Sodium Tetradecyl Research Articles

Stomal Varices: Management With Decompression TIPS and Transvenous Obliteration or Sclerosis

Stomal or parastomal varices are extraperitoneal ectopic mesenteric varices. Parastomal varices are not common but can be a source of considerable bleeding. They usually occur in the setting of portal hypertension, although, in theory, they can occur because of vascular thrombosis of the mesentery. An obstructive element (not necessarily venous thrombosis, but a constrictive effect) most likely exists and thus localizes the bleeding to the stomal mesenteric varices. This obstruction can be due to postsurgical changes associated with the stoma creation itself. Bleeding is the main presentation of stomal varices. Bleeding can be life threatening; however, most of it can be controlled by manual compression by patients who are consciously aware. Anecdotally, there are 2 pathologic bleeding presentations. Certain stomas are diffusely congested and ooze blood diffusely, and others bleed focally from a particular site (from a particular mesenteric varix). The focal bleeders are the ones that respond favorably to manual compression by the patient. The stomas that are diffusely congested or engorged with diffuse venous oozing do better with transjugular intrahepatic portosystemic shunt (TIPS) decompression. Bleeding from focal varices in the stoma (with the rest of the stomal mucosa looking normal and not engorged) can be treated with TIPS (if the portal or mesenteric vein or both are patent) or with transvenous obliteration utilizing 1% sodium tetradecyl sulfate (not 3% sodium tetradecyl sulfate). Balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration, trans-TIPS balloon-occluded antegrade transvenous obliteration can all be adequate approaches to transvenous obliteration. However, the least invasive (in the authors' opinion) and simplest is the direct mesenteric venous stick (balloon-occluded antegrade transvenous obliteration-type) approach with ultrasound-guided compression of the systemic outflow vein.

Therapeutic efficacy of norfloxacin for experimental osteomyelitis in rabbits

Norfloxacin (NFLX), a new quinolone antibiotic agent, was evaluated for its efficacy in experimental osteomyelitis in rabbits. Osteomyelitis was induced in male rabbits by the inoculation of 10(7) CFU/ml (0.1 ml) of Staphylococcus aureus (MIC for NFLX: 0.78 micrograms/ml) with 0.4 ml of 3% sodium tetradecyl sulphate into the medullary cavity of the proximal tibia. The rabbits were divided into 3 different groups of 4 animals each. The animals in 2 groups were orally administered with NFLX; 100 mg/kg once-daily (group 2) and 50 mg/kg twice-daily (group 3) for 7 days from the 6th hour after inoculation. Group 1 was established as a control without administration of NFLX. All animals were sacrificed on the 7th day after inoculation. Acute osteomyelitic changes were found microscopically in all animals in group 1. In each of the 2 therapeutic groups, incidence of microscopic changes was 50% associated with remission of S-sialic acid value. Thus, NFLX may be considered a useful antimicrobial agent for the treatment of suppurative osteomyelitis.

European guidelines for sclerotherapy in chronic venous disorders

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. 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. 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.

3:38 PM Abstract No. 162 - A test of nerves. The incidence of neuropathy following sts sclerotherapy of venous malformations

Purpose Sclerotherapy is widely advocated as the treatment of choice for venous malformations (VMs). Several sclerotherapy agents are available and a range of risk factors are associated with their use. There are almost no examples of neuropathy resulting from sodium tetradecyl sulfate (STS) published in the literature. We report our experience of neuropathy as a complication of STS sclerotherapy. Materials and Methods All VM sclerotherapy procedures performed between 1999-2012 were reviewed. Standard technique was used with STS as foam, formed from a 1:1:2 mixture of iohexol contrast, air and 3% STS. At the time of treatment technical details were recorded for all procedures including needle size and insertion technique, number, location and classification of treated lesions, the volume and nature of sclerosant used and whether steroids or antibiotics were given. All nerve lesions were recorded. Routine follow-up included post-operative assessment, post discharge telephone call and outpatient clinic appointments. Results 847 procedures were performed. Motor and/or sensory nerve lesions occurred after 10 (1.2%) of 847 procedures. 7 of the 10 cases were in patients that had undergone at least 1 previous sclerotherapy procedure. Neuropathy was seen following treatment of 5 Puig type II lesions, 5 type III and a single type I lesion. Nerve lesions were managed according to clinical need including surgical consultant with a peripheral nerve specialist, physiotherapy and nerve conduction studies. Neuropathy improved in all cases with complete resolution in 7 and partial resolution in 3 patients of whom two required surgery. Conclusion Nerve injury is a rare complication of STS sclerotherapy and an important factor to consider when deciding to treat VMs. A degree of recovery was seen in most patients, but may be incomplete. The literature to date doesn't report neuropathy with STS but our series demonstrates that nerve injury can occur. We advocate active management of neuropathy with physiotherapy, nerve conduction studies and surgical consultation. Long-term follow up is recommended. The authors advocate sharing of clinical information of sclerotherapy complications, to enable prevention, appropriate management and prognostication of lesions.

