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Variation in level of glycemia after sclerotherapy performed with 10 ml of 75% hypertonic glucose

(Portuguese PDF version)

Cleusa Ema Quilici Belczak¹, José Maria Pereira de Godoy², João Belczak Neto³, Andréia Gineste Pedro da Cunha³, Sergio Quilici Belczak⁴

1. Professor, Escola Superior Argentino-Americana de Flebologia e Linfologia, Associação Médica Argentina (Argentinean Medical Association - AMA). Member of Grupo Internacional de la Compresión (International Group of Compression - GIC).
2. Ph.D., Associate professor, Department of Cardiology and Cardiovascular Surgery, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil.
3. Vascular surgeon, Centro Vascular, Maringá, Paraná, Brazil.
4. Undergraduate student of medicine, Universidade Federal do Paraná, Curitiba, Paraná, Brazil.

Correspondence:
Cleusa Ema Quilici Belczak
Centro Vascular
Av. Tiradentes, 1081
CEP 87013-260 - Maringá - PR, Brazil
Phone: +55 (44) 225.3844/224.5171
E-mail: belczak@wnet.com.br

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ABSTRACT

Objective: To assess and evaluate the variation in the level of glycemia after sclerotherapy performed using 75% hypertonic glucose.

Method: The levels of glycemia were sampled before and immediately after a sclerotherapy performed with a 10 ml dose of 75% hypertonic glucose in 35 fasting patients. They were all non-diabetic, identified as class 1 patients (CEAP), with an average age of 43.8 years.

Results: The levels of glycemia presented a mean variation of 42.8 mg/dl, (49%.)

Conclusion: Sclerotherapy performed with 75% hypertonic glucose leads to a significant increase in the levels of glycemia.

Key-words: glycemia, sclerotherapy, sclerosing agent.
Palavras-chave: glicemia, escleroterapia, esclerosantes.

J Vasc Br 2004;3(2):127-31

The term sclerosis comes from the Greek word skleros, which means 'hard'.¹ Sclerotherapy is a procedure basically designed to produce the fibrosis of tissues. Sclerosing agents are substances which, once introduced into the vascular lumen in adequate concentrations, can trigger a process of vein obliteration.²

Currently, among the most common procedures for the clinical treatment of varicose veins, conventional sclerotherapy stands out as the treatment of choice. Some authors argue that, under certain circumstances and especially according to the preference of disciples of European schools, such as the French school,³ injection of sclerosing agents may be employed for all kinds of varices.

Such substances are designed to disperse the fibrinogen in the tunica intima and damage its endothelial cells. Fibrin deposition both within the lumen and around the vessel wall leads to an inflammatory reaction, which gradually transforms into fibrosis.⁴ Such reaction causes vein collapse, and then it becomes no longer visible.⁵

Since the aim is to achieve obliteration of the vessel, but not its thrombosis (in which case the vein frequently recanalizes,⁶ leading to recurrence), practitioners should look for the ideal substance that is able to produce sclerosis rather than thrombosis. Such agent should be a stable, easily-handled, fluid, colorless, innocuous, anti-clotting, active, effective, non-toxic, hypoallergenic substance, with a limited and controlled local action.⁷

Sclerosing agents may be classified according to their action into the following categories: thrombogenic; detergent; osmotic and irritant.⁸

Hypertonic glucose was used for the first time by Kauch in Germany in 1917;⁹ it is an osmotic solution which leads to cell dehydration in the endothelial layer and consequently causes destruction and degradation of such part of the vessel wall.³ Its slow action takes from 30 minutes to four days, and is considered milder and able to produce fewer areas of desquamation than detergent agents.¹⁰ If nerve endings of the adventitia and underlying muscles are stimulated by the injection, pain, local burning sensation and cramping follow.⁹ Such symptoms vanish quickly (less than 5 minutes.)

Contraindications are ischemic artery diseases, decompensated coronary and/or renal insufficiency, hepatic diseases, intolerance or allergy to the sclerosing agent chosen, infections, pregnancy (which is the stage of development of varices par excellence), history of deep venous thrombosis, oncogenic disease and decompensated diabetes.⁸

Given that the immediate systemic effects of sclerotherapy are still a controversial issue, and the range of variation of levels of glycemia after such procedure using 75% hypertonic glucose (which is the most frequently used sclerosing agent in our daily practice) is still uncertain, we found it relevant to carry out a study to address specifically that question.

