Sclerosant Foam Research Articles

Color Duplex Ultrasound-Guided Foam Sclerotherapy: An Approach in the Management of Patients with Superficial Varicosities of Lower Extremity

Background: Duplex ultrasonography guided foam sclerotherapy is now considered a valuable option in varicose vein treatment; it is conducted as an outpatient procedure, does not require general anesthesia and compared with surgery results in an earlier return to normal activities. However, for foam treatment several sessions may be required. Aim of work: The objective of this study is to describe the efficacy, results and safety of Ultrasound guided foam sclerotherapy (UGFS) for treating superficial venous disease of the lower limbs. Patients and methods: 80 patients (28 males, 52 females) who were diagnosed to have clinical and radiological evidence of lower extremities venous diseases in the Department of Vascular Surgery at Qena and Assiut University Hospitals from November 2014 to November 2015 were included. Their ages ranged from 18 to 57 years. Local ethics committee approval and written informed consent were obtained. As considered suitable for UGFS, the foam was prepared by Tessari’s method. Any residual veins treated with another session. Results: Eighty patients presenting with symptomatic varicose veins of superficial system. There were 52 females (65%), and 28 males (35%) with a mean age of 55.76 ± 9.67. CEAP grades of the patients were as follows; (60.0%) in C2, (10.0%) in C3, (21.25%) in C4 (2.5%) in C5 and (6.25%) in C6. The affected segments of the superficial system which were treated were; (70.0%) great saphenous, (17.5%) small saphenous, (6.25%) were great saphenous vein and varices and (6.25%) were small saphenous vein and varices. The numbers of sessions needed to eradicate the affected segment were one session in (70%), two sessions in (18.75%) and three in (11.25%). Minor complications encountered were skin discoloration in 30% of patients, superficial thrombophlebitis in 16% and an allergy to the foam sclerosant in 2.5%. After one year follow up by colored duplex ultrasound (CDU) (70%) had complete occlusion, (15%) had partial occlusion and (80%) of patients showed improvement of CEAP classification. Conclusion: UGFS is a safe and effective treatment as an alternative to surgical treatment for superficial system varicosities. One and infrequently two to three treatment sessions, leads to complete eradication of superficial reflux in virtually 100% of cases. It is considered as an outpatient procedure. Complications are few, and appear mostly self-limiting.

Injection Sclerotherapy and Ablation

Closure of incompetent superficial veins via endovenous techniques has become the standard of care for treatment of patients with chronic venous insufficiency and symptomatic varicose veins. The safety and efficacy of these procedures have been supported by the peer-reviewed literature, and these procedures have largely replaced the surgical treatments of high ligation and stripping. Three major developments have led to the current endovenous techniques: laser and radiofrequency catheters that deliver thermal energy, tumescent anesthesia, and duplex ultrasonography. This review covers relevant anatomy, pathophysiology, clinical signs and symptoms, diagnostics, treatment, tumescentless therapy, ClariVein (mechanochemical ablation), and the VenaSeal Closure System. Figures show telangiectasias, reticular veins, varicose veins, edema/swelling, hyperpigmentation, venous stasis ulcers, the ClosureFast Catheter, access using the great saphenous vein proximal to the popliteal region, application of tumescent anesthesia, segmental ablation using the ClosureFAST system, the NeverTouch Direct Procedure Kit by AngioDynamics, Varithena foam sclerosant, the ClariVein Occlusion Catheter, and the VenaSeal Sapheon Closure System. Tables list perforating veins of the lower extremity, Clinical, Anatomic, Etiologic, Pathophysiologic classification, and the Venous Clinical Severity Score. This review contains 12 figures, 3 tables, and 103 references

Efficacy and safety of interventional sclerotherapy for intraorbital venous malformation in children

