Long-term follow-up of children with extrahepatic portal vein obstruction: impact of an endoscopic sclerotherapy program on bleeding episodes, hepatic function, hypersplenism, and mortality

Background: Endoscopic sclerotherapy (ES) has been the standard treatment for children with idiopathic extrahepatic portal vein obstruction (EHPVO). Portosystemic shunts are indicated when variceal bleeding cannot be controlled by ES. Recently, mesenteric left portal vein bypass was indicated as a surgical intervention and preventative measure for hepatic dysfunction in children with long-term EHPVO. Nevertheless, there is a lack Of published data confirming the extent of hepatic dysfunction, hypersplenism, and physical development in children with long-term follow-up. Method: We retrospectively verified the long-term outcomes in 82 children with EHPVO treated with ES protocol, focusing on mortality, control of bleeding, hypersplenism, and consequent hepatic dysfunction. Results: Of the children, 56% were free from bleeding after the initiation of ES. The most frequent cause of rebleeding was gastric varices (30%). Four patients had recurrent bleeding from esophageal varices (4.6%). Four patients underwent surgery as a consequence of uncontrolled gastric varices. There were no deaths. Most patients showed good physical development. We observed a mild but statistically significant drop in factor V motion, as well as leukocyte and platelet count. Conclusion: Endoscopic sclerotherapy is an efficient treatment for children with EHPVO. The incidence of rebleeding is low, and there was no mortality. Children develop mild liver dysfunction and hypersplenism with long-term follow-up. Only a few patients manifest symptoms of hypersplenism, portal biliopathy, or liver dysfunction before adolescence. (C) 2009 Elsevier Inc. All rights reserved.

A double-blind, randomized study comparing pure chromated glycerin with chromated glycerin with 1% lidocaine and epinephrine for sclerotherapy of telangiectasias and reticular veins.

BACKGROUND Chromated glycerin (CG) is an effective, although painful, sclerosing agent for telangiectasias and reticular leg veins treatment. OBJECTIVE To determine pain level and relative efficacy of pure or one-third lidocaine-epinephrine 1% mixed chromated glycerin in a prospective randomized double-blind trial. METHOD Patients presenting with telangiectasias and reticular leg veins on the lateral aspect of the thigh (C(1A) or (S) E(P) A(S) P(N1) ) were randomized to receive pure CG or CG mixed with one-third lidocaine-epinephrine 1% (CGX) treatment. Lower limb photographs were taken before and after treatment and analyzed by blinded expert reviewers for efficacy assessment (visual vein disappearance). Patients' pain and satisfaction were assessed using visual analogue scales. RESULTS Data from 102 of 110 randomized patients could be evaluated. Patient pain scores were significantly higher when pure CG was used than with CGX (p<.001). Patient satisfaction with treatment outcome was similar in the two groups. Objective visual assessment of vessel disappearance revealed no significant difference between the two agents (p=.07). CONCLUSION Addition of lidocaine-epinephrine 1% to CG, in a ratio of one-third, significantly reduces sclerotherapy pain without affecting efficacy when treating telangiectasias and reticular leg veins. The authors have indicated no significant interest with commercial supporters.

Gross Hemoglobinuria and Oliguria are Common Transient Complications of Sclerotherapy for Venous Malformations: Review of 475 Procedures.

Estudi retrospectiu per analitzar la incidència, factors de risc i tractament de la hemoglobinuria macroscòpica i oliguria després del tractament de malformacions venoses amb escleroteràpia. Un total de 475 procediments es van realitzar en 131 malalts usant etanol, sulfat tetradecil sòdic o ambdos. Hemoglobinuria temporal es va donar després del 34% de procediments i el 57% d’aquests es van asociar amb oliguria temporal. Aquest risc augmenta amb el increment de dosis. La resolució de la hemoglobinuria i oliguria va ser satisfactòria en tots els malalts. El risc d’hemoglobinuria augmenta a les malformacions que afecten les extremitats inferiors i a les de localitzacions mútiples.

European guidelines for sclerotherapy in chronic venous disorders.

