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Pannier F, Noppeney T, Alm J, Breu FX, Bruning G, Flessenkämper I, Gerlach H, Hartmann K, Kahle B, Kluess H, Mendoza E, Mühlberger D, Mumme A, Nüllen H, Rass K, Reich-Schupke S, Stenger D, Stücker M, Schmedt CG, Schwarz T, Tesmann J, Teßarek J, Werth S, Valesky E. S2k guidelines: diagnosis and treatment of varicose veins. DER HAUTARZT; ZEITSCHRIFT FUR DERMATOLOGIE, VENEROLOGIE, UND VERWANDTE GEBIETE 2022; 73:1-44. [PMID: 35438355 PMCID: PMC9358954 DOI: 10.1007/s00105-022-04977-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- F Pannier
- Praxis für Dermatologie und Phlebologie, Helmholtzstr. 4-6, 53123, Bonn, Germany.
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de Ávila Oliveira R, Riera R, Vasconcelos V, Baptista-Silva JC. Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev 2021; 12:CD001732. [PMID: 34883526 PMCID: PMC8660237 DOI: 10.1002/14651858.cd001732.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Varicose veins are enlarged and tortuous veins, affecting up to one-third of the world's population. They can be a cause of chronic venous insufficiency, which is characterised by oedema, pigmentation, eczema, lipodermatosclerosis, atrophie blanche, and healed or active venous ulcers. Injection sclerotherapy (liquid or foam) is widely used for treatment of varicose veins aiming to transform the varicose veins into a fibrous cord. However, there is limited evidence regarding its effectiveness and safety, especially in patients with more severe disease. This is the second update of the review first published in 2002. OBJECTIVES To assess the effectiveness and safety of injection sclerotherapy for the treatment of varicose veins. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, CINAHL, and LILACS databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registries, on 20 July 2021. SELECTION CRITERIA We included all randomised controlled trials (RCTs) (including cluster-randomised trials and first phase cross-over studies) that used injection sclerotherapy for the treatment of varicose veins. DATA COLLECTION AND ANALYSIS Two review authors independently assessed, selected and extracted data. Disagreements were cross-checked by a third review author. We used Cochrane's Risk of bias tool to assess the risk of bias. The outcomes of interest were cosmetic appearance, complications, residual varicose veins, quality of life (QoL), persistence of symptoms, and recurrent varicose veins. We calculated risk ratios (RRs) or mean difference (MD) with 95% confidence intervals (CIs). We used the worst-case-scenario for dichotomous data imputation for intention-to-treat analyses. For continuous outcomes, we used the 'last-observation-carried-forward' for data imputation if there was balanced loss to follow-up. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 23 new RCTs for this update, bringing the total to 28 studies involving 4278 participants. The studies differed in their design, and in which sclerotherapy method, agent or concentration was used. None of the included RCTs compared sclerotherapy to no intervention or to any pharmacological therapy. The certainty of the evidence was downgraded for risk of bias, low number of studies providing information for each outcome, low number of participants, clinical differences between the study participants, and wide CIs. Sclerotherapy versus placebo Foam sclerotherapy may improve cosmetic appearance as measured by IPR-V (independent photography review - visible varicose veins scores) compared to placebo (polidocanol 1%: mean difference (MD) -0.76, 95% CI -0.91 to -0.60; 2 studies, 223 participants; very low-certainty evidence); however, deep vein thrombosis (DVT) rates may be slightly increased in this intervention group (RR 5.10, 95% CI 1.30 to 20.01; 3 studies, 302 participants; very low-certainty evidence). Residual varicose vein rates may be decreased following polidocanol 1% compared to placebo (RR 0.19, 95% CI 0.13 to 0.29; 2 studies, 225 participants; very low-certainty evidence). Following polidocanol 1% use, there may be a possible improvement in QoL as assessed using the VEINES-QOL/Sym questionnaire (MD 12.41, 95% CI 9.56 to 15.26; 3 studies, 299 participants; very low-certainty evidence), and possible improvement in varicose vein symptoms as assessed using the Venous Clinical Severity Score (VCSS) (MD -3.25, 95% CI -3.90 to -2.60; 2 studies, 223 participants; low-certainty evidence). Recurrent varicose veins were not reported for this comparison. Foam sclerotherapy versus foam sclerotherapy with different concentrations Three individual RCTs reported no evidence of a difference in cosmetic appearance after comparing different concentrations of the intervention; data could not be pooled for two of the three studies (RR 1.11, 95% CI 0.84 to 1.47; 1 study, 80 participants; very low-certainty evidence). Similarly, there was no clear difference in rates of thromboembolic complications when comparing one foam concentration with another (RR 1.47, 95% CI 0.41 to 5.33; 3 studies, 371 participants; very low-certainty evidence). Three RCTs investigating higher concentrations of polidocanol foam indicated the rate of residual varicose veins may be slightly decreased in the polidocanol 3% foam group compared to 1% (RR 0.67, 95% CI 0.43 to 1.04; 3 studies, 371 participants; moderate-certainty evidence). No clear improvement in QoL was detected. Two RCTs reported improved VCSS scores with increasing concentrations of foam. Persistence of symptoms were not reported for this comparison. There was no clear difference in recurrent varicose vein rates (RR 0.91, 95% CI 0.62 to 1.32; 1 study, 148 participants; low-certainty evidence). Foam sclerotherapy versus liquid sclerotherapy One RCT reported on cosmetic appearance with no evidence of a difference between foam or liquid sclerotherapy (patient satisfaction scale MD 0.2, 95% CI -0.27 to 0.67; 1 study, 126 participants; very low-certainty evidence). None of the RCTs investigated thromboembolic complications, QoL or persistence of symptoms. Six studies individually showed there may be a benefit to polidocanol 3% foam over liquid sclerotherapy in reducing residual varicose vein rate; pooling data from two studies showed a RR of 0.51, with 95% CI 0.41 to 0.65; 203 participants; very low-certainty evidence. One study reported no clear difference in recurrent varicose vein rates when comparing sodium tetradecyl sulphate (STS) foam or liquid (RR 1.10, 95% CI 0.86 to 1.42; 1 study, 286 participants; very low-certainty evidence). Sclerotherapy versus sclerotherapy with different substances Four RCTs compared sclerotherapy versus sclerotherapy with any other substance. We were unable to combine the data due to heterogeneity or assess the certainty of the evidence due to insufficient data. AUTHORS' CONCLUSIONS There is a very low to low-certainty evidence that, compared to placebo, sclerotherapy is an effective and safe treatment for varicose veins concerning cosmetic appearance, residual varicose veins, QoL, and persistence of symptoms. Rates of DVT may be slightly increased and there were no data concerning recurrent varicose veins. There was limited or no evidence for one concentration of foam compared to another; foam compared to liquid sclerotherapy; foam compared to any other substance; or one technique compared to another. There is a need for high-quality trials using standardised sclerosant doses, with clearly defined core outcome sets, and measurement time points to increase the certainty of the evidence.
