Precision Oncology in Soft Tissue Sarcomas and Gastrointestinal Stromal Tumors

Soft tissue sarcomas (STSs), including gastrointestinal stromal tumors (GISTs), are mesenchymal neoplasms with heterogeneous clinical behavior and represent broad categories comprising multiple distinct biologic entities. Multidisciplinary management of these rare tumors is critical. To date, multiple studies have outlined the importance of biological characterization of mesenchymal tumors and have identified key molecular alterations which drive tumor biology. GIST has represented a flagship for targeted therapy in solid tumors with the advent of imatinib which has revolutionized the way we treat this malignancy. Herein, the authors discuss the importance of biological and molecular diagnostics in managing STS and GIST patients.

Usefulness of antegrade foam sclerotherapy for portal hypertensive variceal bleeding

PURPOSE

This study investigates the usefulness of antegrade variceal embolization using sclerosant foam to evaluate technical success and clinical outcomes in cases of hypertensive variceal bleeding.

METHODS

A total of 16 patients underwent percutaneous antegrade variceal embolization using foam sclerotherapy from August 2019 to January 2022. Among the patients, 12 cases were of gastroesophageal varices, two were rectal varices, and one case each was duodenal and jejunal varices, respectively. Sodium tetradecyl sulfate (STS) foam was used as a detergent for variceal bleeding sclerotherapy at various anatomical locations. The detergent was used in a foam form to promote clinical outcomes and enable the effective embolization of the entire blood vessel wall, including the ventral side, against gravity. Furthermore, STS foam could be used to help sufficiently deliver the drug to distal segments. A balloon catheter was also used to block the antegrade flow and prevent the dilution of the sclerosant. Technical success was defined as the completion of sclerotherapy for variceal bleeding as planned before the procedure to achieve the disappearance of variceal bleeding. Clinical success was defined as the complete obliteration of varices without recurrent bleeding during the follow-up period after the procedure.

RESULTS

Technical success was 81.3%, and clinical success was 84.6%. Additionally, 15/16 of the procedures were emergencies, and there were no complications related to the procedure.

CONCLUSION

Antegrade foam sclerotherapy using 3% STS for variceal bleeding is clinically safe and effective. Moreover, antegrade foam sclerotherapy can be a useful treatment option for patients with active variceal bleeding in emergency cases.

Low concentration of sodium tetradecyl sulfate and hypertonic glucose solution for the treatment of telangiectasia: A prospective randomized clinical trial

OBJECTIVES

This study aimed to compare telangiectasias disappearance after sclerotherapy with hypertonic glucose (HG) and different concentrations of sodium tetradecyl sulfate (STS).

METHODS

Women aged 18-70 years with telangiectasias were included. The primary efficacy endpoint was telangiectasia disappearance. The clearing of vessels was assessed using a six-point scale (from 0 to 5).

RESULTS

A total of 116 women completed an 8-week follow-up: 31, 27, 25, and 33 were in the HG 75%, STS 0.05%, STS 0.1%, and STS 0.15% groups, respectively. The median score of vein disappearance was significantly lower in the STS 0.05% (3, 0.25-4), STS 0.1% (3, 1.25-4), and STS 0.15% (4, 2-4) groups than in the HG group (4, 3-5) after 56 days, p = .00002.

CONCLUSION

Sclerotherapy of telangiectasias with 75% HG showed significantly better results than low concentrations of STS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04132323.

How Diluted Liquid Sodium Tetradecyl Sulphate Works in Varices with Competent Superficial Valves Versus Stockings Alone

BACKGROUND AND OBJECTIVE

Varicose veins are the most common complaints of referrals to vascular surgeons. Upon the cause, liquid sclerotherapy could be an efficient solution first in regard to competent main superficial valves. To find the impact of diluted liquid sclerotherapy in varices in patients with no superficial valve refluxes compare to whom wearing only stockings.

MATERIALS AND METHODS

Sclerotherapy with 0.3-0.5% liquid form of Sodium Tetradecyl Sulphate (STS) for reticular and spider varicosis, ulcers feeder veins and grade 3-4 sporadic varices were used. Patient's complaints the zone prevalence, response and satisfactoriness were detected clinically and data compared between the two injected cases and who managed by stockings alone with >1 year follow up.

RESULTS

Two groups (156 sclerotherapy, 76 only stockings) with three classifications for severity were obtained. Complete recovery of all varices and ulcers were almost achieved with no considerable complication. Logical regression test in unilateral to bilateral varices predict about 70% more recovery (p = 0.048), mild to severe 85% more (p<0.001), moderate to severe 29% more (p = 0.008) and 10-15% response for severe cases. No significant difference for ages and responses between the 2 groups was existed.

CONCLUSION

Diluted liquid sclerotherapy by STS was shown efficient in all ranges of varices. Stockings alone also were adequate to relief symptoms compare to sclerotherapy.

Use of percutaneous foam sclerotherapy with 1.5% sodium tetradecyl sulfate for treatment of a pelvic limb venous malformation in a dog

CASE DESCRIPTION

A 6-year-old 17-kg (37.4-lb) spayed female mixed-breed dog was evaluated because of swelling and intermittent lameness of the right pelvic limb and perianal and vulvar bleeding caused by a suspected arteriovenous malformation.

CLINICAL FINDINGS

The right pelvic limb had a diffuse, raised, cobblestone-like appearance with lameness, edema, and multifocal ulcerations. The abdominal skin had multifocal circular erythematous lesions, the perianal region was erythematous, and the vestibule had superficial distended vessels. Ultrasonography and CT did not reveal the presence of an arteriovenous malformation; however, digital subtraction venography confirmed the presence of a venous malformation (VM) throughout the limb.

TREATMENT AND OUTCOME

A mixture of foam sclerosant (1.5% sodium tetradecyl sulfate) and contrast medium was agitated with air and injected percutaneously into the VM. The dog received an injection of corticosteroid solution, and a soft-padded bandage was applied to the limb for 3 days. Six weeks later, the dog would intermittently hop when running, and the limb was mildly edematous with ecchymotic lesions; the swelling and lameness had improved considerably. Perianal and vulvar bleeding and dilation of the vestibular vessels had resolved. At 21 months after the procedure, examination revealed no right pelvic limb lameness related to the VM; only small cyst-like lesions and edema around the tarsus remained.

CLINICAL RELEVANCE

The favorable clinical outcome for this dog for a 21-month period after treatment of a pelvic limb VM with foam sclerotherapy has suggested that foam sclerotherapy may be used to successfully treat limb VMs in some dogs.

