Foam sclerotherapy combined with surgical treatment for recurrent varicose veins: short term results.

OBJECTIVE: To study the short term results of combined peroperative foam sclerotherapy (PFS) and surgical treatment for recurrent varicose veins. METHODS: PFS was used to treat 129 limbs with recurrent varices: 100 great saphenous (GSV), 29 small saphenous veins (SSV). Foam was prepared with 1% polidocanol mixed with 4 times its volume of air. The 100 GSVs comprised 28 trunks directly connected with the femoral vein, 28 connected to a lymph node venous network, 11 associated with perforators and 33 isolated trunks. The 29 SSVs comprised 4 trunks directly connected to the popliteal vein, 7 isolated trunks, 15 popliteal perforators and 3 recanalisations after SSV stripping. All operations included phlebectomies. In twenty limbs re-ligation of the SFJ and 4 SPJs was carried out. All were performed under local anaesthesia in an ambulatory setting. Patients were assessed clinically and by colour duplex ultrasound after 3 and 40 days follow-up. RESULTS: 120 patients (93%) showed complete obliteration of saphenous trunks, junctions and varices. The 9 incomplete obliterations were 3 venous recanalisations in the SSV compartment and 6 perforators (4 popliteal and 2 femoral). Two asymptomatic deep venous thromboses were detected by colour duplex 3 days after operation. CONCLUSION: PFS facilitates surgical treatment of recurrent varicose veins. There is a small risk of post-operative deep vein thrombosis.     

Systematic review of foam sclerotherapy for varicose veins

BACKGROUND AND METHOD: Foam sclerotherapy is a potential treatment for varicose veins. A systematic review was undertaken to assess its safety and efficacy. RESULTS: Sixty-nine studies were included. The median rates of serious adverse events, including pulmonary embolism and deep vein thrombosis, were less than 1 per cent. The median rate of visual disturbance was 1.4 per cent, headache 4.2 per cent, thrombophlebitis 4.7 per cent, matting/skin staining/pigmentation 17.8 per cent and pain at the site of injection 25.6 per cent. The median rate of complete occlusion of treated veins was 87.0 per cent and for recurrence or development of new veins it was 8.1 per cent. Meta-analysis for complete occlusion suggests that foam sclerotherapy is less effective than surgery (relative risk (RR) 0.86 (95 per cent confidence interval (c.i.) 0.67 to 1.10)) but more effective than liquid sclerotherapy (RR 1.39 (95 per cent c.i. 0.91 to 2.11)), although there was substantial heterogeneity between studies. CONCLUSION: Serious adverse events associated with foam sclerotherapy are rare. There is insufficient evidence to allow a meaningful comparison of the effectiveness of this treatment with that of other minimally invasive therapies or surgery.     

Foam sclerotherapy for the treatment of varicose veins

Treatment of venous insufficiency with liquid sclerotherapy is considered by some to be an unfulfilled promise. It was heralded in the first half of the last century to be a replacement for surgery, but as recurrences of varicose veins appeared in limbs treated with injection techniques, surgery reappeared and was dominant in the last half of the century. Just as saphenous stripping was proved to be superior to proximal ligation, both were replaced by use of electromagnetic energy, such as radiofrequency and laser venous ablation, as a means of taking the saphenous veins out of the circulation. Now reports of recurrent varices in 20 to 50% of operated cases are making some physicians look to alternatives in treating varicose veins. Foam sclerotherapy must be looked upon as an entirely new method of treatment. It is useful in all types of varices and is proven to be safe, simple, cheap, reliable, and repeatable.     

Indications and technique for sclerotherapy of varicose veins

Sclerotherapy is in general a very safe method for the treatment of teleangiectasias and reticular varicose veins done by an experienced therapist. The complication-rate is very low, with the use of Polidocanol the rate of skin-necrosis ranges between 0.001 and 0.2%, the incidence of superficial thrombophlebitis is 0.08%, the incidence of an allergic reaction is reported with 0.2%. The sclerotherapy of large perforating veins and the long or short saphenous veins is controversially discussed. The results of prospective randomized studies show better results with operative treatment in comparison to sclerotherapy. The recurrence-rate of sclerotherapy of the long saphenous vein varies between 22 and 37% after 3 years, between 40 and 70% after 5 years and 94% after 10 years. Before starting the sclerotherapy the extension of the varicose vein disease should be diagnosed correctly. The diagnosis can be obtained with duplex-ultrasound, that gives either functional and morphologic information about the deep and superficial venous system.     

Ultrasound-guided foam sclerotherapy for the treatment of varicose veins

BACKGROUND: The aim was to assess the early efficacy and complications of ultrasound-guided foam sclerotherapy (UGFS) in a cohort of patients with varicose veins. METHODS: Of 192 consecutive patients referred with varicose veins over 15 months, only 11 chose surgery; the rest underwent UGFS treatment. Polidocanol was foamed 1 : 3 with air. Under ultrasound control via butterfly or Seldinger cannulation, 1 per cent foam was injected into superficial veins and 3 per cent foam into saphenous trunks, up to a total volume of 14 ml. Outcome was defined as complete when occlusion of the saphenous trunk and/or over 85 per cent of the varicosities was achieved, and partial closure when less. RESULTS: In 163 legs, complete occlusion occurred after one intervention, a further 32 after a second, and one after a third (overall 91 per cent). Of the remainder, all other legs achieved partial occlusion after up to three interventions, apart from two legs with great saphenous vein (GSV) incompetence, which failed. All 23 legs with small saphenous veins had complete occlusion after one intervention compared with 64 of 97 legs with GSV incompetence (P < 0.010). Occlusion rates were also higher when the GSV was cannulated directly: 56 of 70 versus 8 of 27 (P < 0.001). CONCLUSIONS: UGFS achieved early complete occlusion safely in over 90 per cent of legs with varicose veins.     

