Search

Objective Mechanochemical ablation (MOCA) is a nonthermal nontumescent method of treating saphenous vein insufficiency. The feasibility and short-term results of MOCA are good, but its long-term results are unknown. A randomized study was performed to compare MOCA with endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) in the setting of unilateral great saphenous vein (GSV) insufficiency. Methods Venous outpatient clinic patients with varicose veins (CEAP class C2-C4) caused by GSV insufficiency were invited to participate in the study; in total, 132 patients met the inclusion criteria and were willing to participate. Patients were randomized to treatment (2:1:1 for MOCA, EVLA, and RFA, respectively). The state of the GSV with duplex Doppler ultrasound examination and the disease-specific quality of life were assessed at 1 month, 1 year, and 3 years after the treatment. Results Some patients declined to continue in the study after randomization; in total, 117 patients underwent treatment. At 3 years, the occlusion rate was significantly lower with MOCA than with either EVLA or RFA (82% vs 100%; P = .005). Quality of life was similar between the groups. In the MOCA group, GSVs that were larger than 7 mm in diameter preoperatively were more likely to recanalize during the follow-up period. The partial recanalizations of proximal GSV observed at 1 year progressed during the follow-up. Conclusions MOCA is a feasible treatment option in an outpatient setting, but its technical success rates are inferior compared with endovenous thermal ablation. Its use in large-caliber veins should be considered carefully.

Objective This study aimed to investigate the efficacy of foam sclerotherapy in the treatment of tortuous Great Saphenous Vein (GSV) insufficiency. Methods In this prospective non-randomized study 62 patients with tortuous GSV insufficiency were included. All patients were delivered sclerosant agent in the form of foam into the GSV through a cannula above the knee level. Characteristics of patients, diameter of veins, reflux grades, Venous Clinical Severity Score (VCSS) and Clinical, Etiological, Anatomical, Pathological (CEAP) scores, concentration of sclerosant agent, complications and follow-up results were recorded. Results Foam sclerotheraphy was performed with 100% technical success in all patients at operative room. There were no allergic reactions or neurological complications during and after the operations. Ecchymosis was the most common complication with 37.1% frequency. . VCSS scores significantly decreased from 6.43% to 2.53%, during follow-up from initial admission to sixth months, respectively ( PConclusions Due to its low complication rate, low cost, acceptable total occlusion rate and reproducibility; Foam sclerotherapy can be considered a reliable treatment for patients with tortuous GSV insufficiency.

Objective: This retrospective trial analyzed the effect of predetermined variables on venous ulcer healing after endovenous ablation of insufficient veins. Methods: A total of 259 patients presenting 273 venous leg ulcers (VLUs) at Oulu University Hospital vascular outpatient clinic between January 2010 and December 2020 were included in the study. In addition to compression therapy, all patients received endovenous ablation (endothermal ablation and/or foam sclerotherapy) to promote venous healing. The hazard ratio (HR) for an ulcer to heal was analyzed in univariate analysis of predetermined factors, including age, sex, recurrent venous ulcer, presence of great saphenous vein or small saphenous vein reflux, persistent superficial vein reflux after ablation, recanalization in treated segments, ulcer age, body mass index >35 kg/m², history of deep vein thrombosis, history of erysipelas, ability to move, smoking, hypertension, atrial fibrillation, coronary artery disease, diabetes mellitus, and cardiac insufficiency. Logistic regression was used in a multivariate analysis to identify independent risk factors for ulcer healing. Results: In the univariate analysis, healing was negatively associated with persistent superficial vein reflux after ablation (HR, 0.117; 95% confidence interval [CI], 0.088–0.354), recanalization in treated segments (HR, 0.161; 95% CI, 0.060–0.433), nonambulatory patient (HR, 0.322; 95% CI, 0.130–0.800), history of deep vein thrombosis (HR, 0.518; 95% CI, 0.294–0.910), and presence of small saphenous vein reflux (HR, 0.565; 95% CI, 0.384–0.830). Independent risk factors included persistent superficial vein reflux after ablation (HR, 0.123; 95% CI, 0.0051–0.295). All the patients in the persistent superficial vein reflux group had their VLUs eventually healed after further endovenous treatment. Conclusions: When treating patients with VLUs, persistent superficial vein reflux after ablation was negatively associated with ulcer healing. After additional endovenous ablative treatment, ulcers with persistent reflux eventually healed.