Intractable hepatic encephalopathy in cirrhotic patients: mid-term efficacy of balloon-occluded retrograde portosystemic shunt obliteration

PURPOSE

To evaluate the efficacy and intermediate-term outcome of balloon-occluded retrograde transvenous obliteration (BRTO) for the treatment of hepatic encephalopathy (HE) secondary to portosystemic shunt (PSS) in cirrhotic patients.

MATERIALS AND METHODS

Institutional review board (IRB) approval was obtained for this study and hospital records of patients who underwent BRTO, from August 2011 to August 2015, were analyzed. Based on the inclusion and exclusion criteria, 39 patients (age, 54.07 ± 9.1 years (37-67 years); 33 males and 6 females) with cirrhosis and spontaneous PSS were included. Clinical and laboratory parameters and HE grade were evaluated in all patients before and after the procedure.

RESULTS

Forty sessions of BRTO were attempted in 39 patients. Follow-up imaging revealed complete obliteration of the treated PSS in all patients with clinical success in 37 patients (94.9%). The 1-, 2-, 3-, 4-, 5-, 6-, and 7-year HE-free survival rates among responders were 91.7%, 91.7%, 88.8%, 85.5%, 80.8%, 80.8%, and 80.8% respectively and overall survival rates were 89.7%, 82.1%, 76.9%, 74.4%, 74.4%, 64.8%, and 64.8% respectively. Logistic regression highlighted Child-Turcotte-Pugh (CTP) score at 6 months as a positive predictive factor of HE recurrence with a cutoff of ≥ 9. Five patients (12.8%) had fever and leukocytosis and 1 (2.6%) patient developed spontaneous bacterial peritonitis after the procedure.

CONCLUSION

BRTO is an effective treatment for refractory HE in cirrhotics secondary to large PSS with a few possible complications.

KEY POINTS

• BRTO is an effective and safe treatment for refractory HE, arising from PSS in cirrhotic patients. • Patients with preserved liver function show better outcome and CTP score is the most important predictor of relapse during follow-up.

Mechanochemical Endovenous Occlusion of Varicose Veins Using the ClariVein® Device

INTRODUCTION

In the last decade, minimally invasive endothermal ablation techniques have replaced surgery for the treatment of superficial venous insufficiency to reduce postoperative complications and recovery time and to improve quality of life. To avoid the risks of nerve damage and need for tumescent anesthesia to improve patient comfort, an alternative heatless technique has been introduced recently.

METHODS

Endovenous mechanochemical occlusion using the ClariVein® catheter (Vascular Insights LLC, Quincy, MA) is a new technique combining mechanical injury to the venous endothelium coupled with simultaneous catheter-guided infusion of a liquid sclerosant. This produces irreversible damage to the endothelium resulting in fibrosis of the vein.

RESULTS

The technique is related to a low complication rate and a success rate of 96% at two years and sustained quality of life improvement. This closure rate is comparable to endothermal techniques, but significantly less postoperative pain and earlier return to normal activities and work has been reported with endovenous mechanochemical occlusion.

CONCLUSION

Mechanochemical occlusion using ClariVein® has proven to be safe and effective and has several advantages compared to endothermal techniques. The possibility of retrograde ablation of distal SSV insufficiency in C6 ulceration is considered a significant advantage. Randomized comparative studies with long-term follow up will continue to define the definite place of mechanochemical occlusion.

Use of sclerotherapy for treatment of vascular malformation in a young girl

Vascular malformations are difficult to treat because of poor results of treatment and recurrence of symptoms. Percutaneous and/or transluminal embolisation has refined the treatment of surface vascular lesions; especially with availability of variety of sclerosants.We report a case of a young girl with vascular malformation of right foot, which was treated with percutaneous sclerotherapy with sodium tetradecyl sulphate (STS). Result was excellent and so far the patient is free of her symptoms.

Management of haemangioma with sclerosing agent: a case report

The use of multiple weekly intralesional injections of 3% sodium tetradecyl sulfate as a sclerosing agent for the management of facial haemangiomas is a safe treatment with acceptable results. As presented in this case report, this technique offers the patient considerable relief of symptoms with minimal complications. However, the possibility of second-stage surgery to correct residual deformity is still considered. Sclerotherapy with 3% sodium tetradecyl sulfate provides a good preparation for further surgery.

Management of oral pyogenic granuloma with sodium tetra decyl sulphate. A case series

Pyogenic granuloma, or granuloma pyogenicum, is a common, tumor-like growth of the oral cavity or skin that is considered to be an exaggerated, localized connective tissue reaction to a minor injury or irritation. A total of five clinical cases of oral pyogenic granuloma were randomly selected in the age group between 26 and 41 years. All these cases were treated with sodium tetra decyl sulphate and examined for regression and reccurrence of the lesion for six months. Various treatment modalities consist of conservative surgical excision, cryosurgery, laser surgery and sclerotherapy. Sclerotherapy with sodium tetra decyl sulphate is a relatively simple and effective method for treating oral pyogenic granuloma.

Staged endovascular and surgical treatment of slow-flow vulvar venous malformations

OBJECTIVE

The objective of the study was to report our experience in a rare series of treated symptomatic slow-flow vulvar venous malformations (VVMs) using a staged, multidisciplinary approach.

STUDY DESIGN

Consecutive patients with symptomatic lesions treated over a 7 year period (2005-2012) were followed up for technical success, resolution of symptoms, aesthetic outcomes, and complications. Direct endovenous sclerotherapy (DEVS) using sodium tetradecyl sulfate (STS) foam was performed in all patients under ultrasound and contrast-enhanced fluoroscopic guidance. Surgical excision and layered primary closure was performed within 24 hours after the last DEVS session.

RESULTS

Eleven patients (mean age, 25 years; range, 4-43 years) were treated. Presenting symptoms included pain (n = 11), soft tissue swelling (n = 11), local heaviness (n = 11), dyspareunia (n = 2), and dysmenorrhea (n = 2). Most were isolated lesions (n = 8). There were 2 cases of Klippel-Trénaunay syndrome and 1 case of Maffucci syndrome. The latter required Nd:YAG laser photocoagulation prior to sclerotherapy. On average, approximately 3 DEVS sessions were required prior to surgical excision (range, 1-6). Mean estimated surgical blood loss was 130 mL (range, 20-400 mL). Mean follow-up was 23 months (range, 3-55 months). Elimination of pain and soft tissue redundancy was achieved in all patients with satisfactory aesthetic outcomes. All patients experienced minor pain and swelling after DEVS. Following surgical excision, there was 1 case of hematoma and wound dehiscence requiring surgical evacuation. No other reinterventions, endovascular or surgical, were required.

