The focus of this investigation is primary great saphenous vein (GSV) varicosities, a manifestation of chronic venous insufficiency affecting 20%–40% of Western populations (1, 2). Pathologically characterized by venous wall dilation and valvular incompetence, this condition progresses through CEAP clinical stages C2-C6, manifesting as pain, edema, skin hyperpigmentation, and ulceration (3). Beyond imposing substantial patient morbidity and quality-of-life impairment, it accounts for approximately 2% of national healthcare expenditures in developed countries (4).

Current guidelines recommend thermal ablation, sclerotherapy, or surgical stripping for GSV management (1, 2). Foam sclerotherapy—through detergent-induced endothelial damage leading to fibrotic occlusion—represents a minimally invasive option with reported 3-year closure rates of 70%–85% (5). However, hemodynamic limitations constrain its efficacy: in large-diameter (>8 mm) GSVs with high flow velocities (>10 cm/s), sclerosant dilution reduces endothelial contact time, diminishing foam stability and biological effectiveness (5–7). Computational fluid dynamics models indicate turbulence reduces therapeutic agent residence time by 40%–60% compared to low-flow states (8–10).

The induction of transient venospasm has been proposed as a potential strategy to treat vein varicosities. Transient vasoconstriction reduces luminal diameter and blood velocity, thereby prolonging contact between the sclerosant and the endothelium (5, 11, 12). To translate this physiological principle into a viable clinical application while addressing the limitations of existing therapies, we developed a hybrid approach: Controlled Venous Spasm-Assisted Foam Sclerotherapy (CVAFS) combined with High Ligation (HL). Controlled venous spasm was achieved through endovenous mechanical stimulation via a 4F vertebral catheter rotated and pulled back within the venous lumen, augmented by targeted external manual compression to induce transient vasoconstriction.

This retrospective cohort study evaluated the efficacy of CVAFS + HL, a technique combining high ligation for proximal flow interruption and pharmacologically-induced spasm for distal flow modulation, in 127 patients with primary great saphenous vein (GSV) varicosities (CEAP C2-C4). The primary objectives were to assess the 12-month anatomical closure rate of the GSV trunk, particularly in the thigh segment, complication rates (including thrombophlebitis and neurological injury), and improvement in Venous Clinical Severity Score (VCSS).

Between January and October 2023, 127 patients underwent controlled venospasm-assisted foam sclerotherapy (CVAFS) combined with high ligation. The cohort had a mean age of 60.2 ± 9.3 years, comprising 62 males and 65 females. Comorbidities included diabetes mellitus (n = 34), hypertension (n = 53), and other cardiovascular conditions (lacunar infarction or coronary artery disease, n = 13) (Table 2).

A total of 145 affected limbs were treated, with CEAP clinical classifications distributed as follows: C2 (n = 104), C3 (n = 19), C4 (n = 16), and C5 (n = 6) (Table 2). All procedures achieved technical success (145/145 limbs, 100%). Among 127 patients, 109 (85.8%) completed the 12-month follow-up, encompassing 125 treated limbs. Ultrasound assessment confirmed sustained great saphenous vein (GSV) occlusion in 117 limbs (93.6%, 117/125, 95% CI: 89.3%–97.9%), with no cases of clinical recurrence observed. The Venous Clinical Severity Score (VCSS) demonstrated significant improvement from a preoperative baseline of 6.18 ± 3.90 to 0.86 ± 0.90 at 12 months (p < 0.001, Wilcoxon signed-rank test; V = 7,875) (Figure 2).

Postprocedural complications included saphenous junction pain (n = 41, 32.8%) and thrombophlebitis (n = 12, 9.6%), all resolving within two weeks without intervention. No instances of deep venous thrombosis or other severe complications occurred during follow-up.

