The History of Sclerosing Foams

The History of Sclerosing Foams 

JAN-CHRISTOPH G. R. WOLLMANN, MD 

Bad Kreuznach, Germany 

BACKGROUND. The use of foamed sclerosants in phlebology is 

undergoing a renaissance. The use of foam sclerotherapy was 

relaunched only a few years ago. Despite this, the early 

developments, pioneer findings, and improvements, especially 

in foaming techniques, are not widely recognized. 

OBJECTIVE. The objective of this study was to give an overview 

from the very beginnings of foam sclerotherapy until the most 

recent and progressive techniques, as described by Tessari or the 

double syringe system technique. 

RESULTS. The publications found after a thorough research for 

literature about foam sclerotherapy allow us to examine what 

has been invented between Orbach’s work in 1944 and now 

RESEARCH AND TRAVEL EXPENSES WERE PROVIDED BY KREUSSLER. 

THE USE of foamed sclerosants in phlebology is not 

new. Nevertheless, the worldwide use of this treatment 

was ‘‘relaunched’’ only a few years ago. The major 

national and international journals reflected the 

interest for this treatment option and for sclerotherapy 

in general, indicated by the increasing numbers of 

lectures or publications on this subject. They usually 

start with a reference to the ‘‘basic invention’’: the 

work of Egmont James Orbach in 1944. 1 Another 

frequently cited publication is the one by Juan Cabrera 

Garrido, who presented the results of his development 

in Spain in 1995. 2 A thorough research on literature 

about foam sclerotherapy revealed a series of highly 

interesting articles. They allow us to look at what has 

been invented between 1944 and 1995, and—surprisingly—even 

before 1944. Basically, the literature 

shows that remarkable work was carried out in the 

field of noncommercial foam sclerotherapy and that 

sclerosing foams have been used by numerous doctors 

continuously for the past six decades, especially for the 

treatment of varicose veins of the lower limbs. 

Results 

A time table gives an overview of the major achievements 

and developments of sclerotherapy with foam 

(Figure 1). The following is a presentation of the 

Address correspondence and reprint requests to: Jan-Christoph G. R. 

Wollmann, MD, Rheinstrasse 29, D-55543 Bad Kreuznach, Germany, 

or e-mail: jan-christoph.wollmann@kreussler.de. 

r 2004 by the American Society for Dermatologic Surgery, Inc. Published by Blackwell Publishing, Inc. 

ISSN: 1076-0512/04/$15.00/0 Dermatol Surg 2004;30:694–703 

and—surprisingly—even before 1944. The contributions of 

greatly reputed and also of unknown colleagues, such as Orbach, 

Sigg, Mayer, or Flückiger, are presented, giving a historical 

overview from the very beginnings of foam sclerotherapy until 

the most recent techniques. Basically, the literature shows that 

remarkable work was carried out in the field of noncommercial 

foam sclerotherapy and that sclerosing foams have been used by 

numerous doctors continuously for the past six decades, 

especially for the treatment of varicose veins of the lower limbs. 

CONCLUSION. The use of foamed sclerosing agents in therapy of 

large or small varicose veins is not new. It started as early as 

1939 and has continuously been improved in the past decades. 

individual authors and an attempt to show their 

respective contributions. 

1939—Stuard McAusland: 3 First Use of Froth in 

Telangiectasia with Shaking-the-Vial Technique 

The literature database search did not reveal any 

earlier publication than the one of McAusland. He 

proposed the use of a ‘‘froth’’ in telangiectasia. The 

foam he prepared was obtained by simply shaking the 

rubber-capped bottle that was filled with sodium 

morrhuate, and then the froth was aspirated into a 

syringe. He treated spider veins or telangiectasia, 

where he noticed that the ‘‘veins suddenly got pink, 

sometimes retracted and almost disappeared at once.’’ 

This probably means (stronger) inflammatory reaction, 

vasospasm, and fast efficacy of the froth in 

telangiectasia. 

1944—Egmont James Orbach: 1 Air-Block Technique 

and Displacement of Blood 

Although frequently cited, Orbach’s 1944 publication 

does not deal with foam at all. Instead, he used two 

‘‘conventional liquid’’ techniques for his patients: 

smaller veins were punctured and treated while the 

patient was standing (‘‘full-vein technique’’); in contrast, 

he used the ‘‘empty-vein technique,’’ in which 

large-diameter varicose vein segments were first isolated 

between two tourniquets. Then, after venipuncture, 

the leg was elevated 451 to 901. By releasing the

Dermatol Surg 30:5:May 2004 WOLLMANN: THE HISTORY OF SCLEROSING FOAMS 695 

Figure 1. Overview about the contributions to foam sclerotherapy. 

proximal tourniquet, blood could flow into the central 

or more proximal direction, while the distal tourniquet 

reduced or eliminated the supply of new blood from 

distally. This technique caused less dilution of the 

liquid sclerosing agent. 

