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Introduction Extensive cervicofacial venous malformations (VM) pose significant challenges to a patient's quality of life (altered breathing, dysphagia, dysarthria). Treatment options include: 1) Surgical debulking; 2) Sclerotherapy; 3) laser therapy; or 4) Combined modalities. Recent studies have demonstrated the importance of multimodality and multidisciplinary management of these patients. However, no studies have described combined single anesthetic laser and sclerotherapy treatment. We sought to demonstrate the safety and efficacy of combined Nd:YAG laser and sclerotherapy under the same anesthetic administration. Methods Retrospective review of 8 patients (Age 6 mo −74 yrs, x 31) with extensive cervicofacial VM with significant airway involvement. Patients were treated with combined suspension laryngoscopy with Nd:YAG laser of airway VM followed by image guided direct puncture sclerotherapy using bleomycin in the airway VM and sodium tetradecyl sulfate (STS) foam in the cervicofacial VM during the same anesthetic encounter. Results All 8 patients had extensive cervicofacial VMs that were symptomatic with snoring or orthopnea. Four of the patients had previously been treated at outside institutions with residual disease or significant complications. All patients remained intubated post procedure (Avg. 1.07 days) and tolerated extubation without re-intubation or any major complications. The average length of hospital stay was 3.2 days, of which 1.9 days were spent in the ICU. Patients reported symptomatic improvement or had decreased VM disease on MRI follow up. Conclusion Combined Nd:YAG laser therapy and sclerotherapy allows treatment of both superficial and deep components of VMs in a safe and efficient manner. In addition, suspension laryngoscopy provides improved visualization and access for the interventional radiologist in difficult to reach areas for sclerotherapy.

Purpose To report clinical and radiographic outcomes of patients with venous malformations (VMs) treated with bleomycin foam. Materials and Methods Twenty patients (age, 2–68 y) presented with symptoms of swelling (n = 19; 95%), pain (n = 14; 70%), and bleeding (n = 4; 20%). Lesions were located in the head and neck in 17 patients (85%), extremities in two (10%), and mediastinum in one (5%). Twenty-seven embolizations were performed, with a mean of 1.7 ± 1.0 treatments per patient (range, 1–4). An average of 0.45 ± 0.4 U/kg of bleomycin foam was used per procedure, with a range of 0.1–2.3 U/kg. Results All procedures were technically successful with no intraprocedural complications. Mean follow-up was 66 days ± 80, with a range of 4–403 days. Postprocedure complications were minor in 6 of 27 procedures (22%) and major in 2 of 27 procedures (7%). All 20 patients (100%) reported improvement in their symptoms after a single treatment session. Postprocedural magnetic resonance (MR) imaging demonstrated volume reduction of treated lesions in 13 of 14 patients (93%), with a mean lesion volume reduction of 66% ± 21. Enhancement on MR imaging after treatment was decreased in 11 of 14 patients (79%), increased in two (14%), and stable in one (7%). T2 signal intensity on MR imaging after treatment was decreased in 12 of 14 patients (86%) and stable in two (14%). Conclusions The use of bleomycin foam for the percutaneous treatment of VMs is safe and effective. Foaming bleomycin may be used to address the dose limitations of the liquid.

To evaluate clinical outcomes and their predictors in patients with venous malformation (VM) treated with foam sodium tetradecyl sulfate (STS) sclerotherapy. We retrospectively evaluated clinical outcomes of foam STS sclerotherapy in 86 patients with 91 VMs to assess reduction in pain and mass after treatment. Univariate and multivariate analysis was performed to determine possible predictors of clinical outcome with foam STS sclerotherapy. A positive response of 49.5 % in pain reduction and 52.7 % in mass reduction was observed. The numerical rating scale (NRS) score improved from 4.36 ± 2.64 to 1.74 ± 1.57, and VM mass volume decreased to 41.7 ± 35.52 % of the initial size. On multivariate analysis, a high baseline NRS score (odds ratio: 1.12, 95 % confidence interval: 1.09–1.15) and VM location in the trunk versus the head and neck (odds ratio: 1.30, 95 % confidence interval: 1.00–1.69) were positive predictors of pain improvement. Minor complications occurred in 11 (12.1 %) patients and recurrence in 12 (13.2 %) patients. Foam STS sclerotherapy is an effective treatment in venous malformation, with low complication risk. A high baseline NRS score and location in the trunk versus the head and neck were positive predictors in improvement of pain. • Foam STS sclerotherapy is effective in VM, with low risk of complications. • Relief of pain tends to be dramatic in patients with severe pain. • Location of VM is a predictor of pain improvement. • The presence of a draining vein does not affect foam sclerotherapy.

Objectives Lymphatic malformations are congenital vascular anomalies that occur from abnormal development of the lymphatic channels. Studies have shown that sclerotherapy can be a reliable alternative to surgery. The purpose of this retrospective study is to evaluate the safety and efficacy of percutaneous sclerotherapy with doxycycline and 3% Sotradecol as primary treatment for pediatric head and neck LMs, and to assess outcomes based on lesion classification, location and sclerosant used. Study design This study was a single center, retrospective, case series study. Materials and methods The medical records of 38 children who underwent percutaneous sclerotherapy of LMs in the head and neck region at our tertiary care center between 1/1/2006 and 1/31/2011 were reviewed. A mean average of 2.9 (range 1–10) sclerotherapy sessions per child were performed. LMs involved primarily the face (61.3%), posterior neck (48.4%), submental area (45.2%), and anterior neck (35.5%). Results Twenty-nine subjects had adequate follow-up data, with 51.7% demonstrating complete resolution, 27.6% moderate improvement, and 20.7% no response. There was no significant difference in the outcome based on the sclerosant agent used or location of the lesion. Lesion type did affect outcome and macrocystic lesions were found to have a significantly higher resolution rate (95.2%) than microcystic or mixed lesions (p Conclusion Our results indicate that percutaneous therapy with doxycycline and Sotradecol is safe and effective for children with LMs of the head and neck. Better outcomes were observed with macrocystic LMs. Level of evidence 4.

