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a
Fig. 11.9 Advancing the needle along the long axis of the ultrasound probe. ( a ) ultrasound image of needle course into
target vein and ( b ) visual image of injection technique
b
air-based foam, while there is evidence that the
use of biocompatible gas to produce foam allows
for higher volumes to be injected safely [ 16 , 20 ].
11.4.2 Effi cacy of Foam
Sclerotherapy
Fig. 11.10 Inserting the needle along the short axis of
the ultrasound probe
of advancing the needle or catheter along the long
axis of the ultrasound probe so that the needle is
visualized all the way from the skin insertion site
to the target vein. This is different than the “triangulation” technique typically favored by radiologists, wherein the needle is inserted along the short
axis of the probe allowing visualization of the tip
only when it arrives at the target vein (Fig.
11.10 ).
The volume of foam injected at each site is
determined by the size of the treatment vein and
the volume required to replace blood in the vein
with foam but is usually limited to 0.5–3 mL. The
total volume of foam used per treatment session
is the subject of debate, as little data has been
published regarding the volume of foam necessary to achieve successful vein sclerosis while
limiting side effects. The upper limit of foam is
generally considered to be 10 mL when utilizing
Effi cacy trials have been conducted internationally [ 8 , 21 – 26 ]. Successful ablation has been
reported to range from 68 to 100 %, with follow up from 1 month to 10 years, though interpretation of these results is diffi cult because of the
differences in defi nitions of success, the use of
surrogate markers (occlusion or narrowing of the
treated vein, resolution of refl ux), differing primary outcome markers (resolution of symptoms,
improved quality of life scores, recurrent varices,
ulcer healing), and the number of ultrasoundguided foam sclerotherapy sessions needed
to achieve success, among others. Recently a
consensus document has been published under
the auspices of the Union Internationale de
Phlebologie (UIP) in an attempt to standardize
duplex reporting following treatment of lower
extremity venous disorders [
27 ].
It is also important to state that simply creating
thrombosis of a target vein will likely not result in
permanent occlusion of the vein. Damage to or
destruction of the vein wall is necessary to ensure
sclerosis [
28 ]. It may be necessary to produce
injury through the intimal layer into the media in
order to achieve the desired destruction [ 29 ].
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11.4.3 Methods to Improve Foam
Sclerotherapy Effi cacy
Various methods have been proposed to improve
effi cacy: agitation methods which enhance the
durability and uniformity of foam [ 18 , 30 , 31 ],
increased sclerosant concentration [ 22 ] or vol-
ume used [ 22 , 32 ], indwelling catheter method
[ 18 , 33 ], foam production methods resulting in
smallest bubble size possible [ 18 ], and leg eleva-
tion (for “empty vein”) [ 34 ]. In spite of a num-
ber of well-conducted studies [ 22 , 25 , 35 , 36 ]
in a review of the published and unpublished
data available in the world literature, Jia et al.
[ 14 ] concluded that there exists insuffi cient data
to determine the optimal volume of foam, optimal concentration, and optimal foam-producing
method.
Recently, a method of catheter-directed foam
sclerotherapy utilizing ultrasound-guided perivenous tumescent injection has gained interest for
reported better effi cacy [ 18 , 33 ].
By increasing the direct contact of the sclerosing agent with the endothelium, foam production
methods that create microbubbles of smaller size
may add to the effi cacy: fi rst, by displacing blood
as much as possible from the targeted vein and
second, by greatly increasing the total surface
area of the smaller bubbles to which the active
sclerosant is attached, thereby increasing endothelial contact [ 23 , 37 , 38 ].
For similar reasons, leg elevation prior to the
injection will also help clear blood from the vein,
thus allowing greater sclerosant contact with the
endothelium and less sclerosant mixing with and
deactivation by blood.
11.4.4 Safety of Foam Sclerotherapy
Early reports regarding UGFS did not study
safety aspects beyond local tissue reactions or
venous thrombosis. Primarily because of concern about neurosensory adverse reactions following UGFS [ 39 , 40 ], more recent reports have
looked at such concerns more closely [ 16 , 41 –
44 ]. Minor or major complications following
Table 11.1 A list of side effects and adverse events
reported to be associated with UGFS
Deep venous thrombosis (DVT)
Superfi cial thrombophlebitis (STP)
Localized perivenous tissue injury
Paradoxical embolism
Neurosensory effects
Respiratory effects
foam sclerotherapy have almost uniformly been
very limited in incidence and in duration [ 62 ].
The practitioner needs to be aware of these risks
and their management in order to discuss riskbenefi t decisions with patients regarding the use
of UGFS.
UGFS may have the potential for pulmonary,
visual, and/or cerebral effects, particularly in a
patient with a patent foramen ovale, or other
right-to-left shunt, which may be more common
in patients with varicose veins than in the general
population [ 45 ] (Table 11.1 ).
