Echosclerotherapy

Echo-sclerotherapy is a varicose vein treatment performed under ultrasound guidance. In this technique, a potent sclerosing agent is injected directly into the target vein using ultrasound imaging. The aim is to create a controlled inflammatory reaction in the vein wall to close the lumen of the vessel. In this way, the appearance and symptoms of varicose veins are significantly reduced.

In patients in whom reflux is detected in the deep or superficial venous system, echo-sclerotherapy offers a minimally invasive alternative to surgery. Thanks to ultrasound guidance during the procedure, injection accuracy increases and the risk of complications is minimized. The treatment is usually performed on an outpatient basis and does not require anesthesia.

The advantages of echo-sclerotherapy include rapid recovery, low cost, and cosmetically satisfying results. When the sclerosing agent is used in foam form, its contact time with the vein surface increases, which enhances efficacy. The use of compression stockings after the procedure supports treatment success.

In the post-treatment period, short-term redness or tenderness may be observed; however, these side effects are generally temporary. With regular ultrasound follow-ups, vein closure and the development of new reflux are monitored. When performed by an experienced physician with proper patient selection, echo-sclerotherapy offers a high success rate.

What is echo-sclerotherapy and how does it act on a varicose vein?

The primary goal of this treatment is to close from the inside a dilated, dysfunctional varicose vein that exhibits backward flow (reflux) instead of surgically removing it. A special medication called a “sclerosant” is used to do this.

This drug acts like a detergent; by disrupting the protein structure of the endothelial cell layer lining the inner surface of the vein, it creates a controlled chemical injury. The body perceives this as a “wound” and immediately initiates a repair process. This process first causes the vein to contract, then its walls to adhere to each other, and finally to transform into permanent connective tissue called “fibrosis.” Blood flow is then automatically redirected to nearby healthy veins.

Why is “foam therapy” more effective than liquid medication?

In the past, sclerotherapy was performed only with the liquid form of the drug. However, this was not very successful, especially in large, high-pressure main veins (such as the saphenous veins). The reason is that the liquid rapidly mixed with blood inside the vein, becoming diluted (reducing its concentration) and quickly neutralized by the blood.

The “foam” form has been a real breakthrough in this treatment. By mixing the drug with air or special gases using a specific technique (the Tessari method), a dense micro-foam is obtained. This foam has tremendous advantages over liquid:

• Piston Effect (Displacing Blood): Foam is much denser than liquid. The moment it is delivered into the vein, instead of mixing with blood, it pushes the blood ahead like a piston and displaces it from the vein. This is crucial because the “blood” that would inactivate the drug is removed from the environment.
• Maximum Contact (Increased Surface Area): When 1 ml of liquid drug is mixed with 4 ml of air, it forms 5 ml of dense foam. The millions of microbubbles in this foam increase the surface area of the drug by thousands of times. Thus, the drug can contact every point of the vein wall.
• Powerful Effect (Prolonged Contact): Since blood is displaced, the concentrated, undiluted drug on the bubble surfaces remains in direct contact with the endothelium for much longer. This maximizes the closing effect.
• Vasospasm (Constriction): The foam itself triggers a strong “spasm” response in the vein wall. The vein immediately contracts and its walls approximate. This physical constriction further enhances the chemical effect and increases the likelihood of permanent closure.

Where does ultrasound (echo) come in? Why is echo-sclerotherapy performed with ultrasound?

The “Echo” (ultrasound) in the name of the treatment is its most critical component. You can think of ultrasound as our “eyes” in this procedure. Without ultrasound, performing foam therapy in the deeper main veins would be equivalent to a blind injection and could be extremely risky.

Ultrasound has four roles in this treatment.

• Pre-treatment Mapping: Before starting, the patient’s leg is examined in detail with ultrasound both standing and lying down. A “varicose map” is created answering questions such as which vein has reflux, where the source of reflux is, what the vein diameters are, and how the course of the vein runs (tortuous or straight). The treatment plan is based on this map.
• Real-time Needle Guidance: During the procedure, the target vein is located on the ultrasound screen. The entry of the needle or cannula into the vein is tracked on-screen with millimetric precision. It is 100% confirmed that the needle tip is in the center of the venous lumen.
• Monitoring Foam Distribution and Dosing: The foam itself appears as a “bright white” (echogenic) structure on ultrasound. While the inside of the vein normally appears “black” (anechoic), at the moment foam is injected you can watch that black space fill with bright white foam. This gives us excellent control. We see how far the foam travels, which side branches it enters, and most importantly, whether it reaches the deep venous system (the main venous network). Injection is stopped the moment the foam reaches the intended endpoint. This is “effect-based dosing” and the key element ensuring treatment safety.
• Post-procedure Check: Immediately after injection, the final distribution of foam within the vein and whether the vein has gone into spasm (constricted) in response are assessed. In the following weeks, ultrasound is again used to evaluate whether the treated vein has completely closed, whether there is any thrombus within it, or whether there is recanalization (reopening).

