Customizing foam sclerotherapy of the great saphenous vein: A proposed algorithm to enhance technical efficacy

OBJECTIVES

The catheter-directed foam sclerotherapy (FS) and the suggested perivenous tumescent application for great saphenous vein (GSV) diameter reduction are suggested to improve technical and clinical results; yet, their use is reported rather indiscriminately. Our aim is to introduce an algorithm categorising the use of technical modalities accompanying ultrasound-guided FS of the GSV and present the technical efficacy of FS through a 5 F × 11  cm sheath placed at the knee level.

METHODS

Representative cases of GSV insufficiency were chosen to describe our methodology.

RESULTS

Sole sheath-directed FS can achieve complete GSV occlusion proximally at a level comparable to the catheter-directed technique. We apply perivenous 4°C cold tumescent to GSV >6 mm even in the standing position to ensure diameter reduction of the proximal GSV as close to the saphenofemoral junction. We use long catheters only to overcome large varicosities above the knee level that could otherwise compromise the adequate foam infusion from the sheath tip. When GSV insufficiency extends along the entire limb and severe skin lesions preclude the antegrade distal catheterisation, the sheath-directed FS in the thigh can be concomitantly combined with retrograde FS from catheterisation just below the knee.

CONCLUSIONS

A topology-oriented methodology with sheath-directed FS is technically feasible and avoids indiscriminate use of more complex modalities.

Treatment for telangiectasias and reticular veins

BACKGROUND

Telangiectasias (spider veins) and reticular veins on the lower limbs are very common, increase with age, and have been found in 41% of women. The cause is unknown and the patients may be asymptomatic or can report pain, burning or itching. Treatments include sclerotherapy, laser, intense pulsed light, microphlebectomy and thermoablation, but none is established as preferable.

OBJECTIVES

To assess the effects of sclerotherapy, laser therapy, intensive pulsed light, thermocoagulation, and microphlebectomy treatments for telangiectasias and reticular veins.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, AMED and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 16 March 2021. We undertook additional searches in LILACS and IBECS databases, reference checking, and contacted specialists in the field, manufacturers and study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared treatment methods such as sclerotherapy, laser therapy, intensive pulsed light, thermocoagulation, and microphlebectomy for telangiectasias and reticular veins in the lower limb. We included studies that compared individual treatment methods against placebo, or that compared different sclerosing agents, foam or laser treatment, or that used a combination of treatment methods.

DATA COLLECTION AND ANALYSIS

Three review authors independently performed study selection, extracted data, assessed risks of bias and assessed the certainty of evidence using GRADE. The outcomes of interest were resolution or improvement (or both) of telangiectasias, adverse events (including hyperpigmentation, matting), pain, recurrence, time to resolution, and quality of life.

