Varicosclerotherapy foam sclerotherapy

Procedure for sclerosing varicose veins with foamed sclerosants. Compared to liquid sclerotherapy, foam is more effective with an almost identical side effect profile. The advantage of foam sclerotherapy is the good visualization of the foam in duplex sonography.

• approved indication varicose veins. Mainly for the treatment of larger or large-calibre varicose veins and for recurrent varicoses.
• off label but also successful use in seroma and malformations.

Foam production:

• Technique according to Monfreux (comparatively rarely used): By retracting the plunger in a glass syringe which is tightly closed at the front, a vacuum is created which leads to an inflow of air, resulting in a coarse-bubbled, rather liquid foam.
• Tessari technique (frequently used method): By turbulent mixing of liquid and air in two syringes connected by a 3-way cock, a foam quality is produced which is liquid in low concentrations of the sclerosing agent and more viscous in higher concentrations. The mixing ratio of sclerosing agent to air is 1:4-5.
• Double syringe system (DSS system; frequently used method): Polidocanol is mixed with air in a sclerosing agent to air ratio of 1:5 by turbulent mixing in two syringes connected by a connector. The product is a fine bubbled, rather viscous foam.
• Spider veins/small lumen veins: Application of liquid sclerosing agents or liquid foams, viscous foams are not indicated here. Max. 0.5 ml foam per injection
• The foam must be produced immediately before injection.

Injection:

• The puncture/injection should be duplex controlled.
• The injection should be carried out lying down! It is not necessary to elevate the leg (in the past this was propagated). The application can be done via direct puncture or via a catheter, if necessary in combination with an endoluminal thermal procedure (e.g. radio wave).
• According to the European consensus conference, a maximum amount of 10ml of foam should not be exceeded per session. Larger foam quantities lead to a higher rate of neurological and thrombotic complications. The amount of foam to be applied depends on the diameter of the vein to be treated - the larger the diameter, the more volume is required. The larger the required volume, the more viscous the foam should be.
• Impression of the crosses with the duplex head when foam sclerosing a truncal vein is outdated.
• After foam sclerotherapy of large varicose veins, a higher percentage of patients experience vasospasm of the sclerosed vein (positive correlation between spasm and good therapy results).

Aftercare:

• Before applying compression, it is advisable to wait a few minutes in order to avoid premature displacement of the sclerosing foam to other regions.

S.u. Sclerotherapy.

• Special features of foam sclerotherapy in comparison to liquid sclerotherapy - more frequent:
  • passagere neurological deficits, especially migraine headaches and visual disturbances
  • Hyperpigmentations

• Cave! Danger of sclerosing foam rising and penetration into the deep vein system exists if used improperly!

• Notice! Foam sclerotherapy belongs in the hands of phlebologically trained physicians experienced in sclerotherapy.

the contraindications for sclerotherapy in general apply. For foam sclerotherapy additionally:

• known open Foramen ovale

• Active substance Polidocanol, trade name Aethoxysklerol: In Germany Polidocanol in liquid and foamed form is approved as sclerosing agent. In other countries the use is off-label.
• Sodium tetradecyl sulphate, trade name Sotradecol (USA), Thrombovar (France): foamed application is off-label

• Cabrera J et al (2003) Treatment of venous malformations with sclerosant in microfoam form. Arch Dermatol 139: 1409-1416
• Guidelines of the German Society of Phlebology (DGP) (2003) AWMF Guidelines Register No. 037/015
• McAusland S (1939) The modern treatment of varicose veins. Med Press Circular 201: 404-410
• Orbach EJ (1944) Sclerotherapy of varicose veins. Utilization of an intravenous air block. On J Surg LXVI: 362-366
• Reich-Schupke S et al. (2008) Foam sclerosing metaanlysis of the studies. Vasomed 20: 22-23
• Reich-Schupke S (2010) Treatment of varicose tributaries with sclerotherapy with polidocabol 0.5% foam. Vasa 39:169-174.
• Reich-Schupke S et al (2013) Foam sclerotherapy with enoxaparin prophylaxis in high-risk patients with postthrombotic syndrome. Vasa 42:50-55.