Atypical leg ulcers after sclerotherapy for treatment of varicose veins: Case reports and literature review

Skin necrosis following sclerotherapy. Part 2: Risk minimisation and management strategies

Tissue necrosis is a serious but rare complication of sclerotherapy. Early detection and targeted management are essential to prevent progression and minimise serious complications. In the first instalment of this paper, we reviewed the pathogenic mechanisms of post-sclerotherapy necrosis. Here, we describe risk minimisation and management strategies.

Risk factors must be addressed to reduce the chance of necrosis following sclerotherapy. These may be treatment-related including poor choice of sclerosant type, concentration, volume or format, poor injection technique, suboptimal ultrasound visualisation and treatment of vessels in high-risk anatomical areas. Risk factors specific to individual patients should be identified and optimised pre-operatively.

Tissue necrosis is more likely to occur with extravasation of irritant sclerosants such as absolute alcohol, sodium iodide, bleomycin and hypertonic saline, whereas extravasation of foam detergent sclerosants rarely results in tissue loss. Proposed treatments for extravasation of irritant sclerosants include infiltration of an isotonic fluid and hyaluronidase. Management of inadvertent intra-arterial injections may require admission for neurovascular observation and monitoring for ischaemia, intravenous systemic steroids, anticoagulation, thrombolysis and prostanoids infusion when required. Treatment of veno-arteriolar reflex vasospasm (VAR-VAS) necrosis follows the same protocol involving systemic steroids but rarely requires hospital admission and may not require anticoagulation.

In general, treatment of post-sclerotherapy necrosis is challenging and most proposed treatment measures are not evidence-based and only supported by anecdotal personal experience of clinicians. Despite all measures, once the necrosis has set in, it is very difficult to reverse the process and all measures described here may only be useful in prevention of progression and extension of the ulceration.

Mid to long-term measures include addressing exacerbating factors, management of medical and psychosocial comorbidities, treatment of secondary infections and referrals to relevant specialists. All ulcers should be managed with compression and prescribed dressing regimes in line with the healing stage of the ulcer.

Skin necrosis following sclerotherapy. Part 1: Differential diagnosis based on classification of pathogenic mechanisms

Background: Tissue necrosis is a significant but uncommon complication of sclerotherapy. The pathogenic mechanisms of this often-debilitating complication have been poorly described in the literature.Purpose: To elucidate the pathological mechanisms, we propose a morphological approach to classify sclerotherapy-induced skin necrosis into two categories of round and stellate (star-like) necrosis.Research Design: Comprehensive literature review was conducted.Results: Round necrosis is typically caused by extravasation of sclerosants. It typically presents as an ulcer with smooth and non-geographic borders. Historically, extravasation has been cited as the main cause of sclerotherapy-related necrosis. While this may be the case with osmotic or irritant sclerosants, it is far less likely with the use of detergent agents particularly in the foam format.The more commonly encountered pattern of stellate necrosis is an ischaemic ulcer secondary to arterial/arteriolar occlusion. In contrast to round necrosis, stellate necrosis follows an intra-vascular injection of sclerosants such as an inadvertent intra-arterial injection. But more frequently, stellate necrosis may follow a perfectly executed intra-venous or intra-telangiectatic delivery of sclerosants. Several pathogenic pathways can be considered. The physiologic response of veno-arteriolar reflex vasospasm (VAR-VAS) is possibly the most frequent pathway. It follows a high-pressure injection of the sclerosant in a target vein resulting in a rapid rise of intravenous pressures which in-turn would trigger a sympathetic neuronal reflex vasospasm of the pre-capillary sphincters and a corresponding opening of the normally closed arterio-venous anastomoses (AVAs). This communication would allow entry of the sclerosing agent into the arteriolar side of the circulation resulting in arteriolar occlusion and infarction of the corresponding skin. Similarly, an intravenous administration of sclerosants in the vicinity of defective boundary valves or persistently open AVAs can result in the entry of detergent agents into the arteriolar side of the microvasculature causing an ischemic stellate ulcer.Conclusions: In this first instalment of these two-part series, we review the pathogenic mechanisms of post-sclerotherapy necrosis. In the second instalment, we describe risk minimisation and management strategies.

Ulzerationen der unteren Extremität – nicht immer venös bedingt

Ulzerationen der unteren Extremität sind ein häufiger Vorstellungsgrund in der phlebologischen Sprechstunde. Dementsprechend können dem phlebologisch tätigen Arzt neben gängigen Differenzialdiagnosen wie dem venösen, arteriellen und gemischten Ulkus auch weniger häufige, mit Ulzerationen assoziierte Krankheitsbilder begegnen. Eine sorgfältige Anamnese und eventuelle Umfelddiagnostik sind neben der sonografischen Untersuchung essenziell.

Wir berichten über einen 77-jährigen Patienten, der vom Hausarzt zur Abklärung von vor 3 Jahren aufgetretenen Ulzerationen am Oberschenkel vorgestellt wurde.

Die vorliegende Kasuistik beschreibt die differenzialdiagnostische Aufarbeitung, an deren Ende die Ulzerationen am Oberschenkel, ursprünglicher Grund der Vorstellung, als ulzerierte Granulome im Rahmen der bekannten Sarkoidose diagnostiziert wurden. In den Vordergrund der ausführlichen Umfelddiagnostik geriet allerdings das Aderhautmelanom mit multiplen Metastasen-verdächtigen Befunden insbesondere im Gehirn und pulmonal.

Bedauerlicherweise verstarb der Patient unerwartet kurz vor Abschluss der Diagnostik und vor der Einleitung einer spezifischen Therapie aufgrund einer akuten Einblutung in einen Metastasen-verdächtigen zerebralen Rundherd.

Different management options for primary varicose veins in females: A prospective study

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.

Acute Hand Ischemia Following Elective Venous Sclerotherapy for Dorsal Hand Varicose Veins

Venous sclerotherapy is an emerging cosmetic treatment option for dorsal hand varicose veins. Although venous sclerotherapy is considered a safe and effective procedure for treatment of venous malformations and varicosities in both the upper and lower extremities, inadvertent injection of the sclerosing agent into the arterial system has led to reported instances of acute ischemic events and distal limb necrosis. This is a rare but well-documented complication of lower-extremity venous sclerotherapy. Only 2 cases have been reported in upper-extremity venous sclerotherapy, both of which occurred during treatment of complex vascular malformations. We report an instance of acute, distal digit ischemia after elective venous sclerotherapy for a dorsal hand varicosity. As this procedure grows in popularity, it is essential for hand surgeons to be aware of this rare but potentially devastating complication.