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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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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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Davies HO, Watkins M, Oliver R, Berhane S, Bradbury AW. Adverse neurological events after sodium tetradecyl sulfate foam sclerotherapy - A prospective, observational study of 8056 treatments. Phlebology 2021; 37:97-104. [PMID: 34657519 DOI: 10.1177/02683555211051490] [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
BACKGROUND Ultrasound guided foam sclerotherapy (UGFS) is a flexible and highly utilised tool in the treatment of varicose veins (VVs), both as a primary treatment and as an adjunct to other treatments. Concern remains regarding the risk of neurological adverse events (AEs) such as migraine, visual disturbance and serious adverse events (SAEs) such as cerebrovascular accident that have been reported after UGFS treatments. AIM To determine the incidence of neurological AEs and SAEs after UGFS. METHODS A prospective, multicentre, post-authorisation safety study across Europe (both private and government) was performed between January 2015-2020. Neurological adverse events after UGFS with Fibrovein® (Sodium Tetradecyl Sulfate) 1 and 3% physician generated foam. RESULTS 8056 patients underwent treatment. There were 46 AE (including 5 SAEs), 30 (65%) SAEs were in female patients. Mean age was 55 years with mean body mass index (BMI) of 27. Univariable logistic regression demonstrate that UGFS only treatment (i.e. no adjunctive treatment), liquid-to-gas ratio, gas type and total foam volume (1% sodium tetradecyl sulfate, STS) were significantly associated with the odds of experiencing the outcome. Multivariable logistic regression model exhibits that migraine and total foam volume (1% STS) maintained statistical significance thus associated with the odds of adverse events. CONCLUSIONS This study demonstrates that UGFS with Fibrovein is safe with a very low incidence of neurological AEs and SAEs. Past history of migraine, use of physiological gas (O2/CO2) and increasing volumes of 1% foam increase the risk of AEs.
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Affiliation(s)
- Huw Ob Davies
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | | | | | - Sarah Berhane
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Solihull Hospital, Birmingham, UK
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Cartee TV, Wirth P, Greene A, Straight C, Friedmann DP, Pittman C, Daugherty SF, Blebea J, Meissner M, Schul MW, Mishra V. Ultrasound-guided foam sclerotherapy is safe and effective in the management of superficial venous insufficiency of the lower extremity. J Vasc Surg Venous Lymphat Disord 2021; 9:1031-1040. [PMID: 34144767 DOI: 10.1016/j.jvsv.2021.03.020] [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] [Received: 08/03/2020] [Accepted: 03/31/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Superficial venous disease of the lower extremity has a significant impact on quality of life. Both truncal and tributary vein reflux contribute to this disease process. Endovenous foam sclerotherapy is a widely used technique throughout the world for the management of superficial venous reflux and ultrasound guidance improves its safety and efficacy. METHODS A PubMed search for ultrasound-guided foam sclerotherapy (UGFS) was conducted and all abstracts were reviewed to identify clinical trials and systematic reviews for a full-text analysis. Additional articles were also identified through searching the references of the selected studies. RESULTS The production of foam for sclerotherapy in a 1:3 or 1:4 ratio of air to sclerosant is optimal in a low silicone, low-volume syringe system. Physiologic gas may decrease any side effects, with the trade-off of decreased foam stability. Proper technique with appropriate sterility and cleansing protocols are paramount for safe and effective treatment. The technical success of UGFS for great saphenous vein disease is inferior to endothermal and surgical modalities and retreatment is more common. However, the clinical improvement in patient-reported quality of life is similar between these three modalities. When used for tributary veins in combination with endothermal approaches of the truncal veins, UGFS has high rates of success with excellent patient satisfaction. UGFS has demonstrated an excellent safety profile comparable with or superior to other modalities. CONCLUSIONS With proper technique, UGFS is safe and effective for the management of superficial venous disease.
