Acs0625 Sclerotherapy

© 2003 WebMD Corp. All rights reserved. ACS Surgery: Principles and Practice
6 VASCULAR SYSTEM 25 SCLEROTHERAPY — 1

25 SCLEROTHERAPY

William R. Finkelmeier, M.D., F.A.C.S.

Sclerotherapy involves the injection of a caustic solution (a scle- sclerotherapy of the greater saphenous vein.3 Obliteration of the
rosant) into an abnormal vein so as to cause localized destruction of greater saphenous vein was noted in only 20% of the injected limbs
the venous intima and obliteration of the vessel. It is not a new tech- and in only 6% of the limbs below a refluxing junction.These poor
nique, having been practiced since the early 20th century, but it has results from sclerotherapy were confirmed in a subsequent study.4
evolved significantly over the past 50 years.1 Improvements in the The superiority of surgical treatment was also demonstrated in a ran-
technology used (e.g., hypodermic syringes, fine needles, sclerosants, domized 10-year study comparing surgery with sclerotherapy alone.5
compression technique, and duplex ultrasonography) have greatly Ultrasound-guided sclerotherapy has also been advocated. The
enhanced the results achievable with sclerotherapy.To ensure opti- advantages of this approach are that it allows much higher con-
mal results, it is essential to have a thorough knowledge not only of centrations of the sclerosant solution and that it permits direct
the technique but also of the indications, expected outcomes, and visualization of the injections. Reported recurrence rates are still
possible complications associated with the procedure. quite high, however: 22.8% at 1 year and 27.2% at 2 years..6 A
Sclerotherapy is primarily used to treat small varicose veins, number of authors, primarily in the dermatologic literature, have
reticular veins, and spider veins. The prevalence of varicose and advocated ultrasound-guided foam sclerotherapy for patients with
spider veins is well documented: they affect millions of people in axial reflux.7,8 The longevity of the results achieved with this tech-
the United States alone.1 The incidence is two to three times high- nique is still in question, and further studies (including random-
er in women than in men and increases with age. The precise eti- ized trials) are needed for validation.
ology of varicose veins and spider veins is unknown. Heredity, Given the available data, my preferred approach in patients with
pregnancy, female sex, obesity, an occupation that requires long axial reflux is to ligate the greater saphenous vein, strip the vein at
periods of standing, and a low-fiber diet all have been implicated least to the knee, and then ligate the lesser saphenous vein before
as causative factors. The choice of treatment method for varicose sclerotherapy. Patients who do not have axial reflux and whose
veins and spider veins must be individualized for each patient. vessels are less than 6 mm in diameter can be treated successfully
Although sclerotherapy is only one of a number of techniques with sclerotherapy alone.Varicose veins more than 6 mm in diam-
available for treatment, it is an important therapeutic tool and a eter are best treated surgically by means of phlebectomy, either
key component of a vascular surgeon’s armamentarium. with a hook or with a transilluminated powered phlebectomy
device. The cosmetic results are far better and the recovery time
much shorter with the surgical option.
Preoperative Evaluation
Proper evaluation of the patient before sclerotherapy is the most
important step in achieving successful results. Such evaluation Operative Planning
should include a thorough clinical arterial and venous examination.
PATIENT PREPARATION
Close attention should be paid to the size, location, and distribution
of vessels; these variables are critical for determining the appropriate Before undergoing sclerotherapy, the patient should receive a
treatment. Any patient who is believed to have axial reflux or whose thorough explanation of the procedure, including the possible risks
clinical complaints far exceed the findings from physical examina- and complications [see Table 1]. He or she should be informed
tion should undergo venous duplex ultrasonography. about the expected outcomes and the length of time needed for
Venous duplex ultrasonography has revolutionized the treatment healing. In particular, it should be emphasized that multiple treat-
of varicose and spider veins. It is reproducible and noninvasive, and it ments are usually necessary to eliminate varicosities. Most patients
can objectively identify areas of reflux in the greater and lesser saphe- can expect to undergo four or five treatments in a 6-month period.
nous systems, as well as detect pathologic conditions in the deep ve- Time and patience are essential for achieving an optimal outcome.
nous system and incompetent perforating vessels. Duplex ultra- Because sclerotherapy is primarily cosmetic and therefore rarely
sonography can also identify the lesser saphenous–popliteal junction reimbursable, it is important to have a clear understanding regard-
and facilitate skin mapping in preparation for surgery. ing costs. A good-faith estimate of the cost per procedure should
Patients with duplex-documented axial reflux or reflux from the be provided to the patient before treatment is initiated. It is advis-
greater or lesser saphenous junction are best managed by means of able to have the patient sign a copy of this estimate so that there is
surgical correction of the reflux rather than primary treatment with no subsequent misunderstanding about the costs to be incurred
sclerotherapy. In a 1993 randomized study, ligation and stripping during the course of therapy.
were compared with compression sclerotherapy in 164 patients who To reduce bruising, aspirin and antiplatelet agents should be
had symptomatic primary varicose veins.2 After 5 years, 74% of the avoided for 10 days before treatment. On the day of the procedure,
patients treated with sclerotherapy were considered to have had treat- the patient should be asked to refrain from applying lotion to the legs
ment failures, compared with only 10% of the patients treated surgi- so that the tape applied after treatment will adhere better to the skin
cally. In a 1991 trial, real-time color duplex ultrasonography was used [see Table 2].The patient should sign and date an informed consent
to evaluate 89 limbs in 55 patients who had previously undergone form. Once informed consent is obtained, photographs of the areas


