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.