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• W2051214228 abstract "This report describes an ischemic stroke following endovenous laser treatment of the great saphenous vein in a patient with a patent foramen ovale. No thrombophilic conditions or other possible sources of emboli could be demonstrated. This report describes an ischemic stroke following endovenous laser treatment of the great saphenous vein in a patient with a patent foramen ovale. No thrombophilic conditions or other possible sources of emboli could be demonstrated. Endovenous laser treatment (EVLT) is currently used in selected patients for the ablation of lower extremity varicose veins. First attempts of EVLT date back to 1989 by Puglisi,1Puglisi R. Tacconi A. Sanfilippo S. L'application du laser ND-YAG dans le traitement du syndrome variquex.in: Proceedings 10th World Congress of Phlebologie, Strasbourg, 25-29 Sept, 1989 John Libbey Eurotext, Paris1992: 677-679Google Scholar but it was in 1999 that Boné2Bone C. Tratamiento endoluminal de las varices con laser de diodo: estudio preliminary.Rev Patol Vasc. 1999; 5: 35-46Google Scholar reported on the successful use of diode laser in the treatment of great saphenous vein (GSV) reflux. Moreover, many reports about the efficacy and safety of EVLT have been published.3van den Bos R. Arends L. Kockaert M. Neumann M. Nijsten T. Endovenous therapies of lower extremity varicosities: a meta-analysis.J Vasc Surg. 2009; 49: 230-239Abstract Full Text Full Text PDF PubMed Scopus (455) Google Scholar Continuous technological and methodological improvements have determined reduction of morbidity which is currently considered lower than with conventional GSV stripping.4Rasmussen L.H. Bjoern L. Lawaetz M. Bleming A. Eklof B. Randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patients with varicose veins: short-term results.J Vasc Surg. 2007; 46: 308-315Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar Major complications were rarely reported.5Eidson J.L. Shepherd L.G. Bush R.L. Aneurysmal dilatation of the great saphenous vein stump after endovenous laser ablation.J Vasc Surg. 2008; 48: 1037-1039Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar This report describes an ischemic stroke following EVLT of a varicose GSV. On April 10, 2008, a 59-year-old Caucasian woman underwent EVLT of the right GSV for primary varicose veins at another institution. Her medical history included left mastectomy (1981) followed by mammary reconstruction. She did not take medication. Preoperative coagulative evaluations (blood cell count, antithrombin 3, prothrombin time, activated partial prothrombin time, and fibrinogen) were normal. Her initial duplex ultrasound (DUS) study demonstrated right sapheno-femoral junction (SFJ) incompetence with GSV reflux. The caliber of the GSV was not reported. Endovenous laser ablation of the right GSV was performed under local anaesthesia with mild sedation (midazolam, 2 mg), by a 600 micrometer fiber connected to a 980 nm diode laser source operating at 8 watts. The fiber was pushed up to the groin just below the orifice of the inferior epigastric and operated under echoguide. Pull-out rate of the fiber was 1 mm/sec, with a continuous emission (energy delivered 78J/cm). At the end of the procedure, a single dose of low molecular weight heparin (LMWH; nadroparin, 03 ml) was administered subcutaneously and a class II elastic stocking was applied. The postoperative report confirmed successful obliteration of the treated segment of the GSV without complication. One hour after the end of the procedure, the patient was able to walk. No signs or symptoms of deep vein thrombosis (DVT) were noted at discharge. On the evening of April 15, the patient reported unspecific visual disturbances and on the next morning she suddenly developed right side hemiparesis with global aphasia. A brain computed tomography (CT) was negative for hemorrhage. Trans cranial Doppler (TCD) demonstrated complete occlusion of the left middle cerebral artery (MCA) at its origin but DUS of carotid arteries did