Foam Sclerotherapy for limb

varicose-veins
Hendro S.Yuwono,MD,PhD
Dept.Surgery,
Padjadjaran State University,
Bandung
Scientific - Souvenier from USA-San Diego
 Sclerotherapy
 The word comes from Greek words of

Sklerosis = hardness (induration).

Therapeia = therapy or treatment of disease.

Sclerotherapy of varicose-veins has the meaning of

an injection of a chemical into the lumen of
varicose-vein segment, that causes scarring of it.
Injected technique: 1.Liquid; 2.Foam
Sclerosing agent: 1.Polidocanol (Aethoxysclerol)
2.Sodium tetradecyl sulfate (STD)
 Foam sclerotherapy
Orbach 1944: the use of froth made by shaking a
syringe of sclerosant with air, resulted 10% more
effective than sclerosant alone.
(Am J Surg 1944;66:362-6)

Cabrera 1997: 500 lower-limbs with long-

saphenous veins (some with 20 mm Ø vein) and 8
cases of vascular malformation : after ≥ 3 years
81% saphenous vein remained occluded and 97%
superficial vein branches disappeared (1 session
86%, 2-3 session in 3% of patients). No
DVT/emboli *)

Henriet 1999: 10000 patients with reticular and Tessari method preparing foam *)
telangiectases, excellent outcome *)

Colleridge-Smith P 2002: after 1 year on 25 long

saphenous and 10 short saphenous veins 2 long Polidocanol
and 5 short saphenous veins showed
recanalisation. No recurrence. *) Coleridge-Smith P
www.bvi.uk.com/Foam2.pdf.
 Foam sclerotherapy
the principle of sclerosing mechanism
 Foam has a greater surface area than liquid,
which increase contact to endothelial surface
irritates the vein inner-wall and causes shrink
faster than liquid sclerotherapy,
 Foam is less dilution from blood,
 Foam displaces blood rather than simply mixing.

So, foam sclerotherapy works extremely well on

large thick wall veins on legs.
 Varicose vein 6 treatment options
analysed after 10 years
prospective, randomized, controlled trial
Belcaro G,Cesarone MR,Di Renzo A,Brandolini,Coen L,Acerbi G et al.Angiology.2003,54(3):307-15

 A. ‘standard’ low-dose sclerotherapy (0.5-1%)

 B. high-dose sclerotherapy (3%)
 C. Multiple ligations.
 D. Stab avulsion.
 E. Foam sclerotherapy.
 F. Surgery (ligation) followed by sclerotherapy.
 Results: when each procedure correctly performed
 All treatments may be similarly effective.
 ‘Standard’ low-dose sclerotherapy less effective than high-
dose sclerotherapy and foam sclerotherapy in selected
subjects resulted comparable to surgery.
 Union of
International
Phlebology
American
Chapter

Manchester Grand Hyatt

Hotel, San Diego,
August 27-Sept.1, 2003
 Sclerotherapy
Optimal Indications*
 Small (4-8 mm Ø),Medium sized
varicose veins (9-19 mm Ø),
 Large (20 mm Ø or >): 2-3 session.
 ( Grade 1-2 of Internal Hemmorrhoidal
disease )
Polidocanol ( Aethoxysklerol ® 3%* ) is
the only one sclerosing agent available and the most frequent
using in Indonesia.

*Kreussler Pharma: instruction for use

 Foam sclerotherapy
*)I=polidocanol; II=Na tetradecyl sulphate
 3 months closure: I - 89% II - 66%
 6 months closure: 85% 61%
 Skin reactions 1% 18%
 Systemic reactions 0% 5%
 Local inflammation 2% 22%
 Pain 1.7% 12%
 Vein thrombosis 7% 22%
 Tolerability (10 optimal,0 very bad) 8.9 2.8
 Saphenous vein:5 year closure 87% 68%
 10 year closure 85% 58%

*) Belcaro G,Cesarone MR,Dugall M,Griffin M,Di Renzo A,Ricci A.IUP World Congress Chapter Meeting, San Diego,USA,2003
 CVI Classification*
 Varicose vein (chronic venous insufficiency=CVI):
C.E.A.P.classification-
Class 0: no visible/palpable; Class 1:telangiectasia, reticular
vein; Class 2: varicose veins; Class 3: edema; Class 4:
pigmentation, eczema, lipodermatosclerosis; Class 5: with
healed ulceration; Class 6: active ulceration.
Etiology: Congenital (Ec); Primary (Ep); Secondary (post-
thrombotic, post-traumatic, others) –Es.
Anatomy: Superficial (As), Deep (Ad),Perforator (Ap).
Pathophysiology: Reflux (Pr), Obstruction (Po), Reflux and
Obstr. (Pro)