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Affiliation(s)
- Todd V Cartee
- Department of Dermatology, Penn State Health, Hershey, Pa.
| | - Paul Wirth
- Department of Dermatology, Penn State Health, Hershey, Pa
| | - Amrit Greene
- Department of Dermatology, Penn State Health, Hershey, Pa
| | | | | | - Chris Pittman
- Department of Radiology, University of South Florida Morsani College of Medicine, Tampa, Fla; Vein911 Vein Treatment Centers, Tampa, Fla
| | | | - John Blebea
- Department of Surgical Disciplines, Central Michigan University College of Medicine, Mount Pleasant, Mich
| | - Mark Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Marlin W Schul
- Indiana University School of Medicine, West Lafayette campus, Lafayette, Ind; Indiana Vascular Associates, LLC, Lafayette, Ind
| | - Vineet Mishra
- Division of Mohs Surgery, Dermatology & Vascular Surgery, Scripps Clinic, San Diego, Calif
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Whiteley MS, Taylor LK, King JC, Hughes BE. Clinical dilemma of management: Cardiac arrest after microsclerotherapy for lower limb telangiectasia with liquid 0.3% aethoxysklerol or idiopathic cardiac arrest? SAGE Open Med Case Rep 2021; 9:2050313X211000866. [PMID: 33786187 PMCID: PMC7958149 DOI: 10.1177/2050313x211000866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/17/2021] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Mark S Whiteley
- The Whiteley Clinic, Guildford, UK.,Faculty of Health and Biomedical Sciences, University of Surrey, Guildford, UK
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7
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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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Skuła M, Hobot J, Czaja J, Simka M. The effect of the calibre and length of needle on the stability of sclerosing foam. Phlebology 2020; 36:322-328. [PMID: 33236673 DOI: 10.1177/0268355520953317] [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: 11/17/2022]
Abstract
OBJECTIVES Little is known how calibre and length of needles affect the stability of sclerosing foam. METHODS Foams were made of 0.5%, 1%, 2% and 3% polidocanol, and 0.2%, 0.5%, 1% and 3% sodium tetradecyl sulfate (STS), which were mixed with air in the proportion of 4:1. These foams were ejected through needles with the length of: 4 mm, 6 mm and 13 mm, and diameter of: 0.26 mm, 0.3 mm and 0.4 mm. RESULTS Foams made of more concentrated polidocanol were more stable. Regarding STS an opposite relationship was revealed. Foams made of polidocanol were more stable if ejected through a longer needle, while the length of needle did not significantly affect stability of STS foams. Foams ejected through 0.26 mm diameter needles were very unstable. In the case of 0.5% polidocanol, 0.3x6mm needle provided atypically stable foam. CONCLUSION In order to inject maximally stable foam, calibre and length of needle should be taken into account.
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Affiliation(s)
- Marcin Skuła
- Department of Anatomy, University of Opole, Opole, Poland
| | - Jacek Hobot
- Department of Anatomy, University of Opole, Opole, Poland
| | - Joanna Czaja
- Department of Anatomy, University of Opole, Opole, Poland
| | - Marian Simka
- Department of Anatomy, University of Opole, Opole, Poland
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Connor DE, Gerbelli J, Chew AN, Cooley-Andrade O, Goonawardhana D, Cheung K, Parsi K. Sirolimus and propranolol inhibit endothelial proliferation while detergent sclerosants induce endothelial activation, microparticle release and apoptosis in vitro. Phlebology 2020; 35:566-575. [PMID: 32216526 DOI: 10.1177/0268355520913384] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To investigate the effects of detergent sclerosants, sodium tetradecyl sulphate and polidocanol, on endothelial cell activation and microparticle release and the effects of detergent sclerosants, sirolimus and propranolol, on apoptosis in vitro. METHODS Cultured human umbilical vein endothelial cells and murine haemangioendothelioma (EOMA) cell lines were incubated with different concentrations of sodium tetradecyl sulphate and polidocanol, as well as sirolimus and propranolol. Endothelial activation was assessed using flow cytometry for CD62e (E-Selectin), CD54 (ICAM-1), CD105 (endoglin), CD144 (VE-Cadherin), CD146 (MCAM) and the release of endothelial microparticles. Cell proliferation was assessed using [3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium] and carboxyfluorescein succinimidyl ester assays. Apoptosis was assessed using flow cytometry for lactadherin/propidium iodide staining and for Caspase-3 expression. RESULTS Sublytic concentrations of sodium tetradecyl sulphate and polidocanol (0.075%-0.3%) increased the expression of the activation markers CD62e and CD54. The expression of CD105 decreased in sclerosant treated cultured human umbilical vein endothelial cells. Both sodium tetradecyl sulphate and polidocanol induced the release of endothelial microparticles. All agents inhibited cell proliferation. Sodium tetradecyl sulphate and polidocanol-induced apoptosis as evidenced by increased phosphatidylserine exposure and caspase-3 expression, whereas sirolimus and propranolol increased caspase-3 expression only. CONCLUSION Sublytic concentrations of detergent sclerosants induce endothelial activation and the release of endothelial microparticles. All agents were anti-proliferative in EOMA cell lines, with sodium tetradecyl sulphate and polidocanol inducing cellular apoptosis.
