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FAILURE TO RESPOND TO SCLEROTHERAPY

Failure of sclerotherapy (defined as failure to eliminate the vessels being treated, or immediate recurrence) usually results from an incorrect diagnosis and treatment plan, failure of medication delivery, or noncompliance with recommended compression. Table 18-1 outlines the measures to ponder when a patient does not respond to sclerotherapy.

TABLE 18-1When Patients Do Not Respond to Sclerotherapy

Diagnosis and Treatment Plan

In the majority of cases, it is found that some high-pressure source of reflux was not adequately addressed prior to sclerosis of terminal varices. After a treatment failure, Duplex ultrasound evaluation should be performed to ensure that the pattern of reflux is fully understood. Although Chapter 7 includes a case study of treatment failure successfully corrected by Doppler-guided sclerotherapy. Today, Duplex ultrasound examination has largely replaced Doppler evaluation. If junctional incompetence is at the root of treatment failure, endovenous ablation of the reflux is indicated before proceeding to secondary sclerotherapy or local phlebectomy. Prolonged pigmentation following sclerotherapy may also be due to continued hydrostatic pressure from a proximal source and should be investigated by Duplex ultrasound.

Sclerosant

In some cases of treatment failure, it is found that the concentration and volume of the sclerosant used were insufficient to overcome dilution by blood flowing in the treated vessel, especially when using liquid sclerosant as opposed to foam. Switching from liquid to foam sclerosant can be a successful method of getting veins larger than 2 mm to respond if they have had a poor response to liquid. If a vessel is too large to be treated using the maximum recommended doses of available sclerosants and/or foamed sclerosants, combinations of more than one sclerosant may be used in sequence. Some patients are resistant to one category of sclerosing solution, yet when switched to another, i.e., from detergent to hyperosmolar, they respond well. Surgical removal by phlebectomy offers an excellent alternative for vessels that are resistant to chemical ablation. Radiofrequency or laser endovenous ablation of the saphenofemoral junction (SFJ) is the preferred and more effective alternative to sclerotherapy of the SFJ in the United States in 2011.

Compression

If the amount of compression used (or patient compliance with compression) is insufficient to adequately compress a large vessel, a large thrombus will form and likely will later recanalize. Drainage of the coagula from this thrombus followed by compression will help it sclerose (Chapter 24). Compression stockings provide dependable compression and the use of two pairs of stockings ...

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