| p>". . . we suggest that ultrasound guided foam | | | | 84% of limbs with recurrent varicose veins |
| sclerotherapy should be the first-line treatment." | | | | received satisfactory treatment with one or two |
| M Perrin and JL Gillet. | | | | sessions. The unhealed ulcer in a diabetic patient |
| Varicose veins recur frequently after primary | | | | remained unhealed despite subsequent placement |
| surgery. The acknowledged rate of recurrence is | | | | of an iliac venous stent, performance of a |
| at least 25%, simply because no mechanical | | | | femorotibial arterial bypass and six treatments |
| means of varicose vein treatment changes | | | | with foam injections. The ulcer eventually |
| heredity or the propensity for varicose veins to | | | | responded to biological dressings. The unimproved |
| follow the Mendelian laws of inheritance. | | | | C4 limbs responded to direct perforator vein |
| Recurrent varicose veins are more prevalent | | | | foam injections, as mentioned above. No |
| after great saphenous ligation (35%) than after | | | | paresthesias were encountered after foam |
| stripping (18%). A review of publications on the | | | | injections. Foot and ankle swelling immediately |
| subject of variceal recurrence from 1954 to 1988 | | | | after treatment was encountered, but this was |
| found rates of return of varices following surgery | | | | usually caused by the compression dressings. |
| of varicose veins to range from 14% to 80%, | | | | Narcotics were not required for pain |
| with the majority of the papers reporting 30-70% | | | | management, but analgesics were taken |
| recurrent varices. | | | | whenever the compression dressing interfered |
| Among patients who have had surgery, the most | | | | with sleep. Endresults, as assessed by the patients |
| commonly cited cause is incorrect surgery. Erik | | | | and by the treating physician, were satisfactory |
| Lofgren, the respected and pioneering phlebologic | | | | for most of the cases. There was elimination of |
| surgeon of the Mayo Clinic, said in 1977: "Early | | | | varicose veins and sources of venous reflux in |
| recurrence of varicosities within 2-3 years of the | | | | every case. No DVTs or treatment ulcerations |
| vein stripping operation is interpreted as being | | | | were detected. |
| caused by incomplete surgery and recurrence | | | | Discussion |
| beyond 3 years is interpreted as being caused by | | | | The idea of enhancing the action of liquid |
| breakdown of other veins that were clinically | | | | sclerosant by mixing it with air was introduced by |
| normal at the operation." With the broad use of | | | | German clinicians. Flückiger, the most |
| diagnostic ultrasound, that conclusion has been | | | | prominent of these, recognized the futility of |
| challenged. Allegra, for example, stated, "Varicose | | | | injecting a liquid sclerosing agent in an orthograde |
| veins recurred despite technically correct surgery | | | | fashion toward the heart, where the agent would |
| confirmed on post-operative duplex | | | | flow into vessels of progressively larger diameter |
| ultrasonography." | | | | and tributaries would not be sclerosed. He then |
| Twenty percent of recurrent varicose veins are | | | | described the essential elements of present-day |
| believed to be due to neovascularization, and a | | | | techniques of foam sclerotherapy: peripherally |
| scattered few are due to abnormal anatomy. | | | | directed injection, steep leg elevation and manual |
| Fischer reported three main patterns of | | | | guidance of the sclerosant. In the absence of |
| neovascularization among patients who had late | | | | ultrasound imaging, he guided the foam by noting |
| recurrent saphenofemoral junction reflux after | | | | subcutaneous crepitus. |
| ligation and stripping. charts these as single-channel | | | | Interventions for recurrent varicose veins actually |
| (29%), multichannel (41%) and circumjunctional | | | | follow the same pattern as primary treatment. |
| (29%). | | | | That is, sources of reflux such as |
| Personal experience | | | | neovascularization are diagnosed with a venogram. |
| Patients were received over 48 months in | | | | These reservoirs of varicose veins that receive |
| referral at a single-site private practice office. A | | | | such reflux need to be closed, and this can be |
| history detailing previous treatments and | | | | achieved surgically with a single operation. But |
| complications was recorded. A focused physical | | | | such procedures are tedious at best, and |
| examination was supplemented by a standardized | | | | dangerous and incomplete at worst. The stump of |
| duplex ultrasound examination. A venous map was | | | | saphenous vein remaining in the groin must be |
| created for each lower extremity considered for | | | | approached through scar, and great difficulty is |
| treatment. | | | | encountered when the femoral vessels are |
| Patients with recurrent varices, whether of | | | | encased in scar and neovascularization is present. |
| primary or post-thrombotic etiology, in the great | | | | In such situations, a lateral approach to the |
| or small saphenous vein distribution were included | | | | femoral vessels is advocated. |
| in this study. These were limbs with protuberant, | | | | Figure 18.3 Venogram illustrating neovascularization |
| saccular varicose veins and a history of previous | | | | feeding a previously ligated, and still refluxing, |
| intervention by surgery, laser or radiofrequency | | | | great saphenous vein. |
| closure. Exclusions were limbs treated by | | | | Actually, there are many patterns of varicose |
| sclerotherapy without surgery, isolated | | | | recurrence. Van Rij found neovascular |
| telangiectasias, limbs that were a part of the | | | | reconnection and persistent abnormal venous |
| Klippel-Trenaunay syndrome, limbs with congenital | | | | function as the major contributors to disease |
| or acquired arteriovenous malformations, and | | | | recurrence. The Freiberg group found no junctional |
| limbs with venous malformations. Not excluded | | | | recurrence in 68% of their limbs with recurrent |
