Comment to: One-shot scleroembolization: a new technique for the treatment of varicose veins disease of lower extremities. Preliminary results by Viani MP, Viani GM, Sergenti J. Phlebology 2013, August 9 [Epub ahead of print].

Stefano Ricci

Abstract

Nine patients with reflux from the groin to the knee due incompetence of terminal and pre-terminal valves of GSV were treated. Caliber of the GSV at the SFJ ranged from 5.6 to 10 mm in standing position (mean 6.4 mm). CEAP classification was C2s, in six patients and C5 in three. An endovascular straight 5-French catheter was inserted at the knee in five patients while in the other four cases the great saphenous vein at the knee was isolated surgically. Under echography control one standard platinum coil (0.03500 Fibered Platinum Coils Boston Scientific), 1 mm wider than the caliber of sapheno-femoral junction was then placed 1 cm below the origin of the epigastric vein, causing the prompt occlusion of the terminal portion of the great saphenous vein. A foam injection with lauromacrogol 2% was successively performed through the catheter under echography control, with foam volumes ranging from 4 to 8 cc. The leg was then compressed with an eccentric elastic bandage and the patient was recommended to stay in bed for 30 min; all patients were discharged after a short medical observation (mean time 5 h), maintaining the compression till the following day and changing to stockings class I for the following 15 days.
Occlusion of the great saphenous vein trunk was immediately obtained in all patients; no perioperative complications have been observed. Mean follow-up was three months, occlusion being present in 8 out of 9 patients (one was re treated with foam). No migration of coil or compression of the common femoral vein was registered at three months’ US follow-up.
Costs are significantly lower when compared to other endoluminal techniques, (radiofrequency, LASER or other minimally invasive mechanical treatments), the average cost of a coil being 120 US dollars.

Comment by Stefano Ricci

This simple method (coil + foam) of achieving GSV occlusion is interesting employing simple non-expensive solutions, needing neither high technology nor a surgical setting. The only uncertainty is related to the possible unwanted mobilization of the coil. Although using a coil wider than the GSV caliber, it is not well established what will the behavior of the tool, especially when if GSV is dilated or funnel shaped, considering that the flow direction is toward an increase of caliber, instead toward e smaller caliber, like the normal conditions of coil placement is. Naturally, the foam injection has a fixing function, but it would be interesting to state if the coil alone could be blocked in place. If confirmed, it could become an interesting method of achieving GSV segmental blockage in a perspective of GSV stem sparing philosophy (similarly to CHIVA or isolated junction ligation).

Reply by the Authors

I believe that the only actual risk of the procedure is the accidental release of the coil in the common femoral vein. Therefore, one-shot scleroembolization has to be performed by a phlebologist who is skilled in endoluminal techniques. For the same reason, during the learning curve I believe it is safer to use controlled-release coils, which are safer, although more expensive.
In my opinion, an unwanted mobilization of the coil could happen only if you release a coil with a diameter that is smaller than the one of the saphenous vein.
I agree that there are some limitations due to sapheno-femoral junction morphology as you pointed out in your comment, such as a funnel shaped saphenous veins or an aneurysm of the sapheno-femoral junction. In these cases, this technique should not be used.
Anyway, in the majority of patients, if the coil is released properly, there is a minimal risk of mobilization. In fact, the coil diameter is larger than the saphenous caliber. Moreover, you should also consider that the coil is released in a saphenous vein in which the flow is inverted in standing position, due to the incompetence of the terminal and preterminal valves. Therefore, in theory in lying position blood flow is towards the sapheno-femoral junction, but venous pressure in the saphenous vein is very low and cannot displace the coil, while in standing position the coil would not be displaced towards the sapheno-femoral junction, but towards the foot, due to flow inversion.
Foam injection has not a fixing function, but it is used to occlude all the shaft of the saphenous vein, as in traditional sclerotherapy. Therefore, One-shot scleroembolization could also be performed according to CHIVA principles. Nevertheless, the more coils are used the more expensive the procedure becomes.
As I stated in the article, the coil placement allows using less foam, reduces the passage of foam in the deep circulation and grants a more efficient closure of the sapheno-femoral junction.
In conclusion, we need to consider the coil as the endovascular evolution of the surgical knot.

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