9:04 AM Abstract No. 125 - Balloon-occluded retrograde transvenous obliteration (BRTO) utilizing 3% sodium tetradecyl sulfate (STS) (3%) foam for the management of gastric variceal bleeding: a multicenter USA study of 100 patients

Purpose To evaluate the technical, hemodynamic and clinical outcomes of BRTO utilizing 3%STS for gastric variceal (GV) bleeding. Materials and Methods A retrospective audit of patients undergoing BRTO only (coexisting TIPS excluded) for the management of GV bleeding was performed (2007-2012) in 8 centers in the United States. Cox proportional hazard was used to evaluate for risk factors for survival (institution, age, gender, etiology, HCC, ascites levels, GV bleeding status and MELD-score). Kaplan-Meier method was used for rebleed and survival rates (comparisons were by the Log-Rank test). Results 100 patients underwent 103 BRTO procedures with a technical and intent-to-treat complete GV obliteration rate of 91% (n=95/103) and 80% (n=80/100), respectively. 18 patients were actively-bleeding, 68 had prior-bleeds and 14 had impending-bleeding. Complication rate, procedure related mortality and 90-day mortality was 12%, 2% and 6%, respectively. Liver failure leading to death or liver transplantation within 90-days was 7% (4% death and 3% transplant). MELD>13 (p Conclusion BRTO utilizing 3%STS foam is safe and effective. Poor outcome is associated with HCC and a MELD>13 at the time of procedure. BRTO is effective in emergently controlling active bleeding (94%), however, elective BRTO has better survival. Table 1

1:38 PM Abstract No. 197 - Portal vein embolization prior to right hepatectomy using sodium tetradecyl sulfate foam: technique and initial results

Purpose Portal vein embolization (PVE) prior to right hepatectomy (RH) has become an integral part of the treatment algorithm for patients with resectable liver tumors. Many techniques and embolic agents have been used for this procedure; however there is no consensus on the ideal agent. We evaluate the safety and efficacy of sodium tetradecyl sulfate (STS) foam as the sole embolic agent for right portal vein (RPV) embolization. Materials and Methods Over a 12 month period, PVE with STS foam was performed in 17 consecutive patients(15 male, 2 female; mean age 60) prior to undergoing RH. Tumor pathology included hepatocellular carcinoma (n = 11) and metastases (n = 7). Preoperative liver volume was performed with CT or MRI using a 3D workstation. Ipsilateral percutaneous RPV access was obtained in all patients and a 7F sheath was placed. A 14mm Python occlusion balloon (Applied Medical, Rancho Santa Margarita, CA) was inflated in the RPV just distal to the portal bifurcation. STS foam was prepared using the Tessari method with 3% STS. Foam was slowly injected through the sheath to fill the entire RPV. Mean volume injected was 43mL (range 30-65). This was left to dwell for 40 minutes. The balloon was then removed. Follow up venogram confirmed complete occlusion of the RPV and patency of the left portal vein (LPV). Future liver remnant (FLR) and total estimated liver volume (TELV) measurements were obtained with CT or MRI pre and post PVE. 30 day major and minor adverse events were evaluated. Results 100% technical success was demonstrated by complete occlusion of the RPV branches and continued patency of the LPV and its branches. Median hospital stay was 1 day. Mean time to followup imaging was 26d ± 12d. FLR volume increased 46.1% ± 24.2%. FLR/TELV ratio increased 13.1% ± 9.6%. There were no major or minor complications. Fifteen (88.2%) patients went on to RH. Two (11.8%) patients had progression of disease into the left hepatic lobe (LHL) during the follow-up period after PVE precluding RH. Mean time from PVE to RH was 52d ± 32.6d. Conclusion PVE with STS foam is safe and effective at achieving LHL hypertrophy prior to RH. Larger scale studies are needed to further demonstrate the efficacy of this technique.

