Whether surgical or sclerotherapeutic, treatments for diseased lower extremity veins are aimed at controlling and limiting the natural progression of this chronic disease. The treatment of varicose veins begins by eliminating all sources of reflux. This is generally taken care of with surgical techniques such as ligation and stripping or, more recently, with heat obliteration techniques using radiofrequency or laser energy. Once these sources of reflux are eliminated, attention is placed on the elimination of the abnormal subcutaneous varicose, reticular and spider veins. The techniques that are available at UCSD include injection therapy (sclerotherapy) and surgical vein removal (ambulatory phlebectomy).

Vein sclerotherapy was first attempted over 150 years ago. Recent advances in technology have increased our understanding of lower extremity venous conditions enhancing our success in applying these therapeutic techniques.

The major principles in treating local veins with sclerotherapy are the following:
1. Choosing appropriate agents to maximize therapeutic effects,
2. Minimizing the side effects,
3. Minimizing patient discomfort, and
4. Maximizing the area of treatment per session.

Contraindications to sclerotherapy may include pregnancy, lactation, allergy to sclerosing agent, hypercoagulable state, air travel within 48 hours, and non-compliance.

We use Polidocanol as our sclerosing agent and perform 30-minute sclerotherapy sessions per visit. Multiple guidance techniques are utilized including ultrasound, transcutaneous illumination or palpation to inject our agent. Our treatment plan includes:
1. First treat proximal reflux (greater, short saphenous vein),
2. Larger and protruding veins are treated before smaller veins,
3. Treat from thigh to foot,
4. Adequate compression therapy (compression stockings) for one week, and
5. Early ambulation and return to normal activities except for strenuous exercise.

Complications of sclerotherapy include:
1. Skin hyperpigmentation and bruising,
2. Bleeding or seroma,
3. Thromboembolism,
4. New spider webs (telangiectatic matting),
5. Vein inflammation, and
6. Pain (may be due to intravascular hematoma, treated with blood evacuation).

Expect the best results 2 to 3 months following therapy. Skin hyperpigmentation can last up to a year (< 1%). Most of the patients will require several treatments to clear their legs of the unwanted veins.

Ambulatory phlebectomy was introduced in the 1960's by Dr. Muller to remove segments of varicose veins of any size and from any location, under local anesthesia, and on an outpatient basis. The indications are:
1. Asymptomatic or symptomatic (painful) varicose veins, and
2. Complicated varicose veins - bleeding, thrombophlebitis, severe pigmentation, and dermatitis.

Contraindications to the procedure include:
1. Skin infections - dermatitis or cellulites,
2. Severe lower extremity swelling,
3. Seriously ill patients, and
4. The very elderly patient, especially the ones that will not be able to follow instructions.

The procedure involves preoperative vein marking while standing. Under local anesthesia and with multiple small 1-3 mm micro incisions strategically distanced from each other, the abnormal vein is surgical removed. All patients are sent to home immediately after the procedure and follow the same postoperative instructions as sclerotherapy patients. The risks and complications are also similar to sclerotherapy patients.