Re: ‘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’

Sclerotherapy of lower limb veins: Indications, contraindications and treatment strategies to prevent complications - A consensus document of the International Union of Phlebology-2023

BACKGROUND

Sclerotherapy is a non-invasive procedure commonly used to treat superficial venous disease, vascular malformations and other ectatic vascular lesions. While extremely rare, sclerotherapy may be complicated by serious adverse events.

OBJECTIVES

To categorise contraindications to sclerotherapy based on the available scientific evidence.

METHODS

An international, multi-disciplinary panel of phlebologists reviewed the available scientific evidence and developed consensus where evidence was lacking or limited.

RESULTS

Absolute Contraindications to sclerotherapy where the risk of harm would outweigh any benefits include known hypersensitivity to sclerosing agents; acute venous thromboembolism (VTE); severe neurological or cardiac adverse events complicating a previous sclerotherapy treatment; severe acute systemic illness or infection; and critical limb ischaemia. Relative Contraindications to sclerotherapy where the potential benefits of the proposed treatment would outweigh the risk of harm or the risks may be mitigated by other measures include pregnancy, postpartum and breastfeeding; hypercoagulable states with risk of VTE; risk of neurological adverse events; risk of cardiac adverse events and poorly controlled chronic systemic illness. Conditions and circumstances where Warnings and Precautions should be considered before proceeding with sclerotherapy include risk of cutaneous necrosis or cosmetic complications such as pigmentation and telangiectatic matting; intake of medications such as the oral contraceptive and other exogenous oestrogens, disulfiram and minocycline; and psychosocial factors and psychiatric comorbidities that may increase the risk of adverse events or compromise optimal treatment outcomes.

CONCLUSIONS

Sclerotherapy can achieve safe clinical outcomes provided that (1) patient-related risk factors and in particular all material risks are (1a) adequately identified and the risk benefit ratio is clearly and openly discussed with treatment candidates within a reasonable timeframe prior to the actual procedure; (1b) when an individual is not a suitable candidate for the proposed intervention, conservative treatment options including the option of 'no intervention as a treatment option' are discussed; (1c) complex cases are referred for treatment in controlled and standardised settings and by practitioners with more expertise in the field; (1d) only suitable individuals with no absolute contraindications or those with relative contraindications where the benefits outweigh the risks are offered intervention; (1e) if proceeding with intervention, appropriate prophylactic measures and other risk-mitigating strategies are adopted and appropriate follow-up is organised; and (2) procedure-related risk factors are minimised by ensuring the treating physicians (2a) have adequate training in general phlebology with additional training in duplex ultrasound, procedural phlebology and in particular sclerotherapy; (2b) maintain their knowledge and competency over time and (2c) review and optimise their treatment strategies and techniques on a regular basis to keep up with the ongoing progress in medical technology and contemporary scientific evidence.

Klippel–Trenaunay Syndrome: Employment of a New Endovascular Treatment Technique—Mechanochemical Ablation Using the Flebogrif System

Background: Klippel–Trenaunay syndrome (KTS) is characterized by a triad of symptoms; varicose veins and venous malformations (VMs), capillary malformations (port-wine stain), and soft tissue and bone hypertrophy. Herein, we retrospectively studied six patients with KTS who underwent treatment with the Flebogrif system and evaluated their outcomes. Methods: Six KTS patients aged 16–22 years who had undergone 18 non-thermal ablations using the Flebogrif system were enrolled. All patients underwent multistage foam sclerotherapy with 3% polidocanol at 3–4-week intervals. Results: Venous clinical severity score (VCSS) analysis showed improvement in the patients’ clinical condition. All patients reported a significant improvement in aesthetic outcomes. One patient presented with recanalization of ablated marginal veins during the 24-month follow-up period. Patients could return to full activity within 7–10 days after the procedure. None of the patients experienced serious systemic complications. Conclusion: The use of the Flebogrif system in treating various forms of chronic venous insufficiency, including in patients with KTS, provides a high success rate with a high closure rate.

Is catheter-directed foam sclerotherapy more effective than the usual foam sclerotherapy for treatment of the great saphenous vein?

Objective

This retrospective study presents the long-term results of catheter-directed foam sclerotherapy of the great saphenous vein.

Method

From January 2003 to June 2017, 277 patients with varices and great saphenous vein incompetence were treated with echo-guided foam sclerotherapy. Forty-six patients were treated with long-catheters guided by foam sclerotherapy. Foaming was carried out with sodium-tetra-decyl-sulphate.