Balloon-occluded retrograde transvenous obliteration is an effective treatment for gastric varices. In this report, we illustrate a consecutive treatment strategy via brachial vein approach and n-butyl cyanoacrylate (NBCA) packing of the gastrorenal shunt (GRS) after injecting sclerosing agent in a severely obese patient. The brachial vein approach reduced the burden on the patient, and the closure of the GRS using NBCA shortened the procedure time. These techniques may improve patient comfort as well as reduce medical costs and the risks of several complications.

Purpose: The aim of this study was to evaluate the clinical effects of the Trivex system in the treatment of primary severe superficial varicose veins of the lower extremity and compare Trivex to the point-form-stripping combined with foam sclerotherapy (FS). Methods: A total of 64 patients (35 females, 29 males; mean age, 57 ± 11 years [range, 29–79 years]) with primary severe superficial varicose veins of the lower extremity involving 64 legs were included between October 2015 and July 2019. The maximum diameter of the vein branches was >20 mm, which appeared to be cystic dilatation and forms large-scale in the crus or the thigh. All patients underwent high ligation and endovenous laser ablation or stripping of the trunk under general anesthesia. The surgical time, pain/phlebitis, number of incisions, amount of bleeding, recurrence of varicose vein, incidence of surgical site infections (SSIs), satisfaction score, and improvement in clinical symptoms were evaluated respectively with the patients in two groups: Group A, with patients who underwent treatment with the Trivex system, and Group B, patients who underwent treatment by point-form-stripping combined with FS. Results: All procedures were performed successfully. The average operative time in Group A was 56 ± 11 min, whereas that of Group B was 90 ± 33 min, which was a significant difference (p 0.05). Conclusions: This study shows that patients benefited from both treatment options. However, primary severe superficial varicose veins of the lower extremity treated with the Trivex system suffered less pain with fewer incisions than severe branches treated with the point-form-stripping combined with foam sclerotherapy (FS). In summary, the Trivex system is a suitable treatment prior to point-form-stripping combined with foam sclerotherapy (FS) for those who demand a high level of appearance, and especially for young patients, the Trivex system is recommended. Keywords: Varicose veins, Trivex system, Point-form-stripping, Foam sclerotherapy

Background Chronic venous insufficiency is a highly prevalent disease. Advanced cases have high morbidity. Objectives To evaluate the risks and benefits of foam sclerotherapy in patients who underwent bilateral treatment of the great saphenous veins in a single procedure, in selected cases of advanced venous insufficiency. Methods We retrospectively reviewed 55 patients (110 limbs) with bilateral incompetence of the great saphenous veins who had undergone foam sclerotherapy treatment bilaterally, using a maximum dose of 20 ml of foam per patient and inelastic compression. Results In 81 (73.6%) of the 110 saphenous veins analyzed, occlusion was obtained in the first session. After a second session this figure rose to 106 (96.3%) and all 110 (100%) veins were occluded after three sessions. Bilateral occlusion of the great saphenous veins was achieved in 27 patients (50%) in one session, in 34 (62%) patients in two sessions, and in 55 (100%) patients in three sessions. At 42 days after sclerotherapy, there was complete ulcer healing in seven (63%) of the 11 patients with ulcers and partial healing in 3 (27%) of these patients. One patient (1.8%) had self-limited lipothymia and visual scotomas, 3 patients (5.45%) had skin spots, and 19 patients (34.5%) developed retained intravascular coagulum. Conclusions Bilateral foam sclerotherapy in a synchronous procedure is an option to be considered for treatment of varicose veins of the lower limbs.

46th Annual VEITH Symposium -- NOV 19-23, 2019 -- New York, NY, Background: Varicose vein treatment has shifted to less invasive techniques owing to the complications associated with traditional treatment. The present study was designed to compare the effectiveness of cyanoacrylate ablation (CAA) with radiofrequency ablation (RFA). Methods: Patients who had undergone RFA vs CAA (634 vs 246 patients) to treat great saphenous vein (GSV) insufficiency during a 5-year period were included in the present study. The preoperative and postoperative CEAP (clinical, etiologic, anatomic, pathophysiologic) class, symptoms, recurrence, and Doppler ultrasound findings were compared. Results: All the veins in both groups were occluded at day 5. The 1-month closure rates were 97.3% and 98.7% for RFA and CAA, respectively. The overall postoperative closure rates at 5 years were 93.1% and 91.1% for RFA and CAA, respectively. The postoperative symptoms, CEAP class, and Doppler ultrasound findings were similar in both groups. The 5-year symptom-free survival rates were 73.5% and 72.0% in the RFA and CAA groups, respectively. The venous clinical severity scores had decreased from 5.9 +/- 1.2 to 0.9 +/- 0.8 and 5.8 +/- 0.9 to 0.8 +/- 0.6 in the RFA and CAA groups, respectively. The Aberdeen varicose vein questionnaire scores had decreased from 19.7 +/- 5.5 to 4.8 +/- 1.5 in the RFA group and from 18.9 +/- 5.8 to 4.9 +/- 1.4 in the CAA group. Conclusions: CAA seems to be the ideal treatment for GSV insufficiency because it is suitable for most patients and is nonthermal and nontumescent, with satisfactory results comparable to those with RFA. Long-term outcomes and cost analyses from larger series are required to confirm our findings., VEITH