11.4.4.1 Deep Venous Thrombosis
Data is lacking on the true incidence of DVT following liquid sclerotherapy. There appears to be a
higher incidence of DVT following UGFS than is
generally assumed following the use of liquid sclerosants, especially in foam sclerotherapy studies
wherein patients are routinely examined for DVT
by duplex scanning as opposed to duplex scanning
only when warranted by symptoms [ 9 , 22 ]
However, these thromboses most often
involve calf veins that, if followed closely, are
most often of limited clinical signifi cance.
Symptomatic or femoral-popliteal DVT remain
rare, except in the smaller diameter duplicated
femoral vein segment [ 46 ] or in Myers’ study,
veins larger than 5 mm in diameter [ 47 ]. There
is confl icting in vitro evidence regarding sclerosant foam effect on coagulation [ 48 , 49 ] and in
vivo as well [ 50 ]. In the clinical setting, however,
Hamel- Desnos has presented evidence that mirrors the author’s experience: foam sclerotherapy
can be successfully and safely performed on
patients with documented thrombophilia with no
increased risk of DVT, given prophylactic anticoagulation [ 51 ].
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11.4.4.2 Superfi cial Thrombophlebitis
Superfi cial thrombophlebitis probably should be
considered a direct consequence of treatment,
unless thrombophlebitis extends beyond the
region treated or if the infl ammation is signifi cantly worse than routinely observed. The incidence varies from less than 1–18 % in the
literature probably because of individual interpretation of the clinical fi ndings [ 52 ].
11.4.4.3 Perivenous Tissue Injury
Extravascular tissue injury with the use of UGFS
has been reported to be less than 2 % likely
because of the benign effects of foam extravasated
in the perivenous tissue (signifi cantly lower concentration). This is in contrast to the more damaging effects of some liquid sclerosants (typically
three to four times the concentration of foam).
11.4.4.4 Paradoxical Embolism
A right-to-left shunt, present in 25–30 % of the general population, and perhaps even higher in patients
with varicose veins [ 45 ], may allow emboli or deg-
radation products released from damaged endothelium to pass to the arterial circulation and affect the
microcirculation of any organ. Whether symptoms
are related to particulate or bubble emboli or to
endothelial destruction products (such as endothelin-1, a potent vasoconstrictor) is currently under
investigation. What is known is that UGFS has
the potential for nearly always rare and transient
pulmonary, cardiac, visual, and/or cerebral effects,
particularly in a patient with a patent foramen ovale
or other right-to-left shunt.
A rare complication, thromboembolism has
also been reported following UGFS when either
a thrombus forms in and embolizes from a deep
vein or a thrombus extension from a truncal or
perforator vein embolizes. In the presence of a
right-to-left shunt, the embolus can progress to
the arterial circulation with variable sequelae
depending on the location of the embolus.
11.4.4.5 Neurosensory Effects
Reports of signifi cant adverse neurologic events are
very few. Forlee et al. reported one case of stroke
following varicose vein foam injection sclero-
therapy [ 40 ]. The patient was subsequently found
to have a very large patent foramen ovale. Also
reporting neurologic events in patients, Ceulen
et al. [ 39 ], Bush and colleagues [ 53 ], and Ma and
Parsi [ 54 ] have also reported neurologic events in
patients. Because of numerous anecdotal reports
of similar events, the true incidence may not be as
rare as is reported. The question could be whether
all patients should be screened for right-to- left
shunt prior to UGFS. The consensus opinion of
international experts [ 55 ] is that these uncommon
neurosensory effects do not justify such pre-sclerotherapy screening, since similar serious incidents
have occurred following liquid sclerotherapy, thermal ablation, or surgical stripping [ 56 – 58 ].
It is imperative, however, that the practicing
phlebologist has protocols to deal with such serious adverse events should one occur.
Transient visual disturbances, or scotomas,
have been mentioned when evaluating adverse
events following foam sclerotherapy. Frequencies
of occurrence vary from 0 to 6 % following airbased foam injection, with most publications
indicating a frequency around 1 % [ 14 , 59 ].
Other events have been described in the literature. True migraine or ocular migraine is uncommon, but Gillet and colleagues found in a study
of 20 patients with visual disturbances following
UGFS that clinical features of migraine with aura
were present in all patients, suggesting a strong
association between visual disturbances following UGFS and migraine [ 60 ]. Since it has been
established that twice as many patients (50 %)
with a history of migraine with aura have rightto- left shunts as is seen in the normal population
(25 %) [ 6 , 61 ], it may be reasonable to expect
that patients with a history of migraine with aura
have an increased risk of suffering neurosensory
events following UGFS.
