Preliminary Experience with a New Sclerosing Foam in the Treatment of Varicose Veins

A keep-it-simple embolisation approach to treat pelvic congestion syndrome without compromising clinical effectiveness

INTRODUCTION

There are two approaches to treating pelvic congestion syndrome (PCS): (i) the keep-it-simple (KIS) approach, which involves embolising only the refluxing vein(s), typically the left ovarian vein (LOV) unless the right ovarian vein (ROV) or left/right internal iliac vein (IIV) tributaries are also refluxing; and (ii) the extensive (EXT) approach, which empirically embolises almost all of the LOV, ROV, and left and right IIV tributaries. The aim of this study is to determine whether the KIS approach can effectively treat PCS while minimising the number of treated veins and coils used, without the need for injecting sclerosing agents into pelvic veins or the use of occlusion balloons.

METHODS

This is a single-institution retrospective cohort study. Our records identified 154 women who underwent venograms for possible PCS, with the intent to proceed with embolisation. Refluxing veins were treated using the KIS approach, deploying minimal number of coils, 'sandwiching' sclerosing foam. Short-term follow-up was conducted at 6 weeks; long-term follow-ups (between 12 and 60 months) were conducted via an electronic survey consisting of 19 questions assessing pelvic pain/pressure, leg and back pain, fatigue, and bladder and menstrual symptoms.

RESULTS

Fifteen women had negative venogram; 139 women had one or more refluxing veins on venogram. Most women (73%) required unilateral ovarian vein (OV) embolisation, 14% required bilateral OV embolisation, and 12% underwent pelvic vein embolisation. Most cases required only four pushable coils. Clinical success was 89% at 6 weeks and 84% at 1-5 years. A visual analogue scale reduction of 5.2 points (from 7.8 to 2.7) was achieved. There were no instances of coil dislodgement or other complications.

CONCLUSION

The keep-it-simple approach, embolising only the refluxing ovarian and/or iliac veins, can achieve a successful clinical outcome for pelvic congestion syndrome. The extensive approach of empirically embolising all ovarian veins and internal iliac veins may not be necessary. This carries implications for potential savings in procedure time, cost and radiation dose.

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.

Value of Dynamic Contrast-Enhanced (DCE) MRI in Predicting Response to Foam Sclerotherapy of Venous Malformations

BACKGROUND

Preoperative imaging assessment of venous malformations (VMs) and prediction of foam sclerotherapy efficacy might be achievable by DCE-MRI but elaborate quantitive analysis was absent.

PURPOSE

To evaluate the value of DCE-MRI in predicting the effectiveness of foam sclerotherapy in VMs.

STUDY TYPE

Retrospective.

POPULATION

Fifty-five patients (M:F = 17:38; mean age ± SD, 15.4 ± 13.0 years) with VMs.

FIELD STRENGTH/SEQUENCE

Three Tesla MRI with 3D T₁ -weighted volume interpolated body examination.

ASSESSMENT

Patients who underwent pretreatment DCE-MRI were divided into "effective" and "ineffective" groups according to the response to foam sclerotherapy. Clinical characteristics and morphologic features were assessed. The semiquantitative parameters, such as maximum intensity time ratio (MITR), enhancement ratio (ER), and Slope, were obtained from ROI and volume of interest (VOI). The quartile and mean values of these parameters were acquired from VOI, while mean values denoted as Mean^# were acquired from ROI. Establishment of two predictive models was based on ROI and VOI respectively. Model 1 was based on morphologic parameters and ROI semiquantitative parameters, while model 2 was based on morphologic parameters and VOI semiquantitative parameters.

STATISTICAL ANALYSIS

Mann-Whitney U-test, Cohen's kappa, multivariate logistic regression analysis (backward stepwise), and ROC analyses.

RESULTS

The lesion classification, presence of phlebolith, semiquantitative parameters of VOI (quartile and mean of MITR), and semiquantitative parameters of ROI (Slope_mean ^# , MITR_mean ^# ) were significantly different between two groups. Lesion classification (P = 0.002) and MITR_mean# (P = 0.027) were independent predictors for poor efficacy in model 1 as determined by multivariate binary logistic regression analysis. For model 2, lesion classification (P = 0.006) and MITR₂₅ (P = 0.001) were independent predictors. The predictive model based on VOI (AUC = 0.961) performed better than that based on ROI (AUC = 0.909) in predicting therapeutic response.

DATA CONCLUSION

DCE-MRI is promising in predicting the response to foam sclerotherapy for VMs. The whole lesion VOI-based model showed better performance and could instruct surgical approach in the future.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 4.

