Sclerotherapy Training Online provides you with our FREE Asclera & Sclerotherapy Certification Training Manual. Please contact us for your complete online training for physicians, nurse practitioners, and physician assistants.
How to inject Asclera & Sclerotherapy: a Beginner’s Guide.
What is Sclerotherapy?
Sclerotherapy is a cosmetic procedure performed to treat blood vessel malformations. The procedure consists of injecting a sclerosing agent into the blood vessel with a fine gauge needle. The injected agent irritates the lining of the vessel, which causes it to swell and stick together. Gradually, in a matter of weeks/months, the vessel changes into scar tissue that fades, and eventually becomes barely noticeable.
Unsightly varicose and spider veins have existed ever since humans assumed an upright posture, and gravity inhibited venous return from the extremities. One of the oldest records of venous disease was observed on a religious tablet dedicated to the gods by a citizen of ancient Greece in hopes of healing a disabling case of varicose veins.
Spider veins, or Telangiectatic leg veins, are estimated to occur in at least half of the adult population, typically occurring more frequently in women. These small, unsightly clusters of veins, usually colored red, purple or blue, appear commonly on the thighs, calves and ankles.
Sclerotherapy has been used in Europe for over 60 years, and was introduced here in the U.S. about 30 years ago. The introduction of mild sclerosing agents that are able to be used in small veins has made sclerotherapy results predictable and relatively painless. Modern sclerotherapy has been demonstrated to result in a relief of symptoms in up to 85% of patients.
Introduction to the Venous System of the Lower Extremities
There are two channels into which the venous system of the lower limbs is divided:
1) A system within the muscular compartment
2) A second system outside of the muscular compartment in which superficial veins are distributed
The superficial and deep venous systems are connected by perforating veins. The deep venous system serves to drain the superficial venous system.
Sclerotherapy should NEVER be performed in the dorsal foot or groin area. Also, be cautious in areas located in close proximity to pulses.
When administering sclerotherapy in the areas noted below, minute amounts of sclerosing agents should be used. In the ankle area, the maximum amount of solution used should be 0.5 cc:
-Vein of Giacomini (ascending superficial vein) located in the Popliteal Fossa. It connects the lesser saphenous vein to the greater saphenous vein in the upper thigh.
-Lesser Saphenous Vein found in the lateral aspect of the foot, dorsal venous arch, lateral malleolus, and the midline of the calf.
-Greater Saphenous Vein located in the dorsal aspect of the foot, medial malleolus, and the medial thigh.
Type I: Telangiectasias- the smallest vessels treated by sclerotherapists, measuring between 0.1 – 1 mm in diameter. They tend to be flush with the skin’s surface, and appear to have a reddish color. They are typically distended arterioles or capillaries.
Type 2: Venulectasias- measure from 1 – 2 mm in diameter. They tend to be slightly elevated from the skin’s surface, and may appear purple/blue in color. These vessels tend to arise from the venous side of capillary loops.
Type 3: Reticular veins- are from 2 – 4 mm in diameter. They appear blue/green in color, and often feed into branch points of telangiectasia and venulectasia.
-Pregnancy (patients may start sclerotherapy 6 months after childbirth)
-Autoimmune disorders/Advanced collagen vascular disease
-Insulin Dependent Diabetes Mellitis
-Acute deep vein thrombosis
-Acute febrile illness
-Severe bronchial asthma
-Severe circulatory problems
-Diseases interfering severely with a patient’s mobility
-Acute superficial thrombophlebitis
-Non-Insulin Dependent Diabetes Mellitus
-Vitamin E/Gingko/St. John’s Wort
-NSAIDS (Motrin, Aleve, Advil, Ibuprofin)
-Birth Control Pills
As a sclerotherapist, you should be aware of other sclerosing agents being administered. This information is provided for background knowledge only, and is subject to change.
-Hypertonic Saline (18-30%)
-Sodium Tetradecyl Sulfate (sotradecol)
-Sodium Morrhuate (fatty acids in cod liver oil)
-Polyiodide Iodine (varigloban)
Hypertonic Saline has been used in treating small veins for approximately 20 years in the United States. Concentrations of 10-30% have been used in treating telangiectasia, venulectasia and reticular veins. Available commercially in 30 mL vials of 23.4% concentration, hypertonic saline may be diluted with lidocaine, procaine, or bacteriostatic water. Hypertonic saline also possesses intrinsic antimicrobial properties, which helps prevent infections in treated patients.
The mechanism of action of hypertonic saline solution is as an osmotic sclerosant which produces endothelial damage via a gradient dehydration effect.
