A Recent Paper Examines Ultrasound-Guided Foam Sclerotherapy: 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 extremity(1) .

“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 e ectiveness 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 examples of UGFS side effects have been reported, which may motivate some clinicians to use physiologic gas instead of room air since physiologic gas microbubbles are smaller and dissipate more rapidly.

Second, the role that post-procedure compression plays in the treatment plan needs more rigorous study.

“Wearing compression hose after UGFS is commonly recommended, but it would be ideal to have published data supporting how long the compression hose should be worn and at what compression level?” added Dr. Mishra.

COST-EFFECTIVE NATURE OF UGFS HAS PROMISE FOR ALTERNATIVE PAYMENT

In the paper, the authors note that UGFS appears to have less long-term success than thermal modalities in treating truncal or larger varicosities, and retreatment may be needed. However, the inherent cost-effectiveness of UGFS seems to give it an important place in the catalog of venous interventions. As Medicare and other payers continue to transition to alternative payment models or bundled payment, the capacity to treat chronic venous insufficiency with a low-cost option that achieves a predictable outcome becomes very attractive.

1. ULTRASOUND-GUIDED FOAM SCLEROTHERAPY IS SAFE AND EFFECTIVE IN THE MANAGEMENT OF SUPERFICIAL VENOUS INSUFFICIENCY OF THE LOWER EXTREMITY

Todd V. Cartee, MD, FAAD, FACMS; Paul Wirth, MD; Amrit Greene, MD; Chelsey Straight, MD; Daniel P. Friedmann, MD, FAAD; Chris Pittman, MD, FAVLS, FACR; Stephen F. Daugherty, MD, FACS, FAVLS; John Blebea, MD, MBA, FACS; Mark Meissner, MD; Marlin W. Schul, MD, RVT, FAVLS, DABVLM; Vineet Mishra, MD, FAAD, FACMS