Dr. Martin : I had a student contact me after having done my sclerotherapy course 10 years ago. She did veins for a while, but got side tracked and is now starting a sclerotherapy practice again. Her question was:
During our course, you taught us to always look for SFJ insufficiency (hand-held doppler) before any injecting, but I don’t recall that you felt colour ultrasound mapping was essential to be done in each patient, especially not those who only have small caliber (under 2mm) cosmetic superficial veins. What is your practice now? I don’t intend treating anything other than cosmetic veins of caliber as mentioned as the clinic is very much a cosmetic facility. I will of course do a physical exam (standing & supine) and will assess with a magnified polarised light system as well; do you think that it will adequately show up reticular feeders to superficial threads? And I’ll obviously test for SFJ sufficiency as you taught.
Dr. Martin’s Answer:
So wonderful to hear from you after all these years! Your question has a short answer and a long one.
Short Answer: When there is no palpable or visible sign of a vein over 2mm or venous insufficiency (swelling, phlebitis, corona, pigmentation), there is no need to undergo a full ultrasound assessment.
Long Answer: There are very few (maybe 20%) “vein” patients that fit into this category. Most have some form of varicosity underlying the spider and reticular veins.
If there is SFJ reflux then certainly, the patient needs an ultrasound and a referral to a more advanced vein clinic for consideration of either surgery, laser or ultrasound guided injection.
If there is no reflux at the SFJ, she may indeed have incompetent perforators which are creating many of the visible cosmetic veins. These varicosities must be dealt with first. If they are not treated, you risk increasing the risk of side effects including staining, phlebitis and poor treatment outcome.
As far as illumination goes, the polarized light is only good for superficial spider veins. It will miss most reticular veins. I recommend that you purchase a “veinlite” from the manufacturer in the states. The LED version is now excellent and not expensive (about $650)
I suggest strongly that you reconsider your decision not to treat any varicose veins. As a physician, you are in the ideal position to deal with the problem at it’s source. You qualify for a 50% reduction on the course cost if you want to come back to see me… Please come!