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Affiliation(s)
| | - Rachel Riera
- Cochrane Brazil Rio de Janeiro, Cochrane, Petrópolis, Brazil
| | - Vladimir Vasconcelos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Cc Baptista-Silva
- Evidence Based Medicine, Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
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Rabe E, Breu FX, Flessenkämper I, Gerlach H, Guggenbichler S, Kahle B, Murena R, Reich-Schupke S, Schwarz T, Stücker M, Valesky E, Werth S, Pannier F. Sclerotherapy in the treatment of varicose veins : S2k guideline of the Deutsche Gesellschaft für Phlebologie (DGP) in cooperation with the following societies: DDG, DGA, DGG, BVP. DER HAUTARZT 2021; 72:23-36. [PMID: 33252705 PMCID: PMC8692296 DOI: 10.1007/s00105-020-04705-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- E Rabe
- Emeritus Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Bonn (AöR), Venusberg-Campus 1, 53127, Bonn, Germany.
| | | | | | | | | | - B Kahle
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - R Murena
- Phlebologische Praxis, Köln, Germany
| | - S Reich-Schupke
- Privatpraxis für Haut- und Gefäßmedizin, Wundtherapie, Recklinghausen, Germany
| | - T Schwarz
- Praxis für Gefäßmedizin, Freiburg, Germany
| | - M Stücker
- Klinik für Dermatologie, Venerologie und Allergologie, Ruhr-Universität Bochum, St. Josef Hospital, Bochum, Germany
| | - E Valesky
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinik Frankfurt, Frankfurt, Germany
| | - S Werth
- Universitäts-Gefäßzentrum, Innere Medizin III, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - F Pannier
- Praxis Dermatologie & Phlebologie Bonn und Dermatologische Universitätsklinik Köln, Bonn, Germany
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[Guidelines for sclerotherapy of varicose veins : S2k guideline of the German Society of Phlebology (DGP) in cooperation with the following professional associations: DDG, DGA, DDG, BVP. German Version]. DER HAUTARZT 2021; 72:50-64. [PMID: 33151348 DOI: 10.1007/s00105-020-04707-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Shahat M. Catheter-directed foam sclerotherapy in chronic venous insufficiency patients with active ulcer single-center experience. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.4103/ijves.ijves_44_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Polidocanol Plus Glucose Versus Glucose Alone for the Treatment of Telangiectasias: Triple Blind, Randomised Controlled Trial (PG3T). Eur J Vasc Endovasc Surg 2020; 61:128-135. [PMID: 32778489 DOI: 10.1016/j.ejvs.2020.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 06/21/2020] [Accepted: 07/07/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to compare the effectiveness and safety of two sclerosing agents used to treat telangiectasias in the lower limbs: 0.2% polidocanol + 70% hypertonic glucose (HG) vs. 75% HG alone. METHODS A prospective, randomised, triple blind, controlled, parallel group trial with patients randomly assigned in a 1:1 ratio between January and December 2015, with a two month follow up, from a single academic medical centre in Brazil, was carried out. Participants were women aged 18-65 years with telangiectasias on the lateral aspect of one thigh, classified as C1EpAsPn who underwent sclerotherapy in a single session with 0.2% polidocanol + 70% HG or 75% HG alone to treat the telangiectasias on an area limited by a rectangular template. The primary effectiveness endpoint was elimination of 75% of the telangiectasias within 60 days vs. the pre-treatment pattern. The length of vessels was measured on images obtained before and after treatment using ImageJ software. Safety outcomes were analysed immediately, 7 days, and 60 days after the treatment, and included pigmentation. RESULTS A total of 115 patients were included, 98 of whom completed the study. Sclerotherapy with 0.2% polidocanol + 70% HG was significantly more effective than with 75% HG alone to treat telangiectasias in the target area (82.2% vs. 63.9%; p < .001); considering a minimum improvement of 75%, there was a 0.49 risk reduction (95% confidence interval 0.24-0.98; p = .047). No severe adverse events occurred in either group. Pigmentation was the most common minor adverse event and was significantly shorter in length in the group treated with 0.2% polidocanol + 70% HG (median 0 cm vs. 0.5 cm, respectively; p = .033). CONCLUSION Polidocanol 0.2% plus 70% HG had better results than 75% HG alone in sclerosing telangiectasias. No severe adverse events occurred. Pigmentation occurred in both groups and was shorter in length in the group treated with 0.2% polidocanol + 70% HG.
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Gonzalez Ochoa AJ, Carrillo J, Manríquez D, Manrique F, Vazquez AN. Reducing hyperpigmentation after sclerotherapy: A randomized clinical trial. J Vasc Surg Venous Lymphat Disord 2020; 9:154-162. [PMID: 32739509 DOI: 10.1016/j.jvsv.2020.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Alejandro Jose Gonzalez Ochoa
- HGZ 12 Instituto Mexicano del Seguro Social, San Luis Rio Colorado, Sonora, Mexico; CLINEDEM, San Luis Rio Colorado, Sonora, Mexico.
| | - Joaquín Carrillo
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Mexicali, Baja California, Mexico
| | - Diana Manríquez
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Mexicali, Baja California, Mexico
| | | | - Alejandro Nuricumbo Vazquez
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Gobierno y Municipios del Estado Baja California, Mexicali, Baja California, Mexico
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Mann MW. Sclerotherapy – How to Achieve a Spectacular Outcome. PHLEBOLOGIE 2020. [DOI: 10.1055/a-1195-4262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractWhen performed correctly, sclerotherapy results in fibrous occlusion that is not amenable to recanalization. Paramount to success is adequate contact time of a sclerosant to the endothelial cells to cause sufficient damage to the vein while minimizing side effects. To optimize sclerotherapy results, one needs to choose the right patient and the right vein and then use the proper sclerosing agent and injection techniques. This paper will review current literature on sclerotherapy, as well as tips and tricks to optimize outcome and minimize complications.
