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By Claudine HAMEL-DESNOS (France)

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.

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By Claudine HAMEL-DESNOS (France)

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  1. 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)

  2. Terminal and preterminal valves must be differentiated from OSTIAL valves Tasch C, Brenner E. Phlebology. 2012;27(4):179-183.

  3. Terminal and pre-terminal valves must be differentiated from the FEMORAL valve • Femoral valve (FV) • (missingin 20-24% of cases) • Terminal valve (TV) • Pre-terminal valve • C/R, compression/release • test 1 3 4 2 Cappelli M, Molino Lova R, Ermini S, Zamboni P. Int Angiol. 2004;23(1):25-28.

  4. GSV caliber also predicts the function/presence of a femoral valve In case of incompetence of GSV trunk + incompetence of SFJ • FV incompetent/absent →GSV ≥ 8 mm • FV competent →GSV = 6-7 mm • TV(and FV)competent →GSV≤ 5mm Level of Ø = 15 cm below the groin 1 3 GSV ≥ 8 mm GSV≤5mm 2 GSV = 6-7 mm Cappelli M, Molino Lova R, et al. Int Angiol. 2006;25(4):356-360.

  5. Ultrasound-guided foam sclerotherapy (UGFS) and clinical trials: a review of the literature

  6. 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

  7. Can foam sclerotherapy be performed in large (>7 mm) incompetent GSVs? Ultrasound-guidedfoam sclerotherapy (UGFS) canbeused for large GSVsaccording to • Cabrera J. (Phlebology, 2000):9-32 mm • Barrett JM. (DermatolSurg, 2004): >10 mm • Sica M. (Phlébologie, 2003): >8 mm But in O’Hare JL. (EurJ VascEndovascSurg, 2008) results showedno significant difference in occlusion rate between veins <7 mm and those >7 mm in diameter

  8. Foam sclerotherapy for incompetent great saphenous vein • Coleridge Smith P. (EurJ VascEndovascSurg, 2006) • Myers K. (EurJ VascEndovascSurg, 2007) • Gonzalez-Zeh R. (J VascSurg, 2008) In these studies,betteroutcomeswereobtained in saphenous trunks less than 5 to 6.5 mm in diameter. GSV ≤ 6.5 mm: Femoral and terminal valves found to be competent

  9. Foam sclerotherapy for incompetent GSV and SFJ reflux Hamel-Desnos C, et al. Eur J VascEndovascSurg. 2007;34:723-729. (multicentre study, 5 centres) • Recruitment : 148 patients • Included incompetent GSV: 4 to 8 mm in diameter • One (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) GSV ≤ 8 mm: Femoralvalve found to becompetent

  10. Foam sclerotherapy for incompetent GSV: indications according to GSV diameter UGFS UGFS or TA TA GSV diameter Thigh level Ø < 4-5 mm 5 to 10 mm 10 to 15 mm Surgery? UGFS : ultrasound-guided foam sclerotherapy TA : thermal ablation (radiofrequency or endovenous laser ablation)

  11. 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 GSV 1st injection SSV 1st injection

  12. Foam sclerotherapy for incompetent GSV: doses to beinjected,regardlessof the vein to beablated or the SFJ • Tailoredinjections: • concentrations dependon veindiameter • volumes depend on the filling of the vein by foam and onvenousspasm 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.

  13. Venous spasm 2 mn after the injection

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

  15. Sclerosis NEVER occludes the SFJ, and tributaries of the SFJ can flow in a physiological way 1-month follow-up 8-year follow-up

  16. Conclusion (1) • There are good correlations betweenhemodynamic patterns in the SFJ and trunkdiametersof 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

  17. 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. «Measuringat proximal thigh has a higheraccuracy in prediction of clinics, of presence or not of reflux ». Mendoza et al1 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.

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