Polidocanol Plus Glucose Versus Glucose Alone for the Treatment of Telangiectasias: Triple Blind, Randomised Controlled Trial (PG3T)

Effectiveness of Sclerotherapy to Cure Lower Limb Chronic Venous Insufficiency Grades 1-6: A Systematic Review and Meta-Analysis

Chronic venous insufficiency is a medical condition that impacts the venous system in the lower limbs. The primary characteristic of this condition is the continual elevation of pressure within the leg veins due to walking, which leads to a range of associated issues, such as discomfort, swelling, alterations in the skin, and the development of ulcers. Sclerotherapy has emerged as a potentially effective treatment for chronic venous insufficiency, involving the injection of a sclerosing agent into the affected veins. This study aimed to evaluate the effectiveness of sclerotherapy in treating chronic venous insufficiency grades 1-6 in the lower limb through a systematic review and meta-analysis. The method for conducting this research is by searching articles with relevant keywords carried out through electronic databases, such as Cochrane Library, Pubmed, and Google Scholar. The researchers conducted a comprehensive search and included randomized controlled trials and clinical trials that assessed outcomes, such as patient satisfaction, clinical resolution, quality of life (QoL), and closure rates. Statistical methods were used to analyze the data. The results of the meta-analysis from 9.670 total samples showed that sclerotherapy is the most effective therapy for reducing clinical severity in lower limb venous insufficiency patients (pooled MD = -0.85, 95% CI (-1.41, -0.29), p < 0.00001, I2 = 99%). Sclerotherapy is the most effective therapy for increasing QoL if we use Venous Insufficiency Epidemiology and Economic Study-Quality of Life (VEINES-QOL) as a tool for measuring the QoL (VEINES-QOL scale types; pooled MD = 10.34, 95% CI (8.78, 11.90), p < 0.00001, I2 = 0%). Additionally, sclerotherapy is a more effective therapy for increasing QoL compared to placebo (pooled MD = -1.64, 95% CI (-2.60, -0.67), p = 0.002, I2 = 90%), deferred ablation (pooled MD = -0.22, 95% CI (-0.40, -0.03), p = 0.02), and ligation therapy (pooled MD = -1.29, 95% CI (-1.62, -0.97), p = 0.00001). It is also the most effective therapy for increasing the closure rate for 12-month duration outcome measures (pooled RR = 0.72, 95% CI (0.55, 0.94), p = 0.001, I2 = 91%). However, high heterogeneity was observed in the meta-analysis results, indicating the need for further research to address this variability. This study contributes to the existing body of knowledge on the treatment options for chronic venous insufficiency and highlights the potential of sclerotherapy as an effective treatment modality.

Brazilian guidelines on chronic venous disease of the Brazilian Society of Angiology and Vascular Surgery

The Brazilian Society of Angiology and Vascular Surgery has set up a committee to provide new evidence-based recommendations for patient care associated with chronic venous insufficiency. Topics were divided in five groups: 1. Classification, 2. Diagnosis, 3. Conservative or non-invasive treatment, 4. Invasive treatment and 5. Treatment of small vessels. This last series is closely related to the activities of Brazilian angiologists and vascular surgeons, who are heavily involved in the treatment of small superficial veins. These guidelines are intended to assist in clinical decision-making for attending physicians and health managers. The decision to follow a guideline recommendation should be made by the responsible physician on a case-by-case basis taking into account the patient's specific condition, as well as local resources, regulations, laws, and clinical practice recommendations.

Low concentration of sodium tetradecyl sulfate and hypertonic glucose solution for the treatment of telangiectasia: A prospective randomized clinical trial

OBJECTIVES

This study aimed to compare telangiectasias disappearance after sclerotherapy with hypertonic glucose (HG) and different concentrations of sodium tetradecyl sulfate (STS).

METHODS

Women aged 18-70 years with telangiectasias were included. The primary efficacy endpoint was telangiectasia disappearance. The clearing of vessels was assessed using a six-point scale (from 0 to 5).

RESULTS

A total of 116 women completed an 8-week follow-up: 31, 27, 25, and 33 were in the HG 75%, STS 0.05%, STS 0.1%, and STS 0.15% groups, respectively. The median score of vein disappearance was significantly lower in the STS 0.05% (3, 0.25-4), STS 0.1% (3, 1.25-4), and STS 0.15% (4, 2-4) groups than in the HG group (4, 3-5) after 56 days, p = .00002.

CONCLUSION

Sclerotherapy of telangiectasias with 75% HG showed significantly better results than low concentrations of STS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04132323.

