A history of injection treatments - II sclerotherapy.

INTRODUCTION: Sclerotherapy in all its current forms is based on experience going back to the 1850s. METHODS: To trace the evolution of sclerotherapy over the past 250 years, using the internet for past documentation and the literature. CONCLUSION: Sclerotherapy principles were established long ago, although current modifications have been made possible by the introduction of detergent sclerosants and ultrasound guidance.

La escleroterapia con espuma es un método eficaz para el tratamiento de la insuficiencia venosa / Foam sclerotherapy is an effective method for the treatment of venous insufficiency

«La escleroterapia puede mucho más de lo que en general imaginamos. Teóricamente lo puede todo (Mollard 1994)». En esta reflexión, este cirujano vascular, intuye la potencialidad de los esclerosantes en la nueva forma farmacéutica acabada de nacer. La escleroterapia, procedimiento técnicamente ciego, no evolucionaba, permanecía durante décadas como complemento a la cirugía. No podía progresar porque estaba presa de limitaciones inherentes a la forma líquida de los productos utilizados que impiden hacer suyos los requerimientos básicos de la escleroterapia: a) Conocimiento de la concentración intravascular del esclerosante. b) Homogénea, extensa y manejable distribución sobre las paredes venosas. c) Control del tiempo de contacto esclerosante-endotelio. La clave de la escleroterapia se encierra en el control de la acción de los fármacos esclerosantes y este control se consigue con la forma farmacéutica de espuma inyectable; con ella la escleroterapia rápidamente evoluciona hasta alcanzar una nueva era

'Sclerotherapy can be much more than we generally imagine. Theoretically, it can be everything. (Mollard 1994)'. In this reflection, a vascular surgeon sensed the potentiality of sclerosing agents in the recently created new pharmaceutical form. Sclerotherapy, technically a blind procedure, did not evolve; it remained as a complement to surgery for years. It was unable to progress because it was a prisoner of the imitations adherent to the liquid form of the products used, which that impeded compliance with the basic requirements of sclerotherapy: a) Knowledge of the intravascular concentration of the sclerosing agent. b) Homogeneous, extensive, and manageable distribution of the venous walls. c) Temperature control of the sclerosing agent-endothelium contact. The key to sclerotherapy involves controlling the action of the sclerosing drugs, and this control is achieved in the pharmaceutical form of an injectable foam, and with this, sclerotherapy rapidly advanced until reaching this new era. Nowadays, different therapies are used in the treatment of varicose veins, including radiofrequency and laser ablation, stripping, surgery, echanical-chemical systems, steam, and glue, with very different outcomes. Sclerotherapy is a minimally invasive technique used for more than a hundred years, and useful for treating tiny little veins, until recently, in 1993, a pharmaceutical grade foam was developed that succeeded in treating large varicose veins, and is imitated by many others. The physical-chemical features of these foams vary considerably among themselves, depending on the production technique, concentration of sclerosing agent, types of gases used, gas/liquid proportion, type of gas/ size of bubble ratio, as well as varying in their safety and therapeutic use. The optimal liquid/gas proportion is obtained when there is sufficient liquid for the bubbles to be spherical and with the smallest diameter possible, but without introducing excess sclerosing liquid, which is described as kugelschaum (wet foam) or alternatively, it forms polyederschaum (dry foam). A series of experimental and theoretical studies have been conducted with the purpose of investigating the mechanical and rheological properties of the foams. However, to study its dynamic behaviour is a challenging theoretical problem, due to the complex interaction between the physical phenomena that occur in different longitudinal scales (that is to say, from the molecular to the macroscopic). And, in this interesting time of the evolution of the injection of drugs deposited over bubbles, is where we currently are

Historical milestones and progress in the research on alcohol septal ablation for hypertrophic obstructive cardiomyopathy.

The first alcohol septal ablation was performed almost 20 years ago in 1994; since then it has become a widely used technique for the treatment of highly symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). It has been shown that postprocedural basal septal shrinking as a result of myocardial scarring is followed by a decrease in left ventricular (LV) obstruction, regression of LV hypertrophy within the first postprocedural year, improvement of diastolic function, and reduction of the degree of mitral regurgitation. All these changes are accompanied by significant symptom relief. Although there is only limited evidence of postprocedural long-term survival, all the studies presented here are consistent in the low incidence of sudden death and similar prognoses with an age- and sex-matched general population. Conversely, we still have to be aware that a certain knowledge gap exists with regard to postprocedural long-term outcome. Therefore, careful selection of patients for alcohol septal ablation is needed, and all patients should be treated in centres offering all therapeutic options.

