A RECENT PAPER EXAMINES ULTRASOUND-GUIDED FOAM SCLEROTHERAPY: WHAT IS THE CONSENSUS? WHERE IS MORE RESEARCH NEEDED? Todd V Cartee, MD, FAAD, FACMS, Associate Professor of Dermatology, Penn State Health Vineet Mishra, MD, FAAD, FACMS, Division of Mohs Surgery, Dermatology & Vascular Surgery, Scripps Clinic
Mixing a sclerosant agent with room air to create foam for vein occlusion or ablation has become a front-line therapeutic intervention for patients suffering from symptomatic chronic venous insufficiency. Yet, paradoxically, scientific literature regarding ultrasound-guided foam sclerotherapy (UGFS) remains very sparse in the United States clinical community and is only slightly better in Europe and the global venous community. In 2019, to better catalog the available literature and highlight current clinical practice in the United States, a small group of phlebologists began to examine existing papers and contemporary clinical practice regarding UGFS. In the July 2021 edition of the Journal of Vascular Surgery Venous and Lymphatic Disorders, the group’s work was published in their paper- Ultrasound-guided foam sclerotherapy is safe and effective in the management of superficial venous insufficiency of the lower extremity1. “When we started the project, I think what surprised us all was that even though UGFS is well-regarded by most clinicians, widely used, and has a good safety record, the literature was indeed uneven, and we need more high-quality comparative trials between UGFS and other modalities,” notes the paper’s lead author and Principal Investigator, Dr. Todd Cartee of Penn State University. In 2014, the American Vein & Lymphatic Society (AVLS), formerly the American College of Phlebology, published multi-organizational Quality Improvement Guidelines. The
guidelines were based on a questionnaire from practitioners at the AVLS Annual Congress. The 2014 guidelines were seminal, but surprisingly, no rigorous follow-up guidelines have been published since then by the venous community in the USA. “I think it’s fair to say that UGFS needs a new national guidelines project that we can all support, and we hope to use this paper to nudge AVLS and others to undertake such a project in the very near term,” added Dr. Cartee. “Our literature review revealed a large body of evidence demonstrating the safety and effectiveness of UGFS. UGFS is an excellent choice for managing numerous medium-sized varicosities for which phlebectomy would be time-consuming, for treating varicose veins that are not bulging on the surface but contributing to a patient’s symptoms, or in areas of advanced venous skin disease, which can make phlebectomy challenging.”
TWO KEY QUESTIONS FOR FOLLOW UP As the research team began their work, it became apparent that clinical practice had changed in recent years. When it comes to creating the sclerosant foam, “room air is still typical, but a sizable minority of practitioners now use gas, such as CO2,” commented paper co-investigator Dr. Vineet Mishra of the Scripps Clinic in California. This preference seems to be mostly based on the individual’s personal experience with UGFS and such issues as foam durability and size of bubbles. Though extremely rare, a few reported
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