Abstract No. 262 - Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices in 18 patients with relative contraindications for TIPS or failed TIPS in single US medical center

Purpose Transjugular intrahepatic portosystemic shunt (TIPS), a well-established treatment for portal hypertension related gastric varices. However, it may not be suitable for some patients with portal vein thrombosis, hepatic encephalopathy and severe thrombocytopenia, etc. We retrospectively review the balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices in 18 patients with relative contraindication for TIPS or technically or clinically failed TIPS in single US medical center. Materials and Methods From Sep 2009 to Jan 2012, eighteen patients (six men and twelve women; mean age, 60.1 yrs; range, 26-85 yrs) were treated with BRTO of gastric varices in single US medical center. Indication of BRTO of gastric varices included portal vein thrombosis (n=3), large HCC (n=3), failed TIPS placement (n=2), failed bleeding control after TIPS placement (n=3), severe thrombocytopenia (n=1), old age (> 75 years) (n=3), refusal of TIPS due to hepatic encephalopathy (n=1), and status post liver transplantation (n=1), hyperbilirubinemia (n=1). Acute gastric bleeding was eight patients, prior bleeding was six patients, and impeding bleeding was four patients. Entanolamine oleate was used as sclerosant agent in four patients and 3% sodium tetradecyl sulfate (sotradecol) was used in fourteen patients. We retrospectively analyzed technical success, complication, and clinical successes (control of acute gastric bleeding, recurrence of gastric or esophageal bleeding). Results BRTO of gastric varices was successfully performed in all patients. Complication was one vein rupture causing small retroperitoneal hematoma. Acute gastric bleeding was controlled in all eight patients. Three patients were lost to follow up. During follow up (22-618 days), two patients underwent prophylactic banding of the esophageal varices. There was no recurrent bleeding from the gastric varices and there was one esophageal bleeding. Follow up CT or MRI images (65 to 618 days) and follow up upper endoscopies (34 to 682 days) showed obliteration of gastric varices. Conclusion BRTO of gastric varices can be a useful treatment for patients with relative contraindications for TIPS or technically or clinically failed TIPS.

3:30 PM Abstract No. 52 - Outcome of endovascular treatment for aneurysmal bone cysts

Purpose Surgical management of aneurysmal bone cysts (ABCs) is associated with perioperative morbidity, mortality and high recurrence. In addition, some ABCs are inoperable. We evaluated the presentation, morphology, technique and outcome of percutaneous image guided sclerotherapy for ABCs. Materials and Methods We retrospectively reviewed the medical records and imaging studies of patients with ABCs who underwent percutaneous sclerotherapy at our institution. Age, location, size, symptoms, image guidance, agents used and outcomes were documented. Symptomatic and radiological changes were evaluated and compared pre and post sclerotherapy. Results 27 pts (5-18 yrs; mean age, 11.5 yrs) including 20 nonspinal ABCs (5-18 yrs; mean age, 11.5 years) and 7 spinal ABCs (8-18 yrs; mean age, 13 yrs) underwent percutaneous sclerotherapy. Most common symptoms were pain, swelling and neurological. 21 pts had biopsy proven ABCs. Sonographic, fluoroscopic or C-arm flat-detector CT (dynaCT) as well as combinations of these modalities was used for guidance. The sclerosant agents were sodium tetradecyl sulfate (n=23), ethanol (n=12) and doxycycline (n=8); either singly or in combinations. In 7 pts (4 nonspinal, 3 spinal) sclerotherapy was combined with transarterial embolization.1-9 sclerotherapy sessions were performed (mean: 5). Range of follow-up was 2-69 (mean, 35.5) months. In 17 (85%) nonspinal and 4 (71%) spinal lesions, pain resolved, completely in 16 pts (14 nonspinal and 2 spinal) and partially in 10 pts (5 non-spinal and 5-spinal). Radiological regression was noted in 14 (70%) nonspinal and 3 (43%) spinal lesions. 3 other pts with spinal ABCs showed radiological progression and spinal instability. 6 pts (5 spinal, 1 nonspinal) required further operative interventions but with significantly lesser blood loss. There were no complications related to sclerotherapy. Conclusion Endovascular treatment is a safe and effective treatment for aneurysmal bone cysts. It can be used as definitive treatment or as a bridge to elective surgical operation. This approach provides symptomatic relief and regression of the size of most ABCs, with more favorable outcome in nonspinal lesions.

