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148 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
18.
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SCLEROTHERAPY AND ULTRASOUNDGUIDED
SCLEROTHERAPY
P a u l K . i b a u l t
S C L E R O T H E R A P Y
Varicose veins are a degenerative disease of the venous system where there is a defect in the strength of the vein wall
with associated valvular dysfunction resulting in re ux
(reverse) ow in a ected areas of the super cial venous system of the legs. Usually re ux from the deep to super cial
system through incompetent venous junctions and perforator veins is a major contributor to the super cial venous
insu ciency. As venous disease is a chronic disease, treatment is usually directed at controlling the disease, rather
than curing it. It is therefore important that interventional
treatment not aggravate the condition in the longterm.
Sclerotherapy refers to a method of treating varicose
veins:a foreign substance, usually a chemical, is introduced
into the lumen of a vein to cause endothelial necrosis and
subsequent brosis of the vein. Apart from reducing the size
of the vein to a small brous cord, e ective sclerotherapy
also eliminates the physiopathological re ux associated
with varicose veins. As such, sclerotherapy is an alternative
treatment to surgery and other physical endovenous ablation techniques such as endovenous laser ablation (EVLA)
in the management of varicose veins. Sclerotherapy di ers
from the other ablative techniques in that it can be e ective
treatment for all types of pathological venous dilatations
from major truncal varicose veins to the nest telangiectases.
Sclerotherapy for varicose veins associated with great
saphenous vein (GSV) and small saphenous vein (SSV)
incompetence has been traditionally relegated to treating
residual varicose veins following surgical stripping or varicose veins associated with isolated perforator vein incompetence.
of the Fegan method of sclerotherapy in the 1960s and early
1970s, surgical methods have generally been accepted as
having a signi cantly better long-term recurrence rate compared to sclerotherapy. is has been thought to be due to
the fact that traditional sclerotherapy was unable to control
the proximal source of re ux—usually the saphenofemoral
1
Apart from a relatively brief period of popularity
(SFJ) and saphenopopliteal (SPJ) junctions—adequately.
In addition, preultrasound methods of sclerosing the GSV
have been shown to be relatively ine ective. Some meth-
2
ods such as the Cloutier technique
administered a single,
“blind” injection of a major sclerosing agent a few centimeters below the SFJ, repeated every 7 to 21 days until
the GSV was occluded. Such methods have been openly
discouraged as creditable methods of treating GSV or SSV
incompetence as they were thought to have an inherently
high risk of damaging the deep venous system or of inadvertent intra-arterial injection.
Duplex ultrasound has become the gold standard in the
investigation of lower limb venous disease. As an independent investigation, duplex scanning has unrivaled relevance
in the clinical decision-making process as well as being used
in the serial assessment of disease progress and e ectiveness
3
of treatment.
Ultrasound guidance of sclerosant injections is a logical extension of the pretreatment evaluation
and gives sclerotherapy the potential to rival other ablative
methods in e ectiveness in the treatment of varicoseveins.
HISTORY OF ULTRASOUNDGUIDED
SCLEROTHERAPYUGS
e method of ultrasonic guidance of injection into the
super cial venous system was rst published in 1989.
e method was initially used for treatment of incompetent saphenous axes, and in 1992 the method of injecting
incompetent perforating veins associated with postsurgical
5
recurrences was described.
Medium-term results of SFJ
incompetence treated by UGS were reported by Kanter
6
and ibault in 1996.
In the late 1990s, several practitioners around the world began using sclerosant foam injected
using ultrasound guidance, and the rst medium-term
7
results were reported by Cabrera in 2000.
Since that time
UGS using microfoamed sclerosants (UGFS) has become
8
the accepted method ofUGS.
4
149
PRETREATMENT ULTRASOUND
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MAPPING
Duplex venous scanning is the essential pretreatment investigation prior to either sclerotherapy or ultrasound-guided
sclerotherapy of major varicose veins and truncal incompe-
3
rough duplex scanning, patterns of venous incom-
tence.
petence will be found to be extremely variable and o en
unexpected. Duplex scanning involves B-mode imaging of
the deep and super cial veins combined with directional
pulsed Doppler assessment of blood ow. Color-duplex
imaging superimposes blood ow information onto the
B-mode ultrasound image, permitting visual assessment of
blood ow while at the same time creating an anatomical
map of the venous anatomy. e details of venous duplex
examination have been described in a previous chapter and
will not be dealt withhere.
