Interaction of detergent sclerosants with cell membranes

Percutaneous procedures for central lymphatic conduction disorders

Percutaneous endovascular techniques established in interventional cardiology and radiology are well-suited for managing lymphatic conduction disorders. In this article, we provide a synopsis of technical aspects of these procedures, including access of the thoracic duct, selective lymphatic embolization, and management of thoracic duct obstruction. In aggregate, these techniques have developed into an integral component of multidisciplinary management of these complex diseases.

Microbial synergies drive simultaneous biodegradation of ethoxy and alkyl chains of Nonylphenol Ethoxylate in fluidized bed reactors

The widely-used surfactant Nonylphenol Ethoxylate (NPEO) produces endocrine-disrupting compounds during biodegradation, with these byproducts being more harmful than untreated NPEO. This study investigates the effectiveness of a Fluidized Bed Reactor (FBR) in reducing the production of 4-Nonylphenol (4-NP) during the biodegradation of NPEO. Two identical FBR filled with sand were used to assess the NPEO degradation and to enhance the microbial consortia capable of breaking down the complex byproducts, ethanol and fumarate were introduced as co-substrates. Our findings demonstrate the significant potential of the FBR, especially when coupled with fumarate, for enhancing the surfactant degradation. It outperforms the efficiency achieved with ethanol as the primary electron donor, albeit with a higher rate of byproduct production. Microbial community taxonomy and metabolic prediction revealed the high abundance of Geobacter (1.51-31.71%) and Methanobacterium (1.08-13.81%) in non-conductive sand. This may hint a new metabolic interaction and expand our understanding of Direct Interspecies Electron Transfer (DIET) in bioreactors applied to micropollutants degradation. Such an intricate relationship between facultative and anaerobes working together to simultaneously biodegrade the ethoxy and alkyl chains presents a new perspective on NPEO degradation and can potentially be extended to other micropollutants.

Safety and efficacy of intralesional polidocanol sclerotherapy in the treatment of plantar warts: a pilot study

Plantar warts are common skin lesions that continue to represent a therapeutic challenge. They are still resistant to therapy and are highly recurrent, despite the diverse number of treatments available. Therapies targeting vasculature, such as pulsed dye laser, have been used successfully in the treatment of plantar warts. Polidocanol, a detergent sclerosant approved for the sclerotherapy of incompetent and dilated saphenous veins, has also been used as an off-label therapy for a wide range of skin conditions with vascular components such as hemangiomas and pyogenic granuloma. The current, open-label, prospective, pilot study aimed to evaluate the safety and efficacy of the intralesional polidocanol 3% in the treatment of plantar warts. Twenty patients (11 females and 9 males), with plantar warts, aged 12-50 years received biweekly sessions of intralesional polidocanol 3% until complete clearance or for a maximum of 6 sessions. Response to treatment was graded as complete (100% clearance), partial (50-99%), and no response (< 50%). At the end of the study, 12 (60%) patients achieved complete clearance of their warts after 1-5 sessions, 5 (25%) patients had only partial response, and 3 (15%) patients did not achieve any clearance of their warts. The procedure was largely tolerable by patients. Pain at the injection site and bruises were reported by 9 (45%) and 2 (10%) patients, respectively. Both side effects resolved spontaneously and completely within a few days. The findings of the current study suggest that intralesional injection of 3% polidocanol in biweekly sessions may be a safe, effective, and tolerable method for the treatment of plantar warts.

Long-term exposure to dietary emulsifier Tween 80 promotes liver lipid accumulation and induces different-grade inflammation in young and aged mice

With the advent of industrialization, there has been a substantial increase in the production and consumption of ultra-processed foods (UPFs). These processed foods often contain artificially synthesized additives, such as emulsifiers. Emulsifiers constitute approximately half of the total amount of food additives, with Tween 80 being a commonly used emulsifier in the food industry. Concurrently, China is undergoing significant demographic changes, transitioning into an aging society. Despite this demographic shift, there is insufficient research on the health implications of food emulsifiers, particularly on the elderly population. In this study, we present novel findings indicating that even at low concentrations, Tween 80 suppressed the viability of multiple cell types. Prolonged in vivo exposure to 1 % Tween 80 in drinking water induced liver lipid accumulation and insulin resistance in young adult mice under a regular chow diet. Intriguingly, in mice with high-fat diet (HFD) induced metabolic dysfunction-associated steatotic liver disease (MASLD), this inductive effect was masked. In aged mice, liver lipid accumulation was replicated under prolonged Tween 80 exposure. We further revealed that Tween 80 induced inflammation in both adult and aged mice, with a more pronounced inflammation in aged mice. In conclusion, our study provides compelling evidence that Tween 80 could contribute to a low-grade inflammation and liver lipid accumulation. These findings underscore the need for increasing attention regarding the consumption of UPFs with Tween 80 as the emulsifier, particularly in the elderly consumers.

Efficacy of foam sclerotherapy with polidocanol for the management of oral venous malformations

The present aimed to examine the effectiveness of polidocanol-based foam sclerotherapy for oral venous malformations (OVMs). The present study performed a retrospective analysis of patients with OVMs who underwent sclerotherapy using polidocanol. Patients achieving the complete resolution of OVM were categorized as having a complete response (CR), those with a reduction in size from the initial diagnosis were categorized as having a partial response (PR), those with no change in size as stable disease (SD), and those with an increase in size as progressive disease (PD). A total of 16 patients, comprising 4 males and 12 females, underwent treatment with polidocanol foam therapy, covering 22 affected areas. The treatment administered resulted in CR in 6 cases and PR in 10 cases, with no instances of SD or PD. Apart from localized injection site pain or swelling, there were no severe side-effects reported, such as circulatory dynamic changes or skin necrosis. On the whole, these findings underscore the effectiveness of foam sclerotherapy with polidocanol as a viable treatment for venous malformations in the oral and maxillofacial regions.

Empty vein ablation (EVA) technique: an in-vivo animal model to assess the effects of sclerosing agent concentration and wall contact time on intima and media tunicae structure

BACKGROUND

Sclerotherapy is a cornerstone of the treatment of chronic venous disease, despite some technical aspects (e.g., sclerosant liquid agent concentration [SLAC] and contact time between sclerosant agent and vein wall [ctSA/VW]) to maximize outcomes remain an unsolved problem and a source of debate. An innovative three-balloon catheter has been developed to allow sclerotherapy in empty vein conditions (Empty Vein Ablation technique, EVA), revolutionizing the definition of SLAC and ctSA/VW. Aim of this experimental study is to analyze EVA effects on intima and media vessel tunicae using different SLAC and ctSA/VW in an in-vivo animal model.

METHODS

Two adult sheep were treated by EVA using jugular and common iliac vein axes (eight vein segments). Different SLAC (polidocanol 0.5% or 1%) and different ctSA/VW (3 or 5 minutes) were combined for testing residual circumferential intima percentage and media thickness after EVA.

RESULTS

Intact circumferential residual intima after the treatment was 21.3±4.9%, 18.2±7.4%, 15.7±2.4% and 8.9±2.0% using 0.5% (3 min), 0.5% (5 min), 1% (3 min) and 1% (5 min), respectively (R2=0.945; control sample: 97.6%). Media thickness after the treatment was 121.6±35.3 µm, 110.9±7.8 µm, 96.1±30.4 µm and 79.1±34.1 µm using 0.5% (3 min), 0.5% (5 min), 1% (3 min) and 1% (5 min), respectively (R2=0.990; control sample 125.7 µm). No significant modifications were detected analyzing the adventitia in all samples.