Objective To investigate the deactivating effects of circulating blood cells on the lytic activity of detergent sclerosants. Methods Samples of whole blood (WB), platelet-rich plasma (PRP), and isolated leukocytes were incubated with various concentrations of sodium tetradecyl sulfate (STS) or polidocanol (POL) and added to human umbilical vein endothelial cells (HUVECs), which were then counted using a fluorescent plate reader. Full blood counting was performed using a hematology analyzer. Platelet lysis and microparticle formation was assessed using lactadherin binding in flow cytometry. Results Detergent sclerosant activity was decreased in WB when compared with plasma and saline controls. The sclerosant lytic activity on endothelial cells was increased 23-fold for STS and 59-fold for POL in saline controls compared with WB. At high concentrations, sclerosants lysed erythrocytes, leukocytes, and platelets. Platelets were more sensitive to the lytic activity of sclerosants than other cell types. Neutrophils were the most susceptible of all leukocytes to the lytic activity of sclerosants. The presence of erythrocytes and leukocytes in samples decreased the lytic activity of sclerosants. Sclerosants at all concentrations induced erythrocyte-derived microparticle formation. Conclusions Detergent sclerosants are consumed and deactivated by circulating blood cells. This deactivating effect is above and beyond the neutralizing effects of plasma proteins and contributes to the overall neutralizing effect of blood. Different blood cell types exhibited varying levels of vulnerability to the lytic activity of sclerosants with platelets being the most and erythrocytes the least vulnerable (platelets > leukocytes > erythrocytes).

Objectives To investigate morphological changes in vascular and circulating blood cells following exposure to detergent sclerosants sodium tetradecyl sulfate and polidocanol. Methods Samples of whole blood, isolated leukocytes, platelets, endothelial cells, and fibroblasts were incubated with varying concentrations of sclerosants. Whole blood smears were stained with Giemsa and examined by light and bright field microscopy. Phalloidin and Hoechst stains were used to analyze cytoplasmic and nuclear morphology by fluorescence microscopy. Endothelial cell and fibroblasts were analyzed by live cell imaging. Results Higher concentrations of sclerosants induced cell lysis. Morphological changes in intact cells were observed at sublytic concentrations of detergents. Low concentration sodium tetradecyl sulfate induced erythrocyte acanthocytosis and macrocytosis, while polidocanol induced Rouleaux formation and increased the population of target cells and stomatocytes. Leukocytes showed swelling, blebbing, vacuolation, and nuclear degradation following exposure to sodium tetradecyl sulfate, while polidocanol induced pseudopodia formation, chromatin condensation, and fragmentation. Platelets exhibited pseudopodia with sodium tetradecyl sulfate and a “fried egg” appearance with polidocanol. Exposure to sodium tetradecyl sulfate resulted in size shrinkage in both endothelial cell and fibroblasts, while endothelial cell developed distinct spindle morphology. Polidocanol induced cytoplasmic microfilament bundles in both endothelial cell and fibroblasts. Patchy chromatin condensation was observed following exposure of fibroblasts to either agent. Conclusion Detergent sclerosants are biologically active at sublytic concentrations. The observed morphological changes are consistent with cell activation, apoptosis, and oncosis. The cellular response is concentration dependent, cell-specific, and sclerosant specific.

Recurrent epistaxis is often the presenting symptom in patients with hereditary hemorrhagic telangiectasia (HHT); in fact, 90% of patients with HHT experience recurrent epistaxis.1 HHT has an overall frequency of 1:5000. It affects all ethnicities, and males and females equally.2 An autosomal dominant disease with variable penetrance and expression, it acts on genes that produce elastic fibers of blood vessels. Affected individuals exhibit vascular malformations, primarily in the nose, gastrointestinal (GI) tract, brain, liver, and lung. Lesions demonstrate markedly dilated, convoluted venules with abnormal smooth muscles, often directly connected to abnormally dilated arterioles.3 In the nasal epithelium, thin-walled telangiectasias are exposed to dryness and nasal crusting, leading to frequent damage to these vessels. When damage causes bleeding, the lack of effective elastic fibers prevents constriction, and difficult-to-control hemorrhage ensues. The severity of epistaxis usually worsens with advancing age; major life-threatening bleeding can result in frequent transfusions, invasive procedures, and hospitalizations.4 A stepwise approach to treatment is recommended, based on the severity of symptoms.5,6 The Epistaxis Severity Score (ESS) is a standardized scoring system assessing epistaxis severity and frequency, and is an accurate, reproducible, validated objective measure of epistaxis severity.7 The ESS is measured on a 10-point scale, with higher scores reflecting more severe and frequent bleeding. Current standard treatment for mild recurrent bleeding relies on careful and diligent moisturization of the nasal passages. Many patients require iron supplementation to treat anemia. Various topical and oral regimens are also used, such as hormones, antifibrinolytics, and antiangiogenic agents.8 Recurrent or severe epistaxis may necessitate blood transfusions and referral to an otolaryngologist. For moderately severe recurrent epistaxis, otolaryngologists use various forms of laser photocoagulation (CO2, argon, neodymium-doped yttrium aluminum garnet [Nd-YAG], flashlamp-pulsed dye, and potassium titanyl phosphate [KTP]), electrical cautery, or surgical microdebridement. More aggressive surgical options include septodermoplasty and complete nasal closure (Young’s procedure). Arterial embolization is used for emergent severe bleeding.8 Yet none of these modalities provide complete relief from bleeding and can be associated with significant side effects, such as nasal crusting, foul odor, and septal perforation. Their limitations have motivated the search for alternative treatment options. One alternative is sclerotherapy, by injecting vascular lesions with an agent that causes thickening of the vessel wall, obstruction of blood flow, clot formation, and collapse of the lesion. An established treatment modality for vascular malformations in the skin, GI tract, and genitourinary tract, sclerotherapy has been adopted for lesions in various sites in the head and neck,9–13 but not for HHT. Case reports and one large series in the literature have described sclerotherapy for epistaxis due to HHT, but have not been followed by prospective studies.14–17 In our previously published retrospective analysis of our pilot study, we described the results of sclerotherapy with sodium tetradecyl sulfate (STS) in 7 patients. All 7 described the procedure as tolerable, and all reported a reduction in the severity and frequency of bleeding. All 7 were willing to undergo sclerotherapy with STS again.8 In our subsequent analysis of outcomes in 36 patients undergoing repeated sclerotherapy, we found no reports of adverse sequelae such as septal perforation, increased bleeding, or foul smell; some patients described minimal transient procedural symptoms, but no serious complications.18 The purpose of the current prospective randomized trial was to determine the effectiveness of sclerotherapy with STS, vs standard treatment, for recurrent epistaxis due to HHT. We hypothesized a priori that the severity and frequency of epistaxis would be reduced with sclerotherapy compared to standard treatment.