In short, duplex examination is able to provide an accurate anatomical and physiological map of super cial and
deep venous incompetence and localize points of re ux
from the deep to super cial venous system. With duplex
examination a detailed map of re ux paths in the super cial
system, from the proximal origin of the re ux (usually from
the deep system), to a distal reentry point, can be created.
is map will allow optimal decisions regarding sclerotherapy intervention and will ensure that all signi cant areas of
re ux are addressed by treatment and, conversely, that all
normal veins are preserved. Diameters of major veins and
junctions are also recorded during the duplex examination.
ese measurements may in uence various parameters of
the treatment process including selection of sclerosing agent
and form, and postsclerotherapy compression.
Following the duplex examination, the treatment process is then directed toward eliminating all the incompetent super cial pathways mapped out with duplex
ultrasound and then, in the posttreatment phase, reexamining with duplex to ensure that the re ux pathways
have not recanalized prior to complete brosis of the vein,
which usually occurs between 6 to 12months following
initial treatment.
TECHNIQUESOFUGS
SCLEROSINGAGENTS
Generally, only relatively strong sclerosants are used in
9
UGS. In an international survey
of forty-four phlebologists
who were known to use UGS extensively, 95% used sodium
tetradecyl sulfate (STS; Fibrovein; STD Pharmaceuticals,
Hereford, England), and 5% used 3% polidocanol (POL;
Aethoxysclerol; Kreusler Pharma, Wiesbaden, Germany).
Asmall minority of phlebolog ists used polyiodinated iodine
as an alternative solution in particular circumstances, such
Table18.1 APPROXIMATE EQUIVALENT
CONCENTRATIONS OF STS AND POL REQUIRED FOR
EFFECTIVE SCLEROSIS OF INCREASING CALIBER OF
LOWER LIMBVEINS.
VEIN
CALIBER
MM
0.1–0.5 0.1 0.25
0.5–1.0 0.15 0.5
1.0–2.0 0.3 1.0
2.0–3.0 0.5 1.5
3.0–5.0 0.75 2.0
5.0–8.0 1.0–3.0 3.0–5.0
STS
CONCENTRATION
%
POL
CONCENTRATION
%
as in the presence of allergy to STS or at deep-to-super cial
junctions. With sclerosant concentration, generally 3% STS
was used, although some phlebologists use STS in various
strengths from 0.75to2%.
In the above survey, 34% of phlebologists used foamed
sclerosants, with STS again being the most common agent
used as foam. It is likely that the ratio of phlebologists using
foam sclerosants compared with solution has increased
signi cantly since that survey, as the bene ts of foam have
become more widely known. e use of foam is described in
more detail in another chapter.
STS and POL, in both solution and foam formulations have been shown to have similar e cacy, toler-
10
ability, and patient satisfaction.
ere is good evidence
however, that POL is a weaker detergent type of scle-
11
rosant than STS
and higher concentrations are necessary to produce complete vascular sclerosis for any given
diameter of vein (Table18.1). is is the most likely reason why many phlebologists prefer STS when performing
UGS, as in general, larger truncal veins are being treated
8
with this technique.
PATIENT POSITIONING
For treatment of veins on the medial aspect of the leg,
patients are placed in the supine position with the treated
leg level and externally rotated at the hip. e knee is
usually slightly exed in order to relax all muscle groups.
Ifsmall incompetent veins are being treated, the patient
can be placed in the semireclining position in order to
dilate the veins, thereby slightly assisting ultrasound visualization and subsequent injection. For treatment of veins
on the posterior thigh or calf, the patient is positioned
in the prone position with the foot supported by a pil-
4
low so that the knee is exed slightly.
is positioning
is important when injecting the SSV near the popliteal
fossa, where the vein will be compressed if the knee is
totally extended.
150 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
CLOSED NEEDLE TECHNIQUE
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M a t e r i a l s
e needle size used can vary from 21 to 25 g. e most
common size used are 25 g 1 1/2inch (0.50mm × 38mm),
as these are the smallest diameter needles that are readily
visualized by B-mode ultrasound and are long enough to
reach most super cial veins from the point of skin penetration. Usually the sclerosant is drawn up into a 2- or 3-ml luer
lock syringe. When microfoam is used, the Tessari method
12
will also require the use of 5-ml luer lock syringe to draw
up air or other gas to form the microfoam. e ratio of
sclerosant to air may vary from 1:3 (wet foam) to 1:6 (dry
13
foam).
Wet foam tends to have longer duration, but dry
foam is a better displacer of blood. Individual practitioners
will inevitably vary this ratio depending on their preferences, although Tessari and Cavezzi basing their opinion of
13
physicochemical properties recommend the ratio of1:4.
