Newer leg vein treatments require caution, care

Seattle - For treating varicose leg veins, various lasers and one radiofrequency (RF) device have replaced vein stripping, one expert says, while foam sclerosants likewise are gaining popularity. However, he cautions that published reports tend to overstate the effectiveness and ease of these newer treatments.

"Instead of doing a stripping procedure, which involves tearing the vein out of the tissue in the leg, one can leave it there and close it permanently using a heat source, which can either be radiofrequency or laser energy," says Nick Morrison, M.D., F.A.C.S., F.A.C.Ph., co-founder and director of the Morrison Vein Institute in Scottsdale, Ariz.

Varying techniques

At the same time, he says that European and, to a lesser extent, South American physicians have begun using a technique called ultrasound-guided foam sclerotherapy.

"That involves taking a sclerosing agent that most everyone uses, making a foam out of it and injecting it into the vein that we would otherwise have heated. The foam chemically treats the vein so that it closes down," Dr. Morrison tells Dermatology Times. European doctors have used this technique routinely for approximately four years and are achieving very good results (Frullini A, Cavezzi A. Dermatol Surg. 2002 Jan;28(1):11-5; Pichot O et al. J Endovasc Ther. 2000 Dec;7(6):451-9.), he adds.

"The South Americans are probably not that far along. And in the United States, because the technique is not Food and Drug Administration (FDA) approved and is a bit experimental, physicians are lagging behind the Europeans," Dr. Morrison says.

Sclerosing detergents used for this procedure include polidocanol and sodium tetradecyl sulfate (STS). STS, manufactured by Bioniche, has earned FDA approval for sclerosing applications as a liquid, but not a foam, he notes.

Conversely, Dr. Morrison says, "Polidocanol is not approved for anything in the United States at this time. Having said that, STS is the most commonly used (sclerosing) drug in the United States, but polidocanol is not far behind. Most of us who do a lot of this work believe that polidocanol is a better drug because it is a bit safer in terms of the side effects." These include local matting (fine red veins), staining (brown discoloration around the treated vein) and ulceration.

"One can actually get an open sore from the STS leaking out of the vein and destroying the surrounding tissue. It's possible with polidocanol but far less common" than with STS, he says.

Foam techniques

Treatment techniques for foam sclerotherapy include direct injection or catheter-directed injection, both performed under the guidance of an ultrasound machine, he says. To perform the latter procedure, which is the subject of ongoing investigational studies, Dr. Morrison says, "one puts a catheter into the vein somewhat like the catheter that one would use to heat the vein. Then one injects foam through this catheter rather than placing a heating instrument. The difference is, one doesn't require any anesthesia with the foam, whereas if one heats the vein, one absolutely needs anesthesia" - also injected under ultrasound guidance.

"All these procedures require ultrasound, both to diagnose the problem and to direct the treatment," Dr. Morrison says. Therein lies a potential limitation of the treatments, he says.

He adds that the training of the technicians interpreting the results is critical to evaluating a patient's results, as is the quality of the machine. Less expensive machines miss open veins that more sensitive ones would catch, he says.

"The trouble is most physicians who do this work can't afford a very expensive ultrasound machine."