AIM: Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy. METHODS: This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7-10 May 2012 in Mainz. The conference was organized by the German Society of Phlebology. These guidelines review the present state of knowledge as reflected in published medical literature. The regulatory situation of sclerosant drugs differs from country to country but this has not been considered in this document. The recommendations of this guideline are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines. RESULTS: This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, polidocanol and sodium tetradecyl sulphate. Other sclerosants are not discussed in detail. The guideline gives recommendations concerning indications, contraindications, side-effects, concentrations, volumes, technique and efficacy of liquid and foam sclerotherapy of varicose veins and venous malformations.

Sclerotherapy of telangiectasias: a painless two-step technique.

BACKGROUND: Sclerotherapy of telangiectasias and reticular leg veins can be unpleasant and painful for some patients. OBJECTIVE: To determine pain level with two different sclerotherapy techniques in a prospective randomized trial. METHODS: Patients with symmetrical telangiectasias and reticular veins on both legs (C(1A) or (S)E(P)A(S)P(N1) were randomized to the standard (successive injections of chromated glycerin mixed with one-third lidocaine-epinephrine 1%) or two-step technique (first treating only reticular veins with a single injection at the base of each cluster of telangiectasias and then successively injecting all remaining telangiectasias a few minutes later. Pain was assessed using a 100-point visual analogue scale (0 = no pain, 100 = maximum pain). RESULTS: Data from 53 consecutive patients could be evaluated. The two-step technique was significantly less painful (28.2) than the standard technique (40.6, p < .001). CONCLUSION: The two-step technique with chromated glycerin mixed with one-third lidocaine-epinephrine 1% significantly reduces sclerotherapy pain. This may be a useful technique for patients who are particularly sensitive or afraid of sclerotherapy.

Percutaneous drainage and sclerotherapy as definitive treatment of renal lymphangiomatosis.

We report the technique and outcome of percutaneous drainage and sclerotherapy as primary treatment of renal lymphangiomatosis. Between January and May 2009, two patients presenting with symptomatic renal lymphangiomatosis were treated in our department by a minimally invasive modality combining percutaneous drainage with repeated sclerotherapy. We retrospectively analysed recurrence, complications and patient satisfaction. In this limited case series, percutaneous drainage and repeated sclerotherapy proved to be safe and effective for treating renal lymphangiomatosis. This procedure provides a minimally invasive option for selected patients, potentially avoiding a surgical procedure and any risk of complications.

Media damage following detergent sclerotherapy appears to be secondary to the induction of inflammation and apoptosis: an immunohistochemical study elucidating previous histological observations

Objective/Background: Traditionally, sclerotherapy has been thought to work by the cytotoxic effect of the sclerosant upon the endothelium alone. However, studies have shown that sclerotherapy is more successful in smaller veins than in larger veins. This could be explained by the penetration of the sclerosant, or its effect, into the media. This study aimed to investigate intimal and medial damage profiles after sclerosant treatment. Methods: Fresh human varicose veins were treated ex vivo with either 1% or 3% sodium tetradecyl sulphate (STS) for 1 or 10 minutes. The effect of the sclerosant on the vein wall was investigated by immunofluorescent labelling of transverse vein sections using markers for endothelium (CD31), smooth muscle (a-actin), apoptosis (p53) and inflammation (intercellular adhesion molecule-1 [ICAM-1]). Polidocanol (POL; 3%) treatment at 10 minutes was similarly investigated. Results: Endothelial cell death was concentration- and time-dependent for STS but incomplete for both sclerosants. Time, but not concentration, significantly affected cell death (p > .001). A 40% and 30% maximum reduction was observed for STS and POL, respectively. Destruction of 20e30% of smooth muscle cells was found up to 250 mm from the lumen after 3% STS treatment for 10 minutes. POL treatment for 10 minutes showed inferior destruction of medial cells. Following STS treatment and 24-hour tissue culture, p53 and ICAM-1 were upregulated to a depth of around 300 mm. This effect was not observed with POL. Conclusion: Inflammatory and apoptotic markers show the same distribution as medial cell death, implying that sclerotherapy with STS works by inducing apoptosis in the vein wall rather than having an effect restricted to the endothelium. Incomplete loss of endothelial cells and penetration of the sclerosant effect up to 250 mm into the media suggest that medial damage is crucial to the success of sclerotherapy and may explain why it is less effective in larger veins.