Manufacturer – Merz Aesthetics
• FDA approved agent indicated to treat spider veins
and reticular veins in the lower extremity.
• The most common adverse reactions occurring at
least 3% more frequently than on placebo are mild
local reactions at the site of injection. Known
allergies to polidocanol. Patients with acute
Dosage and Administration
• Spider veins (varicose veins ≤1 mm in diameter): Use
• Reticular veins (varicose veins 1 to 3 mm in diameter):
Use Asclera 1%.
• Use 0.1 to 0.3 mL for each injection into each varicose
• The maximum recommended volume per treatment
session is 10 mL.
• Repeat treatments may be necessary if the extent of
the varicose veins requires more than 10 mL. These
treatments should be separated by1 to 2 weeks.
Maintain compression for 2 to 3 days after treatment
of spider veins and for 5 to 7 days for reticular veins.
• For extensive varicosities, longer compression
treatment with compression bandages or a gradient
compression stocking of a higher compression class is
• Posttreatment compression is necessary to reduce the
risk of deep vein thrombosis.
• Small intravaricose blood clots (thrombi) that develop
may be removed by stab incision and thrombus
• 0.5% solution in 2 mL glass ampules. 2 or 5
ampules are provided in a package.
• 1% solution in 2 mL glass ampules. 2 or 5
ampules are provided in a package.
Which should be treated first, small diameter vessels, or reticular veins?
Whether the sclerotherapist should proceed from the top of the leg down, or starting distally and working proximally is a question of preference. One approach is to ask the patient which area is most bothersome and pay special attention to that area. The patient should be educated that full treatment of Telangiectasia should also include treatment of the reticular veins.
Patients are typically placed in a recumbent position, with the sclerotherapist positioned at or below the patient’s knee level. In treating vessels located on the lateral or posterior thigh may be treated with the patient in a prone position, or on the side. Visibility of areas to be treated along with patient comfort are the most important considerations to keep in mind.
The sclerotherapist should be positioned comfortably so that treatment can be carried out with minimal complications.
Skin tension is important to keep in mind. The sclerotherapist should hold the syringe in the dominant hand between the index and middle fingers. Three-point tension is achieved with proper hand placement. The non-dominant hand should stretch the skin adjacent to the treated vessels.
Typically, no more than 0.5 mL of sclerosing agent is used per injection site to avoid initiating the formation of new telangiectasia.
Injecting with the bevel of the needle facing the skin’s surface minimizes the likelihood of vascular transection by decreasing the vacuum produced between the bevel and the skin’s surface. With continuous tissue tension applied, the sclerosing agent is slowly injected.
Most telangiectasias are located in the upper papillary dermis, and a common problem is inserting the needle too deeply, which results in vascular transection.
If the vessel is properly injected, blanching will occur immediately in the treated vessel and its local tributaries. If the needle is not within the vessel, however, extravation occurs and the sclerosant leaks out onto the skin’s surface or superficial tissue swelling is observed.
Brisk cannulation and small volumes of sclerosing agent injected will help to minimize patient discomfort, extravasation and damage to the deep venous system.
Injection pressure should be slow and gentle to help prevent complications. Filling a vessel should take between 5-10 seconds. Rapid pushes of large amounts of sclerosants can lead to complications.
Keep in mind that treatment of the feeding arborizing foci of telangiectasia will minimize the number of puncture sites necessary to achieve the desired results. This will lead to a decrease in hyperpigmentation.
Overview of Treatment Scenario in Sclerotherapy Training
-Patient is wearing a gown or loose-fitting shorts, and is placed in a supine position on the treatment table. (Positioning may change depending on which areas will be treated.)
-Treatment sites are properly visualized using a high-intensity magnifying headlamp, a magnifying floor lamp, and magnifying glasses.
-Appropriate gloves are part of Universal Precautions in this blood-contact procedure. Gloves should be snug-fitting to allow for optimal palpation.
-The skin is cleansed with alcohol. The wetness of the alcohol helps to render the skin more transparent, and allows for enhanced visualization of the veins to be treated.
-Injections are usually performed with 30 g 0.5 inch disposable needles. The needle is inserted at a 30-45 degree angle with the bevel side up. This allows the vascular lumen to be transected at an acute angle, which minimizes the possibility of transecting the vessel.
-A 3 mL syringe is adequately-sized and allows for slow, gentle injection of the sclerosing agent. Smaller 1 mL tuberculin or insulin syringes are often associated with leakage of sclerosant and higher injection pressures, which may lead to complications.
-Documenting the areas treated using an anatomic treatment chart is useful for future evaluation, treatment, and follow-up treatments.
Asclera and Sclerotherapy Certification Training Online
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