Ultrasound Guided Foam Sclerotherapy
Recently several new techniques have been reported
in the medical literature. The main aim of
these is to avoid surgical removal of varicose
veins. The idea is to avoid the need for general
anaesthetic, incisions in the legs and a hospital
operating theatre. One of the most promising
of these is Ultrasound Guided Foam Sclerotherapy.
The use of injections to cure varicose veins
dates back more than 100 years. In 1942 Orbach
described a method of creating a foam or froth
with the solution he injected. He found that
this increased the efficacy of injection treatment
by five times. This method was used by a small
number of surgeons but never found a great following.
In 1992 Juan Cabrera, a surgeon from Granada
in Spain, found that he could greatly enhance
the effect of injection treatment by making a
foam of very small bubbles, which he called 'microfoam'.
He used ultrasound imaging to guide his injections
into the main surface veins and found that he
no longer needed surgical methods to treat his
Over the last 15 years the use of foam injections
has spread widely in France, Spain, Italy and
Germany. It is now being enthusiastically taken
up in several European countries, United States,
South America, Australia and New Zealand. Experts
in treating vein problems have used a number
of different methods to create the foam that
they inject but the result is the same: using
a foam greatly increases the effect of the treatment
without producing any additional side-effects.
Recently a pharmaceutical company, Provensis,
has commenced development of a foam called 'Varisolve'.
This is specifically intended to treat varicose
veins. 'Varisolve' is currently only in use in
clinical trials. The National Institute of Clinical
Excellence has considered this treatment and
published draft advice.
What is injected?
The solutions that are injected are exactly the
same as those which are already used to treat
varicose veins. These are mixed with air to create
a mousse or foam consisting of very small bubbles.
It has been shown that this is perfectly safe
to inject into the veins. The air is rapidly
absorbed from the veins leaving the solution
to treat the veins.
Why does foam work?
When a solution is injected into a vein it is
immediately diluted by the blood, reducing its
efficacy. Foam pushes the blood out of the way
and completely fills the vein: the foam is not
diluted by the blood. In fact, far less solution
has to be injected to obtain the same effect.
Treatment is usually performed in a treatment
room or ultrasound examination room, and not
an operating theatre. The patient rests comfortably
on a bed. Very little discomfort results from
the injections so no sedation or anaesthetic
In order to treat large varicose veins it is
necessary to block the main vein feeding the
varices. This could be done surgically, but with
foam treatment all that is necessary is to put
a needle into the main affected surface vein.
This is the only part of the procedure which
might cause discomfort and is usually performed
with a small amount of local anaesthetic. The
position of the needle is carefully monitored
using ultrasound imaging so that it is in exactly
the right place.
Next, the foam is injected whilst watching its
progress using the ultrasound machine. Surprisingly,
injecting the foam causes no discomfort, although
the leg may ache slightly afterwards.
The varicose veins in the leg are checked to
see if foam has entered these from the main surface
vein where the injection was given. A few further
injections are usually given through a tiny needle
in order to make sure that all the varicose veins
have been completely injected. The whole treatment
usually takes no more than 20 - 30 minutes.
Finally a firm bandage is applied to the leg.
The aim of this is to keep the veins compressed
so that they do no fill with blood when the patient
stands up. The bandage is usually worn for a
week or two followed by an elastic compression
stocking for a further week.
When the bandages are removed at the follow-up
appointment it is usual to find that all the
varicose veins have gone. Sometimes small lumps
can be felt beneath the skin. The leg may be
a little bruised, although this is usually fairly
minor. Lumps present at this stage slowly resolve
over several weeks. If any varicose veins have
not been completely treated in the first session
they are injected and the leg bandaged to complete
removal of all veins.
If varicose veins are present in both legs it
is standard practice to treat them on separate
occasions about two weeks apart. This avoids
having both legs bandaged at once.
Who is suitable for foam sclerotherapy?
Most patients with small or moderate size varicose
veins can be treated in this way. Those patients
with very extensive large varicose veins are
usually best treated surgically to obtain a more
rapid result. Some patients with large veins
lying close to the skin are better treated surgically
since brown discoloration of the skin over the
treated vein may occur. If there has been previous
surgery to the veins of the leg this does not
cause any difficulty in using foam sclerotherapy.
In fact, it is often far easier to treat recurrent
varicose veins by foam injections than by more
surgery. If varicose veins recur some years after
initial treatment then it is straightforward
to use the same method foam sclerotherapy again.
Who performs this treatment?
At present only a handful of surgeons in the
UK are experienced in this treatment. It needs
a specialist who is skilled at ultrasound imaging
as well as injecting veins. By calling the BVI
you can obtain an appointment with your nearest
How well does ultrasound guided foam sclerotherapy
Several detailed clinical series have been published
in the medical press. These suggest that 80 -
90% of saphenous veins (the main surface vein)
are permanently occluded by this treatment when
examined one or two years later using ultrasound
imaging . This is similar to the success rate
claimed for other new techniques such as VNUS
Closure and Endovenous Laser Treatment (See:
New Techniques). Surgery also has its failures
and after two years further varicose veins may
have appeared in about 10% of patients. Clinical
trials are currently in progress which directly
compare surgery and foam sclerotherapy.
Stripping of the vein is avoided and there is
little or no discomfort after treatment.
There is much less bruising than following surgery.
There is no need for general anaesthetic, incisions
in the leg, admission to hospital or an operating
Re-treatment for further varices is simple.
Much less expensive than surgical treatment -
less than half the cost of surgery.
No time needed off work, except for the treatment
The treatment produces mild discomfort in the
leg which may last for 2 - 4 weeks. It also produces
mild bruising which may last for several weeks
following treatment. However, both of these features
are usually seen following surgical treatment
for varicose veins.
The final outcome may take a number months to
evolve following treatment, and this is longer
than would be taken following surgery.
publications and abstracts
Paper br Dr Cabrera
Abstract from Venous Forum
of the Royal Society of Medicine (0.1MB)
Abstract from Pacific
Vascular Symposium (0.15MB)
Ultrasound guided foam sclerotherapy is a new
method of treating varicose veins.
There is NO need for an operation under general
The treatment only involves injections under
A treatment session is complete in 30 - 40 minutes.
The treatment is carefully monitored using ultrasound
firm compression bandage must be worn for
week or two afterwards.
discomfort and a little bruising often follow
treatment. This is much less than following
time off work is needed, except to attend the
costs of treatment are much lower than for surgical
small lumps may be felt in place of the veins
after treatment. These resolve completely over
a few specialists in the UK have experience
with this technique. The BVI can put you in
touch with the nearest one.