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.

3:46 PM Abstract No. 163 - Risk of complications of sclerotherapy for venous malformations

Purpose To assess risk of complications of sclerotherapy for venous malformations in children and young adults. Materials and Methods The medical records and procedural details for patients with venous malformations who were treated with sclerotherapy by one interventionalist were reviewed. The size, location and type of sclerosing agents used were noted. The incidence, type and risk factors for complications were documented. Complications were categorized according to the Society of Interventional Radiology classification system for complications by outcome. Results 122 patients (age: 2 months-34 years) underwent 314 procedures. Sodium tetradecyl sulfate 3% (STS) was used in 279 procedures (89%); of those STS was combined with other agents (dehydrated ethanol and nBCA glue) in 92 procedures (33%). STS volume use ranged from 0.2 ml to 20 ml. Ethanol was used in 87 procedures (27%), 80 of these (92%) were in combination with other agents with a volume range of 0.5 to 26 ml. Glue was used in 56 procedures (18%), 54 (97%) of which were combined with other agents with a total volume of 0.1-6 ml. Minor complications occurred in 23 procedures (7%) including blistering/ ulceration of involved skin (n=8), basilic vein thrombosis treated with simple thrombectomy (n=1), mild urethral bleeding from urine catheter (n=1) and transient hemoglobinuria. There were no major complications or nerve injury. Conclusion Sclerotherapy for venous malformations is a safe procedure even with the use of combinations of agents without major complications. Minor complications, such as blistering are expected with cutaneous involvement and heal without sequelae.

2:42 PM Abstract No. 215 - Comparison of percutaneous sodium tetradecyl sulfate with ethanol injection in the treatment of benign thyroid nodules

Purpose Sonographically guided percutaneous ethanol injection has been used for treating benign thyroid nodules. The side effects include mild local pain in all patients and transient vocal cord palsy and venous thrombosis in sporadic cases.Sodium tetradecyl sulfate (STS) is an alternate sclerosant but has not been used for treating thyroid nodules. The purpose of this study was to compare the efficacy of percutaneous STS with ethanol injection in benign thyroid nodules in patients with colloid goiter. Materials and Methods After obtaining institutional review board approval, 50 euthyroid patients with cytologically proven benign thyroid nodules were prospectively randomized into two groups; 20 in the ethanol arm and 30 in the STS arm. The patients were matched with respect to age, gender and nodule consistency (solid, cystic and mixed solid cystic). The mean volume of the nodule was 25.58cc (range 4-122.10 cc) in the ethanol arm and 25.39cc (range 0.72-129 cc) in the STS arm. Percutaneous instillation of sclerosant was done once in 20 patients while multiple injections were given in 30 patients. The mean volume of ethanol and STS instilled per sitting was 5.33cc and 7.85cc respectively. Follow-up sonography of the thyroid gland was done at 1,3,6 and 12 months after the last instillation and the volume of the nodules was recorded. Results The final mean volume of the nodules at 12 months was 4.07cc (range 0.34-15.18cc) and 4.36cc (range 0.01-29.57cc) in the ethanol group and the STS group respectively (p=0.846). The mean volume reduction was 84% and 82.86% in the two groups. Greater than 50% volume reduction was seen in 80% and 76.7% patients in the ethanol group and the STS group respectively (p=0.33). Mild overlying tissue necrosis occurred in one patient in the STS group. However, the degree of local pain experienced was less in all the patients in this group. No other significant adverse effects were seen in either of the two groups. Conclusion Sonographically guided percutaneous STS and ethanol instillations are not significantly different from each other in terms of the volume reduction of the benign thyroid nodules. STS may be used as an alternate sclerosing agent in such nodules.

