2003 Papers - Puggioni


Treatment of Chronic Venous Disease with Ultrasound Guided Sclerotherapy of Perforating Veins
Alessandra Puggioni, Fedor Lurie, Elna M.Masuda, Robert L. Kistner, Bo Eklof
Straub Clinic & Hospital, University of Hawaii Residency Program

Background and Purpose: Interruption of incompetent calf perforators is commonly performed in the setting of advanced chronic venous disease. Reported complications of surgery, including subfascial endoscopic procedures (SEPS) are: deep venous thrombosis, wound complications, superficial thrombophlebitis, and saphenous neuralgia. Ultrasound-guided sclerotherapy of perforating veins (USGS) is an alternative minimally invasive technique whose long-term success in interrupting the blood flow through incompetent perforators has not been investigated yet. The objective of this study was to report on our USGS technique and to evaluate the efficacy of this treatment in interrupting the blood flow through perforating veins.

Patients and Methods: Fifty-three limbs in 45 patients treated with USGS of incompetent calf perforators between 2000 and 2001 were included in the study. There were 28 men and 17 women with a mean age 63±15 years (range 35 to 85). Main presenting symptoms were: edema in 21 limbs (40%), pain in 8 (15%), inflammatory skin changes in 10 (19%) and active ulcers in 14 (26%). Procedures were performed in the outpatient clinic, and no sedation or local anesthesia was required. Follow-up duplex study was obtained between 1 and 31 months (mean 12±9, median 11). In 24 extremities duplex follow-up was 1 year or more.

Results: Two complications occurred after USGS (1.4%): one superficial skin necrosis and one severe skin inflammation. In one case a calf varix had been injected at the same time of the perforator, and it could not be ascertained which procedure was responsible for the complication. Both resolved with no sequelae. Thirty-four of 146 injected perforators recurred (23.3%) in 21 limbs, 50% were re-injected. Perforator recurrence occurred in 71% of limbs with ulcers compared to 28% with no ulcers (p=0.005). Recurrence was similar between limbs with primary and secondary disease. Possible recurrence occurred after 13 injections (8.9%). Sixteen new incompetent perforators were identified in 14 extremities.

Conclusion: This study shows that USGS of calf perforating veins is a safe and effective treatment for symptomatic CVD in outpatients. At least 77% of perforators remained closed after injection with a complication rate of 1.4%. This is cheap and minimally invasive technique since no sedation or anesthesia is necessary, and there are no postoperative scars. We obtained success rates at longer follow-up comparable to those previously described at 6 months. USGS of perforators should be considered as a valid alternative when treating symptomatic patients with incompetent perforating veins as outpatients or during saphenous vein ablation.