PHLEBOLOGY

Recurrent Varicose Veins Part 2: Injection of Incompetent Perforating Veins Using Ultrasound Guidance PAUL KENNETH THIBAULT, MBBS WARREN ANTHONY LEWIS, DMU

Treatment options following duplex evaluation of re- current varicose veins are discussed and a method of injecting incompetent perforating veins using ultra- sound guidance is described. The results of duplex evaluation 6 months postinjection using this technique are presented. These early results indicate that sclero- sant injection employing ultrasound guidance is an efective and safe method of treating incompetent per- forating veins. J Dermatol Surg Oncol1992;18:895 - 900.

lthough inadequate evaluation and surgical techniques are common causes of recurrent varicose veins, new varices may develop after A technically correct surgery.' In many areas of

surgical practice operative procedures are regarded by the doctor and patient as curative. This certainly does not apply to varicose vein surgery; many patients having ex- perienced one apparently unsuccessful procedure are re- luctant to undergo another. These patients often look to sclerotherapy, which offers a less traumatic procedure with minimal, if any interruption to their normal daily activities. If compression sclerotherapy is preferred by patient and clinician, precise functional and anatomic diagnosis of areas or points of reflux is essential. Duplex evaluation of recurrent varicose veins is well accepted as a reliable and safe method of assessment, especially in the detection of sources of reflux from the deep ~ y s t e m . ~ , ~

Following duplex evaluation a rational decision can be made concerning optimal management. These manage- ment decisions will vary between practicing phlebolo- gists according to their particular expertise. If there is a significant communication greater than 4 mm in diame- ter with reflux from the common femoral vein re-explor- ation of the groin may be required. Persistent varicose tributaries without evidence of reflux from the deep veins

From the Newcastle Laser Center, Newcastle, Australia. Address correspondence and reprint requests to: Paul Kenneth Thibault,

MBBS, Level 6, State Bank Building, Bolton Street, Newcastle, Australia 2300.

can be treated with compression sclerotherapy .' The al- ternative surgical approach is to remove the varicose trib- utaries by the stab avulsion or Muller Fre- quently recurrences are associated with incompetent perforating If incompetent thigh, posterior tibial, or gastrocnemius perforating veins are found a decision must be made concerning whether further surgery or, alternatively, sclerotherapy should be recommended.

Surgical searches for incompetent perforating veins can be frustrating and futile. Recurrences fed by long narrow perforating veins are difficult to find at operation with the patient lying flat, and sclerotherapy has been recommended in these situation^.^ However, often there is not an obvious varicosity lying over the incompetent perforating vein5 and while venography has been used to localize incompetent perforating veins before surgery, ul- trasound localization is more practical if sclerotherapy is to be used. Similarly, ultrasound localization can be uti- lized prior to surgery to accurately determine the site of incompetent perforating veins.

Studies of surgical interruption of incompetent poste- rior tibial perforating veins have been confined to man- agement of chronic venous ulcers. Reported results have been poor with recurrent ulcers forming in 40-554b of patients within 5 years.1°-12 hesson13 has been unable to show any improvement in venous function following perforating vein ligation in patients with deep venous insufficiency and the long incisions down the medial aspect of the leg and the stocking-seam line incisions down the back of the leg risk interrupting the cutaneous arterial blood supply, thereby further impairing the cuta- neous circulati~n.~,'~,~'

The authors are not aware of any studies on the effec- tiveness of sclerotherapy for lower leg perforator disease. However in his comparative study of surgery and sclero- therapy in the treatment of varicose veins, Hobbs15 con- cluded that incompetent lower leg perforating veins were best treated with injection-compression. The Fegan16 method of compression sclerotherapy requires localiza- tion of incompetent perforating veins by palpation fol- lowed by injection of sclerosant into the adjacent superfi- cial vein while the limb is elevated to empty the vein.