MAIN RESULTS

We included 3632 participants from 35 RCTs. Studies compared a variety of sclerosing agents, laser treatment and compression. No studies investigated intensive pulsed light, thermocoagulation or microphlebectomy. None of the included studies assessed recurrence or time to resolution. Overall the risk of bias of the included studies was moderate. We downgraded the certainty of evidence to moderate or low because of clinical heterogeneity and imprecision due to the wide confidence intervals (CIs) and few participants for each comparison. Any sclerosing agent versus placebo There was moderate-certainty evidence that sclerosing agents showed more resolution or improvement of telangiectasias compared to placebo (standard mean difference (SMD) 3.08, 95% CI 2.68 to 3.48; 4 studies, 613 participants/procedures), and more frequent adverse events: hyperpigmentation (risk ratio (RR) 11.88, 95% CI 4.54 to 31.09; 3 studies, 528 participants/procedures); matting (RR 4.06, 95% CI 1.28 to 12.84; 3 studies, 528 participants/procedures). There may be more pain experienced in the sclerosing-agents group compared to placebo (SMD 0.70, 95% CI 0.06 to 1.34; 1 study, 40 participants; low-certainty evidence). Polidocanol versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD 0.01, 95% CI -0.13 to 0.14; 7 studies, 852 participants/procedures), hyperpigmentation (RR 0.94, 95% CI 0.62 to 1.43; 6 studies, 819 participants/procedures), or matting (RR 0.82, 95% CI 0.52 to 1.27; 7 studies, 859 participants/procedures), but there were fewer cases of pain (SMD -0.26, 95% CI -0.44 to -0.08; 5 studies, 480 participants/procedures) in the polidocanol group. All moderate-certainty evidence. Sodium tetradecyl sulphate (STS) versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD -0.07, 95% CI -0.25 to 0.11; 4 studies, 473 participants/procedures). There was more hyperpigmentation (RR 1.71, 95% CI 1.10 to 2.64; 4 studies, 478 participants/procedures), matting (RR 2.10, 95% CI 1.14 to 3.85; 2 studies, 323 participants/procedures) and probably more pain (RR 1.49, 95% CI 0.99 to 2.25; 4 studies, 409 participants/procedures). All moderate-certainty evidence. Foam versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD 0.04, 95% CI -0.26 to 0.34; 2 studies, 187 participants/procedures); hyperpigmentation (RR 2.12, 95% CI 0.44 to 10.23; 2 studies, 187 participants/procedures) or pain (SMD -0.10, 95% CI -0.44 to 0.24; 1 study, 147 participants/procedures). There may be more matting using foam (RR 6.12, 95% CI 1.04 to 35.98; 2 studies, 187 participants/procedures). All low-certainty evidence. Laser versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD -0.09, 95% CI -0.25 to 0.07; 5 studies, 593 participants/procedures), or matting (RR 1.00, 95% CI 0.46 to 2.19; 2 studies, 162 participants/procedures), and maybe less hyperpigmentation (RR 0.57, 95% CI 0.40 to 0.80; 4 studies, 262 participants/procedures) in the laser group. All moderate-certainty evidence. High heterogeneity of the studies reporting on pain prevented pooling, and results were inconsistent (low-certainty evidence). Laser plus sclerotherapy (polidocanol) versus sclerotherapy (polidocanol) Low-certainty evidence suggests there may be more resolution or improvement (or both) of telangiectasias in the combined group (SMD 5.68, 95% CI 5.14 to 6.23; 2 studies, 710 participants), and no clear difference in hyperpigmentation (RR 0.83, 95% CI 0.35 to 1.99; 2 studies, 656 participants) or matting (RR 0.83, 95% CI 0.21 to 3.28; 2 studies, 656 participants). There may be more pain in the combined group (RR 2.44, 95% CI 1.69 to 3.55; 1 study, 596 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Small numbers of studies and participants in each comparison limited our confidence in the evidence. Sclerosing agents were more effective than placebo for resolution or improvement of telangiectasias but also caused more adverse events (moderate-certainty evidence), and may result in more pain (low-certainty evidence). There was no evidence of a benefit in resolution or improvement for any sclerosant compared to another or to laser. There may be more resolution or improvement of telangiectasias in the combined laser and polidocanol group compared to polidocanol alone (low-certainty evidence). There may be differences between treatments in adverse events and pain. Compared to other sclerosing agents polidocanol probably causes less pain; STS resulted in more hyperpigmentation, matting and probably pain; foam may cause more matting (low-certainty evidence); laser treatment may result in less hyperpigmentation (moderate-certainty evidence). Further well-designed studies are required to provide evidence for other available treatments and important outcomes (such as recurrence, time to resolution and delayed adverse events); and to improve our confidence in the identified comparisons.

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.

An Optical Method for Immediate Evaluation of Microfoam Stability in Foam Sclerotherapy

OBJECTIVES

The objective of our study was to develop an optical method that instantly evaluates the stability of sclerosing foam, which would enable early predictions of the clinical performance of the foam and reduce the occurrence of clinical side effects.

METHODS

Based on the principle of light scattering, we developed a method to optically test foam stability and verified it experimentally using sodium morrhuate (2 mL; 0.05 g/mL) and carbon dioxide. A self-made foam preparation instrument was used to achieve a preparation speed of 275 mm/s. The liquid-gas ratios were considered as 1:3, 1:4, and 1:5. Curves of illuminance with respect to the drainage rate and decay time were obtained. By fitting the curve, the relationship between foam half-life time (FHT) and foam decay was obtained. Thus, foam stability was evaluated using the initial illuminance value; the foam transfer time was approximately 3 s.