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Affiliation(s)
- David E Connor
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St. Vincent's Centre for Applied Medical Research, St. Vincent's Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Jessica Gerbelli
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St. Vincent's Centre for Applied Medical Research, St. Vincent's Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia.,Centro Universitário Barão de Mauá, Ribeirão Preto, Brazil
| | - An-Ning Chew
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St. Vincent's Centre for Applied Medical Research, St. Vincent's Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Osvaldo Cooley-Andrade
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St. Vincent's Centre for Applied Medical Research, St. Vincent's Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Dulani Goonawardhana
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St. Vincent's Centre for Applied Medical Research, St. Vincent's Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Kelvin Cheung
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St. Vincent's Centre for Applied Medical Research, St. Vincent's Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Kurosh Parsi
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St. Vincent's Centre for Applied Medical Research, St. Vincent's Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
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The Efficacy of Absolute Ethanol and Polidocanol in the Treatment of Venous Malformations. J Craniofac Surg 2020; 31:e272-e275. [PMID: 32068725 DOI: 10.1097/scs.0000000000006268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Using meta-analysis to evaluate the efficacy of absolute ethanol and polidocanol in the treatment of venous malformations. MATERIALS AND METHODS A systematic search of the English literature was conducted in April 2019 including PubMed, Embase and Web of Science. Article selection was based on preset criteria. The included literature was scored on the MINORS scale, and the meta-analysis and the forest plot were made using the R 3.5.1 software for efficiency. RESULTS Ten articles were included in the meta-analysis. Absolute ethanol response rate ranged between 79% and 92% with a pooled rate of 85%, and polidocanol response rate ranged between 63% and 94% with a pooled rate of 77%. DISCUSSION Although sclerotherapy is effective in most studies, a large number of randomized controlled trials are still needed to confirm the best treatment options at different sites.
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Hougaard A, Younis S, Iljazi A, Sugimoto K, Ayata C, Ashina M. Intravenous Endothelin-1 Infusion Does Not Induce Aura or Headache in Migraine Patients With Aura. Headache 2020; 60:724-734. [PMID: 31994720 DOI: 10.1111/head.13753] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/20/2019] [Accepted: 12/20/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To investigate whether intravenously infused provokes migraine aura and migraine headache in migraine patients with aura. BACKGROUND Migraine with aura has been associated with endothelial dysfunction and increased stroke risk. The initiating mechanism of migraine aura symptoms is not known. Experimental provocation of migraine headache using vasoactive peptides has provided tremendous advances in the understanding of migraine pathophysiology but substances that can induce migraine aura have not been identified. Endothelin-1 (ET-1), an endogenous, potent vasoconstrictor peptide released from the vascular endothelium, has been proposed to trigger migraine aura. This hypothesis is based on reports of increased plasma ET-1 levels early during the migraine attacks and the observation that ET-1 applied to the cortical surface potently induces the cortical spreading depolarization, the underlying electrophysiological phenomenon of migraine aura, in animals. Further, endothelial damage due to, for example, carotid puncture and vascular pathology is known to trigger aura episodes. METHODS We investigated whether intravascular ET-1 would provoke migraine aura in patients. Using a two-way crossover, randomized, placebo-controlled, double-blind design, we infused high-dose (8 ng/kg/minutes for 20 minutes) intravenous ET-1 in patients with migraine with typical aura. The primary end-point was the difference in incidence of migraine aura between ET-1 and placebo. Experiments were carried out at a public tertiary headache center (Danish Headache Center, Rigshospitalet Glostrup, Denmark). RESULTS Fourteen patients received intravenous ET-1. No patients reported migraine aura symptoms or migraine headache during or up to 24 hours following the ET-1 infusion. Four patients reported mild to moderate headache only on the ET-1 day, 3 patients reported moderate headache on the placebo day, and 1 patient reported mild headache on both days. No serious adverse events occurred during or after infusion. CONCLUSIONS Provocation of migraine aura by procedures or conditions involving vascular irritation is unlikely to be mediated by ET-1.
