GSV treatment by means of CFS and adjuvant PST + ISI, combined with phlebectomy of varicose tributaries, proved to be safe and effective in terms of clinical and duplex based outcomes at short/mid-term follow-up.

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Re: 'Catheter-directed Foam Sclerotherapy of Great Saphenous Veins in Combination with Pre-treatment Reduction of the Diameter Employing the Principals of Perivenous Tumescent Local Anesthesia' We read with interest the article by Devereux et al. 1 The authors report no benefit in terms of venous occlusion using peri-saphenous ultrasound guided tumescence infiltration (UGTI) in addition to long catheter foam sclerotherapy (LCFS) of great saphenous veins (GSV). The positive role of tumescence in foam sclerotherapy, to decrease vein size, blood content, and inflow in the target vein, has been highlighted previously. 2,3 At the 2012 EVF meeting, we presented a prospective comparative study, which demonstrated better outcomes when UGTI was added to LCFS of the GSV 4 (82.4% occlusion rate after 14 months vs. 71% in patients treated without UGTI). Firstly, the authors acknowledge adrenaline was not included in the tumescent solution (because of legal issues). In our experience with UGTI, adding a vasoconstricting agent increases and prolongs GSV calibre reduction, and this may explain our own better outcomes. Furthermore, the statistical value of the study is possibly biased by the quite small number of patients and by the five patients (20%) and two patients (8%) not available for 12-month follow-up in the non-UGTI/UGTI groups, respectively. We acknowledge that the positive effect of adding tumescence to foam sclerotherapy has to be validated through future studies on larger cohorts.

A prospective comparative observational study was performed to assess the short--term efficacy and safety of the peri-saphenous infiltration of tumescence solution (PST) in great saphenous vein (GSV) long catheter foam sclerotherapy (LCFS) combined with phlebectomy of the varicose tributaries. Since November 2006 through November 2010 fifty-one consecutive patients (16 males and 35 females, mean age 51.5 years) who underwent LCFS of GSV + multiple phlebectomies were prospectively enrolled, without any pre-selection criteria, in three different groups (17 patients per group) and reviewed as to their outcomes: i) patients without additional PST; ii) with PST under visual control; iii) with ultrasound-guided PST. All procedures were performed in local anesthesia and an average of 7 mL [interquartile range (IQR) 6.5-7.5] of 3% sodiumtetradecylsulfate CO2+O2-based sclerosant foam was injected in the diseased segment of GSV (median caliber 7) (IQR 6-8) by means of a 4F long catheter. Clinical and color-duplex ultrasound (CDU) follow-up was performed at regular intervals, the last of which 14 months after the treatment.At 14 months follow-up no varicose veins were visible in 94%, 94% and 100% of the cases in group I, II and III respectively. The CDUbased outcomes were the following: 71%, 71% and 84% GSV occlusion rate in group I, II and III respectively; reflux was found in 5, 4 and 1 cases in group I, II and III respectively. Clinical and CDU morphologic and hemodynamic results were assembled and scored through an arbitrary system. The relative statistical analysis showed a significant (P<0.0001) improvement of the results for patients who received ultrasound guided PST over the other two groups. No relevant complications were recorded in all 51 cases.GSV treatment by means of LCFS + phlebectomy of varicose tributaries proved to be effective and safe in this prospective observational study. The addition of ultrasound guided PST resulted in a significant improvement of GSV occlusion rate and of varicose vein clinical resolution.

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