Side Effects
Varicose Vein Injections


By Ken Biegeleisen, M.D., Ph.D.



Summary: Vein injections are probably just as safe as any other commonly-performed medical procedure.

Face-lifts, fat suctioning and wisdom-tooth extraction, for example, all have side effects on occasion. I believe that vein injections are as safe as any of these.

However, side effects are possible.


Table of Contents


Side Effects from damage to tissues.


  1. "Death"
  2. Loss of limb
  3. Loss of skin and subcutaneous tissue



A. Injuries from varicose vein injections



  1. Intra-arterial injection
  2. Injection into a previously-injected vein



B. Injuries from spider vein injections



  1. Less serious injuries
  2. More serious injuries


Blood clot (phlebitis)


  1. Superficial phlebitis
  2. Deep vein phlebitis
    1. Permanent vascular damage









After the VeinDoctorNY web site was posted, I began to receive complaints because there was nothing on it about side-effects.

That's because the subject is so unpleasant that one wants to put it out of one's mind.

I put it out of my mind!

But my readers have more-or-less forced me to put it back in. So here it is.

WARNING!! I have decided to proceed from most-to-least-horrible side effects. So the worst horrors, although almost never seen, shall be presented before the common and more trivial side-effects.

If you have a weak stomach, go to the bottom of this discussion and read up!


I. Side effects from damage to tissues


1. "Death"


 Side effects of varicose vein injections range from trifling problems which hardly merit a telephone call, to death.

Now, before you "run for your life", let me assure you that there are no well-documented cases of anyone actually dying from treatment! The idea that death is even possible comes from a 30-year old British study, where statistics were compiled from numerous smaller reports, with a final patient group size of several hundred thousand people. In that group, there were 2 or 3 deaths. But ... were they from vein treatment? I doubt it.

Let me present you with some statistics, and then you'll have to decide for yourself. Think about this: If a human being lives for, say, about 80 years, and if a year is 365 days, then an average human being will live a total of

80 x 365 = 29,200 days

(That's all, folks! You get 29,200 days! Enjoy them!)

Everyone in a population of, say, 100,000 people, will die during one of the 29,200 days which the Lord allots to us. Therefore, on any given day, the number of deaths in any group of 100,000 people, regardless of who they are, will be (on the average):

100,000 / 29,200 = 3.4 deaths

In other words, in any population of 100,000 people whatsoever, regardless of who they are, an average of more than 3 deaths will be observed every day. These may be from old age, from disease, from accidents, or from any number of other causes -- whether or not any one of the people have varicose veins!

Therefore, the British mega-study of hundreds of thousands of vein patients, within which there were 2 or 3 deaths, does not necessarily prove that the people died from vein injections, since in a population that size there will be at least 3 deaths per day whether or not anyone gets a vein injection -- or, for that matter, any other injections.

Consequently, I would tell you that "death" as a complication of varicose vein injections is possible in theory only. I don't think it's ever actually happened.


2. Loss of limb


Depending upon how much you love your legs, you might -- or might not -- think that losing a leg is worse than death. Be that as it may, it's not very likely. I've certainly never seen a case of anyone actually losing a leg.

But there is a possibility of serious injury after injection treatment of varicose veins.

Before telling you any more about such horrendous things, let me first give you some idea of how many people have had their veins injected. In the United States, there are at least 10,000,000 (that's 10 million) vein injection treatments per year. This number may be derived from a review of health insurance statistics. Since some of the patients have more than one treatment, the number of people treated may be less than 10,000,000, but it's still in the millions. That's a lot of treatments! Consider this: There's nothing in the world, including getting in and out of bed, or taking a shower, that you can do 10 million times without something going wrong at least once!

If you did no more than walk across the street 10,000,000 times, you'd be bound to stumble and fall at least once, and you'd probably get hit by a car sooner or later.

Now I'll tell you what I know about lost or damaged limbs from vein injection. First of all, there was a report from the French medical literature, many years ago, suggesting that a patient had lost part of a leg from a bad injection. The report was from a review of the French literature on all sorts of injection accidents, and no details were given. Thus, we do not know what medicine was given, what vein was (allegedly) injected, or who actually gave the injection.

