Injection Of Sclerosing Agent Research Articles

Computational Fluid Dynamics of Liquid and Foam Sclerosant Injection in a Vein Model

The aim of this study was to develop a computational fluid dynamics (CFD) model to simulate the injection of liquid and foam sclerosants into a varicose vein. The CFD model results were compared with sclerosant flow in an experimental model of a straight or a branched vein. The effects of injection angle, injection velocity and tubing contents (blood, saline) on sclerosant spreading were assessed by CFD. The simulation of liquid sclerosants injection was able to provide a good representation of forward flow, but underrepresented sclerosant backflow. Due to the complex nature of computational modelling of foams, CFD modelling of foam sclerosants injection was less accurate and provided only limited information on foam spreading. CFD modelling can be used as a representation of liquid and foam sclerosant injection, but further research is required to provide a more accurate analysis.

Sklerosierung orbitaler Lymphangiome mit OK-432

Orbital lymphangiomas are mostly congenital, apparent vascular space-occupying lesions, which can lead to disfiguring swelling of the periorbital soft tissues, ocular motility disorders, optic nerve compression and keratopathy. The treatment is challenging because the disease is principally incurable. Lymphangiomatous tissue can be surgically partially reduced or treated by intralesional injection of various sclerosants. In this review we report the successful use of OK-432 for destruction of a macrocystic orbital lymphangioma.

Therapeutic Approach of Wrist Ganglion Using Electroacupuncture: Two Case Reports

A ganglion cyst is a relatively common benign tumor on the wrist. Conservative and surgical approaches have been used for its treatment. Various conservative treatment methods have been suggested such as reassurance, aspiration, sclerosant injection, and direct compression. But, there is no acceptable treatment of choice yet because each suggested method has a relatively high recurrence rate. We want to report two cases in which the size of the wrist ganglion was decreased by using electroacupuncture. One patient presented with a chronic ganglion for six years and the other patient presented with a recently occurred acute ganglion. We applied electroacupuncture for 20 minutes once a week for eight weeks to both of them. Afterwards, the size of the wrist ganglion diminished in the follow-up sonography and the accompanying pain was also relieved. Herein we report both cases along with a review of the relevant literature.

Oral capillary hemangioma: A clinical protocol of diagnosis and treatment in adults

Hemangiomas are benign vascular anomalies characterized by benign proliferation of blood vessels. There are no well-defined criteria for the diagnosis and treatment of oral capillary hemangioma (OCH). The objective of this study is to report a safe, effective, and low-cost protocol for diagnosis and treatment of OCH. Eight patients were diagnosed with OCH, through two physical examination maneuvers-the diascopy and head lowering maneuver with abdominal compression (HLMAC). The treatment performed was sclerotherapy with ethanolamine oleate, weekly, until the disappearance of the lesion. No local anesthetics were administered prior to the sclerosing agent injection. All cases showed a complete remission of the lesions after sclerotherapy. There were no visible scars or compromise esthetics or normal function, and there was no evidence of recurrence. Only one patient had superficial ulceration, which remained asymptomatic and healed without specific treatment. This protocol was effective in the diagnosis of OCH through two physical examination maneuvers with low-cost and easy implementation, the diascopy and the HLMAC. The low concentration associated with a reduced amount of the sclerosing agent was responsible for the excellent results in the cases treated.

Novel Use of Endoscopic Ultrasound and Injection of Sclerosant for the Treatment of Bleeding Stomal Varices

Purpose: An 82-year-old male presented to the ED with large volume red blood from his ileostomy. His PMH was significant for a total proctocolectomy with end-ileostomy 8 years prior due to diverticulitis. He had similar presentations multiple times over the past few years with numerous ileoscopies and EGDs. No definite source had been identified. At presentation, hemoglobin was 5 gm/dL with symptoms of weakness and fatigue. Chemistry and coagulation panel were unremarkable. Physical exam was remarkable for red blood in the ostomy bag. There had been no report of preceding melenic stools,change in ostomy output, history of NSAID use or upper GI complaints. EGD was normal. Ileoscopy revealed no intraluminal bleeding source, but a small oozing area at the inferior margin of the ostomy was seen. Surgical evaluation was obtained and the area was treated with silver nitrate with successful hemostasis. Forty eight hours later, the patient had a repeat episode of clinically significant stomal bleeding. Peristomal Doppler ultrasound revealed prominent vessels in the abdominal wall adjacent to the ostomy opening. With concomitant Stage IV chronic kidney disease, the patient was unable to undergo a contrast enhanced CT or MR. As a result of this and continued, clinically significant bleeding, the patient underwent curvilinear EUS through the stoma. Five cm proximal to the stomal opening, a prominent, dilated vessel was seen. Doppler confirmed venous flow and using a 19G needle the varix was successfully injected with 5% ethanolamine. Repeat doppler post-injection confirmed absence of flow. The patient was discharged 48 hours later and has experienced no further bleeding over the last 9 months. Stomal varices are a rare, but clinically important cause of stomal bleeding. Unlike other ectopic varices throughout the GI tract, stomal varices have traditionally not been amenable to endoscopic treatment due to location exterior to the bowel wall. Historically, treatment included external compression, and percutaneous, blind injection of sclerosant. Percutaneous therapy is limited due to high risk for stomal breakdown/stenosis, ulceration and possible blind injection of a high pressure varix. Currently, the mainstay of therapy for recurrent bleeding includes decompressive procedures such as TIPS or other shunting procedures. These invasive procedures have systemic consequences and risk of their own. We describe a novel approach utilizing therapeutic EUS to treat bleeding stomal varices which appears both safe and efficacious in this challenging clinical situation. Further study is warranted before this modality can be recommended for widespread clinical use.

