Sclerotherapy and Diagnosis Abstracts from the Congress of the American College of Phlebology

Mid term follow-up of foam sclerotherapy for medium and large size veins
Alessandro Frullini, MD, FACS

Foam sclerotherapy has recently renewed the interest in sclerosing treatment of medium-large size veins. In 1993 Cabrera begun to use a micronized form of polidocanol (POL) or sodiumtetradecyl sulphate (STS) introducing a new concept in sclerotherapy: the foam with its displacing effect was capable to produce a better and more stable endosclerosis because of the controlled administration of the drug. In fact the complete absence of blood, pushed away from the bolus of foam injected, gave the chance of a controlled and predictable concentration inside the tract of vein to be treated. Moreover a new parameter was introduced: the time of exposure to the sclerosant was then controllable because of the unique properties of foam.

From that time many other techniques of foam production were introduced. Now it is possible to classify sclerosing foam according to different parameters: we can identify 1) extemporary foam and 2) standardized or industrial foam; moreover we can classify foams according to the size and the range of variation of bubble's size(1- froth, 2-foam, 3-minifoam and 4- microfoam). We have treated 56 venous districts at the beginning of 2000 with a sclerosing foam produced with STS according to the Tessari method. The patients were studied with duplex or color doppler analyzing and recording the anatomy and the emodinamic pattern. Moreover digital pictures of the limbs were taken. During the entire period of observation additional duplex scan were made and digital pictures taken.

The mean concentration of STS used to produce foam was 1.6% and a mean of 2.7 ml of foam were administered per session. Only in 1 vein spasm was not achieved. According to initial outcome we had 52 good results, 3 partial occlusion and 1 failure.

We are presenting the follow up of these patients at 18 months, analyzing different parameters as type of vein treated, size, initial spasm and STS concentration, aiming to identify the possible predictive factors of success and the reasons for failure.

Duplex Guided Foam Sclerotherapy (DGFS): A 12 Month Follow-Up Study
Rodrigo Ernesto González Zeh MD, FACP

Objective: Evaluate the treatment using Polidocanol foam under duplex guidance of the long safenous vein (LSV) incompetence, short safenous vein (SSV) insufficiency or long safenous vein junk recurrences (LSVJR) after surgery.

Material and Method: Patients C 0 - 5 E p A s P r, which presented incompetence of the LSV, SSV or LSVJR. Evaluation consisted of: physical examination and Color Duplex scan. Patients should have NO contraindications for sclerotherapy and gave informed consent.

230 patients were included, a total of 325 DGFS were made, 214 incompetent LSV, 84 SSV and 27 LSVJR. DGFS consisted guided injection using Polidocanol 6%, 3% or 1% foam and Class I compression stockings. We looked for complications 1, 2 and 3 weeks after the treatment and followed up patients up to 12 month with Duplex scan.

Results: Complications for each procedure included: matting (5,5%), pigmentation (3,7%), perimaleolar edema (3,4%) and superficial thrombophlebitis (1,9%). No DVT or intra-arterial injections were observed.

23 patients were followed up for 12 months, no reflux was observed (0/23), 67 for 6 months, 1.5% of this patients presented reflux (1/67). 140 patients were followed up for 3 months, 1.4% of them had reflux (2/140). Reflux was only founded in the LSV.

Conclusion: Treatment of venous insufficiency due to LSV incompetence, SSV reflux or LSVJR using DGFS is a safe procedure with few recurrences and no severe complications.

Investigating the Superficial Lymphatic System with Color Doppler Ultrasound and Integration with Sclerotherapy Treatment
J. Leo Harry, MD and Elizabeth A. Mudge, RDMS

Findings of lymphatic vein varicosities of inguinal node origin have previously been reported by a limited number of authors, implicating lymphatic system involvement with varicose vein disease of the lower extremities. Sources of information that describe detailed pathophysiological relationships between the superficial lymphatic venous systems are at present, limited, at best.

Three years, utilizing high frequency color Doppler ultrasound for evaluation has enabled us to image and document numerous findings of the anatomical and hemodynamic relationships between the superficial lymphatic and venous systems of the lower extremities in conjunction with varicose vein disease. Scans, both prior to and again 30 minutes subsequent to treatment with sclerotherapy enabled us to evaluate treatment methods and assess pathological changes when compared.

Findings, when treated accordingly, include: cases of normalized flow in lymphatic veins status post treatment of varicose vein disease. Accelerated fibrotic changes of the GSV seen at three, six and 12 months intervals due to markedly diminished neovascular activity seen on follow-up scans which correlate with findings of marked decrease in the hyper-inflammatory response seen post treatment and secondary to further lymphatic insult.

