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192 Chapter 20/Sclerotherapy and Ultrasound-Guided Sclerotherapy
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FIGURE 20.1 Correct alignment of the needle along the sagittal plain of the transducer. IPV (incompetent perforat-
ing vein). (From Thibault PK, Lewis WA. J Dermatol Surg Oncol. 1992. 18: 895–900.)
FIGURE 20.2 B-mode ultrasound image of needle angling toward target vein (IPV). The angle of insertion is deter-
mined by measuring the depth of proposed injection site on the ultrasound image prior to needle insertion. (From Thibault
PK, Lewis WA. J Dermatol Surg Oncol. 1992. 18: 895–900.)
When using the longitudinal approach, during injection
the direction of fl ow of sclerosant can be determined, and
with a combination probe pressure and digital pressure
applied distal or proximal to the injection site, the direction
of sclerosant fl ow can be modifi ed to optimize the localization of the sclerosant.
The volume of sclerosant injected at any one site varies
between practitioners, but usually ranges from 0.25 ml to
2.0 ml depending on the site and size of the vein. It is the
author’s preference to inject smaller quantities at multiple
sites rather than larger volumes at one site, as the former
technique, although equalizing the sclerosant concentration
Techniques of Ultrasound-Guided Sclerotherapy (UGS) 193
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FIGURE 20.3 B-mode ultrasound image of refl ective needle tip indenting vein wall immediately prior to vein punc-
ture. (From Thibault PK, Lewis WA. J Dermatol Surg Oncol. 1992. 18: 895–900.)
FIGURE 20.4 B-mode ultrasound image of needle located in vein with sclerosant fl owing toward the right of image.
(From Thibault PK, Lewis WA. J Dermatol Surg Oncol. 1992. 18: 895–900.)
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along the segment of vein,12 minimizes the risk of overfl ow
of sclerosant into the deep system through nearby perforating veins that can cause deep and muscular vein sclerosis
and possible subsequent DVT.
When injecting the incompetent GSV or SSV, it is usual
to place the fi rst injection 5–10 cm distal to the incompetent
saphenofemoral (SFJ) or saphenopopliteal (SPJ) junction.
The author uses STS 3% or POL 3% microfoam at a sclerosant: air ratio of 1 : 3. As the recommended maximum dose
of FibroveinTM is 4 ml, the maximum microfoam volume is
16 ml. The maximum volume of POL will vary according to
concentration used and patient weight (2 mg/kg/day). When
using foam the author prefers to draw up 1.5 ml of foam
in each syringe (so this becomes the maximum injectate
volume), although many practitioners inject 2 ml at most
6
sites.
Kanter13 compared the effect of 1 ml and 2 ml sclerosant
(3% STS) injectate volumes on immediate vasospasm and
later clinical outcomes after UGS. He found that 2 ml injectate volumes were less effective than 1 ml and did not reduce
the number of injections given. Therefore this group received
twice the volume of sclerosant, and some reported transient
fl u-like symptoms four to six hours after treatment. Hence,
when injecting solution (rather than foam), it is advisable
not to inject more than 1 ml at any one site. When injecting
within several centimeters of visible calf perforating veins,
it is advisable to inject less than 0.5 ml.
3,14
Injections proceed distally as previously injected segments are observed to spasm or fi ll with foam. Treatment
endpoint is when all segments of incompetent vein have
undergone spasm and become incompressible to probe
maneuvers. The ultrasound transducer also can be used to
compress the treated vein in a rhythmical up and down
motion, as the vein is followed post injection to observe for
uniform vasospasm. The maneuver also has the effect of
uniformly distributing the sclerosant longitudinally and circumferentially along the venous endothelium, thereby accelerating the process of vasospasm.
Catheter Techniques
Open Catheter Technique
In the early days of UGS, especially when the procedure
was being developed and techniques refi ned, there were a
number of reports of inadvertent intraarterial injections that
concerned many phlebologists.
