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Shah AH, Horlick EM, Kass M, Carroll JD, Krasuski RA. The pathophysiology of patent foramen ovale and its related complications. Am Heart J 2024; 277:76-92. [PMID: 39134216 DOI: 10.1016/j.ahj.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Accepted: 08/02/2024] [Indexed: 08/29/2024]
Abstract
The foramen ovale plays a vital role in sustaining life in-utero; however, a patent foramen ovale (PFO) after birth has been associated with pathologic sequelae in the systemic circulation including stroke/transient ischemic attack (TIA), migraine, high altitude pulmonary edema, decompression illness, platypnea-orthodeoxia syndrome (POS) and worsened severity of obstructive sleep apnea. Importantly, each of these conditions is most commonly observed among specific age groups: migraine in the 20 to 40s, stroke/TIA in the 30-50s and POS in patients >50 years of age. The common and central pathophysiologic mechanism in each of these conditions is PFO-mediated shunting of blood and its contents from the right to the left atrium. PFO-associated pathologies can therefore be divided into (1) paradoxical systemic embolization and (2) right to left shunting (RLS) of blood through the PFO. Missing in the extensive literature on these clinical syndromes are mechanistic explanations for the occurrence of RLS, including timing and the volume of blood shunted, the impact of age on RLS, and the specific anatomical pathway that blood takes from the venous system to the left atrium. Visualization of the flow pattern graphically illustrates the underlying RLS and provides a greater understanding of the critical flow dynamics that determine the frequency, volume, and pathway of flow. In the present review, we describe the important role of foramen ovale in in-utero physiology, flow visualization in patients with PFO, as well as contributing factors that work in concert with PFO to result in the diverse pathophysiological sequelae.
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Affiliation(s)
- Ashish H Shah
- Department of Internal Medicine, St Boniface Hospital, Section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Eric M Horlick
- Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Malek Kass
- Department of Internal Medicine, St Boniface Hospital, Section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - John D Carroll
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO.
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Parsi K, De Maeseneer M, van Rij AM, Rogan C, Bonython W, Devereux JA, Lekich CK, Amos M, Bozkurt AK, Connor DE, Davies AH, Gianesini S, Gibson K, Gloviczki P, Grabs A, Grillo L, Hafner F, Huber D, Iafrati M, Jackson M, Jindal R, Lim A, Lurie F, Marks L, Raymond-Martimbeau P, Paraskevas P, Ramelet AA, Rial R, Roberts S, Simkin C, Thibault PK, Whiteley MS. Guidelines for management of actual or suspected inadvertent intra-arterial injection of sclerosants. Phlebology 2024:2683555241260926. [PMID: 39046331 DOI: 10.1177/02683555241260926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
BACKGROUND Inadvertent intra-arterial injection of sclerosants is an uncommon adverse event of both ultrasound-guided and direct vision sclerotherapy. This complication can result in significant tissue or limb loss and significant long-term morbidity. OBJECTIVES To provide recommendations for diagnosis and immediate management of an unintentional intra-arterial injection of sclerosing agents. METHODS An international and multidisciplinary expert panel representing the endorsing societies and relevant specialities reviewed the published biomedical, scientific and legal literature and developed the consensus-based recommendations. RESULTS Actual and suspected cases of an intra-arterial sclerosant injection should be immediately transferred to a facility with a vascular/interventional unit. Digital Subtraction Angiography (DSA) is the key investigation to confirm the diagnosis and help select the appropriate intra-arterial therapy for tissue ischaemia. Emergency endovascular intervention will be required to manage the risk of major limb ischaemia. This includes intra-arterial administration of vasodilators to reduce vasospasm, and anticoagulants and thrombolytic agents to mitigate thrombosis. Mechanical thrombectomy, other endovascular interventions and even open surgery may be required. Lumbar sympathetic block may be considered but has a high risk of bleeding. Systemic anti-inflammatory agents, anticoagulants, and platelet inhibitors and modifiers would complement the intra-arterial endovascular procedures. For risk of minor ischaemia, systemic oral anti-inflammatory agents, anticoagulants, vasodilators and antiplatelet treatments are recommended. CONCLUSION Inadvertent intra-arterial injection is an adverse event of both ultrasound-guided and direct vision sclerotherapy. Medical practitioners performing sclerotherapy must ensure completion of a course of formal training (specialty or subspecialty training, or equivalent recognition) in the management of venous and lymphatic disorders (phlebology), and be personally proficient in the use of duplex ultrasound in vascular (both arterial and venous) applications, to diagnose and provide image guidance to venous procedure. Expertise in diagnosis and immediate management of an intra-arterial injection is essential for all practitioners performing sclerotherapy.
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Affiliation(s)
- Kurosh Parsi
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Australasian College of Phlebology (ACP), Chatswood, NSW, Australia
- Department of Dermatology, St Vincent's Hospital, Sydney, NSW, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Dermatology, Phlebology and Fluid Mechanics Laboratory, St Vincent's Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | | | - Andre M van Rij
- Australasian College of Phlebology (ACP), Chatswood, NSW, Australia
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Christopher Rogan
- Interventional Radiology Society of Australasia (IRSA), Camperdown, NSW, Australia
- Department of Medical Imaging, Sydney Adventist Hospital, Sydney, NSW, Australia
- Macquarie University Hospital, Sydney, NSW, Australia
| | - Wendy Bonython
- Faculty of Law, Bond University, Gold Coast, QLD, Australia
| | - John A Devereux
- University of Queensland Law School, University of Queensland, Saint Lucia, QLD, Australia
| | | | - Michael Amos
- Department of Anaesthesiology, Concord Hospital, Sydney, NSW, Australia
| | - Ahmet Kursat Bozkurt
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Department of Cardiovascular Surgery, Istanbul University, Istanbul, Turkie
| | - David E Connor
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Dermatology, Phlebology and Fluid Mechanics Laboratory, St Vincent's Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | - Alun H Davies
- European College of Phlebology, Rotterdam, The Netherlands
- Vascular Surgery, Imperial College London, Charing Cross and St Mary's Hospital, London, UK
| | - Sergio Gianesini
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Vascular Surgery, University of Ferrara, Ferrara, Italy
| | | | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Anthony Grabs
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Vascular Surgery, St Vincent's Hospital, Sydney, NSW, Australia
| | - Lorena Grillo
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Vascular Surgery, University of Medical Sciences (UCIMED), San Jose, Costa Rica
| | - Franz Hafner
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - David Huber
- Art of Vein Care, Wollongong, NSW, Australia
| | - Mark Iafrati
- American Venous Forum (AVF), East Dundee, IL, USA
- Vanderbilt University Medical Center, Vanderbuilt University, Nashville, TN, USA
| | - Mark Jackson
- Australian and New Zealand Society for Vascular Surgery(ANZSVS), Melbourne, VIC, Australia
- Department of Vascular Surgery, Gold Coast University Hospital, Gold Coast, QLD, Australia
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Ravul Jindal
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Vascular Surgery, Fortis Hospital, Mohali, India
| | - Adrian Lim
- Department of Dermatology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Fedor Lurie
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Jobst Vascular Institute, Toledo, OH, USA
- Section of Vascular Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Lisa Marks
- Australasian College of Phlebology (ACP), Chatswood, NSW, Australia
- Brighton Day Surgery, Adelaide, SA, Australia
| | - Pauline Raymond-Martimbeau
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Dallas Non-Invasive Vascular Laboratory and Vein Institute of Texas, Dallas, TX, USA
| | | | | | - Rodrigo Rial
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Vascular and Endovascular Surgery, University Hospital HM Madrid, Torrelodones, Spain
| | | | - Carlos Simkin
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Clínica Simkin, Buenos Aires, Argentina
| | - Paul K Thibault
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Australasian College of Phlebology (ACP), Chatswood, NSW, Australia
- Central Vein and Cosmetic Medical Centre, Newcastle, NSW, Australia
| | - Mark S Whiteley
- The College of Phlebology, Guildford, UK
- The Whiteley Clinic, Guildford, UK
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Cui L, Zhang X, Xu L. Topical injection of sclerosant to treat cheek subcutaneous venous malformation resulting in blindness: a case report. BMC Ophthalmol 2023; 23:384. [PMID: 37726700 PMCID: PMC10510258 DOI: 10.1186/s12886-023-03128-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 09/08/2023] [Indexed: 09/21/2023] Open
Abstract
Loss of vision after topical injection of sclerosant is a rare and uncommon complication. We describe a case with vision loss following the facial injections of physician-compounded (PCP) foam sclerotherapy which was created by room air. A 3-year-old boy underwent injection of 5ml polidocanol foamed with room air to treat the venous malformation on the cheek near the left orbit. The boy experienced the whole facial swelling on day 2 after the third injection, especially involving the left side, the visual acuity in the left eye was counting fingers at 30 cm and the swelling reduced at 7 days later after referral. Fundus examination on day 15 revealed hemorrhage inferior to the optic disc and fluorescein angiography revealed blocked fluorescein. The OCT on day 15 showed the edema of the nerve fiber layer beside the fovea. The patient's hearing was also impaired. PCP foam sclerotherapy with room air produced in typical concentrations, preparations as well as volumes always causes vision loss among children. Continued evaluation on the effects of product, gas, volume, and patient age identify optimal approaches will avoid the toxicity and side-effects caused by facial foam sclerotherapy.
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Affiliation(s)
- Lihong Cui
- Department of Ophthalmology, Shenyang Fourth People Hospital, Liaoning, China
| | - Xinyue Zhang
- Department of Ophthalmology, Shengjing Hospital, Chinese Medical University, Liaoning, China
| | - Li Xu
- Department of Ophthalmology, Shenyang Fourth People Hospital, Liaoning, China.
