A Review of Sclerosing Foam Stability in the Treatment of Varicose Veins

Low temperature offers better foam stability

BACKGROUND

The foam's structural longevity, linked to the effectiveness of sclerotherapy, depends on preparation conditions. The factors enhancing the treatment's effectiveness and efficacy are still under discussion.

METHODS

We conducted an in vitro preclinical research, which included 144 independent trials. A total of 8 combinations involving 18 trials were designed according to settings of +4°C and room temperature (20-22°C), liquid-to-air ratios of 1/1 and 1/4, and polidocanol concentrations of 0.5% and 1% using the modified Tessari method. Our study aimed to examine the effect of air ratio, agent temperature, and polidocanol concentration on stability by assessing the foam half-time (FHT) and defining the optimal preparation conditions.

RESULTS

The mean FHT was 117 ± 30.4 s. The longest FHT was in a 1:4 air-to-sclerosant ratio at +4°C, regardless of the sclerosant concentration (for %0.5 mean FHT: 146.2 ± 13.9 s, for % 1 mean FHT: 146.9 ± 18 s). There was a significant interaction among the three variables on FHT (p = 0.001). Temperature emerged as the primary factor (F(1, 136) = 124, p < 0.001, ηp2 = 0.477), with lower temperatures markedly enhancing the longevity (p < 0.001). Preparation at a temperature of 4°C resulted in an extended FHT of 32.5 s compared to 22°C (95% CI: 24.06-41.04 s).

CONCLUSION

The temperature, agent concentration, and gas ratio significantly influence the stability of the physician-compounded foam. The low temperature at +4°C may offer better FHT for sclerotherapy.

Three-year follow-up analysis of automated microfoam preparation system for great saphenous vein incompetence and varicose veins sclerotherapy treatment

BACKGROUND

To describe the treatment of patients with great saphenous vein (GSV) incompetence and varicose veins (VVs), utilizing an Automated Microfoam Preparation System (AMPS, Varixio®, VB Devices, Barcelona, Spain).

METHODS

Adults between January and June 2021 were included. The AMPS system was used for foam preparation. Sclerotherapy treatment followed international recommendations. The primary endpoint was GSV closure rate after 36 months.

RESULTS

164 patients were enrolled. During the 7-day follow-up period, all GSVs showed complete closure, which was maintained at the 1-year mark. No major complications were reported. A cumulative complete GSV recanalization rate of 6.1% and a partial recanalization rate of 26.8% after 36 months were noted. Some patients (9.7%) required additional treatment. A higher BMI was associated with complete recanalization.

CONCLUSION

The AMPS offers an easy-to-use and standardized procedure, potentially enhancing treatment outcomes if compared with manual preparation. Caution is advised when treating obese patients.

The Effect of Pushing Rate on Foam Stability in the Tessari Method

BACKGROUND

The Tessari method is commonly used in sclerotherapy for producing foam, involving 2 syringes pushed back and forth 20 times with the use of a 3-way connector. Many factors affect the foam stability which is crucial for clinical efficacy.

OBJECTIVE

This study aimed to identify the optimal pushing rate which may impact the foam stability.

MATERIALS AND METHODS

Polidocanol (POL) solution (1% and 3%) was used to make sclerosant foam via the Tessari method, with a total of 20 pushes performed at different time durations: 10, 15, 20, 25, 30, 35, and 40 seconds. The foam stability was recorded using foam half-life time (FHT), and the pushing pressure to the syringe was recorded using a self-made electric device. Both FHT and the pressure among different groups were compared respectively.

RESULTS

The FHT was decreased as pushing duration exceeding 20 seconds in POL 1% and 15 seconds in POL 3%. Both the highest FHT and pressure point were located in the 10-second group.

CONCLUSION

It is recommended to complete 20 back-and-forth passages within 10 seconds to create stable foam.