Table 1 Complications of Sclerotherapy

Complication Comment

Itching Usually mild; lasts for 1–2 days

Hyperpigmentation Occurs in about 20%–30% of patients treated; usually fades in a couple of weeks but
may take several months to a year to resolve totally; lasts longer than 1 yr in 1% of cases

Telangiectatic matting Occurs in approximately 10% of patients treated; usually resolves in 3–12 mo if left
untreated but in rare cases can be permanent
Common
Pain Lasts 1 to, at most, 7 days

Bruising May be minimized by avoiding aspirin and ibuprofen for 10 days before and after each
treatment session

Minor allergic reaction Typically resolves within about 1 hr

Ulceration at injection site Can take 4 to 6 wk to heal completely; small scar may result

Rare Anaphylaxis Incidence is extremely low

PE or DVT Incidence is extremely low
DVT—Deep venous thrombosis PE—pulmonary embolism

to be treated should be taken. Either a digital camera or a conven- with the addition of lidocaine, injection of HS is associated with
tional 35 mm camera may be used. Digital photography offers some degree of patient discomfort. Moreover, HS is more viscous
much greater flexibility, in that there is no need to wait for film de- than STS and thus more difficult to administer. Extravasation of HS
velopment.The pictures should be standardized as much as possible is also associated with a higher risk of skin necrosis.
with respect to lighting and background. The problem areas are
photographed again after treatment, and additional pictures are ob-
tained during subsequent treatments to document progress. The
aim is to give patients a reliable means of objectively comparing the Table 2 Sample Instructions to Patients
legs’ appearance before and after sclerotherapy [see Figures 1 through after Sclerotherapy
3]. Such photographs often reassure patients that significant cos-
metic improvement has been achieved and encourage them to con- NEXT APPOINTMENT TIME
tinue treatments.
Be sure to keep your follow-up appointment so the physician can
monitor your progress.
MATERIALS
Please be considerate and give our office at least 72 hours’ notice if
Sclerosants cause thrombosis and subsequent fibrosis when you are unable to keep an appointment. This will allow us time to call
injected into a blood vessel. An ideal sclerosant would exert this patients who are on the waiting list for an appointment.
effect reliably while also being inexpensive, widely available,
Please walk for a few minutes before driving home.
approved by the Food and Drug Administration (FDA), and non- Wear your support hose for 48 continuous hours.
toxic. In addition, it would be painless on injection and would After 48 hours, remove the hose, cotton balls, and tape before getting
not cause hyperpigmentation or ulceration with extravasation. your legs wet.
Unfortunately, this ideal sclerosant does not exist. All of the solu- After 48 hours, wear your support hose for a minimum of 7 days during the
waking hours. Note, you may continue to wear them longer if you prefer.
tions currently available have disadvantages.
Do not run, do high-impact aerobics, lift weights with your legs, or do
Sclerosants may be classified into two main categories: osmotic sit-ups for 2 weeks. These activities can increase the venous pressure
agents and detergents. Hypertonic saline (HS) is the most widely in your legs.
used osmotic agent. FDA-approved as an abortifacient, it is com- For 2 weeks, do not take hot baths or showers or sit in a hot tub. The
monly employed to treat superficial telangiectasias. HS in a 23.4% heat can cause vein dilatation. You may take a warm shower or bath
after 48 hours.
concentration damages the endothelial cells of the vessel walls Avoid aspirin and ibuprofen products for 10 days before and after each
through hyperosmolarity-induced dehydration. Such damage leads treatment. These products may increase the amount of bruising that
to thrombosis and fibrin deposition. Sodium tetradecyl sulfate may develop from the treatment. Acetaminophen is permitted.
(STS) and polidocanol (POL) are the most widely used detergent For further information regarding sclerotherapy, please refer to the hand-
out “Sclerotherapy Informed Consent and Before and After Treatment
agents in the United States. These agents form aggregates on en- Instructions.”
dothelial cell surfaces and cause endofibrosis by disrupting the in-
tegrity of the cells. Preparation for Your Next Treatment
In the United States, HS has been used to treat spider and vari- Bring your support hose.
cose veins for more than 50 years. Because it is a naturally occurring Do not apply creams, lotions, or powders to your legs the evening before
or the morning of your treatment.
bodily substance, it does not cause allergic reactions; however, it Bring a pair of loose shorts to wear during your treatment.
causes patients much more pain and discomfort than either STS or Avoid aspirin and ibuprofen products for 10 days before and after each
POL does.9 Adding lidocaine to HS reduces the pain associated treatment. These products may increase the amount of bruising that
with the injections without significantly decreasing the effectiveness may develop from the treatment. Acetaminophen is permitted.
of treatment or increasing the incidence of complications.10 Even


