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Secondary telangiectasia after radiofrequency closure of saphenous vein: a result of blocked outflow of a feeding vein?

Telangiectatic matting is a well-known side-effect of various phlebological procedures, from sclerotherapy (70–84%) and phlebectomies (0.5–9%) to stripping of saphenous veins. In many patients with new vessel formation, they disappeared spontaneously within a year. In a prospective analysis of 100 patients treated by endovenous laser ablation, Timperman noted the occurrence of new spider veins in one subject. It is believed that secondary telangiectasia are a consequence of neoangiogenesis as a response to inflammation and/or trauma to venous blood vessels, but firm evidence is lacking. Over the past years we have noticed that some patients undergoing radiofrequency segmental ablation (RFSA) of saphenous veins have reported that new telangiectasia and venulectasia within the area of treated veins appeared de novo several weeks following the procedure. In some of them the vessels persisted for a year and longer. We used to treat them successfully with polidocanol foam sclerotherapy. A 54-year-old woman complained of unsightly varicose veins in both lower legs, heavy legs, swelling of ankles at the end of day and occasional burning sensation over some varicosities. Duplex ultrasound examination revealed dilated and refluxing both great saphenous veins (GSV) and numerous subcutaneous varicose veins in both lower legs. In September 2011 we performed segmental RFA (VNUS ClosureFAST) of both GSV along with phlebectomies of subcutaneous varicosities in the local tumescent anaesthesia. At a follow-up visit six weeks later she drew our attention to newly formed telangiectasia on the medial aspect of her left thigh (Figure 1). She claimed that the new vessels became visible as early as three weeks after the procedure. Both GSV were completely closed from the saphenofemoral junction to the proximal third of her legs. Other superficial and deep veins were unremarkable. On clinical examination, even with transillumination, no feeding vein could be traced from the telangiectatic flare. However, ultrasound revealed a small subcutaneous vein (diameter 1 mm) going from underneath the telangiectasia, directed cranially through subcutaneous tissue, piercing saphenous fascia and ending into the GSV (Figure 2). The feeding vein was not refluxing. We then injected 0.8 mL of the 0.5% polidocanol foam (Tessari, liquid:air ratio 1:4) into the visible cutaneous vessels. The foam quickly spread into the feeding vein we easily tracked by ultrasound up to its connection to the obliterated GSV (Figure 2). Four weeks later the feeding vein was closed and most telangiectasia Figure 1 (a) A flare of spider veins on the inner aspect of thigh in a patient six weeks after radiofrequency closure of the great saphenous vein. (b) Four weeks after sclerotherapy of the feeding vein by 0.5% polidocanol foam most previous telangiectasia disappeared replaced by finer telangiectatic matting over the area (white arrows)