Varicose vein - dilated and tortuous vein

*Bergan JJ.Vascular Medicine.Saunders co.2000:1992-93

 Sclerotherapy
Formerly Less Optimal Indications*
 Symptomatic reflux
 Aged patient
 Who are not surgical patient

Questionable indications:
Reflux: Saphenous vein, Large varicosities
Now: clearly answered by foam sclerotherapy
as first line treatment in varicosity vein.**
*Bergan JJ.Vascular Surgery.Saunders Co.2000:2015
** Bergan JJ, Melkenas LV.Treatment of severe CVI with sclerosant foam.UIP World Congress Chapter Meeting,USA,2003.
Belcaro G, Cesarone MR.Treatment of venous aneurysm with foam sclerotherapy. UIP World Congress Chapter
Meeting.USA,2003
 Compression Sclerotherapy
Sclerosing Solutions*
 Category 1 :Strongest- Polidocanol 3%
(Aethoxysclerol® from Kreussler pharma); Na-tetradecyl
sulfate 1,5-3%;polyiodinated iodium 3-12%.
 Category 2: Strong-Polidocanol 1-2%
 Category 3: Moderate-Polidocanol 0.75%,
hypertonic NaCl 11.7%-23.4%
 Category 4: Weak-Polidocanol 0.25-0.50%
POLIDOCANOL is the lowest allergic and
anaphylactic incidence.*
* Bergan JJ, Vascular Surgery.WB Saunders.2000:2007-2020
 Normal Anatomy :
Saphenous vein

Unidirection valves in perforators

Saphenous vein (subcuticular)

Fascia

Deep vein (under fascial plane)

Vein Anatomy
Compression Sclerotherapy

Intraluminal injection Compression

Painful extravascular injection !!

Compression Sclerotherapy
 Compression Sclerotherapy

Blood Flow
 Compression Sclerotherapy
Required Materials :
Adrenalin 0.0001 & Corticosteroid

Micropore adhesive tape

1 ml syringe with 27G - 30G needle

 Micro-sclerotherapy (Ø1-2mm):
telangiectasia
Before injection after staining
 Foam sclerotherapy

After

Before
Macrosclerotherapy:
(Ø3-8 mm) TECHNIQUE
Elastic bandaging/stocking
Immediately post-injection
Maintained 3-4 weeks

Immediate Post-sclerotherapy jogging

 Compression Sclerotherapy

Technique
 Very slow injection: 10-15 seconds per
injection per 0.1-0.2 ml.
 The injection is done while the patient is
reclining, not standing !
 >5 mm vein: should be commpressed
immediately and be maintained after
injection without interruption using cotton
balls/gauze/foam rubber that be taped over
the site with hypoallergenic tape.
 Sclerotherapy:
The veins-should Not be injected
 Lower ⅓ of the leg Saphenous veins
and foot, particularly
the incompetent ankle
(Cockett) perforators,
veins in fat legs
(painful fat necrosis),
the areas of
postphlebitic stasis
dermatitis.
Saphenous anatomy & tests

Trendelenburg-Brodie Test for reflux

Perthes test for DVT

 post-sclerotherapy

 Post-sclerotherapy : immediate exercise

helps flushes out any sclerosant that have
leaked into the deep veins.
 Pigmentation – hemosiderin deposit in
the dermis- is prevented by the weaker
concentration of sclerosant, and slow
injection.
 Sclerotherapy
Side effects and Complications
 Pain
 Injection ulcer
 Extravascular staining,
black, painful.
 Cutaneous necrosis
 Pigmentation
 Damage to the nerve
 Thrombophlebitis
 Arterial occlusion
 Allergy, anaphylactic
 Sclerotherapy
Contraindications
 Inability to walk (advanced age with poor general
condition,ischemic limb, bed-ridden)
 Impaired lower limb arterial circulation (Grade 3-rest pain
and 4-ischemic ulcer Fountaine’s classification)
 Swollen legs/edema that cannot influence by compression
 Uncontrolled Diabetes mellitus.
 Acute severe heart disease (endocarditis, myocarditis)
 Episodes of difficulty breathing (bronchial asthma)
 The 1st trimester and after the 36th week of Pregnancy.
 Acute cellulitis
 Febrile states.
 Hystory of allergic reaction
 Sclerotherapy
Warnings

 Never be
injected into
artery !!
Sclerotherapy