BACKGROUND No study has evaluated the use of foam sclerotherapy in treating clinically conspicuous reticular chest veins. OBJECTIVE This retrospective study evaluates patient-rated efficacy, safety, and satisfaction after foam sclerotherapy for reticular veins of the chest. MATERIALS AND METHODS A telephone-based questionnaire was used for patient self-assessment of overall improvement, satisfaction, and adverse events. All patients had been treated with 0.25% to 0.50% sodium tetradecyl sulfate (STS) foam using room air (1:4 ratio). The mean length of follow-up was 3.7 years. RESULTS Twelve of 23 patients were successfully contacted, with a total of 14 treatment sessions. Overall, patients reported scores of 2.4 ± 0.8 for overall improvement (0 = none, 1 = mild, 2 = moderate, and 3 = complete resolution) and 1.75 ± 0.6 for satisfaction with results (0 = not satisfied at all, 1 = mildly satisfied, and 2 = very satisfied), with minor treatment-related adverse events. CONCLUSION Foam sclerotherapy with STS is effective for management of reticular veins of the chest with an excellent safety profile and high long-term patient satisfaction.

This study was performed to compare the long-term outcomes of balloon-occluded retrograde transvenous obliteration (BRTO) for gastric varices using ethanolamine oleate (EO) and sodium tetradecyl sulfate (STS). From January 2002 to June 2015, 142 patients underwent BRTO for the treatment of gastric varices using EO (n = 59) or STS (n = 83). We retrospectively reviewed the follow-up data related to the obliteration of gastric varices, rebleeding, and clinical complications. The cumulative recurrence rates of gastric varices after BRTO in each group were analyzed using the Kaplan–Meier method and compared using the log-rank test. The median follow-up periods were 23.9 (range 0.2–170.7) months in the BRTO with EO group and 19.9 (range 0.2–84.7) months in the BRTO with STS group. Technical success was achieved in 53 of 59 (89.8%) cases in the BRTO with EO group and 80 of 83 (96.4%) cases in the BRTO with STS group. The clinical success rates were 94.9% (56/59) in the BRTO with EO group and 96.4% (80/83) in the BRTO with STS group. The cumulative 1-, 3-, and 5-year recurrence rates for gastric varices were 3.8, 9.4, and 9.4% in the BRTO with EO group and 1.3, 2.5, and 3.8% in the BRTO with STS group, respectively (p = 0.684). BRTO using STS has comparable long-term outcomes to BRTO using EO for gastric varices.

Background Sodium tetradecyl sulfate (STS) is Food and Drug Administration approved for treatment of varicose veins, but numerous other off-label applications have been reported. Objective To describe the clinical uses of STS, as well as efficacy and adverse effects. Methods Review of studies searchable on PubMed from 1938 to 2016 describing clinical uses of STS to determine efficacy and adverse effects associated with various applications. Results Sodium tetradecyl sulfate has shown efficacy in the treatment of varicose veins, telangiectasias, hemangioma, pyogenic granuloma, cherry angioma, Kaposi sarcoma, lymphangioma circumscriptum, digital mucous cyst, ganglion cyst, glomangioma, angiokeratoma of Fordyce, pseudocyst of the auricle, and verruca. Commonly reported side effects include pain, erythema, swelling, hyperpigmentation, telangiectatic matting, and ulceration. Serious side effects such as anaphylaxis, pulmonary embolism, stroke, and myocardial infarction have also been reported. Most sources were case reports and small prospective studies, as such the strength of data supporting many uses is limited by small sample sizes and lack of controls. Conclusion Although not always the most effective method of treatment in off-label usage, use of STS has been frequently selected for a variety of applications for reasons of simplicity, low cost, lack of availability of technologically advanced equipment, and intricacies related to anatomic location.