Results

Results were examined in the two groups: A (long-catheters) and B (other procedures). The median overall follow-up was 52.1 months. In the A-group, the complete occlusion rate was 34/46 pts (73.9%) and partial occlusion was 10/46 (21.7%). In the B-group, respectively, 130/231 (56.2%) and 90/231 (38.9%). Comparisons between groups were statistically significant (p = 0.023; p = 0.021). Failures involved, respectively, 2/46 (4.3%) and 11/231 (4.7%) with no statistical significance. The complication rates were similar in the two groups.

Conclusions

In this long-term experience (median follow-up exceeding four years), foam-guided sclerotherapy of the great saphenous vein with a long-catheter turned out to be more effective than the usual foam-guided sclerotherapy.

Foam sclerotherapy of segments of the saphenous vein with adjuvant hyaluronan compression

Background: Thermal, mechano-chemical and chemical methods of vein closure are increasingly less effective in saphenous veins with diameters above 10 mm. Furthermore, increasing vein size is associated with unpleasant inflammatory reactions, in particular in locations close to sensitive structures like the skin. External compression media are not able to prevent these unwanted sequela in a tolerable way. As a possible solution, perivenous hyaluronan compression was evaluated combined with microfoam sclero-therapy.

Methods: 34 patients (25 f, 9 m, 43–71 yr/o) with saphenous insufficiency (GSV), dia -meters 10.1–23.1 mm (M: 14.1 mm), distance to skin: >10 mm, received a vein lumen compression oft thigh- or calf segments by perivenous injection of a NASHA gel mediated by a coaxial paravenous catheter prior to catheter-applied microfoam sclerotherapy (aethoxysklerol 1 %). Injection of both, hyaluronan and microfoam, were performed during catheter withdrawal. The aim of hyaluronan compression was a 2/3 reduction oft the native vein cross section. For comparison, adjacent segments were compressed with common tumescent fluid. Segments for both modalities had similar diameter and were randomized. Due to department rules, the junction segment was closed with endovenous lasers to warrant elimination of reflux. No textile compression media were applied. Clinical controls including ultrasound were performed after 2, 8, 26 and 54 weeks.

Results: All treated vein segments showed total occlusion after 2 weeks (first visit). The lumen reduction was 54–81 % (M: 68.4 %) in segments with hyaluronan compression and 8–29 % (M: 19.2 %) in segments with tumes-cent fluid. Time needed for hyaluronan compression was 1.1–3.5 min (M: 2.2 min) and for tumescence 0.8–2.7 min (M: 1.8 min) per 10 cm-segment. Clinical investigations up to 8 weeks did not reveal any symptoms, visible inflammations or stainings in segments covered with hyaluronan, while tumescent-compressed segments had such findings in 20/34 cases (58.8 %). Perivenous hyaluronan did not induce any discomfort or side effects during follow-up.

Conclusions: Even large saphenous veins can be effectively and safely treated by microfoam sclerotherapy without any postinterventional symptoms when the vein lumen is reduced by perivenous injection of hyaluronan gel. However, it takes additional interventional effort to achieve this goal. Future applications could also include combinations with thermal or gluing device or support novel foams like Varithena or biomatrix sclerofoam when treating very large veins or venous aneurysms, and furthermore serve in vein shaping fort the purpose of establishing laminar flow or modifying pressure relations (venoplasty).

Results of Ultrasound-Guided Foam Sclerotherapy of the Great Saphenous Vein With New Parameters of the Technique

Aim:

To report the outcome of a series of patients with chronic venous disease due to incompetence of the great saphenous vein (GSV) managed by ultrasound-guided foam sclerotherapy (USGFS).

Design:

Controlled clinical trial with maximum 5-year follow-up of results of USGFS of the GSV with new parameters of the procedure.

Materials and Methods:

This research analyzes the results of USGFS of the GSV (395 GSV) and its tributaries in 326 patients with varicose veins of the lower extremities over the period from January 2009 to January 2014 with the following parameters of the procedure: 60° limb elevation, calf bandage, and cooled foam injection.

Results:

Ultrasound control of 395 GSV after the first injection of sclerosant from the sixth to the eighth day revealed GSV occlusion in the femoral segment with the absence of reflux in 94.9% of cases (375 GSV). After 5-year follow-up, GSV occlusion was diagnosed in 91.9% of cases.

Conclusion:

Our improved technique of foam sclerotherapy allows improving immediate and long-term results. This technique is characterized by the low incidence of side effects and complications.