Objective To evaluate the efficacy and safety of interventional sclerotherapy for intraorbital venous malformation in children. Methods A retrospective analysis of 12 cases with intraorbital venous malformation from March 2007 to July 2013 in our department was made. Twelve lesions including 7 in left eyes and 5 in right eyes were evaluated. Three patients had surgical resection before interventional treatment. Sclerosing agent such as sclerosant foam or pingyangmycin was injected into the lesions guided by DSA. Interventional sclerotherapy was performed once every month until no blood return was observed. Then MRI was used to detect the lesions 1 month after operation. If there were residual lesions in MRI images, then repeat treatment was performed. Postoperative observation included patients' general situation and adverse reactions of eye after each treatment. Results Interventional sclerotherapy were performed to all patients for a total of 42 times (mean time 3.5 ±1.0 per patient). After a follow- up of 24months, 7 cases were cured, 3 cases improved significantly and 2 cases with partial remission. Postoperative adverse reactions: transient exophthalmos in 39 case-times, peri-orbital and maxillofacial tissue swelling in 32 case- times. No severe complications were observed. Conclusion Interventional sclerotherapy is an easy, safe and effective method for treatment of intraorbital venous malformation. Key words: Intraorbital venous malformation; Interventional; Sclerotherapy; Children

A new method for using radiopaque sclerosing foam to treat venous malformations.

Sclerosing foam is recommended to treat venous malformations (VMs). However, determining the precise dosage for satisfactory efficacy and few side effects are still challenging. To develop a new method of preparing sclerosing foam by adding contrast agent to treat patients with VMs visibly and precisely under radiologic guidance. Sclerosant (polidocanol) and contrast agent (iopromide) were mixed to prepare a new sclerosing foam according to Tessari method, and different ratios of the 2 materials were used to study the stability (half-life) of the produced foams. X-ray absorption of the radiopaque foams was observed during patient treatment with digital subtraction angiography (DSA). The foams generated with the new method demonstrated a high x-ray absorption under DSA. The foam half-life among groups varied. The ratio of iopromide/polidocanol at 1:2 had a significantly longer half-life than the 1:1 or polidocanol-only group. The 1:2 group had a relative high x-ray absorption and was radiopaque to allow visualization of the sclerosing foam and lesion with DSA. Mixing contrast agent with sclerosant to prepare radiopaque foams is a new method for treating complex VMs with DSA, and a ratio of 1:2 is recommend for polidocanol and iopromide.

Ultrasound-guided perisaphenous tumescence infiltration improves the outcomes of long catheter foam sclerotherapy combined with phlebectomy of the varicose tributaries

A prospective comparative observational study was performed to assess the short--term efficacy and safety of the peri-saphenous infiltration of tumescence solution (PST) in great saphenous vein (GSV) long catheter foam sclerotherapy (LCFS) combined with phlebectomy of the varicose tributaries. Since November 2006 through November 2010 fifty-one consecutive patients (16 males and 35 females, mean age 51.5 years) who underwent LCFS of GSV + multiple phlebectomies were prospectively enrolled, without any pre-selection criteria, in three different groups (17 patients per group) and reviewed as to their outcomes: i) patients without additional PST; ii) with PST under visual control; iii) with ultrasound-guided PST. All procedures were performed in local anesthesia and an average of 7 mL [interquartile range (IQR) 6.5-7.5] of 3% sodiumtetradecylsulfate CO2+O2-based sclerosant foam was injected in the diseased segment of GSV (median caliber 7) (IQR 6-8) by means of a 4F long catheter. Clinical and color-duplex ultrasound (CDU) follow-up was performed at regular intervals, the last of which 14 months after the treatment. At 14 months follow-up no varicose veins were visible in 94%, 94% and 100% of the cases in group I, II and III respectively. The CDUbased outcomes were the following: 71%, 71% and 84% GSV occlusion rate in group I, II and III respectively; reflux was found in 5, 4 and 1 cases in group I, II and III respectively. Clinical and CDU morphologic and hemodynamic results were assembled and scored through an arbitrary system. The relative statistical analysis showed a significant (P<0.0001) improvement of the results for patients who received ultrasound guided PST over the other two groups. No relevant complications were recorded in all 51 cases. GSV treatment by means of LCFS + phlebectomy of varicose tributaries proved to be effective and safe in this prospective observational study. The addition of ultrasound guided PST resulted in a significant improvement of GSV occlusion rate and of varicose vein clinical resolution.

