Chapter VI

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COMPRESSION  SCLEROTHERAPY

In compression sclerotherapy the points of abnormal flow from the deep to the superficial veins are located, and the veins at these sites are then permanently obliterated by the injection of a sclerosant, which initiates controlled thrombosis, and by the application of continuous pressure. It is essentially based on the restoration of the pumping capacity of the multiple pumps of the foot, calf and thigh, rather than towards the eradication of superficial varices or the opening up of proximal obstruction. Advantage is also taken of the fact that not all incompetent valves are permanently injured. Valves may be incompetent only because the vein containing them is dilated (secondary incompetence). They can regain normal function when the vein reduces in size after the efficiency of the pumps is restored and normal ambulatory venous hypertension achieved. It is unnecessary to be so radical as to strip out superficial veins, or to thrombose them along their entire length by indiscriminate multiple injections. The proximal half of the long saphenous vein is one of the best 'spare parts' that the human beings carries, and should not be light heartedly stripped out.

Attention is first directed to the most distal leaks from the deep system. The proximal dilated veins are then watched for improvements; a surprising degree of resolution often takes place in a grossly dilated tortuous vein above the knee following the restoration of the efficiency of the pumps of the foot and calf. Even large saphena varices often disappear within a few weeks of treatment of a perforating vein in the calf.

It should be appreciated that there is usually a large pathological reserve (see Chapter III) in the lower limb, and that considerable damage must be done before the signs and symptoms of venous insufficiency appear. Conversely, it is unnecessary to restore the pumps completely to normal in order to relieve congestion and effect clinical cures. In fact, if complete and perfect restoration of the pumps were essential for successful treatment, then few patients would ever be cured by any form of treatment.

Selection of patients is carried out for two reasons; to find those with no indication for compression sclerotherapy, and to reject those with some contra-indication to it. Patients are occasionally referred for treatment of signs and symptoms which are not, in fact, due to chronic venous insufficiency of the lower limb. The commonest conditions found in these patients are orthopaedic causes of pain in the lower limb, arterial inadequacy, oedema of systemic nature, erythrocyanosis frigida, and non-varicose leg ulcers. Frequently one of these conditions co-exists with chronic venous insufficiency, and, in such cases, it must be explained to the patient that treatment of the veins will not give complete relief from the symptoms.

(i) Fat legs. It is essential that the bandages, applied immediately after injection, stay in place for up to six weeks. If the patient's legs are fat, the bandages cannot be satisfactorily applied and it is also very difficult to find the perforating veins. Such patients are advised to lose weight before treatment is begun. If a varicose ulcer is present, however, compression over the ulcer is applied immediately and maintained as well as possible.

(ii) Inability to walk. Walking for an hour every day is very important in the treatment. If the patient is unable to do this, due to paralysis, arthritis, cardio-pulmonary disease, confinement to bed, etc., treatment should not be undertaken.

(iii) Acute cellulitis. Injections should not be given until the acute inflammation has resolved. However, a localized area of cellulitis surrounding an ulcer is not a contra-indication.

(iv) Veins in a site impossible to compress. Veins above the level of mid-thigh cannot usually be compressed satisfactorily, with the exception of vulval varices. Therefore, they should not be injected.

(v) Cosmetic reasons. Treatment of asymptomatic veins for cosmetic reasons should be avoided. Injections can cause staining of the overlying skin. These stains may not disappear for a year or two. Injections can also occasionally cause ulcers, which leave a small scar on healing. Both will be deeply resented by the patient who seeks treatment for cosmetic reasons only. It is common for minor degrees of symptomless varices to remain unprogressive for many years in cases where pregnancy or some other aggravating cause does not intervene.

(vi) Hot weather. If the weather is very hot, the bandages and elastic stocking are liable to become very uncomfortable. It is advisable to warn patients seeking treatment during summer of this, and in hot climates it would probably be better to undertake injection sclerotherapy only in the winter.

(vii) Allergic reactions. A severe allergic reaction to sodium tetradecyl is an obvious contra-indication to further treatment.