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896 THIBAULT AND LEWIS J Dermatol Surg Oncol 1992;18:895- 900

Immediately after injection a piece of compression foam is placed over the injection site and bandaged into place. There are two inherent weaknesses in this method. First, success depends upon accurate clinical localization of the incompetent perforating vein. However, the accuracy of clinical examination in locating incompetent perforating veins has been found to be around 50%.17,18 Second, Fegan’s method of sclerosing incompetent perforating veins depends on a “relatively” uncontrolled spreading phlebitis from the adjacent injected superficial varicosity. It is therefore likely that inadequate sclerosis of incompe- tent perforating veins by this technique contributes to the high 5-year recurrence rate. B-mode ultrasound localiza- tion and subsequent direct injection of the incompetent perforating vein under ultrasound guidance theoretically should improve the long-term success rate of compres- sion sclerotherapy and reduce the incidence of inadver- tent intra-arterial injection that can occur when ”blind” injection of incompetent perforating veins is attempted. The aim of this prospective study was to determine the effectiveness of sclerosant injection to incompetent per- forating veins using ultrasound guidance.

Materials and Methods Thirty-six patients (38 limbs) with incompetent perforat- ing veins were treated with sclerosant injection of incom- petent perforating veins using ultrasound guidance. There were 31 females and 5 males with a mean age of 54 years (range 27 to 78). A total of 43 incompetent perforat- ing veins were injected. There were 12 incompetent thigh perforating veins, 13 incompetent gastrocnemius or soleus perforating veins, and 18 incompetent posterior tibia1 perforating veins. The duplex scanner used was an ATL Ultramark 4 (Advanced Technology Laboratories, Bothel, NJ) with a multifrequency sector scanhead.

The patients were positioned in the semi-reclining po- sition with the legs extended. For incompetent perforat- ing veins on the medial aspect of the thigh and calf the leg was externally rotated and abducted at the hip. The semi- reclining position dilated the veins slightly thereby assist- ing ultrasound visualization. For perforating veins on the posterior calf or thigh the patient was positioned in the prone position with the head of the treatment couch slightly raised and the foot supported by a pillow so that the knee was flexed slightly. (This position can also be used for injection of the short saphenous vein.)

The vascular sonographer located and measured the diameter of the incompetent perforating vein and the depth from the skin surface to the segment of incompe- tent perforating vein immediately beneath the muscle fascia, which was the usual site of injection (Figure 1). The incompetent perforating vein was imaged in a sagittal

Sagittal Axis Line on transducer 1 Transducer

Skin surface

surface to IPV

Figure 1 . Needle is inserted close to the transducer tip and along sagittal plane of transducer. Depth of target incompetent perforating vein (IPV) is measured on the B-mode image from skin surface to segment of incompetent perforating vein immediately beneath muscle fascia.

plane and the transducer held perpendicular to the skin. The 10-MHz imaging frequency was selected for this procedure. The cylindrical multifrequency sector trans- ducer used on the ATL Ultramark 4 has a vertical line down the transducer that aligns with the sagittal plane. This allowed the physician to guide the needle accurately along the axis of the transducer. Twenty-three-gauge Terumo needles (Terumo, Melbourne, Australia) have been found to be suitable for this purpose as their tip is ultrasound reflective. A high quality 2-mL plastic syringe (Becton Dickinson, Singapore) loaded with 1 mL of so- dium tetradecyl sulphate 3% (STD; STD Pharmaceuti- cals, Hereford, England) was attached to the needle. When the skin was pierced along the line of axis of the transducer the needle tip could be visualized.

As the needle was slowly inserted, it appeared as a reflective straight line angling towards the perforating vein (Figure 2). (It is important to verify early in the pro- cedure of needle insertion that the needle is being intro- duced in the correct sagittal plane, ie, the needle and vein must be imaged simultaneously at all times.) If the needle moved off axis the sonographer localized the needle tip in relation to the perforating vein and informed the clinician in which direction (anterior, posterior, medial, lateral) an adjustment of needle plane insertion was to be made. As the needle tip contacted with the perforating vein an in- dentation was seen on the vein wall (Figure 3). At this stage a little extra pressure was required to pierce the vein wall and when this occurred the needle tip could be seen within the lumen and a small amount of blood was with- drawn in the needle hub.

