Journal of Angiology & Vascular Surgery Category: Medical Type: Brief Short Reports

Endochemical Venous Ablation with Foam Prepared with Pure Oxigen, Excellent and Easy Alternative

Fernando Vega Rasgado1, Felipe Rendón2, Eugenio Jiménez1, Lourdes Amable Vega Rasgado3, Víctor Carmona4, Italia Robles4 and Gloria Reyes4
1 Department Of General Surgery, Instituto Mexicano De Flebología, Ciudad De México, Mexico
2 Department Of General Surgery, Instituto Mexicano De Flebología, Colegio De Medicos Cirujanos J.R. Tournay, Ciudad De México, Mexico
3 Department Of General Surgery, Colegio De Medicos Cirujanos J.R. Tournay, Environmental Systems Engineering-ENCB-IPN, Ciudad De México, Mexico
4 Department Of General Surgery, Clínica De Varices Y Ulceras De México, Ciudad De México, Mexico

Received Date: Jun 20, 2019
Accepted Date: Jul 29, 2019
Published Date: Aug 05, 2019

Abstract

Sclerotherapy with Polidocanol Foam prepared with room air causes some side effects which can become dangerous. In order to decrease or even avoid such adverse effects, the Foam with pure oxygen was prepared. The study was approved by the ethics committee, with the informed consent of the patients. The sclerotherapy was made with polidocanol Foam prepared with the gas-liquid proportion of Tessari's method. Two groups were formed, one was treated with polidocanol-room air foam and the other with polidocanol-oxygen foam, which used pure oxygen (O2) n instead Room air (Ra). No special exclusion criteria between groups.

Results
Patients = 1300, adverse effects: Cough (0.15% O2, 3.7% Ra), Dizziness and migraine (0%, O2, 0.53% Ra), Visual disturbances (0%, O2, 0.13% Ra), Back pain (0%, O2, 0.73% Ra). The effectiveness of treatment was the same in both groups, but the Foam prepared with oxygen had better performance. Although Dr.Frullini has demonstrated that endothelin is the cause of the neurologic side effects, the use of physiological gases can prevent most of the undesirable’s effects of the sclerosing Foam. In conclusion, Foam sclerotherapy performed with Oxygen is a good option to reduce or even prevent adverse effects of polidocanol, easy to performance and with better stability in the Foam.

Keywords

Endochemical Venous Ablation; Sclerotherapy; polidocanol-oxygen foam

INTRODUCTION

Sclerotherapy is a technique that has rapidly spread throughout the world, especially because it is ease and economic [1]. Liquid sclerosis has been reserved for telangiectasias and reticular veins whereas that FOAM has become more important for large trunks [2]. The study of sclerosis with FOAM has extended not only for the quality of the sclerosant agent but also because of the way that bubbles interact with the venous endothelium. The formula TP = ¼ r2 d / 2D Sf (where TP is the time of persistence of the bubbles, r the radius of the microbubbles, d the density of the gas inside the microbubble, D the diffusibility of the gas through the membrane of the microbubbles and Sf the saturation factor of the gas in the blood, summarizes the most important factors that interfere with the time of the bubbles stability [3]. Sclerotherapy may require several sessions, especially when there is an abundance of telangiectasias in legs and thighs, therefore the application of high volumes would be necessary. CO2 bubbles are 50 times more diffusible than nitrogen bubbles through the endothelium of the venous capillary and the membrane, thus the use of CO2 provides greater diffusion in the blood compared to oxygen. In another hand, the mixture of CO2 and O2 produces smaller bubbles. Experimental and clinical studies with polidocanol bubbles show a clear reduction of the size of the microbubbles with CO2 but its half-life decreased significantly. When CO2 and O2 were combined, the average life of the bubbles increased markedly and the diameter decreased compared with room air [4]. In a study conducted by Dr. Nick Morrison, sclerosant Foam in volumes of 2 to 42 ml was injected, with an average of 17.5ml (± 7.8ml) for the mixture CO2-O2 and 17ml (± 9ml) for room air [5]. Dr. Morrison also reported on the use of CO2 as the only gas to prepare the foam, succeeding in reducing the complications [6]. In 2009 we started a study on post-sclerotherapy complications using pure oxygen to prepare the polidocanol Foam reporting the first results at the Phlebology Congress in Mexico in 2010. We found that the concentrations and volumes used were to much higher than those we currently use. The results so far have been good [7].

