Atrial embolism of floating thrombus of the great saphenous vein ...

258J Vasc Bras 2010, Vol. 9, Nº 4Atrial embolism after microfoam ultrasound-guided sclerotherapy - Lopes RPF et al.normal sinus rhythm. At physical examination, a dilatedand pulsatile greater saphenous vein (GSV) at the saphenofemoraljunction (SFJ) on both lower limbs was observed(Figure 1). Preoperative duplex ultrasound showed theright saphenofemoral junction with 15 mm in diameter,dilatation and reflux in all the length of the GSV and invaricose tributary veins, as well as a patent and competentdeep venous system.The procedure was performed in supine position anda tourniquet at the level of the patient’s knee. The greatersaphenous vein was punctured with Jelco 18-gauge needleat the distal portion of the thigh using Doppler ultrasoundguidance. Microfoam was prepared by mixing polidocanol3% and room air in a 1:4 proportion (Tessari method);afterwards, 8 mL of this solution was injected under realtimeultrasound guidance, while the limb was kept in a45-degree elevation and the saphenofemoral junction wasFigure 1 - Dilated, visible and pulsatile great saphenous vein at physicalexamination of the right thighcompressed by an ultrasound transducer. The right lowerlimb and the saphenofemoral junction were maintained inthe same position for ten minutes and, then, the whole limbwas wrapped with a compression inelastic bandage for 24hours. There were no intercurrences during the procedure,and elastic stockings (30-40 mmHg of pressure) were prescribedfor 30 days.The patient returned seven days after the procedurewith clear subjective clinical improvement. Follow-upDoppler ultrasound showed total occlusion of the greatersaphenous vein in the two distal thirds of the thigh. Theproximal segment of the great saphenous vein was partiallyoccluded, and Doppler ultrasound also showed a floatingthrombus in the saphenofemoral junction, that fragmentedduring the ultrasound examination. There were no signs ofdeep venous thrombosis (DVT). The thrombus was immediatelyidentified ascending the inferior vena cava, and immediatelythereafter, transthoracic echocardiogram showeda floating embolus in the right atrium (Figure 2). The patientwas placed in left lateral decubitus position and sentto the Intensive Care Unit. The absence of thrombi on thesaphenofemoral junction allowed emergency ligation-divisionof the greater saphenous vein, under local anesthesia.Anticoagulation therapy with unfractionated heparin wasinitiated. At repeat transthoracic echocardiogram two dayslater, the embolus was no longer seen. Arterial blood gaswas normal and helical CT scan showed no signs of pulmonaryembolism (PE). The patient was found to be asymptomaticand was discharged after five days on warfarinfor outpatient follow-up and anticoagulation control. Noevidence of DVT or PE was detected six months after theprocedure and the anticoagulation therapy was terminated.Informed consent was obtained from the patient in order toreport this case.DiscussionFigure 2 - Trans-thoracic echocardiogram showing floating embolus inthe right atriumMS is a promising therapeutic procedure that has beenradically changing the management of varicose veins 1,2 . Theadoption of fast microfoam preparation systems and routineguidance by Doppler ultrasound have increased the interestin the method, which may be performed in outpatientclinics without anesthesia in one or more sessions, besidesresulting in a shorter recovering period in comparison toclassic surgery 1,3,4 . Virtually all kinds of varicose veins canbe treated even when the conventional surgical treatmenthas limitations, includind instances in which conventionalsurgical treatment present limitations, such as patients offunctional classifications CEAP C4, C5 and C6, recurrent

Atrial embolism after microfoam ultrasound-guided sclerotherapy - Lopes RPF et al. J Vasc Bras 2010, Vol. 9, Nº 4 259varicose veins and high surgical risk patients 3,4 . The numberof publications on the method is increasing, but there is stillno consensus regarding indications and contraindications,technical variations and the rate of complications 5,6 .The efficacy and safety of the method have been emphasizedby many studies 1,3,6 , but only a relatively smallnumber of complications, often not severe, has been published1,2,4 . However, the actual incidence of complicationsis unknown 2 , and potentially severe and lethal events havealready been described, including the rare and well-documentedcase of stroke in a patient with an 18-mm patentoval foramen and left shunt 7 , and