Ultrasound Guided Sclerotherapy: A Vein Procedure That Gets No Respect

Ultrasound Guided Sclerotherapy: A Vein Procedure That Gets No Respect

Varicose Veins Ultrasound Guided Sclerotherapy Facts

Rodney Dangerfield couldn’t get any respect much like ultrasound guided sclerotherapy for the treatment of varicose veins.

Rodney’s lack of respect was legendary.

He said:

“As a kid, all I got was rejection. My yo-yo, it never came back”.

I don’t get no respect. I met the surgeon general. He offered me a cigarette.

I don’t get no respect. I told my dentist I had yellow teeth. He told me to wear a brown tie.

With my dog, I don’t get no respect. He keeps barking at the front door. He don’t want to go out. He wants me to leave.

I tell you, with my doctor, I don’t get no respect. I told him, “I’ve swallowed a bottle of sleeping pills.” He told me to have a few drinks and get some rest.

When I worked at a pet store, they asked me how big I would get.


As with the last joke, you also need to know how big will your varicose veins will get, if you neglect them.

Can you handle the truth?

Your varicose veins will only get larger over time.

Varicose veins should be treated when they start to cause symptoms.

Injections (also called sclerotherapy) are one of the tools used to get rid of varicose veins.

The purpose of this article is to teach you about the latest form of sclerotherapy.

It is called ultrasound guided or echosclerotherapy. Other names for this technique are aimed sclerotherapy or sonographic sclerotherapy.

Using ultrasound is often helpful to guide the needle into the targeted vein. This helps enhance the accuracy, precision and completeness of the procedure.

It makes it possible to inject varicose veins that are not visible on the skin’s surface.

Why is Ultrasound Guided Sclerotherapy So Important?

Ultrasound guidance is mandatory for accurate placement of the sclerotherapy needle for introduction of the sclerosing chemical for many varicose veins.

With ultrasound, injections into varicose veins can be done more easily and efficiently when the patient is lying down or if the legs are elevated.

BTG is the leading FDA approved foam sclerosing agent company in the world. They recommend that the legs be elevated during sclerotherapy.

Elevation of the leg empties the vein of its blood.

If the patient stands to make the veins more visible during a treatment, the sclerosing chemical becomes diluted out and less effective. A collapsed vein without blood makes the injected medicine more effective because the blood does not dilute it.

The dilemma is that a dilated, bulging vein filled with blood makes the treatment unsuccessful. However, elevation of the leg makes it more difficult to see the varicosities without ultrasound. This makes ultrasound guidance invaluable with sclerotherapy.

When ultrasound guidance is used, deeper abnormal veins can be identified immediately while the procedure is being done.

The doctor can actually watch the medicine flow into the deeper varicose veins.

This ensures that the injected medicine reaches all of the abnormal varicose vein branches deep inside the leg.

It also helps the doctor to determine when to stop injecting the medicine. Too much medicine can result in the medicine reaching the deep venous system. This could result in a blood clot.

Obesity is a common risk factor in causing varicose veins.

Obesity is a nationwide problem and is getting worse. Many patients who have varicose veins are obese or morbidly obese. Morbid obesity is commonly defined as 100 pounds over their ideal body weight.

In obese patients, the varicose veins are obscured from the skin surface.

They are not visible with the naked eye because of the surrounding fatty tissue.

Therefore, ultrasound-guided sclerotherapy is safer and more effective in people who are overweight.

It is a great advance.

It is medically necessary.

So Why Do I Say That Doesn’t Ultrasound Guided Sclerotherapy Get Any Respect?

Because it is not covered by Medicare, Aetna, Highmark and many other commercial insurance plans!


A multitude of well-controlled studies and decades of clinical use support the use of ultrasound-guided sclerotherapy.

Several medical studies have been done to prove the effectiveness and the improved quality of life that ultrasound guided sclerotherapy provides.

The simple truth is that insurance companies just don’t want to pay for it.

Scientific Data to Support the Use of Ultrasound-guided Sclerotherapy for Varicose Veins

Most people have heard of injections or sclerotherapy to get rid of varicose veins.

However, most people are not aware that ultrasound can be used to guide the needle and syringe to give you treatments that are more effective.

For example, the pivotal Vanish trial after three initial trials and a phase 3 trial and phase 1, supports ultrasound guidance, and has been done twice. It was extremely rigorous each involving 250 patients over 14 years.

The Class trial, published in British Journal of Surgery 2014 by Tassie, showed an increased quality of life per year from ultrasound guided sclerotherapy. It also demonstrated that ultrasound guided sclerotherapy was relatively cheap compared to alternative forms of treatment for varicose veins.