In which situations is echo-sclerotherapy (foam therapy) preferred?

In modern varicose vein treatment there is no longer a “one-size-fits-all.” Thermal methods such as Laser (EVLA) and Radiofrequency (RFA) deliver excellent long-term results particularly for “trunk” (great and small saphenous) vein incompetence. The 2022 European Society for Vascular Surgery (ESVS) guidelines also recommend these thermal methods as first-line for trunk treatment.

However, echo-sclerotherapy is not excluded from this equation. On the contrary, in many scenarios where laser or radiofrequency are insufficient, unsuitable, or not enough alone, it stands out as a “primary” treatment option or a complementary “problem-solver.”

Situations in which echo-sclerotherapy is first choice include:

• Varicose Tributaries (Side Branches): After laser/RF is applied to the trunk vein, echo-sclerotherapy is the gold standard for treating the remaining visible, greenish, tortuous large varices. The 2023 SVS/AVF (U.S.) guidelines recommend echo-sclerotherapy (or mini-phlebectomy) for these veins at “Grade 1B” (Strong).
• Recurrent Varicose Veins (REVAS): In patients who previously had varicose surgery (stripping) but experienced recurrence, the region is often full of scar tissue, making it impossible to advance a laser/RF catheter. Foam, thanks to its fluid nature, can easily penetrate this complex, distorted anatomy, making it “particularly suitable” for recurrence cases.
• Extremely Tortuous Veins: Laser or RF catheters are rigid, straight devices. If a vein is tortuous enough to form “S-curves,” these catheters cannot pass through. Foam can flow along these winding paths to treat the vein.
• Veins Too Superficial or Too Small for Laser/RF: Heat from laser can pose a burn risk in veins very close to the skin. Since foam therapy involves no heat, this risk is absent.

Can echo-sclerotherapy be performed for patients with venous ulcers (leg wounds)?

Yes—this is in fact one of the strongest and most effective indications for echo-sclerotherapy. The most advanced stage (C6) of “chronic venous insufficiency” involves non-healing wounds (venous ulcers) on the lower leg. The greatest obstacle to healing is excessively high venous pressure at the ulcer site.

The culprits behind this high pressure are often “incompetent perforator veins.” These are short connecting veins between the superficial and deep systems. While they should normally carry blood in one direction—from superficial to deep—when their valves fail, they allow blood to flow from deep to superficial (i.e., back to the ulcer area).

Echo-sclerotherapy targeted to these perforators can have a remarkable effect on ulcer healing. A high-level (Level 1) scientific study has clearly demonstrated this. In the study, patients with venous ulcers were divided into two groups:

• Group A (Treatment): Compression (bandage/stocking) + Echo-sclerotherapy of perforator veins
• Group B (Control): Compression only (bandage/stocking)

The results were striking.

• Ulcer Closure Time: In Group A, the median time to ulcer closure was 35 days, compared with 56 days in Group B. (p = .008)
• Complete Healing Rate: At 3 months, 97% (28/29) in the echo-sclerotherapy group had completely healed, compared with 75% (27/36) in the control group. (p = .01)
• Ulcer Size Reduction: The echo-sclerotherapy group showed a “significantly faster” reduction in ulcer size. (p < .0001)

These findings prove that foam treatment of perforators is a highly targeted and effective intervention that rapidly lowers local venous pressure and thereby accelerates ulcer closure.

Is foam therapy also suitable for special patient groups?

Absolutely yes. The minimally invasive nature of echo-sclerotherapy makes it a first-line treatment for certain special groups.

For example, in patients with comorbidities such as severe heart, lung, or kidney disease, where general anesthesia is risky or surgery cannot be tolerated, echo-sclerotherapy is an “especially useful” and safe option.

Likewise, in patients with obesity where surgical access may be difficult, this ultrasound-guided treatment is an effective alternative.

What are the advantages of echo-sclerotherapy over other varicose treatments (laser, surgery)?

The advantage of echo-sclerotherapy over laser (EVLA) or radiofrequency (RFA) is not greater long-term permanence (laser/RF is more durable for trunk veins), but that the procedure itself is much simpler, more comfortable, and more versatile.