11.4.4.6 Respiratory Effects
Acute respiratory diffi culties are rarely reported
in the literature but may be commonly seen in
phlebologic practice. Chest tightness, transient
shortness of breath, and dry cough have been
described as uncommon or rare adverse events,
but all appear self-limited [ 16 ].
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11.4.4.7 Long-Term Effects: Pulmonary,
CNS, Visual
Long-term adverse pulmonary effects such as
pulmonary fi brosis are of theoretical concern
but have not been identifi ed. Such side effects
have also been reported with liquid sclerosants.
Pulmonary embolism is a concern, but its
occurrence is rare and may relate more to other
patient conditions than to the procedure itself
[ 20 , 63 ].
11.4.5 Foam Sclerotherapy: Methods
to Improve Safety
Several methods have been proposed to improve
the safety of foam sclerotherapy (Table 11.2 ).
The use of an indwelling catheter is thought to
improve safety of UGFS by minimizing extravasation of foam (as seen with direct needle injection) and by allowing for immediate instillation
of foam following production in order to deliver
the highest quality of foam possible (no lag time
Table 11.2 Proposed methods for improved safety
Indwelling catheter (balloon-tipped or open-ended)
Saphenofemoral junction occlusion
Limitations of volume
Low-silicone syringe
Non-air-based foam
Maneuvers to limit or prevent foam migration
between foam production and instillation as with
direct needle injection) [ 64 , 65 ].
When performing UGFS, a balloon-tipped
catheter can be used to occlude the saphenofemoral or saphenopopliteal junction, theoretically
preventing foam from entering the deep venous
system. However, it has been shown [ 66 – 68 ] by
ultrasound examination that foam is still seen in
the deep system as having moved through myriad
perforator veins. In fact, many phlebologists
believe it is better to have foam gradually migrating into the deep venous system than to have a
large bolus enter the central circulation when the
occlusive balloon is defl ated.
Limiting the volume of foamed sclerosant
injected at any one time has been proposed as a
method to minimize the risk of symptomatic bubble embolization [ 55 , 69 ]. However, in studies of
foam sclerotherapy with simultaneous monitoring using transthoracic echocardiography and
transcranial Doppler, the author has shown that
the use of even very small volumes of foam does
not prevent foam migration to the central venous
circulation or across a PFO (Fig. 11.11 ) [ 70 ].
It is presumed that the use of low-silicone
syringes enhances foam stability, because
silicone helps speed foam degradation. Thus,
foam will remain of good quality longer with
silicone- free or low-silicone syringes, allowing for more time to complete a successful
injection [ 18 , 30 ].
Fig. 11.11 In studies of
foam sclerotherapy with
simultaneous monitoring
using transthoracic
echocardiography and
transcranial Doppler, the
use of even very small
volumes of foam does not
prevent foam migration to
the central venous circulation
or across a PFO
11 Chemic a l S u p e r fi cial Vein Ablation
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The type of gas used to create the foam will
also infl uence foam degradation. Tessari has
shown that a gas combination of CO 2 and O 2 with
70 % CO 2 and 30 % O 2 to produce foam will
result in more stable, longer-lasting foam than
pure CO 2 -based foam [ 71 ]. Because of its pre-
sumably more rapid dissolution, CO 2 /O 2 -based
foam (70 % CO 2 /30 % O 2 combination) has been
shown by the author to be 7 and 40 times less
likely, respectively, to produce side effects or
complications compared to pure CO 2 -based foam
and air-based foam [ 44 ].
Maneuvers such as preinjection and/or postinjection leg elevation and limiting patient mobility
for a few minutes immediately after injection
were found to be ineffective in eliminating foam
migration into the central circulation or, for that
matter the arterial circulation in the presence of a
right-to-left shunt [ 17 ].
However, in a study of a proprietary manufactured foam injected into patients with
known right-to-left shunts, Regan et al. [ 42 ]
noted no cardiac, neurologic, or visual field
changes in patients undergoing foam sclerotherapy. It is uncertain whether to assume the
findings of this study of a proprietary manufactured foam are similar for “home-made”
foam used by most phlebologists. But the lack
of evidence for serious long-term adverse
events in spite of the huge worldwide
experience with self-manufactured foam is
reassuring [ 72 ].
11.5 Postoperative Care
Although Level 1 evidence for the use of postoperative compression is lacking, compression
and early ambulation are regarded by many
phlebologists as the cornerstones of successful
postoperative management, no matter which
modality of truncal vein ablation is chosen.
Extrinsic compression using foam padding,
short stretch and/or elastic bandages, compression hose, and early ambulation and return to
normal activities all will likely help to minimize
postoperative discomfort and avoid complications, such as deep venous thrombosis.