Abstract No. 203 - Fast balloon-occluded retrograde transvenous obliteration using n-butyl cyanoacrylate after foam sclerosants for gastric varices

Abstract No. 203 - Fast balloon-occluded retrograde transvenous obliteration using n-butyl cyanoacrylate after foam sclerosants for gastric varices

Pathomorphological characteristic of the impact of foam sclerosant on the venous wall in case of varicose disease

In treatment of varicose disease methods of intraoperative phlebosclerotic obliteration involving injection of sclerosant into vein lumen come to the fore. Issues of morphological changes in venous wall are actual and unstudied.The aim was to characterize morphological changes in the wall s of veins in the early and distant periods after the injection of foam polidocanol of different concentrations into patients’ varicose veins and into veins of experimental animals.Methods and results. Segments of veins were investigated using the light and electron microscopy. It was confirmed that application of foam polidocanol for 10 minutes both in patients and rats influences endothelium cells and causes their damage. In vasa vasorum we saw hyperemia, stasis, thrombosis and in venous wall oedema and diapedesis of erythrocytes.Conclusion. We revealed in experiment that in remote period (after 1 month) the injection of sclerosant leads to vessel obstruction with fibrosis.

Ultrasound guided foam sclerotherapy of recurrent varices of the great and small saphenous vein: 5-year follow up

Ultrasound guided foam sclerotherapy (UGFS) proved to be effective in recurrent varices. In this observational study from 2006 and 2012 we treated 142 neovascularization, 155 inguinal recurrence and 28 popliteal recurrent varices. For neovascularization 0.3-0.5% polidocanol (POL) sclerosant foam (SF) was injected for vein having diameter <3 mm and 0.5-1% POL or sodium tetradecylsulphate (STS) SF for higher vein diameters. The patients with residual sapheno-femoral or sapheno-popliteal junctions were treated with 1% STS SF for diameter up to 5 mm, while for larger veins 3% STS was used. From 1 to 3 sessions were necessary in both groups with 4 to 10 ml injected per session. In the group of neovascularization the 3-5years follow up revealed good results in 90.8% of the cases. In the group of popliteal recurrences the 3-5 years follow up showed 60.7% of good results, while in the group of inguinal recurrences we observed 80% of good results at 3-5 years. We did not have major complication. As minor complications we had 0.2% of gastrocnemial vein thrombosis, 0.1% of minor neurological problems, 2.8% of superficial vein thrombosis, 3.9% of pigmentation and light to mild post-treatment pain in 16.5% of the cases. In conclusion our data show that UGFS is a well tolerate technique, preferred by previously operated patients, safe and easily repeatable with good medium-term results both in case of neovascularization and of recurrence from residual femoral or popliteal stump.

Scintigraphy-based analysis of possible pulmonary lesions after foam sclerotherapy: a pilot study

The aims of this study were to assess extemporaneous in vivo binding between 99mTcO4- and two sclerosant detergents in foam sclerotherapy, and subsequently to control any possible damage in lungs and other organs related to sclerosant foam passage. A prospective comparative pilot study was performed on two male patients (62 and 56 years old) affected by varicose veins; each of them underwent scintigraphy investigations with free radiotracer and a scintigraphy investigation after each of the four sessions of sclerotherapy of varicose tributaries of the lower limbs with labeled sclerosant foam. One of the two patients underwent two further scintigraphic investigations, with free radiotracer and with labeled sclerosant foam, at a later stage. Four mL of 2% polidocanol (POL) foam, or four mL of 1% sodiumtetradecylsulfate (STS) foam for session were injected. The sclerosant foam was labeled with the radioactive tracer technetium pertechnetate, 99mTcO4- (120 MBq per exam). Two scintigraphy assessments for free tracer (basal) and five scintigraphy investigations of bound-tosclerosant tracer uptake/transit were obtained. No relevant variations in time/activity curves of the lungs and other organs were documented between the basal and post-sclerotherapy findings, also at the later stage. Free radiotracer mean region-of-interest data were: 336 counts (heart), 208 counts (lungs) and 371 counts (thyroid). Mean values extrapolated from each curve at each step for labeled CO2O2-based sclerosant foam were respectively: 351 counts (POL) and 328 counts (STS) for heart, 202 counts (POL) and 188 counts (STS) for lungs, 335 (POL) and 263 (STS) for thyroid. No pulmonary damage by sclerosant foam was caused. Neither immediately after treatments, nor at short-term follow-up.

