Venous gas embolism during foam sclerotherapy of saphenous veins despite recommended treatment modifications

Abstract

Bubble emboli entered the heart during foam UGS of saphenous veins despite all treatment modifications and low volumes of foam used.

Paradoxical embolism, stroke and sclerotherapy

“…155 However, in a recent study by the author, CO 2 bubbles arrived in the right heart within 60 seconds and continued for another 25 minutes following a single injection of 2.5 mL of sclerosant foam in a small saphenous vein. 109 Similar findings have been reported by Morrison et al 150 Total volume of sclerosant Neurological symptoms are reported with as little as 20 mL of air injected intravenously. 106 In humans, an intravenous injection of 200-300 mL of air (5 mL/kg) has been fatal.…”

“…Bubbles are observed to enter the right heart following the injection of 1 -2.5 mL of the sclerosant foam. 109 In a recent study, manual compression or ligation of the saphenofemoral junction did not prevent, but reduced the flow of foam into the femoral vein. 162 In a study by the author, once the junction was occluded by the initial foam injection, subsequent injections in the proximal trunk of the great saphenous vein (GSV) did not result in further systemic embolization of bubbles.…”

“…146 -150 Recent studies have shown these manoeuvres to be ineffective in prevention of VGE. 109,151 Leg elevation was performed in all four PSS cases with an immediate onset of stroke (Table 2). Prolonged supine position does not prevent bubbles from reaching the right heart but may reduce the bolus volume compared with immediate sitting up or standing at the completion of the procedure.…”

“…162 In a study by the author, once the junction was occluded by the initial foam injection, subsequent injections in the proximal trunk of the great saphenous vein (GSV) did not result in further systemic embolization of bubbles. 109 As recommended by the 'French School', sclerosants are administered in a proximal to distal sequence of injections targeting the larger veins and the most proximal sources of reflux first. 163 By contrast, following the original Fegan approach, sclerosants are injected distally, and often directly into visible superficial tributaries 164 and when monitored by ultrasound, the infusion is continued until the foam has reached the junction.…”

Myocardial infarction after ultrasoundguided foam sclerotherapy for varicose veins - a case report and review of the literature of a rare but serious adverse event

“…Interestingly, an even higher prevalence of RLS of 58.9 % has been reported in patients with symptomatic GSV incompetence [26]. After UGFS, gas bubbles have been shown to enter the right heart in most patients [27], and may be detected in brainsupplying arteries in ¾ of patients in presence of a RLS [20,24]. Fusion of several bubbles to form bubbles large enough to occlude intracranial arteries or bubble-induced vasospasm followed by activation of the coagulation system have been suggested to be responsible for a number of post-sclerotherapy strokes occurring within few minutes after foam sclerotherapy [20].…”