Phlebology and treatment of leg veins Flashcards
What treatment should be avoided if a patient has a known symptomatic patent foramen ovale?
Foamed sclerotherapy (concern for stroke)
Sx’s of patent foramen ovale can be migraine w/ aura or recurrent stroke/TIA
Screening not recommended still
Which sclerosing agent carries the highest risk of anaphylaxis?
Sodium morrhuate (not used often anymore)
-3-10% of cases
What sclerosing agent has the lowest risk of a severe allergic reaction?
Hypertonic saline
What are some risk factors for varicose veins?
Genetic predisposition, hormones (estrogen and progesterone), obesity, and pregnancy
What are the most significant components of the superficial venous system on the legs?
Small and great saphenous veins
Varicose veins in what part of the leg suggest greater saphenous involvement?
The medial thigh
What are the most important veins in the deep venous system of the leg?
Femoral and popliteal veins
What procedures can be used for the treatment of varicose veins?
Sclerotherapy, ambulatory phlebectomy, endovenous radiofrequency ablation, and laser ablation (Nd:YAG [long pulsed 1064], IPL, and PDL)
What times of veins are sclerotherapy best for?
Telangiectasias and reticular veins (can address larger varicose veins and perforating veins w/ foaming agents)
What post-procedural intervention is needed for ALL forms of sclerotherapy?
Postprocedural compression stockings
What are the 3 categories of sclerotherapy for vein treatment?
Hyperosmotic agents, chemical irritants, and detergents
What are the hyperosmotic agents used for sclerotherapy?
Hypertonic saline (+/- dextrose)
What is the mechanism of vein destruction with hypertonic saline?
Stimulates endothelial cell destruction and dehydration
What is the mechanism of chemical irritants for sclerotherapy?
Injure the endothelial cells by corrosive action
What are two chemical irritants?
Polyiodide iodide and Glycerin (72%)
What is the mechanism of detergents in sclerotherapy?
Induce vascular injury by altering the surface tension around endothelial cells
What are 4 examples of detergents used in sclerotherapy? Which is most common?
Sodium tetradecyl sulfate (STS) is the most common
Others: polidocanol, sodium morrhuate, ethanolamine oleate
Which two detergents can induce severe necrosis when used for sclerotherapy?
Sodium morrhuate and ethanolamine oleate
Occurs w/ extravasation, also can cause severe allergic reactions. Should not be used for routine sclerotherapy
What is the advantage of “foaming” with the sclerosing agents?
1:4 ratio (liquid to air), decreases the number of needed treatments, increases efficacy when treating larger veins, and can be applied over a longer segment of a vein
What are 4 contraindications to sclerotherapy?
Allergy to sclerosants, DVT, advanced arterial occlusive disease, symptomatic patent foramen ovale (contraindication for foam sclerosant)
What is a common rash that is a side effect of sclerosing therapy?
Urticaria
Which sclerosing agent is most likely to cause urticaria?
Ethanolamine oleate
What is the treatment for post-inflammatory hyperpigmentation from sclerotherapy?
Q-switched lasers
What sclerosing agents have the highest risk of telangiectatic matting?
Highest risk w /detergents
Glycerin has the lowest risk of the detergents
How can telangiectatic matting be prevented?
Use appropriate volume and concentration, low pressure when injecting
Which sclerosing agent is associated with the most injection pain?
Hypertonic saline
What are the highest risk areas for ulceration/cutaneous necrosis after sclerotherapy?
Dorsal foot and ankle
Which detergents have the lowest risk of anaphylaxis?
Glycerin and polidocanol
What are the most common sites of inadvertent injection of sclerotherapy agent into an artery?
Posterior medial malleolus (posterior tibial artery; superficial injections) and the popliteal fossa (deep injections)
Why can dextrose be added to hypertonic saline for sclerotherapy?
Decreases pain of injection
What is an important potential side effect with sodium tetradecyl sulfate?
Hyperpigmentation
Which sclerotherapy agent can cause a disulfiram-like reaction?
Polidocanol
In which sclerotherapy agent can acute renal failure and hemolytic reactions occur?
Ethanolamine oleate (also is the one associated with urticarial reaction)
Which sclerotherapy is thick/viscous and difficult to inject?
Ethanolamine oleate and glycerin
Which sclerotherapy agent causes the least amount of pain usually?
Polidocanol
Which two sclerosing agents have the lowest dose allowance?
Polidocanol and polyiodiide ioidide (5mL)
Most others are 10mL (6-10 for hypertonic saline)
Which injectable sclerosing agent has the lowest risk of hyperpigmentation?
Chromated glycerin
