SCLEROTHERAPY in .NET framework

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CHAPTER 25 SCLEROTHERAPY
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SOLUTION Hypertonic saline (234%)
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FDA APPROVAL Yes, as abortifacient
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ADVANTAGES Nonallergenic
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RISKS/DISADVANTAGES Off-label Pain and cramping Skin necrosis Hyperpigmentation Microthrombi formation Pain upon extravasation Skin necrosis Hyperpigmentation Microthrombi formation Rare anaphylaxis Hyperpigmentation Microthrombi formation Allergic reactions Rare anaphylaxis Pain and cramping Rare allergy Too weak for large veins
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RECOMMENDED DOSE LIMITATIONS PER TREATMENT SESSION 10 mL
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Sodium tetradecyl sulfate (Sotradecol) (025%)a
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Can be foamed to treat varicose veins under ultrasound guidance
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10 mL of 3%
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Polidocanol (025%)a
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Painless Can be foamed to treat varicose veins under ultrasound guidance Rare hyperpigmentation
10 mL of 3%
Glycerin (72% glycerin mixed with 1% lidocaine and 1:100,000 epinephrine, combined 2:1)b
10 mL
Average reported concentration used to treat veins from 1 to 4 mm in diameter Best used for the treatment of ne telangiectasias (vessels up to 1 mm in diameter)
Hyperpigmentation after sclerotherapy is delayed and can take several months to a year to resolve It has been associated with high total body iron stores31 This type of hyperpigmentation is caused by hemosiderin deposition and is not melanocytic; therefore, it does not respond to topical bleaching agents as much as to tincture of time Telangiectatic matting is usually permanent and more common in hyperestrogenemic states6,32 It may also be a sign of underlying venous reflux and should be investigated by duplex ultrasound Both hyperpigmentation and telangiectatic matting may benefit from treatment with intense pulsed light as this modality has shown some success in treating vascular lesions, including telangiectasias,33,34 as well as treatment of dyspigmentation34,35 It is important to emphasize that necrosis with subsequent ulceration can potentially occur with extravasation of any of the sclerosants into the skin or by inadvertent intra-arterial or periarterial injection of sclerosants The sclerosant with the least risk of inducing necrosis seems to be glycerin, effective only for the treatment of leg telangiectasias When extravasation of sclerosant occurs in the skin it is generally secondary to the treatment of small vessels, such as telangiectasias or reticular veins This complication presents as a small and painful slow-toheal blister, erosion, or ulceration Healing typically resolves with a skin-colored scar In contrast, reports of intra-arterial injection occur when treating larger, deeper vessels This risk is increased when targeting veins around the ankle or when treating deeper veins, both cases where veins and their accompanying arteries are in close proximity to one another When arteries are accidentally injected, the entire area supplied by the artery quickly becomes ischemic and pale, and is usually painful In this situation, affected areas are large, involving a segment of the leg or foot Fortunately, intra-arterial injection is a very rare event, but the risk is not completely avoidable and can still occur even under ultrasound guidance36 Management in this case is emergent, and may result in possible amputation To minimize the incidence of most complications, use of proper injection technique is critical Using the minimal concentration of sclerosant for the vessel size, small volumes, and slow injection to maintain low pressure in the vessel will assure the best results Cosmetic treatment of veins around the ankle with sclerotherapy should be avoided and, in this specific group of patients, the possibility of reflux should be explored
SCLEROTHERAPY FOR THE COSMETIC PATIENT
When treating leg veins, it is important to treat proximal sites and larger vessels first, as treatment of these vessels may obliterate those vessels that are smaller and distally located As previously mentioned, cosmetic treatment is undertaken only if the patient does not have any clinical signs or symptoms of chronic venous insufficiency or has had all sources of reflux already treated Preoperative photographs and fully informed consent outlining all possible risks and complications should be obtained prior to therapy A discussion of postprocedure care is also essential A body map with segmental divisions of the legs is helpful in documenting each session (Fig 25-2) Treatment is repeated at 6-week intervals to allow for complete resolution of previously treated sites The number of treatment sessions may vary, usually from one to six, based on the aggressiveness of the physician as well as the clinical presentation and expectations of the patient There are four injection techniques commonly used in the treatment of cosmetic leg veins: the puncture-fill technique, the aspiration technique, the empty vein technique, and the air-bolus technique The puncture-fill technique relies on the feeling associated with perforating a vessel wall It is probably the most common, but also the most difficult to grasp for beginners and better mastered over time while using the other listed approaches The aspiration technique is
most useful for the treatment of reticular veins, with the observation of the aspirated dark blood into the hub of the syringe or the tubing of a butterfly needle confirming correct needle placement The empty vein technique involves leg elevation and kneading the vessel to remove as much blood as possible prior to injecting the sclerosant The air-bolus technique uses the injection of a small amount of air (02 cc or less) prior to the introduction of sclerosant The air in the tip of the syringe displaces the blood in the vessel confirming correct needle placement Alcohol is used to clean the skin as well as increase the refractile index of the skin, rendering vessels more visible upon the skin surface A common approach by the author is to use a combination of the aspiration and empty vein techniques for reticular veins, and puncture-fill for venulectasias and telangiectasias It is also helpful when using the puncture-fill technique to target the most superficial portion of the vessel For telangiectasias less than 1 mm in size, where cannulating the vessel is a challenge, it is necessary to start injecting with the tip of the needle just barely underneath the skin surface, bevel side facing up (Fig 25-3) When treating reticular veins, the use of a butterfly needle helps to secure venous access; however, prior to injecting these vessels it is essential to pull back on the plunger to visualize dark blue blood in the tubing and ensure location inside the lumen of the vein (Fig 25-4) Injection can then proceed slowly In all cases, when resistance is encountered,
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