M e t h o d
e closed needle technique is the most commonly used
method.
the syringe containing the sclerosant at all times. Asmall
proportion of phlebologists use an open needle technique
(needle is removed to determine color/ ow of blood). e
procedure may be performed with the assistance of a vascular sonographer, or with the phlebologist performing both
the ultrasound and the injections alone (“solo” technique).
proximal origin of the venous re ux.
of practitioners inject more distally then manually “milk”
the sclerosant proximally toward the proximal source of
re ux using real-time ultrasound monitoring.
the nal objective is to have the total segment of incompetent vein, from the proximal re ux point to the distal reentry point, uniformly lled with sclerosant foam. is can
be observed with real-time B-mode ultrasound and will be
accompanied by vasospasm of the treatedvein.
vein to be injected in transverse view. e depth of the vein
below the skin surface will be noted, as this will determine
the angle of approach of the needle. e injection can then
be performed either with the vein viewed in transverse section or in sagittal or longitudinal section. Approximately
50% of practitioners utilize the transverse approach solely,
33% the longitudinal approach solely, and the remainder use
both approaches depending on various technical variables
associated with each individual injection.
approach is favored by some, especially when performing the
procedure “solo” because it appears to be technically easier
to cannulate the vein with this method. It is therefore particularly useful when injecting smaller veins less than 3mm
in diameter. e advantages of the longitudinal approach
9
With this technique, the needle is attached to
e initial injection is usually performed near to the
5
Asmall proportion
14
Either way,
e sonographer initially will localize the site of the
9
e transverse
9
are: rst, that the direction of ow of the sclerosant can be
observed and, second, the linear array probes can be used to
compress the segment of vein for a length of about 50mm
during the injection, thereby allowing better contact of the
sclerosant with the vein wall at the injectionsite.
e imaging frequency of the transducer used may
vary from 7.5 to 15 MHz, the lower frequencies are used
for deeper-placed subcutaneous veins (>3 cm below the
skin) and higher frequencies for more super cial veins.
Commonly a 10-MHz transducer is used for its ability to
imagine most subcutaneous veins adequately. Most transducers will have an indicator line or light-emitting diode
(LED) that will indicate the alignment of the sagittal plane
of the transducer. For either approach, the needle is inserted
close to the transducer tip and along the sagittal plane of the
5
transducer (Figure18.1).
When the needle pierces the skin,
the tip should be visualized by the ultrasound. Adequate
amounts of ultrasound gel need to be applied to the skin to
obtain optimum visualization.
As the needle is slowly inserted it appears as a re ective
straight line angling toward the target vein. It is important
to verify early in the procedure that the needle is being introduced in the correct sagittal plane of the transducer. When
injecting in the transverse section of the vein, the transducer
can be moved in small increments to align with the needle.
When injecting in the longitudinal section of the vein, the
direction of needle may need to be altered in small increments, to align with the sagittal plane of the transducer. For
either method, the needle and vein should be imaged simultaneously at alltimes.
As the needle tip makes contact with the target vein, an
indentation will be seen on the vein wall (Figure18.2). At
Figure18.1 e needle is aligned directly along the longitudinal axis of
the ultrasound probe prior to piercing theskin.
SCLEROTHERAPY AND ULTRASOUNDGUIDED SCLEROTHERAPY • 151
Skin
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Skin
Needle tip
Vein lumen
Figure18.2 B-mode ultrasound image of needle tip indenting vein wall
immediately prior to vein puncture.
this stage a little extra pressure is required to pierce the vein
wall and a er this occurs, the needle can be seen within the
lumen (Figure18.3) and a small amount of blood is drawn
into the needle hub to con rm correct intraluminal positioning of the needle tip. Asmall volume (approx. 0.2 ml)
of sclerosant is then injected and should be seen on the
ultrasound image to be owing into the vein (Figure18.4).
Extravasation is readily visible on the B-mode image and is
manifested as a separation between the vein wall and the
perivenous tissues. Should this occur, injection is stopped
immediately, and the needle tip is repositioned correctly,
or alternatively, the needle withdrawn and reinserted at an
appropriate nearby site. When the initial small volume is
seen to ow intraluminally, the remainder of the injection
is then completed under continuous ultrasound imaging
(Figure18.5).
Sclerosant foam
Needle
Figure18.4 B-mode ultrasound image demonstrating initial bolus of
sclerosant foam entering the vein lumen and owing upstream initially.