The aim of this study was to evaluate complications in patients with head and neck venous malformations (VMs) treated with foam sclerotherapy using sodium tetradecyl sulfate (STS).The authors retrospectively evaluated the complications, pain. and degree of satisfaction in 69 consecutive patients affected by cervicofacial VM managed with STS using the Tessari method in a single institution.The average number of procedures for each patient was 2.1. The most frequent complication was blistering. We observed 1 patient of temporary weakness of a facial nerve branch, 1 paradoxical embolism, and 1 orbital compartment syndrome.The average pain score was 0 (no pain at all) (51.5%). There was no statistically significant correlation between patient satisfaction and the presence of complications or the degree of pain.Sclerotherapy with STS is an effective treatment that yields to very high patient satisfaction. This procedure has an overall low complication rate and is usually effective within a few sessions. However, severe complications may occur; these must be pointed out in the informed consent and the surgeon must be aware of and ready to quickly treat them to prevent long-term sequelae.

This chapter reviews the history of Foam sclerotherapy (FS) and discusses the currently available sclerosants and techniques. It presents the results of FS from large observational and randomized studies and suggests how FS might fit within a multimodality endovenous treatment offer and provides some recommendations regarding further research. In Europe, most phlebologists use “home-made” sodium tetradecyl sulfate and/or polidocanol microfoam for FS. FS is particularly appropriate for complex recurrent disease associated with neovascularization, where the varicose veins (VV) to be treated are often too small, tortuous, and superficial to be treated easily by means of endothermal ablation and where the versatility and adaptability of FS is a major advantage. The phlebologist has a wide variety of endovenous techniques to treat VVs, and these can be combined in imaginative ways so that the overall treatment offer is tailored to the individual patient’s needs, expectations, and desires.

To evaluate the efficacy and safety of sclerotherapy with sodium tetradecyl sulfate (STS) and bleomycin for treatment of venous malformations (VMs) of the oropharyngeal region.A retrospective study of 33 patients with 46 VMs of the buccal and pharyngolaryngeal cavity associated with impairment of eating, respiration, or elocution was performed. Individual lesions were divided based on their anterior or posterior location, using the base of the tongue as an anatomic landmark. Lesion size was estimated with the use of orthogonal measurements on magnetic resonance or ultrasound images before and after treatment to assess radiologic response. Sclerotherapy sessions were performed under ultrasound, fluoroscopic, and, if needed, endoscopic guidance. Clinical response was assessed with the use of the Manchester Orofacial Pain Disability Scale. Methods for airway management were also compiled.Following sclerotherapy, average VM diameter was reduced by 31.4% (P.0001) on a per-patient basis and by 30.8% (P.0001) on a per-lesion basis. The Manchester score improved by an average of 37.0% (P = .013). Four patients reported a worsening of symptoms, and 11 patients experienced symptomatic recurrence. Complications include pneumonia (5 patients) and urgent placement of a post-procedure tracheostomy (4 patients). Patients with posterior malformations experienced more complications (emergency tracheostomies in 4 and pneumonias in 4).Sclerotherapy using STS is an efficient treatment for venous malformations of the buccal and pharyngolaryngeal cavity but can lead to significant complication for posterior lesions. Careful assessment of the airway is needed before treatment, and prophylactic tracheotomy should be considered in patients with posterior lesions.

Sclerotherapy is a safe, effective, and easily available treatment modality, its role in cherry hemangioma is still unexplored.This study aims at establishing the role and efficacy of sclerotherapy in treating cherry angiomas and its dermatological complications.This prospective study included 20 patients with 100 lesions of cherry hemangiomas of size0.2 mm. Intralesional injection of 0.1 mL of 3% sodium tetradecyl sulfate was used. Scarring, if any, was evaluated using "The Stony Brook Scar Evaluation Scale." Patients were called for weekly sessions for a maximum of 4 weeks.Of 100 lesions treated, 42 lesions responded with a single dose of sclerosant, 44 lesions required a second setting. Remaining lesions were injected for 3 weeks, of which 14 lesions did not remit completely and required a fourth sitting. Depending on response to sclerotherapy, patients were divided into 2 groups (Group A and Group B). On comparing these groups, no statistically significant (χ test) difference in the rate of healing was observed.Sclerotherapy with sodium tetradecyl sulfate 3% is effective in the treatment of cherry hemangiomas. It offers an economical alternative to other available conventional methods.

Purpose: The objective of the present study was to evaluate the efficacy of a sclerosing solution for inducing epididymal occlusion in male rats. Materials and Methods: Male Sprague-Dawley rats were divided into two groups: an injection group (n=20) and control group (n=20). Before injecting the sclerosing agent, seminal vesiculectomy and sperm identification using electrostimulation were performed in all of the rats. In the injection group, 0.2 mL of 0.1% sodium tetradecyl sulfate solution was injected into the epididymis. In the sham group, only the identification of the epididymis was performed. At 4 and 12 weeks after the injection, semen was collected by electrostimulation and evaluated to assess the contraceptive effect. Epididymis was evaluated by hematoxylin and eosin (H&E) staining. Results: After 4 and 12 weeks, semen collection was performed in the two groups. Sperms were not observed in the injection group, while there was no change in the sperms in the sham group. H&E staining showed the obstruction of epididymal tubules and an accumulation of inflammatory cells in the injection group. Conclusions: This study showed that the sclerosing agent induced sterilization in male rats. This result suggests that the injection method can replace vasectomy as a contraceptive method. However, a further study of large animals and a clinical study are needed. Further, the long-term effectiveness of this method needs to be studied.