CONCLUSIONS

EVA proved to be effective in venous wall destruction even with a very low SLAC and ctSA/VW (0.5% in 3 minutes), in quite large caliber veins. Direct comparisons with foam/liquid sclerotherapy should be done to confirm therapeutic effectiveness of these results, despite EVA has provided a maximized and controlled SA/VW contact time and ratio.

Occupational contact dermatitis caused by sodium tetradecyl sulfate in a healthcare worker: A case report

Healthcare workers are known to be at a higher risk of experiencing occupational contact dermatitis and attention should be paid to new materials that cause contact dermatitis. Sodium tetradecyl sulfate is widely used in the treatment of small varicose veins of the legs and venous malformations. We report the case of a 42-year-old woman, a healthcare worker, who presented with contact dermatitis caused by sodium tetradecyl sulfate. The contact dermatitis induced by sodium tetradecyl sulfate resolved completely after sodium tetradecyl sulfate avoidance at the last follow-up. Thus, we recommend increased protective measures when handling this substance.

Trio fluorophore-based phenotypic assay for the detection of artemisinin-induced growth-arrested Plasmodium falciparum in human erythrocytes

Artemisinin combination therapy remains effective for the treatment of falciparum malaria. However, Plasmodium falciparum can escape the effects of artemisinin by arresting their growth. The growth-arrested parasites cannot be distinguished from nonviable parasites with standard microscopy techniques due to their morphological similarities. Here, we demonstrated the efficacy of a new laboratory assay that is compatible with the artemisinin susceptibility test. As a result of the differential cell permeabilities of two DNA-binding fluorophores, growth-arrested P. falciparum can be distinguished from parasites killed by artemisinin, since the latter lose cell membrane permeability. This fluorescence-based assay increased the sensitivity and specificity of the ring survival assay in the assessment of artemisinin susceptibility. When combined with a third fluorophore-conjugated anti-human leukocyte antibody, this trio fluorophore assay became more useful in identifying growth-arrested parasites in mock human blood samples. This novel assay is a simple and rapid technique for monitoring artemisinin resistance with greater sensitivity and accuracy compared with morphology-based observations under a light microscope.

Clinical outcomes and predictors of bleomycin polidocanol foam sclerotherapy treatment response in venous malformations

OBJECTIVE

To evaluate the safety and efficacy of bleomycin polidocanol foam (BPF) sclerotherapy for venous malformations (VMs) and analyze the associated clinical outcomes and predictors.

METHODS

We retrospectively assessed BPF sclerotherapy outcomes in 138 patients with VMs. We analyzed pain levels, lesion volume reduction, and subjective perception of response. Logistic regression analysis was performed to identify potential predictors of treatment outcome. Additionally, we carefully monitored and recorded complications.

RESULTS

There was a notable average reduction in lesion volume by 78.50% ± 15.71%. The pain numerical rating scale (NRS) score decreased from 4.17 ± 2.63 prior to treatment to 1.05 ± 1.54 afterward, and 70.3% of the patients experienced effective relief after a single BPF treatment. Multivariate analysis revealed that a high baseline NRS (odds ratio [OR]:  4.026) and elevated activated partial thromboplastin time (APTT, OR: 1.200) were positive predictors of pain reduction. Additionally, a high baseline NRS score (OR: 1.992) and elevated thrombocytocrit (PCT, OR: 2.543) were positive predictors of incomplete postoperative pain relief. Minor complications occurred in 31 (22.46%) patients.

CONCLUSION

BPF sclerotherapy is safe and effective for VMs, resulting in significant reduction in lesion volume, improved symptoms, and minimal complications. APTT and PCT levels are important predictors of pain outcomes following BPF treatment.

A fish perspective on SARS-CoV-2: Toxicity of benzalkonium chloride on Danio rerio

SARS-CoV-2 outbreak led to an increased marketing of disinfectants, creating a potential environmental problem. For instance, pre-pandemic environmental levels of the disinfectant benzalkonium chloride (BAC) ranging from 0.5 to 5 mgL-1 in effluents were expected to further increase threatening aquatic life. Our aim was to characterize potential adverse effects after an acute exposure of zebrafish to different concentrations of BAC. An increase in the overall swimming activity, thigmotaxis behavior, and erratic movements were observed. An increase in CYP1A1 and catalase activities, but inhibitions of CY1A2, GSTs and GPx activities were also noticed. BAC is metabolized by CYP1A1, increasing the production of H2O2, thereby activating the antioxidant enzyme CAT. Data also showed an increase of AChE activity. Our study highlights adverse embryonic, behavioral, and metabolic effects of noteworthy environmental significance, especially considering that the use and release of BAC is most likely to increase in a near future.

Sclerotherapy of lower limb veins: Indications, contraindications and treatment strategies to prevent complications - A consensus document of the International Union of Phlebology-2023

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.

Toxic Effect of Anionic Surfactants on Freshwater Sponge Lubomirskia baikalensis and Its Endosymbiotic Microalgae Chlorella sp

A number of reports on sponge diseases, including from Lake Baikal, have increased dramatically all over the world in recent years. Herewith, there are various hypotheses for sponge mortality. Lubomirskia baikalensis (phylum Porifera, order Spongillida) is a unique endemic freshwater sponge of Lake Baikal that contains a complex community of eukaryotic and prokaryotic endosymbiotic microorganisms. In this work, we present the first results for the effect of anionic surfactants viz. linear alkylbenzene sulphonates (LAS) at low 10 and 20 µg L−1 concentrations on Baikal sponge species and their symbiotic community as an experimental model. A new toxicity test protocol under conditions close to natural is proposed. It uses the sponge amoebocytes called as SA1-cells, which contain eukaryotic green microalgae Chlorella sp. These SA1-cells are shown to be representative indicator in assessing the impact of anionic surfactants. The acute toxic effect resulted in 97–100% sponge cell death in less than 48 h, as well as 100% symbiotic microalgae Chlorella sp. death over 72 h was noted under LAS solution (20 μg L−1) exposure during in vivo experiments. This includes the cell membrane fatty acid changes, change in the cell sizes, cell swelling, and lysis. Long term exposure to LAS solution (10 μg L−1) reflected in cellular stress (oxidative stress) and accompanied by malondialdehyde formation (0.16–2.0 μg g−1 of dry weight) during 14-day exposure was noted. Oxidative stress and mortality of L. baikalensis are associated with their low antioxidant activity. Trolox-equivalent antioxidant capacity (TEAC) found in the range from 0.00031 to 0.00077 Trolox equivalents for these freshwater sponges.

A systematic review and network meta-analysis of the effectiveness of sclerotherapy for venous malformation

OBJECTIVE

Sclerotherapy for venous malformation has been widely used; however, no guidelines are available to assess the effectiveness of different sclerotherapy agents. We conducted a systematic review and network meta-analysis to investigate the effectiveness of sclerotherapy agents for venous malformations.

METHODS

Three electronic databases were searched from their inception (1950) to April 29, 2021. Studies comparing the effectiveness of different sclerotherapy agents were included. The risk of bias within and across studies was assessed. Pairwise meta-analyses were conducted, followed by a network meta-analysis. We also assessed inconsistency and publishing bias using various approaches.