Comparative effects of different sclerosing agents used to treat rectal prolapse: An experimental study in rats

Background/PurposeSclerosing agents injected into the rectal submucosal area produce an inflammatory response and scar that prevent rectal prolapse. This study aimed to investigate the histopathological changes following submucosal injection of different sclerosing agents in rats. MethodsRats (n=35) were divided into control, sham, and five experimental groups, each treated with a different sclerosing agent: cow's milk, 30% saline solution, 30% dextrose solution, 70% ethyl alcohol, and 5% phenol in almond oil (PAO). All agents were injected into the submucosal area. After 4weeks, all animals were sacrificed. Histopathological evaluation was performed according to a semi-quantitative fibrosis scoring system (grades 0 to 3), by using Masson trichrome and hematoxylin and eosin staining. ResultsHistopathological changes in the 5% phenol in almond oil group were significantly different from other groups (p=0.0001). Prominent submucosal fibrosis (grade 3), lymphatic vascular dilation, foreign body reaction, and lipogranuloma were observed in the 5% PAO group (p=0.007). No significant histopathological differences were seen between the 30% saline, 30% dextrose, and 70% ethyl alcohol groups. Significantly increased mucosal fibroblast proliferation (grade 2) was seen in 60% rats of the 30% dextrose group (p=0.026). The cow's milk and ethyl alcohol groups had mucosal erosions and congestion (grade 1) which were significantly different from the control group (p=0.024). No statically significant difference was observed between the 30% saline group and the control group. ConclusionsIn this study we showed that 5% PAO can induce some histopathological changes in the submucosal area that increase the mucosal tightness of the mucosa, which are necessary for the treatment of rectal prolapse.

Orbicular oris muscle flap wrapped by acellular dermis for the treatment of upper lip atrophy in children

To investigate the treatment of upper lip atrophy resulted by previous therapy. From Mar. 2008 to Mar. 2012, 4 cases with upper lip atrophy resulted by radiotherapy and sclerosing agent injection were treated with lower orbicularis oris muscle flap wrapped by acellular dermis. The thickness and height of upper lip were increased to improve the lip atrophy. Primary wound healing was achieved in all the 4 cases. All the patients were followed up for 3 years with obvious improvement and inconspicuous scar. The volume of lower lip in children is not sufficient as donor site. The lower orbicularis oris muscle flap wrapped by acellular dermis can effectively improve the lip thickness and vermilion portion of upper lip.

DOES THE TENDINOPATHIC PATELLAR TENDON NORMALISE, ACCORDING TO ULTRASOUND FINDINGS, AFTER TREATMENT WITH SCLEROSING INJECTIONS OR ARTHROSCOPIC SHAVING? A LONG TERM FOLLOW-UP (3–5 YEARS)

IntroductionTreatment of patellar tendinopathy/jumper's knee with ultrasound-guided sclerosing injections and arthroscopic shaving has shown good clinical results, but patients treated with the one-stage procedure arthroscopic shaving had a faster return...

US AND DOPPLER-GUIDED SURGICAL TREATMENT BASED ON IMMUNOHISTOCHEMICAL FINDINGS IN MIDPORTION ACHILLES TENDINOPATHY SHOWS GOOD CLINICAL RESULTS AND FAST RETURN TO ACTIVITY

IntroductionTreatment of midportion Achilles tendinopathy has been known to be difficult. Recent ultrasound(US) and Doppler(CD) findings (high blood flow outside ventral tendon), together with results of immunohistochemical analyses (marked presence...