Except for patients with fat legs, who are common, these contra-indications arise very infrequently. Almost every patient with varicose veins can be treated by injection sclerotherapy, either immediately at the first visit or following weight reduction. Perhaps it should be emphasized that ulceration, eczema, thrombophlebitis, and a history of previous deep vein thrombosis are not contra-indications to treatment by this method. The first two, however, would make surgery undesirable. The method can also be applied safely to patients suffering from systemic conditions which would make unessential operations undesirable.

Inspection. A patient is examined while he is standing still. The whole limb, up to, and including, the saphenous opening should be exposed. It may be a minute or two before full dilatation of the superficial venous system is seen. The veins are inspected, and all visible veins are marked with a skin pencil.

Palpation, patient standing. The limb is then palpated. This will often reveal further veins, and these, too, are marked with a skin pencil.

Percussion. A large dilated vein is now percussed while the limb is palpated. The percussion thrill can often be felt for considerable distances along veins which are otherwise undetectable. These veins, too, are marked.

Palpation, patient supine. The patient now sits down on a couch and lies back, with the legs hanging over the end of the couch. The limb being examined is raised and, with the muscles relaxed, the heel is rested on the doctor's shoulder or chest. The limb is then thoroughly palpated with both hands. The limb in this position feels strikingly different from the limb of the standing patient. The veins are empty, the muscles are relaxed, and the whole limb is much softer. The leg should be examined by applying the hands to the leg with the fingers slightly flexed and moving the hands fairly rapidly up and down the leg. Palpation of the raised leg is carried out in order to detect orifices in the deep fascia. It is through such orifices that incompetent perforating veins pass. These orifices may be felt as definite openings with a sharp edge all round, or as areas of abnormal softness. A space in the superficial fascia produced by a varix of the superficial vein may give a very similar feeling, and is very difficult to distinguish by palpation from an opening in the deep fascia unless one has had considerable experience. However, they can be distinguished by a further test.

Controlling of filling. All the suspected fascial orifices are marked with a skin pencil. The most likely sites of retrograde filling can be chosen by considering the relation of the suspected fascial orifices to the marked complex of superficial veins and the known sites of perforating veins (Chapter I).

As many of the likely sites of retrograde filling as possible are compressed with the tips of the doctor's fingers, and the patient then stands up. With the compression maintained, the limb is watched for filling of the superficial veins. If this occurs, the test is repeated with pressure placed on different sites. Once filling of the superficial vein is controlled by the pressure of the fingertips on a few sites, the fingers are removed one by one. When the finger is withdrawn from an orifice which is transmitting a perforating vein, the valve of which is incompetent, the superficial veins slowly fill. There is often more than one point of retrograde filling in a limb, but seldom more than three.

There are further aids to the location of incompetent perforating veins. The point at which such a vein passes through the deep fascia is often tender, and warm (a 'hot spot'). There may be pigmentation over it. Incompetent perforating veins often bear a characteristic relation to varicose lesions. For example, a patch of eczema over the anterolateral aspect of the leg suggests incompetence of one of the anterior tibial perforating veins. Eczema or ulceration on the posterolateral aspect suggests incompetence in the peroneal or soleal perforating veins. A typical varicose ulcer above the medial malleolus is almost diagnostic of incompetence of a lower posterior tibial perforating vein, which may be beneath the base of the ulcer itself. In particularly difficult cases additional help may be obtained from stereoscopic ascending phlebograms. This is not a routine procedure in our clinic.

Oedematous legs. The method of examination described here is sometimes made impossible because of oedema of the lower limb. In these cases, an elastic bandage and elastic stocking are applied from the roots of the toes to above the highest point of swelling. The patient is advised to walk as much as possible, to rest with the feet up two or three times a day, and to raise the foot of the bed. After a month, the patient returns, having stayed in bed that day, with the lower limbs elevated, until it was time to leave home for the appointment with the doctor. On removing the stockings and bandages the oedema is found to be greatly reduced, and it is now possible to detect the superficial veins and fascial orifices.

The patient sits upright on a couch with the legs horizontal. The pressure of blood within the veins in this position is sufficient to make venepuncture possible, but low enough to obviate the danger of bleedback along the needle track. It is quite unnecessary for the patient to stand upright, or for a tourniquet to be applied.