RESULTS

Seven studies with 547 patients in six arms were included in the present study. We defined the response and complete response as two separate outcomes. Significant differences were observed in four comparisons with respect to the response (ethanol vs bleomycin, ethanol vs polidocanol, ethanol vs sodium tetradecyl sulfate, polidocanol vs sodium tetradecyl sulfate). No statistically significant differences were found in the other comparisons. The evidence network revealed that for the response outcome, ethanol ranked first, followed by pingyangmycin, polidocanol, sodium morrhuate, bleomycin, and, finally, sodium tetradecyl sulfate. For the complete response outcome, pingyangmycin had the best results, followed by sodium morrhuate, polidocanol, ethanol, bleomycin, and, finally, sodium tetradecyl sulfate. Major complications, such as facial nerve palsy, serious local swelling, and necrosis, had occurred mostly in the ethanol group and rarely in the other groups. Because of the limited data, no further analysis of major complications was conducted. Our confidence in the comparisons and rankings was low. We found no verified inconsistency or publishing bias in the present study using the existing approaches.

CONCLUSIONS

Ethanol showed a significantly better response statistically compared with the other agents. However, ethanol had also resulted in the highest incidence of complications. Pingyangmycin showed the second-best response, best complete response, and a low rate of complications, respectively. Overall, pingyangmycin achieved excellent performance and balance in terms of the different outcomes. However, they could not be adequately recommended from the available data. More superior trials, especially randomized controlled trials, are needed in the future.

Foam-in-Vein: Characterisation of Blood Displacement Efficacy of Liquid Sclerosing Foams

Sclerotherapy is among the least invasive and most commonly utilised treatment options for varicose veins. Nonetheless, it does not cure varicosities permanently and recurrence rates are of up to 64%. Although sclerosing foams have been extensively characterised with respect to their bench-top properties, such as bubble size distribution and half-life, little is known about their flow behaviour within the venous environment during treatment. Additionally, current methods of foam characterisation do not recapitulate the end-point administration conditions, hindering optimisation of therapeutic efficacy. Here, a therapeutically relevant apparatus has been used to obtain a clinically relevant rheological model of sclerosing foams. This model was then correlated with a therapeutically applicable parameter-i.e., the capability of foams to displace blood within a vein. A pipe viscometry apparatus was employed to obtain a rheological model of 1% polidocanol foams across shear rates of 6 s^-1 to 400 s^-1. Two different foam formulation techniques (double syringe system and Tessari) and three liquid-to-gas ratios (1:3, 1:4 and 1:5) were investigated. A power-law model was employed on the rheological data to obtain the apparent viscosity of foams. In a separate experiment, a finite volume of foam was injected into a PTFE tube to displace a blood surrogate solution (0.2% w/v carboxymethyl cellulose). The displaced blood surrogate was collected, weighed, and correlated with foam's apparent viscosity. Results showed a decreasing displacement efficacy with foam dryness and injection flowrate. Furthermore, an asymptotic model was formulated that may be used to predict the extent of blood displacement for a given foam formulation and volume. The developed model could guide clinicians in their selection of a foam formulation that exhibits the greatest blood displacement efficacy.

Polidocanol: A Review of Off-Label Dermatologic Uses

BACKGROUND

Polidocanol is an FDA-approved treatment of incompetent great saphenous veins, accessory saphenous veins, and visible varicosities of the great saphenous vein system, but numerous other off-label dermatological applications have been reported.

OBJECTIVE

To describe the various off-label dermatological clinical uses of polidocanol, as well as efficacy and adverse effects.

METHODS

The review of studies searchable on PubMed from 2004 to 2021 describing clinical uses of polidocanol to determine efficacy and adverse effects associated with various dermatologic applications.

RESULTS

Polidocanol has shown efficacy in the treatment of mucocele of minor salivary gland, hemangioma, upper extremity veins, reticular veins of the chest, facial veins, pyogenic granuloma, lymphangioma circumscriptum, digital mucous cyst, mixed skin ulcers, cutaneous focal mucinosis, seromas, glomuvenous malformations, acne cysts, lymphocele, and dissecting cellulitis. Commonly reported side effects include pain, erythema, swelling, ecchymosis, and ulceration. Most sources were case reports and small prospective studies, as such the strength of data supporting many uses is limited by small sample sizes and lack of controls.

CONCLUSION

Although polidocanol is currently only FDA approved for incompetent great saphenous veins, accessory saphenous veins, and visible varicosities of the great saphenous vein system, the use of polidocanol has been selected for a variety of off-label clinical applications.

Treatment of venous malformations with tumescent-assisted sclero-embolic and ablative lasers (SEALs): Safe and effective long-term outcomes

Background

Perivascular infiltration of tumescent anaesthesia (TA) is an essential element of endovenous thermal ablative procedures employed to treat superficial venous disease. In addition to anaesthesia, TA is administered to achieve vessel wall approximation and to protect surrounding structures from thermal damage. However, its role in the treatment of venous malformations (VMs) has not been established.

Objectives

To assess the safety and efficacy of tumescent-assisted thermal and chemical ablative methods in the treatment of VMs.

Methods

Adult and paediatric patients presenting with VMs were treated using a combination of endovenous laser ablation, foam embolo-sclerotherapy and liquid embolisation using n-BCA. All procedures were ultrasound-guided. Treatment outcomes were assessed in early and late follow-ups. To assess the efficacy of TA in achieving vessel wall approximation, cross-sectional lesional diameters were measured by ultrasound, before and after the administration of TA during endovenous procedures.

Results

In a 12 month period, 22 patients recruited in the study presented with 27 VMs which included 23 extra-truncular lesions (16 subcutaneous and seven intramuscular) and four truncular anomalies. On average the subcutaneous lesions measured 5.5 mm (1.9–24.5 mm) in diameter, intramuscular lesions measured 9.2 mm (5.9–15.1 mm) and truncular anomalies measured 4.9 mm (1.2–12 mm) in diameter. Perivascular infiltration of TA resulted in a significant reduction in vessel calibre (90% reduction on average). Intramuscular VMs were less compressible with TA (69.2% reduction) compared to subcutaneous lesions (98% reduction). Truncular anomalies such as the embryonic marginal vein achieved complete approximation (100% reduction). Procedures were safely tolerated with no major complications such as thromboembolism, stroke, nerve damage or tissue necrosis. Most patients had significant clinical as well as ultrasonographic improvement.

Conclusion

Tumescent-assisted endovenous laser ablation and foam sclerotherapy provides safe and effective outcomes in patients with a variety of VMs.

Phenotypic and Gene Expression Profiles of Embryo Development of the Ascidian Ciona robusta Exposed to Dispersants

Within EU approval policies, most dispersant ecotoxicity testing considers lethal concentrations for marine adult species, overlooking the embryotoxicological effects. Here we studied the ecotoxicity of two commercial dispersant formulations (dispersant A and B) on the embryogenesis of the ascidian Ciona robusta. Embryotoxicity and phenotypic alterations stated that dispersant B resulted more toxic than A (EC50 value of 44.30 and 160 μg mL−1, respectively) and induced severe larvae malformations at lower concentrations. Furthermore, the analysis of genes involved in different cellular response pathways indicated that those belonging to biotransformation were upregulated by dispersant A treatment, likely related to the presence of hydrocarbons. Instead, dispersant B induced cas8 gene downregulation, probably as a result of the prolonged exposure to mixture components. Our preliminary findings support the use of the C. robusta embryotoxicity test as a valuable tool for dispersant approval procedures, by providing sub-lethal responses on marine invertebrates closely related to vertebrates.