| were legs with venous ulceration, a history of | | | | varices, and Rutherford et al from the Royal |
| ulceration and/or lipodermatosclerosis (CEAP | | | | Surrey County Hospital in the United Kingdom |
| classification C4, C5 and C6). | | | | focused on perforating veins as a cause of |
| Patients and methods | | | | recurrent varices. |
| A total of 75 lower extremities from 62 patients | | | | Clearly, a technique designed to deal with these |
| had recurrent varicose veins following either great | | | | several patterns of recurrence must have broad |
| saphenous stripping (35 lower extremities), ligation | | | | applicability to all patterns of recurrent varices. |
| and phlebectomy (38 lower extremities), or VNUS | | | | Foam sclerotherapy does this: the foam can be |
| Closure" (2 lower extremities). There were 49 | | | | manipulated into each of the areas of recurrence |
| women (mean age: 52.7 years) and 13 men | | | | with little effort. |
| (mean age: 59.6 years) who had 68 limbs that | | | | Finally, the best treatment of recurrent varicose |
| were symptomatic by CEAP classification C2, five | | | | veins should minimize post-treatment discomfort |
| were C4, 1 was C3 and 1 was C6. | | | | and disability and have a reliably successful |
| Sclerosant foam was made by the two-syringe | | | | outcome. Our experience in treating recurrent |
| Tessari technique with a 1/4 sclerosant-to-air | | | | varices demonstrates that success has been |
| mixture. The sclerosant was polidocanol | | | | achieved with no need for sedation, analgesia or |
| administered through one or more varices, | | | | anesthesia. |
| directed by massage into previously marked | | | | Our experience is almost identical to that reported |
| varicose veins using ultrasound guidance. For the | | | | from the Ealing Hospital in London, where 38 |
| most part, the great saphenous vein was absent | | | | patients with recurrent varicose veins were |
| or obliterated, so this was not regularly a target | | | | treated by the same techniques used in the |
| for therapy. | | | | present study. Their report was that in 87% of all |
| After instillation of foam, the treated limb was | | | | legs, complete elimination of varicose veins and all |
| held in a 45° elevated position for 10 minutes | | | | reflux points was achieved. Also, they did not |
| to fix the foam distally and to allow foam to | | | | encounter DVT or systemic complications. |
| revert to its liquid state. This was done to avoid | | | | The absence of complications in our experience |
| adverse events and was successful. The dosage | | | | and from the Ealing Hospital are in contrast to |
| of sclerosant foam ranged from 5 to 17 mL per | | | | reports of surgical treatment of recurrent |
| limb (1% polidocanol in 2 limbs, 3% in 18 limbs and | | | | varicose veins. For example, in a report from |
| 2% in the remaining 55 limbs). The number of | | | | Milan, 61 lower extremities were treated surgically. |
| treatments ranged from 1 to 4 (average: 2.1). | | | | The immediate complications included hemorrhage |
| Class II or III thigh-high support stockings with | | | | (1.6%), wound infections (4.9%) and one case of |
| added focal pressure over large varices were | | | | lymphorrhagia. Similarly, from Naples comes a |
| applied immediately after treatment and left in | | | | report in which 98 limbs in 82 patients were |
| place for 48-72 hours. Afterwards, the stockings | | | | treated for recurrent varicose veins. There were |
| were worn only during the day for 2 weeks or | | | | five wound infections and four lymphorrheas, but |
| for comfort according to patients' wishes. Deep | | | | no thrombotic or phlebitic complications. |
| venous thrombosis (DVT) surveillance was done | | | | It must be acknowledged that conventional |
| at 7 and 21 days. | | | | treatment of recurrent varicose veins is no more |
| Results | | | | successful than primary treatment. Eklof reviewed |
| Immediately after treatment, all patients returned | | | | published reports of results of surgical treatment |
| to normal activity. None were instructed to forced | | | | of recurrent varicose veins4 and found that the |
| ambulation. Absence of sedation, analgesia and | | | | long-term results revealed a recurrence rate of |
| anesthesia allowed unaccompanied patients to | | | | approximately 35% for the "re-do" surgery. Thus, |
| drive themselves from the office. No adverse | | | | it must be concluded that neither standard |
| events such as dry cough, ocular signs, chest pain | | | | primary surgical treatment of varicose veins nor |
| or panic attacks developed. Unlike surgical | | | | secondary surgical treatment of recurrent |
| interventions, no treatment hematomas or wound | | | | varicose veins gives acceptable results with |
| infections developed. After treatment, one ulcer | | | | minimal complications. Foam sclerotherapy holds |
| remained unhealed. Three limbs remained C4, but | | | | promise as being a better treatment for both |
| the inflammatory component of | | | | primary and recurrent varicose veins. |
| lipodermatosclerosis slowly disappeared following | | | | Conclusions |
| direct ultrasound-guided perforating vein injections. | | | | This experience in treating 62 patients having 75 |
| The remaining 71 became either C0 or C1. (The | | | | lower extremities with recurrent varicose veins |
| CEAP score was not designed to provide an | | | | showed that foam sclerotherapy of recurrent |
| evaluation of clinical results in general, but in this | | | | varicose veins is successful and causes little |
| study did show elimination of recurrent varicose | | | | morbidity. Treatment with foam sclerotherapy is |
| veins.) Clinical and an associated duplex | | | | quick and efficient: no operating room time, no |
| examination led to supplemental treatment with | | | | local or general anesthesia, and no time off work |
| foam injection in all but three limbs. These three | | | | or away from normal activities make the |
| received only one treatment. In 60 of 75 limbs, | | | | technique attractive to the patient and to the |
| the second treatment was the last required. Thus, | | | | physician. |