CONCLUSION

VVMs require increased awareness and appropriate preoperative evaluation for proper identification and treatment. A multidisciplinary approach can provide improvement in clinical signs and symptoms with satisfactory cosmesis and minimal complications.

Palatal sclerotherapy for the treatment of intermittent dorsal displacement of the soft palate in 51 standardbred racehorses

This retrospective study evaluated the efficacy and side effects of palatal sclerotherapy in standardbred racehorses suspected to have intermittent dorsal displacement of the soft palate (IDDSP). Fifty-one horses were treated with multiple endoscopically guided injections of 3% sodium tetradecyl sulfate in the soft palate. Two groups were identified: those that had respiratory noises during exercise (n = 27) and those that did not (n = 24). Treatment was well-tolerated. Furthermore, horses significantly reduced their racing times for the last 400 m compared with their times before treatment and even when their times were compared to the mean times for horses in the same race. In conclusion, palatal sclerotherapy appears to be a suitable alternative therapeutic option for horses suspected to have IDDSP.

Palatal sclerotherapy: a potentially useful treatment of intermittent dorsal displacement of the soft palate in juvenile standardbred racehorses

This study was aimed at evaluating the tolerability and the efficacy of palatal sclerotherapy in juvenile standardbred racehorses with easily audible "snoring-like" respiratory noises suspected to be the result of intermittent dorsal displacement of the soft palate. The palate of 8 horses was injected with sodium tetradecyl sulfate under videoendoscopic guidance. Palatal sclerotherapy resulted in resolution of the respiratory noise in 7 horses, improvement of performance in 6 horses, and mild side effects in only 3 horses. This preliminary study suggests that palatal sclerotherapy is a safe, repeatable, inexpensive, and promising technique that should be considered as an alternative to existing treatments of intermittent dorsal displacement of the soft palate.

[Sclerotherapy of sapheno-femoral reflux of blood in patients with initial stages of varicose disease of the lower extremity veins]

The results of ultrasonic investigation and the following phlebosclerosing treatment of an incompetent saphenofemoral anastomosis were analyzed in two groups of patients with initial stages of varicose disease of the lower extremity veins. The first group included 48 patients treated by injection-sclerosing therapy by the technology of "empty vein". The second group consisted of 82 patients treated by catheter sclerotherapy of the sapheno-femoral anastomosis. In the first group the treatment was effective in 73.1%, in the second group - in 91.5%. The terminal hemodynamic criteria of performing the injectional and catheter sclerotherapy were determined in elimination of high sapheno-femoral reflux of blood.

Comparison of ethanol and sodium tetradecyl sulfate in the sclerotherapy of renal cyst

BACKGROUND AND PURPOSE

Renal cysts are common in the adult population. Symptomatic cysts traditionally have been treated by percutaneous aspiration with injection of sclerosant agents. Our aim was to compare the efficacy and side effects of ethanol and sodium tetradecyl sulfate (STDS) as sclerosants for symptomatic simple renal cyst.

PATIENTS AND METHODS

Sixty-five patients with 68 symptomatic simple renal cysts were included in this study. An 8F pigtail catheter was inserted into the cyst under ultrasound guidance followed by aspiration of the cyst fluid. Either 95% ethanol (N = 34) or 3% STDS (N = 34), assigned randomly, was then instilled into the empty sac. Patients recorded any flank pain on a visual analog scale and were followed up by ultrasonography for 6 to 18 months.

RESULTS

There was complete ablation of 28 (82%) and 26 (76%) cysts, partial regression of 3 (9%) and 6 (18%) cysts, and failure of treatment in 3 (9%) and 2 (6%) cysts in the ethanol and STDS groups, respectively. There was no major complication in either group. The pain caused by the injection was significantly less for the group receiving STDS (pain score 2.1 +/- 1.1 v 3.8 +/- 1.2 for ethanol; P = 0.019).

CONCLUSIONS

Ethanol and STDS are simple, noninvasive, cost-effective, and well-tolerated sclerosants for the treatment of simple renal cysts. We prefer STDS as a first choice because it causes less pain.

Use of intraoperative sodium tetradecyl sulfate for the treatment of a spinal epidural hemangioma. Technical note

Spinal hemangiomas can be categorized into three different groups based on location. Vertebral body (VB) hemangiomas are frequent incidental findings on magnetic resonance (MR) imaging. There is a subdivision of these with spinal epidural extension that have been reported in the literature. Spinal hemangiomas can also be epidural without VB involvement; these are extremely rare with few reported cases in the thoracic epidural spinal column. The diagnosis and imaging characteristics as well as the surgical tools used in gross-total resection of spinal epidural hemangioma are not well understood. The authors present a detailed characterization of a spinal epidural hemangioma in a 30-year-old woman who presented with complaints of gradual onset of low-back pain that worsened over 1 year. The MR imaging findings indicated a large L2-S1 epidural spinal mass causing thecal sac compression. The patient underwent an L2-S1 laminectomy, and a vascular extradural mass was noted on the posterior aspect of the dura mater. Preoperative spinal angiography as well as intraoperative angiography was performed. Total resection of the tumor was achieved using intraoperative embolization with sodium tetradecyl sulfate and microscopic dissection. The postoperative MR imaging findings and clinical outcome were excellent. The findings and use of sodium tetradecyl sulfate in gross-total resection are discussed. The authors also review treatment modalities and demonstrate the utility and effectiveness of intraoperative sodium tetradecyl sulfate in grosstotal resection of large difficult spinal epidural hemangiomas.

Balloon control of the saphenofemoral junction during foam sclerotherapy: Proposed innovation

Venous obliteration using foam sclerosant is a relatively new procedure that holds great promise and may prove to be as effective as conventional surgical treatments in obliteration of the great saphenous vein. Foam sclerotherapy can have minor and major complications, most of which occur as a result of gas or sclerosant leakage into the systemic venous system. Conventionally, the saphenofemoral junction is occluded by digital pressure to prevent escape of sclerosant foam into the deep venous system. We propose balloon control of the saphenofemoral junction to prevent sclerosant leakage. This also promotes foam contact with the endothelium in a prolonged, controlled fashion. This method requires no anesthesia, is suitable for ambulatory care, and has been safe and successful in all five cases. Duplex examinations at 1 week and 3 months have shown complete obliteration of the great saphenous vein using this technique.