When using the longitudinal approach, during injection the direction of 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 ow can be modi ed to optimize the localization of the sclerosant.
e volume of sclerosant injected at any one site varies between practitioners, but usually ranges from 0.25 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, while equalizing the sclerosant concentration
15
along the segment of vein,
minimizes the risk of over ow
of sclerosant into the deep system through nearby perforating veins that can cause deep and muscular vein sclerosis and
possible subsequent deep venous thrombosis(DVT).
Figure18.3 B-mode ultrasound image of needle tip clearly centered in
the vein lumen. It is important to verify correct placement of the needle
tip by withdrawing a small amount of blood into the hub of the needle
prior to injection.
Skin
Vein lumen
Needle tip
Figure18.5 B-mode ultrasound image demonstrating uniform
distribution of the sclerosant foam throughout the visualized lumen of
the vein in both directions from the injectionpoint.
152 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
Skin
Sclerosant foam
within vein lumen
Injection point
When injecting the incompetent GSV or SSV, it is usual
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to place the rst injection 5 to 10cm distal to the incompetent SFJ or SPJ. e author uses STS 3% or POL 3% microfoam at a sclerosant:air ratio of 1:3. As the recommended
maximum dose of Fibrovein is 4 ml, the maximum microfoam volume is 16 ml. If a ratio of 1:4 is used, the maximum
volume becomes 20 ml. e maximum volume of POL will
vary according to concentration used and patient weight
(2mg/kg/d). 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
8
2 ml at most sites.
16
Kanter
compared the e ect of 1 ml and 2 ml sclerosant
(3% STS) injectate volumes on immediate vasospasm and
later clinical outcomes a er UGS. He found that 2-ml
injectate volumes were less e ective than 1 ml and did not
reduce the number of injections given. e 2-ml injectate
group received twice the volume of sclerosant and therefore
some reported transient u-like symptoms 4 to 6 hours a er
treatment. Hence, when injecting solution (rather than
foam), it is advisable not to inject more than 1 ml at any one
site. When injecting with several centimeters of visible calf
perforating veins, it is advisable to inject less than 0.5 ml.
4,15
Injections proceed distally, as previously injected segments are observed to spasm or ll with foam. Treatment
end-point is when all segments of incompetent vein have
undergone spasm and become incompressible to probe
maneuvers. e ultrasound transducer can also 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. e maneuver also has the e ect
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 re ned, there were a number of reports of inadvertent intra-arterial injections that
concerned many phlebologists.
UGS were rst introduced to minimize the risk of inadvertent intra-arterial injection and the resultant extensive tissue loss that could occur. e rst “open catheter” technique
was described by Grondin in 1992.
ommended a 20-gauge 44-mm cannula for cannulation of
the GSV or SSV 6 to 8cm distal to the SFJ and SPJ, which
were thought to be the sites of maximum risk of inadvertent
intra-arterial injection. Correct placement of the cannula
could be con rmed by aspiration of nonpulsatile venous
blood, ultrasound visualization of the cannula tip and nally,
injection of normal saline into the vein prior to sclerosant
injection. A er con rmation that the cannula was correctly
5,17
Catheter techniques of
18
is technique rec-
inserted into the vein, the sclerosant was injected at that site
as a bolus in a similar manner to that described above in the
“closed” technique. e technique could be used to treat the
remaining distal trunk by recannulating distal to the initial
cannulationpoint.
19
Coleridge Smith
has described a modi ed version of
the open cannula technique whereby he inserts multiple
cannulas or 23-gauge butter y needles into previously
ultrasound-mapped varicose veins and incompetent trunks
while the patient lies in the supine position. e limb being
treated is then elevated to an angle of 30 degrees to empty
the veins prior to injection. A er the sclerosant foam is
injected at each site, the progress of foam is monitored by
ultrasound as described previously.
Extended Long Line Echosclerotherapy(ELLE)
e ELLE technique was rst described by Parsi in 1997 20
and later by Min and Navarro.
oped not only to reduce the risk of intra-arterial injection,
but also to improve the e ectiveness of UGS especially in the
treatment of larger diameter incompetent trunks by improving the delivery of the sclerosant to the venous endothelium.
e method is described in detail by Parsi andLim.
