•Scotoma

•DVT- clear deep system with foot dorsiflexion immediately post tx and encourage ambulation

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Before/ After Foam Sclerotherapy

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6 Weeks After One Treatment!

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Facial Telangiectasias

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Adverse Sequelae

• Post Sclerotherapy Hyperpigmentation- transient

• Localized Urticaria d/t inflammatory response/ histamine release

• Angiogenesis/ Telangiectatic Matting- R/O truncal insufficiency or perforators to decrease risk

• Discomfort at injection site

• Recurrence- hereditary8/31/08 23

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Complications

• Cutaneous necrosis

• Superficial thrombophlebitis

• DVT

• Nerve Injury

• Allergic Reaction

• Migraine

• Scotoma

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In Summary• Reticular veins & associated telangiectasia can be

easily treated in the office setting

• R/O truncal insufficiency or incompetent perforators

• Microphlebectomy if needed for large reticular veins

• Laser/ RF first and follow with sclerotherapy

• Foam sclerotherapy to reticular veins if appropriate candidate

• Dilute sclerotherapy to telangiectasia

• Most patients require 3-5 treatments spaced 4-6 weeks apart for optimal results

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