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. Investigating the practice of French vascular physicians for sclerotherapy and the use of post-sclerotherapy compression. A questionnaire concerning their practices was sent to French vascular physicians through their regional vascular medicine professional development associations. 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. 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.

Computational Fluid Dynamics of Liquid and Foam Sclerosant Injection in a Vein Model

The aim of this study was to develop a computational fluid dynamics (CFD) model to simulate the injection of liquid and foam sclerosants into a varicose vein. The CFD model results were compared with sclerosant flow in an experimental model of a straight or a branched vein. The effects of injection angle, injection velocity and tubing contents (blood, saline) on sclerosant spreading were assessed by CFD. The simulation of liquid sclerosants injection was able to provide a good representation of forward flow, but underrepresented sclerosant backflow. Due to the complex nature of computational modelling of foams, CFD modelling of foam sclerosants injection was less accurate and provided only limited information on foam spreading. CFD modelling can be used as a representation of liquid and foam sclerosant injection, but further research is required to provide a more accurate analysis.

Basic physiochemical and rheological properties of detergent sclerosants

To determine the basic physiochemical properties and rheological activity of detergent sclerosants. Sodium tetradecyl sulphate and polidocanol liquid and foam sclerosants were investigated in a range of concentrations (0.1-3%), liquid-plus-air fractions (1+2 to 1+8) and dilutions in water (stock solutions) or in normal saline. The embolic agent ethanol was investigated for comparison. Density was measured using a digital balance. Surface tension was measured by the Du Nuoy ring method and used to determine the critical micellar concentration. Viscosity was measured using a cone-plate rheometer for liquid and a modified parallel plate method for foam. Liquid sclerosant density decreased as the sclerosant concentration increased while foam density decreased with the increasing air fraction. The critical micellar concentration of polidocanol was 0.002% in both normal saline and water while that of sodium tetradecyl sulphate was 0.075% in normal saline and 0.200% in water. Viscosity of liquid sodium tetradecyl sulphate was lower than that of polidocanol. Foam sclerosants were at least 10,000-fold more viscous than liquid sclerosants and ethanol. All agents demonstrated a Non-Newtonian shear-thinning behaviour with a fall in viscosity at lower shear rates (<10 s(-1)). Polidocanol (but not sodium tetradecyl sulphate) foam viscosity progressively increased with increasing sclerosant concentration and liquid-plus-air fractions. Liquid and foam sclerosants and ethanol are Non-Newtonian shear thinning fluids. Foam sclerosants are significantly more viscous than liquid agents.

Short-Term Rebleeding Rates for Isolated Gastric Varices Managed by Transjugular Intrahepatic Portosystemic Shunt versus Balloon-Occluded Retrograde Transvenous Obliteration

PurposeTo assess the short-term rebleeding rate associated with the use of a transjugular intrahepatic portosystemic shunt (TIPS) compared with balloon-occluded retrograde transvenous obliteration (BRTO) for management of gastric varices (GV). Materials and MethodsA single-center retrospective comparison of 50 patients with bleeding from GV treated with a TIPS or BRTO was performed. Of 50 patients, 27 (17 men and 10 women; median age, 55 y; range, 31–79 y) received a TIPS with covered stents, and 23 (12 men and 11 women; median age, 52 y; range, 23–83 y) underwent a BRTO procedure with a foam sclerosant. All study subjects had clinical and endoscopic evidence of isolated bleeding GV and were hemodynamically stable at the time of the procedure. Clinical and endoscopic follow-up was performed. Kaplan-Meier analysis was used to evaluate rebleeding rates from the GV. ResultsThe technical success rate was 100% in the TIPS group and 91% in the BRTO group (P = .21). Major complications occurred in 4% of the patients receiving TIPS and 9% of patients the undergoing BRTO (P = .344). Encephalopathy was reported in 4 of 27 (15%) patients in the TIPS group and in none of the patients in the BRTO group (0%; P = .12). At 12 months, the incidence of rebleeding from a GV source was 11% in the TIPS group and 0% in the BRTO group (P = .25). ConclusionsBRTO appears to be equivalent to TIPS in the short-term for management of bleeding GV. Further comparative studies are warranted to determine optimal management strategies in individual patients.