ClariVein Mechanochemical Ablation

The 2 primary objectives of this publication are to provide a practical step-by-step procedure for the ClariVein system and a focused literature review of endovenous ablation. The ClariVein system is the first venous ablation technique to employ a hybrid (dual-injury) technique built into 1 catheter-based delivery system. Endomechanical abrasion is produced by the tip of the catheter's rotating wire (mechanical component); and endovenous chemical ablation (EVCA) is via simultaneous injection of sclerosant over the rotating wire (chemical component). The author is an early adopter of this technique and via experience has developed a detailed step-by-step protocol. To date, there have been 2 pivotal clinical studies published using the ClariVein system. These data are compared with the results using other methods of endovenous ablation. The ClariVein system is an exciting addition to the phlebologist's toolbox and has the potential to become a first-line treatment.

Endovascular Treatment of Slow-Flow Vascular Malformations

Symptomatic slow-flow vascular malformations include venous malformations and lymphatic malformations, as well as combined anomalies. Endovascular therapy, consisting mainly of intralesional sclerosant injection, is now accepted as the primary treatment for most of these lesions. Magnetic resonance imaging and ultrasonography supplement physical examination for diagnosis and assessment of the extent of malformation. Endovascular treatment is usually carried out under general anesthesia. Sclerosants for venous malformations include ethanol, 3% sodium tetradecyl sulfate, and bleomycin. Lymphatic malformations can be injected with doxycycline, bleomycin, OK-432, or other sclerosants. Complications of sclerotherapy include tissue necrosis, peripheral nerve injury, hemoglobinuria, deep vein thrombosis, and pulmonary embolism. Although most vascular malformations are not cured, the majority of patients benefit from endovascular treatment.

Management of cystic lymphangioma

Introduction/aim Cystic lymphangioma is a benign rare malformation of the lymphatic system consisting of masses of abnormal lymphatic channels, occurring in one out of 2000–4000 live births. Conventional surgical excision remains the most popular method of treatment in many developing countries. Recent advances in sclerotherapy have expanded contemporary management options, particularly when complete surgical resection is difficult because of the presence of multiple loculi and extensive lesions. This study aims to present our experience in the management of these cases. Material and methods Records of all cases of lymphangioma seen at the Pediatric Surgical Unit from Mansoura and Tanta University hospitals in the period from January 2007 to November 2010 were reviewed. Special charts were designed to retrieve the following data from records: age at presentation, sex, site of the pathology, clinical presentation, investigations, management modality, and outcome of treatment. Results There were 93 children; 40 (43%) were males and 53 (57%) were females. Surgery was the line of treatment in 89 cases (one stage in 56 cases and two stages in 33 cases). Four patients underwent injection sclerotherapy as the primary treatment. Recurrence occurred in 16 cases. Other complications included a disfiguring scar in nine patients, seroma in seven patients, skin disruption, hematoma, and hypoglossal nerve palsy in two patients, facial nerve palsy in one patient, and cellulitis following a sclerosant injection in one case. Conclusion A staged operative procedure may be necessary in order to reduce mortality, and sclerotherapy has almost the same efficacy as the first line of management as surgery, although it is not widely practiced in developing countries. There is a high postoperative complication associated with surgical excision, especially with head and neck cystic lymphangiomas. Anesthesia in these patients requires careful monitoring. Long-term follow-up is desirable after excision because of the possibility of recurrence. Keywords : cystic lymphangioma, management, sclerotherapy

The Morel-Lavallee lesion: a review and a proposed algorithmic approach

Morel-Lavallee lesions (MLL) are rarely diagnosed posttraumatic sequel. They follow closed degloving injuries due to accumulation of blood and debris in the subcutaneous plane. Though they are not uncommon, they are rarely diagnosed which results in delay in their treatment. Diagnosis is through a combination of clinical examination, history, and imaging studies. MRI is the diagnostic modality of choice. Different treatments have been used for their management like compression therapy, sclerosant injection, pulse lavage, and open debridement. These treatments have met with varying success. Treatment protocols vary when managing acute and chronic MLL. The knowledge of such lesions hastens their diagnosis and treatment.

