from 39% to 11%.16 [Q6: B] Multiple small-dose injections have been shown to reduce the passage of sclerosant foam into the deep veins using ultrasound inspection immediately post sclerotherapy.17 [Q6: A]The optimum ratio of gas to liquid is 4:1 although a large range of ratios are reported. [Q6: D] Leg elevation is advised prior to injection to empty the venous reservoir and reduce the amount of blood contact which can de-activate foam.18 [Q6: C] A high thigh GCS applied for 2–3 weeks has been shown to be more effective and cheaper than compression bandaging with a reduction in thrombophebitis.19 [Q6: E] Our protocol is to apply this stocking at the time of sclerotherapy and instruct the patient to wear this continuously for 2 weeks, but only during the day on the third week.

Ankleswellingispartofthestagingandseverityinvenousdiseaseandisthereforemost likely to be related to venous insufficiency.20,21 Oedema after surgical treatment however raises the possibility of a DVT or lymphatic compromise. Conventional varicose vein surgery has been shown to cause lymphatic damage.22 It is likely that this may contribute to ankle swelling and lymphedema in predisposed patients. Foam sclerotherapy has not been shown to cause lymphatic disruption and subsequent lymphedema. Its use in recurrent disease will prevent this complication by removing the need for redo groin surgery. [Q7]

The incidence of complications and side effects are as follows: headache (4.2%), deep vein thrombosis (under 1%), induration/pigmentation (17.8%), pulmonary embolism (under 1%) and visual disturbance (1.4%).23 [Q8] The incidence of a patent foramen ovale is 27%24 which may explain the presence of left sided heart micro bubbles after foam treatment in several patients.25 Their clinical significance and correlation with transient neurological complications however remains unclear.

References

 1. Kakkos SK, Bountouroglou DG, Azzam M, Kalodiki E, Daskalopoulos M, Geroulakos G. Effectivenessandsafetyofultrasound-guidedfoamsclerotherapyforrecurrentvaricoseveins: immediate results. J Endovasc Ther. 2006;13:357-364.

 2. Perrin MR, Guex JJ, Ruckley CV, et al. Recurrent varices after surgery (REVAS), a consensus document. Cardiovasc Surg. 2000;8(4):233-245.

 3. Fischer R, Linde N, Duff C, Jeanneret C, Chandler JG, Seeber P. Late recurrent saphenofemoral junction reflux after ligation and stripping of the greater saphenous vein. J Vasc Surg. 2001;34:236-240.

 4. Winterborn RJ, Foy C, Earnshaw JJ. Causes of varicose vein recurrence: Late results of a randomized controlled trial of stripping the long saphenous vein. J Vasc Surg. 2004;40: 634-639.

 5. Lamont JP, Pearl GJ, Patetsios P, et al. Prospective evaluation of endoluminal venous stents in the treatment of the May-Thurner syndrome. Ann Vasc Surg. 2002;16:61-64.

 6. Christopoulos DC, Nicolaides AN, Szendro G. Venous reflux: quantitation and correlation with the clinical severity of chronic venous disease. Br J Surg. 1988;75:352.

 7. Gloviczki P, Driscoll DJ. Klippel-Trenaunay syndrome: current management. Phlebology. 2007;22:291-298.

 8. Kundu S, Lurie F, Millward SF, et al. Recommended reporting standards for endovenous ablation for the treatment of venous insufficiency: Joint Statement of the American Venous Forum and the Society of Interventional Radiology. J Vasc Surg. 2007;46:582-589.

 9. Smith JJ, Garratt AM, Guest M, Greenhalgh RM, Davies AH. Evaluating and improving health-related quality of life in patients with varicose veins. J Vasc Surg. 1999;30:710-719.

10.Breu FX, Guggenbichler S, Wollmann JC. Second European consensus meeting on foam sclerotherapy 2006, Tegernsee, Germany. Vasa. 2008;37(71):1-29.

11.Breu FX, Guggenbichler S. European consensus meeting on foam sclerotherapy, April, 4–6, 2003, Tegernsee, Germany. Dermatol Surg. 2004;30(5):709-717.