a b

Figure 1 Sclerotherapy. Shown is a 63-year-old woman (a) before and (b) after two treatments with
0.2% STS.

STEP 1: POSITIONING AND SKIN PREPARATION
Of the detergent sclerosants, both STS and POL are widely
used in the United States, but only STS is FDA approved. FDA Sclerotherapy is best performed with the patient supine. On
approval of POL has been pending for years, and it is unclear why very rare occasions, it may be necessary to puncture a vein with
it has not yet been granted. POL appears to be a very good scle- the patient standing. However, the sclerosant is not injected until
rosant, comparable to STS: it is safe, relatively painless, and high- the patient has been returned to the supine position, thus allowing
ly effective in all vein types.11,12 In a 2002 randomized study com- the vein to empty.
paring STS with POL, both agents were found to be safe and The skin is wiped with alcohol swabs to increase the visibility of
effective, yielding a 70% clinical improvement, and there were the vessels. The sclerosant is then placed in plastic 3 ml syringes.
no significant differences in adverse effects, aside from a small These syringes fit more easily in the hand than tuberculin syringes
decrease in ulcerations with POL.13 Nevertheless, until POL is do and are less cumbersome to use. In addition, because injection
approved by the FDA, we recommend that it not be used. Two pressure is inversely proportional to the squared radius of the
other FDA-approved detergent sclerosants are available: sodium plunger, a 3 ml syringe generates less pressure than a 1 ml syringe
morrhuate (SM) and ethanolamine oleate (EO). However, both does.The endothelial cells in these small vessels are quite fragile, and
SM and EO are associated with an unacceptably high risk of com- using a syringe that generates less pressure substantially reduces the
plications, including but not limited to ulceration and anaphylac- risk of vessel disruption.
tic reactions, and hence are rarely used. For these reasons, my
STEP 2: CHOICE OF SCLEROSANT CONCENTRATION
practice is to use STS for sclerotherapy, and the ensuing technical
discussion will focus solely on this agent. The solution concentration selected depends on the size of the
Sclerotherapy is an outpatient procedure performed in the physi- vessel. I use 0.2% STS for vessels less than 2 mm in diameter and
cian’s office. Aside from the sclerosant, very few special materials are 0.5% for larger vessels. The volume per injection site is generally
needed [see Table 3]. Because there is a risk of significant allergic reac- less than 0.5 ml, but larger volumes may be preferable for reticu-
tions (albeit an extremely small risk), a fully stocked resuscitation lar or small varicose veins.
cart including intubation equipment should be available and At present, there is enthusiasm in the literature for the use of foam
checked regularly to confirm that all equipment is up to date and sclerotherapy, a technique in which air is repetitively injected into
ready for immediate use. STS to create a foam.14 This technique is ultimately based on the
work of Orbach, who in 1944 advocated expelling blood from the
vein by injecting small boluses of air before injecting the sclerosant.15
Technique The rationale for foam sclerotherapy is that the foam displaces blood
A variety of sclerotherapy techniques have been developed. in the vessel, resulting in less dilution of the solution.The sclerosant
Typically, each individual practitioner develops his or her own then has more contact with the surface area of the venous endotheli-
variation of the procedure. um and thus can sclerose the endothelial cells more efficiently at


a b

Figure 2 Sclerotherapy. Shown is a 52-year-old woman (a) before and (b) after two treatments with
0.5% STS.

