Avoiding Sclerotherapy Complications Decreasing Risks of Terri Harper, APRN, FNP-C Macon, GA

Visual Sclerotherapy: Outcome Oriented NO, but there are things we can do to decrease risks of complications All about getting good results in cosmetic sclerotherpay It should be like we have a blueprint to follow Is there a blue print to guarantee good outcomes?

Sclerotherapy Outcomes: Risks/Odds Good Day Bad day NOT like playing the lottery where: Sometimes your ticket may end up causing you to dress in a silly outfit to get a big check And sometimes your tickets end up as litter worth nothing.

Post Sclerotherapy: A GOOD day at the office… We want to be more scientific than the lottery odds. Lets look at some good days: Photos property of Vein Specialists of the South, LLC®

Post Sclerotherapy: A GOOD day at the office… Photos property of Vein Specialists of the South, LLC®

Post Sclerotherapy: A GREAT day at the office… Photos property of Vein Specialists of the South, LLC®

But, we all know if you practice long enough, odds are, you’ll have a bad day. (or two) Picture But we can all say…

Post Sclerotherapy: A BAD day at the office… BUT we all know if you practice long enough, you.re bound to have some bad days. Matting Photos property of Vein Specialists of the South, LLC®

Post Sclerotherapy: A BAD day at the office….. Trapped Blood Photos property of Vein Specialists of the South, LLC®

Post Sclerotherapy: A BAD day at the office….. Please notice, these are our actual patients at VSS.. Hyperpigmentation Photos property of Vein Specialists of the South, LLC®

Post Sclerotherapy: A BAD day at the office….. Please notice, these are our actual patients at VSS.. Dermal Necrosis Photos property of Vein Specialists of the South, LLC®

Post Sclerotherapy: A TERRIBLE day at the office… Please note the subscript. Arterial Injection Photos ARE NOT property of Vein Specialists of the South, LLC® Taken from Goldman,M, Guex,J., Weiss,R; Sclerotherapy:Treatment of varicose and tealngiectatic leg veins, 2011

But we can all say…

GOAL: Decrease Risks of Sclerotherapy Complications ASSETS = knowledge technique skills equipment, etc One way is to build your assets= knowledge, technique, etc And reduce risks of complications Learn risks factors and how to reduce them. That is what I will be sharing with you today.

Risks of Visual, Liquid Sclerotherapy In general order of development and severity: Pain at injection site Erythema Histamine response Urticaria Bruising Trapped Blood Matting Hyperpigmentation Dermal Necrosis SVT Anaphylaxis Arterial Injection Most of AEs listed on the left are mild transient, maybe even expected- with exception of trapped blood or coagulum On the right- more severe – I have chosen the 3 most common Aes listed in literature as well as what I see in my practice Bergen, J, Bunke-Paquette, N, The Vein Book, Oxford Press, 2nd edition, 2014:115-126

Matting Defined: neovascularization within dermis <0.2mm Easily blanches 1Appearing 4-6 weeks post sclerotherapy Most common location is medial and lateral knee 2Affects up to 30% of patients Photos property of Vein Specialists of the South, LLC® 1Bergen, J, Bunke-Paquette, N,The VeIn Book, Oxford Press, 2nd edition, 2014, 129 2Gloviczki, P., Handbook of Venous Disorders, Hoddner Arnold, 3rd edition, 2009, 376

Matting 1Risks Factors: High concentrations of sclerosant Overweight Female 2High estrogen state during Tx Long duration of spider veins Persistent underlying pathology Crap shoot High estrogen- Weis and Weiss study effect of exogenous estrogen on matting Crap shoot- none of the factors listed are contributing risks Photos property of Vein Specialists of the South, LLC® 1 Bergen, J, Bunke-Paquette, N,The VeIn Book, Oxford Press, 2nd edition, 2014, 116-117 2Weiss, R. Weiss, Journal of Dermatol Surg, 1990