The Role of Hormones in the Results of Sclerotherapy and Post-Treatment Complications
Neil S. Sadick, MD, FACP

Introduction: Estrogen and progesterone derivatives are felt to play an important role in the etiology of telangiectatic and varicose vein disease. They have also been felt to diminish sclerotherapeutic efficiency and increase the incidence of side effects such as telangiectatic matting.

Materials and Methods: 100 female patients (mean age 39) were entered into the study; 50 patients were on OCP or ART (hormone replacement therapy) and 50 patients entered as control subjects during their sclerotherapy treatment regimen.

Clearing in a 5 cm2 grid of Class I-II telangiectasias/venulectasia (0.1-2.0mm) were carried out utilizing sodium tetradecyl sulfate 0.25%.

A maximum of three treatment sessions was carried out at 4-week intervals. 18 mm Hg post-sclerotherapy compression was carried out during waking hours for three weeks. Follow-up was carried out at weeks 1, 6, 12 and 24.

Results: A statistically greater degree of vessel clearing was noted in the group of patients not on hormone therapy at the time of sclerotherapy (P ³ 0.05).

A statistically increased incidence of TM was noted in the hormone replacement study population while bruising and hyperpigmentation did not differ in the hormone vs. control patient populations.

Conclusions: Diminished sclerotherapy therapeutic efficiency and increased incidence of telangiectatic matting may ensue in patient on hormone therapy at the time of the vein treatments.

Telangiectasias: Origin and Treatment with a Foam Sclerosing Agent
Michel Schadeck, MD

Many methods have been proposed for treating telangiectasias and reticular varicose veins. Their multiplicity betray their relative efficacy. The presence of telangiectasias is often the witness of a complex incompetent subjacent hypodermic network. In practice, the standard treatment of telangiectasias is microsclerotherapy and a "blind" injection of a sclerosing agent in the reticular veins is at the present time the therapeutic answer for treating the incompetent subjacent network.

The simultaneous use of a foam sclerosing agent and Duplex with a height frequency probe is a method to explore the hypodermic and intramuscular nutrient veins. The foam becomes a hemodynamic tracer. In connecting this method with the transillumination and even a scanner, the drawing up of a reticular mapping becomes possible. Different examples will be presented during the communication.

In the short-term, owing to a better pathophysiologic understanding of this network, it would be desirable if new comparative studies evaluate the efficacy of available treatments. The "foam block" of polidocanol is a promising treatment because it embolizes the vessels and spreads at a low speed, "burning" the vessels at the origin of the telangiectasias.

Effective Sclerotherapy Of Reticular And Telangiectatic Veins of Challenging Locations
Simon J. Simonian, MD, ScD, (Hon.) DSc, FACS, FRCSE

Objective: To determine the effectiveness of sclerotherapy of reticular and telangiectatic veins in difficult areas.

Methods: Reticular veins measuring 3-8 (mean 5) mm in diameter of the foot (n=20), hands (n=10), wrist (n=10), forearm (n=6), arm (n=4), breast (n=4) and pudental veins (n=30) and telangiectatic veins and "bleeding blebs" measuring 0.5 - 3.0 (mean 1.0) mm in diameter, of the ankle and foot (n=100) were treated with sclerotherapy. 95% were female. Sodium tetradecyl sulfate 0.5-1.0% was used. Injection of digital and eye vessels were avoided.

Results: 70% of reticular veins responded with a single injection. The rest required a second or a third injection. 80% of telangiectatic veins were sclerosed with a single injection. The remainder needed a second or a third injection. Sclerosis of reticular veins were uniformly satisfactory with no complications. Sclerosis of telangiectatic veins were satisfactory in 94%. Six patients developed "matting" and 2 had small necrotic ulcers that healed. No injuries to vessels of digits or eyes occurred.

Conclusion: Sclerotherapy of veins in difficult areas when administered with precautions can be highly effective.

"The CO² Bolus Method" A New Field of Clinical Application and Research in Sclerotherapy
Adalberto Urbina Quintana, MD

The study is aimed to demonstrate that a previous bolus of CO² in a volume of 10 to 15 ml at every injection site, followed by injection of sclerosant, by producing an empty vein, allows an excellent way to sclerose large veins with very low concentration of sclerosing agent and lower secondary effects. At the same time, resulting in a safe method easy to perform, and superior to standard method for sclerotherapy.

120 patients with large varicose veins were included in the study. The vein is approached with a 25 gauge butterfly needle or a 26 gauge needle, at the selected sites. With the patient recumbent, the injection of 10 to 15 ml of CO² charged in a 60 ml syringe is flushed into the vein, immediately followed by 0.75 to 1 ml of sclerosing solution, using a 12 ml syringe.

Results: 60% of cased were sclerosed with the first treatment. A second or more treatments at higher concentration were necessary in the remaining cases.

With this method any large varicose vein could be sclerosed with a concentration of 0.18 to 0.5 of Polidocanol.

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