The concept of foam sclerotherapy was originally introduced by Orbach in 1944 who described the use of a froth made by shaking a syringe of sclerosant with air. He found that this was 10% more effective than the sclerosant used alone.

Little was heard of this technique until Cabrera published an article in 1997 describing his experience in 261 limbs with long saphenous varices and 8 patients with vascular malformations. Some of the varicose veins reached 20 mm in diameter. He considered that foam greatly extended the range of vein sizes which could be managed by ultrasound guided sclerotherapy. He felt that the increased efficacy of foam was attributable to it displacing blood from the treated vein and increasing the contact time between the sclerosant and the vein. He used a ‘microfoam’, that is a foam made of very small bubbles. His method of preparing this foam was not published.

Subsequently a series of authors has described methods of preparing ‘home-made’ foam which may be used for ultrasound guided sclerotherapy. Monfreux described a method necessitating a glass syringe which produced small quantities of polidocanol foam which he used in a series of patients with truncal varicose veins. Sadoun described a method of preparing foam using a plastic syringe avoiding the need for reusable glass syringes.

In 1999 Henriet reported his results in 10,000 patients with reticular varices and telangiectases of the lower limb treated between the years 1995-8. He found that the outcome of foam treatment in small varices was excellent and that reduced volumes and concentrations of sclerosant could be employed compared to liquid sclerosants. Benigni reported the findings of a pilot study comparing liquid and foam sclerosants. He measured the outcome using a visual analogue scale to describe the improvement in appearance. He found that foam resulted in a 20% improved appearance compared to liquid sclerosant.

Subsequently Tessari has described a method of preparing foam using two disposable syringes and a three-way tap. This method can be used to produce large quantities of foam suitable for treating saphenous trunks and large varices. Frullini has added his own method of producing foam to this increasing list.

No randomised clinical trial comparing this technique to surgery has so far been published. However, a large multi-centre trial is currently in progress in Europe comparing surgery to a commercial pharmaceutical foam (Varisolve^®, Provensis, UK). Cabrera has published a clinical series of 500 lower limbs treated by foam sclerotherapy. He reported that after three or more years 81% of treated long saphenous trunks remained occluded and 97% of superficial varices had disappeared. This required one session of sclerotherapy in 86% of patients, two in 11% and three sessions in 3% of patients. No DVT or pulmonary embolism was encountered in this series. Frullini and Cavezzi have reported similar data in a series of 453 patients. Early observations showed that 93% of veins remained occluded after treatment with Tessari foam. A number of instances of limited calf vein thrombosis have been observed following foam sclerotherapy.

Currently ultrasound guided foam sclerotherapy is being taken up by an increasing number of phlebologists. In the short term its efficacy is probably equivalent to that of surgery. It has the advantage that it requires no general or regional anaesthesia to perform and takes much less time than equivalent surgical techniques. The long term efficacy of this treatment in comparison to surgery is unlikely to be established for several years.

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2. Understanding Varicose Veins: Basics, Symptoms, Treatment, & Prevention
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Trends in the treatment of venous disease have mirrored those of arterial pathology with the development and advancement of minimally invasive technologies.

Patients with venous ulcerations or painful varicosities whose only option had previously been only traditional saphenous vein ligation and/or stripping or open perforator ligation can now be treated with a variety of endoluminal approaches. These procedures may also be combined with microphlebectomy. The goal of open and endovenous therapy is to obliterate the affected veins, thereby eliminating reflux, reducing pain, and preventing recurrence of venous ulcers

The decision as to which therapy is appropriate for any given patient depends on the patients clinical presentation, anatomy, medical co-morbidities, and treatment goals. Patients with large, tortuous varicosities and extensive reflux are best served with an open ligation and stripping. Patients with less challenging anatomy are candidates for endovenous intervention.

Endovenous techniques can be used to treat reflux in the long or short saphenous vein, in duplicate systems, and even in perforating veins. These procedures can be accomplished in an outpatient setting and with a low morbidity.

There are several methods that can be used to perform endovenous ablation. The basic unifying principal is damage to the vessel wall which results in sclerosis and obliteration of the lumen. The most common methods utilize heat energy to close the lumen.