Conclusion
All published reports support UGFS as a
reasonably safe method of superfi cial venous
ablation. Effi cacy, simplicity, economy, and
serial applications have made UGFS an attractive and effi cient treatment option. Side effects
and complications of UGFS are nearly always
transient and infrequent or rare. Evaluations
of the use of foam sclerotherapy are ongoing
and likely will result in more refi ned evidencebased guidelines that will address its indications and methods to enhance effi cacy and
ensure safety. Most investigators agree on the
need for adequate training in this technique to
reduce the risk of complications.
Acknowledgements The author gratefully acknowledges the contribution of Diana Neuhardt, RVT, of
Compudiagnostics for her clinical assistance and provision of the excellent duplex images in this manuscript, as
well as editing assistance provided by Adrienne Travis
and Denise Bork.
References
1. Goldman MP. Sodium tetradecyl sulfate for sclerotherapy treatment of veins: is compounding pharmacy
solution safe? Dermatol Surg. 2004;30:1–3.
2. Weiss R, et al. Absence of concentration congruity in
six compounded polidocanol samples obtained for leg
sclerotherapy. Dermatol Surg. 2011;37:812–5.
3. Yamaki T, Nozaki M, Sasaki K. Color duplex-guided
sclerotherapy for the treatment of venous malformation. Dermatol Surg. 2000;26:323–8.
4. Ricci S, Georgiev M, Jawien A, Zamboni P. Sciatic
nerve varices. Eur J Vasc Endovasc Surg. 2005;
29:83–7.
5. Tessari L. Foam Sclerotherapy Alcock Channel (P
point) in pelvic varicose veins. In: 14th annual congress, Melbourne, Australia. Australasian College of
Phlebology. 2011.
6. Carod-Artal FJ, et al. Prevalence of patent foramen
ovale in migraine patients with and without aura compared with stroke patients. A transcranial Doppler
study. Cephalalgia. 2006;26:934–9.
7. Ouvrey P, et al. Effi cacy of polidocanol foam versus liquid in sclerotherapy of the great saphenous
vein: a multicentre randomised controlled trial with
a two- year follow up. Eur J Vasc Endovasc Surg.
2008;36(3):366–70.
8. Rabe E, Otto J, Schliephake D, Pannier F. Effi cacy
and safety of great saphenous vein sclerotherapy
using standardised polidocanol foam (ESAF): a ran-
158
https://t.me/med1917
N. Morrison
domised controlled multicentre clinical trial. Eur J
Vasc Endovasc Surg. 2008;35:238–45.
9. Wright D, Gobin JP, Bradbury AW, et al. Varisolve®
polidocanol microfoam compared with surgery
or sclerotherapy in the management of varicose
veins in the presence of trunk vein incompetence:
European randomized controlled trial. Phlebology.
2006;21:180–90.
10. Rasmussen L, et al. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation,
foam sclerotherapy and surgical stripping for great
saphenous varicose veins. Br J Surg. 2011;98:
1079–87.
11. Hamel-Desnos C, Desnos P, Wollmann JC, Ouvry P,
Mako S, Allaert FA. Evaluation of the effi cacy of polidocanol in the form of foam compared with liquid
form in sclerotherapy of the greater saphenous vein:
initial results. Dermatol Surg. 2003;19(12):1170–5.
12. Coleridge Smith P. Saphenous ablation: sclerosant or
sclerofoam? Semin Vasc Surg. 2005;18(1):19–24.
13. Yamaki T, Nozaki M, Iwasaka S. Comparative study
of duplex-guided foam sclerotherapy and duplexguided liquid sclerotherapy for the treatment of
superfi cial venous insuffi ciency. Dermatol Surg.
2004;30:718–22.
14. Jia X, Mowat G, Burr JM, Cassar K, Cook J, Fraser C.
Systematic review of foam sclerotherapy for varicose
veins. Br J Surg. 2007;94:925–36.
15. Tessari L. Nouvelle technique d’obtention de la
sclero-mousse. Phlebologie. 2000;53:129.
16. Morrison N, Neuhardt DL, Rogers CR, McEown J,
Morrison T, Johnson E, Salles-Cunha SX.
Comparisons of side effects using air and carbon
dioxide foam for endovenous chemical ablation.
J Vasc Surg. 2008;47:830–6.
17. Morrison N. Foam sclerotherapy: how to improve
results and reduced side effects. Phlebologie. 2008;
37:211–20.
18. Cavezzi A, Tessari L. Foam sclerotherapy techniques:
different gases and methods of preparation, catheter
versus direct injection. Phlebology. 2009;24:247–51.
19. Hamel-Desnos C, et al. Échosclerotherapie a la
Mouse par Ponction-Injection Directe aL’Aiguille:
Technique et Doses. J Mal Vasc. 2006;31(4):180–9.