The most comprehensive report on such serious injuries, however, was from Britain. Britain has about 1/5 our population in America, therefore to extrapolate to America, multiply by 5. A highly respected British surgeon examined the British National Health Service (i.e. "socialized medicine") legal files for cases involving serious injuries from vein injections and surgery. Based on this report, it seems that in Britain, about once a year, a surgeon will accidentally operate on an artery instead of a vein. This causes very serious complications, including possible loss of part of the leg. Also, about once a year, a British vein injector will accidentally inject an artery instead of the vein, which also can cause loss of part of the leg.

Scary? Perhaps. But you've also got to consider the number of patients who are treated in Britain. There are millions of vein operations and injections given in Britain every year, and the chances of losing part of a limb are therefore in the one-out-of-a-million range. In other words, very unlikely.

To put this in perspective, rest assured that every year, without fail, people die from minor surgery, dental procedures, or just from slipping on a bar of soap in the bathtub. Unfortunately, as Dustin Hoffman said in the movie "The Marathon Man":

"It's not safe".

Life is not safe! Not entirely, at any rate. But the good news is that life is pretty safe, most of the time.


3. Loss of skin and subcutaneous tissue


Okay, you probably won't lose your leg from a vein injection. But you may lose some tissue.

This introduces us to the realm of more realistic problems. A bad injection can cause loss of, or damage to tissues, often enough to merit serious discussion.

I will divide this discussion into two parts: (A) injuries from varicose vein injections, and (B) injuries from spider vein injections.


A. Injuries from varicose vein injections


A "bad" injection is one which either (a) goes into the wrong blood vessel, or (b) doesn't go into any blood vessel at all.

The practitioner is supposed to pull back slightly on the syringe plunger before injecting medicine. The purpose is to see if the needle is actually in the target blood vessel. If it is, then a drop of blood will be seen to enter the syringe. Then it's (relatively) safe to inject. If there's no blood, then the needle is not in the vessel, and it is forbidden to inject.

If the practitioner is sloppy, and does not check to see if the needle is really in the blood vessel, and if he/she injects the medicine anyway, the medicine will pile up under the skin, and sit there, burning the skin and subcutaneous tissues. If you're lucky, the burn will heal without trouble. If you're not lucky, a serious chemical burn will ensue, which will heal with a scar.

The terminology for this error is "extravasation", which means that the medicine was mistakenly deposited outside the vein. In 20 years, I have never had an extravasation injury. It so easy to avoid that there's almost no excuse for it.


1. Intra-arterial injection


The most horrendous side-effect of injection treatment of varicose veins -- of those which actually occur with enough frequency to warrant even mentioning -- is "intra-arterial injection". This means that the medicine accidentally goes into an artery instead of a vein. The risk is in the neighborhood of one-in-a-thousand patients who are treated.

What's the difference between intra-arterial and intra-venous injection? A lot!

Think of the human leg circulation as an upside-down tree. The trunk is the aorta -- the large vessel which emerges from the heart. As it travels down toward the legs, the trunk breaks up into branches, exactly as a tree does -- only upside down.

The blood has the job of delivering oxygen (and other nutrients) into the leg. What happens after this delivery is over? The old blood, now carrying carbon dioxide (and other wastes), must leave. It is the veins which carry the blood up and out of the leg. They are also an upside down tree. The small veins in the arms, legs, and elsewhere, merge to form ever larger veins, until they all meet at two mega-veins, called the superior vena cava (which drains the whole upper half of your body) and the inferior vena cava (which drains the entire lower half of your body.

So, bearing in mind that the veins of the leg are like an upside-down tree, with the small branches at the bottom, ever-merging into larger and larger vessels as you move up, we may again ask, "What's the difference between an injection into an artery and an injection into a vein?

Here's the answer. When you inject a vein, the medicine moves up. When it reaches the next vein up, the two blood streams mix, to give rise to one larger vein. Think again of an upside down tree. As you move from the tiny outer branches toward the trunk, the branches get larger and larger.