a case of cardiorespiratoryarrest associated with polidocanol sclerotherapy forvenous malformation in a child with Klippel-Trenaunaysyndrome 8 .Extravasation of the sclerosing agent into the deep venoussystem through perforating veins or at the saphenofemoraljunction during the procedure may be responsiblefor some of these complications. Some ways of avoiding ithave been described, including digital compression or ultrasonographicmonitoring during sclerosing agent injection1,9,10 . A prospective, controlled and randomized trialsuggested that SFJ ligature under local anesthesia prior tothe GSV sclerotherapy increases the procedure safety bylimiting the extravasation 11 . Recently, Bidwai et al. proposeda clipping ligature of the perforating veins under local anesthesiaafter locating them by means of Doppler ultrasoundand SFJ monitoring by Fogarty balloon catheter 12 .Delayed major complications are rare and almost exclusivelypresent as venous thrombosis, which is often asymptomaticand diagnosed by Doppler ultrasound within 7 to14 days after the procedure 2,4 . DVT is commonly limited tothe calf muscular veins or tibial veins. Femoral or poplitealDVT rarely occurs by direct extension of thrombosis fromthe saphenofemoral/saphenopopliteal junctions or perforatingveins 9,10 . A large prospective multicenter study of 12,173sclerotherapy sessions reported one single case of femoralDVT and no case of embolism 2 . Yamaki et al. reporteda DVT case with symptomatic PE after ligature of the greatsaphenous vein associated with polidocanol sclerotherapy 13 .Compression of the limb after sclerotherapy reducesthe pathological reflow and the diameter of the treated vein,besides reducing the DVT risk 3 . It should be performed immediatelyafter the therapy session in all patients. However,there are neither consensus about the ideal compressionmethod and duration nor studies that confirm its unquestionablerelevance as an adjuvant to sclerotherapy 3,5,6 . In ourcase, it is probable that the wide diameter of the saphenofemoraljunction, associated with the pulsatility resultingfrom CHF and the difficulty in maintaining compressionafter the procedure have contributed to non-obliteration ofthe great saphenous vein and the local floating thrombusformation. Although there are not studies that determine amaximal acceptable diameter of the saphenofemoral junctionfor use of this method, the present clinical observationmay limit its indication for patients with wide SFJ and reducepossible complications.ConclusionMS is a promising treatment for varicose veins becauseit is a simple, easily reproducible, less invasive, cost-effectiveand safe method 11 . However, it can rarely result in severecomplications like those reported in this paper. Someprecautions such as the patient careful selection, choiceof the sclerosing agent and of the puncture site, compressivetherapy and the experience of the physician with othermethods of sclerotherapy – as well as his ability to diagnoseand treat possible complications – may increase the efficacyand safety of this procedure 3 .References1. Redondo P, Cabrera J. Microfoam sclerotherapy. Semin Cutan MedSurg. 2005;24:175-83.2. Guex JJ, Allaert FA, Gillet JL, Chleir F. Immediate and midtermcomplications of sclerotherapy: report of a prospective multicenterregistry of 12,173 sclerotherapy sessions. Dermatol Surg.2005;31:123-28.3. Zimmet SE. Sclerotherapy treatment of telangiectasias and varicoseveins. Tech Vasc Interv Radiol. 2003;6:116-20.4. Munavalli GS, Weiss RA. Complications of sclerotherapy. SeminCutan Med Surg. 2007;26:22-8.5. Breu FX, Guggenbichler S. European Consensus Meeting on FoamSclerotherapy, April, 4-6, 2003, Tegernsee, Germany. Dermatol Surg.2004;30:709-17.6. Rabe E, Pannier-Fischer F, Gerlach H, Breu FX, Guggenbichler S,Zabel M; German Society of Phlebology. Guidelines for sclerotherapyof varicose veins (ICD 10: I83.0, I83.1, I83.2 and I83.9). DermatolSurg. 2004;30:687-93.7. Forlee MV, Grouden M, Moore DJ, Shanik G. Stroke after varicosevein foam injection sclerotherapy. J Vasc Surg. 2006;43:162-4.8. Marrocco-Trischitta MM, Guerrini P, Abeni D, Stillo F. Reversiblecardiac arrest after polidocanol sclerotherapy of peripheral venousmalformation. Deramtol Surg. 2002;28:153-5.9. Smith PC. Chronic venous disease treated by ultrasoundguided foam sclerotherapy. Eur J Vasc Endovasc Surg. 2006;32:577-83.10. O’Hare JL, Earnshaw JJ. The use of foam sclerotherapy for varicose veins:a survey of the members of the Vascular Society of Great Britain andIreland. Eur J Vasc Endovasc Surg. 2007;34: 232-5.