20. Cabrera J, Cabrera Jr J, Garcia-Olmedo MA,
Redondo P. Treatment of venous malformations with
sclerosant in microfoam form. Arch Dermatol. 2003;
139:1409–16.
21. Cabrera J, Cabrera Jr J, Garcia-Olmedo MA.
Treatment of varicose long saphenous veins with sclerosant in microfoam form: long term outcomes.
Phlebology. 2000;15:19–23.
22. Myers KA, Jolley D, Clough A, Kirwan J. Outcome
of ultrasound-guided sclerotherapy for varicose veins:
medium-term results assessed by ultrasound surveillance. Eur J Vasc Endovasc Surg. 2007;33:116–21.
23. Frullini A, Cavezzi A. Sclerosing foam in the treatment of varicose veins and telangiectasias: history
and analysis of safety and complications. Dermatol
Surg. 2002;28:11–5.
24. Smith PC. Chronic venous disease treated by ultrasound guided foam sclerotherapy. Eur J Vasc
Endovasc Surg. 2006;32:577–83.
25. Darvall K, et al. Duplex ultrasound outcomes
following ultrasound-guided foam sclerotherapy of
symptomatic primary great saphenous varicose veins.
Eur J Vasc Endovasc Surg. 2010;40:534–9.
26. Stucker M, et al. Review of published information on
foam sclerotherapy. Dermatol Surg. 2010;36:983–92.
27. De Maeseneer M, Pichot O, Cavezzi A, Earnshaw J,
van Rij A, Lurie F, Coleridge Smith P. Duplex ultrasound investigation of the veins of the lower limbs after
treatment for varicose veins – UIP consensus document. Eur J Vasc Endovasc Surg. 2011;42(1):89–102.
28. Fegan WG. Injection with compression as a treatment
for varicose veins. Proc R Soc Med. 1965;58:874–6.
29. McAree B, et al. Comparative stability of sodium tetradecyl sulphate (STD) and polidocanol foam: impact
on vein damage in an in-vitro model. Eur J Vasc
Endovasc Surg 2012;43:721–725.
30. Wollman JC. Sclerosant foams: stabilities, physical
properties and rheological behavior. Phlebologie.
2010;39:208–17.
31. Eckmann DM, Kobayashi S, Li M. Microvascular
embolization following polidocanol microfoam
sclerosant administration. Dermatol Surg. 2005;31:
636–64.
32. Bhogal RH, et al. Can foam sclerotherapy be used to
safely treat bilateral varicose veins? Phlebology.
2012;27(1):19–24..
33. Parsi K. Catheter-directed sclerotherapy. Phlebology.
2009;24:98–107.
34. Bergan J, Pascarella L, Mekenas L. Venous disorders:
treatment with sclerosant foam. J Cardiovasc Surg
(Torino). 2006;47:9–18.
35. Hamel-Desnos C, Ouvry P, Benigni J-P, Boitelle G,
Schadeck M, Desnos P, Allaert F-A. Comparison of
1 % and 3 % polidocanol foam in ultrasound guided
sclerotherapy of the great saphenous vein: a randomised, double-blind trial with 2 year-follow-up.
“The 3/1 study”. Eur J Vasc Endovasc Surg. 2007;
20:1–7.
36. Ceulen RP, Bullens-Goessens YI, Pi-VAN de Venne
SJ, Nelemans PJ, Veraart JC, Sommer A. Outcomes
and side effects of duplex-guided sclerotherapy in the
treatment of great saphenous veins with 1 % versus
3 % polidocanol foam: results of a randomized controlled trial with 1-year follow-up. Dermatol Surg.
2007;33:276–81.
37. Wollman JC. The history of sclerosing foams.
Dermatol Surg. 2004;30:694–703.
38. Van Deurzen B, Ceulen R, et al. Polidocanol concentration and time affect the properties of foam used for
sclerotherapy. Dermatol Surg. 2011;37:1448–55.
39. Ceulen R, et al. Microembolism during foam sclerotherapy of varicose veins. N Engl J Med. 2008;
35:8–14.
40. Forlee MV, Grouden M, Moore DJ, Shanik G. Stroke
after varicose vein foam injection sclerotherapy.
J Vasc Surg. 2006;43:162–4.
11 Chemic a l S u p e r fi cial Vein Ablation
https://t.me/med1917
159
41. Guex JJ, et al. The French polidocanol study on longterm side effects: a survey covering 3,357 patient
years. Dermatol Surg. 2010;36:993–1003.
42. Regan J, et al. Clinical signifi cance of cerebrovascular
gas emboli during polidocanol endovenous ultra-low
nitrogen microfoam ablation and correlation with magnetic resonance imaging in patients with right-to- left
shunts. J Vasc Surg. 2011;53:131–8.