Polidocanol versus hypertonic glucose for sclerotherapy treatment of reticular veins of the lower limbs: study protocol for a randomized controlled trial

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Comparison of Laser Versus Sclerotherapy in the Treatment of Lower Extremity Telangiectases: A Prospective Study

BACKGROUND Lower extremity telangiectasia affects approximately 40% of women. The demand for aesthetic treatment of these veins continues to grow. Few studies have compared laser and sclerotherapy to treat leg telangiectasias. OBJECTIVE To compare the efficacy of conventional sclerotherapy and neodymium-doped yttrium aluminum garnet (Nd:YAG) laser in the treatment of leg telangiectasias. METHODS AND MATERIALS Thirty women were enrolled in the study. One leg was randomly assigned laser treatment and the other sclerotherapy with 75% glucose solution. All patients were photographed before and after treatment. The applying physician and two independent observers rated photographic improvement of the treated areas. Complications and adverse effects were noted during follow-up. Patients answered a questionnaire that addressed pain, clearing of the vessels, and satisfaction with the results. RESULTS There was a significant difference between the modes of treatment regarding pain. Twelve patients using laser and 16 using sclerotherapy considered the clearing of the vessels to be good to excellent after three sessions of both laser and scleratherapy. Mean scores after photographic assessment were 7.9 for laser and 7.0 for sclerotherapy. CONCLUSION Lower extremity telangiectases may be treated equally well using Nd:YAG 1064-nm laser or conventional sclerotherapy.

A double-blind, randomized study comparing pure chromated glycerin with chromated glycerin with 1% lidocaine and epinephrine for sclerotherapy of telangiectasias and reticular veins

Chromated glycerin (CG) is an effective, although painful, sclerosing agent for telangiectasias and reticular leg veins treatment.

Visual disturbance following sclerotherapy for varicose veins, reticular veins and telangiectasias: a systematic literature review

The objective of the study was to review the literature reporting visual disturbance (VD) following sclerotherapy for varicose veins. Underlying mechanisms will be discussed. A literature search of the databases Medline and Google Scholar was performed. Original articles including randomized trials, case series and case reports reporting VD in humans following sclerotherapy for varicose veins were included. Additional references were also obtained if they had been referenced in related publications. The search yielded 4948 results of which 25 reports were found to meet the inclusion criteria. In larger series with at least 500 included patients the prevalence of VD following sclerotherapy ranges from 0.09% to 2%. In most reports foam sclerotherapy was associated with VD (19); exclusive use of liquid sclerosant was reported in two cases, some reports included foam and liquid sclerosant (4). There were no persistent visual disorders reported. VD occurred with polidocanol and sodium tetradecyl sulphate in different concentrations (0.25-3%). Various forms of foam preparation including various ways of foam production and the liquid - air ratio (1 or 2 parts of liquid mixed with 3, 4 or 5 parts of air) were reported in association with the occurrence of VD. VDs following sclerotherapy for varicose veins are rare and all reported events were transient. Bubble embolism or any kind of embolism seems unlikely to be the only underlying mechanism. A systemic inflammatory response following sclerotherapy has been suggested. Further research to clarify the mechanism of action of sclerosants is required.

Neurological complications of sclerotherapy for varicose veins

Sclerotherapy has been shown to be an effective and increasingly popular therapeutic strategy for the treatment of varicose veins. However, recent reports of serious side effects, including cerebrovascular accidents (CVA) and transient ischemic attacks (TIA), as well as speech and visual disturbances, have caused serious concern regarding its use. This review evaluated the reported incidences of neurological side effects associated with the use of sclerotherapy.

Sclerotherapy in tumescent anesthesia of reticular veins and telangiectasias

Some leg telangiectasias may be refractory to treatment, including sclerotherapy and lasers.