1 / 23

Side Effects of Foam Sclerotherapy

2. Ultrasound-guided Foam Sclerotherapy (FS) has becomea common treatment for patients with varicose veins.As all treatments, sclerotherapy is associated with a numberof side effects and complications.The expansion of FS has changed the features of the sideeffects and some seem to occur specifi

brasen
Download Presentation

Side Effects of Foam Sclerotherapy

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. 1 Side Effects of Foam Sclerotherapy J L GILLET, France

    2. 2 Ultrasound-guided Foam Sclerotherapy (FS) has become a common treatment for patients with varicose veins. As all treatments, sclerotherapy is associated with a number of side effects and complications. The expansion of FS has changed the features of the side effects and some seem to occur specifically with FS. We will not discuss local effects (pigmentation, inflammatory reactions, matting) ? technical or tactical problems. To focus on the main controversial and serious complications: Thromboembolic Neurological Complications

    3. 3 Jia X: Systematic review of foam sclerotherapy for varicose veins, BJS 2007 < 1% serious complications including DVT and PE Bradbury AW. J Vasc Surg 2010 977 patients 3 symptomatic DVT (0.3%) – 1 (0.01%) PE Coleridge Smith P, EJVES 2006 : 808 patients with saphenous insuf. : 13 (13 / 808 = 1.6 %) 10 distal DVT, treated without AC 1 thrombosis of the CFV : AC for 6 months 1 Non-occlusive thr. of the CVF and PV: no AC. Bergan J, J Cardiovasc Surg 2006 : 6 / 332 (1.8 %), distal. Cavezzi A, Phlebology 2002 : 2 / 194 (1%) Guex jj , Dermatol Surg 2005 : 9 / 6395 = 0.3 %

    4. 4 Personal study A multicentre, prospective and controlled study was carried out in which GSV and SSV trunks were treated with FS. Inclusion criteria - Terminal or preterminal valve and truncal reflux of the GSV or a truncal reflux of the SSV starting at the terminal valve. Systematic DUS examination between D8 and D30

    5. 5 Results Population 1025 Patients 20 Phlebology Clinics GSV : 818 (79.8%) SSV : 207 (20.2%) Follow up 99 % of patients were checked with DUS (median : 20 days) and the non-checked patients (n=11) were all called : ? no patient was completely lost to follow-up

    6. 6 Results Thrombo-Embolic Events 11 events (11/ 1025 = 1.07%) * 5 symptomatic DVT (5/1025 = 0.5%) - all distal - 4 muscular vein (MGV) - 1 Post Tibial Vein * 5 asymptomatic DVT (0.5 %), all not completely occlusive - 3 distal, with 1 controlateral - 2 Femoral Common Vein * 1 PE, but its association with FS was not certain : D + 19 - DUS (repeated) : no DVT Satisfactory outcome

    7. 7 Discussion Surgery : only 1 study with systematic control of patients : Van Rij AM, B J Surg 2004 : 5 % DVT Radiofrequency : 0 – 16 % Weiss RA, Dermatol Surg 2002 - Merchant RF, Dermatol Surg 2005 Kistner RL, JJP 2002 - Hingorani AP, J Vasc Surg 2004 Endovenous Laser : 0 – 8 % Min RJ, JVIR 2001 - Anatasie B, Phlébologie 2002 Proebstle TM, Der. Surg 2003 - Mozes G, J Vasc Surg 2005 ? FS does not lead to more Thrombo-Embolic Complications than the other methods

    8. 8 Neurological Complications

    9. 9 1)The issues can be summarized : What are the neurological risks of FS? 2) Among the neurological disturbances : - Visual disturbances - Cerebro-vascular events

    10. 10 Cerebro-vascular events While millions of FS sessions have been performed * No death or stroke with significant after-effects * 2 cases of stroke (with minimal after-effects – D15) Forlee MV, J Vasc Surg 2006 Bush RG, Phlebology 2008 * A few cases of TIA Bush RG, Phlebology 2008 Gillet JL Phlebology 2009 Hartmann K, EJVES 2009 Leslie-Mazwi TM, Neurocrit Care 2009 Hahn M, Vasa 2010 Picard C, J N P 2010

    11. 11 Foam volume or quality or both may be involved in most cases of stroke occuring after FS. All patients had an undiagnosed PFO. Considering the high prevalence of PFO in the adult population (# 30%), the risk of stroke following FS appears to be very low. According to the opinion of experts, screening for FPO is not necessary before FS Consensus of Tegernsee , Breu FX, Vasa 2008 Symptomatic PFO: CI for FS We must remember that strokes have complicated liquid sclerotherapy and endovenous laser as has been reported.