For patients, these advantages mean:

• No Anesthesia Required: General or spinal anesthesia is not needed.
• No “Tumescent Anesthesia”: This is the most important difference from laser/RF. Because laser and RF close veins with heat, to protect surrounding tissues (nerves, skin) from heat and prevent pain, large amounts of cooled anesthetic fluid (“tumescent anesthesia”) must be injected along the vein via multiple needle punctures. This can be the most painful and time-consuming part. In echo-sclerotherapy there is no heat, so this onerous anesthesia is unnecessary.
• No Incisions, Stitches, or Scars: The procedure is performed only through needle punctures.
• Can Be Performed in a Clinic Setting: No operating room required.
• No Anatomical Limitations: As noted above, foam can reach everywhere laser cannot—highly tortuous, superficial, or recurrent veins.
• Easily Repeatable: If complete closure is not achieved or a small reopening occurs years later, the procedure can be easily and safely repeated.
• Low Cost: It is more cost-effective since it does not require expensive catheter technologies like laser/RF and avoids operating room/anesthesia expenses.

Who should not undergo foam therapy (echo-sclerotherapy)?

Although echo-sclerotherapy is extremely safe, as with any medical intervention there are situations in which it should not be performed. European sclerotherapy guidelines clearly define these.

There are two groups of contraindications:

• Absolute Contraindications (situations in which treatment must not be performed):
• A known, proven severe (anaphylactic) allergy to the sclerosant used (Polidocanol or STS).

Acute Deep Vein Thrombosis (DVT) or Pulmonary Embolism ongoing at the time of treatment.

Active infection or wound in the area of the leg to be treated.

Bedbound patients with prolonged immobility.

Foam-specific: Presence of a known, symptomatic “right-to-left shunt” (Patent Foramen Ovale – PFO). This is a hole between the atria that can allow foam bubbles to pass to the brain.

Relative Contraindications (situations requiring individualized risk–benefit assessment):

• Pregnancy (especially the first and last trimesters) and breastfeeding period.
• Severe peripheral arterial disease (PAOD) in the legs.
• High thrombosis risk (history of thrombophilia, active cancer).
• Acute superficial thrombophlebitis.

Foam-specific: Having experienced transient visual disturbance, severe migraine attack, or a neurological symptom after a previous foam session.

How successful is echo-sclerotherapy and is this varicose treatment permanent?

The answer depends on which vein is being treated and how far out you look.

In the short and mid term (first 1–2 years), echo-sclerotherapy is highly successful. Studies show closure rates of the main veins (GSV) around 85–90% at 1 year. Success is even higher for tributaries and recurrent veins. Improvements in quality of life and reductions in symptoms (pain, cramps, swelling) are similarly high.

However, in the long term (5 years and beyond), particularly for trunk vein treatment, laser and radiofrequency are scientifically proven to be more durable than foam. In a large 5-year randomized controlled trial (RCT), the 5-year closure rate was 93% for trunk veins treated with laser (EVLA) versus 64% for veins treated with echo-guided foam sclerotherapy (UGFS) (p = .001).

This does not mean echo-sclerotherapy is a poor treatment. It suggests the following strategy: if the patient’s trunk vein is straight and suitable for laser, laser should be first choice for long-term durability. However, most of these patients also have tributaries that laser cannot treat; for those branches, foam is essential.

If the vein is unsuitable for laser (tortuous, recurrent, superficial, etc.), foam therapy—with a 64% 5-year success rate—remains an excellent option. The remaining 36% (often a small partial reopening rather than full recanalization) can usually be easily retreated with a simple additional session even 5 years later.

What side effects may occur after echo-sclerotherapy (foam therapy)?

The safety profile is very high. The vast majority of side effects are temporary, local, and benign reactions. Serious complications are extremely rare.

Common (10–30%) and temporary side effects include:

• Hyperpigmentation (Staining): A brownish discoloration along the treated vein path. This is not a burn mark but a “rust-like” stain caused by iron (hemosiderin) from red blood cells leaking from the vein into the skin. It is usually cleared by the body within 6–12 months.
• Matting (Telangiectatic Matting): Formation of new, very fine red capillary networks around the treated area. This is an “angiogenesis” response and usually regresses spontaneously within 3–12 months.
• Superficial Thrombophlebitis: An exaggerated inflammatory reaction to the clot formed inside the treated vein (which is desired). It presents as a painful, firm, red cord-like swelling. It is not dangerous but can be uncomfortable; it resolves quickly with appropriate measures (cooling, anti-inflammatory drugs).

Rare (<1%) systemic side effects:

These are almost entirely related to the gas bubbles in the foam (not the drug itself) entering the circulation. Especially in people with PFO, microbubbles can pass into the cerebral circulation.

• Transient visual disturbances (flashes, blurring)
• Transient headache or triggering of a migraine attack
• Transient chest tightness or dry cough

Almost all of these symptoms disappear spontaneously within 5–15 minutes without sequelae. Neurological events such as transient ischemic attack (TIA) have been reported very rarely. The risk of Deep Vein Thrombosis (DVT) is well below 1%.