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Wong M, Parsi K, Myers K, De Maeseneer M, Caprini J, Cavezzi A, Connor DE, Davies AH, Gianesini S, Gillet JL, Grondin L, Guex JJ, Hamel-Desnos C, Morrison N, Mosti G, Orrego A, Partsch H, Rabe E, Raymond-Martimbeau P, Schadeck M, Simkin R, Tessari L, Thibault PK, Ulloa JH, Whiteley M, Yamaki T, Zimmet S, Kang M, Vuong S, Yang A, Zhang L. Sclerotherapy of lower limb veins: Indications, contraindications and treatment strategies to prevent complications - A consensus document of the International Union of Phlebology-2023. Phlebology 2023; 38:205-258. [PMID: 36916540 DOI: 10.1177/02683555231151350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Sclerotherapy is a non-invasive procedure commonly used to treat superficial venous disease, vascular malformations and other ectatic vascular lesions. While extremely rare, sclerotherapy may be complicated by serious adverse events. OBJECTIVES To categorise contraindications to sclerotherapy based on the available scientific evidence. METHODS An international, multi-disciplinary panel of phlebologists reviewed the available scientific evidence and developed consensus where evidence was lacking or limited. RESULTS Absolute Contraindications to sclerotherapy where the risk of harm would outweigh any benefits include known hypersensitivity to sclerosing agents; acute venous thromboembolism (VTE); severe neurological or cardiac adverse events complicating a previous sclerotherapy treatment; severe acute systemic illness or infection; and critical limb ischaemia. Relative Contraindications to sclerotherapy where the potential benefits of the proposed treatment would outweigh the risk of harm or the risks may be mitigated by other measures include pregnancy, postpartum and breastfeeding; hypercoagulable states with risk of VTE; risk of neurological adverse events; risk of cardiac adverse events and poorly controlled chronic systemic illness. Conditions and circumstances where Warnings and Precautions should be considered before proceeding with sclerotherapy include risk of cutaneous necrosis or cosmetic complications such as pigmentation and telangiectatic matting; intake of medications such as the oral contraceptive and other exogenous oestrogens, disulfiram and minocycline; and psychosocial factors and psychiatric comorbidities that may increase the risk of adverse events or compromise optimal treatment outcomes. CONCLUSIONS Sclerotherapy can achieve safe clinical outcomes provided that (1) patient-related risk factors and in particular all material risks are (1a) adequately identified and the risk benefit ratio is clearly and openly discussed with treatment candidates within a reasonable timeframe prior to the actual procedure; (1b) when an individual is not a suitable candidate for the proposed intervention, conservative treatment options including the option of 'no intervention as a treatment option' are discussed; (1c) complex cases are referred for treatment in controlled and standardised settings and by practitioners with more expertise in the field; (1d) only suitable individuals with no absolute contraindications or those with relative contraindications where the benefits outweigh the risks are offered intervention; (1e) if proceeding with intervention, appropriate prophylactic measures and other risk-mitigating strategies are adopted and appropriate follow-up is organised; and (2) procedure-related risk factors are minimised by ensuring the treating physicians (2a) have adequate training in general phlebology with additional training in duplex ultrasound, procedural phlebology and in particular sclerotherapy; (2b) maintain their knowledge and competency over time and (2c) review and optimise their treatment strategies and techniques on a regular basis to keep up with the ongoing progress in medical technology and contemporary scientific evidence.
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Affiliation(s)
- Mandy Wong
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kurosh Parsi
- Department of Dermatology, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia.,Faculty of Medicine, 7800University of New South Wales, Sydney, NSW, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia.,Australasian College of Phlebology, Chatswood, NSW, Australia
| | - Kenneth Myers
- Australasian College of Phlebology, Chatswood, NSW, Australia
| | | | - Joseph Caprini
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | | | - David E Connor
- Department of Dermatology, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia.,Faculty of Medicine, 7800University of New South Wales, Sydney, NSW, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Alun H Davies
- 4615Department of Surgery & Cancer, Imperial College London, UK
| | - Sergio Gianesini
- Department of Translational Medicine, University of Ferrara, Italy
| | | | | | | | - Claudine Hamel-Desnos
- Department of Vascular Medicine, Saint Martin Private Hospital Ramsay GdS, Caen,France and Paris Saint Joseph Hospital Group, France
| | | | | | | | | | - Eberhard Rabe
- Emeritus, Department of Dermatology, University of Bonn, Germany
| | | | | | - Roberto Simkin
- Faculty of Medicine, 28196University of Buenos Aires, Argentina
| | | | - Paul K Thibault
- Australasian College of Phlebology, Chatswood, NSW, Australia.,Central Vein and Cosmetic Medical Centre, Newcastle, Australia
| | - Jorge H Ulloa
- Hospital Universitario Fundación Santa Fé - Universidad de los Andes, Bogotá, Colombia
| | | | - Takashi Yamaki
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University Adachi Medical Center, Japan
| | | | - Mina Kang
- Department of Dermatology, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia.,Faculty of Medicine, 7800University of New South Wales, Sydney, NSW, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Selene Vuong
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Anes Yang
- Department of Dermatology, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Lois Zhang
- Department of Dermatology, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia.,Faculty of Medicine, 7800University of New South Wales, Sydney, NSW, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
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Bahtiri L, Thomsen AV, Ashina M, Hougaard A. Migraine aura-like episodes following sclerotherapy for varicose veins of the lower extremities-A systematic review. Headache 2023; 63:40-50. [PMID: 36633095 PMCID: PMC10108023 DOI: 10.1111/head.14448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE This systematic review provides a summary and evaluation of cases of migraine aura-like episodes elicited by sclerotherapy of veins of the lower extremities and discusses possible underlying mechanisms. BACKGROUND Sclerotherapy is a commonly used treatment for varicose veins. Symptoms resembling migraine aura have been reported during and following sclerotherapy of the lower extremities, suggesting that sclerotherapy may elicit migraine aura. METHODS We searched PubMed for articles reporting neurological complications that were transient and fully reversible following sclerotherapy treatment for varicose veins in the lower limbs. There were no restrictions regarding article language or publication date. Only original studies and case reports were included. Two authors independently reviewed included articles in detail. Data were extracted from each article, including details on symptoms, previous migraine history, sclerotherapy method, and the presence of a right-to-left cardiac shunt in patients. We evaluated whether episodes fulfilled modified International Classification of Headache Disorders, 3rd edition, criteria for 1.2 Migraine with aura or 1.5.2 Probable migraine with aura. RESULTS The search yielded 777 articles, 28 of which were included. Twenty-six articles reported 119 episodes of transient neurological symptoms in 34,500 sclerotherapy sessions. Two additional articles reported six episodes of transient neurological symptoms with no specification of the number of sessions. Of the 125 episodes, 119 involved transient visual disturbances, and eight met the modified criteria for Probable migraine with aura. In most episodes (98%), clinical information was insufficient to determine if the criteria were fulfilled. CONCLUSIONS Symptoms that are clinically indistinguishable from migraine with aura attacks may occur following sclerotherapy, although this likely is rare. Microembolization through a right-to-left shunt triggering cortical spreading depolarization is a possible mechanism. Our findings are limited by infrequent specific assessments for neurological complications and a low level of detail in the description of symptoms in the available literature. Future prospective studies are needed to determine this phenomenon's incidence and underlying mechanisms.
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Affiliation(s)
- Lionesa Bahtiri
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical SciencesUniversity of CopenhagenGlostrupDenmark
| | - Andreas Vinther Thomsen
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical SciencesUniversity of CopenhagenGlostrupDenmark
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical SciencesUniversity of CopenhagenGlostrupDenmark
| | - Anders Hougaard
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical SciencesUniversity of CopenhagenGlostrupDenmark
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Kim J, Park CG, Chu MK. Interictal plasma endothelin-1 levels do not change in individuals with episodic and chronic migraine. Cephalalgia 2022; 42:761-768. [PMID: 35166151 DOI: 10.1177/03331024221075616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Individuals with migraine present ictal elevation of endothelin-1 levels. Migraine can be subclassified into episodic migraine and chronic migraine. Apart from the inconsistent reports on interictal endothelin-1 levels, most studies did not distinguish between episodic migraine and chronic migraine. METHODS We measured plasma endothelin-1 levels in participants with episodic migraine (n = 87), with chronic migraine (n = 88), and controls (n = 50). RESULTS Interictal endothelin-1 levels were not significantly different among participants with episodic migraine, those with chronic migraine, and controls (pg/ml, median and interquartile range, 10.19 [7.76-13.69] vs. 9.25 [6.91-10.73] vs. 9.46 [7.00-14.19], p = 0.131). After excluding participants with fibromyalgia (n = 50) and medication-overuse headache (n = 21), endothelin-1 levels were still similar among groups (10.51 [7.96-14.10] vs. 9.24 [6.96-10.81] vs. 9.46 [7.00-14.19], p = 0.230). Endothelin-1 levels did not significantly differ among participants with migraine with aura, those with migraine without aura, and controls (9.36 [4.26-13.35] vs. 9.50 [7.23-13.02] vs. 9.46 [7.00-14.19], p = 0.975). There was no significant association of endothelin-1 with headache intensity (mild, 8.99 [8.99-8.99] vs. moderate, 8.71 [6.85-12.15] vs. severe, 9.55 [7.23-13.13], p = 0.517) or headache frequency per month (exponential and 95% confidence interval, 0.709 [0.296-1.698], p = 0.440) in participants with episodic migraine and chronic migraine. CONCLUSIONS Interictal plasma endothelin-1 level is an unlikely marker for episodic migraine and chronic migraine.