Treatment of facial hypertrophic capillary malformations with tumescent-assisted sclerotherapy

Facial capillary malformations (CMs) become hypertrophic and nodular overtime and pose great therapeutic challenge. Here, we describe safe and effective use of tumescent-assisted sclerotherapy (TAS) in conjunction with yellow vascular laser (577 nm) for the treatment of HFCMs. Three patients underwent TAS were included in the case series, and complete resolution in nodularity was achieved in all patients with TAS, with no major complications such as skin necrosis, distal embolisation, blindness and neurological adverse events such as stroke or TIA occurred in any patients.

Comparison of foaming properties between Shirasu porous glass membrane device and Tessari's three-way stopcock techniques for polidocanol and ethanolamine oleate foam production: A Benchtop Study

PURPOSE

To compare the characteristics of polidocanol (POL) and ethanolamine oleate (EO) sclerosing foams produced by a Shirasu porous glass membrane (SPGM) device with those made using a three-way stopcock (3WSC).

MATERIALS AND METHODS

Foam half-life times were measured in an ex vivo benchtop study. Computed tomography (CT) images of each foam were obtained over the time course, and CT texture analysis was conducted. Bubble size in each foam was measured by an optical microscope.

RESULTS

Median foam half-life times were longer in the SPGM group than in the 3WSC group (POL: 198 vs 166 s, p = 0.02; EO: 640 vs 391 s, p < 0.01). In CT texture analysis, median standard deviation (SD) and entropy (randomness) were lower, and median energy (uniformity) and gray-level co-occurrence matrix (GLCM) homogeneity (homogeneity) were higher in the SPGM group than in the 3WSC group (POL SD: at 30 s and 50-300 s; POL entropy: at 0-60 s; EO SD: at 0-600 s; EO entropy: at 0-460 s; POL energy: at 0-40 s; POL GLCM homogeneity: at 0-250 s; EO energy: at 0-360 s; EO GLCM homogeneity: at 0-480 s; all p < 0.05). Median bubble diameters in the SPGM group and in the 3WSC group were 69 and 83 μm (p < 0.01), respectively, in POL foam; and 36 and 36 μm (p = 0.45), respectively, in EO foam.

CONCLUSION

POL and EO foams had greater uniformity and longer foam half-life time when prepared with an SPGM device than with a 3WSC.

Successful Sclerotherapy for Cervicofacial Macrocystic Lymphatic Malformations Using Polidocanol and Pingyangmycin Combined Foam Sclerosants

Background: Sclerotherapy is the first-line therapeutic method for lymphatic malformations (LMs). This retrospective cohort study evaluated the effectiveness and safety of a novel combined foam sclerosant: polidocanol and pingyangmycin foam (PPF), for treating cervicofacial macrocystic LMs. Methods and Results: From July 2018 to October 2020, 51 patients with cervicofacial macrocystic LMs were enrolled in this study. All patients received intralesional 3% polidocanol or PPF injections. The outcome was evaluated regarding demographic and clinical characteristics, degree of treatment response, and post-treatment complications. Overall, 16 patients (31.4%) underwent PPF sclerotherapy. All these patients (100%) showed remarkable reduction in lesion size within three sessions. Excellent responses were shown in 88.5% of these patients within three sessions, which is higher than single polidocanol sclerotherapy (80%). The average sessions (duration) of PPF sclerotherapy were 2.5, which was significantly shorter than the single foam sclerotherapy (p < 0.05). Treatment duration was significantly associated with age, lesion location, lesion size, and number of cysts (p < 0.05). No severe complications were noted in this study. Local or systemic complications, such as swelling and mild fever occurred but subsided without any specific treatment. Conclusions: PPF is a safe, and effective combined foam sclerosant for the treatment of cervicofacial macrocystic LMs. This combined foam can improve treatment response and reduce treatment duration compared with a single sclerosant. It can be broadly used if further large-scale clinical trials verify its efficacy and safety.

Vascular anomalies of the head and neck: diagnosis and treatment

Vascular malformations and vascular tumors comprise the two specific subsets of vascular anomalies that arise as a result of disorganized angiogenesis and neoplasm, respectively. Malformations are separate entities from vascular tumors (e.g., hemangiomas) and are recognized by the International Society for the Study of Vascular Anomalies (ISSVA) as such. Vascular malformations are classified into four main groups: simple, combined, anomalies of major vessels, and those associated with other vascular anomalies. Vascular tumors are neoplastic growths of blood vessels and are morphologically and molecularly distinct from malformations but can arise in the head and neck and have syndromic association. Head and neck vascular anomalies are not uncommon in the pediatric population and require special care in the workup, diagnostic imaging and clinical care. The purpose of this manuscript is to discuss the diagnosis and management of the most common intracranial and extracranial vascular malformations and tumors in the head and neck in children and adolescents.

Imaging features and enhancement technique to diagnose and classify intrathoracic Lymphatic-venous malformations: A case report and literature review

The diagnosis and treatment of pediatric intrathoracic lymphatic-venous malformations (LVM) can be complex due to their rarity, variable presentation and confusing nomenclature in the literature. The International Society for the Study of Vascular Anomalies (ISSVA) has recently (2018) updated their classification to help guide the correct diagnosis, nomenclature and management of such cases. We present the case of a 12-month-old Caucasian female with a lymph-venous malformation (LVM) classified in the updated ISSVA classification as a combined vascular malformation (CLVM) defined as two or more vascular malformations found in one lesion, associated with an underlying “malformation of an individual named vessel”. The patient presented with tachypnea, tachycardia and fever. While all the previous cases underwent surgical treatment, our patient was successfully treated with rapamycin and sclerotherapy. Appropriate imaging can aid in the diagnosis of vascular anomalies and in the proper ISSVA classification, saving the patient the need for a biopsy and allow for proper referral to Multidisciplinary Vascular Anomalies centers. The accurate classification can identify cases that can be treated through Interventional Radiology with sclerosing agents and medical therapy as opposed to surgery.

The Addition of Lipid-Based Contrast Medium does not Inactivate the Detergent Sclerosant Sodium Tetradecyl Sulfate in-vitro

PURPOSE

To investigate if the detergent sclerosant sodium tetradecyl sulfate (STS) is deactivated by the lipid-based contrast agent ethiodised oil.

METHOD

3% STS was mixed with ethiodised oil and room air in a 2:1:4 ratio in two luer lock syringes and a three way connector and agitated to make foam (the Tessari technique) to replicate the clinical use of the products. The assay of STS in the mixture was assessed using the British Pharmacopoeia method. Briefly this is a manual titration method where the solution of STS is mixed with an indicator solution and titrated with hyamine solution of known concentration; the concentration of the STS can then be calculated with the titration results. To further mimic the clinical environment with the presence of blood, the effect of adding increasing amounts of albumin to the STS-ethiodised oil mixture was assessed.

RESULTS

The assay of STS in the solution after mixing with ethiodised oil was 3% indicating that the ethiodised oil did not deactivate the STS. The addition of albumin to the STS-contrast mixture resulted in near linear neutralisation of the STS with increasing concentrations in the same quantities as with STS alone.