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Affiliation(s)
- Margaret W. Mann
- Department of Dermatology at Case Western Reserve University, Cleveland, OH. Innova Dermatology, Hendersonville, TN
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Elastic compression after ultrasound-guided foam sclerotherapy in overweight patients does not improve primary venous hemodynamics outcomes. J Vasc Surg Venous Lymphat Disord 2020; 8:110-117. [DOI: 10.1016/j.jvsv.2019.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/19/2019] [Indexed: 12/12/2022]
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Short Term Outcome of Adjunct Foam Sclerotherapy for Varicose Veins in Patients Subjected to RFA at Dhulikhel Hospital, Nepal. Int J Vasc Med 2019; 2019:4956437. [PMID: 31687213 PMCID: PMC6800920 DOI: 10.1155/2019/4956437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/29/2019] [Accepted: 08/10/2019] [Indexed: 11/18/2022] Open
Abstract
Background Varicose veins are dilated, tortuous, superficial veins usually seen on lower limbs. Various surgical modalities are available for varicose veins including open surgery (Trendelenburg operation), Endovenous Laser Ablation (EVLA), Radiofrequency Ablation (RFA) and Sclerotherapy. The aim of this study is to look for the outcome of adjunct sclerotherapy for varicose veins done as an adjunct with Radio Frequency Ablation. Objective To know the possible outcome regarding benefits and complications of adjunct sclerotherapy with Radio Frequency Ablation. Methodology We combined Radio Frequency Ablation of varicose veins with necessary phlebectomy and perforator ligation and performed adjunct sclerotherapy for residual significant varicosities with polidocanol (2%) mixed with 2 ml NS and 2 cc of air (Tessari method) to patients undergoing varicose vein surgery in between 2016 and 2017. Records on complications were enquired immediately following surgery and on 1st follow up done within 3-5 days of the procedure. Results Among 256 limbs subjected to varicose veins surgery 51 limbs were given adjunct sclerotherapy. Among them, five limbs had perivenous spillage with some localized swelling while there was allergic reaction in one patient as immediate postprocedural complication. Nine limbs had painful thrombosed veins during early follow-up. Conclusions Adjunct sclerotherapy showed complication rate of roughly one tenth and one fifth of the treated cases in immediate and early postoperative follow-up.
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Abstract
Objectives The aim of sclerotherapy is to induce fibrosclerosis of superficial veins. We postulated that inadvertent entry of sclerosants into deep veins can result in sclerotic occlusion, deep vein sclerosis, a non-thrombotic process distinct from spontaneous deep vein thrombosis. The aim of this study was to assess the role of d-dimer in differentiating between deep vein sclerosis and deep vein thrombosis. Methods Proximal trunks of great and small saphenous veins were treated with endovenous laser ablation. Venous tributaries and perforators were treated with foam ultrasound guided sclerotherapy. Ultrasound studies of lower limb deep veins were performed before and one week after the procedures, to detect deep vein occlusions (DVOs). d-dimer levels were measured for DVOs and long-term ultrasound studies monitored the recanalisation rates. Results In a six-year period, 9143 procedures were performed in 1325 patients for bilateral varicose veins. This included 1124 endovenous laser ablation and 8019 foam ultrasound guided sclerotherapy procedures. A total of 259 DVOs (2.83%) were identified on ultrasound which included 251 deep vein sclerosis (2.74%), seven deep vein thrombosis (0.07%) and one endovenous heat-induced thrombosis (EHIT, 0.08%). d-dimer values <0.5 µg/mL excluded deep vein thrombosis s, 0.5–1.0 µg/mL were more likely to be associated with deep vein sclerosis and >1.0 µg/mL were a more likely to be associated with deep vein thrombosis. Lower sclerosant concentrations and higher foam volumes were associated with increased risk of DVO ( p < .0001). No significant relationship was found between DVO and gender or thrombophilia. Deep vein thrombosis and EHIT cases but not deep vein sclerosis patients were anticoagulated. None had thromboembolic complications. Patients were followed up for a median of 299 days (37–1994 days). Recanalisation rates were 71.1% for deep vein sclerosis (92.3% competent) and 71.4% for deep vein thrombosis (60.0% competent). Conclusions Deep vein sclerosis is a relatively benign clinical entity distinct from deep vein thrombosis and does not require anticoagulation. Majority of affected veins on long-term follow-up regain patency and competence. d-dimer can be used to assist in differentiating deep vein sclerosis from deep vein thrombosis.
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Liu ZX, Guo PM, Zhang LL, Shi MJ, Wang RH, Meng QY. Efficacy of Endovenous Laser Treatment Combined with Sclerosing Foam in Treating Varicose Veins of the Lower Extremities. Adv Ther 2019; 36:2463-2474. [PMID: 31240628 DOI: 10.1007/s12325-019-01011-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Indexed: 01/20/2023]
Abstract
INTRODUCTION This study aims to investigate the efficacy of incision-free endovenous laser treatment (EVLT) combined with sclerosing foam in treating varicose veins of the lower extremities. METHODS A total of 140 patients (186 limbs) who underwent laser closure of the great saphenous vein + injection sclerotherapy were included in the present study. Preoperative information, intraoperative conditions, duration of the operation, and length of hospital stay were recorded in detail. During the 6-month follow-up, the closure of the trunk and branches of the great saphenous vein, postoperative pain, the recovery of ulcer and dermatitis, and postoperative complications were traced. RESULTS All patients were treated with laser closure of the great saphenous vein and lauromacrogol injection. Twenty-six stage C6 limbs (lower extremity with ulcer) healed within 6 months, and the postoperative subjective pain disappeared after 1 month. In six patients, pigmentation in the surgical site did not completely disappear at 6 months after the operation. Saphenous nerve injury was found in five patients within 3 months after the operation, and all healed at 6 months after the operation. CONCLUSION EVLT combined with sclerosing foam is effective for treating varicose great saphenous veins. TRIAL REGISTRATION This study was registered at http://www.chictr.org.cn (registration number: ChiCTR1900021409).
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Impact of Great Saphenous Vein Foam Sclerotherapy on Quality of Life and Photoplethysmography Findings in Chronic Venous Insufficiency: One-Year Follow-up. Dermatol Surg 2019; 46:369-375. [PMID: 31397782 DOI: 10.1097/dss.0000000000002063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ultrasound-guided foam sclerotherapy (UGFS) for treatment of chronic venous insufficiency (CVI) has been attracting significant interest over the past 20 years. It is a minimally invasive technique that comprises a safe treatment option and has yielded good results, especially in cases of advanced disease, with high rates of wound healing. OBJECTIVE To examine clinical, ultrasound, and photoplethysmography outcomes after a 1-year follow-up of UGFS for CVI. MATERIALS AND METHODS Twenty-nine legs classified as C4, C5, or C6 of the CEAP classification were included. Patients answered the VEINES questionnaire on quality of life and symptoms. and their venous filling time (VFT) was measured using photoplethysmography before and 45, 180, and 360 days after treatment of CVI with UGFS. RESULTS The results showed statistically significant improvements in VEINES quality-of-life and symptom scores and in VFT measured by photoplethysmography and a reduction in great saphenous vein diameter (p < .0001) at 45, 180, and 360 days after treatment with UGFS. CONCLUSION Ultrasound-guided foam sclerotherapy demonstrated efficacy and resulted in high satisfaction levels, confirmed by improvement in questionnaire scores, venous refilling time, and ultrasound findings.
