Tibial vein thrombosis after foam sclerotherapy: A single-institution case series

Objective Ultrasound-guided foam sclerotherapy is commonly used for superficial venous disease but carries a small risk of deep vein thrombosis (DVT). Management of tibial vein thrombosis following sclerotherapy remains controversial, with practices ranging from anticoagulation and antiplatelet therapy to observation alone. We sought to characterize the natural history of tibial DVTs identified after foam sclerotherapy and evaluate outcomes based on management strategy. Methods We retrospectively analyzed patients who underwent physician-compounded foam sclerotherapy (Asclera) at a multi-institutional healthcare system between January 2016 and January 2022 and developed duplex-diagnosed tibial DVT. Patients underwent standardized follow-up duplex examinations at approximately 2-, 4-, and 6-weeks post-procedure. Thrombus evolution (resolution, reduction, stability, enlargement, propagation, and embolization) and clinical symptoms were recorded. Outcomes were compared across management groups: antiplatelet therapy, anticoagulation, and observation. Statistical analyses utilized Kruskal-Wallis and chi-square tests. Results Out of 877 foam sclerotherapy patients, 622 had follow-up imaging, and 54 patients (55 legs; 9%) developed tibial DVT, forming the study cohort (median age 53 years; 51% female). At initial duplex ultrasound (median 14 days post-procedure), all thrombi were ipsilateral to treatment, with concurrent proximal DVT in 5 cases (4 popliteal, 1 femoral; 9%). Initial management of the tibial thrombus included antiplatelet therapy (55%), anticoagulation (26%), or observation (20%). At final follow-up (median 35 days), thrombus completely resolved in 53%, decreased in 20%, and remained stable in 27%. No patients had enlargement or pulmonary embolism. Symptom resolution was achieved in 87% of patients, with no significant differences between management strategies. Conclusions In our series, tibial DVTs following foam sclerotherapy demonstrate a benign clinical course regardless of management strategy. Routine anticoagulation or antiplatelet therapy may not be necessary in asymptomatic patients with isolated distal thrombus. Prospective studies are required to confirm these findings and guide evidence-based recommendations.