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Veins and Lymphatics 2023 [online ahead of print]
To cite this article:
Lorenzo Tessari, Mirko Tessari. Foam-glue syringe: a novel combined echo-guided endovascular treatment. Veins and Lymphatics.
2023;12:11594. doi:10.4081/vl.2023.11594
©The Author(s), 2023
Licensee PAGEPress, Italy
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Foam-glue syringe: a novel combined echo-guided endovascular treatment
Lorenzo Tessari, Mirko Tessari
Tessari Studi Legs Medical Institute, Peschiera del Garda, Italy
Corresponding author: Mirko Tessari, via Oscar Righetti 2, 37019 Peschiera del Garda, Italy.
E-mail: mirko@tessaristudi.it
Key words: glue, foam, sclerofoam, sclerotherapy, varicose vein.
mailto:mirko@tessaristudi.it
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Background
I would like to begin this introduction by describing what Bassi called the "mixed method".
The "mixed" or "combined" method of treatment aims to use surgery and sclerosis only to the best of their
respective aptitudes and at the same time to take advantage of the functional restoration capabilities of the residual
varicosities. The aim of combining the two techniques was to allow one technique to partially or totally annul the
limitations or defects of the other.1,2
Bassi said: “the advantages of the mixed method are numerous, important and varied”. Physiopathological
advantages first of all, limiting stripping to the proximal vein tract allows avoiding unnecessary venous sacrifice,
as it has been demonstrated that the distal segment of the internal saphenous vein is not insufficient in the most
advanced cases sclerotherapy, for its part, is greatly facilitated by the preliminary suppression of ostial reflux, so
that the process of fibrous transformation of the injected varices takes place in the best possible way.1,2
In this way Bassi argued for the necessity of combining surgery and sclerotherapy, limiting the former to the
closure of the leakage points or so-called compartment jumps and the latter to the cleaning of the limb of all
residual varicosities after closure of the leakage points.
This principle later became the basis of the Conservatrice Hemodynamique de I'Insuffisancie Veineuse en
Ambulatoire (CHIVA) method/philosophy3 wonderfully decribed by Claude Franceschi that will lead us all to
perform our treatments on the guidance of a meticulous haemodynamic examination, and in respect of the venous
haemodynamic of the lower limbs.
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Nowadays, the application of the mixed method can be found in the techniques known as MechanOChemical
Ablation (MOCA) and the latest Sclero Foam Assisted Laser Treatment (SFALT), which uses the combination
of laser and sclerofoam.
Based on these premises, we fully agree on the need for conservative haemodynamic phlebological therapy for
varicose veins of the lower limbs with the characteristics of: i) invasiveness reduced to a minimum; ii) no use of
operating theatres; iii) ltrasound control of the therapeutic act; iv) easy repeatability and correctability; v) perfect
compliance with CHIVA haemodynamic standards.
I had the idea of building a device "syringe for successive injection of substances" with which it is possible to
replace the series of ligatures proposed by C. Franceschi with this device, which combines the advantages of
sclerofoam and glue with an extremely simple act, without the use of operating room, without anaesthesia, and
with a simple act under ultrasound guidance.
It is therefore possible to perform all the CHIVA manoeuvres listed above for a haemodynamic conservative
therapy of the superficial venous system (interruption of the leakage points and fragmentation of the haematic
column).4 The synergy between two well-known and established therapeutic methodologies lies in the symbiosis
of the two techniques, one correcting the limitations and errors of the other in an easy and practical outpatient
therapeutic procedure. CHIVA is a strategy and not a technique. So advanced technology may permit to perform
CHIVA with more sophisticated and less invasive techniques.5,6
Let us now list the merits and limitations of each technique performed individually and the advantages of
symbiosis (Table 1).
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The symbiosis between the two procedures only creates advantages because: i) the echogenicity of the foam
allows an act as precise and safe as a phlebography; ii) the aspiration of blood into the syringe does not create
polymerization of the glue as this is only injected after the foam; iii) the spasm that the foam generates eliminates
the need for compression after glue injection; iv) no need for anaesthetist nor operating room.