The most distal incompetent perforating vein should be injected first, followed by the next most distal, and so on until all the selected sites have been injected. This direction of progression is chosen so as to allow complete emptying of the veins for each injection; this is more difficult to achieve if there is already a tight bandage around the limb proximal to the injection site. However, it may be found that if the distal perforating vein is injected first, the veins proximal to the site of injection go into spasm, making injection of the more proximal sites impossible for several minutes. If two sites are at about the same level on the leg they cannot both be injected at the same session. The which appears to have the more important relation to the complex of veins should therefore be injected first, and injection of the other vein postponed until the patient's second visit.

Injection. A 2 ml. all-glass syringe containing 1 ml. of sodium tetradecyl and fitted with a 20 gauge disposable needle is used. Before making the injection it should be checked that the plunger of the syringe moves smoothly and very freely. The skin at the site chosen for injection is cleansed, the needle is inserted, and a little blood is aspirated into the syringe to show that the tip of the needle is within the vein. About 0.1 ml. of sclerosant is injected to clear the needle. The syringe is then held firmly against the legs, the patient lies back, and the leg is raised to empty the vein. The ring and index finger of the left hand (if the doctor is right-handed) are pressed on the vein above and below the needle, and about 11/2 in. apart, in order to localize the effect of the injection  0.5 to 1 ml. of the sclerosant is injected into the isolated, and almost empty, segment of vein, and the needle removed. The sclerosant is retained in the isolated segment of the vein by the compressing fingers of the left hand for about 30 seconds.

The injection is normally painless. If the patient feels a stinging pain, this suggests that the sclerosant has been injected outside the vein, and the injection should be stopped. Extravascular injection can usually be detected before it causes pain, because the resistance of the movement of the plunger of the syringe is greater than if it is intravascular. The difference can be detected only if the freedom of movement of the plunger has been tested before the injection is given.

Bandaging. The most important step in the technique is the bandaging. It cannot be stressed too much that the best results are the results of the best bandaging. This part of the technique should be carried out by the doctor, and should not under any circumstances be delegated, except to somebody who is known to be competent. Three types of compression are used; bandages, rubber pads and elastic stockings. All three are different and essential. The bandages used are of stiff cotton crepe and are 3 in. wide. The end of the bandage is secured with the middle finger or thumb of the left hand, and the bandage rolled around the leg, once above and once below the site of injection. The third turn covers the site of injection, and it is not until then that the fingers isolating the injected segment of vein are removed. A bevelled rubber pad is immediately placed over the injection site and bandaged firmly into position. The bevelling of these pads must extend to their edges in order to avoid the production of painful pressure marks on the legs. We have used pads of polyethylene foam, orthopaedic felt, and laminated gauze, as well as small dental gauze rolls, but these all have been rejected in favour of sorbo rubber. None of the other materials produced consistently satisfactory compression over the site of the injection. Both hands are used simultaneously during bandaging; the right hand holds the bandage and wraps it round the limb. The left hand, which is more important, continuously palpates the bandage, assessing its firmness and tension. The correct result is achieved when the bandaged leg feels firm, but the patient does not complain that the bandages feel too tight. It is the left which guides the right hand in the direction and tension with which the bandage is to be applied, by checking that the tension at the edges of the bandage is equal. If one end of the bandage is tighter than the other the bandage will tend to slip. The method of bandaging is essential. If the bandages are applied in any other way it cannot be claimed that compression sclerotherapy is being used.

Any other injections which may be necessary are given at the same session. Finally further bandages are applied so that the limb is covered from the base of the toes up to just above the highest injection site. The ankle should be held in a neutral position between dorsiflexion and plantarflexion while being bandaged, and the knee should be slightly bent. A 3 in. square rubber pad is placed behind the knee and bandaged into position, as this prevents the bandages from rolling up at this site. Another piece of sponge rubber should protrude above the edge of the bandages over the long saphenous vein, to prevent the sharp rubber edge of the bandages traumatizing the vein and causing ascending thrombophlebitis.