Integration of patient safety technologies into sclerotherapy for varicose veins

The American College of Surgeons, the Joint Commission, the Needlestick Safety and Prevention Act, and the Occupational Safety and Health Administration all direct surgical departments, including vascular surgeons who supply sclerotherapy services, to develop formal mechanisms to improve the safety of the patient and health care worker (HCW), including integration of new safety technologies. The purpose of the present study was to identify and evaluate new safety technologies for outpatient sclerotherapy for chronic venous disease. Using national resources for patient safety and literature review, the following safety technologies were identified: (1) a safety needle to reduce inadvertent needlesticks to workers, and (2) the reciprocating procedure device (RPD) to reduce iatrogenic injuries to patients. Both devices were evaluated in the clinic, and physician responses were determined. Although the safety sheath of the needle was somewhat bulky and could interfere with the ultrasound transducer, sclerotherapy could be performed with it. The RPD safety device required instruction to show how the RPD functioned ("push-push" to aspirate-inject with the RPD rather than the usual "push-pull" with the conventional syringe), but the RPD permitted better needle control and more precise injections. The RPD was well accepted by physicians who found it to be convenient, safer, and less painful. Subsequently, the involved services successfully integrated these safety technologies into their routine clinical practices. As recommended by the Joint Commission, safety technologies can be successfully evaluated and introduced into the clinic to improve patient and HCW safety during physician-performed syringe and needle procedures, including sclerotherapy.     

Stripping operation with sclerotherapy for primary varicose veins due to greater saphenous vein reflux: three-year results

The purpose of this study was to compare the recurrence-free rates of stripping with varicectomy and stripping with sclerotherapy for the treatment of primary varicose veins due to greater saphenous vein insufficiency. This is a multicenter retrospective analysis of 186 patients and 220 limbs treated for primary varicose veins due to greater saphenous vein reflux from January 1996 to December 1997. The difference between the two groups was evaluated by the Chi(2) test or t-test. The recurrence-free rates were estimated by the Kaplan-Meier life-table method. The mean follow-up period was 3.2 +/- 1.1 years. The clinical backgrounds of patients with varicectomy stripping and sclerotherapy stripping were not significantly different between the two groups. The overall recurrence-free rates at 1 and 3 years were 97.0% and 91.4%, respectively. The recurrence-free rates at 3 years were 93.5% for stripping with varicectomy and 88.6% for stripping with sclerotherapy. No statistical difference was found between the two groups. The recurrence rate after stripping with sclerotherapy was equivalent to that after stripping with varicectomy. Thus concurrent varicectomy can be replaced with sclerotherapy.     

Endoscopic sclerotherapy of esophageal varicose veins in portal hypertension

The results of endoscopic sclerotherapy (EST) in the patients with portal hypertension (PH) are analyzed. Efficacy of methods in the treatment of gastroesophageal varicosity in urgent situations (bleeding) and "cold" period was evaluated. Schemes of staged minimally-invasive surgical correction of PH syndrome are described. Etoxisclerol is regarded as the most appropriate sclerosant. It is concluded that EST is an effective method of treatment in PH, it is alternative to "open" abdominal surgery and may improve results of treatment in this group of patients.     

Assessment of the results of surgery for varicose veins.

Fifty-six patients undergoing primary surgery for unilateral varicose veins by a standardized Trendelenburg procedure were reviewed postoperatively by a panel of three observers. Agreement between the observers was high in assessing symptomatic response (up to 98%), but only moderate in evaluation of any visual changes in affected legs (60%). Moreover, intr-observer agreement comparing symptomatic response and visual impression was very low (30-4%). It is suggested that inter-series comparisons should be made solely upon the response of specific symptoms to treatment.     

Prolonged bandaging is not required following sclerotherapy of varicose veins

Following sclerotherapy of varicose veins, 158 limbs of 154 patients were randomized to be bandaged with either crepe or Coban for 6 weeks each, or with Coban for 3 days only. Objective assessment of vein eradication and subjective evaluation of symptoms 3 months after completion of treatment showed no clear differences between these regimens. Significantly more discomfort was experienced with Coban than crepe when used for 6 weeks. It is suggested that, following sclerotherapy, 3 days is an adequate period of bandaging when using Coban. Such a policy would considerably reduce the inconvenience to patients during treatment.     

Follow-up results of carotid angioplasty with stenting as assessed by duplex ultrasound surveillance

BACKGROUND: Carotid artery stenting (CAS) has become an alternative modality to carotid endarterectomy (CEA) for the treatment of carotid occlusive disease. We report a retrospective review of our institution's experience with CAS versus CEA. METHODS: Postprocedure surveillance duplex, recurrent symptoms, postprocedure strokes, progression of lesions, and rates of re-operation were analyzed in 46 patients who underwent CAS and 48 patients who underwent CEA. The mean length of follow-up evaluation was 13 months. All CAS procedures included neuroprotection devices. RESULTS: Statistically significant differences in progression to critical restenosis (2% vs 2%, P = 1.0), rate of subsequent symptoms or stroke (2% vs 10%, P = .1), or rate of re-interventions were not observed between CAS and CEA groups (2% vs 4%, P = .98). Total mortality (0% vs 2%, P = .33), and the occurrence of major adverse events (2% vs 10%, P = .18) also were not significantly different in the CAS compared with the CEA patients. The average rate of increase in internal carotid velocity at 6 to 12 months (-1% vs 1.1%, P = NS) and 12 to 24 months (-5% vs -6.5%, P = NS) also were equivalent. CONCLUSIONS: Our observed results indicate that CAS may be performed with comparable clinical outcomes and durability of repair comparable with CEA.