Sclerotherapy: Indications and safety volumes

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Cyanoacrylate closure for peripheral veins: Consensus document of the Australasian College of Phlebology

Background: Cyanoacrylates are fast-acting adhesives used in procedural medicine including closure of superficial wounds, embolization of truncal vessels pre-operatively, vascular anomalies, visceral false aneurysms, endoleaks, gastrointestinal varices and gastrointestinal bleeding. More recently, catheter-directed cyanoacrylate adhesive closure was introduced as an alternative to endovenous thermal ablation (ETA) to occlude superficial veins of the lower limbs. Objectives: To formulate policies for the safe and effective delivery of cyanoacrylate adhesive closure procedures in Australasia, based on current experience and evidence. Methods: A panel of phlebologists including vascular surgeons, interventional radiologists, dermatologists and research scientists systematically reviewed the available data on cyanoacrylate products used in medicine and shared personal experience with the procedure. The reviewed material included bibliographic and biomedical data, material safety data sheets and data requested and received from manufacturers. Results and recommendations: Cyanoacrylate adhesive closure appears to be an effective treatment for saphenous reflux with occlusion rates at 36 months of 90–95%. We recommend a maximum dose of 10 mL of cyanoacrylate per treatment session. Serious complications are rare, but significant. Hypersensitivity to acrylates is reported in 2.4% of the population and is an important absolute contraindication to cyanoacrylate adhesive closure.1 Post-procedural inflammatory reactions, including hypersensitivity-type phlebitis, occur in 10–20% of patients.2 In the long term, cyanoacrylate adhesive closure results in foreign-body granuloma formation within 2–12 months of the procedure. We recommend against the use of cyanoacrylate adhesive closure in patients with uncontrolled inflammatory, autoimmune or granulomatous disorders (e.g. sarcoidosis). Caution should be exercised in patients with significant active systemic disease or infection and alternative therapies such as thermal ablation and foam sclerotherapy should be considered. Conclusions: Cyanoacrylate adhesive closure appears to be an effective endovenous procedure, with short-term closure rates comparable to ETA and therefore greater efficacy than traditional surgery for treating superficial veins of the lower limbs. Ongoing data collection is required to establish the long-term safety

Triage of patients with venous and lymphatic diseases during the COVID-19 pandemic – The Venous and Lymphatic Triage and Acuity Scale (VELTAS):: A consensus document of the International Union of Phlebology (UIP), Australasian College of Phlebology (ACP), American Vein and Lymphatic Society (AVLS), American Venous Forum (AVF), European College of Phlebology (ECoP), European Venous Forum (EVF), Interventional Radiology Society of Australasia (IRSA), Latin American Venous Forum, Pan-American Society of Phlebology and Lymphology and the Venous Association of India (VAI)

The coronavirus disease 2019 (COVID-19) global pandemic has resulted in diversion of healthcare resources to the management of patients infected with SARS-CoV-2 virus. Elective interventions and surgical procedures in most countries have been postponed and operating room resources have been diverted to manage the pandemic. The Venous and Lymphatic Triage and Acuity Scale was developed to provide an international standard to rationalise and harmonise the management of patients with venous and lymphatic disorders or vascular anomalies. Triage urgency was determined based on clinical assessment of urgency with which a patient would require medical treatment or surgical intervention. Clinical conditions were classified into six categories of: (1) venous thromboembolism (VTE), (2) chronic venous disease, (3) vascular anomalies, (4) venous trauma, (5) venous compression and (6) lymphatic disease. Triage urgency was categorised into four groups and individual conditions were allocated to each class of triage. These included (1) medical emergencies (requiring immediate attendance), example massive pulmonary embolism; (2) urgent (to be seen as soon as possible), example deep vein thrombosis; (3) semiurgent (to be attended to within 30-90 days), example highly symptomatic chronic venous disease, and (4) discretionary/nonurgent- (to be seen within 6-12 months), example chronic lymphoedema. Venous and Lymphatic Triage and Acuity Scale aims to standardise the triage of patients with venous and lymphatic disease or vascular anomalies by providing an international consensus-based classification of clinical categories and triage urgency. The scale may be used during pandemics such as the current COVID-19 crisis but may also be used as a general framework to classify urgency of the listed conditions

Interaction of detergent sclerosants with coagulation, antithrombotic and fibrinolytic mecanisms

The effects of detergent sclerosants, sodium tetradecyl sulphate (STS) and polidocanol (POL), on coagulation, antithrombotic and fibrinolytic mechanisms were investigated in vitro.All samples were spiked with each sclerosant at therapeutic concentrations. Coagulation was investigated in clotting tests and functional assays for clotting factors in plasma. Fibrinogen was measured by the Clauss method and factor (F) XIII by ELISA. At low concentrations, sclerosants shortened phospholipid-dependent clotting times. At high concentrations, STS prolonged all clotting times and destroyed fibrinogen, FV, FVII, FX and FXIII.Lytic activity in whole blood (WB), albumin and saline was investigated by absorbance densitometry. Both agents induced haemolysis, platelet, platelet microparticle (PMP) and endothelial lysis at high concentrations. The lytic effect was neutralised by albumin and plasma proteins.Antithrombotic mechanisms were investigated in functional assays for activated protein C (APC), PC, protein S, antithrombin and FXa in normal plasma (NP). High concentration STS demonstrated anti-IIa, anti-Xa and anti-Va activity and potentiated the anticoagulant effects of APC. POL induced APC resistance.Fibrinolytic enzymes/inhibitors were measured by ELISA in WB and plasma, and plasminogen by a chromogenic assay in NP. Inhibitors of fibrinolysis were elevated at low concentrations of sclerosants. Fibrinolytic enzymes/inhibitors were destroyed by high concentration STS.Clot formation was assessed by thromboelasotometry in WB. Both agents induced strong clots at low concentrations, weak clots at mid-range and prevented clot formation at high concentrations. In turbidity measurements, neither agent had a lytic effect on cross-linked fibrin but STS destroyed non-cross-linked fibrin.Platelet and PMP counts were assessed by flow cytometry and platelet activation by ELISA for soluble markers and by flow cytometry for CD62p, CD63 and calcium. Platelet aggregation was assessed by light transmission and impedance aggregometry, and by flow cytometry for glycoprotein (GP)IIb/IIIa. At low concentrations, both agents induced platelet activation, released phosphatidylserine+ PMPs but inhibited aggregation by suppressing the activation of GPIIb/IIIa.In conclusion, detergent sclerosants interfered with coagulation, antithrombotic and fibrinolytic mechanisms. Both agents activated platelets, released procoagulant PMPs and potentiated prothrombotic and antifibrinolytic mechanisms at low concentrations. At high concentrations, both agents prevented clot formation. High concentration STS exhibited more anticoagulant activity than POL

Truncal ablation: Techniques

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