Nevertheless, he sometimes noticed therapeutic 

failures, so he had the ‘‘famous idea’’: to intensify the 

contact between the sclerosant and the endothelium, 

the diameter of the vein should not only be reduced as 

far as possible prior to injection, but the vein should be 

rather free from any blood. Therefore, he injected a 

small amount of air into the venous segment to be 

treated to completely displace the remaining blood (see 

Figure 2). 

Experimentally, he had shown that 1 cm 2 of air 

injected into a 6-mm infusion tube pending vertically 

and filled with water did not separate into several 

ascending bubbles but remained in the area of 

injection as one large bubble, if the injection was not 

given too slowly. He then injected a colored solution 

into this air bubble, which, over a period of 3 to 5 s, 

did not get mixed with water but remained undiluted 

in the ‘‘air pocket.’’ 

Clinically, he used the ‘‘air-block technique’’ only 

for smaller and medium-sized varicose veins; He 

recommended the conventional technique, without 

air injection, for larger veins. Unfortunately, Orbach’s 

article does not reveal the reasons for this recommendation. 

It remains unclear why the method that he 

considered to be more effective should not be suited 

for large varicose veins which usually were more 

difficult to treat. In 1970, Stemmer 4 et al. showed in an 

experiment that the air-block technique was only 

reliable with vessel diameters of up to 4 mm and was 

never successful with diameters of more than 8 mm. 

Sclerosis was rather impeded with such diameters: The 

air bubble floating on the blood column protected the 

vessel from contact with the sclerosant at the upper 

Figure 2. The air-block technique: a small amount of air was injected 

before (top) the injection of sclerosant (bottom) to avoid dilution of the 

liquid. 

Figure 3. The air-block technique in large vessels: A floating air 

bubble (top) was able to prevent contact between the endothelium on 

the upper vessel wall and the sclerosant. 

circumference (see Figure 3), thus being effective only 

partially. The original air-block technique is basically 

no longer used today, but its development to a ‘‘foam 

block’’ (air block with large-bubbled foams) is still 

used today by some phlebologists under various names 

for smaller vessels. Small advantages in efficacy 

(increase by 20%) are believed to be outweighed by 

the disadvantages (plus 100% side effects). 5 The 

maximum amount of air injected was 3 mL, a limit 

that became an orientation for most physicians using 

the air-block technique. 

1944—Robert Rowden Foote: 6 Foam in Feeder 

Veins with Shaking-the-Syringe Technique 

In the same year as Orbach’s publication, a book by 

Robert Rowden Foote was published in London. In 

addition to an overview of his ‘‘empty-vein technique,’’ 

he wrote about the treatment of spider veins: ‘‘The 

feeder vein should be dealt with first, whenever 

possible. The best injection fluid is the soapy froth 

obtained by shaking up 1 cc of ethamoline (ethanolamine 

oleate) in a 2-cc syringe. [It should be 

mentioned that the ratio of 1 plus 1 is, strictly 

speaking, not foam but an air/liquid dispersion. 

Usually a mixture is defined as foam if the gas portion 

is higher than 0.52. 7 A characteristic order of 

magnitude of gas/fluid systems is the gas proportion 

j. Depending on the gas proportion, distinction is 

made between gas dispersion, spherical foam (wet 

foam), and polyhedral foam (dry foam). In gas 

dispersions, there are individual air bubbles in liquid; 

the gas proportion j is less than 0.52. In the spherical 

foam, the number of individual bubbles is higher— 

there is still a rather high amount of liquid; the gas

696 WOLLMANN: THE HISTORY OF SCLEROSING FOAMS Dermatol Surg 30:5:May 2004 

proportion is 0.524j40.74. In the polyhedral foam, 

in contrast, the amount of liquid between the bubbles 

is so small that the individual bubbles get closer and 

closer to each other, thus forming polyhedrons. The 

gas proportion j is greater than 0.74. In a foaming 

fluid (e.g., beer), all types generally occur, the 

polyhedral foam being above the spherical foam and 

the gas dispersion and liquid below.] Once the needle 

is in the vein, the bubbles can be made to course along 

the minute veins and can be followed visually in their 

transit.’’ Nowadays, ethanolamine oleate is no longer 

available in most countries. The ‘‘agitation technique’’ 

was refined in the following years and is no longer in 

use. The air:sclerosant ratio of 1 plus 1 described by 

Foote suggests that the dispersion was very fluid so 

that it could not be used for displacing the blood in 

larger diameter veins. 

