Does competence of the terminal and/or pre-terminal valve

influence the modalities of foam sclerotherapy for the treatment

of trunk varices ?

By Claudine HAMEL-DESNOS (France)

Terminal and preterminal valves must be differentiated from

OSTIAL valves

Tasch C, Brenner E. Phlebology. 2012;27(4):179-183.

Terminal and pre-terminal valves must be differentiated from

the FEMORAL valve

Cappelli M, Molino Lova R, Ermini S, Zamboni P. Int Angiol. 2004;23(1):25-28.

1

2

3

4

• Femoral valve (FV) (missing in 20-24% of

cases)• Terminal valve (TV)• Pre-terminal valve• C/R,

compression/release test

GSV caliber also predicts the function/presence of a femoral

valve

Cappelli M, Molino Lova R, et al. Int Angiol. 2006;25(4):356-360.

In case of incompetence ofGSV trunk + incompetence of SFJ

1.FV incompetent/absent →GSV ≥ 8 mm

2.FV competent →GSV = 6-7 mm

3.TV(and FV)competent →GSV≤ 5mm

Level of Ø = 15 cm below Level of Ø = 15 cm below the grointhe groin

1

2

3

GSV ≥ 8 mm

GSV = 6-7 mm

GSV≤5mm

Ultrasound-guided foam sclerotherapy (UGFS)

and clinical trials:

a review of the literature

Introduction

There are some data available regarding UGFS results and vein diameters.

Studies of sclerotherapy of the GSV that

differentiate results between isolated GSV trunk incompetence and GSV trunk incompetence + SFJ incompetence are scarce.

None of these UGFS studies tackled FV incompetence

Can foam sclerotherapy be performed in large (>7 mm) incompetent GSVs?

Ultrasound-guided foam sclerotherapy (UGFS) can be used for large GSVs according to Cabrera J. (Phlebology, 2000): 9-32 mm Barrett JM. (Dermatol Surg, 2004): >10 mm Sica M. (Phlébologie, 2003): >8 mm

But in O’Hare JL. (Eur J Vasc Endovasc Surg, 2008)results showed no significant difference in occlusion rate between veins <7 mm and those >7 mm in diameter

Foam sclerotherapy for incompetent great saphenous vein

Coleridge Smith P. (Eur J Vasc Endovasc Surg, 2006)

Myers K. (Eur J Vasc Endovasc Surg, 2007) Gonzalez-Zeh R. (J Vasc Surg, 2008)

In these studies, better outcomes were obtained in saphenous trunks less than 5 to 6.5 mm in diameter.

GSV ≤ 6.5 mm:Femoral and terminal valves found to be competent

GSV ≤ 8 mm:Femoral valve found to be

competent

Foam sclerotherapy for incompetent GSV

and SFJ reflux

Hamel-Desnos C, et al. Eur J Vasc Endovasc Surg. 2007;34:723-729.

(multicentre study, 5 centres)

Recruitment : 148 patientsIncluded incompetent GSV: 4 to 8 mm in diameterOne (1) UGFS session, no reinjection GSV incompetence with SFJ incompetence = 62% GSV incompetence without SFJ incompetence = 38%

Success rates at 2 years:•64% with SFJ incompetence•78% without SFJ incompetence (NS, Chi-square 0.22)

UGFS UGFS or TA

TA

Ø < 4-5 mm Ø < 4-5 mm 5 to 10 mm 5 to 10 mm 10 to 15 mm 10 to 15 mm

Surgery?

UGFS : ultrasound-guided foam sclerotherapyTA : thermal ablation (radiofrequency or endovenous laser ablation)

Foam sclerotherapy for incompetent GSV:

indications according to GSV diameter

GSV diameterThigh level

Foam sclerotherapy for incompetent GSV:

always the same technique, regardless of SFJ

Direct puncture with needle

Staged injections: for the GSV, the first injection is performed at the third median-upper third junction of the thigh

GSV1st

injection

SSV1st

injection

Foam sclerotherapy for incompetent GSV:

doses to be injected, regardless of the vein to be ablated or the SFJ

Tailored injections:•concentrations depend on vein diameter•volumes depend on the filling of the vein by foam and on venous spasm

POL, polidecanol

1. Hamel-Desnos C. et al. Dermatol. Surg. 2003. 2. Hamel-Desnos C. et al. J Mal Vasc 2006. 3. Hamel-Desnos C. et al. “The 3/1 Study”. Eur J Vasc Endovasc Surg. 2007. 4. Hamel-Desnos C. et al. in Traité de Médecine vasculaire Tome 2. Elsevier Masson SAS 2011.

Venous spasm 2 mn after the

injection

The filling of the vein by foam:in case a 2nd injection is needed

Sclerosis NEVER occludes the SFJ, and tributaries of the SFJ can flow in a

physiological way

1-month follow-up 8-year follow-up

Conclusion (1)• There are good correlations between

hemodynamic patterns in the SFJ and trunk diameters of the GSV

• In daily practice, the competence of the terminal and/or pre-terminal valve(s) does not influence the choice of UGFS treatment, and hemodynamic patterns of the SFJ are not a real concern

• The GSV diameter is a relevant criterion, easier to assess than hemodynamics in the SFJ

Conclusion (2)• Recent data1 confirm that the GSV diameter

is a relevant criterion correlated with clinical class.

• Measurement of GSV diameter at the proximal thigh level is more sensitive and more specific than measurement at the SFJ.

• The diameter of the GSV at the proximal thigh level has a better correlation with reflux.

1. Mendoza E. et al. Great saphenous vein diameter at the saphenofemoral junction and proximal thigh as parameters of venous disease class. Eur J Vasc Endovasc Surg 2013;45:76-83.

« Measuring at proximal thigh has a higher accuracy in prediction of clinics, of presence or not of reflux ».

Mendoza et al1