Dr. Milleret Rene

Prof. Dr. Rene Milleret
Clinica Venart, Cluj-Napoca, România
Membru al Academiei Naționale de Chirurgie

Recurrences after foam ablation of saphenous trunks

Authors: R. Milleret, Z. Galajda
Medical Center SanConfind Poiana Campina, Romania

Ultrasound guided foam sclerotherapy is a safe and inexpensive technique for closing incompetent Saphenous trunks.
Medium term results show a re-opening rate of 25 to 35%, while thermal techniques: Laser and Radio-Frequency only re-open in 5 to 10 % of patients.
How can we improve these results?
2 parameters are important for the success of sclerotherapy: time of contact of the foam to the vein wall, and removal of blood in the lumen, as blood proteins inactivate the sclerosing agent.
Another issue is the depth of penetration of the sclerosant: without adjunctive manoeuvres, it is limited to 300 microns, enough to destroy the endothelium, but not to damage the media, which is necessary to obtain a retraction of the vein wall.
Over the last 25 years, many techniques have been tested in order to improve the long- term closure rate.
2 trends are possible: improve the delivery of foam, or add another ablation method: hybrid technique.
Foam delivery: Instead of a single needle puncture, we can use several Short Catheters: Venflon®, one every 10 cm. These staged injections avoid dilution and inactivation of the foam in blood. But the time of contact is not significantly improved.
Long catheter delivery is often combined by external compression f the vein to remove as much blood as possible. This can be obtained either by global compression of the limb with an Esmarch bandage: Alpha-Technique, or by intra-fascial tumescence, as when performing laser ablation.
Our 3 years results after Alpha-Technique confirm the improvement with 85 % of veins still closed.
Recently a specific catheter was introduced: the Sclero Safe device. Its double channels allow simultaneous injection of foam and removal of blood.
First results are good, but long term closure rate ate not available yet.
Hybrid techniques: Frullini studied heating of the vein at 60 °C with a Holmium laser combined with foam injection: this method was supposed to avoid tumescent anesthesia around the vein, which is necessary with conventional laser procedures. It did not become popular because the cost of the laser and its fibers was too high. More recently Carlos Boné used a 1940 nm laser at low powzer: 3 watts, again combined with foam injection with promising short term results.
MOCA: mechanical and chemical ablation was invented by Michael Tal and Steve Elias; They introduce in the vein a long catheter with a rotating tip driven by an electric engine to ablate the endothelium, combined with an injection of liquid sclerosing agent or foam. This Clari- Vein® catheter has been used in thousands of patients and long-term results are good in trunks up to 8 mm of diameter.
A non-mechanical option is the Phlebogrif® catheter which deploys several metal struts to remove endothelium, while injecting foam.
Conclusion: these different options do improve the closure rate but it is still inferior to what is achieved with thermal techniques, and the cost can be similar. Alpha-technique and probably the most economical way to achieve better results at a reasonable cost.

Scurt CV

Member of Académie Nationale de Chirurgie
Dr. Milleret is a vascular surgeon with a training in electronics.
He built his own Doppler machines since 1971 and used them to develop new techniques in Phlebology.
He performed the first deep vein valvuloplasty in Europe (1978), introduced Cryo-fibrosis
And Cryo-stripping for ablation of Saphenous trunks. When endovenous surgery appeared he devised a Steam Ablation technique which allows thermal ablation of tributary veins perforators.
His current research is focused on Transcutaneous Ultrasonic methods to treat refluxing veins Non-invasively, and on Prosthetic venous valves for deep venous insufficiency.