Download Managing Sclerotherapy Complications

Managing Sclerotherapy
Complications
Barbara Deusterman, RN
Objectives
 The learner will be able to describe the most common
complications of visually-guided sclerotherapy of the lower
extremities
 The learner will be able to identify prevention techniques or
techniques that may minimize complications.
 The learner will be able to list treatment strategies of the
most common complications of visually-guided sclerotherapy
of the lower extremities
Complications……
“We look for medicine to be an orderly field of knowledge and
procedure. But it is not. It is an imperfect science, an
enterprise of constantly changing knowledge, uncertain
information, fallible individuals, and at the same time lives on
the line. There is science in what we do, yes, but also habit,
intuition, and sometimes plain old guessing. The gap between
what we know and what we aim for persists. And this gap
complicates everything we do.”
-Atul Gawande, Complications: A Surgeon’s Notes on an Imperfect Science
Know who you are treating!
• Physical assessment
• Through and current history
• Duplex ultrasound (if needed)
• Know risk factors that would increase likelihood of
complication
• Before photos
• Consent form
• Manage patient expectations
Urticaria
Histamine releases from mast cells in the skin causing localized edema, often in
the form of wheal
• Red, raised and itchy areas at the
site of injection
• Physically induced by sclerosant,
not an allergic reaction
• Self limiting, no treatment
necessary
– May use a topical corticosteroid
• Verbally reassure patient that the
itching and redness will be
resolved in 4-24 hours
Intravascular Hematoma
(intravascular coagulum, trapped blood, dead blood)
A liquefied thrombus trapped between the two ends
of a treated vein
• Diagnostic evaluation
 Visual inspection and palpation
 Ultrasound
• Interventions
 Puncture/Aspiration of post-sclerotherapy
hematoma
Coagulum, if left in place, turns into
hemosiderin.
Intravascular Hematoma
(intravascular coagulum, trapped blood, dead blood)
Considerations
 Intervene with in 2-4 weeks
 Choose most efficient/effective sclerosant concentration for
location and size of vein
 Injection of small volumes from single points of entry
 Encourage compliance with graduated compression stockings
and ambulation
Coagulum, if left in place, turns into
hemosiderin.
Hyperpigmentation
Hemosiderin staining happens when blood leaves a ruptured blood vessel, the
red blood cell dies and the hemoglobin from the red blood cell is released into
the dermis.
•
Incidence- 10-30%
• Occurs within 4-6 Weeks
• 60% resolve within 6 months
• 90% resolve within 1 year
• 1-10% have pigment > 1 year
•
Possible risk factors
• Taking Minocycline
• History of high iron stores
• Intense, persistent sun exposure during
treatment process
• Possible link to those patients with dark hair
and darker pigmented skin tones
(controversial)
An Ounce of Prevention….
• Minimize Risk of Vessel Rupture and RBC Extravasation by Reduced
Syringe Pressure
•
Smaller syringes = greater pressure
• Appropriate Solution Type and Concentration For Vessel Size
• Eliminate Feeder Sources First
• Post Treatment Compression
• Prompt Removal of Trapped Blood
• Avoid Treatment in High Risk Patients
Hyperpigmentation
Interventions
Time is the first line intervention!
• Topical agents
• Bleaching creams
• Exfoliants
• IPL laser
• Iron Chelation
Hyperpigmentation
Considerations
 Pigmentation post VGS happens despite good technique
 Assess for possible risk factors before treating the patient
 Review with patient the possibility of hyperpigmentation prior
to the start of therapy
 Go low and go slow
 Prevention is better than intervention
 Take photographs and document
Telangiectatic Matting
Presents as “ blush type” area containing large numbers of tiny red blood vessels that are
less than 0.2 mm in diameter, directly associated with previously sclerosed or surgically
removed veins.
• The etiology is unknown
– Angiogenesis
– Inflammation secondary to endothelial injury
– Exposure to estrogen containing hormones
15-24% incidence
• Common areas that TM will occur are medial and
lateral thighs, medial and lateral calves, medial
ankles
• Develops rapidly, can resolve spontaneously
Telangiectatic Matting
Treatment options
• Reevaluate possible sources of reflux not recognized on initial exam.
• Time – TM may resolve on own with out any further intervention, use verbal
reassurance liberally
• Inject remaining TM with Glycerin or low concentration of detergent
sclerosant if not resolved after all sources of reflux are treated and the area
was given time to resolve on own.