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Kürşat Bozkurt A, Lawaetz M, Danielsson G, Lazaris AM, Pavlovic M, Olariu S, Rasmussen L. European College of Phlebology guideline for truncal ablation. Phlebology 2019; 35:73-83. [DOI: 10.1177/0268355519857362] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background The purpose of the guideline was to achieve consensus in the care and treatment of patients with chronic venous disease, based on current evidence. Method A systematic literature search was performed in PubMed, Embase, Cinahl, and the Cochrane library up until 1 February 2019. Additional relevant literature were added through checking of references. Level of evidence was graded through the GRADE scale and recommendations were concluded. Results For the treatment of great and small saphenous vein reflux, endovenous ablation with laser or radiofrequency was recommended in preference to surgery or foam sclerotherapy. If tributaries are to be treated it should be done in the same procedure. Treatment with mecanicochemical ablation and glue can be used but we still need long term follow up results. Conclusion For the treatment of truncal varicosities, endovenous ablation with laser or radiofrequency combined with phlebectomies is recommended before surgery or foam.
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Affiliation(s)
- A Kürşat Bozkurt
- Department of Cardiovascular Surgery, Istanbul University – Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Martin Lawaetz
- Rigshospitalet, Department of Vascular Surgery, Copenhagen, Denmark
- The Danish Vein Centers, Naestved, Denmark
| | | | - Andreas M Lazaris
- Department of Vascular Surgery, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Milos Pavlovic
- Infinity Family Medicine Clinic, Dubai, United Arab Emirates
| | - Sorin Olariu
- Victor Babes University of Medicine and Pharmacy of Timisoara
- UMFT, Surgery 1st, Timişoara, Romania
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Cuffolo G, Hardy E, Perkins J, Hands LJ. The effects of foam sclerotherapy on ulcer healing: a single-centre prospective study. Ann R Coll Surg Engl 2019; 101:285-289. [PMID: 30602297 PMCID: PMC6432956 DOI: 10.1308/rcsann.2018.0218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2018] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION This prospective study of foam sclerotherapy for varicose veins aimed to determine the outcomes of treatment including ulcer healing and complication rates in our unit. Data were collected prospectively over a 10-year period and maintained on a database by our vascular sciences unit, which performed the planning and post-treatment venous duplex scans. Patients undergoing treatment due to venous ulceration were identified from this database. An initial cohort of patients underwent a follow-up scan and assessment at one year. MATERIALS AND METHODS Patients were treated with foam sclerotherapy, in multiple sessions if required, to occlude all incompetent superficial veins greater than 3 mm in size. We used 3% sodium tetradecyl sulphate as our sclerosing agent, according to our departmental protocol, followed by a period of compression therapy. Patients underwent pre- and post-treatment scans to assess venous competence, the effects of treatment and any complications that arose. RESULTS We identified 336 patients treated for clinical, aetiological, anatomical and pathophysiological stage 5/6 venous ulceration. At six weeks post-treatment, 21% had fully healed ulcers and a further 46.1% were clinically improving with no further venous incompetence. The remainder continued treatment. An initial cohort of 162 patients was assessed at one year and 77.1% ulcers remained healed. The remainder demonstrated some venous incompetence and ultimately 12.5% required further treatment. Our complication rates were similar to those quoted in published meta-analyses including a deep vein thrombosis rate of 1.16%. CONCLUSIONS Foam sclerotherapy remains a useful treatment option for venous ulceration with a low morbidity rate.
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Affiliation(s)
- G Cuffolo
- Department of Vascular Surgery, Oxford University Hospitals, Oxford, UK
- Department of General Surgery, Wexham Park Hospital, Wexham, Slough, UK
| | - E Hardy
- Department of Vascular Surgery, Oxford University Hospitals, Oxford, UK
| | - J Perkins
- Department of Vascular Surgery, Oxford University Hospitals, Oxford, UK
| | - LJ Hands
- Department of Vascular Surgery, Oxford University Hospitals, Oxford, UK
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
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Oliveira RDÁ, Mazzucca ACP, Pachito DV, Riera R, Baptista-Silva JCDC. Evidence for varicose vein treatment: an overview of systematic reviews. SAO PAULO MED J 2018; 136:324-332. [PMID: 30020324 PMCID: PMC9881696 DOI: 10.1590/1516-3180.2018.0003240418] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/24/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Varicose veins affect nearly 30% of the world's population. This condition is a social problem and needs interventions to improve quality of life and reduce risks. Recently, new and less invasive methods for varicose vein treatment have emerged. There is a need to define the best treatment options and to reduce the risks and costs. Since there are cosmetic implications, treatments for which effectiveness remains unproven present risks to consumers and higher costs for stakeholders. These risks and costs justify conducting an overview of systematic reviews to summarize the evidence. DESIGN AND SETTING Overview of systematic reviews within the Discipline of Evidence-Based Health, at Universidade Federal de São Paulo (UNIFESP). METHODS Systematic reviews on clinical or surgical treatments for varicose veins were included, with no restrictions on language or publication date. RESULTS 51 reviews fulfilled the inclusion criteria. Outcomes and comparators were described, and a narrative review was conducted. Overall, there was no evidence that compression stockings should be recommended for patients as the initial treatment or after surgical interventions. There was low to moderate evidence that minimally invasive therapies (endovenous laser therapy, radiofrequency ablation or foam sclerotherapy) are as safe and effective as conventional surgery (ligation and stripping). Among these systematic reviews, only 18 were judged to present high quality. CONCLUSIONS There was evidence of low to moderate quality that minimally invasive treatments, including foam sclerotherapy, laser and radiofrequency therapy are comparable to conventional surgery, regarding effectiveness and safety for treatment of varicose veins.
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Affiliation(s)
- Ricardo de Ávila Oliveira
- MD, MSc. Vascular Surgeon, Adjunct Professor, Universidade Federal de Uberlândia (UFU), Uberlândia (MG), and Postgraduate Student in the Evidence-Based Health Program, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
| | - Andréa Castro Porto Mazzucca
- BSc. Pharmacist and Postgraduate Student in the Evidence-Based Health Program, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
| | - Daniela Vianna Pachito
- MD, MSc. Neurologist and Postgraduate Student in the Evidence-Based Health Program, Universidade Federal de São Paulo, (UNIFESP), São Paulo (SP), Brazil.
| | - Rachel Riera
- MD, PhD. Rheumatologist, Assistant Professor of the Discipline of Evidence-based Health, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), and Assistant Coordinator at Cochrane Brazil, São Paulo (SP), Brazil.
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Prospective Comparison of Effect of Ligation and Foam Sclerotherapy with Foam Sclerotherapy Alone for Varicose Veins. Ann Vasc Surg 2018; 49:75-79. [PMID: 29428536 DOI: 10.1016/j.avsg.2018.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 09/29/2017] [Accepted: 01/29/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND To compare the efficacy of ligation after foam sclerotherapy (FSL) with foam sclerotherapy (FS) alone for patients with varicose veins prospectively. METHODS Ninety-four patients with varicose veins underwent foam sclerothrapy alone and 88 patients with varicose veins received FSL. Patients were followed up at 1, 3, 6, and 12 months after treatment. The postoperative complications were documented prospectively. RESULTS In comparison with patients who underwent FSL, patients treated with FS only had higher incidence of phlebitis within 4 weeks (14.9% vs. 1.1%, P = 0.002) and at 6 months (10.6% vs. 0, P = 0.002) after treatment and had higher incidence of tenderness or discomfort (9.8% vs. 0, P = 0.003) and recanalization rate (8.5% vs. 1.1%, P = 0.007) at 6 months after treatment. All patients in both groups had no deep vein thrombosis and pulmonary embolism. CONCLUSIONS Patients treated with FSL have less postoperative complications than those with foam sclerotheray alone. FSL is an alternative procedure for management of patients with varicose veins. Also, a randomized prospective study is required to observe the long-term outcomes of the FSL.