12.Gillet JL, Guedes JM, Guex JJ, et al. Side-effects and complications of foam sclerotherapy of the great and small saphenous veins: a controlled multicentre prospective study including 1025 patients. Phlebology. 2009;24:131-138.

13.Morrison N, Cavezza A, Bergan J, Partsch H. Regarding ‘Stroke after varicose vein foam injection sclerotherapy’. J Vasc Surg. 2006;44:224-225.

14.Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg. 2001;27:58-60.

15.Parsi K. Catheter-directed sclerotherapy. Phlebology. 2009;24:98-107.

16.Morrison N, Neuhardt DL, Rogers CR, et al. Comparisons of side effects using air and carbon dioxide foam for endovenous chemical ablation. J Vasc Surg. 2008;47:830-836.

17.Yamaki T, Nozaki M, Sakurai H, Takeuchi M, Soejima K, Kono T. Multiple small-dose injections can reduce the passage of sclerosant foam into deep veins during foam sclerotherapy for varicose veins. Eur J Vasc Endovasc Surg. 2009;37(3):343-348.

18.Parsi K, Exner T, Connor DE, Ma DDF, Joseph JE. In vitro effects of detergent sclerosants on coagulation, platelets and microparticles. Eur J Vasc Endovasc Surg. 2007;34:731-740.

19.Scurr JH, Coleridge-Smith P, Cutting P. Varicose veins: optimum compression following sclerotherapy. Ann Royal Coll Surg Eng. 1985;67:109-111.

20.Eklof B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40:1248-1252.

21.Kakkos SK, Rivera MA, Matsagas MI, et al. Validation of the new venous severity scoring system in varicose vein surgery. J Vasc Surg. 2004;39:696-697.

22.Van Bellen B, Gross WS, Verta MJ Jr, Yao JS, Bergan J. Lymphatic disruption in varicose vein surgery. Surgery. 1977;82(2):257-259.

23.Jia X, Mowatt G, Burr JM, Cassar K, Cook J, Fraser C. Systematic review of foam sclerotherapy for varicose veins. Br J Surg. 2007;94:925-936.

24.Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984;59: 17-20.

25.Hansen K, Morrison N, Neuhardt DL, Salles-Cunha SX. Transthoracic echocardiogram and transcranial Doppler detection of emboli after foam sclerotherapy of leg veins. J Vasc Ultrasound. 2007;31(4):213-216.

Seshadri Raju

A 46-year-old female schoolteacher and non-smoker presented with an ulcer on the medial side of the ankle. The ulcer had persisted for the past year despite compressive dressings at a hospital wound care center. Ulcers in the same general area had occurred intermittently in the past but had healed with local wound care and dressings. The ulcer was very painful, particularly with dependency of the leg (7/10 over a visual analogue scale) and frequently at night. The patient had made a habit of elevating her legs during the day whenever feasible, and to sleep with her legs elevated on a pillow at night. She had been using a nonsteroidal anti-inflammatory drug once or twice a day at work for pain relief, but lately a narcotic prescribed by her physician was required for sleep at night. Even so, on some nights, she had to “walk off” the pain for 20–30 min before she could fall asleep.

Past medical history: She had been hospitalized on two occasions during the past year for cellulitis of the leg, which required intravenous antibiotics. Her saphenous vein was stripped 15 years ago when the ulcer initially appeared. This resulted in healing of the ulcer but it recurred 2 years later. During adolescence, she sustained a closed tibial fracture of the same extremity during a ski accident and was in a plaster cast and crutches for several weeks. Family history: No one in the family had varicose veins or deep venous thrombosis.

Examination: The patient was found to be healthy except for the affected extremity, which had a large 5 10-cm indolent ulcer on the medial aspect of the lower third of the leg. The ulcer bed had clean granulation tissue with serous drainage. The ulcer was surrounded by a broader area of hyperpigmentation in the “gaiter” area. No obvious varicosities or “blow outs” were noted. Good pedal pulses were present.

S. Raju

Department of Surgery, University of Mississippi Medical Center, Flowood, MS, USA