Comment to: Catheter-directed foam sclerotherapy for insufficiency of the great saphenous vein: occlusion rates and patient satisfaction after one year, by Williamsson C, Danielsson P, Smith L. Phlebology 2012:1-6.

Between November 2007 and October 2008, 100 consecutive symptomatic patients with verified axial reflux in the GSV were treated with a catheter-directed foam sclerosation technique (CDS). CDS delivers the foam during a short period of time directly to the intended site, along the length of the GSV, with less impact from surrounding factors. The catheter induces a vasospasm which might further enhance drug interaction with the vein wall. Median age was 52.5 years (range 18–92), 28 men and 72 women. All patients had visible varicose veins. Twenty-three had recurrent varicose veins. The treatment was performed in the outpatient clinic by a team consisting of two vascular surgeons and two nurses. Exclusion criteria were allergy to polidocanol, a very tortuous vein (which could make the catheters impossible to advance) or a GSV diameter exceeding 10 mm at the terminal valve. The skin was infiltrated with local anesthesia. The vein was accessed by a micro-puncture introducer set and a 0.35 Fr guide wire was advanced proximally under US surveillance and positioned at the SFJ. A catheter was introduced over the guide wire and positioned approximately 2 cm distal to the SFJ and the guide wire was removed. The table was slightly tilted to elevate the leg to empty the GSV. Ten mL sclerosing foam (SF) was made by mixing 2 mL chilled 3% polidocanol and 8 mL air. The SFJ and site of puncture was compressed for five minutes and the thigh massaged to fill superficial varicosites with foam. No additional local injection of foam was given. All patients wore two-layer short stretch compression bandages for one to five days after treatment. Evaluation with US was performed at two weeks and at one year after treatment. Foam delivery along the GSV was technically successful in 94 of the 100 patients. The median time for the procedure was 22 (8–90) min. The complete treatment exceeded 30 min in 20 patients, but only in two patients following the 50th patient. At the US control two weeks after treatment, the GSV was completely occluded in 92 of the 94 successfully treated patients. At the one-year follow-up, 84% (79/94) were satisfied with the result. The one-year US showed that 70% (64/91) of the GSVs were completely occluded, 15% (14/91) of the GSVs were recanalized and 14% (13/91) were partly occluded. No major complications occurred such as visual disturbance, pulmonary embolism, DVT or infection. Two patients had superficial thrombophlebitis; at the one-year follow-up 26 patients had pigmentations to some extent. The cost for the drugs and the single-use medical material was calculated to be 106 EUR.