Foam Phlebectomy:Technique & OutcomesMichael Cumming, MD, FRCPC, MBACDI Vascular CareMinneapolis, MN

DisclosureSpeaker name: Michael Cumming.................................................................................No potential conflicts of interest related to this talk

Typical Treatment Early 2000s

REALITIES OF A STAGED APPROACHToo many clinic visitsToo many separate proceduresToo much time off work

Patients do not like it

Ann Surg. 2015 Apr;261(4):654-61Earlier improved QoLProlonged improved clinical statusPatient preference

April 29, 2015Copyright UPM-Kymmene Group5

Secondary ProceduresUSGFSAP

Simultaneous PathwaysLarger bulging varicositiesSmaller varicositiesEither-or?

Why not use both?

Foam Phlebectomy (FP)

1 Week post EVLA + FP

1 Month

3 Months

Unexpected advantages?Better sclerotherapyPotential safer sclerotherapyEasier APLess bleeding problems

Foam and TumescentCompresses veinsBetter wall contactLess foam required

Foam Removal

Tumesce one vein (small area) Incise veinCompress and express foam

Advantages of Foam RemovalMinimize uncontrolled foam dispersionRemoval of biologic mediatorsLess microthrombectomy

Clin Radiol. 2015 Jan;70(1):48-53.

Easier APUse US to see VV missed during APUse US to guide AP

Technical ConsiderationsTumescent for EVA may interfere with USGFS (spasm/compression)

Foam from USGFS may interfere visualization during positioning for EVA

Typical Procedural Steps

Alternative Procedure Steps

EVAAccessPosition

USGFSFoam Sclero VVs

APTumesceExpress foamAP

EVATumesceTreatEVATumesceTreat

USGFSFoam Sclero VVs

APTumesceExpress foamAP

My Practice134 Consecutive patients 162 EVLA3 Month FU81 EVLA & FP

81 EVLA & FP EVLA GSV or SSVAP, 4 33 incisions, average 13.5USGFS, 1 or 3% sotradecol, 1:3 air

1 Week3 (4%) EHIT, no treatment7 (8%) infections requiring treatmentNo DVT/PE*No bleeding (No phone calls or RTC)

3 5 Weeks15 (19%) microthrombectomyDiscomfortDiscoloration1 DVT & PENegative US at 1 week

3 Months3 (4%) GSV recanalizations > 5 cm1 symptomatic4 (5%) Unplanned procedures1 EVLA, recanalization3 USGFS, residual symptomatic VV

Not trackedNo VCSS/QoL scoring ParesthesiaPermanent vs transientCosmeticScars/keloidsPigmentation

My (Anecdotal) 8 Year ExperienceFoam PhlebectomyUSGFS

AP

Benefits of both proceduresNo apparent downsidesSingle treatment session

Foam PhlebectomyBetter FSWall ContactLess FoamRemoval of foamLess micro-thrombectomyBetter APUSG AP for difficult VVs Missed VVs treated by USGFSLess bleeding