1949—Karl Sigg: 8 Foam-Block Technique and 

Viscosity of Foam 

In 1949, Karl Sigg picked up the air-block technique 

described 5 years before: Also for other varices than 

spider veins, i.e., larger veins, he used the new 

technique and reported more than 4000 treatments 

performed ‘‘without problems.’’ Sigg describes the 

rationale for the use of the air-block technique in a 

similar manner as Orbach and Foote: ‘‘The purpose is 

to prevent the dilution of the solutions for injection in 

the vein by the blood and to ensure that the sclerosant 

gets in contact with the intima of the vein in a rather 

concentrated formy. Even with this small-scale use, 

the air bubble chased the blood before the injection 

fluid arrived and thus cleared the way for a closer 

contact of the sclerosant with the venous intima.’’ 

Later, Sigg combined Orbach’s air-block technique 

and Foote’s foam application and thus introduced a 

new aspect into the therapeutic options known to that 

date: ‘‘Orbach’s method becomes even more beneficial 

if foam is injected instead of airy. This foam is less 

rapidly washed away in the varicose vein than it 

happens with the pure injection of air.’’ Thus Sigg 

introduced for the first time the idea (even if not 

pronounced) of increased viscosity of foam. With the 

use of foam, he improved the air-block technique 

(introducing a foam block), but without omitting the 

fluid sclerosant (see Figure 4). Sigg described his own 

procedure for the manufacture of foam; the glass 

syringe filled with fluid sclerosant was held with the 

opening pointing downward. Approximately 1 mL of 

air was aspirated through it, pearls developed in the 

solution, and thus more or less large bubbles were 

generated in the syringe. 

Figure 4. The foam-block technique: First, foam was injected to 

maintain the displacing effect of the air block for a longer time (top), 

and then normal liquid sclerosant was injected (bottom). 

1950—Egmont James Orbach: 9,10 Vasospasm 

after Foam Sclerotherapy 

A later publication by Orbach reveals the first attempt 

to compare the efficacy of foam (administered as air 

block and foam) with the efficacy of fluid sclerosants. 

The end point was the length of the sclerothrombus 

generated by the injection of the respective substance. 

The efficacy of the foam generated by agitation of the 

syringe or drug vial was increased approximately 3.5to 

4-fold compared with the same amount of ‘‘conventional’’ 

fluid. The observation of a ‘‘marked 

vasospasm’’ after injection of foam is nowadays 

considered to be an important immediate end point 

for the assessment of the efficacy of modern sclerotherapy. 

11–13 This (reversible) vasospasm, which is 

often clearly detectable in duplex-guided sclerotherapy, 

can be considered to be a sign of initial vascular 

damage after sclerotherapy. After administration of a 

viscous foam, vasospasm is more common and more 

pronounced than after sclerotherapy with conventional 

fluid. 42 An important factor in this respect is 

that a given volume of a blood-displacing foam can 

spread over a much longer venous segment after a 

vasospasm occurs and can even act at a certain 

distance from the site of administration. (For example, 

1 mL of a viscous foam completely fills a vein of 8 mm 

in diameter over a length of approximately 20 mm. A 

reduction of the vessel diameter owing to spasm to 

2 mm distributes the same foam volume to a length of 

almost 32 cm. In vivo, a spasm of a mean length of 

28 cm could be provoked with vessels of 4 to 8 mm in 

diameter and a foam application of 2 to 2.5 mL of 

double-syringe-system foam.) As long as vasospasm 

exists, venipuncture at the same site is aggravated. The 

use of small venous cannulae or catheters may help 

dealing with this. 

Because foams in current use are very different from 

those used by Orbach, it is impossible to draw 

conclusions about the general efficacy of foam from 

this experiment. Nevertheless, according to all findings 

and based on theoretical considerations, the efficacy of 

foam is always higher than that of the same amount 

and concentration of fluid. The level of increased 

efficacy cannot be predicted in the individual case 

without sufficient standardization. The increased


strength of foams needs to be respected if thinking 

about sclerosing smaller vessels with foam. 

1953—Arve Ree: 14 First Use of ‘‘Pure Foam’’ 

The Norwegian doctor Ree introduced a new era in 

1953: He was the first to inject ‘‘pure’’ foam, not in 

addition to air and common fluid sclerosant but 

instead of the sclerosant and, in particular, without 

the previous injection of air. With his technique 

(agitation of a detergent solution in the vial and 

subsequent aspiration of the bubbles into the syringe) 

he first treated a series of 50 patients very successfully. 

He injected 2 to 7 mL of foam, depending on the vessel 

diameter, corresponding to an amount of air of up to 

6.6 mL. The bubble sizes seem to have been in the 

millimeter range with that technique. Owing to the 

higher kinetic energy (agitation of a vial and subsequent 

passage through a bottleneck with turbulent 

flow), it may be considered that a foam with smaller 

bubbles than with the previous techniques could be 

generated. 

