Taro Kono

Prospective randomized efficacy of ultrasound-guided foam sclerotherapy compared with ultrasound-guided liquid sclerotherapy in the treatment of symptomatic venous malformations

OBJECTIVE To compare the clinical outcome between ultrasound-guided foam sclerotherapy (UGFS) and ultrasound-guided liquid form sclerotherapy (UGLS) in patients with venous malformations (VM). METHODS Eighty-nine patients with symptomatic VM were treated with ultrasound-guided sclerotherapy. There were 22 males and 67 females with mean age of 14.5 years. The sclerosing agents used were 1% polidocanol (POL) or 10% ethanolamine oleate (EO). POL was injected predominantly into smaller, superficial lesions, whereas EO was used for large, deeper lesions. Foam sclerosing solution was provided using Tessaris method. Patients were randomized to receive either UGFS or UGLS. Post-sclerotherapy surveillance was done at 6 months after last session using duplex ultrasound. Findings obtained by duplex scanning were divided into four groups: (1) disappeared group: the venous space was occluded and was totally shrunk; (2) partially recanalized group: the venous space was partially recanalized and was partially shrunk; (3) totally recanalized group: the venous space was totally recanalized and returned at the same size; and (4) worsened group: the venous space was totally recanalized and became worse. RESULTS Forty-nine patients were treated with UGFS and the remaining 40 were treated with UGLS. There were no significant differences in age and men:women ratio. There was no significant difference in the anatomic distribution of VMs between the two groups. The amount of POL was significantly smaller in patients who were treated with UGFS (P = .022). Similarly, there was a significant reduction in the use of EO in patients treated with UGFS (P = .005). The proportion of VM with total disappearance and partial recanalization was significantly higher in patients treated with UGFS (P = .002). No major complications related to sclerotherapy were encountered in both groups. CONCLUSIONS These findings suggest that UGFS could have greater promise compared with UGLS in the treatment of VMs.

A review of the metabolism of 1,4-butanediol diglycidyl ether-crosslinked hyaluronic acid dermal fillers.

BACKGROUND Cosmetic procedures are growing ever more common, and the use of soft tissue fillers is increasing. Practicing physicians need to be aware of the biological behavior of these products in tissue to enable them to respond to any safety concerns that their patients raise. OBJECTIVES To provide an overview of the metabolism of 1,4‐butanediol diglycidyl ether (BDDE)‐crosslinked hyaluronic acid (HA) dermal fillers and to examine the safety of the resulting byproducts. METHODS A review of available evidence was conducted. RESULTS After reaction with HA, the epoxide groups of BDDE are neutralized, and only trace amounts of unreacted BDDE remain in the product (<2 parts per million). When crosslinked HA, uncrosslinked HA, and unreacted BDDE degrade, they break down into harmless byproducts or into byproducts that are identical to substances already found in the skin. CONCLUSION Clinical and biocompatibility data from longer than 15 years support the favorable clinical safety profile of BDDE‐crosslinked HA and its degradation products. Given the strength of the empirical evidence, physicians should be confident in offering these products to their patients.

Multiple Small-Dose Injections Can Reduce the Passage of Sclerosant Foam into Deep Veins During Foam Sclerotherapy for Varicose Veins

OBJECTIVE To compare the proportion of foam sclerosant that enters deep veins between multiple injections of <0.5 ml foam per injection and a few injections of >0.5 ml foam per injection. DESIGN & METHODS One hundred and seven patients with superficial venous incompetence were randomised to receive either multiple injections of <0.5 ml 1% polidocanol (POL) -foam (multiple injections) or a few injections of >0.5 ml 1% POL-foam per injection (few injections) for the treatment of varicose tributaries. All patients then received ultrasound-guided foam sclerotherapy for refluxing great saphenous vein (GSV) using 3% POL-foam. Only a single session was allowed per patient in order to standardise treatment. Qualitative ultrasonographic inspection of the foam was carried out during a 5-min period before compression was applied. Post-sclerotherapy surveillance was done at day 3, 2 weeks, 1 month, 3 months, and 6 months. RESULTS Fifty-six limbs in 53 patients were treated with multiple injections and the remaining 56 limbs in 54 patients were treated with a few injections. There were no significant differences in age or male:female ratio between the groups. The mean volume of 1% POL-foam was 2.2 S.D. 0.6 ml (range: 0.7-4.0 ml) in the multiple injections group and 2.5 S.D. 0.6 ml (range: 1.0-4.0 ml) in the few injections group (p=0.003). The mean volume of 3% POL was 1.5 ml (range: 0.7-3.0 ml) and 1.4 ml (range: 0.7-3.0 ml), respectively (p=0.137). Ultrasonographic inspection immediately after sclerotherapy demonstrated that foam was distributed significantly more commonly in the deep veins of patients treated with a few injections (p=0.0003). Two (4%) of the patients treated with a few injections developed migraine during the procedure, but recovered quickly with no further complications. There was no significant difference in the success rate between the groups at 6 months (p=0.257). CONCLUSIONS These findings suggest that multiple small-dose injections can reduce the amount of foam sclerosant and the risk of foam sclerosant entering the deep veins in patients with superficial venous insufficiency.

