No matter what the size, all varicosities result from an elevated venous pressure that produces dilatation of the vein walls. To effectively treat large varicose veins, abnormal sources of high pressure must be found and eliminated. In treating veins of any size by any method, the best results will be obtained when the treatment plan is based on a complete understanding of the anatomy of the refluxing circuit. Main high-pressure reflux points should be treated first, even though more distal areas may be more visibly disturbing to the patient.
When a correct underlying diagnosis has been made and an appropriate treatment plan developed, sclerotherapy can be an effective therapy for veins of any caliber. However, the larger and more proximal the reflux entry point, and the higher the pressure at that point, the greater the likelihood of early recurrences.
Although there is a widespread preference for endovenous ablation in patients with junctional incompetence, successful sclerotherapy of the saphenofemoral junction (SFJ) is possible under Duplex guidance.1 Many experienced practitioners do use sclerotherapy for junctional incompetence, but sclerosis of truncal varices with high-grade junctional reflux often requires special techniques and high-potency sclerosants that are not part of the basic armamentarium. The inexperienced phlebologist is unlikely to have success in such efforts and this is not accepted standard of care in the United States. A reasonable rule of thumb is that if maneuvers such as Valsalva can elicit reflux through the SFJ with the patient supine, the junction probably will be resistant to basic methods of large vessel sclerotherapy.
Varicosities that arise from perforator incompetence usually are amenable to sclerotherapy, no matter how large and convoluted they may appear.2 Large varices can be as much as 30 mm or more in diameter, but the same basic approach is useful for all vessels in which reflux can be identified. Principles of large-vein sclerotherapy are listed in Table 12-1.
TABLE 12-1Principles of Large Vein Sclerotherapy |Favorite Table|Download (.pdf) TABLE 12-1 Principles of Large Vein Sclerotherapy
Identify and treat specific reflux points
Proximal to distal is the order of treatment
Treat larger veins before smaller veins
Empty vein of blood by various maneuvers
Treat entire varicosity at one time
Compress immediately and adequately
Patient ambulates following treatment
It is possible to have a certain amount of short-term success with the occasional patient simply by injecting sclerosants into any visible spider veins and varicose veins. However, this haphazard approach will not lead to a successful phlebology practice, because the number of treatment failures and of complications will be too much high. Long-term success depends upon first making the correct diagnosis: identifying the sources of reflux that have caused the problem and that will cause it to recur if not properly treated.