Objectives Little is known how calibre and length of needles affect the stability of sclerosing foam. Methods Foams were made of 0.5%, 1%, 2% and 3% polidocanol, and 0.2%, 0.5%, 1% and 3% sodium tetradecyl sulfate (STS), which were mixed with air in the proportion of 4:1. These foams were ejected through needles with the length of: 4 mm, 6 mm and 13 mm, and diameter of: 0.26 mm, 0.3 mm and 0.4 mm. Results Foams made of more concentrated polidocanol were more stable. Regarding STS an opposite relationship was revealed. Foams made of polidocanol were more stable if ejected through a longer needle, while the length of needle did not significantly affect stability of STS foams. Foams ejected through 0.26 mm diameter needles were very unstable. In the case of 0.5% polidocanol, 0.3x6mm needle provided atypically stable foam. Conclusion In order to inject maximally stable foam, calibre and length of needle should be taken into account.

Introduction: While traditional ambulatory phlebectomy (AP) is a safe and effective procedure, few adverse effects such as hematoma, bleeding, bruising and nerve injury have been reported. To improve AP and to reduce some of these adverse events, herein we report a novel technique – Foam Sclerotherapy Assisted Phlebectomy (SAP). Report: The details of the above technique, along with the potential advantages and limitations will be discussed. Discussion: Foam sclerotherapy and DUS act as valuable adjuncts to traditional AP. SAP increases precision and creates additional venospasm leading to reduced bruising, reduced nerve injury and sclerosis of residual vein segments. Keywords: Varicose veins, Sclerotherapy, Foam sclerotherapy, Phlebectomy, Venous insufficiency

Purpose: To report the midterm results of mechanochemical ablation (MOCA) for treating great saphenous vein (GSV) insufficiency. Methods: In a 1-year period, 85 consecutive patients (median age 51.4 years; 71 women) undergoing MOCA with polidocanol in 104 limbs were enrolled in a prospective registry. The patients were evaluated at baseline and during follow-up (4 weeks and 1, 2, and 3 years) using duplex ultrasound, the CEAP (clinical, etiologic, anatomic and pathophysiologic) classification, the Venous Clinical Severity Score (VCSS), the RAND Short Form 36-Item Health Survey (RAND-SF36), and the Aberdeen Varicose Vein Questionnaire (AVVQ). Primary outcome measures were clinical and anatomic success. Secondary outcome measures included general and disease-specific quality of life and reinterventions. Results: Technical success (99%) was achieved in all but 1 patient in whom technical problems with the device led to conversion to another method for treatment of 2 limbs. After a median follow-up of 36 months (interquartile range 12.5, 46.3), recanalization occurred in 15 (15%) of 102 successfully treated vein segments. Anatomic success was 92%, 90%, and 87% after 1, 2, and 3 years, respectively. The VCSS improved at all time intervals compared to the preprocedure median. The clinical success at 3 years was 83%. The AVVQ and RAND-SF36 scores showed an improvement at all time intervals compared to baseline values. Between 12 and 36 months, however, a significant deterioration was observed in VCSS, which was accompanied by worsening of disease-specific and general quality of life. Conclusion: In the longest follow-up of MOCA to date, this study shows MOCA to be an effective treatment modality for GSV insufficiency at midterm follow-up, but clinical results seem to drop over time.