Efficacy of local sclerosing agents on hemostasis of hepatic bleeding

BACKGROUND/AIMS

Hepatic bleeding following abdominal trauma is a serious problem. The implementation of various materials and techniques have been attempted to prevent bleeding but a standard method is indefinite.

METHODOLOGY

Hepatic resection model was performed on rats. The efficacy of hemostasis with Polidocanol and Tetradecyl Sulfate has been evaluated through the comparison of perioperative bleeding amount and preoperative and postoperative hematocrit levels in the 24th hour. Also, histopathologic changes on parenchyma have been compared at a microscopic level.

RESULTS

Preoperative and postoperative hematocrit differences were 5.50 +/- 0.59 in Polidocanol group and 10 +/- 1.30 in Tetradecyl Sulfate group (MW: 2, p < 0.001). Perioperative bleeding amounts were: 1.50 +/- 0.20 mL in the Polidocanol group, 3.50 +/- 0.15 mL in the Tetradecyl Sulfate group and 7.50 +/- 0.41 mL in the Control Group. Upon comparison of perioperative bleeding amounts: the Control Group values were very high in comparison to the Polidocanol group (p < 0.001) and the Tetradecyl Sulfate group values were higher than those of the Polidocanol group (p < 0.05).

CONCLUSIONS

Local sclerosing agents, especially Polidocanol, appear to be an effective alternative method in hemostasis of hepatic bleeding.

The use of foam sclerotherapy for varicose veins: a survey of the members of the Vascular Society of Great Britain and Ireland

OBJECTIVES

The aim was to explore the current experience and practice of vascular surgeons in the United Kingdom and Ireland regarding foam sclerotherapy for varicose veins.

METHOD

A postal questionnaire was sent to 609 members of the Vascular Society of Great Britain and Ireland.

RESULTS

There were 281 responses (47%). Seventy surgeons (25%) used foam sclerotherapy. Most use it selectively; few (29%) offer it to all patients. It was more likely to be used for recurrent varices (71%), in older patients (61%) and for smaller non-saphenous varices (67%). The majority of surgeons (69%) used sodium tetradecyl sulphate and up to a maximum of 10-12 ml of foam. The majority used ultrasound guidance (95%), leg elevation (69%) and direct pressure over the saphenofemoral or saphenopopliteal junction during injection (63%). Eighty per cent used compression bandaging after treatment, usually for 7 days (44%). Ninety percent advised compression stockings, usually Class II (64%) for 14 days (39%). Serious complications were few, but eleven surgeons had seen a deep vein thrombosis, two had seen a patient with a stroke and one a transient ischaemic attack.

CONCLUSION

Foam sclerotherapy was used by a quarter of surgeons who replied to the survey. Aspects of technique varied considerably and studies to determine optimal techniques are needed. Serious complications with the technique were rare.

Profuse bleeding in patients with chronic venous insufficiency

AIM

The aim of this retrospective study was to compare the healing rates of patients where the bleeding points were sutured (n=52) against those where the bleeding was controlled using compression sclerotherapy (n=72). The incidence of re-bleeding was also followed over a 12-month period.

METHODS

During 1999-2003, we treated 124 patients (86 women and 38 men; mean age: 64 years, age range: 36-85 years) with profuse bleeding from varicose veins as emergency cases. Seventy-two patients (58%) were treated with compression sclerotherapy. In the suture group of 52 patients (42%) the bleeding points were treated in the emergency outpatients department. Usually a cross stitch was used and the same type of uninterrupted compression as in the sclerotherapy group was applied for 6 weeks afterwards.

RESULTS

In the group of patients where compression sclerotherapy (Fegan's method) was used to control the bleeding (65 patients), the average time taken for the wound to heal completely was 7 days (5-13 days). There was no recurrence of bleeding in the subsequent 12 months. In the group of patients where a suture was used to control the bleeding, the average time of healing was 14 days (11-19 days) and re-bleeding occurred in 12 cases (23%).

CONCLUSIONS

Using Fegan's technique of compression sclerotherapy with a low concentration of sclerosant (0.2% sodium tetradecyl sulfate), it is possible to treat bleeding varicose veins effectively with significantly faster healing of the wound.

[Assessing efficacy of combined use of endovasal laser congulation and echosclerotherapy in comprehensive management of complicated forms of varicose disease]

The article seals with the findings obtained in management of 96 patients diagnosed with varicose disease in the stage of trophic disordwrs treated by means of rndovasal laser obliteration combined with echosclerotherapy. Presented herein are peculiarities of carrying out laser coagulation of the greater and minor saphenous veins, as well as incomperetent perforating veins without ligation of the sapheno-femoral and sapheno-popliteal junction. The duration of the follow up of the patients amounted oj the patients amounted to three years. In all the cases we managed to achive persistent epitheliali-sation of the ulcerative defect and attain considerable improve-ment of the patients' quality of life by virtue of shortening the terms of medical and social rehabilitation and heightening the cosmetic effect. Endovasal laser coagulation combined with sclertherapy is a method of choice in a comprensive treatment of complication forms of varicose disease.

Classification, diagnosis, and interventional radiologic management of vascular malformations

Vascular anomalies are comprised of either hemangiomas or vascular malformations.Low-flow vascular malformations can be divided into capillary, venous, and lymphatic types and are usually present at birth, undergo pari passu growth, and produce symptoms related to mass effect or stasis. High-flow malformations are comprised pre-dominantly of arteriovenous malformations that follow a more aggressive clinical course of hyperemia, adjacent mass effect, steal phenomenon, tissue destruction, and ultimately high output failure. Ultrasound, CT, nuclear medicine, angiography, and particularly MRI have greatly enhanced diagnostic accuracy and provide detailed information for percutaneous and surgical treatment planning and an objective means of following therapeutic efficacy. Interventional radiologic percutaneous sclerotherapy for low-flow lesions and embolosclerotherapy for high-flow lesions with or without adjunctive surgical intervention have become the mainstay of therapy.

Chronic venous disease treated by ultrasound guided foam sclerotherapy

AIM

To report the outcome of a series of patients with chronic venous disease due to incompetence of saphenous trunks managed by ultrasound guided foam sclerotherapy (UFS).