UGS fi rst were introduced to minimize the risk of inadvertent intraarterial injection and the resultant extensive tissue
loss that could occur. The fi rst “open catheter” technique
was described by Grondin in 1992.
mended a 20 G 44 mm cannula for cannulation of the GSV
or SSV 6 to 8 cm distal to the SFJ and SPJ, which were
thought to be the sites of maximum risk of inadvertent intra-
3,14
Catheter techniques of
15
This technique recom-
arterial injection. Correct placement of the cannula could be
confi rmed by aspiration of nonpulsatile venous blood, ultrasound visualization of the cannula tip, and, fi nally, injection
of normal saline into the vein prior to sclerosant injection.
After confi rmation that the cannula was inserted correctly
into the vein, the sclerosant was injected at that site as a
bolus in a similar manner to that described earlier in the
“closed” technique. The technique could be used to treat the
remaining distal trunk by recannulating distal to the initial
cannulation point.
Extended Long Line Echosclerotherapy (ELLE)
The ELLE technique was fi rst described by Parsi in
199716 and later reported by Min and Navarro.17 This technique was developed not only to reduce the risk of intraarterial injection, but also to improve the effectiveness of UGS.
Its special indication is the treatment of larger diameter
incompetent trunks. This was the pioneer technique, which
preceded other catheter-based procedures used to treat varicose veins such as endovenous laser ablation. The technique
involves catheterization of a target vein under ultrasound
guidance and introduction of the sclerosant as the catheter
is withdrawn. Parsi and Lim18 describe the method in
detail.
Cannulation
The entry point for cannulation is selected after completion of pretreatment mapping of the superfi cial truncal
incompetence. The ideal entry point is distal calf for SSV
and medial knee for GSV. The segment of vein chosen for
cannulation should ideally be straight and superfi cial. A
subcutaneous injection of a local anesthetic is given prior to
cannulation. The anesthetic should not contain adrenaline to
avoid vasoconstriction.
Cannula Selection and Penetration
The depth and luminal diameter of the selected vein is
measured to assist in appropriate cannula selection. Usually
16 G to 18 G cannula are used with cannula lengths varying
from 4 cm to 7 cm.
The procedure is carried out using aseptic technique. The
vein is visualized with B-mode ultrasound in the longitudinal axis and the selected entry point is marked on the skin.
A tourniquet can be applied proximal to the selected point
of entry to facilitate the cannulation. Once local anesthesia
is achieved, the vein is cannulated under ultrasound guidance. The probe should be perpendicular to the skin and
perfect alignment of the longitudinal axis of the probe with
longitudinal axis of the cannula should be attempted. Successful entry of the cannula into the vein is signaled by
spontaneous venous return. Tapping of the vein with the
cannula can cause vasospasm and is best avoided. If vasospasm occurs, it is preferable to choose another point of
Techniques of Ultrasound-Guided Sclerotherapy (UGS) 195
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entry. Technically, cannulation can be the most challenging
part of this procedure.
Catheterization
The length of the selected vein is measured to assist in
selection of the appropriate catheter (Cavafi x MT134,
Cavafi x Certo 375) (B.Braun Medical Suppliers, Sydney,
Australia). The selected catheter is fed through the cannula
(catheter through cannula technique) and introduced into the
lumen of the vein and advanced toward the junction under
ultrasound guidance. Once the catheter is about 2 cm distal
to the junction the leg is raised to 30 to 45 degrees to empty
the vein and reduce the vessel diameter. It is this maneuver
that is readily performed with the ELLE technique, but more
diffi cult with the closed needle technique, that theoretically
will result in better contact of the sclerosant with the venous
endothelium with larger truncal veins. The sclerosant is then
introduced as the catheter is being withdrawn. Both foam
and liquid sclerosants can be used. Some practitioners would
compress the junction to prevent the entry of the sclerosant
into the deep system (Cloutier technique).19 Parsi and Lim
believe that a number of “pulse” injections of approximately
0.8 ml of STS 3% solution is more effective than continuous
and gradual infusion of sclerosant. This is consistent with
the principles of sclerosant distribution described by
12
Guex.
