Does competence of the terminal and/or pre-terminal valve influence the modalities of foam sclerotherapy for the treatment of trunk varices ? By Claudine HAMEL-DESNOS (France)

Terminal and preterminal valves must be differentiated from OSTIAL valves Tasch C, Brenner E. Phlebology. 2012;27(4):

Terminal and pre-terminal valves must be differentiated from the FEMORAL valve Cappelli M, Molino Lova R, Ermini S, Zamboni P. Int Angiol. 2004;23(1): Femoral valve (FV) (missing in 20-24% of cases) Terminal valve (TV) Pre-terminal valve C/R, compression/release test

GSV caliber also predicts the function/presence of a femoral valve Cappelli M, Molino Lova R, et al. Int Angiol. 2006;25(4): In case of incompetence of GSV trunk + incompetence of SFJ 1.FV incompetent/absent → GSV ≥ 8 mm 2.FV competent → GSV = 6-7 mm 3.TV(and FV)competent → GSV≤ 5mm Level of Ø = 15 cm below the groin GSV ≥ 8 mm GSV = 6-7 mm GSV≤5mm

Ultrasound-guided foam sclerotherapy (UGFS) and clinical trials: a review of the literature

Introduction  There are some data available regarding UGFS results and vein diameters.  Studies of sclerotherapy of the GSV that differentiate results between isolated GSV trunk incompetence and GSV trunk incompetence + SFJ incompetence are scarce.  None of these UGFS studies tackled FV incompetence

Can foam sclerotherapy be performed in large (>7 mm) incompetent GSVs? Ultrasound-guided foam sclerotherapy (UGFS) can be used for large GSVs according to  Cabrera J. (Phlebology, 2000): 9-32 mm  Barrett JM. (Dermatol Surg, 2004): >10 mm  Sica M. (Phlébologie, 2003): >8 mm But in O’Hare JL. (Eur J Vasc Endovasc Surg, 2008) results showed no significant difference in occlusion rate between veins 7 mm in diameter

Foam sclerotherapy for incompetent great saphenous vein  Coleridge Smith P. (Eur J Vasc Endovasc Surg, 2006)  Myers K. (Eur J Vasc Endovasc Surg, 2007)  Gonzalez-Zeh R. (J Vasc Surg, 2008) In these studies, better outcomes were obtained in saphenous trunks less than 5 to 6.5 mm in diameter. GSV ≤ 6.5 mm: Femoral and terminal valves found to be competent

GSV ≤ 8 mm: Femoral valve found to be competent Foam sclerotherapy for incompetent GSV and SFJ reflux Hamel-Desnos C, et al. Eur J Vasc Endovasc Surg. 2007;34: (multicentre study, 5 centres)  Recruitment : 148 patients  Included incompetent GSV: 4 to 8 mm in diameter  One (1) UGFS session, no reinjection  GSV incompetence with SFJ incompetence = 62%  GSV incompetence without SFJ incompetence = 38% Success rates at 2 years: 64% with SFJ incompetence 78% without SFJ incompetence (NS, Chi-square 0.22)

UGFS UGFS or TA TA Ø < 4-5 mm5 to 10 mm10 to 15 mm Surgery? UGFS : ultrasound-guided foam sclerotherapy TA : thermal ablation (radiofrequency or endovenous laser ablation) Foam sclerotherapy for incompetent GSV: indications according to GSV diameter GSV diameter Thigh level

Foam sclerotherapy for incompetent GSV: always the same technique, regardless of SFJ Direct puncture with needle Staged injections: for the GSV, the first injection is performed at the third median-upper third junction of the thigh GSV 1 st injection SSV 1 st injection

Foam sclerotherapy for incompetent GSV: doses to be injected, regardless of the vein to be ablated or the SFJ Tailored injections: concentrations depend on vein diameter volumes depend on the filling of the vein by foam and on venous spasm POL, polidecanol 1. Hamel-Desnos C. et al. Dermatol. Surg Hamel-Desnos C. et al. J Mal Vasc Hamel-Desnos C. et al. “The 3/1 Study”. Eur J Vasc Endovasc Surg Hamel-Desnos C. et al. in Traité de Médecine vasculaire Tome 2. Elsevier Masson SAS 2011.

Venous spasm 2 mn after the injection

The filling of the vein by foam: in case a 2 nd injection is needed

Sclerosis NEVER occludes the SFJ, and tributaries of the SFJ can flow in a physiological way 1-month follow-up8-year follow-up

Conclusion (1) There are good correlations between hemodynamic patterns in the SFJ and trunk diameters of the GSV In daily practice, the competence of the terminal and/or pre-terminal valve(s) does not influence the choice of UGFS treatment, and hemodynamic patterns of the SFJ are not a real concern The GSV diameter is a relevant criterion, easier to assess than hemodynamics in the SFJ

Conclusion (2) Recent data 1 confirm that the GSV diameter is a relevant criterion correlated with clinical class. Measurement of GSV diameter at the proximal thigh level is more sensitive and more specific than measurement at the SFJ. The diameter of the GSV at the proximal thigh level has a better correlation with reflux. 1. Mendoza E. et al. Great saphenous vein diameter at the saphenofemoral junction and proximal thigh as parameters of venous disease class. Eur J Vasc Endovasc Surg 2013;45: « Measuring at proximal thigh has a higher accuracy in prediction of clinics, of presence or not of reflux ». Mendoza et al 1