Our protocol uses a simple and easily available device to obtain excellent saphenous closure using NBCA plus MS.The advantage of this technique are simplicity, speed, and precision of use for an expert operator, Helping to demonstrate that the procedure will be Pier Luca Bellandi-Alberti. To begin, prepare the room and the operating table with all the required materials. Place the 5%dextrose solution into a bowl and immerse a three milliliter syringe, a 10 milliliter syringe, an 18 gauge needle, and either a one or two milliliter vial containing NBCA and MS surgical glue in it.
Completely depilate the leg to be treated from the groin to the foot. Disinfect the leg to be treated with an alcoholic solution of 2%chlorhexidine digluconate. Then initiate the ecocolor doppler in the orthostatic and clenostatic positions by setting the instrument through the manufacturer's software, which provides various presets.
Position the patient up right on a step in front of the operator and map the entire venous vascular tree through the ultrasound probe. Map out the pathway of venous incompetence on the skin using a dermographic pen. With the patient placed in the supine position for GSV or prone position for SSV treatment, disinfect the leg again as demonstrated earlier and prepare the sterile field with a surgical drape.
Perform the ultrasound-guided study of the lengths and diameters of the veins to be treated. Place the patient in the clenostatic position and perform the vascular study through the ultrasound probe. Evaluate the reflux time with the ultrasound, which defines the degree of the incompetence of the terminal valve.
Carry out the severity classification by evaluating the Galeandro quartile. Using the ecocolor doppler, identify the junction between the epigastric vein and pre-terminal valve for the treatment of the GSV. Perform ultrasound-guided catheterization of the GSV or SSV according to the cell Seldinger technique 14 to 16 centimeters downstream of the relevant junction.
Percutaneously insert a 6 French vascular introducer into the vessel with the help of a guide wire. Under ultrasound guidance, place the tip of the introducer two to three centimeters from the bifurcation of the epigastric vein and pre-terminal valve for GSV treatment or two to four centimeters below the saphenous popliteal junction for SSV treatment. Draw one milliliter of NBCA plus MS surgical glue in one syringe for veins with a diameter between 8 to 10 millimeters.
For veins over 10 millimeter diameter, use two milliliters of NBCA plus MS surgical glue. Then draw 7 to 10 milliliters of 5%dextrose solution into another syringe. Connect the two syringes to the stopcock of the introducer's washing catheter.
Compress the leg with the ultrasound probe at the level of the bifurcation immediately downstream of the bifurcation itself to stop the blood flow in the saphenous vein. Flush the dead volume of the introducer with approximately two milliliters of dextrose solution. Close the dextrose solution inlet through the stopcock and inject one milliliter NBCA plus MS surgical glue.
Similarly, close the NBCA plus MS surgical glue inlet through the stopcock and inject the dextrose solution to push the surgical glue into the vein. Simultaneously, retract the introducer until it is remove to perform a retrograde release of the liquid, adhesive, occlusive, and sclerosing agent. Immediately perform manual compression with the palm, starting from the insertion site and along the course of the vein for three to five minutes.
At the same time, always keep the compression with the ultrasound probe at the level of the junction. At the end of the compression, raise the hand and verify that there is no bleeding from the insertion site. Perform an ecocolor doppler to check that there is no more blood flow in the saphenous vein and that the GSV is occluded for a length of approximately 10 centimeters.
Under ultrasound guidance, occlude the varicose collateral veins by direct puncture with polidocanol foam according to the normal and consolidated clinical practice for this treatment. Perform an eccentric compression of the saphenous axis with latex strips or rolls of gauze wrapping the leg from the groin to the knee. With the patient still in the clenostatic position, apply a class two compression stocking with an open toe.
90 patients with a mean age of 59.8 years were selected for this observational research. All patients had a reflex time of 10 seconds. 60 were in the second quartile, 24 were in the third quartile, and six were in the fourth quartile.
Of the patients, 66.7%needed two ampules of glue to completely fill the vessels. While for the rest, a single vial was sufficient to obtain a total vein occlusion. All patients obtained complete occlusion of the treated vein immediately after treatment.
Six patients showed a re-canalization of the vessel between one month to a year after treatment. However, none of the patients presented a re-canalization of the vessel more than 50%of its diameter and none showed blood reflux in the orthostatic posture. None of the patients were affected by post-surgical thrombosis.
No other adverse events occurred during the observation period. The resolution of leg pain was maintained for all the follow-up times and 70%of patients had a notable reduction of leg edema. All patients returned to their normal routine in two days and all restarted their work activity within one week post-treatment.
This procedure has paved the way for a simple and effective methodology. It could be of help in other areas of vascular surgery where rapid and precise vascular occlusion is required.
