French sclerotherapy and compression: Practice patterns

Based on the recommendations of experts, and supported by a low level of proof, compression after sclerotherapy is applied all over the world.

OBJECTIVE

Investigating the practice of French vascular physicians for sclerotherapy and the use of post-sclerotherapy compression.

METHODS

A questionnaire concerning their practices was sent to French vascular physicians through their regional vascular medicine professional development associations.

RESULTS

A total of 366 vascular physicians replied to the questionnaire, of whom 63% (229/366) were in private practice, 6% (21/366) in hospitals and 31% (115/366) had a mixed private-hospital practice. Sclerotherapy was practised by 88% (323/366) of them. Two-thirds of the vascular physicians used sclerosing foam and practised sclerotherapy using ultrasound guidance. Less than one-third of the vascular physicians regularly applied compression after sclerotherapy. When compression was applied, it was usually after treatment of saphenous or accessory saphenous veins and, in most cases, medical compression stockings of 15-20 mm Hg were used. With respect to the period recommended for wearing compression, this ranged from 48 h to 1 week for 65% (193/299) of the vascular physicians questioned.

CONCLUSION

The great majority of vascular physicians who answered the questionnaire employ ultrasound guidance to perform sclerotherapy and use sclerosing foam. Compression after sclerotherapy is diversely applied in France and does not comply with the recommendations of the French Health Authorities who recommend wearing a stocking of 15-20 or 20-36 mm Hg for a period of 4-6 weeks. Thus, less than one-third of the vascular physicians regularly used elastic compression and when they did, it was usually a medical compression stocking of 15-20 mm Hg, for 1 week or less.

Thermal ablation of saphenous veins is feasible and safe in patients older than 75 years: A prospective study (EVTA study)

OBJECTIVES

To investigate the tolerance and safety of thermal ablation (TA), consisting of radiofrequency or endovenous laser (EVLA) of saphenous veins (SV) in elderly (group 1 ≥75 years), compared with a control group (group 2 <75 years).

METHOD

An Observational multicenter-prospective study was conducted, under the aegis of the French and Swiss Societies of Phlebology (18 centers). Ninety patients were included in group 1, 617 in group 2 (mean age 80 years and 53 years; 69% women in both groups), representing 863 SV. Mean trunk diameters were similar in both groups (small SV: 6 mm; great SV: 7 mm). In group 1, comorbidities were more frequent, particularly cardiac insufficiency, diabetes, history of thrombosis, and CEAP clinical class was significantly higher.

RESULTS

EVLA was used in 86% of cases. Settings used were similar in both groups for each technique. Only 6% of TA was performed in an operating room for group 1 (14% group 2). Tumescent local anaesthesia (TLA) alone was used in 91% of cases in group 1 (85% group 2). The mean pain score was only 1.6 for the procedure itself (VASP 0-10; 10 max.) and 1.4 for the 10 days following the procedure. Side effects were few, but rate of paraesthesia was higher when general anaesthesia was used (11.8%) compared with TLA alone (2.2%). At three months, 100% of SV was occluded in group 1 (99.5% group 2), with high satisfaction score (9.3/10).

CONCLUSION

TA is safe and effective in elderly; it should be performed strictly under TLA to minimize side effects.

[Quality standards for ultrasound assessment of the superficial venous system of the lower limbs. Report of the French Society for Vascular Medicine]

The quality standards of the French Society for Vascular Medicine for the ultrasound assessment of the superficial venous system of the lower limbs are based on the two following requirements: technical know-how (mastering the use of ultrasound devices and the method of examination); medical know-how (ability to adapt the methods and scope of the examination to its clinical indications and purpose and to rationally analyze and interpret its results).

AIMS OF THE QUALITY STANDARDS

To describe an optimal method of examination in relation to the clinical question and hypothesis; to achieve consistent practice, methods, glossary terminologies and reporting; to provide good practice reference points and to promote a high quality process.