The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine

The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the patients, interventions, comparators, and outcome system to answer critical questions. Part I discussed the role of duplex ultrasound scanning in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually noncontroversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Parts I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose veins.

Clinical efficacy comparison of sclerosing embolization with 3% polidocanol and the microsurgical subinguinal varicocelectomy in primary varicocele patients

Varicocele is a more common male genitourinary system disease with sperm quality dysfunction or discomfort. This study was aimed to compare the clinical efficacy of sclerosing embolization with 3% polidocanol and the microsurgical subinguinal varicocelectomy in treating primary varicocele. Total of 59 patients with primary varicocele receiving a 3-month postoperative follow-up were included to analyse their biochemical parameters and clinical outcomes, including the operative time, hospitalization time, postoperative recurrence rates, and complication rate. Nineteen patients were treated with sclerosing embolization with 3% polidocanol (SE group), while 40 patients were treated with microsurgical subinguinal varicocelectomy (MSV group). For the SE group, 17 patients were treated on the left side, and two patients have treated on both without recurrences and complications during the follow-up period. For the MSV group, three patients were treated bilaterally, and 36 patients were treated separately on the left side with a total 5% recurrence rate and 10% complication rate. The duration of surgery and the hospitalization time of the SE group (46.2 ± 9.79 min and 2.53 ± 0.90 days, respectively) are significantly lower than MSV group (100.5 ± 13.76 min and 3.6 ± 1.58 days, respectively), p < 0.05. The total sperm count at 3 months was significantly higher in the SE group than in the MSV group (p < 0.05). In summary, sclerosing embolization is more effective for varicocele in improving sperm quality, shortening recovery time, and reducing recurrence rates and complications.

Comparison of foaming properties between Shirasu porous glass membrane device and Tessari's three-way stopcock techniques for polidocanol and ethanolamine oleate foam production: A Benchtop Study

PURPOSE

To compare the characteristics of polidocanol (POL) and ethanolamine oleate (EO) sclerosing foams produced by a Shirasu porous glass membrane (SPGM) device with those made using a three-way stopcock (3WSC).

MATERIALS AND METHODS

Foam half-life times were measured in an ex vivo benchtop study. Computed tomography (CT) images of each foam were obtained over the time course, and CT texture analysis was conducted. Bubble size in each foam was measured by an optical microscope.

RESULTS

Median foam half-life times were longer in the SPGM group than in the 3WSC group (POL: 198 vs 166 s, p = 0.02; EO: 640 vs 391 s, p < 0.01). In CT texture analysis, median standard deviation (SD) and entropy (randomness) were lower, and median energy (uniformity) and gray-level co-occurrence matrix (GLCM) homogeneity (homogeneity) were higher in the SPGM group than in the 3WSC group (POL SD: at 30 s and 50-300 s; POL entropy: at 0-60 s; EO SD: at 0-600 s; EO entropy: at 0-460 s; POL energy: at 0-40 s; POL GLCM homogeneity: at 0-250 s; EO energy: at 0-360 s; EO GLCM homogeneity: at 0-480 s; all p < 0.05). Median bubble diameters in the SPGM group and in the 3WSC group were 69 and 83 μm (p < 0.01), respectively, in POL foam; and 36 and 36 μm (p = 0.45), respectively, in EO foam.

CONCLUSION

POL and EO foams had greater uniformity and longer foam half-life time when prepared with an SPGM device than with a 3WSC.

Ultrasound-guided foam sclerotherapy is safe and effective in the management of superficial venous insufficiency of the lower extremity

BACKGROUND

Superficial venous disease of the lower extremity has a significant impact on quality of life. Both truncal and tributary vein reflux contribute to this disease process. Endovenous foam sclerotherapy is a widely used technique throughout the world for the management of superficial venous reflux and ultrasound guidance improves its safety and efficacy.

