Foamed Sclerosant Ablation of Saphenous Veins and Varices Periprocedural Care

Updated: Nov 02, 2017
  • Author: Eric Mowatt-Larssen, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
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Periprocedural Care

Patient Education and Consent

For the purposes of patient satisfaction, it is good practice to manage patient expectations and inform patients that any specific vein injected may later require retreatment.

Patient-centered information is available from the American College of Phlebology and the American Venous Forum.

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Preprocedural Planning

Abnormal veins are usually treated in a specific order: superficial veins first, perforator veins next, and deep veins last. Superficial vein therapies have good efficacy and minimal side effects. When symptomatic reflux is present, the superficial veins are usually treated in the following order: saphenous veins, tributary veins, and localized veins.

Perforator vein treatments are technically efficacious but are of uncertain benefit to the patient in many cases. Deep vein treatments carry a higher risk, have more variable success rates, and are usually performed only in patients with particularly severe symptoms and only at specialized centers.

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Equipment

Duplex ultrasonography should be used in the treatment of saphenous veins, perforator veins, veins near deep-superficial junctions, long veins, or large-diameter veins. If there is any doubt, this imaging modality is not discouraged during any use of foam. Wire-guided catheter access is generally used for saphenous veins and other longer veins.

Materials required for foam sclerotherapy include the following:

  • Two 5-mL syringes
  • Liquid sclerosant
  • 3-way stopcock valve
  • Butterfly needle, 27 gauge
  • Isopropanol wipes
  • 4 × 4 gauze pads
  • Tape
  • Compression stocking

Both sodium tetradecyl sulfate (STS) and polidocanol are approved by the US Food and Drug Administration (FDA) for use as a liquid sclerosant. In general, STS is twice as potent as polidocanol at the same concentration; thus, a physician could achieve similar effects with STS 0.5% and polidocanol 1.0%. By using varying concentrations and different foaming techniques, foam can be used to treat almost any type of vein.

STS and polidocanol at a concentration of 1% or higher are often used for saphenous veins. Local varicosities are usually treated with STS 0.25-1.0% or polidocanol 0.5-1.0%, depending on vessel diameter and treatment response. Emerging evidence, however, indicates that higher sclerosant concentrations may not always be more effective than lower concentrations, as had been previously assumed. [18]

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Patient Preparation

No anesthesia is usually required for foamed sclerosant ablation. Patient positioning is important. The reverse Trendelenburg position facilitates venous access by increasing vein diameter.

In patients whose veins collapse with extremity elevation, veins can be accessed in a dependent position via a 27-gauge butterfly needle with normal saline, with the butterfly then taped in place. Subsequent extremity elevation decreases vein diameter, making foam administration more effective and less risky. Tumescent anesthesia can potentially be used to decrease vein diameter. Elevating the treated extremity 45º also theoretically limits the passage of bubbles into the systemic circulation.

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Monitoring & Follow-up

In well-selected patients, current venous treatment techniques improve quality of life by decreasing pain and swelling and reducing ulcer recurrence risk; however, they are not curative. After successful treatment, patients can be followed annually, or more frequently if the condition recurs.

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