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.

Stefano Ricci

Abstract

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 18–92), 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 (8–90) 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.

Comment by Stefano Ricci

Catheter-direct foam sclerotherapy is interesting because, as demonstrated by the Authors, it is safe, cheap and easy to perform. In particular it do not need high technology or a dedicated setting, so can be also performed in unfavorable social and economical conditions. About 70% occlusion rate is not an ideal outcome even if could be largely ameliorated by further subsequent sclerotherapy. Unfortunately no specific data about US pre-treatment findings (terminal valve competence, calibers, AASV, extension of varicosities, isolated dilatations, pelvic reflux, recurrence of GSV incompetence?? etc.) are reported, all situations mixed up.
US was performed in a 60° upright position, which could have different results compared to 90° standing position. Also the concept of satisfaction is questionable, no distinction being made, for example, between cosmetic and clinical state. Over a 24% incidence of pigmentation, only 6 cases were displeased: what an advantage to live and work in Sweden!! In Mediterranean countries this result would be accepted with lower compliance. Interestingly, post treatment compression was very limited (1-5 days) indicating a very good sclerotherapy technique, however it is surprising that also C4 (19) patients, as C5 (8) and C6 (4) were left without hosiery with still good outcome.

Reply by the Authors

Thank you for commenting the article. An important aim of the study was to show the simplicity of this minimally invasive technique. With an increasing elderly population it is important to find a safe and easy method to address superficial venous insufficiency.
In studies, ultrasound detected recanalization, totally or segmentally, is usually evaluated and defined as success or failure. However, the clinical result is more relevant and most treated patients experience relief of symptoms, probably due to less reflux compared to pre-treatment. Our experience is that only patients with totally recanalized saphenous veins are in need of a new treatment. This makes the result better than the figures presented in the study.
The low rate of displeased patients although some had pigmentations might be explained by relief of symptoms. None were treated due to cosmetic complaints alone. It is though very true that bruising is a problem. Previously we did not take any cosmetic consideration. In public healthcare this may be an acceptable strategy but not in a private practice. We have learned that the patients skin type must be considered, a very light skin is unfavorable for foam. The depth of the saphenous vein is important. Low amount of subcutaneous fat and a distance from the saphenous vein less the 10 mm is not recommended due to risk for permanent bruising. It is also possible to resect superficial tributaries by mini phlebotomies in local anesthesia in a combined session with CDS.
The bottom line is that there are ways to avoid bruising and a very good cosmetic result can be achieved in most cases. For this, experience is needed and is probably more important in private clinics dealing with patients suffering cosmetically from their varicose veins.

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