Quantitative analysis validation for sclerotherapy treatment of lower limb telangiectasias

BACKGROUND

The evaluation of sclerotherapy efficacy for lower limb telangiectasias, which is the standard treatment for such condition, is commonly assisted by scores based on before and after pictures. This method is marked by its subjectivity, which impairs the precision of studies on the subject, making it unfeasible to evaluate and compare different interventions. We hypothesize that a quantitative method for evaluating the effectiveness of sclerotherapy for lower limb telangiectasias may present more reproducible results. Reliable measurement methods and new technologies may become part of the clinical practice in the near future.

METHODS

Before and after treatment photographs were analyzed using a quantitative method and compared with a validated qualitative method based on improvement scores. Reliability analysis of the methods was performed, applying the intraclass correlation coefficient (ICC) and kappa coefficient with quadratic weights (Fleiss Cohen), for analysis of inter-examiner and intra-examiner agreement in both evaluation methods. Convergent validity was evaluated by applying the Spearman test. To assess the applicability of the quantitative scale, the Mann-Whitney test was used.

RESULTS

A better agreement between examiners is shown for the quantitative scale, with a mean kappa of .3986 (.251-.511) for qualitative analysis and a mean kappa of .788 (.655-.918) for quantitative analysis (P < .001 for all examiners). Convergent validity was achieved by correlation coefficients of .572 to .905 (P < .001). The quantitative scale results obtained between the specialists with different degrees of experience did not show statistical difference (seniors: 0.71 [-0.48/1.00] × juniors: 0.73 [-0.34/1.00]; P = .221).

CONCLUSIONS

Convergent validity between both analyses has been achieved, but quantitative analysis has been shown to be more reliable and can be applied by professionals of any degree of experience. The validation of quantitative analysis is a major milestone for the development of new technology and automated, reliable, applications.

Nd:Yag laser combined with injection sclerotherapy in the treatment of reticular veins and telangiectasias (CLaCS method): A triple-blind randomized clinical trial comparing two sclerosing agents associated with same laser patterns

BACKGROUND

Cryo-Laser & Cryo-Sclerotherapy (CLaCS) is a technique which combines thermal sclerotherapy and injection sclerotherapy. Telangiectasias and small varicosities are targeted by a transdermal laser and right after receive injection sclerotherapy. A cooling device blows -20°C air onto the skin and needle in a pre-, parallel-, and post-fashion.

OBJECTIVE

Our objective was to establish if there is a difference in result and complications by varying the sclerosing agent but keeping the same ND:Yag long pulse laser parameters in the treatment of small varicosities.

METHODS

Fifty five patients were enrolled prospectively and randomized to two groups; in the group 1 dextrose 75% was the sclerosing agent used in combination with the ND:Yag long pulse laser and, in the group 2, the same laser technique was used but the sclerosing agent was polidocanol 0.3% and dextrose 67%.

RESULTS

The results were evaluated 30 days after the treatment by the patients and for blinded evaluators using before and after standardized photos with and without augmented reality. In the patient's perspective and in the blinded evaluation of the regular photos, no differences between the groups were found. Both groups had low rates of hyperpigmentation and bruising with no statistical difference. Patients treated with polidocanol had less pain after the treatment and a better clearance rate in the photos with augmented reality. No major complications were found.

CONCLUSION

The treatment of small varicosities with CLaCS using Dextrose 75% or polidocanol 0.3% and Dextrose 67.5% is a safe and effective procedure and both sclerosing agents can be used with similar results. Possibly, in the polidocanol group more nonvisible reticular veins were cleared, but the implication of this find is not clear.

Treatment for telangiectasias and reticular veins

BACKGROUND

Telangiectasias (spider veins) and reticular veins on the lower limbs are very common, increase with age, and have been found in 41% of women. The cause is unknown and the patients may be asymptomatic or can report pain, burning or itching. Treatments include sclerotherapy, laser, intense pulsed light, microphlebectomy and thermoablation, but none is established as preferable.

OBJECTIVES

To assess the effects of sclerotherapy, laser therapy, intensive pulsed light, thermocoagulation, and microphlebectomy treatments for telangiectasias and reticular veins.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, AMED and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 16 March 2021. We undertook additional searches in LILACS and IBECS databases, reference checking, and contacted specialists in the field, manufacturers and study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared treatment methods such as sclerotherapy, laser therapy, intensive pulsed light, thermocoagulation, and microphlebectomy for telangiectasias and reticular veins in the lower limb. We included studies that compared individual treatment methods against placebo, or that compared different sclerosing agents, foam or laser treatment, or that used a combination of treatment methods.

DATA COLLECTION AND ANALYSIS

Three review authors independently performed study selection, extracted data, assessed risks of bias and assessed the certainty of evidence using GRADE. The outcomes of interest were resolution or improvement (or both) of telangiectasias, adverse events (including hyperpigmentation, matting), pain, recurrence, time to resolution, and quality of life.

