Performance of endovenous foam sclerotherapy in the USA for the treatment of venous disorders: ACP/SVM/AVF/SIR quality improvement guidelines.

OBJECTIVE: This report summarizes the findings of the consensus panel based on the results of the comprehensive questionnaire of US American College of Phlebology annual congress attendees and results of the systematic meta-analysis of the literature and provides quality improvement guidelines for the use of endovenous foam sclerotherapy (EFS) for the treatment of venous disorders, as well as identifies areas of needed research. METHODS: Based on the above data, quality improvement guidelines were developed and reviewed by the ten US consensus panel members and approved by their respective societies. RESULTS: EFS is effective for the treatment of truncal and tributary varicose veins, both as primary treatment and for treatment of recurrence. It may improve the signs and symptoms associated with varicose veins including pain and swelling. EFS is contraindicated in patients who have experienced an allergic reaction to previous treatment with foam or liquid sclerosant, and in patients with acute venous thrombosis events secondary to EFS. CONCLUSION: These guidelines for the use of EFS in the treatment of venous disorders provide an initial framework for the safe and efficacious use of this therapy, and the impetus to promote the evaluation of the questions remaining regarding the use of EFS through well-designed randomized and cohort studies.

Performance of endovenous foam sclerotherapy in the USA.

PURPOSE: To assess practice patterns of endovenous foam sclerotherapy (EFS) use in the USA. METHODS: A multidisciplinary panel of US experts was convened and developed a questionnaire to assess use of EFS. US attendees at the American College of Phlebology 2009 Annual Congress were asked to complete the questionnaire. RESULTS: Of 776 questionnaires distributed, 239 were completed (31%). The majority of respondents (87%) reported using EFS for the treatment of venous disorders. Foam sclerotherapy was used by a wide variety of specialists in every region of the USA. The most common indication was sclerosis of recurrent truncal or tributary veins of the leg. There was variation among practitioners in the indications for use, pre- and postprocedural evaluation and procedure methodology. CONCLUSIONS: The results of this questionnaire show widespread usage of EFS and are important in the development of national quality improvement guidelines for the performance of EFS.

Clinical and histologic evaluation of polyiodinated iodine with and without hypertonic saline/dextrose in the rabbit ear vein model.

BACKGROUND: Certain types of varicose veins can be successfully sclerosed with polyiodinated iodine (PII). Although this sclerosant is widely used in Canada and in Europe, it is not marketed in the United States. OBJECTIVE: The following study was undertaken to determine whether an American polyiodinated iodine (APII) formula, compounded in a hospital pharmacy, is as effective as a commercially available brand of PII in the rabbit ear vein model. The two sclerosants were identical in composition. METHODS: After being mixed with either normal saline (NS), Sclerodex, or an American dextrose-hypertonic solution (ADHS) compounded in a hospital pharmacy, each sclerosant was injected in concentrations of 0.1% and 0.5%. The veins were examined clinically and histologically 1 hour, and 2, 8, and 28 days after injection. They were examined with electron microscopy at 8 and 28 days. RESULTS: When diluted with NS, Sclerodex, or ADHS and injected in a 0.1% concentration, each sclerosant produced a hyperplastic regenerating endothelium without evidence of mixed cellular infiltrates at 2 days. By 28 days, the endothelium was regenerated. When diluted with NS, Sclerodex, or ADHS and injected in a 0.5% concentration, each sclerosant produced more thrombosis, yielding a mild perivascular mixed cellular infiltrate and fibrin coagulum at 8 days and thrombus cord formation at 28 days. CONCLUSION: When mixed with NS, Sclerodex, or ADHS, APII has the same efficacy as PII.

Advanced sclerotherapy treatment of varicose veins with duplex ultrasonographic guidance.

Advanced sclerotherapy of varicose veins is described in this article using duplex ultrasonographic guidance in three phases of the process. In the presclerotherapeutic stage, patency and competency of the deep venous system are evaluated, location and morphology of the highest point of reflux are determined, luminal and parietal diameters of the target vein, venous compressibility, leaflets of the incompetent valve, and the degree, extent, and velocity of reflux are assessed. In the sclerotherapeutic stage, ultrasonographic guidance is helpful when the anatomy is intricate and points of reflux would otherwise be inaccessible. In the postsclerotherapeutic stage, duplex ultrasonography is indispensable for determination of the extent of the sclerosing reaction, measurement of luminal and parietal diameters, and to elucidate luminal content and its degree of adherence to the venous wall. Duplex ultrasonography provides a sound basis for clinical decision making and thereby enhances the precision and safety of advanced sclerotherapy.