Comment to: Catheter-directed foam sclerotherapy for insufficiency of the great saphenous vein: occlusion rates and patient satisfaction after one year, by Williamsson C, Danielsson P, Smith L. Phlebology 2012:1-6.

Between November 2007 and October 2008, 100 consecutive symptomatic patients with verified axial reflux in the GSV were treated with a catheter-directed foam sclerosation technique (CDS). CDS delivers the foam during a short period of time directly to the intended site, along the length of the GSV, with less impact from surrounding factors. The catheter induces a vasospasm which might further enhance drug interaction with the vein wall. Median age was 52.5 years (range 18&ndash;92), 28 men and 72 women. All patients had visible varicose veins. Twenty-three had recurrent varicose veins. The treatment was performed in the outpatient clinic by a team consisting of two vascular surgeons and two nurses. Exclusion criteria were allergy to polidocanol, a very tortuous vein (which could make the catheters impossible to advance) or a GSV diameter exceeding 10 mm at the terminal valve. The skin was infiltrated with local anesthesia. The vein was accessed by a micro-puncture introducer set and a 0.35 Fr guide wire was advanced proximally under US surveillance and positioned at the SFJ. A catheter was introduced over the guide wire and positioned approximately 2 cm distal to the SFJ and the guide wire was removed. The table was slightly tilted to elevate the leg to empty the GSV. Ten mL sclerosing foam (SF) was made by mixing 2 mL chilled 3% polidocanol and 8 mL air. The SFJ and site of puncture was compressed for five minutes and the thigh massaged to fill superficial varicosites with foam. No additional local injection of foam was given. All patients wore two-layer short stretch compression bandages for one to five days after treatment. Evaluation with US was performed at two weeks and at one year after treatment. Foam delivery along the GSV was technically successful in 94 of the 100 patients. The median time for the procedure was 22 (8&ndash;90) min. The complete treatment exceeded 30 min in 20 patients, but only in two patients following the 50th patient. At the US control two weeks after treatment, the GSV was completely occluded in 92 of the 94 successfully treated patients. At the one-year follow-up, 84% (79/94) were satisfied with the result. The one-year US showed that 70% (64/91) of the GSVs were completely occluded, 15% (14/91) of the GSVs were recanalized and 14% (13/91) were partly occluded. No major complications occurred such as visual disturbance, pulmonary embolism, DVT or infection. Two patients had superficial thrombophlebitis; at the one-year follow-up 26 patients had pigmentations to some extent. The cost for the drugs and the single-use medical material was calculated to be 106 EUR.

Foam Sclerotherapy for a Symptomatic Hepatic Cyst: A Preliminary Report

PurposeWe evaluated our initial experience of performing sclerotherapy for symptomatic hepatic cysts using polidocanol foam instead of a liquid sclerosant.MethodsThree consecutively registered patients with symptomatic hepatic cysts (one with polycystic liver disease) underwent polidocanol foam sclerotherapy. A pigtail catheter was inserted into the targeted cyst following percutaneous cyst puncture under ultrasound guidance, and the cyst fluid was aspirated. To confirm the absence of communications between the cyst and surrounding hepatic vessels, 3 % polidocanol foam sclerosant was injected at a 1:4 ratio of polidocanol to air following digital subtraction cystography with carbon dioxide. C-arm computed tomography (CT) guidance also was used to monitor foam filling of the targeted cyst. The maximum dose of sclerosant injected per treatment session did not exceed 10 ml. The catheter was kept unclamped overnight for open drainage, and additional sclerotherapy sessions were performed on subsequent days, if needed.ResultsEfficient sclerotherapy was achieved with an average of two sessions. The initial mean cyst volume was 1,052 ml, and gradual resolution was observed without recurrence. The mean reduction rate was 97.9 % (97.7–98.3 %), and all cyst-associated symptoms disappeared. The median follow-up period was 17 (range 6–21) months. Although one patient experienced moderate-grade fever and another moderate pain at the puncture site, no major complications were observed.ConclusionPolidocanol foam sclerotherapy is a safe and effective treatment for symptomatic hepatic cysts.