Special attention is given to T-junctions with tributaries
and perforators as the catheter is gradually withdrawn. Extra
volume of sclerosant may be required at these escape points
to ensure full sclerosis of these openings. Failure to sclerose
the escape points may lead to segmental recanalization of
the vein.4 As with the closed needle technique, the endpoints
of the treatment include vasospasm, noncompressibility
along the entire length of the treated vein, and absence of
any blood fl ow in the vein, all confi rmed with ultrasound.
There are several limitations of the ELLE technique.
First, it is not useful in treating complex patterns and tortuous postsurgical recurrences. Second, it is technically diffi cult to treat smaller incompetent veins less than 4 mm in
diameter owing to diffi culty in cannulating these veins with
a relatively large diameter cannula that is required for the
procedure. Its advantages include total avoidance of intraarterial or extravascular injections, reducing the effective
diameter of the target vein, minimizing the number of injections and hence less pain and the ability to reach veins
located deep in the subcutaneous tissue.
UGS for Resistant Telangiectases
and Telangiectatic Matting
Using a high frequency ultrasound imaging transducer,
Somjen et al.20 have shown that 89% of areas of thigh
telangiectases have associated incompetent reticular veins
identifi able. A large proportion of these were found to be
associated with deeper subcutaneous vein refl ux or with
perforating vein refl ux. Some of the incompetent reticular
veins were invisible from the surface and these invisible
reticular veins can be a cause of treatment failure when using
standard techniques of sclerotherapy. Using high frequency
22
duplex ultrasound, Forrestal
also has observed incompetent reticular veins associated with resistant telangiectases
and telangiectatic matting. Using ultrasound guidance, these
“invisible” veins can be injected with STS 0.5–1% or polidocanol 1%.
Post Sclerotherapy Compression Techniques
External Compression
Various forms of external compression have been recommended following sclerotherapy to varicose veins. Although
Fegan advised six weeks of continuous external compression with bandages,21 this is not generally required with
UGS owing to the fact that the principle of the technique is
that all proximal sources of refl ux are controlled in the initial
treatment.
The reasons for using external compression with UGS
relate to increased patient comfort, reduction of symptomatic chemical phlebitis and maintenance of optimal deep
venous fl ow during the post injection period. For this reason,
the most commonly used compression following treatment
is the application of Class II (25–35-mmHg) graduated compression stockings. Generally the stockings are worn during
the day for two to three weeks. Some practitioners also
advise their patients to wear the stockings at night for the
fi rst three to four days in order to maintain optimum deep
venous fl ow in the early post-injection period, thereby minimizing the risk of deep venous thrombosis. The stocking
may be removed each day for showering, without any undue
adverse effects.
Internal Compression (Perivenous Compression)
This novel method has been introduced recently to
improve sclerosant contact with the vein wall during the
immediate post-sclerotherapy period. The technique was
developed from the perivenous local anesthetic technique
for endovenous laser ablation. With this method, following
completion of injection of the main stem (GSV or SSV) with
sclerosant foam, normal saline with 1 : 500,000 adrenaline is
injected perivenously in the compartment between the deep
and superfi cial fascia (see Figure 20.5) at three to four locations equally spaced along the axial vein in the thigh (GSV)
or calf (SSV). Usually between 10 and 20 ml of normal
saline is required, or about 5 ml at each cross-sectional
segment. The injection is performed using ultrasound guidance with a cross-sectional approach using a 25 gauge 1
1
/2
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At the fi rst post-UGS visit, once proximal closure of the
treated veins has been confi rmed, residual distal branch
varicose veins and telangiectases may be treated with standard sclerotherapy methods. The patient is then reviewed
four to six weeks after the initial treatment, when repeat
ultrasound examination is performed and any intravascular
coagula are removed through a small stab-incision using
either an 18–21-gauge needle or no. 11 blade. Generally this
procedure can be performed without any anesthesia.