J Dermatol Surg Oncol 1992;18:895 - 900

THIBAULT AND LEWIS 897 RECURRENT VARICOSE VEINS: PART 2

Figure 2. B-mode ultrasound image of needle angling towards incompetent perforating vein (IPV). The angle of insertion is determined by measuring the depth of proposed injection site on the ultrasound image prior to needle insertion. The needle and the incompetent perforating vein should be imaged simultaneously throughout the procedure.

A small volume (z 0.1 mL) of sclerosant was then in- jected and, providing the needle tip was still located in the vein, sclerosant was seen on the ultrasound image to be flowing into the vein (Figure 4). If any of the solution appeared to be collecting outside the vein wall the injec- tion was stopped until the needle tip was again sighted within the vein lumen. During injection the direction of flow of sclerosant could usually be determined and digital pressure was applied proximal or distal to the injection site to ensure that the sclerosant acted on the selected

Figure 3. B-mode ultrasound image of reflective needle tip indenting vein wall immediately prior to vein puncture.

Figure 4. B-mode ultrasound image of needle located in vein with sclerosant flowing towards the right of image.

segment of vein. The volume of sclerosant injected was 0.5 to 1.0 mL depending on the incompetent perforating vein length and diameter. Within several minutes of in- jection the incompetent perforating vein would spasm and become indistinct on the B-mode image, indicating a successful injection (Figure 5).

Immediately following injection a foam pad (C Pad; STD Pharmaceuticals, Hereford, England) was placed over the injection site and firmly held in place by a low- stretch crepe bandage. Additional graduated venous compression with a Class 3 (40 to 50 mm Hg at the ankle) compression stocking (Medi Forte; Medi Strumpf, Bayr-

Figure 5. Postinjection B-mode image of incompetent perforating vein (IPV). There is spasm of the incompetent perforating vein which is now indistinct.

898 THIBAULT AND LEWIS J Dermatol Surg Oncol 1992;18:895- 900

Figure 6. B-mode ultrasound image and pulsed Doppler spectral display of 4-mm diameter thigh incompetent perforating

euth, Germany) was applied over the crGpe bandage. This compression was kept in place continuously for 2 weeks. The pad and bandage were then removed and the stock- ing was worn during the day for another 4 weeks to prevent symptomatic thromb~phlebitis.'~ During the postinjection period the patient was instructed to walk at least 3 kilometers daily. This appeared to reduce postin- jection pain and assisted resolution of the sclerosing pro- cess by reducing hydrostatic pressure in the superficial veins.20

The patients were assessed 6 to 8 weeks following injection. If there was clinical evidence of persistent vari- ces or reflux in the perforating vein, the perforating vein was re-evaluated by duplex. An ultrasound image and pulsed Doppler spectral display of a typical thigh incom- petent perforating vein is shown in Figure 6. Ultrasound examination 7 weeks following injection shows the signs of a successful injection with reduction of vein diameter, incompressibility of the vein and absence of flow (Figure 7), indicating firm fibrosis. If repeat duplex examination revealed persistent incompetence in the perforating vein, the injection was repeated.

All patients were then assessed by duplex ultrasound imaging 6 months following initial injection. Three alter- native criteria for successful treatment were used: 1) complete absence of the perforating vein, 2) firm fibrosis of the perforating vein with absent flow, or 3) reduced diameter of the perforating vein with normal flow. De- tection of deep to superficial flow in the perforating vein designated treatment failure. Results were recorded on an Apple Macintosh SE/30 (Apple Computer, Cupertino, CA) using Clans Filemaker I1 data base. For analysis, each incompetent perforating vein was treated as an indepen- dent observation.

vein prior to injection. SFA = superficial femoral artery; SFV = superficial femoral vein.