Purpose To compare the efficacy of percutaneous sodium tetradecyl sulfate (STS) injection with ethanol injection in the treatment of benign nonfunctioning thyroid nodules. Materials and Methods This prospective study included 47 patients with 50 benign thyroid nodules. The lesions were randomly assigned into two groups: 20 in the ethanol arm and 30 in the STS arm. The mean lesion volume was 25.6 mL ± 28.5 (range, 4–122.1 mL) in the ethanol arm and 25.4 mL ± 27 (range, 0.72–129 mL) in the STS arm. One sitting of sclerosant injection was done in 20 lesions, and two injections, three injections, four injections, five injections, six injections, seven injections, and eight sittings of injections were done in 9 lesions, 4 lesions, 8 lesions, 4 lesions, 2 lesions, 2 lesions, and 1 lesion. The mean volumes of the instilled ethanol and STS were 5.3 mL and 7.8 mL, respectively, per sitting. Follow-up sonography was performed at 1, 3, 6, and 12 months after the procedure. Results The final 12-month follow-up lesion volumes were 4.1 mL ± 3.7 (range, 0.3–15.2 mL) in the ethanol group and 4.4 mL ± 5.8 (range, 0.01–29.6 mL) in the STS group ( P = .85). The mean volume reduction was 84% and 82.8% in the two groups. No significant adverse effects were seen in either of the two groups. Conclusions Sonographically guided percutaneous ethanol and STS injections are not significantly different from each other in terms of the volume reduction achieved in benign nonfunctioning thyroid nodules.

Purpose: To evaluate the safety and efficacy of portal vein embolization (PVE) with sodium tetradecyl sulfate (STS) foam. Materials and Methods: A single-center retrospective review of 35 patients (27 men and 8 women; mean age, 61 y) who underwent PVE with STS foam was performed. The technical success rate, rate of PVE at producing adequate future liver remnant (FLR) hypertrophy, and rate of disease progression precluding resection after PVE were analyzed. Complications of PVE and liver resection after PVE were recorded. Results: PVE was performed on 35 patients before right hepatic resection for both primary and secondary hepatic malignancies (22 hepatocellular carcinoma, 10 metastasis, 2 cholangiocarcinoma, 1 invasive gallbladder carcinoma). Technical success was achieved in 97.1% (34 of 35) of patients. Mean FLR of the total estimated liver volume increased from 24.5% (SD, 7.7%) to 36.5% (SD, 14.5%), a mean percentage increase of 48.8% (SD, 34.3%). PVE produced adequate FLR hypertrophy in 31 of 35 patients (88.6%). Proposed right hepatectomy was subsequently performed in 27 patients (77.1%). One patient remains scheduled for surgery, two had peritoneal spread at surgery and resection was aborted, two had disease progression on imaging after PVE, and three had inadequate FLR hypertrophy with no surgery. One major complication was observed related to PVE that involved nontarget embolization to segment III, which was managed conservatively. Conclusions: Preoperative PVE with STS foam is a safe and effective method to induce hypertrophy of the FLR.

Commonly used detergent sclerosants including sodium tetradecyl sulphate (STS) and polidocanol (POL) are clinically used to induce endovascular fibrosis and vessel occlusion. They achieve this by lysing the endothelial lining of target vessels. These agents are surface active (surfactant) molecules that interfere with cell membranes. Surfactants have a striking similarity to the phospholipid molecules of the membrane lipid bilayer. By adsorbing at the cell membrane, surfactants disrupt the normal architecture of the lipid bilayer and reduce the surface tension. The outcome of this interaction is concentration dependent. At high enough concentrations, surfactants solubilise cell membranes resulting in cell lysis. At lower concentrations, these agents can induce a procoagulant negatively charged surface on the external aspect of the cell membrane. The interaction is also influenced by the ionic charge, molecular structure, pH and the chemical nature of the diluent (e.g. saline vs. water). The ionic charge of the surfactant molecule can influence the effect on plasma proteins and the protein contents of cell membranes. STS, an anionic detergent, denatures the tertiary complex of most proteins and in particular the clinically relevant clotting factors. By contrast, POL has no effect on proteins due to its non-ionic structure. These agents therefore exhibit remarkable differences in their interaction with lipid membranes, target cells and circulating proteins with potential implications in a range of clinical applications.

It is unknown whether spontaneous gastrorenal shunts actually develop in the pediatric population. The minimum age documented in studies from Asia is 32 (range 32-44) years. This study describes three pediatric patients undergoing balloon-occluded retrograde transvenous obliteration (BRTO) for bleeding gastric varices with two of the three patients undergoing combined partial splenic embolization. The first BRTO is a selective-BRTO via a surgical splenorenal shunt (15 years old) and the other two patients underwent conventional-BRTO via a spontaneous gastrorenal shunt (8 and 14 years old). The recurrent significant bleeding that they exhibited before the combined endovascular therapy did not recur for an average of 7.1 (range 1.4-14) months. In the second patient, quantitative digitally subtracted angiography was utilized to evaluate the inline portal venous flow before and after BRTO.

Massive tumoral calcinosis developed in a 29-year-old woman with type 1 diabetes and failed pancreas and kidney transplant on peritoneal dialysis. The patient had a symptomatic calcified, fluid-filled posterior thigh mass. After percutaneous drainage of 260 mL of milky fluid, she had rapid recurrence of the collection. She underwent catheter-based sclerotherapy first with 110 mL of povidone-iodine followed 2 days later by 40 mL of 3% sodium tetradecyl sulfate foam. At 5.5 months after the procedure, the patient remained asymptomatic, and computed tomography imaging showed complete resolution of the collection.

Diverticula of the vascular system are rare. A diverticulum involving the retromandibular vein has not been described to date. We describe the imaging findings and a novel therapeutic strategy for the management of this rare diverticulum. A 25-year-old male presented with complaints of swelling behind the angle of mandible that enlarged on straining. On imaging, a retromandibular vein diverticulum was seen. The diverticulum was punctured percutaneously with the patient performing Valsalva maneuver and injected with sclerosant microfoam. There was no sclerosant reflux into the normal neck veins. At 6-month follow-up, the patient had complete resolution of his symptoms. We also have done a review of literature for patients with venous diverticula in the head and neck region treated by endovascular techniques.