Therefore, as the medicine moves upward in the veins, it enters into ever larger and larger veins, continuously mixing with more and more blood. In other words, it gets DILUTED. Therefore, if the medicine, G-d forbid, gets into the wrong vein, it might damage that vein, but as it moves up it gets weaker and weaker, through dilution with ever-larger amounts of blood. Therefore, the medicine does no harm as it moves upward, because it has been "watered down" by mixing with blood.

With arteries, however, it's the opposite. Blood in arteries is on its way down the leg. If medicine is accidentally injected into an artery, it travels to the next branch point, where the artery divides into two (or more) SMALLER vessels. There is no new blood introduced, and the medicine moves forward, full-strength, undiluted, until it reaches the target tissue. The target tissue (usually skin and subcutaneous tissue) is brought into the most intimate possible contact with the medicine via its own blood supply. You couldn't possibly do a better job of exposing the tissue to the medicine if you tried.

What happens? It turns out that human tissue is very sensitive to injection of foreign substances into arteries. Even a harmless-sounding substance such as penicillin, if accidentally injected into an artery, can sometimes cause grievous damage. In fact, even injection of pure water can cause problems, because the body fluids have salt, and they don't "like" pure water with no salt in it.

With accidental injection of a varicose vein medicine, which is even more irritating than penicillin, there is a high probability of serious tissue damage. The medical term is "necrosis", meaning death of tissue.

At the time of this writing, I have been in practice for 20 years. For the first 10 of those, I accidentally injected about 1 artery per year. About half of those injections healed completely with no lasting damage or scarring. The other half had damage. The damage, in the cases I've seen, has been limited to scarring of the skin and subcutaneous tissues.

The areas, after accidental arterial injection, look like hell. If you have a strong stomach, click here for "Dr. Biegeleisen's House of Horrors" photo gallery (these are from my publication on the subject --as of the date of this writing, I am the only doctor in America who has ever seen fit to write about this unpleasant subject).

Actually, in spite of how horrible these pictures look, most of these injuries heal with astonishingly little residual scarring. The largest scar I have ever seen was the size of a standard sized Band-Aid. This is not to say that the patients are "happy" about having a scar the size of a Band-Aid. Approximately half of the patients who sustain these scars sue the doctor. That's not fun.

The situation has improved greatly now. In more than ten years, we have injected no arteries. Did we "get better" at giving injections? I suppose we must have. You "hang around, and you learn".

When ultrasound became available for vein injections, it was believed, at first, that it would eliminate all arterial injection accidents, because you actually see the vein you're injecting, on screen. Actually, at first, it increased them! This is because ultrasound emboldened doctors to inject deeper in the leg than was previously possible. There are more arteries down there, and you've got to be very careful.

With experience, however, ultrasound eventually fulfilled its early promise, and arterial injection accidents can now be largely avoided. But it will never be "entirely" avoided -- only "largely" avoided.

One important strategy to avoid arterial injection is to use the method originally proposed by the great Swiss Phlebologist, Karl Sigg, which consists of entering the vein with a needle only -- no syringe. The "trick" is to examine the blood flow which comes out of the open end of the needle. If you're in a vein (which is good), it will drip out slowly. If you're in an artery (bad!) it will squirt out with every heart-beat (a little like a scene from a low-budget horror movie!).

This method has never been universally adopted because it is messy with the patient standing (which was formerly the position of most vein injections). Now, however, with the advent of ultrasound, the injections are given with the patient lying down, and the blood flow through the needle is vastly reduced, and much less (how shall I put it?) ... unsightly.

When ultrasound was introduced, most of us abandoned the above-mentioned "open needle" technique, believing it unnecessary. But my colleague, Dr. Dennis Miller, of Scottsdale, Arizona, proposed reinstating it. I resisted it at first, but after a few arterial accidents, I threw in the towel. All injections into large varicose veins, in this office, are done using the "open needle" technique. It must work, because we have not (thank G-d) had an arterial accident in the last 10 years.