Further follow-up visits may be scheduled at three, six,
and 12 months to ensure that there has not been recanalization of the treated vein.
FIGURE 20.5 Post UGS perivenous compression of GSV with normal
saline.
Adverse Effects of Ultrasound-
Guided Sclerotherapy
Varcoe8 performed a survey of 44 experienced UGS phle-
inch needle. The effect is to give greater immediate compression to the vein, thereby decreasing the diameter of the
already spasmed vessel by approximately another 50%,
resulting in better apposition of the veins walls and more
complete contact of the veins wall with the sclerosant.
The author now uses this method routinely when treating
larger axial vessels (GSV and SSV) greater than 4 mm in
diameter and axial veins that have recanalized. Early
experience indicates a reduction in early recurrence and
recanalization.
Post Treatment Methods and Follow-up
Immediately after treatment, patients are advised to walk
continuously for 15 to 20 minutes and are then instructed to
walk for at least 45 minutes daily. This signifi cantly improves
any discomfort, which is generally minimal. Pain requiring
treatment following the procedure is unusual and indicates
that the patient needs to be reviewed by the phlebologist to
ascertain the cause. Walking reduces superfi cial ambulatory
pressures and ensures high fl ow in the deep venous system
of the leg for a prolonged period at least once per day.
Patients are usually reviewed one to two weeks following
treatment, at which time the venous system is reexamined
with duplex ultrasound to determine:
1. Whether the treated veins are incompressible and have
no fl ow.
2. The patency and fl ow in the deep veins.
If a treated segment of vein is found to be partially or completely patent and have persistent refl ux, the segment is
reinjected using ultrasound guidance. The phlebologist
should be aware that lower concentrations of sclerosant
might be necessary, as the vein endothelium will be partially
destroyed, making the vein more prone to chemical thrombophlebitis if too strong a concentration is used.
bologists from seven countries and reported on their experience with adverse effects from UGS. In this survey, side
effects were grouped into minor or major reactions. Minor
reactions were phlebitis, pigmentation, edema, pain, minor
(asymptomatic) DVT, and minor allergic reaction. Major
reactions were major DVT, pulmonary embolus, and severe
allergic reaction. In this survey, the incidence of major
adverse effects was less than 0.1%. Only one phlebologist
reported pulmonary embolus occurring, indicating the low
risk of this event. In 15 years of performing UGS, the author
has not observed any pulmonary emboli following UGS and
only one DVT (affecting the popliteal vein extending from
a sclerosed gastrocnemius perforating vein).
Several intraarterial injections were reported early on
in the history of UGS,
Varcoe survey was 0.01%. The risk of this event appears to
be directly related to the experience and training of the
phlebologist in this procedure and rarely occurs in skilled
hands.
The most common serious adverse effect experienced by
the author has been anaphylactoid reactions to the sclerosant
23
STS.
The incidence of anaphylactoid reaction in 2686
treatment sessions was 0.15%. This reaction appears to be
concentration and volume dependent. Interestingly, since
the advent of foam this incidence has been greatly reduced.
The author has not observed any anaphylactoid reactions to
STS 3% foam in the past fi ve years.
A relatively common, but minor adverse effect reported
after UGS (and possibly more frequently when using foam)
is transient visual disturbance sometimes associated with
migraine headache and less frequently associated with chest
tightness. The mechanism for this adverse effect is not
entirely understood and although it has been suggested that
it is caused by air passing through a right to left shunt in the
heart, the author has never been able to document such a
defect in affected patients, and the adverse effect also occurs
3,14
and the incidence reported in the
Techniques of Ultrasound-Guided Sclerotherapy (UGS) 197
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in sclerotherapy when foam is not used. The author believes
that this is a refl ex vasospastic event as the patients affected
generally have a past history of migraine.