1956—Peter Flückiger: 15 Retrograde Injection, 

Aspiration Technique, and Leg Elevation 

Flückiger recommended the technique known as 

‘‘retrograde sclerotherapy,’’ a technique characterized 

by leg elevation and sclerosant injection into saphenous 

veins from a proximal injection site in the distal 

direction. Thus, the sclerosant could reach all insufficient 

collaterals and the saphenous vein by one 

injection. He obtained better results by using sclerosing 

foam than with fluid sclerosants: ‘‘Basically, the 

procedure consists in injecting y Varsyl foam (ethanolamine 

oleate) into an appropriate vein. Due to the 

buoyancy, the foam has only a low tendency to move 

in central direction with the blood flowy. After 

removal of the needle, the location of the ‘‘foam seal’’ 

can be determined by palpationy. The foam usually 

spreads in the surrounding of the injection site in distal 

and proximal direction. After injection, the intravascular 

foam depot y is displaced by manual massage 

against the periphery.’’ Flückiger additionally mentioned 

major aspects of modern foam sclerotherapy in 

his publication: He saw that the foam he used 

remained in the region of the injection site as a 

‘‘depot,’’ noticed that it was able to displace the blood 

in the proximal direction and was not washed away 

from the blood, and noticed that the foam could be 

directed to other regions by manual manipulation. 

Moreover, he postulated and discussed further treatment-relevant 

foam properties for the first time: 

Increased efficacy by increase of the effective surface 

of foam compared to fluid sclerosants; 

A stronger sclerosing effect with smaller amounts of 

sclerosants; 

Postulation of a minimized bubble size; and 

Postulation of homogeneity of foam. 

It is obvious that a given amount of sclerosant in the 

form of foam has a much larger surface than it has in 

an unchanged, fluid state: the smaller the bubbles of 

the foam are, the greater the surface. Since damage to 

the intima y is based on the contact of the intima 

with the sclerosant, the use of foam allows an 

extended sclerosation with a small amount of sclerosant. 

The preparation of a homogenous, fine-bubbled 

foam is an important condition for the success of the 

procedure. 

(The homogeneity of foam, i.e., a foam whose 

bubbles are as homogenous as possible, is an 

important prerequisite for its flow behavior (viscosity) 

and its stability. Ideally, a foam has only bubbles of the 

same diameter, which is, in reality, barely or never 

feasible. Foam is subjected to aging, which involves 

mainly two aspects: In contrast, the fluid that is 

between the gas bubbles in a young foam drains owing 

to the force of gravity, so that the upper bubbles slowly 

break down because of the ‘‘fluid deficiency.’’ In 

contrast, bubbles disappear because a gas diffusion 

takes place between the foam bubbles. The internal gas 

pressure is higher in small bubbles owing to the higher 

surface tension, so that gas moves from those bubbles 

into larger bubbles. Smaller bubbles of a foam get even 

smaller and large ones even larger—until they break 

down. In a homogenous foam, all bubbles would have 

the same inner gas pressure. A gas diffusion from one 

bubble to the adjacent bubble would not take place 

and the foam would remain stable until just the drain 

process would contribute to aging.) 

Flückiger considered the various known foam 

manufacturing procedures, and suggested his own 

new technique: ‘‘In order to obtain a homogenous finebubbled 

foam, the procedure consisting in the agitation 

of a syringe filled with air and sclerosant 

[Orbach’s technique 1950] is completely inappropriate. 

The drawing of air through a sclerosant in the 

syringe [Sigg’s technique 1949] does not yield a small 

fine-bubbled foam either. Moreover, none of these 

methods is able to convert the entire amount of 

sclerosant into foam. There is always a certain amount 

of remaining fluid, which cannot be used for retrograde 

sclerotherapy with the elevated leg. A perfect, 

fine-bubbled foam is obtained by the simultaneous 

aspiration of sclerosant y and air through a thin 

injection needley. The thin injection needle (the 

narrower the lumen, the finer the foam) y is


Figure 5. The aspiration technique: The tip of the needle was placed 

at the liquid–air interface, thus allowing coaspiration of air and 

sclerosant that would generate foam in one run. 

introduced into the ampoule in such a way that 

approximately two thirds of the opening of the bevel 

are imbibed in the fluid (see Figure 5). When drawing 

back the plunger, the syringe fills with Varsyl foam 

under a sizzling noise, the foam remaining stable for 

several minutes.’’ 