Let’s look a little closer at what a national venous expert says about the advantages of using ultrasound to the difficult or impossible to see deeper varicose veins.

The following link is a very important YouTube from national vein expert, Dr. Ronald Bush, a board certified vascular surgeon, discussing the Revata ultrasound guided sclerotherapy study.

The information is extremely detailed and with hard-core science and data.  This information proves the efficacy of this method.

This is a presentation at a national conference for doctors treating varicose venous disease.

It is interesting to see the “behind the scenes” details on how generalized statements are generated from rigorous data and multiple randomized controlled trials.

The bottom line is that ultrasound guidance is invaluable in the treatment of difficult or recurrent varicose veins.

A Common Misconception about the Medicine Used for Sclerotherapy

Don’t believe everything that you read on the internet.

Saline was the traditional sclerosing agent decades ago. Doctors don’t inject saline anymore into varicose or spider veins in this country.

The FDA approved medicines that are used for injection sclerotherapy today is called sotradecol or polidocanol.

Sclerotherapy has been around since the 1600s.

The first use of making the injectable solution into foam was described in 1939. The foam is more effective than plain liquid solution.

Foam is more effective because it can push the blood out of the way. Its strength is more than doubled by changing the liquid solution into a foam.

Sclerotherapy is still considered the gold standard for the treatment of smaller varicose veins and spider veins.

Both medications are FDA approved and are in common use. This history of sclerotherapy summarizes the most important medications that have been used in the past to inject varicose veins.

These medicines are classified as detergents. Detergents become foamy when they are agitated.

Most vein doctors prefer to use foam rather than solution for bigger varicose veins.

With ultrasound-guided sclerotherapy, the solution is easily changed into a foam that looks like shaving cream.

Foam helps push the blood out of the way. Foam works much better at displacing blood than just plain liquid solution for large veins.

Foam sclerotherapy is a viable, inexpensive and very useful treatment for many veins. The proper indications for its use and the technical expertise of the vein specialist are vital in the success of this form of treatment.

These medicines destroy the lining of the blood vessel. That causes the targeted vein to eventually shrink and be absorbed by your body.

Ask the Expert: How Do I Treat Varicose Veins by John Happel MD

Depending on the patient’s venous pathology, I commonly use – laser, radiofrequency, phlebectomy, or sclerotherapy to treat varicose veins. Often people will need a combination of these treatments.

With sclerotherapy, medication is injected through a very fine needle into the vein. I find ultrasound guided sclerotherapy for varicose veins very useful for all of the reasons that I have discussed.

Some people feel some minor discomfort that lasts less than a minute when larger veins are injected. The procedure takes about thirty minutes or less.

The number of injections per session depends on the size and the location of the veins. There is a maximum volume of medicine that can be safely injected at any one visit.

In Europe, the consensus is that no more than 10 ml of foam be used per treatment. BTG, the only FDA approved proprietary manufacturer of polidocanol foam, recommends no more than 15 ml of foam be injected per treatment.

The patient is encouraged to walk and stay active after the treatment.

The varicose veins gradually dissolve are absorbed by your body over the following weeks to months.


Sclerotherapy has come a long way since its introduction centuries ago.

Ultrasound-guided sclerotherapy helps guide the injection of medicine into hard-to-see varicose veins that are not visible when you lie down.

It is especially helpful when new varicose veins come back after a previous varicose vein treatment.

The bad news is that many insurance companies including Medicare do not cover it.

It is especially useful in patients with recurrent varicose veins or in obese patients.

With the newer techniques for treating varicose veins emerging and getting all of the headlines, ultrasound guidance is not getting the press it deserves.

It is a workhorse and is an invaluable tool in most vein specialist’s armamentarium for the treatment of varicose veins.

Make sure your vein specialist is well versed in ultrasound before choosing your vein doctor. Dr Happel is credentialed in both the performance and the interpretation of vascular ultrasound (RVT and RPVI).

Doppler ultrasound is crucial in diagnosing and also during the treatment of varicose veins. He has over thirty years of experience. He is a vein specialist trained in vascular surgery at the Mayo Clinic.

Call today at 724-969-0600 to make an appointment with Dr. Happel or contact us here.

About The Author

Dr. John Happel

Dr. John Happel has been in practice as a surgeon since 1986 in the Pittsburgh region. He specializes in vascular surgery and has subspecialized in the treatment of varicose and spider veins since 1999. Dr. Happel is board certified in vascular surgery and recertified in vascular surgery in 2012. He was chosen in 1985 to fulfill the position for the vascular surgical fellowship at the world renowned Mayo Clinic.