Foam-in-vein: A review of rheological properties and characterization methods for optimization of sclerosing foams

Varicose veins are chronic venous defects that affect >20% of the population in developed countries. Among potential treatments, sclerotherapy is one of the most commonly used. It involves endovenous injection of a surfactant solution (or foam) in varicose veins, inducing damage to the endothelial layer and subsequent vessel sclerosis. Treatments have proven to be effective in the short-term, however recurrence is reported at rates of up to 64% 5-year post-treatment. Thus, once diagnosed with varicosities there is a high probability of a permanently reduced quality of life. Recently, foam sclerotherapy has become increasingly popular over its liquid counterpart, since foams can treat larger and longer varicosities more effectively, they can be imaged using ultrasound, and require lower amounts of sclerosing agent. In order to minimize recurrence rates however, an investigation of current treatment methods should lead to more effective and long-lasting effects. The literature is populated with studies aimed at characterizing the fundamental physics of aqueous foams; nevertheless, there is a significant need for appropriate product development platforms. Despite successfully capturing the microstructural evolution of aqueous foams, the complexity of current models renders them inadequate for pharmaceutical development. This review article will focus on the physics of foams and the attempts at optimizing them for sclerotherapy. This takes the form of a discussion of the most recent numerical and experimental models, as well as an overview of clinically relevant parameters. This holistic approach could contribute to better foam characterization methods that patients may eventually derive long term benefit from.

Successful Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varices Using Foam Sclerosant Followed by Glue Embolization of Gastrorenal Shunt via the Brachial Vein Approach in a Severely Obese Patient

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.

Effects of Different Mixing Agents on the Stability of Sodium Tetradecyl Sulfate (STS) Foam: An Experimental Study

PURPOSE

To evaluate the effect of air, CO₂ and contrast medium-air on the dwell time (DT) stability of sodium tetradecyl sulfate (STS) foam.

MATERIALS AND METHODS

Three types of foam sclerosants (air-foam, CO₂-foam, contrast-air-foam) were injected eight times into an inclined straight plastic tube (internal diameters 4 mm and 10 mm) filled with a blood substitute. Injections were captured by CCD camera, and images were transferred for digital analysis and calculation of DT.

RESULTS

Contrast-air-foam and air-foam in a 4-mm tube showed 5.6-/3.3-fold greater DT compared to CO₂-foam, respectively (P = 0.001). Contrast-air-foam in a 10-mm tube showed 2.1-fold greater DT compared to CO₂-foam (P = 0.0167).

CONCLUSION

A mixture of air and iodinated contrast improves the stability of STS foam compared to mixtures using only air or CO₂. Further, animal and clinical studies are needed to validate this in vitro result.

Foam Sclerotherapy during Shunt Surgery for Portal Hypertension and Varices

Objective

This preliminary study investigated the clinical safety and efficacy of foam sclerotherapy during shunt surgery to treat portal hypertension and gastroesophageal varices.

Methods

Seven patients with confirmed portal hypertension and a variceal bleeding history underwent mesocaval shunt with simultaneous polidocanol foam injection into the varices. Computed tomography and endoscopic reviews were conducted within two weeks following the procedures and around six months later.

Results

Six patients underwent side-to-side mesocaval shunt. One received a prosthetic mesocaval shunt. Polidocanol foam was injected into the gastric varices or the inferior mesenteric vein during the surgery. Surgical success and survival was achieved in all patients. Gastric ulcer formation and thrombocytopenia occurred in one patient respectively, which were ameliorated by conservative treatment. During 12 to 24 months’ follow-up, three patients had obvious decrease or eradication of gastroesophageal varices; four patients had obvious decrease of gastric varices but residual esophageal varices; and all patents had unobstructed shunts. Encephalopathy occurred in one patient two months postoperatively. No sclerosant-related complications were observed and no postoperative recurrent variceal bleeding occurred.

Conclusions

Foam sclerotherapy during shunt surgery is safe and effective for portal hypertension and varices treatment.

Balloon-Occluded Retrograde Transvenous Obliteration for the Treatment of Gastric Varices: Polidocanol Foam Versus Liquid Ethanolamine Oleate

OBJECTIVE

The purpose of this study was to evaluate the clinical results of the management of gastric varices by balloon-occluded retrograde transvenous obliteration with polidocanol foam versus ethanolamine oleate.

MATERIALS AND METHODS

Twenty patients treated with ethanolamine oleate and 21 patients treated with polidocanol foam were enrolled in this study. Early therapeutic effects were assessed mainly by dynamic contrast-enhanced CT. Subjective symptoms, objective findings associated with the procedures, and changes in laboratory data during the obliteration process were evaluated. Rebleeding from gastric varices was assessed after the procedures.

RESULTS

Complete obliteration was confirmed in all but one case of early recanalization after treatment with polidocanol foam. One patient died of acute respiratory distress syndrome after treatment with ethanolamine oleate. The total sclerosant volume was significantly lower for 3% polidocanol foam (13.5 ± 6.8 mL) than for 5% ethanolamine oleate (30.6 ± 15.6 mL) (p < 0.01). Polidocanol foam caused fewer severe reactions, including pain, during and after injection. High body temperature, hemoglobinuria, and reactive pleural effusion were not observed with polidocanol foam. The variance in laboratory data values associated with hemolysis was significantly greater with ethanolamine oleate. No postprocedural rebleeding from the gastric varices was observed during a median follow-up time of 39.5 months after procedures with ethanolamine oleate and 34 months after procedures with polidocanol foam.

CONCLUSION

Polidocanol foam can achieve obliteration of gastric varices comparable to that of ethanolamine oleate but with a significantly lower sclerosant dose and reduced risk of hemolysis-induced complications and harmful reactions, including pain and fever.