PATIENTS AND METHODS

A group of 808 patients comprise this series. CEAP clinical class for limbs was C1: 15%, C2: 81%, C3: 0.5%, C4: 2%, C5: 0.2%, C6: 0.4%. UFS using 1% polidocanol (107 limbs), 1% sodium tetradecyl (102 limbs), 3% sodium tetradecyl (900 limbs) was employed to treat incompetent saphenous trunks. In patients with unilateral varices 1 treatment was required in 43% of patients and 2 treatments in 48% of patients to obliterate incompetent saphenous trunks and varices. For bilateral varices 2 treatments were required in 40% of patients and 3 treatments in 46% of cases. The clinical outcome and patency of treated veins on duplex ultrasonography was assessed at a mean follow-up interval of 11 months.

RESULTS

A total of 459 limbs were available for assessment at a follow-up interval of 6 months or greater. The CEAP clinical stage was C0:182 limbs, C1: 241, C2: 22, C3: 0, C4: 11, C5: 2, C6:1. The GSV had remained obliterated in 88% of limbs and the SSV in 82% of limbs. Recurrent venous incompetence following previous surgery was as effectively treated by UFS as primary incompetence.

CONCLUSIONS

This technique is useful in the management of chronic venous disease as an alternative to surgery.

Effectiveness and Safety of Ultrasound-Guided Foam Sclerotherapy for Recurrent Varicose Veins:Immediate Results

PURPOSE

To evaluate the effectiveness and safety of ultrasound-guided foam sclerotherapy in treating recurrent varicose veins.

METHODS

Between July 2003 and January 2005, 38 outpatients (25 women; median age 59 years, interquartile range 53.5-66.0) with recurrent varicose veins in 45 legs were treated. Ultrasound was used to identify sites of reflux. The Tessari method was used to produce foam using 3% sodium tetradecyl sulphate; up to 6 mL of foam was injected per session under ultrasound control. Results are shown as median (interquartile range).

RESULTS

A single sclerotherapy session was adequate in 26 (58%) legs. In 87% of all legs, complete elimination of both varicose veins and all reflux points was achieved. A positive association between the amount of injected foam and CEAP class (r=0.45, p=0.002) and venous clinical severity score (r=0.37, p=0.012) was found. There was a trend for more sclerotherapy sessions [median 2 (1-2)] in legs with incomplete saphenofemoral junction/ great saphenous vein (GSV) ligation or accessory GSV (n=16) to achieve varicose vein ablation versus legs with other primary sites of reflux [median 1 (1-2), p=0.12]. There were no instances of deep vein thrombosis or systemic complications; superficial thrombophlebitis occurred in 6 (8.2%) of the 73 injection sessions. Legs with proximal reflux due to previous incomplete ligation or fed by an incompetent pelvic vein experienced superficial thrombophlebitis more frequently (4/12, 33%) than legs without proximal reflux [1/33 (3%); OR 16, 95% CI 1.6-164, p=0.014].

CONCLUSION

In most patients, ultrasound-guided foam sclerotherapy is a safe treatment for recurrent varicose veins, with an excellent immediate result. However, the presence of proximal reflux may decrease the immediate results and predispose to superficial thrombophlebitis.

Foam sclerotherapy: an overview of use for primary venous insufficiency

Ultrasound-guided sclerotherapy with foam is able to suppress blood flow in almost all types of varicose veins. The technique is efficient, simple, safe, inexpensive, and easily repeatable, although it requires training and skill. It should be considered as the best primary treatment for most varicose patients. Evaluation of long-term results, with regard to comparison with other techniques, should take into account all advantages and drawbacks and evaluate cost-effectiveness from a life-long point of view.

Compartmentalization of massive vascular malformations

A total of 18 patients with massive vascular malformations of the head and neck region were treated with compartmentalization using nonabsorbable sutures followed by injection of a sclerosant agent into each compartment. The indication for compartmentalization was either to stop potentially uncontrollable, life-threatening hemorrhage during the dissection of the lesion or to reduce its vascularity to allow a less dangerous subsequent resection. Compartmentalization was used in both high-flow and low-flow vascular malformations. In this technique, large nonabsorbable sutures are placed deeply in multiple areas within the lesion. The aim is to divide the malformation into multiple compartments by changing the direction of the suturing; in this way the sclerosing agent is provided with a more effective environment. The sclerosant used was either sodium tetradecyl sulfate 3%, absolute alcohol, or both. The total amount of infiltrate varied from 3 to 35 cc, according to the size of malformation. After compartmentalization, swelling was the most noticeable complication. With this technique, it was possible to treat what were considered untreatable malformations using standard techniques and to control the inevitable serious bleeding.

Roentgenoendovascular treatment of Conn's syndrome

This paper describes the first in the world experience with the treatment provided in 1990 to a female patient suffering from hypereldosteronism associated with adenoma of the left adrenal. The treatment consisted in endovascular destruction of the adrenal, which was performed by means of acute occlusion of the adrenal venous bed using a sclerosing agent. The intervention resulted in a decrease of arterial pressure (AP) from 240/140 to 130/80 mm Hg. The patient has been followed up for 13 years. No recurrence of the disease has been recorded. AP is within normal.

[Sclerotherapy of small pelvis varicosis]

This paper analyses the results of sclerotherapy provided to 89 patients with small pelvis varicosis. Selection of the treatment technology depended on the clinical variant of disease. In patients with damage to the parietal venous system of the pelvis, the treatment was realized by multiple repeat injections of a sclerosing agent to the pelvic veins in a minimal dose which may induce only proliferative processes in varicose vein walls. Elastic compression was not applied. Women with the syndrome of blood overfilling of the pelvic organs (visceral pattern of lesion) were provided sclerotherapy of the left ovarian vein followed by its pharmacological spasm. The treatment results were evaluated by clinical examination of patients, duplex scanning end estimation of the quality of life based on the patients' self-estimation according to the recommendations of the International Association of Phlebologists. Excellent results were obtained in 32.6%, good in 46.1%, satisfactory in 19.1% and unsatisfactory results in 2.2% of patients.

Aspiration and sclerotherapy versus hydrocelectomy for treatment of hydroceles

OBJECTIVES

To compare aspiration and sclerotherapy using sodium tetradecylsulfate (STDS) with open hydrocelectomy in the treatment of hydroceles with regard to safety, efficacy, and cost-effectiveness.

METHODS

Patients with symptomatic hydroceles were prospectively enrolled in an aspiration and sclerotherapy protocol between October 1998 and June 2000. Patients in this group underwent percutaneous aspiration followed by sclerotherapy with an STDS-based solution. This group was compared with a group of patients chosen consecutively who underwent hydrocelectomy between December 1996 and August 1999. Primary outcome measures included patient satisfaction and procedural success. Secondary outcome measures included complications and comparative costs.