Effect of foam sclerotherapy of lauromacrogol on peripheral venous malformations

Objective To investigate the efficacy and safety of lauromacrogol foam sclerosant in the treatment of peripheral venous malformations.Methods 21 patients with peripheral venous malformations were treated with foam sclerotherapy.The sclerosing foam was produced by Tessari's method using 1％ lauromacrogol.When necessary,the injections were repeated at an interval of four weeks,and this process contained 3 to 5 injections.Therapeutic outcomes and safety were established by evaluating size of lesion,symptom,duration of treatment and side-effects of treatment before and after treatment.Results 21 patients were followed up for 3 to 18 months.10 cases showed markedly shrinked or even disappeared of treated malformations,9 cases showed a reduction in size over 50 ％,and 2 cases showed a reduction in size less 50 ％.Local swelling occurred in almost per session,pyrexia in 5 patients,which resolved spontaneously within several days to 1 week.No major complication occurred.Conclusions Foam sclerotherapy using lauromacrogol seems to be a safe and effective therapeutic method for peripheral venous malformations. Key words: Lauromacrogol; Foam; Sclerotherapy; Venous malformations

Scrotal antegradesclerotherapy demonstrates anatomical variations on venous drainage in paediatric, adolescent and young adult varicoceles

Anatomical variations on venous drainage in varicoceles are under-reported. We report our experience in scrotal antegrade sclerotherapy (SAS) for adolescent varicoceles. Since 2011, 15 consecutive boys with left varicoceles were recruited. Under general anaesthesia, a 5-mm transverse incision was made at scrotal neck, testicular vein was cannulated at pampiniform plexus with venogram performed. Foam sclerosant by mixing sodium tetradecyl sulphate (STS), Lipiodol(®) and air was slowly injected under fluoroscopy. Postoperatively the patients were followed-up for varicocele grading, testicular size, and complications. Median age at operation was 14 (10-19) years. 80 % had grade three varicoceles, 33.3 % had smaller left testis before operation. Intra-operative venogram showed three different anatomical variations. Group I: eleven patients (73.3 %) had single distinct internal spermatic vein; Group II: two patients demonstrated duplication of internal spermatic vein draining into left renal vein; Group III: two patients had pampiniform plexus draining to iliac and/or paraspinal veins. SAS was performed in Group I and II patients. Sclerosant volume injected ranged from 1.5 to 4.5 ml. In Group III patients, surgical ligation of testicular veins was performed rather than SAS to avoid uncontrolled systemic sclerosant spillage. Mean length of stay was 1.13 day. One patient with scrotal haematoma and one other with minor wound dehiscence were managed conservatively. Mean follow-up period was 10.9 (1-22) months. Thirteen patients (86.7 %) achieved varicocele grading ≤ 1. There was no postoperative testicular atrophy, hydrocele and epididymo-orchitis. Scrotal antegrade sclerotherapy using STS foam is a safe and effective treatment for adolescent varicoceles. Anatomical variations on venous drainage in varicoceles are common.

Clinical effectiveness and cost-effectiveness of minimally invasive techniques to manage varicose veins: a systematic review and economic evaluation

