SCLEROTHERAPY INFORMED CONSENT AND BEFORE AND AFTER TREATMENT INSTRUCTIONS


WHAT IS SCLEROTHERAPY?

Sclerotherapy is an injection treatment used to eliminate small to medium size varicose veins and "spider" veins. "Spider" veins are superficial telangiectasias, tiny vessels that are red, blue or purple in color. The majority of these veins present as a cosmetic problem.


HOW DOES SCLEROTHERAPY WORK?

A very small needle is used to inject a sclerosing solution into a varicose or "spider" vein. Different solutions are used depending on the type of vein. Different strengths of the solutions are used based on the size of the vessel. Once injected the cells that line the vein wall (endothelium) will become irritated, inflamed and damaged. External compression is applied using cotton balls, tape and support hose. The compression causes the vein walls to seal together and the vein no longer can transport blood. Your body will then break down and absorb the damaged vein. When healing is complete the vein is no longer visible. The process is very similar to how your body heals a bad bruise. "Spider" veins do not have any useful function and eliminating them will not affect your circulation. Reducing or eliminating varicose veins can improve your circulation and symptoms of heaviness, aching and fatigue.


HOW MANY TREATMENTS ARE NEEDED?

The number of treatments needed varies from patient to patient depending on the type, size and quantity of veins to be treated. Varicose veins and "spider" veins may require multiple injection sessions. Subsequent treatments are usually scheduled every four to six weeks to allow time for the body to respond to the treatment. It is important to realize that the best results require patience. It takes time for your body to respond to the injections. It is important to follow the post-treatment instructions to optimize your results. Your body will continue to heal and "fade" injection sites for months after treatment.
After your initial screening exam your doctor will give you an estimate as to the number of treatments that may be required. This is based on the doctor's assessment, your history and expectations. You may end up needing fewer or more treatments than the surgeon estimated. It is important to discuss your expected outcomes with your doctor and to keep them realistic. Your doctor will do everything possible to meet or exceed your expectations.



WHAT TO EXPECT:

Photographs will be taken before treatment is initiated. This helps to monitor your progress. Your legs will look worse before they look better. After the vein is damaged the body needs time to heal. Most people will notice a dramatic improvement approximately four weeks after their initial treatment. Maximal improvement often takes several months and several treatments. There is no guarantee sclerotherapy will be effective in every case. Some veins and areas will need to be retreated. Recurrence of the same vein treated rarely occurs with proper injection technique and compliance with post treatment instructions. New varicose veins or "spider" veins may form requiring subsequent treatment. Periodic re-evaluations are encouraged so that any new veins that develop can be injected before they become too large or too numerous.


COMMON SIDE EFFECTS:

ITCHING-you may experience itching around the area injected. If this occurs, it is usually mild and lasts for one to two days.
HYPERPIGMENTATION-a light brown discoloration of the skin may develop along the vein in the area injected. Approximately 20-30% of patients treated note the discoloration, which is lighter and less obvious than the vein being treated. The hyperpigmentation usually fades in a couple weeks, but may take several months to a year to totally resolve. There is a one-percent incidence of hyperpigmentation continuing after one year.
A small amount of blood may become trapped and hardened in the vein when injecting varicose veins or some "spider" vein complexes. This may feel like a knot or cord and it may look dark blue or bruised. This is a common occurrence. You may need to return before your next treatment so this area can be drained to remove the trapped blood. This will reduce the hyperpigmentation that can occur. The chance of this occurring can be decreased with proper compression of the vein and use of compression hose after your treatment.
TELANGIECTATIC MATTING-the formation of new, fine "spider" veins in the area injected occurs in less than 1% of patients injected. The exact reason for this occurring is unknown. If untreated, the matting usually resolves in three to twelve months, but very rarely it can be permanent. If the matting does not fade it can be re-injected or treated with a laser/light source.
PAIN-it is common to have some tenderness or stinging at the injection site. Injection of the sclerosing agent can be uncomfortable, but is usually well tolerated by most patients. The discomfort is temporary, lasting one to at most seven days. Acetaminophen (Tylenol) can be used if needed, according to product directions.
BRUISING-may occur at the injection site. Bruising may be minimized by avoiding Aspirin and Ibuprofen products for ten days before and after each treatment session.


RARE SIDE EFFECTS:

ULCERATION AT INJECTION SITE-very rarely a small ulcer will occur at the site where the vein is injected. An ulcer can take four to six weeks to completely heal. A small scar may result.
ALLERGIC REACTION-there is a very rare incidence of an allergic reaction to the solution injected. You will be observed for such reaction and will be treated appropriately should it occur. Please inform us of any allergic history.
PULMONARY EMBOLUS/DEEP VEIN THROMBOSIS-a blood clot to the lungs/a blood clot in the deep vein. In the medical literature there is an extraordinarily low incidence of this complication.


ALTERNATIVES TO SCLEROTHERAPY:

You may choose no therapy. The existing varicose and "spider" veins may progress and new veins may form. You should be re-evaluated periodically to monitor your condition for changes.