METHODS

A PubMed search for ultrasound-guided foam sclerotherapy (UGFS) was conducted and all abstracts were reviewed to identify clinical trials and systematic reviews for a full-text analysis. Additional articles were also identified through searching the references of the selected studies.

RESULTS

The production of foam for sclerotherapy in a 1:3 or 1:4 ratio of air to sclerosant is optimal in a low silicone, low-volume syringe system. Physiologic gas may decrease any side effects, with the trade-off of decreased foam stability. Proper technique with appropriate sterility and cleansing protocols are paramount for safe and effective treatment. The technical success of UGFS for great saphenous vein disease is inferior to endothermal and surgical modalities and retreatment is more common. However, the clinical improvement in patient-reported quality of life is similar between these three modalities. When used for tributary veins in combination with endothermal approaches of the truncal veins, UGFS has high rates of success with excellent patient satisfaction. UGFS has demonstrated an excellent safety profile comparable with or superior to other modalities.

CONCLUSIONS

With proper technique, UGFS is safe and effective for the management of superficial venous disease.

The effect of the calibre and length of needle on the stability of sclerosing foam

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.

Comparison of the Safety and Efficacy of Foam Sclerotherapy With 1: 2 Polidocanol to Air Ratio Versus 1: 4 Ratio for the Treatment of Reticular Veins of the Lower Extremities

BACKGROUND

Foam sclerotherapy is a common treatment of lower extremity reticular veins. The effect of different liquid-gas ratios on foam stability and efficacy has been controversial.

OBJECTIVE

To evaluate the use of 2 different polidocanol (POL) to air ratios for the treatment of reticular veins of the lower extremities.

METHODS AND MATERIALS

Patients with lower extremity reticular veins were randomized to foam sclerotherapy with POL mixed with 4 mL of room air for one lower extremity or 2 mL for the other lower extremity. All telangiectasias were treated with glycerin immediately after treatment of the reticular veins. Adverse events (AEs) and efficacy were evaluated by both subject and blinded investigator.

RESULTS

Thirty subjects completed the study. No statistically significant difference was seen in AEs between the 2 different POL to air ratios by subject questionnaire and blinded investigator scores at all time points. Subjects and blinded investigator reported a mean improvement between 0% and 50% at Day 21 and 26% to 75% at Day 90, which was not significantly different between groups.

CONCLUSION

Two different POL to air ratios, 1:2 versus 1:4, were similarly safe and efficacious for the treatment reticular veins of the lower extremities.

The safety and efficacy of Sclerosing foam on treating venous leg ulcers: Protocol for systematic review and meta-analysis

BACKGROUND

Venous leg ulcers (VLUs) are common throughout the world, which seriously affects the patient's work and life. Relevant researches suggested that sclerosing foam (SF) has potential benefits for VLUs. However, there is no consistent conclusion. The purpose of our study is to assess whether SF is effective and safe for VLUs.

METHODS

Relevant clinical randomized controlled trials will be obtained from a search of 8 databases (with no language restrictions) from their inception to May 2020: PubMed, the Cochrane Library, EMBASE, Web of Science, China National Knowledge Infrastructure Database, Wanfang Database, China Science and Technology Journal Database, and Chinese Biological Medicine. Data will be analyzed using RevMan 5.3 after literature screening and data extraction according to predefined inclusion and exclusion criteria. Cochrane Collaboration Risk of bias Tool will be applied in evaluating the quality of enrolled articles. The primary outcome is Closure of venous leg ulcers, ulcer healing rate, adverse events related to SF. The secondary outcomes include ulcer healing time, ulcer recurrence rate, pain. Risk ratio will be used for categorical data; mean differences will be used for measurement data. Where possible and appropriate, meta-analysis will be performed for each outcome.

RESULTS

To clarify whether Sclerosing foam can be safe and efficient on treating venous leg ulcers.

CONCLUSION

Our review will provide useful information to judge whether Sclerosing Foam is an effective and safe intervention for patients with venous leg ulcers.