In one case radiofrequency energy is employed and in another laser energy is used. Mechanical ablation using foams or other sclerosing agents can also be performed. These agents cause endothelial and vessel wall damage by interfering with the function of endothelial and subendothelial cell surface proteins, leading to thrombosis and fibrous obliteration of the vein.

Radiofrequency energy is a type of electrical energy whose waves cause excitement in the molecules of an object by virtue of the object’s resistance. This causes heating of the object, called “resistive heating”, resulting in collagen shrinking and fibrosis as well as denuding of the endothelium. The walls of the vein can therefore be heated in a controlled and efficient manner.

Laser treatment utilizes an optical fiber to deliver laser energy and heat the blood inside a vein. The laser delivers energy that heats the blood, damaging the vein as a result of the steam bubble and inducing the blood to clot.

Either method can used to treat the Greater (Long) Saphenous vein, the Lesser (Short) Saphenous vein, or even duplicate systems. In both procedures a percutaneous puncture is made and a catheter is introduced into the vein over a guidewire under ultrasound guidance. The catheter is then pulled back along the length of the segment to be treated. These procedures are performed under duplex ultrasound guidance with a minimal blood loss and reduced post-operative swelling and ecchymosis. Recently the radiofrequency procedure has been expanded to the treatment of incompetent perforator veins. A newer version of the radiofrequency catheter and generator permits a greatly reduced treatment time. There are several different lasers available for endovenous ablation.

In foam sclerotherapy a solution of an irritating chemical is used to damage the vessel wall. These procedures are also performed under duplex guidance.

As in other endovenous therapies a percutaneous puncture is made and a catheter placed over a guidewire. When position is confirmed, the foam agent is injected under ultrasound observation. The catheter is then slowly withdrawn and the vein closed

by virtue of the chemical reaction with the wall.

Foam sclerotherapy may be useful for the treatment of varicosities emanating from pelvic venous reflux as well as in the ablation of incompetent communicating veins and perforators.

Other non-endovenous, minimally invasive vein treatments are available including Transilluminated Powered Phlebectomy and, Subfascial Endoscopic Perforator Surgery (SEPS) Color duplex ultrasonography can visualize, guide

and monitor all aspects of the radiofrequency, laser, and foam sclerosant ablation procedures. This approach eliminates exposure to ionizing radiation and contrast agents. Endovenous therapy for the treatment of venous disease has continued to gain popularity. Some authors have used the methods in combination in an attempt to achieve improved results. Refinements in technology, experience, and patient selection should further improve results.

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2. Understanding Varicose Veins: Basics, Symptoms, Treatment, & Prevention
3. Preventing Spider Veins

What Are Varicose Veins?

Varicose veins usually announce themselves as bulging, bluish cords running just beneath the surface of your skin. They can appear anywhere in the body but most often affect legs and feet. Visible swollen and twisted veins — sometimes surrounded by patches of flooded capillaries known as spider-burst veins – are considered superficial varicose veins. Although they can be painful and disfiguring, they are usually harmless. When inflamed, they become tender to the touch and can hinder circulation to the point of causing swollen ankles, itchy skin and aching in the affected limb.

Besides a surface network of veins, your legs have an interior, or deep, venous network. On rare occasions, an interior leg vein becomes varicose. Such deep varicose veins are usually not visible, but they can cause swelling or aching throughout the leg and may be sites where blood clots can form.

Varicose veins are a relatively common condition, and for many people they are a family trait. Women are at least twice as likely as men to develop them. In the United States alone, they affect up to 60% of all Americans.

What Causes Varicose Veins?

To help circulate oxygen-rich blood from the lungs to all parts of the body, your arteries have thick layers of muscle or elastic tissue. To push blood back to your heart, your veins rely mainly on surrounding muscles and a network of one-way valves. As blood flows through a vein, the cup-like valves alternately open to allow blood through, then close to prevent backflow.