Objective The combination of endovenous therapies with stab avulsion or ultrasound guided foam sclerotherapy is widely performed. However, these conventional techniques tend to result in incomplete avulsions or persistent varicosities. Methods One hundred and thirteen legs in 97 consecutive patients who underwent 1470 nm laser ablation for great saphenous varicose veins were enrolled. The foam sclerosing agent was injected via the sheath after endovenous laser ablation (EVLA). Patients were divided into two groups: EVLA only group (Control; n = 50) and EVLA and transluminal injection of foam sclerotherapy (TLFS) group (SCL; n = 63). Results At three month follow up, reflux was abolished throughout all treated great saphenous veins (GSVs) when assessed with Duplex ultrasound. Thrombophlebitis was observed in two patients in the SCL group (p = .13). Additional second stage sclerotherapy was needed in the Control group (n = 33, 66%) vs. SCL group (n = 2, 3%; p < .0001). The venous clinical severity score (VCSS) was significantly improved in the SCL group (changes of VCSS, Control −3.3 ± 1.7 and SCL -4.4 ± 1.0; p < .0001). Univariable and multivariable analyses revealed that, among age, sex, Clinical-Etiology-Anatomy-Pathophysiology classification, linear endovenous energy density, and TLFS, TLFS was the only significant factor of improved VCSS (hazard ratio = −0.96; 95% confidence interval = −1.4 to −0.58; p < .0001). Conclusions TLFS combined with EVLA may be an easy, safe, and effective procedure with acceptable complications vs. EVLA alone and reduces additional second stage interventions., Highlights • Stab avulsion tends to result in incomplete avulsions. • Ultrasound-guided foam sclerotherapy also tends to result in non-sclerotic vessels. • Foam sclerosing agent injected via the sheath covers the whole varicose vein. • Transluminal foam sclerotherapy improves VCSS and reduces additional interventions.

Background Thermal ablation techniques have become the first-line treatment of truncal veins in the management of chronic venous disease (CVD). Despite excellent outcomes, these methods are often associated with pain; generally due to their use of heat and the necessity of fluid infiltration around the vein. More recently, novel non-thermal techniques, such as mechanochemical ablation (MOCA) and cyanoacrylate adhesive (CAE) have been developed to overcome these unwelcome effects. So far, the novel techniques have been found to have similar efficacy to thermal methods, yet no direct comparisons between the non-thermal treatment techniques have been conducted to date, giving rise to this study. Methods/design This is a prospective, multicentre, randomised clinical trial, recruiting patients with truncal saphenous incompetence. Patients will be randomised to undergo either MOCA or CAE truncal ablation, followed by treatment of any varicosities. All patients will be required to wear compression stockings for 4 days post intervention. The primary outcome measure is the pain score immediately following completion of truncal ablation, measured by a 100-mm Visual Analogue Scale (VAS). The secondary outcomes are entire treatment pain scores, clinical scores, quality of life scores, occlusion rates, time to return to usual activities/work at 2 weeks, 3, 6 and 12 months. Re-intervention rate will be considered from the third month. Cost-effectiveness will be assessed for each intervention at 12 months. The study is powered to detect a mean 10-mm difference in maximum pain score. Allowing for loss to follow-up, the total target recruitment is 180 patients. Discussion The study will be the first study to compare MOCA against CAE and is designed to determine which method causes less pain. Completion of this study is expected to be the end of 2019. Trial registration ClinicalTrials.gov, ID: NCT03392753. Registered on 17 November 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2807-0) contains supplementary material, which is available to authorized users.

Background Venous leg ulcers impair quality of life significantly, with substantial costs to health services. The aim of this study was to estimate the cost-effectiveness of interventional procedures alongside compression therapy versus compression therapy alone for the treatment of chronic venous leg ulceration. Methods A Markov decision analytical model was developed. The main outcome measures were quality-adjusted life-years (QALYs) and lifetime costs per patient, from the perspective of the UK National Health Service at 2015 prices. Resource use included the initial procedures, compression therapy, primary care and outpatient consultations. The interventional procedures included superficial venous surgery, endothermal ablation and ultrasound-guided foam sclerotherapy (UGFS). The study population was patients with a chronic venous ulcer who were eligible for either compression therapy or an interventional procedure. Data were obtained from systematic review and meta-analysis of RCTs. Results Surgery gained 0·112 (95 per cent c.i. -0·011 to 0·213) QALYs compared with compression therapy alone, with a difference in lifetime costs of €-1330 (-3570 to 1262). Given the expected savings in community care, the procedure would pay for itself within 4 years. There was insufficient evidence regarding endothermal ablation and UGFS to draw conclusions. Discussion This modelling study found surgery to be more effective and less costly than compression therapy alone. Further RCT evidence is required for both endothermal ablation and UGFS.

In the literature cases of stroke and transient neurological symptoms have been described after sclerotherapy for chronic venous disease The initial interpretation of these phenomena was that of a micro air embolism in association with a patent foramen ovale. This explanation did not always manage to justify all neurological manifestations. Recent theories have demonstrated that in the area of sclerosis, a significant amount of endothelin 1. We carried out a retrospective assessment of sclerotherapy case studies on 540 patients at ten phlebological centres to search for a relationship between the use of aminaftone (a venotropic drug with demonstrated anti-endothelin action) and the occurrence of side effects after sclerotherapy was performed. Significant reduction of side effects was observed in sclerotherapy for teleangectasias and in patients with migraine history.