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Affiliation(s)
- Jiyoung Kim
- Department of Neurology, Bio Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Chae Gyu Park
- Laboratory of Immunology, Severance Biomedical Science Institute, 37991Yonsei University College of Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Therapeutic Antibody Research Center, Genuv Inc., Seoul, Republic of Korea.,Institute for Immunology and Immunological Diseases, 37991Yonsei University College of Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Kyung Chu
- Department of Neurology, 37991Yonsei University College of Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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de Ávila Oliveira R, Riera R, Vasconcelos V, Baptista-Silva JC. Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev 2021; 12:CD001732. [PMID: 34883526 PMCID: PMC8660237 DOI: 10.1002/14651858.cd001732.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Varicose veins are enlarged and tortuous veins, affecting up to one-third of the world's population. They can be a cause of chronic venous insufficiency, which is characterised by oedema, pigmentation, eczema, lipodermatosclerosis, atrophie blanche, and healed or active venous ulcers. Injection sclerotherapy (liquid or foam) is widely used for treatment of varicose veins aiming to transform the varicose veins into a fibrous cord. However, there is limited evidence regarding its effectiveness and safety, especially in patients with more severe disease. This is the second update of the review first published in 2002. OBJECTIVES To assess the effectiveness and safety of injection sclerotherapy for the treatment of varicose veins. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, CINAHL, and LILACS databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registries, on 20 July 2021. SELECTION CRITERIA We included all randomised controlled trials (RCTs) (including cluster-randomised trials and first phase cross-over studies) that used injection sclerotherapy for the treatment of varicose veins. DATA COLLECTION AND ANALYSIS Two review authors independently assessed, selected and extracted data. Disagreements were cross-checked by a third review author. We used Cochrane's Risk of bias tool to assess the risk of bias. The outcomes of interest were cosmetic appearance, complications, residual varicose veins, quality of life (QoL), persistence of symptoms, and recurrent varicose veins. We calculated risk ratios (RRs) or mean difference (MD) with 95% confidence intervals (CIs). We used the worst-case-scenario for dichotomous data imputation for intention-to-treat analyses. For continuous outcomes, we used the 'last-observation-carried-forward' for data imputation if there was balanced loss to follow-up. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 23 new RCTs for this update, bringing the total to 28 studies involving 4278 participants. The studies differed in their design, and in which sclerotherapy method, agent or concentration was used. None of the included RCTs compared sclerotherapy to no intervention or to any pharmacological therapy. The certainty of the evidence was downgraded for risk of bias, low number of studies providing information for each outcome, low number of participants, clinical differences between the study participants, and wide CIs. Sclerotherapy versus placebo Foam sclerotherapy may improve cosmetic appearance as measured by IPR-V (independent photography review - visible varicose veins scores) compared to placebo (polidocanol 1%: mean difference (MD) -0.76, 95% CI -0.91 to -0.60; 2 studies, 223 participants; very low-certainty evidence); however, deep vein thrombosis (DVT) rates may be slightly increased in this intervention group (RR 5.10, 95% CI 1.30 to 20.01; 3 studies, 302 participants; very low-certainty evidence). Residual varicose vein rates may be decreased following polidocanol 1% compared to placebo (RR 0.19, 95% CI 0.13 to 0.29; 2 studies, 225 participants; very low-certainty evidence). Following polidocanol 1% use, there may be a possible improvement in QoL as assessed using the VEINES-QOL/Sym questionnaire (MD 12.41, 95% CI 9.56 to 15.26; 3 studies, 299 participants; very low-certainty evidence), and possible improvement in varicose vein symptoms as assessed using the Venous Clinical Severity Score (VCSS) (MD -3.25, 95% CI -3.90 to -2.60; 2 studies, 223 participants; low-certainty evidence). Recurrent varicose veins were not reported for this comparison. Foam sclerotherapy versus foam sclerotherapy with different concentrations Three individual RCTs reported no evidence of a difference in cosmetic appearance after comparing different concentrations of the intervention; data could not be pooled for two of the three studies (RR 1.11, 95% CI 0.84 to 1.47; 1 study, 80 participants; very low-certainty evidence). Similarly, there was no clear difference in rates of thromboembolic complications when comparing one foam concentration with another (RR 1.47, 95% CI 0.41 to 5.33; 3 studies, 371 participants; very low-certainty evidence). Three RCTs investigating higher concentrations of polidocanol foam indicated the rate of residual varicose veins may be slightly decreased in the polidocanol 3% foam group compared to 1% (RR 0.67, 95% CI 0.43 to 1.04; 3 studies, 371 participants; moderate-certainty evidence). No clear improvement in QoL was detected. Two RCTs reported improved VCSS scores with increasing concentrations of foam. Persistence of symptoms were not reported for this comparison. There was no clear difference in recurrent varicose vein rates (RR 0.91, 95% CI 0.62 to 1.32; 1 study, 148 participants; low-certainty evidence). Foam sclerotherapy versus liquid sclerotherapy One RCT reported on cosmetic appearance with no evidence of a difference between foam or liquid sclerotherapy (patient satisfaction scale MD 0.2, 95% CI -0.27 to 0.67; 1 study, 126 participants; very low-certainty evidence). None of the RCTs investigated thromboembolic complications, QoL or persistence of symptoms. Six studies individually showed there may be a benefit to polidocanol 3% foam over liquid sclerotherapy in reducing residual varicose vein rate; pooling data from two studies showed a RR of 0.51, with 95% CI 0.41 to 0.65; 203 participants; very low-certainty evidence. One study reported no clear difference in recurrent varicose vein rates when comparing sodium tetradecyl sulphate (STS) foam or liquid (RR 1.10, 95% CI 0.86 to 1.42; 1 study, 286 participants; very low-certainty evidence). Sclerotherapy versus sclerotherapy with different substances Four RCTs compared sclerotherapy versus sclerotherapy with any other substance. We were unable to combine the data due to heterogeneity or assess the certainty of the evidence due to insufficient data. AUTHORS' CONCLUSIONS There is a very low to low-certainty evidence that, compared to placebo, sclerotherapy is an effective and safe treatment for varicose veins concerning cosmetic appearance, residual varicose veins, QoL, and persistence of symptoms. Rates of DVT may be slightly increased and there were no data concerning recurrent varicose veins. There was limited or no evidence for one concentration of foam compared to another; foam compared to liquid sclerotherapy; foam compared to any other substance; or one technique compared to another. There is a need for high-quality trials using standardised sclerosant doses, with clearly defined core outcome sets, and measurement time points to increase the certainty of the evidence.
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Affiliation(s)
| | - Rachel Riera
- Cochrane Brazil Rio de Janeiro, Cochrane, Petrópolis, Brazil
| | - Vladimir Vasconcelos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Cc Baptista-Silva
- Evidence Based Medicine, Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
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8
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Rabe E, Breu FX, Flessenkämper I, Gerlach H, Guggenbichler S, Kahle B, Murena R, Reich-Schupke S, Schwarz T, Stücker M, Valesky E, Werth S, Pannier F. Sclerotherapy in the treatment of varicose veins : S2k guideline of the Deutsche Gesellschaft für Phlebologie (DGP) in cooperation with the following societies: DDG, DGA, DGG, BVP. DER HAUTARZT 2021; 72:23-36. [PMID: 33252705 PMCID: PMC8692296 DOI: 10.1007/s00105-020-04705-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- E Rabe
- Emeritus Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Bonn (AöR), Venusberg-Campus 1, 53127, Bonn, Germany.
| | | | | | | | | | - B Kahle
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - R Murena
- Phlebologische Praxis, Köln, Germany
| | - S Reich-Schupke
- Privatpraxis für Haut- und Gefäßmedizin, Wundtherapie, Recklinghausen, Germany
| | - T Schwarz
- Praxis für Gefäßmedizin, Freiburg, Germany
| | - M Stücker
- Klinik für Dermatologie, Venerologie und Allergologie, Ruhr-Universität Bochum, St. Josef Hospital, Bochum, Germany
| | - E Valesky
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinik Frankfurt, Frankfurt, Germany
| | - S Werth
- Universitäts-Gefäßzentrum, Innere Medizin III, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - F Pannier
- Praxis Dermatologie & Phlebologie Bonn und Dermatologische Universitätsklinik Köln, Bonn, Germany
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Gajo EC, Kavinsky CJ, Murphy J, Suradi HS. The pivotal role of PFO in paradoxical embolism following venous sclerotherapy: a unique case report with pathological correlations. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab228. [PMID: 34514300 PMCID: PMC8422334 DOI: 10.1093/ehjcr/ytab228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/12/2021] [Accepted: 05/12/2021] [Indexed: 11/14/2022]
Abstract
Background Vein sclerosing therapy for varicose veins remains an extremely popular procedure. Cerebrovascular accidents can be a serious complication. A patent foramen ovale (PFO) can act as a conduit to the arterial circulation, which could explain the adverse neurologic consequence of this procedure. This case provides pathologic evidence of this concept. Case summary A 66-year-old female presented with syncope after undergoing varicose vein sclerotherapy. A computed tomography angiography of the head and neck in the emergency room revealed an occluded right distal M1 middle cerebral artery. Clot retrieval was performed with final pathology revealing amorphous material consistent with an exogenous agent, polidocanol foam, which was used for the patient’s vein sclerotherapy. A transthoracic echocardiogram and transoesophageal echocardiogram showed a PFO, which was ultimately closed percutaneously. Discussion In a quarter of the population, lack of closure of the intrauterine interatrial shunt leads to the existence of a PFO. This direct communication between the atria provides an anatomical conduit for paradoxical emboli and eventually infarction of affected tissues. While a paradoxical embolism is an uncommon cause of acute arterial occlusion, it can have catastrophic sequelae. Historically, the presence of an arterial thrombus from the venous circulation has been difficult to establish unless the thrombus is visualized in transit through a PFO. Complications from vein sclerotherapy have been reported in the literature and include transient ischaemic attacks and strokes, however, this is the first case to provide pathological proof of a paradoxical embolism, which ultimately resulted in percutaneous closure of the PFO.
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Affiliation(s)
- Eileen C Gajo
- Division of Cardiology, Department of Medicine, Rush University Medical Center, 1620 West Harrison Street, Chicago, IL 60612, USA
| | - Clifford J Kavinsky
- Division of Cardiology, Department of Medicine, Rush University Medical Center, 1620 West Harrison Street, Chicago, IL 60612, USA
| | - Joshua Murphy
- Division of Cardiology, Department of Pediatrics, Rush University Medical Center, 1620 West Harrison Stress, Chicago, IL 60612, USA
| | - Hussam S Suradi
- Division of Cardiology, Department of Medicine, Rush University Medical Center, 1620 West Harrison Street, Chicago, IL 60612, USA
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10
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[Guidelines for sclerotherapy of varicose veins : S2k guideline of the German Society of Phlebology (DGP) in cooperation with the following professional associations: DDG, DGA, DDG, BVP. German Version]. DER HAUTARZT 2021; 72:50-64. [PMID: 33151348 DOI: 10.1007/s00105-020-04707-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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11
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Kim PS, Elias S, Gasparis A, Labropoulos N. Results of polidocanol endovenous microfoam in clinical practice. J Vasc Surg Venous Lymphat Disord 2020; 9:122-127. [PMID: 32353594 DOI: 10.1016/j.jvsv.2020.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 04/11/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Initial phase III clinical studies with polidocanol endovenous microfoam (PEM) demonstrated its safety and efficacy in the treatment of superficial venous reflux. In those studies, the primary outcome requirement was to assess the improvement in symptoms related to superficial venous disease. The goal of the present study was to evaluate the efficacy of PEM technology in routine clinical practice-specifically, the closure rates after treatment. METHODS We performed an observational study during which data were prospectively collected from 2 vein centers using an electronic database. Patients with CEAP (clinical, etiologic, anatomic, pathophysiologic) class ≥2 and symptomatic superficial axial reflux (great saphenous vein, anterior accessory saphenous vein, and small saphenous vein) were included and followed up prospectively. PEM was used to treat the saphenous vein and varicosities. The CEAP classification was used to classify chronic venous disease, and the venous clinical severity score (VCSS) was applied to measure the disease severity. Pain and discomfort were assessed using a visual analog scale, and the residual veins were assessed by physical examination. RESULTS PEM was used to treat superficial reflux in 60 patients. The CEAP classification was C2 for 32 patients, C3 for 14, C4 for 10, and C5 for 4 patients. The average pretreatment VCSS was 7.3. The saphenous vein diameter was 6.5 mm, and the average length was 31 cm. The average volume of PEM used to treat the saphenous veins was 9.3 mL. The closure rate at 3 and 6 months was 93% (54 of 58) and 93% (51 of 55), respectively. The VCSS had improved from 7.3 to 1.4. Complications included 1 case of deep vein thrombosis (1.7%), 5 patients (8.3%) with thrombophlebitis, and 4 patients (6.6%) with skin pigmentation. CONCLUSIONS PEM is safe and effective for the treatment of saphenous reflux and varicosities. The early closure rates using PEM were maintained at 6 months and are comparable to the results reported with nonthermal, nontumescent technologies and thermal tumescent technologies.
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Affiliation(s)
- Pamela S Kim
- Department of Surgery, Stony Brook Medicine, Stony Brook, NY
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12
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Kahraman N, Özsin KK. Ultrasound-guided catheter-directed foam sclerotherapy can be safely applied for the treatment of great saphenous varicose veins in elderly patients. Vascular 2020; 28:597-603. [PMID: 32281494 DOI: 10.1177/1708538120915102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Although many published series have shown the results of ultrasound-guided catheter-directed foam sclerotherapy, little is known about the outcomes and complications in older patients. METHODS A total of 152 patients older than 65 years (group 1: 61.8% male, mean age 69.0 ± 4.5 years) and 244 patients younger than 65 years (group 2: 48.8% male, mean age 45.7 ± 11.2 years) were included in the study. Ultrasound-guided catheter-directed foam sclerotherapy was performed in patients with great saphenous vein valvular incompetence and saphenofemoral junction incompetence. Occlusion status was recorded by ultrasonography. Venous clinical severity score and visual analog score were calculated pre- and post-intervention. RESULTS Complete occlusion rate of the great saphenous vein at 12 months post-procedure for the groups 1 and 2 was 86.4% and 86.3%, respectively. Venous clinical severity score and visual analog score were significantly different before ultrasound-guided catheter-directed foam sclerotherapy and four weeks after ultrasound-guided catheter-directed foam sclerotherapy (p < 0.001) in both the groups. There were no observed major complications in both the groups. CONCLUSIONS With low complication rate and acceptable total occlusion rate, ultrasound-guided catheter-directed foam sclerotherapy can be considered a reliable treatment for older patients.
