Treatment of Recurrent Varicose Veins by Sclerosant Foam
Van Cheng, M.D. asked:
“. . . we suggest that ultrasound guided foam sclerotherapy should be the first-line treatment.”
M Perrin and JL Gillet.
Varicose veins recur frequently after primary surgery. The acknowledged rate of recurrence is at least 25%, simply because no mechanical means of varicose vein treatment changes heredity or the propensity for varicose veins to follow the Mendelian laws of inheritance.
Recurrent varicose veins are more prevalent after great saphenous ligation (35%) than after stripping (18%). A review of publications on the subject of variceal recurrence from 1954 to 1988 found rates of return of varices following surgery of varicose veins to range from 14% to 80%, with the majority of the papers reporting 30-70% recurrent varices.
Among patients who have had surgery, the most commonly cited cause is incorrect surgery. Erik Lofgren, the respected and pioneering phlebologic surgeon of the Mayo Clinic, said in 1977: “Early recurrence of varicosities within 2-3 years of the vein stripping operation is interpreted as being caused by incomplete surgery and recurrence beyond 3 years is interpreted as being caused by breakdown of other veins that were clinically normal at the operation.” With the broad use of diagnostic ultrasound, that conclusion has been challenged. Allegra, for example, stated, “Varicose veins recurred despite technically correct surgery confirmed on post-operative duplex ultrasonography.”
Twenty percent of recurrent varicose veins are believed to be due to neovascularization, and a scattered few are due to abnormal anatomy. Fischer reported three main patterns of neovascularization among patients who had late recurrent saphenofemoral junction reflux after ligation and stripping. charts these as single-channel (29%), multichannel (41%) and circumjunctional (29%).
Personal experience
Patients were received over 48 months in referral at a single-site private practice office. A history detailing previous treatments and complications was recorded. A focused physical examination was supplemented by a standardized duplex ultrasound examination. A venous map was created for each lower extremity considered for treatment.
Patients with recurrent varices, whether of primary or post-thrombotic etiology, in the great or small saphenous vein distribution were included in this study. These were limbs with protuberant, saccular varicose veins and a history of previous intervention by surgery, laser or radiofrequency closure. Exclusions were limbs treated by sclerotherapy without surgery, isolated telangiectasias, limbs that were a part of the Klippel-Trenaunay syndrome, limbs with congenital or acquired arteriovenous malformations, and limbs with venous malformations. Not excluded were legs with venous ulceration, a history of ulceration and/or lipodermatosclerosis (CEAP classification C4, C5 and C6).
Patients and methods
A total of 75 lower extremities from 62 patients had recurrent varicose veins following either great saphenous stripping (35 lower extremities), ligation and phlebectomy (38 lower extremities), or VNUS Closure” (2 lower extremities). There were 49 women (mean age: 52.7 years) and 13 men (mean age: 59.6 years) who had 68 limbs that were symptomatic by CEAP classification C2, five were C4, 1 was C3 and 1 was C6.
Sclerosant foam was made by the two-syringe Tessari technique with a 1/4 sclerosant-to-air mixture. The sclerosant was polidocanol administered through one or more varices, directed by massage into previously marked varicose veins using ultrasound guidance. For the most part, the great saphenous vein was absent or obliterated, so this was not regularly a target for therapy.
After instillation of foam, the treated limb was held in a 45
“. . . we suggest that ultrasound guided foam sclerotherapy should be the first-line treatment.”
M Perrin and JL Gillet.
Varicose veins recur frequently after primary surgery. The acknowledged rate of recurrence is at least 25%, simply because no mechanical means of varicose vein treatment changes heredity or the propensity for varicose veins to follow the Mendelian laws of inheritance.
Recurrent varicose veins are more prevalent after great saphenous ligation (35%) than after stripping (18%). A review of publications on the subject of variceal recurrence from 1954 to 1988 found rates of return of varices following surgery of varicose veins to range from 14% to 80%, with the majority of the papers reporting 30-70% recurrent varices.
Among patients who have had surgery, the most commonly cited cause is incorrect surgery. Erik Lofgren, the respected and pioneering phlebologic surgeon of the Mayo Clinic, said in 1977: “Early recurrence of varicosities within 2-3 years of the vein stripping operation is interpreted as being caused by incomplete surgery and recurrence beyond 3 years is interpreted as being caused by breakdown of other veins that were clinically normal at the operation.” With the broad use of diagnostic ultrasound, that conclusion has been challenged. Allegra, for example, stated, “Varicose veins recurred despite technically correct surgery confirmed on post-operative duplex ultrasonography.”
Twenty percent of recurrent varicose veins are believed to be due to neovascularization, and a scattered few are due to abnormal anatomy. Fischer reported three main patterns of neovascularization among patients who had late recurrent saphenofemoral junction reflux after ligation and stripping. charts these as single-channel (29%), multichannel (41%) and circumjunctional (29%).
Personal experience
Patients were received over 48 months in referral at a single-site private practice office. A history detailing previous treatments and complications was recorded. A focused physical examination was supplemented by a standardized duplex ultrasound examination. A venous map was created for each lower extremity considered for treatment.
Patients with recurrent varices, whether of primary or post-thrombotic etiology, in the great or small saphenous vein distribution were included in this study. These were limbs with protuberant, saccular varicose veins and a history of previous intervention by surgery, laser or radiofrequency closure. Exclusions were limbs treated by sclerotherapy without surgery, isolated telangiectasias, limbs that were a part of the Klippel-Trenaunay syndrome, limbs with congenital or acquired arteriovenous malformations, and limbs with venous malformations. Not excluded were legs with venous ulceration, a history of ulceration and/or lipodermatosclerosis (CEAP classification C4, C5 and C6).
Patients and methods
A total of 75 lower extremities from 62 patients had recurrent varicose veins following either great saphenous stripping (35 lower extremities), ligation and phlebectomy (38 lower extremities), or VNUS Closure” (2 lower extremities). There were 49 women (mean age: 52.7 years) and 13 men (mean age: 59.6 years) who had 68 limbs that were symptomatic by CEAP classification C2, five were C4, 1 was C3 and 1 was C6.
Sclerosant foam was made by the two-syringe Tessari technique with a 1/4 sclerosant-to-air mixture. The sclerosant was polidocanol administered through one or more varices, directed by massage into previously marked varicose veins using ultrasound guidance. For the most part, the great saphenous vein was absent or obliterated, so this was not regularly a target for therapy.
After instillation of foam, the treated limb was held in a 45
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