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

2. 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?

3. 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.

4. Post Sclerotherapy: A GOOD day at the office…
We want to be more scientific than the lottery odds. Lets look at some good days:
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5. Post Sclerotherapy: A GOOD day at the office…
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6. Post Sclerotherapy: A GREAT day at the office…
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7. 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…

8. 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
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9. Post Sclerotherapy: A BAD day at the office…..
Trapped Blood
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10. Post Sclerotherapy: A BAD day at the office…..
Please notice, these are our actual patients at VSS..
Hyperpigmentation
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11. Post Sclerotherapy: A BAD day at the office…..
Please notice, these are our actual patients at VSS..
Dermal Necrosis
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12. 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

13. But we can all say…

14. 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.

15. 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:

16. 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
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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

17. 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
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1 Bergen, J, Bunke-Paquette, N,The VeIn Book, Oxford Press, 2nd edition, 2014,
2Weiss, R. Weiss, Journal of Dermatol Surg, 1990

18. 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

19. 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,
2Goldman, M ,et al Sclerotherpay: treatment of varicose and telangiectatic leg veins, Elsevier, 5th edition 2015

20. 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

21. Post Treatment Hyperpigmentation
Reducing Risks & Treatment:
Compression therapy
1Evacuation of 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

22. 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
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23. 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

24. 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

25. 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

26. 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

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