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Affiliation(s)
- Anders Hougaard
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Samaira Younis
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Afrim Iljazi
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Kazutaka Sugimoto
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA.,Department of Neurosurgery, Yamaguchi University School of Medicine, Yoshida, Japan
| | - Cenk Ayata
- Stroke Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Glostrup, Denmark
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Gianesini S, Obi A, Onida S, Baccellieri D, Bissacco D, Borsuk D, Campisi C, Campisi CC, Cavezzi A, Chi YW, Chunga J, Corda D, Crippa A, Davies A, De Maeseneer M, Diaz J, Ferreira J, Gasparis A, Intriago E, Jawien A, Jindal R, Kabnick L, Latorre A, Lee BB, Liew NC, Lurie F, Meissner M, Menegatti E, Molteni M, Morrison N, Mosti G, Narayanan S, Pannier F, Parsi K, Partsch H, Rabe E, Raffetto J, Raymond-Martimbeau P, Rockson S, Rosukhovski D, Santiago FR, Schul A, Schul M, Shaydakov E, Sibilla MG, Tessari L, Tomaselli F, Urbanek T, van Rijn MJ, Wakefield T, Wittens C, Zamboni P, Bottini O. Global guidelines trends and controversies in lower limb venous and lymphatic disease: Narrative literature revision and experts' opinions following the vWINter international meeting in Phlebology, Lymphology & Aesthetics, 23-25 January 2019. Phlebology 2019; 34:4-66. [PMID: 31495256 DOI: 10.1177/0268355519870690] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Guidelines are fundamental in addressing everyday clinical indications and in reporting the current evidence-based data of related scientific investigations. At the same time, a spatial and temporal issue can limit their value. Indeed, variability in the recommendations can be found both among the same nation different scientific societies and among different nations/continents. On the other side, Garcia already published in 2014 data showing how, after three years in average, one out of five recommendations gets outdated (Martinez Garcia LM, Sanabria AJ, Garcia Alvarez E, et al. The validity of recommendations from clinical guidelines: a survival analysis. CMAJ 2014;186(16):1211–1219). The present document reports a narrative literature revision on the major international recommendations in lower limb venous and lymphatic disease management, focusing on the different countries’ guidelines, trends and controversies from all the continents, while identifying new evidence-based data potentially influencing future guidelines. World renowned experts’ opinions are also provided. The document has been written following the recorded round tables scientific discussions held at the vWINter international meeting (22–26 January 2019; Cortina d’Ampezzo, Italy) and the pre- and post-meeting literature search performed by the leading experts.
