Impact of a new maneuver on foam sclerotherapy for the treatment of large varicose veins with a one-step approach

Abstract

BACKGROUND: The maneuver is useful to increase the result of ultrasound guided foam sclerotherapy for large varicosities. It consists of performing vigorous rubbing on the skin overlying the varicosities selectively, using the knuckles of the fingers of the right hand. Baraldi’s Maneuver causes locally an initial and progressive increase in the pain evoked on the patient which favors increasing and complete action/adhesion of the sclerosing agent on the venous endothelium, partially damaged by the physical trauma. This is significant because this new maneuver allows treatment of varicose veins of long extension in a single time, reducing the impact to the patient. This study assessed the outcomes and impact on the Baraldi’s maneuver following one-step outpatient ultrasound guided foam sclerotherapy (UGFS) for large varicosities of tributary saphenous veins and extrasaphenous veins.METHODS: The study is retrospective on 1800 symptomatic patients (1083 women, 717 men) having reflux in the saphenous tributaries varicosities (CEAP C3 to C6) and extrasaphenous veins were treated with UGFS (with Polidocanol 0.5-1.0%), in a single-step procedure, from September 2015 to December 2023. The patients were divided into two homogeneous groups: the first group (A) treated with UGFS and Baraldi’s Maneuver, the second group (B) treated with UGFS without any maneuver. All patients were treated by UGFS of the varicose veins at the thigh and leg by practicing Baraldi’s Maneuver, which consists of performing vigorous rubbing on the skin overlying the varicosities selectively, using the knuckles of the fingers of the right hand. Baraldi’s maneuver causes locally an initial and progressive increase in the pain evoked on the patient which favors increasing and complete action/adhesion of the sclerosing agent on the venous endothelium. Selective compression, which is done using spiral-curled cotton gauze, was performed after US check, after treatment and each patient remained in the clinostatic position for at least ten minutes. All 1800 patients were followed up at 1 week, 1, 3, 6 months and 1 year. Clinical outcomes, changes in the quality of life (QoL) questionnaires, Venous Clinical Severity Score (VCSS) and Aberdeen Varicose Vein Questionnaire (AVVQ), evolutive vein occlusion rates were assessed by duplex ultrasound.RESULTS: In both groups, the diameter of the treated vessels ranged from 7-12 mm. Baraldi’s Maneuver from the study performed is effective on all patients, immediately promoting obliteration of the vessel, allowing to have better sclerofoam action/adhesion determining mechanical damage, added to chemical damage, evidenced at the ultrasound check performed immediately after the maneuver itself and prior to selective compression. No major adverse event was observed, and the postoperative minor adverse event rates were similar between the two groups. A significant improvement was observed in VCSS and AVVQ from the preoperative levels to the third month, six months and one-year follow-up. The entire sample had a significant increase in all groups but in group A the overall first week occlusion rate was 97.9% and 96.7% at the 1-year follow-up. Group B differently showed from the first week an occlusion rate of 80,1% and 77.9% at 1-year follow-up. No skin complications such as burning or eschar occurred on all patients; only 2 patients of group A and 3 of group B required evacuation of an endovascular thrombus at the first postoperative checkup. Inflammatory-based hyperpigmentation (dermatitis) occurred on only 12 patients, four on group A, eight on group B).CONCLUSIONS: Exclusively outpatient, Baraldi’s maneuver from the study performed is safe and feasible with no major adverse events, despite the large diameters of the veins treated; indeed, particularly in the group A the Baraldi’s maneuver is effective on all patients, immediately promoting obliteration of the vessel, checked by US. Within 1 year, it showed an improvement in all QoL parameters and satisfactory veins occlusion.