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19
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Laghlam D, Hamadouche S, Dautry R, Spagnoli V. Right heart transiting thrombi caused by endovenous sclerotherapy: the treatment is not consensual. BMJ Case Rep 2017; 2017:bcr-2017-223032. [DOI: 10.1136/bcr-2017-223032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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20
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Moon KH, Dharmarajah B, Bootun R, Lim CS, Lane TRA, Moore HM, Sritharan K, Davies AH. Comparison of microbubble presence in the right heart during mechanochemical and radiofrequency ablation for varicose veins. Phlebology 2016; 32:425-432. [DOI: 10.1177/0268355516661113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective Mechanochemical ablation is a novel technique for ablation of varicose veins utilising a rotating catheter and liquid sclerosant. Mechanochemical ablation and radiofrequency ablation have no reported neurological side-effect but the rotating mechanism of mechanochemical ablation may produce microbubbles. Air emboli have been implicated as a cause of cerebrovascular events during ultrasound-guided foam sclerotherapy and microbubbles in the heart during ultrasound-guided foam sclerotherapy have been demonstrated. This study investigated the presence of microbubbles in the right heart during varicose vein ablation by mechanochemical abaltion and radiofrequency abaltion. Methods Patients undergoing great saphenous vein ablation by mechanochemical abaltion or radiofrequency ablation were recruited. During the ablative procedure, the presence of microbubbles was assessed using transthoracic echocardiogram. Offline blinded image quantification was performed using International Consensus Criteria grading guidelines. Results From 32 recruited patients, 28 data sets were analysed. Eleven underwent mechanochemical abaltion and 17 underwent radiofrequency abaltion. There were no neurological complications. In total, 39% (11/28) of patients had grade 1 or 2 microbubbles detected. Thirty-six percent (4/11) of mechanochemical abaltion patients and 29% (5/17) of radiofrequency ablation patients had microbubbles with no significant difference between the groups ( p=0.8065). Conclusion A comparable prevalence of microbubbles between mechanochemical abaltion and radiofrequency ablation both of which are lower than that previously reported for ultrasound-guided foam sclerotherapy suggests that mechanochemical abaltion may not confer the same risk of neurological events as ultrasound-guided foam sclerotherapy for treatment of varicose veins.
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Affiliation(s)
- KH Moon
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, UK
| | - B Dharmarajah
- Academic Section of Vascular Surgery & Division of Experimental Medicine, Imperial College London, UK
| | - R Bootun
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, UK
| | - CS Lim
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, UK
| | - TRA Lane
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, UK
| | - HM Moore
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, UK
| | - K Sritharan
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, UK
| | - AH Davies
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, UK
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21
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Bruijninckx CMA. Fatal pulmonary embolism following ultrasound-guided foam sclerotherapy combined with multiple microphlebectomies. Phlebology 2016; 31:449-55. [DOI: 10.1177/0268355515603873] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ambulatory ultrasound-guided foam sclerotherapy (UGFS) for refluxing saphenous veins is considered a safe therapy. Venous thromboembolic complications after UGFS as well as after all other ambulatory ablative venous interventions are rarely reported. This paper reports a fatal pulmonary embolism (PE) following UGFS in combination with an extended phlebectomy, and questions what measures should be taken to minimize the risk for thromboembolic complications after these procedures. In the reported case (unsuspected), extensive non-occluding atherosclerosis as well as obesity in combination with use of an oral contraceptive might have contributed to the development of the PE while the use of a β-blocker might have increased its fatal course considerably. Routine measurement of the ankle-brachial pressure index reduces the risk for undetected atherosclerosis. It appears that ‘in the real world’ of ambulatory phlebological treatments thromboembolic complications are more common (2.4–4.7%) and appear accompanied by post-procedural mortality. It is concluded therefore that pharmacological thromboprophylaxis appears warranted in selected cases, perhaps even routine application could be considered. Attention is drawn to the highly thrombogenic but not uncommon combination of overweight and use of oral contraceptive. Apart from applying some form of pharmacological thromboprophylaxis, technical adaptations that might prevent or reduce spill over of foam into the deep venous system should be considered. Firstly, next to adherence to the generally accepted maximum of 10 mL of foam per session, it seems prudent to maximize the injected volume of foam per site. Secondly, it seems best to inject the foam in an elevated leg without groin compression. The concentration of the sclerosant does not appear decisive in this respect, although higher concentrations appear more effective and therefore might be injected in lower volumes without compromising efficacy.
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Wittens C, Davies AH, Bækgaard N, Broholm R, Cavezzi A, Chastanet S, de Wolf M, Eggen C, Giannoukas A, Gohel M, Kakkos S, Lawson J, Noppeney T, Onida S, Pittaluga P, Thomis S, Toonder I, Vuylsteke M, Kolh P, de Borst GJ, Chakfé N, Debus S, Hinchliffe R, Koncar I, Lindholt J, de Ceniga MV, Vermassen F, Verzini F, De Maeseneer MG, Blomgren L, Hartung O, Kalodiki E, Korten E, Lugli M, Naylor R, Nicolini P, Rosales A. Editor's Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2015; 49:678-737. [PMID: 25920631 DOI: 10.1016/j.ejvs.2015.02.007] [Citation(s) in RCA: 501] [Impact Index Per Article: 55.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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de Franciscis S, Nobile C, Larosa E, Montemurro R, Serra R. Air contamination in the sclerosing foam for the treatment of varicose veins. Phlebology 2014; 31:96-100. [PMID: 25514923 DOI: 10.1177/0268355514565194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Fluids and drugs formulated for intravenous infusion may potentially promote the growth of microorganisms that can cause infections. The aim of this study is to test the sterility of sclerosing foam. METHODS Polidocanol was used for the production of the foam. The Tessari method was used in order to generate the foam. The preparation was carried out both in the operating theater and in an outpatient room. A validation test with microorganisms was also performed. RESULTS The measurements showed no evident growth of microorganisms and in the validation tests the foam appeared to even display bacteriostatic and/or bactericide properties. CONCLUSIONS Sclerosing foam seems to be safe from a microbiological point of view.