lower concentrations. Of the various methods of creating a foam shown that using some type of bandage or pad in addition to sup-
sclerosant solution,16 that described by Tessari and coworkers ap- port hose is beneficial.The degree of compression achieved with
pears to be the easiest.17 In this approach, air is injected into the solu- this approach can be as much as 50% greater than that achieved
tion via a three-way stopcock and two syringes. Because of the size of with support hose alone.18 Gauze pads or cotton balls are more
the bubbles in a foam solution, foam sclerotherapy is best suited to cost-effective than foam pads while providing comparable com-
treatment of reticular and varicose veins. Spider telangiectasias are pressive effects.19
best treated with standard solutions. Compression approximates the endothelial surfaces of the vein
walls after sclerotherapy, thereby reducing thrombus formation
STEP 3: INJECTION OF SCLEROSANT
and promoting sclerosis of the vessel. It also enhances the calf
I use 30-gauge needles for all sclerotherapy treatments; some muscle pump function to help clear any solution that has pro-
physicians prefer 27-gauge needles for larger reticular and small vari- gressed into the deep venous system. Reduction of thrombus for-
cose veins. The needle is bent at a 45º angle, with the bevel up. mation after sclerotherapy is important for minimizing hyperpig-
Countertraction is applied with the nondominant hand, and the nee- mentation. In a multicenter randomized trial that evaluated patients
dle is inserted parallel to the vessel and the skin surface [see Figure 4]. who underwent bilateral sclerotherapy but who received compres-
As the vessel is entered, the sclerosant is gently injected.The slight sion to only one leg, hyperpigmentation and edema were signifi-
reduction of pressure that occurs when the vessel is entered becomes cantly greater in the uncompressed leg.20
increasingly easy to appreciate as the physician accumulates experi- Varying recommendations have been made as to how long com-
ence with sclerotherapy. Blanching of the vein is another signal of en- pression hose should be worn after sclerotherapy. A controlled com-
try into the vessel. If the solution is injected outside the vein, a small parative trial of the effects of compression in patients with reticular
superficial wheal will appear, in which case the injection should be and telangiectatic veins found that patients who wore hose for 3
discontinued and a new site selected for injection. Such wheals are weeks exhibited greater improvement (e.g., less hyperpigmentation)
unlikely to be a problem when STS concentrations lower than than those who wore no hose.21 However, the improvement in pa-
0.25% are used.When more concentrated solutions are used in larg- tients wearing hose for 3 weeks was not appreciably greater than that
er veins, aspiration of blood ensures correct placement of the needle in patients wearing hose for 1 week. I find that it is difficult to get pa-
within the vein before injection. tients to wear compression hose for several weeks.Therefore, I have
adopted the standard practice of instructing the patient first to wear
STEP 4: COVERAGE AND COMPRESSION OF INJECTION AREAS
the hose for 48 hours without removing them, then to wear them
After injection, cotton balls or foam or gauze pads are secured during waking hours only for the next 7 days.
with tape and applied to the injection areas. Compression hose Once the compression hose are in place, the patient is asked to
(20 to 30 or 30 to 40 mm Hg) are then applied. Studies have walk for 15 minutes before leaving the office. This further assists


a b

Figure 3 Sclerotherapy. Shown is a 36-year-old woman (a) before and (b) after four treatments
with a combination of 0.5% and 0.2% STS. Mild hyperpigmentation may be seen on the lateral thigh.

in clearing any solution that may have progressed into the deep release. In the vast majority of cases, such reactions are self-limit-
venous system. ed, typically resolving in less than 1 hour. Itching often accompa-
nies this response, but it usually resolves by the time the patient
STEP 5: SCHEDULING OF RETREATMENT
leaves the office. Should reactions persist, oral antihistamines or,
As noted (see above), multiple treatments are usually required for on rare occasions, steroids may be required.
optimal outcome.Therefore, all patients are instructed to return in 4 With the sclerosants used today, anaphylactic reactions are
to 6 weeks for assessment and possible retreatment. After this inter- extraordinarily rare but can be life-threatening. The incidence of
val, vessels requiring further treatment are apparent, and additional anaphylaxis with STS is not known with precision but is certainly
injections can be performed.The average patient undergoes four or very low. The reaction is usually mediated by immunoglobulin E
five treatments. and occurs within minutes of exposure. Appropriate emergency