OBJECTIVES: This pilot study investigated the safety and efficacy of a novel shunt surgery combined with foam sclerotherapy of varices in patients with prehepatic portal hypertension. METHODS: Twenty-seven patients who were diagnosed with prehepatic portal hypertension and underwent shunt surgeries were divided into three groups by surgery type: shunt surgery alone (Group A), shunt surgery and devascularization (Group B), and shunt surgery combined with foam sclerotherapy (Group C). Between-group differences in operation time, intraoperative blood loss, portal pressure decrease, postoperative complications, rebleeding rates, encephalopathy, mortality rates and remission of gastroesophageal varices were compared. RESULTS: Groups A, B and C had similar operation times, intraoperative bleeding, and portal pressure decrease. The remission rates of varices differed significantly (p

Introduction: Low-flow vascular malformations (LFVMs) of the tongue are one of the most common presentations among different vascular anomalies of oral and maxillofacial regions. The present study was conducted with the objective to assess the outcome of a simple, easily available, safe and cost-effective therapeutic measure using foamed polidocanol in patients with LFVMs of the tongue. Materials and Methods: Fifteen patients with LFVMs of tongue were randomly selected in the study from the pool of 32 individuals affected with vascular malformation of oral and maxillofacial region. The diagnosis was made by a combination of clinical presentation and Doppler ultrasound. Lesions on the tongue were measured along their longer axis using a calliper and assigned to one of the three groups according to size: small-sized (3 cm; eight patients). Foam sclerotherapy was done by directly injecting the foam (polidocanol) into identified sinusoids, under real-time ultrasound guidance. Foam polidocanol was prepared using the Tessari method. Results: Fifteen patients (Nine males and Six females), aged 7–50 years, with an average age of 23.53 years were included in our study. Of these 15 vascular lesions, three were small (3 cm) in size. Treatment results were evaluated based on a reduction in lesion size. Complete or partial regression of lesions was reported by 14 (93.33%) patients and remained unchanged in one (6.67%) patient. The number of sclerotherapy sessions performed in this study ranged from 1 to 6 and was directly related to lesion size. Small- and medium-sized lesions responded well and complete resolution was seen in 1–3 sessions. Of the eight large lesions, seven showed complete or partial resolution in 4–6 sessions except one lesion which did not show any responses in subsequent sessions. Conclusion: Foam polidocanol therapy for LFVM of tongue is cost-effective, less invasive and with added advantage of local anesthetic effect.

Objective: The aim of this study was to evaluate whether foam sclerotherapy (FS) induces changes in CAT (calibrated automated thrombinography) and other coagulation parameters which could indicate an increased risk of thrombotic events. Methods: Blood samples from eight patients treated with FS were taken before treatment and 30 minutes, one and four hours and one week after treatment. CAT parameters (ETPln, Peakln, Lag time 1), thrombin antithrombin complexes (TAT), d-dimers, fibrinogen, Von Willebrand (vWf Ag) factor and platelet-derived microparticles (MIPAs) were measured. Results: Significant changes over time for Peakln, fibrinogen, d-dimers, vWfAg and TAT complexes were observed. CAT parameters decreased over time, except for Lag time 1. D-dimers and TAT complexes increased and fibrinogen, vWf Ag, MIPA's decreased during the first hours. Conclusion: The findings in this study support the hypothesis that FS initiate coagulation pathways, but there is no evidence that this activation results in an increased thrombosis risk.

Objective Mechanochemical ablation is a novel technique for ablation of varicose veins utilising a rotating catheter and liquid sclerosant. Mechanochemical ablation and radiofrequency ablation have no reported neurological side-effect but the rotating mechanism of mechanochemical ablation may produce microbubbles. Air emboli have been implicated as a cause of cerebrovascular events during ultrasound-guided foam sclerotherapy and microbubbles in the heart during ultrasound-guided foam sclerotherapy have been demonstrated. This study investigated the presence of microbubbles in the right heart during varicose vein ablation by mechanochemical abaltion and radiofrequency abaltion. Methods Patients undergoing great saphenous vein ablation by mechanochemical abaltion or radiofrequency ablation were recruited. During the ablative procedure, the presence of microbubbles was assessed using transthoracic echocardiogram. Offline blinded image quantification was performed using International Consensus Criteria grading guidelines. Results From 32 recruited patients, 28 data sets were analysed. Eleven underwent mechanochemical abaltion and 17 underwent radiofrequency abaltion. There were no neurological complications. In total, 39% (11/28) of patients had grade 1 or 2 microbubbles detected. Thirty-six percent (4/11) of mechanochemical abaltion patients and 29% (5/17) of radiofrequency ablation patients had microbubbles with no significant difference between the groups ( p=0.8065). Conclusion A comparable prevalence of microbubbles between mechanochemical abaltion and radiofrequency ablation both of which are lower than that previously reported for ultrasound-guided foam sclerotherapy suggests that mechanochemical abaltion may not confer the same risk of neurological events as ultrasound-guided foam sclerotherapy for treatment of varicose veins.

