Chemical Venous Closure

Some phlebologists have advocated liquid sclerotherapy of the saphenous vein, but the results of such treatment have been disappointing, and published long-term results are absent. Comparisons between liquid and foam sclerotherapy have been done and the results strongly favor foam.20,21 Ultrasound-guided sclerotherapy (USGS) with foam must be considered as a completely new treatment of varicose veins. Although it needs proper training and some skill, it is simple, affordable, and extremely efficient.

Sclerosing agents produce a lesion of the venous wall, predominantly of the endothelium and, to a minor extent, of the media. The reaction that follows depends on the concentration of the agent and on the duration of the contact. If the venous diameter is greater than 3 mm, injections of liquid do not achieve this aim and dilution with blood quickly decreases their efficacy at short distances from the point of injection. Injections of foam have the advantage of a total filling of the vein, at least under 12 mm diameter. A further reduction in venous diameter can be obtained by leg elevation, compression with the hand, duplex probe or bandage, and venous spasm. In very large veins, foam will float over blood and induce a lesion of the upper venous wall, despite apparent correct filling of the vein observed on duplex, thus the importance of massaging and compression.

Making the foam is easy and quick. Based on the technique initially described by Tessari, it can be prepared with two 5 cc syringes and a three-way stopcock.20 Only detergent sclerosing agents can be used: Sotradecol and Polidocanol at any desired concentration from 0.25% to 3%. Micro-bubbles of foam sclerosing agents are hyperechogenic and represent an excellent contrast medium for ultrasound techniques. They appear as a shadow within the lumen early, and like a hyperechogenic mass later with a acoustic shadow. Massaging the sclerosing agent to the desired part of the varicose network with the duplex probe or the hand is also very easily carried out. Progression from the varicose clusters to the GSV and then to the SFJ is always visible, provided a sufficient volume has been injected. Venous spasm usually is observed within minutes. The importance of the initial spasm has been emphasized in several studies and protocols.22,23

Post-sclerotherapy compression is mandatory: on the varicose clusters for 48 hours, and then whole limb compression with 20-30 mmHg thigh-high medical elastic stockings.24 They must be worn during the daytime for at least 15 days. Patients must be examined both clinically and with duplex at 7 to 15 days.

The absolute risk of deep venous thrombosis is not confirmed. A few cases have been reported: most of them are gastrocnemius vein thrombosis, typically after telangiecta-sia and reticular vein sclerotherapy. Most frequent complications are visual disorders. These adverse reactions have been observed also with liquid sclerosing agents but their incidence is much higher with foam; they can be estimated at 0.5-1 per 100 foam sessions.25 They are observed more frequently in patients suffering from migraine with visual aura. They usually reproduce this aura. The patho-physiol-ogy of this phenomenon has been questioned but has received no answer so far. The existence of a patent foramen ovale is the most likely explanation, as has been the liberation of toxic component associated with endothelial cell destruction (endothelin).

All published results demonstrate an immediate efficacy better than 80% in terms of immediate/primary venous occlusion. Repetition of injections in case of initial failure allows closure to approach 95% of efficacy with two to three sessions. Early and mid-term results demonstrate a recurrence rate of about 20%. The re-do injections remain as simple as primary injections and at least as efficient.

References

1. Takase S, Pascarella L, Bergan J, Schmid-Schönbein, GW. Hypertension-induced venous valve remodeling, J Vasc Surg. 2004. 39: 13291334.

2. Takase S, Pascarella L, Lerond L, Bergan JJ, Schmid-Schönbein GW. Venous hypertension, inflammation and valve remodeling, Eur J Vasc Endovasc Surg. 2004. 28: 484-493.

3. Pascarella L, Schmid-Schönbein GW, Bergan JJ. An animal model of venous hypertension: The role of inflammation in venous valve failure, J Vasc Surg. 2005. 41: 303-311.

4. Pascarella L, Schmid-Schönbein GW, Bergan JJ. Microcirculation and venous ulcers, Annals of vascular surgery. 2005. 19(6): 921-927.

5. Mashiah A, Ross SS, Hod I. The scanning electron microscope in the pathology of varicose veins, Isr J Med Sci. 1991. 27: 202-206.

6. Travers JP, Brookes CE, Evans J et al. Assessment of wall structure and composition of varicose veins with reference to collagen, elastin, and smooth muscle content, Eur J Vasc Endovasc Surg. 1996. 11: 230-237.

