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N.S. Sadick et al. (eds.), Practical Approach to the Management and Treatment of Venous Disorders,

DOI 10.1007/978-1-4471-2891-5_9, © Springer-Verlag London 2013

Introduction

Over the past decade there has been an evolution

from ultrasound-guided liquid sclerotherapy [ 1 ]

to ultrasound guided foam sclerotherapy [ 2, 3 ] .

Liquid sclerotherapy is used extensively to ablate

small and medium sized tributary varicies usually

with visual guidance. US guided liquid sclero-

sants have been shown to be able to close truncal

veins but their success rates, whether injected by

needle or catheter were inferior to that now

achieved with EVTA. Ultrasound-guided foam

sclerotherapy (UGFS), increasingly being

referred to as endovenous chemical ablation, may

be de ﬁ ned as the injection into a vein of a scleros-

ing agent which has been rendered foam in order

to permanently ablate the target vein [ 4 ] .

UGFS has become a common treatment for

patients with venous incompetence [

2, 5 ] . Foam

is hyperechoic thus improving ultrasound visual-

ization of the venous lumen and enhancing safety

by minimizing the risk of extra-venous or arterial

in ﬁ ltrations. Furthermore, foam is more effective

than liquid at lower dosages of sclerosant, effec-

tively increasing the extent of treatment possible

per session [

6 ] , and has been used as an ef ﬁ cient

complement or alternative to microphlebectomy,

endovenous thermal ablation, or stripping for

some practioners [ 3, 6– 19 ] .

Patients with all clinical, etiologic, anatomic, and

pathophysiologic (CEAP) classes have been treated

with UGFS [ 2, 3, 5, 8– 10, 13– 30 ] . Foam sclerother-

apy has been successful in: (i) treating saphenous

veins primarily, (ii) complementing, completing, or

extending stripping or thermal ablation, (iii) and in

treating vein recurrence [ 31, 32 ] , venous malforma-

tions [ 33, 34 ] , venous aneurysms, sciatic nerve

varices [ 35 ] , and saphenous or nonsaphenous perfo-

rating veins [ 2, 3, 5, 6, 8– 10, 12– 20, 33, 35– 39 ] .

Foam Production Methods

Foam is produced by agitating a gas with a liquid

detergent sclerosing agent, most commonly via a

three-way tap or straight connector (Fig. 9.1 ) between

two syringes containing the gas and sclerosant in a

four parts gas to one part liquid ratio, described by

Tessari in 2000 [ 7 ] . Twenty to 40 agitation cycles

will produce durable microbubble foam [

8 ] .

Foam produced for injection should be durable

enough to allow adequate time for injection of the

microbubbles, but should also break down quickly

once injected to protect against gas embolization.

Sterile or room air has been most commonly

employed, but a more physiological gas such as car-

bon dioxide (CO

) or gas combining carbon dioxide

and oxygen (O

) may have the advantage of greater

solubility and less in-vivo stability than air (limited

gas embolization) [ 2, 3, 5, 9, 10, 36, 37, 40, 41 ] .

The detergents used to create foam for sclero-

sis are: sodium morrhuate, ethanolamine oleate,

sodium tetradecyl sulfate (STS), and polidocanol.

Foam Sclerotherapy

Nick Morrison

N. Morrison , M.D.

Morrison Vein Institute ,

AZ , USA

e-mail: nickmorrison2002@yahoo.com

https://t.me/med1917

N. Morrison

Most reports utilize either polidocanol or STS [ 2, 5 ]

Foam can be prepared in various concentration to

treat small or large veins [ 2, 42 ] , and can be

instilled via indwelling catheter [ 42, 43 ] or by

direct needle puncture [

44 ] .

Ultrasound guided foam sclerotherapy may

be performed by the practitioner alone or with

the aid of an assistant or sonographer. If the

indwelling catheter method is used, the sclero-

therapist can easily produce high quality (small

bubble size) foam and inject it into the target

vein quickly before foam degradation occurs

(large bubbles, lower ef ﬁ cacy, greater risk of

adverse events). If however the direct injection

method is used, it is dif ﬁ cult to produce the foam,

image the vein by ultrasound, insert the needle,

and inject foam before degradation is apparent,

especially when using carbon dioxide or carbon-

dioxide/oxygen combination. With the direct

injection method, the practitioner may want to

use an assistant to produce the foam or a sonog-

rapher to help with imaging of the target veins

(Fig.

9.2 ), all of which make UGFS more ef ﬁ cient

and time-effective.

Fig. 9.2 Ultrasound guided

foam sclerotherapy

performed by sclerotherapist

with the aid of a sonogra-

pher and an assistant (only

one or the other necessary)

Fig. 9.1 Top apparatus –

syringes connected by 3-way

tap (Tessari) Bottom

apparatus – syringes attached

to straight connector (Tessari

DSS)

https://t.me/med1917

859 Foam Sclerotherapy

Imaging of the target vein for cannulation may

be in the transverse (Fig.

