Foam Sclerotherapy and Patent Foramen Ovale (PFO) Gillet J-L J L (France)

Transcription

1 Foam Sclerotherapy and Patent Foramen Ovale (PFO) Gillet J-L J L (France) Abano Terme, October

2 Definition PFO is an incomplete closure of the atrial septum that results in the creation of a flap or a valve- like opening in the atrial septal wall. When a person creates pressure inside his or her chest (coughing, sneezing,, etc., Valsalva manœuvre), the flap can open and blood can move from the right to the left atrium, bypassing the filtering system of the lungs. 2

3 PFO is present in everyone before birth % in the adult population > 50% in patients with varicose veins [Wright D et al] Size is variable : small / large PFO Associated with an atrium septal aneurysm (ASA) 3

4 Right-to to-left Shunt (RLS) Woods et al, Chest healthy volunteers search for RLS using modern US technology combined with a rigourous saline contrast echocardiogram protocol, followed by a completion of a migraine questionnaire RLS : 71% - PFO : 38% (large : 13%) - Pulmonary arteriovenous malformation : 28% - PFO + PAVM : 5 % 4

5 According to Neurologists No evident relationship between PFO and migraine headache. Possible relationship between PFO and migraine with aura. Woods el al, Chest 2010 Rigarelli et al,, JACC: Cardiovascular Intervention 2010 Lucas C, Revue Neurologique

6 Neurological complications after Foam Sclerotherapy - Visual disturbances - Cerebro-vascular events - immediate onset of symptoms - delayed onset of symptoms 6

7 Cerebrovascular events * Strokes were reported following liquid sclerotherapy 4 cases of CVA (earliest( case report: 1951) - 7 cases of TIA The concern has increased with the use of foam (inject. of gas) It is essential to distinguish strokes caused by: - paradoxical clot embolism (delayed onset of symptoms) - paradoxical gas embolism (immediate onset) specific complication of FS Strokes have been reported after saphenous vein stripping endovenous laser [Harzheim TDMW 2000], endovenous laser [Caggiati JVS 2010] and phlebectomy [Passariello F, Phlebology 2011]. 7

8 While millions of FS sessions have been performed * No death or stroke with significant after-effects effects * A few cases of stroke related to air embolism with complete or near complete recovery [ Bush et al, Phlebology 2008 Leslie-Mazwi et al,, N Care 2009 De Laney et al,, W J E Med 2010 Ma et al, Phlebology 2011 ] 8

9 PFO : most consistent risk factor High prevalence of PFO : Very low risk of stroke following FS Prior FS, a screening for PFO is not necessary Symptomatic PFO : absolute contraindication for FS [ Grade 1C - Rabe et Al. European guidelines for sclerotherapy in CVD [Recommendation 2 - Phlebology 2013, online ] 9

10 Visual Disturbances (ViD) Reservible symptoms including * Positive features (flickering lights,, spots, lines or scotoma) * Negative features (ie, loss of vision) * One or both eyes * Isolated or combined with sensory symptoms or a dysphasic speech disturbance # Migraine Aura as defined by the International Headache Society 10

11 Pathophysiological Cortical Spreading Depression (CSD) is the underlying mechanism of Migraine Aura. It is a depolarization wave that propagates in the cerebral cortex: It starts in the occipital cortex and spreads towards the front: - limited at the occipital cortex visual aura - parietal cortex paresthesia (numbness) - temporal cortex dysphasic speech disturbance [Lauritzen et al.. Pathophysiologie of the migraine aura. Brain 1994] 11

12 Demonstrating that VD corresponds to MA and is not a cerebro-vascular event is a crucial issue in the assessment of the safety of FS. We carried out a prospective muticentre study : - Collaboration with the Neurology Department of the Marseille University Hospital (Specialist of migraine : Dr A Donnet) - Clinical assessment combined with a brain MRI (T1, T2, T2*, diffusion) 12 Plebology ; ; 25:

13 Clinical assessment (by neurologist specialized in migraine) ViDs (isolated or combined) presented characteristics of Migraine with Aura in all patients All the MRIs performed within 2 weeks (average:: 8 days) were normal MA: symptoms appear progressively TIA: symptoms appear suddenly 13

14 Two pathophysiological mechanisms of Visual Disturbances and Migraine with Aura occurring after FS are possible and might coexist I Release of endothelin That could reach the cerebral cortex through a PFO. * Endothelin 1 has been demonstrated as being a triggering factor for MA Dreier JP et al. Brain 2002 * Significant increase of endothelin 1 level was identified after FS in rats Frullini A et al. Phlebology 2010 * 11 patients - Polidocanol FS Significant increase of endothelin 1 level at 3 mn Frullini A, Dermatol Surg

15 II Microemboli Nozari A, Moskowitz et al. Ann Neurol 2010 Mice : microemboli of microbubbles of air, polystyrene micropheres or cholesterol crystals into the carotid artery could trigger a cortical spreading depression (CSD) (pathophysiological correlate with Migraine with Aura) without requisite tissue damage. CSDs were preceded by local or regional hypoperfusion. Histopathological evaluation: no ischemic infarct in mice brains after microemboli of air. 15

16 2 pathophysiological mechanisms might be involved in MA after FS These data reinforce the demonstration that ViDs occuring after FS correspond to Migraine Aura and are not TIA. Two pathophysiological mechanisms are not contradictory : Depending on the sensibility of the patient, either ET or microembolism could be the pathophysiological correlate with FS-induced MA Might coexist: Release of Endothelin + Microembolization extended symptoms Large PFO? Other vasoconstrictors : serotonin,, etc. 16

17 CONCLUSION * Prevalence of PFO is very high in the adult population. Screening for FPO is not necessary before FS. Symptomatic PFO: absolute CI for FS * ViDs occuring after FS correspond to Migraine with Aura and are not Transient Ischemic Attack. * Though strokes are exceptional, their prevention must be our main concern. next presentation Thank you for your attention 17

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