7. Gradman WS, Segalowitz J, Grundfest W. Venoscopy in varicose vein surgery: Initial experience, Phlebology. 1993. 8: 145-150.

8. Van Cleef IF, Desvaux P, Hugentobler JP et al. Endoscopie veineuse, J Mal Vasc. 1991. 16: 184-187.

9. Van Cleef JF, Desvaux P, Hugentobler JP et al. Etude endoscopique des reflux valvulaires sapheniens, J Mal Vasc. 1992. 17: 113-116.

10. Ono T, Bergan JJ, Schmid-SchOnbein GW, Takase S. Monocyte infiltration into venous valves, J Vasc Surg. 1998. 27: 158-166.

11. Satokawa H, Hoshino S, Igari T. Angioscopic external valvuloplasty in the treatment of varicose veins, Phlebology. 1997. 12: 136-141.

12. Wilkinson LS, Bunker C, Edwards JC, Scurr JH, Coleridge Smith PD. Leukocytes: Their role in the etiopathogenesis of skin damage in venous disease, J Vasc Surg. 1993. 17: 669-675.

13. Sarin S, Scurr JH, Coleridge Smith PD. Stripping of the long saphenous vein in the treatment of primary varicose veins, Br J Surg. 1994. 81: 1455-1458.

14. Dwerryhouse S et al. Stripping of the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: Five year results of a randomized trial, J Vasc Surg. 1999. 29: 589-592.

15. Jones L et al. Neovascularisation is the principal cause of varicose vein recurrence: Results of a randomised trial of stripping the long saphenous vein, Eur J Vasc Endovasc Surg. 1996. 12: 442-445.

16. Woodyer AB, Dormandy JA. Is it necessary to strip the long saphenous vein? Phlebology. 1986. 221-224.

17. Min RJ, Zimmet SE, Isaacs MN, Forrestal MD. Endovenous laser treatment of the incompetent greater saphenous vein, JVIR. 2001. 12: 1167-1171.

18. Lurie F, Creton D, Eklof B, Kabnick LS, Pichot O, Schuller-Petrovic S, Sessa C. Prospective randomized study of endovenous radiofre-quency obliteration (Closure Procedure) versus ligation and stripping in a selected patient population (EVOLVeS Study), J Vasc Surg. 2003. 38: 207-214.

19. Morrison NM. Saphenous ablation: What are the choices, laser or RF energy? Semin Vasc Surgery. March 2005.

20. Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new sclerosing foam in the treatment of varicose veins, Dermatol Surg. 2001. 27: 58-60.

20. Yamaki T, Nozaki M, Iwasaka S. Comparative study of duplex-guided foam sclerotherapy and duplex-guided liquid sclerotherapy for the treatment of superficial venous insufficiency, Dermatol Surg. 2004. May, 30(5): 718-722; discussion 722.

21. Hamel-Desnos C, Desnos P, Wollmann JC, Ouvry P, Mako S, Allaert FA. Evaluation of the efficacy of polidocanol in the form of foam compared with liquid form in sclerotherapy of the greater saphenous vein: Initial results, Dermatol Surg. 2003. Dec, 29(12): 1170-1175; discussion 1175.

22. Frullini A, Cavezzi A. Sclerosing foam in the treatment of varicose veins and telangiectases: History and analysis of safety and complications, Dermatol Surg. 2002. Jan, 28(1): 11-15.

23. Barrett JM, Allen B, Ockelford A, Goldman MP. Microfoam ultrasound-guided sclerotherapy of varicose veins in 100 legs, Dermatol Surg. 2004. Jan, 30(1): 6-12.

24. Barrett JM, Allen B, Ockelford A, Goldman MP. Microfoam ultrasound-guided sclerotherapy treatment for varicose veins in a subgroup with diameters at the junction of 10 mm or greater compared with a subgroup of less than 10 mm, Dermatol Surg. 2004. Nov, 30(11): 1386-1390.

25. Guex JJ, Allaert FA, Gillet JL, Chleir F. Immediate and midterm complications of sclerotherapy: Report of a prospective multicenter registry of 12,173 sclerotherapy sessions, Dermatol Surg. 2005. Feb, 31(2): 123-128; discussion 128.

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