Enhanced fluorescence emitted by microdroplets containing organic dye emulsions

In this paper, laser beam resonant interaction with pendant microdroplets that are seeded with a laser dye (Rhodamine 6G (Rh6G)) water solution or oily Vitamin A emulsion with Rhodamine 6G solution in water is investigated through fluorescence spectra analysis. The excitation is made with the second harmonic generated beam emitted by a pulsed Nd:YAG laser system at 532 nm. The pendant microdroplets containing emulsion exhibit an enhanced fluorescence signal. This effect can be explained as being due to the scattering of light by the sub-micrometric drops of oily Vitamin A in emulsion and by the spherical geometry of the pendant droplet. The droplet acts as an optical resonator amplifying the fluorescence signal with the possibility of producing lasing effect. Here, we also investigate how Rhodamine 6G concentration, pumping laser beam energies and number of pumping laser pulses influence the fluorescence behavior. The results can be useful in optical imaging, since they can lead to the use of smaller quantities of fluorescent dyes to obtain results with the same quality.

Vascular anomalies: A pictorial review of nomenclature, diagnosis and treatment

Vascular anomalies, including vascular malformations and tumors, are frequently straightforward to detect; however, accurate diagnosis and appropriate treatment are often challenging. Misdiagnosis of these lesions can lead clinicians in the wrong direction when treating these patients, which can have unfavorable results. This review presents an overview of the classification systems that have been developed for the diagnosis of vascular lesions with a focus on the imaging characteristics. Pictorial examples of each lesion on physical examination, as well as non-invasive and minimally invasive imaging are presented. An overview of the endovascular treatment of these lesions is also given. In some cases, vascular anomalies may be associated with an underlying syndrome and several of the most commonly encountered syndromes are discussed. Understanding of the classification systems, familiarity with the treatment options and knowledge of the associated syndromes are essential for all physicians working with this patient population. The approach to the described entities necessitates an organized multi-disciplinary team effort, with diagnostic imaging playing an increasingly important role in the proper diagnosis and a combined interventional radiologic and surgical treatment method showing promising results.

The use of foam sclerotherapy to treat low-flow vascular malformations of the head and neck

Liquid sclerotherapy, laser and surgery have been used in the treatment of head and neck vascular anomalies with variable success for many years. A multidisciplinary team consisting of plastic surgery, maxillofacial surgery and interventional radiology currently treats such lesions by converting liquid sclerosant into foam. Foam sclerotherapy is currently used successfully to treat varicosities of the lower limbs and in this study, we present four cases in which 3% sodium tetradecyl sulfate has been used to treat low-flow vascular malformations in the head and neck.

Vascular anomalies: classification, imaging characteristics and implications for interventional radiology treatment approaches

The term vascular anomaly represents a broad spectrum of vascular pathology, including proliferating vascular tumours and vascular malformations. While the treatment of most vascular anomalies is multifactorial, interventional radiology procedures, including embolic therapy, sclerotherapy and laser coagulation among others, are playing an increasingly important role in vascular anomaly management. This review discusses the diagnosis and treatment of common vascular malformations, with emphasis on the technique, efficacy and complications of different interventional radiology procedures.

Portal vein embolization before right hepatectomy or extended right hepatectomy using sodium tetradecyl sulfate foam: technique and initial results

PURPOSE

To evaluate the safety and efficacy of portal vein embolization (PVE) with sodium tetradecyl sulfate (STS) foam.

MATERIALS AND METHODS

A single-center retrospective review of 35 patients (27 men and 8 women; mean age, 61 y) who underwent PVE with STS foam was performed. The technical success rate, rate of PVE at producing adequate future liver remnant (FLR) hypertrophy, and rate of disease progression precluding resection after PVE were analyzed. Complications of PVE and liver resection after PVE were recorded.

RESULTS

PVE was performed on 35 patients before right hepatic resection for both primary and secondary hepatic malignancies (22 hepatocellular carcinoma, 10 metastasis, 2 cholangiocarcinoma, 1 invasive gallbladder carcinoma). Technical success was achieved in 97.1% (34 of 35) of patients. Mean FLR of the total estimated liver volume increased from 24.5% (SD, 7.7%) to 36.5% (SD, 14.5%), a mean percentage increase of 48.8% (SD, 34.3%). PVE produced adequate FLR hypertrophy in 31 of 35 patients (88.6%). Proposed right hepatectomy was subsequently performed in 27 patients (77.1%). One patient remains scheduled for surgery, two had peritoneal spread at surgery and resection was aborted, two had disease progression on imaging after PVE, and three had inadequate FLR hypertrophy with no surgery. One major complication was observed related to PVE that involved nontarget embolization to segment III, which was managed conservatively.

CONCLUSIONS

Preoperative PVE with STS foam is a safe and effective method to induce hypertrophy of the FLR.