2. Injection into a previously-injected vein


Another sort of mishap, mainly at the hands of inexperienced practitioners, may follow injection into a vein which has been previously injected. This may be done either because (a) the first injection was not completely successful, or (b) the doctor is sloppy, and neither knows nor cares what has been done previously.

When a vein has been previously injected, one of the effects of the previous injection is that the blood no longer flows easily through the injected vein. The reason is that the injection results in a narrowing of the opening in the vein (called the "lumen" of the vein). When you re-inject the same vein, you have to press harder on the syringe plunger to get the medicine into the vein. This can be dangerous!

Several investigators, the most well-known being the Swedish vascular surgeon Lars Schalin, have shown that varicose veins have tiny connections to neighboring arteries. These are called "arteriovenous communications". I'll call them "AVC's" for short. It seems that normal veins do NOT have these AVC's, but varicose veins do have them.

If the vein has been previously injected, and if the doctor carelessly pushes medicine into it a second time, thoughtlessly allowing himself to push as hard as necessary to get the medicine in, he may build up a very large pressure inside the vessel. This can cause medicine to flow through the AVC's into the neighboring arteries. The result is, in effect, an intra-arterial injection. We wrote about those above.

The difference here is that the medicine tends to move into multiple small arteries, rather than into one discreet artery as in direct intra-arterial injection. This introduction of medicine into multiple small arteries causes a more superficial, but more widespread pattern of skin damage. It's not a pretty sight.

This can be easily avoided by keeping the problem in mind. There's nothing wrong with injecting into a previously-injected vein, as long as you mind your pressures.


B. Injuries from spider vein injections

1. Less serious injuries


Our theory of the cause of spider veins is given in the "Advanced Information" section on that subject. In short, we believe that they are multi-factorial in etiology, i.e. that they have more than one cause. But the most important, we believe, is the existence of "arteriovenous communications" ("AVC's"), which means that the tiny veins of the skin get connected to tiny high-pressure arteries, which causes them to blow up and become unsightly.

Why AVC's appear is not known with certainty, and a discussion of it would be too long even for this Internet web site. Let's just say that they're there -- that much is known.

When medicine is injected into spider veins, therefore, it will routinely pass through the AVC's, into the arterial system. If you read the passages above, about intra-arterial injection accidents, then you already know that this is a potentially serious situation. And yet, most of the time, nothing bad happens. How come?

Again, the answer cannot be given with 100% certainty, but it appears to be the case that the arteries in question are not involved in the nutrition of the local skin. They are apparently part of a vast system of small arteries which are involved in the regulation of body temperature. These arteries, which are not often discussed in books and articles on circulation, nevertheless constitute 90% of the arteries in the skin! They carry little blood when the body is cool, but when the body is overheated, they open up wide, and flood the skin with extra blood (these are also the arteries whose opening up makes you turn red when you blush).

When the skin is thereby flooded with extra blood, the skin gets hotter (the skin temperature is normally 5-10 degrees cooler than the blood). This heat, now being on the surface of your body, can leave, radiating out into the surrounding air. Thus, your body, having dumped this excess heat, has now cooled itself off.

This vast system of tiny arteries is a global thermostat, responding to the "instructions" of the central nervous system, and not to local stimuli. It is thus involved in total body temperature, and not merely in the regulation of the temperature of any particular patch of skin. That is presumably why there has never been any sign or evidence, during the 3/4 of a century that spider veins have been injected, that such injections cause any problems with this thermostatic system.

But local cosmetic damage to the skin is another story. This can, and on occasion, does occur. Whether or not there is damage may depend upon how much medicine is injected. Ultimately, all the arteries are connected, and if enough medicine is injected into spider veins, and it passes through AVC's, and it passes beyond the temperature-regulating arteries into the nutritional arteries -- i.e. the arteries which are actually supplying the skin with oxygen and nutrients, then the skin can be burned.

That is a very, very long way of saying that when spider veins are injected, one has to be careful not to put in too much medicine. What happens if too much medicine is put in?

The first thing one sees is a blister. It is typically the size of a small fingernail, and at first it looks just like an ordinary friction blister. But usually, the roof comes off after a day or two. Then you have an open sore. These sores take 1-3 months to heal, and they leave behind permanent scars.

