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

2. Varicose veins – treatment options

3. 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

4. 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%

6. 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

7. 0.4% incidents or accidents:
Immediate and midterm complications of sclerotherapy: report of a prospective multicenter registry of 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

8. 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

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

11. 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%

12. 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.

13. 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

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

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

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

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

18. 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

19. 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

21. Pre - op
Post - op

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

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

25. 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

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