Foamed Sclerosant Ablation of Saphenous Veins and Varices

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Foamed sclerosant ablation is a safe and effective treatment for saphenous veins and superficial varicosities. Thermal ablation currently competes successfully with foam for treatment of saphenous veins in the United States, and ambulatory phlebectomy competes with foam for treatment of tributary veins and localized varicosities, especially when these are large.

Sclerotherapy is the chemical ablation of abnormal veins. The modern goal of therapy is irreversible fibrotic occlusion, followed by reabsorption of the target vessel. Absence of endothelium and subendothelial edema are seen within 2 minutes of foam injection. At 15 minutes, necrosis of the vein wall into the tunica media is seen. ^[1]

Sclerotherapy is an old technique that was revolutionized by technologic advances. ^{[2, 3]} Foaming detergent sclerosants offered increased potency and could be visualized by means of ultrasonography. Ultrasound guidance allowed better anatomic visualization, greater hemodynamic understanding, more precise foam targeting and delivery, and monitoring for unwanted foam passage into deep veins. ^[4] With these advances, sclerotherapy has now become a competitive treatment for any type or size of vein.

Sclerotherapy’s development has been limited somewhat by the wide range of techniques available. This practice variation has yielded varying results and has made generalizing about the procedure more difficult. The differences between techniques have now begun to be tested, however, and the resulting knowledge has improved overall results. Two European Consensus Meetings on Foam Sclerotherapy ^[5] determined consensus opinions on the basis of the views of a panel of experienced sclerotherapy experts. European guidelines for foam sclerotherapy in chronic venous disorders were published in 2014. ^[6]

Foam can be used to treat almost any abnormal vein. It is most effective for veins less than 6-7 mm in diameter but can be effective for veins of almost any diameter if excellent technique is employed. ^[7] Sclerotherapy produces minimal procedural and postprocedural pain. It is easier to perform than most alternative strategies. Even with improved recent techniques, however, the need to repeat treatment is significant.

Currently, in the United States, endovenous thermal ablation and surgical ligation and stripping are performed more often than sclerotherapy for saphenous veins. ^{[8, 9]} Ambulatory phlebectomy is an alternative for tributary veins or localized varicosities, especially at larger vein diameters. Surface laser therapy can be used for telangiectasias and reticular veins, but liquid sclerotherapy is considered first-line therapy for these veins on the lower extremity.

Relative contraindications to foam sclerotherapy include the following:

Evaluation of the location and severity of venous disease should be carried out, and alternative diagnoses should be considered.

Grossly, the venous system is composed of venules and small and great veins, which serve to return blood from tissues to the heart. The systemic venous system brings deoxygenated blood from tissues and organs back to the right atrium of the heart, whereas the pulmonary venous system brings oxygenated blood from the pulmonary circulation back to the left atrium of the heart.

The systemic venous channels are further classified as superficial veins, deep veins, or venous sinuses. The superficial, or cutaneous, veins reside just beneath the surface of the skin. They channel blood from cutaneous tissues to deep veins via perforations in the deep fascia. Most of the deep veins share routes with the arteries, and many are enclosed in the same sheaths. Venous sinuses are present only within the skull.

For more information about the relevant anatomy, see Venous Drainage Anatomy.

In patients with evidence of chronic venous disease (eg, varicose veins, telangiectasias, extremity pain or swelling worsened by standing and improved by elevation, or skin changes around the ankle area), a careful history and physical examination are necessary. Duplex ultrasonography should be performed to permit assessment of the venous anatomy and hemodynamics. Superficial, perforator, and deep venous systems are examined for obstruction or reflux. Venous reflux is retrograde blood flow of over 0.5 seconds in the saphenous system.

The symptoms of chronic venous disease all have a large differential diagnosis. Because varicose veins (see the image below) produce symptoms ranging from none to severe, alternative explanations for patient symptoms should be entertained. Three related venous diseases that result in patient presentation with symptomatic varicose veins are iliac vein obstruction, pelvic congestion syndrome (PCS), and vascular malformation.

Iliac vein obstruction can be caused by thrombosis or by anatomic compression of the iliac vein (usually by the iliac artery). The diagnosis is generally missed on standard lower-extremity duplex ultrasonography. It should be considered in patients who have symptoms and signs that are out of proportion to the reflux seen. Patients with a history of thrombosis or duplex signs indicative of prior thrombosis are also to be at higher risk. Exercise claudication (pain with exercise) is a more specific but less sensitive symptom.