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Affiliation(s)
- Nail Kahraman
- Bursa Yüksek İhtisas Training and Research Hospital Cardiovasculary Surgery Department, Bursa, Turkey
| | - Kadir K Özsin
- Bursa Yüksek İhtisas Training and Research Hospital Cardiovasculary Surgery Department, Bursa, Turkey
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14
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Sommer RJ, Nazif T, Privitera L, Robbins BT. Retrospective review of thienopyridine therapy in migraineurs with patent foramen ovale. Neurology 2019; 91:1002-1009. [PMID: 30478066 DOI: 10.1212/wnl.0000000000006572] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 07/12/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We retrospectively reviewed our clinical experience using off-label thienopyridine agents in patients with migraine headache (MHA) and patent foramen ovale (PFO). METHODS Between 2011 and 2017, MHA/PFO patients referred to our practice were clinically treated with clopidogrel specifically for MHA. Those with ≥50% reduction in monthly MHA days compared with baseline were deemed MHA responders. MHA nonresponders with inadequate platelet inhibition by PRU testing were offered prasugrel. Thienopyridine-responsive patients were then offered PFO closure. RESULTS Of 136 patients (86% female, mean age 37.9 years, mean MHA burden 14.7 days/month), 80 (59%) were MHA responders to clopidogrel. The clopidogrel responder rate was equivalent in episodic, chronic, aura, and nonaura subgroups. A total of 19/45 (40%) MHA nonresponders had inadequate platelet inhibition by PRU testing on clopidogrel. Sixteen of those patients received prasugrel, were adequately platelet inhibited by PRU, and 10/16 (62%) converted to MHA responders. A total of 56/90 thienopyridine-responsive patients underwent subsequent PFO closure with thienopyridine discontinuation after 3 months. Ninety-four percent had ongoing MHA relief. A total of 8/8 responders who stopped thienopyridine without PFO closure had resumption of MHA symptoms. CONCLUSION Successful P2Y12 platelet inhibition seemed to reduce MHA symptoms in some patients with PFO, suggesting a platelet-based mechanism/trigger. The nearly parallel response to PFO closure may mechanistically link venous platelet activation with the right-to-left shunt of PFO. Thienopyridine responsiveness could be used to enrich the study population for a new MHA/PFO trial. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that in patients with PFO, P2Y12 inhibition improved MHA symptoms.
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Affiliation(s)
- Robert J Sommer
- From the Herbert and Sandi Feinberg Interventional Cardiology and Heart Valve Center, New York-Presbyterian Hospital/Columbia University Medical Center, NY.
| | - Tamim Nazif
- From the Herbert and Sandi Feinberg Interventional Cardiology and Heart Valve Center, New York-Presbyterian Hospital/Columbia University Medical Center, NY
| | - Lauren Privitera
- From the Herbert and Sandi Feinberg Interventional Cardiology and Heart Valve Center, New York-Presbyterian Hospital/Columbia University Medical Center, NY
| | - Barbara T Robbins
- From the Herbert and Sandi Feinberg Interventional Cardiology and Heart Valve Center, New York-Presbyterian Hospital/Columbia University Medical Center, NY
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15
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Kürşat Bozkurt A, Lawaetz M, Danielsson G, Lazaris AM, Pavlovic M, Olariu S, Rasmussen L. European College of Phlebology guideline for truncal ablation. Phlebology 2019; 35:73-83. [DOI: 10.1177/0268355519857362] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background The purpose of the guideline was to achieve consensus in the care and treatment of patients with chronic venous disease, based on current evidence. Method A systematic literature search was performed in PubMed, Embase, Cinahl, and the Cochrane library up until 1 February 2019. Additional relevant literature were added through checking of references. Level of evidence was graded through the GRADE scale and recommendations were concluded. Results For the treatment of great and small saphenous vein reflux, endovenous ablation with laser or radiofrequency was recommended in preference to surgery or foam sclerotherapy. If tributaries are to be treated it should be done in the same procedure. Treatment with mecanicochemical ablation and glue can be used but we still need long term follow up results. Conclusion For the treatment of truncal varicosities, endovenous ablation with laser or radiofrequency combined with phlebectomies is recommended before surgery or foam.
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Affiliation(s)
- A Kürşat Bozkurt
- Department of Cardiovascular Surgery, Istanbul University – Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Martin Lawaetz
- Rigshospitalet, Department of Vascular Surgery, Copenhagen, Denmark
- The Danish Vein Centers, Naestved, Denmark
| | | | - Andreas M Lazaris
- Department of Vascular Surgery, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Milos Pavlovic
- Infinity Family Medicine Clinic, Dubai, United Arab Emirates
| | - Sorin Olariu
- Victor Babes University of Medicine and Pharmacy of Timisoara
- UMFT, Surgery 1st, Timişoara, Romania
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Bittencourt AH, Dallanora DV, Bacega NR, Cembranel VS. Cerebrovascular ischemia following ultrasound-guided foam sclerotherapy. J Vasc Bras 2019; 17:333-336. [PMID: 30787953 PMCID: PMC6375263 DOI: 10.1590/1677-5449.004418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Cerebral ischemia is a very rare and harmful complication of ultrasound-guided foam sclerotherapy for treatment of varicose veins. This case describes a documented cerebrovascular ischemia in Broca’s area following ultrasound-guided foam sclerotherapy. Less than one hour after intravenous injection of 10 ml of sclerosing foam, an otherwise healthy woman experienced aphasia without any other signs of neurological changes. When she arrived home, a complete inability to talk was observed. The event was misdiagnosed by another doctor as an allergic reaction. Next morning she came to the office to report the allergic reaction, where an appropriate diagnosis was made. She recovered just two days after the injection, but signs of recent cerebral ischemia were seen in Broca’s area on magnetic resonance and transesophageal bubble study echocardiogram revealed a patent foramen ovale. Although rare, we must make great effort to prevent these events instead of treating them.
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17
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Mawet J, Karst M. An open window to close the hole. Neurology 2018; 91:993-994. [DOI: 10.1212/wnl.0000000000006559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Deak ST. Retrograde administration of ultrasound-guided endovenous microfoam chemical ablation for the treatment of superficial venous insufficiency. J Vasc Surg Venous Lymphat Disord 2018; 6:477-484. [PMID: 29909854 DOI: 10.1016/j.jvsv.2018.03.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/08/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This study measured patient outcomes among symptomatic patients with superficial chronic venous insufficiency who were treated with retrograde ultrasound-guided polidocanol microfoam 1% in a community setting. METHODS Between March 2015 and June 2017, 250 symptomatic patients with C2-C6 chronic venous insufficiency received polidocanol microfoam 1% and were followed for 16 ± 7 months. Sixteen of the 250 patients (6.4%) had skin ulcers, and 56 (22.4%) were treated previously with thermal or surgical interventions. All patients underwent a duplex ultrasound venous incompetence study to map perforators and veins to be treated. Incompetent veins were accessed with a micropuncture needle distal to the midthigh perforator, approximately 10 cm above the knee fold. The leg was then elevated 45°. Under ultrasound guidance, the incompetent greater saphenous vein was closed with polidocanol microfoam 1%. A second injection was administered through the same catheter directing the microfoam to flow in a retrograde fashion through the incompetent venous valves to the ankle. RESULTS All patients completed the initial treatment; 55 (22.0%) required planned secondary treatment during the follow-up period for residual venous reflux in the below-knee greater saphenous vein. Complete elimination of venous valvular reflux and symptom improvement was documented in 236 patients (94.4%). Minor adverse events included asymptomatic deep vein thrombi (n = 2), common femoral vein thrombus extension (n = 1), and superficial venous thrombi (n = 4). Of the 16 patients with skin ulcers, 10 were C6 patients and 80% experienced wound closure within 4 weeks of treatment. CONCLUSIONS Retrograde administration of polidocanol microfoam 1% is a safe and effective treatment with important clinical benefit for superficial venous insufficiency in community practice.
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Oliveira RDÁ, Mazzucca ACP, Pachito DV, Riera R, Baptista-Silva JCDC. Evidence for varicose vein treatment: an overview of systematic reviews. SAO PAULO MED J 2018; 136:324-332. [PMID: 30020324 PMCID: PMC9881696 DOI: 10.1590/1516-3180.2018.0003240418] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/24/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Varicose veins affect nearly 30% of the world's population. This condition is a social problem and needs interventions to improve quality of life and reduce risks. Recently, new and less invasive methods for varicose vein treatment have emerged. There is a need to define the best treatment options and to reduce the risks and costs. Since there are cosmetic implications, treatments for which effectiveness remains unproven present risks to consumers and higher costs for stakeholders. These risks and costs justify conducting an overview of systematic reviews to summarize the evidence. DESIGN AND SETTING Overview of systematic reviews within the Discipline of Evidence-Based Health, at Universidade Federal de São Paulo (UNIFESP). METHODS Systematic reviews on clinical or surgical treatments for varicose veins were included, with no restrictions on language or publication date. RESULTS 51 reviews fulfilled the inclusion criteria. Outcomes and comparators were described, and a narrative review was conducted. Overall, there was no evidence that compression stockings should be recommended for patients as the initial treatment or after surgical interventions. There was low to moderate evidence that minimally invasive therapies (endovenous laser therapy, radiofrequency ablation or foam sclerotherapy) are as safe and effective as conventional surgery (ligation and stripping). Among these systematic reviews, only 18 were judged to present high quality. CONCLUSIONS There was evidence of low to moderate quality that minimally invasive treatments, including foam sclerotherapy, laser and radiofrequency therapy are comparable to conventional surgery, regarding effectiveness and safety for treatment of varicose veins.
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Affiliation(s)
- Ricardo de Ávila Oliveira
- MD, MSc. Vascular Surgeon, Adjunct Professor, Universidade Federal de Uberlândia (UFU), Uberlândia (MG), and Postgraduate Student in the Evidence-Based Health Program, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
| | - Andréa Castro Porto Mazzucca
- BSc. Pharmacist and Postgraduate Student in the Evidence-Based Health Program, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
| | - Daniela Vianna Pachito
- MD, MSc. Neurologist and Postgraduate Student in the Evidence-Based Health Program, Universidade Federal de São Paulo, (UNIFESP), São Paulo (SP), Brazil.
| | - Rachel Riera
- MD, PhD. Rheumatologist, Assistant Professor of the Discipline of Evidence-based Health, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), and Assistant Coordinator at Cochrane Brazil, São Paulo (SP), Brazil.
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Abstract
Varicose veins are a very common condition and have been the subject of a recent proliferation of treatment modalities. The advent of the endovenous treatment era has led to a confusing array of different techniques that can be daunting when making the transition from traditional surgery. All modalities offer excellent results in the right situation, and each has its own treatment profile. Thermal ablation techniques have matured and have a reassuring and reliable outcome, but the arrival of nonthermal techniques has delivered further options for both patient and surgeon. This article provides an overview of the different treatment devices and modalities available to the modern superficial vein surgeon and details the currently available evidence and summation analysis to help surgeons to make an appropriate treatment choice for their patients.