THEMES OF THE QUALITY STANDARD

The three levels of examination. Their clinical indications and goals. The reference standard examination (level 2) and its variants according to clinical needs. The minimal content of the examination report, the letter to the referring physician (synthesis, conclusion and management suggestions) and iconography. Commented glossary (anatomy, hemodynamics, semiology). Technical basis. Ultrasound devices settings. We discuss of use of Duplex ultrasound for the assessment of the superficial veins of the lower limbs in vascular medicine practice.

European guidelines for sclerotherapy in chronic venous disorders

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.

Liquid versus foam sclerotherapy

Objectives

A systematic review to compare efficacy and safety of foam (F) sclerotherapy versus liquid (L) sclerotherapy for primary varicose veins of the lower limbs.

Methods

Systematic searches of electronic databases were conducted in April 2009 to identify relevant published studies. Database searches were augmented with abstracts from conference proceedings and electronic and hand searching of journals not consistently indexed in the major databases.

Results

For treatment of saphenous veins, six trials (four randomized controlled trials) were considered. Despite containing much less sclerosing agent, F was markedly more effective compared with L, the difference being put at between 20% and 50%. Four studies were included in a meta-analysis showing efficacy of F at 76.8% (95% confidence interval [CI] 71–82) versus L at 39.5% (95% CI 33–46), χ2 = 60.9740; P ≤ 0.0001. For reticular veins and telangiectases, only two comparative trials were found and do not at present provide any conclusive evidence to support the superiority of efficacy of one form over the other. Statistically, the side-effects reported in all the available comparative trials do not differ between F and L forms, even if visual disturbances seem to be more common with F.

Conclusion

In the treatment of varices of the lower limbs, F shows much greater efficacy compared to L. Concerning the side effects, no statistical significant differences were found between L and F.

Side-effects and complications of foam sclerotherapy of the great and small saphenous veins: a controlled multicentre prospective study including 1,025 patients

OBJECTIVES

Increasing interest in foam sclerotherapy (FS) for saphenous insufficiency has highlighted the need to study the side-effects and complications of this treatment. The aim of this study is to better assess their nature and incidence.

METHODS

A multicentre, prospective and controlled study was carried out in which patients treated with FS for great (GSV) and small saphenous veins (SSV) trunk incompetence were included. Immediate untoward events were reported. Duplex ultrasound (DUS) examination was carried out to assess all patients between the eighth and 30th day. In addition, 20% of patients were called by an external auditor.

RESULTS

In total, 818 GSV and 207 SSV were treated in 1025 patients in 20 phlebology clinics. Ninety-nine percent of patients were controlled with DUS and non-duplex-checked patients were all called. The saphenous trunk was occluded in 90.3% of patients. Twenty-seven (2.6%) side-effects were reported: migraine (n = 8, 4 with visual disturbance); visual disturbance alone (n = 7); chest pressure alone (n = 7); and chest pressure associated with visual disturbance (n = 5). Eleven thrombo-embolic events occurred: 10 deep vein thrombosis (DVT) but only five in symptomatic patients, and one pulmonary embolism that occurred 19 days following the FS without DVT identified by DUS. One transient ischaemic stroke, with complete clinical recovery in 30 minutes, and one septicaemia with satisfactory outcome were reported as well.

CONCLUSION

This study demonstrates in a large sample of patients a low rate of adverse reactions after FS of great and small saphenous trunks. However, but the eventuality of exceptional but more serious complications has to be taken into account in the management of patients. A multicentre study like this one takes into account different practices and reports all possible complications, thus demonstrating the need for a common validated protocol.

Endovenous laser procedure in a clinic room: feasibility and side effects study of 1700 cases

Objectives

To assess the feasibility of saphenous veins ablation by laser in a clinic room. To study immediate and short term (1 to 6 months) complications and to pinpoint those that could be directly linked to this environment. Efficacy of the technique should also be documented.