We compared our results with previous studies to evaluate the performance of CVAFS + HL relative to established treatments for great saphenous vein (GSV) incompetence, as summarized in Table 3. The results demonstrate that CVAFS + HL achieved a technical success rate of 100% (145/145 limbs) within 6 weeks, with a 1-year occlusion rate of 93.6% (117/125 limbs). In comparison, ultrasound-guided foam sclerotherapy (UGFS) showed lower long-term efficacy, with occlusion rates of 23%–33% at 5 years, while endovenous laser ablation (EVLA) and mechanochemical ablation (MOCA) exhibited 1-year occlusion rates of approximately 88% and 80%–82%, respectively (22–24). Surgery (high ligation and stripping, HL/S) had a 5-year occlusion rate of 83%. The complication profile for CVAFS + HL included thrombophlebitis (9.6%) and saphenous junction pain (32.8%), with no instances of deep vein thrombosis (DVT), pulmonary embolism (PE), or skin necrosis. This contrasts with UGFS, which had higher rates of hyperpigmentation (10%–15%) and superficial vein thrombosis (SVT; 5.9–13.7%), and surgery, which was associated with nerve injury (11.3%). Quality of life improvement, measured by the Venous Clinical Severity Score (VCSS), showed a significant reduction from 6.18 ± 3.90 to 0.86 ± 0.90 (86.1% improvement, p < 0.001) for CVAFS + HL, comparable to the significant improvements seen with EVLA and MOCA. CVAFS + HL required only local anesthesia with tumescence, allowed outpatient procedures, and facilitated rapid recovery (ambulation within 6 h, return to normal activities in 1–2 days), outperforming surgery which typically necessitated general/regional anesthesia and longer recovery (2–3 weeks). Cost-effectiveness was a key advantage of CVAFS + HL due to the absence of proprietary devices, whereas EVLA and MOCA involved higher costs. CEAP class suitability for CVAFS + HL was confirmed for C2–C4 cases, aligning with guidelines for first-line treatments like EVLA. Long-term data for CVAFS + HL are currently limited to 12 months, whereas other modalities have 3- to 5-year follow-up data available. Overall, these results contextualize CVAFS + HL as a competitive alternative to existing therapies, with efficacy and safety profiles that support its use in clinical practice.

The global burden of great saphenous vein (GSV) varicosities remains substantial, with an estimated 30% prevalence among adults imposing significant healthcare costs (4, 15). While established modalities like surgical ligation, endothermal ablation (EVLA/RFA), and ultrasound-guided foam sclerotherapy (UGFS) offer therapeutic options, each carries inherent limitations. Foam sclerotherapy—despite its minimally invasive appeal—demonstrates reduced efficacy in larger-diameter veins (>6 mm), where diminished foam-fill ratios and accelerated blood flow compromise endothelial contact time and promote sclerosant dilution (1, 2, 9). This pathophysiological limitation is corroborated by mechanistic studies highlighting the inverse relationship between venous diameter and sclerotherapy success rates (4, 16, 17).

In addressing this challenge, mechanochemical ablation (MOCA) emerged as an innovative approach combining rotational mechanical endothelial injury with liquid sclerosant infusion (18, 19). Contemporary evidence confirms MOCA's short-term efficacy, achieving 88.2% 1-year anatomical occlusion and 93% clinical improvement (19). Its non-thermal nature significantly reduces postoperative pain (mean VAS: 4.8–19.3 mm vs. 18.6–34.5 mm for RFA/EVLA) and accelerates return to normal activities (median 1 day) (19, 20). Nevertheless, MOCA exhibits declining long-term efficacy—3-year occlusion rates drop to 80%–82%, with veins >7 mm demonstrating substantially higher recanalization risk (20). Additionally, a significant advantage of the CVAFS + HL technique is its potential for improved cost-effectiveness compared to MOCA, which relies on proprietary devices such as the ClariVein® catheter (20). Published studies have reported the cost of the single-use ClariVein® device to be approximately $500 - $700. In contrast, the CVAFS + HL technique induces venospasm using a conventional and reusable 4F vertebral catheter, which represents a minimal and recurrent cost. By eliminating the need for a dedicated, single-use device, CVAFS + HL substantially reduces the per-procedure material cost, potentially enhancing its viability and adoption in healthcare settings with limited resources.