1957: Heinz Mayer and Hans Brücke: 16 First 

Microfoam Device (Double-Piston Syringe) 

A milestone regarding the improvement and standardization 

of sclerosing foam was the publication by two 

surgeons Mayer and Brücke: they described the first 

device that had been developed specifically for the 

preparation of viscous sclerosing foams, a syringe with 

a double plunger (see Figure 6). (A double-plunger 

syringe following the principle of Mayer-Brücke was 

‘‘reinvented’’ several times in the following decades. A 

very homogenous, extremely fine microbubble foam 

can be produced using a simple reproduction of that 

syringe—unfortunately, the original is no longer 

available. More than 40 years ago, Mayer and Brücke 

worked with foams that are now suggested to be 

classified as ‘‘microfoam.’’ 17 ) 

‘‘Before the main plunger, there is a second, thin 

plunger with numerous holes, whose piston leads to a 

central bore of the main plunger and protrudes it. 

When the main plunger is fixed, the plunger provided 

with holes can rapidly be moved forward and backward 

and the Phlebocid (ethanolamin oleate) can be 

mixed with the air contained in the syringe. A finebubbled, 

viscous foam developsy. We have tested 

Figure 6. The Mayer-Brücke device: The inner plunger with numerous 

tiny holes can rapidly be moved forward and backward to mix 

sclerosant and air contained in the syringe. The outer plunger was used 

for injection of the viscous and fine-bubbled foam. 

most sclerosants of similar composition and selected 

Phlebocid, which provides the stiffest foam upon 

agitation with a homogenous distribution of air 

bubblesy. We consider the greatest advantage of the 

use of foam y to be the homogenous distribution of 

the sclerosanty.’’ Clinically, they stated after administration 

of foam: ‘‘The fibrous tissue of the venous 

lumen is so complete that in general, recanalizationydoes 

not occur. We never observed recurrent 

varicose veins after using Phlebocid foam. We never 

observed complications after foam filling such as air 

embolisms or skin necroses.’’ 

1962—Peter Flückiger: 18 Turbulent Flow 

In 1962, Flückiger described another technique for the 

preparation of foam: pumping of air and sclerosant 

forward and backward between a drug vial and the 

attached syringe. Later, this technique was modernized 

and improved by Alessandro Frullini 19,20 by adding an 

adapter between the syringe and the bottle seal. 

Furthermore, Flückiger changed some points since 

his first publication in 1956: he maintained leg 

elevation not only during sclerotherapy but also for 

some minutes thereafter, to allow the foam to degrade. 

He warned therapists to be cautious while ‘‘stroking’’ 

the foam seal in a peripheral direction to prevent any 

unintended movement of foam into the deep venous 

system. Today, it is recommended that you wait some 

minutes after foam sclerotherapy of large veins before 

applying compression. 42 

1963—Peter Lunkenheimer: 21 First Use of 

Polidocanol Foam 

Even before polidocanol received its first marketing 

authorization, a German physician had the chance to 

use the novel sclerosing solution for research purposes 

for the first time. Kreussler’s archives revealed a letter 

from that phlebologist, which contains a written ‘‘case 

report’’ about the first patient treatment: ‘‘The first 

patient was treated with 2 mL Aethoxysklerol s 

foamy.’’


1969—Walter Gillesberger: 22 Low-Pressure 

Technique 

Gillesberger’s technique was based on the generation 

of a negative pressure in a (glass) syringe, so that air 

could enter through the capillary gap between the 

syringe piston and the plunger and thus generate 

bubbles (see Figure 7). Gillesberger’s syringe was not 

closed hermetically like the Monfreux syringe tip later 

on, but the negative pressure was strong enough to 

create a foam and was not compensated by the inflow 

of the sclerosant from the vial. The technique by 

Gillesberger or its refinement by Monfreux, who 

generated foam with an ‘‘absolute’’ negative pressure, 

is very simple. What is problematic is that there is no 

standardized ratio between air and sclerosant. Therefore, 

the foams produced in that manner are different, 

depending on the syringe type, needle, generated 

suction, and the resulting gas content; they may be 

more fluid one time and more viscous another time. 

This leads to different behavior in the vessel (degree 

and duration of the displacement of blood) and thus 

probably to an unpredictable efficacy in vivo. (The 

ability of foam to displace blood depends on its quality 

or characteristics: foams obtained with low sclerosant 

concentrations, with small amounts of air, and/or with 

rather large bubbles have a more or less fluid behavior; 

i.e., they are more easily washed away by liquids 

(blood) and have no or just a small and short-term 

displacing effect. Viscous foams (higher concentration, 

higher gas content, and small bubbles), in contrast, 

basically have a displacing effect in larger vessels. 41 If 

sclerosing foam is to be used for small diameter veins, 

precaution is recommended owing to the enhancement 

of the efficacy. A viscous foam would probably have 

too a strong effect in small veins; moreover, the foam 

breaks down as a result of the passage through the 

required fine needles. 42 

Figure 7. The low-pressure technique: Pulling down the piston 

allowed air to enter the syringe through the tiny gap between the 

syringe piston and the plunger. 

