Complications of Sclerotherapy: How to identify the risks and treat problems
Welcome to my presentation. My name is Dr Haroun Gajraj director of The VeinCare Centre. I am going to talk to you about how to avoid and manage common problems related to sclerotherapy and this is based on a presentation I gave to the Venous Forum at the Royal Society of Medicine in April 2013. It is pitched mainly at a medical audience but members of the public might find it useful. Now sclerotherapy is really popular. It has grown in popularity in the United Kingdom over the last 10 years and the reason is that nearly any vein in the leg can be treated by sclerotherapy.
For example sclerotherapy is the treatment of choice for reticuar veins and telangiectasia. It has been compared with other treatments such as electrical treatments and laser but sclerotherapy but sclerotherapy always comes out best. Foam sclerotherapy is comparable to standard surgery for major saphenous reflux and very people now need to be treated by surgical stripping. Sclerotherapy is also effective in treating tributary varicose veins incompetent perforator veins of the legs residual and recurrent varicose veins after other interventions such as endovenous laser or radiofrequency ablation and it is also effective in the treatment of varicose veins of pelvic origin. So as I have said nearly any vein in the leg can be treated by sclerotherapy it really is very versatile. The other reason why sclerotherapy is so popular is that sclerotherapy is really safe. A large French registry of over twelve thousand procedures confirms a very low incidence of major complications. And a clinical audit of foam sclerotherapy in over seven thousand procedures from nine UK centres also confirms the safety of scleortherapy particularly in relation to stroke and this was published by the National Institute for Clinical Excellence in 2010.
Now there are complications from sclerotherapy and if patients are not selected well or if treatment is given with poor technique disasters can occur. And Cavessi and Parsi in the Phlebology Journal in 2012 discussed and reviewed complications from sclerotherapy and they divided them into major complications and minor complications. I am going to consider the major complications first.The most feared complication which is potentially life threatening is of course anaphylaxis. This is an allergic reaction that can in severe cases result in death. Now it is very rare. There are only very isolated reports of severe anaphylaxis occuring after sclerotherapy.
It is sporadic and it is unpredictable. At present there is no test or marker that might indicate who will get an anaphylactic reaction from sclerotherapy and nearly any sclerosant with the exception of hypertonic saline could theoretically cause anaphylaxis. Thromboembolism the development of a deep vein thrombois and pulmonary embolism has been recorded with scleortherapy. The incidence is low. Many of the deep vein thromboses are silent and never cause any harm but again it is a potentially serious and potentially life threatening complication. Neurological events occur after sclerotherapy.
The most common is visual disturbance which is always transient there has never been a report of permanent visual damage after sclerotherapy but it has been also been associated with transient ischaemic attacks and there have been reports of stroke after sclerotherapy. Tissue necrosis can occur either locally possibly because of extravasation this appears to be more of an issue with liquid sclerosant but obviously if sclerosant is injected into the artery it can cause very significant tissue loss and there have been reports in fact of amputation being required after intra-arterial injection. More recently there is this phenomenon that has been described and recognised called veno-arteriolar reflex vasospasm. That is little arterioles near veins that are being injected go into very intense spasm so severe that the skin usually becomes very white and there can be associated skin loss. There have also been reports of nerve damage.
Both sensory nerve damage and motor nerve damage and this appears to be a particular issue or a particular risk though it is very of course in the popliteal fossa behind the knee. Less common is swelling oedema after sclerotherapy. This appears again it is very rare to be an issue after small saphenous vein sclerotherapy. It is associated with intense phlebitis and it can sometimes be associated with poor bandaging or stocking fitting.
So those are the major complications identified by Cavessi and Parsi. More minor complications include telangiectatic matting. This is the appearance of very fine new blood vessels in the skin near the injection sites. They can be very upsetting to the patient.
They can marr an otherwise very good cosmetic result. Telangiectatic matting can occur after surgery as well but it appears to be a problem after sclerotherapy. The incidence is probably in the order of 10-20%. Pigmentation can occur after sclerotherapy. I think some degree of pigmentation occurs in everyone. But again, it can marr a cosmetic result. Skin irritation is another issue either at the injection site or in relation to tapes or stockings.
And some veins after injection develop clot in them and retained coagulum can cause irritation and continued inflammation at the injection site. And this is not so much a complication but in my experience it is one that needs to be managed quite carefully and that is disappointment. Some people have very high expectations of what can be achieved from their treatment and it is very important that during the consultation these expectations are managed carefully. So those are the major and minor complications associated with sclerotherapy. How do we avoid them? Well as I have said anaphylaxis is sporadic and rare.