CONCLUSIONS

The mixture of the lipid-based contrast agent ethiodised oil with the detergent sclerosant STS did not affect the availability of the sclerosant. The continued use of STS-ethiodised oil in the management of vascular malformations can be supported.

Clinical dilemma of management: Cardiac arrest after microsclerotherapy for lower limb telangiectasia with liquid 0.3% aethoxysklerol or idiopathic cardiac arrest?

A 48-year-old woman attended to discuss a dilemma. She had suffered a cardiac arrest immediately following microsclerotherapy of leg telangiectasia with 0.3% aethoxysklerol. She had successful defibrillation and been transferred to hospital. In hospital, despite normal cardiac tests, she was diagnosed as having idiopathic cardiac arrest. The exposure to aethoxysklerol was discounted by her cardiologists as a cause of her arrest. Following the hospital protocol, she was strongly advised to have an implantable defibrillator. Cardiac arrest and myocardial infarction are documented after aethoxysklerol injection with proposed mechanisms being anaphylaxis, direct cardiotoxicity or endothelin-1 release. Before consenting to an implantable defibrillator, which may have its own complications in the long term, doctors and the patient need to be certain that this arrest was not due to a reaction to aethoxysklerol.

Ultrasound-guided percutaneous endovenous laser treatment combined with sclerotherapy for the treatment of large intramuscular venous malformations

BACKGROUND

Among vascular anomalies, congenital venous malformations (VMs) are the most common lesions. Treatment of VMs is sometimes difficult or cumbersome, depending on their size and tissue involvement. Surgery may lead to invasive and mutilating excisions, often allowing only partial removal, with an increased risk of recurrence. Sclerotherapy is a mainstream technique, resulting in endothelium destruction, fibrosis and subsequent shrinkage of the vascular lesion, also with a risk of recurrence. However, this technique may not be efficient in cases of large and infiltrating VMs. Endovenous thermal ablation has been found to be more effective than sclerotherapy for transmural vascular destruction and has therefore been employed in the treatment of VMs.

METHODS

In this study we described a combined technique for the treatment of large intramuscular VMs in seven consecutive patients, associating endovenous laser ablation with sclerotherapy. The aim was to assess feasibility and safety of the procedure.

RESULTS

We reported a high immediate technical success, clinical and radiological improvement, with no complications.

CONCLUSIONS

The preliminary results presented herein show, that combining EVLA and sclerotherapy for the treatment of voluminous persistent intramuscular VM is safe and technically feasible. The combination of a wide direct intimal thermal damage with chemical sclerotherapy is the force of this approach. The small number of cases and the medium term follow up represent though a limitation.

Effect of Hyaluronic Acid and Pluronic-F68 on the Surface Properties of Foam as a Delivery System for Polidocanol in Sclerotherapy

The use of foams to deliver bioactive agents and drugs is increasing in pharmaceutics. One example is the use of foam as a delivery system for polidocanol (POL) in sclerotherapy, with the addition of bioactive compounds to improve the delivery system being a current subject of study. This work shows the influence of two bioactive additives on the structure and stability of POL foam: hyaluronic acid (HA) and Pluronic-F68 (F68). HA is a natural non-surface-active biopolymer present in the extracellular matrix while F68 is a surface-active poloxamer that is biocompatible with plasma-derived fluids. Both additives increase the bulk viscosity of the sample, improving foam stability. However, HA doubled and F68 quadruplicated the foam half lifetime of POL. HA reduced the size and polydispersity of the bubble size distribution and increased the surface elasticity with respect to POL. Both facts have a positive impact in terms of foam stability. F68 also altered bubble structure and increased surface elasticity, again contributing to the enhancement of foam stability. The surface characterization of these systems is important, as in foam sclerotherapy it is crucial to assure the presence of POL at the surface of the bubbles in order to deliver the sclerosant agent in the target vein.

Polidocanol Plus Glucose Versus Glucose Alone for the Treatment of Telangiectasias: Triple Blind, Randomised Controlled Trial (PG3T)

OBJECTIVE

The aim of this study was to compare the effectiveness and safety of two sclerosing agents used to treat telangiectasias in the lower limbs: 0.2% polidocanol + 70% hypertonic glucose (HG) vs. 75% HG alone.

METHODS

A prospective, randomised, triple blind, controlled, parallel group trial with patients randomly assigned in a 1:1 ratio between January and December 2015, with a two month follow up, from a single academic medical centre in Brazil, was carried out. Participants were women aged 18-65 years with telangiectasias on the lateral aspect of one thigh, classified as C1EpAsPn who underwent sclerotherapy in a single session with 0.2% polidocanol + 70% HG or 75% HG alone to treat the telangiectasias on an area limited by a rectangular template. The primary effectiveness endpoint was elimination of 75% of the telangiectasias within 60 days vs. the pre-treatment pattern. The length of vessels was measured on images obtained before and after treatment using ImageJ software. Safety outcomes were analysed immediately, 7 days, and 60 days after the treatment, and included pigmentation.

RESULTS

A total of 115 patients were included, 98 of whom completed the study. Sclerotherapy with 0.2% polidocanol + 70% HG was significantly more effective than with 75% HG alone to treat telangiectasias in the target area (82.2% vs. 63.9%; p < .001); considering a minimum improvement of 75%, there was a 0.49 risk reduction (95% confidence interval 0.24-0.98; p = .047). No severe adverse events occurred in either group. Pigmentation was the most common minor adverse event and was significantly shorter in length in the group treated with 0.2% polidocanol + 70% HG (median 0 cm vs. 0.5 cm, respectively; p = .033).

CONCLUSION

Polidocanol 0.2% plus 70% HG had better results than 75% HG alone in sclerosing telangiectasias. No severe adverse events occurred. Pigmentation occurred in both groups and was shorter in length in the group treated with 0.2% polidocanol + 70% HG.

Reducing hyperpigmentation after sclerotherapy: A randomized clinical trial

OBJECTIVE

Sclerotherapy for the treatment of varicose veins is one of the most common medical procedures performed in the Western world, and hyperpigmentation is one of the most frequent, dreaded, minor adverse events. There has recently been some interest in investigating the inflammatory response of the local endothelium after sclerotherapy and the possible benefits of venoactive drugs because of their pleiotropic properties. The aim of this study was to evaluate whether adding a venoactive drug (sulodexide) to the standard sclerotherapy treatment protocol for patients with varicose veins can reduce the occurrence of postsclerotherapy hyperpigmentation.

METHODS

We carried out a prospective, multicenter, randomized controlled trial with a parallel group design. It included 720 patients with telangiectasia, reticular veins, or varicose veins who were candidates for sclerotherapy. Patients with reflux in deep system or saphenous veins were excluded. Group A consisted of 354 patients who received an oral dose of sulodexide twice a day for 7 days before scheduled sclerotherapy; the treatment then continued for 3 months. Group B consisted of 366 patients who received the standard sclerotherapy protocol. Polidocanol was used as the sclerosing agent, and 20 to 30 mm Hg compression stockings were used in both groups for 7 days. Control photographs were taken, and a follow-up examination took place after 1 month and 3 months. Computer software was used to analyze the treated area for incidence of hyperpigmentation, total area of hyperpigmentation, skin tone increase in the hyperpigmented area, vein disappearance, and incidence of major bleeding. The sample size was calculated to give a statistical power of 80%. Student t-test and the χ² test were used for comparative analyses, as appropriate. The level of significance was set at P < .05.