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Affiliation(s)
| | - Andrea Obi
- 2 University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Denis Borsuk
- 6 Clinic of Phlebology and Laser Surgery, 'Vasculab' Ltd, Chelyabinsk, Russia
| | | | | | - Attilio Cavezzi
- 9 Eurocenter Venalinfa, San Benedetto del Tronto (AP), Italy
| | - Yung-Wei Chi
- 10 University of California, Davis Vascular Center, Sacramento, CA, USA
| | | | | | | | | | | | - Josè Diaz
- 15 Vanderbilt University Medical Center, Nashville, TN, USA
| | - Julio Ferreira
- 16 Instituto Brasilerio de Flebologia, Sao Paulo, Brazil
| | | | | | - Arkadiusz Jawien
- 19 Collegium Medicum, University of Nicolaus Copernicus, Bydgoszcz, Poland
| | | | | | | | | | - N C Liew
- 24 Putra University, Serdang, Malaysia
| | - Fedor Lurie
- 25 Jobst Vascular Institute, Toledo, OH, USA
| | | | | | | | | | | | | | | | - Kurosh Parsi
- 32 St. Vincent's Hospital, University of NSW, Sydney, Australia
| | | | | | | | | | - Stanley Rockson
- 37 Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Cees Wittens
- 44 Maastricht University Medical Center, Maastricht, Netherlands.,45 Uniklinik Aachen, Aachen, Germany
| | | | - Oscar Bottini
- 46 Universidad de Buenos Aires, Buenos Aires, Argentina
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Mousa A, El Azzazi M, Elkalla MA. Different management options for primary varicose veins in females: A prospective study. Surg Open Sci 2019; 1:25-33. [PMID: 32754689 PMCID: PMC7391904 DOI: 10.1016/j.sopen.2019.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/26/2019] [Accepted: 05/02/2019] [Indexed: 02/08/2023] Open
Abstract
Background The aim of this study was to evaluate the long-term follow-up results of different management modalities in treating primary uncomplicated lower limb female varicosities. Methods A prospective study took place within a 3-year period from June 2010 until May 2012. Patients were divided into 3 groups: group I (n = 35) included those who underwent open surgical treatment. Group II (n = 25) included those who subjected to ultrasound-guided foam sclerotherapy (USGFS). While group III (n = 20) included those who treated with endovenous laser therapy (EVLT). The patients were followed up for 6 years. Results All selected patients were female aged from 35-62 years with a mean of 47 ± 7.6 years. Thirty-five patients (43.75%) were treated surgically by saphenofemoral junction disconnection (SFJD), and great saphenous vein (GSV) stripping; 25 patients (31.25%) with ultrasound-guided foam sclerotherapy and the remaining 20 patients (25%) were treated with endovenous laser therapy. A significant success rate of GSV ablation was obtained for the endovenous laser therapy treated group over the ultrasound-guided foam sclerotherapy treated patients (P = .023). There was no significant difference between the surgically treated group and those group treated with endovenous laser therapy (P = .85). Recurrence was observed following long-term follow-up after 6 years in 8.5% in group I, 36% in group II, and 10% in group III, respectively. Venous clinical severity score (VCSS) and health-related quality of life score (HRQOLS) improved significantly in all treated groups. Conclusions Long-term follow-up of patients with primary superficial varicosities among females is mandatory to elucidate the postoperative recurrence, especially those who underwent ultrasound-guided foam sclerotherapy. In addition to the observation of the development of newly formed varicosities in susceptible individuals which might develop later following long-term follow-up.
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Affiliation(s)
- Ahmed Mousa
- Department of Vascular & Endovascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt.,Division of Vascular & Endovascular Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Mohamed El Azzazi
- Department of Diagnostic and Interventional Radiology, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt
| | - Mai A Elkalla
- Medical Student, Faculty of Medicine, Helwan University, Cairo, Egypt
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BLIND-SIDED BY COSMETIC VEIN SCLEROTHERAPY: A CASE OF OPHTHALMIC ARTERIAL OCCLUSION. Retin Cases Brief Rep 2019; 13:185-188. [PMID: 28267111 DOI: 10.1097/icb.0000000000000559] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Cosmetic vein sclerotherapy is increasingly used to treat varicose veins because of its effectiveness and adherence with British Pharmacopoeia specifications. We present the first documented case of ophthalmic artery occlusion resulting in panocular ischemia secondary to intravascular injection of sodium tetradecyl sulfate sclerosant in a young healthy women seeking treatment for prominent facial veins in her forehead. METHODS The patient presented with unilateral sudden loss of vision. Funduscopy demonstrated a pale retina, cherry-red spot, and sclerosant visualized directly at the macula. She underwent emergency treatment for central retinal artery occlusion followed by fundal photographs, fluorescein angiography, and optical coherence tomography. RESULTS Despite intervention, the vision remained no perception to light. Magnetic resonance imaging, echocardiography, and Doppler ultrasound were unremarkable. The patient later developed neovascular sequelae requiring laser pan-retinal photocoagulation. CONCLUSION Widely regarded as safe, and approved by the U.S. Food and Drug Administration, the only published ocular side effects of foam sclerotherapy are transient visual disturbances or temporary scotomas. This case demonstrates irreversible loss of vision as a previously unreported complication. While undoubtedly rare, we believe physicians and surgeons using sclerosant in the orbital adnexa, face, nose, and sinuses should be aware of this sight-threatening complication of injection and counsel potential patients accordingly.
