1. pp29 - 32
Original A R T I C L E
ABSTRACT
Objective: To describe a novel method of
compressing venous trunks following foam
INTERNAL COMPRESSION ultrasound guided sclerotherapy (UGS) to the great
(PERI-VENOUS COMPRESSION) and small saphenous veins in order to improve the
success rate of ablating these veins.
FOLLOWING ULTRASOUND Methods: The technique of perivenous compression
GUIDED SCLEROTHERAPY TO with ultrasound-guided injections of normal saline is
THE GREAT AND SMALL described. Early results of 47 limbs treated with the
technique are reported.
SAPHENOUS VEINS Results: Forty-seven limbs were treated with the
DR PAUL THIBAULT method over a 6-month period. Five venous trunks
Central Vein and Cosmetic Medical Centre
required a second treatment to obtain ablation. One
Newcastle, NSW, Australia
of these still had a small segment of incompetent
vein following the second treatment. There were no
U
ltrasound guided sclerotherapy (UGS) has been used
since 1986 to treat major varicose veins. There are
1
significant adverse effects attributable to the
now are number of studies documenting the effectiveness of
technique and there are indications that some
ultrasound guided sclerotherapy (UGS) in treating greater
saphenous vein (GSV) and small saphenous vein (SSV) adverse effects of foam UGS may be reduced when
incompetence.2-11 The first reported objective ultrasound using this method.
results of SFJ and GSV incompetence treated with UGS Conclusion: Immediate perivenous compression by
were those of Kanter and Thibault.2 Using STS 3%
ultrasound guided injections of normal saline may
solution, they reported a 76% success rate at 24 months.
Interestingly, the success rate at 2 years was virtually the reduce the early recurrence rate after foam UGS to
same as at one year indicating that recanalisation generally the incompetent great and small saphenous veins.
occurred early in the first 12 months. Most studies have
indicated that multiple treatments may be required in the
first 12 months in a significant number of patients.3-7 In
In contrast to the results of UGS, recent reports of
general, recurrence rates have been higher with larger
success with other endovenous techniques such as radiofre-
diameter veins.2,4,8
quency and laser ablation have suggested success rates as
There have been few long-term studies on the effectiveness high as 90% after 3 years.9,10 Does this indicate that physical
of UGS. Thibault reported the 5-year recurrence rate in 35
9
means of ablation of saphenous trunks is inherently more
limbs with GSV incompetence treated with UGS. Nine effective than chemical means, or is there some other
limbs (25.7%) had recurrent varicose veins clinically. Ten
independent factor peculiar to the techniques that makes
had persistent reflux at the SFJ and fourteen limbs (40%)
the physical ablation techniques more effective particularly
had persistent reflux in the proximal thigh segment of the
with larger veins?
GSV. Comparing these results with the shorter-term studies
indicates that there is a slow but steady increase in
Address Correspondence to:Dr Paul Thibault, Central Vein and
cumulative recurrence with time, indicating the need for
Cosmetic Medical Centre. 41 Belford Street, Broadmeadow NSW
periodic review and re-treatment when clinically indicated Australia 2292. Telephone:+61 2 4961 0688 Facsimile: +61 2 4961
in this group of patients. 0687 E-mail:vein1@hunterlink.net.au
AUSTRALIAN & NEW ZEALAND JOURNAL OF PHLEBOLOGY VOLUME 9(1):DECEMBER 2005 29

2. P Thibault
Poczwa8 has suggested that when using UGS there are Method
three factors important to achieve effective endofibrosis of
The technique was developed from the perivenous local
the incompetent great saphenous vein (GSV) which he has
anaesthetic technique for endovenous laser ablation. With
labelled the “triple E” protocol: Effective sclerosant concen-
this method, following completion of injection of the main
tration, Effective vasospasm and Effective compression.
stem (GSV or SSV) with sclerosant foam, normal saline is
With endovenous laser ablation, the tumescent anaesthetic
injected peri-venously in the compartment between the
initially achieves compression of the treated vein. It is
deep and superficial fascia (Fig. 1) at 3 to 6 locations
thought that this reduces the diameter of the vein resulting
equally spaced along the axial vein in the thigh (GSV) or
in better application of laser energy to the venous
endothelium. The author has now applied an adaptation of calf (SSV). Usually between 10 and 30 mls of normal saline
this technique to UGS in an attempt to reduce the recanal- is required, or about 5mls at each cross-sectional segment.
isation rate following UGS to the incompetent GSV and The injection is performed using ultrasound guidance with
SSV by improving sclerosant contact with the vein wall a cross-sectional approach using a 25g 1 1/2 inch needle.
during the immediate post-sclerotherapy period. This The effect is to give greater immediate compression to the
technique positively influences all 3 factors of Poczwa’s vein, thereby decreasing the diameter of the already
“triple E” protocol. spasmed vessel by approximately another 50% (Fig. 2 and
Figure 1: Cross sectional B-mode image
of thigh segment of great saphenous
vein (GSV) during perivenous
compression injection with normal saline.
Figure 2: Great saphenous vein (GSV)
diameter immediately after foam
injection
30 VOLUME 9(1):DECEMBER 2005 AUSTRALIAN & NEW ZEALAND JOURNAL OF PHLEBOLOGY

