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454 D. West
Fig. 45.5 Tessari technique for mixing STD foam using two luer lock syringes and a three-way tap
• Mix 3% sodium tetradecyl sulphate (STD) with air/CO2(1 ml STD: 3 ml
air/CO
) ratio into foam by rapidly squirting from one syringe to another via
2
a three-way tap (Tessari method) (Fig. 45.5).
• Elevate leg to empty veins.
• Inject foam: the foam is easily recognized on ultrasound due to the reflective
nature of the trapped air.
• Watch progress of foam up the vein on ultrasound until the foam has reached the
proximal part of the vein to be treated.
• Apply pressure at this point to prevent passage of foam into deep veins.
• Actively exercise foot to stimulate flow in deep veins.
• Repeat injection as per operator’s preference. The ultrasound probe can be used
to milk the foam up and down the vein.
Clinical Scenarios
Gonadal/internal iliac veins. If duplex ultrasound or clinical history/examination
suggests significant contribution from the pelvis, then undertake venography and
embolization as necessary (see Chapter 44 ).
Truncal vein ablation. This is most commonly the great or small saphenous vein
but can be the anterolateral thigh tributary or the Giacomini vein or other variants.
Although some operators use foam sclerosant for this purpose, most use a thermal
method as it is more reliable and quicker.
Perforating veins. Incompetent perforators from the deep to the superficial veins
are an important but often overlooked cause of varicosities. These are especially
important as a source of high-pressure venous blood beneath ulcers. Some will
45 Varicose Veins 455
occlude after the truncal vein they feed is ablated, but many will remain a problem
and lead to a varicosity requiring treatment.
• The perforating vein is punctured under ultrasound guidance and a guidewire
passed into the deep venous system. The technique is then as for laser or RFA.
AS ALWAYS BE CAREFUL NOT TO APPLY HEAT INTO THE DEEP VEINS
(Fig. 45.2).
Varicosities
• Varicosities can be dealt with at the time of initial treatment or more commonly
at follow-up after 6 weeks.
• Immediate treatment is more convenient for the patient but may not be possible
due to spasm induced by the first treatment or due to the dose of local anesthetic
administered.
• Delayed treatment often reveals that the varicosities have disappeared to the
patients’ satisfaction and require no further treatment.
Two main methods are used and are as follows:
Foam Sclerotherapy
• The varicosities are needled either by direct vision/palpation or using ultrasound
and injected with 3%, 1%, or 0.5% STD foam one-fourth sclerosant/air ratio. The
strength depends on vein size with most veins requiring 1%.
Av ul s io n s
• Varicosities are marked pre-operatively with the patient standing.
• Patient placed supine and tumescent local anesthetic injected.
• 19G needle used to puncture skin every 2–4 cm over the varicosities.
• Vein hook inserted through needle puncture and the vein wall hooked and
withdrawn through the skin.
• Vein teased out grabbing it with mosquito forceps. Pulled until one end tears off.
• Hook inserted into next puncture point and vein again teased out. Try to remove
long lengths of vein rather than small fragments.
• Repeat until all marked varicosities removed.
Prominent Veins in Other Sites
Varicose veins usually occur on the legs but prominent and unsightly veins can occur
in other sites.
456 D. West
Fig. 45.6 Foam sclerotherapy injection in prominent breast veins
• Periorbital. Do not use chemicals in this region. Treated with avulsions. Best left
to a specialist.
• Breast. Especially after breast augmentation. Treated by injection of 0.5% STD
foam. No compression necessary (Fig. 45.6).
• Genitalia. Usually due to pelvic reflux. Treat by embolization of the pelvic
source with coils or STD foam. Dislodgement of coils and travel to lung reported
especially with internal iliac embolization.
• Hands. Often cosmetically unappealing especially for women. Treated using
foam injections or avulsions.
Aftercare
• Discuss pain control with the patient and ensure that they have a supply of
analgesics.
