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Intradermal Injection of Normal Saline Prevents Cutaneous Complications Associated with Sclerotherapy for Superficial Venous Malformations

Kurita, Masakazu M.D., Ph.D.; Ozaki, Mine M.D., Ph.D.; Ihara, Aki M.D.; Kaji, Nobuyuki M.D., Ph.D.; Harii, Kiyonori M.D., Ph.D.

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Plastic and Reconstructive Surgery: April 2012 - Volume 129 - Issue 4 - p 772e-774e
doi: 10.1097/PRS.0b013e318245ea13
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Sir:

Figure
Figure

Sclerotherapy is an effective first-line therapeutic option for the treatment of venous malformations. Several types of sclerotic agents, including absolute ethanol, 5% ethanolamine oleate, and 3% polidocanol, have proven to be effective.13 However, stronger sclerotic agents are associated with an increased likelihood of complications caused by damage to the surrounding healthy tissues.4 Strong agents are thus often not well used, especially for the treatment of superficial venous malformation, because of the risk of cutaneous complications such as ulceration, necrosis, subsequent scarring, and hyperpigmentation.5

We devised a new therapeutic protocol aimed at overcoming these clinical drawbacks, in which normal saline was administered into the subcutaneous tissues just above a venous malformation lesion immediately after intraluminal injection of sclerotic agents. We recently reported experimental verification of the protective effect of this protocol on skin using a rabbit ear sclerotic agent–retention model.4 Absolute ethanol was used as the sclerotic agent in this previous experiment; although this agent is known to be effective, it is not recommended for superficial lesions because of the high risk of cutaneous complications.1 However, prophylactic subcutaneous injection of normal saline completely prevented skin necrosis in an experimental setting. It is likely that this was the result of dilution of the leaked agent with saline, elongation of the distance to the skin by hydrodissection, and interstitial fluid flow4 (Fig. 1).

Fig. 1
Fig. 1:
Schematic depiction of mechanisms by which subcutaneous injection of normal saline could prevent cutaneous disorders. After intravenous injection of a sclerotic agent, a proportion of the injected agent leaks through the vascular wall. Leaked sclerotic agent causes subcutaneous inflammation and damage to the skin (left). Subcutaneous injection of normal saline after intravenous injection of a sclerotic agent reduces the risks of potential complications by dilution, elongation of the distance to the skin by hydrodissection, and interstitial fluid flow from superficial subcutaneous tissues toward deep tissues (center). The injection of normal saline into the thick dermis in clinical settings is relatively easy. The thick dermis retains the normal saline and acts as an efficient defensive wall, preventing leakage of sclerotic agents (right).

Based on these experimental findings, we initiated the clinical use of prophylactic normal saline injection during sclerotherapy of superficial venous malformations. To date, a total of 10 cases of superficial cutaneous venous malformation have been treated with satisfactory results and no evidence of substantial cutaneous complications. This early series of clinical experiences revealed that the human dermis was particularly well suited to the use of this procedure because its thick strong nature aided the injection and retention of normal saline. A schematic depiction of the procedure and the clinical findings during the treatment are shown in Figure 2. Intradermal injection of normal saline can be performed more easily in human skin than in experimental animals. The dermis retains the normal saline and works as an efficient defensive wall, preventing infiltration of leaked sclerotic agents (Fig. 1).

Fig. 2
Fig. 2:
Ethanol sclerotherapy with intradermal injection of normal saline. The lesional vein is punctured directly (1). Immediately after intralesional injection of absolute ethanol, normal saline is injected into the dermis using a fine needle to cover the transparent bluish vascular lesion (2). Intradermal injection of normal saline results in dilatation of the dermis, which acts as a defensive wall between the vascular lesion and the epidermis.

We consider that the clinically protective effect of this new protocol is superior to that demonstrated in experimental settings, and the results suggest that it is suitable for use with any type of sclerotic agent (including foam sclerotherapy3). The injection of normal saline is essentially a safe procedure that should not harm the surrounding tissues, provided that no accidental puncture of the lesional vascular surface occurs.

We therefore recommend the use of intradermal injection of normal saline during the treatment of superficial venous malformation. This technique would allow the use of larger volumes of stronger sclerotic agents to treat even superficial venous malformation lesions and would thus contribute to the enhancement of sclerotherapeutic efficacy.

Masakazu Kurita, M.D., Ph.D.

Mine Ozaki, M.D., Ph.D.

Aki Ihara, M.D.

Nobuyuki Kaji, M.D., Ph.D.

Kiyonori Harii, M.D., Ph.D.

Department of Plastic Surgery, Kyorin University School of Medicine, Tokyo, Japan

DISCLOSURE

The authors have no competing financial interests to disclose.

REFERENCES

1. Berenguer B, Burrows PE, Zurakowski D, Mulliken JB. Sclerotherapy of craniofacial venous malformations: Complications and results. Plast Reconstr Surg. 1999;104:1–11; discussion 12–15.
2. Kaji N, Kurita M, Ozaki M, et al.. Experience of sclerotherapy and embolosclerotherapy using ethanolamine oleate for vascular malformations of the head and neck. Scand J Plast Reconstr Surg Hand Surg. 2009;43:126–136.
3. Yamaki T, Nozaki M, Sakurai H, Takeuchi M, Soejima K, Kono T. Prospective randomized efficacy of ultrasound-guided foam sclerotherapy compared with ultrasound-guided liquid sclerotherapy in the treatment of symptomatic venous malformations. J Vasc Surg. 2008;47:578–584.
4. Ihara A, Kurita M, Ozaki M, et al.. Subcutaneous injection of normal saline prevents cutaneous complications of ethanol sclerotherapy for superficial vascular lesions: An experimental study. Dermatol Surg. 2011;37:1125–1132.
5. Goldman MP, Sadick NS, Weiss RA. Cutaneous necrosis, telangiectatic matting, and hyperpigmentation following sclerotherapy: Etiology, prevention, and treatment. Dermatol Surg. 1995;21:19–29.

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