The Controversial Truth About Foam Sclerotherapy: Experts Clash in Heated Debate

As a consultant vascular surgeon, I've always been open to exploring new perspectives and challenging my own assumptions. Recently, I had the opportunity to engage in a truly stimulating debate with Christopher Pittman, M.D., FAVLS, FACR, FACP (Hon) a passionate advocate for #ultrasoundguidedfoamsclerotherapy , and it completely reshaped my understanding of this innovative treatment.

This in-depth post recounts my fascinating conversation with Dr Pittman, where we delved into the nuances of foam sclerotherapy, dissected controversial topics, and ultimately found common ground in our pursuit of better patient outcomes.

Join me as I recount the key takeaways from our debate and share how it has influenced my own approach to vein care.

1. A Provocative Introduction to Foam Sclerotherapy: The Pittman Method

Dr Pittman, an interventional radiologist with extensive experience in foam sclerotherapy, kicked off our conversation with a compelling presentation outlining his unique approach. He immediately challenged my preconceived notions by emphasising:

• Efficiency at Scale: Dr Pittman passionately argued for the use of mid-level providers, such as physician assistants and nurse practitioners, alongside ultrasound technologists to administer foam sclerotherapy. This model, he explained, allows for greater efficiency and accessibility to treatment, particularly in resource-constrained settings.
• Simplified Technique: He advocated for a streamlined technique, favouring 1% polidocanol foam with room air, small repeated injections, and freehand ultrasound guidance. This simplified approach, he suggested, is easier to learn and implement, potentially broadening the availability of qualified practitioners.
• Aggressive Treatment: Dr Pittman stressed the importance of achieving complete venous spasm during treatment, recommending multiple sessions and injecting partially closed veins to ensure comprehensive and durable results. This proactive approach, he argued, minimises the risk of recurrence and complications.
• Dispelling Fears: He directly challenged common concerns surrounding foam sclerotherapy, downplaying the risks of extravasation and deep vein thrombosis when proper techniques are employed. This demystification of the procedure aims to alleviate patient anxiety and encourage wider adoption.
• Patient-Centric Approach: Dr Pittman emphasised the importance of prioritising patient comfort and long-term vein health, advocating for ongoing maintenance treatments with foam sclerotherapy to address recurrent or new varicose veins. This proactive approach, he asserted, ensures continued relief and improved quality of life for patients.

2. Presenting My Counterpoint: A More Traditional Approach

In response to Dr Pittman's bold claims, I presented my own perspective on vein treatment, grounded in established guidelines and my experience as a surgeon. I highlighted the following key points:

• Hierarchy of Treatment: I advocated for a hierarchical approach to vein treatment, prioritising thermal ablation for truncal reflux, followed by foam sclerotherapy and phlebectomy for tributary veins. This stepwise approach, I argued, ensures that the most appropriate treatment is applied based on the individual patient's needs.
• Combined Approach: I expressed my belief in a combined approach to treat varicose veins comprehensively. I favour utilising both foam sclerotherapy and phlebectomy to address different types of veins and achieve optimal cosmetic and clinical outcomes.
• Emphasis on Compression: I stressed the importance of compression therapy, recommending eccentric compression and hosiery to minimise thrombus formation and promote healing after foam sclerotherapy. This conservative approach, I believe, helps reduce complications and improve patient comfort.
• Cautious Approach to SVT: I strongly cautioned against injecting foam into veins with superficial vein thrombosis (SVT). I expressed concern that this practice could increase the risk of complications, such as deep vein thrombosis and pulmonary embolism, particularly in patients who may be in a hypercoagulable state.

3. A Clash of Perspectives: Debating Controversial Topics

Our conversation evolved into a spirited debate as we delved into specific controversial topics, each of us presenting compelling arguments to support our positions:

• The Role of Phlebectomy: Dr Pittman argued that phlebectomy is an outdated and unnecessary procedure, believing that foam sclerotherapy alone can effectively treat all types of veins. I countered by highlighting the value of phlebectomy, particularly for larger veins, in achieving optimal cosmetic results and reducing the risk of complications.
• Managing Superficial Vein Thrombosis: Dr Pittman advocated for treating SVT with foam sclerotherapy, arguing that it can quickly resolve symptoms and prevent further complications. I expressed strong disagreement, emphasising the potential risks of injecting foam into an already inflamed vein and advocating for a more conservative approach.
• The Brittenden Study : Dr Pittman criticised a prominent study comparing foam sclerotherapy to thermal ablation, arguing that its methodology is flawed and misleading due to the allowance of adjunctive foam sclerotherapy in the thermal ablation arm. This bias, he asserted, undermines the study's conclusions and perpetuates misconceptions about the efficacy of foam sclerotherapy.
• Choice of Tools and Techniques: We engaged in a lively discussion about our preferred tools and techniques for foam sclerotherapy, including ultrasound guidance methods, foam concentrations, and compression strategies. Dr Pittman favoured a simplified approach with readily available materials and minimal patient discomfort, while I prioritised precision and control, utilising specialised equipment and techniques to optimise outcomes.

4. Finding Common Ground: Embracing Collaboration and Future Possibilities

Despite our passionate disagreements, Dr Pittman and I both recognised the value of open dialogue and the importance of collaborating to advance the field of vein care. Through our conversation, I came to appreciate the potential of foam sclerotherapy to address the growing burden of venous disease, particularly in underserved populations. I believe that a more balanced and evidence-based approach to treatment, incorporating the best aspects of both traditional and innovative techniques, will ultimately lead to better outcomes for our patients.

What are your thoughts?

This thought-provoking encounter has inspired me to continue exploring the potential of foam sclerotherapy and to critically evaluate my own practices in light of new evidence and expert opinions. I encourage my fellow healthcare professionals to join me in this pursuit of knowledge and innovation.

• What are your thoughts on the role of foam sclerotherapy in vein treatment?
• How do you navigate the evolving landscape of evidence and expert opinion in your own practice?
• What opportunities do you see for collaboration and innovation to improve vein care for all?

Share your insights and experiences in the comments below. Let's continue this important conversation on FOAM SCLEROTHERAPY EXPERTS and work together to shape the future of vein care.

#veintreatment #foamsclerotherapy