For the first year or two, these scars look nasty, because they have all sorts of colors associated with them ("black-and-blue" discoloration, brown pigmentation, and/or redness from inflammation). Then the colors usually fade, leaving a little white circle. Since most people have a few white spots here and there, it's not a problem after that. But it takes 1-2 years to get to that point.

This is the most common side-effect of spider veins. In this office, the frequency is one blister per 100 patients.

In some offices, the doctors water down the medicine to avoid this side-effect. That indeed prevents the patient from suffering any blisters or scars, but it also prevents the patient from getting any good results as well. So that approach to "safety" doesn't work.

Conversely, increasing the medicine strength produces better treatment results, and faster. But it also increases the incidence of blistering and scarring. So that doesn't work either.

In this office we use 0.33 % sodium tetradecyl sulfate ("STS") for the injection of spider veins. This medicine is strong enough to get the job done. In the hands of an experienced operator, who knows the signs which signal that too much medicine has been injected (these involving color changes in the skin), blisters and scars are almost completely preventable while using 0.33% STS.


2. More serious injuries


I have seen one case in which medicine behaved as if it went right through a network of spider veins into a larger artery, causing a serious skin burn, i.e., considerably larger than a finger nail. Since I've only seen one case, and since there is nothing in the medical literature on the subject (as far as I know), I can't really say why it happened.

In 20 years, I've seen only that one case.


4. Blood clot (phlebitis)


Popular literature has the whole world in terror about the subject of "blood clots". The expression "blood clot to the heart" is heard all the time. But there's no such thing as a "blood clot to the heart"!

Blood clotting is not a "disease", it's a sign of any number of underlying disorders. A blood clot can be your body's defense against infection. Imagine, for example, that you go to the beach and step on a nail or a piece of broken glass. Now imagine that that nail, or piece of glass, is contaminated with dangerous bacteria. If these germs "set up shop" in one of your foot veins, they can then begin to travel through the blood stream to every inch of your body, from head-to-foot (actually from foot-to-head), and kill you!

Therefore, if your body caused a blood-clot in the infected vein, which would prevent the bacteria from traveling, would that be a good thing? You bet it would! That's a blood clot you wouldn't want to be without.

In general, then, a blood clot should be understood to be a normal defense mechanism. It prevents excessive blood loss after an injury, and it confines dangerous foreign invaders to the first vessel they enter.

However, blood clots can also cause problems by themselves. If a blood clot forms -- for any reason -- in an important vein, the blood clot will surround, and incorporate into itself, everything in the vein. What if there's no injury, and no bacteria in the vein? What else is in veins? Answer: Valves. And valves can be damaged, in some cases, by blood clots. Here's how.

Studies have shown that blood clots can be removed one of two ways. The first way is through "thrombolysis". This means that your body's blood-clot-dissolving enzymes go to work and remove the clot rapidly. You may have read about such enzymes in the health media, because they have been both purified and manufactured by pharmaceutical companies, and sold for the purpose of "opening up" arteries in people with heart attacks. One name you may have seen is "TPA", which stands for tissue plasminogen activator. This substance, now manufactured by genetic engineering, causes the release of blood-clot dissolving enzymes in the body.

If a blood clot is removed rapidly, by blood-clot dissolving enzymes, then the vein usually recovers -- completely.

If, however, the blood clot is not removed quickly, then a second process begins. This is termed "organization" of the blood clot, and what it means is that the blood is gradually replaced by collagen, which is like a scar (scar tissue is predominantly collagen). A completely "organized" blood clot is therefore like a tubular scar. It is completely blocked with respect to the blood stream, because there is no opening, or "canal", though which blood can flow.

A blood vessel with a fully-organized clot can still be salvaged by your body, by a process called "re-canalization". The enzymes involved are different. Collagen is a protein, and cannot be removed by blood-clot-removing enzymes. It has to be removed by "proteolytic" enzymes. These are enzymes which dissolve protein (some common examples which you may have heard of include papaya, pepsin, and trypsin).

