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Previous Volume 358:1525-1526 April 3, 2008 Number 14 Next

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To the Editor: Chronic venous insufficiency is a common disease in adulthood. One recently developed therapy for varicose veins is foam sclerotherapy.¹

We used foam sclerotherapy in a 51-year-old man and a 33-year-old woman who had symptomatic varicose great saphenous veins and were otherwise healthy. Immediately after the initiation of treatment, transient scotomas developed in the man, and a migraine attack in the woman.

On the basis of these observations, we decided to monitor by echocardiography the foam distribution during foam sclerotherapy in 33 consecutive patients with chronic venous insufficiency. The treatment in each patient was carried out according to European consensus guidelines.² Briefly, patients received a single injection of 5 ml of 1% polidocanol foam (air-to-liquid ratio, 4:1). The foam was injected with the patient's leg slightly elevated, while the saphenofemoral junction was manually compressed until full vasospasm occurred and blood-flow velocity in the great saphenous vein decreased to zero.

In all patients studied, we detected foam microemboli in both the right atrium and ventricle between 45 seconds and 15 minutes after foam injection (Figure 1A). In five patients, microembolism was also detectable in the left atrium and ventricle (Figure 1B); however, neurologic signs did not develop in any of them. Careful echocardiographic examination of these five patients showed a right-to-left shunt through a patent foramen ovale. Because the neurologic symptoms observed in the two index patients could have reflected adverse effects of foam sclerotherapy due to a right-to-left shunt, we subsequently examined both patients by echocardiography and detected a patent foramen ovale in each.

View larger version (79K): [in this window] [in a new window]   Figure 1. Echocardiographic Images Obtained during Sclerotherapy with Foam Injection. Panel A shows apical four-chamber images before and during foam sclerotherapy. Foam microemboli are present in the right atrium and ventricle of the heart. Panel B shows paradoxical foam microembolism during foam sclerotherapy. Microemboli in the left atrium and ventricle of the heart (arrows) are due to a right-to-left shunt through a patent foramen ovale. RV denotes right ventricle, and LV left ventricle.

 
These findings suggest that foam-induced microembolism is a common phenomenon during foam sclerotherapy. The prevalence of patent foramen ovale, which can be a source of paradoxical embolism, is approximately 26% in the general population.³ Still, serious neurologic symptoms after foam sclerotherapy, which include scotomas, migraine, and stroke, occur in only 2% or less of patients.^4,5 Thus, the findings in our cohort are in line with previous reports. Although the overall number of neurologic adverse effects during foam sclerotherapy might be underestimated, it appears that neurologic complications develop in relatively few patients with right-to-left shunts and foam microembolism.

Nevertheless, we suggest that caution be exercised when foam sclerotherapy is performed in patients with a known patent foramen ovale and that patients with overt neurologic symptoms undergo an additional echocardiographic examination for the presence of a patent foramen ovale. Further prospective studies are needed to evaluate and confirm our observations.

Roeland P.M. Ceulen, M.D.
Anja Sommer, M.D., Ph.D.
GROW School for Oncology and Developmental Biology
6202 AZ Maastricht, the Netherlands
rpmceulen{at}gmail.com

Kevin Vernooy, M.D., Ph.D.
Cardiovascular Research Institute Maastricht
6200 MD Maastricht, the Netherlands

References

1. Jia X, Mowatt G, Burr JM, Cassar K, Cook J, Fraser C. Systematic review of foam sclerotherapy for varicose veins. Br J Surg 2007;94:925-936. [CrossRef][ISI][Medline]
2. Breu FX, Guggenbichler S. European Consensus Meeting on Foam Sclerotherapy, April 4-6, 2003, Tegernsee, Germany. Dermatol Surg 2004;30:709-717. [CrossRef][ISI][Medline]
3. Meier B, Lock JE. Contemporary management of patent foramen ovale. Circulation 2003;107:5-9. [Free Full Text]
4. Forlee MV, Grouden M, Moore DJ, Shanik G. Stroke after varicose vein foam injection sclerotherapy. J Vasc Surg 2006;43:162-164. [CrossRef][ISI][Medline]
5. Guex JJ, Allaert FA, Gillet JL, Chleir F. Immediate and midterm complications of sclerotherapy: report of a prospective multicenter registry of 12,173 sclerotherapy sessions. Dermatol Surg 2005;31:123-128. [ISI][Medline]

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Related Letters:

More on Microembolism and Foam Sclerotherapy
Rush J. E., Wright D. D.I., Ceulen R. P.M., Vernooy K.
Extract | Full Text | PDF  
N Engl J Med 2008; 359:656-657, Aug 7, 2008. Correspondence

This article has been cited by other articles:

• Guex, J-J, Raymond-Martimbeau, P, Simka, M, Passariello, F (2008). Letter regarding article titled 'Microembolism during foam sclerotherapy of varicose veins' in the New England Journal of Medicine. Phlebology 23: 249-249 [Full Text]  
• Ceulen, R P M, Vernooy, K (2008). Reply to letter regarding article titled 'Microembolism during foam sclerotherapy of varicose veins' in the New England Journal of Medicine. Phlebology 23: 250-250 [Full Text]  
• Rush, J. E., Wright, D. D.I., Ceulen, R. P.M., Vernooy, K. (2008). More on Microembolism and Foam Sclerotherapy. NEJM 359: 656-657 [Full Text]