Intravascular ultrasonography, magnetic resonance venography (MRV), computed tomographic venography (CTV), and standard venography are all used for diagnosis, depending on the practitioner’s preference. Stent placement is often effective in relieving patient symptoms.

Some extremity varices originate in the pelvis. PCS can produce varices at the vulva, the proximal medial thigh, the buttocks, and the perianal area. The source is typically in the ovarian or internal iliac vein systems. The pathophysiology is analogous to that of male varicocele. Pelvic pain that is worse with standing or after intercourse suggests PCS. Patients may have a history of vulvar varicosities during an earlier pregnancy. They may also have urinary frequency or irritable bowel syndrome.

Ultrasonography, standard venography, MRV, and CTV are all used for diagnosis, depending on practitioner preference. Typical treatment is ablation with coils with or without sclerotherapy.

Patients with evidence of a vascular malformation, such as lesions manifesting early (often at birth or puberty) or abnormal anatomy or blood flow on ultrasonography, should undergo further testing, usually with magnetic resonance angiography (MRA), to determine whether the abnormality is a high-flow malformation or a low-flow malformation. ^[10]

Such malformations should be treated by a team comprising multiple disciplines, often including phlebology, vascular surgery, plastic surgery, dermatology, and orthopedic surgery. Low-flow venous malformations can often be treated successfully with foam sclerotherapy by practitioners experienced in handling these abnormalities. ^[11]

Compression after foam injection improves the efficacy of the procedure and reduces the risk of DVT and superficial phlebitis. Some research suggests that there is a benefit to continuing postsclerotherapy compression for as long as 6 weeks, but these data must be balanced against the likelihood that many patients will be reluctant to comply with physician instructions for long-term compression.

The authors typically use a 20-30 mm Hg compression hose that covers the area treated (either knee high or thigh high) day and night for 2 weeks. Large varicosities are initially (ie, for the first 48 hours) compressed with a localized compression dressing of cotton gauze and self-adherent elastic wrap in the hope of reducing the risk of trapped blood.

In a randomized, controlled trial, polidocanol microfoam to be proved noninferior to nonspecific surgical therapy for treatment of saphenous vein reflux. ^[12]

In a meta-analysis, ultrasound-determined pooled saphenous ablation rates at 3 years were 77% for foam, 78% for stripping, 84% for radiofrequency ablation, and 94% for laser ablation. ^[13]

In one study, sclerofoam injection improved ulcer healing rates in patients with severe chronic venous insufficiency. ^[14]

Thermal (laser or radiofrequency) ablation is currently recommended over foamed sclerosant ablation for saphenous veins. ^{[15, 16, 17]}

Orsini C, Brotto M. Immediate pathologic effects on the vein wall of foam sclerotherapy. Dermatol Surg. 2007 Oct. 33(10):1250-4. [Medline].

Hobbs JT. Surgery and sclerotherapy in the treatment of varicose veins. A random trial. Arch Surg. 1974 Dec. 109(6):793-6. [Medline].

Cabrera J, Cabrera J Jr, Garcia-Olmedo MA. Treatment of varicose long saphenous veins with sclerosant in microfoam form: long-term outcomes. Phlebology. 2000. 15:19-23.

Kumar S, Bhavana K, Kumar S, Kumar P. Ultrasound-guided polidocanol foam sclerotherapy for treating venous malformations. J Clin Ultrasound. 2017 Oct 28. [Medline].

Breu FX, Guggenbichler S, Wollmann JC. 2nd European Consensus Meeting on Foam Sclerotherapy 2006, Tegernsee, Germany. Vasa. 2008 Feb. 37 Suppl 71:1-29. [Medline].

[Guideline] Rabe E, Breu FX, Cavezzi A, Coleridge Smith P, Frullini A, Gillet JL, et al. European guidelines for sclerotherapy in chronic venous disorders. Phlebology. 2014 Jul. 29 (6):338-54. [Medline]. [Full Text].

Myers KA, Jolley D, Clough A, Kirwan J. Outcome of ultrasound-guided sclerotherapy for varicose veins: medium-term results assessed by ultrasound surveillance. Eur J Vasc Endovasc Surg. 2007 Jan. 33(1):116-21. [Medline].