• Explain difference between superficial thrombophlebitis and deep vein thrombo-
sis and instruct patient to return immediately if any sign of DVT.
• Explain care of compression bandaging and make arrangements for removal in 1
week followed by compression hosiery.
• The patient may be discharged as soon as they are comfortable.
Follow-Up
• Follow-up is essential if only truncal veins are treated.
• Recommend clinical follow-up at 6 weeks.
• At this stage, any residual varicosities can be treated with foam sclerotherapy or
avulsions. Duplex ultrasound is normally performed to check truncal vein closure
but rarely reveals persistent flow.
45 Varicose Veins 457
• Follow-up can be at patients discretion if foam sclerotherapy or avulsions were
performed at the initial treatment session.
Keypoints
• Varicose veins are typically a benign condition.
• Most patients with venous reflux disease can be managed without
surgery.
• Listen to patients and understand what they want from the treatment.
• Carefully establishing the sources/causes of reflux is essential for success-
ful treatment planning and execution.
• Treatment should abolish all sources of reflux starting with the most
central.
• Abolishing reflux will usually be sufficient to relieve itching and aching
but may leave prominent varicosities.
Safety
• Get properly trained to use new technology!
• Take care in patients with procoagulant conditions.
• Avoid heating the deep veins.
• Warn patients of the small risk of DVT and encourage them to return if
they develop suggestive symptoms.
• Warn patients regarding visual effects of STD foam.
Suggested Reading
A. Cavezzi, N. Labropoulos, H. Partsch, S. Ricci, A. Caggiati, K. Myers, A. Nicolaides and
P.C. Smith. Duplex Ultrasound Investigation of the Veins in Chronic Venous Disease of the
Lower Limbs – UIP Consensus Document. Part II. Anatomy. European Journal of Vascular and
Endovascular Surgery 2006;31:288–299
P. Coleridge-Smith, N. Labropoulos, H. Partsch, K. Myers, A. Nicolaides and A. Cavezzi. Duplex
Ultrasound Investigation of the Veins in Chronic Venous Disease of the Lower Limbs – UIP
Consensus Document. Part I. Basic Principles. European Journal of Vascular and Endovascular
Surgery 2006;31:83–92
B Eklöf, R Rutherford,J Bergan, P Carpentier, P Gloviczki, R Kistner , M Meissner, G Moneta,
K Myers, F Padberg. Revision of the CEAP Classification for Chronic Venous Disorders:
Consensus Statement. Journal of Vascular Surgery 2004;40(6):1248–1252.
R Muller. Ambulatory phlebectomy [article in German]. Ther Umsch 1992;49(7):447–450.
Describes the technique of avulsion therapy
“Miscellaneous Embolic Agents: Laser and Radiofrequency” Chapter 6 in this book
Miscellaneous agents and tools
Chapter 46
Lymphatic Malformations: Sclerotherapy
Richard J.T. Owen
Clinical Features and Presentation
Etiology: lymphatic malformations (LM) are part of the spectrum of congenital vascular malformations. LMs are developmental abnormalities related to the failure of
normal differentiation of mesenchymal lymphatic tissue.
• LMs are usually isolated but may coexist as part of lymphatico-venous or
lymphatico-arterial malformations, such as Proteus or Klippel-Trenaunay syndromes.
• Histologically appearances vary, but enlarged lymphatic channels and spaces
with septae composed of fibrous tissue unconnected to lymphatic channels are
universally seen.
• Lumen usually contains lymphatic fluid, but proteinaceous material and erythrocytes may be present.
• Lymhangioma contents may be clear, serosanguineous, or greenish fluid. Fresh
or altered blood may be present following recent swelling or injury.
Occurrence
• Roughly half of all LM are detected at or before birth, with an incidence of
1:6,000–16,000 live births.
• 80–90% detected by the age of 2 years.
• The majority are seen in the head and neck, but can be widely distributed
elsewhere in the body (Fig. 46.1).
• Often present with cosmetic or functional difficulties.