not show occlusions, stenosis, or other possible sources of emboli. Pharmacologic treatment was adjuvated by sonothrombolysis enhanced with endovenous administration of five bolus of sulphur hexafluoride-filled microbubbles. The day after, also the A1 segment of the anterior cerebral artery (ACA) was occluded and sonothrombolysis repeated. Four days after the stroke, TCD demonstrated “recanalization of the ACA, occlusion of the MCA with compensatory increase of flow in the left posterior cerebral.” Brain CT showed an extensive hypodense area in the territory of distribution of the frontoparietal branches of the MCA (Fig 1). On April 24, both legs were investigated by Duplex ultrasound but no thrombosis could be found in deep, superficial, and calf veins. In turn, transesophageal echocardiography (TEE) showed patent foramen ovale (PFO) with an associated atrial septal aneurism (type IC). The bubble test demonstrated a grade 3 right-to-left shunt in basal conditions. One month after the stroke, TCD demonstrated the recanalization of the M1 segment of the MCA, with high resistance in the M2 tract. Finally, the PFO was corrected percutaneously, by BioSTAR 28 mm NMT Medical Inc, Boston, Mass). One year after the stroke, she still suffers from aphasia and severe hemiparesis. No cancer recurrence or other malignancies could be demonstrated. Hematologic investigations excluded hypercoagulability. In fact, homocystein, LAC screen, SCT screen, protein C and S, APCR, Factor V Leyden, ACA, ANA, and ENA antibodies were negative. MTHFR mutation C677T was present in heterozygosis. DUS demonstrated the fibrotic involution of GSV trunk. The proximal border of GSV occlusion was at about 4 cm from the saphenous ending and 2 cm from the orifice of the inferior epigastric (Fig 2). Previous reports have claimed efficacy and overall safety of EVLT. Bruising and a “pulling” sensation along the inner thigh are common side-effects of EVLT.5Eidson J.L. Shepherd L.G. Bush R.L. Aneurysmal dilatation of the great saphenous vein stump after endovenous laser ablation.J Vasc Surg. 2008; 48: 1037-1039Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar The overall rate of minor-complication, skin burn injuries, induration, self-limited superficial phlebitis, and skin pigmentation ranges between 0% and 15%.5Eidson J.L. Shepherd L.G. Bush R.L. Aneurysmal dilatation of the great saphenous vein stump after endovenous laser ablation.J Vasc Surg. 2008; 48: 1037-1039Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Major non-thrombotic complications like aneurism of the saphenic stump,5Eidson J.L. Shepherd L.G. Bush R.L. Aneurysmal dilatation of the great saphenous vein stump after endovenous laser ablation.J Vasc Surg. 2008; 48: 1037-1039Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar arteriovenous fistula,6Timperman P.E. Arteriovenous fistula after endovenous laser treatment of the short saphenous vein.J Vasc Interv Radiol. 2004; 15: 625-627Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar and diffuse phlegmonous hypodermitis7Dunst K.D. Huemer G.M. Wayand W. Shamiyeh A. Diffuse phlegmonous phlebitis after endovenous laser treatment of the greater saphenous vein.J Vasc Surg. 2006; 43: 1056-1058Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar are seldom reported. To our knowledge, no pulmonary embolism (PE) or stroke have been described. PE has been described after radiofrequency ablation of the GSV11Puggioni A. Kalra M. Carmo M. Mozes G. Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications.J Vasc Surg. 2005; 42: 488-493Abstract Full Text Full Text PDF PubMed Scopus (261) Google Scholar and a transient stroke after foam sclerotherapy of the GSV.14Forlee M.V. Grouden M. Moore D.J. Shanik G. Stroke after varicose vein foam injection sclerotherapy.J Vasc Surg. 2006; 43: 162-164Abstract Full Text Full Text PDF PubMed Scopus (215) Google Scholar Prevalence of DVT after EVLT ranges between 0% and 7.7% for the GSV8Gibson K.D. Ferris B.L. Polissar N. Neradilek B. Pepper D. Endovenous laser treatment of the short saphenous vein: Efficacy and complications.J Vasc Surg. 2007; 45: 795-803Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar and between 0% and 5.7% for the small saphenous vein (SSV).9Kontothanassis D. Di Mitri R. Ferrari R.S. Zambrini E. Camporese G. Gerard J.L. Labropoulos N. Endovenous laser treatment of the small saphenous vein.J Vasc Surg. 2009; 49: 973-979Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Differences in rates of DVT are probably related to different timing of post operative DUS.8Gibson K.D. Ferris B.L. Polissar N. Neradilek B. Pepper D. Endovenous laser treatment of the short saphenous vein: Efficacy and complications.J Vasc Surg. 2007; 45: 795-803Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar In fact, EVLT-DVT consists of a tail of thrombus extending into the femoral vein10Mozes G. Kalra M. Carmo M. Swensen L. Gloviczki P. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation techniques.J Vasc Surg. 2005; 41: 130-135Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar or even of a floating thrombus,11Puggioni A. Kalra M. Carmo M. Mozes G. Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications.J Vasc Surg. 2005; 42: 488-493Abstract Full Text Full Text PDF PubMed Scopus (261) Google Scholar which would develop in the first postoperative days to possibly regress later.8Gibson K.D. Ferris B.L. Polissar N. Neradilek B. Pepper D. Endovenous laser treatment of the short saphenous vein: Efficacy and complications.J Vasc Surg. 2007; 45: 795-803Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar Since femoral and popliteal veins are incompletely occluded by the thrombus, EVLT-DVT is mostly asymptomatic and can be evidenced only by DUS.8Gibson K.D. Ferris B.L. Polissar N. Neradilek B. Pepper D. Endovenous laser treatment of the short saphenous vein: Efficacy and complications.J Vasc Surg. 2007; 45: 795-803Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar, 9Kontothanassis D. Di Mitri R. Ferrari R.S. Zambrini E. Camporese G. Gerard J.L. Labropoulos N. Endovenous laser treatment of the small saphenous vein.J Vasc Surg. 2009; 49: 973-979Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 10Mozes G. Kalra M. Carmo M. Swensen L. Gloviczki P. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation techniques.J Vasc Surg. 2005; 41: 130-135Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar Therefore, prevalence of DVT is higher in studies with early post-procedure DUS.7Dunst K.D. Huemer G.M. Wayand W. Shamiyeh A. Diffuse phlegmonous phlebitis after endovenous laser treatment of the greater saphenous vein.J Vasc Surg. 2006; 43: 1056-1058Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 8Gibson K.D. Ferris B.L. Polissar N. Neradilek B. Pepper D. Endovenous laser treatment of the short saphenous vein: Efficacy and complications.J Vasc Surg. 2007; 45: 795-803Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar, 9Kontothanassis D. Di Mitri R. Ferrari R.S. Zambrini E. Camporese G. Gerard J.L. Labropoulos N. Endovenous laser treatment of the small saphenous vein.J Vasc Surg. 2009; 49: 973-979Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 10Mozes G. Kalra M. Carmo M. Swensen L. Gloviczki P. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation techniques.J Vasc Surg. 2005; 41: 130-135Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar, 11Puggioni A. Kalra M. Carmo M. Mozes G. Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications.J Vasc Surg. 2005; 42: 488-493Abstract Full Text Full Text PDF PubMed Scopus (261) Google Scholar On the contrary, most studies which timed the first DUS at a longer distance to evaluate long-term efficacy of EVLT did not evidence DVT.12Min R.J. Khilnani N. Zimmet S.E. Endovenous laser treatment of saphenous vein reflux: long-term results.J Vasc Interv Radiol. 