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Iatrogenic gas embolism after foam sclerotherapy?
Annales Franc¸aises d’Anesthe´sie et de Re´animation 30 (2011) e31
Letter to editor Iatrogenic gas embolism after foam sclerotherapy? Embolie gazeuse iatroge`ne apre`s scle´rothe´rapie a` la mousse ?
A R T I C L E I N F O
Keywords: Varicose Foam sclerotherapy Stroke Iatrogenic gas embolism Mots cle´s: Varice Scle´rothe´rapie a` la mousse Accident vasculaire ce´re´bral Embolie gazeuse
Varicose veins of the lower extremity are very common. As many as 75% of adults will suffer them during their lifetime with 25% of them seeking medical or surgical intervention for the disorder for the French Haute Autorite´ de sante´ (HAS). For those who are treated, use of a sclerosing agent such as polidocanol or sotradecol suspended in a foam is often used. However, data on the long-term effects of these agents is currently lacking, which has resulted in the United States Food and Drug Administration (FDA) to request assistance in obtaining data. While a recent retrospective study from France yielded reassuring results [1], troublesome side effects such as cough, chest discomfort, and migraine with visual aura during or just after the foam injection as well as serious and/or life-threatening instances of transient ischemic attack (TIA) or stroke have also been reported [1]. The specific pathophysiology leading to these complications has yet to be well elucidated and is a matter of some contention. Visual disturbances and complicated migranous headaches have been ascribed to the release of endothelin in response the sclerosing reaction in the vein. The symptoms are typical, and no cerebral infarct has ever been observed on RMI imaging. An alternative hypothesis involves the formation of embolic material. This is supported by the timing of events, the exam finding suggestive of stroke, and the recent sonographic description of high-intensity signals in both right heart and cerebral circulation. Iatrogenic gas embolism (IGE) is a rare complication of invasive medical or surgical procedures [2]. IGE may originate in the venous system or in the systemic arterial circulation. In the former case, the gaseous embolus may reach the systemic circulation via pulmonary shunting or via patent foramen ovale (PFO). IGE are often asymptomatic but they can lead to various minor clinical signs (neurological, cardiovascular and respiratory) or major sequalae such as seizure, shock from acute right heart failure, or complete cardiopulmonary collapse or arrest [2]. The appearance 0750-7658/$ – see front matter ß 2011 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.annfar.2011.06.001
of headache, visual disturbances (scotomas, amaurosis) or chest discomfort during or just after sclerotherapy strongly suggests an IGE. Moreover, the high intensity signals reported by recent sonographic studies (echocardiography and transcranial Doppler studies) may be due to (micro) gaseous emboli in right heart cavities and in the middle cerebral artery (MCA) just after sclerotherapy [3]. Others have suggested that they are, in fact, endothelial debris. Such a mechanism is the hypothesized cause of a recently reported paradoxical IGE leading to aphasia with right hemiparesis after foam sclerotherapy [4]. In this case, CT-scan demonstrated air in the left MCA and MRI showed a flow reduction in the left MCA territory on FLAIR sequences. The patient was treated with hyperbaric oxygen and made a good clinical recovery. In addition, another case has been described in which a young healthy man appeared to suffer an IGE caused by administration of echo-contrast in the evaluation of a PFO after a diving accident [5]. The preparation of the syringe (0.1 mL of air with 9.9 mL of saline solution) and the infusion procedure described in the report represent standard practice. In summary, physicians should be alerted of symptomatic IGE possibility after foam sclerotherapy [4]. Further studies are needed to assess incidence and clinical significance of sclerotherapy-induced IGE. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Guex JJ, Schliephake DE, Otto J, Mako S, Allaert FA. The French Polidocanol Study on long-term side effects: a survey covering 3,357 patient years. Dermatol Surg 2010;36:993–1008. [2] Bessereau J, Genotelle N, Chabbaut C, Huon A, Tabah A, Aboab J, et al. Long-term outcome in iatrogenic gas embolism. Intensive Care Med 2010;36:1180–7. [3] Morrison N, Neuhardt DL. Foam sclerotherapy: cardiac and cerebral monitoring. Phlebology 2009;24:252–9. [4] Leslie-Mazwi TM, Avery LL, Sims JR. Intra-arterial air thrombogenesis after cerebral air embolism complicating lower extremity sclerotherapy. Neurocrit Care 2009;11:247–50. [5] Christin F, Bouffard Y, Rossi R, Delafosse B. Paradoxical symptomatic air embolism after saline contrast transesophageal echocardiography. Echocardiography 2007;24:867–9.
J. Bessereaua,b,*, M. Coulangea,b, A. Boussugesa, H. Chenaitiab, P. Micheleta,b a UMR MD2 (P2COE), physiologie et physiopathologie en conditions d’oxyge´nation extreˆmes, faculte´ de me´decine Nord, universite´ de la Me´diterrane´e, boulevard Pierre-Dramard, 13916 Marseille cedex 20, France b Poˆle RUSH, hoˆpital de la Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France *Corresponding author. E-mail address: [email protected] ( J. Bessereau) Disponible sur Internet le 20 July 2011
Letter to editor Iatrogenic gas embolism after foam sclerotherapy? Embolie gazeuse iatroge`ne apre`s scle´rothe´rapie a` la mousse ?