• Adult LMs are rare and development is linked to predisposing factors such as
trauma, infection, tumor growth, or iatrogenic stimuli.
Transcatheter Embolization and Therapy,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-897-7_46,
C
Springer-Verlag London Limited 2010
459
460 R.J.T. Owen
Classification
• LM should be classified according to their radiological and pathological appearances into micro or macrocystic lesions. These differences to some extent predict
treatment response.
• Macrocystic LMs contain one or more cystic spaces greater than 2 cm in
diameter, whereas microcystic LMs contain multiple small cavities (Fig. 46.1).
• Macrocystic and microcystic types commonly coexist within the same lesion.
Lesions often show a progression from macrocystic to microcystic, and this may
occur with treatment.
• Historical classifications into capillary LM, cavernous LM, and cystic hygroma
are to be discouraged.
a
Fig. 46.1 (a) Coronal T2-weighted image showing microcystic lympangioma involving the face
and orbit. (b) T2 FS coronal image of the chest wall of a 12-year-old girl with a recurrent multicystic LM following three treatments with OK 432. The internal septae are clearly seen. The lesion
showed complete resolution after two treatments of doxycycline
b
Manifestations
Lesions may be solitary or multifocal; well circumscribed or deeply infiltrative;
remain unchanged in size, enlarge slowly, or rarely involute.
• Size varies, but in general lesions continue to grow in proportion to the patient.
• When seen in the head and neck, LM may be diffusely infiltrative or discrete.
Depending on the anatomic location, proptosis or other manifestations may be
present.
• During episodes of hemorrhage or infection, adjacent vital structures may
become compressed.
46 Lymphatic Malformations: Sclerotherapy 461
• Overlying skin changes may be present and vary from abnormal pigmentation to
lymphedema and hyperkeratosis.
• Lymphangioma circumscriptum is the terminology used to describe the intradermal form of LM, where thin-walled vascular channels lined by a single layer of
endothelium are seen in the papillary dermis. These are characterized by translucent papulovesicles that may demonstrate evidence of intravesicular bleeding.
These changes may overlie the macrocystic form of LM.
• Patients often give a history of intermittent swelling, erythema, and pain.
• Intralesional hemorrhage may occur spontaneously or as a result of trauma
(Fig. 46.2) and may predispose to infection.
• Cellulitis is common and may present with rapid expansion, erythema, fever, and
tenderness, and there may be a lengthy clinical course.
a
Fig. 46.2 (a and b) Large LM detected at birth, which resulted in tilting of the head. (a) Coronal
and (b) axial T1-weighted images show a loculated transfacial multicystic mass with multiple fluid
levels of different signal intensity that represent intracystic hemorrhage. Lesion measures 10.4 ×
10.6 × 9.7 cm, approximately the same volume as the cranial cavity. (c) Marked shrinkage and
predominantly microcycstic appearance following treatment
b
c
Diagnostic Evaluation
• Thorough clinical evaluation of the anatomical site, cosmetic deformity, adjacent structures involved or potentially at risk from injury (direct or indirect), is
required prior to treatment considerations.
• Requires a multidisciplinary approach involving pediatricians, plastic surgeons,
interventional radiologists, maxillofacial surgery, and ophthalmic surgeons.
These lesions are often complex, requiring multiple treatments, and may require
surgery.
• Lengthy consultation may be required to outline the goals and expectations of
treatment to patients and parents.
462 R.J.T. Owen
Laboratory
• Clinical and radiological diagnoses are usually adequate.
• Biopsy of the more superficial microcystic lesions may reveal the classic
histological features, particularly in the case of lymphangioma circumscription.
• Aspiration of lesions is discouraged as it may predispose to infection. Avoid
“diagnostic aspiration” in emergency departments!
Imaging
Ultrasound: initial diagnosis is usually suggested on ultrasound.
• Macrocystic LM
◦ Show septa separating anechoic cavities that can contain debris (Fig. 46.3a).
◦ Flow is absent.
◦ There may only be a single cavity (Fig. 46.3b).
