Sclerotherapy: old‐ or new‐fashioned?

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Sclerotherapy, including foam sclerotherapy, has two main indications: the treatment of telangiectasias and reticular varicose veins. echo-guided treatment of saphenous (mostly short saphenous) and saphenous accessory veins. The discovery of sclerotherapy is a good example of serendipity. Although some anecdotal attempts at sclerotherapy were reported in the XVIIth century1 it was at the start of the XXth century that sclerotherapy really began. Syphilis was then treated with intravenous Luargol solution (novarsenobenzol) and this was sometimes complicated by local venous thrombosis and obliteration.1,2 Linser in Germany and Sicard in France both had the idea of using this adverse effect as a deliberate treatment for varicose veins.1,2 Less toxic and more effective sclerosants have since been developed. They may be classified according to their mode of action: (i) osmotic sclerosants (hypertonic dextrose, saline), (ii) chemical irritant sclerosants (iodide, chromated glycerine) and (iii) detergent sclerosants (polidocanol, sodium tetradecylsulphate). The last sclerosant, polidocanol, was introduced in 1966. For the next 30 years, research in sclerotherapy was scanty. Meanwhile fascinating new venous therapeutic techniques were evolving, including Muller's phlebectomy and lasers. Injection sclerotherapy appeared to be in decline. Then an unexpected renaissance occurred. In 1997, Monfreux in France3 and Cabrera in Spain4 simultaneously described the foam technique. Only detergent agents (most commonly polidocanol) can be used to prepare foam. Foam is induced by air turbulence in a syringe.3,5 First attempts were conducted with glass syringes. Newer methods have been developed using disposable syringes, such as the 3-way tap technique of Tessari5,6 (Fig. 1). CO2 turbulence is a more attractive approach, but the technique of Cabrera is still secret. The main drawback of foam sclerotherapy is that the foam is not stable. Foam sclerotherapy. The 3-way tap technique of making foam. Foam sclerotherapy has numerous advantages over traditional sclerotherapy. There is a lesser dilution of the sclerosant by the circulating blood because, within the target section of the treated vein, the foam replaces the blood rather than mixing with it as happens in traditional sclerotherapy. There is a better positioning of the sclerosant agent within the vein, as the air (within the foam) drives the sclerosant (within the foam) against the walls of the target section of the vein. There is a more prolonged duration of treatment because foam has a slower wash-out time than traditional sclerosants. These advantages mean a greater chance of complete and uniform alteration of the intima and thus better obliteration of the vein. Moreover, foam is more echogenic (because of the presence of air, which is easily seen with duplex), which is valuable in echo-guided sclerotherapy. Transitory blindness (syn. amaurosis) is a recognized but rare adverse effect of sclerotherapy. All the sclerotherapeutic agents can cause it. If it occurs once, it recurs in subsequent treatments. Its pathophysiology is unclear. It may be due to an atypical ocular migraine. It may be a consequence of intravascular nitrogen injection. To help prevent this frightening, although benign event, the patient should remain flat for some minutes after sclerotherapy. Polidocanol sclerotherapy and polidocanol foam sclerotherapy share the same range of adverse effects, except that amaurosis seems more frequent with foam. Either old- or new-fashioned, sclerotherapy is again a major treatment method in phlebology and fascinating developments are to be expected. In experienced hands and with a lesser concentration, foam sclerotherapy achieves better results with fewer side-effects than traditional sclerotherapy.5 However, the crux is not just to inject veins, but to master both venous diagnosis and skill in all phlebological treatments.