1. Chronic Venous Disease Treatment - Part II Vein closure and rerouting of blood through normal veins with Ultrasound Guided Foam Sclerotherapy S. Lakhanpal MD, FACS President & CEO Center for Vein Restoration

2. Ultrasound Guided Foam Sclerotherapy (USGFS)

3. CVR, in following the SVS guidelines, believes that USGFS is an adjunct to thermal ablations. Indications – Treatment for extensive networks of symptomatic varicose veins. Varicose Vein treatment for patients on coumadin or blood thinners. – Treatment for tortuous, superficial or small segments of refluxing tributaries of the saphenous vein not amendable to laser or RF treatment.

4. Ultrasound Guided Foam Sclerotherapy (USGFS) Indications (Cont’d) – Treatment for refluxing vessels in the distal calf, neovascularization and microvasculature associated with non healing ulcers. – Insurance mandated treatment modality becoming more common.

5. Ultrasound Guided Foam Sclerotherapy (USGFS) History Injections to treat varicose veins date back 150 years. Using foam preparations of solutions date back 60 years. Techniques evolved in the late 1980’s with the aid of duplex ultrasonography. Prior to 2004, USGFS was the main modality of treatment for diseased vessels outside of vein stripping.

6. Ultrasound Guided Foam Sclerotherapy (USGFS) Sclerosing Agents – Sotradecol –Sodium tetradecyl sulfate (STS) – Received FDA approval in 2004 – Aslcera-Polidocanol (POL) Received FDA approval in 2010 Different strengths of sclerosant are used for different sized veins. Foam is made at bedside- Tessari method is most common.

7. Ultrasound Guided Foam Sclerotherapy (USGFS) Procedure – Office based, takes 30 minutes or less. – Requires little or no local anesthesia. – More than one vein may be treated during the same session. – If any vein is incompletely treated, further injections may be given in the same or subsequent session.

8. Ultrasound Guided Foam Sclerotherapy (USGFS) Closure Rates – Foam Sclerotherapy 77% closure rate at 22 months Barret J, Allen B, Ockelford A, Goldman M. Microfoam ultrasound-guided sclerotherapy of varicose veins in 100 legs. Dermatol Surg 2004;30:6-12

9. Ultrasound Guided Foam Sclerotherapy (USGFS) Post Procedure – Immediate return to normal activity – Walking encouraged – Limit vigorous exercise for 1-2 weeks – Recommend compression stockings for 1-2 weeks

10. Ultrasound Guided Foam Sclerotherapy (USGFS) Contraindications – Known allergy to the sclerosant – Acute deep vein thrombosis – Known patent foramen ovale – Pregnancy – Breast Feeding

11. Ultrasound Guided Foam Sclerotherapy (USGFS) Adverse Reactions – Blood Trapping- 30% – Staining and matting of the skin- 30% Due to hemosiderin in the skin as a result of extravasation of red blood cells. Resolves spontaneously in 80% of patients within a year. Occurs more commonly with Fitzpatrick skin types IV, V, and VI. – Headaches and transient vasospastic reactions- 2%

12. Ultrasound Guided Foam Sclerotherapy (USGFS) Adverse Reactions (cont’d) – DVT- 1% to 3% – Allergy to compound- very rare POL estimated 1 in 10,000 STS allergy risk 0.15%-0.30% 5 deaths due to anaphylaxis published to date – Ulceration of the skin- very rare Typically does not occur with low concentrations, 0.1% to 0.5% STS

13. Ultrasound Guided Foam Sclerotherapy (USGFS) Adverse Reactions (cont’d) – Stroke- 0.01% 15 case reports since 1947 13 case reports since 1994 (9 with foam and 4 with liquid sclerosant) 3 patients with irreversible deficits

14. Ultrasound Guided Foam Sclerotherapy (USGFS) Summary – Minimally invasive procedure No incisions No heavy anesthesia No extended recovery times involved Immediately return to your daily life – Low Risk – Economical – High Utility of Use

15. Ultrasound Guided Foam Sclerotherapy (USGFS)

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