• Consider discontinuing contraceptive therapy for 1 month prior to beginning
sclerotherapy and delaying reinstitution of such therapy for at least 2 months
following the last treatment session
• Encourage weight loss in obese individuals prior to institution of therapy
• IPL laser
Telangiectatic Matting
Considerations
 Educate patient of the possibility of complication prior start of treatment
 Assess for risk factors prior to treatment
 Use the lowest concentration and lowest volume of the chosen sclerosant
that will effectively obliterate the vein
 Use low pressure when injecting the sclerosant to minimize excessive
vessel injury
 Do not use stronger sclerosant or multiple treatments in effort to resolve
TM.
 Document progress or resolution by photographing patient every 6 to 8
weeks
 Consider stopping Estrogen therapy only after careful consideration and
consultation with both supervising physician and patients prescribing
physician.
Cutaneous Necrosis
Localized superficial tissue damage as a direct result of sclerotherapy.
Ischemic necrosis that is caused by the arterial component of the vascular bed becoming
occluded
• Bright erythema may be seen immediately
after injection
• Prolonged blanching, can also be described
as porcelain-white appearance immediately
after injection
• Pain can be immediate or delayed
• Dermis can turn pale or dusky
• Dermal sloughing starts 24-72 hours after
the ischemic event
• Ulcer can occur at site
Cutaneous Necrosis
Measure and document and monitor
Day
7
Day
12
Day
20
Day
29
Day
52
Cutaneous Necrosis
Interventions
• Vigorous massage of extravasated area may decrease tissue damage
• If arteriolar injection or spasm suspected vigorously massage using 2%
nitroglycerine ointment
• Hyaluronidase
– Enzyme that rapidly diffuses extravasated solution thus minimizing tissue damage
– Dose 75 units re-constituted in 0.9% sodium chloride
– Must be injected into affected area with in 60 minutes to be effective
• Occlusive dressings are used to speed healing process and decrease pain
• Debridement of wound using either hydrocolloid dressings or surgical
excision of necrotic tissue will promote granulation tissue formation.
• Short stretch wraps can be used if edema present
Cutaneous Necrosis
Careful and methodical technique must be used
•
•
•
•
Stop injecting if you feel resistance
Stop injecting if a bleb or wheal forms
Stop injecting if prolonged blanching occurs
Use the lowest volume and weakest concentration of sclerosing agent
needed to close down target vein
• Inject using slow steady pressure
•
Smaller syringes = greater pressure
• Ultrasound guidance should be used for foam sclerotherapy of deeper
reticular veins
Cutaneous Necrosis
High incidence of litigation with this complication
 Areas of skin necrosis after Sclerotherapy take 4-12 weeks to heal
 Explain length of healing process, frequent follow-up in the beginning
 Reassure patient that the wound will heal, usually with a cosmetically
acceptable scar
 Photo document ulcer at discovery and continue to photo document
progress of healing at follow up appointments
 Document location and size of necrosis, and note the amount and
concentration of sclerosant used in last treatment session prior to
discovery.
 Monitor patient for signs and symptoms of infection
Superficial Venous Thrombosis
A tender red, hard cord along length of superficial vein
Etiology
• Hypercoaguable state
• Change in vessel wall
• Change in blood flow
Signs and symptoms
• Erythema, induration, tenderness
• Can have associated warmth and edema
• Must r/o cellulitis or lymphangtis if no SVT seen on ultrasound
Diagnostic evaluation
• Visual inspection
• Duplex ultrasound
(Binder B, et al. Association between superficial vein thrombosis and deep vein thrombosis of the lower
extremities. Archives of Dermatology 2009; 145(7): 753-757.)
Superficial Venous Thrombosis
Rule out DVT in a patient with superficial
phlebitis
• Patients with SVT have a 5%-40% chance of
developing DVT 1,3
• One study showed SVT patients have concurrent
DVT in 28% of cases 2
1. Hanson, J.N., Ascher, E., DePippo, P., Lorensen, E., Scheinman, M., Yorkovich, W., Hingorani , A. Saphenous vein thrombophlebitis (SVT): a deceptively
benign disease J Vasc Surg. 1998 April; 27(4): 677–680.
2. Galanaud, J. P., Gentry, C., Sevestre, M. A., & Bisot, D. , et al .Predictive factors for concurrent deep-vein thrombosis and symptomatic venous thrombotic
recurrence in case of superficial venous thrombosis. The OPTIMEV study. Thrombosis and haemostasis 2011, 105(1), 31-39.
