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Kang M, Yang A, Hannaford P, Connor D, Parsi K. Skin necrosis following sclerotherapy. Part 2: Risk minimisation and management strategies. Phlebology 2022; 37:628-643. [DOI: 10.1177/02683555221125596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Tissue necrosis is a serious but rare complication of sclerotherapy. Early detection and targeted management are essential to prevent progression and minimise serious complications. In the first instalment of this paper, we reviewed the pathogenic mechanisms of post-sclerotherapy necrosis. Here, we describe risk minimisation and management strategies. Risk factors must be addressed to reduce the chance of necrosis following sclerotherapy. These may be treatment-related including poor choice of sclerosant type, concentration, volume or format, poor injection technique, suboptimal ultrasound visualisation and treatment of vessels in high-risk anatomical areas. Risk factors specific to individual patients should be identified and optimised pre-operatively. Tissue necrosis is more likely to occur with extravasation of irritant sclerosants such as absolute alcohol, sodium iodide, bleomycin and hypertonic saline, whereas extravasation of foam detergent sclerosants rarely results in tissue loss. Proposed treatments for extravasation of irritant sclerosants include infiltration of an isotonic fluid and hyaluronidase. Management of inadvertent intra-arterial injections may require admission for neurovascular observation and monitoring for ischaemia, intravenous systemic steroids, anticoagulation, thrombolysis and prostanoids infusion when required. Treatment of veno-arteriolar reflex vasospasm (VAR-VAS) necrosis follows the same protocol involving systemic steroids but rarely requires hospital admission and may not require anticoagulation. In general, treatment of post-sclerotherapy necrosis is challenging and most proposed treatment measures are not evidence-based and only supported by anecdotal personal experience of clinicians. Despite all measures, once the necrosis has set in, it is very difficult to reverse the process and all measures described here may only be useful in prevention of progression and extension of the ulceration. Mid to long-term measures include addressing exacerbating factors, management of medical and psychosocial comorbidities, treatment of secondary infections and referrals to relevant specialists. All ulcers should be managed with compression and prescribed dressing regimes in line with the healing stage of the ulcer.
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Affiliation(s)
- Mina Kang
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW Australia
- Department of Dermatology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Anes Yang
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW Australia
- Department of Dermatology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Patricia Hannaford
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW Australia
- Department of Dermatology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
| | - David Connor
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW Australia
| | - Kurosh Parsi
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW Australia
- Department of Dermatology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Sydney Skin and Vein Clinic, Chatswood, NSW, Australia
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Wang J, Chiang N. Unusual case of extensive leg ulceration following ultrasound-guided foam sclerotherapy. ANZ J Surg 2020; 90:E212-E214. [PMID: 32396676 DOI: 10.1111/ans.15984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/26/2020] [Accepted: 05/03/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Judy Wang
- Department of Vascular Surgery, Northern Health, Melbourne, Victoria, Australia
| | - Nathaniel Chiang
- Department of Vascular Surgery, Northern Health, Melbourne, Victoria, Australia
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Nguyen T, Bergan J, Min R, Morrison N, Zimmet S. Curriculum of the American College of Phlebology. Phlebology 2016. [DOI: 10.1258/026835506779613534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- T Nguyen
- Dermatology, Mohs Micrographic & Dermatologic surgery, Procedural Dermatology, University of Texas-MD Anderson Cancer Center, Houston, TX, USA
| | - J Bergan
- Department of Surgery, UCSD School of Medicine, San Diego, CA, USA
| | - R Min
- Department of Radiology, Cornell University School of Medicine, New York, NY, USA
| | - N Morrison
- Morrison Vein Institute, Scottsdale AZ, USA
| | - S Zimmet
- Zimmet Vein and Dermatology, Austin, TX, USA
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Parsi K, Hannaford P. Intra-arterial injection of sclerosants: Report of three cases treated with systemic steroids. Phlebology 2015; 31:241-50. [DOI: 10.1177/0268355515578988] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Intra-arterial injection of sclerosants is a significant but uncommon complication of sclerotherapy that may result in extensive tissue necrosis and in rare cases digit or limb amputation. We have managed three cases in the past 10 years. One patient was referred for immediate treatment following intra-arterial injection of liquid polidocanol. The other two had undergone foam sclerotherapy with polidocanol and sodium tetradecyl sulphate, respectively. All patients were treated with a combination of oral steroids (prednisone 0.5–1 mg/kg) and systemic anticoagulants (enoxaparin 1.5 mg/kg daily subcutaneous injection). One case progressed to skin ulceration where prednisone was started five days after the adverse event and prematurely stopped after four weeks. The other cases did not progress to necrosis or other long-term sequelae. In these patients, prednisone was commenced immediately and slowly reduced over the following 12 weeks. The inflammation that follows ischemia plays a significant role in tissue necrosis and the immediate management of this adverse event may benefit from anti-inflammatory measures and in particular systemic steroid therapy unless contraindicated.
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Affiliation(s)
- Kurosh Parsi
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent’s Centre for Applied Medical Research (AMR), St. Vincent’s Hospital, Sydney, Australia
- Department of Dermatology, St. Vincent’s Hospital, Sydney, Australia
- University of New South Wales, Sydney, Australia
| | - Patricia Hannaford
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent’s Centre for Applied Medical Research (AMR), St. Vincent’s Hospital, Sydney, Australia
- University of New South Wales, Sydney, Australia
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