◦ In some cases, although a multiloculated lesion is suspected, this may rep-
resent a single interconnecting cavity. This can often be demonstrated during
treatment when small air bubbles trapped in the sclerosing fluid show clearly
which cysts have been injected and if communication exists between cysts.
• Microcystic LMs have small cavities resulting in innumerable reflective interfaces and a hyperechoic appearance.
a
Fig. 46.3 (a and b) Ultrasound of macrocystic LN showing septae and debris within the cysts.
There is absence of flow in the lesion on color flow (c) Unilocular cyst
b
c
MRI
• MRI is generally required prior to treatment to establish the extent of the lesion.
Although often considered localized and superficial, these lesions extend into
adjacent structures and are much larger than suspected on ultrasound.
46 Lymphatic Malformations: Sclerotherapy 463
• Where there is a history of trauma or recent swelling, hemorrhage may be
present with lesions showing a progression through fresh hemorrhage, old blood,
solidification, and sometimes spontaneous resolution.
• Macrocystic LM
◦ Usually demonstrate iso- or hypointense signal on T1-weighted sequences and
high signal on T2 sequences.
◦ Proteinaceous fluid, hemorrhage, or fluid–fluid levels can cause a more
heterogeneous appearance. No vascular signal voids are present (Fig. 46.2).
◦ Do not usually contrast enhance, although mild enhancement may be seen
within the walls particularly after surgery or sclerotherapy.
• Microcystic LM
◦ Individual cystic spaces are often too small to be discernible by MRI.
◦ The overall more homogeneous appearance is hypointense on T1-weighted
imaging and hyperintense on T2-weighted imaging (Fig. 46.1).
CT
LM may also be seen on CT.
• Low-attenuating fluid-filled non-enhancing mass.
• CT does not usually demonstrate the cyst walls (Fig. 46.4).
a
Fig. 46.4 Lymhangioma in the neck and chest. (a) CT shows low attenuation without enhancement.
(b) T2 FS MRI shows the true complexity of the cysts
b
Other Cystic Lesions in the Head and Neck
Differentiation of LMs from other cystic lesions in the head and neck may pose
some difficulties, and CT and/or MRI are required to differentiate between a
lymphangioma and other entities such as the following:
• Ranula: ranulas retain tapered communication with the sublingual space and are
homogeneous, thin-walled, anatomically defined, fluid-containing masses.
464 R.J.T. Owen
• Branchial cleft cysts.
• Thyroglossal duct cysts.
• Other cystic spaces in the neck.
• Of interest is that both pediatric plunging ranulas and branchial cysts have been
treated with sclerotherapy using (OK 432) to good effect.
Treatment Options
• Sclerotherapy is now widely regarded as the first-line treatment, although the
traditional approach has been surgical excision.
• Surgery is often complex and prolongued procedure with the potential for poor
cosmesis and morbidity.
• Complete excision is only possible in a third of cases.
• Surgery remains an option when
◦ Percutaneous sclerotherapy is proving ineffective
◦ The lesion is predominantly microcystic
◦ A combined approach has been planned, e.g., surgical excision of residual LM
following sclerotherapy
Contraindications to Treatment and Specific
Complications of Treatment
These relate to the following:
• The site and size of the lesion.
• Associated abnormalities.
• Related structures: airway compression may require ventilation; nerve palsy may
take many months to recover.
• The agents used:
◦ Fatal bleomycin-induced pulmonary fibrosis has been reported.
◦ Fever, pain, and erythema have been reported with all agents.
Evidence for Sclerotherapy
Acevedo et al. reviewed 289 treatments published in 22 articles. The two most
commonly used agents were OK 432 and bleomycin. When used as first-line therapy
• Complete regression (inability to detect the lesion radiologically or clinically)
was seen in 43%.
• Good response (50% or greater decrease in size of the lesion) was seen in 23%.
• 87.5% of patients exhibited a response of some sort.
• Only 12% required salvage surgery.