RESULTS

A total of 609 patients completed the 3-month follow-up: 312 in group A and 297 in group B. After 1 month, the incidence of hyperpigmentation was 8.7% in group A and 14.8% in group B (P = .01). Group A developed an average area of hyperpigmentation of 10.7% compared with 18.2% in group B (P = .01), and the skin tone of the hyperpigmented area was lower in group A than in group B (P = .02). However, the latter difference was not significant after 3 months. The overall vein disappearance rate was similar in both groups.

CONCLUSIONS

Our analysis shows that by adding a venoactive drug (sulodexide) to the standard sclerotherapy protocol, the occurrence of hyperpigmentation is reduced without affecting the desired therapeutic vein elimination response.

In vitro oxidations of low-density lipoprotein and RAW 264.7 cells with lipophilic O(3P)-precursors

A beneficial property of photogenerated reactive oxygen species (ROS) is the capability of oxidant generation within a specific location or organelle inside a cell. Dibenzothiophene S-oxide (DBTO), which is known to undergo a photodeoxygenation reaction to generate ground state atomic oxygen [O(³P)] upon irradiation, was functionalized to afford localization within the plasma membrane of cells. The photochemistry, as it relates to oxidant generation, was studied and demonstrated that the functionalized DBTO derivatives generated O(³P). Irradiation of these lipophilic O(³P)-precursors in the presence of LDL and within RAW 264.7 cells afforded several oxidized lipid products (oxLP) in the form of aldehydes. The generation of a 2-hexadecenal (2-HDEA) was markedly increased in irradiations where O(³P) was putatively produced. The substantial generation of 2-HDEA is not known to accompany the production of other ROS. These cellular irradiation experiments demonstrate the potential of inducing oxidation with O(³P) in cells.

Foam-in-vein: A review of rheological properties and characterization methods for optimization of sclerosing foams

Varicose veins are chronic venous defects that affect >20% of the population in developed countries. Among potential treatments, sclerotherapy is one of the most commonly used. It involves endovenous injection of a surfactant solution (or foam) in varicose veins, inducing damage to the endothelial layer and subsequent vessel sclerosis. Treatments have proven to be effective in the short-term, however recurrence is reported at rates of up to 64% 5-year post-treatment. Thus, once diagnosed with varicosities there is a high probability of a permanently reduced quality of life. Recently, foam sclerotherapy has become increasingly popular over its liquid counterpart, since foams can treat larger and longer varicosities more effectively, they can be imaged using ultrasound, and require lower amounts of sclerosing agent. In order to minimize recurrence rates however, an investigation of current treatment methods should lead to more effective and long-lasting effects. The literature is populated with studies aimed at characterizing the fundamental physics of aqueous foams; nevertheless, there is a significant need for appropriate product development platforms. Despite successfully capturing the microstructural evolution of aqueous foams, the complexity of current models renders them inadequate for pharmaceutical development. This review article will focus on the physics of foams and the attempts at optimizing them for sclerotherapy. This takes the form of a discussion of the most recent numerical and experimental models, as well as an overview of clinically relevant parameters. This holistic approach could contribute to better foam characterization methods that patients may eventually derive long term benefit from.

Common (Cystic) Lymphatic Malformations: Current Knowledge and Management

The approach to treating common (cystic) lymphatic malformations (LMs) has evolved significantly over the last decade due to clinical research and recent developments in molecular biology. Surgery, sclerosing agents, and medical drugs with specific targets for biological therapy have been reported for the management of LMs. We will discuss the importance to standardize the location and imaging characterization of LMs to improve the knowledge about the outcome of the different therapeutic options. Our goal is to help the reader understand the different options for the management of LMs with the balance between risk and benefit for the patients.

Deep vein sclerosis following sclerotherapy: Ultrasonic and d-dimer criteria

Objectives

The aim of sclerotherapy is to induce fibrosclerosis of superficial veins. We postulated that inadvertent entry of sclerosants into deep veins can result in sclerotic occlusion, deep vein sclerosis, a non-thrombotic process distinct from spontaneous deep vein thrombosis. The aim of this study was to assess the role of d-dimer in differentiating between deep vein sclerosis and deep vein thrombosis.

Methods

Proximal trunks of great and small saphenous veins were treated with endovenous laser ablation. Venous tributaries and perforators were treated with foam ultrasound guided sclerotherapy. Ultrasound studies of lower limb deep veins were performed before and one week after the procedures, to detect deep vein occlusions (DVOs). d-dimer levels were measured for DVOs and long-term ultrasound studies monitored the recanalisation rates.

Results

In a six-year period, 9143 procedures were performed in 1325 patients for bilateral varicose veins. This included 1124 endovenous laser ablation and 8019 foam ultrasound guided sclerotherapy procedures. A total of 259 DVOs (2.83%) were identified on ultrasound which included 251 deep vein sclerosis (2.74%), seven deep vein thrombosis (0.07%) and one endovenous heat-induced thrombosis (EHIT, 0.08%). d-dimer values <0.5 µg/mL excluded deep vein thrombosis s, 0.5–1.0 µg/mL were more likely to be associated with deep vein sclerosis and >1.0 µg/mL were a more likely to be associated with deep vein thrombosis. Lower sclerosant concentrations and higher foam volumes were associated with increased risk of DVO ( p <  .0001). No significant relationship was found between DVO and gender or thrombophilia. Deep vein thrombosis and EHIT cases but not deep vein sclerosis patients were anticoagulated. None had thromboembolic complications. Patients were followed up for a median of 299 days (37–1994 days). Recanalisation rates were 71.1% for deep vein sclerosis (92.3% competent) and 71.4% for deep vein thrombosis (60.0% competent).

Conclusions

Deep vein sclerosis is a relatively benign clinical entity distinct from deep vein thrombosis and does not require anticoagulation. Majority of affected veins on long-term follow-up regain patency and competence. d-dimer can be used to assist in differentiating deep vein sclerosis from deep vein thrombosis.

Impacts of low concentration surfactant on red blood cell dielectrophoretic responses

Cell dielectrophoretic responses have been extensively studied for biomarker expression, blood typing, sepsis, circulating tumor cell separations, and others. Surfactants are often added to the analytical buffer in electrokinetic cellular microfluidic systems to lower surface/interfacial tensions. In nonelectrokinetic systems, surfactants influence cell size, shape, and agglomeration; this has not been systematically documented in electrokinetic systems. In the present work, the impacts of the Triton X-100 surfactant on human red blood cells (RBCs) were explored via ultraviolet-visible spectroscopy (UV-Vis) and dielectrophoresis (DEP) to compare nonelectrokinetic and electrokinetic responses, respectively. The UV-Vis spectra of Triton X-100 treated RBCs were dramatically different from that of native RBCs. DEP responses of RBCs were compared to RBCs treated with low concentrations of Triton X-100 (0.07-0.17 mM) to ascertain surfactant effects on dielectric properties. A star-shaped electrode design was used to quantify RBC dielectric properties by fitting a single-shell oblate cell model to experimentally-derived DEP spectra. The presence of 0.07 and 0.11 mM of Triton X-100 shifted the RBC's DEP spectra yielding lower crossover frequencies ( f C O ) . The single-shell oblate model revealed that cell radius and membrane permittivity are the dominant influencers of DEP spectral shifts. The trends observed were similar for 0.11 mM and 0.07 mM Triton X-100 treated cells. However, a further increase of Triton X-100 to 0.17 mM caused cells to only exhibit negative DEP. The magnitude of the DEP force increased with Triton X-100 concentration. This work indicates that dynamic surfactant interactions with cell membranes alter cell dielectric responses and properties.