23
Short- and Long-Term Results
There are now a number of studies documenting the
effectiveness of UGS. Most of these studies have examined
the results of treating GSV incompetence although there are
several now published on SSV incompetence.
Greater Saphenous Vein Incompetence
The fi rst reported objective ultrasound results of SFJ and
GSV incompetence treated with UGS were those of Kanter
and Thibault.4 Using STS 3% solution, they reported a 76%
success rate at 24 months. Cabrera et al.5 followed up 500
lower limbs with SFJ and GSV incompetence treated with
UGS using Lauromacrogol 400 (polidocanol) microfoam.
After three years, 81% of treated GSVs were obliterated and
96.5% of superfi cial branches disappeared. The obliteration
of saphenous veins required one treatment in 86%, two in
10.5%, and three in 3.5%.
Cavezzi and Frullini24 in a study of 106 saphenous axes
or recurrent postsurgical varices achieved 95% sclerosis at
21 weeks using STS 1% or 3% sclerosant foam. There were
three completely unsuccessful cases despite three treatment
sessions, and 10 cases of early recanalization (with refl ux or
retrograde fl ow), subsequently successfully retreated with
UGS.
Myers et al.25 reported objective ultrasound results on 100
limbs (78 GSV and 22 SSV) after 12 months using STS or
AethoxysclerolTM according to preference and partly determined by the diameter of the veins. All but one vein treated
was less than 10 mm in diameter. Echosclerotherapy was
successful in the fi rst treatment in 86 limbs (primary success),
but it was necessary to repeat treatment once in 11 and twice
in three limbs to give the secondary success. At one year,
the cumulative primary success was 77% and the secondary
success rate was 88%. During the same period, 31 limbs
(24 GSV and 7 SSV) were treated surgically (primary treatment) and then with UGS for early recurrence to give a
secondary success rate. In this group at 12 months cumulative primary success was 71% and the secondary success
rate was 87%.
Several studies have examined the effect that various
clinical determinants had on UGS outcomes. Kanter
at the effects of age, gender, and vein size. He found that
larger doses of STS were required to induce vasospasm in
older patients, males, and those with larger veins. Regardless of gender and age, larger veins were more likely to
recanalize, but were not necessarily associated with clinical
recurrence. Although older patients and males tended to
have larger veins, their recanalization rates were similar to
26
looked
younger patients and females when suffi ciently higher STS
27
doses were used to induce vasospasm. Barrett et al.
in a
study of 115 saphenous veins treated with STS microfoam
UGS confi rmed a small increase in failure to close the SFJ
and SPJ with increasing size of junction diameter (>10 mm),
but this did not signifi cantly alter the results with respect to
clearance of visible varicosities and patient satisfaction with
results.
In a separate study, Barrett et al.28 followed 100 randomly
chosen legs with varicose veins treated by UGS using STS
3% microfoam after an average of 22.5 months (range 20–26
months). An average number of 2.1 treatments were required
to close incompetent varicose veins. Thirty-one percent of
legs required a second treatment at the three-month followup. Such treatments were generally for a small channel in
the saphenous trunk, a small feeding vessel or perforator
creating the channel, or minor residual varicosities. Success
was analyzed from two perspectives: patient satisfaction and
clinical and ultrasound assessment. There was an extremely
high patient satisfaction with 100% of patients stating that
foam UGS had been successful in treating their varicose
veins and related symptoms. Clinically, 92% had complete
removal of their varicosities with 5% developing new varicosities related generally to perforator incompetence unrelated to the treated saphenous veins. Duplex examination
revealed four saphenous veins with persistent refl ux.
Thibault29 reported the fi ve-year recurrence rate in 35
limbs with GSV incompetence treated with UGS. Nine
limbs (25.7%) had recurrent varicose veins clinically. Ten
had persistent refl ux at the SFJ and 14 limbs (40%) had
persistent refl ux in the proximal thigh segment of the GSV.