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Affiliation(s)
- Amjad Belramman
- 1 Section of Vascular Surgery, Imperial College London, London, United Kingdom
| | - Roshan Bootun
- 1 Section of Vascular Surgery, Imperial College London, London, United Kingdom
| | - Tristan R A Lane
- 1 Section of Vascular Surgery, Imperial College London, London, United Kingdom.,2 Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Alun H Davies
- 1 Section of Vascular Surgery, Imperial College London, London, United Kingdom.,2 Imperial College Healthcare NHS Trust, London, United Kingdom
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Critello CD, Fiorillo AS, Cristiano MC, de Franciscis S, Serra R. Effects of sulodexide on stability of sclerosing foams. Phlebology 2018; 34:191-200. [PMID: 29871533 DOI: 10.1177/0268355518779844] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Foam sclerotherapy is a clinical procedure for the treatment of unhealthy veins. The aim of this study was to investigate the effect of sulodexide (SUL) on stability of foams prepared using polidocanol (POL) and sodium tetradecyl sulfate (STS) detergents, more specifically with 0.25% aethoxysclerol and 0.2% Fibro-Vein sclerosing solutions. METHODS Foams were produced by the Tessari method using three different weight ratios of POL-SUL and STS-SUL (1:0, 1:1, and 1:3). RESULTS The half-life of STS foams resulted as follows: 82 ± 1.6 s, 101.8 ± 2.6 s, and 109.7 ± 2.1 s for 1:0, 1:1, and 1:3 STS-SUL weight ratios, respectively. The same ratios were used for POL foams with the following results: 90.6 ± 3 s, 106.8 ± 2.6 s, and 107.6 ± 2.7 s for 1:0, 1:1, and 1:3 POL-SUL weight ratios, respectively. CONCLUSION The addition of SUL in sclerosing solutions can prolong the half-life of foams, and it could be potentially used as a foam stabilizer.
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Affiliation(s)
- Costantino Davide Critello
- 1 Department of Surgical and Medical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy.,2 Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Antonino S Fiorillo
- 3 Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Maria Chiara Cristiano
- 3 Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Stefano de Franciscis
- 1 Department of Surgical and Medical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy.,2 Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- 1 Department of Surgical and Medical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy.,2 Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy
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Prospective Comparison of Effect of Ligation and Foam Sclerotherapy with Foam Sclerotherapy Alone for Varicose Veins. Ann Vasc Surg 2018; 49:75-79. [PMID: 29428536 DOI: 10.1016/j.avsg.2018.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 09/29/2017] [Accepted: 01/29/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND To compare the efficacy of ligation after foam sclerotherapy (FSL) with foam sclerotherapy (FS) alone for patients with varicose veins prospectively. METHODS Ninety-four patients with varicose veins underwent foam sclerothrapy alone and 88 patients with varicose veins received FSL. Patients were followed up at 1, 3, 6, and 12 months after treatment. The postoperative complications were documented prospectively. RESULTS In comparison with patients who underwent FSL, patients treated with FS only had higher incidence of phlebitis within 4 weeks (14.9% vs. 1.1%, P = 0.002) and at 6 months (10.6% vs. 0, P = 0.002) after treatment and had higher incidence of tenderness or discomfort (9.8% vs. 0, P = 0.003) and recanalization rate (8.5% vs. 1.1%, P = 0.007) at 6 months after treatment. All patients in both groups had no deep vein thrombosis and pulmonary embolism. CONCLUSIONS Patients treated with FSL have less postoperative complications than those with foam sclerotheray alone. FSL is an alternative procedure for management of patients with varicose veins. Also, a randomized prospective study is required to observe the long-term outcomes of the FSL.
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Abstract
Sclerotherapy has wide applicability in treating venous disease at every stage of clinical disease. The various sclerosant drugs and formulations each have unique properties, utilities, and side effects. Treating physicians should be aware of the differences between agents, accounting for disease presentation, vein characteristics, and patient comorbidities when selecting the appropriate sclerosing agents. Successful outcomes rely on proper patient evaluation and assessment for contraindications to sclerotherapy. Thorough patient education regarding realistic expectations with sclerotherapy in terms of symptoms relief, recurrence, and improvement in appearance is of chief importance.
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Buture A, Khalil M, Ahmed F. Iatrogenic visual aura: a case report and a brief review of the literature. Ther Clin Risk Manag 2017; 13:643-646. [PMID: 28553121 PMCID: PMC5440068 DOI: 10.2147/tcrm.s134178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Iatrogenic migraine aura following transseptal catheterization has only rarely been reported in the literature. We report the case of a 60-year-old female who presented with new onset of migraine with visual aura 1 day after transseptal cryoballoon catheter ablation for atrial fibrillation. The patient had a 5-year history of typical migraine without aura and had never experienced visual aura before the cardiac intervention. The neurological examination, fundoscopy, and blood tests were normal. The magnetic resonance imaging of the brain showed small vessel ischemia without evidence of vessel ischemic changes in the occipital lobes and large blood vessel disease. A change in the characteristics of existing migraine could occur following an iatrogenic episode, which in this case was catheter ablation for atrial fibrillation. A new onset of aura is considered an indication for a brain scan as it may signify underlying new pathology.
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Affiliation(s)
- Alina Buture
- Neurology Department, Hull Royal Infirmary, Hull, UK
| | - Modar Khalil
- Neurology Department, Hull Royal Infirmary, Hull, UK
| | - Fayyaz Ahmed
- Neurology Department, Hull Royal Infirmary, Hull, UK
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Leger CS, DeSouza JFX. Migraine Modulation and Debut after Percutaneous Atrial Septal Defect Closure: A Review. Front Neurol 2017; 8:68. [PMID: 28373854 PMCID: PMC5357661 DOI: 10.3389/fneur.2017.00068] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 02/15/2017] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Change in migraine headache (MH)-preexisting MH change or development of de novo MH-are known potential complications following percutaneous closure of atrial septal defect (ASD), but consensus on a causal trigger remains elusive. OBJECTIVES To expose potential MH triggers linked, mainly by timing and occurrence, to the emergence of de novo MH or change in preexisting MH subsequent to percutaneous ASD closure (pASDC). METHODS The literature was systematically searched for studies available in English reporting MH status after pASDC published between January 1, 1990 and November 15, 2015. We determined the number and percentage of patients experiencing MH status change within 7 days post procedure and the cumulative total by final follow-up (Mdn = 12 months). RESULTS Twenty-five studies met the inclusion criteria, which accounted for a total of 1,646 pASDC patients. Pre-procedure MH prevalence was 8% (126/1,646). Change in preexisting MH occurred in a total of 72% (91/126), 12% (11/91) within 7-days after pASDC; within follow-up MH improved in 14% (18/126), resolved in 37% (47/126), but persisted in 63% (79/126). De novo MH incidence ranged between 10 (153/1,520) and 18.3% (153/836); 34% incipience (52/153) was within 7-days of pASDC; females accounted for 80% (63/79) of gender differentiated cases; of type distinguished cases, 42% (51/122) were MH without aura (MO) and 58% (71/122) were MH with aura (MA); MH improved in 10% (16/153), resolved in 24% (37/153) but persisted beyond final follow-up in 76% (116/153). Antiplatelet agents were effective modulators of MH in 44% (11/25) studies. Possible adverse MH-predisposing traits were scarce: larger ASD size reported in ~2% (39/1,646) of patients experiencing de novo MH or preexisting MH exacerbation; short aortic rim reported in three de novo MH patients; allergic response to occluder nickel alloy in four patients with MH status change from baseline (de novo or preexisting MH change not specified). INTERPRETATION Early intensification of MH status change but later amelioration (virtually paralleling stages of endothelialization), relatively high efficacy of antiplatelet agents, and the emergence of MA as the dominant de novo MH type favor proinflammatory triggers of MH status change after pASDC.
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Affiliation(s)
- Charles Stevens Leger
- Department of Psychology, Centre for Vision Research, York University, Toronto, ON, Canada
| | - Joseph F. X. DeSouza
- Department of Psychology, Centre for Vision Research, York University, Toronto, ON, Canada
- Neuroscience Diploma, York University, Toronto, ON, Canada
- Centre for Vision Research, York University, Toronto, ON, Canada
- Department of Biology, York University, Toronto, ON, Canada
- Canadian Action and Perception Network (CAPnet), Toronto, ON, Canada
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Critello CD, Fiorillo AS, Matula TJ. Size of Sclerosing Foams Prepared by Ultrasound, Mechanical Agitation, and the Handmade Tessari Method for Treatment of Varicose Veins. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:649-658. [PMID: 28127790 DOI: 10.7863/ultra.16.02052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 06/27/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Sclerotherapy is a therapeutic method used in the treatment of varicose veins and works by occluding damaged blood vessels with a chemical solution. Foam sclerotherapy is an attractive treatment because the results are more effective than those obtained by using liquid sclerosants. However, serious neurologic complications, which are likely related to air embolism, have been reported after treatment with foams generated by the handmade method (Tessari technique) most often used clinically. We present an alternative ultrasonic technique for preparation of sclerosing foams to treat varicose veins. METHODS Three methods of foam generation were compared: ultrasound, mechanical agitation, and Tessari techniques. RESULTS Optical microscopic analyses showed that low-frequency ultrasound can generate foams with smaller bubble distributions compared to those produced by handmade and mechanical agitation methods: 98% of the bubble population was less than 55 ± 10 μm for sonicated foams (mean ± SD, 19 ± 1.8 μm; maximum bubble size, <138.3 ± 32.5 μm), 196.7 ± 38.2 μm for mechanically agitated foams (mean, 37.1 ± 10.6 μm; maximum bubble size, <350 ± 70.9 μm), and 211.7 ± 20.8 μm for handmade foams (mean, 30.8 ± 3.8 μm; maximum bubble size, <445 ± 32.8 μm). CONCLUSIONS Low-frequency ultrasonic foam generation yields smaller bubbles and more uniform size distributions than other investigated methods. These properties may reduce serious adverse events reported for sclerotherapy of varicose veins, increasing the safety of foam treatment.
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Affiliation(s)
| | | | - Thomas J Matula
- Applied Physics Laboratory, University of Washington, Seattle, Washington, USA
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Rastel D. Immediate and transient faintness following a course of foam sclerotherapy treatment for saphenous vein incompetence in an elderly patient. JOURNAL DES MALADIES VASCULAIRES 2016; 41:412-415. [PMID: 27815001 DOI: 10.1016/j.jmv.2016.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 09/18/2016] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Adverse effects of sclerotherapy are rare. They are divided into two categories: immediate and delayed. Immediate adverse effects are mainly represented by visual disturbances. We are reporting the case of an immediate transient faintness following two sessions of foam sclerotherapy. OBSERVATION An 80-year-old active female with superficial chronic venous disorder and no significant medical or surgical backgrounds experienced two similar immediate general adverse events following two sessions of sclerotherapy from a total of five. Adverse reactions included faintness, associated with headache but without visual disturbance, lasting ten minutes with full short and long-term recoveries. The common factor between those two sessions was the injection of a higher volume of sclerosing agent compared to the other sessions, 5mL of which was foam. CONCLUSION Age is not a contraindication of foam sclerotherapy. Nevertheless, we must proceed with caution even when moderate quantities of foam are required.