MAIN RESULTS

We included 3632 participants from 35 RCTs. Studies compared a variety of sclerosing agents, laser treatment and compression. No studies investigated intensive pulsed light, thermocoagulation or microphlebectomy. None of the included studies assessed recurrence or time to resolution. Overall the risk of bias of the included studies was moderate. We downgraded the certainty of evidence to moderate or low because of clinical heterogeneity and imprecision due to the wide confidence intervals (CIs) and few participants for each comparison. Any sclerosing agent versus placebo There was moderate-certainty evidence that sclerosing agents showed more resolution or improvement of telangiectasias compared to placebo (standard mean difference (SMD) 3.08, 95% CI 2.68 to 3.48; 4 studies, 613 participants/procedures), and more frequent adverse events: hyperpigmentation (risk ratio (RR) 11.88, 95% CI 4.54 to 31.09; 3 studies, 528 participants/procedures); matting (RR 4.06, 95% CI 1.28 to 12.84; 3 studies, 528 participants/procedures). There may be more pain experienced in the sclerosing-agents group compared to placebo (SMD 0.70, 95% CI 0.06 to 1.34; 1 study, 40 participants; low-certainty evidence). Polidocanol versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD 0.01, 95% CI -0.13 to 0.14; 7 studies, 852 participants/procedures), hyperpigmentation (RR 0.94, 95% CI 0.62 to 1.43; 6 studies, 819 participants/procedures), or matting (RR 0.82, 95% CI 0.52 to 1.27; 7 studies, 859 participants/procedures), but there were fewer cases of pain (SMD -0.26, 95% CI -0.44 to -0.08; 5 studies, 480 participants/procedures) in the polidocanol group. All moderate-certainty evidence. Sodium tetradecyl sulphate (STS) versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD -0.07, 95% CI -0.25 to 0.11; 4 studies, 473 participants/procedures). There was more hyperpigmentation (RR 1.71, 95% CI 1.10 to 2.64; 4 studies, 478 participants/procedures), matting (RR 2.10, 95% CI 1.14 to 3.85; 2 studies, 323 participants/procedures) and probably more pain (RR 1.49, 95% CI 0.99 to 2.25; 4 studies, 409 participants/procedures). All moderate-certainty evidence. Foam versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD 0.04, 95% CI -0.26 to 0.34; 2 studies, 187 participants/procedures); hyperpigmentation (RR 2.12, 95% CI 0.44 to 10.23; 2 studies, 187 participants/procedures) or pain (SMD -0.10, 95% CI -0.44 to 0.24; 1 study, 147 participants/procedures). There may be more matting using foam (RR 6.12, 95% CI 1.04 to 35.98; 2 studies, 187 participants/procedures). All low-certainty evidence. Laser versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD -0.09, 95% CI -0.25 to 0.07; 5 studies, 593 participants/procedures), or matting (RR 1.00, 95% CI 0.46 to 2.19; 2 studies, 162 participants/procedures), and maybe less hyperpigmentation (RR 0.57, 95% CI 0.40 to 0.80; 4 studies, 262 participants/procedures) in the laser group. All moderate-certainty evidence. High heterogeneity of the studies reporting on pain prevented pooling, and results were inconsistent (low-certainty evidence). Laser plus sclerotherapy (polidocanol) versus sclerotherapy (polidocanol) Low-certainty evidence suggests there may be more resolution or improvement (or both) of telangiectasias in the combined group (SMD 5.68, 95% CI 5.14 to 6.23; 2 studies, 710 participants), and no clear difference in hyperpigmentation (RR 0.83, 95% CI 0.35 to 1.99; 2 studies, 656 participants) or matting (RR 0.83, 95% CI 0.21 to 3.28; 2 studies, 656 participants). There may be more pain in the combined group (RR 2.44, 95% CI 1.69 to 3.55; 1 study, 596 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Small numbers of studies and participants in each comparison limited our confidence in the evidence. Sclerosing agents were more effective than placebo for resolution or improvement of telangiectasias but also caused more adverse events (moderate-certainty evidence), and may result in more pain (low-certainty evidence). There was no evidence of a benefit in resolution or improvement for any sclerosant compared to another or to laser. There may be more resolution or improvement of telangiectasias in the combined laser and polidocanol group compared to polidocanol alone (low-certainty evidence). There may be differences between treatments in adverse events and pain. Compared to other sclerosing agents polidocanol probably causes less pain; STS resulted in more hyperpigmentation, matting and probably pain; foam may cause more matting (low-certainty evidence); laser treatment may result in less hyperpigmentation (moderate-certainty evidence). Further well-designed studies are required to provide evidence for other available treatments and important outcomes (such as recurrence, time to resolution and delayed adverse events); and to improve our confidence in the identified comparisons.