Center for Vein Restoration The Official Journal of Center for Vein Restoration To Foam or Not to Foam ........................................................ Page 2 Vol. 5, Issue 2 New CMEs Announced .......................................................... Page 4 inside this issue New Centers Open in DC & Virginia ....................................... Page 5 Ulcers and Wound Healing of Venous Stasis Ulcers by Robert C. Kiser, DO, MSPH Human skin is messy. Epidermis, from the mechanical forces change interstitial microscopic cells to macroscopic pressures and pressure gradients, flakes are constantly being shed reduce capillary exchange, and create an and replenished from lower layers. environment in which tissue necrosis is Furthermore, if epidermis is injured by favored over tissue healing. trauma it must replenish itself to provide Malignancy the protective, semi-permeable barrier against the environment that it maintains. Skin cancer can manifest as erosive non- This process requires a dynamic balance healing ulcers. between building up of skin and shedding Systemic Diseases or breaking down skin. If the building up of skin is too exuberant, conditions such Numerous systemic diseases are as psoriasis and Ichthyosis occur in which associated with cutaneous ulcers, the skin becomes thick and scaly. When including diabetes, renal disease, lupus skin does not replenish and heal fast and inflammatory bowel diseases. enough, or when conditions favor break- Ulcers of Venous Insufficiency or down of skin more than growth of new Venous Stasis Ulcers skin, ulcers develop. Venous stasis ulcers will be the topic of Types of Ulcers: Mechanical Pressure the rest of this article. Ulcers are the end- Ulcers may be caused by many different stage of venous insufficiency. The region factors, or several factors acting in most commonly affected is the “gaiter concert. Pressure region” – the area just ulcers, decubitus above the ankle, most Editorial Staff ulcers, or “bed commonly the medial, sores” occur when but sometimes the constant pressure lateral malleolus. Editor-in-Chief, President & CEO, and/or sheer forces Venous insufficiency Center for Vein Restoration occurs when the Sanjiv Lakhanpal, MD, FACS are exerted on tissue, usually overlying a valves within the veins Editor bony prominence, no longer function Robert C. Kiser, DO, MSPH over a prolonged properly. Valves within Associate Editor, Director of Research period of time. veins assist venous & Director of Vascular Labs Curiously, although blood to go up the Shekeeb Suian, MD, FACS decubitus ulcers leg against gravity. Associate Editor, Director, Research & have been known When these valves Medical Education of for thousands of no longer function Nicos Labropoulos, PhD, RVT years, the exact properly, blood flows back down the lower Managing Editor pathophysiology has extremity and creates Kathleen A. Hart not been elucidated. It is believed that a gravity-dependent, ISSN 2159-4767 (Print), ISSN 2159-4775 (Online) Continued on Page 3 Copyright © 2012 Center for Vein Restoration. All rights reserved. 1 To Foam or Not To Foam, That Is The Question... by Sean K. Stewart, MS, MD Sclerotherapy has been used to treat varicose veins for the last 150 years. producing vein occlusion. Duplex ultrasound imaging has increasingly been For decades, European physicians have been at the forefront of sclerotherapy incorporated into the procedure in order to locate the incompetent superficial with the goal of obliterating saphenous trunks in patients hoping to achieve vein to be cannulated, to guide cannulation, and to monitor the injection and long-term relief from varices. Most often, concentrated sclerosing chemicals flow of foam. This also minimizes the risk of foam diffusion to the deep venous aimed at fibrosing incompetent veins and symptomatic varices are used. This system. More than one injection may be given during the same session therapy was heralded in the first half of the last century as a replacement for in an attempt to ensure that all of the target veins have been completely surgery; however, as recurrences of varicose veins appeared in limbs treated filled. It is common to apply compression following foam sclerotherapy with injection techniques, the use of surgery resurged and was the dominant although scientific evidence to support this practice is not available and treatment in the last half of the century. the duration for which it should be applied has not been established. In 1950, Orbach published a paper describing his method of producing foam Some authors use bandages and others use stockings alone. The aim of by vigorously shaking a syringe containing air and a sclerosant. With this, post-procedure compression is used to flatten the vein and avoid retained