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Affiliation(s)
- S de Franciscis
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Græcia of Catanzaro, Catanzaro, Italy Department of Surgical and Medical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Cga Nobile
- Department of Health Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - E Larosa
- Department of Health Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - R Montemurro
- Department of Surgical and Medical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - R Serra
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Græcia of Catanzaro, Catanzaro, Italy Department of Surgical and Medical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
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Abstract
Objectives The aim of this paper is to look at the pros and cons of using physiologic gas to produce foam for use in sclerotherapy. With the expanding use of foam sclerotherapy, there have been increased reports of transient neurologic adverse events such as visual disturbance. Although rare, increased numbers of serious adverse events such as transient ischemic attacks (TIAs) and stroke have been described. These events are seen more often in patients who have migraine with aura and those with a right-to-left shunt. Methods A literature search of the databases Ovid and Google Scholar was performed for studies looking specifically at neurologic side effects associated with sclerotherapy and use of physiologic foams. Included studies were randomized controlled trials, meta-analyses, review articles, observational studies and case studies. Results Although physiologic gases have been shown in several studies to reduce the incidence of visual disturbance, increasing evidence from recent studies suggest endothelin, rather than gas bubbles to be the cause of these side effects. The cause of stroke and TIA has not been proven and occlusion of cerebral arterioles from gas emboli should still be considered. Many authors state that only good quality foam be injected and volumes should be kept low in an attempt to prevent these rare, but potentially serious events. Foam made with physiologic gases are more biocompatible compared to air-based foam and have been found to be at least as effective in sclerotherapy as foam made with room air. Conclusion The use of physiologic gases should be considered for those at increased risk of neurologic side effects such as migraineurs with aura and those with a known PFO. Additionally, as there are few disadvantages to the use of physiologic foam, the use of CO2 or CO2/O2 foam should be considered in all patients receiving foam sclerotherapy.
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Affiliation(s)
- M Wong
- Lakeshore Vein & Aesthetics Cinic, Kelowna, BC V1W 3S9, Canada
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25
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Sounderajah V, Moore HM, Thapar A, Lane TRA, Fox K, Franklin IJ, Davies AH. Acoustic reflectors are visible in the right heart during radiofrequency ablation of varicose veins. Phlebology 2014; 30:557-63. [DOI: 10.1177/0268355514542680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective Cerebrovascular events have been noted after foam sclerotherapy for varicose veins. One hypothesis is migration of microemboli to the brain through a cardiac septal defect. The aim of this study was to identify whether acoustic reflectors are found in the right side of the heart during radiofrequency ablation of varicose veins, as neurological events are not reported during these procedures. Methods Transthoracic echocardiography was performed during local anaesthetic radiofrequency ablation (VNUS ClosureFast) of the great saphenous vein in 14 patients. An apical view was captured at the start of the procedure, during each cycle of heating and at 1 min post-treatment. Patients were monitored for 1 h. Video loops were read by an independent cardiologist. The presence of acoustic reflectors was classified as: 0 = absent, 1 = occasional, 2 = stream, 3 = complete opacification. Results Loops were of diagnostic quality in 11/14 (79%) patients. After the second cycle of heating, acoustic reflectors moving through the right heart were seen in 5/11 (45%) patients. These were classified as grade 1 in four patients and grade 2 in one patient. No acoustic reflectors were seen in the left heart. No neurological symptoms were reported. Conclusion Acoustic reflectors in the right heart are a common finding during radiofrequency ablation of varicose veins. Considering the prevalence of cardiac septal defects (17%), more neurological events would be expected if these particles were indeed responsible for these events. Further work is required to elicit the mechanisms underlying neurological complications following sclerotherapy.
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Affiliation(s)
- V Sounderajah
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College School of Medicine, London, UK
| | - HM Moore
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College School of Medicine, London, UK
| | - A Thapar
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College School of Medicine, London, UK
| | - TRA Lane
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College School of Medicine, London, UK
| | - K Fox
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - IJ Franklin
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College School of Medicine, London, UK
| | - AH Davies
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College School of Medicine, London, UK
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Rabe E, Pannier F. Indications, contraindications and performance: European Guidelines for Sclerotherapy in Chronic Venous Disorders. Phlebology 2014; 29:26-33. [DOI: 10.1177/0268355514528127] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aim Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy. Methods This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7th – 10th May 2012 in Mainz. The conference was organized by the German Society of Phlebology. Results This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, Polidocanol (POL) and Sodium tetradecyl sulphate (STS). Other sclerosants are not discussed in detail. In this paper the recommendations concerning indications, contraindications, concentrations, volumes and technique of liquid and foam sclerotherapy of varicose veins and venous malformations are reviewed.
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Affiliation(s)
- E Rabe
- Department of Dermatology, University of Bonn, Bonn, Germany
| | - F Pannier
- Department of Dermatology, University of Cologne, Cologne & Private Practice Dermatology and Phlebology Bonn, Germany
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Gillet JL. Complications and side effects: European Guidelines for Sclerotherapy in Chronic Venous Disorders. Phlebology 2014; 29:34-38. [DOI: 10.1177/0268355514526532] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- JL Gillet
- Vascular Medicine and Phlebology, Bourgoin-Jallieu, France
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Dermody M, Schul MW, O'Donnell TF. Thromboembolic complications of endovenous thermal ablation and foam sclerotherapy in the treatment of great saphenous vein insufficiency. Phlebology 2014; 30:357-64. [PMID: 24699720 DOI: 10.1177/0268355514529948] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We assessed the incidence of venous thromboembolism following treatment of great saphenous insufficiency by endovenous thermal ablation or foam sclerotherapy using meta-analysis of published randomized controlled trials and case series. METHODS Medline, Embase, Cochrane, and Clinical Trials Registry databases were searched from January 2000 through January 2013 for randomized controlled trials and large case series employing endovenous thermal ablation or foam sclerotherapy as a single modality for the treatment of great saphenous insufficiency, with concomitant postoperative duplex scanning. Pooled (stratified) incidence of venous thromboembolism with 95% confidence intervals was estimated using the DerSimonian–Laird procedure for random effects meta-analysis. A bootstrap analysis was performed to examine between-modality differences. RESULTS Twelve randomized controlled trials and 19 case series investigating endovenous thermal ablation (radio frequency ablation with VNUS/Covidien ClosureFAST™ catheter only, endovenous laser ablation, or both) were included. Data from 12 randomized controlled trials and 6 case series investigating nonproprietary foam preparations were analyzed. Estimated incidence of venous thromboembolism was low (mostly <1%) and similar across treatment modalities and study types. CONCLUSIONS Treatment of great saphenous insufficiency by endovenous thermal ablation or foam sclerotherapy is a common vascular intervention. The stratified incidence of venous thromboembolism appears to be low as reported in both randomized controlled trials and case series investigating these modalities. Although duplex scans were obtained postoperatively, a minority of studies specified protocols for venous thromboembolism detection.