METHODS

From 2010 to 2017, 1,300 patients without distinction of sex or age were injected with oxygen Foam and were compared against 1,500 patients who were injected in the office with room air. Polidocanol foam in different concentrations using only pure oxygen as a gas was used prepared with the Tessari technique using a three-way stopcock (1ml of liquid and 4ml of oxygen) [8]. With this Foam different sizes of veins were injected from telangiectasias to saphenous trunks in different volumes. It was done in the operating room with monitoring of Electrocardiography, Oximetry and vital signs for high volumes. After the procedure, the patient was released to the recovery room where was monitored for 3 hours and then were discharged to home. The subsequent control visits were once a week, monthly and after a year. The side effects of polidocanol were evaluated and compared with those of patients injected under the similar conditions with room air. The study was approved by the ethics committee and was performed with the informed consent of the patients (Figure 1).
 
Figure 1: Way to connect the tube from the oxygen tank to prepare the foam.

RESULTS

The sample general description is in tables 1,2. The FOAM prepared with pure oxygen was more stable than that prepared with room air and increased the duration of the bubbles, it was also a little brighter.

 

Oxygen group (1,300)

Room air group (1,500)

Age (mean)

54 years

(28-80 y)

60

(26-82 y)

Male

32%

416 p

28%

418 p

Female

68%

884 p

72%

1082 p

Size

1.6 m

1.43-1.72

1.56 m

1.40-1.83

Weight

71 Kg

43-120

75 Kg

45-125

Right

68 %

884 legs

58.4%

876 p

Left

76 %

988 legs

41.6%

624 p

Volume (mean)

14 ml

3-60 ml

2.8 ml

1-15 ml

Concentration (mean)

1.5%

(0.5-3)%

1.5%

(0.5-3)%

Table 1: General description of the population.
 

Veins

Varicules

Magnus Saphena

Accessory saphena

Cockett I

Cockett II

Cockett III

Boyd

May perf.

Giacomini

Hunter

%

74

16

10

30

12

7.5

42

17

8

10

Patients

2,072

448

280

840

336

210

1,176

476

224

280

Table 2: Veins more frequently affected.

The side effects were practically eliminated and although at present it is not necessary, different volumes were applied having a maximum volume of 60 ml of Foam with average of 14ml.

The veins injected were the following:

In the Oxygen group there were no side effects, in the room air group there were minor side effects. The effectiveness of the treatment was the same in both groups. We had not secondary neurological effects (Table 3).

Side eeffects

Cough

Dizziness and migraine

Transient blindness

Back pain

Faiting

Patients

Room air

56 (3.7%)

8 (0.53%)

2 (0.13%)

11 (0.73%)

2 (0.13%)

1500 (100%)

Pure oxygen

2 (0.15%)

0

0

0

0

1300 (100%)

Table 3: Side effects after injection of polidocanol at different concentrations, Foam prepared with pure oxygen and room air with Tessari technique.

DISCUSSION

For a period the enthusiasm for applying high volumes was generalized, but in recent years this has changed since some neurological problems derived from sclerosing injection have been reported [9,10]. Minor effects have also been reported and studied such as visual disturbances without attributing the effect to the gas used but to the vasoconstrictor effect of endothelin [11]. The stability of the Foam is very good with mixed CO2 and O2, Dr. Morrison reported a decrease of side effects using CO2 to prepare the sclerosing Foam [5].

Dr. Frullini and Cols. demonstrated that endothelin is the cause of neurological side effects [12]. We know that the use of physiological gases reduces significantly the side effects, which may be due to some special interaction of nitrogen with the endothelium, which does not occur when CO2 or Oxygen is used [13]. Especially the prevention of neurological effects justifies the use of oxygen as a way to prevent easily these events. Beckitt et al. used a mixture of O2 and CO2 foam with physiological gases to prevent effects such as thrombophlebitis [14]. Although our series are small we must continue the use of physiological gases to prepare foam. It is believed that oxygen is more accessible than CO2, since it is a gas commonly used in doctors’ offices and hospitals. Likewise the Central Nervous System works better with Oxygen than with CO2 and if there are bubbles in some important area, it could be a factor for having or not neurological effects due to transient hypoxia. The duration of the foam with Oxygen is greater than with room air and it is an advantage when working with endovenous chemical ablation (sclerotherapy). More research is needed, although there is sufficient evidence that physiological gases are better than ambient air [15].

CONCLUSION

Sclerotherapy with Foam prepared with O2 is a good alternative ahead to prevent or diminish the adverse neurological effects and if necessary, allows the injection of large volumes of Foam with safety. This foam is easy to prepare in any medical office, is not expensive and offers longer duration in its stability for the treatment of sclerotherapy, so we strongly suggest its use.

REFERENCES

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Citation: Rasgado FV, Rendón F, Jiménez E, Rasgado LAV, Carmona V, et al. (2019) Endochemical Venous Ablation with Foam Prepared with Pure Oxigen, Excellent and Easy Alternative. J Angiol Vasc Surg 4: 025.

Copyright: © 2019  Fernando Vega Rasgado, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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