foam sclerotherapy was born. In the 1980s, ultrasound was introduced for blood, while increasing the flow of blood up the leg. Many believe it is also the diagnosis of venous disease of the lower limb. In 1997, Cabrera, almost essential to reducing the risk for thrombopheblitis. As with earlier practices 50 years after Orbach’s publications, produced foam composed of very small in sclerotherapy, immediate ambulation and return to work are encouraged. bubbles using polidocanol, a detergent sclerosant. The foam was created There is little need for time away from work. using a small, rapidly rotating brush to agitate the solution. Cabrera treated 261 The most generally accepted contraindications for foam sclerotherapy limbs with long, saphenous varices and 8 patients with vascular malformation. are similar to those for conventional liquid sclerotherapy, such as allergy Notably, some of the varicose veins reached a diameter of 20 mm. Cabrera to the sclerosant, history of acute superficial or deep vein thrombosis, concluded that the increased efficacy of his “microfoam” was attributable to its or hypercoagulopathies. Potential adverse events associated with foam displacing blood from the treated vein and increasing the contact time between sclerotherapy include allergy to a sclerosant, thrombophlebitis (most common), the sclerosant and the vein. This modernized foam sclerotherapy. staining of the skin and a palpable, fibrosed vein (often seen in thin patients Many authors since Cabrera have described with larger-caliber superficial vessels). Other methods of preparing “home-made” foam which risks include potential nerve damage, cutaneous may be used for ultrasound-guided sclerotherapy. necrosis, ulceration and matting in cases of The most widely used is the Tessari method. sclerosant extravasation. There are concerns that Tessari used disposable syringes and a three- the sclerosant can potentially enter the deep veins way valve to prepare foam. The sclerosant is and induce venous thromboembolism; the risk is mixed with air by oscillating the two between higher in obese patients where post-procedure the two syringes (20 cycles). This method can be wrapping is less effective and post-procedure used to produce larger quantities of foam from activity is less likely. a smaller amount of sclerosant and is stable Theoretically, in people with a patent foramen for 2 minutes after mixing stops. Sclerosants ovale (PFO), the sclerosant may enter the arterial used to prepare foam include sodium tetradecyl circulation and induce an ischemic stroke or retinal sulphate (STS) 1 – 3% and polidocanol 0.5 – 3%. artery occlusion. Also, if foam is inadvertently Although polidocanol is about half as potent injected directly into the artery, loss of limb as STS, both may cause ulceration if injected is possible. Transient visual disturbances and into soft tissues. 1% Polidocanol is typically precipitation of migraine headaches are reported mixed with air to create foam suitable for treating following foam sclerotherapy. The mechanism is superficial varicose veins, and 0.5% Polidocanol uncertain but is felt to be vasospastic. Coughing is typically mixed with air to create foam suitable is also a rare but reported side-effect; however, it for treating superficial reticular veins. When is usually transient. The recurrence rate following mixed 1:3 or 1:4 with air, low concentrations of this treatment as compared to surgery has yet polidocanol (0.5%) produce better-performing to be firmly established. Ultrasound imaging foam. A higher concentration of polidocanol or studies suggest that 75 – 90% of veins treated in STS is recommended for larger tributary and this way remain occluded after 3 years although perforator vessels. STS can also be used to more than one treatment may be required to treat superficial varicose veins (1% solution) and achieve these results. reticular veins (0.2% solution) when mixed with Foam sclerotherapy offers an adjunct to surgical air to produce foam. The accepted protocol is to intervention for patients with tortuous tributaries, use 0.5 ml of STS or polidocanol to 1.5-2.0 ml of air. superficial varices, small vascular networks which are not amenable to Foam sclerotherapy is suitable for the treatment of any type of superficial current surgical techniques, and reflux in vessels where health insurance venous incompetence and should be considered for all categories of companies will not approve surgical ablation techniques. Foam sclerotherapy superficial venous disease ranging from telangiectases and reticular veins is FDA approved and can be conducted on an outpatient basis often with no to larger-caliber varicose veins, as well as for chronic venous insufficiency anesthesia required. This technique promises to be