Our study introduces Controlled Venospasm-Assisted Foam Sclerotherapy with High Ligation (CVAFS + HL) as a strategically optimized alternative. This technique replicates MOCA's mechanical endothelial stimulation through controlled manual catheter rotation within the GSV lumen, intentionally inducing localized venospasm. Crucially, CVAFS substitutes liquid agents with foam sclerotherapy while incorporating proximal high ligation (HL) to mitigate reflux and augment closure. The synergistic mechanism operates through:1, Mechanical venospasm reducing venous diameter by >40%, enhancing foam-wall contact; 2, Endothelial microtrauma increasing sclerosant absorption; 3, HL eliminating saphenofemoral reflux, reducing hemodynamic stress on treated segments.

Our results demonstrate that Controlled Venospasm-Assisted Foam Sclerotherapy with High Ligation (CVAFS + HL) achieves clinical outcomes comparable to mechanochemical ablation (MOCA) while offering distinct advantages. Regarding safety equivalence, no deep vein thrombosis, nerve injuries, or clinically significant hematomas occurred. Minor complications, such as transient thrombophlebitis (≤9%), resolved with conservative management, thereby aligning with MOCA's established safety profile. Notably, saphenous junction pain is a recognized and typically transient effect attributable to the high ligation component, and its spontaneous resolution in all our cases within two weeks aligns with this expectation. In terms of technical efficacy, 1-year occlusion rates and symptom improvement (quantified by VCSS reduction) paralleled MOCA benchmarks, while the addition of high ligation (HL) specifically mitigated proximal recurrence risks inherent in pure endovenous techniques. Concerning economic superiority, eliminating proprietary devices like ClariVein® substantially reduced per-procedure costs, enhancing viability in resource-constrained settings. These collective findings affirm CVAFS + HL as a cost-effective refinement of mechanochemical principles. The manual catheter rotation maneuver proved exceptionally safe, with no perforations occurring despite aggressive manipulation—a result attributable to the flexible catheter tip design. Furthermore, integrating HL counteracts the weakness of ultrasound-guided foam sclerotherapy (UGFS) in managing junctional reflux, synergistically improving long-term durability.

Despite these promising outcomes, this retrospective single-center analysis carries inherent limitations, including potential selection bias and unmeasured confounders, which are intrinsic to its non-randomized, observational design (21). Furthermore, the 12-month follow-up period, while adequate for initial efficacy and safety assessment, is insufficient to evaluate long-term durability and recurrence rates, which often manifest beyond 2–5 years. The study also did not formally analyze the learning curve associated with CVAFS + HL; however, anecdotal observation suggests that operator proficiency, reflected in procedural time and consistency, improved with cumulative experience, a factor that should be quantitatively assessed in future prospective studies to inform training requirements. Although the abstract mentions potential cost-effectiveness, a formal economic analysis comparing this hybrid technique to established therapies like EVLA or UGFS was beyond the scope of this initial investigation and remains a critical area for future research. Therefore, future multi-center, randomized controlled trials with longer follow-up, integrated learning curve assessments, and comprehensive cost-effectiveness analyses are essential to validate these findings and thoroughly evaluate the technique's broader applicability and economic value. Specific priority areas for such research include investigating diameter-dependent efficacy—specifically whether CVAFS + HL overcomes MOCA's known diminished efficacy in veins exceeding 7 mm—assessing long-term outcomes such as 3- to 5-year occlusion durability and retreatment rates, and exploring optimal foam formulation parameters, including ideal sclerosant type, concentration, and foam stability characteristics.

CVAFS + HL represents a technically feasible, economically advantageous evolution in minimally invasive varicose vein management. By integrating targeted mechanical venospasm induction with foam sclerotherapy and high ligation, it addresses critical limitations of standalone UGFS while circumventing MOCA's cost barriers. Our results establish its short-term safety and efficacy equivalence to established techniques. Future prospective studies should prioritize long-term outcomes and standardized protocols to solidify its role in evidence-based therapeutic algorithms.