43. Gillet J-L, et al. Side-effects and complications of
foam sclerotherapy of the great and small saphenous
veins: a controlled multicentre prospective study
including 1025 patients. Phlebology. 2009;24:131–8.
44. Morrison N, et al. Incidence of side effects using carbon dioxide-oxygen foam for chemical ablation of
superfi cial veins of the lower extremity. Eur J Vasc
Endovasc Surg. 2010;40:407–13.
45. Wright DD. High prevalence of right-to-left shunt in
patients with symptomatic great saphenous incompetence and varicose veins. J Vasc Surg. 2010;51:104–7.
46. Neuhardt D. Incidence of deep vein thrombosis in a
duplicated femoral vein following Foam USG of the
GSV. Abstract: fi rst days of phlebology. Parma. 2006.
47. Myers K, Jolley D. Factors affecting the risk of deep
venous occlusion after ultrasound-guided sclerotherapy for varicose veins. Eur J Vasc Endovasc Surg.
2008;20:1–4.
48. Parsi K, et al. In vitro effects of detergent sclerosants
on coagulation, platelets and microparticles. Eur J
Vasc Endovasc Surg. 2007;34:731–40.
49. Parsi K, et al. The lytic effects of detergent sclerosants
on erythrocytes, platelets, endothelial cells and microparticles are attenuated by albumin and other
plasma components in vitro. Eur J Vasc Endovasc
Surg. 2008;36:216–23.
50. Hamel-Desnos C, Desnos P, et al. In vivo biological
effects of foam sclerotherapy. Eur J Vasc Endovasc
Surg. 2011;42(2):238–45.
51. Hamel-Desnos C, Gillet J-L, Desnos P, Allaert F.
Sclerotherapy of varicose veins in patients with documented thrombophilia: a prospective controlled randomized study of 105 cases. Phlebology. 2009;24:176–82.
52. Thomasset SC, et al. Ultrasound guided foam sclerotherapy: factors associated with outcomes and complications. Eur J Vasc Endovasc Surg. 2010;40:389–92.
53. Bush RG, Derrick M, Manjoney D. Major neurological events following foam sclerotherapy. Phlebology.
2008;23:189–92.
54. Ma RWL, Parsi K, et al. Three cases of stroke following peripheral venous interventions. Phlebology
2011;26:280–4.
55. Breu FX, Guggenbichler S. 2nd European consensus
meeting on foam sclerotherapy. Tegernsee, Germany.
VASA. Eur J Vasc Med 2008;37:S37–71.
56. Hanisch F, Müller T, Krivokuca M, Winterholler W.
Stroke following variceal sclerotherapy. Eur J Med
Res. 2004;9:282–4.
57. Caggiati A, Franceschini M. Stroke following
endovenous laser treatment of varicose veins. J Vasc
Surg. 2010;51:218–20.
58. Harzheim M, Becher H, Klockgether T. Brain infarct
from a paradoxical embolism following a varices
operation. Dtsch Med Wochenschr. 2000;125:794–6.
59. Morrison N. Studies on safety of foam sclerotherapy. In: Bergan JJ, Chang V, editors. Foam sclerotherapy. London: Royal Society of Medicine Press
Ltd; 2008.
60. Gillet JL, et al. Pathophysiology of visual disturbances
occurring after foam sclerotherapy. Phlebology. 2010;
25:261–6.
61. McCandless RT, et al. Patent foramen ovale in children with migraine headaches. J Pediatr. 2011;
159(2):243–7.
62. Bradbury A, et al. Ultrasound-guided foam sclerotherapy is a safe and clinically effective treatment
for superfi cial venous refl ux. J Vasc Surg. 2010;
52(4):939–45.
63. Wright D, et al. Polidocanol microfoam does not cause
remote sclerosis in the lung. Poster presentation: ACP
23rd annual congress. Palm Desert. Nov 2008.
64. Broderson JP, Geismar U. Catheter-assisted vein
sclerotherapy: a new approach for sclerotherapy of the
greater saphenous vein with a double-lumen balloon
catheter. Dermatol Surg. 2007;33:469–75.
65. Kolbeln T, Hinchliffe R, Lindbladn B. Catheterdirected foam sclerotherapy of axial saphenous refl ux:
early results. Phlebology. 2007;22:219–22.
66. Parsi K. Venous gas embolism during foam sclerotherapy of saphenous veins despite recommended
treatment modifi cations. Phlebology. 2011;26:140–7.
67. Hill D, et al. Assessment of techniques to reduce sclerosant foam migration during ultrasound-guided
sclerotherapy of the great saphenous vein. J Vasc
Surg. 2008;48:934–9.