1984—Gerald Hauer: 23 Twin-Syringe Technique 

Hauer patented a twin-syringe set for foam preparation: 

Two parallel syringes, one filled with air, the 

other one filled with sclerosing solution, are simultaneously 

emptied into a ‘‘mixing chamber’’ by pressure, 

which leads to the formation of bubbles. The ratio of 1 

plus 1 (sclerosing agent and air) suggests a dispersion 

that should have the effect of a foam block. 

1986—Michael Grigg: 24 Double Syringes and 

Connecting Tubes 

In 1986, Grigg demonstrated a new foam production 

procedure: the principle was the generation of a 

turbulent flow between two syringes, connected via a 

plastic infusion tube, so that fluid and air could be 

pumped forward and backward. Belcaro later improved 

this technique by the addition of a further 

strongly foaming detergent solution in small amounts 

(0.1–0.2 mL). (‘‘Improved’’ in this context means 

prolongation of half-life. Owing to the commonly 

relevant amount of silicone in disposables (syringes 

and infusion tubes, etc.), the half-life of the foam was 

evidently limited because silicone, which destroys the 

surfactant arrangement of the foam lamellae, is a very 

strong foam breaker. Therefore, anything that contributes 

to the maintenance of foam bubbles supports 

the foam stability: this is, in addition to an increase of 

the surfactant concentration, in particular the minimization 

of the amount of silicone.) According to him, 

the foam half-life was approximately 4 min. This socalled 

‘‘Irvine technique’’ (named after the laboratory 

in which the technique was demonstrated) can be 

considered to be a precursor of Tessari’s technique and 

the double-syringe system (DSS). Belcaro and coworkers 

24 first performed investigations on the safety of 

the foam generated according to that technique: 5 to 

10 mL of the foam produced with that technique did 

not cause any change of the pulmonary ventilation 

scintigraphy or perfusion scintigraphy in 12 patients. 

1995—Juan Cabrera Garrido: 2 Rotating Brush 

Technique 

In 1995, Cabrera Garrido published data from the 

clinical use of ‘‘microfoam.’’ He had treated venous 

malformations and saphenous veins including collaterals 

with high volumes of foam. His objective was to 

fill the complete venous lumen by injecting high doses 

of foam at one time. A new aspect of the production 

was the use of a high-speed rotating brush (a modified 

dental bur), so that foam was agitated—like cream 

with a food mixer—and the facultative addition of 

CO2 as a carrier gas. In experiments, CO2—if


Figure 8. Foam prepared with 3% polidocanol solution according to 

the double-syringe system (DSS). Sterile air or CO2 was used as gas. 

The degradation of foam is faster if CO2 is used instead of air and even 

more pronounced if the ratio is changed from 1:5 to 1:10. 

employed as the only gas—led to foams with quickly 

degrading bubbles (see Figure 8). Regarding the highdose 

treatment, more recent publications by Cabrera 

Garridos mentioned that the foam could flow from the 

greater saphenous vein into the deep venous system via 

the saphenofemoral junction or other connections, 

where it may provoke thromboses. 25 The number of 

deep venous thromboses in a first study on this foam 

(6% thromboses when administering 20 mL of 

Varisolve foam and more) 26 does not lend support to 

the high-dose foam therapy and requires special safety 

measures. 

1997—Alain Monfreux: 27 Low-Pressure 

Technique and ‘‘Méthode MUS’’ 

Monfreux’s technique, published in 1997 under the 

name of ‘‘Méthode MUS,’’ was picked up primarily by 

French phlebologists. The principle was based on 

Gillesberger’s technique: generation of a negative 

pressure in the glass syringe filled with sclerosing 

solution, thus inlet of air through the fine gap between 

syringe barrel and plunger with corresponding pearling 

of the solution and transformation into a foam. 

Unlike Gillesberger, Monfreux generated an ‘‘absolute’’ 

negative pressure by placing a cap on the syringe. 

Although all concentrations of sclerosants can be used 

with this method, the efficacy cannot be predicted in 

each individual case: a defined ratio of gas and 

sclerosant or a defined bubble size cannot be determined, 

because many variables (e.g., the width of the 

capillary gap between the syringe barrel and plunger, 

force, and duration of traction at the plunger and thus 

the order of magnitude of the effective shearing force 

which is responsible for the pearling of the solution) 

depend on the brand and on the user. 

