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ULTRASOUND GUIDED SCLEROTHERAPY
MICHAEL M. DI IORIO, MD, RPVI, RVT, RPhS, DABR, DABVLM
VASCULAR & INTERVENTIONAL RADIOLOGIST
Disclosures
• No financial disclosures but will be discussing off label use
• Most of this is my opinion “How I Do It”
602-284-2014
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Ultrasound Guidance & Sclerotherapy
• 1939 Stuard McAusland- First used froth in telangiectasia
• 1944 James Orbach (Air Block) & Robert Foote (Shaking syringe)
• 1989- USGS first described (Liquid)• Knight, RM; Vin, F; Zygmunt, JA: Ultrasound Guidance of Injections into the Superficial Venous System.
Phlebologie ‘89, UIP, Strasburg, France
• 1995- Juan Cabrera- Foam Sclerotherapy double syringe
• 2000- Tessari- 2 syringes and 3 way stopcockWollmann, JC. The History of Sclerosing Foams. Dermatol Surg. 2004;30:694‐703.
Indications USGS
• Primary GSV, SSV, Accessories (usually non-compounded foam)• Secondary- post ablation for distal saphenous or tributaries• Recurrence post stripping or ablation• Non-saphenous veins• Perforator veins• Reticular veins• Veins under an ulcer • USGS prior to phlebectomy
Liquid vs Foam
Liquid• Dilutes quickly
• PFO
Foam• More effective
• Lower concentration• Less medication
• Visible on US • Increased accuracy
• Less pigmentation• Only detergent sclerosants
• 2009 Meta‐analysis 76% efficacy for USGS vs 39.5% LiquidHamel‐Desnos C, Allaert FA, Liquid vs foam sclerotherapy. Phlebology. 2009;24:240.
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Compounded (physician made)
• Methods: Tessari, Monfreux, Frullini, Cabrera
• Gas choices:• Room Air (78% N, 21% O2, 0.9% Ar, 0.04% CO2)• CO2• CO2 & O2• CO2 is 28x more soluble than O2 and 54x more soluble N
• Scleroscant to Gas Ratio 1:4, 1:5
Which Gas?
100 Pts 70%CO2 & 30% O2 Foam and compared to published data for CO2 & Air
Morrison, N. et al. Incidence of Side EffectsUsing Carbon Dioxide‐Oxygen Foam for Chemical Ablation of Superficial Veins of the Lower Extremity. Eur J Vasc Endovasc Surg. 2010; 40;407‐413.
Foam Stability
Peterson J, Goldman M. An Investigation into the Influence of Various Gases and Concentrations of Scleroscants on Foam Stability. Derm Surg. 2011;37:12‐18.
• Silicone free syringe longer foam life
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FYI
Asclera [package insert]. Raleigh, NC: Merz North America, Inc.
“The safety and efficacy of polidocanol foamed with room air has not been established and its use should be avoided.”
Sample CO2 Setup
99.996% Purity “Medical Gade” CO2
0.2 micron sterile filter
Sterile tubing
Delivery button
Regulator
Concentrations For USGS
Indication Concentration % of POL Concentration % of STS
Telangiectasias Up to 0.5 Up to 0.25
Reticular Veins Up to 0.5 Up to 0.5
Tributary Varicose Veins Up to 2 Up to 1
Incompetent Perforating Veins 1‐3 1‐3
Large Varicose Veins 1‐3 1‐3
Saphenous Veins (mm)<44‐8>8
Up to 11‐33
Up to 11‐33
European guidelines for sclerotherapy in chronic venous disorders. Phlebology 2014.
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How I Do USGS
• Tray set up
• Linear 14MHz• 7.5-14 MHz
0.5% or 1% POL
3cc 25GAlcohol
Long Approach
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Trans Approach
Transverse Approach
Physician Holds Probe and Injects
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Tech Holds Probe
Butterfly Technique:Physician Probe & Needle
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How I do USGS
• Flat or trendelenberg
• Look for blood return before injection (better seen w/ open needle)
• Compress areas you do not want foam to enter
• End point is spasm
• Limit volume of foam per injection 1.5cc
• I use less then 10cc total per sessions
End Point
Avoid
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Post Procedure Care
• Observe patient (especially if pt’s first session)• Apply compression• Ambulate immediately• Walk 30-45 minutes a day• 20-30mmHg straight for 48hrs then during day for 1-2 weeks• Avoid strenuous activity 48hrs• Follow-up 2-4 weeks• Aggressive with US guided puncture aspiration at F/U
US Guided Puncture Aspiration
Non-compounded Foam (Varithena™)
• 1% Polidocanol injectable microfoam• 65% O2 35% CO2 <0.8% Nitrogen• Liquid to Gas Ration of 1:7• Medium bubble size 100 micron, None >500 micron
• FDA approved for GSV, accessory veins, visible varicosities of the great saphenous vein above and below the knee
• Approved codes 36465 & 36466• Truncal veins only• Otherwise 36470 & 36471
Varithena™ [package insert]. Chapman House, Weydon Lane, Farnham, UK: Biocompatibles UK Ltd.
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Non-compounded Foam (Varithena™)
How I do it
• Mark access & perforators (where you do not want foam to go)
• Obtain access and test with saline injection
• Tilt patient trandelenberg (2-5 min)
• Inject while compressing
• Hold 2 min
• Apply compression
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Post Varithena™ Treatment
https://btgplc.com/en‐US/Varithena/Treatment‐Process
Efficacy
A multicenter, randomized, placebo‐controlled study to evaluate the efficacy and safety of Varithena® (polidocanol
endovenous microfoam 1%) for symptomatic, visible varicose veins with saphenofemoral junction incompetence.
Gibson, K, Kabnick, L. Phlebology. 2017 Apr;32(3):185‐193.
Adverse Events Varithena™
A multicenter, randomized, placebo‐controlled study to evaluate the efficacy and safety of Varithena® (polidocanol
endovenous microfoam 1%) for symptomatic, visible varicose veins with saphenofemoral junction incompetence.
Gibson, K, Kabnick, L. Phlebology. 2017 Apr;32(3):185‐193.
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Thank You!