Introduction of Sclerotherapy

Sclerotherapy gained a reputation for lack of efficacy in the latter part of the 20th century, at least in part, thanks to the work of Hobbs. His 10-year randomized controlled study showed that the clinical recurrence of varices was common in patients with truncal saphenous reflux managed by sclerotherapy, as described by Fegan.

Hobbs found that after 10 years, 71% of patients treated surgically for truncal saphenous incompetence had a good outcome compared with only 6% of patients treated by sclerotherapy. Recent scientific evidence has shown that liquid sclerotherapy is not very effective at eliminating truncal saphenous incompetence and failure to achieve abolition of reflux leads to early recurrence of varices.

Advances in technology led to improvements in the practice of sclerotherapy. In the 1980s ultrasound was introduced for the diagnosis of venous disease of the lower limb. In France this led Schadeck and Vin to improve the efficacy of their treatment using ultrasound imaging to guide the placement of injections into incompetent saphenous trunks.

However, this treatment was not as successful as had been hoped. Bishop examined a series of patients in whom some legs had been managed by ultrasound-guided liquid sclerotherapy. He found that 57% showed residual saphenofemoral reflux and 75% of patients had great saphenous vein reflux. The problem of recanalization of veins was encountered in up to one-quarter of patients at one year according to Kanter and Thibault.

The next significant advancement came in 1995 when Cabrera et al. suggested that foam could be created using carbon dioxide mixed with a polidocanol, a detergent sclerosant. This invention built on the work of several previous authors who had experimented with various types of foam. Foote described a method of foam sclerotherapy in 1944.

Foote's method was improved by Orbach in 1950 who published a paper describing the use of a foam which he created by vigorously shaking a syringe containing air and sclerosant to produce a froth. Cabrera used sclerotherapy with foam, guiding his injections by ultrasound imaging. He called his invention ‘microfoam’, comprising very small bubbles in contrast to the large bubble froths that had been used previously.

Cabrera et al. published a further article describing his experience in legs with great saphenous varices and patients with vascular malformations. Some of the varicose veins reached 20 mm in diameter. He considered that foam greatly extended the range of vein sizes which could be managed by sclerotherapy. He felt that the increased efficacy of foam was attributable to it displacing blood from the treated vein and increasing the contact time between the sclerosant and the vein.

In the intervening years, several clinical series and one randomized clinical trial have confirmed that foam sclerotherapy is effective in managing truncal saphenous incompetence. Over the years, medical professionals and the general public have been showing greater interest in the development of plant medicines.

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