The above allows us to treat the leakage points, the so-called compartment jumps, and the splitting of the varicose
blood column in accordance with the CHIVA rules written by C. Franceschi with a simple, easy and ambulatory
act.
Materials and Methods:
The preparation of the sclerosing foam needs no further explanation, I will however summarise some key steps:
Two 5 ml syringes with little or no silicone are used, joined together by a three-way tap with, in my modus
operandi, a 2-micron filter in between, which allows the foam to be homogeneous; in the first syringe, 1 ml of
drug (3% sodium tetradecyl sulphate or 3% polyethoxydodecane) is sucked in; in the second syringe, 4/5 ml of
air or biocompatible gas CO2 + O2 or air alone is sucked in; about 20 passes are made between one syringe and
the other, and the foam is ready to be injected.7-12
The cyanacrylate glue is drawn into a second 2ml syringe. Some glues are very viscous and therefore requires a
needle no smaller than G21 to be injected. Syringe and needles can be pre-washed with glucosate solution if
necessary, for some glues.13 There is currently an Italian glue composed by n-butyl 2 cyanoacrylate (NBCA)
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monomer plus Methacryloxy-Sulpholane Monomer (MS) that does not need this procedure as it has a density
similar to water.14
After having used the various types of glue offered by the American and Turkish markets (Cases 1-3), with the
various limitations that the products had excessive viscosity, delayed polymerization, the need to pre-wash
needles and syringes with the glucose solution, I started using an Italian glue (Case 4) NBCA + MS. It is a very
fluid product, not need pre-washed with glucosate solution, it is well distributed inside the vessel, polymerizes
rapidly in the release zone and therefore can be used in small quantities.
Once the foam has been prepared with the 5 ml Foam Glue Syringe, the 2 ml syringe pre-filled with the glue to
be used and its G21 needle, 16 mm short, is inserted into the syringe's perforated plunger (Figure 1, Figure 2).
Under ultrasound guidance the perforant or the compartment jump to be treated is identified, the chosen foam is
injected, immediately the spasm is observed with the complete gluing of the vein itself, at this point the glue
syringe is advanced into the foam-glue syringe so that the needle of the 2 ml syringe pierces the rubbery diaphragm
of the first syringe. You can then inject the glue at the precise point where you want the closure of the compartment
jump with the certainty that since the vein walls are firmly clamped on themselves for a period of 15/20 minutes
you will have a perfect bonding of the walls themselves without any need for external compression (Figure 3).
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Clinical cases
V. R., male, 65 years old
2008 left internal saphenous vein varicophlebitis, the haemocoagulative genetics check showed
hyperhomocysteinemia (MTHFR heterozygosity), in the same year the left internal saphenous vein was
deconnected from the femoral to saphenous vein, subsequently due to the appearance of scotomas after
sclerotherapy with foam, patency of the foramen ovale was diagnosed.
On December 17th, 2020, check-up shows marked incontinence of Boyd's perforant on the left. It is therefore
decided to proceed with joint foam-glue therapy at the same time (Figure 4).
With the Foam-Glue Syringe 5ml of foam Sodium Tetradecyl Sulfate 3% is injected followed by 0,5 ml of glue
(n-BCA-polymer).
The patient was monitored for 2 years and half from the start of the foam-glue treatment. The follow-up
highlighted the elimination of the reflux in Boyd's perforator (Figure 5).
F. M. T., female, 65 years old
In 1990 the patient underwent a left internal safenectomy with multiple varicectomies and ligation of left gluteal
perforant. On December 7th, 2020, during the ECD examination, a perforant incontinence of left thigh of gluteal
origin was found, above the scar from a previous ligation (Figure 6).
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With the Foam-Glue Syringe 5ml of foam Sodium Tetradecyl Sulfate 3% is injected followed by 0,5 ml of glue
(n-BCA-polymer).