In varicose veins, the valves do not work properly — allowing blood to pool in the vein and making it difficult for the muscles to push the blood “uphill.” Instead of flowing from one valve to the next, the blood continues to pool in the vein, increasing venous pressure and the likelihood of congestion while causing the vein to bulge and twist. Because superficial veins have less muscle support than deep veins, they are more likely to become varicose.

Any condition that puts excessive pressure on the legs or abdomen can lead to varicosity. The most common pressure inducers are pregnancy, obesity and standing for long periods. Chronic constipation and – - in rare cases — tumors also can cause varicose veins. Being sedentary likewise may contribute to varicosity, because muscles that are out of condition offer poor blood-pumping action.

The likelihood of varicosity also increases as veins weaken with age. A previous leg injury may damage the valves in a vein which can result in a varicosity. Genetics also plays a role and if other family members have varicose veins there is a greater chance you will too. Contrary to popular belief, sitting with crossed legs will not cause varicose veins, although it can aggravate an existing condition.

What Are the Symptoms?

Symptoms of varicose veins include:

#Prominent dark blue blood vessels, especially in the legs and feet.

#Aching, tender, heavy, or sore legs; often accompanied by swelling in the ankles or feet after standing for any length of time.

Call Your Doctor If:

Swelling becomes incapacitating, or if the skin over your varicose veins becomes flaky, ulcerated, discolored, or prone to bleeding — you could be developing stasis dermatitis. You may want to have the veins removed to avoid further discomfort and prevent potentially more serious circulatory problems.

You have red, warm and tender varicose veins. This may be a sign of phlebitis.

You cut a varicose vein. Control the resulting burst of blood and have the vein treated to prevent complications.

What Are the Treatments?

A mild case of varicose veins does not usually require a doctor’s care. You can find relief from the discomfort of varicose veins with basic at-home treatment and various alternative remedies.

Superficial varicose veins normally do not require medical attention, but they should not be ignored. To relieve the discomfort, your doctor may recommend elastic support stockings, which you can buy in most pharmacies and medical supply stores. Support stockings help your leg muscles push blood upward by concentrating pressure near the ankles. Put them on before you get out of bed in the morning. Raise your legs in the air and pull the stockings on evenly; they should not feel tight in the calf or groin. You should wear them all day and also elevate your legs for 10-15 minutes several times throughout the day.

To alleviate occasional swelling and pain, your doctor will probably suggest an over-the-counter anti-inflammatory drug such as aspirin or ibuprofen. If you notice skin around a varicose vein becoming ulcerous or discolored, or if you have continuing pain with no obvious outward signs, contact a doctor at once about the possibility of deep vein involvement.

Most varicose veins do not need to be removed. If particularly bothersome, varicose veins can be eliminated by one of several methods. Spider veins can be removed quite simply through laser treatment. A mild case of superficial varicose veins can be treated by sclerotherapy: A chemical known as a sclerosing agent is injected into the vein to collapse its walls so it can no longer transport blood. There are other catheter assisted methods that use heat or radiofrequency waves to destroy and ultimately close the vein. More severe cases may merit surgical removal, or stripping.

Unfortunately, no treatment can prevent new veins from becoming varicose. Before pursuing a particular treatment, discuss all options with a dermatologist or vascular surgeon.

How Can I Prevent Varicose Veins?

Exercise regularly! Staying fit is the best way to keep your leg muscles toned, your blood flowing and your weight under control. Avoid wearing tight clothing.

Eat foods low in fat, sugar and salt. Drink plenty of water.

If your daily routine requires you to be on your feet constantly, stretch and exercise your legs as often as possible to increase circulation and reduce pressure buildup.

If you smoke, quit. Studies show that smoking may contribute to elevated blood pressure, which in turn can aggravate varicosity.

If you’re pregnant, be sure to sleep on your left side rather than on your back to minimize pressure from the uterus on the veins in your pelvic area. This position will also improve blood flow to the fetus.

Related posts:

1. Foam Sclerotherapy in Treatment of Varicose Veins: Results From Europe
2. Preventing Spider Veins
3. Varicose Vein Treatment Options: Stripping, Ligation, Phlebectomy, Endovenous Treatment (Thermal Or Chemical)