9.3 ) or longitudinal

view (Fig.

9.4 ). When the target vein is straight

for several centimeters, a longitudinal approach

works well. However, in tortuous veins with short

straight segments, inserting the needle along the

long axis of the transducer (Fig. 9.5 ) while view-

ing the vein in the transverse view is most

ef ﬁ cient. This approach allows the sclerothera-

pist to visualize the needle all the way to and into

the target vein, as opposed to seeing the tip only

when it arrives at the target vein in the tranverse

view. It allows one to target a speci ﬁ c part of the

vein that can be challenging in the longitudinal

vein with a tortuous vein.

Fig. 9.3 Super ﬁ cial leg vein

imaged by ultrasound in

transverse format. On left ,

needle is inside vein; on

right , foam has been injected

Fig. 9.4 Longitudinal

ultrasound image of needle in

super ﬁ cial leg vein prior to

injection of foam

Fig. 9.5 Sclerotherapist inserting needle for injection of

foam along the long axis of the transducer to allow visual-

ization of the needle all the way to the target vein

https://t.me/med1917

N. Morrison

Results of Foam Sclerotherapy

Ef ﬁ cacy [ 3, 8, 9, 20, 21, 23, 25, 27– 30, 33, 45– 50 ]

and comparative studies [

3, 6, 9, 14– 18, 21, 23,

49, 51– 54 ] have been conducted internationally.

Successful ablation has been reported to range

from 68% [ 9 ] to 100% [ 27 ] , although interpreta-

tion of these results is dif ﬁ cult because of the dif-

ferences in de ﬁ nitions of success, the use of

surrogate markers (occlusion of the treated vein,

resolution of re ﬂ ux), differing primary outcome

markers (resolution of symptoms, improved qual-

ity of life scores, recurrent varices, ulcer healing),

and the number of ultrasound-guided foam sclero-

therapy sessions needed to achieve success, among

others. Moreover, reports of follow-up periods

range from 1 month to 10 years, although the

studies reporting results of over 3 years demon-

strated success rates of 81–92% [ 8, 21, 55, 56 ] .

Methods to Improve Foam

Sclerotherapy Ef ﬁ cacy

Guidelines [ 57 ] and suggestions to improve

ef ﬁ cacy have included those listed in Table 9.1 .

In a review of the published and unpublished •

data available in the world literature, Jia et al.

[ 61 ] concluded that there exists insuf ﬁ cient

data to determine the optimal volume of foam,

optimal concentration and optimal foam-pro-

ducing method.

Foam sclerotherapy of the saphenous vein via •

an indwelling catheter may better deliver scle-

rosant foam to the endothelium of the targeted

vein [ 62 ] , but according to the 2nd European

Consensus Conference on Foam Sclerotherapy,

there is no clear consensus on the use of cath-

eters for foam sclerotherapy [

14 ] .

Foam production methods that create •

microbubbles of smaller size may add to the

ef ﬁ cacy by increasing the direct contact of the

sclerosing agent with the endothelium 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 [ 21, 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 mix-

ing with and deactivation by blood [ 16 ] .

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 [ 16, 63 ] .

Foam Safety

Many reports in the literature mention the safety

of foam sclerotherapy anecdotally [ 8, 10, 19,

24– 26, 30, 45, 48, 57, 64 ] and there are numerous

reports describing infrequent or rare neurologic

or visual disturbances [ 8, 10, 19, 21, 24, 25, 44,

47, 65 ] , A few reports examine speci ﬁ c compli-

cations of foam [

37, 65– 69 ] but studies that criti-

cally examine the overall safety of foam for

sclerosis of abnormal leg veins remain scant [ 18,

21, 47, 54 ] . All such reports emphasize the need

for adequate training in this technique to reduce

the risk of complications.

Side effects and adverse events have been

described not only for UGFS but for all methods

of treating the super ﬁ cial veins of the lower

extremity, surgical or nonsurgical [ 2, 3, 5, 6, 8–

10, 12– 20, 33, 36– 38, 45, 47, 70– 75 ] . Side

effects, adverse reactions, and minor or major

complications following foam sclerotherapy have

been limited in incidence and in duration. The

author has demonstrated small volume (1 mL) of

foam injected into peripheral super ﬁ cial leg veins

Table 9.1 Guidelines and suggestions for improved

ef ﬁ cacy of foam sclerotherapy

Agitation methods which enhance the durability and

uniformity of foam [

7, 54 ]

Increasing the concentration of the liquid sclerosant

[

19, 58 ]

Increasing the volume of foam utilized during an

injection session [

19, 59, 60 ]

Use of an indwelling catheter [

42, 43 ]

Foam production methods resulting in smallest bubble

size possible

Leg elevation (for ‘empty vein’) [

28 ]

https://t.me/med1917

879 Foam Sclerotherapy

can be followed rapidly into the deep venous cir-

culation, into the heart, and in the presence of a

right-to-left shunt, into the cerebral circulation

within seconds [

76 ] (Fig. 9.6 ).