The Bulletin of the North American Society of Phlebology. Insurance Advisory Committee Report.

The treatment of varicose veins as taught within the specialty of phlebology consists of the best combinations of sclerotherapy and surgery after a thorough evaluation by physical examination and Doppler ultrasound, as well as other techniques. Although patients can experience some relief of symptoms by external compression hosiery, only treatment that closes up leaky valves will stop the progression of disease. Sclerotherapy is a safe, well-accepted, non-investigational, highly effective method to treat abnormally enlarged veins. Surgical procedures may be necessary to supplement sclerotherapy in certain anatomic sites. Varicose veins cause patients to experience pain, lose time from work, and can ultimately lead to permanent disability. Our healthcare system must provide the most high quality cost effective care for these patients. By keeping costs down as compared with full-scale surgical procedures, the approach of sclerotherapy or sclerotherapy with outpatient surgery, performed by properly trained physicians, provides a means to accomplish this. Medical necessity criteria allow exclusion of payments for patients seeking treatment purely for cosmetic needs.

[Endovascular echography]. / Echographie endo-vasculaire.

The author reports data obtained by endoluminal pre and post-therapeutical ultrasound imaging of the wall architecture and lumen morphology of the arteries and varicose veins. In these studies, 20 and 25 MHz probes were used. These probes were covered with a 1 to 1.6 mm diameter flexible catheter and were introduced into the lumen of the vessels. Then, the probe was mechanically oriented in order to give, in cross-sectional section and real time, 360 degrees 2D images. The anatomical elements of the vessel wall and lumen, visualized with this technique, were described. The intima and adventitia appeared as echogenic structures while the media appeared as a non echogenic structure. The characteristics of endoluminal reactions such as atheromatous plaque, stenosis, thrombogenic and sclerogenic reactions were described. In conclusion, endovascular ultrasound imaging shows, accurate images of the morphology and dynamics of the arterial and venous vessel lumen and wall. This new technology can be used helpfully before, during and after vessel medical or surgical treatment.

[Intravenous ultrasonography]. / Echographie endo-veineuse.

The author used in vivo endovenous ultrasonography to study the architecture and dynamics of varicose veins of the lower limbs. In this study, segments of the great saphenous vein were examined, before and after sclerosing injections, using a miniaturised 20 mHz ultrasound probe. This probe incorporated in a 1.6 mm diameter flexible catheter was inserted into the varicose vein. The probe was then pivoted mechanically in order to obtain, in transverse section and in real time, 360 degree two-dimensional venous images. The anatomical structures of the wall, lumen and venous valves were visualised. The layers of the vein wall, the intima and adventitia, were seen to be echogenic structures while the media was an anechogenic zone. The spread between valve cusps, endoluminal diameter and the thickness of the layers of the vein wall were measured. It is concluded that endovenous ultrasonography provides precise images of the morphology and dynamics of valves, lumen and vein wall. This new technique is useful before, during and after the treatment of venous diseases by sclerosing injections or surgery.

[Sclerotherapy of the internal saphenous vein in the standing and sitting position. A comparative study]. / Sclérothérapie de la saphène interne en position debout et en position assise. Etude comparative.

A study was undertaken to compare two methods of sclerosing injection of the sapheno-femoral junction (SFJ). The study involved a sample of 2186 patients. In the first method, with the patient in sitting position, injections were administered below the junction with digital compression applied directly to the SFJ. In the second method, with the patient in standing position, injections were administered below the junction with digital compression applied directly to the junction as well as below the injection site. Results showed that sequestration of the proximal saphenous segment with the patient in standing position is a valid technique for the treatment by sclerosing injections of incompetence of the long saphenous.

Two different techniques for sclerosing the incompetent saphenofemoral junction: a comparative study.

A study comparing two methods of sclerosing the saphenofemoral junction (SFJ) that included 2186 patients was conducted. In the first method, injections were made below the junction with digital pressure applied at the SFJ, with the patient in a sitting position. In the second, injections were made below the junction with digital pressure at the SFJ and below the injection site, with the patient in a standing position. The results indicated that higher saphenous sequestration with the patient in a standing position is a valuable sclerotherapy technique.