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Neto FC, de Araújo GR, Kessler IM, de Amorim RFB, Falcão DP. Treatment of severe chronic venous insufficiency with ultrasound-guided foam sclerotherapy: a two-year series in a single center in Brazil. Phlebology 2013; 30:113-8. [PMID: 24335090 DOI: 10.1177/0268355513517225] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To portray the initial experience at a public health center of the Federal District of Brazil in the treatment of chronic venous insufficiency with ultrasound-guided foam sclerotherapy in patients in advanced stages of the disease. METHOD Eighty-seven reports of patients in C5 and C6 stages, according to CEAP classification, were evaluated for clinical improvements, ulcer-healing rates, and complications of ultrasound-guided foam sclerotherapy. McNemar test was used for statistical analysis with the level of significance set at 5% (P-value, 0.05). RESULTS The results showed high rates of ulcer healing (85%) and significant improvement of symptoms after treatment, such as pain, heaviness, fatigue, burning, paresthesia, and itching (P < 0.0001). CONCLUSIONS An outpatient, low-cost and high-resolution technique, without the need for hospitalization and use of the operating room showed to be a safe and effective alternative for the treatment of varicose disease associated with severe chronic venous insufficiency.
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Affiliation(s)
- F Coelho Neto
- School of Medicine, Universidade de Brasília, Brasília, Brazil
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30
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Devereux N, Recke AL, Westermann L, Recke A, Kahle B. Catheter-directed foam sclerotherapy of great saphenous veins in combination with pre-treatment reduction of the diameter employing the principals of perivenous tumescent local anesthesia. Eur J Vasc Endovasc Surg 2013; 47:187-95. [PMID: 24268395 DOI: 10.1016/j.ejvs.2013.10.017] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 10/22/2013] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate occlusion rates of great saphenous veins (GSV) with a diameter between 5-10 mm that received a pre-treatment size reduction via perivenous tumescent application (TA) followed by catheter-directed foam sclerotherapy (CDFS). METHODS A prospective blinded randomized clinical trial comparing the occlusion rates of GSV at 1-, 6-, and 12-month follow-up. Fifty patients were included and randomized into two groups. CDFS was performed accessing the GSV at knee level and applying 8 mL of 2% polidocanol-foam (EasyFoam) while the catheter was withdrawn. Strictly perivenous TA was performed in group 1 before applying the sclerosant agent. Occlusion rates and clinical scores were assessed by blinded examiners. RESULTS After 12 months in group 1 full occlusion was achieved in 73.9%, partial occlusion in 8.7%, and 17.4% were classified as treatment failure. In group 2, 75% of the targeted GSV were fully occluded, 20% were partially occluded, and 5% were diagnosed as treatment failure. Both groups showed a significant reduction of the vein diameter. Patient's tolerance and satisfaction with the treatment was high in both groups. CONCLUSION No benefit could be found using additional TA to reduce the vein diameter before the treatment.
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Affiliation(s)
- N Devereux
- Department of Dermatology, University of Schleswig-Holstein, Campus Luebeck, Germany
| | - A L Recke
- Department of Dermatology, University of Schleswig-Holstein, Campus Luebeck, Germany
| | | | - A Recke
- Department of Dermatology, University of Schleswig-Holstein, Campus Luebeck, Germany
| | - B Kahle
- Department of Dermatology, University of Schleswig-Holstein, Campus Luebeck, Germany.
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Abstract
OBJECTIVES Documentation and analysis of adverse neurological and chest symptoms in a large single centre series of sclerotherapy treatments. METHOD In this retrospective study, patient-reported adverse events occurring during liquid or foam sclerotherapy were recorded over a 30 month period and subsequently analyzed. The relevant patient records were reviewed to determine patient characteristics, treatment details and results of subsequent investigations. RESULTS A total of 1744 ultrasound guided sclerotherapy treatments were performed during the study period. Almost all treatments were done with air-based sodium tetradecyl sulphate foam. During the same time period, 6504 direct vision surface vein sclerotherapy treatments were completed. Approximately 1/4 of these utilized air-based foam in varying concentrations. There were 14 adverse events in 14 patients involving neurological or chest symptoms for an incidence of 0.17%. Five patients injected with foam complained of isolated chest discomfort, tightness or shortness of breath. Nine patients reported various brief neurological symptoms. These events occurred with both liquid and foam, although the majority involved foam. More neurological events were associated with direct vision sclerotherapy of smaller superficial veins than with ultrasound guided injection of intrafascial truncular veins. Seven patients who experienced neurological symptoms had a history of migraine. Five of the patients who had neurological events were investigated for right to left shunts and found to be positive. CONCLUSIONS These events were uncommon and brief. The incidence of neurological and chest symptoms was higher with foam sclerotherapy than with liquid. A history of migraine with aura was associated with an increased risk of post-treatment neurological symptoms. Events occurred with both large vein and small vein treatment. Some events were associated with liquid sclerotherapy rather than foam and with carbon dioxide based foam as well as air foam. There were no long-term adverse consequences.
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Kulkarni SR, Messenger DE, Slim FJA, Emerson LG, Bulbulia RA, Whyman MR, Poskitt KR. The incidence and characterization of deep vein thrombosis following ultrasound-guided foam sclerotherapy in 1000 legs with superficial venous reflux. J Vasc Surg Venous Lymphat Disord 2013; 1:231-8. [PMID: 26992580 DOI: 10.1016/j.jvsv.2012.10.060] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 10/16/2012] [Accepted: 10/19/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The incidence of deep vein thrombosis (DVT) following ultrasound-guided foam sclerotherapy (UGFS) ranges from 0% to 5.7%. The aim of this study was to assess the incidence of DVT following UGFS in a single vascular center. METHODS Patients undergoing UGFS between December 2005 and September 2011 underwent quality control duplex imaging within 2 weeks of treatment. This was performed by an independent senior vascular technologist, and data were entered on a prospectively maintained database. Deep venous segments assessed included common femoral vein, femoral vein, above- and below-knee popliteal veins, gastrocnemius, and tibial veins. DVT when present was labeled as endovenous foam-induced thrombosis (EFIT) type 1 when thrombus was lining <25% of the lumen of the deep vein; type 2 when thrombus extension was 25% to 50%; type 3 when thrombus extension was 50% to 99%; and type 4 when the deep vein was occluded. RESULTS A total of 1166 UGFS treatments were performed in 1000 legs (776 patients). Complete occlusion of the treated veins was seen in 84.5% of the legs after one session of treatment. Overall, 17 DVTs were detected (1.5%) with no DVTs detected in legs undergoing multiple treatments. Of the 17 episodes of DVT, 16 legs had DVT following treatment for truncal reflux (658 legs; 2.43%). Seven DVTs were EFIT type 1, two were type 2, two were type 3, and five were type 4. One DVT was seen in the gastrocnemius vein alone. Two of 1166 treatments (0.2%) resulted in a symptomatic DVT, both of which were EFIT type 4. On regression analysis, there was an increase in the risk of DVT when ≥10 mL of foam was injected (odds ratio, 4.63; 95% confidence interval, 1.44-14.9; P = .01). CONCLUSIONS The incidence of duplex-detected DVT following foam sclerotherapy is low and may be associated with the injection of ≥10 mL of foam.
