1:24-1:36 Now 10 minutes flying along Visual Sclerotherapy Nick Morrison, MD, FACPh, FACS President, International Union of Phlebology Sedona, Arizona
Canyon de Chelly, Airzona Disclosures Educational Grant, Speakers Bureau mediusa Consultant Merz SAB, Research Grant Speakers Bureau Medtronic Speakers Bureau Pierre-Fabre Speakers Bureau Craveri Medical Director Morrison Vein/Training Institute
Disclosures Off label and/or Non-FDA Approved Drugs Polidocanol and STS foam, as referred to in this presentation, may be considered off-label or unapproved by the FDA
Key Steps in Sclerotherapy Evaluation and Assessment Photo documentation Patient Education Sclerosant choice Injection Techniques Post-Injection care Follow-up visits
Evaluation and Assessment Medical vs Cosmetic Determine if patients are medical or cosmetic in the early screening process If medical, need further study (duplex) If patients meet the medical criteria, the underlying medical process must be treated first, before the surface veins, for better outcome
Photographic Documentation Photographic documentation is important for both the physician and patient in order to document the results and efficacy of therapy. a) This helps assure the patient about the progress of treatment b) May be required by the insurance carrier c) Is helpful for legal documentation
Patient Education Establish Realistic Expectations!! No "Quick Fix": most pt's require a minimum of 2-5 sessions approx. 4-6 weeks apart Legs will ALWAYS look worse before they look better.
Establish Realistic Expectations Pt's with significant/severe symptoms often begin to notice a favorable improvement in how legs feel and possible resolution of many symptoms before they will see changes of the appearance. There currently is no known cure for venous disease: pt's will develop more spider veins as they get older and/or will also continue to develop refluxing veins as well.
Financial Planning Full Disclosure Patient costs sheet Insurance coverage Deductible met? Co-Pay Out-of-Network Non-covered procedures Denial appeals Medical Necessity requirements
Sclerosants Choose the appropriate sclerosant and strength of sclerosant Minimum volume and concentration to cause sufficient endothelial damage Looking for the perfect sclerosant? : Painless, non-allergenic, effective for all veins, inexpensive, FDA approved, no matting, no ulcerations, no staining, locally available IT DOES NOT EXIST!
Foam Sclerosants Any detergent can be foamed Foaming increases effectiveness by increasing the surface area of the solution on the vein wall and displacing the blood for a longer time Foam is not commonly indicated for use on veins < 2 mm Sometimes used for reticular veins or veins using ultrasoundguidance; not for small diameter spider veins
Injection Techniques Aspiration- gentle aspiration of blood into the needle hub to assure placement Puncture Feel The feel of perforating the vein wall can be mastered with experience Empty Vein- emptying blood by elevation prior to injection to assure contact with the endothelial surface; generally for larger veins
Injection Techniques Basic Principles Opinions Treat Proximal to distal Treat larger to smaller vessels Treat reticular and spider veins in each area Apply local compression immediately following injection Ambulation should occur immediately following treatment
Correct Sclerotherapy Position Ergonomically comfortable for sclerotherapist and patient
Cutaneous Sclerotherapy
STS Protocol < 3mm veins-.1-.25 % liquid solution >3mm veins.5 % - 3 % liquid or foam Maximum dosage recommendation not to exceed 10 ml per treatment session
Polidocanol Protocol < 3mm veins-.5 %-1% liquid solution >3mm veins 1% liquid or foam (That s all that is FDA-approved and available) Maximum dosage recommendation not to exceed 10 ml per treatment session
Foam Sclerotherapy for telangiectasias/reticular veins notes of caution NOT for beginners works well but very strong technically difficult to manage dripping obscures target veins must inject quickly after foam production Neurosensory complications increased
Injection Techniques Basic Principles Opinions Bend needle to 15-30% angle to enable cannulation of small superficial veins Stretch skin taut Brisk cannulation of the vein reduces vascular trauma, vasoconstriction and chance of extravasation Maintain low injection pressure to prevent vascular distention Inject small amounts of solution at each site to help prevent matting and extravasation Inject at appropriate intervals until the entire vessel has been treated
Post Injection Care Patients walk immediately after each treatment session Treatment sessions are carried out at 4-6 week intervals to allow enough time to evaluate the results of the prior treatment Most patients will require 2-5 treatments
Post Injection Care Graduated Support Hose Reduces risk of DVT post treatment Reduces incidence of microthrombi* Objective outcome measurement improved* Helps alleviate pt. symptoms and contributes to vein sclerosis *Kern, et al. J Vasc Surg 2007;45:1212-16
Post Injection Care Compression Pearls Spot compression may be applied over injection sites with cotton and micro pore tape or beveled compression pads (STD, Hereford, England) may be applied. Compression pads are particularly helpful when treating bulging vessels and for patients who bruise easily.
