Leg Vein Thrombosis and Pulmonary Embolism after Varicose Sclerotherapy

A female patient underwent foam sclerotherapy with ethoxysclerol under the clinical diagnosis of varicosis. 5 days later, the patient presented again with severe pain in the calf area and severe walking problems, and based on minor clinical findings with discrete evidence of redness a clinical diagnosis of thrombophlebitis wasmade and treated with ibuprofen. An appointment for a duplex sonographic examination was made 11 days later, but the patient did not attend until 16 days later. A phlebography was performed to exclude thrombosis, which showed deep vein thrombosis. Subsequent inpatient treatment additionally revealed pulmonary artery embolism. The patient claimed mistreatment by the dermatologist. Due to an incorrect sclerotherapy treatment or follow-up check, a deep thrombosis with subsequent pulmonary embolism had not been recognised, and an incorrect treatment had been carried out by misjudging obvious symptoms. A dermatological expert and the Independent Medical Expert Council (IMEC) confirmed a treatment error. While the sclerotherapy was an accepted treatment method for varicosis according to specialist standards, and although deep vein thrombosis after sclerotherapy is a very rare complication, further diagnostic measures, in particular a duplex sonographic examination, would have been indicated without significant delay after the patient presented again due to considerable complaints. This was a deficiency in performing required medical examinations, which in the specific case led to a reversal of the burden of proof with regard to the causation of the treatment error for the damage that occurred. Deep vein thrombosis with the risk of pulmonary embolism is a rare, but typical complication after endovenous procedures for varicosis. If limb pain develops after foam sclerotherapy, deep vein thrombosis should be considered as a differential diagnosis and immediately confirmed or ruled out by duplex sonography and determination of D-dimers and, if necessary, treated according to guidelines. The delay of an indicated exclusion of thrombosis can be regarded as a culpable error in the performing of required medical examinations with the possible consequence of a reversal of the burden of proof.