Regarding “Balloon control of the saphenofemoral junction during foam sclerotherapy: Proposed innovation”

Abstract

In the article by Bidwai et al,1Bidwai A. Beresford T. Dialynas M. Prionidis J. Panayiotopoulos Y. Browne T. Balloon control of the saphenofemoral junction during foam sclerotherapy: proposed innovation.J Vasc Surg. 2007; 46: 145-147Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar the authors report on utilizing perforator ligation and a balloon catheter to occlude the saphenofemoral junction during foam sclerotherapy of the great saphenous vein. Several objections to this method of saphenous vein ablation deserve mention. It appears that all thigh and proximal leg perforators identified by duplex scan were systematically ligated, no matter their flow characteristics. Presumably, this resulted in occlusion of at least some perfectly normal perforator veins. The rationale for the sacrifice of normal veins to theoretically prevent foam escaping into the deep venous system is flawed, since the perforators seen by duplex scan represent only a minority of the actual number of perforator veins in the leg. Furthermore, following removal of the saphenous vein from the venous circulation, previously incompetent perforators will often become competent.2Danielsson G. Eklof B. Kistner R.L. What is the role of incompetent perforator veins in chronic venous disease?.JP. 2001; 1: 67-71Google Scholar A priori destruction of normal or even incompetent perforators is meddlesome at best. It also appears that there was no duplex examination during foam injection to prove foam did not progress into the deep venous system. Consequently, the claim that perforator ligation and proximal saphenous vein occlusion successfully prevented foam entering the deep venous system is simply not justifiable. Had the authors performed intraoperative duplex examination of the deep venous system, simultaneous transthoracic echocardiography, or transcranial Doppler monitoring during injection, as we have done in our center, they would have noted foam progressing not only into the deep venous system, but into the central circulation and indeed into the cerebral circulation in patients with right-to-left shunts (estimated to be over 25% of the normal population).3Meier B. Lock J.E. Contemporary management of patent foramen ovale.Circulation. 2003; 107: 5-9Crossref PubMed Scopus (220) Google Scholar Further, occlusion of the proximal saphenous vein, rather than preventing progression of foam into the deep venous system, actually encourages flow into deep veins, because it is prevented from progressing gradually through the saphenofemoral junction and is forced into perforator veins. This was also proven in our center using a different balloon-tipped catheter with simultaneous foam injection and ultrasound examination of the deep venous system, particularly the common femoral vein. Additionally, on release of the balloon, there will be an immediate bolus of foam into the deep venous system which progresses to the heart. It is much more likely that a bolus of foam bubbles will progress through a right-to-left shunt, such as a patent foramen ovale, than bubbles that gradually migrate to the heart as following foam injection of a nonoccluded great saphenous vein. It is precisely for this reason that an occlusion balloon-tipped catheter is rarely used in European countries wherein chemical foam ablation is commonly performed (specifically Germany, France, Italy, and the United Kingdom). Finally, using simultaneous transthoracic echocardiography and/or transcranial Doppler monitoring of the middle cerebral artery during ultrasound guided foam sclerotherapy, we have shown that the use any of the suggested methods to prevent migration of at least some bubbles from the injected superficial vein into the deep venous system and beyond (eg, leg elevation, small foam volumes, postinjection rest) is simply ineffective. Complications such as deep venous thrombosis and systemic symptoms will occur at a certain (albeit low) rate, and asserting that use of an occlusive balloon and ligation of a few perforators will prevent such complications is wishful thinking.