RESULTS

A total of 27 patients with 28 hydroceles were enrolled in the aspiration and sclerotherapy protocol and compared with 24 patients with 25 hydroceles in the hydrocelectomy group. Mean follow-up for the aspiration and sclerotherapy group and hydrocelectomy group was 8.9 and 16.4 months, respectively. Patient satisfaction was 75% for aspiration and sclerotherapy and 88% for hydrocelectomy. The overall success rate for aspiration and sclerotherapy was 76% compared with 84% for hydrocelectomy. The complication rate was only 8% in the aspiration and sclerotherapy group, but 40% in the hydrocelectomy group. Comparative costs per procedure demonstrated that hydrocelectomy was almost ninefold more expensive than aspiration and sclerotherapy.

CONCLUSIONS

In the treatment of hydroceles, aspiration and sclerotherapy with STDS represents a minimally invasive approach that is simple, inexpensive, and safe but less effective than hydrocelectomy. Aspiration and sclerotherapy is a viable first-line therapeutic option in the management of hydroceles.

Comparative pilot study evaluating the treatment of leg veins with a long pulse ND:YAG laser and sclerotherapy

BACKGROUND AND OBJECTIVE

To date there have been very few side by side comparison studies of laser versus sclerotherapy in treating small leg veins. This study compares a long pulsed Nd:YAG laser with contact cooling to sclerotherapy for treating small diameter leg veins by evaluating objective and subjective clinical effects.

STUDY DESIGN/MATERIALS AND METHODS

Twenty patients were selected with leg veins ranging from 0.25 to 3 mm at two comparable sites. One site was treated with long pulsed Nd:YAG laser and the other received sotradecol sclerotherapy. The patients followed up at 8 weeks for another possible laser retreatment and 3 months following the last treatment. Photographs were taken pre- and post-operatively and at each follow-up visit and used for objective comparative analysis. The patients also completed a Quality of Life survey.

RESULTS

Improvement was tabulated from the photographic assessment on an improvement scale from 0 (no change)-4 (greater than 75% clearing). The laser treated areas averaged 2.50 and sclerotherapy treated sites averaged 2.30. Patient surveys show 35% preferred laser and 45% choose sclerotherapy.

CONCLUSION

This pilot study demonstrates that the Lyra Long Pulse Nd:YAG laser can yield results similar to sclerotherapy in the treatment of small leg veins.

Clinical comparison of sclerotherapy versus long-pulsed Nd:YAG laser treatment for lower extremity telangiectases

BACKGROUND

Sclerotherapy has traditionally been considered the gold standard of treatment for leg veins, but patient fear of multiple needle injections and side effects of treatment have fueled investigation into other treatment alternatives. As a result, vascular-specific laser and light sources have been developed in an effort to treat these vessels with minimal morbidity and improved efficacy.

OBJECTIVE

To compare the clinical efficacy of leg telangiectasia treatment with sodium tetradecyl sulfate sclerotherapy to long-pulsed 1064 nm Nd:YAG laser irradiation.

METHODS

A series of 20 patients with size-matched superficial telangiectases of the lower extremities were randomly assigned to receive two consecutive monthly treatments with injectable sodium tetradecyl sulfate on one leg and long-pulsed 1064 nm Nd:YAG laser irradiation on the other. Patients were evaluated by two masked assessors at each treatment visit and at 1 and 3 months after treatment to assess clinical improvement within matched sites.

RESULTS

Leg telangiectases responded best to sclerotherapy in fewer treatment sessions than to long-pulsed 1064 nm Nd:YAG laser irradiation. The incidence of adverse sequelae was minimal and equivocal in both treatment groups.

CONCLUSION

Despite recent advances in laser technology for treatment of lower extremity telangiectases, sclerotherapy continues to offer superior clinical effect in the majority of cases. Laser leg vein treatment appears to be most beneficial in patients with telangiectatic matting, needle phobia, or sclerosant allergy.

Intralesional vinblastine vs. 3% sodium tetradecyl sulfate for the treatment of oral Kaposi's sarcoma. A double blind, randomized clinical trial

In this double-blind, randomized trial, we compared the clinical efficacy of intralesional vinblastine (VNB) and 3% sodium tetradecyl sulfate (STS) in the treatment of oral Kaposi's sarcoma (OKS). Subjects with OKS were randomly assigned to receive a single intralesional injection of either VNB or STS, at a standard dose (0.2 mg/cm(2)). Differences were evaluated by the Mann-Whitney U and Fisher's exact tests. Sixteen HIV-infected patients were included, eight received VNB and eight received STS; clinical response was evaluated at days 7, 14, and 28 following treatment. Tumor size reduction was 0.68 and 0.61 cm in the VNB and STS groups, respectively (P=0.80). Two VNB patients had complete or partial response whereas four STS subjects had partial responses (P=0.61). Patients in both groups experienced minimal toxicity. We conclude that intralesional vinblastine or STS are adequate for the management of OKS. The benefits of STS are its low cost and ease of use.

Treatment of varicose and telangiectatic leg veins: double-blind prospective comparative trial between aethoxyskerol and sotradecol

BACKGROUND

One hundred twenty-nine patients were treated with either polidocanol (POL) or sodium tetradecyl sulfate (STS) to compare the efficacy and adverse sequelae of each agent.

OBJECTIVE

To determine the safety and efficacy of two sclerosing solutions.

METHODS

Each patient's leg veins that did not have incompetence from the saphenofemoral junction (SFJ) were divided into three categories by size (<1 mm, 1-3 mm, 3-6 mm). Each leg was randomly treated with either 0.25%, 0.5%, or 1.5% of STS or 0.5%, 1.0%, or 3% of POL respective of size. An independent, three-panel, blindly randomized photographic examination was obtained pretreatment and at 4 and 16 weeks. Patient satisfaction index and overall clinical improvement assessment were also obtained.

RESULTS

All patients had an average of 70% improvement and were 70-72% satisfied in all vein categories treated with either solution. There was no significant difference in adverse effects between each group except for a decrease in ulcerations and swelling in the POL group.

CONCLUSION

Both STS and POL are safe and effective sclerosing solutions for varicose and telangiectatic leg veins.