Background The aim of this study was to identify and evaluate adverse clinical outcomes following office-based sclerotherapy using sodium tetradecyl sulfate (STS) for epistaxis due to hereditary hemorrhagic telangiectasias (HHT or Osler-Weber-Rendu). Methods A retrospective chart review of 36 adult patients treated with STS sclerotherapy for severe and/or recurrent epistaxis due to HHT was performed. Results A total of 153 separate treatment sessions were analyzed. Each patient underwent an average of 4.3 sessions with an average of 7 intralesional injections per session. Bleeding during the procedure was experienced by 8 patients with a maximum reported blood loss of 200 mL in 1 patient, but less than 50 mL in all others. Seven patients reported some postinjection pain, which included nasal, cheek, and eye pain. Nasal congestion, sneezing, and vasovagal responses were each noted to occur 2 times. No complications of postprocedural visual loss, deep venous thrombosis/pulmonary embolus, transient ischemic attack (TIA)/stroke, or anaphylaxis were encountered. Conclusion Conventional therapies used in the management of HHT-related epistaxis, such as laser coagulation, septodermoplasty, selective arterial embolization, and Young's occlusion each have specific associated complications, including worsened epistaxis, septal perforation, foul odor, nasal crusting, and compromised nasal breathing. STS is a safe office-based treatment option for HHT-mediated epistaxis that is associated with exceedingly few of the aforementioned serious sequelae.

Vascular malformations are one of the most common lesions of the oral cavity. The lesion may be a congenital malformation observed in neonates or arteriovenous malformation observed in adults. Various surgical and medical managements are possible for vascular lesions which include surgical excision, laser therapy, cryotherapy, selective embolization, intralesional sclerosing agents, β-blockers and steroid therapy. Here we report a case of oral vascular lesion where intralesional injection with 30 mg/ml of sodium tetradecyl sulfate (STS) was given, which resulted in local complications with severe inflammatory response including pain, swelling, and surface ulceration that remained for 2 weeks. Sclerotherapy with STS still remain an effective agent in treating benign oral vascular lesions and provides alternative or support for surgical methods. Sometimes it can lead to undesirable complications like allergic reactions, local inflammatory response, etc.

PURPOSE To describe a patient with ophthalmic artery occlusion after sodium tetradecyl sulfate foam injection in the forehead. METHODS In this case report, a description of the clinical examination and imaging findings, including fundus photography, spectral-domain optical coherence tomography, and fluorescein angiography are reported. RESULTS A 33-year-old white woman presented with severe painless vision loss in the left eye after cosmetic treatment of a forehead vein with sodium tetradecyl sulfate foam. Her visual acuity in the left eye was hand motions, and her fundus revealed diffuse retinal whitening in the macula with the absence of a cherry red spot and disruption of the arteriolar blood supply. Spectral-domain optical coherence tomography revealed intense hyperreflectivity of the inner and outer retina with loss of the foveal contour, and fluorescein angiography revealed delayed filling of the choroidal vasculature and cilioretinal artery with incomplete filling of the retinal arterioles in the late frames consistent with ophthalmic artery occlusion. CONCLUSION This case represents a devastating ocular complication after the inadvertent injection of sodium tetradecyl sulfate into a forehead artery, resulting in occlusion of the ophthalmic artery and severe vision loss.

Orbital lymphangioma is a lymphatic system lesion that commonly presents in childhood. Management of these lesions is complex. Sclerotherapy is a therapy used to treat and shrink lesions prior to or as an alternative to surgery. We present three cases of orbital lymphangioma that were treated with sclerotherapy. Case 1: A 6-month-old boy was presented in 2010 with right ptosis and proptosis. Magnetic resonance imaging (MRI) identified a lesion involving the right orbit and face. Case 2: A 3-year-old girl was presented in 2011 with intermittent right periorbital swelling and medial canthal bleeding. MRI identified a soft-tissue lesion in the right orbit, extending into the face. Case 3: A 3-year-old girl was presented in 2012 with vomiting, and painful right proptosis. MRI identified an intra-conal lesion in the right orbit with fluid filled levels. All three patients were treated with sclerotherapy (sodium tetradecylsulfate). Sclerotherapy is a promising treatment for orbital lymphangioma. Its use may prevent the need for, or minimise the amount of surgical management. Several sclerosants are now commonly used to treat these lesions.

Purpose To evaluate 90-day outcomes after balloon-occluded retrograde transvenous obliteration (BRTO) with ethanolamine oleate (EO) in patients with gastric varices (GVs). Materials and Methods An 8-site prospective single-arm clinical trial was conducted. Patients who had endoscopically confirmed GVs with a gastrorenal shunt were eligible for the study. Overnight BRTO was performed, and efficacy was evaluated by endoscopy and contrast-enhanced computed tomography (CT). Results Forty-five patients (26 men and 19 women; mean age, 67.8 y) were enrolled. The complete regression rate of GVs based on endoscopic images on day 90 was 79.5% (35 of 44 patients; 95% confidence interval, 64.7%–90.2%). The rate of complete thrombosis of GVs based on contrast-enhanced CT on day 90 was 93.0% (40 of 43 patients; 95% confidence interval, 80.9%–98.5%). One patient experienced 2 events of bleeding from GVs, which was different from the GVs treated with BRTO. Appearance of new esophageal varices (EVs) or worsening of existing EVs occurred in 16 of 45 patients (35.6%). Forty-four of 45 patients (97.8%) experienced adverse events (AEs) related to EO, which included fever in 24 (53.3%), hematuria in 23 (51.1%), hemolysis in 16 (35.6%), back pain in 16 (35.6%), and abdominal pain in 10 (22.2%). One case of moderate to severe ascites (2.3%) was observed on day 90. One case of sepsis was the only serious AE observed in relation to EO. Conclusions The present study demonstrates that BRTO with EO for the treatment of GVs is a clinically effective procedure with many mild to moderate AEs.