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.

Foam Sclerotherapy: Adverse Events

Visual disturbances or scotomas have been •

mentioned when evaluating adverse events

following foam sclerotherapy. Frequencies of

occurrence varies from 0% to 6% following

air-based foam injection [

8, 21, 23, 24, 26, 28,

30, 47, 48 ] , with most publications indicating

a frequency of less than 1%. Respiratory

dif ﬁ culties are reported as rare [ 77 ] .

Pulmonary embolism is a concern but its occur-•

rence is rare and may relate more to other

patient conditions than to the procedure itself

[ 27 ] .

Long-term adverse pulmonary effects such as •

pulmonary ﬁ brosis are of theoretical concern,

but not have been identi ﬁ ed (Butler B, per-

sonal communication, 2007.x). Such effects

are considered unlikely since the dose of active

sclerosing agent that reaches the pulmonary

bed is miniscule because of rapid protein inac-

tivation [ 22 ] .

Fig. 9.6 ( a ) Four chamber view of heart on transthoracic

echocardiography. ( b ) Bubbles ﬁ lling right atrium and

ventricle following injection of foam sclerosant into

peripheral leg vein. ( c ) Bubbles ( yellow arrow ) progress-

ing from right atrium through patent foramen ovale into

left atrium. ( d , e ) Transcranial Doppler images depicting

HITS ( blue arrows ) in middle cerebral artery following

foam injection into peripheral leg vein

https://t.me/med1917

N. Morrison

Chest tightness, paresthesia, and dry cough •

were mentioned by Bergan et al. as uncom-

mon or rare adverse events [ 28 ] .

True migraine or occular migraine was experi-•

enced by less than 1% of patients described by

Bergan et al. [

28 ] . Transient confusion had a

frequency of about 1% according to Frullini

et al. [ 21 ] . Neurasthenia has been reported but

with an insigni ﬁ cant frequency [ 23, 26 ] .

The frequency of tissue necrosis has been •

reported as less than 2% [ 21, 28, 45 ] . This

may be secondary to the benign effects of

foam extravasated in the peri-venous tissue in

contrast to the more damaging effects of some

liquid sclerosants [ 11 ] .

As one might expect, venous thrombosis has •

also been reported [ 78 ] . Extensive femorop-

opliteal thrombosis following chemical abla-

tion is thought to be rare. A pre-procedure

historical pro ﬁ le for familial and individual

hypercoagulable states can minimize occur-

rence of this event [ 2 ] . Extension of thrombo-

sis to the femoral or popliteal veins has been

described by several authors with an incidence

of less than 2% [ 19, 21, 30, 48, 49 ] . Calf vein

thrombosis limited to the posterior tibial or

gastrocnemius veins has also been described

with an incidence varying from near zero to

4% [ 19, 23, 26– 28, 30 ] . Such frequencies may

also be dependent on patient co-morbidities

and also may be lower for patients with simple

varicose veins as compared to patients with

advanced chronic venous insuf ﬁ ciency.

Super ﬁ cial thrombophlebitis, in principle, •

should be considered a direct consequence of

the treatment. This ﬁ nding, however, is con-

sidered an adverse event if thrombophlebitis

extends beyond the region treated or if the

in ﬂ ammation is signi ﬁ cantly worse than com-

monly expected. Therefore it should be

expected that the reports are highly variable

and subject to individual interpretation.

Incidences have been reported varying from

1% to 11%, or even 33% for a speci ﬁ c popula-

tion with re ﬂ ux starting in the veins at the

groin [ 8, 21, 30, 45, 48 ] .

Hamel-Desnos described the incidence of •

hematoma at about 2% [ 12 ] . Frequency of

telangiectatic matting was insigni ﬁ cant

according to Barrett et al. [

23, 26 ] .

Signi ﬁ cant adverse neurologic events are •

extremely rare. Forlee et al. reported one case

of stroke following varicose vein foam injec-

tion sclerotherapy [ 74 ] . The patient was subse-

quently found to have a very large patent

foramen ovale. Anzola et al., in a 2006 report

of 420 patients, found a direct correlation

between a history of migraine and/or stroke

and the size of the right-to-left shunt [ 79 ] . More

recently Bush and colleagues have reported

serious neurologic events in two patients [ 75 ] .

The opinion of international experts has been

that these rare complications do not justify pre-

sclerotherapy screening for patent foramen

ovale or right-to-left shunts [ 14 ] . Serious inci-

dents may occur not only after foam sclerother-

apy but also after liquid sclerotherapy or

surgical stripping as attested by the reports on

cardiac arrest and brain infarct [ 70, 71, 80 ] . It is

imperative, however, that the practicing phle-

bologist have protocols to deal with such seri-

ous adverse events should one occur.