Results Two incompetent thigh perforating veins, three incom- petent posterior tibial perforating veins, and one incom- petent gastrocnemius perforating vein required repeat in- jections. Of these, one posterior tibial perforating vein remained incompetent at the 6 month follow-up evalua- tion. The 6 month follow-up results are shown in Table 1. Sixteen treated incompetent perforating veins classified as successful at 6 months have been followed up over 12 months. The ultrasound results in these patients at 12 months did not differ from the 6 month results and it can therefore be inferred that treatment failure will be de- tected in the first 6 months when using this protocol. There were no complications reported by the patients or detected on follow-up in this study.

Discussion Six month follow-up results of injection of incompetent perforating veins under ultrasound guidance indicate that the procedure will become a worthwhile supple- mentary method in the treatment of varicose veins and especially in the management of recurrent varicose veins. The method eliminates several of the uncertain variables of compression sclerotherapy by accurately localizing the incompetent perforating vein and allowing precise injec- tion of the point of reflux. We have applied the method to injection of incompetent thigh, posterior tibial, and gas- trocnemius perforating veins, as well as impalpable, in- competent short saphenous veins and impalpable incom- petent recurrent thigh tributaries following the stripping operation. In addition to postsurgical recurrences, this procedure has been used in the treatment of recurrences

J Dermatol Surg Oncol 1992;18:895 - 900

THIBAULT AND LEWIS 899 RECURRENT VARICOSE VEINS: PART 2

Figure 7. B-mode ultrasound image and pulsed Doppler spectral display of thigh incompetent perforating vein shown in Figure 6, 7 weeks following injection. The incompetent

following compression sclerotherapy when duplex imag- ing has revealed inadequate sclerosis of incompetent per- forating veins. In most cases the procedure has resulted in rapid subsidence of patient symptoms with absence of thrombophlebitis, which can develop with Fegan’s method. The best results have been achieved with injec- tion of incompetent gastrocnemius perforating veins. Treatment failures when injecting incompetent thigh perforating veins could be attributed to technical diffi- culty in accurately locating small incompetent perforating veins more than 2.5 cm beneath the skin. Treatment failures when injecting incompetent posterior tibia1 perforating veins were most likely because of the type and concentration of sclerosant used. Theoretically, polyiodinated iodine (which is not approved for use in Australia) should give more consistent results when in- jecting distal calf incompetent perforating veins because of its more localized, potent action on venous endothe- lium compared with sodium tetradecyl sulphate.

Complications, such as deep vein thrombosis, pulmo- nary embolus, or inadvertent intra-arterial injection have not occurred when injecting incompetent perforating

Table 1. lnjection of lncompetent Perforating Veins, Using Ultrasound Guidance

Successful at lPVS 6 Months

Location (N) Mean Age (N [%I) Thigh IPV 12 50 10 (83) Gastrocnemius

IPV 13 48 13 (100) Posterior Tibia1

IPV 18 61 13 (72)

perforating vein is now an incompressible cord measuring 2 mm in diameter with no recordable flow.

veins. However, there has been one case of intra-arterial injection when injecting a symptomatic 3-mm diameter incompetent short saphenous vein receiving reflux from an incompetent Giacomini vein. There was no sapheno- popliteal junction in this patient and a cutaneous branch of the popliteal artery was injected in the popliteal fossa. This resulted in a 5 X 5 cm area of skin necrosis that healed in 3 months using hydrocolloid occlusive dress- ings. Despite this, the Giacomini vein and short saphe- nous vein were successfully sclerosed by the procedure and the patient was asymptomatic after the ulcer healed. We have since modified the technique to avoid this com- plication. We now scan with pulsed Doppler for arterial signals along the line of needle approach and around high risk sites such as calf perforating veins and the short sa- phenous vein in the popliteal fossa. If an arterial signal is detected the needle approach is modified to avoid any risk of intra-arterial injection. This incident highlights the need for extreme diligence in performing each injection and the technique should only be undertaken by a skilled vascular technologist and an experienced sclerotherapist. There is need for further refinement of the procedure, which is often technically difficult, and development of a needle guide probe attachment to aid precise localization of the needle tip at a depth of 0.5 to 3.0 cm from the skin surface.

Acknowledgment. We w i s h t o thank Carole Shedden for her secretarial assistance in preparing the manuscript.

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