To assess the efficacy of stop-flow foam sclerotherapy (SFFS) in high-flow pelvic varicoceles using 3 % sodium tetradecyl sulfate (STS) foam. Our institutional review board granted approval and waived informed consent for this retrospective study of 26 patients (mean age 37.3 years, range 23–46 years) with pelvic congestion syndrome (PCS) who had high-outflow venous collaterals treated by SFFS between June 2005 and June 2011 in our department. PCS was diagnosed by physical and transvaginal color Doppler ultrasound examination, while high-outflow venous collaterals were detected at selective ovarian venography. SFFS was performed by injection of 3 % STS foam into the pelvic varices after balloon occlusion of the major venous vessels (hypogastric and/or ovarian veins) to which the high-outflow venous collaterals were tributary. Follow-up was performed at 1, 3, 6, and 12 months by physical and transvaginal color Doppler ultrasound examination and by a questionnaire-based assessment of pain using a symptom severity score. The procedure was technically successful in all patients. After the injection of 3 % STS foam, all patients had a colic like pain that spontaneously resolved after 5 min. During follow-up, no recurrences of PCS were detected. Significant improvement of symptoms (Student’s t test P

Cavernous hemangioma of the glans penis is a very rare lesion, and only a few cases are reported in the literature. Urologists are in a dilemma to treat such lesion with cosmetic and to obtain good functional outcome. Here, we report a case of cavernous hemangioma of the glans penis in a 22-year-old boy with a successful outcome by intralesional sclerotherapy with 3% sodium tetradecyl sulfate with a review of the literature on the subject.

Hemangiomas are common tumors characterized microscopically by proliferation of blood vessels. The congenital hemangioma is often present at birth and may become more apparent throughout life. They are probably developmental rather than neoplastic in origin. Despite their benign origin and behavior, hemangiomas in the oral cavity are always of clinical importance to the dental profession and require appropriate clinical management. Surgery and other treatment modalities are not always satisfactory and have a higher morbidity, recurrence, and complication rate. This case report presents a case of hemangioma of mandibular left lower region in 47-year-old female and its treatment using sclerosing agent.

Hemangiomas are one of the most common neoplasms of infancy with an estimated prevalence of 1-3% among neonates and 10% among children of 1 year of age. It has a female predominance and occurs more frequently among Caucasians than other racial groups. Sixty percent of hemangiomas arise in the head and neck. In 80% of cases, hemangiomas occur as single lesions. They are probably developmental rather than neoplastic in origin. Despite their benign origin and behavior, hemangioma in the oral cavity is always of clinical importance to the dental profession and requires appropriate clinical management as sometimes it is associated with complications like bleeding and ulceration. Here, we report a case of hemangioma of tongue treated with sodium tetradecyl sulfate, a sclerosing agent.

ObjectivesTo determine the effects of sclerosant foam preparation and composition on foam structure, the time course of liquid drainage, and foam coarsening.MethodsSodium tetradecyl sulphate (STS) and polidocanol (POL) foams were investigated in a range of concentrations (0.5–3%) and liquid-plus-air fractions (LAF; 1 + 2 to 1 + 8). Foam was injected into a vein simulation model (polyvinyl chloride tubing, inner diameter 3 mm, constant pressure 5–7 mmHg) filled with saline or blood. Liquid drainage, bubble count, and diameter were measured and documented by serial photography.ResultsLiquid drainage was faster in the vertical position than the horizontal one. In all variations, very small bubbles (diameter 250 μm) and by 7.5 minutes macro-foams (>500 μm) were formed. Following injection, the upper regions of foam coarsened faster as liquid drained to the bottom of the vessel. Wet preparations produced significantly smaller bubbles. Low concentration POL foam produced significantly higher bubble counts and coarsened slower than STS.ConclusionsFoam structure is strongly influenced by the LAF. Despite the initial formation of micro-bubbles in the syringe, mini- and macro-bubbles are formed in target vessels with time post-injection.

Objective: To determine the efficacy of sclerotherapy for venous malformations (VMs). Methods: PubMed was used to search the medical literatures for publication on the combined topics of “VMs and sclerotherapy.” The final evaluation of the venous lesions was based on both objective parameters and subjective parameters. Complications were also recorded. Results: A total of 35 studies published between 1986 and 2011 matched the selection criteria and were included. Ethanol, polidocanol, ethanolamine oleate, and sodium tetradecyl sulfate (STS) are the 4 mainstream sclerosants. The total efficiency of these 4 sclerosants all exceeded 90% except STS. Skin damage (10.0%) was the most common minor complication. Other complications included renal damage (3.9%), nerve damage (1.85%), muscle damage (0.66%), pulmonary embolism (0.25%), cardiovascular collapse (0.08%), and others. Conclusions: Sclerotherapy is effective for VMs. However, there is limited evidence from randomized clinical trials to support the use of any kinds of sclerosants.

