Phlebology and treatment of leg veins

Question 1

What treatment should be avoided if a patient has a known symptomatic patent foramen ovale?

Answer 1

Foamed sclerotherapy (concern for stroke)

Sx’s of patent foramen ovale can be migraine w/ aura or recurrent stroke/TIA

Screening not recommended still

Question 2

Which sclerosing agent carries the highest risk of anaphylaxis?

Answer 2

Sodium morrhuate (not used often anymore)

-3-10% of cases

Question 3

What sclerosing agent has the lowest risk of a severe allergic reaction?

Answer 3

Hypertonic saline

Question 4

What are some risk factors for varicose veins?

Answer 4

Genetic predisposition, hormones (estrogen and progesterone), obesity, and pregnancy

Question 5

What are the most significant components of the superficial venous system on the legs?

Answer 5

Small and great saphenous veins

Question 6

Varicose veins in what part of the leg suggest greater saphenous involvement?

Answer 6

The medial thigh

Question 7

What are the most important veins in the deep venous system of the leg?

Answer 7

Femoral and popliteal veins

Question 8

What procedures can be used for the treatment of varicose veins?

Answer 8

Sclerotherapy, ambulatory phlebectomy, endovenous radiofrequency ablation, and laser ablation (Nd:YAG [long pulsed 1064], IPL, and PDL)

Question 9

What times of veins are sclerotherapy best for?

Answer 9

Telangiectasias and reticular veins (can address larger varicose veins and perforating veins w/ foaming agents)

Question 10

What post-procedural intervention is needed for ALL forms of sclerotherapy?

Answer 10

Postprocedural compression stockings

Question 11

What are the 3 categories of sclerotherapy for vein treatment?

Answer 11

Hyperosmotic agents, chemical irritants, and detergents

Question 12

What are the hyperosmotic agents used for sclerotherapy?

Answer 12

Hypertonic saline (+/- dextrose)

Question 13

What is the mechanism of vein destruction with hypertonic saline?

Answer 13

Stimulates endothelial cell destruction and dehydration

Question 14

What is the mechanism of chemical irritants for sclerotherapy?

Answer 14

Injure the endothelial cells by corrosive action

Question 15

What are two chemical irritants?

Answer 15

Polyiodide iodide and Glycerin (72%)

Question 16

What is the mechanism of detergents in sclerotherapy?

Answer 16

Induce vascular injury by altering the surface tension around endothelial cells

Question 17

What are 4 examples of detergents used in sclerotherapy? Which is most common?

Answer 17

Sodium tetradecyl sulfate (STS) is the most common

Others: polidocanol, sodium morrhuate, ethanolamine oleate

Question 18

Which two detergents can induce severe necrosis when used for sclerotherapy?

Answer 18

Sodium morrhuate and ethanolamine oleate

Occurs w/ extravasation, also can cause severe allergic reactions. Should not be used for routine sclerotherapy

Question 19

What is the advantage of “foaming” with the sclerosing agents?

Answer 19

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

Question 20

What are 4 contraindications to sclerotherapy?

Answer 20

Allergy to sclerosants, DVT, advanced arterial occlusive disease, symptomatic patent foramen ovale (contraindication for foam sclerosant)

Question 21

What is a common rash that is a side effect of sclerosing therapy?

Answer 21

Urticaria

Question 22

Which sclerosing agent is most likely to cause urticaria?

Answer 22

Ethanolamine oleate

Question 23

What is the treatment for post-inflammatory hyperpigmentation from sclerotherapy?

Answer 23

Q-switched lasers

Question 24

What sclerosing agents have the highest risk of telangiectatic matting?

Answer 24

Highest risk w /detergents

Glycerin has the lowest risk of the detergents

Question 25

How can telangiectatic matting be prevented?

Answer 25

Use appropriate volume and concentration, low pressure when injecting

Question 26

Which sclerosing agent is associated with the most injection pain?

Answer 26

Hypertonic saline

Question 27

What are the highest risk areas for ulceration/cutaneous necrosis after sclerotherapy?

Answer 27

Dorsal foot and ankle

Question 28

Which detergents have the lowest risk of anaphylaxis?

Answer 28

Glycerin and polidocanol

Question 29

What are the most common sites of inadvertent injection of sclerotherapy agent into an artery?

Answer 29

Posterior medial malleolus (posterior tibial artery; superficial injections) and the popliteal fossa (deep injections)

Question 30

Why can dextrose be added to hypertonic saline for sclerotherapy?

Answer 30

Decreases pain of injection

Question 31

What is an important potential side effect with sodium tetradecyl sulfate?

Answer 31

Hyperpigmentation

Question 32

Which sclerotherapy agent can cause a disulfiram-like reaction?

Answer 32

Polidocanol

Question 33

In which sclerotherapy agent can acute renal failure and hemolytic reactions occur?

Answer 33

Ethanolamine oleate (also is the one associated with urticarial reaction)

Question 34

Which sclerotherapy is thick/viscous and difficult to inject?

Answer 34

Ethanolamine oleate and glycerin

Question 35

Which sclerotherapy agent causes the least amount of pain usually?

Answer 35

Polidocanol

Question 36

Which two sclerosing agents have the lowest dose allowance?

Answer 36

Polidocanol and polyiodiide ioidide (5mL)

Most others are 10mL (6-10 for hypertonic saline)

Question 37

Which injectable sclerosing agent has the lowest risk of hyperpigmentation?

Answer 37

Chromated glycerin