Cannulation
e entry point for cannulation is selected a er completion of pretreatment mapping of the super cial truncal
incompetence. e ideal entry point will be at the most distal incompetent point of the axial trunk that is to be treated
(GSV or SSV). For example, if the SSV is incompetent to
the mid calf, the SSV would be cannulated in the mid calf;
if the GSV was incompetent to the proximal calf, the GSV
would be cannulated just below the knee. In the presence
of signi cant perforator incompetence, the cannulation is
done distal to the incompetent perforators. e segment of
vein chosen should ideally be straight, and cannulation is
easier if super cial segments of vein are chosen.
Cannulation can be performed with or without local
anesthesia. If local aesthesia is used, the injection should be
performed intradermally and not contain adrenaline so as to
avoid causing vasoconstriction of the vein to be cannulated.
Cannula selection and penetration
e depth and lumen diameter of the selected vein is
measured to assist in appropriate cannula selection. Usually
16- to 18-gauge cannulas are used with cannula lengths
varying from 4 to7cm.
e procedure is carried out using aseptic techniques.
e vein is visualized with B-mode ultrasound in the longitudinal axis, and the selected entry point is marked on the skin.
Atourniquet 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.
Successful entry of the cannula into the vein is signaled by
21
is technique was devel-
22
SCLEROTHERAPY AND ULTRASOUNDGUIDED SCLEROTHERAPY • 153
spontaneous venous return. e tourniquet is then released
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and the cannula is ushed with normal saline, which is also
visualized with ultrasound, ensuring correct placement. e
cannula is then taped to the skin. Technically, cannulation is
usually the most challenging part of this procedure.
Catheterization
e length of the selected vein is measured to assist in
selection of the appropriate catheter. e 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 5cm distal to the junction, the
guide wire is removed. e leg is then raised to about 45
degrees to empty the vein as much as possible. It is this maneuver that is readily performed with the ELLE technique, but
more di cult with the close needle technique, that theoretically will result in better contact of the sclerosant with the
venous endothelium with larger truncal veins. e proximal
22
SFJ/SPJ is then compressed (Cloutier technique)
and the
leg is brought back to about 30 degrees while maintaining
the compression on the junction. e sclerosant is then
introduced as the catheter is being withdrawn. Parsi and Lim
believe that a number of “pulse” injections of approximately
0.8 ml of STS 3% solution is more e ective than continuous
and gradual infusion of sclerosant. is is consistent with the
15
principles of sclerosant distribution described by 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 partial recanalization
6
of the vein.
As with the closed needle technique, the end
point of the treatment include vasospasm, noncompressibility along the entire length of the treated vein, and absence of
any blood ow in the vein, all con rmed with ultrasound.
ere are several limitations of the ELLE technique.
First, it is not useful in treating complex patterns and tortuous postsurgical recurrences. Second, it is technically dif cult to treat smaller incompetent veins less than 5mm in
diameter owing to di culty in cannulating these veins with
the relatively large diameter cannula that is required for the
procedure.
UGS FOR RESISTANT TELANGIECTASES
AND TELANGIECTATIC MATTING
Using a high frequency ultrasound imaging transducer,
23
Somjen etal.
have shown that 89% of areas of thigh telangiectases have associated incompetent reticular veins
identi able. Alarge proportion of these were found to be
associated with deeper subcutaneous vein re ux or with perforating vein re 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 duplex
24
ultrasound, Forrestal
has also 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 POL1%.
P O S T S C L E R O T H E R A P Y
COMPRESSION TECHNIQUES
External Compression
Various forms of external compression have been recommended following sclerotherapy to varicose veins. Although
25
Fegan
advised 6 weeks of continuous external compression with bandages, this is not generally required with UGS
owing to the fact that the principal of the technique is that
all proximal sources of re ux are controlled in the initial
treatment.
e reasons for using external compression with UGS
relate to increased patient comfort, reduction of symptomatic chemical phlebitis, and maintenance of optimal
deep venous ow during the postinjection period. For this
reason, the most commonly used compression following
treatment is the application of ClassII (25- to 35-mmHg)
graduated compression stockings. Generally the stockings
are worn during the day for 2 to 3 weeks. Some practitioners also advise their patients to wear the stockings at night
for the rst 3 to 4days in order to maintain optimum deep
venous ow in the early postinjection period, thereby minimizing the risk of DVT. e stocking may be removed each
day for showering, without any undue adverse e ects.