8:48 AM Abstract No. 123 - BRTO of gastric varices without an indwelling balloon: comparison between conventional BRTO with an indwelling balloon vs. intraprocedural replacement of the balloon with an amplatzer vascular plug

Purpose For 20-years the invariable feature of the BRTO procedure for the management of gastric varices (GV) was an indwelling balloon occlusion. The purpose is to compare between conventional BRTO (balloon dwelling over hours) and a new technique which replaces the balloon intra-procedurally with Amplatzer plugs. Materials and Methods A retrospective audit of BRTO procedures performed at a single institution utilizing 3% sodium tetradecyl sulfate foam was performed over 5-years (2007-2012). The cohort was divided into conventional BRTO (balloon-occlusion catheter left to dwell for hours and patient returned for balloon deflation) and the new BRTO-technique without an indwelling balloon occlusion catheter. The new technique uses a balloon-occlusion guide-sheath that allows placement of 16-mm Amplatzer plugs prior to balloon deflation. Once the Amplatzer plugs are in place, the balloon is deflated. Results 16 patients underwent 16 BRTO procedures with the new technique (Amplatzer group) and 46 patients underwent 47 conventional BRTO procedures with indwelling balloons (indwelling group). No difference in demographics or techical details (p>0.05). Technical results are shown in table. The Kaplan-Meier 6 month survival for Amplatzer- vs. Indwelling-group was 80% vs. 93%, respectively (p>0.05). The Kaplan-Meier 6 month rebleed rate for Amplatzer- vs. Indwelling-group was 7% vs. 8%, respectively (p>0.05). The balloon dwell time was significantly (p Conclusion In the absence of a major right to left shunt, the new technique of replacing the balloon occlusion with Amplatzer plugs is safe and effective. Table 1

Sclerosing Agents in Ophthalmology

Sclerotherapy is a surgical procedure used for vascular and lympha c malforma ons, in all age groups, wherein a sclerosing agent is injected into a vessel to make it shrink. It involves injec on of the agent intravascularly intralesionally or topically, under direct vision or under the guidance of radiological imaging. Sclerotherapy has primarily been used in ophthalmology for treatment of arteriovenous malforma ons like hemangiomas and caro co-cavernous fi stulas, and lympha c abnormali es like lymphangiomas. Sclerosing agents are chemical compounds which cause endothelial injury leading to infl amma on and vascular thrombosis. They may be classifi ed into various categories like detergents, hyperosmo c agents, cor costeroids, cytotoxic agents etc. A short descrip on on beta-blockers has also been included in this ar cle, even though beta-blockers are not sclerosants per se. Polyvinyl alcohol, sodium tetradecyl sulphate (STS) and ethanol may be used for arterio-venous malforma ons, while for lymphangiomas agents like sodium morrhuate, STS, doxycycline and OK-432 are used. In hemangioma pa ents, cor costeroids and beta-blockers are amongst the fi rst line therapy. Del J Ophthalmol 2012;23(3):219-224.

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.

Sclerotherapy in venous malformation

Venous malformations are the result of an arrested development of the venous system during the embryogenesis. In the treatment of venous malformations the standard of care is a multidisciplinary approach including the use of traditional surgical therapy if applicable and endovascular treatment. Endovascular techniques include embolization therapy for instance with coils but also sclerotherapy with liquid or foamed sclerosants. The aim of this paper is to give an overview of foam sclerotherapy in venous malformations. Sclerotherapy of venous malformations has been performed in superficial and intramuscular malformations. In many cases ethanol has been used for the treatment. Since more than 10 years, less aggressive sclerosants like polidocanol and sodiumtetradecyl sulphate have been used to treat venous malformations. These substances can be used without anaesthesia and the rate of side-effects is much lower. Yamaki and Cabrera are the first who used foam sclerotherapy for the treatment of symptomatic venous malformations. Compared with liquid sclerotherapy foam sclerotherapy has the advantage of a better and longer lasting contact of the sclerosing agent with the vessel wall which leads to a more effective treatment and to a reduction of concentrations needed. In a recent European Guideline on Sclerotherapy foam sclerotherapy is recommended over liquid therapy for the treatment of venous malformations. Foam sclerotherapy is an effective treatment option for low flow extratruncular and truncular venous malformations. Foam is significantly more effective than liquid sclerotherapy and side-effects with polidocanol or sodiumtetradecyl sulphate foam are less compared with sclerotherapy with ethanol. With foam sclerotherapy a significant reduction of pain and volume of the venous malformations can be reached.

