To the Editor: Chronic venous insufficiency is a common diseasein adulthood. One recently developed therapy for varicose veinsis foam sclerotherapy.1
We used foam sclerotherapy in a 51-year-old man and a 33-year-oldwoman who had symptomatic varicose great saphenous veins andwere otherwise healthy. Immediately after the initiation oftreatment, transient scotomas developed in the man, and a migraineattack in the woman.
On the basis of these observations, we decided to monitor byechocardiography the foam distribution during foam sclerotherapyin 33 consecutive patients with chronic venous insufficiency.The treatment in each patient was carried out according to Europeanconsensus guidelines.2 Briefly, patients received a single injectionof 5 ml of 1% polidocanol foam (air-to-liquid ratio, 4:1). Thefoam was injected with the patient's leg slightly elevated,while the saphenofemoral junction was manually compressed untilfull vasospasm occurred and blood-flow velocity in the greatsaphenous vein decreased to zero.
In all patients studied, we detected foam microemboli in boththe right atrium and ventricle between 45 seconds and 15 minutesafter foam injection (Figure 1A). In five patients, microembolismwas also detectable in the left atrium and ventricle (Figure 1B);however, neurologic signs did not develop in any of them. Carefulechocardiographic examination of these five patients showeda right-to-left shunt through a patent foramen ovale. Becausethe neurologic symptoms observed in the two index patients couldhave reflected adverse effects of foam sclerotherapy due toa right-to-left shunt, we subsequently examined both patientsby echocardiography and detected a patent foramen ovale in each.
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 acommon phenomenon during foam sclerotherapy. The prevalenceof patent foramen ovale, which can be a source of paradoxicalembolism, is approximately 26% in the general population.3 Still,serious neurologic symptoms after foam sclerotherapy, whichinclude scotomas, migraine, and stroke, occur in only 2% orless of patients.4,5 Thus, the findings in our cohort are inline with previous reports. Although the overall number of neurologicadverse effects during foam sclerotherapy might be underestimated,it appears that neurologic complications develop in relativelyfew patients with right-to-left shunts and foam microembolism.
Nevertheless, we suggest that caution be exercised when foamsclerotherapy is performed in patients with a known patent foramenovale and that patients with overt neurologic symptoms undergoan additional echocardiographic examination for the presenceof a patent foramen ovale. Further prospective studies are neededto 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
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