3. Gloviczki, P., Dalsing, M. C., Eklof, B., Moneta, G. L., & Wakfield, T. W. (2009). Handbook of Venous Disorders (3rd ed.). London: Hodder Education
Superficial Venous Thrombosis
Interventions
•
•
•
•
•
•
•
Can be benign and self limiting
Warm compresses
NSAID’s
Graduated compression stockings
Low Molecular Weight Heparin
Endovenous Laser Ablation
High Saphenous ligation, and sometimes stripping
Deep Vein Thrombosis
A thrombus in the deep venous system
Pathophysiology
• Virchow’s triad
• Injection of large volume of
sclerosing agent can travel
into deep system
• Compression wrap
administered too tight on
thigh can occlude deep flow
Deep Vein Thrombosis
Signs and Symptoms
• Leg pain
• Erythema/warmth of
affected limb
• Enlargement of calf or thigh
• Dilated superficial veins
50% of DVTs have no signs or
symptoms
Deep Vein Thrombosis/PE
Diagnosis
• Duplex Ultrasound
• Venogram
• If Pulmonary embolism
suspected
• CT Angiogram
• V/Q scan
Deep Vein Thrombosis
Interventions
•
•
•
•
•
•
•
Low Molecular Weight Heparin
Warfarin, dabigatran, rivaroxaban
Therapy to continue for 3 months (Grade 1B)
Intravenous Heparin
Graduated compression stockings (2 years)
Ambulation
Consider cessation of birth control pills or estrogen
replacement therapy
http://www.chestnet.org/Guidelines-and-Resources/Guidelines-and-Consensus-Statements/Antithrombotic-Guidelines-9th-Ed
Deep Vein Thrombosis
Considerations
 Assess for risk factors prior to treatment
 Does patient have an acute DVT, history of DVT, known thrombophilia, active CA, Acute
SVT?
 Discuss possibility of complication with patient prior to start of treatment
 Educate patient on signs and symptoms of DVT and PE
 Encourage ambulation and compliance with graduated compression
stockings
 Limit volume of sclerosant even on surface sclerotherapy
 Be aware if combining surgical intervention and sclerotherapy in same
treatment visit there is an increased risk of DVT and PE
 If placed on anticoagulant, monitor daily or weekly INR’s for therapeutic
level and document in chart ( > 2.5 , ACCP 2012 recommendation).
Nerve Injury
The Saphenous nerve
is the largest and
longest branch of the
femoral nerve and
supplies the skin over
the medial side of the
leg
The sural nerve runs with
the small saphenous vein
on the posterior leg just
lateral to the Achilles
tendon. The sural nerve
innervates lateral &
posterior third of leg and
lateral aspect of foot &
heel, & lateral portion of
the ankle
Almeida, Jose. Atlas Of Endovascular Venous Surgery. Philadelphia, PA:
Elsevier, 2011. 16,18. Print.
Nerve Injury
Irritation or injury to the Saphenous or Sural nerves or cutaneous branches after sclerotherapy
• Diagnostic evaluation
• History and physical
• Pin prick test
• “Numbness” versus Hypoesthesia
• Intervention
• Usually self limiting
• NSAIDs
High incidence of litigation with this complication
• Considerations
 Assess for loss of sensory and/or motor function
 Document location and size of surface area affected
 Verbally reassure patient that nerves can regenerate over time
Neurological Complications
Variety of neurologic events occurring after injection of liquid sclerosant, foamed
sclerosant, or use of “ air block” technique
• Visual disturbances
• Blurred vision
• Pulsatile headache
• Visual aura preceding migraine
• Migraine
• Monocular blindness
• Transient Ischemic attack (rare)
• Cerebral Vascular Accident (rare)
Neurological Complications
Patent Foramen Ovale
Air bubbles from foam
sclerotherapy can travel from the
right atrium to the left atrium and
out to the brain. This can cause a
variety of neurological symptoms
from mild to severe
Neurological Complications
Interventions
• May be self limiting and no
treatment necessary
• Neurological exam
• 100% oxygen
• Transfer to acute care
facility
• Hyperbaric chamber
indicated if symptomatic
cerebral artery air embolus
Considerations
 Assess patient for history of
cardiac abnormalities or
migraines
 Limit the volume of foamed
sclerosant on first visit
 Keep patient supine for 5 minutes
after injection of foam sclerosant
 Document onset of neurological
event and associated symptoms,
progression or resolution of
symptoms, vital signs, also note
volume and concentration of
sclerosant used
Allergic Reaction/ Anaphylaxis
Mild vs. Severe
Close observation
Be prepared!