Follow up Visits: Evaluation for Complications Complications of sclerotherapy can be minimized by proper patient selection, accurate examination to r/o medical vs. cosmetic, appropriate sclerosant choice, and use localized compression post treatment
Follow up Visits: Evaluation for Complications Microthrombi (trapped blood) Bruising Itching Cramping Hyperpigmentation Telangectatic matting Ulceration Scarring Phlebitis DVT
Microthrombi Blood may become trapped in a partially closed vein Presents as a dark bruise or sliver like appearance Should be evacuated using topical and/ or local anesthetic and an 18 ga. Needle Contributes to hyperpigmentation May be palpable and tender to touch Best to wait 7-10 days post sclerotherapy to evacuate If accompanied by inflammation, pre-treat the pt. with anti-inflammatory meds and compression to minimize discomfort and for 24-48 hrs post aspiration
Follow up Visits: Evaluation for Complications Hyperpigmentation Most common side effect, occurring in 10-30% of patients Brown discoloration along the vessel due to hemosiderin staining from trapped blood Rarely occurs in veins < 1 mm Spontaneous clearing in 6-12 months TIME
Follow up Visits: Evaluation for Complications Telangiectatic matting Matting or blushing may occur in 15% of post-sclerotherapy treatments Tiny red spider veins that appear like a blue or red bruise Possible causes are too high sclerosant strength, too much pressure and or volume when injecting
Follow up Visits: Evaluation for Complications Telangiectatic matting Look for hidden reticular veins visually or by ultrasound that are contributing Laser therapy may be used: 585nm pulse dye, 532 or 1064 long pulse, IPL
Follow up Visits: Evaluation for Complications Ulceration More common with Hypertonic saline, but can occur with other sclerosants Common on the anterior tibial or malleolar area Probably caused by injection into an arteriole or pressure greater than capillary pressure with reversed flow into arteriole
Follow up Visits: Evaluation for Complications Ulceration Increase risk with elderly, anorexics, smokers Minimize risk with proper concentrations, appropriate pressure, attention to risk areas Treat with occlusive wound dressing and care Will persist for 2-4 months, leaves a scar
Follow up Visits: Evaluation for Complications DVT Rare but not never Requires Standard Workup Compression Ambulation Anti-inflammatory
Embolia Cutis Medicamentosa (Nicolau s syndrome) 28 March, 2006 28 October, 2006
Follow up Visits: Evaluation for Complications Unusual complication Embolia cutis medicomentosa Prevention: Low volume/pressure injections Treatment: Local wound care Analgesics, sleeping aids (lesion painful) Time many will resolve over several weeks to months with minimal scarring and without full thickness tissue loss Others, on the other hand.
Compounded Drugs Contamination NECC* About 2,330,000 results (0.20 seconds) Steroid Injection Lawsuit 1 (866) 630 2911 www.pulaskilawfirm.com/ Pulaski & Middleman Law Firm Will Fight For Your Case. Call Us Today! *Search: November 11, 2012
Compounded STS Product ph % Carbitol 7.8-8.1 2.85-3.15 0% Sotradecol 7.9 3.01 0.000% CAP 7.89 2.59 1.79% McGuff 8.01 3.39 4.18% Kronos 7.99 3.21 0.33% Almeida JI, Raines JK. FDA-approved sodium tetradecyl sulfate (STS) versus compounded STS for venous sclerotherapy. Dermatol Surg 2007; 33: 1037-44.
Compounding-Physician Liability If a physician chooses to use a compounded drug AND A connection can be made between injury and the drug THEN The physician is liable PERIOD!
Compounded Drug Use Conclusion AVOID DISASTER
Conclusions Sclerotherapy, when properly administered, is a safe and effective method of eliminating abnormal veins Complications can be reduced by careful attention to technique Sclerotherapy is an often necessary and desirable complement to other invasive treatment of chronic venous insufficiency
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nickmorrison2002@yahoo.com Thank you very much for your kind attention