Ultrasound-Guided Sclerosis of Neovessels in Patellar Tendinopathy

Background: A randomized controlled study has shown promising clinical results after treatment with sclerosing injections in a group of patients with patellar tendinopathy, but no study has investigated medium- or long-term outcome in a large and unselected group of patients. Purpose: To investigate if sclerosing treatment would affect the level of patellar tendon pain and knee function after 24 months in a large group of patients with patellar tendinopathy. Study Design: Case series; Level of evidence, 4. Methods: This prospective study recruited patients with a clinical diagnosis of jumper’s knee and visible neovascularization corresponding to the painful area on power Doppler ultrasound. They received up to a maximum of 5 ultrasound-guided sclerosing injections using polidocanol at 4- to 6-week intervals. Knee pain and function were recorded using the Victorian Institute of Sport Assessment–Patella (VISA-P) score before treatment and 6, 12, and 24 months after the first injection. Results: In total, 101 patients (15 women and 86 men) with 120 tendons were included and given from 1 to 5 sclerosing injections (mean [SD], 2.5 [0.9]). The patients reported a significantly improved VISA-P score from baseline (mean, 39; 95% confidence interval [CI], 36-42) to the 24-month follow-up (mean, 65; 95% CI, 60-70) (range, 21-100; P < .001, paired t test). However, a VISA-P score of >95 points was reported in only 22 cases (20%), whereas 37 cases (36%) reported a VISA-P score of <50 at 24 months. Conclusion: Sclerosing treatment with polidocanol resulted in a moderate improvement in knee function and reduced pain in a heterogeneous group of patients with patellar tendinopathy. Nevertheless, few of the patients were cured, and the majority still had reduced function and substantial pain after 24 months of follow-up.

Prospective Randomised Comparative Study of Visual Foam Sclerotherapy Alone or in Combination with Ultrasound-guided Foam Sclerotherapy for Treatment of Superficial Venous Insufficiency: Preliminary Report

ObjectiveThe aim of the study is to compare ultrasound-guided foam sclerotherapy (UGFS: injection of foam sclerosant under ultrasound guidance) of the great saphenous vein (GSV) combined with visual foam sclerotherapy (VFS: injection of foam sclerosant under visual control) for varicose tributary veins and VFS alone in the treatment of GSV reflux. Design and methodsA total of 133 limbs in 97 patients with GSV reflux were randomised to receive either VFS alone or VFS combined with UGFS. In both groups, 1% polidocanol foam was used. Assessments included duplex ultrasonography, evaluation of Venous Clinical Severity Scores (VCSS) and CEAP (clinical, etiologic, anatomic, and pathophysiologic) scores. Ultrasonographic inspection of the foam in the GSV was carried out during 5 min before compression was applied. The primary ‘end’ point of the study was obliteration of the GSV at 6 months. ResultsA total of 51 limbs in 48 patients were treated with UGFS + VFS and the remaining 52 limbs in 49 patients were treated with VFS alone. There were no significant inter-group differences in patient age, male: female ratio, height, weight, body mass index, CEAP clinical scores or VCSS. The GSV diameter was 6.0 ± 1.7 mm (median ± interquartile range) in the UGFS + VFS group and 5.7 ± 1.6 mm in the VFS group (p = 0.419). The mean injected volume of foam for varicose tributary veins was 4 ± 2 ml in the UGFS + VFS group and 6 ± 2 ml in the VFS group, a significantly higher amount of foam being used in the latter (p < 0.001). However, the mean total amount of foam was greater in limbs treated with UFGS + VFS than in those treated with VFS alone (p = 0.017). Ultrasonographic inspection revealed complete vasospasm of the GSV in 37 (72.5%) limbs in the UGFS + VFS group and 29 (55.8%) in the VFS group during sclerotherapy (p = 0.097). At 6-month follow-up, complete occlusion was found in 23 limbs (45.1%) treated with UGFS + VFS and in 22 limbs (42.3%) treated with VFS. The difference between the two groups was not significant (p = 0.775). Reflux was absent in 30 limbs (58.8%) treated with UGFS + VFS and in 37 (71.2%) treated with VFS (p = 0.190). There was no inter-group difference in post-treatment VCSS (p = 0.223). ConclusionsThese results show that UGFS + VFS and VFS are equally effective for the treatment of GSV reflux, despite the lower volume of foam used for VFS alone.

Three benefits of microcatheters for retrograde transvenous obliteration of gastric varices

To evaluate the usefulness of the microcatheter techniques in balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices. Fifty-six patients with gastric varices underwent BRTOs using microcatheters. A balloon catheter was inserted into gastrorenal or gastrocaval shunts. A microcatheter was navigated close to the varices, and sclerosant was injected into the varices through the microcatheter during balloon occlusion. The next morning, thrombosis of the varices was evaluated by contrast enhanced computed tomography (CE-CT). In patients with incomplete thrombosis of the varices, a second BRTO was performed the following day. Patients were followed up with CE-CT and endoscopy. In all 56 patients, sclerosant was selectively injected through the microcatheter close to the varices. In 9 patients, microcoil embolization of collateral veins was performed using a microcatheter. In 12 patients with incomplete thrombosis of the varices, additional injection of sclerosant was performed through the microcatheter that remained inserted overnight. Complete thrombosis of the varices was achieved in 51 of 56 patients, and the remaining 5 patients showed incomplete thrombosis of the varices. No recurrence of the varices was found in the successful 51 patients after a median follow up time of 10.5 mo. We experienced one case of liver necrosis, and the other complications were transient. The microcatheter techniques are very effective methods for achieving a higher success rate of BRTO procedures.