Preparation, characterization and in vitro thrombolytic activity of a novel streptokinase foam

Vascular thrombosis is a potentially fatal disease. Thrombolysis represents an efficient therapeutic option, although it still presents intrinsic bleeding risks. In order to minimize this problem, intra-thrombus injections, alone or associated with some kind of mechanical thrombectomy, have been used. In this work, a new approach to thrombolysis is presented, where the preparation, characterization and in vitro thrombolytic activity of a novel streptokinase foam are reported. Foams were prepared by mixing albumin solution with CO2 at different volume ratios. Foam stability and apparent viscosity were the parameters used to characterize the foams. The volume ratio between CO2 and albumin solution that yielded the samples with the best properties was used to prepare the thrombolytic foams, where streptokinase was used as the thrombolytic agent. The thrombolytic effect of this foam was assessed in vitro by delivering it intra-thrombus and the results were compared with those of the foam without streptokinase as well as those of a regular streptokinase solution. Both foam stability and viscosity increased as the ratio of CO2:albumin solution increased and the 3:1 ratio was used to incorporate streptokinase. The in vitro thrombolytic activity study revealed that the streptokinase foam caused a 46.6 % of thrombus lysis after 30 min of experiment against 21 and 31 % of those of the foam without streptokinase and the regular streptokinase liquid solution, respectively. Thus, the use of CO2:albumin foam enhanced the in vitro thrombolytic effect of streptokinase, which indicates its potential as a novel vehicle for carrying and delivering streptokinase to targeted thrombi.

Foam sclerotherapy for a symptomatic hepatic cyst: a preliminary report

PURPOSE

We evaluated our initial experience of performing sclerotherapy for symptomatic hepatic cysts using polidocanol foam instead of a liquid sclerosant.

METHODS

Three consecutively registered patients with symptomatic hepatic cysts (one with polycystic liver disease) underwent polidocanol foam sclerotherapy. A pigtail catheter was inserted into the targeted cyst following percutaneous cyst puncture under ultrasound guidance, and the cyst fluid was aspirated. To confirm the absence of communications between the cyst and surrounding hepatic vessels, 3 % polidocanol foam sclerosant was injected at a 1:4 ratio of polidocanol to air following digital subtraction cystography with carbon dioxide. C-arm computed tomography (CT) guidance also was used to monitor foam filling of the targeted cyst. The maximum dose of sclerosant injected per treatment session did not exceed 10 ml. The catheter was kept unclamped overnight for open drainage, and additional sclerotherapy sessions were performed on subsequent days, if needed.

RESULTS

Efficient sclerotherapy was achieved with an average of two sessions. The initial mean cyst volume was 1,052 ml, and gradual resolution was observed without recurrence. The mean reduction rate was 97.9 % (97.7-98.3 %), and all cyst-associated symptoms disappeared. The median follow-up period was 17 (range 6-21) months. Although one patient experienced moderate-grade fever and another moderate pain at the puncture site, no major complications were observed.

CONCLUSION

Polidocanol foam sclerotherapy is a safe and effective treatment for symptomatic hepatic cysts.

A novel biomimetic analysis system for quantitative characterisation of sclerosing foams used for the treatment of varicose veins

A novel analysis system for the quantification of sclerosing foam properties under clinically relevant conditions was developed with the purpose of establishing a robust methodology for comparative characterisation of different foam formulations and production strategies. The developed biomimetic-inspired model comprised of 4 or 10 mm inner diameter polytetrafluoroethylene tubing, filled with a blood substitute and fixed to a platform with an adjustable inclination angle. Sclerosing foams were produced by mixing polidocanol with either atmospheric air or 100 % CO₂, using a double-syringe system method. Individual foams were injected into the tube, while videos were captured simultaneously. Videos were then transferred to an in-house computational foam analysis system (CFAS) which performed a sequence of semi-automated operations, allowing quantitative characterisation of sclerosing foam dynamic behaviour. Using CFAS, degradation rates of different foams were measured and the effect of gas composition, liquid sclerosant concentration and time delay between foam production and injection were evaluated.

Carbon dioxide (CO2) vs iodinated contrast digital subtraction angiography during balloon-occluded retrograde transvenous obliteration (BRTO) using foam sclerosant for gastric varices

PURPOSE

To compare the visualization of the target gastric varices (GV) on balloon-occluded retrograde transvenous venography (BRTV) using iodinated contrast material vs carbon dioxide (CO(2)) in preparation for subsequent balloon-occluded retrograde transvenous obliteration (BRTO) using foam sclerotherapy.

MATERIALS AND METHODS

In 16 consecutive patients with nonruptured GV, BRTV was performed first using iodinated contrast material and then with CO(2). BRTV was repeated whenever there were changes in the catheter or patient position or when coil embolization of collaterals was needed. Each visualization grade of GV (grade 1 = GV only; grade 2 = GV > collaterals; 3 = GV < collaterals; grades 4-5 = collaterals only) was determined by two observers in consensus. During foam BRTO, the GV visualization grade was recorded again and confirmed by C-arm computed tomography (CT).

RESULTS

In 38 pairs of BRTV, GV grades were significantly (P < .0001) lower (ie, favoring BRTO) on CO(2) BRTV (mean ± standard deviation, 1.8 ± 0.8) than on iodine BRTV (3.4 ± 0.8). GV grades on foam BRTO (1.4 ± 0.7) were similar to the grades obtained on the most recent CO(2) BRTV (1.3 ± 0.5) but were significantly smaller (P < .0001) than on iodinated BRTV (3.1 ± 0.9). GV were opacified by foam on initial C-arm CT in 14 patients (87.5%), and complete thrombosis of GV was obtained without any complication in all 16 patients (100%). CO(2) reached the GV even when iodinated contrast material could not (grade 4) in seven of our 16 patients (43.8%), leading to successful BRTO.

CONCLUSIONS

CO(2) BRTV visualized GV better than did iodine BRTV and changed the management of more than 40% of patients by enabling successful foam BRTO in patients in which conventional liquid BRTO could not be performed.