Complications
Although sclerotherapy is generally quite safe, complications do
occur. Physicians must therefore be cognizant of the potential risks
and prepared to treat any adverse events that arise. The most sig-
nificant complications of sclerotherapy are allergic reactions
(either minor or major), skin necrosis, hyperpigmentation, deep
venous thrombosis (DVT), and telangiectatic matting. Cramping,
pain, edema, and blistering from tape or compression may be
observed as well.
Minor allergic reactions are quite common. For example, local-
ized urticaria and edema may occur secondary to histamine

Table 3 Materials Needed for Sclerotherapy
Alcohol swabs Cotton balls and tape
Protective gloves 18-gauge needles
3 ml syringes 4 × 4 in. gauze pads Figure 4 Sclerotherapy. Illustrated is the standard hand position
30-gauge needles Adhesive bandages for sclerotherapy. Countertraction is applied with the nondomi-
nant hand.


measures must be undertaken immediately, including subcuta-
neous administration of epinephrine, delivery of supplemental
oxygen, and securing of the airway. The patient should then be
given antihistamines and transferred to an emergency department
for continued evaluation and treatment. As noted (see above), a
properly stocked emergency response cart, including endotracheal
intubation supplies and medications, is essential in any ofﬁce
where sclerotherapy is performed. Periodic review of procedures
with staff and maintenance of the emergency medications and
supplies is imperative.
Skin necrosis occurs with 0.2% to 1.2% of sclerotherapy injec-
tions.22 It is a potentially devastating complication and is often
unpreventable. Depending on the extent of necrosis, healing may
take months. The main causes of necrosis are extravasation of the
sclerosant into subcutaneous tissue, inadvertent injection into an
arteriole, and vasospasm. Extravasation of the sclerosant can des-
troy tissue, with the degree of damage determined by the type, con-
centration, and amount of sclerosant used [see Figure 5]. Necrosis
is rare when small amounts of dilute (< 0.25%) STS are given, but
extensive skin and soft tissue necrosis has been observed when
higher concentrations of STS (3%) are administered to treat vari-
cose veins.23 Inadvertent injections into the arteriole feeding the
telangiectasia is impossible to prevent and probably occurs fre-
quently. In a 2001 study, pulsatile Doppler sounds could be de-
tected above spider vein complexes in 72% of cases.22 Backwash
of the solution through arteriovenous shunts may cause occlusion
of the arteriole and skin necrosis. Blanching of the skin often
occurs with intra-arteriolar injections. Skin massage or, if spasm
persists, application of nitroglycerin ointment to the skin may
increase microcirculation.Why ulcerations develop in some patients
but not others is unknown.The question of whether it is related to
Figure 5 Sclerotherapy. Shown is skin necrosis on the injection pressure or injectate volume also remains unanswered.
left posterior calf of a 48-year-old woman after ultra- Hyperpigmentation [see Figure 6] is quite common, occurring in a
sound-guided sclerotherapy. signiﬁcant percentage of patients, and it may be caused by any of the

a b

Figure 6 Sclerotherapy. Shown is residual hyperpigmentation in a 56-year-old woman after treatment
with 0.2% STS.


achieved with weekly subcutaneous injections of the chelating agent
deferoxamine mesylate.24 That various different treatments continue
to be recommended suggests that none of them is clearly superior at
eliminating hyperpigmentation. The passage of time appears to be
the most reliable therapy.
The precise incidence of DVT after sclerotherapy is unknown
but appears to be extremely low overall. The risk is somewhat
higher when more concentrated solutions are used or larger vol-
umes administered; however, it may be minimized by performing
sclerotherapy only for established indications.Treating axial reflux
and larger vessels surgically, with sclerotherapy limited to an
adjunctive role, will reduce the volume and concentration of solu-
tion needed. Ambulation in the physician’s office after treatment
will help wash away any solution that has progressed into the deep
venous system.
The development of tiny new red vessels at an area of previous
injection is called telangiectatic matting [see Figure 7]. Like ulcer-
ation, it is unpredictable. Excessive pressure during injections is
thought to play a causative role, but the exact etiology is unknown.
Telangiectatic matting is very difficult to treat once it has devel-
oped. Occasionally, it resolves spontaneously, but more often, it
must be addressed by means of either repeat sclerotherapy with
treatment of the feeding reticular vein or laser therapy. Treatment
of telangiectatic matting may in fact be the one potential effica-
cious use for laser-type devices in treating diseased leg veins.