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Affiliation(s)
- D Rastel
- Selurl Philangio, 30, place Louis-Jouvet, 38100 Grenoble, France.
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Lindblad M, Hougaard A, Amin FM, Ashina M. Can migraine aura be provoked experimentally? A systematic review of potential methods for the provocation of migraine aura. Cephalalgia 2016; 37:74-88. [DOI: 10.1177/0333102416636097] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background The nature of the migraine aura and its role in migraine pathophysiology is incompletely understood. In particular, the mechanisms underlying aura initiation and the causal relation between aura and headache are unknown. The scientific investigation of aura in patients is only possible if aura can be triggered. This paper reviews potential methods for the experimental provocation of migraine aura. Methods We systematically searched PubMed for studies of experimental migraine provocation, including case reports of patients with aura and reports of the occurrence of aura following exposure to any kind of suspected trigger. Results We identified 21 provocation studies, using 13 different prospective provocation methods, and 34 case reports. In the prospective studies, aura were reported following the administration of intravenous and sublingual glyceryl trinitrate, visual stimulation, physical activity, calcitonin gene-related peptide infusion, chocolate ingestion, and the intravenous injection of insulin. In addition, carotid artery puncture has consistently been reported as a trigger of aura. Conclusions No safe and efficient method for aura provocation exists at present, but several approaches could prove useful for this purpose.
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Affiliation(s)
- Marianne Lindblad
- Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Anders Hougaard
- Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Faisal Mohammad Amin
- Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Messoud Ashina
- Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Güneş T, Serinken M, Alur İ, Beydilli H, Karcioglu O, Eken C. YouTube as a source of information on varicose veins. Phlebology 2016; 31:501-505. [PMID: 26187946 DOI: 10.1177/0268355515596894] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2024]
Abstract
BACKGROUND There has been little investigation of videos related to varicose veins in Internet media. This study aimed to investigate the characteristics and scientific accuracy of the videos related to varicose veins which were uploaded to the youtube.com website. METHODS The YouTube site was searched in October 2014 using the keywords varicose vein, varicose veins, and varicosis with no filter. The contents of the reviewed videos were assigned to three groups as useful, partly useful, and not useful by using the criteria including the scientific contents of the videos, contemporariness and accuracy of the insight, and presentation of the data particularly regarding the visual features. The statistical analysis was based only on the videos rated as 'useful.' RESULTS In total, 1519 (84.4%) of 1800 videos evaluated were excluded. Many of the sources uploading videos to the website were healthcare professionals (32.7% n = 92). Regarding the source of the upload, those from official institutions/associations were viewed statistically significantly more often than videos uploaded by all others (p = 0.001). The rated usefulness was significantly higher for videos uploaded by official institutions/associations (100%) than those uploaded by others (p = 0.01). CONCLUSIONS Official institutions/associations should be encouraged to produce and upload videos including up-to-date and comprehensive information regarding the disease. Likewise, additional search tools would be useful to locate videos uploaded by academic figures and institutions.
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Affiliation(s)
- Tevfik Güneş
- Department of Cardiovascular Surgery, Faculty of Medicine, Pamukkale University, Denizli, Turkey
| | - Mustafa Serinken
- Department of Emergency Medicine, Faculty of Medicine, Pamukkale University, Denizli, Turkey
| | - İhsan Alur
- Department of Cardiovascular Surgery, Faculty of Medicine, Pamukkale University, Denizli, Turkey
| | - Halil Beydilli
- Department of Emergency Medicine, Faculty of Medicine, Mugla Sıtkı Koçman University, Mugla, Turkey
| | - Ozgur Karcioglu
- Department of Emergency Medicine, Faculty of Medicine, Acıbadem University, Istanbul, Turkey
| | - Cenker Eken
- Department of Emergency Medicine, Faculty of Medicine, Akdeniz University, Antalya, Turkey
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Malvehy MA, Asbjornsen C. Transient neurologic event following administration of foam sclerotherapy. Phlebology 2016; 32:66-68. [DOI: 10.1177/0268355516628721] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This report describes a complication of symptoms consistent with transient ischemic attack following administration of physician-compounded foam sclerotherapy created with room air. After intravenous administration of 8 cc of foam sclerosant prepared with room air and polidocanol using the Tessari method, an otherwise healthy man experienced transient neurologic changes. Immediately following injection of foam, a dense hemiplegia consistent with interruption of the middle cerebral arterial circulation was observed. The patient’s symptoms resolved completely over approximately 30 min with interventions including Trendelenburg positioning and supplemental oxygen via nasal cannula. PCP foam sclerotherapy with room air administered in typical concentrations, preparations, and volumes may result in severe neurologic events in otherwise healthy individuals. Continued investigation into the potential role of product, gas, volume and technique to identify optimal approaches may further refine the consistency and safety of foam sclerotherapy.
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Thomson L. Sclerotherapy of telangiectasias or spider veins in the lower limb: A review. JOURNAL OF VASCULAR NURSING 2016; 34:61-2. [PMID: 27210454 DOI: 10.1016/j.jvn.2016.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Lily Thomson
- Section of Vascular Surgery, Health Sciences Centre, Vascular Research Lab, Winnipeg, Manitoba, Canada; St. Boniface General Hospital, Operating Room, Winnipeg, Manitoba, Canada.
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Kim M, Niroumandpour M, Poustinchian B. Transient Ischemic Attack After Foam Sclerotherapy in a Woman With a Patent Foramen Ovale. J Osteopath Med 2016; 116:320-3. [DOI: 10.7556/jaoa.2016.063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Sclerotherapy is an increasingly popular treatment modality for patients with chronic venous insufficiency and varicose veins. Potential complications of foam sclerotherapy include cerebrovascular accidents and transient ischemic attacks (TIAs). We report the case of a 55-year-old woman who had a TIA shortly after undergoing foam sclerotherapy. She had presented for treatment with no confirmed risk factors for microemboli formation or thrombus. After the procedure, however, she had transient visual loss, dysarthria, confusion, and frontal headache, which resolved within 30 minutes of onset. A subsequent diagnosis of a patent foramen ovale was thought to have put her at risk for TIA in the setting of foam sclerotherapy. Osteopathic physicians should be aware of the potential for neurologic sequelae after foam sclerotherapy and inform patients prior to consent.
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Gillet JL, Desnos CH, Lausecker M, Daniel C, Guex JJ, Allaert FA. Sclerotherapy is a safe method of treatment of chronic venous disorders in older patients: A prospective and comparative study of consecutive patients. Phlebology 2016; 32:234-240. [DOI: 10.1177/0268355516642659] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives An aging population requires evaluation of methods of treatment for older patients. Our objective was to evaluate the indications, practical modalities, safety and tolerability of sclerotherapy in patients 75 years of age and older (group 1) and compare with a control group of patients 18 to74 years of age (group 2). Method This observational, multicentre, prospective and comparative study was conducted by the French Society of Phlebology. Each centre collected in 10 to 20 patients ≥75 years of age and an equal number of patients <75 years of age treated by sclerotherapy, the treatment indication, the patient's personal history, the CEAP clinical class, the type of the veins being treated, the characteristics of sclerotherapy and the complications (immediately after treatment and at one-month follow-up). Results Population: In total, 418 patients were enrolled in 15 centres: 176 patients in group 1 (mean: 79.4 years) and 242 patients in group 2 (mean: 52.7 years).CEAP clinical classes C4, C5 and C6, history of deep vein thrombosis (12.5%) and superficial vein thrombosis (11.9%), long-term anticoagulant therapy (9.1%) and antiplatelet therapy (16.5%) were more frequent in older patients.All types of veins were treated from saphenous veins to telangiectasias. Sclerotherapy features: There was no difference in concentration of the sclerosing agents. When foam sclerotherapy was used (84% of patients), the injected volume was lower in group 1. Complications: One vasovagal syncope occurred in group 1. One asymptomatic distal deep vein thrombosis, confined to the Medial Gastrocnemius Veins, was reported in both groups at one-month follow-up. Conclusions This study shows the feasibility and safety of sclerotherapy in older patients, with no specific complications nor need for special precautions.
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Carugo D, Ankrett DN, Zhao X, Zhang X, Hill M, O'Byrne V, Hoad J, Arif M, Wright DDI, Lewis AL. Benefits of polidocanol endovenous microfoam (Varithena®) compared with physician-compounded foams. Phlebology 2015; 31:283-95. [PMID: 26036246 PMCID: PMC4838175 DOI: 10.1177/0268355515589063] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare foam bubble size and bubble size distribution, stability, and degradation rate of commercially available polidocanol endovenous microfoam (Varithena®) and physician-compounded foams using a number of laboratory tests. METHODS Foam properties of polidocanol endovenous microfoam and physician-compounded foams were measured and compared using a glass-plate method and a Sympatec QICPIC image analysis method to measure bubble size and bubble size distribution, Turbiscan™ LAB for foam half time and drainage and a novel biomimetic vein model to measure foam stability. Physician-compounded foams composed of polidocanol and room air, CO2, or mixtures of oxygen and carbon dioxide (O2:CO2) were generated by different methods. RESULTS Polidocanol endovenous microfoam was found to have a narrow bubble size distribution with no large (>500 µm) bubbles. Physician-compounded foams made with the Tessari method had broader bubble size distribution and large bubbles, which have an impact on foam stability. Polidocanol endovenous microfoam had a lower degradation rate than any physician-compounded foams, including foams made using room air (p < 0.035). The same result was obtained at different liquid to gas ratios (1:4 and 1:7) for physician-compounded foams. In all tests performed, CO2 foams were the least stable and different O2:CO2 mixtures had intermediate performance. In the biomimetic vein model, polidocanol endovenous microfoam had the slowest degradation rate and longest calculated dwell time, which represents the length of time the foam is in contact with the vein, almost twice that of physician-compounded foams using room air and eight times better than physician-compounded foams prepared using equivalent gas mixes. CONCLUSION Bubble size, bubble size distribution and stability of various sclerosing foam formulations show that polidocanol endovenous microfoam results in better overall performance compared with physician-compounded foams. Polidocanol endovenous microfoam offers better stability and cohesive properties in a biomimetic vein model compared to physician-compounded foams. Polidocanol endovenous microfoam, which is indicated in the United States for treatment of great saphenous vein system incompetence, provides clinicians with a consistent product with enhanced handling properties.