RESULTS

The experimental FHT varies between 205 and 232 s. Illuminance is exponentially related to drainage rate and linearly related with time. FHT can be expressed by the initial illuminance and illuminance curve fitting coefficients. The half-life of the foam decreases as the initial illuminance value increases, for the same sclerosing drug. The suitability of foam stability is determined by the position of the initial value in the chart.

CONCLUSION

Optical methods are feasible for evaluating foam stability over a short period of time. Clinically predicting the stability of freshly prepared foam can reduce number of incidences of further complications. This will promote the development of foam sclerotherapy and provide a basic understanding of the internal mechanical properties of foam.

Reducing hyperpigmentation after sclerotherapy: A randomized clinical trial

OBJECTIVE

Sclerotherapy for the treatment of varicose veins is one of the most common medical procedures performed in the Western world, and hyperpigmentation is one of the most frequent, dreaded, minor adverse events. There has recently been some interest in investigating the inflammatory response of the local endothelium after sclerotherapy and the possible benefits of venoactive drugs because of their pleiotropic properties. The aim of this study was to evaluate whether adding a venoactive drug (sulodexide) to the standard sclerotherapy treatment protocol for patients with varicose veins can reduce the occurrence of postsclerotherapy hyperpigmentation.

METHODS

We carried out a prospective, multicenter, randomized controlled trial with a parallel group design. It included 720 patients with telangiectasia, reticular veins, or varicose veins who were candidates for sclerotherapy. Patients with reflux in deep system or saphenous veins were excluded. Group A consisted of 354 patients who received an oral dose of sulodexide twice a day for 7 days before scheduled sclerotherapy; the treatment then continued for 3 months. Group B consisted of 366 patients who received the standard sclerotherapy protocol. Polidocanol was used as the sclerosing agent, and 20 to 30 mm Hg compression stockings were used in both groups for 7 days. Control photographs were taken, and a follow-up examination took place after 1 month and 3 months. Computer software was used to analyze the treated area for incidence of hyperpigmentation, total area of hyperpigmentation, skin tone increase in the hyperpigmented area, vein disappearance, and incidence of major bleeding. The sample size was calculated to give a statistical power of 80%. Student t-test and the χ² test were used for comparative analyses, as appropriate. The level of significance was set at P < .05.

RESULTS

A total of 609 patients completed the 3-month follow-up: 312 in group A and 297 in group B. After 1 month, the incidence of hyperpigmentation was 8.7% in group A and 14.8% in group B (P = .01). Group A developed an average area of hyperpigmentation of 10.7% compared with 18.2% in group B (P = .01), and the skin tone of the hyperpigmented area was lower in group A than in group B (P = .02). However, the latter difference was not significant after 3 months. The overall vein disappearance rate was similar in both groups.

CONCLUSIONS

Our analysis shows that by adding a venoactive drug (sulodexide) to the standard sclerotherapy protocol, the occurrence of hyperpigmentation is reduced without affecting the desired therapeutic vein elimination response.

Single Blind, Randomised Study Regarding the Treatment of the Telangiectasia of the Lower Limbs (C1EAP) Using Polidocanol 0,5%, 1%, and Nd:YAG Laser

The treatment of leg telangiectasias could be done with liquid sclerotherapy or Nd:YAG laser. We evaluated randomly, in a simple blind, the efficacy of the treatment with 0,5% polidocanol (POL-0,5), 1% polidocanol (POL-1) and Nd:YAG laser (LAS) on 132 patient (264 limbs) with telangiectasia of the lower limbs with less than 2mm diameter (C1EAP). The main objective was to evaluate the efficacy of the sclerotherapy (chemical compared with Nd:YAG-LAS). Secondary objectives were: possible major complications (deep thrombosis, severe burns, ischemic complications, etc.), the percentage of the local complications, the cosmetic aspect-evaluated by both the patient and the doctor and the grade of discomfort of the patient during and after the procedure. Comparing the treatment with Nd:YAG laser (LAS), polidecanol-0.5% (POL-0.5), polidecanol 1% (POL-1), it was noticed that telangiectasias smaller than 1mm led to good and very good results in all the cases treated with Nd:YAG laser and the same outcome was obtained in one third of the subjects treated with POL-0.5, vs. 47.81% of patients treated with POL-1. When telangiectasias were larger than 1mm diameter, good and very good results occurred in 86.36% of patients treated with LAS and 100% of the cases treated with POL-0.5 and POL-1. In conclusion, we consider that leg telangiectasias can be treated with good results using Nd:YAG laser or sclerotherapy with polidocanol, Nd:YAG laser being reccomended for telangiectasia under than 1 mm diameter while sclerotherapy in larger vessels.

