Dr Ponosh is a one of Perth’s leading vascular surgeons, highly experienced in sclerotherapy treatment for varicose veins. Find out more about veins and the sclerotherapy treatment below.
Veins are blood vessels that drain used blood up the leg back to the heart. There are two types of veins in your legs. The deep veins which do the bulk of the work, and the more superficial draining system.
The deep veins are larger veins deeper in the muscles that drain the majority of your legs blood back to the heart. These veins develop conditions such as deep vein thrombosis, colloquially known as “economy class syndrome”.
The skin draining system consists of 2 veins, the long saphenous vein running from the ankle to the groin on the inside of your leg and the short saphenous vein running up you calf from the Achilles to the back of your knee. These veins drain into the deep system. The malfunctioning of these veins is the common cause of varicose veins and are the focus of treatment in many cases.
These veins have no pump but rely on a system of hydraulics moving blood up the leg against gravity. When compressed, blood moves up these veins with one-way valves stopping the blood flowing back down the leg. Under certain circumstances these valves fail or become “incompetent” with blood now flowing up and down the leg. This reverse flow back down the leg causes abnormally high pressure in the veins. The veins cannot cope with this abnormally high pressure and dilate, thus causing varicose veins.
In addition, veins particularly at the ankle are “watertight” at these high pressures and thus become “leaky”. Fluid and inflammatory cells leak out causing many more sinister, non-cosmetic symptoms such as swelling, pigmentation, itching and even ulcers. This is known as chronic venous hypertension.
There are many treatments for varicose veins and patients are not always suitable for every treatment. The key for the safest, most effective and durable cosmetic and clinical result is tailored treatment utilising the most up to date method, based upon an accurate ultrasound and by an experienced vascular surgeon. Dr Ponosh has vast experience in varicose vein management and treatment and will recommend the optimal tailored treatment for you.
When the varicose veins are isolated to the skin without an underlying cause, or if there are some residual veins following the above procedures, injection sclerotherapy is often utilised as the treatment of choice. This can be conducted under direct vision (DV) or more commonly as ultrasound guided sclerotherapy (UGS).
This is an ambulatory “walk in-walk out” procedure conducted within our practice’s specialist treatment facility. Sclerotherapy involves the injection of a sclerosant detergent solution through a tiny needle into the diseased vein. This sclerosant can be administered as a liquid or as a “foam”. This causes the vein wall to collapse. The veins dissolve and disappear as the body gradually absorbs them. Sclerotherapy is a safe and effective method for the eradication of varicose veins. Unlike surgery, there is no need for hospitalisation or an anaesthetic. There is no surgical scarring and virtually no “downtime”. Some patients will require follow-up treatments to achieve the best results. Time to complete resolution and final appearance varies from person to person and even from vein to vein.
The cost of sclerotherapy depends on the patient’s requirements and how many treatments they may require. Most people have a satisfactory result after 3-6 weeks, but the final appearance may take up to 12-24 months. These methods have been used globally for many years with universal clinical acceptance and medical evidence-based research proving effective, durable and extremely safe use.
The Australian Government through the Therapeutic Goods Administration (TGA) approved the use of sclerosant solution for clinical use in Australia many years ago. However, this approval was granted before “foam” sclerotherapy was introduced and properly evaluated. Applications have been made to TGA for the use of foam, but this approval process takes time. Until then, the use of foam does not have formal TGA approval and the foam is therefore an “off-label” use of the drug; despite this lack of formal approval numerous studies have confirmed that foam is safe and very effective for the treatment of varicosities.
There are a number of possible side effects seen with non-surgical vein treatment that are considered a normal consequence of successful treatment.
Stinging sensations may be experienced at the time of treatment, which settles within minutes. Most patients find the treatment almost painless.
Bruising will disappear over a couple of weeks.
Darkness of varicose veins soon after treatment is common and is a sign of successful therapy. This slowly fades. The time taken to complete resolution varies but most people have achieved a satisfactory result by 3 months. The final appearance may take up to 2 years and there may be residual skin staining which the vast majority of patients prefer to varicose veins.
Blood trapping can lead to tender lumps along the course of the treated veins. It is harmless but may make the vessels more noticeable in the first few weeks. Trapped blood is usually drained with a needle at review appointments. This accelerates the healing process. Persistent lumps (even without draining) will usually disappear within several months. Blood trapping is common with treatment of all vein sizes.
Aching in the legs for the first few days can occur after treatment. This more commonly occurs when larger veins are treated and is usually relieved by walking. You may take Panadol or Nurofen to help relieve any aching. Most people do not need any pain relief after treatment.
Phlebitis is the appearance of tender, red swollen areas and is due to inflammation of the treated veins. It may be associated with tender lumps along the line of the treated veins. This is a sterile inflammation resulting from the vein closing and is almost never due to infection. Phlebitis can be treated with anti-inflammatory medication (such as Nurofen or Voltaren Rapid) and improves with walking and the continued wearing of the compression stocking.
Recurrence of varicose veins can develop in the future and therefore it may be necessary to have further intervention in the future. This is not uncommon with isolated skin veins as an underlying cause cannot be addressed.
Cosmetic Issues: Whilst your leg will be dramatically improved by your intervention, it is impossible to achieve perfection. Additional sclerotherapy or topical laser may be required. Spider veins will commonly be persistent. The focus is an “age appropriate” outcome.
There are a number of possible complications that can occur with non-surgical vein treatment even when the greatest of care is taken.
