Chapter 19: Foam Sclerotherapy

INTRODUCTION

Sclerotherapy with a foamed solution has become the standard treatment of many varicosities, perforating veins, reticular veins, and larger telangiectasias or venulectasias (1.0–2 mm). Although any detergent solution may be agitated with air and foamed, the two most popular solutions that are typically foamed are the detergent solutions, sodium tetradecyl sulfate (STS, sold in the United States as Sotradecol®; Bioniche Pharma, USA, LLC, Lake Forest, IL) and polidocanol (POL, sold in the United States as Asclera®; Chemische Fabrik Kreussler & Co., GmbH, Wiesbaden, Germany). Currently, to agitate and foam these U.S. Food and Drug administration (FDA)-cleared sclerosants is an off-label use in the United States. Foaming of solutions cannot be discussed or suggested by the companies manufacture or distribute the solutions in the United States because of the off-label use status.

Foamed sclerosant completely fills and displaces the blood in the vein, maximizing endothelial cell injury and subsequent fibrosis. Most phlebologists agree that this more effective form of sclerotherapy usually requires fewer treatment sessions than liquid sclerotherapy. Foam sclerotherapy has been thought to be as effective as surgery for larger branch varicosities.¹

HISTORY

Sclerotherapy with foamed sclerosant is not a new concept. In fact, physicians have been experimenting with foam injections since the 1940s. Within this longer than originally thought history of foam sclerotherapy, there have been several key contributions along the way.² Until recently, foam techniques were not uniformly reproducible or particularly effective and did not garner mainstream acceptance. In 1995, a re-emergence of the foam sclerotherapy concept began with the work of Dr. Juan Cabrera, a Spanish vascular surgeon.³ He experimented with the use of detergent sclerosant (POL) mixed under high speeds with CO₂ gas to create a therapeutic sclerotherapy foam. He studied high-volume foam injections into patients with incompetent great saphenous veins (GSVs) in order to replace surgical ligation. The resurgence of foam sclerotherapy was continued by Alain Monfreux in 1997 and Javier Garcia-Mingo in 1999.^4,5 Monfreux developed a low-pressure foaming technique widely utilized in France and Garcia-Mingo described a sterilizable medical device for the preparation of a standardized foam. In the year 2000, sclerosant foam was introduced and by 2001 was widely accepted into the mainstream practice of phlebology by the work of an Italian phlebologist, Dr. Lorenzo Tessari.^6,7 The foaming technique he developed was simple, inexpensive, and easily reproducible.

TECHNIQUES OF SCLEROTHERAPY FOAM PREPARATION

Currently, the Tessari and the closely related Frullini and double syringe system (DDS) techniques are the most utilized techniques for the creation of foam sclerotherapy. In Tessari’s method, he connected two 3-cc Luer lock syringes with a disposable three-way stopcock (Figure 19-1). One syringe is filled with air and the other is filled with a detergent type of sclerosant. He found the optimal ratio of solution to air to be 1:4. For example, our practice ...