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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”

michaeldiiorio@yahoo.com

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!