Foam also known as Ultrasound Guided Foam Sclerotherapy is a technique used to treat varicose veins. It is approved by NICE for use in patients who are not suitable for Endothermal Ablation (Laser or RFA). It is also permitted as an adjunctive treatment used in combination with Endothermal Ablation.
The technique is a modification of the basic sclerotherapy technique that has been around since the development of Sodium Tetradecyl Sulphate in 1946. The foam technique was developed in 2000 by Tessari and uses the same sclerosant medication but instead of the medication being injected directly into the vein as a liquid it is mixed with gas (air or carbon dioxide) between 2 syringes to make a foam. This foam can then be injected through a needle into the vein under ultrasound control.
The injected Foam pushes the blood out and completely fills the vein, allowing the sclerosant to better contact the vein wall. The surgeon can control the strength of the sclerosant used and the volume of foam injected to achieve the desired effect. The lining of the vein is removed by the foam and the treatment starts a healing process. The vein walls stick together, and the channel is closed off. With time the vein is normally absorbed by the body.
Treatment is performed in a treatment room and not an operating theatre. The patient rests comfortably on an examination couch. Small butterfly needles are inserted into the affected veins. The position of the needle is carefully monitored using ultrasound so that the feeder veins are closed. Because the needles are so small, anaesthetic injections are not normally required.
Foam is then injected and its progress into the varicose veins is carefully monitored with ultrasound. The whole treatment usually takes no more than a few minutes.
Finally a firm bandage or a stocking is applied to the leg. The aim of this is to keep the veins compressed so that they do not fill with blood when the patient stands up.
The treatment is not normally painful, however after about 10-14 days the treated veins become hard and inflamed and sore. This is known as thrombophlebitis and this is essentially how foam works. The amount of thrombophlebitis can be reduced by good compression and if needed the treated veins can be aspirated with a small needle to remove some of the trapped blood that is causing the inflammation.
It is unusual for all the treated veins to close with a single session of injections and most patients have 2 injection sessions for one leg or 3 if both legs are treated. The higher the concentration of the sclerosant used, the more veins will seal but at the expense of more severe phlebitis.
It is normally preferable to use a lower concentration and accept that a second injection session may be needed.
The National Institute for Health and Care Excellence (NICE) has reviewed all the modern treatments for people with varicose veins and its experts have produced guidance on the subject: NICE Clinical Guideline CG168. Ultrasound-Guided Foam Sclerotherapy is recommended when endothermal treatments such as Endovenous Laser or Radiofrequency are not possible.
Most people with small or moderate size varicose veins can be treated in this way and feeder veins associated with thread veins and spider veins can also be treated by foam sclerotherapy.
People with very extensive or large (>6mm) varicose veins are usually best treated by an alternative method such as laser due to the high recurrence rates and increased risks of complications such as severe thrombophlebitis and skin staining in these patients.
Recovery is individual to each patient and may depend on how many veins are treated and their size.
Patients are generally advised against driving home post-treatment. They will asked expected to have a friend or relative arranged to take them home, at least for the first treatment.
Bandages and Compression Stockings
Patients will generally be required to wear stockings for at least one week. Patients will have the option to remove them at night for comfort. Often wearing stocking for longer can be helpful.
Discomfort Management
Patients may experience warmth and lumpiness at the site of treated veins or mild pain around 10-14 days after treatment, it could indicate phlebitis due to trapped blood. This condition responds well to ibuprofen or diclofenac gel. In cases where the discomfort is severe, patients will be brought in to have the trapped blood removed with a small needle in the clinic.
Post-Procedure Activity
Patients will be instructed to wait until they feel confident enough to perform an emergency stop before driving again. This is normally that evening or the following day. Patients will be advised against flying for 2 weeks prior to surgery and, ideally, for 4-6 weeks afterward to reduce the risk of clots (DVT). They will also be advised to avoid activities that increase leg temperature, such as vigorous aerobic exercise or sauna visits. While gentle walking will be encouraged, patients will be advised to avoid excessive exercise for about 2 weeks post-procedure.
Whilst foam is not quite as safe as laser, Foam Sclerotherapy has proven to be safe is approved by the National Institute for Health and Care Excellence (NICE).
The main risks for Foam Sclerotherapy are:
- That the treated vein can reopen (up to 20% of patients if large (>6mm) veins are treated)
- Blood clots in other leg veins (less than 1 in 200 patients)
- Thrombophlebitis – almost all patients treated with foam sclerotherapy will get some thrombophlebitis in the treated veins in the first few weeks after injection.
- Skin staining over the treated vein, again most patients will get a visible brown mark over the treated vein but this will fade in most cases by 12-18 months.
- Headaches - rarely
- Temporary vision problems – very rarely
In extremely rare cases, sclerotherapy has been known to have serious potential complications, such strokes or transient ischaemic attacks (mini strokes that last <24h). Most of these cases have happened in patients who have a small hole in the heart known as a “Patent Foramen Ovale” that is present in less than 1 in 100 people. These risks are mitigated by limiting the dose of sclerotherapy in any one session and not treating veins over 6mm in diameter.
Foam sclerotherapy is an effective treatment in small veins and may be considered permanent in these however it is not effective in the long term in larger veins (>6mm) as some of these (approx. 20%) can re-open (recanalize) and then be difficult to retreat. A detailed assessment and careful patient selection ensure good long term results.
However, foam sclerotherapy will not prevent more varicose or spider veins from forming. Your lifestyle and genetics will largely determine if you will develop further varicose or spider veins in the future.
The costs of foam sclerotherapy vary from patient to patient. They will depend on the number and extent of veins that need treating, the number of sessions required, and your Ramsay hospital of choice.
You will receive a formal quotation price for your sclerotherapy after your consultation with one of our experienced vascular surgeons. This formal quote will be valid for 60 days.
The costs of your foam sclerotherapy may be covered by medical insurance. Health insurance typically does not cover foam sclerotherapy for varicose or spider veins if it is for cosmetic reasons. However, if foam sclerotherapy is recommended for medical reasons such as they are causing you pain and discomfort, it may be covered by your insurance. We advise you get written confirmation from your insurance provider before your foam sclerotherapy commences.
If you are paying for yourself, we offer a variety of payment options including interest-free finance.
Foam sclerotherapy is a commonly performed procedure at Ramsay Health Care to remove unwanted and unsightly varicose and spider veins.
Our patients can simply book directly with their local Ramsay hospital without a GP referral. This walk-in and walk-out treatment is fast and effective and requires no downtime.
Our vascular surgeons are highly experienced in sclerotherapy is a good choice for treating smaller veins and veins not suitable for laser or radiofrequency ablation.
¹ https://www.bassclerotherapy.com/information-on-leg-vein-treatment/sclerotherapy-faqs/
Rob Windhaber is a vascular surgeon who specialises in the treatment of varicose veins, leg thread veins, facial thread veins and their related conditions. He has over 15 years experience in treating these conditions using minimally invasive techniques.
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