Servier – Phlebolymphology

VI. Emergencies

Kurosh Parsi, Australia


Even though emergencies in phlebology are rare, they can be life-threatening. Complications with foam sclerotherapy may be related to the drug and/or gas and can be localized or generalized. Significant complications include anaphylactic reactions (<0.1%), deep vein thrombosis (1%-3%), superficial venous thrombosis (4.4%), tissue necrosis, edema (0.5%), nerve damage (0.2%), pulmonary embolism, cardiac manifestations, stroke (0.01%), and other neurological events. Cosmetic complications include telangiectatic matting (15%-24%) and pigmentation (10%-30%). Anaphylaxis is a sudden, severe hypersensitivity reaction. It occurs on reexposure to antigen, it is not dose-related, and is usually a type I hypersensitivity, IgE-mediated reaction. Nonallergic anaphylactic reactions, formerly called anaphylactoid, are not immune mediated, are dose-dependent, and can happen with first exposure. Even though anaphylaxis can result in gastrointestinal, renal or hematologic manifestations, cutaneous (90%; flushing, pruritus, angioedema), respiratory (70%; bronchospasm, stridor, wheeze, cough), and cardiovascular (50%; hypotension and tachycardia) repercussions are the most common. Differentiation from other conditions such as vasovagal reaction (which is much more common) or acute anxiety should be made. Treatment requires: 1) keeping the airway secure; 2) giving oxygen; 3) gaining access for IV fluids; and 4) administering drugs. With regard to the latter, adrenalin is the key (0.3 to 0.5 mg intramuscular), although hydrocortisone and premathazine can also be administered. Calling for an ambulance should be done in parallel with initial patient support. The speaker stressed the importance of having a clear protocol established for these situations. Tissue necrosis can arise either by direct arterial/arteriolar injection or by venoarterial reflex vasospasm. The latter usually occurs after a rapid dilatation of the vein and can be overcome by avoiding rapid injections especially in telangectasias and reticular veins.

Jean-Luc Gillet, France (Discussant)


Dr Gillet reported that direct arterial/arteriolar injection is exceptionally rare. In fact, less than 70 cases have been described to date. Most of them have occurred after injection in the ankle area, and the site of the perforating veins above the medial ankle. Ultrasound guidance has helped to minimize the occurrence of this catastrophic event, which most frequently results in amputation.

The most common neurological complication is visual disturbance usually associated with migraine. Stroke, a much less frequent event, is ischemic in 85% of cases and can result either from a paradoxical clot or a gas embolism. Patent foramen ovale (PFO) and other cardio-pulmonary right-to-left shunts are the most consistent risk factors. Meanwhile, screening for PFO should only be performed in patients at risk (history of cryptogenic stroke, recurrent classic migraine). During the procedure, movements that lead to Valsalva must be avoided, as well as rapid sitting or standing immediately after the procedure. The bubble load should also be minimized. Kurosh Parsi emphasized that saphenofemoral junction compression and release during foam injection does not prevent it entering the deep venous system, and can even induce a foam bolus to enter into the systemic circulation1. Jean-Luc Gillet added that a small volume of injected foam (less than 10 ml) and its respective quality can further limit neurological events. It was also noted that polidocanol can lead to cardiac toxicity, which is dose related.

In conclusion, sclerotherapy is an effective and safe treatment when used by trained and careful hands. Meanwhile, as with every medical treatment, side effects and complications may occur. Fortunately, most of them are benign, but physicians must be aware of the potentially serious events and should be trained to react adequately. Good technique, satisfactory imaging, general precautions and compliance with posttreatment instructions may help avoid some of the adverse events.


Reference
1. Hill D, Hamilton R, Fung T. J Vasc Surg. 2008;48:934-939