Fluoroscopic-guided approaches to radiofrequency vein ablation

PURPOSE

Ultrasound-guided antegrade access during endovenous lower-extremity vein ablation may be problematic. This study describes fluoroscopic-guided retrograde access to the target veins in cases in which antegrade access proved unfeasible.

MATERIALS AND METHODS

The retrograde technique was used to treat a total of 38 legs in 33 patients in whom antegrade access failed. This approach was selected because of small caliber or spasm of the proximal (ie, lower) great saphenous vein (GSV; n = 22), proximal (ie, lower) GSV spasm during access (n = 2), previous incomplete vein ablation (n = 7), skin disease over the proximal GSV (n = 6), and tortuous proximal GSV anatomy (n = 1). Thirty-two legs were treated with an ipsilateral retrograde approach and six were treated with a contralateral retrograde approach. Radiofrequency ablation with or without sclerotherapy was then performed.

RESULTS

The technical success rate for retrograde access and subsequent ablation was 100%. No procedural complications occurred. At 1 month, five patients with active ulcers exhibited ulcer healing (100%).

CONCLUSIONS

The fluoroscopic retrograde approach can be used to treat GSV reflux when traditional antegrade access is not feasible.

Balloon-occluded retrograde transvenous obliteration of gastric varices: use of CT-guided foam sclerotherapy to optimize technique

OBJECTIVE

Balloon-occluded retrograde transvenous obliteration has been traditionally based on liquid sclerotherapy. However, overdose and systemic spillage of liquid sclerosant can cause severe complications, such as hemolysis, which lead to hemoglobinuria, allergy, acute respiratory distress syndrome, and other disorders. The purpose of this study was to evaluate the performance of foam sclerotherapy with C-arm CT guidance to reduce the amount of sclerosant and to optimize the safety of balloon-occluded retrograde transvenous obliteration while preserving its efficacy.

MATERIALS AND METHODS

Twenty consecutively registered patients with gastric varices underwent balloon-occluded retrograde transvenous obliteration with polidocanol foam. C-arm CT guidance was used to confirm gas filling of the target vessels. In this retrospective analysis of a prospectively encoded database, total net doses of polidocanol used for transvenous obliteration and of contrast medium used for venography before transvenous obliteration were compared, and subsequent complications, including hemoglobinuria, were documented.

RESULTS

In all patients, foam was observed in the target vessels at C-arm CT. The mean dose of polidocanol used for balloon-occluded retrograde transvenous obliteration (3.9 ± 1.5 mL) was significantly smaller (p < 0.001) than the dose of contrast medium used for venography (16.4 ± 7.9 mL). Hemoglobinuria was found in only one patient. Except in one instance of recanalization, full variceal thrombosis was confirmed at contrast-enhanced CT 1 week after transvenous obliteration (success rate, 95%). In one patient, air migrated into the liver during transvenous obliteration but was spontaneously absorbed. No serious complication occurred.

CONCLUSION

Balloon-occluded retrograde transvenous obliteration with polidocanol foam under C-arm CT guidance allowed significant reduction of sclerosant dose and resulted in a low complication rate while a high technical success rate and efficacy were maintained.

Hepatic embolotherapy in interventional oncology: technology, techniques, and applications

Embolotherapy continues to play a growing role in the management of primary and secondary hepatic malignancies. In this review article, we examine the basis of therapy with a focus on neovascularization, which makes treatments via the hepatic artery possible. An overview of the three generations of embolic and therapeutic agents follows. The techniques, technologies, and complications of bland embolization, transarterial chemoembolization, drug-eluting beads, and selective internal radiotherapy are covered to give the reader an overview of this exciting field in interventional radiology.

Optimal and safe treatment of spider leg veins measuring less than 1.5 mm on skin type IV patients, using repeated low-fluence Nd:YAG laser pulses after polidocanol injection

Treatment of micro-veins of less than 1.5 mm with laser and with chemical sclerosis is technically challenging because of their difficulty to remedy. Laser treatment is even more difficult when dark phototypes are involved.Three groups of 30 patients each, skin type IV, and vessels measuring less than 1.5 mm in diameter, were enrolled for two treatment sessions 8 weeks apart: group A, polidocanol (POL) micro-foam injection; group B, Nd:YAG laser alone; and group C, laser after POL injection. Repeated 8-Hz low-fluence pulses, moving the hand piece over a 3-cm vein segment with an average of five laser passes maximum and with a total time irradiation of 1 s were used. Sixteen weeks after the second treatment, statistically, degree of clearance after examining photographs and patients satisfaction index, plotted on a visual analogue scale and comparing results of all three groups, results were significantly better for group C (p<0.0001). No significant differences in complications were noticed between the three groups. Efficacy of combining POL and laser proved safe and satisfactory in 96 % of patients using low-fluence laser pulses with a total cumulative energy in the 3 cm venous segment, lower than that of conventional treatment. Very few and transient complications were observed. POL foam injection followed by laser pulses is safe and efficient for vein treatment in dark-skinned patients.

