Mechanochemical Ablation Versus Ultrasound-Guided Foam Sclerotherapy of the Great Saphenous Vein

Introduction:

Ultrasound-guided foam sclerotherapy is a widely used method for the treatment of lower limb varicose veins. Its main advantages include applicability in patients at high surgical risk and immediate or early return to daily activities. However, it requires a higher number of reinterventions compared to other techniques due to increased rates of venous recanalization, particularly in larger-caliber veins. In contrast, mechanochemical ablation shares these advantages and is associated with lower recanalization rates.

Objective:

To compare ultrasound-guided foam sclerotherapy of the great saphenous vein (GSV) with mechanochemical ablation using the Flebogrif® catheter in the treatment of chronic venous insufficiency (CVI) associated with GSV disease. The primary endpoints will be quality of life assessment and GSV occlusion rate, as determined by lower limb venous color Doppler ultrasonography over the proposed follow-up period. Secondary endpoints include the incidence of treatment-related complications and pain level during the procedure.

Patients and Methods:

A total of 50 patients with primary varicose veins will be selected. Inclusion criteria include lower limb pain, edema, or skin changes such as hyperpigmentation, eczema, and lipodermatosclerosis (CEAP classification C2-C4, EpAsPr), as well as GSV insufficiency with a diameter between 6 and 12 mm measured at the mid-thigh using color Doppler ultrasonography. Clinical evaluations and ultrasound examinations will be conducted at the venous disease outpatient clinic, and procedures will be performed in the minor surgery operating room of the University of São Paulo Hospital.

This will be a prospective randomized study, with patients allocated into two groups according to the treatment technique.

Group 1: Percutaneous puncture and ultrasound-guided injection of sclerosant foam through a short 18G catheter.

Group 2: Use of the Flebogrif® catheter, positioned under ultrasound guidance 2 cm from the saphenofemoral junction, followed by catheter withdrawal combined with sclerosant foam injection.

In both groups, 20 mL of 0.9% saline solution will be infused prior to polidocanol administration. The GSV puncture site will depend on the extent of insufficiency (segmental or total), being performed at the knee or medial malleolar region, respectively, after local anesthesia with 2% lidocaine without vasoconstrictor and without infiltration along the venous course.

For knee-level puncture, a tourniquet will be applied distal to the access site and maintained for 5 minutes after foam injection to prevent dispersion into healthy venous segments.

In all patients, varicose tributaries will be treated immediately after the GSV procedure using 1% polidocanol sclerotherapy.

Expected Results:

Mechanochemical ablation is expected to demonstrate a higher target vein occlusion rate with lower recanalization rates, without increased procedural pain and with at least a comparable complication rate to ultrasound-guided foam sclerotherapy. This study aims to contribute to the refinement of treatment strategies, seeking greater efficacy with monotherapy.

Inclusion criteria

• CEAP Classification C2, 3 or 4
• Insufficient great saphenous vein measuring 6-12 mm in the mid-thigh on Doppler ultrasound.

Exclusion criteria

• Allergy to sclerosing substances
• Deep venous thrombosis, stroke, or pulmonary embolism
• Local or generalized infection at the sclerotherapy site
• Prolonged immobilization
• Asymptomatic patent foramen ovale
• Pregnancy Occlusive peripheral arterial disease