Catheter-directed sclerotherapy.

BACKGROUND: Catheter directed sclerotherapy (CDS) involves the use of a long catheter to deliver a sclerosing agent into a target vessel (saphenous trunks or venous malformations) under ultrasound guidance. Aims and Methods This article reviews the history, current techniques and devices and the evidence as it relates to these procedures. RESULTS: CDS was developed to increase the safety and efficacy of ultrasound-guided sclerotherapy (UGS). With the advent of foam sclerosants and tumescent anaesthesia, the procedure has enjoyed a higher primary success rate. CDS has a better safety profile when compared with UGS with virtually no risk of intra-arterial injection or sclerosant extravasation. Compared with endovenous laser (EVLA) and radiofrequency ablation (RFA), CDS is a quicker procedure with less associated pain. Some balloon catheters, however, have been found to force the sclerosant down the perforators causing femoral vein occlusion. Based on the current level of evidence, no firm conclusion regarding the efficacy of CDS techniques can be drawn in comparison with EVLA or RFA, but the primary success rate is probably higher than the standard UGS. CONCLUSION: CDS ensures a safe intraluminal delivery of the sclerosing agent into the trunk of the saphenous veins using a single access point. This procedure preceded EVLA and RFA, and remains a safe alternative for the treatment of saphenous incompetence and venous malformations.

Trombose venosa profunda como complicação da escleroterapia química no tratamento de telangiectasias dos membros inferiores / Deep venous thrombosis as complication of chemical sclerotherapy in the treatment of leg telangiectasias

Os autores relatam dois casos de escleroterapia de telangiectasias, as quais complicaram com trombose venosa profunda. O primeiro caso foi confirmado por flebografia, e o segundo, por duplex scan. Um paciente, 8 anos após, apresentou uma tromboflebite espontânea de veia safena parva, que resultou em pesquisa de trombofilia positiva para o Fator V Leiden. A outra paciente teve pesquisa de trombofilia negativa. Os relatos de tromboembolismo relacionado à escleroterapia são escassos na literatura. O objetivo do trabalho é alertar para essa possibilidade, valorizando as queixas de dor e edema após a escleroterapia. Havendo suspeita clínica, o duplex scan deve ser realizado.

The history of sclerosing foams.

BACKGROUND: The use of foamed sclerosants in phlebology is undergoing a renaissance. The use of foam sclerotherapy was relaunched only a few years ago. Despite this, the early developments, pioneer findings, and improvements, especially in foaming techniques, are not widely recognized. OBJECTIVE: The objective of this study was to give an overview from the very beginnings of foam sclerotherapy until the most recent and progressive techniques, as described by Tessari or the double syringe system technique. RESULTS: The publications found after a thorough research for literature about foam sclerotherapy allow us to examine what has been invented between Orbach's work in 1944 and now and--surprisingly--even before 1944. The contributions of greatly reputed and also of unknown colleagues, such as Orbach, Sigg, Mayer, or Flückiger, are presented, giving a historical overview from the very beginnings of foam sclerotherapy until the most recent techniques. Basically, the literature shows that remarkable work was carried out in the field of noncommercial foam sclerotherapy and that sclerosing foams have been used by numerous doctors continuously for the past six decades, especially for the treatment of varicose veins of the lower limbs. CONCLUSION: The use of foamed sclerosing agents in therapy of large or small varicose veins is not new. It started as early as 1939 and has continuously been improved in the past decades.

Bleeding oesophageal varices.

BACKGROUND: The Danish contribution to evaluation and treatment of bleeding oesophageal varices. METHODS: Danish papers dealing with portal hypertension and oesophageal varices have been reviewed and set in relation to international publications. RESULTS: The Danish papers have mainly contributed with controlled clinical trials concerning both primary and secondary prophylaxis. Furthermore, they have dealt with pathophysiologic, clinical and experimental studies concerning portal haemodynamics and the evolution and treatment of variceal bleeding. CONCLUSION: The Danish studies have been well designed and are frequently cited. Further prospective randomized studies in the new treatment modalities are encouraged.