    12. 12 Though strokes are exceptional, their prevention must be our main concern. ? Quality Volume Injection of large volume of foam remains controversial Most physicians recommend limiting the volume : Maximum volume of foam per session 10 ml : Tegernsee Consensus 12 ml : Venous Forum of the Royal Society of Medicine 15 ml : Australasian College of Phlebology

    13. 13 Prevention We recommend patients avoid the Valsalva manśuvre (they should not put compression stockings on by themselves) Additional measures have been suggested: - elevating the leg 30° during injection and remaining supine for 5 min - compression of the SF junction ? Efficiency is not established

    14. 14 Visual Disturbances (ViD)

    15. 15 Visual Disturbances (ViD) : reversible symptoms * Positive features (Flickering lights, spots, lines or scotoma) * Negative features (loss of vision) One or both eyes The frequency of occurrence : 0% - 14 % average rate : 1.4% Jia X: Systematic review of foam sclerotherapy for varicose veins, BJS 2007 Some clues indicated that they could correspond to migraine with aura (MA) and were not TIA Ratinahirana H et al. Cephalalgia 2003 Coleridge Smith P. EJVES 2006

    16. 16 Demonstrating that ViD corresponds to MA and is not a cerebro-vascular event is a crucial issue in the assessment of the safety of FS. We carried out a prospective muticentre study : - Collaboration with the Neurology Department of the Marseille University Hospital (Specialist of migraine : Dr A Donnet) - Clinical assessment combined with a brain MRI (T1, T2, T2*, diffusion)

    17. 17 Results 20 patients were included in 11 phlebology clinics Clinical assessment : ViDs presented characteristics of MA in all patients 15 MRIs were performed within 2 weeks (average: 8 days) ? All the MRIs were normal

    18. 18 2 pathophysiological mechanisms could be involved in MA after FS I – Release of endothelin that could reach the cerebral cortex through a PFO. * Endothelin has been demonstrated as being a trigger factor for MA Dreier JP et al. Brain 2002 * Significant increase of endothelin 1 level was identified after FS in rats Frulini et al. ACP meeting 2010

    19. 19 2 pathophysiological mechanisms could be involved in MA after FS II – Microemboli Moskowitz et al. Ann Neurol 2010 Mice : microemboli of microbubbles of air, polystyrene micropheres or cholesterol crystals into the carotid artery could trigger a cortical spreading depression (CSD) (pathophysiological correlate with MA) without requisite tissue damage. CSDs were preceded by local or regional hypoperfusion. Histopathological evaluation: no ischemic infarct in mice brains after microemboli of air.

    20. 20 2 pathophysiological mechanisms could be involved in MA after FS II – Microemboli Caputi et al. Headache 2010 Performed contrast-enhanced transcranial Doppler with air-mixed saline in 159 patients with MA. A typical MA attack was observed in 12 patients, only in PFO positive ones (12/ 79 = 15.2%)

    21. 21 2 pathophysiological mechanisms could be involved in MA after FS These data reinforce the hypothesis that ViDs occuring after FS correspond to MA and are not TIA. Two pathophysiological mechanisms are possible and might coexist: - Release of Endothelin - Microembolization with a decrease in cerebral oxygen saturation, Both triggering CSD and Migraine with Aura.

    22. 22 CONCLUSION

    23. 23 Ultrasound-guided FS is a safe and effective treatment for varicose veins. Most side effects and complications are benign. However, the eventuality of exceptional but more serious complications has to be taken into account in the management of patients. As in all treatments, it is necessary to evaluate the ratio benefit / risk before treating a patient.

    24. 24 We insist on: - The necessary preliminary training in this method should be done by expert for practitioners and the educational process should be ongoing. - We must remember that the physicians have to provide accurate, documented information to the patients and the physicians have to obtain the patient’s consent. Thank you for your Attention

More Related