What precautions are taken during foam therapy to reduce these risks?

These rare risks are minimized by adhering to simple but strict rules. An experienced hand always follows these safety protocols.

• Proper Patient Selection: Before the procedure, patients are always asked about PFO, migraine history, or previous similar symptoms. Foam is avoided in suspicious cases.
• Continuous Ultrasound Monitoring: Foam spread toward the deep veins is monitored in real time and injection is stopped as soon as a risk is observed.
• Limiting Foam Volume: The total foam volume per session is generally limited to about 10 mL. This reduces systemic gas load.
• Gas Choice: In patients with PFO risk or prone to neurological symptoms, carbon dioxide ({CO}₂), which dissolves much faster in blood, may be preferred over room air.

Is it necessary to wear compression stockings after echo-sclerotherapy?

Post-procedure compression (bandage or stockings) is a standard part of treatment. However, there is no clear consensus on how long they should be worn, and evidence is limited.

Whereas longer durations were recommended in the past, the current trend is to shorten the duration. The 2022 ESVS guidelines have actively downgraded the recommendation strength for compression after trunk vein treatments (due to weaker evidence).

The commonly accepted modern practice is bandaging for 24–48 hours after the procedure, followed by wearing compression stockings for about one week (daytime only). The aim is to help the vein walls adhere and to reduce post-procedural superficial phlebitis pain. There is no strong scientific evidence that wearing them longer than one week provides additional durability.

In conclusion, what is the role of echo-sclerotherapy in varicose vein treatment?

Echo-sclerotherapy is one of the most versatile, flexible, and indispensable tools in modern management of venous insufficiency.

It is not a magical method that can treat every varicose vein on its own, but it is an excellent “complementary” and “problem-solving” option wherever other methods (laser, radiofrequency) cannot reach or are unsuitable.

We can summarize the role of echo-sclerotherapy in modern varicose treatment as follows:

• Primary Treatment: Non-telangiectatic varicose tributaries.
• Primary Treatment: Recurrent (post-surgical) varicose veins (REVAS).
• Primary Treatment: Veins too tortuous for laser/RF catheters.
• Primary Treatment: High-risk, anesthesia-contraindicated, or obese patients.
• Primary Treatment: Perforator incompetence in venous ulcer (C6) patients to accelerate wound healing.
• Secondary Treatment: Trunk (GSV/SSV) incompetence where laser/RF is not feasible or not preferred by the patient.
• Adjunct Treatment: All remaining tributaries after trunk treatment with laser/RF.

Being a cost-effective, safe, anesthesia-free office procedure makes echo-sclerotherapy an invaluable treatment option for both patients and physicians.

Frequently Asked Questions

In which cases is echo-sclerotherapy preferred?

Echo-sclerotherapy is a varicose vein treatment performed under ultrasound guidance. It is preferred for deep-seated or non-visible vein dilatations. It is particularly effective for veins that conventional foam sclerotherapy cannot reach.

How is echo-sclerotherapy performed?

During the procedure, the problematic vein is visualized with an ultrasound device. A fine needle is used to inject a sclerosing agent into the vein. This agent closes the vein wall, stops blood flow, and the vein gradually disappears.

Is there a difference between echo-sclerotherapy and foam sclerotherapy?

Yes. Foam sclerotherapy is applied to more superficial veins, whereas echo-sclerotherapy is used under ultrasound guidance to treat deeper or connecting veins. Thus, treatment is more targeted and safer.

What is the recovery like after echo-sclerotherapy?

Patients can usually walk immediately after the procedure. Mild bruising, firmness, or itching may occur but resolves within a few days. Full recovery is completed in 2–4 weeks.

Is it necessary to use compression stockings after echo-sclerotherapy?

Yes, wearing compression stockings is generally recommended for about 1 week after the procedure. This supports vein closure and reduces the risk of complications.

Does echo-sclerotherapy provide a permanent solution?

The treated vein closes permanently, but new varicose veins can develop in other areas. Therefore, regular follow-ups and lifestyle changes are important for long-term success.

What should be considered after echo-sclerotherapy?

Avoid hot baths, saunas, or prolonged standing after the procedure. Daily walking increases circulation and accelerates recovery.

Is echo-sclerotherapy a painful procedure?

The procedure is generally almost painless. Apart from the sensation of a fine needle prick, there is no significant discomfort.

Are there any side effects after echo-sclerotherapy?

Temporary bruising, mild firmness, or discoloration of the skin may occur. In rare cases, superficial clots or allergic reactions may develop, but these can be easily managed.

Who is not a candidate for echo-sclerotherapy?

Echo-sclerotherapy is not recommended during pregnancy, in patients with coagulation disorders, or those with active infections. Vein mapping should always be performed beforehand.