These processes -- organization of a blood clot and re-canalization of it -- take a much longer time. Studies show that what happens, during this time, is that the valves, which are located along the inside of the vessel, become irreversibly fixed to the blood clot, and get dissolved along with it. Then, if your body restores the opening inside the vessel, you have a valveless vein.

Valveless veins are not good. They function poorly, and in some instances they are actually considered to be worse than no vein at all! They cannot prevent blood from being pulled down into the feet by gravity. People who have a lot of valveless veins have swollen legs, a condition called chronic venous insufficiency. This is associated with tired, aching legs in milder cases, and with open sores which heal poorly in more severe cases.

Therefore, blood clots which form in veins after injections for varicose veins are not good. But some are worse than others.

The term "phlebitis" does not mean exactly the same thing as "blood clot". "Phlebitis" means "inflammation in a vein", just as "bronchitis" means "inflammation in your lungs" (or bronchial tubes).

When a vein is inflamed, it may often clot off, so that the two terms "phlebitis" and "blood clot" are sometimes used interchangeably. Strictly speaking, this should be avoided.

There are two types of "phlebitis" which are seen in medical offices: "Superficial phlebitis" and "deep vein phlebitis". Either one can occur after varicose vein injections. One is dangerous, and the other one isn't. Let's look at both:


1. Superficial phlebitis


The most common form of phlebitis seen after injections for varicose veins is superficial phlebitis. This means "phlebitis in a surface vein". In actual practice, except for people with rare genetic disorders, superficial phlebitis only occurs in varicose veins. It may occur spontaneously, or it may occur following a vein injection.

When a vein develops superficial phlebitis, it becomes red, hot, swollen and very sore.

This reaction is completely different from the normal outcome of injections, where there is little, if any heat, redness or swelling. In a normal outcome, the vein is a bit sore if you press on it, but not when you walk, or go about your daily activities.

With superficial phlebitis, however, the pain is continuous, and the patient may limp into the office.

Is this condition dangerous? No. There are no long-term complications from superficial phlebitis. After a few days, it starts to subside. It's usually all over in 7-10 days.

I think of superficial phlebitis as being the vascular equivalent of a cold, kind of like a sore throat.

It is widely believed, by general practitioners, that superficial phlebitis can "cause blood clots to shoot all over the body". But in 20 years of injecting veins, I have never seen a traveling blood clot arise from a superficial vein. I would advise you, based on my personal experience and observations, that this does NOT occur.

Superficial phlebitis occurs in about 1%, or 1-out-of-100 patients who are injected for varicose veins. In some cases there is a previous history of spontaneous superficial phlebitis, so we attribute it to a peculiarity of that person's biochemical makeup. In other cases, there is no such history, and we really don't know why it occurs.

We're not at all concerned about the "long-term" effect of superficial phlebitis on the injected vein, because it's a vein which we're trying to get rid of anyway! We're sorry that the patient has a sore leg for 7-10 days, but since that's the extent of the trouble, we don't worry about it too much.


2. Deep vein phlebitis


When you read things like "100,000 Americans died from phlebitis", you're reading about phlebitis of the deep veins, called, appropriately enough, deep vein phlebitis. It's very different from the superficial variety.

The most common causes of deep vein phlebitis are pregnancy, cancer and hip surgery -- not vein injections!

Pregnancy causes deep vein phlebitis by altering the everyday hormonal balance, which somehow predisposes to blood clotting. The weight of the gravid uterus, pressing on the leg veins, may also contribute.

Cancer also causes massive biochemical alterations to the body, among which are derangements of the blood clotting system.

Hip surgery is commonly performed in senior citizens, who seem to be predisposed to falling down and fracturing their hips. Orthopedic surgeons are inclined to repair these hips surgically, so that the patients can get back on their feet in a reasonable period of time. The operation is followed by a very high incidence of blood clotting in the deep veins of the thigh and pelvis.

These are the common causes of deep vein phlebitis. Ordinary, "garden variety" varicose veins are NOT a common cause of deep vein phlebitis.