Coagulation abnormalities in pediatric and adult patients after sclerotherapy or embolization of vascular anomalies

OBJECTIVE

The purpose of our study was to examine the coagulation status in patients with vascular anomalies who had undergone sclerotherapy or embolization.

SUBJECTS AND METHODS

Ours was a prospective pilot study of 29 patients who had undergone sclerotherapy or embolization of large vascular anomalies. Fibrinogen, platelet, and d-dimer levels and prothrombin time were obtained before, immediately after, and on the day after the procedure.

RESULTS

Five patients with venous malformations had positive d-dimer levels before the procedure. A subgroup analysis revealed a relationship between the type of agent used and the change in coagulation status. Specifically, a positive relationship was found between the use of dehydrated alcohol or sodium tetradecyl sulfate and a disruption in coagulation profiles as evidenced by a decrease in platelets and fibrinogen, an increase in prothrombin time, and a conversion from negative to positive d-dimers. In contrast, sclerotherapy or embolization with cyanoacrylic, polyvinyl alcohol foam particles, or platinum microcoils was not associated with coagulation disturbances.

CONCLUSION

The coagulation disturbances that occur in response to dehydrated alcohol or sodium tetradecyl sulfate sclerotherapy or embolization could compromise the patient's clotting ability. Patients who receive dehydrated alcohol or sodium tetradecyl sulfate during a preoperative sclerotherapy or embolization may experience coagulation disturbances that could increase the risk of bleeding, thrombosis, or hematoma. This patient population may benefit from the use of glue, foam, or coils as a substitute for dehydrated alcohol or sodium tetradecyl sulfate.

Prospective randomized comparison of sodium tetradecyl sulphate & polidocanol for oesophageal variceal sclerotherapy

BACKGROUND & OBJECTIVE

A number of sclerosing agents have been tried for sclerotherapy of oesophageal varices. However, none of them have emerged as an ideal agent. Hence, this study was designed to compare the efficacy and safety of sodium tetradecyl sulphate and polidocanol for sclerotherapy of oesophageal varices.

METHODS

A total of 100 consecutive patients with bleeding oesophageal varices were included in the study. Patients with associated gastric varices and hypersplenism were excluded. Of the 100 patients, 50 received emergency sclerotherapy with either 3 per cent sodium tetradecyl sulphate or 3 per cent polidocanol, randomized using the sealed envelope technique. Following control of bleeding, these patients were included in the elective sclerotherapy schedule. The remaining 50 patients with past history of bleeding varices received elective sclerotherapy. Thus all 100 patients received elective sclerotherapy at 4 weekly intervals.

RESULTS

There was no significant difference between the sodium tetradecyl sulphate and polidocanol groups with respect to the control of acute variceal bleeding (100% vs 96%), the mean number of injection sessions (4.5 +/- 0.3 vs 4.7 +/- 0.4) and the mean amount of scleroscent required (33.3 +/- 2.7 ml vs 37.0 +/- 3.3 ml) per patient for variceal eradication. The cost of polidocanol required for variceal obliteration was significantly higher than that of sodium tetradecyl sulphate (P < 0.001). The use of sodium tetradecyl sulphate in contrast to polidocanol was associated with a significantly higher incidence of variceal recurrence (11% vs 0%) and other complications such as oesophageal ulcer (14% vs 2%), retrosternal pain (22% vs 2%), fever (16% vs 4%), tachycardia (14% vs 2%) and dysphagia (20% vs 6%). Rebleeding rate and mortality rate were not significantly different between the two groups.

INTERPRETATION & CONCLUSION

Polidocanol is superior to sodium tetradecyl sulphate as it has lower incidence of complications, even though the drugs are similar in efficacy in the control of bleeding and obliteration of varices in long-term.

Injection snoreplasty: how to treat snoring without all the pain and expense

OBJECTIVE

We introduce Injection Snoreplasty: an innovative, safe, and effective palatal snoring procedure with minimal cost and discomfort to the patient. A well-described sclerotherapy agent, Sotradecol, is injected into the soft palate to reduce/eliminate palatal flutter snoring.

STUDY DESIGN AND SETTING

Twenty-seven patients with a diagnosis of palatal flutter snoring (respiratory disturbance index less than 10) by sleep study were enrolled in the protocol. Office treatment sessions were performed 6 to 8 weeks apart. Success was judged by subjective improvement in snoring and objective evidence of palatal stiffening/scarring.

RESULTS

Twenty-five (92%) of 27 patients reported significant decrease in snoring. There were no significant postinjection complications. Visual analog pain scale confirmed minimal discomfort. Most patients received more than 1 treatment (average, 1.8) in order to receive optimal palatal stiffening.

CONCLUSION/SIGNIFICANCE

Injection Snoreplasty is a simple, safe, and effective office treatment for primary snoring. Advantages over current snoring procedures include simplicity, low cost, decreased posttreatment pain levels, and minimal/no convalescence.

Removal of periocular veins by sclerotherapy

PURPOSE

Prominent periocular veins, especially of the lower eyelid, are not uncommon and patients often seek their removal. Sclerotherapy is a procedure that has been successfully used to permanently remove varicose and telangiectatic veins of the lower extremity and less frequently at other sites. Although it has been successfully used to remove dilated facial veins, it is seldom performed and often not recommended in the periocular region for fear of complications occurring in adjacent structures. The purpose of this study was to determine whether sclerotherapy could safely and effectively eradicate prominent periocular veins.

DESIGN

Noncomparative case series.

PARTICIPANTS

Fifty adult female patients with prominent periocular veins in the lower eyelid were treated unilaterally.

PATIENTS AND METHODS

Sclerotherapy was performed with a 0.75% solution of sodium tetradecyl sulfate. All patients were followed for at least 12 months after treatment.

MAIN OUTCOME MEASURES

Complete clinical disappearance of the treated vein was the criterion for success.

RESULTS

All 50 patients were successfully treated with uneventful resorption of their ectatic periocular veins. No patient required a second treatment and there was no evidence of treatment failure at 12 months. No new veins developed at the treated sites and no patient experienced any ophthalmologic or neurologic side effects or complications.

CONCLUSIONS

Sclerotherapy appears to be a safe and effective means of permanently eradicating periocular veins.

Incidence and management of esophageal stricture formation, ulcer bleeding, perforation, and massive hematoma formation from sclerotherapy versus band ligation

OBJECTIVES

The aim of this study was to compare the incidence and endoscopic management of esophageal stricture formation, significant ulcer bleeding, massive esophageal hematoma, and perforation resulting from endoscopic band ligation or sclerotherapy of esophageal varices.