Methods

Retrospective study (22 centres) carried out in France and Switzerland. Patients with insufficiency of great saphenous vein (GSV) or small saphenous vein (SSV). Clinical stages of clinical, aetiological, anatomical and pathophysiological classification (CEAP) were C2 to C6. Endovenous laser procedures were performed outside an operating theatre, under local anaesthesia and without high ligation. Efficacy criteria: occlusion of the vein and disappearance of the pathological reflux (duplex scan assessment). The side effects and complications were studied.

Results

A total of 1703 procedures (1422 patients) were performed; 74% of the patients were women. The mean age of the patients was 57. A total of 1394 GSV and 309 SSV were treated (mean diameters 7.2 mm and 6.4 mm, respectively). Overall success level was 97% and mean length of veins treated was 40 cm for GSV and 21 cm for SSV. Energy applied in joules per centimeter was homogenous (mean and median 64 for GSV and 65 for SSV). Complications were rare and ‘simple’ apart from one pulmonary embolism which occurred 10 days after a GSV procedure, although no deep vein thrombus was found. A total of two infections were observed: one was an infection localized at the site of access and the other was erysipelas.

Conclusion

Except 2 limited infections (0.1%), this large retrospective study of laser procedures performed outside the operating theatre did not reveal any significant specific complications as regards the environment required. The efficacy results were equivalent to those found in the literature. Regarding cost and constraints induced by operating theatre environment, the clinic room should be able to offer an easier and economic alternative option for saphenous veins ablation with laser.

Efficacy of polidocanol foam versus liquid in sclerotherapy of the great saphenous vein: a multicentre randomised controlled trial with a 2-year follow-up

OBJECTIVE

To compare the relative efficacy of polidocanol (Aetoxisclerol, Kreussler, Germany) when used as a foam or liquid in the treatment of saphenous incompetence.

MATERIALS AND METHODS

Multicentre, prospective, randomised controlled trial conducted in patients with incompetence of the great saphenous vein (GSV) with a truncal diameter of 4-8 mm. The great saphenous vein was injected using a single injection 2-2.5 ml of either 3% polidocanol or sclerosant foam containing one-fifth 3% polidocanol to four-fifths air (DSS technique). Clinical assessments and duplex ultrasound scanning were performed after 3 weeks and then every 6 months for 2 years. No re-injection was performed irrespective of the immediate result. The main outcome measure was elimination of GSV reflux.

RESULTS

Ninety-five patients participated in the study, 47 were randomised to the foam sclerosant group and 48 to the liquid group. No significant difference between the 2 groups was found regarding sex, age, height, weight and saphenous vein diameter. At 3 weeks, complete elimination of reflux was obtained in 17 of the 48 patients (35%) who received liquid sclerotherapy, versus 40 of the 47 subjects (85%) in the foam group (p<0.001, Chi squared). The incidence of immediate venous spasm and the length of the sclerotic reaction, occlusion measured by echography, were significantly greater in the foam group. There was no difference in the incidence of ecchymosis, inflammatory reactions or other side effects. Follow-up of 6, 12, 18 and 24 months confirms our early results published in 2003. In total only 5 patients were lost to follow-up at 2 years (all of them were in foam group). These patients were included in the final outcome analysis as treatment failures (success rates at 2 years: 53% in foam group and 12% in liquid group).

CONCLUSION

The sclerosant foam used in this study was more than twice as effective as the liquid from which the foam was prepared.

Comparison of 1% and 3% Polidocanol Foam in Ultrasound Guided Sclerotherapy of the Great Saphenous Vein: A Randomised, Double-Blind Trial with 2 Year-Follow-up. “The 3/1 Study”

OBJECTIVES

To compare 1% and 3% POL foam in treating the great saphenous vein (GSV) by ultrasound guided sclerotherapy.

DESIGN

Multicentre, prospective, randomised, double-blind trial with 2 year-follow-up.