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Affiliation(s)
- Sachin R Kulkarni
- Department of Vascular Surgery, Cheltenham General Hospital, Cheltenham, United Kingdom
| | - David E Messenger
- Department of Vascular Surgery, Cheltenham General Hospital, Cheltenham, United Kingdom
| | - Fiona J A Slim
- Department of Vascular Surgery, Cheltenham General Hospital, Cheltenham, United Kingdom
| | - Lorraine G Emerson
- Department of Vascular Surgery, Cheltenham General Hospital, Cheltenham, United Kingdom
| | - Richard A Bulbulia
- Department of Vascular Surgery, Cheltenham General Hospital, Cheltenham, United Kingdom
| | - Mark R Whyman
- Department of Vascular Surgery, Cheltenham General Hospital, Cheltenham, United Kingdom
| | - Keith R Poskitt
- Department of Vascular Surgery, Cheltenham General Hospital, Cheltenham, United Kingdom.
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Rathbun S, Norris A, Morrison N, Gibson K, Raymond-Martimbeau P, Worthington-Kirsch R, Hohenwalter E, Lohr J, McLafferty R, Stoner J. Performance of endovenous foam sclerotherapy in the USA for the treatment of venous disorders: ACP/SVM/AVF/SIR quality improvement guidelines. Phlebology 2013; 29:76-82. [DOI: 10.1177/0268355512471920] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Objective This report summarizes the findings of the consensus panel based on the results of the comprehensive questionnaire of US American College of Phlebology annual congress attendees and results of the systematic meta-analysis of the literature and provides quality improvement guidelines for the use of endovenous foam sclerotherapy (EFS) for the treatment of venous disorders, as well as identifies areas of needed research. Methods Based on the above data, quality improvement guidelines were developed and reviewed by the ten US consensus panel members and approved by their respective societies. Results EFS is effective for the treatment of truncal and tributary varicose veins, both as primary treatment and for treatment of recurrence. It may improve the signs and symptoms associated with varicose veins including pain and swelling. EFS is contraindicated in patients who have experienced an allergic reaction to previous treatment with foam or liquid sclerosant, and in patients with acute venous thrombosis events secondary to EFS. Conclusion These guidelines for the use of EFS in the treatment of venous disorders provide an initial framework for the safe and efficacious use of this therapy, and the impetus to promote the evaluation of the questions remaining regarding the use of EFS through well-designed randomized and cohort studies.
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Affiliation(s)
- S Rathbun
- Society for Vascular Medicine, Deerfield, IL, USA
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - A Norris
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center
| | - N Morrison
- American College of Phlebology, San Leandro, CA, USA
| | - K Gibson
- American College of Phlebology, San Leandro, CA, USA
| | | | | | - E Hohenwalter
- Society for Interventional Radiology, Fairfax, VA, USA
| | - J Lohr
- American Venous Forum, Milwaukee, WI, USA
| | | | - J Stoner
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center
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Rabe E, Breu FX, Cavezzi A, Smith PC, Frullini A, Gillet JL, Guex JJ, Hamel-Desnos C, Kern P, Partsch B, Ramelet AA, Tessari L, Pannier F. European guidelines for sclerotherapy in chronic venous disorders. Phlebology 2013; 29:338-54. [DOI: 10.1177/0268355513483280] [Citation(s) in RCA: 166] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy. Methods This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7–10 May 2012 in Mainz. The conference was organized by the German Society of Phlebology. These guidelines review the present state of knowledge as reflected in published medical literature. The regulatory situation of sclerosant drugs differs from country to country but this has not been considered in this document. The recommendations of this guideline are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines. Results This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, polidocanol and sodium tetradecyl sulphate. Other sclerosants are not discussed in detail. The guideline gives recommendations concerning indications, contraindications, side-effects, concentrations, volumes, technique and efficacy of liquid and foam sclerotherapy of varicose veins and venous malformations.
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Affiliation(s)
- E Rabe
- Department of Dermatology, University of Bonn, Bonn, Germany
| | - FX Breu
- Practice for Vascular Medicine, Tegernsee, Germany
| | - A Cavezzi
- Vascular Unit, Poliambulatorio Hippocrates and Clinic Stella Maris, San Benedetto del Tronto (AP), Italy
| | | | - A Frullini
- Studio Medico Flebologico – Figline Valdarno, Florence, Italy
| | - JL Gillet
- Vascular Medicine and Phlebology, Bourgoin-Jallieu, France
| | - JJ Guex
- Cabinet de Phlébologie, Nice, France
| | - C Hamel-Desnos
- Department of Vascular Medicine, Saint Martin Private Hospital, Caen, France
| | - P Kern
- Private office Vevey, Service of Angiology, Lausanne University Hospital, Lausanne, Switzerland
| | | | - AA Ramelet
- Department of Dermatology, University of Bern, Switzerland
| | | | - F Pannier
- Department of Dermatology, University of Cologne, Cologne, Germany
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Shadid NH, van der Velden SK, van Oerle R, Ten Cate H, Sommer A, Nelemans P. In vivo effects of foam sclerotherapy on coagulation. Phlebology 2013; 29:287-92. [PMID: 23535444 DOI: 10.1177/0268355513479590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2013] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate whether foam sclerotherapy (FS) induces changes in CAT (calibrated automated thrombinography) and other coagulation parameters which could indicate an increased risk of thrombotic events. METHODS Blood samples from eight patients treated with FS were taken before treatment and 30 minutes, one and four hours and one week after treatment. CAT parameters (ETP1n, Peak1n, Lag time 1), thrombin antithrombin complexes (TAT), d-dimers, fibrinogen, Von Willebrand (vWf Ag) factor and platelet-derived microparticles (MIPAs) were measured. RESULTS Significant changes over time for Peak1n, fibrinogen, d-dimers, vWfAg and TAT complexes were observed. CAT parameters decreased over time, except for Lag time 1. D-dimers and TAT complexes increased and fibrinogen, vWf Ag, MIPA's decreased during the first hours. CONCLUSION The findings in this study support the hypothesis that FS initiate coagulation pathways, but there is no evidence that this activation results in an increased thrombosis risk.
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Affiliation(s)
- N H Shadid
- Department of Dermatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - R van Oerle
- Department of Internal Medicine, Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - H Ten Cate
- Department of Internal Medicine, Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A Sommer
- Department of Dermatology, Kolbach kliniek, Maastricht, The Netherlands
| | - P Nelemans
- Department of Epidemiology, Maastricht University Medical Center, Maastricht, The Netherlands
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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. Lasers Med Sci 2012; 28:925-33. [PMID: 22886138 DOI: 10.1007/s10103-012-1180-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 07/25/2012] [Indexed: 10/28/2022]
Abstract
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.
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