Ultrasound Monitoring During Sclerofoam Ablation Of Varicose Veins

Advent of foam sclerotherapy has added a new tool for the treatment of chronic venous insufficiency. Sclerosant agents provoke endothelial damage by several mechanisms.25 They change either the surface tension of the plasma membrane (detergents) or the intravascular pH and osmolarity. The final result is a chemical fibrosis of the treated vessel.25

Sclerosing foams (SF) are mixtures of gas with a liquid solution with surfactant properties. In 1993, Cabrera proposed the use of SF, made of sodium tetradecyl sulfate or polidocanol in the treatment of varicose veins.26 One of the intrinsic limits of liquid sclerosants in the treatment of r :

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FIGURE 23.7 Duplex examinations (longitudinal views) of the Great Saphenous vein (GSV) at the saphenofemoral junction (SFJ). A. Pretreatment scan demonstrated an incompetent SFJ after augmentation. B. Intraoperative color duplex interrogation showed successful occlusion of the GSV with a patent, 3-mm proximal stump (arrow 1) and absence of flow within the treated segment (arrow 2). (Adapted from Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: Analysis of early efficacy and complications, J Vasc Surg. 2005. Sep;42(3): 488-493.)

Sclerofoam

FIGURE 23.9 Evidence of a noncompressible GSV with thickened walls and absence of flow on color ultrasound analysis are signs of successful obliteration. (Adapted from Pichot O, Atlas of Ultrasound Images, Copyright VNUS® Closure)

Sclerofoam
FIGURE 23.8 Early post treatment duplex scanning should be performed. Evidence of a protruding thrombus from the saphenous vein into the femoral vein should be looked for. (Adapted from Pichot O, Atlas of Ultrasound Images, Copyright VNUS® Closure)

FIGURE 23.9 Evidence of a noncompressible GSV with thickened walls and absence of flow on color ultrasound analysis are signs of successful obliteration. (Adapted from Pichot O, Atlas of Ultrasound Images, Copyright VNUS® Closure)

varicose veins is dilution by the bloodstream with reduction of their efficacy.27 Also, they are rapidly cleared by the moving bloodstream. Sclerosing foams do not mix with blood and instead remain in the vessel, continuing to strip the endothelium.27 This persistence of the agent in the vessel causes an increased contact time with the intimal surface. Foam preparation is remarkably simple.27 The Tessari 3-way stop-cock method is the most commonly used.27,28

As in electromagnetic ablation, the treatment starts with clear ultrasound mapping. Varicose veins can be accessed by the placement of 25 G butterfly needle, or the Great Saphenous or the Small Saphenous vein can be directly can-nulated with an angiocath, an echogenic Cook® needle, or a 25 G butterfly.27'29-30 Most descriptions of the technique explain direct ultrasound-guided access to the saphenous vein.27,31 In contrast, we achieve a satisfactory and rapid

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