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Affiliation(s)
- Dario Carugo
- Bioengineering Science Research Group, Faculty of Engineering and the Environment, University of Southampton, Southampton, UK Electro-Mechanical Engineering Research Group, Faculty of Engineering and the Environment, University of Southampton, Southampton, UK
| | - Dyan N Ankrett
- Electro-Mechanical Engineering Research Group, Faculty of Engineering and the Environment, University of Southampton, Southampton, UK
| | - Xuefeng Zhao
- Bioengineering Science Research Group, Faculty of Engineering and the Environment, University of Southampton, Southampton, UK
| | - Xunli Zhang
- Bioengineering Science Research Group, Faculty of Engineering and the Environment, University of Southampton, Southampton, UK Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Martyn Hill
- Electro-Mechanical Engineering Research Group, Faculty of Engineering and the Environment, University of Southampton, Southampton, UK Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Vincent O'Byrne
- Biocompatibles UK Ltd., A BTG International group company, Farnham, Surrey, UK
| | - James Hoad
- Biocompatibles UK Ltd., A BTG International group company, Farnham, Surrey, UK
| | - Mehreen Arif
- Biocompatibles UK Ltd., A BTG International group company, Farnham, Surrey, UK
| | | | - Andrew L Lewis
- Biocompatibles UK Ltd., A BTG International group company, Farnham, Surrey, UK
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Durability of treatment effect with polidocanol endovenous microfoam on varicose vein symptoms and appearance (VANISH-2). J Vasc Surg Venous Lymphat Disord 2015; 3:258-264.e1. [PMID: 26992303 DOI: 10.1016/j.jvsv.2015.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 03/01/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objectives of this study were to assess the durability of response to treatment with polidocanol endovenous microfoam (Varithena; Provensis Ltd, a BTG International group company) and to assess the long-term safety of the study patients. METHODS This report presents efficacy and safety data from the day after visit 5/week 8 (the primary end point of the study) through the 1-year study visit. As the approved dose concentration is 1%, this analysis focuses on those patients who were randomized to polidocanol endovenous microfoam 1% at study visit 2. Because the objective of the 1-year analysis was to assess the durability of response to treatment with polidocanol endovenous microfoam 1%, the 1-year efficacy analyses based on the efficacy population included all patients who were randomized and received at least one treatment with polidocanol endovenous microfoam 1%. Efficacy end points in the Polidocanol Endovenous Microfoam Versus Vehicle for the Treatment of Saphenofemoral Junction Incompetence (VANISH-2) trial were evaluated at 1 year (n = 221; 96% of those completed the primary end-point measurement at week 8) and included the following: Varicose Vein Symptoms Questionnaire (VVSymQ, Provensis Ltd) score, an assessment of symptoms by patients using electronic daily diaries; Independent Photography Review: Visible Varicose Veins (IPR-V(3)) and Patient Self-assessment of Visible Varicose Veins (PA-V(3)) scores, the assessment of appearance by an Independent Physician Review panel and by patient self-assessment, respectively; duplex ultrasound response (physiologic response to treatment); Venous Clinical Severity Score (disease severity); and Venous Insufficiency Epidemiological and Economic Study on Quality of Life (VEINES-QOL) score (quality of life). RESULTS Of the 230 patients who completed visit 5/week 8, 56 received polidocanol endovenous microfoam 1% at visit 2/week 0 and were subsequently assessed for efficacy at visit 5/week 8 and visit 10/1 year (one patient of the 57 who completed visit 5/week 8 received a nonpolidocanol endovenous microfoam intervention and was not included in the assessment). At 1 year after the first study treatment, patients treated with polidocanol endovenous microfoam demonstrated consistent, durable, and clinically meaningful improvements in symptoms, as measured by reductions in mean VVSymQ score; appearance, as measured by IPR-V(3) (clinician assessment) and PA-V(3) (patient self-assessment) scores; disease severity, as measured by the Venous Clinical Severity Score; and quality of life, as measured by the VEINES-QOL score. At 1 year, there were no new venous thrombus adverse events (VTAEs) and no clinically important sequelae in patients who had a VTAE in the study. In addition, there were no serious adverse events that were determined by the investigator to be related to the study drug. No new safety signals were identified. In patients who previously had a VTAE, none had a recurrence of thrombus or evidence of post-thrombotic syndrome at 1 year. CONCLUSIONS Treatment with polidocanol endovenous microfoam 1% led to durable, clinically meaningful, and ongoing improvements at 1 year in varicose vein symptoms and appearance. Serious adverse events were those expected during long-term follow-up of the population of patients studied and were unrelated to treatment.
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Wittens C, Davies AH, Bækgaard N, Broholm R, Cavezzi A, Chastanet S, de Wolf M, Eggen C, Giannoukas A, Gohel M, Kakkos S, Lawson J, Noppeney T, Onida S, Pittaluga P, Thomis S, Toonder I, Vuylsteke M, Kolh P, de Borst GJ, Chakfé N, Debus S, Hinchliffe R, Koncar I, Lindholt J, de Ceniga MV, Vermassen F, Verzini F, De Maeseneer MG, Blomgren L, Hartung O, Kalodiki E, Korten E, Lugli M, Naylor R, Nicolini P, Rosales A. Editor's Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2015; 49:678-737. [PMID: 25920631 DOI: 10.1016/j.ejvs.2015.02.007] [Citation(s) in RCA: 505] [Impact Index Per Article: 56.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Coudray S, Aïchoun I, Ricci JE, Penne C, Schuster I, Pérez-Martin A. [Unusual consequences of foam sclerotherapy]. ACTA ACUST UNITED AC 2015; 40:37-41. [PMID: 25554653 DOI: 10.1016/j.jmv.2014.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 11/16/2014] [Indexed: 10/24/2022]
Abstract
Neurological disorders are rare complications of foam sclerotherapy. Visual disturbances and headache are the most commonly reported events and are thought to be equivalent to migraine with aura. Exceptionally, strokes have been reported. Papillary fibroelastoma is a rare cardiac tumor, which may embolize in cerebral arteries. We report the case of a patient in whom neurological disorders occurred during a session of foam sclerotherapy, and led to the discovery of a cardiac fibroelastoma.
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Affiliation(s)
- S Coudray
- Service d'exploration et de médecine vasculaire, centre hospitalier universitaire de Nîmes, place Robert-Debré, 30009 Nîmes cedex 9, France.
| | - I Aïchoun
- Service d'exploration et de médecine vasculaire, centre hospitalier universitaire de Nîmes, place Robert-Debré, 30009 Nîmes cedex 9, France
| | - J-E Ricci
- Service de cardiologie, centre hospitalier universitaire de Nîmes, place Robert-Debré, 30009 Nîmes cedex 9, France
| | - C Penne
- Service d'exploration et de médecine vasculaire, centre hospitalier universitaire de Nîmes, place Robert-Debré, 30009 Nîmes cedex 9, France
| | - I Schuster
- Service d'exploration et de médecine vasculaire, centre hospitalier universitaire de Nîmes, place Robert-Debré, 30009 Nîmes cedex 9, France
| | - A Pérez-Martin
- Service d'exploration et de médecine vasculaire, centre hospitalier universitaire de Nîmes, place Robert-Debré, 30009 Nîmes cedex 9, France
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Abstract
Objectives The aim of this paper is to look at the pros and cons of using physiologic gas to produce foam for use in sclerotherapy. With the expanding use of foam sclerotherapy, there have been increased reports of transient neurologic adverse events such as visual disturbance. Although rare, increased numbers of serious adverse events such as transient ischemic attacks (TIAs) and stroke have been described. These events are seen more often in patients who have migraine with aura and those with a right-to-left shunt. Methods A literature search of the databases Ovid and Google Scholar was performed for studies looking specifically at neurologic side effects associated with sclerotherapy and use of physiologic foams. Included studies were randomized controlled trials, meta-analyses, review articles, observational studies and case studies. Results Although physiologic gases have been shown in several studies to reduce the incidence of visual disturbance, increasing evidence from recent studies suggest endothelin, rather than gas bubbles to be the cause of these side effects. The cause of stroke and TIA has not been proven and occlusion of cerebral arterioles from gas emboli should still be considered. Many authors state that only good quality foam be injected and volumes should be kept low in an attempt to prevent these rare, but potentially serious events. Foam made with physiologic gases are more biocompatible compared to air-based foam and have been found to be at least as effective in sclerotherapy as foam made with room air. Conclusion The use of physiologic gases should be considered for those at increased risk of neurologic side effects such as migraineurs with aura and those with a known PFO. Additionally, as there are few disadvantages to the use of physiologic foam, the use of CO2 or CO2/O2 foam should be considered in all patients receiving foam sclerotherapy.
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Affiliation(s)
- M Wong
- Lakeshore Vein & Aesthetics Cinic, Kelowna, BC V1W 3S9, Canada
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41
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Alvarez-Garcia J, Riera-del-Moral L, Stefanov-Kiuri S, Salazar-Alvarez A, Riera-de-Cubas L. Accidentes neurológicos tras esclerosis de varices: a propósito de un caso. ANGIOLOGIA 2014. [DOI: 10.1016/j.angio.2014.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Abstract
BACKGROUND Migraine, particularly with aura, increases the risk for ischemic stroke, at least in a subset of patients. The underlying mechanisms are poorly understood and probably multifactorial. METHODS We carried out an extended literature review of experimental and clinical evidence supporting the association between migraine and ischemic stroke to identify potential mechanisms that can explain the association. RESULTS Observational, imaging and genetic evidence support a link between migraine and ischemic stroke. Based on clinical and experimental data, we propose mechanistic hypotheses to explain the link, such as microembolic triggers of migraine and enhanced sensitivity to ischemic injury in migraineurs. DISCUSSION We discuss the possible practical implications of clinical and experimental data, such as aggressive risk factor screening and management, stroke prophylaxis and specific acute stroke management in migraineurs. However, evidence from prospective clinical trials is required before modifying the practice in this patient population.
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Affiliation(s)
- Jerome Mawet
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, MA, USA Emergency Headache Center, Lariboisiere Hospital, Assistance Publique-Hopitaux de Paris, France DHU NeuroVasc, France
| | - Tobias Kurth
- Inserm Research Center for Epidemiology and Biostatistics (U897), Team Neuroepidemiology, France University of Bordeaux, College of Health Sciences, France Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, MA, USA
| | - Cenk Ayata
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, MA, USA Stroke Service and Neuroscience Intensive Care Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, MA, USA
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43
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Sounderajah V, Moore HM, Thapar A, Lane TRA, Fox K, Franklin IJ, Davies AH. Acoustic reflectors are visible in the right heart during radiofrequency ablation of varicose veins. Phlebology 2014; 30:557-63. [DOI: 10.1177/0268355514542680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective Cerebrovascular events have been noted after foam sclerotherapy for varicose veins. One hypothesis is migration of microemboli to the brain through a cardiac septal defect. The aim of this study was to identify whether acoustic reflectors are found in the right side of the heart during radiofrequency ablation of varicose veins, as neurological events are not reported during these procedures. Methods Transthoracic echocardiography was performed during local anaesthetic radiofrequency ablation (VNUS ClosureFast) of the great saphenous vein in 14 patients. An apical view was captured at the start of the procedure, during each cycle of heating and at 1 min post-treatment. Patients were monitored for 1 h. Video loops were read by an independent cardiologist. The presence of acoustic reflectors was classified as: 0 = absent, 1 = occasional, 2 = stream, 3 = complete opacification. Results Loops were of diagnostic quality in 11/14 (79%) patients. After the second cycle of heating, acoustic reflectors moving through the right heart were seen in 5/11 (45%) patients. These were classified as grade 1 in four patients and grade 2 in one patient. No acoustic reflectors were seen in the left heart. No neurological symptoms were reported. Conclusion Acoustic reflectors in the right heart are a common finding during radiofrequency ablation of varicose veins. Considering the prevalence of cardiac septal defects (17%), more neurological events would be expected if these particles were indeed responsible for these events. Further work is required to elicit the mechanisms underlying neurological complications following sclerotherapy.