Foam Sclerotherapy: Methods

to Improve Safety

Several methods have been proposed to improve

the safety of foam sclerotherapy, Table 9.2 :

Use of biocompatible gas for foam produc-•

tion, such as carbon dioxide (CO

) or a com-

bination of CO

and oxygen (O

) will reduce

the incidence of visual and neurologic side

effects [ 86 ] .

Table 9.2 Guidelines and suggestions for improved

safety of foam sclerotherapy

Indwelling catheter (balloon-tipped or open-ended)

Saphenous femoral junction occlusion

Limitations on volume

Low silicon syringe

Non air-based foam

Avoidance of duplicated femoral vein thrombosis

Leg elevation pre-injection

Leg elevation post-injection

Patient immobility

https://t.me/med1917

899 Foam Sclerotherapy

One method proposed to improve safety of •

ultrasound-guided foam sclerotherapy by

minimizing extravasation is to insert an

indwelling catheter or angiocatheter for the

delivery of foam rather than direct needle

injection [

42, 62, 81 ] .

A balloon-tipped catheter can be used to •

occlude the saphenous junction, theoretically

preventing foam from entering the deep

venous system when performing GSV chemi-

cao ablation. However, during a study using

just such a catheter in the author’s center, foam

bubbles could be seen by duplex examination

entering the deep venous system during bal-

loon in ﬂ ation through small thigh perforators,

resulting in a signi ﬁ cantly higher incidence of

deep venous thrombosis (4 of 27 patients, 15%

unpublished data [ 82 ] ). In fact many phlebolo-

gists 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 de ﬂ 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 [ 13, 14, 21 ] . However, in

studies of foam sclerotherapy with simultane-

ous monitoring using transthoracic echocar-

diography and transcranial Doppler, the author

has shown that the use of even very small vol-

umes of foam does not prevent foam migra-

tion to the central venous circulation or across

a PDA [

76 ] (Fig. 9.6 ).

Use of low-silicone syringes enhances foam •

stability: it is presumed 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

[

38, 83, 84 ] .

The type of gas used to create the foam will •

also in ﬂ uence foam degradation. Tessari has

shown that a gas combination of CO

and O

with 70% CO

and 30% O

to produce foam

will result in more stable, longer-lasting foam

than pure CO

-based foam [ 85 ] . Because of its

presumably more rapid dissolution, CO

based foam (70% CO

/30%O

combination)

has been shown by the author to be seven (7)

and forty (40) times less likely respectively to

produce side effects or complications com-

pared to air-based foam [

86 ] .

Maneuvers such as pre-injection and/or post-•

injection 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 cir-

culation in the presence of a right-to-left

shunt [ 87 ] .

Gibson et al. [ • 88 ] noted no cardiac, neuro-

logic, or visual ﬁ eld changes in patients

undergoing foam sclerotherapy using a pro-

prietary manufactured polidocanol foam

(Varisolve).

Postoperative Care

Compression and ambulation are widely regarded

as the cornerstones of successful postoperative

management, no matter which modality of trun-

cal vein ablation is chosen, although Level 1 evi-

dence for the use of postoperative compression is

lacking. Extrinsic compression using foam pad-

ding, short stretch and/or elastic bandages,

30–40 mmHg compression hose, and early

ambulation and return to normal activities all

will help to minimize postoperative discomfort

and avoid complications, such as deep venous

thrombosis

Conclusion

The published clinical evidence supports UGFS

as a reasonably safe method of super ﬁ cial

venous ablation. Ef ﬁ cacy, simplicity, economy,

and serial applications have made UGFS an

attractive and ef ﬁ cient treatment modality in the

armamentarium of the phlebologist. 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 re ﬁ ned evidence based

guideline that will address its indications and

methods to enhance ef ﬁ cacy and ensure safety.

https://t.me/med1917

N. Morrison

Acknowledgements The author gratefully acknowl-

edges the contribution of Diana Neuhardt, RVT, of

Compudiagnostics for her investigational help and provi-

sion of the excellent duplex images in this manuscript.

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Summary Box

UGFS has become a common treatment •

for patients with chronic venous

insuf ﬁ ciency.

Foam signi ﬁ cantly enhances ef ﬁ cacy of •

sclerotherapy.

Some infrequent or rare side effects of •

foam sclerotherapy, such as visual dis-

turbances, headache, and neurologic

events, remain of some concern.

Maneuvers designed to restrict migra-•

tion of foam are largely ineffective.

The safety pro ﬁ le of foam sclerotherapy •

is overall excellent.

https://t.me/med1917

919 Foam Sclerotherapy

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