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Iljazi A, Ayata C, Ashina M, Hougaard A. The Role of Endothelin in the Pathophysiology of Migraine-a Systematic Review. Curr Pain Headache Rep 2018; 22:27. [PMID: 29557064 DOI: 10.1007/s11916-018-0682-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW Vasoactive peptides play a key role in the attack-initiating cascade of migraine. Recent studies have highlighted a potentially important role for endothelin-1, a potent vasoconstrictor peptide, in migraine pathophysiology. Here, we review the current data on endothelin's involvement in migraine. RECENT FINDINGS We identified 23 articles. Nine studies reported on endothelin-1 plasma concentrations in patients with migraine, eight studies investigated relevant genetic associations, five studies investigated endothelin-1 and spreading depression in animals, and one randomized controlled clinical trial tested the efficacy of an endothelin antagonist in the acute treatment of migraine in patients both with and without aura. Elevated endothelin-1 plasma levels have been reported in the early phase of migraine attacks. Genetic abnormalities related to the endothelin type A receptor have been reported in migraineurs. Endothelin-1 potently induces spreading depression in animals, which may explain the connection between endothelial irritation and migraine aura. Endothelin-1 could be a primary factor in the attack-triggering cascade of migraine attacks with and without aura. Additional studies in humans and animal models are needed to further elucidate the role of endothelin-1 in migraine.
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Affiliation(s)
- Afrim Iljazi
- Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Nordre Ringvej 57, DK-2600, Glostrup, Denmark
| | - Cenk Ayata
- Stroke Service and Neuroscience Intensive Care Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Messoud Ashina
- Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Nordre Ringvej 57, DK-2600, Glostrup, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Anders Hougaard
- Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Nordre Ringvej 57, DK-2600, Glostrup, Denmark.
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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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Thirty-sixth-month follow-up of first-in-human use of cyanoacrylate adhesive for treatment of saphenous vein incompetence. J Vasc Surg Venous Lymphat Disord 2017; 5:658-666. [DOI: 10.1016/j.jvsv.2017.03.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 03/22/2017] [Indexed: 12/14/2022]
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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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Kendler M, Kratzsch J, Schmidt R, Wetzig T, Simon J. Serum endothelin 1 levels before, during and after mechanochemical endovenous ablation with foam and surgical correction of incompetent great saphenous veins. J Eur Acad Dermatol Venereol 2015; 30:546-7. [DOI: 10.1111/jdv.12944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- M. Kendler
- Department of Dermatology, Venereology and Allergology; Leipzig University; Ph.-Rosenthal-Str. 23 Leipzig 04103 Germany
| | - J. Kratzsch
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics; Leipzig University; Paul-List-Str.13-15 Leipzig 04103 Germany
| | - R. Schmidt
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics; Leipzig University; Paul-List-Str.13-15 Leipzig 04103 Germany
| | - T. Wetzig
- Department of Dermatology, Venereology and Allergology; Leipzig University; Ph.-Rosenthal-Str. 23 Leipzig 04103 Germany
| | - J.C. Simon
- Department of Dermatology, Venereology and Allergology; Leipzig University; Ph.-Rosenthal-Str. 23 Leipzig 04103 Germany
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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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22
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23
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Prevention of excessive endothelin-1 release in sclerotherapy: in vitro and in vivo studies. Dermatol Surg 2014; 40:1306-8. [PMID: 25418804 DOI: 10.1097/dss.0000000000000234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Allevi F, Rabbiosi D, Mandalà M, Colletti G. Paradoxical embolism following intralesional sclerotherapy for cervical venous malformation. BMJ Case Rep 2014; 2014:bcr-2014-206781. [PMID: 25422340 DOI: 10.1136/bcr-2014-206781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present a rare case of a 47-year-old woman admitted to our maxillofacial surgery department for a large cervicofacial venous malformation. The patient underwent fluoroscopy-guided intralesional foam sclerotherapy with sodium tetradecyl sulfate and air under general anaesthesia. On awakening, after 48 h of endotracheal intubation, she displayed dysarthria and dysmetria. Her brain CT scan showed no haemorrhagic lesions. A chest CT scan ruled out a potential pulmonary embolism. Suspicion for a paradoxical embolism was high and echocardiography confirmed a patent foramen ovale, which acted as a passageway for the embolus. Transcranial ultrasound showed mild right-to-left heart shunting. The dysarthria and dysmetria disappeared gradually over 48 h, thus confirming a reversible ischaemic neurological deficit. A brain MRI performed 1 week later showed no ischaemic or haemorrhagic lesions. The patient recovered completely. She was advised cardiosurgical follow-up and discharged.