1998—Symon Sadoun/Jean-Patric Benigni: 5,28 

Advanced Low-Pressure Technique 

Both authors improved Monfreux’s technique by 

making it usable for plastic syringes: The principle— 

generation of a negative pressure in a syringe closed by 

a Luer stopper—remained similar: pulling down the 

piston to generate subatmospheric pressure was 

followed by quickly releasing the piston several times. 

As with Monfreux and his predecessors, a defined 

gas:sclerosant ratio could not be stated. 

1998—Miguel Santos Gaston: 29 Advanced 

Low-Pressure Technique 

Gaston basically adopted the Monfreux technique, but 

added some more steps to the preparation procedure: 

once the foam was prepared according to Monfreux, 

he emptied the foam into a glass container and then 

aspirated the foam again. This was repeated several 

times, making—on the one hand—the foam more fine, 

but—on the other hand—more dry. 

1999—Javier Garcia Mingo: 30,31 High-Pressure 

Technique and ‘‘Foam Medical System’’ 

Mingo was the first to describe a sterilizable, reusable 

device for the preparation of foam, which generates 

foam by the introduction of various gases from a 

pressure-gas cylinder and subsequent passage of the 

mixture through a fine nozzle, the ‘‘foam medical 

system.’’ The handling and cleaning of the device, 

which appears a little complicated, has prevented its 

wide use so far, although Mingo’s clinical results are 

considered very promising. 

2000—Lorenzo Tessari: 32,33 Double Syringes, 

Three-Way Tap, and the ‘‘Tourbillon Technique’’ 

Tessari’s Tourbillon technique is at present, together 

with the similar DSS technique, the most commonly 

used technique. It corresponds basically to Irvine’s 

technique 24 but has clear advantages over the latter. 

Tessari uses two syringes as well (various sizes being 

described), but Tessari’s technique does not require 

‘‘foaming aids’’: The two syringes are connected by a 

three-way stopcock, and the sclerosing solution and air 

are drawn back and forth by pump movements. Owing 

to the absence of a connecting tube, a lot of disturbing 

silicone is no longer present. A more detailed 

description of the pumping procedure (at least 10 

times) to improve the standardization of the foam was 

given in 2001. 34 

The three-way stopcock has an additional ‘‘technical 

finesse’’: it is possible to vary the size of the passage


by turning the cock—a narrow passage generates high 

turbulences and generates smaller blubbles than a wide 

passage. This procedures uses 2 to 2.5 mL of air and 

0.5 mL of sclerosing solution (all concentrations, 

mainly 1 and 3% for large and very large vessels). 

Irrespective of the concentration, the gas proportion j 

is approximately 0.7 to 0.83; the gas bubbles are very 

fine, and the half-life depends on the concentration and 

on the syringe. The foam prepared according to the 

Tessari method has successfully been tested in clinical 

trials. 35,36 

2000—Alessandro Frullini: 17–19 Advanced 

Turbulent Flow 

In 2000, Frullini improved the technique developed by 

Flückinger in 1962 and made it usable for disposable 

syringes by adding an adapter 18 and in 2001 by 

optionally using sterile air. 17,19 

2001—Gilles Gachet: 37 Aspiration Technique 

The aspiration technique published by Gachet in 2001 

is, regarding foam preparation, very similar with the 

description of Flückiger’s method from 1956. 

2001—Double-Syringe System (DSS), 11,12,38–40 

Two-Way Connector, and Pressure 

When searching for a suitable technique for the 

preparation of foam, it was noticed that the methods 

available to date all had at least one disadvantage that 

aggravated experiments with sclerosing foam or even 

made it impossible from the scientific point of view: 

the foams were not reproducible, because important 

foam characteristics (e.g., the gas proportion, the 

sclerosant concentration, the bubble size, or others) 

were stated incompletely or not at all, because the 

required materials were not described in detail, or 

because the very preparation was not defined clearly. 

The foams prepared for laboratory experiments and 

preclinical experiments all had a different consistence 

and an inhomogeneous flow behavior, if minor 

changes were made. Various types, manufacturers, 

and sizes of syringes; changes to the needle diameters 

and lengths; different temperatures during preparation; 

and other factors led to completely diverging 

results. Therefore, a preparation variant was searched 

for that was simple, fast, sterile and especially 

reproducible. In a laboratory experimental series, the 

various variables that may affect the stability of the 

foam were changed systematically and the best 

possible combination of syringe type, gas:fluid ratio, 

sclerosant concentration, and manufacturing instructions 

was looked for. 

The most stable and fine-bubbled foam was obtained 

according to the following instructions: the required 

materials were a 10-mL Omnifix syringe, a 10-mL 

Inject syringe (each with a Luer-Lock connection), one 

Combidyn adapter (to connect the syringes), and a 0.2mm 

filter (for sterilization of air) (see Figure 9). 