Peripheral arterial occlusive disease (PAOD) is reported in about 15-20% of patients with venous leg ulcers (VLU). In such cases arterial recanalization is often recommended, and compression therapy is considered a contraindication when the ankle brachial pressure index (ABPI) is 0.8. The aim of this study was to compare the outcome of patients with recalcitrant VLU, both without any arterial impairment ("pure venous recalcitrant leg ulcer" [pvRLU]) and with associated PAOD ("mixed arterial and venous recalcitrant leg ulcer" [mavRLU]), by treating only the venous disease.The records of 180 outpatients with recalcitrant ulcers treated between January 2011 and July 2014 were reviewed retrospectively. In total, 109 were affected by pvRLU and 71 by mavRLU, with moderate PAOD defined by an ABPI between 0.5 and 0.8. In addition to the same local wound dressing, the patients received ultrasound guided foam sclerotherapy of the refluxing superficial veins and a modified inelastic compression with a pressure ≤ 40 mmHg. No patient was referred for arterial revascularization. The patients were followed until ulcer healing.Patients with pvRLU and mavRLU showed comparable demographic characteristics. Twenty-five patients were lost to follow up and the outcomes were analyzed in 93 patients with pVLU (85.4%) and in 62 patients with mavRLU (87.4%). The maximum time to complete healing was 48 weeks in the pvRLU group and 52 weeks in the mavRLU group (p = .009), The median healing time was 23 (pvRLU) versus 25.5 weeks (mavRLU) (p = .030). Deep venous incompetence (p .001), ulcer surface area (p .001), arterial disease (p = .002), and ulcer duration (p .010) were risk factors for prolonged healing.Treatment of recalcitrant leg ulcers by treating venous incompetence by foam sclerotherapy and modified compression is successful, even if underlying moderate PAOD is not actively treated.

Objectives Ultrasound-guided foam sclerotherapy (UGFS) is a technique in which a mixture of sclerosing drug and gas is used to treat varicose veins. Several authors have demonstrated transient systemic effects after UGFS. These effects are not well understood but probably originate from a systemic distribution of the sclerosing foam. Therefore, safety measures have been developed to prevent foam from flowing into the deep venous system. The aim of the study is to evaluate whether blockage of the saphenofemoral (SF) junction by either manual compression or surgical ligation prevents microbubbles from leaking into the deep venous circulation. Methods To detect the distribution of microbubbles, radioactive pertechnetate ( 99m TcO 4 − ) was added to the foam solution. Initially, in vitro trials were performed in the laboratory to investigate the effect of 99m Tc on foam stability. The time taken for foam to liquefy was measured for foam alone and for the mixture with 99m Tc. In subsequent research, eight varicose great saphenous veins (GSVs) were treated by UGFS. In three patients, this treatment was preceded by surgical ligation of the SF junction. In three patients, the groin was manually compressed during UGFS. In two patients, UGFS was performed without compression of the groin. Results In vitro , 99m Tc did not influence foam stability; after 2.6 min all foam had reduced to liquid, regardless of whether 99m Tc had been added or not. In vivo trials showed that all patients showed a decrease in the cumulative amount of 99m Tc detected in the GSV following polidocanol- 99m Tc mixture injection. However, the decrease of radioactivity was slightly reduced when compression or ligation of the SF junction was performed. Conclusions Blocking the SF junction during UGFS using either manual compression or ligation does not prevent, but may reduce the flow of foam into the femoral vein.