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Affiliation(s)
- Fabiana Allevi
- Department of Maxillofacial Surgery, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy
| | - Dimitri Rabbiosi
- Department of Maxillofacial Surgery, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy
| | - Marco Mandalà
- Department of Otolaryngology, Borgo Roma Hospital, Verona, Italy
| | - Giacomo Colletti
- Department of Maxillofacial Surgery, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy
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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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26
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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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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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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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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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Leyon JJ, Littlehales T, Rangarajan B, Hoey ET, Ganeshan A. Endovascular Embolization: Review of Currently Available Embolization Agents. Curr Probl Diagn Radiol 2014; 43:35-53. [DOI: 10.1067/j.cpradiol.2013.10.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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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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Rabe E, Breu FX, Cavezzi A, Smith PC, Frullini A, Gillet JL, Guex JJ, Hamel-Desnos C, Kern P, Partsch B, Ramelet AA, Tessari L, Pannier F. European guidelines for sclerotherapy in chronic venous disorders. Phlebology 2013; 29:338-54. [DOI: 10.1177/0268355513483280] [Citation(s) in RCA: 166] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy. Methods This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7–10 May 2012 in Mainz. The conference was organized by the German Society of Phlebology. These guidelines review the present state of knowledge as reflected in published medical literature. The regulatory situation of sclerosant drugs differs from country to country but this has not been considered in this document. The recommendations of this guideline are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines. Results This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, polidocanol and sodium tetradecyl sulphate. Other sclerosants are not discussed in detail. The guideline gives recommendations concerning indications, contraindications, side-effects, concentrations, volumes, technique and efficacy of liquid and foam sclerotherapy of varicose veins and venous malformations.
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Affiliation(s)
- E Rabe
- Department of Dermatology, University of Bonn, Bonn, Germany
| | - FX Breu
- Practice for Vascular Medicine, Tegernsee, Germany
| | - A Cavezzi
- Vascular Unit, Poliambulatorio Hippocrates and Clinic Stella Maris, San Benedetto del Tronto (AP), Italy
| | | | - A Frullini
- Studio Medico Flebologico – Figline Valdarno, Florence, Italy
| | - JL Gillet
- Vascular Medicine and Phlebology, Bourgoin-Jallieu, France
| | - JJ Guex
- Cabinet de Phlébologie, Nice, France
| | - C Hamel-Desnos
- Department of Vascular Medicine, Saint Martin Private Hospital, Caen, France
| | - P Kern
- Private office Vevey, Service of Angiology, Lausanne University Hospital, Lausanne, Switzerland
| | | | - AA Ramelet
- Department of Dermatology, University of Bern, Switzerland
| | | | - F Pannier
- Department of Dermatology, University of Cologne, Cologne, Germany
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Stephens R, Dunn S. Non-ST-elevation myocardial infarction following foam ultrasound-guided sclerotherapy. Phlebology 2013; 29:488-90. [DOI: 10.1177/0268355513481765] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of the study was to describe a very rare complication of foam ultrasound-guided sclerotherapy (FUGS). An unusual case of persisting chest discomfort following FUGS in a 61-year-old woman led to a diagnosis of non-ST-elevation myocardial infarction. The patient was found to have a patent foramen ovale (PFO). The differential diagnoses of paradoxical embolism, gas embolism or vasospasm are discussed, with reference to relevant literature. A hypothesis of post sclerotherapy release of endothelin-1 (in a patient with a known PFO) leading to sustained coronary artery spasm causing sufficient myocardial damage to be reflected in elevated troponin levels is suggested. Any episode of chest tightness or pain following FUGS should be considered as possibly cardiac in origin. Sustained symptoms warrant admission to hospital for troponin monitoring and ECG assessment.