Comparing these results with the shorter-term studies indicates that there is a slow but steady increase in cumulative
recurrence with time, indicating the need for periodic review
and retreatment when clinically indicated in this group of
patients.
Small Saphenous Vein Incompetence
Padbury and Benveniste30 reported patient satisfaction,
clinical, and sonographic success in a prospective study
on 15 limbs with SSV incompetence. Primary success was
achieved in all patients (SSV injected and obliterated). At
six months, fi ve (33%) had minor residual varices. Duplex
examination at six months revealed one limb with a residual
patent incompetent SSV. This patient had a 9 mm vein pretreatment. Patient satisfaction as gauged by the Aberdeen
QoL questionnaire demonstrated an excellent response with
all patients recording a positive improvement.
Perforator Vein Incompetence
The effectiveness of UGS for incompetent perforator
veins (IPVs) was reported by Thibault.3 Thirty-six patients
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(38 limbs) with incompetent perforating veins were treated
with UGS using STS 3% solution. The IPVs were classifi ed
according to anatomical location as thigh (n = 12), gastrocnemius (n = 13), or posterior tibial (n = 18). Two thigh IPVs,
three posterior tibial IPVs, and one gastrocnemius IPV
required repeat injection at the six- to eight-week follow-up
examination. The IPVs were then reexamined with duplex
ultrasound six months after treatment. All (100%) gastrocnemius IPVs remained sclerosed with no fl ow at six months,
83% of thigh IPVs were sclerosed, and 72% of posterior
tibial IPVs remained occluded with no refl ux at six months.
The diffi culty of obtaining good long-term results with posterior tibial IPVs probably relates to the high hydrostatic
forces present in the distal leg.
Management of Post-Surgical
Recurrent Varicose Veins
UGS has become the preferred management of postsurgical recurrent varicose veins. There are four common
sources of refl ux associated with recurrence of varicose
veins after surgical ligation and stripping: 1) recurrence
of refl ux at the SFJ or SPJ because of neovascularization
or inadequate ligation; 2) incompetent thigh or calf perforating veins; 3) incompetent gastrocnemius veins; 4)
persistent varicose tributaries or duplication of the GSV in
the thigh, with these medial thigh veins receiving refl ux
from pelvic tributaries.31 For obvious technical reasons and
to avoid the risks of redo surgery (nerve and lymphatic
damage), these sources of recurrent refl ux are best treated
with UGS.
As with primary varicose veins, there needs to be a thorough mapping of the superfi cial venous refl ux and assessment of the deep venous system in the leg. The segments
and points of refl ux are then methodically treated using realtime ultrasound guidance. Standard sclerotherapy is then
used to treat any residual superfi cial varicosities one to four
weeks later.
Management of Venous Ulcers
Foam UGS has been reported to be an effective method
for accelerating healing of venous ulcers associated with
superfi cial venous incompetence.32 Thirteen patients with
lower leg ulceration clinically suggestive of venous ulceration were confi rmed to have superfi cial venous incompetence with or without deep venous insuffi ciency. The average
ulcer duration was 27 months (range 3 to 96 months). The
13 limbs then were treated with foam echosclerotherapy to
all areas of superfi cial venous incompetence detected on
duplex scanning. Nine patients had complete healing of their
ulcers within fi ve months of commencing treatment, two
ulcers healed by 12 months and another healed after 20
months. The remaining patient’s ulceration was still improving but not fully healed at 14 months.
The advantage of this approach is that the underlying
cause of the ulceration is addressed, thereby reducing prolonged morbidity and cost of long-term management of
chronic venous ulceration.
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26. Kanter A. Clinical determinants of ultrasound-guided sclerotherapy
outcome. Part 1: The effects of age, gender, and vein size, Dermatol
Surg. 1998. 24: 131–135.