Varicose veins are enlarged, visibly lumpy knotted veins, usually in the legs. Uncomplicated varicose veins can cause major discomfort and some complications. They are part of chronic venous disease (CVD), which is reported to have a substantial negative impact on health-related quality of life (HRQoL). Traditional treatments for varicose veins involve surgical stripping and ligation and liquid sclerotherapy (LS), but can be invasive and painful. New minimally invasive treatments offer an alternative. These treatments typically involve use of laser, radiofrequency or foam sclerosant. They are increasingly widely used and offer potential benefits such as reduced complications, faster recovery, fewer physical limitations and improved quality of life. The aim of this report is to evaluate the clinical effectiveness, safety and cost-effectiveness of the minimally invasive techniques of foam sclerotherapy (FS), endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) in comparison with other techniques, including traditional surgical techniques, LS and conservative management, in the management of varicose veins. A systematic search was made of 11 bibliographic databases of published and unpublished literature from their inception to July 2011: MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature; The Cochrane Library; Biological Abstracts; Science Citation Index (SCI); Social Sciences Citation Index; Conference Proceedings Citation Index-Science; UK Clinical Research Network; Current Controlled Trials; and ClinicalTrials.gov. A systematic review of randomised controlled trials (RCTs) to assess the clinical effectiveness of minimally invasive techniques compared with other treatments, principally surgical stripping, in terms of recurrence of varicose veins, retreatment and clinical symptoms, as measured by the Venous Clinical Severity Score (VCSS), pain and quality of life. Network meta-analysis and exploratory cost-effectiveness modelling were performed. The literature search identified 1453 unique citations, of which 34 RCTs (54 papers) satisfied the criteria for the clinical effectiveness review. The minimally invasive techniques reported clinical outcomes similar to surgery. Rates of recurrence were slightly lower for EVLA, RFA and FS, especially for longer follow-up periods; VCSS score was lower for EVLA and FS than for stripping, but slightly higher for RFA; short-term pain was less for FS and RFA but higher for EVLA; higher quality-of-life scores were reported for all evaluated interventions than for stripping. Differences between treatments were therefore negligible in terms of clinical outcomes, so the treatment with the lowest cost appears to be most cost-effective. Our central estimate is that total FS costs were lowest and FS is marginally more effective than stripping. However, this result was sensitive to the model time horizon. Threshold analysis indicated that EVLA and RFA might be considered cost-effective if their costs are equivalent to stripping. These findings are subject to uncertainty on account of the risk of bias present in the evidence base and the variation in costs. The relative clinical effectiveness and cost-effectiveness of the techniques are principally based on rates of post-operative technical recurrence rather than symptomatic recurrence, as this was the reported outcome in all trials. The true proportion of treated individuals who are likely to present with symptoms of recurrence requiring retreatment is therefore not certain. A figure reflecting the likely proportion of treated individuals who would experience symptomatic recurrence requiring retreatment (with its associated costs), therefore, had to be calculated by the authors based on a small number of studies. The findings of this report also need to be verified by data from future trials with longer follow-up and using more standardised outcome measures. This assessment of the currently available evidence suggests there is little to choose between the minimally invasive techniques in terms of efficacy or cost, and each offers a viable, clinically effective alternative to stripping. FS might offer the most cost-effective alternative to stripping, within certain time parameters. High-quality RCT evidence is needed. Future trials should aim to measure and report outcomes in a standardised manner, which would permit more efficient pooling of their results. PROSPERO number CRD42011001355. The National Institute for Health Research Health Technology Assessment programme.

Catheter-directed foam sclerotherapy for chronic venous leg ulcers

This study presents the results of catheter-directed foam sclerotherapy (CDS) for chronic venous ulcer refractory to compression treatment, four weeks and one year after treatment. In sum, 31 patients (32 limbs) with refractory chronic venous ulcer and duplex-verified superficial insufficiency were offered CDS. CDS was conducted with 10 ml of sclerosant foam of 3% polidocanol. Four weeks and one year after treatment, the patients were evaluated regarding ulcer healing and ultrasound appearance of the saphenous trunk. CDS was successfully performed in all patients. After one year, 65% of the ulcers were healed. Only two (6%) recurred. 86% of the treated saphenous trunk were completely occluded, 3% was partly occluded and 10% were recanalised. No serious side effects occurred. CDS is one alternative of eliminating superficial venous reflux when treating refractory venous leg ulcers. This study suggests that the treatment is safe and induce a quick ulcer healing.

Foam Sclerosants are More Stable at Lower Temperatures

Sclerosant foams are aqueous and break down under the influence of gravity, pressure, and temperature. The aim of this study was to investigate the effects of temperature on foam stability. Sodium tetradecyl sulphate (STS) and polidocanol (POL) liquid and foam (1 + 4, liquid-plus-air fraction) were investigated in a range of concentrations (0.5%, 1.5%, 3.0%) and temperatures. Surface tension was measured by the Du Nuoy ring method. Liquid drainage from foam was measured and documented by serial photography. Both pre- and post-cooling variations were investigated. Surface tension decreased at higher temperatures. Surface tension of POL was higher than STS at concentrations tested. POL foam half-time increased significantly at higher concentrations while the half-time of STS foam was not affected by concentration. Heating the sclerosant foam above the ambient temperature reduced its half-time while cooling below the ambient temperature prolonged the half-time. Both pre- and post-cooling of the foams resulted in significant prolongation of half-times when compared to no cooling. Maximum stability of the two sclerosant foams tested was achieved at 10 °C. Foam sclerosants are more stable at cooler temperatures.