Ultrasound-guided Foam Sclerotherapy of Incompetent Perforator Veins in a Patient with Venous Leg Ulcers

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Recent advances in sclerotherapy using foam have extended the indications for sclerotherapy in the treatment of varicose veins. One of the new indications may be foam sclerotherapy of incompetent perforator veins for the treatment of venous leg ulcers.
This case report, by Marieke Waard, MD, pertains to a 56-year old woman who presents with bilateral ulcers at the medial malleoli. The ulcers kept increasing in size despite local wound care and compression therapy.

The patient had a history of venous disease, with a deep venous thrombosis 22 years prior to the study. After 10 years, she started having recurrent ulcers at both legs, for which she had saphenous vein stripping and subfascial endoscopic perforator surgery (SEPS).
Physical examination revealed an area of 8×4.5 cm with lipodermatosclerosis, hyperpigmentation, and atrophic blanching in which ulcers had developed.

Ultrasound examination of the right leg demonstrated two incompetent perforator veins at 25 and 35 cm above the foot. The left leg demonstrated an incompetent perforator vein at 22 cm above the foot. Both legs also demonstrated significant reflux in the deep venous system.

The incompetent perforator veins of both legs were treated with foam sclerotherapy. The foam was made from 2 ml of 1% polidocanol and was injected into the saphenous vein under ultrasound guidance between the incompetent perforator veins and the ulcer.
Four days after foam sclerotherapy, the ulcers showed a significant improvement. After 10 days, the left leg ulcer was closed, and after 3 weeks, the right leg ulcer was closed. Ultrasound evaluation of the legs after 3 weeks showed closed perforator veins and great saphenous veins.

Venous ulcers are a major problem in health care. Venous ulceration is caused by increased pressure in the venous system, which is mainly caused by valve insufficiency in the lower perforator veins and the deep system. Perforator veins normally direct blood from the superficial to the deep system. There seems to be an important association between incompetent perforator veins and venous ulceration.
The healing process of the ulcers in this patient is likely to have been improved by treating the perforator veins. Before the foam sclerotherapy of the perforator veins, the leg ulcers were gradually worsening despite compression therapy. After treatment with foam sclerotherapy, the ulcers improved rapidly, suggesting an important role for perforator veins in maintaining venous ulcers.

Foam sclerotherapy is controllable by using ultrasound, and complications are rare when the procedure is done properly. The advantage of foam over liquid sclerotherapy lies in the fact foam pushes the blood forward, with very little drug dilution, instead of mixing with the blood as does liquid sclerotherapy. This way, it provides a better homogeneous contact with the endothelium, making it more effective in irritating the vascular wall.

This case demonstrates the association between the healing of a venous leg ulcer and the closure of an incompetent perforator vein. When a patient has a venous leg ulcer that will not heal with compression therapy, the next step should be to search for an incompetent perforator vein, and to treat those veins with ultrasound-guided foam sclerotherapy.

Although more and extensive studies are needed to make a definite conclusion, foam sclerotherapy seems to be a promising, safe, minimally invasive additional therapy for the treatment of venous leg ulcers associated with incompetent lower leg perforator veins.

Northside Vein Care Now Offers Transilluminated Powered Phlebectomy (Trivex)

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I am happy and proud to announce that I am now able to offer the procedure of powered-phlebectomy, the “Trivex” procedure as an in-office procedure in selected cases.

Inavein, the developer of the Trivex procedure, has chosen Northside Vein Care’s Chicago office as only one of two surgical practices in the country to offer this procedure in the office.

The other office, being that of the developer of the product, Dr. Gregory Spitz.

The Trivex procedure, prior to this, has only been offered as a minimally-invasive procedure to remove varicose veins in the operating room.(To see the procedure, go to: www.youtube.com/amerivein) This continues to be an option in cases that warrant that venue. Trivex continues to provide an efficacious method to remove varicose veins completely and quickly. Transilluminated Powered Phlebectomy (Trivex) has significantly improved the overall outcomes of patients with venous varicosities:

  • A positive patient satisfaction rate of 99.7% with both the Trivex procedure, and the outcome
  • A mean operative time of 19.7 minutes
  • No recurrences at 3-month, post-operative follow up

The Trivex procedure done in the office will be performed entirely under local anesthetic. This technique will be performed under tumescent local anesthetic, whereby the area to be operated on will be locally infiltrated with lidocaine, and the procedure performed. The procedure will take approximately 20-30 minutes.

I am excited and honored to be able to offer this procedure to your patients. If you have any questions, please contact me at your convenience.

How does Transilluminated Powered Phlebectomy Work?

Step 1
First step in Transilluminated Powered Phlebectomy procedure
The Trivex procedure starts with a cannula illuminator delivering tumescent local anesthesia while simultaneously hydrodissecting the vein for easy removal.

Step 2
step 2 in the Transilluminated Powered Phlebectomy procedure
Targeted veins are easily identified for removal and a clearly visualized end point.

Step 3
step 3 in the Transilluminated Powered Phlebectomy procedure
Resector gently extracts veins by suction and morcellation in a controlled fashion.

How can I prevent varicose veins and spider veins?