Effects of sulodexide on stability of sclerosing foams

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.

Detergent sclerosants at sub-lytic concentrations induce endothelial cell apoptosis through a caspase dependent pathway

To investigate the apoptotic effects of detergent sclerosants sodium tetradecylsulphate (STS) and polidocanol (POL) on endothelial cells at sub-lytic concentrations. Human umbilical vein endothelial cells (HUVECs) were isolated and labelled with antibodies to assess for apoptosis and examined with confocal microscopy and flow cytometry. Isolated HUVECs viability was assessed using propidium iodide staining. Early apoptosis was determined by increased phosphatidylserine exposure by lactadherin binding. Caspase 3, 8, 9 and Bax activation as well as inhibitory assays with Pan Caspase (Z-VAD-FMK) and Bax (BI-6C9) were assessed to identify apoptotic pathways. Porimin activation was used to assess cell membrane permeability. Cell lysis reached almost 100 % with STS at 0.3 % and with POL at 0.6 %. Apoptosis was seen with both STS and POL at concentrations ranging from 0.075 to 0.15 %. PS exposure increased with both STS and POL and exhibited a dose-dependent trend. Active Caspase 3, 8 and 9 but not Bax were increased in HUVECs stimulated with low concentrations of both STS and POL. Inhibitory assays demonstrated Caspase 3, 8, 9 inhibition at low concentrations (0.075 to 0.6 %) with both STS and POL. Both agents increased the activation of porimin at all concentrations. Both sclerosants induced endothelial cell (EC) apoptosis at sub-lytic concentrations through a caspase-dependant pathway. Both agents induced EC oncosis.

Sclerotherapy for Reticular Veins in the Lower Limbs: A Triple-Blind Randomized Clinical Trial

Importance

Reticular veins are subdermal veins located in the lower limbs and are mainly associated with aesthetic complaints. Although sclerotherapy is the treatment of choice for reticular veins in the lower limbs, no consensus has been reached regarding to the optimal sclerosant.

Objective

To compare the efficacy and safety of 2 sclerosants used to treat reticular veins: 0.2% polidocanol diluted in 70% hypertonic glucose (HG) (group 1) vs 75% HG alone (group 2).

Design, Setting, and Participants

Prospective, randomized, triple-blind, controlled, parallel-group clinical trial with patients randomly assigned in a 1:1 ratio between the 2 treatment groups from March through December 2014, with 2 months' follow-up. The study was conducted in a single academic medical center. Eligible participants were all women, aged 18 to 69 years, who had at least 1 reticular vein with a minimum length of 10 cm in 1 of their lower limbs.

Interventions

The patients underwent sclerotherapy in a single intervention with either 0.2% polidocanol plus 70% HG or 75% HG alone to eliminate reticular veins.

Main Outcomes and Measures

The primary efficacy end point was the disappearance of the reticular veins within 60 days after treatment with sclerotherapy. The reticular veins were measured on images obtained before treatment and after treatment using ImageJ software. Safety outcomes were analyzed immediately after treatment and 7 days and 60 days after treatment and included serious adverse events (eg, deep vein thrombosis and systemic complications) and minor adverse events (eg, pigmentation, edema, telangiectatic matting, and hematomas).

Results

Ninety-three women completed the study, median (interquartile range) age 43.0 (24.0-61.0) years for group 1 and 41.0 (27.0-62.0) years for group 2. Sclerotherapy with 0.2% polidocanol plus 70% HG was significantly more effective than with 75% HG alone in eliminating reticular veins from the treated area (95.17% vs 85.40%; P < .001). No serious adverse events occurred in either group. Pigmentation was the most common minor adverse event, with a 3.53% treated-vein pigmentation length for group 1 and 7.09% for group 2, with no significant difference between the groups (P = .09).

Conclusions and Relevance

Sclerotherapy with 0.2% polidocanol diluted in 70% HG was superior to 75% HG alone in sclerosing reticular veins, with no statistical difference for complications. Pigmentation occurred in both groups, with no statistical difference between them. No serious adverse events occurred in either group.

Trial Registration

clinicaltrials.gov Identifier: NCT02054325.

Sodium Tetradecyl Sulfate: A Review of Clinical Uses

BACKGROUND

Sodium tetradecyl sulfate (STS) is Food and Drug Administration approved for treatment of varicose veins, but numerous other off-label applications have been reported.

OBJECTIVE

To describe the clinical uses of STS, as well as efficacy and adverse effects.

METHODS

Review of studies searchable on PubMed from 1938 to 2016 describing clinical uses of STS to determine efficacy and adverse effects associated with various applications.

RESULTS

Sodium tetradecyl sulfate has shown efficacy in the treatment of varicose veins, telangiectasias, hemangioma, pyogenic granuloma, cherry angioma, Kaposi sarcoma, lymphangioma circumscriptum, digital mucous cyst, ganglion cyst, glomangioma, angiokeratoma of Fordyce, pseudocyst of the auricle, and verruca. Commonly reported side effects include pain, erythema, swelling, hyperpigmentation, telangiectatic matting, and ulceration. Serious side effects such as anaphylaxis, pulmonary embolism, stroke, and myocardial infarction have also been reported. Most sources were case reports and small prospective studies, as such the strength of data supporting many uses is limited by small sample sizes and lack of controls.

CONCLUSION

Although not always the most effective method of treatment in off-label usage, use of STS has been frequently selected for a variety of applications for reasons of simplicity, low cost, lack of availability of technologically advanced equipment, and intricacies related to anatomic location.

Pelvic venous reflux in males with varicose veins and recurrent varicose veins

Objectives To report on a male cohort with pelvic vein reflux and associated primary and recurrent lower limb varicose veins. Methods Full lower limb duplex ultrasonography revealed significant pelvic contribution in eight males presenting with bilateral lower limb varicose veins. Testicular and internal iliac veins were examined with either one or a combination of computed tomography, magnetic resonance venography, testicular, transabdominal or transrectal duplex ultrasonography. Subsequently, all patients received pelvic vein embolisation, prior to leg varicose vein treatment. Results Pelvic vein reflux was found in 23 of the 32 truncal pelvic veins and these were treated by pelvic vein embolisation. Four patients have since completed their leg varicose vein treatment and four are undergoing leg varicose vein treatments currently. Conclusion Pelvic vein reflux contributes towards lower limb venous insufficiency in some males with leg varicose veins. Despite the challenges, we suggest that pelvic vein reflux should probably be investigated and pelvic vein embolisation considered in such patients.

Orbital infarction syndrome after multiple percutaneous sclerotherapy sessions for facial low-flow vascular malformation: A case report and literature review

Vision loss following sclerotherapy for facial vascular malformations (VMs) is a rare but detrimental complication. Here, we report a case of an 11-year-old boy with acute onset blepharoptosis, ophthalmoplegia, and blindness in his right eye after the 14^th sclerotherapy session (percutaneous intralesional injection of sodium tetradecyl sulfate) for a right facial low-flow VM without orbital involvement. Computed tomography angiography revealed no contrast enhancement in the right ophthalmic artery, superior ophthalmic vein, or extraocular muscles. He presented with the hallmarks of orbital infarction syndrome: Clear signs of anterior and posterior segment ischemia and disrupted arterial flow to the extraocular muscles. His blepharoptosis and eye movement improved 4 months later; however, he remained blind, and phthisis bulbi developed eventually. Thus, sclerotherapy for facial VM—even without orbital involvement—may result in severe ocular and orbital complications.