Exactly 8 mL air is drawn into the Inject syringe via 

the sterile filter; afterwards, after removal of the filter, 

exactly one ampoule (2 mL) of polidocanol 3% 

(Aethoxysklerol). The two syringes are connected to 

the adapter. First some pumping movements (5 )are 

performed against resistance (by thumb pressure onto 

the other syringe piston) until the two components are 

well mixed. Afterward, the foam is pumped again 

quickly forth and back seven times between the two 

syringes without resistance like in the Tessari technique, 

until a homogenous foam has formed (see Figure 10). 

The double-syringe-system foam has a fixed sclerosant:air 

ratio of 1:5 ( 5 1 plus 4), a half-life of 

approximately 150 s, with an initial mean bubble size 

of 70 mm. Divergent syringes, concentrations, scler- 

Figure 9. Components used in the double-syringe technique. 

Figure 10. Double-syringe-system (DSS) foam.


osant:air ratios, or pump procedures make the foam 

less stable and less viscous. 

The first prospective, randomized multicenter study 

compared foam sclerotherapy with double-syringe 

system with conventional fluid sclerotherapy in 88 

patients with greater saphenous vein insufficiency. A 

single injection (the protocol did not include further 

injections) of 2 to 2.5 mL of double-syringe-system 

foam or 3% liquid polidocanol showed a 2-year 

occlusion rate of 84% in the foam group versus 40% 

in the fluid group. Vasospasm was clearly more 

frequent and more pronounced in the group treated 

with foam (mean length 28 cm) than in the control 

group, the rate of side effects being identical. 11,12 

Conclusion and Discussion 

The use of foamed sclerosing agents in therapy of large 

or small varicose veins is not new. It started as early as 

1939. The publications about foam sclerotherapy 

found and presented in this text allow us to look at 

what has been invented between the very beginnings 

and now. The contributions of widely known and also 

of less known colleagues show that remarkable work 

was performed in the field of noncommercial foam 

sclerotherapy continuously for the past six decades, 

especially for the treatment of varicose veins of the 

lower limbs. But they also show that there sometimes 

is a lack of accuracy in describing the particular foams 

used, which does not make it easy to reproduce the 

individual reported results and/or findings. The suggestion 

therefore is to describe any foam used in 

nonclinical or clinical trials according to the ‘‘definition 

of sclerosing foams’’: Sclerosing foam is characterized 

by (at least) the following variables: type and 

concentration of the tensioactive sclerosing agent, type 

of gas, ratio of liquid to gas, the method of 

preparation, the time between processing and use, 

and bubble sizes. This could really help to make 

sclerosing foams, and clinical results, comparable. 

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Commentary 

Many authors have claimed to have developed a technique for 

foaming detergent solutions to increase the efficacy of 

sclerotherapy treatment of varicose veins. In this article, Dr. 

Wollmann has researched the literature to provide us with an 

accurate history of this therapeutic advance. As with ambulatory 

phlebectomy and many other surgical techniques, foaming 

sclerosing solutions is not new. This technique was first 

described in 1939 and has been reported using many different 

methods over the past six decades. Present ‘‘advances’’ in 

38. Ouvry P, Barrellier MT, Escalard JM, et al. Sclerotherapy of the 

long saphenous vein with foam of Lauromacrogol: a prospective 

duplex controlled randomized study protocol and first result. Int 

Angiol 2001;20(Suppl 1):343. 

39. Wollmann JC. Schaum zwischen Vergangenheit und Zukunft. 

Vasomed 2002;16:34–5. 

40. Hamel-Desnos C, Desnos P, Ouvry P, et al. Nouveautés thérapeutiques 

dans la prise en charge de la maladie variqueuse: échosclérothérapie 

et mousse. Phlébologie 2003;56:41–8. 

41. Wollmann JC. An Experimental Model to Pinpoint Properties and 

Behavior of Sclerosing Foams. 17th Annual Congress of the 

American College of Phlebology; 2003 Aug 27–31; San Diego, 

CA. Oakland, CA: ACP, 2003. 

42. Breu FX, Guggenbichler S. European Consensus Meeting on Foam 

Sclerotherapy April 4–6, 2003, Tegernsee, Gemany. Dermatol Surg 

2004;30:709–717. 

sclerotherapy technique represent minor modifications of 

previously reported techniques and should not be named after 

their recent revivalists. One wonders whether a language barrier 

prevents a wider appreciation of the past achievements of 

medicine. Perhaps a universal language of medical and scientific 

reports will better help to disseminate information. Certainly, in 

this, the ‘‘information–computer age’’ it is possible. 

MITCHEL GOLDMAN, MD 

La Jolla, California

The History of Sclerosing Foams

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