Protocol-based treatment of spontaneous hemorrhage from varicose veins prevents recurrence of bleeding.

Background: Spontaneous hemorrhage from erosion of varicose veins through the skin is a serious and occasionally fatal complication of varicose vein disease. Various treatments, both acute and delayed, have been advocated. Our two-step clinical protocol was designed to prevent further hemorrhage without delay and to provide durable freedom from recurrent bleeding.

Methods: All patients referred to our surgical vein practice with hemorrhage from varicose veins were entered into a prospective registry. On presentation, all patients underwent diagnostic duplex ultrasound for venous reflux. Immediate treatment consisted of ultrasound-guided polidocanol/CO₂ foam sclerotherapy of the bleeding varicosity and adjacent veins. Subsequent endovenous ablation of underlying incompetent axial veins, with concurrent microphlebectomy when indicated, was scheduled and performed within 8 weeks.

Results: Fifty-nine patients were referred with recent hemorrhage from varicose veins over a period of 4 years. Fifty-six (95%) had an ultrasound-identified tributary varicosity underlying the point of bleeding, and three had a skin-surface erosion only and no ultrasound-identified underlying tributary. Of the 59 study patients, 52 underwent prompt polidocanol/CO₂ foam sclerotherapy, targeted to both the underlying tributary (when present) as well as the cutaneous bleeding varicosity. The remaining seven either declined sclerotherapy or were ineligible. Underlying incompetence of axial (great, small, or anterior saphenous) veins was found in 54 patients (92%). Of these patients with truncal vein incompetence, 48 underwent ablation-5 declined and 1 was too frail for any further intervention. There were no recurrent bleeds in the interval between immediate sclerotherapy and scheduled ablation. During a mean follow-up of 2.2 years, 55 of the 59 patients (93%) had no recurrence of bleeding. Four patients (7%) had late, recurrent hemorrhage: one had failed to return for their scheduled ablation, two were on chronic anticoagulation, and one had severe right heart failure. All four were retreated without further recurrence.

Conclusions: A two-step protocol of immediate ultrasound-guided foam sclerotherapy, followed within 8 weeks by endovenous ablation of incompetent axial veins and concurrent microphlebectomy, provided rapid and efficient treatment with durable freedom from subsequent hemorrhage.