Implication of foam sclerosant inactivation by human whole blood in a laboratory setting

Background During sclerotherapy, it has been recommended to confirm intravenous placement of the needle by aspirating blood into the sclerosant syringe. This may inactivate some, or all of the sclerosant. Aims To quantify the volume of human blood needed to completely inactivate 1 ml of sodium tetradecyl sulphate, and comparing fresh blood and blood that has been stored in an ethylenediaminetetraacetic acid tube. Methods A series of manual titrations were carried out following a procedure developed at STD Pharmaceutical Products Ltd (Hereford, UK) and listed in the British Pharmacopeia. Three percent of sodium tetradecyl sulphate stock solutions were made with increasing volumes of blood and titrated against benzethonium chloride to determine the active concentration (% w/v) of sodium tetradecyl sulphate remaining in the solution. Results A calculated approximation showed 0.3 ml of blood is required to fully inactivate 1 ml of 3% sodium tetradecyl sulphate when made into a foam. A comparison was made between the use of fresh blood and blood stored in ethylenediaminetetraacetic acid tubes. Blood stored in ethylenediaminetetraacetic acid tubes showed more inactivation of sodium tetradecyl sulphate, but this was not significant at the P ≤ 0.05 level. Conclusion The data from our study have shown that a minimum of 0.3 ml of fresh blood is required to inactivate 1 ml of 3% sodium tetradecyl sulphate as a foam and it is not significantly affected by storing blood in an ethylenediaminetetraacetic acid tube. Our methodology suggests that during foam sclerotherapy treatment, blood should not be aspirated into the syringe to confirm position, and that ultrasound guidance is more appropriate for needle placement.

Mechanochemical ablation causes endothelial and medial damage to the vein wall resulting in deeper penetration of sclerosant compared with sclerotherapy alone in extrafascial great saphenous vein using an ex vivo model

BACKGROUND

Nonthermal, tumescentless devices are the next generation of minimally invasive devices to treat varicose veins. We aimed to investigate the effects of mechanochemical ablation (MOCA) using ClariVein (Vascular Insights, Quincy, Mass) on ex vivo great saphenous vein with histology and immunofluorescent staining.

METHODS

Extrafascial great saphenous veins were harvested during surgery for varicose veins and were treated ex vivo for 10 to 11 minutes with either liquid sclerotherapy or the use of ClariVein, with and without 3% sodium tetradecyl sulfate. Veins were sectioned and subjected to hematoxylin and eosin staining and immunofluorescent staining for endothelial and smooth muscle cell markers (CD31 and α-actin) to assess overall damage and cell death in the vein wall compared with control sections.

RESULTS

Histologic observations confirmed intimal damage from ClariVein, as has been previously shown; however, medial damage was also evident, which was not observed in control or liquid sclerotherapy sections. Immunofluorescent staining in the three sections studied showed a 42% decrease in CD31 staining and 27% mean reduction in α-actin staining up to a depth of 300 μm with liquid sclerotherapy. This cytotoxic effect was significantly enhanced by MOCA with a reduction in CD31 staining just above 60% and a 46% mean decrease in α-actin staining noted up to a depth of 300 μm. Far greater reductions in staining compared with sclerotherapy were observed up to a depth of 600 μm.

CONCLUSIONS

MOCA using 3% sodium tetradecyl sulfate increases the penetration of the sclerosant and its effect into the vein wall and shows superior rates of tissue destruction compared with liquid sclerotherapy alone. In this model, it appears not solely to damage the endothelium but also to shear the medial layer, creating small lesions into which sclerosant can flow and exert its cytotoxic effect.

Evaluation of sodium tetradecyl sulfate and polidocanol as sclerosants for leg telangiectasia based on histological evaluation with clinical correlation

Introduction This study was designed to determine by histological evaluation and clinical correlation the most effective sclerosant concentration of Sotradecol® (sodium tetradecyl sulfate) and Asclera® (polidocanol) for the treatment of leg telangiectasia. Methods Histological studies were completed on 40 patients, all of whom were female with a mean age of 53. After sclerotherapy with varying concentrations of sclerosant solutions for the treatment of 0.8 mm and 1 mm leg telangiectasia, histological specimens were examined for the following criteria: luminal changes, subintimal changes, smooth muscle wall alterations, and vessel wall integrity. Six patients from this group were also treated with sodium tetradecyl sulfate foam 0.1%-0.2% or polidocanol foam 0.31% for the treatment of 2 mm reticular veins. In a second group of 20 patients, clinical results after treatment with sodium tetradecyl sulfate 0.15% and polidocanol 0.31% were evaluated. Results Histological findings in patients treated with sodium tetradecyl sulfate 0.05% and polidocanol 0.25% were minimal. Sclerosant concentrations of sodium tetradecyl sulfate ≥0.2% revealed intraluminal debris and greater smooth wall damage. Polidocanol 0.5% was equivalent in strength to sodium tetradecyl sulfate 0.2% on histological evaluation. Sodium tetradecyl sulfate 0.15% and polidocanol 0.31% had similar findings on histological examination with mild smooth muscle wall changes, endothelial cell lysis, and subintimal layer damage. Reticular veins treated with 0.1%, 0.15%, and 0.2% sodium tetradecyl sulfate foam and 0.31% polidocanol foam produced identical histological findings. Conclusion Sodium tetradecyl sulfate 0.15% and polidocanol 0.31% based on histological evaluations and clinical correlation are the best sclerosant concentrations for 0.8 mm to 1 mm leg telangiectasia. Sodium tetradecyl sulfate foam is comparable to polidocanol foam at these concentrations as well.

Ocular Tolerability of Preservative-Free Tafluprost and Latanoprost: in vitro and in vivo Comparative Study

Objective:

Detrimental effects of the preserved prostaglandin analogs (PGAs) have been thoroughly documented in the published literature. The current work studied two preservative-free (PF) prostaglandin eye drops: PF tafluprost and PF latanoprost. The aim of the study was to compare these two PF formulations in vitro for viability of the human corneal epithelial (HCE-T) cells and in vivo for ocular tolerability of the rabbit eye.

Method:

Viability of the HCE-T cells was measured by the MTS assay. The SV40-immortalized HCE-T cells were exposed to 100 µL of the drug solutions (at their commercial concentrations) or the culture medium. Ocular irritation was evaluated after repeated instillation of the drug solutions in Japanese white rabbits (Kbl:JW).

Results:

A significant loss of HCE-T cell viability was observed in vitro immediately after the exposure to PF latanoprost formulation but not immediately after the exposure to PF tafluprost formulation. Congruently, PF latanoprost induced in vivo more irritation on the rabbit eye than PF tafluprost.

Conclusion:

Comparing these two PF formulations in vitro and in vivo, it is considered that ocular tolerability of PF tafluprost is better than PF latanoprost. Taking into account the composition of these two PF PGA formulations, the solubilizing agent macrogolglycerol hydroxystearate 40 (MGHS40) contained in PF latanoprost formulation is a plausible cause for the negative effects.