History of Sclerotherapy From Liquid to Froth to Foam

Transcription

1 History of Sclerotherapy From Liquid to Froth to Foam Satish Vayuvegula, MD, MS National Medical Director Vein Clinics of America

2 Disclosures: Financial None Off-Label Use: STS foam 2015 Physician Sclerotherapy Course

3 References JC Wollmann: The History of Sclerosing Foams; Dermatol Surg 2004;30: Goldman, M; Bergan, J. (2001). Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins, 3 rd Edition. St. Louis, MO: Mosby.

4 Useful Definitions Sclerotherapy The injection of a chemical into a vein to sclerose or harden it Sclerosant The chemical used to cause damage to the vein Foam- A mixture of a gas (usually air) and sclerosant that is injected into the vein, displacing the blood and creating a greater surface area for action (foam is defined as having a gas portion > 0.52)

5 Historical Treatment for Varicose Veins Hippocrates describes treating varicose veins with a slender instrument of iron over 2000 years ago Celsus practices stripping and cauterization from 30 BC to 30 AD Compression therapy dates back to the Book of Isaiah in the eighth century BC

6 1682 D. Zollikofer of St. Gallen, Switzerland reported the injection of an acid into a vein to create a thrombus First documented attempt at sclerotherapy

7 1836 Extravascular sclerotherapy of a hemangioma performed by the surgeon, Mr. Lloyd 3 drops of nitric acid in a drachm of water 2 nd reported case was fatal

8 1851 Pravaz injected a solution of ferric chloride to sclerose veins

9 1854 Desgranges reports cure of 16 cases of varicose veins with a mixture of iodine and tannin diluted in water Patients kept in bed for days A lot of septic complications developed

10 1904 to 1910 P. Scharf used sublimate on 90 patients as well as himself, who suffered from varicose veins

11 1916 Linser used perchloride of mercury with an intrvascular technique Encouraged walking 1-3% developed Mercury intoxication

12 1920 Sicard reported a series of cases using carbonate of soda (sodium carbonate) In 1922 he perfected his technique with the use of salicylate of soda (sodium salicylate)

13 1928 Tournay described the technique of thrombotic evacuation He was instrumental in the development of a sclerotherapy school in France

14 1939 McAusland reported successful treatment of patients Popularized technique in the United States

15 1946 Advent of synthetic sclerosing agents Sclerotherapy considered a viable treatment for varicose veins (mainly in Europe)

16 Foam Sclerotherapy

17 Benefits of Foam Sclerosants Displace the blood, minimizing the hemodilutional effect Fully occupy the vein creating circumferential endothelial contact Causes early spasm of the vein, which enhances the previous points

18 History of Foam First documented use as early 1939 Has continually been improved over several decades Now routinely used around the world A commercial formulation is available

19 1939 Stuart McAsuland described the use of a froth in the treatment of telangectasias He shaked a bottle of sodium morrhuate and aspirated out the froth Noted veins suddenly got pink, sometimes retracted and almost disappeared at once

20 1944 Egmont James Orbach reported the widely cited air-block technique Although often credited with the first use of foam, his technique did not use a foam at all He injected a large air bubble into small and medium veins and then injected solution into the bubble

21 The air-block technique: a small amount of air was injected before (top) the injection of sclerosant (bottom) to avoid dilution of the liquid.

22 1944 Robert Foote published a book about his empty-vein technique and the use of a froth His froth was made of 1 cc ethanolamine oleate shaken in a 2 cc syringe Interesting point: Also described a method of treatment of spider veins suggesting that the feeder veins be treated first

23 1949 Karl Sigg created the Foam-Block Technique He used Orbach s air-block technique but with Foote s froth as the block, he then injected liquid sclerosant into this froth He showed that foam took longer to wash away compared to air

24 1950 Orbach compared the efficacy of foam to liquid (using the air-block technique) He used the length of sclerothrombus created as the endpoint He found that foam (created by agitation) was times more effective than liquid He also noted the effect of marked vasospasm after the injection of foam

25 1953 Arve Ree was the first to inject pure foam without the foam-block or air-block technique He agitated a detergent solution in a vial and aspirated out the bubbles into a syringe

26 1956 Peter Fluckiger postulated and discussed the properties of foam for the first time: - Increased efficacy by increasing the effective surface area with foam - Stronger sclerosing effect with smaller amounts of sclerosant - Postulated increased effect with smaller bubble size - Postulated the homogeneity of foam (i.e. same bubble size)

27 1956 Fluckinger also described the aspiration technique of making foam He described simultaneous aspiration of sclerosant and air through a thin injection needle (narrower the needle the finer the foam)

28 The aspiration technique: The tip of the needle was placed at the liquid air interface, thus allowing simultaneous removal of air and sclerosant that would generate foam in one run.

29 1957 Heinz Mayer and Hans Brucke, two surgeons developed the first Microfoam device

30 1962 Peter Fluckiger described the turbulent flow technique He made foam by pumping air and sclerosant back and forth between a drug vial and an attached syringe Interesting Observation: Warned to be careful while stroking the foam to prevent foam from moving into the deep venous system

31 1963 Peter Lunkenheimer was the first to use Polidocanol foam in a patient

32 1969 Walter Gillesberger invented the low-pressure technique He used negative pressure in a glass syringe so that air could enter through the gap between the syringe piston and the plunger Drawback is the inability to standardize the ratio between air and foam

33

34 1984 Gerald Hauer patented a foam preparation using a twin-syringe system Two syringes, one with air the other with sclerosant are emptied simultaneously under pressure into a mixing chamber creating foam

35 1986 Michael Grigg invented the Irvine Technique Two syringes were connected by a connecting tube and air and fluid were pumped back and forth Considered a precursor to Tessari s technique

36 1995 Juan Cabrera Gurrido created foam with a high-speed rotating brush, while adding CO2 Initial study had a 6% rate of DVT

37 1997 Alain Monfreux developed the Methode MUS He modified the Gillesberger negative pressure technique by placing a cap on the syringe creating an absolute negative pressure

38 1998 Symon Sadoun and Jean-Patric Benigni made Monfreux s technique usable with plastic syringes Miguel Santos Gaston also modified the Monfreux method

39 1999 Javier Garcia Mingo created a Foam Medical System He passed gases from a pressurized cylinder through a fine nozzle The complicated cleaning of the system has limited its use

40 2000 Lorenzo Tessari created the Tourbillon technique, the method most commonly employed Two syringes are connected via a three-way stopcock and the air and sclerosant are pumped back and forth at least 10 times 2 to 2.5 cc of air is mixed with 0.5 cc of sclerosant

41 2000 Alessandro Frullini modified the turbulent flow technique developed by Fluckinger He added an adapter and made it usable for disposable syringes In 2001 he started using sterile air

42 2001 Double-Syringe System (DSS) created Variables that affect foam stability were systematically changed in a lab to determine the best combination of syringe type, gas:fluid ratio, sclerosant concentration The DSS foam has a ratio of 1:5, half-life of 150s, mean bubble size of 70 microns

43 DSS

44 Conclusion Treatment of varicose veins has been around for thousands of years. Sclerotherapy has been around sin the 1600s Foam sclerotherapy has been reported since at least 1939 It has undergone many advancements to get to the most widely used methods (Tessari, DSS) Sclerotherapy is still considered the gold-standard for reticular and telangiectatic legs veins Foam sclerotherapy has provided a viable, inexpensive, non-surgical alternative for the treatment of varicose veins