Pigmentation is the appearance of brown marks on the skin located over or near the treated veins. This is a common consequence of therapy. Pigmented areas are composed of haemosiderin (a form of iron) that can become trapped in the skin. In most patients the pigmentation gradually fades, disappearing completely within 3-12 months although pigmentation lasting greater than 12 months can occur. However the vast majority of patients prefer the pigmentation to the veins. While the skin is pigmented it should be protected from the sun as it is believed UV exposure can result in “fixing” the pigmentation and thereby make it permanent.
Matting is the development of an extremely fine network of spider veins over a treated vein. Matting usually resolves spontaneously though some will resolve with further injection treatment. Some may persist despite further treatment. Matting is more common in people with extensive surface veins and in overweight people with poor muscle tone.
Persistent lumps under the skin may still be present after many months. They are often harmless, not cosmetically disfiguring and continue to fade with time.
Swelling of the leg or ankle occurs occasionally and will settle with time. It is due to inflammation under the skin. Wearing the compression stocking, elevating the leg when sitting and regular walking will help.
Numbness of the skin is rare and temporary but can last up to three months. It is usually located down the inner aspect or back of the calf. It is due to irritation of nerves that lie in close proximity to an injected vein.
Migraine sufferers may experience visual disturbances lasting a few minutes when treated with injection sclerotherapy. This may be followed by the onset of a headache. Taking a mild analgesic such as Panadol or Panadeine or anti-migraine medication can provide relief. Please let Dr Ponosh know if you have a history of migraines.
Ulcers of the skin are extremely rare and usually appear as small, painful sores within two weeks of injection sclerotherapy treatment. They heal slowly and leave a tiny scar. They occur due to sclerosant passing from the injected veins into the small associated skin arteries.
Allergic reactions to the sclerosant used are rare but may be serious and life threatening. Please let Dr Ponosh know if you have any concerns.
Deep Vein Thrombosis is a clot in the deep venous system – not in the treated varicose veins. This potentially serious problem is extremely rare. The approximate risk is less than 1:2000 patients for sclerotherapy. You will be provided with an injection of preventative medication before your procedure.
Deep vein thrombosis may lead to clots in the lung (pulmonary embolism), which can be a life threatening condition requiring hospitalisation. It is advisable to avoid long distance travel (greater than 4 hours duration) for at least 4 weeks following the treatment of varicose veins. Symptoms of deep venous thrombosis and pulmonary embolism include a painful swollen calf or leg unrelieved by walking, unusual shortness of breath, cough with or without blood stained sputum and stabbing chest pain. Should you experience any of the above symptoms please contact our doctors immediately.
Intra-arterial injection is an extremely rare (1:10,000) complication that can result in significant muscle and skin damage. This now rarely occurs due to the use of ultrasound guidance of the needle, which allows for a more accurate placement during the injection procedure.
Pregnancy and breastfeeding – sclerotherapy is best avoided when pregnant or breastfeeding. This is advised even though there is no current documented evidence to suggest that sclerotherapy is unsafe during pregnancy or breastfeeding. Vein treatments during pregnancy are not as effective often producing poor results. It is recommended that sclerotherapy should be avoided if pregnancy is contemplated within the treatment course. Veins that appear during pregnancy should be treated before the next pregnancy to avoid deterioration with subsequent pregnancies.
Oral contraception and hormone replacement therapy – There is no current evidence that during sclerotherapy treatment the taking of low dose contraceptive pill or HRT actually increases the small risk of thrombosis.
Long haul travel – You should avoid long haul (> 4 hours) travel for 4 weeks after the procedure. This includes long car journey which, if undertaken, should have frequent (2 hourly) stops with 10 minutes of brisk walking at each stop. If you are planning to travel, please discuss this with our doctors.
Operations – You should not undergo major surgery, including any orthopaedic procedure such as arthroscopy, within 6 weeks of the procedure.
Do not apply moisturiser to your legs on the day of the treatment. Avoid using fake tan for at least two weeks prior to treatment and if possible, do not expose your legs to the sun for at least one week before treatment.
You may prefer to wear trousers to your appointment, as they will help to conceal the compression stocking. Wear comfortable shoes so you can go for a walk after the procedure. Please ensure you are familiar with the information presented in this document and don’t hesitate to ask any questions to Dr Ponosh or his staff.
To relieve pain, take simple analgesics such a regular paracetamol if required.
Compression stockings: A form will have been provided to you by the rooms to obtain these stockings PRIOR to your procedure ONLY from the recommended supplier. Please bring them to every appointment.
To be worn: Continuously for 4 days
Not to be removed for bathing/showering (we will provide advice for bathing options)
Then, during the day for 10 days
Contact Dr Ponosh’s office or see your GP if you have:
A routine ultrasound will be undertaken at 2 weeks. A form will be provided to you for this. We will also see you at our office approximately 4 weeks following your treatment. Further therapy may be required at that visit.
Please bring your stockings to every appointment
A letter will be sent to your GP and/or referring doctor advising them of your management.
Our friendly team will contact you the day following your procedure to ensure all is well and address any concerns.
If any concerns arise or you would like to see Dr Ponosh earlier, please contact the rooms on 9386 6200 and we will see you as clinically indicated.
Terms and Conditions: Not to be reproduced without the approval of Ponosh Vascular. Version 2.0 2016. Authorised Dr Stefan Ponosh. This information is in addition to the detailed patient information personally provided by Dr Ponosh. Please refer to the Royal Australasian College of Surgeons Vein brochure also provided.