Ultrasound-guided cyanoacrylate embolization of refluxing tributaries during truncal cyanoacrylate closure (SLICE): Technique description and a proof-of-concept feasibility study

Source abstract

Objectives Truncal cyanoacrylate closure (CAC) does not treat refluxing tributary varicosities. We describe Side-branch Local Injection of Cyanoacrylate Embolization (SLICE) — ultrasound-guided injection of the VenaSeal adhesive into refluxing tributaries during truncal CAC — and assess its technical feasibility and periprocedural safety. Methods Single-center retrospective review of 32 consecutive patients (49 limbs, 58 truncal veins) treated by truncal CAC between September 2024 and December 2025; SLICE was performed in 14. The primary endpoint was technical success, defined as the absence of reflux within an injected tributary on the first postoperative duplex study. Secondary endpoints included 3-month durability, truncal occlusion, and adverse events. Results 22 refluxing tributaries were injected; all were epifascial, at a median depth of 4.0 mm (range 1.2–9.6). A median of four dispenser trigger pulls was used per site (range 3–8); the series was underpowered to relate pull count to diameter (Spearman rho −0.16, p = 0.50). Technical success was 21/22 (95%; 95% confidence interval 77.2–99.9) initially and 19/20 (95%; 75.1–99.9) at 3 months. On 3-month computed tomography (CT), 14 of 17 evaluable injected tributaries were occluded whereas 16 of 17 were free of reflux: anatomical occlusion lagged behind hemodynamic success. Truncal occlusion was preserved (30/30 at 1 week; 26/27 at 3 months). There was no phlebitis, deep vein thrombosis, pulmonary embolism, or adhesive removal. Hyperpigmentation occurred in 3/14 patients, all with an injection <2 mm below the skin; two mild delayed hypersensitivity reactions occurred, both over the truncal rather than an injected site. One patient (7%) required re-intervention. Conclusions SLICE is technically feasible and reproducible within a narrow range of adhesive delivery, with no adhesive-related complication at an injected site in this small series with short follow-up. Prospective comparative evaluation with patient-centered endpoints is required before efficacy can be claimed.