Treatment of Lower Limbs Telangiectasias with Nd: Yag Laser-Prospective Study on 446 Patients

In the last two decades Nd: YAG laser has become a standard of treatment of telangiectasias of the lower limbs in C₁EAP stage of chronic venous insufficiency. This paper shows the results of a two years study period of telangiectasias of lower limbs with Nd: YAG laser conducted in a specialised centre in this type of procedures. The study group consisted of 446 patients (21 males and 425 females) with telangiectasias (C₁EAP) on the lower limbs between January 2016-December 2017. The patients had to complete a form in which they noted the initial state on a scale from 1 to 10 but also the result of the treatment and the intensity of the pain during the laser treatment. Moreover, the doctor also evaluated the results of the treatment for each and every patient taking also into account the initial phase of the disease. We observed a significant improvement of the clinical appearance (the reduction of telangiectasias) almost in the entire study group, regardless of the gender and the age, but the intensity of the pain was higher in men and in persons under the age of 30. Based on these data we can conclude that Nd: YAG laser represents a minimally invasive therapeutic option with minor side effects and major aesthetic results and furthermore it can be combined with several other methods (microsclerotherapy, radiofrequency, complex surgery) in order to improve peripheral chronic venous insufficiency.

Effect of Multiple Factors on Foam Stability in Foam Sclerotherapy

Foam sclerotherapy is a widely used treatment for varicose veins. However, complications caused by poor foam stability still remain. Most studies ignore multiple influencing factors and only study a single factor. Furthermore, a stable foam preparation using different preparation conditions has not been developed. This study aimed to explore the changing laws of foam stability under multifactorial conditions, and to determine the influence of various factors and optimal preparation conditions on the half-life of foam. A two-level orthogonal test was conducted using four factors (syringe size, surfactant, preparation temperature, and pump speed). Classifications were established as follows: syringe sizes, 2.5 mL and 5 mL; surfactant concentrations, 6% and 0%; preparation temperatures, 20 °C and 10 °C; and pump speeds, 250 mm/s and 125 mm/s, respectively. Eight experimental group (EG) multi-factor combinations were tested. Half-life and drainage time were recorded for analysis. The initial drainage time was within 200 s, but the difference between the groups was also about 200 s. The drainage rate curves of all EGs gradually increased over time. Conversely, the foam half-life extended by about 10 times for the four factors. In addition, the analyses revealed that the order of influence was surfactant >temperature >pump speed >syringe size. The most stable foam preparation was determined. Syringe size, surfactant, temperature, and pump speed had markedly observable influences on foam half-life. A combination of multiple factors can be used to prepare a more stable foam in clinical scenarios and to suitably superimpose favorable conditions to avoid unfavorable conditions.

Immediate and transient faintness following a course of foam sclerotherapy treatment for saphenous vein incompetence in an elderly patient

INTRODUCTION

Adverse effects of sclerotherapy are rare. They are divided into two categories: immediate and delayed. Immediate adverse effects are mainly represented by visual disturbances. We are reporting the case of an immediate transient faintness following two sessions of foam sclerotherapy.

OBSERVATION

An 80-year-old active female with superficial chronic venous disorder and no significant medical or surgical backgrounds experienced two similar immediate general adverse events following two sessions of sclerotherapy from a total of five. Adverse reactions included faintness, associated with headache but without visual disturbance, lasting ten minutes with full short and long-term recoveries. The common factor between those two sessions was the injection of a higher volume of sclerosing agent compared to the other sessions, 5mL of which was foam.

CONCLUSION

Age is not a contraindication of foam sclerotherapy. Nevertheless, we must proceed with caution even when moderate quantities of foam are required.