A R T I C L E I N F O
Keywords: Varicose Foam sclerotherapy Stroke Iatrogenic gas embolism Mots cle´s: Varice Scle´rothe´rapie a` la mousse Accident vasculaire ce´re´bral Embolie gazeuse
Varicose veins of the lower extremity are very common. As many as 75% of adults will suffer them during their lifetime with 25% of them seeking medical or surgical intervention for the disorder for the French Haute Autorite´ de sante´ (HAS). For those who are treated, use of a sclerosing agent such as polidocanol or sotradecol suspended in a foam is often used. However, data on the long-term effects of these agents is currently lacking, which has resulted in the United States Food and Drug Administration (FDA) to request assistance in obtaining data. While a recent retrospective study from France yielded reassuring results [1], troublesome side effects such as cough, chest discomfort, and migraine with visual aura during or just after the foam injection as well as serious and/or life-threatening instances of transient ischemic attack (TIA) or stroke have also been reported [1]. The specific pathophysiology leading to these complications has yet to be well elucidated and is a matter of some contention. Visual disturbances and complicated migranous headaches have been ascribed to the release of endothelin in response the sclerosing reaction in the vein. The symptoms are typical, and no cerebral infarct has ever been observed on RMI imaging. An alternative hypothesis involves the formation of embolic material. This is supported by the timing of events, the exam finding suggestive of stroke, and the recent sonographic description of high-intensity signals in both right heart and cerebral circulation. Iatrogenic gas embolism (IGE) is a rare complication of invasive medical or surgical procedures [2]. IGE may originate in the venous system or in the systemic arterial circulation. In the former case, the gaseous embolus may reach the systemic circulation via pulmonary shunting or via patent foramen ovale (PFO). IGE are often asymptomatic but they can lead to various minor clinical signs (neurological, cardiovascular and respiratory) or major sequalae such as seizure, shock from acute right heart failure, or complete cardiopulmonary collapse or arrest [2]. The appearance 0750-7658/$ – see front matter ß 2011 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.annfar.2011.06.001
of headache, visual disturbances (scotomas, amaurosis) or chest discomfort during or just after sclerotherapy strongly suggests an IGE. Moreover, the high intensity signals reported by recent sonographic studies (echocardiography and transcranial Doppler studies) may be due to (micro) gaseous emboli in right heart cavities and in the middle cerebral artery (MCA) just after sclerotherapy [3]. Others have suggested that they are, in fact, endothelial debris. Such a mechanism is the hypothesized cause of a recently reported paradoxical IGE leading to aphasia with right hemiparesis after foam sclerotherapy [4]. In this case, CT-scan demonstrated air in the left MCA and MRI showed a flow reduction in the left MCA territory on FLAIR sequences. The patient was treated with hyperbaric oxygen and made a good clinical recovery. In addition, another case has been described in which a young healthy man appeared to suffer an IGE caused by administration of echo-contrast in the evaluation of a PFO after a diving accident [5]. The preparation of the syringe (0.1 mL of air with 9.9 mL of saline solution) and the infusion procedure described in the report represent standard practice. In summary, physicians should be alerted of symptomatic IGE possibility after foam sclerotherapy [4]. Further studies are needed to assess incidence and clinical significance of sclerotherapy-induced IGE. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Guex JJ, Schliephake DE, Otto J, Mako S, Allaert FA. The French Polidocanol Study on long-term side effects: a survey covering 3,357 patient years. Dermatol Surg 2010;36:993–1008. [2] Bessereau J, Genotelle N, Chabbaut C, Huon A, Tabah A, Aboab J, et al. Long-term outcome in iatrogenic gas embolism. Intensive Care Med 2010;36:1180–7. [3] Morrison N, Neuhardt DL. Foam sclerotherapy: cardiac and cerebral monitoring. Phlebology 2009;24:252–9. [4] Leslie-Mazwi TM, Avery LL, Sims JR. Intra-arterial air thrombogenesis after cerebral air embolism complicating lower extremity sclerotherapy. Neurocrit Care 2009;11:247–50. [5] Christin F, Bouffard Y, Rossi R, Delafosse B. Paradoxical symptomatic air embolism after saline contrast transesophageal echocardiography. Echocardiography 2007;24:867–9.
J. Bessereaua,b,*, M. Coulangea,b, A. Boussugesa, H. Chenaitiab, P. Micheleta,b a UMR MD2 (P2COE), physiologie et physiopathologie en conditions d’oxyge´nation extreˆmes, faculte´ de me´decine Nord, universite´ de la Me´diterrane´e, boulevard Pierre-Dramard, 13916 Marseille cedex 20, France b Poˆle RUSH, hoˆpital de la Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France *Corresponding author. E-mail address: [email protected] ( J. Bessereau) Disponible sur Internet le 20 July 2011