Description and outcomes using combined ultrasound guided sclerotherapy and ambulatory phlebectomy.

1. Foam Phlebectomy:
Technique & Outcomes
Michael Cumming, MD, FRCPC, MBA
CDI Vascular Care
Minneapolis, MN

2. Disclosure
Speaker name: Michael Cumming
.................................................................................
 No potential conflicts of interest related to this talk

3. Typical Treatment Early 2000’s
Initial
Visit
US
3
Month
CS
EVA
1 Week
FU
US
3
Month
FU
US
AP
1
Month
FU
USGFS
Final
Visit

4. REALITIES OF A STAGED APPROACH
 Too many clinic visits
 Too many separate procedures
 Too much time off work
Patients do not like it

5. Ann Surg. 2015 Apr;261(4):654-61
 Earlier improved QoL
 Prolonged improved clinical status
 Patient preference

6. Secondary Procedures
USGFS AP
Fast
Safe
Effective
Painful lumps
Staining
CNS
Safe
Effective
No lumps
Time
More
discomfort
Not all areas

7. Simultaneous Pathways
EVA
AP
USGFS
Larger bulging
varicosities
Smaller
varicosities
Either-or?

9. Why not use both?
USGFS
AP
Foam
Phlebectomy

10. Foam Phlebectomy (FP)
Treat complete range of VV’s
Avoid limitations of AP & USGFS
Spillage of foam into soft
tissues?

11. Unexpected advantages?
 Better sclerotherapy
 Potential safer sclerotherapy
 Easier AP
 Less bleeding problems

12. Foam and Tumescent
 Compresses veins
 Better wall contact
 Less foam required

13. Foam Removal
 Tumesce one vein
(small area)
 Incise vein
 Compress and
express foam

14. Advantages of Foam Removal
 Minimize uncontrolled foam dispersion
 Removal of biologic mediators
 Less microthrombectomy
Clin Radiol. 2015 Jan;70(1):48-53.

15. Easier AP
 Use US to see VV
missed during AP
 Use US to guide AP

16. Technical Considerations
EVA
USGFS
AP
 Tumescent for EVA may
interfere with USGFS
(spasm/compression)
 Foam from USGFS may
interfere visualization
during positioning for
EVA

17. EVA
• Access
• Position USGFS
• Foam
Sclero
VV’s
AP
• Tumesce
• Express
foam
• AP
EVA
• Tumesce
• Treat
EVA
• Tumesce
• Treat
USGFS
• Foam
Sclero
VV’s
AP
• Tumesce
• Express
foam
• AP

18. My Practice
 134 Consecutive patients
 162 EVLA
 3 Month FU
 81 EVLA & FP
EVA
Only
15%
EVA &
FS
32% EVA
& AP
3%
EVA &
FP
50%

19. 81 EVLA & FP
 EVLA GSV or SSV
 AP, 4 – 33 incisions, average 13.5
 USGFS, 1 or 3% sotradecol, 1:3 air

20. 1 Week
 3 (4%) EHIT, no treatment
 7 (8%) infections requiring treatment
 No DVT/PE*
 No bleeding (No phone calls or RTC)

21. 3 – 5 Weeks
 15 (19%) microthrombectomy
Discomfort
Discoloration
 1 DVT & PE
Negative US at 1 week

22. 3 Months
 3 (4%) GSV recanalizations > 5 cm
1 symptomatic
 4 (5%) Unplanned procedures
1 EVLA, recanalization
3 USGFS, residual symptomatic VV

23. My (Anecdotal) 8 Year Experience
Foam
Phlebectomy
USGFS
AP
 Benefits of both
procedures
 No apparent
downsides
 Single treatment
session

24. Initial
Visit
US
3
Month
CS
EVA
1 Week
FU
US
3
Month
FU
US
AP
1
Month
FU
Sclero
Final
Visit
Initial
Visit
US
3
Month
CS
EVA AP
USGFS
1 Week
FU
US
3
Month
FU
US
Final
Visit

25. Foam Phlebectomy
Better FS
 Wall Contact
 Less Foam
 Removal of foam
 Less micro-
thrombectomy
Better AP
 USG AP for
difficult VV’s
 Missed VV’s
treated by USGFS
 Less bleeding