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W. G. FEGAN, M.Ch., F.R.C.S.I.

The treatment of varicose veins by compression sclerotherapy has been used in Dublin for over twenty years, and is increasingly being adopted throughout the world. This technique involves the diagnosis of incompetent perforating veins in the foot, calf, and thigh, and the injection of a sclerosant, sodium tetradecyl sulphate, at these sites. Pressure is then maintained over the injection sites by bandages, sorbo-rubber pads and elastic stockings until the vein at these sites has been reduced to a non-tender, hard fibrous cord.

Because of the widespread use of this technique it now appears essential to describe the complications which may arise and the methods of avoiding and, if necessary, treating them.

Classification of complications. - (1) At site of injection, (2) vascular,  (3) general.

1. Pain. - Some patients suffer pain at the sites of injection, particularly on the first few nights following treatment. The patient will volunteer the information that walking relieves the pain. The cause of this pain is not known and the injection sites, if examined, do not appear to differ from non-painful sites. The treatment of this pain is to reassure the patient, telling him that it will go in a day or two. Check that the bandages are not too tight, advise him to take an analgesic and especially to increase the amount of walking he is doing. Walking is particularly important in relieving pain.
2. Localized thrombophlebitis. - Localized thrombophlebitis may occur in patients in whom it has been difficult to empty completely the vein to be injected, and in whom inadequate compression has been applied to the injection site. It is more likely to occur if there is a second undiagnosed incompetent perforator in the region. The treatment is to apply firm compression over the area until it is painless, and to encourage walking. Failure to do this will result in recanalization of the vein at the site.
3. Ulcer. - Infrequently, extravascular injection of a superficial vein may produce a shallow ulcer, which is usually painless. This does not occur often in the hands of an experienced operator and is avoided by ensuring that the needle has not slipped out of the vein when the leg is elevated, and also by not injecting more than 0.5 ml. of sclerosant at each site. Treatment involves a dry dressing over the site and maintaining good compression on the area. Walking should be encouraged. Healing of the ulcer may take several weeks.
4. Pigmentation. - Pigmentation of the skin along the course of an injected vein occur occasionally. This is only a cosmetic disfigurement, but is important if the veins have been treated for cosmetic reasons only - a practice not to be encouraged. The pigmentation usually fades gradually over about twelve months.
5. Local paraesthesia. - Occasionally a patient may complain of an area of paraesthesia in the treated leg. This is due to the injection affecting a superficial nerve. It does not require treatment and recovers completely in a matter of months.

1. Ascending superficial thrombophlebitis. - Ascending phlebitis in the long saphenous vein, starting at the upper edge of the bandages and extending towards the groin, can occur if the bandages slide down and form a sharp, traumatizing upper limit. To avoid this it is essential that a sorbo-rubber pad should project above the upper limit of the bandages over the course of the long saphenous vein. This creates a gradual transition of pressure from the compressed to the uncompressed vein and prevents damage to the vein by the sharp upper limit of the bandages. Treatment is to bandage the area firmly, apply a sorbo-rubber pad over the thrombosed vein, to give reassurance and analgesics, and to encourage walking.
2. Deep-vein thrombosis and pulmonary embolism. - These are rare complications of compression sclerotherapy. Occasional cases have been reported. One case of fatal pulmonary embolism has been reported, but the patient in whom it occurred was taking a contraceptive pill. Several facts explain why deep-vein thrombosis and pulmonary embolism occur so rarely in this treatment. First, the sclerosant, which is injected in small amount, affects only the intima of the vein and not the blood. It is rapidly inactivated by the blood and is, in fact, a haemolytic and not a thrombotic agent. Also, patients must walk for at least an hour within minutes of completing treatment and must continue this walking every day until treatment is completed. If this complication occurs, the standard treatment for deep-vein thrombosis and pulmonary embolism for the hospital involved should be applied.
3. Intra-arterial injection of sclerosant. - A rare but serious complication of this technique is the accidental intra-arterial injection of the sclerosant. In most cases in which it has been reported the vessel involved has been the posterior tibial artery in the posterior malleolar position. The changes in the foot following intra-arterial injection suggest that the sclerosant produces a widespread endotheliitis blocking the arterioles and this may lead to gangrene of some part of the foot. More than ordinary careshould be exercised when injecting incompetent perforating veins behind the medial malleolus. The doctor should palpate the posterior tibial artery before injecting to ensure that he knows its position. If this complication occurs a scheme of treatment which appears to be effective consists in injection of procaine around the injected artery, local cooling, systemic heparinization and infusion with low-molecular-weight dextran.
4. Excessive compression. - Pain in the leg, due to the bandages being applied too tightly, can occur, especially in older patients. This is due to increased pressure on the blood supply to the leg, and naturally therefore more often affects patients with atherosclerosis. It occurs most commonly when heavy elastic bandages have been applied to overcome high tension in superficial veins or to disperse oedema. This can be avoided by careful bandaging. Patients with heavy elastic bandages should be warned to remove them at night and to re-apply them before getting out of bed in the morning. In some cases it may be necessary for the doctor to remove the bandages and immediately to re-apply them more loosely but firmly. The pain will always being the patient to seek advice before the ischaemia has caused any damage.

Allergic reactions occur in some patients and are a contraindication to continuing treatment.

1. Anaphylactic shock. - Anaphylactic shock has occurred very occasionally. The patient complains of tightness in the chest, nausea and a feeling of faintness. In a few cases there has been loss of consciousness. Patients should be questioned regarding allergies before injection, and the necessary equipment for treating shock should be at hand.
2. Delayed hypersensitivity. - A more common, but still unusual, form of allergy in patients is delayed hypersensitivity. In these cases the patients complain of a rash varying from mild "prickly heat" to a ganeralized urticaria and oedema. All these cases can be successfully treated with antihistamines.

These complications are in general far more likely to occur in the hands of the occasional injector. It is advisable that compression sclero- therapy should be carried out in a clinic which is entirely devoted to the treatment of varicose veins. The technique should be carried out by someone who frequently uses it because it is a craft in which expertise increases in direct proportion to practice. The sporadic injection of varicose veins in an out-patient clinic should be avoided.

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