Aim To report the outcome of a series of patients with chronic venous disease due to incompetence of saphenous trunks managed by ultrasound guided foam sclerotherapy (UFS). Patients and methods A group of 808 patients comprise this series. CEAP clinical class for limbs was C1: 15%, C2: 81%, C3: 0.5%, C4: 2%, C5: 0.2%, C6: 0.4%. UFS using 1% polidocanol (107 limbs), 1% sodium tetradecyl (102 limbs), 3% sodium tetradecyl (900 limbs) was employed to treat incompetent saphenous trunks. In patients with unilateral varices 1 treatment was required in 43% of patients and 2 treatments in 48% of patients to obliterate incompetent saphenous trunks and varices. For bilateral varices 2 treatments were required in 40% of patients and 3 treatments in 46% of cases. The clinical outcome and patency of treated veins on duplex ultrasonography was assessed at a mean follow-up interval of 11 months. Results A total of 459 limbs were available for assessment at a follow-up interval of 6 months or greater. The CEAP clinical stage was C0:182 limbs, C1: 241, C2: 22, C3: 0, C4: 11, C5: 2, C6:1. The GSV had remained obliterated in 88% of limbs and the SSV in 82% of limbs. Recurrent venous incompetence following previous surgery was as effectively treated by UFS as primary incompetence. Conclusions This technique is useful in the management of chronic venous disease as an alternative to surgery.

619, 622, BACKGROUND:New sclerosing foam is considered to have the advantage of causing more damage on the intima than liquid form. Therefore we recently applied duplex-guided foam sclerotherapy in a patient with venous malformations of the face.METHODS:A 20-year-old man was referred to our institute for the evaluation and treatment of vascular malformations of the face. Preoperative duplex scanning and magnetic resonance imaging (MRI) revealed subcutaneous and intramuscular venous malformations. The sclerosing foam was produced by Tessari's method using 1% polidocanol, and the duplex-guided foam sclerotherapy was performed under general anesthesia. A 20-gauge plastic needle was inserted into the venous space using ultrasound guidance and a total of 5 ml of sclerosing foam was infused followed by immediate tie-over dressing.RESULTS:The venous malformations were successfully reduced in size and postoperative MRI showed significant reduction of the venous malformations.CONCLUSION:Although further collective study is necessary to ensure the validity of this treatment, duplex-guided foam sclerotherapy could have great promise in the treatment of symptomatic venous malformations.

Background Foam sclerosants are widely used in sclerotherapy and have been accepted as more effective than the liquid form; however, there is no consensus about the most applicable and effective concentration. Objective The aim of this study was to investigate the histopathological changes caused by various widely used concentrations of foam sclerosant. Methods Fifty-six varicose vein segments of 5–10 mm diameter were gently resected and exposed to various concentrations of foam sclerosant (0.5%, 1%, 2%, 3%) for 5 min, and were then prepared for routine histopathological examination. A total damage scoring system, including the presence of endothelial swelling, intimal thickening, cellular vacuolization in the muscle layer, edema in the tunica media and extent of necrosis, was established. Results The total damage score of the foam sclerosant groups was significantly higher than that of the control group (median 2.75 vs 1, p = 0.007). The highest damage score was achieved by 1% and 2% foam sclerosants (3.5 and 2.5). No significant difference was found among the different concentrations of sclerosant, although the 1% group caused more severe damage at a near significant level ( p = 0.074). Conclusion Significant pathological damage can be caused by even the lowest doses of foam sclerosant. The most injurious concentrations were found to be 1% and 2%, morphologically. A working concentration of 1% could thus be preferable to 0.5%, especially in larger veins. Further in-vivo studies are needed in order to validate these findings.

The bleeding from various veins can be intense and may be mistaken for arterial haemorrhage. Several fatal cases are reported due to delay of treatment and inappropriate first aid. We describe five cases of haemorrhage from varicose veins that were treated with foam sclerotherapy. Polidocanol foam was injected in the various veins using ultrasound guidance. There was no recurrence of haemorrhage in any patient during the 17.4 months follow-up period. Foam sclerotherapy can be performed easily in an out-patient clinic setting. This method is an ideal therapy for haemorrhage from varicose veins because it mitigates problematic varicose veins.

ObjectivesTo describe duplex ultrasound (DUS) outcomes 12 months following ultrasound-guided foam sclerotherapy (UGFS) of primary great saphenous varicose veins (GSVV).MethodsA consecutive series of UK National Health Service patients underwent serial DUS examinations following UGFS with 3% sodium tetradecyl sulphate for symptomatic primary GSVV.Results344 treated legs (CEAP C2/3 237, C4 72, C5 14, C6 21) belonging to 278 patients (103 male) of median age 57 (range 21–89) years were enrolled between November 2004 and May 2007. The median volume of foam used was 10 (range 2–16) ml. Above-knee (AK) and below-knee (BK) GSV reflux was present in 333 (96.8%) and 308 (89.5%) legs respectively prior to treatment. AK and BK-GSV reflux was completely eradicated by a single session of UGFS in 323 (97.0%) and 294 (95.5%) legs respectively; and by two sessions of UGFS in 329 (98.8%) and 304 (98.7%) legs respectively. In those legs where GSV reflux had been eradicated, recanalisation occurred in 18/286 (6.3%) AK and 23/259 (8.9%) BK-GSV segments after 12 months follow-up.ConclusionsA single session of UGFS can eradicate reflux in the AK and BK-GSV in over 95% of patients with symptomatic primary GSVV. Recanalisation at 12 months is superior to that reported after surgery and similar to that observed following other minimally invasive techniques.