The objective of the present study was to assess the variation in levels of glycemia after sclerotherapy performed with 10 ml of 75% hypertonic glucose.

METHOD

For two months, the levels of glycemia of 35 Caucasian, non-diabetic female patients, identified as class 1 patients according to CEAP classification, with ages ranging from 30 to 69 years (average of 43.8 years) were evaluated before and after sclerotherapy of small varices in lower limbs. It was performed in fasting patients with a 10 ml dose of 75% hypertonic glucose injected with disposable 3 ml BD syringes and 27.5 gauge Terumo needles. The procedures started at approximately 8:30 a.m. and took 22.3 minutes on average. Samples were collected before and after the procedure from a superficial vein (median basilic or cephalic veins) in the upper limb (from either side), and immediately taken to the laboratory of clinical studies. The 2 ml blood samples were collected in BD Vacutainer System containing preanalytical solution (made in UK) and were analyzed with enzymatic colorimetric methods.

All patients signed a previous consent letter, were perfectly lucid, with no fever and were not under influence of any drug that could interfere with the results.

Statistical analysis was performed with paired Student's t test, with a confidence interval of 95% and P < 0.05

RESULTS

Paired Student's t test evidenced a highly significant difference between average levels of glycemia sampled before and after sclerotherapy, with P < 0.0001. The smaller difference observed was 21 mg/dl (before = 88 mg/dl and after = 109 mg/dl), and the greater difference was 67 mg/dl (before = 76 mg/dl and after = 143 mg/dl), and the mean difference was 42.8 mg/dl. Table 1 shows the mean and standard deviation in the patients' levels of glycemia.

Table 1 - Mean values (standard deviation) of the levels of glycemia before and after sclerotherapy

Level of glycemia	Mean (mg/dl)	Standard deviation (mg/dl)
Before sclerotherapy	86.62	9.93
After sclerotherapy	129.42	14.94

Bootstrap estimation of the ratio of means (before and after sclerotherapy) is 1.49 (± 0.018), which indicates a mean variation of probably 49% between the two periods of observation. The bootstrap confidence interval of 99% for the estimation of this ratio was given by (1.42; 1.56). Figure 1 shows the increasing levels of glycemia observed in each patient, and figure 2 shows the empirical distribution of the ratio of means, obtained after 10,000 bootstrap simulations.

Figure 1 - Increasing levels of glycemia of each patient.

Figure 2 - Ratio of means.

DISCUSSION

The present study evidences that the choice of sclerosing agents (among which is the hypertonic glusoce) for sclerotherapy is crucial.

Besides assuming that it has an indisputable cosmetic importance, it is considered a big mistake to regard such therapeutic modality as a mere aesthetic procedure. Varicules or small varices and telangiectasias are frequently the first sign of a chronic venous insufficiency. Our study evidences the importance that the patient always be adequately examined and questioned about other disorders that may affect him/her simultaneously. It is crucial that the practitioner has a precise knowledge about the therapeutic indication, the adequate technique and specially the effects of the sclerosing agent chosen. The variation in levels of glycemia diagnosed after sclerotherapy performed with 75% hypertonic glucose illustrates the importance of preparatory steps and the limitations of such procedure. The observation that the levels of glycemia undergo significant variation when a dose of 10 ml of 75% hypertonic glucose is used may indicate that, for certain patients with confirmed genetic-familial predisposition to diabetes (pre-diabetics) or for patients with compensated diabetes who are indicated to undergo such a procedure, another sclerosing agent should be chosen or a lower dose of this agent should be employed in order to avoid hyperglycemia and further consequences. Crucially, along with providing the patients with convincing and long-lasting results, the safety of the procedure should be assured. The greatest advantages of this therapeutic modality are its low cost and the possibility that it be performed in the medical office in sessions, so that it does not affect patients' daily activities after the end of treatment. With the exception of some rare cases, sclerotherapy is indicated for the treatment of small varicosities, such as telangiectasias, small varices and venulectasias.¹¹

CONCLUSION

Conventional sclerotherapy performed with 75% hypertonic glucose causes a significant increase in the level of glycemia. Such variation suggests greater caution in using that substance, specially in patients with predisposition to diabetes.

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