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Information for Patients undergoing Foam Sclerotherapy for Varicose Veins
under the care of The Vein Clinic Ltd (TVC)

Introduction
The development of new treatments for varicose veins disease has led to renewed interest in managing this common condition. Venous duplex directed minimally invasive varicose vein surgery, performed by a consultant vascular surgeon with expertise in venous disease, remains the best standard of treatment for varicose veins disease. Operative varicose veins treatment has three main components:

ii removal of the main truncal vein in the thigh (stripping)

iii stab (micro) incisions to remove the visible varicose veins.

Properly performed duplex directed surgery is undoubtedly effective, however the necessary surgical incisions may cause discomfort, and require a period of healing of several days to a few weeks. Further, surgery may be attended by complications such as bleeding, bruising, wound infections, neuropathy, deep venous thrombosis, flare veins and recurrence.

These factors have stimulated renewed interest and refinements in the technique of Foam Sclerotherapy for the treatment of varicose veins. Foam sclerotherapy is currently only being offered by specialist venous clinics in the UK. The Vein Clinic (TVC) offers Foam Sclerotherapy and other ultrasound-guided minimally invasive approaches such as Radio Frequency Ablation and Endovenous Laser Therapy for varicose veins. These new treatments have the common advantage of eliminating the need for a groin incision and stripping (i.e. i and ii above). Uniquely, Foam Sclerotherapy can also treat the varicosities themselves and offers outpatient treatment for varicose veins disease. Foam sclerotherapy therefore has potential advantages over all other treatments.

Your Foam Sclerotherapy treatment
Ultrasound guided Foam Sclerotherapy treatment is performed by using colour duplex ultrasound imaging for accurate placement of injections. Before the injection needles are inserted you will be examined in the standing position when the veins to be treated will be then marked with a black marker pen. You will will then be layed down on the treatment couch.

Under local anaesthetic cover, the duplex-ultrasound is used to guide the insertion of small plastic needles (cannula’s) into the main varicose veins. Smaller needles (butterflies) are used for the varicose veins that lie nearer to the skin. These needles are held in place by sticky tape

After inserting the needles the leg to be treated is raised and held in position with a sling so that the varicose veins can be emptied of blood. The sclerotherapy foam is then slowly injected into the veins. The spread of the foam through the varicose veins is monitored with the duplex ultrasound scanner. This ensures that foam fills all the varicosities that are being treated.

We will ask you to wiggle your foot ‘to and fro’ after each lot of injections so that any foam that enters the main (deep) veins is quickly flushed away and diluted in the blood stream.

After all the injections have been completed your treated leg will be compressed with elasticated bandages and then a medical grade compression stocking will be rolled over the top. These dressings are worn for 5 days. After this time you should remove the bandages and wear the stocking for a period of 2 weeks. Thereafter, the stocking is removed for bathing and then re-worn.

You will be reviewed again after 2-weeks and a further duplex ultrasound scan will be performed. Any veins that have not closed at that time will be treated with further injections of foam.

This regimen effectively treats the majority of patients with suitable varicose veins. In a few people, the treated veins may reopen over the first 3-6 months, therefore a further duplex ultrasound scan is performed at 6 months and any reopened veins are treated again.

After each course of injections you will be advised to go for a 20-minute walk. After this walk you can return to your normal activities. You may drive after this treatment (and walk) and you can return to your usual daily activities. There are no restrictions on activities other than that prolonged-standing should be avoided and that the legs should be elevated when at rest.

Effective treatment via ultrasound guided foam sclerotherapy reduces the discomfort of open surgery and speeds recovery from varicose veins treatment.

Potential problems of Foam Sclerotherapy
Unfortunately, not all varicose veins are suitable for duplex ultrasound-guided foam sclerotherapy. It is not suitable for veins that are very large because it may not be possible to fill the vein with foam. It is also not suitable for very thin or fat leg. In thin legs the treated vein may appear lumpy for a period until your own body removes the lumps. In fatter legs it is not possible to apply effective compression bandaging that fully empty the veins.

Thrombophlebitis (inflammation of a surface varicose vein) is the most frequent complication of foam sclerotherapy. Thrombophlebitis is inflammation of the treated veins, appearing as a painful reddened area around the varicosities. Thrombophlebitis can usually be treated with painkilling tablets and further compression. Sometimes the thrombophlebitic vein can be drained under local anaesthetic at the two week review in order to provide faster relief of symptoms.

Deep vein thrombosis has been seen occasionally after Foam Sclerotherapy treatment. It is usually seen to affect the calf veins. If this were to happen to you then you would need to take warfarin (blood thinning medicine) for 6 months in order to stop the clots from spreading into the larger veins.

Recurrence of varicosities. Veins that have been effectively treated with foam sclerotherapy can recanalise in a few patients, usually within the first 6 months. This cause of recurrent varicose veins can be retreated with further injections.

Other complications. A temporary dry cough may occur immediately after the injection has been given. Some patients also report minor and temporary visual disturbances. These symptoms are transient and self limiting.

Effective treatment of varicose veins

Effective treatment of varicose veins usually involves 2 components. The large varicose veins (truncal veins), which cause the varicose veins lie in the thigh and occasionally behind the knee. This may not be visible in you but it is essential that this component of varicose veins undergoes effective treatment before dealing with the more visible varicosities. The newer treatments such as ultrasound oblation and laser oblation aim to achieve this effect by passing catheters (more tubes) from the knee into the vein in the thigh. Once there heat treatment is applied to the vein. This gradually shrivels up the vein before the body absorbs it. In foam sclerotherapy this effect is achieved by cannula injections under local anaesthesia.

The second component of varicose veins is the removal of the visible varicosities themselves. After the catheter-based techniques have been used to treat the truncal veins, varicose veins themselves are usually removed via an operation by small stab incisions.

Only foam sclerotherapy has the potential to obliterate not only the truncal causative veins but also the visible varicose veins without recourse to an operation.

The Foam Sclerotherapy Procedure

We will mark your truncal varicose veins and the causative varicose veins using the duplex ultrasound scanner whilst you are in a standing position. These black marks will give us a clear idea of where the veins are once we have you in the lying position (when the veins usually collapse and disappear). We would then lye you down and the skin will be anaesthetised using local anaesthetic similar to that used at the dentists. Once the area of the skin is numb, a needle (cannula) will be inserted into the vein using the duplex ultrasound scan to insure accurate placement of the veins. We will stick the needles onto your skin once accurate placement is ensured. We then raise your leg in a sling held on a drip stand. Once the leg is raised and the veins emptied of blood, the foam treatment is then injected into the vein. We will use the ultrasound scan to ensure that the veins to be treated are filled with the foam. After each injection we will asked you to wiggle your feet 10 times in order to flush the deep veins and to ensure that the varicose veins receive effective doses of the treatment.

We will then bandage your leg using an elasticated stocking. A medical grade compression stocking will then be rolled over the top of the bandage in order to achieve full compression of the veins.

We will normally treat your truncal varicose veins first and we will wait for 2 weeks before going on to treat the visible varicose veins. In this time most people notice that the varicose veins themselves shrink down markedly. At the 2-week visit visible varicose veins are themselves treated. After this, a further follow-up is arranged for 6 months in order to identify the few patients who recannulised their vein and who require a further dose of treatment.