The patient was monitored for 2 years and half from the start of the foam-glue treatment. The follow-up
highlighted the elimination of the reflux in gluteal perforant. (Figure 7)
F. M. T., female, 65 years old (the same patient of Case 2, but in a different reflux point)
In 1990 the patient underwent a left internal safenectomy with multiple varicectomies and ligation of left gluteal
perforant. On February 26th, 2021, during the ECD examination, a perforant incontinence of left thigh of Thiery
or perforating popliteal fossa was found (Figure 8).
With the Foam-Glue Syringe 5ml of foam Sodium Tetradecyl Sulfate 3% is injected followed by 0,5 ml of glue
(n-BCA-polymer).
The patient was monitored for 2 years from the start of the foam-glue treatment. The follow-up highlighted the
elimination of the reflux in Thiery’s perforant (Figure 9).
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Figure 9. Follow up case 3. A) no reflux by ECD in gluteal perforant at 1 month. B) check at 6 months, no reflux.
C) check at 12 months, no reflux. D) after 24 months, no reflux in Thiery’s perforant.
C. R., male, 39 years old
For 2 years the patient has been reporting that he has a post-trauma varicose vein. The ECD examination reveals
a reflux of the atypical postero-lateral perforant of the left thigh (Figure 10).
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Figure 10. A) haemodynamic cartography by Ecocolordoppler (ECD). In red, the incontinent perforant vein. B)
leg area to be treated. C) reflux of perforant vein to the ECD investigation,
With the Foam-Glue Syringe 5ml of foam Sodium Tetradecyl Sulfate 3% is injected followed by 0,3 ml of glue
(NBCA + MS).
The patient was monitored for 2 years from the start of the foam-glue treatment. The follow-up highlighted the
elimination of the reflux in perforant vein (Figure 11).
Early Access Veins and Lymphatics
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Figure 11. Follow up case 4. A) foam-glue coaxial injection site. Note the hyperechogenicity on B-mode analysis.
B) check at 6 months, no reflux. C) check at 12 months, no reflux. D) after 24 months, no reflux in atypical
postero-lateral perforant vein.
Conclusions
We used the novel technique mainly on non-terminal perforators, which are very challenging both by using open
surgery and endovascular technique. Our preliminary results seem to suggest that this novel technique could be
also applied to classic GSV, SSV varicose vein, and maybe this could merit a clinical trial. However, it is
mandatory to respect the CHIVA indication for the treatment of the SFJ or just of the N2-N3 escape points.15,16
These first data from clinical cases are encouraging. After more than two years of follow-up, no adverse events
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and/or allergies were found. The venous symptomatology and the reflux were eliminated with a simple treatment.
A new revolution in the field of phlebology is born with this method. The combination of these two methods
creates a synergy that allows the phlebologist, under echo guidance, to treat any venous pathology in a simple
way and with a precise act and in line with the concept of a haemodynamic conservative phlebology of the
superficial venous system.
References
1) Bassi G. Compendio di terapia flebologica. Ed Minerva Medica 1990.
2) Bassi G. Varicose veins of Lower Members edition Doins 1967
3) Franceschi C. Theory and Practice of the Conservative and Hemodynamical Cure of Veinous in Ambulatory
Insufficiency Edition de l'Armancon 1988
4) Bellmunt-Montoya S, Escribano JM, Pantoja Bustillos PE, et al. CHIVA method for the treatment of chronic
venous insufficiency. Cochrane Database Syst Rev. 2021;9:CD009648.
5) Zamboni P, Mendoza E, Gianesini S. Saphenous Vein-Sparing Strategies in Chronic Venous Disease. Ed
Springer 2018
6) Gianesini S, Menegatti E, Zuolo M, et al. Short endovenous laser ablation of the great saphenous vein in a
modified CHIVA strategy. Veins and Lymphatics 2013;2:e21
7) Tessari L. New technique for obtaining sclero-foam. Phlebology 2000;53:129.
https://link.springer.com/book/10.1007/978-3-319-70638-2#author-1-0
https://link.springer.com/book/10.1007/978-3-319-70638-2#author-1-1
https://link.springer.com/book/10.1007/978-3-319-70638-2#author-1-2
Early Access Veins and Lymphatics
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The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries
should be directed to the corresponding author for the article.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that
may be made by its manufacturer is not guaranteed or endorsed by the publisher.