Matting Reducing risks & Treatment: Addressing factors listed previously if possible Compression therapy 1May be self-resolving within a year 532nm cutaneous laser High estrogen- Weis and Weiss study effect of exogenous estrogen on matting Crap shoot- none of the factors listed are contributing risks Photos property of Vein Specialists of the South, LLC® 1 Gloviczki, P., Handbook of Venous Disorders, Hoddner Arnold, 3rd edition, 2009, 376

Post Treatment Hyperpigmentation Defined: 1Brown staining of the skin thought to be caused by hemosiderin or 2post-inflammatory process Linear or macular presentation 1 Bergen, J, Bunke-Paquette, N,The VeIn Book, Oxford Press, 2nd edition, 2014, 116-117 2Goldman, M ,et al Sclerotherpay: treatment of varicose and telangiectatic leg veins, Elsevier, 5th edition 2015

Post Treatment Hyperpigmentation Risks Factors: 1Extravasation of RBC into dermis 2Vessel fragility High sclerosant concentrations Increased pressure on injection Vessel size Sclerosant (> with HS than POL) Development of coagulum Vessel fragility can lead to rupture of the vessel leaking RBC into dermal layers High concentration can lead to Hyper inflammatory response 1 Bergen, J, Bunke-Paquette, N,The VeIn Book, Oxford Press, 2nd edition, 2014, 129 2Goldman, M, Geux, J., Weiss, R, Sclerotherapy: treatment of varicose and telangiectatic leg veins, 5th edition

Post Treatment Hyperpigmentation Reducing Risks & Treatment: Compression therapy 1Evacuation of coagulum @ 2-3 weeks Meticulous technique and protocols 1Self resolving over 6-12 month period in 80% 2Cutaneous 532nm laser Compression may help if the cause is extravasation and decrease formation of coagulum 1Gloviczki, P., Handbook of Venous Disorders, Hoddner Arnold, 3rd edition, 2009, 376 2Bergen, J, Bunke-Paquette, N,The VeIn Book, Oxford Press, 2nd edition, 2014, 129

Cutaneous Necrosis Defined: Dermal necrotic ulceration at injection site May result in extensive loss of tissue May be delayed May leave scar May be delayed in relation to other Aes Permanent issue - scar Photos property of Vein Specialists of the South, LLC®

Cutaneous Necrosis Risks Factors: Extravasation of RBC into dermis Vessel fragility High sclerosant concentrations Increased pressure on injection Vessel size Sclerosant (> with HS than POL) Vessel fragility can lead to rupture of the vessel leaking RBC into dermal layers High concentration can lead to Hyper inflammatory response Photos property of Vein Specialists of the South, LLC® 1 Bergen, J, Bunke-Paquette, N,The VeIn Book, Oxford Press, 2nd edition, 2014, 129

Cutaneous Necrosis Reducing Risks & Treatment: Compression therapy Meticulous technique and protocols with sclerosant concentration and injection pressure Babysit, open communication Compression may help if the cause is extravasation and decrease formation of coagulum Photos property of Vein Specialists of the South, LLC® 1 Bergen, J, Bunke-Paquette, N,The VeIn Book, Oxford Press, 2nd edition, 2014, 129

Other Rare Complications Symptomatic SVT- Incidence greater when sclerosing veins >3mm Anaphylaxis- estimated at 0.3% incidence Arterial Injection- most common in posterior tibial at ankle and posterior popliteal arteries SVT- other than the Arterial- post tib is very superficial at the ankle

Six Contributing Factors to Medical Malpractice Faulty Communication Lack of Informed Consent Failure to stay up-to-date on standards and training Inadequate follow-up of diagnostic tests and specialist referrals Variations in policy and procedures Avoidance behavior Kremier, S. Medical Economics, Dec 2013

Thank you! terri@veinspecialists.com Picture here Thank you! terri@veinspecialists.com