The pattern of bandaging is different in the various parts of the limb. The foot and ankle are bandaged with the figure of eight, the cross-over taking place in front of the ankle. The spindle shape of the calf allows the bandage to spiral up and down the leg, forming a criss-cross pattern.  The knee is bandaged with a figure of eight, the cross-over taking place behind the knee over the rubber pad placed in the popliteal fossa. As the thigh is cone-shaped it is necessary to make reverse turns at the upper limit of bandaging. If the thigh is fat, the bandages have a strong tendency to roll down and become ineffective and dangerous by causing a constriction round the limb, and traumatizing the superficial veins, causing ascending thrombophlebitis. It may therefore be necessary to secure the upper edge of the bandages with a turn of 3 in. elastic adhesive strapping. A full length elastic stocking is fitted over the bandages. It must be long enough to reach above the upper limits of the bandages and should be supported by a suspender belt. The stocking and suspender belt are worn day and night. The stocking has two functions; it applies compression to the whole limb, which is particularly valuable in holding the bandage in position after the disappearance of oedema; its second, and possibly more important function, is that it prevents the bandages from becoming ruffled, especially at night. The rubber pad applies compression which is specific to the site of injection, while the bandage provides what we describe as isometric pressure; by this we mean that there is little tendency for the bandage to increase in length and consequently it will prevent the limb from swelling.

Walking. The patient is instructed not to remove either the stocking or the bandages until the next visit to the clinic, and to walk a total of three uninterrupted miles per day. The most important half-hour for walking is the half-hour immediately after the injections, and the most important day for walking is the day of the injections. It is emphasized that standing still is to be avoided. If the patient has to stay in one place for a length of time, the feet should be kept on the move, either by going up and down on the toes or by taking a few steps every minute or so.

The patient is seen one to two weeks after the injection. On this visit it is quite safe to remove all bandages and to stand the patient up for a short time. The injection sites are examined, and the reactions to the injections noted. The ideal result is a 2 in. segment of painless cord-like vein, which is only slightly tender to palpation. The lesion needs compression by bandage and elastic stocking until all tenderness has disappeared, usually after about six weeks. If compression of the injection site has been insufficient, a localized area of thrombophlebitis is found, equal in length to the distance between the localizing fingers at injection. This area should be compressed firmly with bandages, rubber pad and elastic stocking until all tenderness has disappeared. This usually takes longer than six weeks. Occasionally it is found that there has been no reaction to injection, in which case the injection is repeated, particular being given to obtaining an empty segment of vein at the injection site and to localizing the sclerosant for a longer time. Very rarely there is no reaction even after three injections at the same site. In such a case we feel ligation is justified.

The veins are examined as before, and any further injections that are necessary are given. The limb is then bandaged again, the elastic stocking re-applied, and the patient instructed to continue the daily three miles of walking, and to keep both the stocking and the bandages on all the time. The patient is seen at weekly or fortnightly intervals until no more injections are necessary. The next visit is arranged so that it will be at least six weeks after injection. At this visit, careful examination is made of the injection sites, particularly for residual tenderness. If an injected vein is still tender after six weeks of adequate compression, the reason is very probably that there is an undiagnosed incompetent perforating vein nearby. This should be carefully searched for and injected. Compression should not be removed until all tenderness has disappeared from the injection site, or for six weeks after the injection, whichever is longer. The patient is ready for discharge when all the injection sites have lost their tenderness, superficial veins have returned to normal size and all the signs and symptoms in the limb have cleared up.

Patients generally remark on a general improvement in their health and a feeling of wellbeing after their veins have been satisfactorily treated. Whether this is a specific result of improved venous return following treatment of the chronic venous insufficiency, or whether it is due simply to the increased exercise which is part of the treatment, is uncertain. All patients should be followed up for at least five years. They should be seen three months after the course of treatment, and again at six months. Another visit one year after the course of treatment is important, as it will generally be found that if recurrence is going to take place it does not do so within the first year. If recurrence occurs, a further course of injection treatment can be given with little objection from the patient.

1. Pain. Some patients suffer pain at the injection sites for a day or two following the injections. It is relieved by walking or by mild analgesics, such as aspirin, and is of no significance.