[Foam sclerotherapy. Uses and indications in dermatology and phlebology]

Foam sclerotherapy is a minimally invasive, effective technique for the treatment of varicoses up though venous malformations. This efficient therapy can be easily integrated in daily clinical practice and shows only minor side effects. It provides an alternative to invasive therapies like vein stripping, endovenous laser therapy or endovenous radiofrequency ablation, but without the need for anesthesia. The treatment can be performed in an outpatient setting and the patient is able to return quickly to everyday life.

Use of three-dimensional MRI-angiography in preoperative evaluation and postoperative management of hemangiomas of head and neck region

Hemangiomas (proliferating endothelial tumors) are the most common benign tumors of infancy. Most often hemangiomas are self-regressing lesions without any treatment. Approximately 10% of hemangiomas cause complications such as major ulceration/destruction, distortion of involved tissues, and obstruction of a vital structure. When the situation becomes complicated, there are different treatment alternatives, ranging from systemic or local corticosteroid use to surgery. Sclerotherapy using intralesional polidocanol (Aethoxysklerol) injection may be used before surgery to decrease blood loss or when a vital structure of the face is in danger because of sudden increase in size of a surrounding hemangioma. Before any kind of treatment for both hemangiomas and vascular malformations, preoperative diagnosis and anatomic position of the lesion must be documented thoroughly. With the help of magnetic resonance imaging, tridimensional vascular pattern of such lesions can be shown successfully. We used three-dimensional contrast-enhanced time-resolved magnetic resonance angiography to detect the changes of lesions for 2 children who have large hemangiomas on their faces, before and after sclerotherapy with polidocanol injection. The findings of three-dimensional magnetic resonance imaging studies help to better assess the success rate of treatment not only for us as the physicians but also for the parents of these children who cannot understand anything with standard two-dimensional radiologic imaging.

Varicose vein: current management

The continued advancement of RFA and EVLS technology should provide for an increased safety profile and lasting efficacy for treating the major saphenous veins. The challenge lies in determining what type of patient comorbidities and anatomic variability result in higher recurrences after endothermal varicose vein treatment so that one can modify the choice of treatment appropriately. Further standardization of the FS technique may allow for its wider use in treating truncal varicosities. The powered phlebectomy system seems to be suited for isolated branch varicosities, but the sequelae of pain and ecchymosis may prevent it from becoming a mainstream treatment with stab phlebectomy and sclerotherapy as alternatives.

Retrospective analysis of facial paralysis caused by ethanol sclerotherapy for facial venous malformation

BACKGROUND

Absolute ethanol sclerotherapy provides a reliable treatment for facial venous malformation, although facial nerve injury may occur after sclerotherapy. This study is a retrospective review of facial nerve dysfunction after sclerotherapy.

METHODS

A total of 91 patients with facial venous malformations accepted 288 ethanol sclerotherapy sessions. The facial nerve dysfunctions caused by the therapy were evaluated and analyzed.

RESULTS

There were 9 instances of facial nerve injury. For 18 sessions of sclerotherapy in the temporal region, 5.6% of patients experienced injury to the temporal branch; for 12 sessions in the zygomatic region, 41.7% of patients experienced injury to the zygomatic branch. After patients were treated with medication, 8 of 9 instances of nerve injury recovered.

CONCLUSIONS

The zygomatic and temporal branches of the facial nerve were the most vulnerable to injury after ethanol sclerotherapy. Surgeons are thus called on to pay more attention when performing ethanol sclerotherapy in those areas.

Safety and effectiveness of transcatheter foam sclerotherapy for testicular varicocele with a fluoroscopic tracing technique

PURPOSE

To evaluate the safety and effectiveness of percutaneous sodium morrhuate foam sclerotherapy of varicoceles with the use of fluoroscopic tracing technique.

MATERIALS AND METHODS

At baseline and at 6-month follow-up, 58 patients with grade II/III left varicocele (mean age, 21.1 years; range, 19-25 y) with abnormal semen parameters underwent clinical assessment, Doppler ultrasonography, and semen analysis between September 2002 and January 2007. In all 58 cases, selective catheterization of the spermatic vein was performed with a right transfemoral approach. The standardized sclerosing foam was prepared with the Tessari method. Foam sclerotherapy was performed by the "filling-defects technique" under fluoroscopic guidance, with the sclerosing foam visualized as translucent filling defects in the internal spermatic vein filled with contrast medium during injection of the foam.

RESULTS

Technical success was achieved in all patients. Sodium morrhuate foam dose ranged from 2 mL to 8 mL (0.4-1.6 mL of solution) per patient, with an average dose of 5.3 mL (approximately 1.1 mL of solution). There were no major side effects or complications of the procedure. At 6-month follow-up, 53 of 58 patients (91.4%) reported disappearance of previous varicoceles and five had slight, asymptomatic residual varicoceles. Seminal parameters showed significant increases after treatment. No major complications occurred, and no recurrent/persistent varicoceles were found.

CONCLUSIONS

Fluoroscopy-guided transcatheter foam sclerotherapy is a safe and effective approach for varicoceles, and the filling-defects technique under fluoroscopy is a feasible method for tracing the sclerosing foam.