68. Ceulen R, et al. Blocking the saphenofemoral junction
during ultrasound-guided foam sclerotherapy: assessment of a presumed safety-measure procedure. Eur J
Vasc Endovasc Surg. 2010;40:772–6.
69. Yamaki T, et al. Multiple small-dose injections can
reduce the passage of sclerosant foam into deep veins
during foam sclerotherapy for varicose veins. Eur J
Vasc Endovasc Surg. 2009;37(3):343–8.
70. Morrison N, Neuhardt D. Foam sclerotherapy: cardiac
and cerebral monitoring. Phlebology. 2009;00:1–8.
71. Tessari L, Cavezzi A, Rosso M, Cabrera Garrido A.
Variables in foam sclerotherapy: literature and experimental data. Aust NZ J Phlebol. 2008;11(1):83–4.
72. Gillet J-L. Neurological complications of foam
sclerotherapy: fears and reality. Phlebology. 2011;
26:277–9.
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1 2
Contents
12.1 Introduction ................................................ 161
12.2 Patient Evaluation ...................................... 162
12.2.1 Indications .................................................... 162
12.2.2 Diagnostic Evaluation .................................. 162
12.3 Classifi cation............................................... 163
12.4 Clinical Decision Making .......................... 164
12.4.1 Failure of Nonoperative Measures ............... 164
12.4.2 Clinical Severity ........................................... 165
12.4.3 Patient Risk Factors ..................................... 166
12.4.4 Anatomic Varicose Vein Distribution
and Pattern ................................................... 166
12.4.5 Staged vs. Combined Approaches ............... 166
12.5 Operative Setting ....................................... 167
12.6 Patient Expectations .................................. 167
12.7 Operative Techniques ................................ 167
12.7.1 Great Saphenous Vein .................................. 167
12.7.2 Small Saphenous Vein ................................. 168
12.7.3 Varicose Veins .............................................. 168
12.8 Outcomes .................................................... 170
12.8.1 Postoperative Follow-Up ............................. 170
12.9 Complications ............................................. 170
12.10 Results ......................................................... 171
12.11 Evidence-Based Guidelines ....................... 171
12.12 Summary..................................................... 172
References ................................................................. 173
M. A. Passman , MD
Section of Vascular Surgery and Endovascular
Therapy , University of Alabama at Birmingham ,
Birmingham , AL , USA
e-mail: marc.passman@ccc.uab.edu
Abstract
Coordinated treatment of superfi cial venous
insuffi ciency involves comprehensive patient
evaluation, appropriate venous testing usually
with venous ultrasound as the cornerstone of
diagnostic evaluation, and sound clinical decision making based on current evidence-based
guidelines. While nonoperative measures
focusing on compression are recommended
as initial therapy, operative approaches offer
additional opportunity for improved outcomes. As treatment options are shifting to
less invasive options, traditional open operative approaches directed at both axial saphenous vein refl ux and varicose vein problems
still have a role in appropriately selected
patients with symptomatic superfi cial venous
insuffi ciency. This chapter discusses surgical
techniques for venous disease.
12.1 Introduction
Superfi cial venous insuffi ciency involves incompetence of the great saphenous vein (GSV), small
saphenous vein (SSV), and associated patterns of
secondary varicose veins. Within the superfi cial
venous system, there is also the potential for primary varicose veins without associated axial or
segmental refl ux, dilated reticular veins, and
venous telangiectases. Venous insuffi ciency can
be isolated to the superfi cial venous system or
can include concomitant deep (see Chap.
perforator disease (see Chap.
14 ).
16 ) and
E. Mowatt-Larssen et al. (eds.), Phlebology, Vein Surgery and Ultrasonography,
DOI 10.1007/978-3-319-01812-6_12, © Springer International Publishing Switzerland 2014
161
162
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M.A. Passman
The prevalence of all chronic venous
insuffi ciency has varied in reports but may be as
high as 40 % in women and 17 % in men. Active
venous ulcers are present in up to 0.5 % of individuals, and between 0.6 and 1.4 % have healed
ulcers. Estimates for varicose veins are even
higher at 73 % in women and 56 % in men. For
all patients with chronic venous insuffi ciency,
those with isolated superfi cial venous refl ux may
involve up to 35 %. The age-matched distribution of venous insuffi ciency corresponding to
these prevalence estimates has also translated to a
fi nancial burden to patients and society with lost
productivity, employment issues, and disabilities.
Fortunately, superfi cial venous insuffi ciency and
associated problems are very amenable to surgical correction [ 1 – 4 ].
This chapter will review treatment of superfi cial venous insuffi ciency including patient evaluation, clinical decision making, nonoperative
measures, traditional open operative approaches
directed at axial saphenous vein refl ux and
thrombosis and varicose vein problems, outcomes, and current evidence-based guidelines.