2. Injection ulcer. For several years deliberate extravascular injections were given in the clinic, in the belief that they produced a fibrous ring around the injected vein. In the light of experience, and histological examination of biopsy specimens, it was discovered that this was not so. When the sclerosant does damage the skin, it may produce an area of necrosis. The slough later separates to leave an ulcer. These ulcers are usually painless, if compression and ambulation have been adequate. A clean dry dressing should be placed on the ulcer, and compression applied with bandages, rubber pad and elastic stocking. These ulcers heal rather slowly and compression should be maintained until full epithelialization is achieved.

3. Extravascular reaction short of ulceration. An extravascular injection occasionally produces a circular patch of tissue damage which does not ulcerate. It is black in colour, and painful. It should be treated by compression.

4. Pigmentation. A patch of greenish-brown pigmentation sometimes appears over the injection site, especially if the reaction to the injection has been one of local thrombosis.

The pigmentation later changes to brown and may persist.

5. Damage to nerves. Damage to a nerve by an extravascular injection may cause pain in the area of distribution of the nerve, or, if the damage is more severe, paraesthesia or numbness in this area. This complication, which fortunately occurs very rarely, may take three to six months for recovery.

6. Deep vein thrombosis. While it is probable that some of the injected sclerosant spills into the deep veins, in 16,000 patients treated in the clinic there has not been one in which conclusive clinical signs of deep vein thrombosis were produced by injection. The reason for this is probably the rapid fixation of the sclerosant by the protein of the wall of the vein into which it is injected, and by the protein of the blood. This means that there is probably very little damage done to the intima of the deep veins. The immediate ambulation following injection, by producing a rapid flow of blood along the deep veins, probably prevents any such damaged area of intima from becoming a site for propagation of thrombus. The lytic activity of the vein wall and the circulating blood will also tend to reverse thrombus formation.

7. Pulmonary embolism. No fatal case of pulmonary has occurred in a patient undergoing compression sclerotherapy, nor are there any clinically proven cases of pulmonary embolism.

8. Allergy to sodium tetradecyl. There have been about fifteen cases of serum sickness, with hot stinging pain in the skin, and an erythematous rash developing 30 to 90 minutes after injection. These cases were satisfactorily treated on subsequent visits by the administration of antihistamines before injection. Very rarely a mild asthmatic attach has been caused. There have been about ten cases of mild anaphylaxis which required treatment with adrenaline. A severe reaction to an injection of sodium tetradecyl is a contra-indication to further injections.

1. Superficial thrombophlebitis. Treatment of this condition may take two forms, depending on whether the patient is ambulant when first seen or whether he has been already been in bed for some time. In either case, careful examination is necessary to exclude the possibility of co-existent deep vein thrombosis.

If the patient is ambulant, incompetent perforating veins in the vicinity of the lesion may be injected. A rubber pad is cut to the size and shape of the region of the thrombophlebitis and bandaged into position over the lesion. An elastic stocking is applied and the patient instructed to walk and to avoid standing. Analgesics such as aspirin are given to relieve the pain. If the lesion is fluctuant when first seen it may be aspirated, but squeezing blood clot out through an incision is unnecessary. It is also unnecessary to ligate the superficial veins affected and, in fact, if this operation is performed under general anaesthesia it is dangerous. There is no indication for the administration of antibiotics. If the patient is in bed when first seen it is necessary to consider the possibility of recent clot extension within the superficial veins and it is theoretically unwise to proceed with active treatment for 48 hours. During this time the patient is heparinized, the foot of the bed is raised and compression is applied to the limb with bandages and elastic stocking. After the pain has subsided the patient exercises on a pedalling machine for five minutes every half-hour. When the swelling has also subsided the patient is allowed up and encouraged to walk, but instructed to avoid standing still. When the patient is fully ambulant the bandages may be removed and the incompetent perforating veins injected, pressure being re-applied and ambulation being continued. Under no circumstances should any injection be given until the patient is able to walk for at least one hour per day.

2. Post-thrombotic leg. For certain diagnosis of previous deep vein thrombosis, phlebography is necessary in order to demonstrate the irregularities in the recanalized vein. Following thrombosis of the deep vein, recanalization to a major or minor degree is inevitable and usually takes place in a matter of six to eight weeks. However, the partially or totally recanalized vein is almost certainly valve-less, or has damaged valves, and functioning with reduced efficiency.