27. Barrett JM, Allen B, Ockelford A, Goldman MP. Microfoam ultrasound-guided sclerotherapy treatment for varicose veins in a subgroup
with diameters at the junction of 10 mm or greater compared with a
subgroup of less than 10 mm, Dermatol Surg. 2004. 30: 1386–1390.
28. Barrett JM, Allen B, Ockleford A, Goldman MP. Microfoam ultrasound-guided sclerotherapy of varicose veins in 100 legs, Dermatol
Surg. 2004. 30: 6–12.
29. Thibault PK. “5 year” follow-up of greater saphenous vein incompetence treated by ultrasound guided sclerotherapy, ANZ J Phleb. 2003.
7: 5–8.
30. Padbury A, Benveniste GL. Foam echosclerotherapy of the small
saphenous vein, ANZ J Phleb. 2004. 8: 5–8.
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618–624.
32. Thibault S. Active treatment of venous ulceration with foam echosclerotherapy, ANZ J Phleb. 2004. 8: 26.
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CHAPTER
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21
Sclerofoam for Treatment of Varicose Veins
JEAN-JÉRÔME GUEX
HISTORY AND BACKGROUND
Sclerofoam is not a brand new idea. Many authors have
presented their own recipes, and sometimes results, decades
ago.1 However, Sclerofoam became much more popular
after Cabrera’s (in Spain) and Monfreux’s (in France) fi rst
presentations.
mostly surgeons unaccustomed to sclerotherapy foam, they
began to raise unexpected interest since it “worked amazingly well”!
At that time, “evidence-based medicine” had expanded
its infl uence over the world, and had even penetrated phlebology. The time had come for a true evaluation. The
problem was the usual one in trying to apply the rules of
evidence-based medicine: Sclerofoam worked so well that
nobody wanted to waste time to demonstrate what was
obvious.
The fi nal (salutary) pitfall to test foam sclerotherapy was
the demonstration of effi cacy presented by endovenous ablation, VNUS Closure
combination of methods frustrated any attempt to test each
new technique. Despite this problem, thanks to several
authors we now have evidence on which to base our
medicine. A little more “medicine-based evidence” is still
necessary.
With all the new techniques, the problem has been that
during the last 10 years treatments have evolved faster than
the varicose veins of patients. The time tested and multiply
requested long-term evaluations were not feasible in the
short period of time after introduction of each new technique. It became obvious that new ideas sprouted before
outcomes of the previous ones were harvested.
2,3
After a period of reluctant observation by
©
, and Laser EVLT. The subsequent
4
WHAT IS SCLEROFOAM?
Advantages and How to Prepare It
All details of all the techniques are extensively and suffi ciently described in the literature.1 So we will focus on the
most commonly used and well-described methods.
Sclerofoam is obtained by mixing a liquid with a gas. For
sclerotherapy, detergent sclerosing agents such as Polidocanol (POL) and Sodium Tetradecyl Sulfate (STD or
STS) are the most logical ingredients. The usual gas is air,
although many others have been tried or are being used.
Foam is obtained after repeated alternate passages from one
syringe to another through a connector that may have a
reduced diameter to decrease the size of each foam bubble.
This has even been automated in order to standardize foam
(Turbofoam®, I2M, Caen, France). Foam will vary according to the nature of the sclerosing agent: POL or STS and
in its initial concentration; according to the nature of the gas
and to the ratio (volume of liquid/volume of gas) of the
mixture. This and the preparation mode can modify the size
of bubbles, their range of diameters, the “wetness” of the
foam, and its overall stability. These characteristics probably
change the power and effi cacy, but there are so many variables that this is unclear so far.
Compared to liquid sclerosing injections, foam has
several advantages: a smaller quantity of sclerosing agent to
inject, no dilution with blood, and it ensures an even and
homogenous effect along the injected vein, provided the
diameter remains reasonable (see Figure 21.1).
Another advantage of foam is its ultrasound echogenicity.
Liquid/air interfaces act like refl ectors and foam appears as
5–7
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