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.

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.

According to literature data, up to 59% of incompetent great saphenous veins (GSV) have no reflux at the terminal valve (TV) of the saphenofemoral junction (SFJ). The aim was to compare color duplex ultrasound (CDU) investigation and direct intra-operative assessment of competence of the TV at SFJ.A prospective comparative study was performed on 28 patients, who consecutively presented for surgical intervention for their primary varicose veins of the lower limbs with GSV incompetence. CDU assessment was performed pre-operatively to define GSV and SFJ terminal valve morphology and hemodynamics. Under local anesthesia these patients underwent SFJ disconnection (crossectomy) and segmental inverted saphenous stripping of the incompetent GSV tract + phlebectomy of the varicose tributaries. SFJ disconnection was performed in four stages in an ascending fashion: I) division of GSV below the lower SFJ tributaries, II) disconnection of lower SFJ tributaries, III) disconnection of upper tributaries, IV) flush to CFV ligature of GSV stump. After the completion of stage I, the SFJ stump was opened and kept open when needed throughout the subsequent stages, in order to highlight any possible blood leak through the SFJ stump. To highlight intraoperative blood leak from SFJ stump visual observation was carried out both during respiration and when performing Valsalva maneuver and manual compression of homolateral iliac fossa.As to pre-operative CDU all limbs showed GSV reflux and they were divided in two groups according to TV competence (group A) or incompetence (group B). Group A comprised 18 patients (6 M and 12 F), mean age 50.6 years.Group B included 10 patients (4 M and 6 F), mean age 54.8 years. Mean calibre of GSV at proximal/mid thigh was 6.4 mm in group A and 7.8 in group B. Concerning the intra-operative findings: in the group A, 5 patients had blood leak in the SFJ stump after stage I, 4 patients showed blood leak after stage II. After completion of stage III, only one severely obese patient had persistent reflux, whereas 17 patients had no reflux. Conversely the 10 patients from group B had reflux within GSV stump throughout the 3 stages.CDU pre-operative assessment matches intra-operative findings with regards to GSV TV competence/incompetence, with a good overall accuracy (27/28-94%). Different SFJ retrograde flow patterns should be elicited through CDU investigation. Obese patients need a more thorough CDU examination to avoid false negatives.