Lawaetz M, Serup J, Lawaetz B, Bjoern L, Blemings A, Eklof B, et al. Comparison of endovenous ablation techniques, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Extended 5-year follow-up of a RCT. Int Angiol. 2017 Jun. 36 (3):281-288. [Medline].

Ran F, Shi Y, Qiao T, Shang T, Liu Z, Liu CJ. Comparison of Foam Sclerotherapy Alone or Combined With Stripping of the Great Saphenous Vein for Treating Varicose Veins. Dermatol Surg. 2017 Apr. 43 (4):541-547. [Medline].

Blaise S. [Vascular medicine and foam sclerotherapy for venous malformations]. J Med Vasc. 2017 Oct. 42 (5):315-319. [Medline].

Azene E, Mitchell S, Radvany M, Agrawal N, Eisele D, Weiss C. Foamed bleomycin sclerosis of airway venous malformations: The role of interspecialty collaboration. Laryngoscope. 2016 Dec. 126 (12):2726-2732. [Medline].

Wright D, Gobin JP, Bradbury AW, et al. Varisolve polidocanol microfoam compared with surgery or sclerotherapy in the management of varicose veins in the presence of trunk vein incompetence: European randomized controlled trial. Phlebology. 2006. 21:180-190.

van den Bos R, Arends L, Kockaert M, Neumann M, Nijsten T. Endovenous therapies of lower extremity varicosities: a meta-analysis. J Vasc Surg. 2009 Jan. 49(1):230-9. [Medline].

Pascarella L, Bergan JJ, Mekenas LV. Severe chronic venous insufficiency treated by foamed sclerosant. Ann Vasc Surg. 2006 Jan. 20(1):83-91. [Medline].

Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011 May. 53(5 Suppl):2S-48S. [Medline].

van der Velden SK, Biemans AA, De Maeseneer MG, Kockaert MA, Cuypers PW, Hollestein LM, et al. Five-year results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins. Br J Surg. 2015 Sep. 102 (10):1184-94. [Medline].

Brittenden J, Cotton SC, Elders A, Ramsay CR, Norrie J, Burr J, et al. A randomized trial comparing treatments for varicose veins. N Engl J Med. 2014 Sep 25. 371 (13):1218-27. [Medline].

Hamel-Desnos C, Ouvry P, Benigni JP, Boitelle G, Schadeck M, Desnos P, et al. Comparison of 1% and 3% polidocanol foam in ultrasound guided sclerotherapy of the great saphenous vein: a randomised, double-blind trial with 2 year-follow-up. “The 3/1 Study”. Eur J Vasc Endovasc Surg. 2007 Dec. 34(6):723-9; discussion 730. [Medline].

Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg. 2001 Jan. 27(1):58-60. [Medline].

Myers KA, Roberts S. Evaluation of published reports of foam sclerotherapy: what do we know conclusively?. Phlebology. 2009 Dec. 24(6):275-80. [Medline].

Guex JJ, Allaert FA, Gillet JL, Chleir F. Immediate and midterm complications of sclerotherapy: report of a prospective multicenter registry of 12,173 sclerotherapy sessions. Dermatol Surg. 2005 Feb. 31(2):123-8; discussion 128. [Medline].

Myers KA, Jolley D. Factors affecting the risk of deep venous occlusion after ultrasound-guided sclerotherapy for varicose veins. Eur J Vasc Endovasc Surg. 2008 Nov. 36(5):602-5. [Medline].

Morrison N, Neuhardt DL. Foam sclerotherapy: cardiac and cerebral monitoring. Phlebology. 2009 Dec. 24(6):252-9. [Medline].

Guex JJ. Complications and side-effects of foam sclerotherapy. Phlebology. 2009 Dec. 24(6):270-4. [Medline].

Mowatt-Larssen E. Management of secondary varicosities. Semin Vasc Surg. 2010 Jun. 23(2):107-12. [Medline].

Eric Mowatt-Larssen, MD Assistant Professor of Surgery, Duke University Medical Center

Disclosure: Received consulting fee from BTG International, Inc for consulting.

Cynthia K Shortell, MD Professor of Surgery, Associate Professor of Radiology, Chief of Vascular Surgery, Program Director, Vascular Surgery Residency Program, Duke University Medical Center

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Surgical Association, Pacific Coast Surgical Association, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Western Vascular Society

Disclosure: Nothing to disclose.

Foamed Sclerosant Ablation of Saphenous Veins and Varices

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