Cost Considerations
Figure 7 Sclerotherapy. Shown is telangiectatic I strongly believe that all sclerotherapy, with the exception of
matting in a 43-year-old woman after treatment that performed for spontaneous hemorrhage, is cosmetic.
with 0.2% STS. Accordingly, in the practice to which I belong, patients seeking
sclerotherapy for reasons other than hemorrhage are informed
well in advance that the procedure is cosmetic and not reim-
sclerosants in current use. It is more common in persons with dark bursable, and they receive a good-faith estimate of expected costs
complexions and in those with dark-purple vessels. Fortunately, hy- in writing. As noted (see above), venous ligation is the treatment
perpigmentation usually resolves with time, but the process can take of choice for symptomatic axial reflux and large varicose veins;
months. Postsclerotherapy compression lowers the incidence of hy- therefore, sclerotherapy for these conditions is considered med-
perpigmentation, and removal of any intraluminal thrombi remain- ically unnecessary.
ing after sclerotherapy reduces the degree of hyperpigmentation Obtaining reimbursement from insurance carriers for sclerother-
present.The latter is accomplished by puncturing the skin with an apy performed to treat small varicose veins or hemorrhage is frus-
18-gauge needle and manually expressing the thrombus.There is no trating at best. Both physicians and patients have contributed to the
firm consensus on how hyperpigmentation should be treated once it problem in the past by filing inappropriate claims for reimbursement
develops. Some authorities recommend the use of fade creams, of cosmetic procedures.This past misuse of insurance coverage has
whereas others advocate laser treatments to lighten the pigmen- made it difficult to obtain reimbursement even for the one solid
tation. A 2001 study found that 80% depigmentation could be medical indication for sclerotherapy, hemorrhage.

References

1. Goldman MP, Bergan JJ: Sclerotherapy: Treat- vascular sclerotherapy, surgery, and surgery plus nique in the management of greater saphenous
ment of Varicose and Telangiectatic Leg Veins, sclerotherapy in superficial venous incompetence: varicosities with saphenofemoral incompetence.
3rd ed. Mosby–Year Book, Inc, St Louis, 2001, a randomized, 10-year follow-up trial—final Phlebology l7:19, 2002
p1 results. Angiology 51:529, 2000
9. McCoy S, Evans A, Spurrier N: Sclerotherapy
2. Einarsson E, Eklof B, Neglen P: Sclerotherapy or 6. Kanter A, Thibault P: Saphenofemoral incompe- for leg telangiectasia—a blinded comparative
surgery as treatment for varicose veins: a prospec- tence treated by ultrasound-guided sclerothera- trial of polidocanol and hypertonic saline. Der-
tive randomized study. Phlebology 8:22, 1993 py. Dermatol Surg 22:648, 1996 matol Surg 25:381, 1999
3. Bishop C, Fronek H, Fronek A, et al: Real-time 7. Cabrera J, Cabrera J Jr, Garcia-Olmedo MA: 10. Bukhari R, Lohr J, Paget D, et al: Evaluation of
color duplex scanning after sclerotherapy of the Treatment of varicose long saphenous veins with lidocaine as an analgesic when added to hyper-
sclerosant in microfoam form: long-term out-
greater saphenous vein. J Vasc Surg 14:505, 1991 tonic saline for sclerotherapy. J Vasc Surg 29:479,
comes. Phlebology 15:19, 2000
4. Goren G: Real-time color duplex scanning after 1999
8. McDonagh B, Huntley DE, Rosenfeld R, et al:
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Efficacy of the comprehensive objective map-
ter). J Vasc Surg 16:497, 1992 ping, precise image-guided injection, anti-reflux canol. J Dermatol Surg Oncol 19:959, 1993
5. Belcaro G, Nicolaides A, Ricci A, et al: Endo- positioning, and sequential sclerotherapy tech- 12. Conrad P, Malouf GM, Stacey MC: The Austra-


lian polidocanol (aethoxysklerol) study. Dermatol 17. Tessari L, Cavezzi A, Frullini A: Preliminary 21. Weiss RA, Sadick NS, Goldman MP, et al: Post-
Surg 21:334, 1995 experience with a new sclerosing foam in the sclerotherapy compression: controlled comparative
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