Presence of lower limb deep vein thrombosis and prognosis in patients with symptomatic pulmonary embolism: preliminary report.

OBJECTIVES To investigate the presence of lower limb deep vein thrombosis (DVT) and prognosis in patients with symptomatic pulmonary embolism (PE). MATERIALS AND METHODS A total of 203 consecutive referral patients with PE were included. The distribution of DVT was evaluated with compression ultrasound (CUS), and all patients were then followed for 12 months for investigation of recurrence of venous thromboembolism (VTE) and fatal events as adverse outcome. RESULTS The mean age of the patients was 62.8 years, and 78 (38.4%) were males. DVT was found in 118 (58.1%) patients. Of these patients, 61 (30.0%) had proximal DVT. Multivariate analysis demonstrated that active cancer, inadequate anticoagulation, leg symptoms, male gender, presence of DVT, presence of proximal DVT, and previous DVT were independent risk factors for adverse outcome. A clinical risk score ranging from 0 to 10 points was generated on the basis of multivariate regression coefficients. Receiver operating characteristic curve analysis showed that an appropriate cut-off point for discriminating between the presence and the absence of an adverse event was 4. Using this category, 166 (81.8%) patients were classified as low risk and 37 (18.2%) as high risk for adverse outcome. The adverse event rates were 6.0% for the low-risk group and 59.5% for the high-risk group. CONCLUSIONS This study has confirmed the clinical significance of surveillance CUS in patients with a first episode of PE. Furthermore, a simple risk score on the basis of available variables can identify patients at risk of an adverse outcome in patients with PE.

High peak reflux velocity in the proximal deep veins is a strong predictor of advanced post-thrombotic sequelae.

Summary.  Background: The presence of reflux in the femoral vein (FV) and popliteal vein (POPV) after acute deep vein thrombosis (DVT) is considered to contribute to the development of advanced post‐thrombotic syndrome (PTS). However, a quantification of reflux has yet to be determined. The purpose of study was to determine the indicative parameters reflecting the progression of PTS. Methods: Venous abnormalities were evaluated in 131 limbs out of 130 patients who completed a six‐year follow‐up after an acute DVT. Clinical manifestations were categorized according to the clinical, etiologic, anatomic, and pathophysiologic (CEAP) classification, and the patients were divided into two groups at a six‐year follow‐up point: group I, C0–3Es,As,d,p,Pr,o, early chronic venous insufficiency (CVI); group II, C4–6Es,As,d,p,Pr,o, advanced CVI. Venous segments were examined whether they were occluded or recanalized. The reflux parameters assessed were the diameter (cm), the reflux time (RT; s), the peak reflux velocity (PRV; cm s−1), and total refluxed volume, and these parameters were assessed especially in the FV and POPV at the two‐year (early phase) and subsequent six‐year (late phase) follow‐up points after DVT. Results: There were 98 limbs in group I and 33 in group II. The frequency of venous reflux was significantly higher in group II (<0.0001). In contrast, the proportion of occlusion did not differ between the groups (P = 0.138). The proportions of FV and POPV incompetence were significantly higher in group II (P < 0.0001 and P < 0.0001, respectively). In these veins, the RT did not improve the discrimination power between the two groups. In contrast, the PRV had significant discrimination power in these veins at both the two‐ and six‐year follow‐up points. In the superficial venous system, there were no significant differences in any of the determined parameters between the groups. In group II, 19 patients (58%), who had early symptoms of CVI at the two‐year follow‐up point, subsequently developed advanced symptoms of PTS. After calculating a suitable cutoff point using receiver operating characteristic curves analysis at the two‐year follow‐up point, multivariable analysis showed that a PRV of >25.4 cm s−1 in the POPV was the strongest independent predictor of advanced CVI [odds ratio (OR) 60.32; 95% confidence interval (95CI) 43.1–1238.97, P < 0.0001]. Similarly, in the FV, a PRV of >24.5 cm s−1 was found to be a strong predictor of advanced CVI (OR 25.77, 95CI 10.56–331.12, P < 0.0001). Conclusions: These findings suggest that the presence of a high PRV in the proximal deep veins is an independent predictor of advanced symptoms of PTS.

The flashlamp-pumped pulsed dye laser (585 nm) treatment of hypertrophic scars in Asians.