Internal Compression (Perivenous Compression)
is novel method has been introduced recently to improve
sclerosant contact with the vein wall during the immediate
postsclerotherapy period and therefore reduce the incidence
of recanalization.
perivenous local anesthetic technique for EVLA. With this
method, following each injection of the main stem (GSV or
SSV ) with sclerosant foam, normal saline or preferably Klein’s
tumescent solution
ment between the deep and super cial fascia (Figure18.6)
at 3 to 5 locations equally spaced along the axial vein in the
thigh (GSV ) or calf (SSV). Usually between 20 and 30 ml of
tumescent solution is required, or about 5 to 10 ml at each
cross-sectional segment. e injection is performed using
ultrasound guidance with a cross-sectional approach using a
25g 1 1/2inch needle. e e ect 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.
e author now uses this method routinely when treating larger axial vessels (GSV and SSV) greater than 3mm in
26
e technique was developed from the
27
is injected perivenously in the compart-
154 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
Needle
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Fascial envelope
foam in vein
Saline
with standard sclerotherapy methods. e patient is then
reviewed 4–6weeks a er the initial treatment, when repeat
ultrasound examination is performed and any intravascular
coagula are removed through a small incision using either a
18- to 21-gauge needle or number 11 blade. Generally this
procedure can be performed without any anesthesia or with
local anesthetic when using the number 11blade.
Further follow-up visits may be scheduled at 3, 6, and
12months to ensure that there has not been recanalization
of the treatedvein.
Figure18.6 Post-UGS perivenous compression of GSV with normal
saline.
diameter and early experience indicates a reduction in early
recurrence and recanalization resulting in less early retreatments. In addition further bene ts including reduced incidence of transient neurological episodes including migraine
and chest tightness are obtained by using this method.
Many sclerotherapists now also use the tumescent compression techniques prior to injection of the sclerosant when
using the cannula or catheter techniques resulting in improved
sclerosis and reduced concentration and volumes of sclerosant, again resulting in reduced incidence of local adverse
e ects. (personal communications Parsi K, CavezziA).
P O S T T R E A T M E N T M E T H O D S A N D
FOLLOWUP.
Immediately a er treatment, patients are advised to walk
continuously for 15 to 20 minutes and are then instructed to
walk for at least 45 minutes daily. is signi 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 super cial ambulatory
pressures and ensures high ow in the deep venous system of
the leg for a prolonged period at least once perday.
Patients are usually reviewed 1 to 2 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 ow and
(2)the patency and ow in the deepveins.
If a treated segment of vein is found to be partially or
completely patent and have persistent re ux, the segment
is reinjected using ultrasound guidance. e phlebologist
should be aware that lower concentrations of sclerosant
may be necessary, as the vein endothelium will be partially
destroyed making the vein more prone to chemical thrombophlebitis if too strong a concentration isused.
At the rst post-UGS visit, once proximal closure
of the treated veins has been con rmed, residual distal
branch varicose veins and telangiectases may be treated
ADVERSE EFFECTSOFUGS
Varcoe 9 performed a survey of forty-four experienced UGS
phlebologists from seven countries and reported on their
experience with adverse e ects from UGS. In this survey,
side e ects 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 e ects were all less than 0.1%. Only one phlebologist reported pulmonary embolus occurring, indicating
the low risk of this event. In 20years of performing UGS,
the author has not observed any pulmonary emboli following UGS and only one DVT (a ecting the popliteal vein
extending from a sclerosed gastrocnemius perforatingvein).
Several intra-arterial injections were reported early on
4,17
in the history of UGS,
and the incidence reported in
the Varcoe survey was 0.01%. e risk of this event appears
to be directly related to the experience and training of the
phlebologist in UGS and rarely occurs in skilledhands.
e most common serious adverse e ect experienced by
the author has been anaphylactoid reactions to the sclerosant
28
e incidence of anaphylactoid reaction in 2,686
STS.
treatment sessions was 0.15%. is reaction appears to be
concentration- and volume-dependent. Interestingly, since
the advent of foam this incidence has been greatly reduced.
e author has not observed any anaphylactoid reactions
to STS 3% foam in the circa 2000, and Chapman-Smith
29
similarly reports zero incidence of this complication when
using STSfoam.
SHORT AND LONGTERM RESULTS
ere are now are number of studies documenting the e ectiveness of UGS. Most of these studies have examined the
results of treating GSV incompetence, although there are
several now published on SSV incompetence.
G S V I N C O M P E T E N C E
e rst reported objective ultrasound results of SFJ and
GSV incompetence treated with UGS were those of Kanter
SCLEROTHERAPY AND ULTRASOUNDGUIDED SCLEROTHERAPY • 155
and ibault. 6 Using STS 3% solution, they reported a 76%
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7
success rate at 24months. Cabrera etal.
followed-up 500
lower limbs with SFJ and GSV incompetence treated with
UGS using Lauromacrogol 400 (POL) microfoam. A er
3years, 81% of treated GSVs were obliterated, and 96.5% of
super cial branches disappeared. e obliteration of saphenous veins required one treatment in 86%, two in 10.5%,
and three in3.5%.
