Microfoam ablation of the long saphenous vein Update Nalaka Gunawansa Vascular and Transplant Surgeon Vascular Symposium August 2011

Varicose veins – treatment options

Foam instead of liquid Stuard McAusland (1939): First Use of Froth in Telangiectasia with Shaking-the-Vial Technique Orbach (1944): the air block technique Orbach (1950); the use of foam for LSV Greater surface area of contact with a smaller volume of sclerosant Displaces blood and becomes more effective

1ml of 3% liquid STS injected in a vein dilutes with 10ml of blood Final drug concentration: 0.3% 1ml of 1% Foam STS injected in the same vein displaces blood Final drug concentration: 1%

2 disposable 10cc syringes A 3 way tap 2ml of 3% STS 8ml of room air (STS:Air = 1:4) Tessari L et al. A Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg 27:58-60, 2001

0.4% incidents or accidents: Immediate and midterm complications of sclerotherapy: report of a prospective multicenter registry of 12.173 sclerotherapy sessions. Guex JJ et al., Derm Surg 2005, 31: 123 0.4% incidents or accidents: 12 with liquid, 37 with foam Most numerous: 20 cases of transient visual disturbances (19 with foam or air block) 1 femoral thrombosis

Factors for DVT 1931 sessions of sclerotherapy in 852 patients 28 DVT (1.45%) – all asymptomatic Foam volume > 10 ml (OR 3.64) Vein diameter > 5 mm (OR 3.70) Myers K. et al Eur J Vasc Endovasc Surg. 2008

Systematic Review on Foam Sclerotherapy (69 trials) Complications DVT, PE < 1% Visual disturbances 1.4-2% Phlebitis 4.7% Matting, Hyperpigmentation 17.8% Jia X. et al. Brit J Surg 2007 Aug;94(8):925-36.

Ratio liquid : gas 0% 4% 19% 78% 27 74% 15% 81% 8% 62% 26 11% 16% 53%   1 + 1 1 + 2 1 + 3 1 + 4 1 + 5 others participants GSV 0% 4% 19% 78% 27 SSV Tributaries 74% Recurrent Perforaters 15% 81% Reticular 8% 62% 26 Telangiectasia 11% 16% 53% 19 Venous Malformations 5% 95%

Access Direct Puncture Open Needle, Butterfly, Short and long Catheter Open cut-down US guided >The majority of participants use “direct puncture“ to access the GSV and the SSV in foam sclerotherapy.

Safety aspects Safety during foam sclerotherapy of the GSV and SSV can be improved by: - Avoiding immediate compression of the injected areas - Using ultrasound to monitor foam distribution - Injecting a highly viscous foam - Ensuring there is no patient or leg movement for 2 to 5 minutes, no Valsalva manoeuvre or other muscle movement - Leg elevation (30 cm) during injection

Stucker et al. Dermatol Surg. 2010 Jun;36 Suppl 2:983-92

Stucker et al. Dermatol Surg. 2010 Jun;36 Suppl 2:983-92

Stucker et al. Dermatol Surg. 2010 Jun;36 Suppl 2:983-92

Stucker et al. Dermatol Surg. 2010 Jun;36 Suppl 2:983-92

Our experience University Vascular Surgical Unit, Colombo March 2004 to October 2008 284 consecutive patients with primary SF incompetence and /or above knee LSV reflux Prospectively randomized (Grooup-1, n=148) – standard SF ligation, stripping of LSV and multiple phlebectomy under GA/SA (Group-2, n=136) – High ligation of LSV and retrograde injection of foam sclerotherapy under LA Mean follow up 34 (18-72) months

Technique Local anaesthesia Day case Clinical localization of proximal LSV approx 3cm below SFJ Proximal ligation Distal insertion of 5Fr feeding tube/ ureteric catheter 10ml of foam (2ml STS, 8ml air) Visual analog pain score

Pre - op Post - op

CDU of a patient after 12 months L – SFJ R – LSV remains unidentifiable in the thigh

Post procedure Compression stocking Immediate mobilization Simple oral analgesics Follow up at 1,4, 8, 12 weeks; 6months, 12 months

Group 1 Standard surgery Group 2 Foam ablation N 148 136 Mean intra-op pain score ---- 3 Mean post-op pain score 1-2 P value NS Time to full activity 11d 6d

Conclusion Foam ablation is a useful tool in the armamentarium Cheap and effective Acceptable ablation/occlusion rates Strict adherence to safety precautions Learning curve