Hypertrophic scars are common and cause functional and psychologic morbidity. Various treatment modalities have been advocated in the past, but the flashlamp-pumped pulsed-dye laser-585 nm (PDL) has been shown to be effective in the treatment of a variety of traumatic and surgical scars. This study was performed to determine the effectiveness of the PDL treatment of hypertrophic scars in Asians and to elucidate possible side effects and complications. Thirteen Asian patients with 19 hypertrophic scars that had no response to conservative therapies, such as pressure therapy, intralesional corticosteroid injection, or silastic gel sheeting for more than 6 months, were treated with the PDL. Three months after the last laser treatment, improvement in the appearance, reduction in scar height, and erythema as a result of the PDL treatment were evaluated and compared with baseline values. Compared with the baseline appearance, hypertrophic scars treated with the PDL showed a satisfactory clinical improvement of 84% (16 of 19), a significant percentage of scar flattening of 58.9 ± 22.1%, and of erythema elimination of 75.7 ± 19.9% at month 3 after the last laser treatment. The PDL treatment of hypertrophic scars can effectively improve scar pliability and texture and decrease erythema and associated symptoms. In addition, multiple treatment sessions are suggested for achieving greater response, but lower fluences are recommended for prevention of side effects in Asians with a higher melanin content of the skin.

The Use of Focused Ultrasound for Non-Invasive Body Contouring in Asians

Previous studies demonstrated that multiple treatments using focused ultrasound can be effective as an non‐invasive method for reducing unwanted localized fat deposits. The objective of the study is to investigate the safety and efficacy of this focused ultrasound device in body contouring in Asians.

Treatment of hypertrophic scars using a long-pulsed dye laser with cryogen-spray cooling.

Hypertrophic scars are common and cause functional and psychologic morbidity. The conventional pulsed dye laser (585 nm) has been shown previously to be effective in the treatment of a variety of traumatic and surgical scars, with improvement in scar texture, color, and pliability, with minimal side effects. This prospective study was performed to determine the effectiveness of the long-pulsed dye laser (595 nm) with cryogen-spray cooling device in the treatment of hypertrophic scars. Fifteen Asian patients with 22 hypertrophic scars were treated by the long-pulsed dye laser (595 nm) with cryogen-spray cooling device. In 5 patients, the scar area was divided into halves, one half of which was treated with the laser, whereas the other half was not treated and was used as a negative control. All patients received 2 treatments at 4-week intervals, and evaluations were done by photographic and clinical assessment and histologic evaluation before the treatment and 1 month after the last laser treatment. Treatment outcome was graded by a blind observer using the Vancouver General Hospital (VGH) Burn Scar Assessment Scale. Symptoms such as pain, pruritus, and burning of the scar improved significantly. VGH scores improved in all treated sites, and there was a significant difference between the baseline and posttreatment scores, corresponding to an improvement of 51.4 ± 14.7% (P < 0.01). Compared with the baseline, the mean percentage of scar flattening and erythema elimination was 40.7 ± 20.7 and 65.3 ± 25.5%, respectively (P < 0.01). The long-pulsed dye laser (595-nm) equipped with cryogen spray cooling device is an effective treatment of hypertrophic scars and can improve scar pliability and texture and decrease scar erythema and associated symptoms.

The use of variable pulse width frequency doubled Nd:YAG 532 nm laser in the treatment of port-wine stain in Chinese patients

Background. Variable pulse width frequency doubled Nd:YAG 532 nm laser has previously been shown to be effective in the treatment of vascular lesions in Caucasians. For dark‐skinned patients, such as Asians, its role has not been determined. Objective. To assess the clinical efficacy and complication rate of the 532 nm Nd:YAG laser in the treatment of port‐wine stain in Chinese patients. Methods. Chinese patients with port‐wine stain who had undergone Nd:YAG laser treatment were called for questionnaire assessment of their degree of clearing and clinical examination for complications by two independent observers. For 22 patients with pre‐ and posttreatment photographs, the two independent observers further assessed the degree of clearing. Results. Assessment of the questionnaire indicated that 62.9% of the patients subjectively considered that they had more than 25% clearing, with 33.3% having more than 50% clearing. For those with pre‐ and posttreatment photographs, the objective degree of improvement was less impressive with 18.1% of patients having at least 25% improvement and only 13.6% having more than 50% improvement. Pigmentary and texture changes were seen in both groups (33% in group I and 11% in group II). The number of treatment sessions rather than previous use of pulsed dye laser therapy was an important risk factor for complications. Conclusion. Nd:YAG laser is only partially effective for the treatment of port‐wine stain in Chinese patients. Although most patients recorded some degree of subjective improvement, many did not improve by objective assessment. High fluence is necessary to achieve the desirable clinical response, and while contact cooling reduces the risk of epidermal damage, texture changes can still occur. Further study is necessary to compare its use with other similar devices, such as a pulsed dye laser with cryogen spray cooling.

A retrospective analysis on the management of pigmented lesions using a picosecond 755-nm alexandrite laser in Asians

Photo‐aging in Chinese often presents with benign pigmentary lesions. Q‐switched lasers for pigmentary lesions in Asians had reported a risk of post‐inflammatory hyperpigmentation (PIH) up to 25%. Longer pulse widths in the millisecond domains were advocated with reduced risk of PIH. Recently, picosecond lasers of various wavelengths were introduced with proven efficacy in tattoo removal. The objective of this study is to assess the efficacy and safety of a novel picosecond 755‐nm alexandrite laser for the treatment of benign pigmented lesions in Asians retrospectively.