Anaphylaxis Following Foam Sclerotherapy: A Life Threatening Complication of Non Invasive Treatment For Varicose Veins☆
Article Outline
We report an anaphylactic reaction following ultrasound guided foam sclerotherapy (UGFS) to lower limb varicosities. A tortuous anterolateral thigh vein of a 62 year-old woman was unsuccessfully ablated with UGFS. A further session of UGFS, 6 months later, resulted in a non-fatal anaphylactic reaction that required resuscitation with adrenaline. The patient was not known to be allergic to the sclerosant used and had not suffered any adverse effects after her initial treatment. This case demonstrates the possibility of anaphylaxis following UGFS. Those performing sclerotherapy require appropriate resuscitation equipment and training.
Keywords: Anaphylaxis, Foam sclerotherapy, Complication, Varicose veins
Introduction
Sclerotherapy is not a new treatment for varicose veins.1 The use of ultrasound guidance and the intravenous injection of sclerosants as foam, rather than liquid, has re-established sclerotherapy (ultrasound guided foam sclerotherapy, UGFS) as an alternative to surgery for the treatment of varicose veins.2, 3
Anaphylaxis is a rare but recognized complication of liquid sclerotherapy4 and the manufacturers of sclerosants advise that sclerotherapy should not be performed unless adequate resuscitation equipment is available.5 We report anaphylaxis following foam sclerotherapy in order to alert specialists to the possibility of this life threatening complication. We also consider the implications of this complication and review guidelines for management (Fig. 1).
Fig. 1
Algorithm for the management of anaphylaxis in adults by first medical responders (reproduced with permission of Resuscitation Council UK).
Case Report
A 62 year-old woman with a large tortuous anterolateral thigh vein (basic CEAP classification C2,S,EP,As,Pr) attended for day case UGFS. There was no history of previous venous surgery or sclerotherapy. She was obese (BMI >35) and had angina, hypertension and mild asthma with hay fever. She described allergies to pollen and perfume, but to no conventional medications.
UGFS was considered to be preferable to conventional surgery and was performed in a dedicated ambulatory day surgery unit assisted by a vascular technologist. Cannulation of the vein was performed under ultrasound guidance without local anaesthesia. A total of 4
mL of 3% purified sodium tetradecyl sulphate (STD - Fibrovein®, STD Pharmaceuticals Ltd, Hereford, UK) was administered as foam (The Tessari method, Sclerosant:Air=1:3).1 A compression bandage was applied and the patient observed in a recovery area before discharge.
Six month clinical and duplex follow up identified persistent patency and incompetence of the treated vein for which she agreed to further treatment. This involved further canulation of the vein, again without local anesthesia. A total of 12 mL (3 mL, 1% STD) of foam was injected under ultrasound guidance and the leg placed in compression.
Within 20 minuets of this procedure, whilst in the recovery area, the patient reported her tongue and lips as feeling “hot”. She was observed to have facial flushing and at this stage 10mg of IV Chlorphenamine was administered. Rapidly her tongue and lips started to swell and her breathing became wheezy. She developed a tachycardia (120 beats/minute) and became hypotensive (79/50mmHg).
Her resuscitation was co-ordinated by an anaesthetist who administered high flow oxygen and Adrenaline (epinephrine) [1:1000 solution 0.5mL (500 micrograms) intramuscularly]. Intravenous fluids and Hydrocortisone (100mg) were also administered. Although she did not lose consciousness or require intubation, her recovery was monitored on a critical care unit overnight. She was discharged home after 24 hours of uneventful observation.
Discussion
Although anaphylaxis has been reported following liquid sclerotherapy to lower limb varicosities, a recent systematic review identified no reported cases of anaphylaxis following UGFS.6 Nonetheless, practitioners should be aware that exposure to sclerosant in either liquid or foam form can precipitate an allergic reaction particularly in atopic individuals and/or those previously exposed to sclerosants.
Local anaesthesia may also be responsible for the development of adverse reactions either as an allergic reaction or from systemic side effects. In this case however, the patient had not received local anaesthetic as part of her UGFS treatment and anaphylaxis was attributed solely to repeated exposure to sclerosant.
Although rare, anaphylaxis after sclerotherapy is potentially life threatening. Nonetheless, a survey of the Vascular Surgical Society in 1998 found that only five percent of members discussed with their patients the possibility of an allergic reaction to sclerotherapy and only 17 percent obtained written consent for the procedure.7 Against a background of increasing litigation against practitioners, failure to obtain fully informed written consent may be unwise.
Foam sclerotherapy is generally considered a low risk procedure and it is often performed in an outpatient ‘office’ setting with early ambulation and discharge of the patient. While this may be acceptable in most cases, practitioners should ensure that they are trained in resuscitation techniques and that appropriate resuscitation equipment is available.
References
- . Saphenous ablation: sclerosant or sclerofoam?. Semin Vasc Surg. 2005;18(1):19–24
- . European consensus meeting on foam sclerotherapy. [April, 4–6, 2003, Tegernsee, Germany] Dermatol Surg. 2004;30:709–717
- . Treatment options for primary varicose veins- a review. Eur J Vasc Endovasc Surg. 2005;30:83–95
- . Compression sclerotherapy. In: Varicose veins: compression sclerotherapy. William Heinemann Med Books; 1967;Available at: http://www.fegan.com/cs/Chapter%252520VI.htm[accessed 19/01/07]
- . Fibro-vein-prescribing-information. Available at: http://www.fibro-vein.co.uk/content/Fibro-Vein-Prescribing-Information.pdf[accessed 19/01/07]
- . A systematic review on the safety and efficacy of foam sclerotherapy for venous disease of the lower limbs. Nov 2006; Commissioned by the National Institute for Clinical Excellence (NICE). Available at: http://www.nice.org.uk/docref.aspx?o=ip244review[accessed 30/01/07]
- . A survey of current attitudes of British and Irish vascular surgeons to venous sclerotherapy. Eur J Vasc Endovasc Surg. 1998;16:43–46
☆ The authors have no commercial, proprietary, or financial interest in any products or companies described in this article.
PII: S1533-3167(07)00010-6
doi:10.1016/j.ejvsextra.2007.02.005
© 2007 Elsevier Ltd. All rights reserved.
Refers to article:
- Anaphylaxis Following Foam Sclerotherapy: A Life Threatening Complication of Non Invasive Treatment for Varicose Veins , 28 April 2007
