Sclerotherapy is very useful to treat varicose veins, and probably, is cheaper than other methods. However, until the present, it is the less studied method. Chronic venous insufficiency CVI is characterized by cutaneous alterations caused by venous hypertension 1 - 3.
Lower limb varicose veins are the most frequent cause of CVI 4 and the most severe form of the disease is venous ulcer 5. CVI causes pain, functional impairment and worsening of quality of life 11 - From to , there were 5,5 thousand retirements due to incapacity and lower limb varicose veins In a study of patients followed and examined for more than six years, varicose vein prevalence increased from Among patients with GSV reflux, Reflux to great saphenous vein is the most frequent event associated to CVI and ulcer formation 4 , In the presence of venous reflux, a long liquid column is formed, increasing hydrostatic pressure and venous hypertension Guidelines based on evidences recommend evaluation of patients with interview and physical exam, Doppler vascular ultrasound exam DUS and categorization of patients using CEAP classification 1 , 4.
CEAP classification describes systematically CVI according to clinical presentation, etiology primary or secondary , anatomy superficial, deep and perforating veins and physiopathology obstruction, reflux, or both. It guides treatment 24 - 26 , but with low sensitivity to slight alterations of the severity of the disease Follow-up of treatment results must include evaluation of quality of life, severity score and anatomic and physiologic data obtained by DUS.
Clinical score of severity of disease proposed by the American Venous Forum is based on signals and symptoms identified by the examiner and allows follow-up of CVI evolution The score does not measure quality of life, but is sensitive to clinical presentation and is considered the best method nowadays to follow up the results of treatment 4 , Recently, it is becoming popular the evaluation of quality of life QL to quantify the impact of CVI on patients QL of patients with CVI is altered by physical aspect, pain, functional impairment and mobility deficit 31 , Specific questionnaires for CVI QL evaluation are validated in English and are difficult to use in other languages, since they must be translated and validated 33 - Charing Cross and Aberdeen question forms are translated and validated in Portuguese 36 , Evolution of disease is best assessed when multiple instruments are used, avoiding systematic errors of single question forms 37 - Anatomic and functional evaluation of venous system must be made by Doppler ultrasound DUS , the ideal method, since is reproducible and non-invasive, allowing the access to venous patency or occlusion, identification and quantification of venous reflux, measure of caliber of veins and differentiation of primary and secondary venous disease 40 - DUS does not identify venous hypertension.
Venous pressure measure is invasive and in the present is not often performed Clinical treatment is based in rest with elevation of lower limbs and use of compressive socks. Most patients may benefit of compressive treatment that is recommended to open or healed varicose ulcer and is not indicated to patients with arterial obstruction.
Compressive treatment improves symptoms and is efficient for ulcer healing, but with low adherence. Clinical treatment does not eliminate varicose veins and does not alter anatomic basis of venous hypertension. Low adherence to treatment is responsible for ulcer recurrence Single compressive therapy is not efficient for patients with varicose veins and CVI 49 - In our country, the most common treatment for varicose veins and GSV reflux is surgical proximal ligature and flebo-extraction of great saphenous vein 1 , 2 , In patients with GSV reflux and intact deep venous system, surgery is efficient and indicated to avoid recurrence of varicose ulcer 5 , Surgery improves quality of life 12 , but cannot be performed in a considerable amount of patients.
Surgical patients present more pain and post-operatory discomfort and delay resuming work activities Among minimally invasive techniques for the treatment of varicose veins and reflux of GSV it is included ultra-sound guided foam sclerotherapy UFS and thermal ablation using radiofrequency or laser. Thermal ablation is performed by inserting a thermal element catheter in the distal part of GSV by puncture.
Handbook of venous disorders : guidelines of the American Venous Forum - Details - Trove
The procedure is performed with femoral blockage or with local anesthesia. Catheter must progress proximally inside the vein, in all extension to be treated. Thermal energy released by the catheter destroys venous endothelium. Veins with excess tortuosity, occluded segments, stenotic, or with parietal irregularities may impair progression of catheter.
Big diameter veins are challenging for thermal ablation, since they distance thermal element from endothelium. Excessively superficial veins increase the risk of thermal lesion of skin.
Handbook of Venous Disorders
Finally, costs of catheters and generators limit their use. Minimally invasive treatments present advantages such as rapid recovery of patients and possibility of ambulatory treatment. According to recommendations of the British National Institute for Health and Clinical Excellence , these treatments must by primarily used in relation to conventional surgery Patients with worse quality of life had better benefits when submitted to minimally invasive techniques, regardless the one used 38 , Ultrasound guided foam sclerotherapy is less expensive than other methods, but cost analysis in Brazil is lacking.
Elsholz was the first to perform injection in humans and Zollikofer was the first to perform sclerotherapy Varicose veins sclerotherapy was used and favored until XIX Century. In the XX Century, surgical technique developed and became the treatment with better results; therefore, sclerotherapy for trunk veins was abandoned Also, during XX Century, many reports of the use of detergent sclerosing agents were published, with higher sclerosing power, forming foam when mixed with gas. In , Biegeleisen used etanolamine; in , Reiner used tetradecyl sodium sulfate and, in , Henschel described sclerotherapy with polidocanol The first description of foam sclerotherapy was in In , Orbach described the technique of blood displacement with air bubble to treat varicose veins with diameter of up to 4mm, and, in , Fluckiger described that foam reached distant places from the point of injection by manual massage orientation 67 - In , Knight 70 described the ultrasound-guided venous puncture and, in , Schadeck 71 described that foam was visible at ultrasound, allowing observation of its progress.
