Invited Commentary re: Comparison of 1% and 3% Polidocanol Foam in Ultrasound Guided Sclerotherapy of the Great Saphenous Vein: A Randomised, Double-blind Trial with 2 Year-Follow-up. “The 3/1 Study”

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Foam sclerotherapy techniques: different gases and methods of preparation, catheter versus direct injection

Introduction Foam sclerotherapy has gained a great popularity among phlebologists worldwide, although a major lack of homogeneity in the material used to produce sclerosant foam (SF) and to inject SF has been reported. Aims To highlight the literature data and a few personal clinical and experimental outcomes concerning the main variables in SF production and injection. Methods A review of the published literature and of our own 12 year clinical and experimental experience has been undertaken in order to focus on a few variables of the material and methods used to produce SF with Tessari method and to inject SF. Results In SF production, differences in gas components, liquid to gas ratio, as well in disposable material can variably influence the resulting SF. Similarly SF injection through ultrasound guidance, with needle, or with short/long catheter may exhibit different foam behaviours according to the variable material and techniques which are employed. More recently the introduction of long catheters, possibly together with hook phlebectomy, seems to potentiate the short-mid term outcomes of foam sclerotherapy. Conclusion SF formation is greatly influenced by the choice of the gas component, the liquid-to-gas ratio, the type of syringes; also larger needles are to be preferred for injection of SF, while long catheters seem to represent a valid alternative especially when combined with tumescence to minimise saphenous diameter. </jats:sec

Echo-Anatomy of Long Saphenous Vein in the Knee Region: Proposal for a Classification in Five Anatomical Patterns

Objective: Ultrasonography of the anatomical course of the long saphenous vein (LSV) and its tributaries to produce and verify an anatomical classification (five types). Methods: Four hundred and ninety-three limbs (293 healthy; 200 with varicose veins, VV) were investigated by ultrasonic duplex imaging by the two authors independently, identifying the LSV as the vessel in the (ultrasonic) saphenous fascial ‘eye’ compartment (SFEC), in the thigh, and within two fascial layers between tibia and medial gastrocnemius muscle, below the knee. Results: Type A: LSV runs entirely in the SFEC without relevant tributaries: overall (O) 112 (23%), limbs with vv (V) 13, normal limbs (N) 99. Type B: LSV runs in the SFEC with one or more relevant tributaries below the knee: O 133 (27%), V 70, N 63. Type C: LSV runs in the SFEC with a relevant tributary above the knee: O 89 (18%), V 28, N 61. Type D: LSV runs in the SFEC from the foot upwards, continuing at the middle third of the leg in a large side vein with the calibre and role of the LSV but in a more superficial location. LSV stem is absent (or hypoplasic) in the para-tibial position. At the thigh level the tributary re-enters the true LSV: O 72 (14.5%), V 42, N 30. type E: similar to type D but the LSV is absent only at the knee level: O 72 (14.5%), V 38, N 34. Unclassified: O 15 (3%), V 9, N 6. Conclusions: We found a good reproducibility and clinical utility of the suggested classification. Remarks: (a) the absence (or hypoplasia) of LSV at the knee level with prevalence of a tributary in almost 30% of the limbs is of importance for arterial bypass and saphenous sparing management; (b) there is a low rate of LSV complete incompetence (6%); (c) there is a correlation between absent LSV (or presence of a relevant tributary) and the incidence of VV. </jats:sec