You may choose to only wear compression support hose (if this is an appropriate treatment for your problem). Compression hose promote venous blood return to the heart. If support hose are worn faithfully symptoms such as aching, heaviness and tiredness are often alleviated. They also may help prevent the progression and formation of varicose and "spider veins".

Vein stripping and/or ligation may be appropriate to treat some patients with larger varicose veins. Laser/light source therapy may be an option if you have spider veins. Your doctor will discuss these alternative choices with you.


SCLEROTHERAPY PRE TREATMENT INSTRUCTIONS:

COMPRESSION HOSE-are required to be worn immediately after each injection treatment or if you have had aspiration of trapped blood from an injected vein. Hose can be purchased from our office or you may request a prescription to purchase at a pharmacy or medical supply store. You cannot be injected without your compression hose. The hose must be worn continuously for 48 hours after your treatment. Then they may be removed and worn daily, during the waking hours, for seven more days. Your doctor may adjust the length of time to wear your hose. The compression hose are critical to the success of the treatment.
LEG PREPARATION-do not apply oil, lotion or powder to your legs the night before or the day of your injections. Use of these toiletries will not allow the cotton balls and tape to adhere to your skin.
CLOTHING-bring a pair of loose, comfortable shorts to wear during your treatment. Dress in loose clothes and comfortable shoes to accommodate the cotton balls, tape and hose after your treatment.
MEDICATIONS-discontinue Aspirin (Bufferin, Anacin etc.) and Ibuprofen (Motrin, Advil, Aleve etc.) for 10 days before and after injections to reduce bruising. Acetaminophen (Tylenol) is allowed.
TIME ALLOTTMENT-a sclerotherapy treatment should last approximately 30 minutes. You should arrive 10-15 minutes early for your first sclerotherapy treatment to allow time for photographs and to sign your consents. You should then allow 15 to 30 additional minutes to apply your support hose, get dressed and to check out of the office. If you need to cancel or reschedule your sclerotherapy treatment, please give our office at least 72 hours notice.
PHOTOGRAPHS-photographs will be taken before your first treatment to document progress and/or for the purpose of medical education, research, scientific publication or educational presentations. You will not be identified in your photographs and informed consent will be obtained before you are photographed.


SCLEROTHERAPY POST TREATMENT INSTRUCTIONS:

COMPRESSION-cotton balls and tape provide local compression over each area injected. Before standing, you will put on your compression hose. Proper compression is very important because it minimizes the blood re-entering the injected vein, decreases the incidence of post sclerotherapy hyperpigmentation and telangiectatic matting and improves venous blood flow. The cotton balls and tape can be very uncomfortable and may even irritate and blister sensitive skin. After the first 48 hours the hose, cotton balls and tape may be removed. If tape blisters occur, keep clean with soap and water, use Neosporin or Bacitracin ointment and cover with a dry non-adhering dressing. These heal within seven to ten days. After the initial 48 hours you should continue to wear your hose for one week, during the waking hours. If larger varicose veins are injected, you may be advised by your doctor to wear them for two to three weeks.
BATHING-a shower is allowed after the first 48 hours. Hot baths, hot tubs and saunas should be avoided for two weeks after sclerotherapy to avoid venous dilatation.
HYPERPIGMENTATION-if you develop hyperpigmentation after sclerotherapy you should apply sun block to those areas when sun exposure is anticipated to avoid increasing the hyperpigmentation. Continue to use sun block until the hyperpigmentation has resolved.
DRIVING-you may drive immediately after your treatment. If your trip home is longer than an hour we recommend you stop hourly to stretch your legs.
ACTIVITY-in most cases, you may return to work and resume normal activity after treatment. Please take a 15-minute walk immediately following your treatment. This will help circulate the solution that was injected. Walking is encouraged; it promotes efficient venous circulation. Avoid sitting and standing for extended periods and elevate your leg(s) above the level of your heart when possible for the next two to three days. If large varicose veins were injected, your doctor may recommend you stay off your feet with your leg(s) elevated for the rest of the day. Avoid high impact aerobics, jogging, running, leg weight lifting and sit-ups for one to two weeks after each injection treatment.
MEDICATIONS-do not use Aspirin or Ibuprofen products for ten days after each treatment to reduce bruising. Acetaminophen (Tylenol) can be used if you experience any discomfort from sclerotherapy.
FOLLOW-UP-subsequent treatments are usually every two to four weeks. Your doctor will advise you when you should return. If you notice dark knots or cords at your injection sites please call our office; you may need to return sooner to have these areas aspirated. Remember it is important to call our office if you have any questions or concerns before or after your sclerotherapy treatment. Please keep your follow up appointment after treatment. It is important for the physician to assess the results you achieved from each treatment. If you need to cancel or reschedule your sclerotherapy treatment or follow up appointment, please give our office at least 72 hours notice.



COST OF TREATMENT

Initial evaluation:

Per session rate:

Maximum cost of tratment:

 

I have read and understood all information presented to me before signing this consent.


 

Signed: _____________________________ Date: _____________

 

 

Name:________________________________