Phenol as a novel sclerosing agent: A safety and efficacy study on experimental animals

BackgroundVaricose and ectatic cutaneous vessels are common chronic conditions that might need surgical treatment. There are several treatment modalities, but all can cause complications and have significant recurrence rates. A new effective and safe treatment with low or no recurrence is needed. Phenol seems to be a potential therapeutic agent. ObjectiveTo assess the efficacy and safety of phenol as a sclerosing agent in the treatment of varicose veins and other vascular ectatic conditions. MethodsThe dorsal ear veins of white New Zealand rabbits were injected with 0.1ml of a sclerosing agent. Four experimental groups were used to test the sclerosant efficacy of different concentrations of phenol (1%, 5%, 20% and 50%). Sodium tetradecyl sulphate (STS), a commonly used sclerosing agent, was used as a positive control, while normal saline was used as a negative control. The blood vessels of the treated ears were photographed before and 1h, 2days, 8days and 45days after treatment. Biopsies from the treated areas were obtained for histologic examinations. ResultsA concentration of 1% phenol was too low to cause significant vascular changes, whereas a concentration of 5% phenol caused 90% lumen narrowing. Interestingly, 1% STS only caused 25% lumen narrowing. Concentrations of 20 and 50% phenol caused 100% lumen narrowing but caused haemorrhage and necrosis. Toxicity monitoring showed no apparent haematologic, cardiac, pulmonary, hepatic or renal toxicity associated with the concentrations of phenol used in this study. ConclusionA concentration of 5% phenol appears to be a potent and safe sclerosing agent for ectatic small vessels. This provides a significant new therapeutic option, which may eventually advance to the clinic and have an impact on the treatment of patients suffering from varicose veins and other vascular ectatic conditions.

Evaluation of the Role of Sodium Tetradecyl Sulfate as a Sclerosant in the Treatment of Primary Hydrocele

The present study was carried out with an aim to perform a prospective study to establish the role of sodium tetradecyl sulfate (3%) (STDS) as a safe and effective sclerosant in the management of primary hydrocele. Sclerotherapy was performed with 3% STDS on an outdoor basis. The amount of sclerosant injected depended on the amount of fluid drained. All patients were given prophylactic antibiotics. Patients were clinically reassessed at 1week, 1month, 3months, and 6months and earlier if complications occur. The data were analyzed using Statistical Package for Social Sciences Version 15.0. The data have been represented as frequencies and percentages. Chi-square test was used to compare the data. A total of 57 patients with primary vaginal hydrocele gave consent for being enrolled in the study. The age of patients ranged from 18 to 65years with a mean age of 35.72 ± 13.18years. The success rate at the end of the study was observed to be 84.2%. As regards patient satisfaction, in present study, in a limited time period of follow up, all the patients who had a successful procedure were satisfied. Overall, sclerotherapy was observed to be a relatively cost-effective (including both direct and indirect costs) procedure with low complications, high satisfaction, and a high success rate within the limited period of follow-up.

Staged endovascular and surgical treatment of slow-flow vulvar venous malformations