8) Tessari L. Frullini A. Cavezzi A. Sclero mousse with Fibro-vein® (bloom technique) new alternative practice
to sclerotherapy of varicose diseases. XXIIth Meeting European Society of Phlebectomy Brussels April 1, 2000
9) Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new sclerosing foam in the treatment of
varicose veins. Dermatol Surg. 2001;27:58-60.
10) Cavezzi A, Tessari L, Frullini A. A new sclerosing foam in the treatment of varicose veins: Tessari method.
Minerva Cardioangiol. 2000;48:248.
11) Cavezzi A, Tessari L, Rosso M, Cabrera Garrido A. Variables in foam sclerotherapy with Tessari method:
experimental data. Int Angiol. 2009;28:9.
12) Cavezzi A, Tessari L. Foam sclerotherapy techniques: different gases and methods of preparation, catheter
versus direct injection. Phlebology 2009; 24:247-51.
13) Parsi K, Roberts S, Kang M et al. Cyanoacrylate closure for peripheral veins: Consensus document of the
Australasian College of Phlebology. Phlebology. 2020;35:153-75.
14) Montanaro L, Arciola CR, Cenni E, et al. Cytotoxicity, blood compatibility and antimicrobial activity of two
cyanoacrylate glues for surgical use. Biomaterials. 2001;22:59-66.
15) Zamboni P. 2016: The year of Phlebological Olympic Games. Veins and Lymphatics 2016;5:6249.
16) P Zamboni et al. Great saphenous varicose vein surgery without saphenofemoral junction
disconnection, British Journal of Surgery. 2010;97:820-5.
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Early Access Veins and Lymphatics
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GLUE FOAM
Limits Advantages Limits Advantages
Complex use of the
device now in use
Perfect closure of the
treated segment
Foam dislocation due
to spasm effect
Extreme ease and
versatility of use
Immediate
polymerization of the
glue on contact with
the blood
Rapid stabilisation of
the treatment
Neutralisation of the
effect
High echogenicity,
which allows the
treatment to be
controlled like a
phlebography
Need compression to
bring the venous
walls closer together
(difficult for
compression of
muscle perforant)
Only one treatment for
that area
Production of a long
and power spasm
leading to venous wall
collapsing
no anaesthesia
no operating room
no anaesthesia
no operating room
Table 1. Limits and advantages of glue and foam during the single treatment.
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Figure 1. Foam-Glue Syringe.
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Figure 2. Foam glue syringe system ready for treatment
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Figure 3. Foam glue syringe system echo-guide injection.
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Figure 4. A) haemodynamic cartography by ecocolordoppler (ECD). In red, the incontinent perforant vein. B)
leg area to be treated. C) reflux of Boyd's perforant vein to the ECD investigation.
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Figure 5. Follow up case 1. A) no reflux by ECD in Boyd's perforant at 1 month. B) at 3 months no reflux. C)
check at 6 months, no reflux. D) check at 12 months, no reflux. E) after 30 months, no reflux in Boyd's perforant.
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Figure 6. A) haemodynamic cartography by ecocolordoppler (ECD). In red, the incontinent perforant vein. B)
leg area to be treated. C) reflux of perforant vein to the ECD investigation.
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Figure 7. Follow up case 2. A) no reflux by ECD in gluteal perforant at 1 month. B) check at 6 months, no reflux.
C) check at 12 months, no reflux. D) After 30 months, no reflux in gluteal perforant.
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Figure 8. A) haemodynamic cartography by ecocolordoppler (ECD). In red, the incontinent perforant vein. B)
leg area to be treated. C) reflux of perforant vein to the ECD investigation.