Digital Subtraction Angiography–Guided Foam Sclerotherapy of Peripheral Venous Malformations

Abstract

W439As a result of the development of sclerosants in foam form, sclerotherapy has entered a new era [1][2][3]. Foam sclerosants have several advantages over conventional liquid sclerosants [1][2][3]. First, it is easy to manipulate and control the sclerosing action. The foam sclerosant displaces the blood, instead of mixing with it, and occupies the interior of the vessel completely, which makes it a manageable sclerosant that produces predictable results. Second, foam sclerosants have very limited or no toxicity [1-3]. The presence of very small microbubbles increases the contact area between the sclerosant and the walls of the vessel, which results in a more homogeneous dosage and better results. This increased contact area means that the amount of sclerosant required is much lower than with conventional liquid sclerosants and, therefore, never reaches toxic levels [1-3]. Thus, a lower concentration of foam sclerosants gives a similar or better effect than liquid sclerosants. Third, foam sclerotherapy is pain free [1-3] and easy to repeat. The discomfort experienced is about the same as that experienced during the taking of a Va s c u l a r a n d I nt e r ve nt io n a l R a d io l og y • O r ig i n a l R e s e a rc h WEB This is a Web exclusive article.

A New Method for Using Radiopaque Sclerosing Foam to Treat Venous Malformations

“…21 However, few side effects were observed with the combination of POL and iopromide according to Li's studies. 13,16 The half-life of POL-only foams was 111.5 seconds in this study and was almost equal to the results of the research by Rao and Goldman (110 seconds). 18 The foam stability varied with different ratios of iopromide.…”

“…10 Guided visible foam sclerotherapy for VMs with ultrasound or digital subtraction angiography (DSA) has become a research focus and academic front contributing to its accuracy and safety. 5,[11][12][13][14][15] The ultrasonography is limited to detecting the venous outflow and extravasation of sclerosing agents and requires special skills of operators. 16 However, foam flows can be traced with a "filling defects" technique under DSA.…”

“…This procedure occurs by first injecting the contrast agent (usually iopromide) into the lesion to display the malformed blood vessels and then infusing the sclerosant to replace the initial contrast agent. 13,16 This 2-step filling defects technique is relatively complicated and may cause the percutaneous puncture needle displacement from the correct lesion position, especially in complicated anatomical regions such as the head and neck (which account for 40% of VMs). 17 Additionally, a small amount of contrast agent probably remains in large lesions, although the sclerosing foam has already arrived distal venous drainage.…”

Vascular anomalies: classification, imaging characteristics and implications for interventional radiology treatment approaches

“…The injection of the foamed or nonfoamed sclerosant is then monitored by direct fluoroscopy or digital fluoroscopic angiographic angiography until it exits through the added needle or cannula confirming that treatment of the malformation is complete. 72,73 For palpable lesions, attention should be paid to the amount of induration of the VM during sclerotherapy, 74 and the cessation of treatment should occur when lesions become firm, as this suggests complete closure of the vascular channels. Finally, the physician should always look for signs of local extravasation or systemic circulation of the sclerosing agents.…”

Radio-opaque ethylcellulose-ethanol is a safe and efficient sclerosing agent for venous malformations

“…Absolute ethanol mixed with zein and oleum papavaris (Ethibloc®, Ethicon, Hamburg, Germany), which was frequently used in Europe, but not approved by the Food and Drug Administration (FDA, USA), is no longer commercially available due to post-sclerotherapy corrections needed to remove residual zein [21,22]. Detergent sclerosants, with or without microfoam, are less aggressive than ethanol, but there is a greater tendency for recanalization of the vascular channels [23][24][25]. Hence, there is a great need for a better sclerosing agent, which would be as efficient as absolute ethanol, but less dangerous.…”