Successful lysis in a stroke following endovenous laser ablation and extensive miniphlebectomy of varicose veins

Report

A 63-year-old Caucasian woman presented on April 2015 at the emergency department with a motoric aphasia and a right-sided brachiofacial hemisyndrome. She was smoker and had a treated arterial hypertension.

The day before she underwent at another institution an endovenous laser ablation (EVLA) of both great saphenous vein (GSV) combined with extensive miniphlebectomy on both legs and ligation of a perforating vein on her left leg performed under tumescence anesthesia. The EVLA was performed by a 1470 nm Intros radial laser operating at 10 W. The treated length was left 25 cm (1200 J) and right 70 cm (4013 J). The intervention was echoguided, and the fiber was pushed on both sides up to 1 cm distal of the confluence of the GSV in the common femoral vein. At the end of the procedure, a dressing by cotton wool pads and a bandage of both legs was applied. A prophylactic dose of low-molecular weight heparin (enoxaparinum natricum) was administered subcutaneously after a total procedure duration of approximately 90 min.

At the emergency department, an immediate computed tomographic brain scan showed signs of an occlusion of the anterior branch of the left middle cerebral artery and an ischemic formation of the left frontal operculum. After a weight-adapted intravenous thrombolysis with 50 mg rtPA, the clinical signs showed a remission (initial NIHSS 13 points, after the lysis NIHSS 2 points with 1 point for facial palsy and 1 point for drift down of the right arm). Magnetic resonance imaging 24 h after the lysis showed diffusion abnormalities consistent with an acute left-sided ischemic stroke and no signs of intracranial bleeding (Figure 1). OPEN IN VIEWER

In the search for the source of embolism, a carotid artery duplex showed no stenosis or other possible sources of emboli, a 24 h ECG showed no relevant arrhythmia and the investigations for thrombophilia were negative. Three days postoperative, a lower extremity vein ultrasound showed no deep vein thrombosis (femoro-popliteal and crural) in either extremity, but a bilateral thrombus extension up to the level of the GSV-femoral vein junction (EHIT class I) (Figure 2). On the transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE), there was evidence of a big atrial septum aneurysm without thrombus formation, a big PFO and 1–2 little defects of the septum showing right-to-left shunt in basal conditions. OPEN IN VIEWER

During and after the lysis treatment, compression of the legs using three-layer bandaging was continued and limited bleedings in the area of the miniphlebectomy were recorded (Figure 3). The follow-up was characterized by a daily neurological improvement returning nearly to baseline, and the patient was discharged on oral anticoagulation therapy with a recommended duration of minimal of three months. Furthermore, a closure of the PFO is still in evaluation. OPEN IN VIEWER

Discussion

Given the similar efficacy and better overall safety compared to the saphenofemoral ligation and vein stripping, endovenous thermal treatments (EVLA, RFA) are meanwhile the first-line treatment option for varicose veins. ¹ EVLA is a safe procedure; however, complications can occur. Minor complications are pain, bruising, erythema, hematoma, hyperpigmentation, teleangiectatic matting and nerve injury. Major complications are rare and include venous thromboembolism (0–2%), infection, skin burns (<1%), arterial damage (<1%), fiber breakage during EVLA and stroke. ²

In this case, an ischemic stroke occurred in a patient with an unknown right-to-left shunt one day after EVLA. No other evident sources of emboli other than an extension of the saphenic EVLA-induced thrombus could be detected. Ablation of both GSV and bilateral concomitant miniphlebectomy along with a prolonged procedure duration might have had increased the risk for thrombus formation. In contrast with the previously reported cases,^3,4 a lysis therapy was successfully performed. Concomitant compression therapy is recommended to limit bleedings from the miniphlebectomy area.