In 20 years of injecting varicose veins, I have never seen a phlebitis in the important deep veins of the leg. The worse phlebitis I've seen has been that involving the "gastrocnemius veins", i.e. the veins of the calf muscle. These patients return to the office with a swollen and tender calf. Ultrasound studies show the blood clot in the calf muscle vein.

The condition subsides gradually, without treatment, in a few weeks. The worse case I ever saw took somewhere between 4-6 weeks to subside (i.e., she was still a bit swollen at 4 weeks, but not at 6). Most of the cases resolved more quickly.

I have had the opportunity to do long-term follow ups on a number of such cases, and there is no discernable long-term swelling or other trouble, as far as I can see. The medical literature also contains no studies (which I have seen, at any rate) which suggest that long-term damage results from gastrocnemius vein injection.

General practitioners and other non-specialists usually over-treat calf-muscle phlebitis, with hospitalization and blood-thinning drugs, neither of which actually have any significant effect on the disorder. Ironically, these days most specialists, e.g. vascular surgeons, avoid hospitalization of such patients, treating them rather by simply applying an ace bandage, and advising the patient to walk, not to go to bed.

A more serious form of deep vein phlebitis would be that affecting the major "trunk" veins of the leg, namely the femoral or popliteal veins. There have been no cases of that in this office. The theoretical dangers of such forms of phlebitis are two:

  1. Traveling blood clots, and
  2. Permanent vascular damage.

The first of these, traveling blood clots, are the things you keep reading about in your health magazines. I have never personally known a patient, in any medical setting, who had a traveling blood clot, but I too keep reading about it. I have no doubt that it occurs, I have just never seen it with my own eyes.

What would happen if a blood clot traveled? It would return to the heart, but contrary to what is implied by the false expression "blood clot to the heart", the clot will never stop there. The heart has huge openings in it, and no blood clot could possibly be so large as to get trapped in the heart.

Beyond the heart are the lungs, and it's there that blood clots can, and undoubtedly do get trapped (although I have never personally seen a case). Nothing can get through the lungs, because they are packed with microscopic filters, and every particle which is larger than the normal cells which flow with the blood gets filtered out.

So the correct term is "blood clot to the lungs". What happens if a blood clot lodges in the lungs?

If it's very small, the blood will travel around it, since the lungs are jam-packed with vessels; more than are needed. Eventually, the blood clot will be dissolved, and life will go on. The patient will never even know it had been there.

If the blood clot is a bit larger, there may be clogging of enough blood vessels in the lungs to cause symptoms. In such cases, there may be a bit of pain, and perhaps a cough. It seems likely that most such cases are written off as "colds", since they also resolve largely, or completely.

It's only when the blood clot is very large that it comes to the attention of doctor and patient. Here, the blood clot will lodge in a large vessel, blocking it, and a significant segment of the lung is thereby deprived of its blood-supply. If the blockage is severe enough, the segment of lung may actually die. This is called "necrosis" or "infarction". A "pulmonary infarction" can be just as serious as its cousin, the "myocardial infarction", more commonly known as a heart attack. Pulmonary infarction can cause death in severe cases.

I've never personally known a varicose vein injection to result in a blood clot to the lungs, but all practitioners believe that it's possible. I, too, believe that it's possible. I've just never seen it.


a. Permanent vascular damage


A more relevant concern, after a blood clot appears in the femoral or popliteal vein, is permanent vascular damage. This was described above, in the discussion of blood clots. The mechanism, as previously stated, is that the valves of these veins get incorporated into the clot. After the clot organizes and the resulting tubular scar is removed by the body, the opening in the inside of the vein is restored -- only the vein, at that point, will have no valves. See above for a discussion of the "valveless vein".

In the 20 years that I have been injecting veins, I have never seen a patient sustain a deep vein blood clot as a result of vein treatment (in my own office, at any rate). I have certainly, therefore, never seen any "permanent vascular damage".

In conclusion, there are two types of phlebitis: superficial and deep. Superficial phlebitis is benign. It heals itself in 7-10 days, and has no long-term consequences. Deep vein phlebitis can be more serious, but (thank G-d) we have had no serious cases in this office.


5. Pigmentation


It is part of the ordinary outcome of this treatment that brown discolorations appear in the skin. Normally, they fade in a matter of months.