METHODS

Consecutive esophagogastroduodenoscopies in which band ligation or sclerotherapy was performed for acute or obliterative therapy were entered into a computerized endoscopy database during a 7-yr period. Patients were excluded if they died within 72 h of treatment session from complications unrelated to the procedure. Sclerotherapy was performed using a 25-gauge needle with 1.5% sodium tetradecyl sulfate and banding was primarily performed with a Wilson-Cook 6 or 10 shooter. Complications were assessed at scheduled endoscopy and outpatient clinic visits, review of quality assurance data tallied on a monthly basis, and patient records.

RESULTS

Two hundred twenty-one cases of sclerotherapy were performed in 59 patients compared to 110 cases of band ligation in 52 patients. Five patients were excluded because of death within 72 h of the procedure. The incidence of complications from sclerotherapy:banding on a per patient basis included: esophageal stricture formation 25.6%:1.9%, ulcer bleed 25.4%:5.7%, esophageal perforation 2.2%:0%, and massive esophageal hematoma 1.6%:0%. A significant difference in complications between sclerotherapy and band ligation was noted for both stricture formation (p < 0.0005) and ulcer bleeding (p < 0.0001). The majority of ulcer bleeds required no therapeutic intervention, whereas stricture formation required multiple dilation sessions.

CONCLUSIONS

Band ligation has a significantly lower incidence of stricture formation and ulcer bleeding compared to sclerotherapy. The majority of complications can be managed with endoscopic interventions.

Sotradecol (sodium tetradecyl sulfate) injection of orbital lymphangioma

PURPOSE

To describe the results of intralesional injection of the sclerosing agent sodium tetradecyl sulfate in patients with lymphangioma.

METHODS

Three patients (one child and two adults) were treated.

RESULTS

Two patients had improvement in the size of the lymphangioma, although the result was short-lived in one instance. Minimal change was noted in the third patient. Two patients had transient edema and ecchymosis, and one patient had a mild allergic reaction to the injected solution.

CONCLUSIONS

Sodium tetradecyl sulfate may be a useful therapeutic option for some patients with eyelid or orbital lymphangioma, particularly if a previous operation has not been performed.

Sclerotherapy of craniofacial venous malformations: complications and results

Of all vascular anomalies, venous malformations are the most common, and they have a propensity for the head and neck. The authors retrospectively analyzed 40 patients with craniofacial venous malformations who underwent sclerotherapy between October of 1994 and June of 1996 to determine (1) the results of sclerotherapy with ethanol and/or sodium tetradecyl sulfate, (2) the types and rate of complications, and (3) whether outcome correlated with age, sex, location, size, tissues involved, morphology (lobular or varicose), venous outflow, or number of sclerotherapy sessions. The authors also reviewed the results after sclerotherapy and contour resection (n = 18). Comparisons between the results with ethanol and sodium tetradecyl sulfate and between sclerotherapy alone and sclerotherapy and resection combined were not done. The study was composed of three parts. They were (1) a review of records and imaging studies, (2) a panel evaluation of pretreatment and posttreatment photographs, and (3) a questionnaire that determined the patient's (or parent of the patient's) impression of therapy. Interrater and intrarater agreement were analyzed. Sclerotherapy was performed in an angiographic suite, under general anesthesia, using absolute ethanol and/or sodium tetradecyl sulfate. Complications of the treatment included acute blistering (50 percent), hemoglobinuria (28 percent), deep ulceration (13 percent), and nerve injury (7.5 percent). Two patients suffered transient facial paresis, and one had permanent unilateral vocal cord paralysis. Thirty patients (75 percent) were rated as having marked improvement or as being cured by all three members of the panel; 10 patients (25 percent) were rated as having no change or only slight improvement by one or more members of the panel. Interrater reliability was moderately positive, and intrarater reliability was highly positive. Thirty-seven patients or parents of patients (93 percent) responded to the questionnaire. The outcome was considered to be marked improvement or cured in 28 patients (76 percent), and nine respondents (24 percent) described only minor improvement or no change. Logistic regression analysis revealed that only male sex and number of sclerotherapeutic procedures were significant multivariate predictors of outcome. Size, location, tissues involved, morphology, or venous outflow were not determinant. In conclusion, sclerotherapy with ethanol or sodium tetradecyl sulfate is an effective and safe treatment for craniofacial venous malformations. Often, sclerotherapy has to be repeated. For extensive perioral malformations, combined sclerotherapy and resection give the best result.

Prevalence of paraesophageal varices and gastric varices in patients achieving variceal obliteration by banding ligation and by injection sclerotherapy

BACKGROUND

The impact of banding ligation and injection sclerotherapy on paraesophageal varices and gastric varices has received scarce attention. We conducted a study using endoscopic ultrasound (EUS) to visualize paraesophageal varices and gastric varices in patients who underwent sclerotherapy and banding ligation.

METHODS

Patients with esophageal variceal bleeding whose varices were obliterated by ligation (44 patients) and by sclerotherapy (35 patients) were enrolled. EUS was used to compare the prevalences of paraesophageal varices and gastric varices between the treatment groups. The correlation between paraesophageal varices and esophageal variceal recurrence and recurrent bleeding was assessed.

RESULTS

The prevalence of paraesophageal varices was 86% in the ligation group compared with 51% in the sclerotherapy group (p = 0.002). The prevalence of gastric varices was slightly higher in the ligation group than in the sclerotherapy group (43% vs. 26%, p = 0.18). Esophageal varices recurred in 70% of the ligation group and 43% of the sclerotherapy group (p = 0.04). Patients in both groups with more severe paraesophageal varices had a significantly higher rate of variceal recurrence (p = 0.002 in ligation group and p = 0.001 in sclerotherapy group). Bleeding recurred in 6 patients in the ligation group and 4 patients in the sclerotherapy group. All patients with recurrent bleeding had paraesophageal varices. The rate of recurrent bleeding was significantly higher in patients with paraesophageal varices (p < 0.0001).

CONCLUSIONS

EUS was helpful in the imaging of paraesophageal and gastric varices after sclerotherapy or banding ligation. Paraesophageal varices were more frequently noted in patients undergoing ligation. The presence of paraesophageal varices may predict the recurrence of esophageal varices and recurrent bleeding.

[Sclerosis in varicose veins]

The authors report their experience in the sclerotherapy of varicose veins. They have used the technique of French school: with the patient half sitting, direct puncture not far from the gulf of saphena without tourniquet, on a weekly basis.