There is no test to identify who might get the problem but I would suggest to you and you might think this reasonable that if someone says they are allergic to sclerosant that you would not inject them. Of course that is an absolute contraindication to sclerotherapy. I also would suggest to you that if someone has a number of allergies they are very severely allergic to a number of various different things perhaps if they have had an anaphylactic reaction to some other agent you would have caution. Thromboembolism this again is a concern. If someone has a recent or acute deep vein thrombosis or pulmonary embolism you would not wish to treat them with sclerotherapy. It they give you a history of a previous thromboembolism if they have a known thrombophilia or they have an active cancer that again might well be a contraindication to sclerotherapy. And if they have active acute superficial venous thrombosis again this is a risk factor for deep vein thrombosis and sclerotherapy should be avoided in this group. Neurological events.
Well sclerotherapy is contraindicated in people who are known to have a symptomatic right to left shunt particularly a patent foramen ovale. Now right to left shunts and patent foramen ovale are associated with paradoxical gas embolism. There has never been any permanent neurological damage associated with paradoxical gas embolism. But if you know they have a right to left shunt then you should avoid sclerotherapy in these patients. You should also exercise caution in people who are known to have migraine or who have had neurological events after previous sclerotherapy. There is a lot of evidence to suggest that the volume of sclerosant is important. Neurological events become more frequent as the volume of sclerosant increases and a recent European Document that suggests that foam sclerosants should be limited to 10ml in one session.
Interestingly, there is no evidence that carbon dioxide based foam reduces events. That is evidence from Peterson and Goldmann published in Phlebology 2012 and there is no evidence that CO2 based foam or indeed a number of other maneouvers such as elevating the legs avoiding Valsalva compressing the sapheno-femoral junctions also prevent paradoxical gas embolism. Tissue necrosis well obviously you want to avoid intra-arterial injection by careful imaging and mapping of the veins. I would suggest to you that an open needle technique or a cannula technique reduces the risk.
I have no evidence for this but it seems intuitive. If you can see the back flow of dark venous looking deoxygenated blood and if that back flow is slow and non-pulsatile as well as seeing the needle in the vein this gives you added confidence that you are not injecting into an artery. You also need to inject slowly under low pressure to prevent reflex arteriolar spasm. And if there is any pain or blanching of the skin you need to stop. Now we get blanching of the reticular veins and telangiectasia but if there is blanching of the skin rather than the blood vessels then you may have this reflex vasospasm which is associated with skin loss.
Nerve damage. You obviously want to carefully place your sclerosant inside the vein and I like to image the surrounding nerves. I like to cannulate and inject in transverse section which is controversial a lot of people are very skilled at injecting in longitudinal section and I have no problem with that.
But you need to be sure you have an idea where the surrounding nerves are. Careful padding and bandaging in the popliteal region is very important. And your stocking need to be carefully fitted and you need to avoid any rucks or folds. Oedema. Againg careful bandaging and well fitted stockings reduces this risk. And you need to use care in people who already have oedema and limit the extent of your sclerotherapy sessions.
We know that telangiectatic matting can be aggravated if there is persistent proximal reflux. Proximal reflux needs to be treated first and you need to consider using low volumes of appropriate strength sclerosant under low pressure. Pigmentation. I do not think you can avoid this. Some degree of pigmentation is unavoidable. You can limit it however by using the lowest strenth of sclerosant appropriate to the vessel using good post procedure compression and releasing any retained coagulum as soon as possible. That limits the inflammation and limits the pigmentation that is partly melanin and partly extravasated red blood cells. I think there may also be a place for topical steroids after injection to minimise post inflammatory pigmentation.
Skin irritation and disappointment. You need to be very careful in the use of tapes and bandaging you need to use well fitted stockings. Manage expectations carefully by consenting them appropriately and giving them lots of information. I routinely use one application of topical steroid after injection sclerotherapy.
I have no evidence for it but it seems intuitive in reducing inflammation and irritation after the injection session. So in summary serious complications of sclerotherapy are very rare and most can be avoided by careful patient selection very precise treatment imaging making sure that the needle is in the vein and injecting under ultrasound control. Minor complications are quite common but fortunately they are usually self limiting. However we know there is a general trend to increasing complaint and litigation and it very important that we give plenty of information manage expectations and we consent our patients carefully before sclerotherapy.
Anaphylaxis is unpredictable and anyone providing sclerotherapy needs to identify patients with anaphylaxis and manage it appropriately. And I think sclerotherapy should only be performed in an environment in which there is appropriate help and assistance to provide resuscitation. In addition for very rare and potentially life threatening or limb threatening complications there need to be protocols and referral pathways so that these problems can be dealt with appropriately and promptly. So thank for this thank you for taking part in this presentation and watching. I hope you have enjoyed it.
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