Endovenous therapy for the treatment of congenital venous malformations

The treatment of a congenital venous malformation using endovenous radiofrequency ablation in a patient is described. The patient initially underwent two treatments of foam sclerotherapy with moderate success. Later the main feeding vessel of the venous malformation became evident on examination with venous duplex and was identified as the great saphenous vein. At this point, endovenous radiofrequency ablation was used to ablate the feeding vessel and successfully treat the lesion. The procedure proceeded without complications, and the patient made a good recovery. It is recommended that patients presenting with such malformations be considered for endovenous therapy as early as possible.

Male varicocele: transcatheter foam sclerotherapy with sodium tetradecyl sulfate--outcome in 244 patients

PURPOSE

To retrospectively evaluate the recurrence rate, resolution of pain, improvement of semen parameters, and achievement of pregnancy after transcatheter foam sclerotherapy (TCFS) in varicocele by using sodium tetradecyl sulfate (STS) foam.

MATERIALS AND METHODS

The institutional review board approved the study; informed consent was waived. A retrospective study was conducted in 244 consecutive male patients (mean age, 28.2 years; range, 17-42 years) with 280 varicoceles treated with TCFS between January 2000 and January 2004. The gonadal vein was selectively catheterized by using left antecubital transbrachial venous access; a foam of 3% STS and air was injected. Follow-up was performed with physical and Doppler ultrasonographic examinations and by using a questionnaire-based assessment of pain and pregnancy. Semen analysis was performed according to World Health Organization guidelines. Significant differences in semen parameters before and after treatment were determined by using the Wilcoxon signed rank test.

RESULTS

Technical success rate was 97.1% (272 varicoceles). Complete follow-up results (mean, 40.3 months +/- 19.46 [standard deviation]) in 225 varicoceles (80.4%) revealed eight (3.6%) grade II-III recurrent varicoceles and resolution of pain in 164 (96.5%) of 170 cases. Statistically significant improvement of all semen parameters was achieved in infertile patients after treatment (P < .001). Of 59 patients with pretreatment sperm alterations who desired pregnancy, 23 (39.0%) achieved pregnancy (mean follow-up, 28.6 months +/- 7.77).

CONCLUSION

TCFS in male varicocele with 3% STS foam was associated with a low recurrence rate, a high rate of pain resolution, and a significant improvement of pretreatment sperm parameter alterations; a substantial increase in pregnancy achievement was obtained for patients with pretreatment sperm alterations who desired pregnancy.

Single-center experience with foam sclerotherapy without ultrasound guidance for treatment of varicose veins

BACKGROUND

Varicose veins are a common disorder and many treatment methods are available.

OBJECTIVE

The aim of this study was to evaluate the short-term efficacy of foam sclerotherapy and the safety of performing the treatment in an outpatient clinic without ultrasound guidance. METHODS This was a prospective, nonrandomized study with foam sclerotherapy. All the patients were assessed before and after the procedure with a CEAP (Clinical, Etiology, Anatomy, Pathology) class and clinical score. At the same visit, duplex scanning was performed to evaluate the anatomic distribution of the varicose disease. The mean age of the patients was 49.2 years (SD,+/-10.6 years; median, 50.0 years). Altogether 41% of the legs had undergone a previous operation and 24% were recurrences. The follow-up time was 3 months.

RESULTS

Twenty-five patients with 27 legs were treated successfully using foam sclerotherapy without ultrasound guidance. Twenty-one cases (78%) involved the great saphenous vein and 6 cases (22%) involved the small saphenous vein. The mean bandage time was 7.7 days (SD,+/-2.50 days; median, 8.50 days). The CEAP score decreased 73% after the procedure from 2.61 (SD,+/-0.80; median, 2.0) to 0.71 (SD,+/-0.95; median, 0; p<.001). and the mean clinical score decreased 45% from 4.45 (SD,+/-1.96; median, 4.0) to 2.46 (SD,+/-1.50; median, 2.0; p<.001), respectively. Three months after the treatment, duplex scanning showed saphenofemoral reflux in 63% of the legs and saphenopopliteal reflux in 40% of the legs. The most common complication was postoperative thrombophlebitis (66%). Other minor complications included pain (38%) and hematoma (4%). There were no major complications. Subjectively, 71% of the patients assessed the procedure as good or excellent and 29% as acceptable or poor.

CONCLUSION

Foam sclerotherapy is also an effective and safe procedure when performed without duplex guidance. Thrombophlebitis is frequent when using a high concentration of polidocanol and a short bandage time. The high frequency of saphenofemoral and saphenopopliteal junction reflux after the procedure can have a negative effect on the long-term results.

Foam sclerotherapy — A possible option in therapy of varicose veins

The therapy of varicose veins is multimodal and depends on the individual clinical findings. In addition to compression therapy, invasive approaches for elimination of reflux for the treatment of varicose veins are available, such as surgical and interventional methods and sclerotherapy. The administration of a sclerosing agent into a varicose vein results in an occlusion of the treated vein. Recently the use of foam sclerotherapy had a renaissance. Several studies have documented the efficacy of foam sclerotherapy in selected patients. The possibility of treating patients in an outpatient setting, with low costs and rapidly, makes foam sclerotherapy very attractive compared to invasive and minimally invasive methods. However long-term follow-ups in properly controlled randomized trials are needed before foam sclerotherapy can be recommended as a routine procedure. This paper introduces the method and the treatment possibilities with foam sclerotherapy in chronic venous insufficiency.