The objective of the study was to review the literature reporting visual disturbance (VD) following sclerotherapy for varicose veins. Underlying mechanisms will be discussed. A literature search of the databases Medline and Google Scholar was performed. Original articles including randomized trials, case series and case reports reporting VD in humans following sclerotherapy for varicose veins were included. Additional references were also obtained if they had been referenced in related publications. The search yielded 4948 results of which 25 reports were found to meet the inclusion criteria. In larger series with at least 500 included patients the prevalence of VD following sclerotherapy ranges from 0.09% to 2%. In most reports foam sclerotherapy was associated with VD (19); exclusive use of liquid sclerosant was reported in two cases, some reports included foam and liquid sclerosant (4). There were no persistent visual disorders reported. VD occurred with polidocanol and sodium tetradecyl sulphate in different concentrations (0.25–3%). Various forms of foam preparation including various ways of foam production and the liquid – air ratio (1 or 2 parts of liquid mixed with 3, 4 or 5 parts of air) were reported in association with the occurrence of VD. VDs following sclerotherapy for varicose veins are rare and all reported events were transient. Bubble embolism or any kind of embolism seems unlikely to be the only underlying mechanism. A systemic inflammatory response following sclerotherapy has been suggested. Further research to clarify the mechanism of action of sclerosants is required.

Symptomatic slow-flow vascular malformations include venous malformations and lymphatic malformations, as well as combined anomalies. Endovascular therapy, consisting mainly of intralesional sclerosant injection, is now accepted as the primary treatment for most of these lesions. Magnetic resonance imaging and ultrasonography supplement physical examination for diagnosis and assessment of the extent of malformation. Endovascular treatment is usually carried out under general anesthesia. Sclerosants for venous malformations include ethanol, 3% sodium tetradecyl sulfate, and bleomycin. Lymphatic malformations can be injected with doxycycline, bleomycin, OK-432, or other sclerosants. Complications of sclerotherapy include tissue necrosis, peripheral nerve injury, hemoglobinuria, deep vein thrombosis, and pulmonary embolism. Although most vascular malformations are not cured, the majority of patients benefit from endovascular treatment.

The present study was carried out with an aim to perform a prospective study to establish the role of sodium tetradecyl sulfate (3 %) (STDS) as a safe and effective sclerosant in the management of primary hydrocele. Sclerotherapy was performed with 3 % STDS on an outdoor basis. The amount of sclerosant injected depended on the amount of fluid drained. All patients were given prophylactic antibiotics. Patients were clinically reassessed at 1 week, 1 month, 3 months, and 6 months and earlier if complications occur. The data were analyzed using Statistical Package for Social Sciences Version 15.0. The data have been represented as frequencies and percentages. Chi-square test was used to compare the data. A total of 57 patients with primary vaginal hydrocele gave consent for being enrolled in the study. The age of patients ranged from 18 to 65 years with a mean age of 35.72 ± 13.18 years. The success rate at the end of the study was observed to be 84.2 %. As regards patient satisfaction, in present study, in a limited time period of follow up, all the patients who had a successful procedure were satisfied. Overall, sclerotherapy was observed to be a relatively cost-effective (including both direct and indirect costs) procedure with low complications, high satisfaction, and a high success rate within the limited period of follow-up.

Background: Varicose veins and its dermatological complications like stasis dermatitis, ulcers, spontaneous bleeding are commonly seen in the dermatology clinics. Surgery has been the most often used treatment for varicose veins. Sclerotherapy refers to introduction of sclerosing solution into the varicose veins, which causes endothelial damage and subsequent fibrosis. Sclerotherapy is being practised extensively by dermatosurgeons in the west. However, there are no Indian studies which specifically evaluate the role of sclerotherapy in the management of varicose veins and its skin complications. Hence, this study aims to evaluate the efficacy of sclerotherapy in managing varicose veins and its complications. Aims: To study the safety and efficacy of sclerotherapy in the treatment of varicose veins and its dermatological complications. Methods: This is a prospective study involving 50 patients with varicose veins and its dermatological complications attending the dermatology out-patient department. The study was conducted over a period of 18 months. After thorough clinical, laboratory, and radiological evaluation, the patients were treated with sclerotherapy using Sodium Tetradecyl Sulphate of various concentrations depending on the vessel size. The patients were then followed up to look for disappearance of veins, healing of ulcers and eczema, and any complications.Results: Patients showed a good response to treatment with sclerotherapy. 70-80% of patients showed symptomatic improvement along with disappearance of veins and healing of eczema and ulcers. Most of the complications were minor, which resolved over a period of few weeks. Conclusion : Sclerotherapy is a simple, safe and effective procedure for the treatment of varicose veins and its dermatological complications. The procedure is particularly effective for smaller, early varicosities and also for residual veins after surgery. Hence we recommend more and more of our fellow dermatologists to take up this procedure, which can be an efficient tool to manage patients with varicose veins and its related complications.

Summary Introduction and aims Sclerotherapy has become first line treatment for most venous malformations and some lymphatic malformations. We aimed to measure our sclerotherapy treatment success using 3% sodium tetradecyl sulphate (STD) and describe our experience. Materials and methods Retrospective five year review (Jan 04–09) of children with vascular malformations treated at our centre with 3% STD. Patients were classified using the Birmingham classification and treatment success was measured through case note review and pre- and post-treatment photographs. Findings and results Forty-three (84.3%) of the 51 patients with vascular malformations (VM) who underwent sclerotherapy derived a benefit. Twelve patients (23.5%) had an excellent result, 31 (60.8%) were improved whilst eight (15.7%) were unchanged. Using Fisher's exact test, there was a statistically significant difference in achieving complete resolution of superficial VMs compared to lesions involving the deeper layers of the head and neck. 17.6% of patients developed a complication with an overall complication rate of 12.2% per injection. There was one major complication with the remainder consisting of superficial skin necrosis that resolved conservatively. Conclusions Treatment with 3% STD sclerotherapy is effective in venous and some lymphatic vascular malformations. It should be considered an important treatment modality within a multi-disciplinary setting in these difficult problems.