On rare occasions, a brown discoloration may be permanent. With few exceptions, this results from one of two causes. Either (1) the skin has been burned by the medicine, leaving a permanent scar which may in some cases have some brown color in it, or (2) the patient may have profound disease of the deep veins, in which case the legs are predisposed to brown staining of the skin.

If you look at the legs of senior citizens, you will frequently find brown discolorations, especially around the ankles. This results from chronic venous insufficiency, which, to a greater or lesser extent, accompanies the aging process. In certain patients with severe varicose veins, a similar brown staining can start at an early age. This sort of leg can develop further brown discoloration at an injection site, and it can last a very long time.

The brown color, by the way, is from iron. In advanced deep venous insufficiency states, the leg veins are so engorged that blood cells are squeezed right through the walls of the tiniest of blood vessels in the ankle area. The iron from this blood is what turns the skin brown. This iron is presumably cleared away at some rate, but unless the underlying disease can be corrected (usually not possible in advanced deep venous insufficiency), more iron will constantly be laid down, so that the area remains brown, sometimes forever.

Prolonged brown discoloration is not a side-effect of treatment in legs with ordinary "garden variety" varicose veins, only legs with profound disturbances of the deep circulation. These patients have obvious signs, and they generally know who they are. If your legs look pretty normal except for some enlarged veins, you are not of that group.


5. "Other"


There are lots of things which are reported, rarely, after injections. I've had patients complain of stomach pain, headache, "spots before the eyes", dark urine, and just about anything else you can name.

Are they caused by treatment? Who can say? They come ... and they go.


5. Summary and Conclusions


That wraps up our discussion of side-effects of treatment.

It should perhaps be noted that the spectrum of side-effects discussed here are those I know of from my own medical practice. Although I am confident that most other reputable vein specialists will agree with most of what has been said, that does not mean that they will agree with all of it. Every doctor has his/her own experience, from which conclusions are drawn. Other doctors' conclusions may be different from mine.

In this office, then, after injection of varicose veins...

  1. There is a 1% incidence of superficial phlebitis, which means the vein is pretty sore for 7-10 days, then gets better by itself.
  2. There is a tiny incidence of deep vein phlebitis, which can be serious, but never has been, in our experience.
  3. There is a tiny incidence of intra-arterial injection accident, which can cause significant damage to patches of skin, with permanent scarring. We have not had a case in about 10 years.

After injection of spider veins...

  1. There is a 1% risk (per patient, for the entire treatment) of an injection causing the appearance of a blister which heals with a small scar.

That's the worst of it. Is it worth the risk? You have to decide!


























Dr. Biegeleisen's "House of Horrors"



We are told, by our colleagues in the legal profession, that patients are supposed to be "fully informed". That's actually impossible, since doctors themselves are not really "fully informed", and it's sometimes hard to find two doctors who agree about a question which is at all controversial.

Be that as it may, we have succomed to society's pressures, and hereby show you what a "bad injection" looks like.

The risk of winding up like any of the patients shown below is extremely low. We are not trying to scare you. These reactions are mainly avoidable. In my first ten years of practice, I (rarely) made mistakes like these. Thank G-d, most of them healed pretty well (photos not shown).

These days, these sorts of problems are almost non-existent in this office. When I get called to court these days, it is generally as an "expert" witness for patients who have been injured in other offices.

Well, here they are:

The above pictures are from my publication on the subject of "bad injections" (Inadvertent Intra-Arterial Injection Complicating Ordinary and Ultrasound-Guided Sclerotherapy, by K. Biegeleisen, R.D. Nielsen, & Ann O'Shaughnessy, published in Journal of Dermatologic Surgery and Oncology 19:953-958, 1993).

As far as I know, I'm the only doctor in the United States who has published an article on this unpleasant subject. The others pretend it "never happens" in their offices. (Don't believe it!)

The funny thing is that since publishing these photos, we have had no serious complications! There seems to be something about admitting fault which leads to its removal. The opposite, pretending that you never make a mistake, seems to be associated with the opposite: ongoing error.