Since this is so the basis of treatment is fairly obvious. So far no method has been devised whereby valves can be replaced, while operations for disoblitering the vein or producing a bypass are still in the experimental stage. In the treatment of these cases it is much more important to restore, as far as possible, the efficiency of the pumping mechanism in the foot, leg and thigh rather than to attempt to eradicate the proximal obstruction between the limb and the heart. That this approach is rational is shown by the fact that it is quite possible to tie a ligature on the iliac veins or even on the inferior vena cava and, if the pumping mechanisms are efficient, the venous return from the limb is adequate and the patient will suffer few if any symptoms in the affected limb. The idea that the varicose superficial and perforating veins form an alternative pathway for blood flow past the block in the deep veins is erroneous for the same reason.

These patients require treatment of their incompetent perforators more than do patients with normal deep veins, because the damage to the valves in the deep veins reduces the efficiency of the pumping action and leaks through the incompetent perforating veins reduce it even further.

Clinically these patients present with legs showing firm indurated oedema, thin glossy skin, and, frequently, ulceration. They often give a history of, or actually present with, the symptom of bursting sensation in the leg if they stand for any period of time. The thrombotic episode in the deep veins frequently followed a pregnancy but sometimes occurred after a fracture. Treatment is carried out as already described by locating and injecting the perforating veins which have incompetent valves. The damage to the valves in many cases was most probably due to the perforating veins having been involved in the thrombotic episode.

One can, with confidence, tell these patients that their symptoms will improve, their swelling will decrease and their ulcers will heal. However, it should be made clear that the venous system cannot be restored to normality and although complete symptomatic relief is to be expected, it is wise to advise such patients to wear an elastic stocking during the day time for the rest of their lives.

3. Varicose eczema. This is probably due to venous congestion of the limb occurring in a person liable to allergies, who is in contact with a suitable allergen, such as rubber, metal, etc. The veins should be treated in the normal way, injecting through eczematous skin if necessary. Several layers of absorbent lint should be applied over the eczema with compression, preferably with plastic sponge rather than rubber. Antihistamines may be given, if necessary, to control itching. The patient should be encouraged to get plenty of exercise. If the eczema persists, careful re-examination of the limb should be made for previously missed perforating veins, and persistent small patches may be treated with local corticoids. In almost all cases the eczema clears when the venous disorder has been treated satisfactorily.

4.Varicose ulcers. Many patients with non varicose ulcers on their legs are referred to a clinic specializing in the treatment of venous disorders, and it is important to be on the lookout for them. Ulcers due to arterial insufficiency are common and the possibility that an ulcer may be malignant should always be borne in mind, especially if the venous system is normal or only mildly diseased. Early biopsy is necessary in such cases. In the treatment of true varicose ulcers the veins in the non-ulcerated areas are injected in the way already described. Dry dressings are applied to the ulcer and bandaged firmly in place with a rubber pad over the ulcer to give extra pressure. The daily hour of walking should be carried out conscientiously, and the patient should sleep with the foot of the bed raised. Exercising the legs and ankles while lying in the bed is also advisable. When the ulcer has healed it is important to examine the site, since there is very frequently an incompetent perforating vein to be found there.

5. Angiectids. Treatment of these is often sought for cosmetic reasons and should be discouraged for the reasons already given. An exception is the 'starbust' type of angiectid which is especially common in pregnancy and is often painful. There is frequently an incompetent perforating vein at the centre and this should be injected as deeply as possible. The injection of sodium tetradecyl foam is often successful but may cause sloughing of the skin.

6. Combined arterial and venous disease. Patients who suffer from both arterial inadequacy and chronic venous congestion of the lower limb may have their veins treated in the normal way, but great care should be taken that the compression does not reduce arterial flow below a safe level. Such patients are incapable of performing as much exercise as is usually advised and this should be accepted. Exercise on a pedalling machine at home is a useful alternative. It has been found in many cases that treatment of the venous disorder produces symptomatic relief also of the arterial supply, and that this improvement is maintained .

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