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Affiliation(s)
| | - S Dunn
- Palm Clinic, Auckland, New Zealand
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Parsi K, Connor DE, Pilotelle A, Low J, Ma DD, Joseph JE. Low Concentration Detergent Sclerosants Induce Platelet Activation but Inhibit Aggregation due to Suppression of GPIIb/IIIa Activation in vitro. Thromb Res 2012; 130:472-8. [DOI: 10.1016/j.thromres.2012.03.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 03/16/2012] [Accepted: 03/26/2012] [Indexed: 10/28/2022]
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Frullini A, Barsotti MC, Santoni T, Duranti E, Burchielli S, Stefano RD. Significant Endothelin Release in Patients Treated with Foam Sclerotherapy. Dermatol Surg 2012; 38:741-7. [DOI: 10.1111/j.1524-4725.2012.02390.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Right-to-left shunts and micro-embolization in migraine. Curr Opin Neurol 2012; 25:263-8. [PMID: 22449873 DOI: 10.1097/wco.0b013e3283524103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The present review covers the latest studies on right-to-left shunts (RLSs) in migraine patients and different types of emboli capable of triggering migraine. RECENT FINDINGS Although three recent studies found no increased RLS prevalence in migraine with aura patients, there remains ample evidence that the prevalence of RLS is increased in migraine with aura. Introduced emboli in the carotid artery of mice have been shown to cause cortical spreading depression, which has been considered the pathophysiological mechanism of migraine aura. In humans, iatrogenic introduced (micro)-emboli can provoke migraine attacks; available evidence, however, is limited. SUMMARY RLS and migraine with aura (but not without) are comorbid conditions, but the biological mechanism remains speculative. Specific emboli are probably able (although infrequently) to induce migraine symptoms. There is no convincing evidence that closure of a RLS alters migraine frequency; therefore, diagnosis or treatment of RLS in migraine has no place in daily clinical practice and should only take place in controlled studies.
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Abstract
Foam sclerotherapy may result in drug and/or gas-related complications of a generalized or localized nature. Significant complications include anaphylactic/anaphylactoid reactions (very rare), deep vein thrombosis (1–3%), stroke (0.01%), superficial venous thrombosis (4.4%), tissue necrosis (variable frequency), oedema (0.5%) and nerve damage (0.2%). Cosmetic complications include telangiectatic matting (15–24%) and pigmentation (10–30%). Patent foramen ovale and other cardiopulmonary right-to-left shunts seem to play a role in the systemic gas-related complications. In conclusion, foam sclerotherapy is characterized by an overall high degree of safety, though special attention should be given to the embolic and thrombotic complications. Good technique, adequate imaging, general precautions and compliance with post-treatment instructions may help avoid some of the adverse events and an appropriate early intervention may minimize possible sequelae. Higher volumes of sclerosant foam have been attributed to local and distant thrombotic complications and should be avoided.
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Affiliation(s)
- A Cavezzi
- Vascular Unit, Poliambulatorio Hippocrates
- Clinica Stella Maris, San Benedetto del Tronto, Italy
| | - K Parsi
- Department of Dermatology, St Vincent's Hospital
- University of New South Wales, Sydney, Australia
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Affiliation(s)
- J-L Gillet
- President of the French Society of Phlebology, Vascular Medicine and Phlebology, 51 bis Avenue Professeur Tixier, 38300 Bourgoin-Jallieu, France
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Simka M. Principles and Technique of Foam Sclerotherapy and Its Specific Use in the Treatment of Venous Leg Ulcers. INT J LOW EXTR WOUND 2011; 10:138-45. [DOI: 10.1177/1534734611418154] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Invention of foam sclerotherapy has significantly changed the current phlebological practice. Compared with liquid sclerosants, obliterating foam is more efficient, especially for the closure of larger veins. This review discusses clinical aspects of foam sclerotherapy with a focus on its use for the treatment of venous leg ulceration, including the rationale for its use in the treatment of these chronic wounds, physicochemical mechanisms responsible for stability and disintegration of sclerosant foam, pathomechanism of neurologic adverse events seen after foam sclerotherapy, and techniques that can increase efficacy of this procedure and lower frequency of adverse events.
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Affiliation(s)
- Marian Simka
- Private Healthcare Institution SANA, Department of Angiology, Pszczyna, Poland
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