History.
The use of injections
to eliminate abnormal veins dates back more than 100 years. In 1942 Orbach described a method of creating a foam or froth
with the solution he injected. He claimed that this increased the efficacy of injection treatment. This technique was used
by a small number of surgeons but never caught on.
In 1992 Juan Cabrera,
a surgeon from Granada, Spain, found that he could greatly enhance the effect of injection treatment by making a foam of very
small bubbles, which he called 'microfoam'. He used ultrasound imaging to guide his injections into the main surface veins
and found that surgery was unnecessary.
Over the last 6 or
7 years the use of foam injections has spread widely in Europe, South America, and the U.S.
Phlebologists have used a number of different methods to create the foam that they inject but the result is the same:
using a foam greatly increases the effect of the treatment without producing any additional side-effects.
Recently a pharmaceutical
company, Provensis, has commenced development of a commercial foam called 'Varisolve' which is still undergoing clinical trials.
This is specifically intended to treat varicose veins.
What is injected?
The solutions that
are injected are exactly the same as those which are already used to treat varicose veins. These are mixed with air to create
a mousse or microfoam. It has been shown that this is perfectly safe to inject into the veins. The air is rapidly absorbed
from the veins leaving the solution to treat the veins. Sodium tetradecyl sulfate (STS) is the only highly effective
FDA approved sclerosant available in the United States. Polidocanol is widely used in Europe but is in only limited use in
the U.S. because it is not FDA approved. We primarily use STS in our clinics.
Why does foam
work?
When a solution is
injected into a vein it is immediately diluted by the blood, reducing its efficacy. Foam pushes the blood out of the way and
completely fills the vein: the foam is not diluted by the blood. In fact, far less solution has to be injected to obtain the
same effect.
The treatment.
Treatment is usually
performed in a treatment room or ultrasound examination room, and not an operating theatre. The patient rests comfortably
on a bed.
In order to treat
large varicose veins it is necessary to block the main vein feeding the varices. This could be done either surgically, with
endovenous laser or with foam treatment. Of the three, surgery has very poor
long-term results and foam treatment of the Saphenofemoral Junction is not covered by many insurance plans. Endovenous laser successfully closes the main source of venous reflux at the Saphenofemoral Junction
over 98% of the time using only local anesthesia.
Once the Saphenofemoral
Junction is closed all that is necessary to treat the remaining varicosities is to put a small needle into the remaining tributary
veins. This is the only part of the procedure, which might cause discomfort. The
position of the needle is carefully monitored using ultrasound imaging so that it is in exactly the right place.
Next, the foam is
injected whilst watching its progress using the ultrasound machine. Surprisingly, injecting the foam causes little or no discomfort,
although the leg may ache slightly afterwards. Once the foam has filled the larger abnormal surface veins the
leg may be elevated to allow it the foam to enter more distal varicosities.
The varicose veins
in the leg are checked to see if foam has entered these from the main surface vein where the injection was given. A few further
injections are usually given through a tiny needle in order to make sure that all the varicose veins have been completely
injected. The whole treatment usually takes no more than 30-40 minutes.
Finally a compression
stocking and a firm bandage are applied to the leg. The aim of this is to keep the veins compressed so that they do no fill
with blood when the patient stands up. The bandage is usually worn for 36 hours followed by an elastic compression stocking
for a further week or so.
At the follow-up
appointment it is usual to find that most of the varicose veins have gone. They can sometimes by
felt as small lumps beneath the skin. The leg may be a little bruised at this stage, although this is usually fairly minor.
Lumps which can be felt at this stage slowly resolve over several weeks. The lumps sometimes represent blood that has
been trapped in a closed vein segment. This may be removed by aspiration at the
time of follow-up. Any varicose veins that have not been completely treated in
the first session are injected and bandaged to complete removal of all veins.
Patients who desire
cosmetic treatment of spider veins may need additional treatments depending on how many veins are present.
Who is suitable
for foam sclerotherapy?
Most patients with
small or moderate size varicose veins can be treated in this way. Those patients with very extensive large varicose veins
are usually best treated with endovenous laser to obtain a more rapid result. Some patients with large veins lying close to
the skin are better treated with ambulatory phlebectomy since brown discoloration of the skin over the treated vein may occur.
If there has been previous surgery to the veins of the leg this does not cause any difficulty in using foam sclerotherapy.
In fact, it is often far easier to treat recurrent varicose veins by foam injections than by more surgery. If varicose veins
recur some years after initial treatment then it is straightforward to use the same method foam sclerotherapy again.
Who performs this
treatment?
At present only a
limited number of phlebologists in the US are experienced in this treatment. It needs a specialist who is skilled at ultrasound
imaging as well as injecting veins.
How well does
ultrasound guided foam sclerotherapy work?
Several detailed
clinical series have been published in the medical press. These suggest that 80 - 90% of saphenous veins (the main surface
vein) are permanently occluded by this treatment when examined one or two years later using ultrasound imaging . This is similar
to the success rate claimed for VNUS Closure (86%) and slightly lower than that for Endovenous Laser Treatment (93%). Surgery has many failures and after five years further varicose veins may have
appeared in about 66% of patients. Foam sclerotherapy is the preferred treatment for non-saphenous varicose veins and tortuous
saphenous veins and tributaries.
Advantages
Stripping of the vein is avoided and there is little or
no discomfort after treatment.
There is much less bruising than following surgery.
There is no need for general
anesthetic, incisions in the leg, admission to hospital or an operating theatre.
Re-treatment for further varices is simple.
Reoccurence of varicies
is much less likely.
Much less expensive
than surgical treatment - less than half the cost of surgery.
No time needed off
work, except for the treatment sessions.
Disadvantages
The treatment may produce mild discomfort and or mild
bruising that may last for several weeks following treatment.
Several sclerotherapy treatments are usually required
compared to one operation.
Summary
· Ultrasound guided foam sclerotherapy is an improved method
of treating varicose veins.
·
There is NO need for an operation under
general anesthetic.
·
The treatment only involves injections
with minor discomfort
·
A treatment session is complete in
30 - 40 minutes.
·
The treatment is carefully monitored
using ultrasound imaging.
·
A firm compression bandage must be
worn for 36 hours afterwards.
·
Mild discomfort and a little bruising
often follow treatment. This is much less than following surgical treatment.
·
No time off work is needed, except
to attend the clinic appointments.
·
The costs of treatment are much lower
than for surgical methods.
·
Some small lumps may be felt in place
of the veins after treatment. These resolve completely over several months.