Échosclérothérapie à la mousse par ponction-injection directe à l’aiguille : technique et doses

Foam echosclerotherapy by puncture - direct injection (EMPID) is a technique approved by the French Health Authorities for the management of varicose veins. It combines two principles: the injection of a sclerosing agent by echomonitored direct puncture and the use of this sclerosing agent as a foam. The procedure consists of four stages: targeting of the vein to sclerose and selection of the puncture site, venous puncture under echographic guiding, injection of the sclerosing product under complete echographic monitoring, and post-injection control, checking for the impact of the action and the distribution of the foam in the treated vein. First intention indications concern essentially isolated troncular reflux in lesser and great saphena veins and varicose recurrences. In second intention, EMPID is also an alternative to conventional varicose resection surgery. Emphasizing the principle of precaution, we underline the usefulness of a fine, extemporaneous, standardized and reproducible microfoam - high doses, in particular large volumes of foam, are unwarranted since it has been proven that small volumes are as effective. The recommended concentrations are directly linked to the maximal diameter of the saphena trunks targeted. The volume of foam to be injected must be determined on an individual basis and depends on the presence or not of post-injection spasm, the degree of venous filling and the endothelial impregnation of the treated varicosity (which can be easily monitored because of the spontaneous visualization of the foam producing a tracing effect on the ultrasound); it should not exceed 7.5 ml per session. Apart from the classical side effects due to the liquid form, the foam presents its own, very rare, side effects consisting of minor, constantly and spontaneously reversible, eye disorders. The foam is contraindicated for patients suffering from migraine due to higher incidence of such visual disorders. EMPID is an outpatient procedure for the treatment of varicosities which requires considerable operator skill. This technique cannot be proposed on a large scale without proper and specific training.

Effectiveness and Safety of Ultrasound-Guided Foam Sclerotherapy for Recurrent Varicose Veins:Immediate Results

PURPOSE

To evaluate the effectiveness and safety of ultrasound-guided foam sclerotherapy in treating recurrent varicose veins.

METHODS

Between July 2003 and January 2005, 38 outpatients (25 women; median age 59 years, interquartile range 53.5-66.0) with recurrent varicose veins in 45 legs were treated. Ultrasound was used to identify sites of reflux. The Tessari method was used to produce foam using 3% sodium tetradecyl sulphate; up to 6 mL of foam was injected per session under ultrasound control. Results are shown as median (interquartile range).

RESULTS

A single sclerotherapy session was adequate in 26 (58%) legs. In 87% of all legs, complete elimination of both varicose veins and all reflux points was achieved. A positive association between the amount of injected foam and CEAP class (r=0.45, p=0.002) and venous clinical severity score (r=0.37, p=0.012) was found. There was a trend for more sclerotherapy sessions [median 2 (1-2)] in legs with incomplete saphenofemoral junction/ great saphenous vein (GSV) ligation or accessory GSV (n=16) to achieve varicose vein ablation versus legs with other primary sites of reflux [median 1 (1-2), p=0.12]. There were no instances of deep vein thrombosis or systemic complications; superficial thrombophlebitis occurred in 6 (8.2%) of the 73 injection sessions. Legs with proximal reflux due to previous incomplete ligation or fed by an incompetent pelvic vein experienced superficial thrombophlebitis more frequently (4/12, 33%) than legs without proximal reflux [1/33 (3%); OR 16, 95% CI 1.6-164, p=0.014].

CONCLUSION

In most patients, ultrasound-guided foam sclerotherapy is a safe treatment for recurrent varicose veins, with an excellent immediate result. However, the presence of proximal reflux may decrease the immediate results and predispose to superficial thrombophlebitis.

Sclerotherapy basics

Sclerotherapy involves the injection of a fluid into blood vessels to eradicate them. A thorough understanding of the basics of sclerotherapy are important when beginning sclerotherapy procedures in practice. This article reviews the essential information of sclerosants, treatment of small vessel disease, and patient management.

Sclerotherapy treatment of telangiectasias and varicose veins

Telangiectasias and/or varicose veins are present in about 33% of adult women and 15% of adult men. Although they may be only of cosmetic concern, superficial varices often cause significant symptoms such as pain, aching, heaviness, and pruritus. Venous ulceration is commonly caused solely by superficial venous insufficiency. Superficial thin-walled veins may rupture and hemorrhage. Sclerotherapy is a nonsurgical procedure that can be used to treat both small and large varices of the superficial venous system and perforators. This involves injecting a sclerosant intraluminally to cause fibrosis and eventual obliteration of a vein. The most common sclerosants used in the U.S. include sodium tetradecyl sulfate, polidocanol, 23.4% saline, and a combination of 25% dextrose with 10% saline. Treatment generally proceeds from proximal to distal and largest to smallest vein, based on a reflux map developed from physical examination, Doppler, and duplex ultrasound. Sclerotherapy results can be optimized and the risk of complications minimized by choosing the proper sclerosant, sclerosant concentration, sclerosant volume, and injection sites for the vein(s) being treated. Post-treatment instructions, particularly compression and ambulation, are designed to improve the results and safety of sclerotherapy. Adequate understanding of an appropriate history and physical, ultrasound evaluation, anatomy, pathophysiology, knowledge of sclerosing solutions, patient selection, and post-treatment care, as well as the ability to prevent, recognize, and treat complications are required before embarking on treatment.