Foam Sclerotherapy

A substantial change in medical practice has occurred in the last 20 years. Several minimally invasive techniques for treating vein problems have come into general use. The main aim of these is to avoid surgical removal of varicose veins, the need for general anaesthetic, incisions in the legs and a hospital operating theatre. Another advantage is a more rapid recovery from treatment.

Ultrasound Guided Foam Sclerotherapy has become well established as a method of achieving long-term cure of varicose veins. The National Institute for Health and Clinical Excellence (NICE) now recommends the use of modern minimally invasive treatments for varicose veins, instead of surgery.

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History

The use of injections to cure varicose 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 found that this increased the efficacy of injection treatment by five times. This method was used by a small number of surgeons, but never found a great following.

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Sclerotherapy has been used in the treatment of spider veins and varicose veins for over 150 years. Like varicose vein surgery, sclerotherapy techniques have evolved during that time. Modern techniques including ultrasonographic guidance and foam sclerotherapy are the latest developments in this evolution.

A major development in the evolution of sclerotherapy was the advent of duplex ultrasonography in the 1980s and its incorporation into the practice of sclerotherapy later that decade. In 1992 Juan Cabrera, a surgeon from Granada in 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 he no longer needed surgical methods to treat his patients.

The work of Cabrera and Monfreaux in utilising foam sclerotherapy, commercial products, along with Tessari's "3-way tap method" of foam production further revolutionised the treatment of larger varicose veins with sclerotherapy. This has now been further modified, using non-silicone syringes for longer-lasting foam.

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What is injected

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 a gas (carbon dioxide) to create a mousse or foam, consisting of very small bubbles. It has been shown that this is perfectly safe to inject into the veins. The gas is rapidly absorbed from the veins leaving the solution to treat the veins.

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. Contact with blood strongly inhibits liquid or foam sclerosants, so that they are only effective in the vein into which they have been injected.

Once the foam reaches large veins and mixes with blood, it is inactivated. The gas is breathed out and the sclerosant solution is metabolised by the liver within a few hours. Blood now returns to the treated vein, which has been left without its non-stick lining. Blood sticks to the wall of the vein and blocks it off, which is usually a permanent cure for a varicose vein.

Treatment

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. Very little discomfort results from the injections, so no sedation or anaesthetic is required. In order to treat large varicose veins, it is necessary to block the main vein feeding the varices. This could be done surgically, but thanks to foam treatment, all that is necessary is to put a needle into the main affected surface vein. This is the only part of the procedure, which might cause discomfort and is usually performed with a small amount of local anaesthetic. The position of the needle is carefully monitored using ultrasound imaging, so that it is positioned in exactly the right place. Next, the foam is injected, whilst watching its progress, using the ultrasound machine. Surprisingly, injecting the foam causes no discomfort, although the leg may ache slightly afterwards. If any varicose veins have not been completely treated in the first session they are injected again and the leg bandaged to completely remove of all veins.

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 20 – 30 minutes. Finally, a firm bandage is applied to the leg. The aim of this is to keep the veins compressed, so that they do not fill with blood when the patient stands up. The bandage is usually worn for a week or two, followed by an elastic compression stocking for a further week. When the bandages are removed at the follow-up appointment, it is usual to find that all the varicose veins have gone. Sometimes small lumps can be felt beneath the skin. The leg may be a little bruised, although this is usually fairly minor. Lumps present at this stage slowly resolve over several weeks.

Suitability

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 surgically to obtain a more rapid result. Some patients with large veins lying close to the skin are better treated surgically, since brown discoloration of the skin over the treated vein may occur. Previous surgery to the veins of the leg usually 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. Careful studies have shown that foam sclerotherapy is the most effective way of treating varicose veins which have recurred after previous surgery. If varicose veins recur some years after initial treatment, then it is straightforward to use the same method of foam sclerotherapy again.

Who treats me?

Who performs this treatment?

This treatment needs a specialist, who is skilled at ultrasound imaging, as well as injecting veins. Our surgeons at the British Vein Institute have considerable expertise in this field.

How well does work

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 five years later, using ultrasound imaging. This is similar to the success rate claimed for other new techniques, such as RF ablation and Endovenous Laser Treatment.

Clinical trials have shown that the treatment outcomes are the same for surgical and minimally invasive techniques. There is no advantage to any particular method of treatment.

Advantages
- All treatments are completed in the outpatient clinic
- Each session of treatment lasts about half an hour
- Normal activities can be resumed straight away, but vigorous exercise should be delayed for a week
- 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 anaesthetic, incisions in the leg, admission to hospital or an operating theatre
- Re-treatment for further varices is simple
- It is less expensive than surgical treatment
- There is no time needed off work, except for the treatment sessions
- The treated veins disappear completely after a period of time, and cannot be found even with ultrasound imaging
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Disadvantages
- The treatment produces mild discomfort in the leg, which may last for 2 – 4 weeks
- It also produces mild bruising and some lumps, which may last for several weeks following treatment. However, both of these features are usually seen following surgical treatment for varicose veins
- The final outcome may take a number of months to evolve following treatment, and this is longer thanwould take following surgery
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After treatment

What happens following treatment

Following the varicose veins treatment using foam sclerotherapy, please keep the bandages and stockings on your leg without removing them for 7 days. After this period, please remove the stocking and the bandage, and then put the stocking back on again for another 7 days. You may take the stocking off at night, if you wish,once the bandage has been removed.

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What to expect

The leg may ache slightly for a few days. After two or three weeks you may find that the region of the varicose veins is a little tender and lumpy. This is normal and will resolve slowly. The varicose veins usually disappear completely, however this may take many weeks to complete. Occasionally some of the lumps become very tender and red. This can be managed by wearing the stocking and taking analgesics, such as Nurofen or paracetamol. The problem is due to trapped blood in the vein, which can be removed through a needle under local anaesthetic by one of our specialists. Please arrange an appointment.

Activities after treatment

You should continue normal activities, although it is recommended to avoid vigorous exercise until the bandages have been removed. Any other type of exercise, such as walking, is perfectly acceptable. A vigorous regime of walking for 3 miles per day is NOT required (this won't make the veins heal any faster). We highly recommend, that you do not run whilst wearing the bandage and that you start vigorous exercise gently once the bandage has been removed.

In the shower

Whilst wearing the bandage, you can take a bath, but you will have to hang the bandaged leg out of the bath! Alternatively, you can wrap the leg in a bin liner or cling film and take a shower!! A professionally made sleeve can be purchased – 'Limbo' type M80LL or M100 for about £17 from Amazon, Boots, John Bell & Croydon or from Limbo Products directly ( » 01243 573 417 - » www.limboproducts.co.uk ). You will need a full-length sleeve. While you are wearing the bandage, you can take a bath but will have to hang the bandaged leg out of the bath! Alternatively, you can wrap the leg in a bin liner or cling film and take a shower!! A professionally made sleeve can be obtained – 'Limbo' type M80LL or M100 – for about £17 at Boots, John Bell and Croydon, Wigmore St, London W1 or telephone Limbo Products on 01243 573417 (£17 – ). You will need a full-length sleeve.

Removing the bandage

To remove the bandage, first peel off the stocking and then cut the bandage down the front from top to bottom using scissors and taking care not to injure your leg. Soaking the sticky tape in the bath or shower will help to release this. Nail varnish remover can be used to remove the adhesive and blue pen marks.

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