Sclerotherapy of lower limb veins: Indications, contraindications and treatment strategies to prevent complications - A consensus document of the International Union of Phlebology-2023

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.

Safety and Efficacy of a Novel Shunt Surgery Combined with Foam Sclerotherapy of Varices for Prehepatic Portal Hypertension: A Pilot Study

OBJECTIVES

This pilot study investigated the safety and efficacy of a novel shunt surgery combined with foam sclerotherapy of varices in patients with prehepatic portal hypertension.

METHODS

Twenty-seven patients who were diagnosed with prehepatic portal hypertension and underwent shunt surgeries were divided into three groups by surgery type: shunt surgery alone (Group A), shunt surgery and devascularization (Group B), and shunt surgery combined with foam sclerotherapy (Group C). Between-group differences in operation time, intraoperative blood loss, portal pressure decrease, postoperative complications, rebleeding rates, encephalopathy, mortality rates and remission of gastroesophageal varices were compared.

RESULTS

Groups A, B and C had similar operation times, intraoperative bleeding, and portal pressure decrease. The remission rates of varices differed significantly (p<0.001): one patient in Group A and 6 patients in Group B had partial response, and all 9 patients in Group C had remission (2 complete, 7 partial). Two Group A patients and one Group B patient developed recurrent gastrointestinal bleeding postoperatively within 12 months. No postoperative recurrence or bleeding was observed in Group C, and no sclerotherapy-related complications were observed.

CONCLUSIONS

Shunt surgery combined with foam sclerotherapy obliterates varices more effectively than shunt surgery alone does, decreasing the risk of postoperative rebleeding from residual gastroesophageal varices. This novel surgery is safe and effective with good short-term outcomes.

Polydocanol foam stabilized by liposomes: Supramolecular nanoconstructs for sclerotherapy

Vascular pathology of the lower limbs is a widespread disease affecting the quality of life for more than 30% of the adult world population. Polydocanol foam is presently the main therapeutic option for treating varicosities, inflammation, and chronic disease which affect the vascular endothelium and blood vessels. Unfortunately, the commercial product contains detergents and surfactants which can provoke several side effects and decrease the efficacy of therapy. In an attempt to overcome these drawbacks, polydocanol foam was mixed with different liposomes before use. The resulting mixture was stable and generated supramolecular nanoconstructs, which may prevent the interaction of the components of the commercial polydocanol foam with the vascular endothelium. This effect depends on the presence of liposomes, which can induce polydocanol foam to change its structure from micelles to complex nanostructures, thus improving its stability. In this attempt, the physicochemical features of the resulting nanoconstructs were tested through dynamic- and multiple light scattering analyses, rheological studies and gel permeation chromatography, while the stability was tested in biological fluids. Our preliminary results showed that the nanoconstructs have some potential as therapeutic agents in sclerotherapy.

Novel developments in foam sclerotherapy: Focus on Varithena® (polidocanol endovenous microfoam) in the management of varicose veins

Scope Varithena® is a recently approved commercially available drug/delivery unit that produces foam using 1% polidocanol for the management of varicose veins. The purpose of this review is to examine the benefits of foam sclerotherapy, features of the ideal foam sclerosant and the strengths and limitations of Varithena® in the context of current foam sclerotherapy practices. Method Electronic databases including PubMed, Medline (Ovid) SP as well as trial registries and product information sheets were searched using the keywords, 'Varithena', 'Varisolve', 'polidocanol endovenous microfoam', 'polidocanol' and/or 'foam sclerotherapy/sclerosant'. Articles published prior to 20 September 2016 were identified. Results Foam sclerosants have effectively replaced liquid agents due to their physiochemical properties resulting in better clinical outcomes. Medical practitioners commonly prepare sclerosant foam at the bedside by agitating liquid sclerosant with a gas such as room air, using techniques as described by Tessari or the double syringe method. Such physician-compounded foams are highly operator dependent producing inconsistent foams of different gas/liquid compositions, bubble size, foam behaviour and varied safety profiles. Varithena® overcomes the variability and inconsistencies of physician-compounded foam. However, Varithena® has limited applications due to its fixed sclerosant type and concentration, cost and lack of worldwide availability. Clinical trials of Varithena® have demonstrated efficacy and safety outcomes equivalent or better than physician-compounded foam but only in comparison to placebo alone. Conclusion Varithena® is a promising step towards the creation of an ideal sclerosant foam. Further assessment in independent randomised controlled clinical trials is required to establish the advantages of Varithena® over and above the current best practice physician-compounded foam.

Low-concentration detergent sclerosants stimulate white blood cells and release proinflammatory and proangiogenic cytokines in vitro

OBJECTIVE

The objective of this study was to investigate the effects of the detergent sclerosants sodium tetradecyl sulfate (STS) and polidocanol (POL) on the release of proinflammatory and angiogenic mediators from circulating blood cells.

METHODS

Whole blood, platelet-rich plasma, platelet-poor plasma, and suspensions of polymorphonuclear cells (PMNCs) and mononuclear cells (MNCs) were incubated with varying concentrations of sclerosants. Enzyme-linked immunosorbent assay was used to detect the release of interferon-γ (IFN-γ); tumor necrosis factor-α (TNF-α); interleukins (IL) 1α, 1β, 6, 8, and 17; vascular endothelial growth factor (VEGF); and basic fibroblast growth factor. Leukocyte activation was assessed by flow cytometry.

RESULTS

IFN-γ and TNF-α were released from STS-stimulated PMNCs at high (387 ng/mL; P < .01) and modest (232 ng/mL; P < .05) quantities, respectively. Both sclerosants induced a weak response in MNCs, releasing minor quantities of IL-1α (STS, 18.2 ng/mL; POL, 14.0 ng/mL), IFN-γ (STS, 41.7 ng/mL; POL, 27.7 ng/mL), and TNF-α (STS, 29.7 ng/mL; POL, 14.0 ng/mL). POL at a wide range of concentrations and in all sample types tested stimulated the release of VEGF, whereas the effect of STS was limited to low concentrations and not detected in MNCs. Both agents stimulated moderate release of IL-8 from PMNCs (STS, 223.3 ng/mL, P < .001; POL, 84.23 ng/mL, P < .05). Neither agent induced a significant rise in basic fibroblast growth factor, IL-6, or IL-17. STS at low concentrations increased the expression of CD11b in both PMNCs and MNCs, suggestive of cellular activation. The activating effect of POL was limited to MNCs.

CONCLUSIONS

STS demonstrated proinflammatory activity mediated primarily by IFN-γ released from PMNCs and MNCs. POL had a weak proinflammatory effect limited to MNCs. Both sclerosants (POL > STS) induced a proangiogenic response mediated by VEGF.