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Not all varicose and spider veins can be prevented. But, there are some steps you can take to reduce your chances of getting new varicose and spider veins. These same things can help ease discomfort from the ones you already have:

  • Wear sunscreen to protect your skin from the sun and to limit spider veins on the face.
  • Exercise regularly to improve your leg strength, circulation, and vein strength. Focus on exercises that work your legs, such as walking or running.
  • Control your weight to avoid placing too much pressure on your legs.
  • Don’t cross your legs for long times when sitting. It’s possible to injure your legs that way, and even a minor injury can increase the risk of varicose veins.
  • Elevate your legs when resting as much as possible.
  • Don’t stand or sit for long periods of time. If you must stand for a long time, shift your weight from one leg to the other every few minutes. If you must sit for long periods of time, stand up and move around or take a short walk every 30 minutes.
  • Wear elastic support stockings and avoid tight clothing that constricts your waist, groin, or legs.
  • Avoid wearing high heels for long periods of time. Lower-heeled shoes can help tone your calf muscles to help blood move through your veins.
  • Eat a low-salt diet rich in high-fiber foods. Eating fiber reduces the chances of constipation, which can contribute to varicose veins. High-fiber foods include fresh fruits and vegetables and whole grains, like bran. Eating less salt can help with the swelling that comes with varicose veins.

What factors increase my risk of varicose veins and spider veins?

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Many factors increase a person’s chances of developing varicose or spider veins. These include:

  • Increasing age. As you get older, the valves in your veins may weaken and not work as well.
  • Medical history. Being born with weak vein valves increases your risk. Having family members with vein problems also increases your risk. About half of all people who have varicose veins have a family member who has them too.
  • Hormonal changes. These occur during puberty, pregnancy, and menopause. Taking birth control pills and other medicines containing estrogen and progesterone also may contribute to the forming of varicose or spider veins.
  • Pregnancy. During pregnancy, there is a huge increase in the amount of blood in the body. This can cause veins to enlarge. The growing uterus also puts pressure on the veins. Varicose veins usually improve within 3 months after delivery. More varicose veins and spider veins usually appear with each additional pregnancy.
  • Obesity. Being overweight or obese can put extra pressure on your veins. This can lead to varicose veins.
  • Lack of movement. Sitting or standing for a long time may force your veins to work harder to pump blood to your heart. This may be a bigger problem if you sit with your legs bent or crossed.
  • Sun exposure. This can cause spider veins on the cheeks or nose of a fair-skinned person.

Are varicose veins and spider veins dangerous?

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Spider veins rarely are a serious health problem, but they can cause uncomfortable feelings in the legs. If there are symptoms from spider veins, most often they will be itching or burning. Less often, spider veins can be a sign of blood backup deeper inside that you can’t see on the skin. If so, you could have the same symptoms you would have with varicose veins.

Varicose veins may not cause any problems, or they may cause aching pain, throbbing, and discomfort. In some cases, varicose veins can lead to more serious health problems.

These include:

  • Sores or skin ulcers due to chronic (long-term) backing up of blood. These sores or ulcers are painful and hard to heal. Sometimes they cannot heal until the backward blood flow in the vein is repaired.
  • Bleeding. The skin over the veins becomes thin and easily injured. When an injury occurs, there can be significant blood loss.
  • Superficial thrombophlebitis (throm-bo-fli-BYT-uhs), which is a blood clot that forms in a vein just below the skin. Symptoms include skin redness; a firm, tender, warm vein; and sometimes pain and swelling.
  • Deep vein thrombosis, which is a blood clot in a deeper vein. It can cause a “pulling” feeling in the calf, pain, warmth, redness, and swelling. However, sometimes it causes no significant symptoms. If the blood clot travels to the lungs, it can be fatal.

Should I see a doctor about varicose veins?

You should see a doctor about varicose veins if:

  • The vein has become swollen, red, or very tender or warm to the touch
  • There are sores or a rash on the leg or near the ankle
  • The skin on the ankle and calf becomes thick and changes color
  • One of the varicose veins begins to bleed
  • Your leg symptoms are interfering with daily activities
  • The appearance of the veins is causing you distress

If you’re having pain, even if it’s just a dull ache, don’t hesitate to get help. Also, even if you don’t need to see a doctor about your varicose veins, you should take steps to keep them from getting worse.

How are varicose veins diagnosed?

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Womanshealth.gov says your doctor may diagnose your varicose veins based on a physical exam. Your doctor will look at your legs while you’re standing or sitting with your legs dangling. He or she may ask you about your symptoms, including any pain you’re having. Sometimes, you may have other tests to find out the extent of the problem and to rule out other disorders.

You might have an ultrasound, which is used to see the veins’ structure, check the blood flow in your veins, and look for blood clots. This test uses sound waves to create pictures of structures in your body.

Although less likely, you might have a venogram. This test can be used to get a more detailed look at blood flow through your veins.

If you seek help for your varicose veins, there are several types of doctors you can see, including:

  • A phlebologist, which is a vein specialist
  • A vascular medicine doctor, who focuses on the blood system
  • A vascular surgeon, who can perform surgery and do other procedures
  • An interventional radiologist, who specializes in using imaging tools to see inside the body and do treatments with little or no cutting
  • A dermatologist, who specializes in skin conditions

Each of these specialists do some or all of the procedures for treating varicose veins. You might start out by asking your regular doctor which specialist he or she recommends. You also might check with your insurance plan to see if it would pay for a particular provider or procedure.