A 37-year-old male was treated with 9ml of 3% polidocanol foam, and he immediately reported photopsiae lasting a few minutes, though without migraine. Two hours after sclerotherapy, the patient developed speech disturbance for a few minutes. A pathological examination revealed nothing except a patent foramen ovale (PFO). Given the contrast between the high prevalence of PFO in general population and the extremely low incidence of neurological deficits after foam sclerotherapy, these deficits may only arise due to as-yet-unknown aetiology.

Foam sclerotherapy is a recognised safe treatment modality for low flow vascular malformations. Complications are uncommon. We report the complication of vasospasm in a nineteen year old female with a low flow (venous) malformation of her thenar eminence, leading to dusky discolouration with pain, coolness, numbness and reduced power following foam injection. Treatment with intravenous vasodilators enabled full clinical recovery, preventing irreversible complications.

Objectives To assess whether routine use of foam sclerotherapy, in addition to four-layer compression bandaging, could speed up the healing of venous ulcers. Design Randomised controlled trial involving patients recruited from a nurse-led leg ulcer clinic. A total of 315 new patients were assessed, and eleven patients were identified from follow-up clinics. Methods Inclusion criteria were: patients with an active venous leg ulcer, in the presence of superficial truncal venous incompetence and without total deep venous incompetence on duplex imaging. Patients were randomised to four-layer compression bandages alone (control) or with additional foam sclerotherapy to incompetent superficial truncal veins. The primary endpoint was ulcer healing 24 weeks after randomisation. Results It was only possible to recruit 40 patients who were suitable for analysis: 22 control, 18 additional foam sclerotherapy. There was no complication from the foam treatment and at six months the target vein was occluded in 9 of 11 evaluable patients that had foam. One patient died before 24 weeks from an unrelated cause. At 24 weeks, 17 of 20 (85% - 1 died) in the control group and 12 of 13 (92%) patients with additional foam sclerotherapy had ulcer healing (P=0.72, log rank testing). Conclusion This trial failed to recruit sufficient patients for formal comparison, but foam sclerotherapy was feasible as an adjunct to compression therapy for venous ulceration. Trial registration: Eudra CT 2005-001551-38

ObjectiveThe aim was to describe the results of starting a foam sclerotherapy service, focussing on patients with complicated venous disease.MethodsConsecutive patients undergoing ultrasound-guided foam sclerotherapy for truncal varicose veins underwent clinical and hand-held Doppler assessment at 2 weeks and venous duplex imaging at 6 months.ResultsOne hundred and eighty-five truncal veins were treated in 165 patients. A high proportion of veins were complicated (109 CEAP classes 4–6, 76 CEAP 1–3). Ninety-one percent (168) had a single treatment session. After 2 weeks, ninety-three percent (136/147) of the truncal veins appeared occluded on hand-held Doppler examination. Ten percent (15/147) of patients had remaining visible varicosities in the lower leg. After six months, the truncal vein remained occluded in 74% (68/92), was partially occluded in 10% (9/92) and fully patent in 16% (15/92). There was no significant difference in occlusion rates between: primary (45/60–75%) and recurrent (23/32–72%) veins; CEAP 2–3 (22/30–73%) and CEAP 4–6 (46/62–74%) veins; veins with diameter

Vascular malformations can cause significant symptoms in young patients. Current treatment options, including injection sclerotherapy and surgery, are associated with significant morbidity. We report a case in which a symptomatic paediatric venous malformation was successfully treated using a combination of ultrasound-guided endovenous laser therapy and foam sclerotherapy.

We report an anaphylactic reaction following ultrasound guided foam sclerotherapy (UGFS) to lower limb varicosities. A tortuous anterolateral thigh vein of a 62 year-old woman was unsuccessfully ablated with UGFS. A further session of UGFS, 6 months later, resulted in a non-fatal anaphylactic reaction that required resuscitation with adrenaline. The patient was not known to be allergic to the sclerosant used and had not suffered any adverse effects after her initial treatment. This case demonstrates the possibility of anaphylaxis following UGFS. Those performing sclerotherapy require appropriate resuscitation equipment and training.