The objective of the study was to report our experience in a rare series of treated symptomatic slow-flow vulvar venous malformations (VVMs) using a staged, multidisciplinary approach. Consecutive patients with symptomatic lesions treated over a 7 year period (2005-2012) were followed up for technical success, resolution of symptoms, aesthetic outcomes, and complications. Direct endovenous sclerotherapy (DEVS) using sodium tetradecyl sulfate (STS) foam was performed in all patients under ultrasound and contrast-enhanced fluoroscopic guidance. Surgical excision and layered primary closure was performed within 24 hours after the last DEVS session. Eleven patients (mean age, 25 years; range, 4-43 years) were treated. Presenting symptoms included pain (n = 11), soft tissue swelling (n = 11), local heaviness (n = 11), dyspareunia (n = 2), and dysmenorrhea (n = 2). Most were isolated lesions (n = 8). There were 2 cases of Klippel-Trénaunay syndrome and 1 case of Maffucci syndrome. The latter required Nd:YAG laser photocoagulation prior to sclerotherapy. On average, approximately 3 DEVS sessions were required prior to surgical excision (range, 1-6). Mean estimated surgical blood loss was 130 mL (range, 20-400 mL). Mean follow-up was 23 months (range, 3-55 months). Elimination of pain and soft tissue redundancy was achieved in all patients with satisfactory aesthetic outcomes. All patients experienced minor pain and swelling after DEVS. Following surgical excision, there was 1 case of hematoma and wound dehiscence requiring surgical evacuation. No other reinterventions, endovascular or surgical, were required. VVMs require increased awareness and appropriate preoperative evaluation for proper identification and treatment. A multidisciplinary approach can provide improvement in clinical signs and symptoms with satisfactory cosmesis and minimal complications.

Sclerotherapy in the management of varicose veins and its dermatological complications

Varicose veins and its dermatological complications like stasis dermatitis, ulcers, spontaneous bleeding are commonly seen in the dermatology clinics. Surgery has been the most often used treatment for varicose veins. Sclerotherapy refers to introduction of sclerosing solution into the varicose veins, which causes endothelial damage and subsequent fibrosis. Sclerotherapy is being practised extensively by dermatosurgeons in the west. However, there are no Indian studies which specifically evaluate the role of sclerotherapy in the management of varicose veins and its skin complications. Hence, this study aims to evaluate the efficacy of sclerotherapy in managing varicose veins and its complications. To study the safety and efficacy of sclerotherapy in the treatment of varicose veins and its dermatological complications. This is a prospective study involving 50 patients with varicose veins and its dermatological complications attending the dermatology out-patient department. The study was conducted over a period of 18 months. After thorough clinical, laboratory, and radiological evaluation, the patients were treated with sclerotherapy using Sodium Tetradecyl Sulphate of various concentrations depending on the vessel size. The patients were then followed up to look for disappearance of veins, healing of ulcers and eczema, and any complications. Patients showed a good response to treatment with sclerotherapy. 70-80% of patients showed symptomatic improvement along with disappearance of veins and healing of eczema and ulcers. Most of the complications were minor, which resolved over a period of few weeks. Sclerotherapy is a simple, safe and effective procedure for the treatment of varicose veins and its dermatological complications. The procedure is particularly effective for smaller, early varicosities and also for residual veins after surgery. Hence we recommend more and more of our fellow dermatologists to take up this procedure, which can be an efficient tool to manage patients with varicose veins and its related complications.

Balloon-Occlusion Catheter Rupture During Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices Utilizing Sodium Tetradecyl Sulfate

Balloon-occluded retrograde transvenous obliteration (BRTO) is an established procedure for the management of bleeding gastric varices in Asia. Invariably, the sclerosant utilized in Asia is ethanolamine oleate and the inventory used (vascular sheaths, balloon-occlusion catheters, and microcatheters) is not available outside Asia. A total of 41 BRTO procedures were performed with a technical and obliterative (gastric varix obliteration) success rate of 95% (n = 39 of 41) and 85% (n = 35 of 41), respectively. Complications were 4.9% (n = 2/41). A total of 6 balloon ruptures occurred (14.6%, n = 6 of 41). One rupture (16.7%, n = 1 of 6 of ruptures) lead to a technical failure and 2 ruptures (33.3%, n = 2 of 6 of ruptures) lead to an obliterative failure. Balloon rupture contributed to 50% of technical failures (n = 1/2, P = .274) and 33% of obliteration failures (n = 2/6, P = .148). In conclusion, the incidence of balloon-occlusion catheter rupture utilizing 3% sodium tetradecyl sulfate (STS) and inventory unique to the United States is significantly higher than in Asia (<8% rupture rate). However, these ruptures have no significant technical or clinical consequences.