30
Cavezzi and Frullini
in a study of 106 saphenous axes
or recurrent postsurgical varices achieved 95% sclerosis at
21 weeks using STS 1% or 3% sclerosant foam. ere were
three completely unsuccessful cases despite three treatment
sessions and ten cases of early recanalization (with re ux
or retrograde ow), subsequently successfully retreated
withUGS.
31
Myers et al.
reported objective ultrasound results on
100 limbs (seventy-eight GSV and twenty-two SSV) a er
12months using STS or aethoxysclerol according to preference and partly determined by the diameter of the veins.
All but one vein treated were less than 10mm in diameter.
UGS was successful in the rst treatment in eighty-six limbs
(primary success), but it was necessary to repeat treatment
once in eleven and twice in three limbs to give the “secondary success.” At 1year, the cumulative primary success was
77% and the secondary success rate was 88%. During the
same period, thirty-one limbs (twenty-four GSV and seven
SSV) were treated surgically (primary treatment) and then
with UGS for early recurrence to give a secondary success
rate. In this group at 12months cumulative primary success
was 71% and the secondary success rate was87%.
29
Chapman-Smith,
by using a regular posttreatment
review with weekly ultrasound examinations initially until
closure was achieved and therea er periodical reviews and
retreatment when recanalizations were detected, was able to
achieve a 4% clinical recurrence at 5years with an average
of 2.53 treatments in the rst year. 16.5% of patients then
required an average of 2.0 treatments in the second year,
and 8% of patients required average of 2.0 treatments in the
thirdyear.
Several studies have examined the e ect that various
clinical determinants had on UGS outcomes. Kanter
32
looked at the e ects 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
younger patients and females when su ciently higher STS
7
doses were used to induce vasospasm. Barrett etal.
in a study
of 115 saphenous veins treated with STS microfoam UGS
con rmed a small increase in failure to close the SFJ and SPJ
with increasing size of junction diameter (>10mm), but this
did not signi cantly alter the results with respect to clearance
of visible varicosities and patient satisfaction with results.
33
In a separate study, Barrett et al.
followed 100 randomly chosen legs with varicose veins treated by UGS using
STS 3% microfoam a er an average of 22.5months (range
20to 26months). An average number of 2.1 treatments were
required to close incompetent varicose veins. irty-one
percent of legs required a second treatment at the 3-month
follow-up. 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. ere 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 re ux.
34
ibault
reported the 5-year recurrence rate in
thirty- ve limbs with GSV incompetence treated with
UGS. Nine limbs (25.7%) had recurrent varicose veins
clinically. Ten had persistent re ux at the SFJ, and fourteen
limbs (40%) had persistent re ux at the SFJ. 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 period review and retreatment when clinically indicated in this group of patients.
When comparing the results of foam UGS and solu-
tion or liquid sclerotherapy, it appears that foam is mark-
35
edly superior.
random control trials.
is has been demonstrated by at least two
36,37
For this reason, virtually all phlebologists currently use foam when treating incompetent
saphenous trunks.
S S V I N C O M P E T E N C E
Padbury and Benveniste 38 reported patient satisfaction and
clinical and sonographic success in a prospective study on
een limbs with SSV incompetence. Primary success was
achieved in all patients (SSV injected and obliterated). At
6months, ve (33%) had minor residual varices. Duplex
examination at 6months revealed one limb with a residual
patent incompetent SSV. is 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
e e ectiveness of UGS for incompetent perforator
4
veins (IPVs) was reported by ibault.
irty-six patients
(thirty-eight limbs) with incompetent perforating veins
were treated with UGS using STS 3% solution. e
IPVs were classi ed according to anatomical location as
thigh ( n =12), gastrocnemius ( n =13) or posterior tibial
156 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
( n =18). Two thigh IPVs, three posterior tibial IPVs, and
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one gastrocnemius IPV required repeat injection at the 6- to
8-week follow-up examination. e IPVs were then reexamined with duplex ultrasound 6months a er treatment. All
(100%) the gastrocnemius IPVs remained sclerosed with
no ow at 6months, 83% of the thigh IPVs were sclerosed,
and 72% of the posterior tibial IPVs remained occluded
with no re ux at 6months. e di culty of obtaining good
long-term results with posterior tibial IPVs probably relates
to the high hydrostatic forces present in the distalleg.