PATIENTS AND METHODS

148 patients with GSV reflux (saphenous trunk diameter 4-8 mm) were randomised to undergo ultrasound guided foam sclerotherapy using either 1% or 3% POL foam in a single session. Foam production was standardised using a sterile disposable syringe kit including sterile air and the Turbofoam machine. Duplex ultrasonography was used to assess the outcome at 3 weeks, 6 months, 1 year, 18 months and 2 years. The main criterion of success was the disappearance of the venous reflux. The length of occlusion of the vein (only measured at 3 week-echography assessment) was a secondary criterion. Side effects were assessed.

RESULTS

74 patients were included in each group. The mean volume of foam injected was 4.4 ml for the 3% group and 4.6 ml for the 1% group. After 3 weeks, reflux was abolished in 96% (71 patients) of the 3% group and 88% (68 patients) of the 1% group (NS). The mean occlusion length of the vein was 38 cm for the 3% group and 34 for the 1% group (NS). After 2-years, reflux was absent in 69% of the 3% group and 68% of the 1% group (NS). 14 patients were lost to follow-up at 2 years.

CONCLUSION

This study demonstrates equivalent efficacy for 1% POL and 3% POL foam in sclerotherapy of the GSV where the trunk is less than 8 mm in diameter. These data obtained two years of follow-up confirm our previously reported 6 month-follow-up data published in 2005.

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

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

[Pathologic Doppler flowmetry of the uterine artery and histologic changes of the placenta]

The usefulness of velocimetric study of the uterine arteries during high-risk pregnancies and in particular in the presence of presumed or confirmed maternal pathology is now recognized. Is it possible to identify a link between hemodynamic disturbances affecting the uterine arteries and histological abnormalities of the placenta? This was the aim of the present study. Histological examination of the placenta was routinely requested after delivery when uterine artery Doppler had been pathological during pregnancy (index and/or notch). Fifty five placentas were studied, all but one being pathological. This essentially involved ischemic lesions (including retroplacental hematomas), for which Doppler investigation appears to be a good indicator. Forty placentas were hypotrophic and 2 hypertrophic. Thus uterine artery Doppler during pregnancy appears to accurately reflect the histological state of the placenta and possibly even its functional value.

[Value of a velocimetric study of the uterine arteries in retroplacental hematoma. 3 case reports]

Retroplacental hematoma is a sudden event with a poor prognosis, the latter being aggravated by the very frequent lack of predictive clinical, laboratory or echographic signs. Does studying the velocity of blood flow in uterine arteries have a predictive value in this disease? The equipment used was a continuous Döppler with spectral analysis and probe of 4 MHz, without echographic identification. Each examination systematically included the study of the 2 uterine arteries and the umbilical flow. The technique for recording flow in the uterine arteries is described. A report is given of three cases of retroplacental haematoma. An increase in the resistance index in one of the uterine arteries was found in the three cases (twice on the right, and once on the left), with a protodiastolic notch on the curve, whereas the umbilical index itself was normal and there were no other sign that indicated the placental event. The Döppler is already known to be of value in numerous indications in obstetrics: it should be possible to extend these indications even further, particularly if this preliminary study is confirmed on a broader scale.

[The value of velocimetric investigation of the uterine arteries in retro-placental hematoma. 3 cases]

Retro-placental hematoma is a sudden event with a serious prognosis which is aggravated by the very frequent absence of premonitory clinical, biological or ultrasonic signs. Does a velocimetric investigation of the uterine arteries have any predictive value in this disorder? The apparatus used was a continuous Doppler with spectral analysis and a 4 MHz probe no ultrasonic location. Each examination involved the exploration of 2 uterine arteries and of the umbilical flow. The method of recording the uterine arteries is described. Three cases of retro-placental hematoma are reported. In these three cases, an increase in the resistance index of one of the uterine arteries (the right artery in 2 cases and the left in 1 case) was detected with the presence of a protodiastolic notch on the trace, whereas the umbilical index itself was normal and no other sign was present which could predict the placental event. The value of the Doppler recording is already established in many obstetric indications, and these should be extended yet further, particularly if this preliminary study is confirmed on a larger scale.