3. Internal Compression (Peri-venous Compression) following Ultrasound Guided Sclerotherapy to the Great and Small Saphenous Veins
Figure 3: Reduction of great saphenous
vein diameter (GSV) immediately after
peri-venous saline injection.
3), resulting in better apposition of the veins walls and more with polidocanol foam. In 4 limbs, there were only small
complete contact of the veins wall with the sclerosant. residual channels that required the second treatment. There
The author used this method routinely when treating was one GSV that a small persistent segment of the
incompetent saphenous trunks (GSV and SSV) greater than proximal calf GSV remained open after the second
3mm in diameter and axial veins that had recanalised treatment. This was at the site of an area of superficial
following previous UGS. The sclerosant foam used was thrombophlebitis that was present prior to treatment. The
sodium tetradecyl sulphate (STS) 3% (FibroveinTM, only adverse reaction recorded was one patient who
Australasian Medical and Scientific Limited, Artarmon developed blisters as a reaction to tape or the compression
NSW) made into foam using the Tessari technique11 with a stockings. In particular there was no occurrence of super-
solution to air ratio of 1 to 3. There were 2 limbs treated ficial thrombophlebitis and no visual disturbances recorded
with polidocanol (AethoxysklerolTM, Kreusler and Co, in this group of patients.
Wiesbaden Germany), as the patient had previously had an Discussion
allergic reaction to STS. The sclerosant injections were Barrett et al7 followed 100 randomly chosen legs with
given with an open needle technique, commencing approxi- varicose veins treated by UGS using STS 3% microfoam
mately 5 cm distal to the saphenofemoral or after an average of 22.5months (range 20- 26 months). An
saphenopopliteal junction and using boluses of 1.5ml of average number of 2.1 treatments were required per leg
foam at each injection site. The total dose of foam used in including saphenous trunks, branches and all visible
any one treatment ranged from 1.5ml to 12mls. varicosities. Thirty-one percent of legs required a second
Results treatment at the 3-month follow-up. Such treatments were
A total of 38 patients (47 limbs) were treated over a 6- generally for a small channel in the saphenous trunk, a
month period. There were only 2 males in this group of small feeding vessel or perforator creating the channel, or
patients. The age range of the patients was from 29 to 94 minor residual varicosities. For saphenous trunks less than
years. There were 44 GSVs treated and 3 SSVs. The 10mm in diameter, this repeat treatment rate reduced to
diameter of the proximal segment of vein ranged from 3mm 27.5%.
to 12mm, with an average of 5.6mm. The mean number of In this study, all veins treated were less than 10mm except
treatments per leg was 1.66. for one GSV that measured 12mm in the proximal thigh. In
During the treatment period, only 5 limbs (10.7%) general, patients with larger incompetent trunks (greater
required a second treatment to occlude the incompetent than 6mm in diameter) during the treatment period were
trunk. Two of these limbs were from the patient treated recommended to have endovenous laser ablation. However,
AUSTRALIAN & NEW ZEALAND JOURNAL OF PHLEBOLOGY VOLUME 9(1):DECEMBER 2005 31

4. P Thibault
early results with peri-venous compression indicate that 5. Cavezzi A, Frullini A. The role of sclerosing foam in ultrasound guided
there may be a reduced retreatment rate of around 10% sclerotherapy of the saphenous veins and of recurrent varicose veins: Our
personal experience. ANZ J Phleb 1999;3:49-50.
compared to up to 30% reported in previous studies.3-8 In 6. Myers KA, Wood SR, Lee V. Early results for objective follow-up by duplex
addition, the most common side effects of superficial ultrasound scanning after echosclerotherapy or surgery for varicose veins. ANZ J
thrombophlebitis and visual disturbances occurring after Phleb 2000;4:71-74.
7. Barrett JM, Allen B, Ockleford A, Goldman MP. Microfoam ultrasound-guided
foam echosclerotherapy, previously reported at rates of
sclerotherapy of varicose veins in 100 legs. Dermatol Surg 2004; 30:6-12.
around 2%16 were not observed in this study. The relatively 8. Poczwa HJ. An overview of microfoam ultrasound guided sclerotherapy of great
small number of limbs reported in this study however, does saphenous vein reflux utilizing a “Triple E” protocol. ANZ J Phleb 2005;9: 31 -36
9. Thibault PK. “5 year” follow-up of greater saphenous vein incompetence treated
not allow for any conclusion to be made on whether these
by ultrasound guided sclerotherapy. ANZ J Phleb 2003;7: 5-8.
adverse effects are reduced by this method. 10. Kanter A. Clinical determinants of ultrasound-guided sclerotherapy outcome.
Part 1: the effects of age, gender, and vein size. Dermatol Surg 1998; 24:131-135.
11. Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new sclerosing
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