MANAGEMENT OF POSTSURGICAL
RECURRENT VARICOSEVEINS
UGS has become the preferred management of postsurgical recurrent varicose veins. ere are four common sources
of re ux associated with recurrence of varicose veins a er
surgical ligation and stripping:(1)recurrence of re 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 re ux from pelvic tribu-
39
taries.
For obvious technical reasons and to avoid the risks
of redo surgery (nerve and lymphatic damage) these sources
of recurrent re ux are best treated withUGS.
As with primary varicose veins, there needs to be a thorough mapping of the super cial venous re ux and assessment of the deep venous system in the leg. e segments
and points of re ux are then methodically treated using
real-time ultrasound guidance. Standard sclerotherapy is
then used to treat any residual super cial varicosities 1 to
4 weekslater.
MANAGEMENT OF VENOUSULCERS
Foam UGS has been reported to be an e ective method for
accelerating healing of venous ulcers associated with super-
40
cial venous incompetence.
irteen patients with lower
leg ulceration clinically suggestive of venous ulceration were
con rmed to have super cial venous incompetence with or
without deep venous insu ciency. e average ulcer duration was 27months (range 3 to 96months). e thirteen
limbs were then treated with foam echosclerotherapy to all
areas of super cial venous incompetence detected on duplex
scanning. Nine patients had complete healing of their ulcers
within 5months of commencing treatment (Figure18.7),
two ulcers healed by 12months, and another healed a er
20 months. e remaining patient’s ulceration was still
improving but not fully healed at 14months. Another case
study of nine patients with 13 venous ulcers, showed rapid
41
healing of the ulcers just 7days a er treatment.
e advantage of this approach is that the underlying
cause of the ulceration is being addressed, thereby reducing
prolonged morbidity and cost of long-term management of
A B
Figure18.7 (A) Chronic venous ulcer a ecting the right leg in a
90-year-old male who had had high ligation and stripping of the
GSV 15years previously. Duplex scanning revealed incompetence
in the femoral, popliteal, and posterior tibial veins and associated
incompetence of a medial thigh perforating vein and recurrent
super cial medial thigh and calf veins. (B)Healed venous ulcer
14weeks a er two UGS treatment sessions with STS 3% sclerosant
foam to the incompetent thigh perforating vein and recurrent medial
thigh and calf veins. Also note the signi cant improvement in general
skin condition following treatment.
chronic venous ulceration. UGFS is now used routinely by
many phlebologists as a simple, e ective means of healing
venous ulcers, but randomized clinical controlled trials are
needed to con rm these clinical bene t s .
R E F E R E N C E S
1. Hobbs JT . Surgery and sclerotherapy in the treatment of varicose
veins , Arch Surg. 1974. 190 : 793–796.
2. Cloutier G . Sclerose des crosses des saphenes internes et externes avec
compression:Nouvelle approche , Phlebologie. 1976. 3 : 227–232 .
3 . ibault PK . Duplex examination , Dermatol Surg. 1995. 21 : 77–82.
4. Knight RM , Vin F , Zygmunt JA . Ultrasonic guidance of injections
into the super cial venous system. In: Davy A , Stemmer R , eds.
Phlebologie ’89 . Montrouge, France: John Libbey Eurotext . 1989.
5 . ibault PK , Lewis WA . Recurrent varicose veins:Part2:Injection
of incompetent perforating veins using ultrasound guidance , J Derm
Surg Onc. 1992. 18 : 895–900.
6 . K a n t e r A , ibault P . Saphenofemoral junction incompetence
treated by ultrasound-guided sclerotherapy , Dermatol Surg. 1996.
22 : 648–652.
7. Cabrera J , Cabrera J Jr, Garcia-Olmedo MA . Treatment of varicose
long saphenous veins with sclerosant in microfoam form:Long-term
outcomes , Phlebology. 2000. 15 : 19–23.
8. 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 10mm or greater compared with a subgroup of less than 10mm , Dermatol Surg. 2004.
30 : 1386–1390.
9. Varcoe PF . Ultrasound guided sclerotherapy:E cacy, adverse events,
and dosing:An international survey , ANZ J Phleb. 2003. 7 : 17–24.
10. Rao J , Wildemore JK , Goldman MP . Double-blind prospective
comparative trial between foamed and liquid POL and sodium tetradecyl sulphate in the treatment of varicose and telangiectatic leg
veins , Dermatol Surg. 2005. 31 : 631–635.
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