Allergic Reaction/ Anaphylaxis
Mild Reaction
• Antihistamine PO
• H2 Blockers
• Steroids
• Monitor
• Consider IV access if
progressing
Moderate/Severe Reaction
• O2 via NC or Mask
• Epi-pen or Epinephrine SQ/IV
• Antihistamine IM/IV
• Albuterol MDI for wheezing
• Steroids
• IV Access / IVF
• EMS
• Consider intubation for
hypoxia, airway compromise
Emergency Drug box or Crash Cart
Allergic Reaction
Considerations
 An allergic or anaphylaxis reaction can happen on the first exposure or on
any re-exposure to a sclerosant
 Assess for previous know allergy to sclerosant or history of multiple allergies
 Rapid recognition of an allergic reaction is essential
 Patients should be observed 30 minutes in office after injections
 Patients should be educated on signs and symptoms of allergic reactions
in case of delayed onset
 An emergency plan and emergency kit including medications, supplies and
oxygen should be available in all practice settings
 All staff should be properly trained to alert the emergency medical system
 Document vital signs, onset of symptoms, medications and response to
medications given if an allergic reaction should occur
Arterial Injection
An accidental injection of sclerosant into an artery causing damage ranging from
mild to severe skin, subcutaneous tissue, and muscle necrosis.
Signs and Symptoms
• Immediate burning pain at the site of injection, propagates along artery
distribution
• Demarcated cyanotic pallor of affected area
• Compartment syndrome
• Necrosis of skin, subcutaneous tissue and/or muscle
High Risk Areas!
Arterial Injection
Absence of consistent guidelines!
•
•
•
•
•
•
•
Aspirate sclerosant if noted immediately
Ice?
Heparin
Fibrinolytic therapy
Vasodilators
Catheter-directed thrombolysis
Mechanical thrombectomy
Arterial Injection
This is a medical emergency!!
 Pain can happen quickly, or progress over several hours
 Polidocanol has a local anesthetic effect; pain may not be appreciated
until several days later
 Document name of sclerosing agent volume of sclerosant used,
location of injection, vital signs, skin findings, and presence of pedal
pulses
 Place ice at site of skin pallor to help decrease tissue damage
 Patient must be transported to hospital
 Vascular surgery and interventional radiology consult needed
The most feared complication….
The disappointed or unhappy patient!
• Acknowledge the complication
• OK to say that this is a known complication but you are
sorry that this happened to them
• Get the physician involved (Allied Health professionals)
• Treat the complication
• Follow-up more frequently in the beginning ( show you
care)
• Take photo documentation
• Documentation in chart is important!
Take Aways……
• Complications can happen even to the most
experienced practitioner
• Know what they are and how to manage them
• Prevention is better then intervention!
Thank You!
References
Almeida, J. I., Raines, J.K. (2008). Laser ablation of cutaneous leg veins. Perspectives in Vascular Surgery and Endovascular
Therapy, 20(4), 358-366.
Bergan, J. (2006). The vein book . Amsterdam: Elsevier.
Bergan, J. J., Weiss, R. A., & Goldman, M. P. (2000). Extensive tissue necrosis following high-concentration sclerotherapy for
varicose veins. Dermatol Surg, 26, 535-542.
Bihari, I., & Magyar, E. (2001). Reasons for ulceration after injection treatment of telangiectasia. Dermatol Surg, 27, 133-136.
Bihari, I., Muranyi, A., & Bihari, P. (2005). Laser-doppler examination shows high flow in some common telangiectasias of the
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Galanaud, J. P., Gentry, C., Sevestre, M. A., & Bisot, D. , et al .Predictive factors for concurrent deep-vein thrombosis and
symptomatic venous thrombotic recurrence in case of superficial venous thrombosis. The OPTIMEV study. Thrombosis and
haemostasis 2011, 105(1), 31-39.
Gloviczki, P., Dalsing, M. C., Eklof, B., Moneta, G. L., & Wakfield, T. W. (2009). Handbook of Venous Disorders (3rd ed.). London:
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