At 2-year follow-up, UGFS was not inferior to surgery when reflux associated with venous symptoms was the clinical outcome of interest. UGFS has the potential to be a cost-effective approach to a common health problem. Registration numbers: NCT01103258 (http://www.clinicaltrials.gov) and NTR654 (http://www.trialregister.nl).

We used foam sclerotherapy in a 51-year-old man and a 33-year-old woman who had symptomatic varicose great saphenous veins and were otherwise healthy. Immediately after the initiation of treatment, transient scotomas developed in the man, and a migraine attack in the woman.On the basis of these observations, we decided to monitor by echocardiography the foam distribution during foam sclerotherapy in 33 consecutive patients with chronic venous insufficiency. The treatment in each patient was carried out according to European consensus guidelines. 2 Briefly, patients received a single injection of 5 ml of 1% polidocanol foam (air-to-liquid ratio, 4:1). The foam was injected with the patient's leg slightly elevated, while the saphenofemoral junction was manually compressed until full vasospasm occurred and blood-flow velocity in the great saphenous vein decreased to zero.In all patients studied, we detected foam microemboli in both the right atrium and ventricle between 45 seconds and 15 minutes after foam injection (Fig. 1A). In five patients, microembolism was also detectable in the left atrium and ventricle (Fig. 1B); however, neurologic signs did not develop in any of them. Careful echocardiographic examination of these five patients showed a right-to-left shunt through a patent foramen ovale. Because the neurologic symptoms observed in the two index patients could have reflected adverse effects of foam sclerotherapy due to a rightto-left shunt, we subsequently examined both patients by echocardiography and detected a patent foramen ovale in each.These findings suggest that foam-induced microembolism is a common phenomenon during foam sclerotherapy. The prevalence of patent foramen ovale, which can be a source of paradoxical embolism, is approximately 26% in the general population. 3 Still, serious neurologic symptoms after foam sclerotherapy, which include scotomas, migraine, and stroke, occur in only 2% or less of patients. 4,5 Thus, the findings in our cohort are in line with previous reports. Although the overall number of neurologic adverse effects during foam sclerotherapy might be underestimated, it appears that neurologic complications develop in relatively few patients with right-to-left shunts and foam microembolism.Nevertheless, we suggest that caution be exercised when foam sclerotherapy is performed in patients with a known patent foramen ovale and that patients with overt neurologic symptoms undergo an additional echocardiographic examination for the presence of a patent foramen ovale. Further prospective studies are needed to evaluate and confirm our observations.

In the treatment of primary incompetent greater saphenous veins, 3% polidocanol foam seems to be more effective than 1% polidocanol foam. The side effects were approximately similar in both groups.

In 15% of all patients, varicosis is caused by insufficiency of the small saphenous vein (SSV). In the past it was common to entirely remove the SSV by surgical procedure; however, recently minimally invasive techniques have taken over a significant number of varicose vein treatments. The aim of this paper is a review of the literature of all treatment modalities of the insufficient SSV. The search aimed to identify all papers published describing one or more treatments for SSV insufficiency. International literature databases were searched through for articles eligible for this review. Articles describing one or more treatment techniques for SSV insufficiency were eligible for this review. Also studies describing SSV as well as greater saphenous vein were included as long as they made a clear distinction in their results between the two groups. Studies were excluded if they did not use ultrasound examination to qualify outcome, as this is the golden standard to evaluate venous insufficiency. Seventeen articles were included in this review. Five articles on surgical treatment showed success rates varying from 24% to 100% (follow-up 1.5-60 months). Ten articles on endovenous laser ablation (EVLA) showed success rates varying from 91% to 100% (follow-up 1.5-36 months). Two articles on ultrasound-guided foam sclerotherapy (UGFS) showed success rates varying from 82% to 100% (follow-up 1.5-11 months). Statistical analysis showed a significant difference (P < 0.05) in success rate of 47.8% versus 94.9% for surgery and EVLA/UGFS, respectively. Most complications for all treatment techniques were mild and self-limiting. Rates of deep venous thrombosis were not described often and in the articles that mentioned it, varied from 1.8% to 3.5% (surgery) and 2.5-5.7% for EVLA. In the absence of large, comparative randomized clinical trials, minimally invasive techniques appear to have a tendency towards better results than surgery, in the treatment of the insufficient SSV.

In 1993, Borrone et al. described two Italian brothers affected by a syndrome of severe acne, mitral valve prolapse, dysmorphic facies, and Scheuermann-like changes of the vertebral column. Since then, no further cases have been reported. Here, we report on two Dutch brothers with many features suggestive of this rare syndrome.