12.2 Patient Evaluation
12.2.1 Indications
The most common complaints associated with
superfi cial venous insuffi ciency and varicose veins
are pain, aching, throbbing, heaviness, tingling,
burning, cramping, itching, unsightliness, discoloration, tiredness, restlessness, and swelling of
the extremity. Complaints are usually pronounced
after prolonged limb dependency and relieved
with rest or elevation, with further progression of
symptoms more notable towards the end of the
day. More severe symptoms and advanced venous
problems, including chronic venous skin changes
and progression to venous stasis ulcers, can occur
with both isolated superfi cial venous insuffi ciency and deep or perforator venous incompetence. Other pertinent history should include prior
personal or family history of venous thromboem-
bolism, superfi cial thrombophlebitis, established
thrombophilia, medication history (particularly
oral contraceptives), smoking, pregnancies,
family history of varicose veins, spontaneous
rupture of varicosity, venous ulceration, and
previous venous interventions. It is important to
differentiate symptoms due to venous disease
from other concomitant musculoskeletal, arterial,
neuropathic, dermatologic, pelvic, or lymphatic
etiologies.
12.2.2 Diagnostic Evaluation
Physical examination should be performed with
the patient standing. On inspection, general position of telangiectases, dilated reticular veins,
and varicose veins should be noted, with identifi cation of location, anatomic pattern, size, and
presence of infl ammation. Documentation can
be greatly assisted with handwritten diagrams,
electronic drawing systems, or digital photography. Palpation is performed assessing for palpable cord, tenderness, induration, pulses, thrill,
and groin or abdominal masses. Auscultation
should identify any associated bruits. Evaluation
of swelling components should include unilateral
vs. bilateral, standardized limb measurements,
distribution of edema across the entire extremity, and whether it is pitting or non-pitting, to
differentiate lymphedema and other non-venous
causes. Additional venous stigmata may include
inframalleolar ankle fl are, corona phlebectatica,
and atrophie blanche. More advanced venous
skin fi ndings include hyperpigmentation, venous
eczema, stasis dermatitis and other infl ammatory
changes, induration, lipodermatosclerosis, and
healed or active venous ulcerations.
Bedside venous examinations such as
Trendelenburg, Ochsner-Mahorner, or Perthes’
tests, although occasionally useful, are often
unreliable and have been largely replaced by
diagnostic imaging. Venous duplex ultrasound
is critically important to differentiate obstructive components, presence or absence of venous
thrombosis, and competency of deep, superfi cial,
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163
Fig. 12.1 Anatomic distribution of varicose veins and
their relationship to documented source of superfi cial
venous refl ux, including the great saphenous vein, ante-
and perforator venous systems (see Chap. 6 ).
Identifying sources of refl ux and association to
clinical patterns of venous fi ndings will help
determine the best operative option (Fig. 12.1 ).
Venous physiologic testing (see Chap. 8 ) and
other imaging such as computed tomography
(CT) venography, magnetic resonance (MR)
venography, ascending and descending contrast
venography, and intravascular ultrasound (see
Chaps. 9 and 16 ) can be useful in selected cases
when other venous problems beyond superfi cial
venous insuffi ciency are a consideration, such as
post-thrombotic syndrome, thrombotic or nonthrombotic iliac vein obstruction (May-Thurner
syndrome), pelvic congestion syndrome, nutcracker syndrome, vascular malformations,
venous trauma, or tumors.
12.3 Classifi cation
Venous outcome assessment tools have been
used to evaluate severity of venous disease,
provide standardized evaluation of treatment
effectiveness over time, and are important in
rior saphenous vein, pudendal vein, small saphenous
vein, and posterior thigh circumfl ex vein (vein of
Giacomini)
objectively assessing effectiveness of superfi cial
venous operations. Clinical, etiologic, anatomic,
pathophysiologic (CEAP) classifi cation system
(Table 12.1 ) for chronic venous disease is widely
accepted and allows patient comparison among
different centers and studies but has been recognized to be relatively static and insensitive for
determining changes in venous disease severity over time. Venous Severity Scoring (VSS)
which includes Venous Disability Score (VDS),
Venous Segmental Disease Score (VSDS), and
Venous Clinical Severity Score (VCSS) has
been shown to be more useful for comparing
patient groups with similar degrees of severity
in regard to outcome over time and following
different therapies. The VCSS system includes
10 clinical descriptors (pain, varicose veins,
venous edema, skin pigmentation, infl ammation,
induration, number of active ulcers, duration of
active ulceration, size of ulcer, and compressive
therapy use), scored from 0 to 3 (total possible
score, 30) that may be used to assess changes
in response to therapy (Table 12.2 ). VCSS,
revised in 2010, has been shown to have minimal intraobserver and interobserver variability,
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