2003; 14: 991-996Abstract Full Text Full Text PDF PubMed Scopus (543) Google Scholar, 13Ravi R. Rodriguez-Lopez J.A. Traylor E.A. Barrett D.A. Ramaiah V. Diethrich E.B. Endovenous ablation of incompetent saphenous veins: a large single-center experience.J Endovasc Ther. 2006; 13: 244-248Crossref PubMed Scopus (107) Google Scholar In the reported case, an ischemic stroke occurred five days after EVLT of the right GSV due to embolic occlusion of the left MCA. No evident sources of emboli could be demonstrated at heart and carotid levels, whereas TEE demonstrated PFO. Duplex was negative for leg DVT but it was performed only 14 days after EVLT. The patient was not afflicted by any malignancies or other pro-thrombotic conditions. In the absence of any other obvious source, it is strongly suspected that the stroke resulted from paradoxical embolism from the operated leg through PFO. The temporal relationship of the incident and the TCD findings lends further support to this.8Gibson K.D. Ferris B.L. Polissar N. Neradilek B. Pepper D. Endovenous laser treatment of the short saphenous vein: Efficacy and complications.J Vasc Surg. 2007; 45: 795-803Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar, 9Kontothanassis D. Di Mitri R. Ferrari R.S. Zambrini E. Camporese G. Gerard J.L. Labropoulos N. Endovenous laser treatment of the small saphenous vein.J Vasc Surg. 2009; 49: 973-979Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 10Mozes G. Kalra M. Carmo M. Swensen L. Gloviczki P. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation techniques.J Vasc Surg. 2005; 41: 130-135Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar, 11Puggioni A. Kalra M. Carmo M. Mozes G. Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications.J Vasc Surg. 2005; 42: 488-493Abstract Full Text Full Text PDF PubMed Scopus (261) Google Scholar The development of the saphenic thrombus looks to be not prevented by withdrawing the probe distal to the inferior epigastric vein, this precaution being adopted by all current protocols including the reported case. Moreover, the supra-inguinal location of these thrombi makes postoperative compression ineffective at all. This case illustrates a major, potentially fatal complication of treatment for a benign condition due to an unknown PFO. Routine transthoracic echocardiography may fail to demonstrate a PFO, which exact evaluation needs TEE with bubble test. In order to prevent thromboembolic complications, systematic LMWH administration for seven days was proposed.9Kontothanassis D. Di Mitri R. Ferrari R.S. Zambrini E. Camporese G. Gerard J.L. Labropoulos N. Endovenous laser treatment of the small saphenous vein.J Vasc Surg. 2009; 49: 973-979Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 11Puggioni A. Kalra M. Carmo M. Mozes G. Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications.J Vasc Surg. 2005; 42: 488-493Abstract Full Text Full Text PDF PubMed Scopus (261) Google Scholar We have preferred to advance the first DUS at the fourth postoperative day to possibly intervene during early thrombus development. Further studies are required to possibly determine: 1) The cause of cranial extension of the saphenic EVLT-induced thrombus; 2) which patients are at higher risk of DVT, and 3) if prophylactic anticoagulation11Puggioni A. Kalra M. Carmo M. Mozes G. Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications.J Vasc Surg. 2005; 42: 488-493Abstract Full Text Full Text PDF PubMed Scopus (261) Google Scholar or combined high ligation15Kalteis M. Berger I. Messie-Werndl S. Pistrich R. Schimetta W. Pölz W. Hieller F. High ligation combined with stripping and endovenous laser ablation of the great saphenous vein: Early results of a randomized controlled study.J Vasc Surg. 2008; 48: 822-829Abstract Full Text Full Text PDF Scopus (103) Google Scholar are warranted, at least in selected patients. Conception and design: ACAnalysis and interpretation: AC, MFData collection: AC, MFWriting the article: AC, MFCritical revision of the article: AC, MFFinal approval of the article: AC, MFStatistical analysis: N/AObtained funding: N/AOverall responsibility: AC" @default.
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• W2051214228 title "Stroke following endovenous laser treatment of varicose veins" @default.
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