Ultrasound-Guided Sclerosing Treatment in Patients With Patellar Tendinopathy (Jumper’s Knee)

Background: A randomized controlled study has shown good clinical results after treatment with sclerosing injections into the area with neovessels in patients with patellar tendinopathy, but no study has investigated medium- or long-term outcomes. Purpose: This study investigates the effect of sclerosing treatment 44 months (range, 42-47 months) after start of treatment. Study Design: Case series; Level of evidence, 4. Methods: Patients with a diagnosis of jumper’s knee and neovascularization corresponding to the painful area were recruited and treated with ultrasound-guided sclerosing injections using polidocanol. Primary outcome was Victorian Institute of Sport Assessment (VISA) score, which was recorded before the start of treatment, after 12 months, and 44 months after the start of the study period. Results: Twelve of the 29 patients (14 tendons) who were followed up at 44 months had undergone arthroscopic surgery after sclerosing treatment, either to the patellar tendon (n = 6) or for other intra-articular lesions (n = 8). For patients who did not receive additional treatment after the sclerosing injections (n = 23 tendons), VISA score was 55 (range, 28-71) at baseline and 81 (range, 39-100) at 12-month follow-up (P < .001 vs baseline).Their VISA score at 44 months’ follow-up was 89 (range, 73-100; P = .047 vs 12 months). For patients who went through arthroscopic tendon surgery, VISA score was 53 (range, 39-71) at baseline and 71 before surgery (range, 48-98; P = .14 vs baseline). Their VISA score at 44 months was 91 (range, 76-100; P = .0.16 vs 12 months; P = .005 vs baseline). For patients who went through non–tendon surgery, VISA score was 45 (range, 15-69) at baseline and 57 (range, 32-95) before surgery (P = .29 vs baseline). Their VISA score at 44 months was 92 (range, 72-100; P = .006 vs before surgery; P < .001 vs baseline). Conclusion: Sclerosing treatment with polidocanol was effective for the majority of the patients. Nevertheless, one-third elected to seek additional treatment through arthroscopic surgery during the 44-month follow-up period.

Endoscopic management of early postoperative anastomotic hemorrhage

The study aimed to evaluate the efficacy of endoscopic therapy for early postoperative anastomotic hemorrhage. Fourteen patients experienced an episode of early postoperative anastomotic hemorrhage and were treated endoscopically from January 2005 to June 2010. The clinical data was analyzed retrospectively. Fourteen patients(9 males and 5 females, median age 57.5 years, range 26-74 years) were diagnosed with postoperative hemorrhage between 6 hours to 14 days after surgery. The blood loss ranged from 500 to 1500 ml. Sclerosing agent injection, electrocoagulation, and hemoclips were attempted to control the bleeding. Endoscopic approach to control early postoperative anastomotic hemorrhage was successful in all the patients. No recurrent bleeding was observed during the follow-up. No complications associated with endoscopic therapy. Endoscopic approach for the management of early postoperative anastomotic hemorrhage is feasible with high success rate and associated with no complications.

Percutaneous sclerotherapy: recipe for perfect cooking

Percutaneous sclerotherapy consists of a percutaneous injection of a chemical irritant into vein or lymphatic vessels to cause the destruction of the endothelium and the obliteration of the vascular space. In the literature, different sclerosing agents and injection protocols have been documented, with varying success and complications. Percutaneous sclerotherapy is a treatment modality for: (1) venous malformations, (2) lymphatic malformations and (3) aneurysmal bone cysts (as a treatment option). The main indications to treat venous malformations are pain, articular involvement and disfigurement. Lymphatic malformation sclerotherapy is indicated especially for disfigurement or mass effect. For aneurysmal bone cyst, treatment is indicated either by sclerotherapy and/or surgery.

Sclerosing polidocanol injections or arthroscopic shaving to treat patellar tendinopathy/jumper's knee? A randomised controlled study

BackgroundProximal patellar tendinopathy/jumper's knee (PT/JK) is well known to be difficult to treat. Recent studies using an ultrasound and colour Doppler-based treatment approach on the dorsal side of the tendon,...