In , Cabrera 72 described good results for ultrasound guided sclerotherapy using foam, that was patented for use in saphenous vein. In , Tessari 73 described the reproducible low cost technique to produce foam using syringes connected to three-way stopcock, mixing liquid and air at a proportion, displacing the mix from one syringe to another at least for ten times. Tessari method produces an homogenous and stable foam that popularized foam sclerotherapy 68 , 72 , In , Cabrera et al. They did not report any severe complication Wright et al.
They reported elimination of reflux in Foam sclerotherapy was inferior to surgery to eliminate venous reflux, but patients returned to daily activities more rapidly. Rasmussen et al. Patients had faster recovery with less pain than those treated by surgery. There was no statistical difference among complications of studied groups Brittenden et al. UFS result was inferior to surgical and thermal ablation groups.
Wright, Rasmussen and Brittenden studies, as well as most studies on foam sclerotherapy, are characterized by the small proportion of patients with open or healed ulcer 76 - Myers 84 studied sclerotherapies in patients; GSV were treated and Occlusion rate of tributary veins was higher than of GSV. Veins with diameter higher than 6mm had worse results than those with five or lower diameter. Best results were observed with foam sclerotherapy, with more than 12ml of volume and with sclerosing agents with higher concentration Interest of foam sclerotherapy of varicose veins in patients with severe CVI is justified since frequently these patients are older and less prone to surgical treatment.
Few randomized studies compared UFS to clinical treatment for ulcer healing and casuistic is small. There are evidences of favoring it in detriment to surgical treatment. In a meta-analysis Mauck 85 identified less recurrence of varicose ulcers when venous reflux was surgically removed. Several authors that study healing of varicose ulcers following UFS report healing rates higher than those of ESCHAR study, however, there is a predominance of non-comparative studies.
Twenty three limbs were submitted to UFS and healing occurred in There were no severe complications or differences in relation to surgical group. Ulcer healing rate, clinical improvement and of QL were similar 88 , Silva 91 identified healing of Randomized studies report similar healing of ulcers with surgery, thermal ablation or UFS, with numerous casuistic 77 , 92 , Brittenden 94 showed improvement of QL, however, less intense in patients treated by UFS when compared to surgery.
Wright 76 reported an incidence of deep venous thrombosis DVT in 5. After reduction, 95 patients were treated without new episodes of DVT According to European consensus, foam volume should be limited to 10ml per session 95 , Yamaki 97 affirms that equivalent volumes injected fractioned caused less progression of foam to deep venous system evaluated by Doppler. When foam volume used is reduced, the procedure is safer, but requires a higher number of treatment sessions to eliminate numerous and bulky varicose veins.
Some authors use the maneuver of elevation the limb to reduce venous volume and allow contact of lesser volume with endothelium 96 , More frequent side effects following UFS are phlebitis and cutaneous pigmentation. There are a few reports of severe complications such as DVT, pulmonary thromboembolism, stroke and cerebral embolization in patients with permeate oval foramen. Thomasset 99 states that women have more side effect reactions than men, specifically cutaneous pigmentation. Jia 82 in a systematic review of more than sclerotherapies describes the most frequent complications: 4.
There are evidences that treatment avoids ulcer recurrence and speeds recovery with less pain than conventional surgery. According to NICE, evidences on safety and efficacy of UFS are adequate and recommends that foam sclerotherapy must be offered primarily than surgical treatment European guidelines published in considered UFS evidences adequate and recommend the method to treat saphenous veins and varicose collateral veins Patients submitted to UFS present better QL than surgical patients after four weeks of treatment due to less pain.
After one year of treatment, surgical patients show better QL, but with higher rate of recurrence of varicose veins than those submitted to UDS 77 , UFS has lower cost and the procedure is faster, without the need of anesthesia 88 , It is reported higher recurrence rate of varicose veins and lower occlusion rate of treated veins with UDS, when compared to thermal ablation and surgical treatment.
However, meta-analysis have identified similar efficacy of minimally invasive methods and surgical treatment 83 , CVI is prevalent and causes important economic and social burden. Most studies primarily access patients with less severe disease and, rarely, results are categorized according to clinical class. Patients with severe CVI are usually older and less prone to surgical procedure.
Sclerotherapy may replace surgical treatment of varicose veins in many patients. Main limitations of method include cutaneous pigmentation frequent and usually compromise esthetical result , and the need of repeat treatment until total elimination of varicose veins. Patients must be warranted that esthetical result of foam sclerotherapy is less predictable than surgical resection.
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Low efficacy of a single session of sclerotherapy may be solved by subsequent sessions. Those enhance costs, but have no additional technical difficulty. After surgery of varicose veins, in case of necessity of reoperation, the presence of scars and adhesions may difficult technically the procedure or cause iatrogenic lesions. The main interests of UFS are its low cost, the easy application and low limitation in relation to other therapeutic methods. In literature, most studies show reduced evidence due to bias of selection and randomization 49 and long term results are still lacking and must be checked by controlled randomized trials.
J Vasc Bras. Varizes dos membros inferiores. In: Brito JC, editor. Cirurgia vascular e endovascular. Revinter; The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum J Vasc Surg.
vchecphyriporfarm.tk Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery r and the American Venous Forum. J Vasc Surg. Risk factors for chronic venous insufficiency: a dual case-control study.
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Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study.