Venous disorders: treatment with sclerosant foam.

OBJECTIVE

Treatment of venous insufficiency has been revolutionized by introduction of less invasive endovenous procedures. Foam sclerotherapy competes with these for truly minimal less invasive care. The idea of using air and drug in combination is quite old. Orbach described an air block technique using froth in 1944 and in 1993 Cabrera proposed use of a true foam of sodium tetradecyl sulfate or polidocanol to treat varicose veins. When Tessari presented a three-way tap technique in 2000, very good microfoam could be made at a very low cost. Foam can be used in classical sclerotherapy but it is the new indications that excite interest. This report documents experience in treating severe chronic venous insufficiency (CVI), venous angiomata and varicose veins using foam sclerotherapy.

METHODS

This report describes initial experience in treating 332 patients: 261 patients with varicose veins, 56 patients (77 limbs) with severe CVI, 6 patients with venous angiomata and 9 patients with Klippel-Trenaunay (KT) syndrome. Patients with telangiectasias were also treated but are not a part of this report. A compounding pharmacy supplied the 1-3% polidocanol that was prescribed for each patient according to guidelines on the Food and Drug Administration (FDA) website. Foam was produced by the Tessari technique. Ultrasound guidance was used. Venous access was obtained percutaneously through varices for saphenous vein and variceal closure and through specific targeted veins for treatment of CVI, angiomata and KT syndrome. Deep venous thrombosis (DVT) surveillance was done at 1, 7, 30, and 60 days. Specific perforating vein injection was done only occasionally. Foam volumes varied from 1 to 16 mL for each treatment.

RESULTS

Obliteration of varicose and saphenous veins was entirely satisfactory (2.89 treatments/limb). There was no disability down time, no need for analgesics or sedation. Trapped thrombus in large varices required evacuation and caused local pain and cutaneous staining. Treatment goals but not cure were achieved in limbs with angiomata and KT syndrome. Treatment of CVI resulted in rapid, 2-6 weeks, ulcer healing, relief of painful lipodermatosclerosis and dermatitis and some decrease in skin hyperpigmentation. There was one failure in 77 limbs treated for CVI and one case of cutaneous necrosis in one limb treated for CVI and another in a limb treated for angiomata. Other adverse events (5.4%) lasting 3 to 20 min included dry cough (4), occular migraine (2), true migraine (2), other visual disturbances (3), chest tightness (2), panic attack (2), paresthesias (2) myoclonus (1) and cutaneous necrosis (2). DVT (1.8%) was limited to gastrocnemius veins (3 cases) and posterior tibial veins (3 veins). No pulmonary emboli or lung complications occurred.

CONCLUSIONS

Treatment of a variety of venous disorders can be accomplished using foam sclerotherapy with results comparable to surgery and with an acceptably low rate of adverse events. These results, however, must be confirmed by larger experience in other institutions.