Pulmonary Vascular Disease |

Acute Pulmonary Emboli After Bleomycin Sclerotherapy for a Congenital Venous Malformation FREE TO VIEW

Bishoy Zakhary, MD; Ezra Dweck, MD; Leopoldo Segal, MD; David Steiger, MD
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NYU, New York, NY

Chest. 2015;148(4_MeetingAbstracts):967A. doi:10.1378/chest.2274699
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SESSION TITLE: Pulmonary Vascular Disease Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Venous malformations (VM) are common congenital vascular abnormalities that progressively increase in size. They are associated with pain, cosmetic deformity, and bleeding complications. Sclerotherapy has been used in the treatment of symptomatically enlarging VM. Common sclerosing agents include ethanol, tetracycline, and bleomycin. Sclerotherapy has rarely been associated with pulmonary embolus (PE). We report the first case of PE complicating bleomycin sclerotherapy for a bleeding VM.

CASE PRESENTATION: The patient is a 32 year old man with a large bleeding intraoral VM despite six prior sclerosing injections. The patient underwent out-patient bleomycin sclerotherapy under general anesthesia. Six days post-procedure, he was admitted with hemoptysis, dyspnea, and pleuritic chest pain. Oxygen saturation was 95%. Chest computed tomography with contrast revealed right middle and right lower lobar pulmonary emboli. Transthoracic echocardiogram demonstrated normal biventricular function and doppler ultrasound of upper and lower extremities was normal. The patient was treated with therapeutic anticoagulation and discharged on warfarin. An initial thrombophilia evaluation was normal. Hematology recommended 6 months of anticoagulant therapy with chemical prophylaxis for future sclerotherapy.

DISCUSSION: Complications of sclerotherapy for VM include skin necrosis, infection, sensory neuropathy, and PE. While ethanol is the most effective sclerosant, bleomycin reportedly has fewer complications. Of note, sclerotherapy has only rarely been associated with PE and almost exclusively in the setting of esophageal or gastric varices. To the best of our knowledge, this is the first case report of PE complicating bleomycin sclerotherapy for VM. The underlying mechanism is not well described but likely related to intimal injury. Given the paucity of case reports and uncertain mechanism, it is unclear if periprocedural chemical prophylaxis would be indicated or effective for the prevention of venous thromboembolism.

CONCLUSIONS: Sclerotherapy of vascular malformations can be complicated by venous thromboembolism. Clinicians should be aware of this rare, but potentially dangerous, association.

Reference #1: Qui et al. Outcomes and complications of sclerotherapy for venous malformations. Vasc Endovascular Surg. 2013 Aug;47(6):454-61.

Reference #2: Escardo et al. Pulmonary embolism after sclerotherapy treatment for variceal bleeding. Endoscopy. 2007; 39:E24-25.

DISCLOSURE: The following authors have nothing to disclose: Bishoy Zakhary, Ezra Dweck, Leopoldo Segal, David Steiger

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