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Affiliation(s)
- V Sounderajah
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College School of Medicine, London, UK
| | - HM Moore
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College School of Medicine, London, UK
| | - A Thapar
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College School of Medicine, London, UK
| | - TRA Lane
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College School of Medicine, London, UK
| | - K Fox
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - IJ Franklin
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College School of Medicine, London, UK
| | - AH Davies
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College School of Medicine, London, UK
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44
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Zouitina Y, Terrier M, Hyra M, Seryer D, Chillon JM, Bugnicourt JM. Prolonged acute migraine with aura and reversible brain MRI abnormalities after liquid sclerotherapy. J Headache Pain 2014; 15:41. [PMID: 24948446 PMCID: PMC4068884 DOI: 10.1186/1129-2377-15-41] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 06/14/2014] [Indexed: 11/10/2022] Open
Abstract
Transient visual disturbances constitute the most commonly reported neurological side effect during and immediately after sclerotherapy. A few studies, based on clinical and diffusion-weighted MRI assessments, have suggested that these transient neurological symptoms correspond to migraine with aura. Recently, it has been reported that brain magnetic resonance imaging can reveal transient T2*-weighted abnormalities during the acute phase of migraine with aura. We reported a 36-year-old man who presented with transient neurological symptoms and concomitant T2*-weighted abnormalities on brain magnetic resonance imaging immediately after liquid sclerotherapy. We hypothesize that the reversible nature of the patient's T2*-weighted abnormalities may indicate a relationship with the post-sclerotherapy migraine with aura attack.
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Affiliation(s)
| | | | | | | | | | - Jean-Marc Bugnicourt
- Department of Neurology, Amiens University Hospital, 1 Place Victor Pauchet, F-80054 Amiens cedex, France.
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45
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Gillet JL. Complications and side effects: European Guidelines for Sclerotherapy in Chronic Venous Disorders. Phlebology 2014; 29:34-38. [DOI: 10.1177/0268355514526532] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- JL Gillet
- Vascular Medicine and Phlebology, Bourgoin-Jallieu, France
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46
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Willenberg T, Smith PC, Shepherd A, Davies AH. Visual disturbance following sclerotherapy for varicose veins, reticular veins and telangiectasias: a systematic literature review. Phlebology 2014; 28:123-31. [PMID: 23761921 DOI: 10.1258/phleb.2012.012051] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The objective of the study was to review the literature reporting visual disturbance (VD)following sclerotherapy for varicose veins. Underlying mechanisms will be discussed. A literature search of the databases Medline and Google Scholar was performed. Original articles including randomized trials, case series and case reports reporting VD in humans following sclerotherapy for varicose veins were included. Additional references were also obtained if they had been referenced in related publications. The search yielded 4948 results of which 25 reports were found to meet the inclusion criteria. In larger series with at least 500 included patients the prevalence of VD following sclerotherapy ranges from 0.09% to 2%. In most reports foam sclerotherapy was associated with VD (19); exclusive use of liquid sclerosant was reported in two cases, some reports included foam and liquid sclerosant (4). There were no persistent visual disorders reported. VD occurred with polidocanol and sodium tetradecyl sulphate in different concentrations (0.25–3%). Various forms of foam preparation including various ways of foam production and the liquid –air ratio (1 or 2 parts of liquid mixed with 3, 4 or 5 parts of air) were reported in association with the occurrence of VD. VDs following sclerotherapy for varicose veins are rare and all reported events were transient. Bubble embolism or any kind of embolism seems unlikely to be the only underlying mechanism. A systemic inflammatory response following sclerotherapy has been suggested. Further research to clarify the mechanism of action of sclerosants is required.
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Affiliation(s)
- T Willenberg
- Academic Section of Vascular Surgery Imperial College School of Medicine Charing Cross Hospital, London, UK
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47
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Abstract
This review presents the common diseases associated with superficial venous insufficiency of the leg. These include varicose veins, swelling, skin damage and ulceration. The benefits and rationale behind treatment are discussed, followed by the historical advances from ancient mortality and prayer to the modern endovenous revolution. Finally, an overview of modern treatment options will discuss the evidence supporting the gold standard of endothermal ablation and the cost effectiveness of treatment at this time of challenging resource limitation.
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Affiliation(s)
- D Carradice
- Hull and East Yorkshire Hospitals NHS Trust, UK.
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48
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Devereux N, Recke AL, Westermann L, Recke A, Kahle B. Catheter-directed foam sclerotherapy of great saphenous veins in combination with pre-treatment reduction of the diameter employing the principals of perivenous tumescent local anesthesia. Eur J Vasc Endovasc Surg 2013; 47:187-95. [PMID: 24268395 DOI: 10.1016/j.ejvs.2013.10.017] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 10/22/2013] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate occlusion rates of great saphenous veins (GSV) with a diameter between 5-10 mm that received a pre-treatment size reduction via perivenous tumescent application (TA) followed by catheter-directed foam sclerotherapy (CDFS). METHODS A prospective blinded randomized clinical trial comparing the occlusion rates of GSV at 1-, 6-, and 12-month follow-up. Fifty patients were included and randomized into two groups. CDFS was performed accessing the GSV at knee level and applying 8 mL of 2% polidocanol-foam (EasyFoam) while the catheter was withdrawn. Strictly perivenous TA was performed in group 1 before applying the sclerosant agent. Occlusion rates and clinical scores were assessed by blinded examiners. RESULTS After 12 months in group 1 full occlusion was achieved in 73.9%, partial occlusion in 8.7%, and 17.4% were classified as treatment failure. In group 2, 75% of the targeted GSV were fully occluded, 20% were partially occluded, and 5% were diagnosed as treatment failure. Both groups showed a significant reduction of the vein diameter. Patient's tolerance and satisfaction with the treatment was high in both groups. CONCLUSION No benefit could be found using additional TA to reduce the vein diameter before the treatment.
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Affiliation(s)
- N Devereux
- Department of Dermatology, University of Schleswig-Holstein, Campus Luebeck, Germany
| | - A L Recke
- Department of Dermatology, University of Schleswig-Holstein, Campus Luebeck, Germany
| | | | - A Recke
- Department of Dermatology, University of Schleswig-Holstein, Campus Luebeck, Germany
| | - B Kahle
- Department of Dermatology, University of Schleswig-Holstein, Campus Luebeck, Germany.
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49
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Abstract
OBJECTIVES Documentation and analysis of adverse neurological and chest symptoms in a large single centre series of sclerotherapy treatments. METHOD In this retrospective study, patient-reported adverse events occurring during liquid or foam sclerotherapy were recorded over a 30 month period and subsequently analyzed. The relevant patient records were reviewed to determine patient characteristics, treatment details and results of subsequent investigations. RESULTS A total of 1744 ultrasound guided sclerotherapy treatments were performed during the study period. Almost all treatments were done with air-based sodium tetradecyl sulphate foam. During the same time period, 6504 direct vision surface vein sclerotherapy treatments were completed. Approximately 1/4 of these utilized air-based foam in varying concentrations. There were 14 adverse events in 14 patients involving neurological or chest symptoms for an incidence of 0.17%. Five patients injected with foam complained of isolated chest discomfort, tightness or shortness of breath. Nine patients reported various brief neurological symptoms. These events occurred with both liquid and foam, although the majority involved foam. More neurological events were associated with direct vision sclerotherapy of smaller superficial veins than with ultrasound guided injection of intrafascial truncular veins. Seven patients who experienced neurological symptoms had a history of migraine. Five of the patients who had neurological events were investigated for right to left shunts and found to be positive. CONCLUSIONS These events were uncommon and brief. The incidence of neurological and chest symptoms was higher with foam sclerotherapy than with liquid. A history of migraine with aura was associated with an increased risk of post-treatment neurological symptoms. Events occurred with both large vein and small vein treatment. Some events were associated with liquid sclerotherapy rather than foam and with carbon dioxide based foam as well as air foam. There were no long-term adverse consequences.
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50
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Todd KL, Wright DI. The VANISH-2 study: a randomized, blinded, multicenter study to evaluate the efficacy and safety of polidocanol endovenous microfoam 0.5% and 1.0% compared with placebo for the treatment of saphenofemoral junction incompetence. Phlebology 2013; 29:608-18. [DOI: 10.1177/0268355513497709] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective VANISH-2 Investigator Group: K Gibson, Bellevue, WA, USA; M Goldman, San Diego, CA, USA; P Hertzman, Los Alamos, NM, USA; S Hirsch, Pittsburgh, PA, USA; R Hye, San Diego, CA, USA; M Isaacs, Walnut Creek, CA, USA; M Plaza-Ponte, Monroeville, PA, USA; S Rathbun, Oklahoma City, OK, USA; J Rhodes, Rochester, NY, USA; G Rosenberg, Frederick, MD, USA; M Schul, Lafayette, IN, USA; M Stanbro, Greenville, SC, USA; and R Weiss, Hunt Valley, MD, USA To determine efficacy and safety of polidocanol endovenous microfoam in treatment of symptoms and appearance in patients with saphenofemoral junction incompetence due to reflux of the great saphenous vein or major accessory veins. Method Patients were randomized equally to receive polidocanol endovenous microfoam 0.5%, polidocanol endovenous microfoam 1.0% or placebo. The primary efficacy endpoint was patient-reported improvement in symptoms, as measured by the change from baseline to Week 8 in the 7-day average electronic daily diary VVSymQ™ score. The co-secondary endpoints were the improvement in appearance of visible varicosities from baseline to Week 8, as measured by patients and by an independent physician review panel. Results In 232 treated patients, polidocanol endovenous microfoam 0.5% and polidocanol endovenous microfoam 1.0% were superior to placebo, with a larger improvement in symptoms (VVSymQ (−6.01 and–5.06, respectively, versus –2.00; P < 0.0001) and greater improvements in physician and patient assessments of appearance ( P < 0.0001). These findings were supported by the results of duplex ultrasound and other clinical measures. Of the 230 polidocanol endovenous microfoam-treated patients (including open-label patients), 60% had an adverse event compared with 39% of placebo; 95% were mild or moderate. No pulmonary emboli were detected and no clinically important neurologic or visual adverse events were reported. The most common adverse events in patients treated with polidocanol endovenous microfoam were retained coagulum, leg pain and superficial thrombophlebitis; most were related to treatment and resolved without sequelae. Conclusion Polidocanol endovenous microfoam provided clinically meaningful benefit in treating symptoms and appearance in patients with varicose veins. Polidocanol endovenous microfoam was an effective and comprehensive minimally invasive treatment for patients with a broad spectrum of vein disease (clinical, etiology, anatomy, pathophysiology clinical class C2 to C6) and great saphenous vein diameters ranging from 3.1 to 19.4 mm. Treatment with polidocanol endovenous microfoam was associated with mild or moderate manageable side effects. VVSymQ is an important new, validated instrument for symptom assessment in patients with varicose veins.
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Affiliation(s)
| | - DI Wright
- BTG International, Philadelphia, PA, USA and London, UK
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